Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis

Surgical Treatment for Type A Aortic Dissection after Endovascular Aortic Repair: A 12-year, Single-Center Study

OBJECTIVE

This study aims to investigate the clinical manifestations, operative techniques, and outcomes of patients who undergo open repair after thoracic endovascular aortic repair (TEVAR).

METHODS

From January 2010 to June 2022, 113 consecutive type A aortic dissection (TAAD) patients underwent secondary open operation after TEVAR at our institution, and the median interval from primary intervention to open surgery was 12 (1.9-48.0) months. We divided the patients into two groups (RTAD (retrograde type A dissection) group, N = 56; PNAD (proximal new aortic dissection) group, N = 57) according to their anatomical features. Survival analysis during the follow-up was evaluated using a Kaplan-Meier survival curve and a log-rank test.

RESULTS

The 30-day mortality was 6.2% (7/113), the median follow-up period was 31.7 (IQR 14.7-65.6) months, and the overall survival at 1 year, 5 years, and 10 years was 88.5%, 88.5%, and 87.6%, respectively. Fourteen deaths occurred during the follow-up, but there were no late aorta-related deaths. Three patients underwent total thoracoabdominal aortic replacement 1 year after a second open operation. The RTAD group had a smaller ascending aorta size (42.5 ± 7.7 mm vs 48.4 ± 11.4 mm; P < .01) and a closer proximal landing zone (P < .01) compared to the PNAD group. However, there were no differences in survival between the two groups.

CONCLUSIONS

TAAD can present as an early or a late complication after TEVAR due to stent-grafting-related issues or disease progression. Open operation can be performed to treat TAAD, and this has acceptable early and mid-term outcomes. Follow-up should become mandatory for patients after TEVAR because these patients are at increased risk for TAAD.

Proximal Landing Zone's Impact on Outcomes of Branched and Fenestrated Aortic Arch Repair

Background/Objectives: The impact of the proximal landing zone has not been investigated in fenestrated and branched endovascular aortic arch repair (f/bTEVAR). This study aimed to analyze the f/bTEVAR outcomes in patients with non-native (nNPAL) vs. native proximal aortic landing (NPAL). Methods: The STROBE statement was followed in order to conduct a single-center retrospective analysis of patients with nNPAL vs. NPAL managed, from 1 September 2011 to 30 June 2022, with f/bTEVAR. The primary outcomes were technical success, 30-day mortality and stroke. Results: A total of 83 patients with nNPAL vs. 126 patients with NPAL were included. Among the nNPAL group, 34 (39.7%) underwent previous aortic arch replacement and the remaining underwent an ascending aortic replacement. The nNPAL patients were more commonly treated for chronic dissections (nNPAL: 70.6% vs. NPAL: 21.6%, p < 0.001), presented a more proximal disease (zone 0: nNPAL: 27.7% vs. NPAL: 7.1%, p < 0.001; zone 1: nNPAL: 50.6% vs. NPAL: 10.2%, p < 0.001) and received more triple-branch devices (nNPAL: 16.9% vs. NPAL: 3.2%, p < 0.001), with a higher rate of Ishimaru zone 0 landing (nNPAL: 86.8% vs. NPAL: 51.6%, p < 0.001). Technical success (nNPAL: 98.8% vs. NPAL: 94.4%, p = 0.07) and 30-day mortality (nNPAL: 6.0%, vs. NPAL: 11.9%, p = 0.16) were similar. Stroke was lower among nNPAL patients (nNPAL: 4.8% vs. NPAL: 13.5%, p = 0.04). A multivariate regression analysis confirmed nNPAL as an independent protector for stroke (p = 0.002). Survival (log rank: p = 0.02) was higher within the nNPAL group at 24 months. Conclusions: f/bTEVAR in patients with nNPAL zone showed encouraging outcomes. Despite more proximal landing in zone 0, stroke was significantly lower when compared to NPAL patients.

Predictive factors for size change of aorta in patients with acute blunt traumatic aortic injury

OBJECTIVE

We aimed to investigate the changes in aorta size, the factors affecting size changes in patients with acute blunt traumatic aortic injury and to evaluate the adequacy of the current 120% thoracic endovascular aortic repair graft oversizing policy.

DESIGN AND METHODS

This retrospective review study was conducted using the prospectively collected medical records of 45 patients (mean age: 53.5 years, male: 39 patients) with blunt traumatic aortic injury treated at a level 1 trauma center between 2012 and 2021. Aortic diameter was measured by computed tomography angiographic images at four different levels [ascending aorta (A), isthmus (B), descending thoracic aorta (C), and infrarenal aorta (D)] on arrival and follow-up (median time interval, 13 days). Associated factors including patient characteristics and hemodynamic parameters on arrival and follow-up were collected to determine their influence on changes in the aorta.

RESULTS

The mean diameter of all four aortic levels increased on follow-up computed tomography compared to initial computed tomography (A: + 11.77%, B: + 10.19%, C: + 7.71%, D: + 12.04%). Patient age and injury severity score influenced changes in the diameter of the ascending aorta (P < 0.05). Patient age and blunt traumatic aortic injury grade were significantly associated with changes in the infrarenal aortic diameter (P < 0.05). Three cases of type 1 endoleak were observed at follow-up but all were spontaneously resolved without further intervention at next computed tomography follow-up.

CONCLUSIONS

In patients with acute blunt traumatic aortic injury, aortic diameter is significantly smaller by about 10% under shock and is not considered a basis for oversizing the currently implemented 120% thoracic endovascular aortic repair graft sizing. However, in young patients under the age of 40, the change is significantly large and subsequent computed tomography follow-up is required.

A three-dimensional model of aortic dissection for hybrid surgical simulation and training

Thoracic endovascular aortic repair is widely performed in complicated and uncomplicated type B aortic dissection cases. After the introduction of a stent graft, the use of several types of hybrid approaches has been reported for patients with type A aortic dissection. The procedure is advanced because the complications are fatal; therefore, training is required. However, the surgical simulation of aortic dissection is challenging because no favourable animal model is available. This study aimed to simulate hybrid surgical simulation using a novel three-dimensional aortic dissection model. Three-dimensional polyurethane models of type A and B aortic dissection, both of which have true and false lumens, were manufactured based on computed tomography data. Under fluoroscopy, the entry tear and false lumen flows were visualized using a contrast medium. A stent graft was delivered and deployed under pulsatile conditions in the type B aortic dissection model. Total arch replacement was performed in the type A and B aortic dissection models after thoracic endovascular aortic repair as a hybrid approach. In conclusion, a model with a mock circuit is a useful tool to simulate both open and endovascular aortic repair for aortic dissections as a hybrid approach.

Conservative Treatment of Retrograde Aortic Dissection After Endovascular or Hybrid Repair of Descending Aorta Pathologies

BACKGROUND

Retrograde type A dissection (RTAD) represents a rare but possible lethal complication of thoracic endovascular aortic repair. Intervention is often recommended, but conservative management has been advocated in selected cases.

METHODS

We performed a systematic review of the literature through MedLine and Cochrane databases over the last 24 years to identify reported cases of RTAD managed conservatively. Primary endpoint was the overall and aortic-related mortality, the morbidity, and the need for intervention during follow-up. The underlining causes and indications for conservative management were also investigated. (Protocol on Prospero Centre for Reviews and Dissemination RD42024542966).

RESULTS

A total of 2,305 papers were identified, and 10 articles were included (20 cases). The reasons for conservative treatment were age (n = 8.40%) and/or haemodynamic stability(n = 16,80%) and/or unfitness for surgery(n = 12,60%). The causes of RTAD were fragile aortic wall in acute type B aortic dissection (TBAD) (n = 10, 50%), Marfan syndrome (n = 2, 10%), use of stents with proximal barbs or bare springs (n = 5, 25%), diameter of the ascending aorta>40 mm (n = 2, 10%), and intraoperative type IA endoleak (n = 2, 10%). Three patients (15%) were lost to follow-up immediately after discharge; one (5%) died in hospital from aortic rupture. At a mean follow-up of 33.5 months (range 9-60), the overall survival was 88.2% (n = 15/17) and aortic-related mortality was 10% (n = 2/20). No complications or interventions during the follow-up period were reported.

CONCLUSIONS

The mortality rate following RTAD is high, and surgery allows improvement in survival. Conservative management might represent a viable option for selected patients. However, the current evidence is poor and needs to be validated by further and more robust data before such a strategy could be suggested more widely.

Type A Aortic Dissection After Thoracic Endovascular Aortic Repair for Type B

Type A aortic dissection (TAAD) has been associated with thoracic endovascular aortic repair (TEVAR) for aortic conditions: dissection and aneurysm. Our purpose was to study a subset of patients who had an initial TEVAR for type B aortic dissection, followed by a TAAD, which was treated by open ascending aortic repair. Over a 6-year period, 171 consecutive patients underwent open ascending aortic repair for TAAD, of whom 21 (12%) had a previous cardiovascular procedure, 17 of which were endovascular. A total of 9 (5.2%) of 171 patients with TAAD had a previous TEVAR for a type B. The mean interval from TEVAR to open ascending aortic repair for TAAD was 4.6 years, with only 1 occurring within a month. Only 1 patient had abnormal aortic media by histology. In 5 of the 9 patients, the entry tear was in the proximal ascending aorta, remote from the endograft, which suggests that a TAAD late after TEVAR for type B represents a new spontaneous event.

Questions and Certainty in Diagnosis and Management of Acute Type B Aortic Dissection

Type B aortic dissection (TBAD) is a severe cardiovascular condition that requires timely diagnosis and intervention to prevent life-threatening complications. The aim of this review was to focus on the most crucial and controversial aspects of contemporary TBAD management. It is recognized that in the acute phase, computed tomography angiography (CTA) plays an essential role in evaluating the extent of the dissection and monitoring disease progression. CTA has significantly improved the management of TBAD by providing detailed assessments of aortic anatomy and dynamic flow changes, positioning it as the cornerstone imaging modality for identifying acute high-risk patients who may require early intervention. Recently, new advances in magnetic resonance imaging (MRI) and positron emission tomography (PET) technology have the potential to provide further information beyond imaging alone. However, such sophisticated techniques should be reserved for stable patients after the acute phase. After decades of medical therapy and high risk surgery, thoracic endovascular aortic repair (TEVAR) has emerged as a minimally invasive alternative to open surgery for complicated TBAD, offering lower perioperative morbidity and mortality. Nevertheless, its use in uncomplicated TBAD remains a topic of ongoing debate. While recent studies suggest that preemptive TEVAR combined with optimal medical therapy may reduce late adverse events and improve long-term outcomes, these findings remain controversial. This review critically analyzes the current literature on both diagnosis and TEVAR treatment, evaluating these controversies in the context of clinical practice.

Time is Aorta in Uncomplicated Type B Aortic Dissection

BACKGROUND

Although cardiovascular control optimization through best medical therapy remains the gold standard of treatment for uncomplicated type B aortic dissection (uTBAD) according to international guidelines, thoracic endovascular aortic repair (TEVAR) has increasingly emerged as a viable and appealing treatment option due to its potential to induce favorable aortic remodeling and improve long-term outcomes. However, the optimal timing of TEVAR in uTBAD remains a subject of debate. This narrative review aims at evaluating safety, efficacy, and outcomes of TEVAR at different time points of the disease history.

METHODS

We conducted a comprehensive literature review across multiple electronic databases, including PubMed and Scopus, to synthesize research evidence on the timing of TEVAR in uTBAD.

RESULTS

Hyperacute-phase TEVAR (<24 hours) is associated with prohibitive periprocedural risks and is thus discouraged. Acute-phase TEVAR (1-14 days) may provide benefits in aortic remodeling but it is burdened by rather elevated rates of early complications and reinterventions. The subacute phase (14-90 days) is consistently identified as the optimal therapeutic window, balancing procedural safety and efficacy, with studies reporting superior outcomes in terms of mortality, complications, and aortic remodeling. Chronic-phase TEVAR (>90 days), although sometimes necessary in cases of disease progression, is associated with poorer outcomes, including higher rates of reintervention, complications, and limited aortic remodeling with respect to the subacute phase.

CONCLUSION

The consistent findings across the studies analyzed indicate that the subacute phase offers the best combination of reduced procedural risks and favorable long-term outcomes. However, stronger evidence is needed to refine timing strategies.

Comparison between Zone 2 and Zone 3 distal anastomoses for aortic arch replacement in terms of invasiveness

OBJECTIVES

Zone 2 anastomosis with total cervical branch reconstruction for acute type A aortic dissection and aortic arch aneurysms became possible after stent-graft introduction. This may be an easier procedure and reduce the risk of recurrent laryngeal nerve palsy. Therefore, this study aimed to compare the outcomes between Zone 2 and Zone 3 distal anastomoses.

METHODS

After evaluating the patient data in our institute between April 2016 and April 2022, the patients in whom distal anastomosis was performed at Zone 2 with a stent-graft were defined as the Zone 2 group (n = 70). The patients in whom distal anastomosis was performed at Zone 3 were defined as the Zone 3 group (n = 24).

RESULTS

The incidence of new-onset recurrent nerve palsy was one patient (1.4%) in the Zone 2 group and six patients (25.0%) in the Zone 3 group (p < 0.001). The lower body perfusion arrest time was 44.3 ± 9.1 min in the Zone 2 group and 52.9 ± 12.8 min in the Zone 3 group (p = 0.005). There were no significant differences in in-hospital mortality and morbidities. Multivariable analysis showed that only age was an independent predictor of overall mortality.

CONCLUSIONS

Performing distal anastomosis at Zone 2 with a frozen elephant trunk or stent-graft reduced the lower body perfusion arrest time and possibly prevented recurrent nerve palsy.

Retrograde aortic dissection encountered amidst nephrectomy for renal cell carcinoma with IVC thrombus - a case report

BACKGROUND

Management of RCC with IVC thrombus can be surgically challenging, particularly when the tumour thrombus extends above the diaphragm. Cardiopulmonary bypass is often employed to aid surgical removal of the tumour in such cases.

CASE PRESENTATION

We detail an instance of 67-year-old Male patient suffering from RCC with IVC thrombus, with the tumour thrombus extending into the right atrium, who developed on-table retrograde type A aortic dissection amidst the surgical procedure, thereby precluding cardiopulmonary bypass. Transfixation of the renal arterial stump resulted in disappearance of the dissection flap.

CONCLUSIONS

Operating surgeons should be mindful of the potential for retrograde aortic dissection during Radical Nephrectomy and its implications intraoperatively.

Ascending Geometry After Thoracic Endovascular Aortic Repair for Descending Aortic Dissection

BACKGROUND

This study aimed to assess geometry changes of the ascending aorta after thoracic endovascular aortic repair (TEVAR) for descending aortic dissection and identify potential risk factors for diameter and length change.

METHODS

Between April 2009 and July 2021, 102 patients were treated for acute descending aortic dissections (type B and non-A non-B) with TEVAR and were included in this analysis. Computed tomography angiographic scans were transferred to a dedicated imaging software and detailed aortic measurements (including length, diameter and area) were taken in multiplanar reconstruction postoperatively, after 6 months and annually thereafter.

RESULTS

Sixty-five (58%) patients were male, with a mean age of 66 (±11). Four (4%) patients were diagnosed with connective tissue disease. Before TEVAR, 79% of our patients were treated with a mean of 1.5 (±1.2) different classes of antihypertensive medications. This number rose to 98% after TEVAR and 2.7 (±1.0) different antihypertensive drugs. There was no significant change in length, diameter, cross-sectional area, or volume of the ascending aorta during the follow-up of 3 years after TEVAR. Body height was a negative predictor for mean ascending aortic diameter (P value = -0.013; B = -8.890) and mean aortic diameter at the level of the brachiocephalic trunk (P value = 0.039; B = -14.763).

CONCLUSIONS

Our data suggest no significant changes in the ascending aorta following TEVAR of the descending thoracic aorta during mid-term follow-up when under stringent blood pressure medication. Additionally, we did not find any modifiable risk factors for geometry parameter increase.

Retrograde type B aortic dissection after fenestrated-branched endovascular aortic aneurysm repair

Retrograde type B aortic dissection after perivisceral aortic endograft placement is a rare occurrence, not well described in literature. A handful of case reports describe this complication after infrarenal endovascular aortic aneurysm repair (EVAR). We have identified retrograde type B aortic dissection after fenestrated-branched EVAR (F/BEVAR) as a rare, but real complication. We describe diagnosis and management of 4 such occurrences in the context of 344 F/BEVARs.

Dynamic Morphology of Dilated Ascending Aorta and its Implications for Proximal Landing During Thoracic Endovascular Aortic Repair

INTRODUCTION

To improve the outcomes of thoracic endovascular aortic repair (TEVAR), we investigated the dynamic morphology of dilated and nondilated ascending aortas (AAs) to determine whether an appropriate proximal landing zone for TEVAR exists if the middle AA is dilated.

MATERIALS AND METHODS

Patients with dilated (diameter 40-50 mm) and nondilated (<40 mm) AAs underwent electrocardiogram-gated computed tomography angiography of the entire AA in the systolic and diastolic phases. For each plane of each AA segment, the maximal and minimal diameters in systole and diastole were recorded.

RESULTS

A total of 105 patients were enrolled (54% male; median age: 80 years [IQR 78-85]). A total of 35 patients were included in the dilated AA group (DG), and 70 patients were included in the nondilated AA group (n-DG). The aortic planes of the AA segment at the sinotubular junction (STJ) showed a more oval-shaped morphology compared with the distal planes of the same segment (the differences between the maximum and minimum diameters were 8.9% to 9.4% and 4.8% to 5.6%, respectively). If the mid-ascending aorta was dilated, the aortic segment at the STJ showed a more pronounced reversed-funnel 3D morphology, with a 14% (IQR 11%-19%) difference in diameters between the proximal and distal segmental planes shown in the n-DG and 18% (IQR 16%-22%, p<0.001) in the DG.

CONCLUSION

If the middle AA is dilated, it is considered unsuitable to perform TEVAR using conventional endografts without additional proximal fixation in the aortic segment at the STJ due to its pronounced reversed-funnel segmental morphology. By contrast, the aortic segment at the brachiocephalic trunk seems to be promising for performing TEVAR using an endograft of the appropriate size and conformability. Moreover, endograft sizing using the average aortic diameter instead of the maximal AA diameter in an oval-shaped aortic plane morphology should be considered.

CLINICAL IMPACT

If the middle ascending aorta is dilated, it is considered unsuitable to perform TEVAR with a proximal landing in the aortic segment at the sinotubular junction due to its pronounced reversed-funnel segmental morphology and high risk of type Ia endoleak and endograft migration. By contrast, the aortic segment at the brachiocephalic trunk seems to be promising for performing TEVAR due to its moderate funnel morphology using an endograft of appropriate size and conformability.

The Impact of Oversizing in Thoracic Endovascular Aortic Repair on Long-Term Outcomes in Uncomplicated Type B Aortic Dissection: A Single-Center Retrospective Study

PURPOSE

The purpose of this study was to assess the impact of oversizing in thoracic endovascular aortic repair (TEVAR) on early and long-term survival and major adverse events in patients with uncomplicated type B aortic dissection (TBAD).

METHODS

Between January 2010 and December 2018, 226 patients who were diagnosed with uncomplicated TBAD and received TEVAR were analyzed retrospectively. The patients were divided into ≤5% oversizing (n=153) and >5% oversizing (n=73) groups. Primary end points were all-cause and aortic-related mortalities. Secondary end points were procedure-related complications, including retrograde type A aortic dissection (RTAD), endoleak, distal stent-induced new entry (SINE), and late reintervention. All-cause and aortic-related mortalities were assessed using the Kaplan-Meier survival method, while procedure-related complications were evaluated using a competing risk model with all-cause death as a competing risk.

RESULTS

Mean oversizing was 2.1%±1.5% in the ≤5% oversizing group and 9.6%±4.1% in the >5% oversizing group. Differences in the 30-day mortality and adverse events between the 2 groups were statistically insignificant. The freedom from all-cause mortality was comparable between the ≤5% oversizing group and the >5% oversizing group (≤5%: 93.3% at 5 years, >5%: 92.3% at 5 years, p=0.957). No significant difference was observed between both groups in the freedom from aortic-related mortality (≤5%: 95.0% at 5 years, >5%: 96.7% at 5 years, p=0.928). However, the competing risk analyses revealed that the cumulative incidence of RTAD was statistically significantly greater in the >5% oversizing group than in the ≤5% oversizing group (≤5%: 1(0.7%) at 5 years, >5%: 6(6.9%) at 5 years, p=0.007). All RTADs occurred within a year of TEVAR. The differences in the cumulative incidences of type I endoleak, distal SINE, and late reintervention were not significant between the 2 groups.

CONCLUSION

The differences in the 5-year all-cause mortality and aortic-related mortality between patients with uncomplicated TBAD who received TEVAR with ≤5% oversizing and those who got TEVAR with >5% oversizing were insignificant. However, oversizing >5% was considerably associated with an increased risk of RTAD within a year of TEVAR, suggesting that oversizing ≤5% may be the appropriate size for TEVAR in patients with uncomplicated TBAD.

CLINICAL IMPACT

For patients with uncomplicated TBAD, choosing oversizing ≤5% in endovascular treatment is beneficial to reduce the risk of postoperative retrograde type A aortic dissection. This finding provides a basis for stent size selection in endovascular repair. In addition, one year after TEVAR is the main time period for postoperative retrograde type A aortic dissection, and attention should be paid to the management and follow-up of this period.

Trends in utilization, timing, and outcomes of thoracic endovascular repair for type B aortic dissection in the United States

Background

Aortic dissection is the most common acute aortic syndrome in the United States. Type B aortic dissection (TBAD) can be managed medically, through open surgical repair, or with thoracic endovascular repair (TEVAR). The present study sought to assess contemporary trends in the use and timing of TEVAR.

Methods

Adult nonelective TBAD admissions were identified in the 2010 to 2020 Nationwide Readmissions Database. Patients were categorized as medical management (Medical Management), TEVAR at initial hospitalization (Early), or TEVAR during readmission (Delayed). Multivariable models were developed to assess associations with clinical outcomes and resource utilization.

Results

Of 85,753 patients, 8.7% underwent TEVAR at index hospitalization (Early). From 2010 to 2020, the proportion undergoing TEVAR decreased significantly (from 11.3% to 9.6%; nptrend < .001), while the proportion of TEVAR at a subsequent hospitalization increased (from 13.0% to 21.6%; nptrend < .001). Compared to Medical Management, the Early group was younger (median. 63 [interquartile range (IQR), 52-74] years vs 69 [IQR, 57-81] years), and more frequently privately insured (27.7% vs 17.5%; P < .001). Following adjustment, the Early group had a reduced odds of mortality (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.48-0.66) and increased hospitalization costs (β = +$50,000; 95% CI, $48,000-$53,000). Among 4267 TEVAR patients with available procedure timing data, 15.7% were categorized as Delayed. The Early and Delayed groups did not differ in terms of demographics. The Delayed group had a decreased likelihood of major adverse events (aOR, 0.50; 95% CI, 0.39-0.64); however, this did not affect 90-day cumulative hospitalization costs (β = +$2700; 95% CI, -$5000-$11,000, ref: Early).

Conclusions

This study suggests changes to TBAD management in both treatment modality and TEVAR timing. Focused analysis on the timing and long-term costs of TEVAR are needed to optimize care delivery.

Endovascular Repair of Penetrating Thoracic Aortic Ulcers Using Tubular Stent Grafts Versus Stent Grafts With a Proximal Scallop

PURPOSE

In penetrating aortic ulcers (PAUs), limited data support tubular thoracic endovascular aortic repair (TEVAR) as a viable treatment option. For treatment of more proximal PAUs, hybrid approaches and-more recently-scalloped TEVAR (scTEVAR) have been advocated. Outcomes of scTEVAR specifically for PAUs have not yet been reported. This study reports long-term outcomes for tubular and scTEVAR in PAUs and compares the safety profile in both cohorts regarding the significantly more proximal landing zone (LZ) for scTEVAR.

MATERIALS AND METHODS

This single-center retrospective cohort study includes all nonacute patients treated for complicated PAU with scTEVAR and tubular TEVAR. Patient and PAU characteristics as well as procedural success, complication and reintervention rates, and all-cause and aortic mortality were analyzed.

RESULTS

Of 212 TEVAR procedures reviewed, 21 patients with tubular TEVAR and 19 patients with scTEVAR were included. Patient and PAU characteristics were similar, and LZ was significantly more proximal in the scTEVAR cohort (p=0.0001), with similar number and types of supra-aortic revascularization procedures. Clinical success was reached in all 40 patients (100%), and reintervention rate was 2/21 (9.5%) and 1/19 (5.3%), respectively. Over the mean follow-up of 63 (TEVAR) and 53 (scTEVAR) months, clinical success was stable in all patients with one (abdominal) aortic-related mortality in the scTEVAR cohort.

CONCLUSION

Treatment of complicated PAUs with TEVAR as well as scTEVAR provides excellent and similar clinical success, stability of clinical success, and aortic survival with acceptable complication and reintervention rates. Scalloped TEVAR safely lengthens the proximal sealing zone to address more proximal pathologies.

CLINICAL IMPACT

Treatment of asymptomatic complicated penetrating aortic ulcers (PAUs) with thoracic endovascular aortic repair (TEVAR) provides excellent clinical success and acceptable complication and reintervention rates. More patients become amenable to endovascular treatment by including scalloped TEVAR (scTEVAR) as a means to safely lengthen the proximal sealing zone to address more proximal pathologies.

Outcomes of thoracic endovascular aortic repair with fenestrated surgeon-modified stent-grafts for type B aortic dissection involving the aortic arch: a multicenter retrospective study

Background

Thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-grafts (f-SMSGs) is becoming an option for treating type B aortic dissection (TBAD) involving the aortic arch. This study aimed to evaluate the outcomes of this technique.

Methods

A retrospective multicenter study was conducted, involving consecutive patients from three medical centers in China who underwent TEVAR with f-SMSG for TBAD. A new technique called "Lu's direction-turnover technique" was employed to align the fenestrations with supra-aortic vessels.

Results

From March 2016 to January 2020, 117 patients diagnosed with TBAD were deemed eligible for inclusion. The technical success rate was 94% (n=110). The estimated 30-day survival rate was 97.4% [95% confidence interval (CI): 94.5% to 100.0%], with freedom from re-intervention estimated at 95.7% (95% CI: 92.0% to 99.4%). The median follow-up period was 27 months (interquartile range, 19 to 35 months). The estimated survival rate at 27 months was 94.9% (95% CI: 90.8% to 98.9%) and the rate of freedom from re-intervention was 91.5% (95% CI: 86.3% to 96.6%). Cases of retrograde type A aortic dissection, stroke and endoleaks were documented. Five cases of retrograde type A aortic dissection were documented, with three occurring within 30 days and one during the follow-up. Four cases of stroke were recorded, with one occurring within 30 days and three during the follow-up. Furthermore, eleven cases of endoleaks were recorded, with one occurring within 30 days and ten during the follow-up.

Conclusions

Clinically acceptable technical success and prognosis were observed in a cohort with TEVAR with f-SMSG for the treatment of TBAD involving the aortic arch, which necessitated revascularization of the supra-aortic vessels. Further comparative studies are required to validate the benefits of this approach.

Complications of thoracic endovascular aneurysm repair (TEVAR): A pictorial review

Thoracic endovascular aneurysm repair (TEVAR) has replaced open surgical repair as the treatment of choice for several aortic conditions. Despite its lower morbidity and mortality, several TEVAR-related complications can occur and some of which may necessitate surgical or endovascular re-intervention. The current article reviews common and rare complications of TEVAR procedure with emphasis on complications identifiable on cross-sectional imaging and potential pitfalls of pre-procedural planning.

Computed tomography angiography-guided analysis of morphologic properties of the thoracic aorta and arch branches among the adult population: A cross-sectional study

Background and Aims

Before performing any surgical or endovascular procedure, the anatomical classification of the patient is essential for treatment planning. Computed Tomographic Angiography (CTA) is a standard method to evaluate thoracic aortic anatomy and associated variations.

Methods

This cross-sectional, descriptive study was performed among adult participants without any peripheral vascular diseases undergoing thoracic CTA. Demographic data were collected along with factors retrieved from the patients CTA, such as the type of aortic arch, length, and diameter of ascending and descending aorta, the diameter of the main branches and the distance between branches, the angles by which the main arteries rise from their origins, and left anterior oblique angle of the aortic arch.

Results

164 patients, with a mean age of 57 ± 19.3 years, entered the study. 53 (33.8%) had a bovine arch, which was mostly observed among males. A decrease in the frequency of type I arch and also an increase in the frequency of type 2 and 3 arches was observed with the increase in age (p < 0.001). The BCT diameter had a direct association with both left common carotid artery diameter (r = 0.478, p < 0.001) and left subclavian artery diameter (r = 0.470, p < 0.001). The length of the descending aorta had a direct correlation (r = 0.294, p < 0.001) with the length of the ascending aorta.

Conclusion

Complex endovascular interventions are vital method in treating aorta, head, and neck pathologies. Accurate knowledge of thoracic aortic anatomy is becoming crucial for diagnosis and intervention planning.

Mid- and long-term results of open repair for chronic type B aortic dissection in endovascular era

Medical management is the standard treatment of chronic type B aortic dissection (CTBAD). However, the roles of open surgical repair (OSR) and thoracic endovascular repair (TEVAR) in patients with CTBAD remain controversial. Thus, this study aimed to assess and compare the mid- and long-term clinical outcomes of OSR via left thoracotomy with that of TEVAR for CTBAD. The data of 85 consecutive patients who underwent surgery for CTBAD from April 2007 to May 2021 were retrospectively reviewed. The patients were divided into two groups: Group G, which included patients who underwent OSR, and Group E, which included patients who underwent TEVAR. Groups G and E comprised 33 and 52 patients, respectively. Preoperative and postoperative computed tomography (CT) studies were retrospectively analyzed for the maximum diameter. The mean duration of the follow-up period was 5.8 years. Operative mortality did not occur. There was no difference in complications, such as stroke (G: 2 vs. E: 0, p = 0.30), paraplegia (G: 1 vs. E: 1, p = 0.66), and respiratory failure (G: 2, vs. E: 0, p = 0.30). The difference in preoperative factors was observed, including the intervals between onset and operation (G; 4.9 years vs. E; 1.9 years, p < 0.01), maximum diameter in preoperative CT (G; 59.0 mm vs. E; 50.5 mm, p < 0.001), and maximum false lumen diameter (G; 35.5 mm vs. E; 29.0 mm, p < 0.01). There was no significant difference in the mid- and long-term survival rates (p = 0.49), aorta-related deaths (p = 0.33), and thoracic re-intervention rates (p = 0.34). Postoperative adverse events occurred in Group E: four cases of retrospective type A aortic dissection, two cases of aorto-bronchial fistula, and one case of aorto-esophagus fistula. Aorta-related death and re-intervention rates crossed over in both groups after seven years postoperatively. Although endovascular repair of CTBAD is less invasive, the rate of freedom from re-intervention was unsatisfactory. Some fatal complications were observed in the endovascular group, and the mid- and long-term outcomes were reversed compared with those in the OSR group. Although OSR is an invasive procedure, it could be performed safely without perioperative complications. OSR has more feasible mid- and long-term outcomes.

What is the Optimal Proximal Landing Zone of the Stent Graft in Treatment of Aortic Type B Dissection?

PURPOSE

Retrograde type A aortic dissection (RTAD) represents a serious complication of endovascular treatment for type B aortic dissection (TBAD). To avoid RTAD, it is recommended to land the proximal end of the stent graft in a non-dissected aortic segment. In this study, we investigated whether landing in the dissection area increased the number of events at the proximal site.

METHODS

We conducted a retrospective review of endovascular treatments for TBAD at a single institution between 2009 and 2022. Patients were divided into two groups: group A, with a proximal landing zone entirely within the dissected area, and group B, with the proximal extent of the seal zone in the non-dissected area. We evaluated the occurrence of proximal events, including RTAD, and examined long-term outcomes to assess the validity of landing in the dissection area.

RESULTS

The study included eighty-nine patients who underwent endovascular treatment for TBAD. New intimal tears in the proximal landing site occurred in 3 cases (3.4%), with 1 case (2%) in group A and 2 cases (5.1%) in group B, showing no significant difference. Among the three cases, one (1.1%) in group B with zone 2 landing resulted in RTAD. At 60 months, the overall survival was 85%, and freedom from aorta-related mortality was 88%, with no significant difference between the groups.

CONCLUSION

Even if the proximal landing is in a dissected area, a treatment strategy performed in zone 3 without proximal landing in zone 2, seeking a non-dissected area, can still provide sufficient therapeutic effects. Level of Evidence 3 Retrospective single-center cohort analysis.

Long-term results of etiology-based thoracic endovascular aortic repair: a single-center experience

The use of thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) and Stanford type B aortic dissection (TBAD) has been increasing; however, in terms of etiology, the differences of long term after TEVAR outcomes remain unexplored. Thus, we investigated etiology-specific long-term results of TEVAR for TAA and TBAD. A total of 421 TEVAR procedures were performed at our institution from July 2007 to December 2021; 249 TAA cases and 172 TBAD cases were included. Traumatic aortic dissection and aortic injury cases were excluded. The mean observation duration was 5.7 years. The overall 30-day mortality rate was 1.4% (n = 6), with 1.2% (n = 3) in the TAA group and 1.7% (n = 3) in the TBAD group. The overall incidence of postoperative stroke was 0.9% (n = 4), with 1.2% (n = 3) and 0.6% (n = 1) in the TAA and TBAD groups, respectively (p = 0.90). Paraplegia developed in 1.7% (n = 7) of patients, with 2.4% (n = 6) in the TAA group and 0.6% (n = 1) in the TBAD group. Freedom from aortic-related death was not significantly different between the two etiologies; however, thoracic reintervention was more common in the TBAD group (p = 0.003), with endoleak being the most common indication for reintervention. Additionally, retrograde type A aortic dissection occurred in four TBAD cases, while migration occurred in three TAA cases. The perioperative results of TEVAR for TAA and TBAD were satisfactory. The long-term results were unfavorable owing to the occurrence of etiology-specific and common complications. In terms of the high frequency of reintervention, the long-term complications associated with TEVAR are etiology specific.

Efficacy of intentional undersized thoracic endovascular repair for Stanford type B aortic dissection

OBJECTIVE

Thoracic endovascular aneurysm repair (TEVAR) is widely used for the treatment of aortic dissection. Endograft oversizing is a risk factor for stent graft-induced new entry tears and retrograde type A aortic dissection. However, there is no clear consensus on the optimal graft size selection for Stanford type B acute or subacute aortic dissection (TBAD). Herein, we examined the safety and efficacy of TEVAR using an intentionally undersized endograft to treat TBAD.

METHODS

This retrospective chart review study included 82 patients who underwent TEVAR for acute or subacute Stanford TBAD between 2015 and 2022. We measured the true lumen diameter just distal to the subclavian artery and opted for a stent graft of the same diameter. In instances where deformation resulting from false lumen pressure displacement was pronounced, we measured the diameter at the site just proximal to the subclavian artery. Patients' characteristics, procedural, in-hospital, and follow-up data, and aortic remodeling were analyzed. The aortic diameter was analyzed using one-way analysis of variance followed by Dunnett's test. Survival and freedom from reintervention were estimated using Kaplan-Meier curves.

RESULTS

The follow-up rate was 98.4%. The mean age was 58.3 ± 12.3 years, and 76 were men (92.7%). The mean diameters of the stent graft and native proximal landing zone were 30.9 ± 3.2 mm and 30.8 ± 3.0 mm, respectively. The oversize rate of the stent graft in relation to the native proximal aortic diameter was 0.3% ± 4.7%. In-hospital mortality was observed in one patient, retrograde type A aortic dissection in one patient, distal stent graft-induced new entry tear in zero patients, and type 1a endoleak in 22 patients (26.8%). Type 1a endoleaks, characterized by antegrade false lumen blood flow originating from the primary entry, in 12 patients spontaneously disappeared within 1 year of follow-up. According to aortic remodeling, 59 patients (86.8%) achieved complete aortic remodeling at the aortic arch level and 51 (75.0%) at the eighth thoracic vertebral level. The diameters of the aortic arch and descending aorta were significantly reduced compared with the postoperative measurements (P <.001). Survival rates were 97.5% and 93.6% at 1 and 3 years, respectively. Freedom from reintervention was 84.7% and 84.7% at 1 and 3 years, respectively.

CONCLUSIONS

Intentionally undersized TEVAR was safe and achieved acceptable aortic remodeling despite a high rate of type 1a endoleaks. A type 1a endoleak was acceptable as it primarily diminished during the mid-term follow-up.

Differences in In-Hospital and Follow-Up Outcomes Between Non-A Non-B Aortic Dissection and Type B Aortic Dissection Treated by Endovascular Based Treatment

OBJECTIVES

Non-A non-B aortic dissection (AD) is a rare and life-threatening medical emergency, and it has been controversial whether it should be managed as type B aortic dissection (TBAD). The study aims to compare in-hospital and follow-up outcomes between patients with non-A non-B AD and those with TBAD treated by endovascular based treatment (EBT).

METHODS

From January 2017 to December 2021, 96 consecutive patients with non-A non-B AD met the inclusion criteria and underwent EBT. Patients with TBAD were matched to patients with non-A non-B AD at a 1:1 ratio using propensity score matching analysis to correct for baseline confounding factors. The primary endpoint was all-cause mortality. Aortic-related events were defined as dissection-related death, aortic rupture, retrograde type A aortic dissection, reintervention, and type Ia endoleak.

RESULTS

Patients with non-A non-B AD required more TEVAR-related adjunctive procedures compared to TBAD patients during EBT and they required a longer ICU length of stay (36.0 vs 24.0 hours, P < .05) as well as a longer hospitalization (8.0 vs 7.0 days, P < .05) after EBT. There was no statistical difference in overall survival after EBT for patients with TBAD and non-A non-B AD. However, compared to patients with TBAD, non-A non-B AD patients had a higher rate of reintervention and experienced more aortic-related late events during follow-up.

CONCLUSION

Patients with non-A non-B acute AD who are treated with EBT do not have higher in-hospital or follow-up mortality rates compared to patients with type B AD. However, there is an increased risk of reintervention and aortic-related late events after the intervention during follow-up.

Comparison of chimney technique and single-branched stent graft in a cohort of patients with type B aortic dissections: a retrospective cohort study

Background

Single-branched stent grafts and the chimney technique are widely used in the treatment of type B aortic dissection (TBAD). The main objective of this study was to compare the outcomes of single-branched stent grafts and the chimney technique in the treatment of TBAD.

Methods

From January 2019 to December 2021, the retrospective cohort study contained a cohort of 91 patients with TBAD undergoing thoracic endovascular aortic repair (TEVAR) using single-branched stent grafts and the chimney technique. Group A included 55 patients treated with single-branched covered stents, and Group B included 36 patients treated with the chimney technique. We compared the effects of the procedures on peri-/post-operative outcomes between the two groups. The primary endpoint is clinical death, and the secondary endpoints include the patency of branch stents, the incidence of cerebral infarction, false lumen thrombosis, and the proportion of paraplegia.

Results

For the baseline data, the two groups of patients show no differences in terms of age, gender, and associated symptoms. All procedures were successfully performed in both groups. The median follow-up period was 17.6 months (range, 10-34 months). During TEVAR, 5 (9.1%) type I endoleaks occurred in group A, and 11 (30.6%) occurred in group B (P<0.05). During follow-up, there were 2 cases (3.6%) of paraplegia and 1 case (1.8%) of cerebral infarction in Group A, while Group B had 1 case (2.8%) of paraplegia. Three patients in group B reported retrograde type A aortic dissection (RTAD), and 1 of them died (2.8%); however, there were no RTAD cases in group A. Complete thrombosis of the false lumen in the thoracic aorta was observed in 45.5% (25/55) of patients in group A and in 41.7% (15/36) in group B (P=0.72). No significant difference in the thrombosis-volume ratio in the whole false lumen was found during follow-up between group A (81.0%±2.9%) and group B (81.8%±2.6%; P=0.23).

Conclusions

Branched stent grafts can be used in cases with insufficient proximal landing zones and reduce the occurrence of type 1 endoleak compared to the chimney technique. This may help to prevent RTAD. Further research, including more cases and longer follow-up periods, is needed to substantiate these results.

The safety and prognostic evaluation of subsequent aortic surgery after thoracic endovascular aortic repair: a retrospective cohort study

Background

Thoracic endovascular aortic repair (TEVAR) is a widely employed clinical procedure for treating various aortic pathologies. However, some patients require subsequent surgical interventions post-TEVAR, particularly due to life-threatening complications such as aortic dissection. This study aimed to evaluate the safety and prognosis associated with additional aortic surgeries following TEVAR.

Methods

A retrospective analysis was conducted on 21 patients who underwent aortic surgery after TEVAR at Guangdong Provincial People's Hospital between September 2016 and August 2020. By compiling and reviewing perioperative data, we assessed surgical-related complications and survival rates.

Results

Among the 21 patients, 95.2% were male, with an average age of 53 years. Preoperative comorbidities included hypertension in 15 individuals, abdominal aortic aneurysm in one patient, and coronary heart disease in two patients. The primary complications of TEVAR were stent leakage and retrograde aortic dissection, with the latter being the predominant type in subsequent aortic surgeries. The mean duration of aortic clamping during surgery was 130.0 minutes, with a deep hypothermic circulatory arrest time of 8.5 minutes. Postoperatively, two patients suffered in-hospital mortality, one developed renal dysfunction, four required re-entry into the operating room for further treatment, and the average length of hospital stay was 20 days. Following discharge, 14.3% of patients experienced complications, with central nervous system symptoms being the most prevalent. Kaplan-Meier survival analysis indicated a 5-year survival rate of 85.7%.

Conclusions

Aortic surgical intervention following TEVAR is a safe therapeutic approach that can improve patient prognosis. However, meticulous management of the perioperative period is crucial for reducing the risk of complications and improving survival rates. This study provides valuable insights into aortic surgery post-TEVAR, but large-scale research is needed to validate these findings.

Interventions in Acute or Subacute Phase for Type B Aortic Dissection

The treatment strategy for acute and subacute Stanford type B aortic dissection has changed significantly since the advent of thoracic endovascular aortic repair (TEVAR). Indication for invasive treatment: In addition to the conventional complicated cases (rupture or malperfusion case), the indication for invasive treatment now includes cases with refractory hypertension, persistent or recurrent pain, large aortic diameter, and other conditions that are considered to have a poor prognosis with conservative treatment. Treatment methods: TEVAR is the first choice for acute, subacute, and early chronic-stage treatment, and when this is not possible, other techniques (fenestration and graft replacement) are chosen. Treatment timing: The timing of invasive treatment should be emergent in life-threatening conditions (for rupture or malperfusion case) and immediate in symptomatic cases, while in other cases, preemptive TEVAR is considered appropriate on a scheduled timing within 6 months of onset. (This is a translation of Jpn J Vasc Surg 2023; 32: 157-163.).

Outcomes of thoracic endovascular aortic repair with physician-manufactured partial micropore stent grafts for aortic arch pathologies

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) has been used extensively in the management of thoracic aortic diseases. Numerous efforts have been made to enhance clinical outcomes through the use of stent grafts. This study aimed to investigate the effectiveness and safety of physician-manufactured partial micropore stent grafts (PSMGs) in TEVAR.

METHODS

Between December 2017 and June 2022, data were collected from 56 patients who underwent TEVAR using physician-manufactured PSMGs. The evaluation encompassed technical success, perioperative and follow-up morbidity and mortality, stroke incidence, and branch artery patency.

RESULTS

In this investigation, 56 patients received treatment with physician-manufactured PSMGs. Of these patients, 46 were male, with a mean age of 62.1 ± 11.2 years. Aortic pathologies comprised aortic dissection (n = 31 [55.4%]), aortic aneurysms (n = 10 [17.9%]), penetrating aortic ulcer (n = 8 [14.3%]), and intramural hematoma (n = 7 [12.5%]). During a median follow-up of 18 months (interquartile range, 13-25 months), the stroke rate, supra-aortic branch patency rate, and endoleak rate were 0%, 100%, and 7.1%, respectively. There were no occurrences of all-cause mortality, stroke, or the necessity for open conversion.

CONCLUSIONS

TEVAR with physician-manufactured PSMGs is a viable alternative for addressing aortic arch pathologies in proficient medical centers. The approach demonstrates favorable branch patency, a low complication rate, and minimal postoperative mortality.

Comparison of bare and nonbare stent grafts during thoracic endovascular aneurysm repair of the aortic arch

OBJECTIVE

We compared the outcomes of patients treated with nonbare stents (NBS) and proximal bare stents (PBS) endografts with a proximal landing zone in the aortic arch during thoracic endovascular aortic repair (TEVAR).

METHODS

We conducted a retrospective cohort, observational, multicenter study that included 361 consecutive TEVAR procedures undertaken between November 2005 and December 2021. TEVAR patients with both BS and NBS Relay stent graft configurations with proximal landing in zones 1, 2, or 3 were enrolled. Preoperative anamnestic and morphological data, clinical outcomes, and aortic modifications 30 days after surgery and at the latest follow-up available were collected. The primary outcome was freedom from proximal endoleak (type IA) comparing the two configurations. Total and detailed endoleak rates, clinical and technical success, intraoperative additional maneuvers, major adverse events, and reinterventions were secondary outcomes.

RESULTS

The median follow-up was 4.9 (interquartile range, 2.0-8.1) years. No statistically significant difference between NBS and PBS patients concerning 30-day major adverse events, retrograde aortic dissection, disabling stroke, or late type IA endoleak (10.8% vs 7.8%; P = .597). Aneurysmal disease (P = .026), PLZ diameter of >34 mm (P = .026), aortic tortuosity index of >1.4 (P = .008), type III aortic arch (P = .068), and PLZ thrombus (P = .014) identified as risk factors by univariate Cox regression analysis. PLZ thrombus was the only type IA endoleak risk factor at multivariate Cox regression (P = .016).

CONCLUSIONS

We found no statistically significant difference in freedom from type IA endoleak, retrograde dissection, or disabling stroke observed between the NBS and the BS configuration of the Relay endograft. Proximal landing zone thrombotic apposition was a prominent risk factor for type IA endoleak after TEVAR.

Predicting adverse events after thoracic endovascular aortic repair for patients with type B aortic dissection

The potential of adverse events (AEs) after thoracic endovascular aortic repair (TEVAR) in patients with type B aortic dissection (TBAD) has been reported. To avoid the occurrence of AEs, it is important to recognize high-risk population for prevention in advance. The data of 261 patients with TBAD who received TEVAR between June 2017 and June 2021 at our medical center were retrospectively reviewed. After the implementation of exclusion criteria, 172 patients were finally included, and after 2.8 years (range from 1 day to 5.8 years) of follow up, they were divided into AEs (n = 41) and non-AEs (n = 131) groups. We identified the predictors of AEs, and a prediction model was constructed to calculate the specific risk of postoperative AEs at 1, 2, and 3 years, and to stratify patients into high-risk (n = 78) and low-risk (n = 94) group. The prediction model included seven predictors: Age > 75 years, Lower extremity malperfusion (LEM), NT-proBNP > 330 pg/ml, None distal tear, the ratio between the diameter of the ascending aorta and descending aorta (A/D ratio) > 1.2, the ratio of the area of the false lumen to the total aorta (FL ratio) > 64%, and acute TEVAR, which exhibited excellent predictive accuracy performance and discriminatory ability with C statistic of 82.3% (95% CI 77.3-89.2%). The prediction model was contributed to identify high-risk patients of postoperative AEs, which may serve to achievement of personalized treatment and follow-up plans for patients.

Timing of Intervention and Long-Term Outcomes of Type B Aortic Intramural Hematoma with Intimal Disruption at Admission

BACKGROUND

To compare the 30-day and long-term outcomes between patients with concomitant type B intramural hematoma and intimal disruption upon admission who underwent endovascular repair in the acute or subacute phases.

METHODS

Data were extracted from January 1, 2010, to December 31, 2019. Logistic regression and Cox regression were performed to evaluate the impact of timing of intervention on 30-day and long-term outcomes, respectively.

RESULTS

The study included 241 patients, among which 159 were in the acute group. No significant difference was observed in 30-day mortality (0.6% vs. 0%, P = 1), 30-day complication rate (2.5% vs. 1.2%, P = 0.664), long-term all-cause mortality (10.7% vs. 7.3%, P = 0.540), and aortic reintervention rate (2.5% vs. 2.4%, P = 1) between the acute and subacute group. In multivariable analysis, the timing of intervention was not associated with 30-day mortality (odds ratio (OR) = 0, 95% confidence interval CI: 0-Inf, P = 0.999), 30-day complication (OR = 0.30, 95% CI: 0.02-3.77, P = 0.348), long-term mortality (hazard ratio = 0.56, 95% CI: 0.20-1.61, P = 0.283), and aortic reintervention (OR = 0.97, 95% CI: 0.15-6.08, P = 0.970).

CONCLUSIONS

For patients with concomitant type B intramural hematoma and intimal disruption upon admission, there is no significant difference in 30-day and long-term outcomes between those who undergo endovascular treatment in the acute or subacute phase.

False lumen regurgitation fraction and energy loss in the aorta measured using four-dimensional flow MRI to predict expansion of acute uncomplicated type B aortic dissection: a prospective study

AIM

To assess the relationship between four-dimensional (4D)-flow-derived false lumen regurgitation fraction (FLRF) and energy loss (EL) percentage in the descending thoracic aorta (DTA) with the aortic growth rate in uncomplicated type B aortic dissection (uTBAD).

METHODS AND MATERIALS

In this prospective study performed on 15 patients with uTBAD, computed tomography (CT) angiography and 4D-flow magnetic resonance imaging (MRI) were performed at the initial presentation with follow-up CT at 2 years. 4D-flow parameters, including maximum peak systolic velocity (PSV), FLRF, and percentage of EL were measured using Circle CV42. The significance of these parameters for expansion (>3 mm/year) of aortic dissection was analysed.

RESULTS

Five patients had an enlarging aorta, while 10 had a stable aortic size. The Mann-Whitney U-test showed entry tear >10 mm (p=0.026), FLRF (7.6 ± 8.9 versus 64.8 ± 16.7%; p=0.002), EL in the DTA in (1.61 ± 1.99 versus 2.21 ± 0.32 μW/cm3; p=0.014) and percentage of EL in the DTA to overall energy loss from the ascending aorta to the DTA (37 ± 15% versus 66 ± 17%; p=0.005), having a statistically significant different expanding stable dissection. A positive significant Spearman correlation was noted with the aortic growth rate (in millimetres over 2 years) with FLRF (r=0.71, p=0.003), EL in the DTA (r=0.56, p=0.007), and percentage of EL in the DTA (r=0.62, p=0.003).

CONCLUSION

4D flow parameters, including FLRF and the percentage amount of EL in the DTA may help predict aortic growth at an early stage in uTBAD.

Outcomes of fenestrated endovascular abdominal aortic repair in distal entry tears of chronic debakey IIIb aortic dissection

Currently, there have been very few reports within the literature which specifically address using fenestrated and branched stent grafts to completely isolate and repair distal entry tears of chronic DeBakey IIIb aortic dissection. This study aimed to evaluate the clinical outcomes of a 3-dimensional (3D) printed aortic model-guided fenestrated stent in the treatment of distal tears of chronic DeBakey IIIb aortic dissection after thoracic endovascular aortic repair (TEVAR). The study was a one-center retrospective study comprising 36 patients who underwent TEVAR and fenestrated endovascular abdominal aortic repair (F-EVAR) between April 2014 and December 2022. Patient data was compiled and analysed for preoperative, intraoperative, and perioperative characteristics. In total, 36 patients (12 females and 24 males) were incorporated into this study. All of the patients included in this study had hypertension, and among them, the leading cause for undergoing II-stage F-EVAR was the progression of a false lumen, accounting for 24 cases (66.7% of the total). The technical success rate was 97.2% and there were no cases of 30-day mortality, myocardial infarction, permanent paraparesis, or organ failure. One year post-F-EVAR treatment, surviving patients showed significant false and true lumen remodelling with 100% complete false-lumen thrombosis. A total of five patients died during the follow-up, two patients died related to aorta complications and three patients died of heart failure, multiple organ failure, or septic shock. II-stage F-EVAR was safe and feasible operation to repair all distal tears of chronic DeBakey IIIb aortic dissection.

Endovascular Repair of Zone 0 Ascending Aortic Aneurysm: A Review of Current Knowledge and Developing Technology

Aortic aneurysms represent the 15th leading cause of death in men and women over 55 years of age. Where historically these lesions were all addressed via an open approach, endovascular aortic repair has entirely altered the way that surgeons approach aortic lesions. Although it was initially employed for patients who were poor surgical candidates, endovascular repair is now standard for abdominal aortic aneurysms and aneurysms in the descending thoracic aorta. Open surgery remains the gold standard for management of ascending aneurysms, in part due to the limitations portended by the anatomy of the ascending aorta, although increasing evidence suggests that endovascular approaches are feasible and may sometimes be optimal for patient outcomes. Here, we present some of the anatomical and technical challenges of the endovascular approach to these "Zone 0" aneurysms, the associated complications, and the current state of device development.

Late Endograft Migration After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-analysis

PURPOSE

The objective of this systematic review was to report the cumulative incidence of endograft migration (EM), as well as the morbidity, reintervention rates, and mortality related to EM. This study aimed to provide evidence-based data on patient-relevant sequelae of EM after thoracic endovascular aortic repair (TEVAR) performed using contemporary aortic endografts.

MATERIALS AND METHODS

A systematic electronic search of literature in MEDLINE (via PubMed), Web of Science, and Cochrane Central Register of Controlled Trials was performed. The pooled synthesis of outcomes was performed using the inverse variance method.

RESULTS

Seven prospective non-randomized and 4 retrospective studies, including a total of 1783 patients presenting 70 EMs, were considered for the quantitative analysis. The pooled rate of EM was 4% (95% CI, 2%-7%; range, 0.2%-11%; I2=82%); pooled morbidity rate was 31% (95% CI, 12%-59%; range, 0%-100%; I2=64%) and pooled reintervention rate was 32% (95% CI, 15%-56%; range, 0%-100%; I2=55%). The pooled mortality rate due to EM was 5% (95% CI, 1%-21%; range, 0%-40%; I2=24%).

CONCLUSION

For the first time, this meta-analysis provides pooled reference estimates of EM after TEVAR. Thus, the results hold the potential to further characterize EM after TEVAR. The clinical relevance of EM is underlined by its association with high rates of endoleak-related morbidity, reintervention, and mortality. Close standardized surveillance after TEVAR for early detection of EM and prophylaxis of its sequelae is essential.

Aortic Remodeling After Thoracic Endovascular Aortic Repair for Nonacute Uncomplicated Type B Aortic Dissection

BACKGROUND

Entry closure with thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD) results in aortic remodeling recently. This study aimed to evaluate the relationship between aortic diameter or timing of surgical intervention from onset and remodeling after TEVAR for uncomplicated nonacute TBAD.

METHODS

Between April 2014 and December 2021, 83 consecutive patients underwent TEVAR for TBAD at our center. Forty patients with subacute and chronic uncomplicated TBADs with a patent false lumen, who could be followed up for at least 6 months, were included in this study. Indications for TEVAR included aortic diameter enlargement and preemptive treatment to prevent future aneurysmal changes in patients at risk of aortic diameter enlargement. Aortic remodeling was accessed, and data between the remodeling and nonremodeling groups were compared.

RESULTS

The technical success rate was 97.5%, with a type Ia endoleak remaining in 1 patient. No operative or in-hospital mortality occurred. Paraparesis occurred in only 1 patient (2.5%). Follow-up was completed at a median of 53.5 months. Late death occurred in 3 cases, but there were no aortic-related deaths. Late aortic remodeling was achieved in 22 patients (55%). The preoperative maximum aortic diameter (PMAD) in the thoracic aortic region was 51.5 mm in the nonremodeling group, significantly larger than 42.5 mm in the remodeling group (P < 0.0001). The cutoff value of the PMAD for predicting aortic remodeling was 45 mm (area under the curve, 0.917; P = 0.028). The remodeling group had an earlier time from onset to intervention than the nonremodeling group, with a cutoff value of 6.3 months (area under the curve, 0.743; P = 0.021).

CONCLUSIONS

TEVAR for nonacute uncomplicated TBAD resulted in a late aortic remodeling rate of 55%. This study suggested that a PMAD of >45 mm or a period >6.3 months between dissection onset and surgery hinders aortic remodeling after TEVAR.

Outcomes of Zone 1 Thoracic Endovascular Aortic Repair With Fenestrated Surgeon-Modified Stent-Graft for Aortic Arch Pathologies

OBJECTIVES

This study evaluated the feasibility and safety of zone 1 thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-graft (SMSG) for aortic arch pathologies.

METHODS

Between March 2016 and November 2020, 34 consecutive patients underwent zone 1 TEVAR with fenestrated SMSG for aortic arch pathologies. Outcomes included technical success, perioperative, and follow-up morbidity and mortality.

RESULTS

During the study period, 34 patients were treated with zone 1 TEVAR with fenestrated SMSG. Twenty-four (70.6%) patients presented with type B aortic dissections, 9 (26.5%) patients presented with aneurysms (7 located on the lesser curvature side of aortic arch), 1 (2.9%) patient presented with type Ia endoleak after previous TEVAR owing to traumatic aortic dissection. The proximal landing zone for all patients were in zone 1, and all supra-aortic trunks were reconstructed, except for one left subclavian artery. Technical success was achieved in all cases. The 30-day estimated survival (±SE) was 90.9% ± 5.0% [95% confidence interval (CI): 77.0%-97.0%]. The 30-day estimated freedom from reintervention (±SE) was 87.9% ± 5.7% (95% CI: 73.4%-95.3%). At a median follow-up of 48 months (range, 12-68 months), 2 patients died, including 1 aortic-related death and 1 non-aortic-related death. One patient had reintervention 13 months after the operation owing to type Ia endoleak. All supra-aortic trunks were patent. The estimated survival (±SE) during follow-up was 85.1% ± 6.2% (95% CI: 69.9%-93.6%). One (2.7%) patient had stroke. The estimated freedom from reintervention (±SE) during follow-up was 84.2% ± 6.5% (95% CI: 69.9%-93.5%).

CONCLUSIONS

Zone 1 TEVAR with fenestrated SMSG is an alternate option for treatment of aortic arch pathologies in experienced centers.

Retrograde Type A Acute Aortic Dissection With Cerebral Malperfusion Six Years After Thoracic Endovascular Aortic Repair

A 59-year-old male with prior thoracic endovascular aortic repair presented with altered mental status. Magnetic resonance imaging showed cerebral infarction, and subsequent computed tomography revealed acute type A aortic dissection and right carotid artery occlusion. He underwent total arch replacement with right carotid artery bypass. After successful intervention, he was transferred to a rehabilitation facility for further improvement.

Treatment of Uncomplicated Type B Aortic Dissection: Optimal Medical Therapy vs TEVAR + Optimal Medical Therapy

Optimal Medical Therapy (OMT) has been the accepted mode of treatment for uncomplicated Type B Aortic Dissection (uTBAD). There is growing evidence that despite the short-term benefits of OMT, patients suffer deleterious consequences in the long-term with OMT alone. Thoracic Endovascular Aortic Repair (TEVAR) along with OMT has emerged as an alternative option for patients with uTBAD. This study evaluates the available literature for TEVAR + OMT as an alternative to OMT for treatment of uTBAD. In addition, issues related to TEVAR as a treatment for uTBAD are discussed.

Short-term follow-up of proximal aorta remodeling after zone 2 thoracic endovascular aortic repair for acute type B aortic dissection

BACKGROUND

To evaluate the early remodeling of the proximal aorta in patients with acute type B aortic dissection (ATBAD) after zone 2 thoracic endovascular aortic repair (TEVAR).

METHODS

From January 2016 to May 2022, 53 ATBAD patients underwent zone 2 TEVAR were divided into two groups, the Castor single-branched stent-graft (CSS) group (n = 26) and the common stent-graft group (n = 27). Three-dimensional imaging created by computed tomography angiography was used to measure different parameters of the aorta, such as angulation, cross-sectional area (CSA), length and tortuosity. Early remodeling of the proximal aorta was evaluated by comparing geometric parameters of the proximal aorta before and 3 months after surgery.

RESULTS

In terms of angle, the postoperative angle of aortic arch to ascending aorta, descending aorta increased in all patients compared with that before surgery (all P < 0.05), while the angle of aortic arch to left subclavian artery increased after surgery only in the CSS group (P < 0.001); As for CSA, the CSA of distal aortic arch and true lumen increased (all P < 0.05), while the CSA of false lumen decreased in both groups after operation (all P < 0.05); Only in CSS group, the CSA of the ascending aorta, proximal aortic arch and total descending thoracic aorta decreased after surgery (all P < 0.05); In terms of length, the aortic arch prolonged after operation in both groups (P = 0.018 and P = 0.004, respectively). In addition, the ascending aorta tortuosity decreased in the CSS group after surgery (P = 0.011). There was no significant difference in the alterations of other aortic parameters after operation (P > 0.05).

CONCLUSIONS

The CSS implantation provided a more relatively safe and effective treatment for acute type B aortic dissection patients with unfavorable proximal landing zone. It can promote the earlier remodeling of the proximal aorta compared with the common stent-graft implantation after zone 2 TEVAR.

Endovascular treatment of type B aortic dissection in patients with end-stage renal disease

OBJECTIVES

This study aimed to evaluate the postoperative and intermediate outcomes of thoracic endovascular aortic repair (TEVAR) in patients with end-stage renal disease (ESRD).

METHODS

We retrospectively reviewed patients with type B aortic dissection (TBAD) undergoing TEVAR at our single center from January 2010 to December 2020. Patients with pre-existing ESRD were enrolled as the study group. One hundred consecutive patients from September 2013 to March 2015 without ESRD were included as the control group. The primary and secondary outcomes were adverse events and survival, respectively. Kaplan-Meier curves of survival and freedom from adverse events were calculated and analyzed using the log-rank univariate test. Multivariable analysis was used to isolate the effects of ESRD.

RESULTS

A total of 39 patients with ESRD and TBAD underwent TEVAR during the study period. The median follow-up time of patients with and without ESRD was 45 and 46 months, respectively. There was significant difference between the survival at 4 years of patients with and without ESRD (72.8% vs 94.9%; p = 0.011). Meanwhile, the incidence of adverse events was significantly higher in patients with ESRD (p = 0.026). Multivariable logistic regression analysis showed that ESRD (OR, 2.46; p = 0.049) and peripheral artery disease (OR, 4.11; p = 0.002) were the predictors of adverse events.

CONCLUSIONS

The rates of adverse events and survival expectancy were poor in patients with ESRD and TBAD.

Reinterventions after TEVAR

Thoracic cardiovascular aortic repair is an alternative procedure to open surgery for degenerative thoracic aortic aneurysm and thoracic aortic dissection. The advancements in graft design and imaging techniques have expanded its utility. However, the long-term patency of thoracic endovascular aortic repair (TEVAR) graft is still a concern. This review delves into the literature on re-intervention following TEVAR, highlighting factors that influence the re-intervention rate.

Intramural hematoma in the proximal sealing zone of the thoracic endovascular aneurysm repair: frequency and safety in acute and subacute type B dissections

Introduction

To assess the outcomes after thoracic endovascular aneurysm repair (TEVAR) in the presence of intramural hematoma (IMH) in the proximal sealing zone.

Material and methods

Patient data were retrospectively extracted from the hospital records of patients treated with TEVAR for acute and chronic aortic dissection type B in one single center. The initial, preoperative, first postoperative, and last follow-up CT scans were evaluated in the aortic 3D multiplanar reformats and the centerline regarding IMH presence in the proximal sealing zone, anatomical preconditions, and the morphological TEVAR complications including migration and bird-beak. Groups with (IMH) and without IMH (no-IMH) were compared.

Results

Overall, 84 patients (IMH:42; no-IMH:42) were treated at the age of 63(55; 72) years, of whom 23/84 (27%), 34/84 (40%), and 27/84 (32%) were in the hyperacute, acute and subacute dissection phases, respectively. The bovine arch was found in 10/84(12%) and the type III arch was most common (43/84;51%). IMH maximum extent was found in zones 0, 1, 2, and 3 in 14/84 (17%), 17/84 (20%), 18/84 (21%), and 6/84 (7%), respectively. Sealing was achieved in zone II in 71/84 (85%) and LSA was revascularized in 66/84 (79%) of the overall cohort. Early mortality and paraplegia were 2/84 (2%) each; stroke rate was 3/84 (4%). During the 22 months median follow-up (22;4;43) no RTAD was observed. Migration ≥10 mm (IMH: 11/82; no-IMH: 10/82; P = 1.0) and bird-beaks (IMH: 10/82; no-IMH: 12/82; P = 0.8036) were comparable in both groups and accompanied by a low aorta related mortality (1/82) in both groups.

Conclusion

The presence of the IMH in the proximal TEVAR sealing zone is frequent and may not be relevant for the occurrence of the RTAD, stent-graft migration, or bird-beak formation.

MiR-590-3p Promotes the Phenotypic Switching of Vascular Smooth Muscle Cells by Targeting Lysyl Oxidase

ABSTRACT

We investigated the clinical characteristics of patients with acute aortic dissection (AAD) and miR-590-3p levels in serum, tissue, and vascular smooth muscle cells. The effect of miR-590-3p on the vascular smooth muscle cell phenotype was assessed, and the regulation of lysyl oxidase by miR-5903p was determined. C57BL/6 mice were used to investigate the incidence of AAD and effects of miR-5903p on AAD. The miR-590-3p levels were measured in the aortae of mice, and hematoxylin and eosin staining and Masson staining were performed to identify the morphological features of the aorta. Comparative analysis revealed significant differences in clinical characteristics between patients with AAD and healthy control subjects, with most patients with AAD exhibiting concomitant hypertension and nearly 50% having atherosclerosis. Lysyl oxidase was a direct target of miR-590-3p. Lysyl oxidase overexpression inhibited switching of the vascular smooth muscle cell phenotype from contractile to synthetic, but miR-590-3p overexpression significantly reversed this change. In the mouse model, miR-590-3p upregulation increased the incidence of AAD to 93.3%, and its incidence decreased to 13.3% after miR-590-3p inhibition. Hematoxylin and eosin and Masson staining revealed that the miR-590-3p agomiR group had a greater loss of the contractile phenotype in the dissected aortic wall and an increased number of muscle fibers in the aortic wall, which contributed to thickening of the aortic wall and the formation of a false lumen in aortic dissection. miR-590-3p might be pivotal in the pathogenesis of AAD. Thus, targeting miR-590-3p or its downstream pathways could represent a therapeutic approach for AAD.

Hemodynamics of different configurations of the left subclavian artery parallel stent graft for thoracic endovascular aortic repair

BACKGROUND AND OBJECTIVE

Parallel (chimney and periscope) graft technique is an effective approach for left subclavian artery (LSA) reconstruction in patients treated by thoracic endovascular aortic repair (TEVAR) for the inadequate landing zone. However, certain stent graft (SG) configurations may promote thrombosis and reduce distal blood flow, increasing risks of cerebral infarction and reintervention.

METHODS

In this paper, we first attempt to systematically evaluate the hemodynamic performances of different parallel graft techniques as potential determinants of complication risks. Based on the patient-specific 3D aortic geometry undergoing parallel graft technique, fifteen models in total for five kinds of LSA branched SG configurations (Forward, Backward, Extended, Elliptical and Periscopic) were designed virtually, and the hemodynamic discrepancies between them were analyzed by computational fluid dynamics.

RESULTS

Results show that flow rate of patients undergoing periscope technique reduces by half compared with chimney technique, suggesting that periscope SG may cause more serious flow obstruction to LSA, leading to stroke. For chimney stent structure, the extension length 0has little influence on energy loss and other parameters. Conversely, hemodynamic differences between the retrograde curvature and the antegrade curvature are significant (time average WSS: 47.07%), so the retrograde curvature might prompt SG displacement. Furthermore, the flatter chimney SG induces more aggressive hemodynamic forces, among which the difference of the maximum WSS between the flatter SG and nearly round SG reaches 65.56%, leading to the greater risk of vascular wall damage.

CONCLUSIONS

Results obtained might provide suggestions for physicians to formulate appropriate parallel graft technique schemes in TEVAR.

Physician-Modified Endografts for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch

OBJECTIVE

This study aimed to evaluate the outcomes of physician-modified endografts (PMEGs) for the treatment of thoracic aortic pathologies involving the aortic arch.

METHODS

A retrospective single-center study was performed on consecutive patients with thoracic aortic pathologies treated by PMEGs between February 2018 and May 2022. Data on baseline characteristics, operative procedure, and follow-up information were collected. The endpoints included technical success, complications, mortality, overall survival, re-intervention, and target vessel instability.

RESULTS

This study comprised 173 patients (mean age=58±13, range=28-83, 148 men) with thoracic aortic pathologies, including 44 thoracic aortic aneurysms, 113 aortic dissections (9 type A, 4 residual type A, 75 type B, 32 non-A non-B), 3 aortic intramural hematomas, and 13 penetrating aortic ulcers. Thirty-five of the patients had PMEGs with 3 fenestrations, 32 had 2 fenestrations, and 106 had 1 single fenestration. Technical success was 98% (170/173), and the 30-day mortality was 2% (3/173). Perioperative complications included stroke (n=3, 2%), retrograde type A dissection (RTAD; n=3, 2%) and renal injury (n=3, 2%). Seven deaths (4%) were noted during a median follow-up of 11 (range=1-52) months. Eleven cases of re-intervention were stent-related. There were 5 type Ia endoleaks (3%), 2 type III endoleaks (1%) from the innominate artery (IA), and 3 type Ic endoleaks (2%) from the left subclavian arteries. One case of IA stent-graft (SG) stenosis was noted because of mural thrombus. Estimate rates of overall survival, freedom from secondary intervention, and freedom from target vessel instability at 2 years were 93.4% (95% confidence interval [CI]=88.7%-98.1%), 80.7% (95% CI=73.3%-88.1%), and 89.0% (95% CI=80.4%-97.6%), respectively.

CONCLUSIONS

Physician-modified endografts showed promising immediate therapeutic results in the treatment of thoracic aortic pathologies involving the aortic arch. Our study demonstrates that the technique is feasible and produces acceptable results. Long-term outcomes are required for further refinement of this technical approach to confirm technical success and durability over time as a valuable option for endovascular aortic arch repair in specialized centers.

CLINICAL IMPACT

Our short- and mid-term outcomes of physician-modified endografts in 173 patients showed promising results compared to other branched/fenestrated techniques and backed up the endovascular repair of the aortic arch. Meanwhile, the technical expertise pointed out in our manuscript, including preloaded guidewire, diameter-reducing wire and inner mini-cuffs, provided reference and technical guidance for our peers. Most importantly, it demonstrated that the PMEG, as a device whose components were all commercially available, might be a better option for emergency surgery and for centers who had no access to custom-made devices.

Endovascular Repair of Zone 0 Ascending Aortic Pseudoaneurysm: A Case Report

Although open surgery is standard of care for ascending aortic pathology, endovascular approaches can be viable options. We report the case of a 77-year-old man with a 5.7-cm ascending aorta penetrating ulcer. Given his age and clinical profile, the patient underwent Zone 0 thoracic endovascular aortic repair.