Potential risk factors of re-intervention after endovascular repair for type B aortic dissections

Clinical study of reoperation for acute type A aortic dissection

Objective

The initial operation for type A aortic dissection has limitations, and there may be a need for reoperation in cases such as giant pseudoaneurysm formation and reduced blood supply to the distal vessels. In this study, we collected case data of patients who underwent cardiac major vascular surgery at our hospital to analyze the effectiveness of reoperation treatment options for type A aortic dissection and to summarize our treatment experience.

Method

Between June 2018 and December 2022, 62 patients with type A aortic dissection (TAAD) underwent reoperation after previous surgical treatment. Of these, 49 patients (45 males) underwent endovascular aortic repair (EVAR) with a mean age of (49.69 ± 10.21) years (30-75 years), and 13 patients (11 males) underwent thoracoabdominal aortic replacement (TAAR) with a mean age of (41.00 ± 11.18) years (23-66 years). In this study, we retrospectively analyzed the recorded data of 62 patients. In addition, we summarized and analyzed their Computed Tomographic Angiography (CTA) results and perioperative complications.

Outcome

In the EVAR group, 47 patients (95.92%) were successfully implanted with overlapping stents, and 2 patients died in the perioperative period. Postoperative complications included cerebral infarction (4.08%), acute renal insufficiency (30.61%), pulmonary insufficiency and need for ventilator (6.12%), poor wound healing (2.04%), postoperative reoperation (16.33%), and lower limb ischemia (2.04%). In the TAAR group, 12 patients (92.31%) were successfully revascularized and 1 patient died in the perioperative period. Postoperative complications included cerebral infarction (7.69%), acute kidney injury (46.15%), pulmonary insufficiency and need for ventilator (15.38%), poor wound healing (30.77%) and postoperative reoperation (15.38%).

Conclusion

According to the results of the study, compared with TAAR, EVAR was less invasive, faster recovery, and offered a better choice for some high-risk and high-age patients with comorbid underlying diseases. However, the rate of revascularization was higher after EVAR than TAAR due to vascular lesions. Compared with the use of ascending aortic replacement + hemi-aortic arch replacement for acute type A aortic dissection in many countries and regions, the use of ascending aortic replacement + aortic arch replacement + elephant trunk stent is more traumatic in China, but facilitates reoperation. For young patients, the choice of treatment should be individualized combining vascular lesions and long-term quality of life.

Deep learning-based multi-stage postoperative type-b aortic dissection segmentation using global-local fusion learning

Objective.Type-b aortic dissection (AD) is a life-threatening cardiovascular disease and the primary treatment is thoracic endovascular aortic repair (TEVAR). Due to the lack of a rapid and accurate segmentation technique, the patient-specific postoperative AD model is unavailable in clinical practice, resulting in impracticable 3D morphological and hemodynamic analyses during TEVAR assessment. This work aims to construct a deep learning-based segmentation framework for postoperative type-b AD.Approach.The segmentation is performed in a two-stage manner. A multi-class segmentation of the contrast-enhanced aorta, thrombus (TH), and branch vessels (BV) is achieved in the first stage based on the cropped image patches. True lumen (TL) and false lumen (FL) are extracted from a straightened image containing the entire aorta in the second stage. A global-local fusion learning mechanism is designed to improve the segmentation of TH and BR by compensating for the missing contextual features of the cropped images in the first stage.Results.The experiments are conducted on a multi-center dataset comprising 133 patients with 306 follow-up images. Our framework achieves the state-of-the-art dice similarity coefficient (DSC) of 0.962, 0.921, 0.811, and 0.884 for TL, FL, TH, and BV, respectively. The global-local fusion learning mechanism increases the DSC of TH and BV by 2.3% (p< 0.05) and 1.4% (p< 0.05), respectively, based on the baseline. Segmenting TH in stage 1 can achieve significantly better DSC for FL (0.921 ± 0.055 versus 0.857 ± 0.220,p< 0.01) and TH (0.811 ± 0.137 versus 0.797 ± 0.146,p< 0.05) than in stage 2. Our framework supports more accurate vascular volume quantifications compared with previous segmentation model, especially for the patients with enlarged TH+FL after TEVAR, and shows good generalizability to different hospital settings.Significance.Our framework can quickly provide accurate patient-specific AD models, supporting the clinical practice of 3D morphological and hemodynamic analyses for quantitative and more comprehensive patient-specific TEVAR assessments.

Population risk profile analysis of acute uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair

BACKGROUND

Uncomplicated type B aortic dissection (unTBAD) comprises the estimated majority of type B aortic dissection (TBAD), presenting without any of the complications associated with complicated TBAD (coTBAD). Although first-line treatment for coTBAD is thoracic endovascular aortic repair (TEVAR), and despite the fact that TEVAR has proven its safety and effectiveness in the treatment of unTBAD, unTBAD is still being predominantly managed conservatively with medical therapy, with a small proportion of patients being offered TEVAR.

AIMS

The main scope of this review is to highlight the evidence in the literature of the demographic characteristics and associated co-morbidities of unTBAD patients undergoing TEVAR in order to produce a risk stratification system to achieve favourable outcomes.

METHODS

A comprehensive literature search was conducted using multiple electronic databases including PubMed, Ovid, Scopus, and EMBASE.

RESULTS

Multiple demographic characteristics and associated co-morbidities of unTBAD patients affecting TEVAR outcomes were identified, assessed, and investigated, including age, gender, race, genetics, medical conditions, such as hypertension and diabetes, and lifestyle factors such as smoking. Most factors were associated with increased risks of mortality and morbidity, while others, such as race, were identified as being protective against those when it comes to TEVAR.

CONCLUSION

Despite the favourable results yielded by TEVAR in unTBAD, there remains a grey area concerning its management. Thus, it is important to incorporate the demographics and co-morbidities of unTBAD patients' when into clinical judgement when assessing indications for TEVAR intervention to ensure optimum results can be achieved.

A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection

BACKGROUND

Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments.

METHODS

A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management.

RESULTS

RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001).

CONCLUSION

RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

Reintervention after Thoracic Endovascular Aortic Repair of Uncomplicated Type B Aortic Dissection

BACKGROUND

Data are scarce regarding the incidence, reasons, potential risk factors, and long-term outcomes of reintervention after thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated type B aortic dissection (TBAD).

METHODS

Between January 2010 and December 2020, 238 patients with uncomplicated TBAD who received TEVAR were analyzed retrospectively. The clinical baseline data, aorta anatomy, dissection characteristics, and details of the TEVAR procedure were evaluated and compared. A competing-risk regression model was used to estimate the cumulative incidences of reintervention. The multivariate Cox model was used to identify the independent risk factors.

RESULTS

The mean follow-up time was 68.6 months. A total of 27 (11.3%) cases of reintervention were observed. The competing-risk analyses showed that the 1-, 3-, and 5-year cumulative incidences of reintervention were 5.07%, 7.08%, and 14.0%, respectively. Reasons for reintervention included endoleak (25.9%), aneurysmal dilation (22.2%), retrograde type A aortic dissection (18.5%), distal stent-graft-induced new entry and false lumen expansion (18.5%), and dissection progression and/or malperfusion (14.8%). Multivariable Cox analysis demonstrated that a larger initial maximal aortic diameter (Hazard ratio [HR], 1.75; 95% Confidence interval [CI], 1.13-2.69, p = 0.011) and increased proximal landing zone oversizing (HR, 1.07; 95% CI, 1.01-1.47, p = 0.033) were the significant risk factors for reintervention. Long-term survival rates were comparable between patients with or without reintervention (p = 0.915).

CONCLUSIONS

Reintervention after TEVAR in patients with uncomplicated TBAD is not uncommon. A larger initial maximal aortic diameter and excessive proximal landing zone oversizing are associated with the second intervention. Reintervention does not significantly affect long-term survival.

Endovascular repair of acute complicated type B aortic dissection-systematic review and meta-analysis of long-term survival and reintervention

Background

Thoracic endovascular repair (TEVAR) is considered the first-line therapy in the repair of acute complicated type B aortic dissection (AC-BAD). Given the difficulty of designing randomized trials in this surgical cohort, long-term outcome data is limited. This systematic review and meta-analysis provide a complete aggregation of reported long-term survival and freedom from reintervention of AC-BAD patients based on the existing literature.

Methods

Three databases were searched from date of database inception to January 2021. The relevant references were identified and baseline cohort characteristics, survival and freedom from reintervention were extracted. The primary endpoints were survival and freedom from reintervention, whilst secondary endpoints were post-operative outcomes such as cord ischemia and endoleak. Kaplan-Meier curves were digitized and aggregated as per established procedure.

Results

A total of 2,812 references were identified in the literature search for review, with 46 selected for inclusion. A total of 2,565 patients were identified, of which 1,920 (75%) were male. The mean age of the cohort was 59.8±5.8. Actuarial survival at 2, 4, 6 and 10 years was 87.5%, 83.2%, 78.5% and 69.7%, respectively. Freedom from all secondary reintervention at 2, 4, 6, 8 and 10 years was 74.7%, 69.1%, 65.7%, 63.9% and 60.9%, respectively. When accounting for study quality, actuarial survival at 2, 4, 6 and 8 years was 85.4%, 79.1%, 69.8% and 63.1%, respectively. Freedom from all secondary reintervention at 2, 4, 6 and 8 years was 73.2%, 67.6%, 63.7% (maintained), respectively.

Conclusions

TEVAR is associated with promising long-term survival extended to 10 years, though rates of freedom from reintervention remain an ongoing point for improvement. Randomized controlled trials comparing endovascular with open repair in the setting of acute, complicated type B aortic dissection are needed.

Aortic-related Readmission after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Patients: A Single-center Retrospective Study

OBJECTIVES

This study aimed to investigate the characteristics of and risk factors for aortic-related readmission after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

METHODS

Data from TBAD patients who underwent TEVAR from 2009-2018 at a Chinese tertiary center were retrospectively collected and analyzed. Enrolled patients were categorized into two groups according to whether aortic-related readmission occurred during follow-up, which was defined as hospitalization at least once after the initial procedure due to events that were related to or caused by aortic dissection or the initial procedure.

RESULTS

A total of 1 288 TBAD patients were enrolled, and 99 patients experienced aortic-related readmissions (7.7%), among whom chronic patients had the highest readmission rate (9.8%). The yearly proportion of readmission during the first year after initial procedure revealed a decreasing trend with a -9.7% annual percentage change. Seventy-one patients underwent reintervention (71.7%). Distal aneurysmal degeneration (43.7%) and distal stent graft-induced new entries (32.4%) were two major causes for reintervention. Fourteen patients in the reintervention subgroup underwent a second reintervention (19.7%). In-hospital mortality was 1.0% during the readmission and 14.3% during the second readmission. The overall survival was comparable between two groups (p=.93).

CONCLUSIONS

This study highlighted the importance of surveillance after initial procedure for TBAD patients with potential risk factors for aortic-related readmission, and the predisposition of patients with reintervention to multiple readmissions deserves attention.

Using Machine Learning to Predict Five-Year Reintervention Risk in Type B Aortic Dissection Patients After Thoracic Endovascular Aortic Repair

Purpose: Type B aortic dissection (TBAD) is a high-risk disease, commonly treated with thoracic endovascular aortic repair (TEVAR). However, for the long-term follow-up, it is associated with a high 5-year reintervention rate for patients after TEVAR. There is no accurate definition of prognostic risk factors for TBAD in medical guidelines, and there is no scientific judgment standard for patients’ quality of life or survival outcome in the next five years in clinical practice. A large amount of medical data features makes prognostic analysis difficult. However, machine learning (ML) permits lots of objective data features to be considered for clinical risk stratification and patient management. We aimed to predict the 5-year prognosis in TBAD after TEVAR by Ml, based on baseline, stent characteristics and computed tomography angiography (CTA) imaging data, and provided a certain degree of scientific basis for prognostic risk score and stratification in medical guidelines. Materials and Methods: Dataset we recorded was obtained from 172 TBAD patients undergoing TEVAR. Totally 40 features were recorded, including 14 baseline, 5 stent characteristics and 21 CTA imaging data. Information gain (IG) was used to select features highly associated with adverse outcome. Then, the Gradient Boost classifier was trained using grid search and stratified 5-fold cross-validation, and Its predictive performance was evaluated by the area under the curve (AUC) in the receiver operating characteristic (ROC). Results: Totally 60 patients underwent reintervention during follow-up. Combing 24 features selected by IG, ML model predicted prognosis well in TBAD after TEVAR, with an AUC of 0.816 and a 95% confidence interval of 0.797 to 0.837. Reintervention rate of prediction was slightly higher than the actual (48.2% vs. 34.8%). Conclusion: Machine learning, which combined with baseline, stent characteristics and CTA imaging data for personalized risk computations, effectively predicted reintervention risk in TBAD patients after TEVAR in 5-year follow-up. The model could be used to efficiently assist the clinical management of TBAD patients and prompt high-risk factors.

Risk Factors Associated With Reintervention After Thoracic Endovascular Aortic Repair for Descending Aortic Pathologies

BACKGROUND:

Thoracic endovascular aortic repair (TEVAR) is associated with several short-term benefits, including reduced morbidity and mortality; however, the long-term durability of TEVAR and the need for secondary aortic reintervention remain unclear. We aimed to determine the adverse outcomes, including aortic reintervention, after TEVAR for thoracic aortic aneurysms and dissection.

METHODS:

Between October 2009 and July 2016, 130 patients underwent TEVAR at Kyungpook National University Hospital. We excluded 35 patients with traumatic injury and included the remaining 95 patients in our study after TEVAR. The patients included in this study were categorized into 2 groups (reintervention [R] and nonintervention [N] groups) according to the need for reintervention. The mean follow-up period for all 95 patients was 22.4 (20.6) months.

RESULTS:

The overall actuarial survival rates were 83.7% (4.1%) and 63.6% (8.8%) at 1 and 5 years, respectively. The rates of freedom from aortic reintervention after TEVAR were 94.0% (3.5%), 72.8% (8.2%), and 48.9% (10.5%) at 2, 3, and 5 years, respectively. The independent risk factors for aortic reintervention were endoleaks after TEVAR (odds ratio [OR] 6.13, P = .017), increase in aortic size by over 5% per year (OR 20.40, P = .001), and peripheral vascular occlusive disease (PVOD; OR 13.62, P = .007). Patients with preoperative hemoptysis tended to show a greater need for aortic reintervention ( P = .059). Increase in aortic size by over 5% per year and PVOD were the primary risk factors for endoleaks (OR 3.82, P = .013 and OR 4.37, P = .021, respectively).

CONCLUSION:

Survival after TEVAR for thoracic aortic pathologies was satisfactory in most of the patients chosen as candidates for the procedure. However, the occurrence of endoleaks, increase in aortic size by over 5% per year, and PVOD were the primary causes of aortic reintervention.

Retrospective Comparative Analysis of Computed Tomography Findings of Acute and Chronic Aortic Dissections and Intramural Hematomas

PURPOSE

The objective of this study was to assess the reliability of ancillary imaging findings in distinguishing acute from chronic aortic dissection (AD) and intramural hematoma (IMH) using computed tomography angiography (CTA).

MATERIALS AND METHODS

Two radiologists specializing in cardiothoracic and vascular imaging reviewed paired CTAs of patients with AD or IMH who underwent CTA in the acute (within 24 h of presentation) and chronic settings. The radiologists were blinded to the temporal order of the CTAs. Minimum and maximum flap thicknesses and presence or absence of pleural effusion, pericardial effusion, mediastinal hematoma or fat standing, and mediastinal lymphadenopathy were recorded.

RESULTS

Patients included 25 male individuals and 13 female individuals with a mean age of 59 years (range: 34 to 87 y). The group included 29 AD and 9 IMH cases. The median interval between the paired CTs was 542 days (range: 100 to 2533 d). Respectively, the mean minimum flap thicknesses in the acute and chronic AD were 1.3 and 1.4 mm (P=0.3), and the mean maximum flap thicknesses were 2.7 and 2.9 mm (P=0.29). The incidences of ancillary findings in acute and chronic AD and IMH were as follows: pleural effusion (55% vs. 37%, P=0.143), pericardial effusion (8% vs. 11%, P=1.0), lymphadenopathy (47% vs. 47%, P=1.0), and periaortic fat stranding (87% vs. 76%, P=0.344).

CONCLUSIONS

Ancillary CT imaging findings traditionally ascribed to acute AD and IMH are also often found in the chronic setting and are not reliable indicators of acuity. Flap thickness in AD may not be a reliable imaging indicator of acuity of AD.

Unplanned stents in thoracic endovascular aortic repair for type B aortic dissection: A 16-year single-center report

Background

Unplanned stents in thoracic endovascular aortic repair mean additional stents implantation beyond the preoperative planning to achieve operation success. This study aimed to reveal the prevalence and consequences of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection and explore the reasons, risk factors and solutions for unplanned stents.

Methods

Retrospectively analysis consecutive patients diagnosed as type B aortic dissection with initial tear originating distal from the left subclavian artery and underwent thoracic endovascular aortic repair from September 1998 to June 2014 in our center.

Results

Under the criteria, this study enrolled 322 patients, with 83 (25.8%) patients in unplanned group. The incidence rate of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection in each year demonstrates as a bimodal curve. The curve showed that, 2003 and, 2004 was the first and highest peak and 2007 was the second peak. There was no difference in five-year survival rate between planned and unplanned patients (log-rank test, p = 0.994). The unplanned group had higher hospitalization expenses (142,699.08 ± 78,446.75 yuan vs. 175,238.58 ± 34,838.01 yuan; p = 0.019), longer operation time (104.50 ± 93.24 min vs. 179.08 ± 142.47 min; p < 0.001) and hospitalization time (17.07 ± 16.62 d vs. 24.00 ± 15.34 d; p = 0.001). The reasons for unplanned stents were type Ia endoleak (46 patients, 55.4%), bird beak (25 patients, 30.1%), and inappropriate shaping of stent (9 patients, 10.8%). Asymptomatic aortic dissection patients had higher incidence of unplanned stents. Short proximal neck length (2.66 ± 0.59 mm vs. 2.50 ± 0.51 mm; p = 0.016), short stent coverage length (154.62 ± 41.12 mm vs. 133.60 ± 44.33 mm; p = 0.002), and large distal stent oversize (75.44±10.77% vs. 82.68±15.80%; p <0.001) were risk factors for unplanned stents in thoracic endovascular aortic repair.

Conclusion

There are some special risk factors and reasons for unplanned stents in thoracic endovascular aortic repair for type B aortic dissection. Knowing these can we reduce the utilization of unplanned stents with appropriate methods.

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

Background

Retrograde type A aortic dissection (RTAD) is a potentially lethal complication after thoracic endovascular aortic repair (TEVAR). However, data are limited regarding the development of RTAD post‐TEVAR. This systematic review aims to define the incidence, mortality, and potential risk factors of RTAD post‐TEVAR.

Methods and Results

Multiple electronic searches were performed. Fifty publications with a total of 8969 patients were analyzed. Pooled estimates for incidence and mortality of RTAD were 2.5% (95% confidence interval [CI], 2.0–3.1) and 37.1% (95% CI, 23.7–51.6), respectively. Metaregression analysis evidenced that RTAD rate was associated with hypertension (P=0.043), history of vascular surgery (P=0.042), and American Surgical Association (P=0.044). The relative risk of RTAD was 1.81 (95% CI, 1.04–3.14) for acute dissection (relative to chronic dissection) and 5.33 (95% CI, 2.70–10.51) for aortic dissection (relative to a degenerative aneurysm). Incidence of RTAD was significantly different in patients with proximal bare stent and nonbare stent endografts (relative risk [RR]=2.06; 95% CI, 1.22–3.50). RTAD occurrence rate in zone 0 was higher than other landing zones.

Conclusions

The pooled RTAD rate after TEVAR was calculated at 2.5% with a high mortality rate (37.1%). Incidence of RTAD is significantly more frequent in patients treated for dissection than those with an aneurysm (especially for acute dissection), and when the proximal bare stent was used. Rate of RTAD after TEVAR varied significantly according to the proximal Ishimaru landing zone. The more‐experienced centers tend to have lower RTAD incidences.

Impact of Oversizing on the Risk of Retrograde Dissection After TEVAR for Acute and Chronic Type B Dissection

Purpose: To find a suitable rate of thoracic stent-graft oversizing by exploring its association with the occurrence of retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. Methods: From January 2013 to June 2014, 203 patients (mean age 55 years; 167 men) with type B aortic dissection underwent TEVAR. The mean rate of oversizing at the proximal landing zone was 10% (range 0%–32%). Patients were stratified into 2 groups based on the degree of oversizing: ≤5% (n=105, mean 1.2%±1.5%) and >5% (n=98, mean 18.5%±2.8%). TEVAR-related complications, including RTAD, stent migration, and type I endoleaks, were analyzed. Results: There were no significant differences in the preoperative proximal landing zone diameters between the groups (31.1 mm for the ≤5% group vs 31.8 mm for the >5% group, p=0.229). The incidence of type I endoleaks over a mean follow-up 15.1±6.4 months was 5.4% [6 (5.7%) in the ≤5% group vs 5 (5.1%) in the >5% group, p=0.847]. The stent migration rate was low in both groups (1% vs 2%, respectively; p=0.521). The occurrence of RTAD [0 in the ≤5% group vs 11 (11.2%) in the >5% group] was significantly associated with the rate of oversizing (p<0.001). Conclusion: The early and midterm outcomes of this study demonstrate that ≤5% oversizing may be a suitable option for thoracic endografts used to treat type B dissection. The smaller rate of oversizing can lower the incidence of RTAD without increasing stent migration or type I endoleak rates.

Biomechanical Changes After Thoracic Endovascular Aortic Repair in Type B Dissection

Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives.