Long-Term Survival After Open Repair of Chronic Distal Aortic Dissection

Postdissection aortic aneurysm sac enlargement after fenestrated and branched endovascular aortic aneurysm repair

OBJECTIVES

Aneurysm sac changes after fenestrated-branched endovascular aneurysm repair (FBEVAR) for postdissection thoracoabdominal aortic aneurysms (PD-TAAs) are poorly understood. Partial thrombosis of the false lumen and endoleaks may impair sac regression. To characterize sac changes after FBEVAR for PD-TAAs, this study examined midterm results and predictors for sac enlargement.

METHODS

FBEVARs performed for PD-TAAs in 10 physician-sponsored investigational device exemption studies from 2008 to 2023 were analyzed. The maximum aortic aneurysm diameter was compared between the 30-day computed tomography angiogram and follow-up imaging studies. Aneurysm sac enlargement was defined as an increase in diameter of ≥5 mm. Kaplan-Meier curves and Cox regression were used to evaluate sac enlargement and midterm FBEVAR outcomes.

RESULTS

Among 3296 FBEVARs, 290 patients (72.4% male; median age, 68.4 years) were treated for PD-TAAs. Most aneurysms treated were extent II (72%) and III (12%). Mean aneurysm diameter was 66.5 ± 11.2 mm. Mortality at 30 days was 1.4%. At a mean follow-up of 2.9 ± 1.9 years, at least one follow-up imaging study revealed sac enlargement in 43 patients (15%), sac regression in 115 patients (40%), and neither enlargement nor regression in 137 (47%); 5 (2%) demonstrated both expansion and regression during follow-up. Freedom from aneurysm sac enlargement was 93%, 82%, and 80% at 1, 3, and 5 years, respectively. Overall, endoleaks were detected in 27 patients (63%) with sac enlargement and 143 patients (58%) without enlargement (P = .54). Sac enlargement was significantly more frequent among older patients (mean age at the index procedure, 70.2 ± 8.9 years vs 66.5 ± 11 years; P = .04) and those with type II endoleaks at 1 year (74% vs 52%; P = .031). Cox regression revealed age >70 years at baseline (hazard ratio [HR], 2.146; 95% confidence interval [CI], 1.167-3.944; P = .010) and presence of type II endoleak at 1 year (HR, 2.25; 95% CI, 1.07-4.79; P = .032) were independent predictors of sac enlargement. Patient survival was 92%, 81%, and 68% at 1, 3, and 5 years, respectively. Cumulative target vessel instability was 7%, and aneurysm-related mortality was 2% at 5 years. At least 42% of patients required secondary interventions. Sac enlargement did not affect patient survival.

CONCLUSIONS

Aneurysm sac enlargement occurs in 15% of patients after FBEVAR for PD-TAAs. Elderly patients (>70 years at baseline) and those with type II endoleaks at 1 year may need closer monitoring and secondary interventions to prevent sac enlargement. Despite sac enlargement in some patients, aneurysm-related mortality at 5 years remains low and overall survival was not associated with sac enlargement.

Comparison of open thoracoabdominal repair for chronic aortic dissections and aneurysms

OBJECTIVE

Aortic dissection is common in patients undergoing open surgical repair of thoracoabdominal aortic aneurysms (TAAAs). Most often, dissection is chronic and is associated with progressive aortic dilatation. Because contemporary outcomes in chronic dissection are not clearly understood, we compared patient characteristics and outcomes after open TAAA repair between patients with chronic dissection and those with non-dissection aneurysm.

METHODS

We retrospectively analyzed data from 3470 open TAAA repairs performed in a single practice. Operations were for non-dissection aneurysm in 2351 (67.8%) and chronic dissection in 1119 (32.2%). Outcomes included operative mortality and adverse events, a composite variable comprising operative death and persistent (present at discharge) stroke, paraplegia, paraparesis, and renal failure necessitating dialysis. Logistic regression identified predictors of operative mortality and adverse events. Time-to-event analyses examined survival, death, repair failure, subsequent progressive repair, and survival free of failure or subsequent repair.

RESULTS

Compared with patients with non-dissection aneurysm, those with chronic dissection were younger, had fewer atherosclerotic risk factors, and were more likely to have heritable thoracic aortic disease and undergo extent II repair. The operative mortality rate was 8.5% (n = 296) overall and was higher in non-dissection aneurysm patients (n = 217; 9.2%) than in chronic dissection patients (n = 79; 7.1%; P = .03). Adverse events were less frequent (P = .01) in patients with chronic dissection (n = 145; 13.0%), 22 (2.0%) of whom had persistent paraplegia. Chronic dissection was not predictive of operative mortality (P = .5) or adverse events (P = .6). Operative mortality and adverse events, respectively, were independently predicted by emergency repair (odds ratio [OR], 3.46 and 2.87), chronic kidney disease (OR, 1.74 and 1.81), extent II TAAA repair (OR, 1.44 and 1.73), increasing age (OR, 1.04/year and 1.04/year), and increasing aortic cross-clamp time (OR, 1.02/minutes and 1.02/minutes). Patients with chronic dissection had lower 10-year unadjusted mortality (42% vs 69%) but more frequent repair failure (5% vs 3%) and subsequent repair for progressive aortic disease (11% vs 5%) than patients with non-dissection aneurysm (P < .001); these differences were no longer statistically significant after adjustment.

CONCLUSIONS

Outcomes of open TAAA repair vary by aortic disease type. Emergency repairs and atherosclerotic diseases most commonly occur in patients with non-dissection aneurysm and independently predict operative mortality. Repair of chronic dissection is associated with low rates of adverse events, including operative mortality and persistent paraplegia, along with reasonable late survival and good durability. However, patients with chronic dissection tend to more commonly undergo subsequent repair to treat progressive aortic disease, which emphasizes the need for robust long-term imaging surveillance protocols.

Neural operator learning of heterogeneous mechanobiological insults contributing to aortic aneurysms

Thoracic aortic aneurysm (TAA) is a localized dilatation of the aorta that can lead to life-threatening dissection or rupture. In vivo assessments of TAA progression are largely limited to measurements of aneurysm size and growth rate. There is promise, however, that computational modelling of the evolving biomechanics of the aorta could predict future geometry and properties from initiating mechanobiological insults. We present an integrated framework to train a deep operator network (DeepONet)-based surrogate model to identify TAA contributing factors using synthetic finite-element-based datasets. For training, we employ a constrained mixture model of aortic growth and remodelling to generate maps of local aortic dilatation and distensibility for multiple TAA risk factors. We evaluate the performance of the surrogate model for insult distributions varying from fusiform (analytically defined) to complex (randomly generated). We propose two frameworks, one trained on sparse information and one on full-field greyscale images, to gain insight into a preferred neural operator-based approach. We show that this continuous learning approach can predict the patient-specific insult profile associated with any given dilatation and distensibility map with high accuracy, particularly when based on full-field images. Our findings demonstrate the feasibility of applying DeepONet to support transfer learning of patient-specific inputs to predict TAA progression.

Long-term Thoracic Endovascular Repair follow-up from 1999-2019 - a Single-Center Experience

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990's, and long-term follow-up studies are warranted in current guidelines.

METHODS

Patients undergoing TEVAR were consecutively included from 1999-2019. Thoracic aortic disease includes thoracic aortic aneurysms, aortic dissection, traumatic rupture, penetrating aortic ulcer (PAU) and intramural hematoma (IMH). Our prospective database recorded baseline characteristics, endoleak or aneurysm growth and death. Patients were included at time of treatment and censored at death, or first reintervention depending on the analysis. Primary endpoint was all-cause death, secondary endpoint was reintervention. Survival and failure analysis were done using StataIC 16.0® and truncated at 15 years of follow-up.

RESULTS

256 patients were included - 63% were men. Their mean age at intervention was 66.2 ± 14.5 years and they were followed for a mean of 5.2 ± 4.5 years. Indications for TEVAR were acute aortic syndrome 40.6%, chronic aortic disease 44.5%, and traumatic rupture in 14.8 %. Technical success was seen in 94.1 % of the operations, and the left subclavian artery was covered in 27.7%. 30-day mortality rate was 21.2% (22/104) and 1.75% (2/114) (p<0.001) for urgent and elective patients, respectively. Twelve patients (4.7%) died within 24 hours of treatment. Overall, long-term mortality recorded112 (43,8%) deaths, 29 patients had reinterventions (11.3 % (95% confidence interval: 7.7-15.9)), aneurysms accounted for 62.1% of all reinterventions. 24 (82.8%) reinterventions occurred within the first 5 years.

CONCLUSION

This long-term follow-up study shows excess mortality in patients treated for acute aortic syndrome compared to chronic aortic disease, within the first 30 days, this difference diminishes at the end of follow-up. Most endoleak occur within the first five years, though new endoleak continue to develop decades after in previous endoleak-free patients calling for lifelong surveillance.

Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association

All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.

Laser-assisted "Scissor" Technique to Facilitate Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection

INTRODUCTION

There has been an increase in utilization of thoracic endovascular aortic repair (TEVAR) to treat aneurysms with chronic dissection. Despite significant progress, TEVAR is hindered by persistent perfusion of the false lumen and aneurysm growth. Various techniques to address false lumen perfusion exist. We preset our experience of laser fenestration with disruption of the dissection flap to facilitate TEVAR and avoid persistent retrograde false lumen perfusion.

METHODS

Review a technique to treat patients with thoracic aortic aneurysm complicated by chronic dissection. This is an adjunct to a TEVAR procedure with final goal to treat the aneurysm and avoid retrograde false lumen perfusion. Under IVUS guidance, we performed a Phillips/Spectranetics laser fenestration of the intimal flap followed by a scissoring technique to obliterate the dissection flap and create a distal seal zone. Stent-grafts placed following flap obliteration allow graft expansion and apposition to the entire outer aortic and avoid retrograde perfusion of the false lumen.

RESULTS

Two patients underwent TEVAR in conjunction with laser obliteration of the dissection flap, including one undergoing primary repair of a chronic Type B dissection with aneurysm, and one as a completion second stage elephant trunk procedure. Technical success was achieved in both cases, with successful implantation of the endograft, and freedom from type I and III endoleaks. Absence of false lumen flow, and patency of the visceral vessels was confirmed on completion angiography. True lumen patency and obliteration of the intimal flap were confirmed by IVUS. Early follow up confirms exclusion of the aneurysm, with no evidence of retrograde perfusion of the false lumen.

CONCLUSIONS

Thoracic aortic aneurysms in the context of chronic dissections can be successfully treated with TEVAR and laser obliteration of the chronic dissection flap to fully exclude the aneurysm and avoid retrograde false lumen perfusion.

Proportional meta-analysis of open surgery or fenestrated endograft repair for postdissection thoracoabdominal aneurysms

OBJECTIVE

To determine outcomes of postdissection thoracoabdominal aneurysms by either open or endovascular repair with fenestrated or branched endografts.

METHODS

A systematic review was conducted for open or endovascular repair of postdissection thoracoabdominal aneurysms, between January 2009 and February 2020. A meta-analysis was performed for postoperative complications and both early and late mortality and reinterventions.

RESULTS

Fifteen noncomparative studies (eight endovascular repair and seven open repair) were suitable for meta-analysis. Overall, 1337 patients were included, 1068 in the open repair group (73% male; mean age 58 years) and 269 in the endovascular repair group (79% male; mean age 65 years). The 30-day mortality was 6% for open repair vs 3% for endovascular repair (P = .35), whereas the 30-day reintervention rate was 3% for open repair vs 1% for endovascular repair (P = .66). The only significant difference was reported for 30-day respiratory complication rate (30% open repair vs 2% endovascular repair; P < .01). The incidence of spinal cord ischemia was 9% for open repair vs 8% for endovascular repair (P = .95). The mean follow-up was 44 months: 48 months (range, 10-72 months) after open repair and 17 months (range, 12-25 months) after endovascular repair (P < .01). Late aortic reinterventions were more frequent after endovascular repair (11% vs 32%; P < .001). The late overall mortality rate was 19% for open repair vs 7% for endovascular repair (P = .08), whereas aortic-related mortality was 7% for open repair vs 3% for endovascular repair (P = .22).

CONCLUSIONS

In the absence of comparative studies, this meta-analysis showed that endovascular repair seems to be a viable alternative for patients unfit for open repair.

Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs

OBJECTIVE

To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR).

METHODS

Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods.

RESULTS

Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m²), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m², previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004).

CONCLUSIONS

Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.

A 10-year study of surgical results of descending aorta aneurysm repair following chronic aortic dissection

BACKGROUND

Patients presenting with descending aortic aneurysms developing after aortic dissection often undergo continued aortic expansion which may require operative interventions to address the risk of aortic rupture. In light of the current advances in various treatment options, including endovascular approaches, we analyzed our experience with open surgical repair (OSR) of aneurysms of the descending aorta following aortic dissection.

METHODS

Patients who underwent open repair for aneurysmal changes of the descending aorta after chronic dissection were retrospectively studied. The 30-day operative mortality rate, midterm survival, and major complications were analyzed. Patients were divided into two categories; primary chronic type B aortic dissection and remnant repaired type A aortic dissection (RTAAD).

RESULTS

There were 149 patients with enlargement of the descending thoracic aorta developing after aortic dissection. Of these, 49 patients had medical management, while the remaining 100 patients received OSR. These patients were included in the present analysis. The 30-day mortality and permanent paraplegia rates were 9% and 4%, respectively. The 1-, 3-, and 5-year survival rates were 83%, 80.9%, and 76.1%, respectively. The 1- and 5-year survival rates between the primary chronic type B aortic dissection and remnant RTAAD groups showed no significant between-group differences at 86.7% and 84.3%, and 80% and 71.3%, respectively (P = .289). The overall outcomes of other complications such as renal injury, bleeding reoperation, and extracorporeal membrane oxygenation support showed no significant between-group differences, including an insignificantly higher neurologic complication rate in the remnant RTAAD group. The survival rate in patients with Marfan syndrome was significantly higher than in the patients without Marfan syndrome (P = .033).

CONCLUSIONS

OSR for descending aortic aneurysms developing after chronic aortic dissection showed good early and mid- to long-term outcomes, with acceptably low complication rates. OSR for descending aortic aneurysm after chronic aortic dissection associated with Marfan syndrome also showed good early and mid- to long-term outcomes.

Management of the Left Subclavian Artery in TEVAR for Chronic Type B Aortic Dissection

Objectives:

Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD.

Methods:

The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards.

Results:

Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident ( P = .16), spinal cord ischemia ( P = 1.00), or death ( P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04).

Conclusions:

Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.

Perioperative and long-term outcomes after thoracoabdominal aortic aneurysm repair of chronic dissection etiology

OBJECTIVE

Open repair of thoracoabdominal aortic aneurysms (TAAAs) that have developed secondary to chronic dissection (CD) is often more complex than repair of degenerative aneurysms (DAs). However, the literature is conflicted regarding the effect of CD on perioperative and long-term outcomes after open TAAA repair. The goal of this study was to determine whether CD predicts negative outcomes after TAAA repair.

METHODS

All open type I to type III TAAA repairs performed from 1987 to 2015 were evaluated using a single institutional database. End points included in-hospital death, spinal cord ischemia (SCI), major adverse events (MAEs), and long-term survival. Repairs performed for rupture or acute dissection were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic multivariable regression was used for the in-hospital end points, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques.

RESULTS

During the study period, 453 patients underwent an intact open type I to type III TAAA repair. Ninety (20%) were performed for patients with CD. Those with CD were more likely to be younger (59 years vs 72 years; P < .001), to have an extent II lesion (30% vs 16%; P < .001), and to have Marfan syndrome (18% vs 0.6%; P < .001) and less likely to have coronary artery disease (28% vs 25%; P = .01) or chronic obstructive pulmonary disease (12% vs 27%; P = .004) compared with patients with DA. Twelve percent of patients with CD died perioperatively compared with 6% of those with DA (P = .03). Eighteen percent of CD patients suffered from SCI compared with 12% of DA patients (P = .2). Fifty-nine CD patients suffered a MAE compared with 42% of those with DA (P = .006). Multivariable analysis revealed CD to be an independent predictor of perioperative death (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.2-8.0; P = .02) with adjustment for age and Crawford extent. CD was also found to be independently predictive of any MAE (AOR, 2.5; 95% CI, 1.4-4.6; P = .002). CD was not associated with increased risk of SCI (AOR, 1.4; 95% CI, 0.6-3.2; P = .4). There was a long-term survival advantage in the CD cohort in the unadjusted analysis (log-rank, P = .009) but not in the adjusted analysis (CD adjusted hazard ratio, 0.9; 95% CI, 0.6-1.4; P = .7).

CONCLUSIONS

When analysis is limited to type I to type III TAAAs, open repair of patients with CD leads to increased perioperative mortality and morbidity compared with patients with DA. However, age-adjusted long-term survival is no different between the two cohorts.

Frozen elephant trunk and arch endografts for chronic thoracoabdominal aortic dissections

Chronic aortic dissecting aneurysms (TAAD) presenting after acute Stanford type A or B dissection includes both arch and/or thoracoabdominal aortic aneurysms (TAAA). Approximately 60% of patients who survive surgical treatment of acute type A aortic dissections will require another aortic procedure. Similarly, more than 70% of patients with chronic type B aortic dissections will experience false lumen dilation at 5-year follow-up, often requiring intervention. Open or hybrid aortic repairs of complex TAAD involving the arch and the TAAA are very demanding procedures for both patients and clinicians. Open surgery remains the first line therapy in fit patients. Recent development of branched arch devices has offered an alternative option for high-risk patients. Technical challenges associated with the endovascular management of these complex aneurysms include proximal sealing zone often located in the aortic arch or the ascending aorta, narrow true lumen working space, and aortic branch perfusion by either the true or false lumen, or both. Recent studies have reported encouraging results with endovascular treatment of these complex dissecting aneurysms, especially following open ascending aortic repair. The aim of this review was to describe the available strategies for arch repair in the setting of a chronic TAAD and to determine the subset of patients that can benefit from of a totally endovascular approach.

Endovascular Treatment of Various Aortic Pathologies: Review of the Latest Data and Technologies

The technologies and innovations applicable to endovascular treatment for complex aortic pathologies have progressed rapidly over the last two decades. Although the initial outcomes of an endovascular aortic repair have been excellent, as long-term data became available, complications including endoleaks, endograft migration, and endograft infection have become apparent and are of concern. Previously, the indication for endovascular therapy was restricted to descending thoracic aortic aneurysms and abdominal aortic aneurysms. However, its indication has expanded along with the improvement of techniques and devices, and currently, it has become possible to treat pararenal aortic aneurysms and Crawford type 4 thoracoabdominal aortic aneurysm (TAAA) using the off-the-shelf devices. Additionally, custom-made devices allow for the treatment of arch or more extensive TAAAs. Endovascular treatment is applied not only to aneurysms but also to acute/chronic dissections. However, long-term outcomes are still unclear. This article provides an overview of available devices and the results of endovascular treatment for various aortic pathologies.

Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection

Background

Type B aortic dissection is a life-threatening acute aortic condition often with acute ischemic signs or symptoms. With initial management focusing on alleviating malperfusion and pain, and avoiding propagation of dissection or rupture both systolic blood and pulse pressure should be reduced initially by an aggressive medical approach. In the setting of persistent signs of complications endovascular strategies have replaced open surgery and led to a fourfold increase in early survival and better long-term outcomes.

Methods

An electronic health database search was performed on articles published between January 2006 and July 2017. Publications were included in this review if (I) the index aortic pathology was type B aortic (distal) dissection; (II) when medical management, open surgical replacement or thoracic endovascular aortic repair were among those options; (III) when at least one of all basic outcome criteria such as survival, spinal cord ischemia and cerebrovascular accident was reported; (IV) when ≥15 serial patients were included. A total of 62 studies were eligible and analysed.

Results

Our manuscript has summarized data collected over 12 years on management specific outcomes in the setting of distal aortic dissection and provides an up-to-date interpretation of the published evidence. For complicated cases, treated acutely, the 30-day or in-hospital mortality was 7.3% when managed by endovascular means, whereas the pooled rate for 30-day or in-hospital mortality was 19.0% when subjected to open repair. For acute uncomplicated type B dissection usually treated with blood pressure lowering medications, the pooled 30-day or in-hospital mortality rate was 2.4%. Survival rates at 5 years averaged at 60% (40% mortality). Freedom from any aortic event ranged from 34.0% to 83.9%, underlining an inherent risk of progression and late complications. For chronic complicated type B dissection, the rates of stroke, paraplegia and operative mortality following endovascular repair ranged from 5% to 13%, 2% to 13% and 2 to 13%, respectively, while 5-year survival rates after open repair ranged from 60% to 90%. In chronic uncomplicated type B dissection almost 90% of patients survive initial hospitalization and were subjected to medical management with a 5-year survival of 50-80%. However, up to 20-55% of medically treated patients develop aneurysmal degeneration after 5 years with an unknown risk of rupture.

Conclusions

Currently, the less invasive strategy of endovascular repair (as compared to open surgery) provides improved 30-day or in-hospital survival in the setting of complicated acute type B aortic dissection and may seek broad application. Open surgical aortic reconstruction should be left to experienced aortic centres if endovascular management is not an option.

Infrarenal aortic repair with or without false lumen intentional placement of endografts for hybrid management of complex aortic dissection

OBJECTIVE

Aortic dissection (AD) often involves the infrarenal aorta. We review our experience with open infrarenal aortic repair with or without false lumen intentional placement (FLIP) of endografts in the proximal dissected aorta as part of a hybrid strategy to treat complex AD.

METHODS

A prospectively maintained database of patients undergoing intervention for AD was reviewed. Data regarding diagnosis, imaging features, nature of the infrarenal repair (one- vs two-stage procedure), endoleaks, need for additional interventions, morbidity, and mortality were collected.

RESULTS

Between 2006 and 2017, there were 16 patients with AD with thoracoabdominal aortic aneurysm (TAAA), malperfusion, or both who underwent open infrarenal aortic repair or replacement combined with endovascular repair in a single- or multiple-stage procedure. Fifteen patients had a chronic AD and one patient had an acute AD. The most common indication for intervention was absolute size or rapid growth of the abdominal, thoracic, or thoracoabdominal aortic aneurysm (65%). In four patients with AD, the infrarenal replacement surgical graft was used as a common distal seal zone, allowing FLIP of an endograft to treat the proximal AD. Ten (62%) cases were done in two or more stages. Three patients had infrarenal aortic replacement with debranching only. In two of these patients, the proximal dissected aorta has remained stable without aneurysmal degeneration. One patient died as a result of rupture of his aneurysm while awaiting the second stage (perioperative mortality, 6%). Patients were observed from 1 month to 7 years. One patient had a stable type II endoleak, and one patient required subsequent replacement of ascending aortic arch for aneurysmal disease. One patient died of unrelated causes on follow-up.

CONCLUSIONS

Hybrid infrarenal aortic repair for treatment of complex AD can be performed with low morbidity and mortality and excellent medium-term results. This strategy can resolve malperfusion while simultaneously creating a landing zone using the false lumen as the conduit for the stent graft (FLIP) in selected patients. The FLIP technique allows full expansion of the endograft, potential preservation of lumbar and intercostal artery flow, and exclusion of the weaker false lumen while, in some cases, decompressing and thus stabilizing the proximal dissected aorta.

A Novel Reverse Branch Technique for Reconstruction of a Renal Artery Perfused by the False Lumen After Thoracic Endovascular Aortic Repair

PURPOSE

To describe an innovative endovascular technique that successfully reconstructs a renal artery completely perfused by the false lumen after thoracic endovascular aortic repair (TEVAR).

CASE REPORT

A 65-year-old patient diagnosed with acute Stanford type B aortic dissection underwent successful TEVAR 4 years ago. Regular follow-up found that the thoracic aorta was well repaired, but the false lumen in the abdominal aorta had enlarged year by year. The left renal artery was supplied entirely by the false lumen, which caused kidney hypoperfusion. The abdominal aorta was successfully remodeled using endovascular aneurysm repair with reconstruction of the left renal artery using Viabahn stent-grafts inserted through the patent false lumen. At 6 months, computed tomography showed false lumen thrombosis and patent Viabahn stent-grafts in the false lumen.

CONCLUSION

The false lumen reverse branch technique was feasible in our case, which provides a new idea for dealing with distal dissection involving the renovisceral arteries after TEVAR.

Operative results of the anterolateral thoracotomy with partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch

Objectives

There are various treatment strategies for chronic-type B aortic dissection involving the aortic arch. Our aim was to review our surgical experience in the anterolateral thoracotomy with the partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch.

Methods

From January 2000 to October 2015, 39 patients underwent the single-stage open surgery for chronic-type B aortic dissection involving the aortic arch using the anterolateral thoracotomy with partial sternotomy approach.

Results

Among the 39 patients, 32 were men (82.1%; mean age at surgery, 61.3 ± 11.9 years), with a mean dissecting aortic aneurysm diameter of 50.21 ± 12.20 mm; 28 patients (71.8%) had patent false lumens of the descending aorta. The median interval from dissection occurrence until surgery was 34.05 ± 52.34 months. Twenty-one patients underwent descending aortic replacement plus total aortic arch replacement and 18 underwent descending aortic replacement (plus partial aortic arch replacement). Overall in-hospital mortality and postoperative stroke rates were 5.1% (2 patients) and 10.3% (4 patients), respectively. Survival rates at 1, 3 and 5 years were 94.7%, 94.7% and 90.2%, respectively. Aortic event-free rates at 1, 3 and 5 years were 90.9%, 90.9% and 80.2%, respectively.

Conclusions

The anterolateral thoracotomy with partial sternotomy approach is a useful surgical procedure with acceptable outcomes for chronic-type B aortic dissection cases involving the aortic arch, when aortic remodelling using thoracic endovascular aortic repair cannot be performed.

Rapid Aneurysmal Sac Expansion Following Endovascular Repair of a Dissecting Thoracoabdominal Aneurysm

Endovascular repair of dissecting thoracoabdominal aneurysms (TAAA) is challenging and often requires multiple procedures. A 61-year-old man with a dissecting type-II TAAA treated first by placement of a thoracic endograft, and subsequently implantation of a fenestrated endograft. Six months postoperatively, a 10-mm increase of the aorta was observed. A reentry tear in left external iliac artery (EIA) was perfusing the false lumen in a retrograde fashion connecting with the endoleak caused by the inferior mesenteric artery and lumbar arteries. False lumen embolization of the left EIA and outflow vessels was performed. Thrombosis and rapid decrease of false lumen diameter was then observed. This case illustrates the complexity of endovascular management of extensive chronic aortic dissections.

Late reoperations after acute aortic dissection repair: Single-center experience

Background

After repair of acute type A aortic dissection, aortic complications can develop, and reoperations might be necessary. In our retrospective study, we wanted to assess early and late outcomes in this cohort of patients.

Methods

From September 2005 to July 2012, 21 consecutive patients previously operated on for acute type A aortic dissection underwent 27 redo aortic surgical procedures. Indications for redo procedures were: enlargement of the false lumen in the residual aorta (18 events), severe aortic regurgitation with or without aortic root dilatation (8 events), suture dehiscence and pseudoaneurysm at the proximal or distal aortic graft anastomosis (5 events) or at the coronary button anastomosis in patients who previously underwent a Bentall procedure (1 patient). In all cases, total or partial cardiopulmonary bypass was used. Hypothermic cardiocirculatory arrest was needed in 22 (81%) procedures.

Results

Hospital mortality was 3.7% (1/27), reexploration for bleeding and paraplegia rates were 7.4% and 7.4%, respectively. Marfan patients received 3.2 procedures per patient vs. 1.5 in non-Marfan patients ( p < 0.01). At a mean follow-up of 6.5 years, 2 aortic events occurred: 1 aortic death, and 1 additional aortic redo surgery.

Conclusions

When procedures are carried out on elective basis, redo aortic surgery can be performed in all segments of the aorta with good early and late outcomes. Close lifelong clinical and radiological follow-up is mandatory. After repair of acute type A aortic dissection, Marfan patients are more prone to develop late complications, with a more rapid evolution.

Cost analysis of endovascular versus open repair in the treatment of thoracic aortic aneurysms

OBJECTIVE

For descending thoracic aortic aneurysms (TAAs), it is generally considered that thoracic endovascular aortic repairs (TEVARs) reduce operative morbidity and mortality compared with open surgical repair. However, long-term differences in survival of patients have not been demonstrated, and an increased need for aortic reintervention has been observed. Many assume that TEVAR becomes less cost-effective through time because of higher rates of reintervention and surveillance imaging. This study investigated midterm outcomes and hospital costs of TEVAR compared with open TAA repair.

METHODS

This was a retrospective, single-institution review of elective TAA repairs between 2005 and 2012. Patient demographics, operative outcomes, reintervention rates, and hospital costs were assessed. The literature was also reviewed to determine commonly observed complication and reintervention rates for TEVAR and open repair. Monte Carlo simulation was used to model and to forecast hospital costs for TEVAR and open TAA repair up to 3 years after intervention.

RESULTS

Our cohort consisted of 131 TEVARs and 27 open repairs. TEVAR patients were significantly older (67.2 vs 58.7 years old; P = .02) and trended toward a more severe comorbidity profile. Operative mortality for TEVAR and open repair was 5.3% and 3.7%, respectively (P = 1.0). There was a trend toward more complications in the TEVAR group, although not statistically significant (all P > .05). In-hospital costs were significantly greater in the TEVAR group ($52,008 vs $37,172; P = .001). However, cost modeling by use of reported complication and reintervention rates from the literature overlaid with our cost data produced a higher cost for the open group in-hospital ($55,109 vs $48,006) and at 3 years ($58,426 vs $52,825). Interestingly, TEVAR hospital costs, not reintervention rates, were the most significant driver of cost in the TEVAR group.

CONCLUSIONS

Our institutional data showed a trend toward lower mortality and complication rates with open TAA repair, with significantly lower costs within this cohort compared with TEVAR. These findings were likely, at least in part, to be due to the milder comorbidity profile of these patients. In contrast, cost modeling by Monte Carlo simulation demonstrated lower costs with TEVAR compared with open repair at all time points up to 3 years after intervention. Our institutional data show that with appropriate selection of patients, open repair can be performed safely with low complication rates comparable to those of TEVAR. The cost model argues that despite the costs associated with more frequent surveillance imaging and reinterventions, TEVAR remains the more cost-effective option even years after TAA repair.

Open repair of chronic complicated type B aortic dissection using the open distal technique

AIM

The present study aimed to analyze early and late outcomes after open repair of chronic type B aortic dissection.

METHODS

We retrospectively reviewed our cases of open descending thoracic aortic aneurysm (DTAA) with chronic dissection from 1991-2013. Long-term survival and aortic reinterventions were analyzed and patient comorbidities were evaluated in order to determine the risk of adverse outcomes. Furthermore, the technique for "distal first approach" is described.

RESULTS

Between 1991 and 2013, 240 (40%) descending thoracic aortic repairs with associated chronic dissection were performed. Mean age is 59 years and 178 (74%) are men. The majority of patients (218, 91%) underwent repair using the adjunct of distal aortic perfusion with cerebral spinal fluid drainage. Early mortality was 8.3% (20/240). Permanent neurologic deficit occurred in 1.3% (3/240). Stroke occurred in 2.9% (7/240), and dialysis on discharge in 6% (12/240). 5-, 10-, 15-, and 20-year survival was 72%, 60%, 45%, and 39%, respectively. Freedom from reoperation on the operated segment was 97%, 94%, 94% and 94% at 5, 10, 15 and 20 years.

CONCLUSIONS

Open repairs of chronic descending thoracic dissections can be performed with respectable morbidity and mortality. Risk of neurologic deficit remains low with use of adjuncts, and risk of reintervention on the involved aortic segment is also low. These results allow comparison with endovascular repair for chronic aortic dissection.

Open surgical repair for chronic type B aortic dissection: a systematic review

BACKGROUND

The treatment of chronic type B aortic dissection (CBAD) remains complicated. Thoracic endovascular aortic repair (TEVAR) has supplanted open surgical repair (OSR) as the preferred surgical treatment for CBAD. Despite TEVAR's superior short-term results, much less is understood about its long-term outcomes. As much of the understanding of OSR originates from historical report, contemporary series, with modern surgical techniques and technologies, may present an alternative to TEVAR. The present systematic review will assess the short- and long-term outcomes of historic and contemporary series of OSR for CBAD.

METHODS

Electronic searches were performed using six databases from their inception to March 2014. Relevant studies with OSRs for chronic type B dissection were identified. Data were extracted by two independent reviewers and analyzed according to predefined clinical endpoints. Studies were sub-classified into the pre-endovascular (historic series) and endovascular era (contemporary series) depending on whether the majority of cases were performed after 1999.

RESULTS

Nineteen studies were identified for inclusion for quantitative analysis. Pooled short-term mortality was 11.1% overall, and 7.5% in the nine contemporary studies. Stroke, spinal cord ischemia, renal dysfunction, and reoperation for bleeding were 5.9%, 4.9%, 8.1%, and 8.1%, respectively, for the contemporary series. Absolute late reintervention was identified in 13.3% of patients overall, and in 11.3% of patients in the contemporary series. Aggregated survival at 1-, 3-, 5-, and 10-years of all patients were 82.1%, 74.1%, 66.3%, and 50.8%, respectively.

CONCLUSIONS

OSR for chronic type B dissection in the contemporary era offers acceptable results. Management approaches should be considered carefully, taking into account both short-term and long-term complications. More research is required to clarify specific indications for OSR and TEVAR in chronic type B dissections.

Long-term outcomes in thoracoabdominal aortic aneurysm repair for chronic type B dissection

INTRODUCTION

Open repair for chronic aortic dissection remains a challenging surgical option. Different centers report diverse experiences and outcomes pertaining to thoracoabdominal aortic aneurysm repair (TAAAR) for chronic type B dissection. We highlight our center's experience and results on a background of published literature and current evidence.

METHODS

We reviewed 214 open TAAAR performed between October 1998 and February 2014. Of these, chronic type B dissection was present in 62 (29.0%) patients. We reviewed these patients in terms of demographics, operative characteristics and outcomes. Thirteen (21.0%) patients had surgery on the descending thoracic aorta [Category A =2 (3.2%), B =0 (0%), C =11 (17.7%)] and 49 (79.0%) in the thoracoabdominal thoracic aorta [Crawford extent I =5 (8.1%), extent II =39 (62.9%), extent III =4 (6.5%), extent IV =1 (1.6%)]. Left heart bypass was used in 12 (19.4%) patients.

RESULTS

The composite in-hospital endpoint, adverse outcome-defined as operative death, renal failure necessitating dialysis at discharge, stroke, or permanent paraplegia or paraparesis-occurred after 28 (45.2%) procedures. There were 14 (22.6%) operative deaths. In-hospital mortality was seven (16.3%) out of 43 elective patients, and increased to seven (36.8%) of the 19 non-elective ones. Permanent paraplegia or paraparesis occurred after two (3.2%) cases, stroke occurred after seven (11.3%) and renal failure requiring dialysis occurred after 16 (25.8%). Mean follow-up time was 3.2 years and actuarial 5-year mortality was 27.4% [nine (14.5%) elective and eight (12.9%) non-elective patients].

CONCLUSIONS

TAAAR in chronic type B dissection carries a substantial risk of early adverse outcomes. The results could be well alleviated with cases directed towards specialized regional and supra-regional centers. Although the endovascular approaches offer relatively low mortality and morbidity, there is a lack of long-term data and guidelines on their use. There is a need for a multidisciplinary international registry on the management of thoracoabdominal aortic aneurysms and dissection. This would provide a degree of guidance on relevant clinical and surgical judgments and outcomes.

Current management and outcome of chronic type B aortic dissection: results with open and endovascular repair since the advent of thoracic endografting

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for chronic type B aortic dissection (CTBAD) at our institution. However, it remains incapable of treating all patients with CTBAD. The present study aims to review our contemporary results with open and endovascular CTBAD repairs since the advent of thoracic endografting.

METHODS

The records of all patients undergoing index repair of CTBAD (chronic DeBakey type IIIA, IIIB and repaired type I) at our institution between June 2005 and December 2013, were retrospectively reviewed.

RESULTS

A total of 107 patients underwent CTBAD repair, of whom 70% (n=75) underwent endovascular-based procedures [44 TEVAR, 27 hybrid arch and four hybrid thoracoabdominal aortic aneurysm (TAAA) repair] and 30% (n=32) underwent open procedures (nine open descending and 23 open TAAA). Connective tissue disease (CTD), prior aortic surgery and DeBakey dissection type were strongly associated with the choice of operation. The rates of stroke, paraplegia and operative mortality following endovascular-based repairs were 0%, 0% and 4% (n=3), respectively. Adverse neurologic events were higher following open repair, and rates of stroke, paraplegia, and operative mortality were 16% (n=5), 9% (n=3), and 6% (n=2), respectively. However, 1- and 5-year survival rates were similar for endovascular-based repairs (86% and 65%, respectively), and open repairs (88% and 79%, respectively). Over a median follow-up interval of 34 months, the rate of descending aortic reintervention was 24% (n=18) following endovascular-based repairs and 0% following open repairs (P=0.001). Forty-four percent (n=8) of descending aortic reinterventions were required to treat stent graft complications (five endoleak, two stent graft collapse and one stent graft-induced new entry tear) and the remainder were required to treat metachronous pathology (n=2) or progressive aneurysmal disease related to persistent distal fenestrations (n=8).

CONCLUSIONS

Endovascular repair of CTBAD was associated with excellent procedural and survival outcomes, but at the expense of further reinterventions. Open repair remains relevant for patients who are not candidates for endovascular repair and was associated with higher procedural morbidity but similar overall survival and fewer reinterventions.

Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE Registry

OBJECTIVE

The VIRTUE Registry describes the mid-term clinical and morphological results of thoracic endovascular repair (TEVR) in patients with type B aortic dissection.

METHODS

This was a prospective cohort study. The VIRTUE Registry is a prospective, multicentre clinical trial that enrolled patients with complicated acute (<15 days), subacute (15-92 days), and chronic (>92 days) type B aortic dissections treated with the Valiant endograft. One hundred patients were enrolled and the clinical outcomes described at the 3-year follow-up. Analysis of the aortic area and false lumen thrombosis rates defined the morphological response to TEVR in the three clinical groups.

RESULTS

Three-year all-cause mortality (18%, 4%, and 24%), dissection related mortality (12%, 4%, and 9%), aortic rupture (2%, 0%, and 4%), retrograde type A dissection (5%, 0%, and 0%), and aortic reintervention rates (20%, 22%, and 39%) were, respectively, defined for patients with acute (n = 50), subacute (n = 24), and chronic (n = 26) dissections. Analysis of aortic morphology observed that patients with subacute dissection demonstrated a similar degree of aortic remodelling to patients with acute dissection. Patients with acute and subacute dissection exhibited greater aortic plasticity than patients with chronic dissection.

CONCLUSIONS

The principle clinical findings suggest that TEVR is able to provide good protection from aortic-related death in the mid-term, but with a high rate of aortic reintervention. Analysis of aortic morphology suggested that aortic remodelling in subacute patients is similar to the acute group. Retention of aortic plasticity in the subacute group lengthens the therapeutic window for the treatment of uncomplicated type B dissection.