Results After Thoracic Endovascular Aortic Repair in Penetrating Atherosclerotic Ulcers

Midterm survival after aortic repair versus conservative treatment in patients with penetrating aortic ulcer

Background: The clinical outcomes and survival of patients with penetrating aortic ulcers (PAU) were evaluated in a tertiary care hospital, comparing those who underwent aortic repair to those treated conservatively. Patients and methods: A retrospective single-centre analysis included all patients that underwent a computed tomography angiography (CT-A) scan with the diagnosis of a PAU between January 2009 and May 2019. "PAU" was identified in 1,493 of 112,506 CT-A scan reports in 576 patients. Clinical and angiomorphological data were collected. The primary outcome was overall survival (OS), with secondary outcomes focusing on identifying risk factors for poor OS. Survival probabilities were analysed by the Kaplan-Meier method using the log-rank test. A Cox hazard model using survival as dependent variable with stepwise backward eliminations based on the likelihood ratios was employed. Results: 315 PAUs were identified in 278 patients. The prevalence in the cohort was 0.8%. The mean age of the patients was 74.4 years, and they were predominantly male (n = 208, 74.8%). The mean ulcer depth was 11.8 mm (range 2-50 mm). Out of the patients, 232 were asymptomatic (83.5%). Among 178 PAUs (56.5%), high-risk factors, such as ulcer depth >10 mm, aortic diameter >40 mm, and ulcer length >20 mm, were observed. Aortic repair was associated with a better mean OS compared to conservatively managed patients (72.6 versus 32.2 months, p = 0.001). The Cox hazard model showed that ulcer depth >1 mm was associated with poor OS (HR 0.67, p = 0.048), while aortic repair was related to a better OS (HR 4.365, p<0.013). Conclusions: Aortic repair is associated with better OS, but this finding should be interpreted with caution because of differences in age and comorbidities between the groups. Further evaluation is warranted through prospective studies with randomized groups. Further assessment for angiomorphological parameters is recommended to identify patients at increased risk for poor OS.

Type 1 Endoleak: Management following Thoracic Endovascular Aortic Repair

The best treatment option for type IA endoleak after thoracic endovascular aortic repair (TEVAR) is its avoidance by understanding the underlying disease process, having/creating adequate landing zones, as well as respecting anatomy in combination with knowledge of the capabilities and limitations of the TEVAR device used.

Clinical and Imaging Predictors of Disease Progression in Type B Aortic Intramural Hematomas and Penetrating Aortic Ulcers: A Systematic Review

BACKGROUND

This work aims to review recent literature on penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs), in order to identify clinical and imaging factors connected to aortic-related adverse events (AAE).

METHODS

We performed a systematic review according to the Preferred Reporting Items for Systematic review and Metanalyses (PRISMA) guidelines. An electronic search was conducted on Medline and Embase databases. We included articles reporting on PAUs and/or IMHs localized in the descending thoracic and/or abdominal aorta and analyzing clinical and/or radiological markers of AAE.

RESULTS

Of 964 records identified through database searching, 17 were incorporated in the present review, including 193 and 1298 patients with type B PAUs and IMHs, respectively. The 30-days aortic-related mortality (ARM) was 4.3% and 3.9% for PAUs and IMHs. A total of 21% of patients with IMHs underwent intervention during the follow-up period, and 32% experienced an AAE. PAU markers of AAE were minimum depth (ranging from 9.5 to 15 mm) and diameter (≥12.5 mm). Maximum aortic diameter (MAD) cut-off values ranging from 38 to 44.75 mm were related to AAE for IMHs, together with ulcer-like projection (ULP) of the aortic wall.

CONCLUSIONS

Despite data heterogeneity in the literature, this PAU- and IMH-focused review has highlighted the imaging and clinical markers of disease progression, thus identifying patients that could benefit from an early intervention in order to reduce the AAE rate.

Endovascular treatment of penetrating atherosclerotic ulcers of the arch and thoracic aorta: In-hospital and 5-year outcomes

Objective

Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic aorta diseases including penetrating aortic ulcer (PAU). The objective of this study was to analyze the results of TEVAR for the treatment of PAU in our population.

Methods

From January 1999 to January 2019, 830 patients with type B aortic syndromes were treated with TEVAR in our institution. Of these we selected 73 patients treated for a PAU. Clinical and radiologic follow-up was performed in all patients.

Results

Mean age of our population was 72 ± 8 years. Fifteen patients (20.5%) were treated in an emergency setting. The proximal landing zone was in arch zone 2 in 22 patients (30.1%). In-hospital mortality was 6.8% and was associated with acute presentation (P = .005). Distal arch delivery of the endograft was unrelated to mortality (Fisher exact test, P = .157). Survival at 1 and 5 years was 81.7% and 67.3%, respectively. Sixteen patients underwent reintervention of the thoracic aorta. Patients who underwent emergency surgery and older patients had a shorter survival (log rank test, P < .001). No difference in survival was shown according to the proximal landing zone (log rank P = .292) or the dimension of the thoracic aorta (log rank P = .067). In multivariable Cox regression analysis, only age older than 75 years was associated with 5-year mortality (hazard ratio, 6.60; 95% CI, 2.12-20.56); P < .001).

Conclusions

The use of TEVAR for treatment of aortic PAU is a safe procedure in an elective setting despite necessity of arch stent grafting. An early intervention performed at smaller aortic diameters of <55 mm might be beneficial in selected patients to improve late survival.

Current options and recommendations for the use of thoracic endovascular aortic repair in acute and chronic thoracic aortic disease: an expert consensus document of the European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for Cardio-Thoracic Surgery (EACTS)

Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of—in analogy to the heart team—aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta—the aortic root, in particular in acute type A aortic dissection—which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments.

Intravascular Ultrasound-Assisted Endovascular Exclusion of Penetrating Aortic Ulcers

BACKGROUND

Penetrating aortic ulcer (PAU) is an atherosclerotic lesion penetrating the elastic lamina and extending into the media of the aorta. It may evolve into intramural hematoma, focal dissection, pseudoaneurysm, and eventually rupture. The purpose of this study was to evaluate the effectiveness of a totally intravascular ultrasound (IVUS)-assisted endovascular exclusion of PAU.

METHODS

Thirteen consecutive patients (median age 66 years) underwent IVUS-assisted endovascular exclusion of PAU. The primary end points were fluoroscopy time, radiation dose, and occurrence of type I primary endoleak. Secondary end points were postoperative mortality and morbidity, arterial access complications, postoperative length of stay in the hospital, and occurrence of type II endoleaks.

RESULTS

The median fluoroscopy time was 4 min (4-5). The median radiation dose was 4.2 mGy (3.9-4.5). A proximal and distal landing zone of at least 2 cm could be obtained in all the patients. No patient presented a type I endoleak. No postoperative mortality, no morbidity, or arterial access complication was observed. The median length of postoperative stay in the hospital was 2 days (2-3). The median length of follow-up was 25 months (9.2-38.7). One late type II endoleak was observed (7.7%), because of reflux from the intercostal arteries, without the need for additional treatment.

CONCLUSIONS

IVUS-assisted endovascular treatment of PAU allows durable exclusion of PAU with a short fluoroscopy time and no need for injection of contrast media. Further series are needed to confirm the results of this preliminary study.

The Management of Penetrating Aortic Ulcer

Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management.

The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures

Although follow-up after open surgical and endovascular procedures is generally regarded as an important part of the care provided by vascular surgeons, there are no detailed or comprehensive guidelines that specify the optimal approaches with regard to testing methods, indications for reintervention, and follow-up intervals. To provide guidance to the vascular surgeon, the Clinical Practice Council of the Society for Vascular Surgery appointed an expert panel and a methodologist to review the current clinical evidence and to develop recommendations for follow-up after vascular surgery procedures. For those procedures for which high-quality evidence was not available, recommendations were based on observational studies, committee consensus, and indirect evidence. Recognizing that there are numerous published reports on the role of duplex ultrasound for surveillance of infrainguinal vein bypass grafts, the Society commissioned a systematic review and meta-analysis on this topic. The panel classified the strength of each recommendation and the corresponding quality of evidence on the basis of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system: recommendations were graded either strong or weak, and the quality of evidence was graded high, moderate, or low. The resulting recommendations represent a wide variety of open surgical and endovascular procedures involving the extracranial carotid artery, thoracic and abdominal aorta, mesenteric and renal arteries, and lower extremity arterial revascularization. The panel also identified many areas in which there was a lack of high-quality evidence to support their recommendations. This suggests that there are opportunities for further clinical research on testing methods, threshold criteria, and the role of surveillance as well as on the modes of failure and indications for reintervention after vascular surgery procedures.

Thoracic Endovascular Repair of Complicated Penetrating Aortic Ulcer

Purpose: To analyze an 11-year single-center experience of treating complicated penetrating aortic ulcer (PAU) using thoracic endovascular aortic repair (TEVAR). Methods: This study included 63 consecutive patients (mean age 69.1±11.5 years; 40 men) with complicated PAU (42 symptomatic, 22 with rupture) who underwent TEVAR between 2002 and 2013. The PAUs were located in the aortic arch (n=11), the descending thoracic aorta (n=43), and the thoracoabdominal aorta (n=9). Results: TEVAR was performed within 14 days of diagnosis in 33 (52.3%) cases (19 ruptures treated immediately); the other 30 (47.6%) patients had an average interval between diagnosis and intervention of 40±39 days. Technical success was 98.4% (62/63). One patient had a type I endoleak after stent-graft repair of a PAU in the aortic arch without great vessel transposition; another procedure was required for carotid-subclavian bypass and proximal stent-graft extension. No patient experienced spinal cord ischemia after TEVAR. Five (7.9%) patients died in-hospital; 3 had severe cardiac complications, 1 died from complications of aortic rupture, and the other succumbed to septic shock. Mean follow-up was 45.6±47.2 months, during which 12 (19.0%) patients needed a secondary intervention because of late endoleaks (n=4, 6.3%) or new complications due to disease progression. Multivariate analysis indicated that a PAU depth >15 mm was an independent predictor of mortality (hazard ratio 6.92, p=0.03). In the biomarker analysis, symptomatic patients had significantly higher D-dimer and troponin levels compared to asymptomatic patients [559.5±460.7 vs 283.2±85.2 µg/L (p=0.016) and 0.22±0.61 vs 0.02±0.03 ng/mL (p=0.04), respectively]. Conclusion: Patients with PAU suffer from underlying severe atherosclerotic disease and have a significant number of cardiovascular comorbidities that lead to relevant mortality and morbidity after TEVAR. As a PAU diameter >15 mm represented high risk for disease progression, these patients may be candidates for early intervention. D-dimer levels may help identify patients at risk and with progression of PAU.

Hybrid aortic arch repair

The successes of thoracic endovascular aortic repair (TEVAR) have spurned new approaches to addressing thoracic aortic pathologies. These hybrid techniques offer an alternative in patients with multi-segmental thoracic aortic pathologies which would have otherwise required a two-step arch replacement and open descending arch repair. The following article offers a clinical insight to the available hybrid approaches, such as rerouting of supra-aortic vessels. Unique complications to endovascular repairs, and technical risks and issues, are also presented along with management options and strategies to minimize such concerns.

Recent advances in the diagnosis of acute aortic syndromes

INTRODUCTION

Acute aortic syndrome (AAS) is an acute lesion of the aortic wall involving the aortic media. In patients presenting with AAS, establishing a timely diagnosis is of paramount importance as mortality from AAS increases by 1 - 2% per hour. Acute aortic syndrome comprises a variety of pathologically distinct life-threatening conditions such as aortic dissection, intramural hematoma (IMH) of the aorta, penetrating aortic ulcer (PAU), traumatic transection and symptomatic aortic aneurysm.

AREAS COVERED

The aim of this article was to review recent progress in the diagnosis and therapeutic management of these syndromes. In the past few years, imaging techniques have increased our understanding of the natural history of these disease entities. Patients presenting with AAS require immediate diagnosis in order to rapidly initiate adequate therapeutic measures. Diagnostic imaging modalities that can be used for diagnosing this condition are transthoracic and transesophageal echocardiography (TTE and TEE, respectively), computed tomography angiography (CTA), magnetic resonance imaging and angiography in combination with intravascular ultrasound (IVUS).

EXPERT OPINION

Patients presenting with AAS require immediate diagnosis for rapid initiation of adequate therapeutic measures. The best method to correctly diagnose acute aortic dissection and its complications is complementary use of CTA, TEE and angiography in combination with IVUS to improve visualization of aortic syndromes and to guide aortic stent graft implantation.