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Khabaz K, Kim J, Milner R, Nguyen N, Pocivavsek L. Temporal geometric mapping defines morphoelastic growth model of Type B aortic dissection evolution. Comput Biol Med 2024; 182:109194. [PMID: 39341108 DOI: 10.1016/j.compbiomed.2024.109194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 08/30/2024] [Accepted: 09/21/2024] [Indexed: 09/30/2024]
Abstract
The human aorta undergoes complex morphologic changes that mirror the evolution of disease. Finite element analysis (FEA) enables the prediction of aortic pathologic states, but the absence of a biomechanical understanding hinders the applicability of this computational tool. We incorporate geometric information from computed tomography angiography (CTA) imaging scans into FEA to predict a trajectory of future geometries for four aortic disease patients. Through defining a geometric correspondence between two patient scans separated in time, a patient-specific FEA model can recreate the deformation of the aorta between the two time points, showing that pathologic growth drives morphologic heterogeneity. FEA-derived trajectories in a shape-size geometric feature space, which plots the variance of the shape index versus the inverse square root of aortic surface area (δS vs. [Formula: see text] ), quantitatively demonstrate an increase in δS. This represents a deviation from physiologic shape changes and parallels the true geometric progression of aortic disease patients.
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Affiliation(s)
- Kameel Khabaz
- David Geffen School of Medicine, University of California, Los Angeles, 855 Tiverton Dr., Los Angeles, CA, 90024, USA; Department of Surgery, The University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637, USA
| | - Junsung Kim
- Department of Surgery, The University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637, USA
| | - Ross Milner
- Department of Surgery, The University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637, USA
| | - Nhung Nguyen
- Department of Surgery, The University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637, USA
| | - Luka Pocivavsek
- Department of Surgery, The University of Chicago, 5841 S. Maryland Ave., Chicago, IL, 60637, USA.
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Eidt JF, Gucwa AL, Cha E, Hohmann SE, Vasquez J. Emerging Trends in the Care of Type B Aortic Dissections. Am J Cardiol 2024; 230:62-71. [PMID: 39209243 DOI: 10.1016/j.amjcard.2024.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/02/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
Aortic dissection is the most common of the acute aortic syndromes. Acute aortic dissection remains a highly morbid and potentially lethal condition despite contemporary advances in medical and surgical care. Type B aortic dissection (TBAD) is classified as uncomplicated, uncomplicated with high-risk features, and complicated. The role of thoracic endovascular aortic repair (TEVAR) in uncomplicated TBAD remains uncertain and is the topic of ongoing clinical trials. In most complicated cases, TEVAR is effective at restoring visceral and extremity blood flow. TEVAR has also been shown to arrest hemorrhage in the setting of thoracic aortic rupture. TEVAR has been demonstrated to induce satisfactory remodeling in the covered segment of the thoracic aorta, but progressive enlargement of the visceral aorta has led to a variety of techniques designed to promote remodeling in the uncovered aortic segment. There is a need to better define high-risk features so that treatment can be tailored to specific clinical conditions.
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Affiliation(s)
- John F Eidt
- Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas.
| | | | - Erin Cha
- Texas A&M College of Medicine, College Station, Texas
| | - Steven E Hohmann
- Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas
| | - Javier Vasquez
- Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas
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Wang X, Song F, Jiang L, Huang Z, Luo S, Li X, He X. Efficacy and Safety of Sacubitril/Valsartan in Chronic Type B Aortic Dissection Combined With Mild Hypertension. Am J Hypertens 2024; 37:612-620. [PMID: 38564196 DOI: 10.1093/ajh/hpae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/07/2023] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Optimal antihypertensive medication for chronic type B aortic dissection (AD) remains undecided. This study compared the efficacy and safety of sacubitril/valsartan with valsartan to determine suitable antihypertensive drug combinations. METHODS In this single-center, open-label, randomized, controlled trial, patients with chronic Stanford type B AD and mild hypertension were randomized to receive sacubitril/valsartan 100/200 mg or valsartan 80/160 mg. The primary endpoint was the reduction in mean sitting systolic blood pressure (msSBP) at week 8 in patients with sacubitril/valsartan vs. valsartan. Key secondary endpoints included changes in (i) mean sitting diastolic blood pressure (msDBP); (ii) pulse pressure (PP); and (iii) mean ambulatory blood pressure (BP) for 24-hour, daytime, and nighttime. Safety assessments included adverse events (AEs) and serious AEs. This trial was registered with the Chinese Clinical Trial Registry, identifier: ChiCTR2300073399. RESULTS A total of 315 patients completed the study. Sacubitril/valsartan provided a significantly greater reduction in msSBP than valsartan at week 8 (between-treatment difference: -5.1 mm Hg [95% confidence interval -5.8 to -4.5], P < 0.001). Reductions in msSBP, msDBP, and PP as well as the mean ambulatory BP for 24-hour, daytime, and nighttime, were significantly greater in sacubitril/valsartan compared with valsartan (all P < 0.001). No excessive episodes of AEs occurred in the sacubitril/valsartan group. CONCLUSIONS Sacubitril/valsartan and valsartan reduced BP compared with baseline values. However, sacubitril/valsartan improved BP control to a greater extent than valsartan. It may offer a new treatment option for patients with mild hypertension and chronic type B AD.
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Affiliation(s)
- Xuelin Wang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Shantou University Medical College, Shantou, Guangdong, China
| | - Feier Song
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Department of Emergency Medicine, Emergency Intensive Care Unit, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Lujing Jiang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Ziling Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Songyuan Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Xin Li
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xuyu He
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
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Burger JJ, van Bemmel C, Keukens D, Pomstra R, van der Wees PJ, Koenders N. Losing, regaining, and continuing to build self-confidence - a qualitative, phenomenological study of being physically active with a type B aortic dissection. Disabil Rehabil 2024:1-8. [PMID: 38967799 DOI: 10.1080/09638288.2024.2375060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 06/27/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE To gain a comprehensive understanding of experiences related to being physically active in participants with an uncomplicated type B aortic dissection. MATERIALS AND METHODS We performed a qualitative, phenomenological study. First-person accounts of adults, who at least one year ago had an uncomplicated type B aortic dissection, were collected using semi-structured interviews. The audio recordings of the interviews were transcribed verbatim and analyzed with interpretative phenomenological analysis. RESULTS We collected, in total, 644 min interview data from 14 participants. Three patterns were interpreted: losing self-confidence, regaining self-confidence, and continuing to build self-confidence. Experiencing symptoms when pushing limits, challenges with energy management, and side effects of medication caused loss of self-confidence. Changes in identity, reaching milestones that reflect improvement, and support from others and tools helped participants regain self-confidence. To continuing to build self-confidence, participants indicated they needed success experiences and activities make life worth living. CONCLUSIONS Self-confidence in adults with an uncomplicated type B aortic dissection changes immediately after the diagnosis of the aortic dissection. Rehabilitation professionals can support adults regaining and continuing to build self-confidence, aiming for the perfect balance between blood pressure regulation, quality of life, and being physically active.Implications for rehabilitationRehabilitation professionals should support regaining and continuing to build self-confidence related to being physically active in adults with type B aortic dissection in the early stages of recovery and beyond.Adults with an uncomplicated type B aortic dissection want rehabilitation professionals to tell them primarily what is possible (recommendations) rather than what is not allowed (rules).Rehabilitation professionals should help adults with an uncomplicated type B aortic dissection to explore, push and, ultimately, accept limits related to exercise tolerance.
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Affiliation(s)
- Joren J Burger
- Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
- Clinical Health Sciences, Utrecht University Medical Center, Utrecht, The Netherlands
| | | | - Deborah Keukens
- Stichting Aortadissectie Nederland, The Hague, The Netherlands
| | - Roelie Pomstra
- Stichting Aortadissectie Nederland, The Hague, The Netherlands
| | - Philip J van der Wees
- Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
- IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Niek Koenders
- Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
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Shen Y, Wang J, Zhao J, Huang B, Weng C, Wang T. Development and Validation of a User Friendly Morphology Grading System (PATENT) Predicting Aortic Remodelling After Thoracic Endovascular Aortic Repair in High Risk Uncomplicated Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00568-9. [PMID: 38972631 DOI: 10.1016/j.ejvs.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/28/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE This study aimed to create a morphology grading system, solely based on 2D images from computed tomography angiography, to predict negative aortic remodelling (NAR) for patients with high risk uncomplicated type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). METHODS This single centre retrospective cohort study extracted and analysed consecutive patients diagnosed with high risk uncomplicated TBAD. Negative aortic remodelling was defined as an increase in the false lumen or total aortic diameter, or decrease in the true lumen diameter. The multivariable Cox regression model identified risk factors and a prediction model was created for two year freedom from NAR. A three category grading system, in which patients were classified into low, medium, and high risk groups, was further developed and internally validated. RESULTS Of 351 patients included, 99 (28%) developed NAR. The median age was 52 years (interquartile range 45, 62 years) and 56 (16%) were female. The rate of two year freedom from NAR was 71% (95% CI 65 - 77%). After the multivariable Cox regression analysis, Patent false lumen, Aberrant right subclavian artery, Taper ratio, abdominal circumferential Extent, coeliac artery or reNal artery involved, and four channel dissection (Three false lumens) remained independent predictors and were included in the PATENT grading system. The risk score was statistically significantly associated with NAR (HR 1.21; 95% CI 1.14 - 1.29; p < .001). The medium and high risk groups demonstrated a higher rate of NAR (medium risk, HR 2.82; 95% CI 1.57 - 5.01; p = .001; high risk, HR 4.39; 95% CI 2.58 - 7.48; p < .001). The grading system was characterised by robust discrimination with Harrell's C index of 0.68 (95% CI 0.63 - 0.75). CONCLUSION The PATENT grading system was characterised by good discrimination and calibration, which may serve as a clinician friendly tool to aid risk stratification for TBAD patients after TEVAR.
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Affiliation(s)
- Yinzhi Shen
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China; Department of Vascular Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jiarong Wang
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jichun Zhao
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Huang
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chengxin Weng
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tiehao Wang
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China.
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Spratt JR, Walker KL, Neal D, Arnaoutakis GJ, Martin TD, Back MR, Zasimovich Y, Franklin M, Shahid Z, Upchurch GR, Scali ST, Beaver TM. Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2024; 168:15-25.e11. [PMID: 36509568 DOI: 10.1016/j.jtcvs.2022.10.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center. METHODS Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent. RESULTS Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome. CONCLUSIONS Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.
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Affiliation(s)
- John R Spratt
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
| | - Kristen L Walker
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Yury Zasimovich
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - Michael Franklin
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - Zain Shahid
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
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Luo ZR, Wang ZS, Chen YX, Chen LW. Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with sleep apnea syndrome. J Vasc Surg 2024:S0741-5214(24)01340-5. [PMID: 38925349 DOI: 10.1016/j.jvs.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/23/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE This study aimed to determine the influences of varying severity of sleep apnea syndrome (SAS) on the outcomes after thoracic endovascular aorta repair (TEVAR) in patients with Stanford type B aortic dissection (TBAD). METHODS This observational study focused on individuals with TBAD plus SAS who received TEVAR between January 2018 and December 2022. Patients were divided into groups according to the results of the portable sleep-breathing monitoring systems: mild SAS (MSAS) and moderate-to-severe SAS (MSSAS). Clinical profiles were collected and analyzed. RESULTS A total of 121 cases with TBAD plus SAS who underwent TEVAR were enrolled in this study. Two groups were formed by stratifying these cases: MSAS (74 cases) and MSSAS (47 cases). The MSSAS cases were found to be older relative to MSAS cases (51.7 ± 8.3 years vs 57.1 ± 12.8 years; P = .012) and had a higher body mass index (BMI; 25.7 ± 2.3 kg/m2vs 27.0 ± 2.3 kg/m2; P = .038). The investigation did not find any appreciable differences between the MSAS and MSSAS groups in terms of complications (endoleak, P = .403; stent-induced new entry, P >.999; and stent displacement: P >.999). However, the MSSAS group exhibited a significantly higher overall mortality rate compared with the MSAS group (log-rank P = .027). The tendency continued when examining cases with Marfan syndrome combined with MSSAS, where the overall mortality rate was significantly greater compared with Marfan syndrome cases with MSAS (log-rank P = .037). The absence of a significant difference was noteworthy in the freedom from reintervention between the MSAS and MSSAS groups (log-rank P = .278). The overall mortality rate was significantly higher in MSSAS group even after adjusting for varying potential confounders in the multivariate cox regression analysis (hazard ratio [HR], 1.875; 95% confidence interval [CI], 1.238-2.586; P = .012). A markedly higher rate of distal stent dilation in the MSSAS group was also observed compared with the MSAS group (HR, 2.5 mm/year [95% CI, 2-3 mm/year] vs HR, 4 mm/year [95% CI, 2.0-5.5 mm/year]; P = .029). CONCLUSIONS MSSAS is associated with a significantly higher risk of overall mortality and dilation rate of the distal stent after TEVAR for TBAD patients. Hence, aggressive efforts to reverse the severity of SAS in time in these individuals seem to be necessary.
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Affiliation(s)
- Zeng-Rong Luo
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, PR China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province, PR China
| | - Zhi-Sheng Wang
- Department of Cardio-Thoracic Surgery, Fujian Medical University Affiliated Longyan First Hospital, Longyan, PR China
| | - Yi-Xing Chen
- Department of Cardiology, Fujian Medical University Nanping First Hospital, Nanping, PR China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, PR China; Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province, PR China.
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Azoulay A, Serrand C, Belarbi A, Branchereau P, Prouse G, Hireche K, Canaud L, Alric P. Acute Type B Aortic Dissection: Insights From a Single-Center Retrospective Experience Over 12 Years. J Endovasc Ther 2024:15266028241258401. [PMID: 38898697 DOI: 10.1177/15266028241258401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
INTRODUCTION The treatment of acute type B aortic dissection (ATBAD) is currently a challenge for vascular surgeons, because of the early morbidity and mortality rates and the high risk of late aortic events up to 50% at 5 years. This study presents the initial outcomes of ATBAD treatment using optimal medical therapy alone or combined with proximal entry tear stent-graft coverage. Additionally, it provides an analysis of the evolution of the aortic diameter and its clinical consequences during the chronic phase in each group. MATERIALS AND METHODS Conducted as a retrospective, single-center study, we enrolled all consecutive ATBAD patients (n=130) treated between 2008 and 2020. The primary analysis studies the entire patient cohort based on their initial management approach, namely, medical treatment alone for uncomplicated ATBAD (n=67) or combined with stent-graft entry tear coverage (n=63). We also conducted a subgroup analysis to investigate factors associated with disease progression in the medical management group. RESULTS Median follow-up was 29.5 months. During this time aneurysmal evolution was observed in: 42.4% of cases in the medical group compared with 21.8% in the stent-graft group, primarily affecting the thoracic aorta. The stent-graft group exhibited significant aortic remodeling, with a decrease in false lumen (FL) and thoracic aortic diameters. Initial aortic diameter ≥40 mm and FL ≥22 mm were independent risk factors for aneurysmal degeneration. Five-year survival was consistent at 76.1% in both groups. CONCLUSION This study confirms the safety and efficacy of stent-graft entry tear coverage for ATBAD. Initial thoracic endovascular aortic repair (TEVAR) appears to reduce late aortic events by promoting aortic remodeling. Considering TEVAR's safety and potential to prevent late aortic complications, it may be considered for uncomplicated ATBAD patients with an initial aortic diameter ≥40 mm or an FL ≥22 mm. CLINICAL IMPACT This study validates the efficacy and safety of using endovascular stent grafts to seal the proximal entry tear in cases of acute type B aortic dissections, compared to optimal medical therapy. Aortic remodelling significantly benefits from endovascular stent graft coverage of the proximal entry tear. Given the heightened risk of late aortic events observed in the medical therapy cohort, there appears to be a necessity for including endovascular interventions in the management of uncomplicated acute type B aortic dissections, particularly when aortic diameter is ≥40 mm and false lumen diameter is ≥22 mm.
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Affiliation(s)
- Alexandre Azoulay
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Chris Serrand
- Biostatistics, Epidemiology, Public Health and Methodological Innovation Unit (Unité de biostatistique, épidémiologie, santé publique et innovation méthodologique, BESPIM), Nîmes University Hospital, Nîmes, France
| | - Amine Belarbi
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Pascal Branchereau
- Department of Vascular and Thoracic Surgery, University of Montpellier-Nimes, CHU Nimes, Nimes, France
| | - Giorgio Prouse
- Department of Vascular Surgery, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Kheira Hireche
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
- PhyMedExp, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Ludovic Canaud
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
- PhyMedExp, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Pierre Alric
- Department of Vascular and Thoracic Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
- PhyMedExp, University of Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
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Tanenbaum MT, Figueroa AV, Kanamori LR, Costa Filho JE, Soto Gonzalez M, Sulzer T, Mesnard T, Huang Y, Baig MS, Oderich GS, Timaran CH. Early experience with patient-specific unibody bifurcated fenestrated-branched devices for complex endovascular aortic aneurysm repair. J Vasc Surg 2024:S0741-5214(24)01337-5. [PMID: 38897392 DOI: 10.1016/j.jvs.2024.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/09/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE Short distances between the lowest visceral/renal artery and the aortic bifurcation are technically challenging during complex endovascular aortic aneurysm repair (EVAR), particularly after previous infrarenal repair. Traditionally, inverted limb bifurcated devices have been used in addition to fenestrated-branched (FB) endografts, but short overlap, difficult cannulation, and potential crushing of bridging stents are limitations for their use. This study reviews the early experience of patient-specific company manufactured devices (PS-CMDs) with a unibody bifurcated FB design for complex EVAR. METHODS Consecutive complex EVAR procedures over a 34-month period with unibody bifurcated FB-devices as part of physician-sponsored investigational device exemption studies at two institutions were reviewed. Unibody bifurcated FB designs included FB bifurcated or fenestrated inverted limb devices. End points included technical success, survival, frequency of type I or III endoleaks, limb occlusion, and secondary interventions. RESULTS Among 168 patients undergoing complex EVAR, 33 patients (19.6%; 78.7% male; mean age, 77 years) received unibody bifurcated FB PS-CMDs. FB bifurcated and fenestrated inverted limb devices were used in 31 (93.9%) and 2 (6.06%) patients, respectively. The median maximum aneurysm diameter was 61 mm (interquartile range [IQR], 55-69 mm). Prior EVAR was reported by 29 patients (87.9%), of whom 2 (6.06%) had suprarenal stents. A short distance between the lowest renal artery and aortic bifurcation was demonstrated in 30 patients (90.9%), with median distance of 47 mm (IQR, 38-54 mm). Preloaded devices were used in 23 patients (69.7%). A total of 128 fenestrations were planned; 22 (17.2%) were preloaded with guidewires and 5 (3.9%) with catheters. The median operative time was 238 minutes (226-300 minutes), with a median fluoroscopy time of 65.5 minutes (IQR, 56.0-77.7 minutes) and a median dose area product of 147 mGy∗cm2 (IQR, 105-194 mGy∗cm2). Exclusive femoral access was used in 14 procedures (42.4%). Technical success was 100%. Target vessel primary patency was 100% at a median follow-up time of 11.7 months (IQR, 3.5-18.6 months). Two patients (6.06%) required reintervention for iliac occlusion; one patient required stenting and the other a femoral-femoral bypass. No aortic-related deaths occurred after the procedure. During follow-up, 11 type II endoleaks (33.3%) and 1 type Ib endoleak (3.03%) were detected; the latter was treated with leg extension. No type Ia or III endoleaks occurred. CONCLUSIONS Complex EVAR using unibody bifurcated FB-PS-CMDs is a simple, safe, and cost-effective alternative for the treatment of patients with short distances between the renal arteries and the aortic bifurcation. Further studies are required to assess benefits and durability of unibody bifurcated FB devices.
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Affiliation(s)
- Mira T Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Andres V Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lucas R Kanamori
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Jose Eduardo Costa Filho
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Marilisa Soto Gonzalez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Tita Sulzer
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Thomas Mesnard
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Ying Huang
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Mirza S Baig
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Gustavo S Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
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Takayama H, Hohri Y, Brinster DR, Chen EP, El-Hamamsy I, Elmously A, Derose JJ, Hisamoto K, Lau C, Okita Y, Peterson MD, Spielvogel D, Youdelman BA, Pacini D. Open, endovascular or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options. Eur J Cardiothorac Surg 2024; 65:ezae179. [PMID: 38724247 DOI: 10.1093/ejcts/ezae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 04/03/2024] [Accepted: 04/20/2024] [Indexed: 06/26/2024] Open
Abstract
OBJECTIVES The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices. METHODS In New York, we developed a collaborative group, the New York Aortic Consortium, as a means of cross-linking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature and the integration of endovascular technology into disease management. We summarized the current state of aortic arch surgery in this review article. RESULTS Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve haemostasis, simplify future operations or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Among our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and our management strategies of patients with aortic arch disease. CONCLUSIONS It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.
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Affiliation(s)
- Hiroo Takayama
- Division of Cardiac, Vascular, & Thoracic Surgery, Columbia University, New York, NY, USA
| | - Yu Hohri
- Division of Cardiac, Vascular, & Thoracic Surgery, Columbia University, New York, NY, USA
| | - Derek R Brinster
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adham Elmously
- Division of Cardiac, Vascular, & Thoracic Surgery, Columbia University, New York, NY, USA
- Department of Cardiovascular Surgery, Houston Methodist, Huston, TX, USA
| | - Joseph J Derose
- Department of Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Kazuhiro Hisamoto
- Division of Cardiac Surgery, Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki General Hospital, Takatsuki, Japan
| | - Mark D Peterson
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Benjamin A Youdelman
- Division of Cardiothoracic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Davide Pacini
- Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
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11
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Khabaz K, Kim J, Milner R, Nguyen N, Pocivavsek L. A Patient-Specific Morphoelastic Growth Model of Aortic Dissection Evolution. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.28.596335. [PMID: 38854015 PMCID: PMC11160663 DOI: 10.1101/2024.05.28.596335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
The human aorta undergoes complex morphologic changes that indicate the evolution of disease. Finite element analysis enables the prediction of aortic pathologic states, but the absence of a biomechanical understanding hinders the applicability of this computational tool. We incorporate geometric information from computed tomography angiography (CTA) imaging scans into finite element analysis (FEA) to predict a trajectory of future geometries for four aortic disease patients. Through defining a geometric correspondence between two patient scans separated in time, a patient-specific FEA model can recreate the deformation of the aorta between the two time points, showing pathologic growth drives morphologic heterogeneity. A shape-size geometric feature space plotting the variance of the shape index versus the inverse square root of aortic surface area (δ𝒮 vs. ) quantitatively demonstrates the simulated breakdown in aortic shape. An increase in δ𝒮 closely parallels the true geometric progression of aortic disease patients.
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12
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Afifi RO, Mussa FF. Navigating clinical appropriateness: A review of management strategies for type B aortic dissection. Semin Vasc Surg 2024; 37:240-248. [PMID: 39152002 DOI: 10.1053/j.semvascsurg.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 08/19/2024]
Abstract
Aortic dissection is a catastrophic, life-threatening event. Its management depends on the anatomic location of the intimal tear (type A v B) and the clinical presentation in type B aortic dissection. In this article, the current evidence supporting clinical practice, gaps in knowledge, and the need for more rigorous research and higher-quality studies are reviewed.
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Affiliation(s)
- Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, 6400 Fannin Street, Suite 2850, Houston, TX 77030.
| | - Firas F Mussa
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, 6400 Fannin Street, Suite 2850, Houston, TX 77030
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13
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Tanenbaum MT, Figueroa AV, Lee KB, Costa Filho JE, Gonzalez MS, Baig MS, Timaran CH. Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms. J Vasc Surg Cases Innov Tech 2024; 10:101467. [PMID: 38591014 PMCID: PMC10999806 DOI: 10.1016/j.jvscit.2024.101467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Objective Endovascular repair of chronic dissecting aortoiliac aneurysms is challenging given the rigid septum, compressed true lumen (TL), and target vessels frequently originating in the false lumen. We have used transcatheter electrosurgical aortic septotomy (TEAS) before stent graft implantation under intravascular ultrasound (IVUS) and fusion guidance. The purpose of this study is to assess the outcomes of TEAS during complex endovascular repair of dissecting aneurysms. Methods From 2021 to 2023, 17 patients underwent TEAS. The primary end point was technical success, with secondary end points of proximal and distal seals, target vessel instability, aortic and iliac TL and cross-sectional area (CSA) expansion, and aortic-related death. During the procedure, the aortic septum is crossed through a pre-existing entry or via electrocautery-activated 0.018-in. Astato XS20 wire (Asahi-Intecc) under IVUS and fusion guidance. The penetrated wire is then snared in the false lumen and pulled through the ipsilateral femoral access. A 1-cm length of the middle of the Astato wire coating is kinked in a three-sided polygonal configuration, denuded the inner surface of the wire using a no. 15 blade, and positioned at the apex of the septum. Both ends of the Astato wire are insulated with 0.018-in. microcatheters, and the back end of the wire is denuded and connected to cautery. Gentle traction is applied to the wire, and short bursts of electrocautery cutting are applied at 60 to 80 W. Results The technical success of the septotomy was 100%. No incidence of visceral or lower extremity malperfusion, vascular injury, or distal embolization occurred. Of the 17 patients, 4 underwent thoracic endovascular aneurysm repair, 2 underwent endovascular aortic repair, and 11 underwent fenestrated/branched endovascular aneurysm repair after septotomy. All target vessels were successfully stented. A distal landing zone seal with exclusion of the false lumen was achieved in 16 of the 17 patients (94.1%). One patient required embolization of the false lumen of the celiac artery after septotomy. The TL mean diameter and CSA of the descending thoracic aorta after septotomy was expanded by 7.01 ± 1.9 mm (relative mean diameter expansion, 42.3%; P < .0001) and 2.71 ± 0.4 cm2 (relative mean CSA expansion, 57.3%, P<.0001). For patients who required septotomy through the common iliac arteries, the mean TL was expanded by 8.1 ± 3.7 mm (relative mean diameter expansion, 76%; P < .0001) and 1.76 ± 0.91 cm2 (relative mean CSA expansion, 209%; P < .0001). The 1-year freedom from target vessel instability was 91%. Conclusions The use of IVUS and fusion-guided TEAS offers a promising technique to facilitate TL expansion and false lumen exclusion in chronic dissecting aortic aneurysms before repair. The durability and long-term outcomes of this technique in a larger cohort remain to be elucidated.
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Affiliation(s)
- Mira T. Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Andres V. Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - K. Benjamin Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jose Eduardo Costa Filho
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Marilisa Soto Gonzalez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mirza S. Baig
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H. Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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14
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Ito H, Bessho S, Shomura Y, Kato N, Kanemitsu S, Mizumoto T, Hirano K, Maze Y, Tokui T, Takao M. Long-term results of the frozen elephant trunk technique in primary chronic type B aortic dissection. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02043-9. [PMID: 38822182 DOI: 10.1007/s11748-024-02043-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/18/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES The aim of this study is to analyze long-term results of the total aortic arch replacement with the frozen elephant trunk technique for primary chronic type B aortic dissection. METHODS Among 322 patients who had the frozen elephant trunk technique, 43 (13.4%) patients (median age, 64.0 years) with primary chronic type B aortic dissection were analyzed. The patients underwent surgery at a median of 27.0 months after the onset of aortic dissection. The false lumen was patent in 30 (69.8%) patients preoperatively. RESULTS Two patients suffered paraplegia and another died of cerebral infarction. Complete thrombosis of the peri-stent false lumen was achieved in 36 (83.7%) patients. Overall survival, freedom from aortic events, and freedom from aortic reintervention were 83.5%, 37.2%, and 42.2% at 5 years, respectively. Survival rates of the patients with or without aortic events were 75.0% and 95.8% at 5 years (Log-rank, p = 0.22). Late aortic events occurred in 19 (44.2%) patients including distal stent graft-induced new entry, type Ib endoleak, and false lumen dilation. The ratio of the stent graft diameter to the preoperative short axis diameter of the true lumen (hazard ratio, 1.90; 95% confidence interval, 1.01-3.59), and the maximal diameter of a postdissection aneurysm (1.07; 1.01-1.12) were the significant multivariate risk predictors of late aortic events. CONCLUSIONS Late aortic events occurr fairly frequently, and new strategies need to be explored to enhance the effectiveness of this procedure in the future.
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Affiliation(s)
- Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Saki Bessho
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yu Shomura
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Noriyuki Kato
- Department of Radiology, Mie University Hospital, Tsu, Mie, Japan
| | - Shinji Kanemitsu
- Department of Cardiothoracic Surgery, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Toru Mizumoto
- Department of Cardiothoracic Surgery, Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Koji Hirano
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Yasumi Maze
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Toshiya Tokui
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Motoshi Takao
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
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15
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Shen X, Li J, Yan H, Zhou S, Yang S, Li W. Combined blood pressure and heart rate trajectories are associated with prognosis in critically ill patients with acute aortic dissection: A group-based multi-trajectory analysis. Heliyon 2024; 10:e29934. [PMID: 38707356 PMCID: PMC11066306 DOI: 10.1016/j.heliyon.2024.e29934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 03/16/2024] [Accepted: 04/17/2024] [Indexed: 05/07/2024] Open
Abstract
Background Managing systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) is pivotal in acute aortic dissection (AAD) care. However, no prior studies have jointly analyzed the trajectories of these parameters. This research aimed to characterize their joint longitudinal trajectories and investigate the influence on AAD prognosis. Methods We included AAD patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Using group-based multi-trajectory modeling (GBMTM), we identified combined trajectories of SBP, DBP, and HR within the initial 24 h of intensive care unit (ICU) admission. Cox proportional hazard regression, log-binomial regression, and logistic regression were employed to assess the association between trajectory groups and mortality outcomes. Results Data from 337 patients were analyzed. GBMTM identified five combined trajectory groups. Group 1 featured rapidly declining SBP and DBP with high pulse pressure and low HR; Group 2 showed high to moderate SBP with slight rebound and persistently low HR; Group 3 displayed persistently moderate BP and HR; Group 4 was characterized by moderate blood pressure with persistently high HR; and Group 5 had high to moderate SBP with slight rebound, high but gradually declining DBP, and slightly high HR. Group 3 demonstrated a lower risk of mortality, with an adjusted hazard ratio of 0.32 (95 % CI, 0.14-0.74), and the adjusted relative risks for in-hospital, 30-day, and 1-year mortalities were 0.37 (95 % CI, 0.15-0.87), 0.25 (95 % CI, 0.10-0.62), and 0.41 (95 % CI, 0.22-0.79), respectively. The time-independent C-index curve demonstrated that the multi-trajectory groups had higher C-index values than any univariate trajectory groups or admission values of SBP, DBP, and HR. Conclusions Utilization of GBMTM can yield data-driven insights to identify distinct subphenotypes in AAD patients. The combined trajectories of SBP, DBP, and HR within 24 h of ICU admission significantly influenced the mortality rate.
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Affiliation(s)
- Xuejun Shen
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
- Shantou University Medical College, Shantou, 515041, China
| | - Jufang Li
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
- Shantou University Medical College, Shantou, 515041, China
| | - Hongle Yan
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
- Shantou University Medical College, Shantou, 515041, China
| | - Shuyi Zhou
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
- Shantou University Medical College, Shantou, 515041, China
| | - Shengli Yang
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
| | - Weiping Li
- Clinical Research Center, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
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16
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Lv Z, Pan T, Zhang H, Wang Y, Matniyaz Y, Tang Y, Lu L, Wang D. Safety and efficacy of ketorolac in improving the prognosis of acute type A aortic dissection patients: a protocol of a randomized, double-blinded, and placebo-controlled study. Trials 2024; 25:250. [PMID: 38600561 PMCID: PMC11005260 DOI: 10.1186/s13063-024-08093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/03/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Acute type A aortic dissection (aTAAD) is a critical and life-threatening condition. Previous research has demonstrated that the use of ketorolac not only reduces the progression, incidence, and severity of aortic aneurysms in animal models, but also decreases postoperative mortality and complications in patients undergoing open abdominal aortic aneurysm replacement. However, there is a lack of studies investigating the efficacy of ketorolac in treating aTAAD in humans. Therefore, we conducted a study to evaluate the safety and efficacy of ketorolac in patients with aTAAD. Our hypothesis was that ketorolac treatment for aTAAD patients would meet safety indicators and effectively improve patient prognosis. METHODS/DESIGN This study is a single-center, randomized, double-blinded, and placebo-controlled study. A total of 120 patients with aTAAD will be recruited and will be randomized into the ketorolac group and placebo group with a ratio of 1:1. Ketorolac tromethamine 60 mg per 2 ml will be intramuscularly injected within 2 h before surgery, followed by intramuscular injections of 30 mg per 1 ml BID. on the first and second postoperative days in the Ketorolac group, while 0.9% saline will be administered at the same dose, dosage form, and time in the placebo group. This study aims to evaluate the safety and efficacy of ketorolac in improving the prognosis of aTAAD. The primary endpoint is the composite endpoint event concerning drug-related adverse events. Secondary endpoints include drug-related adverse events, laboratory examination of blood, diagnostic imaging tests, clinical biomarkers, etc. DISCUSSION: This study has been approved by the Medical Ethics Committee of Affiliated Nanjing Drum Tower Hospital, Nanjing University Medical College (approval number: 2023-197-02). This study is designed to evaluate the safety and efficacy of ketorolac in patients with aTAAD. All participating patients will sign an informed consent form, and the trial results will be published in international peer-reviewed journals. TRIAL REGISTRATION The Chinese Clinical Trial Registry ( http://www.chictr.org.cn ) ChiCTR2300074394. Registered on 4 October 2023.
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Affiliation(s)
- Zhikang Lv
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Tuo Pan
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, China
| | - Haitao Zhang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, China
| | - Yapeng Wang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, China
| | - Yusanjian Matniyaz
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yuxian Tang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Lichong Lu
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
| | - Dongjin Wang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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17
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Coleman NAM, Folson AA, Bekui MA, Owusu B. A rare presentation of triple-barrel aortic dissection in a Ghanaian male. Clin Case Rep 2024; 12:e8708. [PMID: 38566980 PMCID: PMC10985938 DOI: 10.1002/ccr3.8708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/02/2024] [Accepted: 02/25/2024] [Indexed: 04/04/2024] Open
Abstract
Acute aortic dissection in unusual/rare circumstances may become chronic and multi lumen. A high clinical acumen, examination and investigations in the acute setting, may help reduce late/misdiagnosis and complications in low resource settings.
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Affiliation(s)
| | - Aba A. Folson
- Department of Internal Medicine and Therapeutics, School of MedicineUniversity of Health and Allied SciencesHoGhana
| | | | - Bennett Owusu
- Department of Internal MedicineHo Teaching HospitalHoGhana
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18
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Lee H, Zhou Q, Zhang H, Jin M, Tang X, Li K, Tuoerxun T. Computed Tomography Scan of the Aorta to Predict Type B Aortic Dissection. Thorac Cardiovasc Surg 2024; 72:126-133. [PMID: 37137329 PMCID: PMC10914493 DOI: 10.1055/s-0043-57026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND The purpose of this study is to find the high-risk morphological features in type B aortic dissection (TBAD) population and to establish an early detection model. METHODS From June 2018 to February 2022, 234 patients came to our hospital because of chest pain. After examination and definite diagnosis, we excluded people with previous cardiovascular surgery history, connective tissue disease, aortic arch variation, valve malformation, and traumatic dissection. Finally, we included 49 patients in the TBAD group and 57 in the control group. The imaging data were retrospectively analyzed by Endosize (Therevna 3.1.40) software. The aortic morphological parameters mainly include diameter, length, direct distance, and tortuosity index. Multivariable logistic regression models were performed and systolic blood pressure (SBP), aortic diameter at the left common carotid artery (D3), and length of ascending aorta (L1) were chosen to build a model. The predictive capacity of the models was evaluated through the receiver operating characteristic (ROC) curve analysis. RESULTS The diameters in the ascending aorta and aortic arch are larger in the TBAD group (33.9 ± 5.9 vs. 37.8 ± 4.9 mm, p < 0.001; 28.2 ± 3.9 vs. 31.7 ± 3.0 mm, p < 0.001). The ascending aorta was significantly longer in the TBAD group (80.3 ± 11.7 vs. 92.3 ± 10.6 mm, p < 0.001). Besides, the direct distance and tortuosity index of the ascending aorta in the TBAD group increased significantly (69.8 ± 9.0 vs. 78.7 ± 8.8 mm, p < 0.001; 1.15 ± 0.05 vs. 1.17 ± 0.06, p < 0.05). Multivariable models demonstrated that SBP, aortic diameter at the left common carotid artery (D3), and length of ascending aorta (L1) were independent predictors of TBAD occurrence. Based on the ROC analysis, area under the ROC curve of the risk prediction models was 0.831. CONCLUSION Morphological characteristic including diameter of total aorta, length of ascending aorta, direct distance of ascending aorta, and tortuosity index of ascending aorta are valuable geometric risk factors. Our model shows a good performance in predicting the incidence of TBAD.
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Affiliation(s)
- Han Lee
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, Jiangsu, China
| | - Haitao Zhang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Min Jin
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - XinLong Tang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Kai Li
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Tayierjiang Tuoerxun
- Department of Cardiothoracic Surgery, Nanjing University, Nanjing, Jiangsu, China
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19
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Khabaz K, Yuan K, Pugar J, Jiang D, Sankary S, Dhara S, Kim J, Kang J, Nguyen N, Cao K, Washburn N, Bohr N, Lee CJ, Kindlmann G, Milner R, Pocivavsek L. The geometric evolution of aortic dissections: Predicting surgical success using fluctuations in integrated Gaussian curvature. PLoS Comput Biol 2024; 20:e1011815. [PMID: 38306397 PMCID: PMC10866512 DOI: 10.1371/journal.pcbi.1011815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/14/2024] [Accepted: 01/09/2024] [Indexed: 02/04/2024] Open
Abstract
Clinical imaging modalities are a mainstay of modern disease management, but the full utilization of imaging-based data remains elusive. Aortic disease is defined by anatomic scalars quantifying aortic size, even though aortic disease progression initiates complex shape changes. We present an imaging-based geometric descriptor, inspired by fundamental ideas from topology and soft-matter physics that captures dynamic shape evolution. The aorta is reduced to a two-dimensional mathematical surface in space whose geometry is fully characterized by the local principal curvatures. Disease causes deviation from the smooth bent cylindrical shape of normal aortas, leading to a family of highly heterogeneous surfaces of varying shapes and sizes. To deconvolute changes in shape from size, the shape is characterized using integrated Gaussian curvature or total curvature. The fluctuation in total curvature (δK) across aortic surfaces captures heterogeneous morphologic evolution by characterizing local shape changes. We discover that aortic morphology evolves with a power-law defined behavior with rapidly increasing δK forming the hallmark of aortic disease. Divergent δK is seen for highly diseased aortas indicative of impending topologic catastrophe or aortic rupture. We also show that aortic size (surface area or enclosed aortic volume) scales as a generalized cylinder for all shapes. Classification accuracy for predicting aortic disease state (normal, diseased with successful surgery, and diseased with failed surgical outcomes) is 92.8±1.7%. The analysis of δK can be applied on any three-dimensional geometric structure and thus may be extended to other clinical problems of characterizing disease through captured anatomic changes.
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Affiliation(s)
- Kameel Khabaz
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Karen Yuan
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Joseph Pugar
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
- Departments of Material Science and Engineering, Biomedical Engineering, and Chemistry, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - David Jiang
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Seth Sankary
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Sanjeev Dhara
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Junsung Kim
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Janet Kang
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Nhung Nguyen
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Kathleen Cao
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Newell Washburn
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Nicole Bohr
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Cheong Jun Lee
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, United States of America
| | - Gordon Kindlmann
- Department of Computer Science, The University of Chicago, Chicago, Illinois, United States of America
| | - Ross Milner
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
| | - Luka Pocivavsek
- Department of Surgery, The University of Chicago, Chicago, Illinois, United States of America
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20
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Nooromid M, Creisher BA, Abai B. Treatment of Uncomplicated Type B Aortic Dissection: Optimal Medical Therapy vs TEVAR + Optimal Medical Therapy. Vasc Endovascular Surg 2024; 58:115-122. [PMID: 37365809 DOI: 10.1177/15385744231184671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Optimal Medical Therapy (OMT) has been the accepted mode of treatment for uncomplicated Type B Aortic Dissection (uTBAD). There is growing evidence that despite the short-term benefits of OMT, patients suffer deleterious consequences in the long-term with OMT alone. Thoracic Endovascular Aortic Repair (TEVAR) along with OMT has emerged as an alternative option for patients with uTBAD. This study evaluates the available literature for TEVAR + OMT as an alternative to OMT for treatment of uTBAD. In addition, issues related to TEVAR as a treatment for uTBAD are discussed.
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Affiliation(s)
- Michael Nooromid
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Brandon A Creisher
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Babak Abai
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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21
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Tang QH, Chen J, Long Z, Su XA, Wang YL, Qiu JY, Qin Z, Yang H, Li Q, Hu M, Qin X. Long-term survival and risk analysis of thoracic endovascular aortic repair for type B aortic dissection. iScience 2023; 26:108359. [PMID: 38034350 PMCID: PMC10682288 DOI: 10.1016/j.isci.2023.108359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/26/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023] Open
Abstract
To explore the safety and efficacy of thoracic endovascular aortic repair (TEVAR) in the treatment of patients with type B aortic dissection, and to evaluate the risk factors for long-term mortality. Our study retrospectively evaluated 729 patients with type B aortic dissection, who were divided into the thoracic endovascular aortic repair group and the optimal medical treatment group according to their treatment. In-hospital mortality, death within 30 days, and aortic-related mortality were lower in the thoracic endovascular aortic repair group than in the optimal medical treatment group (p < 0.05). The cumulative overall survival rates for the thoracic endovascular aortic repair group at 1 year, 5 years, and 10 years were 92.5%, 84.1%, and 73.5%, respectively. The Cox analysis found that TEVAR was beneficial in reducing mortality and that a vertical length of the dissection exceeding 150 mm was a risk factor for mortality.
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Affiliation(s)
- Qian-hui Tang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Jing Chen
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Zhen Long
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Xuan-an Su
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Yu-Lin Wang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Jian-ye Qiu
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Zhong Qin
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Han Yang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Que Li
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Ming Hu
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Xiao Qin
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
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22
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Zhou Z, Zhou M, Ding Y, Li X, Wang Y, Xie T, Shi Z. Endovascular treatment of type B aortic dissection in patients with end-stage renal disease. Vascular 2023; 31:1043-1050. [PMID: 35791091 DOI: 10.1177/17085381221112550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study aimed to evaluate the postoperative and intermediate outcomes of thoracic endovascular aortic repair (TEVAR) in patients with end-stage renal disease (ESRD). METHODS We retrospectively reviewed patients with type B aortic dissection (TBAD) undergoing TEVAR at our single center from January 2010 to December 2020. Patients with pre-existing ESRD were enrolled as the study group. One hundred consecutive patients from September 2013 to March 2015 without ESRD were included as the control group. The primary and secondary outcomes were adverse events and survival, respectively. Kaplan-Meier curves of survival and freedom from adverse events were calculated and analyzed using the log-rank univariate test. Multivariable analysis was used to isolate the effects of ESRD. RESULTS A total of 39 patients with ESRD and TBAD underwent TEVAR during the study period. The median follow-up time of patients with and without ESRD was 45 and 46 months, respectively. There was significant difference between the survival at 4 years of patients with and without ESRD (72.8% vs 94.9%; p = 0.011). Meanwhile, the incidence of adverse events was significantly higher in patients with ESRD (p = 0.026). Multivariable logistic regression analysis showed that ESRD (OR, 2.46; p = 0.049) and peripheral artery disease (OR, 4.11; p = 0.002) were the predictors of adverse events. CONCLUSIONS The rates of adverse events and survival expectancy were poor in patients with ESRD and TBAD.
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Affiliation(s)
- Zhenyu Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Min Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yong Ding
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xu Li
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yonggang Wang
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Tianchen Xie
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
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23
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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24
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Ribieras AJ, Challa AS, Kang N, Kenel-Pierre S, Rey J, Velazquez OC, Milner R, Bornak A. Race-based outcomes of thoracic aortic aneurysms and dissections in the Global Registry for Endovascular Aortic Treatment. J Vasc Surg 2023; 78:1190-1197.e2. [PMID: 37454953 DOI: 10.1016/j.jvs.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/01/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE This study characterizes racial differences in presentation, as well as short- and long-term outcomes after endovascular treatment of thoracic aortic aneurysm (TAA) and type B aortic dissection (TBAD). METHODS We queried the Gore Global Registry for Endovascular Aortic Treatment for thoracic endovascular aortic repairs (TEVARs) performed between 2010 and 2016 and followed through 2022. Pathologies represented were descending TAA, complicated TBAD, and uncomplicated TBAD. Using standard statistical tests, we compared overall and pathology-specific demographics, procedural factors, and outcomes among Black and White patients undergoing TEVAR. RESULTS We identified 438 TEVAR cases, including 236 descending TAA, 121 complicated TBAD, and 74 uncomplicated TBAD. Overall, Black patients were younger and had a higher incidence of renal insufficiency (P = .001), whereas White patients had more chronic obstructive pulmonary disease (P = .003) and cardiac arrhythmias (P = .037). In patients treated for descending TAA, Black patients had increased device- and procedure-related complications (34.3% vs 17.4%; P = .014), conversion to open repair (2.9% vs 0%; P = .011) and type II endoleak (5.7% vs 1.0%; P = .040), but no differences in mortality, length of hospital stay, or major adverse cardiovascular events. Whereas outcomes of TEVAR for uncomplicated TBAD were comparable, Black patients more frequently presented with complicated TBAD than White patients (Black, 40.5% vs White, 24.8%; P = .008) and had subsequently greater reintervention rates (28.1% vs 12.4%; P = .012), all-cause mortality (hazard ratio, 4.28; 95% confidence interval, 1.74-10.5; P = .002) and aortic-related mortality (hazard ratio, 16.7; 95% confidence interval, 1.49-186; P = .022). CONCLUSIONS Despite increased device- and procedure-related complications, similar short- and long-term outcomes are achieved in Black and White patients undergoing TEVAR for descending TAA and uncomplicated TBAD. However, Black patients are more likely to present with, require reintervention for, and suffer mortality from complicated TBAD.
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Affiliation(s)
- Antoine J Ribieras
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Akshara S Challa
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Naixin Kang
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Stefan Kenel-Pierre
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Jorge Rey
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Omaida C Velazquez
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Ross Milner
- Division of Vascular Surgery and Endovascular Therapy, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Arash Bornak
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL.
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25
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Hui DS, Chen EP, DeAnda A, Girardi LN, Kim KM, Woo YJ, Tseng EE, Preventza O. Perspectives on the 2022 joint guidelines on the diagnosis and management of aortic disease. J Thorac Cardiovasc Surg 2023; 166:1413-1417. [PMID: 37543165 DOI: 10.1016/j.jtcvs.2023.07.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Dawn S Hui
- Department of Cardiothoracic Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Tex.
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Abe DeAnda
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, The University of Texas Medical Branch-Galveston, Galveston, Tex
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Tex
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Elaine E Tseng
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, Calif
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
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26
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Shijo T, Shimamura K, Maeda K, Yamashita K, Ide T, Yamana F, Takahara M, Kuratani T, Miyagawa S. Clinical Outcomes and Factors Associated With Aortic Shrinkage After Thoracic Endovascular Aortic Repair for Aneurysmal Chronic Aortic Dissection. J Endovasc Ther 2023:15266028231206993. [PMID: 37882164 DOI: 10.1177/15266028231206993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
PURPOSE The effectiveness of thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection (AD) with aneurysmal degeneration remains controversial. We retrospectively investigated clinical outcomes and assessed predictors of aortic shrinkage after TEVAR for chronic aneurysmal AD. MATERIALS AND METHODS Between January 2010 and December 2021, 70 patients with double-barrel-type chronic AD were enrolled. Major intimal tears in thoracic aorta were covered by stent graft. Early and late clinical outcomes, and diameter change of downstream aorta during follow-up period were reviewed. Subsequently, factors associated with aortic shrinkage were assessed by logistic regression analysis. RESULTS Mean age was 63 (interquartile range [IQR]: 54-68) years, 54 (80%) men, median duration from AD onset was 4 (IQR: 1-10) years, and maximum aortic diameter was 53 (IQR: 49-58) mm. Supra-aortic debranching procedure was required in 57 (81%) patients. Early aorta-related death occurred in 2 (3%) patients. Both stroke and spinal cord ischemia occurred in 1 (2%) patient. Five-year freedom rates from aorta-related death and reintervention were 96% and 51%, respectively. Sixty-four patients underwent follow-up computed tomography (84%) 1 year after TEVAR, with 33 (52%) achieving aortic shrinkage. In multivariable analysis, duration from AD onset (per year) (odds ratio [OR]: 0.82, 0.70-0.97; p=0.017) and maximum aortic-diameter ratio between aortic arch and descending aorta (per 0.1) (morphologic index; OR: 1.34, 1.04-1.74; p=0.023) were independent aortic shrinkage predictors. CONCLUSIONS Thoracic endovascular aortic repair for chronic AD with aneurysmal degeneration achieved satisfactory survival outcomes, but with a considerable reintervention rate. Duration from AD onset and preoperative aortic morphology could affect post-TEVAR aortic shrinkage. Earlier intervention could lead to better aortic shrinkage. CLINICAL IMPACT Thoracic endovascular aortic repair for chronic aortic dissection with aneurysmal degeneration showed low incidence of early and late aorta-related death. By contrast, aortic shrinkage rate was low with high incidence of reintervention to the residual downstream aorta. According to the assessment of preoperative variables, chronicity and aortic morphology could predict postoperative aortic shrinkage.
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Affiliation(s)
- Takayuki Shijo
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Koichi Maeda
- Department of Minimally Invasive Cardiovascular Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kizuku Yamashita
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Toru Ide
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Fumio Yamana
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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27
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Coselli JS, Barron LM. Lifetime Aortic Management in Marfan Syndrome: Puzzle Pieces and Rare Diseases. J Am Coll Cardiol 2023; 82:1077-1079. [PMID: 37673509 DOI: 10.1016/j.jacc.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA.
| | - Lauren M Barron
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
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28
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Lau C, Soletti GJ, Lawrence KM, Rahouma M, Iannacone E, Gambardella I, Gaudino M, Girardi LN. Contemporary outcomes of open repair of acute complicated type B aortic dissection. J Vasc Surg 2023; 78:593-601.e4. [PMID: 37211141 DOI: 10.1016/j.jvs.2023.04.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Open repair of acute complicated type B aortic dissection (ACTBAD), required when endovascular repair is not possible, is historically considered high-risk. We analyze our experience with this high-risk cohort compared with the standard cohort. METHODS We identified consecutive patients undergoing descending thoracic or thoracoabdominal aortic aneurysm (TAAA) repair from 1997 to 2021. Patients with ACTBAD were compared with those having surgery for other reasons. Logistic regression was used to identify associations with major adverse events (MAEs). Five-year survival and competing risk of reintervention were calculated. RESULTS Of 926 patients, 75 (8.1%) had ACTBAD. Indications included rupture (25/75), malperfusion (11/75), rapid expansion (26/75), recurrent pain (12/75), large aneurysm (5/75), and uncontrolled hypertension (1/75). The incidence of MAEs was similar (13.3% [10/75] vs 13.7% [117/851], P = .99). Operative mortality was 5.3% (4/75) vs 4.8% (41/851) (P = .99). Complications included tracheostomy (8%, 6/75), spinal cord ischemia (4%, 3/75), and new dialysis (2.7%, 2/75). Renal impairment, urgent/emergent operation, forced expiratory volume in 1 second ≤50%, and malperfusion were associated with MAEs, but not ACTBAD (odds ratio: 0.48, 95% confidence interval [CI]: [0.20-1.16], P = .1). At 5 and 10 years, there was no difference in survival (65.8% [95% CI: 54.6-79.2] vs 71.3% [95% CI: 67.9-74.9], P = .42, and 47.3% [95% CI: 34.5-64.7] vs 53.7% [95% CI: 49.3-58.4], P = .29, respectively) or 10-year reintervention (12.5% [95% CI: 4.3-25.3] vs 7.1% [95% CI: 4.7-10.1], P = .17, respectively). CONCLUSIONS In an experienced center, open repair of ACTBAD can be performed with low rates of operative mortality and morbidity. Outcomes similar to elective repair are achievable even in high-risk patients with ACTBAD. In patients unsuitable for endovascular repair, transfer to a high-volume center experienced in open repair should be considered.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | | | - Kendall M Lawrence
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Erin Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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29
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Xiang J, Zhang K, Pen T, Wei S. Surgical treatment of acute type B aortic dissection concomitant with retrograde type A intramural hematoma and giant abdominal aortic aneurysm. Asian J Surg 2023; 46:3999-4000. [PMID: 37085415 DOI: 10.1016/j.asjsur.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/06/2023] [Indexed: 04/23/2023] Open
Affiliation(s)
- Jun Xiang
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, P.R. 637000, China
| | - Keping Zhang
- Department of Thoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, P.R. 637000, China
| | - Tailuan Pen
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, P.R. 637000, China
| | - Shuliang Wei
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, P.R. 637000, China.
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30
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Li X, Song C, Zhang L, Yuan L, Dai X, Guo L, Lu Q. A Chinese expert consensus on thoracic endovascular aortic repair of type B aortic dissection with a single-branched stent graft for revascularization of the left subclavian artery. Front Surg 2023; 10:1230334. [PMID: 37663391 PMCID: PMC10469751 DOI: 10.3389/fsurg.2023.1230334] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/21/2023] [Indexed: 09/05/2023] Open
Abstract
Thoracic endovascular repair (TEVAR) is currently the recommended and most widely used treatment for type B aortic dissection. A major challenge is revascularization of the left subclavian artery in order to extend the landing zone to zone 2 (Ishimaru classification). Various strategies have been used for revascularization, including branched stent graft, fenestrated stent graft, the chimney technique, the parallel technique, and bypass surgery. Single-branched stent graft is one of the most promising strategies, and several products have recently been reported as potential candidates for use with this approach. The Castor single-branched stent graft is the only off-the-shelf product available; this product has been developed through collaboration between Chinese corporations and clinicians. In this Perspective article, clinical experience and data obtained from TEVAR with the Castor single-branched stent graft are summarized by experienced Chinese experts.
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Affiliation(s)
- Xiaoye Li
- Department of Vascular Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Chao Song
- Department of Vascular Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Lei Zhang
- Department of Vascular Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Liangxi Yuan
- Department of Vascular Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xiangchen Dai
- Department of Vascular Surgery, General Hospital, Tianjin Medical University, Tianjin, China
| | - Lianrui Guo
- Department of Vascular Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Qingsheng Lu
- Department of Vascular Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
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Clouse WD. Breaking the Rules About Endovascular Aortic Intervention and Connective Tissue Disease. JAMA Surg 2023; 158:840. [PMID: 37314768 DOI: 10.1001/jamasurg.2023.2134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville
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Tang QH, Chen J, Yang H, Qin Z, Lin QN, Qin X. Factors Affecting False Lumen Thrombosis In Type B Aortic Dissection. Arq Bras Cardiol 2023; 120:e20220939. [PMID: 37531471 PMCID: PMC10374264 DOI: 10.36660/abc.20220939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/22/2023] [Accepted: 05/17/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Complete thrombosis of the false lumen facilitates remodeling of type B aortic dissection (TBAD). Morphological characteristics affect thrombosis in the false lumen. OBJECTIVES Discuss the factors present before admission that influence false lumen thrombosis in patients with TBAD. METHODS We studied 282 patients diagnosed with TBAD in our hospital between January 2008 and December 2017. We divided the subjects into a thrombotic group and a non-thrombotic group based on whether any thrombus was detectable in the false lumen. We analyzed the differences between the two groups with respect to clinical data, the vertical length of the dissection, and the diameter of the aorta. P values < 0.05 were considered statistically significantly different. RESULTS Significant differences between the thrombotic group and non-thrombotic group were found with respect to age (53.92 ± 11.40 vs. 50.36 ± 10.71, p = 0.009) and proportion of patients with renal insufficiency (7.83% vs. 16.38%, p = 0.026). In zones 3-9, the true lumen diameter of the thrombotic group was significantly larger than in the non-thrombotic group (p < 0.05). Binary logistic regression analysis showed that true lumen diameter in zone 5 and renal insufficiency were independent predictors of false lumen thrombosis. CONCLUSIONS Age and renal function were associated with thrombosis in the false lumen. Potentially, the difference between the diameter of the true lumen diameter and that of the false lumen may influence the thrombosis of the false lumen.
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Affiliation(s)
- Qian-hui Tang
- Department of Vascular and Endovascular SurgeryThe First Affiliated HospitalGuangxi Medical UniversityGuangxiChinaDepartment of Vascular and Endovascular Surgery – The First Affiliated Hospital of Guangxi Medical University, Guangxi – China
| | - Jing Chen
- Department of Vascular and Endovascular SurgeryThe First Affiliated HospitalGuangxi Medical UniversityGuangxiChinaDepartment of Vascular and Endovascular Surgery – The First Affiliated Hospital of Guangxi Medical University, Guangxi – China
| | - Han Yang
- Department of Vascular and Endovascular SurgeryThe First Affiliated HospitalGuangxi Medical UniversityGuangxiChinaDepartment of Vascular and Endovascular Surgery – The First Affiliated Hospital of Guangxi Medical University, Guangxi – China
| | - Zhong Qin
- Department of Vascular and Endovascular SurgeryThe First Affiliated HospitalGuangxi Medical UniversityGuangxiChinaDepartment of Vascular and Endovascular Surgery – The First Affiliated Hospital of Guangxi Medical University, Guangxi – China
| | - Qiu-ning Lin
- Department of Vascular and Endovascular SurgeryThe First Affiliated HospitalGuangxi Medical UniversityGuangxiChinaDepartment of Vascular and Endovascular Surgery – The First Affiliated Hospital of Guangxi Medical University, Guangxi – China
| | - Xiao Qin
- Department of Vascular and Endovascular SurgeryThe First Affiliated HospitalGuangxi Medical UniversityGuangxiChinaDepartment of Vascular and Endovascular Surgery – The First Affiliated Hospital of Guangxi Medical University, Guangxi – China
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Yildiz M, Nucera M, Jungi S, Heinisch PP, Mosbahi S, Becker D, Siepe M, Schoenhoff F. Outcome of Stanford type B dissection in patients with Marfan syndrome. Eur J Cardiothorac Surg 2023; 64:ezad178. [PMID: 37129561 DOI: 10.1093/ejcts/ezad178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 04/19/2023] [Accepted: 04/28/2023] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVES The aim of this study was to determine the outcome of Stanford type B aortic dissection in patients with Marfan syndrome (MFS) and to evaluate aortic diameters at time of dissection as well as the impact of previous aortic root replacement. METHODS Analysis of all patients with MFS fulfilling Ghent criteria seen at this institution since 1995 until 2022. RESULTS Thirty-six (19%) out of 188 patients with MFS suffered from Stanford type B aortic dissection during the study period. The Mean aortic diameter at the time of dissection was 39.0 mm [95% confidence interval (CI): 35.6-42.3]. The mean pre-dissection diameter (available in 25% of patients) was 32.1 mm (95% CI: 28.0-36.3) and the mean expansion was 19% (95% CI: 11.9-26.2). There was no correlation between age and diameter at the time of dissection (<20, 21-30, 31-40, 41-50, 51-60, <61 years; P = 0.78). Freedom from intervention after dissection was 53%, 44% and 33% at 1, 5 and 10 years. Aortic growth rate in those patients that had to undergo intervention within the 1st year after dissection was 10.2 mm/year (95% CI: 4.4-15.9) compared to 5.8 mm/year (95% CI: 3.3-8.3, P = 0.109) in those thereafter. The mean time between dissection and intervention was 1.8 years (95% CI: 0.6-3.0). While type B dissection seems more frequent after previous elective aortic repair (58% vs 42%), there was no difference between valve-sparing root replacement (VSRR) compared to Bentall procedures [Hazard ratio (HR) for VSRR 0.78, 95% CI: 0.31-2.0, P-value = 0.61]. The mean age of the entire population at the end of follow-up was 42 years (95% CI: 39.2-44.7). The mean follow-up time was 9 years (95% CI: 7.8-10.4). CONCLUSIONS Stanford type B dissection in patients with MFS occurs far below accepted thresholds for intervention. Risk for type B dissection is present throughout lifetime and two-thirds of patients need an intervention after dissection. There is no difference in freedom from type B dissection between a Bentall procedure and a VSRR.
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Affiliation(s)
- Murat Yildiz
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Maria Nucera
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Silvan Jungi
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Paul Philipp Heinisch
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Selim Mosbahi
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Daniel Becker
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Matthias Siepe
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Florian Schoenhoff
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
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Muller M, Yau P, Pham A, Lipsitz EC, DeRose JJ, Cho JS, Shariff S, Indes JE. A comparison of endovascular repair to medical management for acute vs subacute uncomplicated type B aortic dissections. J Vasc Surg 2023; 78:53-60. [PMID: 36889606 DOI: 10.1016/j.jvs.2023.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 03/08/2023]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has emerged as a viable option of treatment for uncomplicated type B aortic dissection (UTBAD) due to the potential for inducing favorable aortic remodeling. The aim of this study is to compare outcomes of UTBAD treated medically or with TEVAR in either the acute (1 to 14 days) or subacute period (2 weeks to 3 months). METHODS Patients with UTBAD between 2007 and 2019 were identified using the TriNetX Network. The cohort was stratified by treatment type (medical management; TEVAR during the acute period; TEVAR during the subacute period). Outcomes including mortality, endovascular reintervention, and rupture were analyzed after propensity matching. RESULTS Among 20,376 patients with UTBAD, 18,840 were medically managed (92.5%), 1099 patients were in the acute TEVAR group (5.4%), and 437 patients were in the subacute TEVAR group (2.1%). The acute TEVAR group had higher rates of 30-day and 3-year rupture (4.1% vs 1.5%; P < .001; 9.9% vs 3.6%; P < .001) and 3-year endovascular reintervention (7.6% vs 1.6%; P < .001), similar 30-day mortality (4.4% vs 2.9%; P < .068), and lower 3-year survival compared with medical management (86.6% vs 83.3%; P = .041). The subacute TEVAR group had similar rates of 30-day mortality (2.3% vs 2.3%; P = 1), 3-year survival (87.0% vs 88.8%; P = .377) and 30-day and 3-year rupture (2.3% vs 2.3%; P = 1; 4.6% vs 3.4%; P = .388), with significantly higher rates of 3-year endovascular reintervention (12.6% vs 7.8%; P = .019) compared with medical management. The acute TEVAR group had similar rates of 30-day mortality (4.2% vs 2.5%; P = .171), rupture (3.0% vs 2.5%; P = .666), significantly higher rates of 3-year rupture (8.7% vs 3.5%; P = .002), and similar rates of 3-year endovascular reintervention (12.6% vs 10.6%; P = .380) compared with the subacute TEVAR group. There was significantly higher 3-year survival (88.5% vs 84.0%; P = .039) in the subacute TEVAR group compared with the acute TEVAR group. CONCLUSIONS Our results found lower 3-year survival in the acute TEVAR group compared with the medical management group. There was no 3-year survival benefit found in patients with UTBAD who underwent subacute TEVAR compared with medical management. This suggests the need for further studies looking at the necessity for TEVAR when compared with medical management for UTBAD as it is non-inferior to medical management. Higher rates of 3-year survival and lower rates of 3-year rupture in the subacute TEVAR group compared with the acute TEVAR group suggest superiority of subacute TEVAR. Further investigations are needed to determine the long-term benefit and optimal timing of TEVAR for acute UTBAD.
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Affiliation(s)
- Matthew Muller
- Department of Vascular and Endovascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY.
| | - Patricia Yau
- Department of Vascular and Endovascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Antoine Pham
- Department of Vascular and Endovascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Evan C Lipsitz
- Department of Vascular and Endovascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Joseph J DeRose
- Department of Cardiothoracic Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Jae S Cho
- Department of Vascular Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Saadat Shariff
- Department of Vascular and Endovascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Jeffrey E Indes
- Department of Vascular and Endovascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
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Dai Y, Wu Z, Zhang X, Cai Y, Ji S, Lin J, Li L, Lin Y, Guo P, Cai F, Hou X, Zhang J. STOP-Bang Questionnaire Is Associated With Aortic Remodeling in Patients With Acute Type B Aortic Dissection Undergoing Standard Thoracic Endovascular Aortic Repair. J Endovasc Ther 2023:15266028231179425. [PMID: 37300399 DOI: 10.1177/15266028231179425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE To determine whether the STOP-Bang questionnaire, which is a tool for evaluating obstructive sleep apnea, is associated with aortic remodeling after thoracic endovascular aortic repair (TEVAR) in patients with type B aortic dissection (TBAD). METHODS Patients with TBAD who underwent standard TEVAR at our center from January 2015 to December 2020 were enrolled. For the included patients, we recorded baseline characteristics, comorbidities, preoperative computed tomographic angiography findings, procedure details, and complications. The STOP-Bang questionnaire was administered to each patient. Total scores comprised points for 4 yes/no questions and 4 clinical measurements. STOP-Bang ≥5 and STOP-Bang <5 groups were then created using the STOP-Bang total scores. We evaluated aortic remodeling 1 year after discharge and the reintervention rate, as well as false lumen complete thrombosis (FLCT) and non-FLCT length. RESULTS Fifty-five patients were enrolled in the study; STOP-Bang <5, n=36, and STOP-Bang ≥5, n=19. Compared with the STOP-Bang ≥5 group, the STOP-Bang <5 group achieved statistically significantly higher descending aorta positive aortic remodeling (PAR) rates in zones 3 to 5 (zone 3: p=0.002; zone 4: p=0.039; zone 5: p=0.023), higher total descending aorta-PAR rate (66.7% vs 36.8%, respectively; p=0.004), and lower reintervention rate (8.1% vs 38.9%, respectively; p=0.005). In the logistic regression analysis, STOP-Bang ≥5 had an odds ratio of 0.12 (95% confidence interval: 0.03-0.58; p=0.008). There was no significant difference in overall survival between the groups. CONCLUSION STOP-Bang questionnaire scores were associated with aortic remodeling after TEVAR in patients with TBAD. Increasing the frequency of surveillance after TEVAR might be beneficial in these patients. CLINICAL IMPACT We analysed aortic remodelling 1 year after thoracic endovascular aortic repair (TEVAR) in acute type B aortic dissection (TBAD) patients with STOP-Bang < 5 and STOP-Bang ≥ 5. Aortic remodelling was better, and the reintervention rate was higher in patients with STOP-Bang < 5 compared with patients with STOP-Bang ≥ 5. In patients with STOP-Bang ≥ 5, aortic remodelling was worse in zones 3-5 compared with zones 6-9. This study suggests that the STOP-Bang questionnaire results is associated with aortic remodelling after TEVAR in patients with TBAD.
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Affiliation(s)
- Yiquan Dai
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhiye Wu
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xunliang Zhang
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yihang Cai
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shiping Ji
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jie Lin
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Luyao Li
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yichen Lin
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Pingfan Guo
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Fanggang Cai
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xinhuang Hou
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jinchi Zhang
- Departments of Vascular and Endovascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Tang QH, Chen J, Long Z, Wang YL, Su XA, Qiu JY, Lin QN, Zhang JF, Qin X. Factors affecting distal false lumen enlargement after thoracic endovascular aortic repair for type B aortic dissection. Heliyon 2023; 9:e17248. [PMID: 37383200 PMCID: PMC10293708 DOI: 10.1016/j.heliyon.2023.e17248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023] Open
Abstract
Objective To investigate the factors influencing distal false lumen enlargement after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. Materials and methods Data were collected on patients with type B aortic dissection who underwent TEVAR from January 2008 to August 2022. Patients were divided into a distal aortic segmental enlargement (DSAE) group and a non-DSAE group based on whether the distal false lumen was dilated more than 5 mm on computed tomographic angiography (CTA) images. To analyze the independent influences on distal false lumen dilatation after TEVAR, the variables with a P value < 0.05 during univariate analysis were included in the binary logistic regression analysis model. Results A total of 335 patients were included in this study, with 85 in the DSAE group and 250 in the non-DSAE group. The mean age was 52.40 ± 11.34 years, 289 (86.27%) were male patients, and the median follow-up time was 6.41 (11.99-29.99) months. There were significant differences in Marfan syndrome, chronic obstructive pulmonary disease (COPD), and follow-up time between the two groups. In terms of morphology, there were statistically significant differences in the number of tears, the size of the primary tear, and the length of dissection between the two groups. Binary logistic regression analysis indicated that Marfan syndrome, COPD, and the primary tear size were associated with distal false lumen dilatation. Conclusions Marfan syndrome, COPD, and the primary tear size influence distal aortic segmental enlargement after TEVAR in type B aortic dissection patients.
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Dong Z, Yang H, Li G, Xu X, Liu H, Gu J, Li M, Gu W, Shao Y, Ni B. Preoperative Predictors of Late Aortic Expansion in Acute Type B Aortic Dissection Treated with TEVAR. J Clin Med 2023; 12:jcm12082826. [PMID: 37109163 PMCID: PMC10141654 DOI: 10.3390/jcm12082826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/10/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND A patent false lumen (FL) in patients with thoracic endovascular aortic repair (TEVAR)-treated type B aortic dissection (TBAD) can cause a significant risk for late aortic expansion (LAE). We hypothesize that preoperative features can predict the occurrence of LAE. METHODS Sufficient preoperative and postoperative follow-up clinical and imaging feature data for patients treated with TEVAR in the First Affiliated Hospital of Nanjing Medical University from January 2018 to December 2020 were collected. A univariate analysis and multivariable logistic regression analysis were used to find potential risk factors of LAE. RESULTS Ninety-six patients were finally included in this study. The mean age was 54.5 ± 11.7 years and 85 (88.5%) were male. LAE occurred in 15 (15.6%) of 96 patients after TEVAR. Two preoperative factors showed strong associations with LAE according to the multivariable logistic regression analysis: preoperative partial thrombosis of the FL (OR = 10.989 [2.295-48.403]; p = 0.002) and the maximum descending aortic diameter (OR = 1.385 [1.100-1.743] per mm increase; p = 0.006). CONCLUSIONS Preoperative partial thrombosis of the FL and an increase in the maximum aortic diameter are strongly associated with late aortic expansion. Additional interventions of the FL may help to improve the prognosis of patients with the high risk of late aortic expansion.
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Affiliation(s)
- Zhiqiang Dong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - He Yang
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Gang Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Xinyang Xu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Hong Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Jiaxi Gu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Minghui Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Weidong Gu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Yongfeng Shao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Buqing Ni
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
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Su S, Liu J, Wang C, Chen R, Liu Y, Huang W, Luo S, Yang F, Luo J. Optimal medical treatment versus endovascular aortic repair in uncomplicated isolated abdominal aortic dissection. J Vasc Surg 2023; 77:1028-1036.e2. [PMID: 36332808 DOI: 10.1016/j.jvs.2022.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 09/18/2022] [Accepted: 10/02/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report the results of optimal medical treatment (OMT) and endovascular aortic repair (EVAR) in patients with uncomplicated isolated abdominal aortic dissection (IAAD). METHODS A retrospective review of 96 consecutive patients with uncomplicated IAAD (uIAAD) managed at a single tertiary vascular unit between January 2011 and July 2021 was conducted. Standard methods for univariate and survival analyses were used. The primary outcomes were all-cause mortality. Secondary end points included uIAAD progression, interventional complications, and follow-up aortic intervention. RESULTS Initially, 53.1% of patients (51/96) were managed with OMT. No in-hospital deaths occurred. During follow-up, three patients died, and three and two patients who were initially managed with OMT subsequently required endovascular treatment and surgical management, respectively. Initially, 46.9% of patients (45/96) underwent EVAR. One patient died during hospital admission; nine patients had an endoleak after operation and one needed reintervention. Furthermore, during follow-up, five patients died; four patients needed reoperation, one surgery and three endovascular treatments. The overall long-term mortality was 8.4%, and follow-up aortic intervention rate was 9.5% (median follow-up, 54 months; interquartile range, 33-81 months) with no significant difference between groups. Of note, 12 patients (12.6%) suffered uIAAD progression, which was higher in the OMT group than EVAR group (10 [19.6%] vs 2 [4.5%]; P = .03). CONCLUSIONS uIAAD may be managed safely by OMT with regular surveillance, despite the risk of disease progression. Compared with OMT, EVAR could significantly prevent uIAAD progression. For anatomically suitable patients with uIAAD progression and who are unresponsive to OMT, pre-emptive EVAR is a safe and feasible option.
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Affiliation(s)
- Sheng Su
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China; Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, China
| | - Jitao Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, China
| | - Changjin Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China; Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, China
| | - Ruirong Chen
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yuan Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, China
| | - Wenhui Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, China
| | - Songyuan Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, China
| | - Fan Yang
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jianfang Luo
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China; Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, China.
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Abstract
This JAMA Clinical Guidelines Synopsis summarizes the 2021 guidelines from the American Association for Thoracic Surgery and the Society of Thoracic Surgeons on management of type A and type B thoracic aortic dissection.
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Affiliation(s)
- Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Milam AJ, Hung P, Bradley AS, Herrera-Quiroz D, Soh I, Ramakrishna H. Open Versus Endovascular Repair of Descending Thoracic Aneurysms: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2023; 37:483-492. [PMID: 36522256 DOI: 10.1053/j.jvca.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Adam J Milam
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | - Penny Hung
- Medical Student, Mayo Clinic Alix School of Medicine, Scottsdale, AZ
| | - A Steven Bradley
- Department of Anesthesiology, Uniformed Services University of Health Sciences, Bethesda, MD
| | | | - Ina Soh
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ
| | - Harish Ramakrishna
- Division of Cardiovascular Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Cheng L, Xiang D, Zhang S, Zheng C, Wu X. Reintervention after Thoracic Endovascular Aortic Repair of Uncomplicated Type B Aortic Dissection. J Clin Med 2023; 12:jcm12041418. [PMID: 36835969 PMCID: PMC9964661 DOI: 10.3390/jcm12041418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/02/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
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.
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Affiliation(s)
- Li Cheng
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Dongqiao Xiang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Shan Zhang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
- Correspondence: (C.Z.); (X.W.)
| | - Xiaoyan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: (C.Z.); (X.W.)
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42
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Leach JR, Zhu C, Burris N, Hope MD. Editorial: Advances in aortic imaging. Front Cardiovasc Med 2023; 10:1137949. [PMID: 36818356 PMCID: PMC9929938 DOI: 10.3389/fcvm.2023.1137949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Affiliation(s)
- Joseph R. Leach
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States,*Correspondence: Joseph R. Leach ✉
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Nicolas Burris
- Department of Radiology, University of Michigan, Ann Arbor, MI, United States
| | - Michael D. Hope
- California Advanced Imaging Medical Associates, San Francisco, CA, United States
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43
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Affiliation(s)
- Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, 982315 Nebraska Medical Center, Omaha, NE 68198.
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44
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The Time Is Now for the Aortic Team. Ann Thorac Surg 2023; 115:549. [PMID: 35598708 DOI: 10.1016/j.athoracsur.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 02/07/2023]
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45
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Kim KM, Hofmann Bowman MA, Eagle KA. Treatment of Uncomplicated Type B Aortic Dissection: The Devil Is in the Details…Or Is It? JAMA Cardiol 2023; 8:54-55. [PMID: 36334257 DOI: 10.1001/jamacardio.2022.4197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Karen M Kim
- Frankel Cardiovascular Center, Department of Cardiac Surgery, University of Michigan, Ann Arbor
| | | | - Kim A Eagle
- Frankel Cardiovascular Center, Department of Medicine, University of Michigan, Ann Arbor.,School of Public Health, University of Michigan, Ann Arbor
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46
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Shu Y, Guo Y, Zheng Y, He S, Shi Z. RNA methylation in vascular disease: a systematic review. J Cardiothorac Surg 2022; 17:323. [PMID: 36536469 PMCID: PMC9762007 DOI: 10.1186/s13019-022-02077-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
Despite the rise in morbidity and mortality associated with vascular diseases, the underlying pathophysiological molecular mechanisms are still unclear. RNA N6-methyladenosine modification, as the most common cellular mechanism of RNA regulation, participates in a variety of biological functions and plays an important role in epigenetics. A large amount of evidence shows that RNA N6-methyladenosine modifications play a key role in the morbidity caused by vascular diseases. Further research on the relationship between RNA N6-methyladenosine modifications and vascular diseases is necessary to understand disease mechanisms at the gene level and to provide new tools for diagnosis and treatment. In this study, we summarize the currently available data on RNA N6-methyladenosine modifications in vascular diseases, addressing four aspects: the cellular regulatory system of N6-methyladenosine methylation, N6-methyladenosine modifications in risk factors for vascular disease, N6-methyladenosine modifications in vascular diseases, and techniques for the detection of N6-methyladenosine-methylated RNA.
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Affiliation(s)
- Yue Shu
- Geriatric Multi-Clinic Center, Hainan ChengMei Hospital, Haikou, Hainan People’s Republic of China ,Department of Special Medical Services, Hainan Cancer Hospital, Haikou, Hainan People’s Republic of China
| | - Yilong Guo
- grid.488137.10000 0001 2267 2324Medical School of Chinese PLA, Beijing, People’s Republic of China ,grid.414252.40000 0004 1761 8894Department of Vascular and Endovascular Surgery, The First Medical Centre of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Yin Zheng
- Geriatric Multi-Clinic Center, Hainan ChengMei Hospital, Haikou, Hainan People’s Republic of China ,Department of Special Medical Services, Hainan Cancer Hospital, Haikou, Hainan People’s Republic of China
| | - Shuwu He
- grid.443397.e0000 0004 0368 7493Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, 570311 Hainan People’s Republic of China
| | - Zhensu Shi
- grid.443397.e0000 0004 0368 7493Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, 570311 Hainan People’s Republic of China
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47
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 477] [Impact Index Per Article: 238.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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48
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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49
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Herajärvi J, Jormalainen M, Mustonen C, Kesävuori R, Raivio P, Biancari F, Juvonen T. 13-year single-center experience with the treatment of acute type B aortic dissection. Scand Cardiovasc J Suppl 2022; 56:360-367. [PMID: 36184791 DOI: 10.1080/14017431.2022.2127873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2022]
Abstract
Background. Acute type B aortic dissection (TBAD) is catastrophic event associated with significant mortality and lifelong morbidity. The optimal treatment strategy of TBAD is still controversial. Methods. This analysis includes patients treated for TBAD at the Helsinki University Hospital, Finland in 2007-2019. The endpoints were early and late mortality, and intervention of the aorta. Results. There were 205 consecutive TBAD patients, 59 complicated and 146 uncomplicated patients (mean age of 66 ± 14, females 27.8%). In-hospital and 30-day mortality rates were higher in complicated patients compared with uncomplicated patients with a statistically significant difference (p = 0.035 and p = 0.015, respectively). After a mean follow-up of 4.9 ± 3.8 years, 36 (25.0%) and 22 (37.9%) TBAD -related adverse events occurred in the uncomplicated and complicated groups, respectively (p = 0.066). Freedom from composite outcome was 83 ± 3% and 69 ± 6% at 1 year, 75 ± 4% and 63 ± 7% at 5 years, 70 ± 5% and 59 ± 7% at 10 years in the uncomplicated group and in the complicated group, respectively (p = 0.052). There were 25 (39.1%) TBAD-related deaths in the overall series and prior aortic aneurysm was the only risk factor for adverse aortic-related events in multivariate analysis (HR 3.46, 95% CI 1.72-6.96, p < 0.001). Conclusion. TBAD is associated with a significant risk of early and late adverse events. Such a risk tends to be lower among patients with uncomplicated dissection, still one fourth of them experience TBAD-related event. Recognition of risk factors in the uncomplicated group who may benefit from early aortic repair would be beneficial.
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Affiliation(s)
- Johanna Herajärvi
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
| | - Mikko Jormalainen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Caius Mustonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
| | - Risto Kesävuori
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Department of Radiology, Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Peter Raivio
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Department of Cardiac Surgery, Anesthesia and Intensive Care, Clinica Montevergine, GVM Care and Research, Mercogliano, Italy.,Department of Cardiac Surgery, San Carlo of Nancy Hospital, GVM Care and Research, Rome, Italy
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
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50
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Mandigers TJ, Trimarchi S, Piffaretti G. Different connective tissue disorders lead to similar outcomes of aortic disease: Are we missing something? J Card Surg 2022; 37:5445-5446. [PMID: 35979693 DOI: 10.1111/jocs.16856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Tim J Mandigers
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Santi Trimarchi
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, Università degli Studi di Milano, Milan, Italy
| | - Gabriele Piffaretti
- Vascular Surgery - Department of Medicine and Surgery, University of Insubria, Varese, Italy
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