Systematic Review of the Growth Rates and Influencing Factors in Thoracic Aortic Aneurysms

Aortic events and relative survival in patients with moderately dilated proximal thoracic aorta

Objectives. This study describes growth, local and remote aortic events, and survival in patients with proximal (root, ascending) aortic diameters just below threshold for operation. Methods. Patients with proximal aortic diameter of 4.5 to 5.4 cm at baseline, were followed with serial computed tomography studies and data collected retrospectively. Aortic growth rate was estimated using mixed effects modelling. Clinical and radiological features associated with outcomes (all-cause death, aortic death, local or remote aortic events (dissection, rupture, intramural hematoma, or intervention)) were assessed with Cox analysis. Survival and freedom from events were estimated using Kaplan-Meier methods. Results. 80 patients underwent 274 CT scans during 265 patient-years. Median proximal aortic growth was 0.2 cm in 3 years. 32 events occurred in 28 patients (35%). Eleven events were local, all elective proximal aortic surgery. Nine events were remote: 5 type B aortic dissections, 3 descending aneurysms undergoing elective repair, and one infrarenal aortic rupture. Twelve patients died, half of type B aortic dissection. Relative survival compared to a matched normal population was 82% (95% confidence limits 55-98%) at 10 years. In Cox analysis, increased descending aortic diameter was an independent predictor of all-cause death (hazard ratio [HR], 1.39) and aortic death (HR 1.96). Conclusions. Descending, but not proximal, aortic growth was predictive of lethal events. The decreased relative survival, the substantial number of remote aortic events and aortic deaths strongly suggest continuous serial CT surveillance of the entire aorta. Other indicators than proximal aortic diameter appear needed to improve management of this patient group.

Sex-related differences in the clinical course of aortic root and ascending aortic aneurysms: the DisSEXion Study

BACKGROUND AND AIMS

To explore male-female differences in aneurysm growth and clinical outcomes in a two-centre retrospective Dutch cohort study of adult patients with ascending aortic aneurysm (AscAA).

METHODS

Adult patients in whom imaging of an AscAA (root and/or ascending: ≥40 mm) was performed between 2007 and 2022 were included. Aneurysm growth was analysed using repeated measurements at the sinuses of Valsalva (SoV) and tubular ascending aorta. Male-female differences were explored in presentation, aneurysm characteristics, treatment strategy, survival, and clinical outcomes.

RESULTS

One thousand eight hundred and fifty-eight patients were included (31.6% female). Median age at diagnosis was 65.4 years (interquartile range: 53.4-71.7) for females and 59.0 years (interquartile range: 49.3-68.0) for males (P < .001). At diagnosis, females more often had tubular ascending aortic involvement (75.5% vs. 70.2%; P = .030) while males more often had SoV involvement (42.8% vs. 21.6%; P < .001). Maximum absolute aortic diameter, at any location, at diagnosis did not differ between females (45.0 mm) and males (46.5 mm; P = .388). In females, tubular ascending growth was faster (P < .001), whereas in males, SoV growth was faster (P = .005), corrected for covariates. Unadjusted 10-year survival was 72.5% [95% confidence interval (CI) 67.8%-77.6%] for females and 78.3% (95% CI 75.3%-81.3%) for males (P = .010). Twenty-three type A dissections occurred, with an incidence rate of 8.2/1000 patient-years (95% CI 4.4-14.1) in females and 2.4/1000 patient-years (95% CI 1.2-4.5) in males [incidence rate ratio females/males: 3.4 (95% CI 1.5-8.0; P = .004)].

CONCLUSIONS

In patients having entered a diagnostic programme, involvement of aortic segments and age- and segment-related growth patterns differ between women and men with AscAA, particularly at an older age. Unravelling of these intertwined observations will provide a deeper understanding of AscAA progression and outcome in women and men and can be used as an evidence base for patient-tailored clinical guideline development.

Effect of a Hypertensive Response During Exercise on Growth Rates of Aortic Diameters

BACKGROUND

Aortic diameters are related to age, sex, and body size. There is a scarcity of data on the long-term sequelae of a hypertensive response to exercise (HRE) on aortic diameters. In this retrospective cohort study, we aimed to evaluate the relationship between the growth rates of the aorta in individuals with a HRE.

METHODS

Our analysis included follow-up data of 649 patients recruited between January 2009 and December 2014 with a HRE. Participants with known connective tissue disease or a history of acute aortic syndrome were excluded. Sinus of Valsalva (SoV) and ascending aorta (AscAo) diameters were measured by transthoracic echocardiography using leading edge to leading edge convention at end-diastole.

RESULTS

At baseline, median age, maximum systolic blood pressure (BP), body mass index (BMI), diameter of the SoV, and AscAo were 62 years, 208 mm Hg, 26.9 kg/m2, 35 mm, and 35 mm respectively. 32% of patients were female and 67% had hypertension. After a median follow-up of 7.1 years, mean yearly growth rates (±SD) of the SoV and AscAo were 0.09 (0.41) mm and 0.13 (0.56) mm, respectively. No significant associations were observed between growth rates of aortic diameters and maximum systolic and diastolic BP or when considering only individuals with a baseline diameter >40 mm.

CONCLUSIONS

In this large cohort study, maximum systolic and diastolic BP during exercise showed no association with growth rates of aortic diameters. Furthermore, the mean growth rates of aortic diameters in this population were in line with growth rates in a normal population.

Identification of congenital aortic valve malformations in juvenile natriuretic peptide receptor 2-deficient mice using high-frequency ultrasound

Mouse models of congenital aortic valve malformations are useful for studying disease pathobiology, but most models have incomplete penetrance [e.g., ∼2 to 77% prevalence of bicuspid aortic valves (BAVs) across multiple models]. For longitudinal studies of pathologies associated with BAVs and other congenital valve malformations, which manifest over months in mice, it is operationally inefficient, economically burdensome, and ethically challenging to enroll large numbers of mice in studies without first identifying those with valvular abnormalities. To address this need, we established and validated a novel in vivo high-frequency (30 MHz) ultrasound imaging protocol capable of detecting aortic valvular malformations in juvenile mice. Fifty natriuretic peptide receptor 2 heterozygous mice on a low-density lipoprotein receptor-deficient background (Npr2+/-;Ldlr-/-; 32 males and 18 females) were imaged at 4 and 8 wk of age. Fourteen percent of the Npr2+/-;Ldlr-/- mice exhibited features associated with aortic valve malformations, including 1) abnormal transaortic flow patterns on color Doppler (recirculation and regurgitation), 2) peak systolic flow velocities distal to the aortic valves reaching or surpassing ∼1,250 mm/s by pulsed-wave Doppler, and 3) putative fusion of cusps along commissures and abnormal movement elucidated by two-dimensional (2-D) imaging with ultrahigh temporal resolution. Valves with these features were confirmed by ex vivo gross anatomy and histological visualization to have thickened cusps, partial fusions, or Sievers type-0 bicuspid valves. This ultrasound imaging protocol will enable efficient, cost effective, and humane implementation of studies of congenital aortic valvular abnormalities and associated pathologies in a wide range of mouse models.NEW & NOTEWORTHY We developed a high-frequency ultrasound imaging protocol for diagnosing congenital aortic valve structural abnormalities in 4-wk-old mice. Our protocol defines specific criteria to distinguish mice with abnormal aortic valves from those with normal tricuspid valves using color Doppler, pulsed-wave Doppler, and two-dimensional (2-D) imaging with ultrahigh temporal resolution. This approach enables early identification of valvular abnormalities for efficient and ethical experimental design of longitudinal studies of congenital valve diseases and associated pathologies in mice.

Unveiling cellular and molecular aspects of ascending thoracic aortic aneurysms and dissections

Ascending thoracic aortic aneurysm (ATAA) remains a significant medical concern, with its asymptomatic nature posing diagnostic and monitoring challenges, thereby increasing the risk of aortic wall dissection and rupture. Current management of aortic repair relies on an aortic diameter threshold. However, this approach underestimates the complexity of aortic wall disease due to important knowledge gaps in understanding its underlying pathologic mechanisms.Since traditional risk factors cannot explain the initiation and progression of ATAA leading to dissection, local vascular factors such as extracellular matrix (ECM) and vascular smooth muscle cells (VSMCs) might harbor targets for early diagnosis and intervention. Derived from diverse embryonic lineages, VSMCs exhibit varied responses to genetic abnormalities that regulate their contractility. The transition of VSMCs into different phenotypes is an adaptive response to stress stimuli such as hemodynamic changes resulting from cardiovascular disease, aging, lifestyle, and genetic predisposition. Upon longer exposure to stress stimuli, VSMC phenotypic switching can instigate pathologic remodeling that contributes to the pathogenesis of ATAA.This review aims to illuminate the current understanding of cellular and molecular characteristics associated with ATAA and dissection, emphasizing the need for a more nuanced comprehension of the impaired ECM-VSMC network.

Thoraflex Hybrid Prosthesis (THP): the profile

INTRODUCTION

With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy due to optimal results. Several FET devices exist commercially on the global market. However, the mainstay and most commonly used and reported device is the Thoraflex Hybrid Prosthesis (THP), with several recent reports suggesting its superiority.

AREAS COVERED

This review aims to collate and summarize the evidence in the literature on the clinical outcomes of TAR with FET using THP, with a focus on mortality, neurological complications, endoleak, distal stent-induced new entry (dSINE), aortic remodeling, coagulopathy, and graft kinking. In addition, the design features of THP is discussed, and an overview of market competitors is also highlighted.

EXPERT OPINION

THP consistently demonstrates its effectiveness in treating complex thoracic aortic pathology through favorable clinical outcomes, which can be attributed to its unique and innovative design. Rates of early mortality ranged 0.6-14.2%, neurological complications 0-25%, endoleak 0-8.4% and dSINE 0-14.5%, with minimal incidence of graft kinking and coagulopathy. Aortic remodeling is favorable and comparable to competitors. All this evidence solidifies THP as the leading FET device, particularly when combined with appropriate patient selection and surgical planning.

Utility of structured follow-up imaging after aortic surgery

BACKGROUND

Although postoperative follow-up after aortic surgery is recommended by guidelines, its clinical utility is not well documented. We hypothesized that structured follow-up imaging by an aortic program would improve outcomes. We then documented radiologic findings on asymptomatic postoperative imaging.

METHODS

All patients who survived to discharge after open thoracic aortic surgery between January 2017 and July 2021 were included, excluding endocarditis. Patients who followed at our center and received scheduled imaging were compared with patients who did not. Survival was analyzed by the method of Kaplan-Meier, and reintervention was assessed using the Fine-Gray subhazard function. Routine imaging was reviewed for aortic growth, pseudoaneurysm, and perigraft density.

RESULTS

After aortic surgery, the cumulative incidence of follow-up was 38.6% at 3 years postoperatively. Patients with follow-up were more likely to have a dissection and fewer comorbidities but were similar in regards to socioeconomic factors and distance to hospital. After matching and accounting for immortal time bias, patients with follow-up had a greater reintervention rate (26.0% vs 9.0%) with similar survival (98.7% vs 95.2%, P = .110) at 4 years. The cumulative incidence of pseudoaneurysm, significant perigraft density, and growth ≥3 mm/year on routine imaging was 49.7% at 3 years.

CONCLUSIONS

Implementation of structured follow-up imaging by an aortic program resulted in low clinical compliance. Follow-up was associated with increased rates of aortic reintervention. Clinically relevant radiologic findings were common on asymptomatic imaging and increased throughout 5-year follow-up rather than plateauing in the early postoperative period.

Three-dimensional aortic geometry mapping via registration of non-gated contrast-enhanced or gated and respiratory-navigated MR angiographies

BACKGROUND

The measurement of aortic dimensions and their evolution are key in the management of patients with aortic diseases. Manual assessment, the current guideline-recommended method and clinical standard, is subjective, poorly reproducible, and time-consuming, limiting the capacity to track aortic growth in everyday practice. Aortic geometry mapping (AGM) via image registration of serial computed tomography angiograms outperforms manual assessment, providing accurate and reproducible 3D maps of aortic diameter and growth rate. This observational study aimed to evaluate the accuracy and reproducibility of AGM on non-gated contrast-enhanced (CE-) and cardiac- and respiratory-gated (GN-) magnetic resonance angiographies (MRA).

METHODS

Patients with thoracic aortic disease followed with serial CE-MRA (n = 30) or GN-MRA (n = 15) acquired at least 1 year apart were retrospectively and consecutively identified. Two independent observers measured aortic diameters and growth rates (GR) manually at several thoracic aorta reference levels and with AGM. Agreement between manual and AGM measurements and their inter-observer reproducibility were compared. Reproducibility for aortic diameter and GR maps assessed with AGM was obtained.

RESULTS

Mean follow-up was 3.8 ± 2.3 years for CE- and 2.7 ± 1.6 years for GN-MRA. AGM was feasible in the 93% of CE-MRA pairs and in the 100% of GN-MRA pairs. Manual and AGM diameters showed excellent agreement and inter-observer reproducibility (ICC>0.9) at all anatomical levels. Agreement between manual and AGM GR was more limited, both in the aortic root by GN-MRA (ICC=0.47) and in the thoracic aorta, where higher accuracy was obtained with GN- than with CE-MRA (ICC=0.55 vs 0.43). The inter-observer reproducibility of GR by AGM was superior compared to manual assessment, both with CE- (thoracic: ICC= 0.91 vs 0.51) and GN-MRA (root: ICC=0.84 vs 0.52; thoracic: ICC=0.93 vs 0.60). AGM-based 3D aortic size and growth maps were highly reproducible (median ICC >0.9 for diameters and >0.80 for GR).

CONCLUSION

Mapping aortic diameter and growth on MRA via 3D image registration is feasible, accurate and outperforms the current manual clinical standard. This technique could broaden the possibilities of clinical and research evaluation of patients with aortic thoracic diseases.

Ascending thoracic aortic aneurysm size at presentation and growth by diameter

AIM

To investigate the hypothesis that lung cancer screening allows for earlier identification of ascending thoracic aortic aneurysms (aTAAs) and that growth rates for aTAAs are greatest at larger sizes.

MATERIALS AND METHODS

This single referral centre retrospective study manually gathered computed tomography (CT) data from 732 patients presenting from July 2002 to August 2022. Five hundred and seventeen patients with aTAA >39 mm were identified to compare presenting diameter by year of presentation. Four hundred and thirty-two patients had CT examinations >3 months apart, allowing for growth analysis. Patients were separated by initial examination date (before or after 12/31/2013) for presenting size comparison. Patients were then divided into five groups based on aTAA diameter for growth rate analysis.

RESULTS

At identification, patients had a median aTAA diameter of 44 mm (IQR 41-47 mm). Patients with aTAAs identified prior to December 2013 (n=129) had an average aTAA diameter 1.7 mm larger than those identified later (n=388; p=0.003). The growth analysis showed an average growth rate of 0.1 mm/year (p<0.001) across the entire cohort. Patients with an aTAA diameter of ≥55 mm (n=12) grew the fastest at 1.9 mm/year (p<0.001). In the <40 mm group (n=43), the aTAAs expanded at 0.2 mm/year, faster than the 0.1 mm/year of the slowest expanding 45-49 mm group (n=130; p=0.04).

CONCLUSION

aTAA size at discovery was larger before lung cancer screening guidelines took effect in December 2013. The largest aTAAs expanded fastest, but growth rates were slowest in the medium-sized 45-49 mm diameter group.

Fate of the unoperated ascending thoracic aortic aneurysm: three-decade experience from the Aortic Institute at Yale University

AIMS

This study aims to outline the 'true' natural history of ascending thoracic aortic aneurysm (ATAA) based on a cohort of patients not undergoing surgical intervention.

METHODS AND RESULTS

The outcomes, risk factors, and growth rates of 964 unoperated ATAA patients were investigated, over a median follow-up of 7.9 (maximum of 34) years. The primary endpoint was adverse aortic events (AAE), including dissection, rupture, and aortic death. At aortic sizes of 3.5-3.9, 4.0-4.4, 4.5-4.9, 5.0-5.4, 5.5-5.9, and ≥6.0 cm, the average yearly risk of AAE was 0.2%, 0.2%, 0.3%, 1.4%, 2.0%, and 3.5%, respectively (P < 0.001), and the 10-year survival free from AAE was 97.8%, 98.2%, 97.3%, 84.6%, 80.4%, and 70.9%, respectively (P < 0.001). The risk of AAE was relatively flat until 5 cm of aortic size, at which it began to increase rapidly (P for non-linearity <0.001). The mean annual growth rate was estimated to be 0.10 ± 0.01 cm/year. Ascending thoracic aortic aneurysms grew in a very slow manner, and aortic growth over 0.2 cm/year was rarely seen. Multivariable Cox regression identified aortic size [hazard ratio (HR): 1.78, 95% confidence interval (CI): 1.50-2.11, P < 0.001] and age (HR: 1.02, 95% CI: 1.00-1.05, P = 0.015) as significant independent risk factors for AAE. Interestingly, hyperlipidemia (HR: 0.46, 95% CI: 0.23-0.91, P = 0.025) was found to be a significant protective factor for AAE in univariable Cox regression.

CONCLUSION

An aortic size of 5 cm, rather than 5.5 cm, may be a more appropriate intervention criterion for prophylactic ATAA repair. Aortic growth may not be an applicable indicator for intervention.

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

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.

Impact of retraining a deep learning algorithm for improving guideline-compliant aortic diameter measurements on non-gated chest CT

PURPOSE/OBJECTIVE

Reliable detection of thoracic aortic dilatation (TAD) is mandatory in clinical routine. For ECG-gated CT angiography, automated deep learning (DL) algorithms are established for diameter measurements according to current guidelines. For non-ECG gated CT (contrast enhanced (CE) and non-CE), however, only a few reports are available. In these reports, classification as TAD is frequently unreliable with variable result quality depending on anatomic location with the aortic root presenting with the worst results. Therefore, this study aimed to explore the impact of re-training on a previously evaluated DL tool for aortic measurements in a cohort of non-ECG gated exams.

METHODS & MATERIALS

A cohort of 995 patients (68 ± 12 years) with CE (n = 392) and non-CE (n = 603) chest CT exams was selected which were classified as TAD by the initial DL tool. The re-trained version featured improved robustness of centerline fitting and cross-sectional plane placement. All cases were processed by the re-trained DL tool version. DL results were evaluated by a radiologist regarding plane placement and diameter measurements. Measurements were classified as correctly measured diameters at each location whereas false measurements consisted of over-/under-estimation of diameters.

RESULTS

We evaluated 8948 measurements in 995 exams. The re-trained version performed 8539/8948 (95.5%) of diameter measurements correctly. 3765/8948 (42.1%) of measurements were correct in both versions, initial and re-trained DL tool (best: distal arch 655/995 (66%), worst: Aortic sinus (AS) 221/995 (22%)). In contrast, 4456/8948 (49.8%) measurements were correctly measured only by the re-trained version, in particular at the aortic root (AS: 564/995 (57%), sinotubular junction: 697/995 (70%)). In addition, the re-trained version performed 318 (3.6%) measurements which were not available previously. A total of 228 (2.5%) cases showed false measurements because of tilted planes and 181 (2.0%) over-/under-segmentations with a focus at AS (n = 137 (14%) and n = 73 (7%), respectively).

CONCLUSION

Re-training of the DL tool improved diameter assessment, resulting in a total of 95.5% correct measurements. Our data suggests that the re-trained DL tool can be applied even in non-ECG-gated chest CT including both, CE and non-CE exams.

Proximal aorta dilatation in hypertension

Dilation of the proximal aorta is a common clinical manifestation in hypertensive patients. Although it is straightforward to link hypertension with proximal aortic dilation, previous studies on their interrelation have yielded controversial results. Cross-sectional design, methodology of blood pressure assessment, confounding factors like medications, and inconsistent reference values may lead to the paradoxical conclusions. Recently, advances have been made in the exploration of determinants and clinical value of proximal aortic dilatation. Thus, we reviewed these findings and summarized that aortic dilatation may be the consequence of hemodynamic and nonhemodynamic co-factors' combined action. Moreover, proximal aortic dilatation tends to be a predictor for aortic aneurysm dissection or rupture, hypertensive target organ damage as well as cardiovascular events. The present review contributes to a comprehensive understanding of the pathological process of proximal aortic dilatation in hypertension.

Fully automated pipeline for measurement of the thoracic aorta using joint segmentation and localization neural network

Purpose

Diagnosis and surveillance of thoracic aortic aneurysm (TAA) involves measuring the aortic diameter at various locations along the length of the aorta, often using computed tomography angiography (CTA). Currently, measurements are performed by human raters using specialized software for three-dimensional analysis, a time-consuming process, requiring 15 to 45 min of focused effort. Thus, we aimed to develop a convolutional neural network (CNN)-based algorithm for fully automated and accurate aortic measurements.

Approach

Using 212 CTA scans, we trained a CNN to perform segmentation and localization of key landmarks jointly. Segmentation mask and landmarks are subsequently used to obtain the centerline and cross-sectional diameters of the aorta. Subsequently, a cubic spline is fit to the aortic boundary at the sinuses of Valsalva to avoid errors related inclusions of coronary artery origins. Performance was evaluated on a test set of 60 scans with automated measurements compared against expert manual raters.

Result

Compared to training separate networks for each task, joint training yielded higher accuracy for segmentation, especially at the boundary (p < 0.001 ), but a marginally worse (0.2 to 0.5 mm) accuracy for landmark localization (p < 0.001 ). Mean absolute error between human and automated was ≤ 1    mm at six of nine standard clinical measurement locations. However, higher errors were noted in the aortic root and arch regions, ranging between 1.4 and 2.2 mm, although agreement of manual raters was also lower in these regions.

Conclusion

Fully automated aortic diameter measurements in TAA are feasible using a CNN-based algorithm. Automated measurements demonstrated low errors that are comparable in magnitude to those with manual raters; however, measurement error was highest in the aortic root and arch.

Computer-aided shape features extraction and regression models for predicting the ascending aortic aneurysm growth rate

OBJECTIVE

ascending aortic aneurysm growth prediction is still challenging in clinics. In this study, we evaluate and compare the ability of local and global shape features to predict the ascending aortic aneurysm growth.

MATERIAL AND METHODS

70 patients with aneurysm, for which two 3D acquisitions were available, are included. Following segmentation, three local shape features are computed: (1) the ratio between maximum diameter and length of the ascending aorta centerline, (2) the ratio between the length of external and internal lines on the ascending aorta and (3) the tortuosity of the ascending tract. By exploiting longitudinal data, the aneurysm growth rate is derived. Using radial basis function mesh morphing, iso-topological surface meshes are created. Statistical shape analysis is performed through unsupervised principal component analysis (PCA) and supervised partial least squares (PLS). Two types of global shape features are identified: three PCA-derived and three PLS-based shape modes. Three regression models are set for growth prediction: two based on gaussian support vector machine using local and PCA-derived global shape features; the third is a PLS linear regression model based on the related global shape features. The prediction results are assessed and the aortic shapes most prone to growth are identified.

RESULTS

the prediction root mean square error from leave-one-out cross-validation is: 0.112 mm/month, 0.083 mm/month and 0.066 mm/month for local, PCA-based and PLS-derived shape features, respectively. Aneurysms close to the root with a large initial diameter report faster growth.

CONCLUSION

global shape features might provide an important contribution for predicting the aneurysm growth.

Evaluation of microRNA Expression Features in Patients with Various Types of Arterial Damage: Thoracic Aortic Aneurysm and Coronary Atherosclerosis

Circulating serum miRNA are increasingly used as biomarkers and potential treatment targets in several clinical scenarios, including cardiovascular diseases. However, the current data on circulating miRNA in thoracic aorta aneurism (TAA) patients are inconclusive. The aim of the present study is to compare the levels of several circulating miRNA in patients with degenerative TAA, coronary artery disease (CAD), and controls for special profile identification. We have identified several candidates for the role of new biomarkers: miR-143-3p, miR-181-5p, miR-126-3p, miR-126-5p, miR-145-5p, miR-150-5p, and miR-195-5p.

MATERIALS AND METHODS

Serum samples of 100 patients were analyzed, including 388 TAA patients scheduled for elective surgery, 67 patients with stable CAD and 17 controls, were used for miRNA isolation and identification.

RESULTS

More specific for TAA with very high predictive ability in ROC analysis was an increase in the levels of miR-21-5p, miR-29b-5p, miR-126-5p/-3p, miR-181b-5p, and miR-92a-3p, with the latter microRNA being investigated as a novel potential marker of TAA for the first time.

CONCLUSION

TAA and CAD patients demonstrated a significant increase in the levels of circulating miR-126-5p/-3p, miR-181b-5p, and miR-29b-3p. More specific for TAA with very high predictive ability in ROC analysis was an increase in the levels of miR-21-5p, -29b-5p, -126-5p/-3p, 181b-5p, and -92a-3p, with the latter microRNA being investigated as a potential marker of TAA for the first time.

Factors affecting distal false lumen enlargement after thoracic endovascular aortic repair for type B aortic dissection

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.

Ascending Aortic Aneurysms <4.5 cm for Nonsyndromic Adults: Very Slow Growth and Low Risk

BACKGROUND

 Current practice guidelines for patients with thoracic aortic aneurysms (TAAs) recommend 6 to 12-month intervals for surveillance imaging based on growth estimates of 0.10 to 0.42 cm/y gleaned from limited studies which included patients with thoracoabdominal aneurysms, known acute or chronic aortic dissection, and other syndromic and nonsyndromic high-risk conditions (TAA-HRC) associated with high-risk for adverse aortic events and death. Our objective was to determine TAA growth and event-free survival rates for patients with aortic root or midascending diameters <5.0 cm, and without thoracoabdominal aneurysms, acute or chronic aortic dissection or higher risk syndromic or nonsyndromic conditions (TAA-NoHRC).

METHODS

 A retrospective review of patient records and imaging studies were done. Aortic diameter measurements were all performed by the lead author.

RESULTS

 For 197 TAA-NoHRC found incidentally during chest imaging, with 616 chest imaging studies over 868 patient-years, the mean aortic root and midascending aortic growth rates were 0.018 and 0.022 cm/y, respectively. The growth rate was significantly lower for aneurysms initially measured at <4.5 cm versus ≥ 4.5 cm at both the aortic root (0.011 vs. 0.068 cm/y) and midascending aorta (0.013 vs. 0.043 cm/y). Survival free from adverse aortic events (dissection, rupture, and surgery) or death at 5 years was 99.5%.

CONCLUSION

 Adult TAA-NoHRC patients with initial aortic root and/or ascending aortic diameters <5.0 cm, and particularly <4.5 cm, have very low aortic growth, and adverse event rates which may permit longer intervals between surveillance imaging, up to 3 to 5 years, after initial (6-12 months) stability is documented.

Cancer, cancer treatment and aneurysmatic ascending aorta growth within a retrospective single center study

Background: Multi-morbidity poses a substantial challenge for health care in an aging population. Recent studies did not provide evidence for general side effects of anti-cancer therapy regarding the growth rate of coincident abdominal aortic aneurysms, although it was suggested that specific therapeutic substances might accelerate growth. Aneurysm pathology, however, differs with respect to localization. Hence, we present the first ever analysis on the association of cancer and cancer therapy with growth alteration of aneurysms of the ascending aorta (AscAA). Patients and methods: A retrospective single-center identification of AscAA+cancer patients was performed in the institutional picture archiving and communication system (PACS). Included were all patients with ≥2 CT angiograms over ≥6 months and additional malignancy. Clinical data and aneurysm diameters were retrieved and analyzed for an association of cancer (stratified by tumor entity) or cancer therapy (stratified by several classes of chemotherapeutic agents and radiation therapy) with annual growth rate, respectively. Statistics included t-test, Wilcoxon test, and a linear regression model accounting for initial AscAA diameter and type of treatment. Results: From 2003 to 2021, 151 patients (median age 70 years; 85% male) with AscAA and coincident 163 malignancies were identified. Prostate (37%) and hematologic cancer (17%) were most frequent. One-hundred-eleven patients (74%) received chemotherapy and 75 patients (50%) had radiation. After exclusion of six patients with an initial AscAA diameter >55 mm, the average annual AscAA growth rate was 0.18±0.64 mm/year, with only 12 patients experiencing a growth rate >1mm/year. Neither tumor entity nor radiation or chemotherapy - alone or in combination - were significantly associated with an alteration of the annual AscAA growth rate. Likewise, a subanalysis for singular chemotherapeutic agents did not reveal a specific association with AscAA growth alteration. Conclusions: Growth rates of AscAA are low in this cohort with coincident malignancy. Cancer and/or chemotherapy or radiation are not associated with an alteration of the annual growth rate. Additional control examinations seem unnecessary.

Assessment of shape-based features ability to predict the ascending aortic aneurysm growth

The current guidelines for the ascending aortic aneurysm (AsAA) treatment recommend surgery mainly according to the maximum diameter assessment. This criterion has already proven to be often inefficient in identifying patients at high risk of aneurysm growth and rupture. In this study, we propose a method to compute a set of local shape features that, in addition to the maximum diameter D, are intended to improve the classification performances for the ascending aortic aneurysm growth risk assessment. Apart from D, these are the ratio DCR between D and the length of the ascending aorta centerline, the ratio EILR between the length of the external and the internal lines and the tortuosity T. 50 patients with two 3D acquisitions at least 6 months apart were segmented and the growth rate (GR) with the shape features related to the first exam computed. The correlation between them has been investigated. After, the dataset was divided into two classes according to the growth rate value. We used six different classifiers with input data exclusively from the first exam to predict the class to which each patient belonged. A first classification was performed using only D and a second with all the shape features together. The performances have been evaluated by computing accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUROC) and positive (negative) likelihood ratio LHR+ (LHR-). A positive correlation was observed between growth rate and DCR (r = 0.511, p = 1.3e-4) and between GR and EILR (r = 0.472, p = 2.7e-4). Overall, the classifiers based on the four metrics outperformed the same ones based only on D. Among the diameter-based classifiers, k-nearest neighbours (KNN) reported the best accuracy (86%), sensitivity (55.6%), AUROC (0.74), LHR+ (7.62) and LHR- (0.48). Concerning the classifiers based on the four shape features, we obtained the best accuracy (94%), sensitivity (66.7%), specificity (100%), AUROC (0.94), LHR+ (+∞) and LHR- (0.33) with support vector machine (SVM). This demonstrates how automatic shape features detection combined with risk classification criteria could be crucial in planning the follow-up of patients with ascending aortic aneurysm and in predicting the possible dangerous progression of the disease.

Augmentation Index in Patients with Thoracic Aortic Aneurysm: A Matched Case-Control Study

Thoracic aortic aneurysms (TAA) may be associated with complications such as rupture and dissection, which can lead to a fatal outcome. Increased central arterial stiffness has been proposed to be present in patients with TAA compared to unmatched controls. We aimed to assess whether wall properties in patients with TAA are also altered when compared to a matched control group. Applanation tonometry was performed in 74 adults with TAA and 74 sex, age, weight, height, and left ventricular ejection fraction matched controls. Subsequently analysis of the pulse wave was done using the SphygmoCor System. For comparing the two groups, AIx was adjusted to a heart rate of 75/min (AIx@75). 148 1-to-1 matched participants were included in the final model. There was no significant difference in the Alx@75 between the TAA group and the matched control group [mean (SD) of 24.7 (11.2) % and 22.8 (11.2) %, p = 0.240]. Adjusted for known cardiovascular risk factors, there was no association between TAA and AIx@75. Patients with TAA showed comparable arterial wall properties to cardiovascular risk factor matched controls. Since higher arterial stiffness is associated with TAA progression, it remains to be investigated if increased central arterial stiffness is a relevant factor of TAA emergence.

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

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.

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

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.

Thoracic and Thoracoabdominal Aneurysms: Etiology, Epidemiology, and Natural History

Thoracic aortic aneurysms and thoracoabdominal aneurysms are often found incidentally. Complications include dissection or rupture. Most of the thoracic aortic aneurysms and thoracoabdominal aneurysms develop in patients with risk factors for atherosclerosis. Younger patients without significant cardiovascular risk factors may have a genetic basis and include syndromes such as Marfan, Ehlers-Danlos, and Loeys-Dietz and bicuspid aortic valve. Most thoracic aneurysms grow slowly over time and factors that accelerate growth rate include dissection, aneurysm size, bicuspid valve disease, and Marfan syndrome. Size cutoffs where complications occur determine when surgery or intervention should be considered.

The prevalence of thoracic aorta aneurysm as an important cardiovascular disease in the general population

BACKGROUND

The aorta is the largest and main artery in the body. The enlargement of the aortic diameter known as ectasia results in aneurysm. Thoracic aorta aneurysm can involve one or more segments of the aorta. Non-invasive imaging techniques play an important role in identifying patients, estimating maximal aneurysm diameter, following up patients, and detecting complications. So, this study was performed to estimate the prevalence of ascending thoracic aorta aneurysm in the general population of Iran.

METHODS

People with an abnormal aortic size (˃ 36 mm) were enrolled and subjected to diagnostic tests, and related risk factors were assessed.

RESULT

Of the 3400 people examined, 410 (12%) had abnormal aorta sizes, and 42 (1.2%) had ascending aorta aneurysm. Out of the 410 patients with elevated aorta size, 235 (57%) were males, and 175 (43%) were females. Overall, 229 patients (56%) had hypertension, and 255 (62%) were over 60 years old.

CONCLUSION

In this study, we showed that the prevalence of ascending aorta aneurysm in the general population of Iran was about 1.2%. Ascending aorta aneurysm is a threatening pathology of the aorta. The high prevalence of hypertension may explain the high incidence of aneurysm in our studied population. Therefore, it is necessary to implement an accurate screening plan to identify patients with hypertension and provide appropriate treatment and adequate follow up to patients. Patients with ascending aorta aneurysm are also recommended to modify their lifestyles.

Growth rate of ascending thoracic aortic aneurysms in a non-referral-based population

Background

Prior studies on ascending thoracic aortic aneurysm (ATAA) growth rates have reported approximately 1 mm of growth per year but these studies are based on referral-based study populations which are biased towards the highest risk patients who may not represent the true natural history of aortic aneurysm disease. We aimed to characterize the growth rate of ATAAs in a non-referral-based population, using a large institutional database of computed tomography (CT) scans.

Methods

We queried the 21,325 CT scans performed at our institution between 2013 and 2016 on patients ages 50–85 years old for radiologic diagnosis of aortic aneurysm or dilatation. 560 patients were identified to have aortic dilatation > 4 cm, of which 207 had follow-up scan intervals > 6 months. This comprised our non-referral-based study population. Linearized annual aneurysm growth rates were calculated by dividing the change in aortic size by the time interval between CT scans.

Results

The median time interval between scans was 2.7 years (interquartile range [IQR] 1.5–4.2) for the 207 patients included in the study. The median initial aneurysm size was 4.3 cm (IQR 4.1–4.5). 38.2% (n = 79) of patients did not experience aortic dilatation. The median growth rate was 0.13 mm/year (IQR − 0.24 to 0.49). Of patients in the top quartile of growth rates, 26.9% of patients were female whereas 12.9% of patients were female in the bottom three quartiles of growth rates.

Conclusion

While some patients’ ATAAs may grow at previously published rates of around 1 mm/year, this is not the predominant pattern in a non-referral-based population and may over-estimate the overall growth rate of ATAAs.

Late Retrograde Aortic Dissection after Hybrid Thoracic Endovascular Aortic Repair (TEVAR): A Case Report

Open total arch replacement is allied to high rates of mortality and morbidity; surgeons, therefore, tend to choose hybrid aortic arch repair as a less invasive operative procedure for the treatment of aortic arch aneurysms, especially in high-risk patients. However, studies on the early and late outcomes of patients undergoing hybrid aortic arch repair have revealed high rates of reintervention and reoperation compared with open total arch replacement. Here, we describe a male patient with late retrograde aortic dissection after hybrid thoracic endovascular aortic repair for aortic arch aneurysms. The patient returned 3 years after the procedure with signs of dyspnea on exertion and chest pain. Transthoracic echocardiography and computed tomography showed dissection of the ascending aorta, for which he underwent a redo Bentall procedure. The patient was weaned from cardiopulmonary bypass without any problem and discharged after 7 days.

Wall Shear Stress Predicts Aortic Dilation in Patients With Bicuspid Aortic Valve

OBJECTIVES

This study sought to assess the predictive value of wall shear stress (WSS) for colocalized ascending aorta (AAo) growth rate (GR) in patients with bicuspid aortic valve (BAV).

BACKGROUND

BAV is associated with AAo dilation, but there is limited knowledge about possible predictors of aortic dilation in BAV patients with BAV. An increased WSS has been related to aortic wall damage in patients with BAV, but no previous prospective study tested its predictive value for dilation rate. Recently, a registration-based technique for the semiautomatic mapping of aortic GR has been presented and validated.

METHODS

Forty-seven patients with BAV free from valvular dysfunction prospectively underwent 4-dimensional flow cardiac magnetic resonance to compute WSS and subsequent follow-up with 2 electrocardiogram-gated high-resolution contrast-enhanced computed tomography angiograms for GR assessment.

RESULTS

During a median follow-up duration of 43 months, mid AAo GR was 0.24 mm/year. WSS and its circumferential component showed statistically significant association with mid AAo GR in bivariate (P = 0.049 and P = 0.014, respectively) and in multivariate analysis corrected for stroke volume and either baseline AAo diameter (P = 0.046 and P = 0.014, respectively) or z-score (P = 0.036 and P = 0.012, respectively). GR mapping further detailed that GR was heterogeneous in the AAo and that circumferential WSS, but not WSS magnitude, showed statistically significant positive associations with GR in the regions with the fastest growth.

CONCLUSIONS

4D flow cardiac magnetic resonance-derived WSS and, in particular, its circumferential component predict progressive dilation of the ascending aorta in patients with BAV. Thus, the assessment of WSS may be considered in the follow-up of these patients.

Registration-based semi-automatic assessment of aortic diameter growth rate from contrast-enhanced computed tomography outperforms manual quantification

OBJECTIVES

Manual assessment of aortic diameters on double-oblique reformatted computed tomography angiograms (CTA) is considered the current standard, although the reproducibility for growth rates has not been reported. Deformable registration of CTA has been proposed to provide 3D aortic diameters and growth maps, but validation is lacking. This study aimed to quantify accuracy and inter-observer reproducibility of registration-based and manual assessment of aortic diameters and growth rates.

METHODS

Forty patients with ≥ 2 CTA acquired at least 6 months apart were included. Aortic diameters and growth rate were obtained in the aortic root and the entire thoracic aorta using deformable image registration by two independent observers, and compared with the current standard at typical anatomical landmarks.

RESULTS

Compared with manual assessment, the registration-based technique presented low bias (0.46 mm), excellent agreement (ICC = 0.99), and similar inter-observer reproducibility (ICC = 0.99 for both) for aortic diameters; and low bias (0.10 mm/year), good agreement (ICC = 0.82), and much higher inter-observer reproducibility for growth rates (root: ICC = 0.96 vs 0.68; thoracic aorta: ICC = 0.96 vs 0.80). Registration-based growth rate reproducibility over a 6-month-long follow-up was similar to that obtained by manual assessment after 2.7 years (LoA = [- 0.01, 0.33] vs [- 0.13, 0.21] mm/year, respectively). Mapping of diameter and growth rate was highly reproducible (ICC > 0.9) in the whole thoracic aorta.

CONCLUSIONS

Registration-based assessment of aortic dilation on CTA is accurate and substantially more reproducible than the current standard, even at follow-up as short as 6 months, and provides robust 3D mapping of aortic diameters and growth rates beyond the pre-established anatomic landmarks.

KEY POINTS

• Registration-based semi-automatic assessment of progressive aortic dilation on CTA is accurate and substantially more reproducible than the current standard. • The registration-based technique allows robust growth rate assessment at follow-up as short as 6 months, with a similar reproducibility to that obtained by manual assessment at around 3 years. • The use of image registration provides robust 3D mapping of aortic diameters and growth rates beyond the pre-established anatomic landmarks.

Prediction of thirty-day mortality risk after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms: Derivation of risk calculator in the Vascular Quality Initiative

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) is associated with high perioperative survival, although mortality is a possible outcome. However, no risk score has been developed to predict mortality after TEVAR for intact DTAA to aid in risk discussion and preoperative patient selection. Our objective was to use a multi-institutional database to develop a 30-day mortality risk calculator for TEVAR after DTAA repair.

METHODS

The Vascular Quality Initiative database was queried for patients treated with TEVAR for intact DTAA between August 2014 and August 2020. Univariable and multivariable analyses aided in developing a 30-day mortality risk score. Internal validation was done with K-fold cross-validation and calibration curve analysis.

RESULTS

Of 2141 patients included in the analysis, 90 (4.2%) died within 30 days after the procedure. Clinically relevant variables identified to be independently associated with 30-day mortality and therefore used to derive the predictive model included age 75 years or greater (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.50-3.44; P < .001), coronary artery disease (OR, 1.60; 95% CI, 1.03-2.47; P = .036), American Society of Anesthesiologists class IV/V (OR, 2.39; 95% CI, 1.39-4.10; P = .002), urgent vs elective procedure (OR, 3.47; 95% CI, 1.90-6.33; P < .001), emergent vs elective procedure (OR, 5.27; 95% CI, 2.36-11.75; P < .001), prior carotid revascularization (OR, 3.24; 95% CI, 1.64-6.39; P = .001), and proximal landing zone <3 (OR, 2.51; 95% CI, 1.65-3.81; P < .001). The model showed an area under the receiver operating characteristic curve of 0.75. Internal validation demonstrated a bias-corrected area under the receiver operating characteristic curve of 0.73 (95% CI, 0.66-0.79) and a calibration slope of 1.00 with a corresponding intercept of 0.00.

CONCLUSIONS

This study provides a novel clinically relevant risk prediction model to estimate 30-day mortality risk after TEVAR for DTAA. The TEVAR Mortality Risk Calculator provides useful prognostic information to guide patient selection and facilitate preoperative discussions and shared decision making. An easily accessible online version of the TEVAR Mortality Risk Score is available to facilitate ease of use.

Non-syndromic thoracic aortic aneurysm: cellular and molecular insights

Thoracic aortic aneurysm (TAA) develops silently and asymptomatically and is a major cause of mortality. TAA prevalence is greatly underestimated, it is usually diagnosed incidentally, and its treatment consists mainly of prophylactic surgery based on the aortic diameter. The lack of effective drugs and biological markers to identify and stratify TAAs by risk before visible symptoms results from scant knowledge of its pathophysiological mechanisms. Here we integrate the structural impairment affecting non-syndromic non-familial TAA with the main cellular and molecular changes described so far and consider how these changes are interconnected through specific pathways. The ultimate goal is to define much-needed novel markers of TAA, and so the potential of previously identified molecules to aid in early diagnosis/prognosis is also discussed. © 2021 The Authors. The Journal of Pathology published by John Wiley & Sons, Ltd. on behalf of The Pathological Society of Great Britain and Ireland.

Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms

BACKGROUND

Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery.

OBJECTIVES

To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations.

SELECTION CRITERIA

We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion.

MAIN RESULTS

No RCTs or CCTs met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.

Determining the optimal interval for imaging surveillance of ascending aortic aneurysms

Background

Cardiovascular guidelines recommend (bi-)annual computed tomography (CT) or magnetic resonance imaging (MRI) for surveillance of the diameter of thoracic aortic aneurysms (TAAs). However, no previous study has demonstrated the necessity for this approach. The current study aims to provide patient-specific intervals for imaging follow-up of non-syndromic TAAs.

Methods

A total of 332 patients with non-syndromic ascending aortic aneurysms were followed over a median period of 6.7 years. Diameters were assessed using all available imaging techniques (echocardiography, CT and MRI). Growth rates were calculated from the differences between the first and last examinations. The diagnostic accuracy of follow-up protocols was calculated as the percentage of subjects requiring pre-emptive surgery in whom timely identification would have occurred.

Results

The mean growth rate in our population was 0.2 ± 0.4 mm/year. The highest recorded growth rate was 2.0 mm/year, while 40.6% of patients showed no diameter expansion during follow-up. Females exhibited significantly higher growth rates than men (0.3 ± 0.5 vs 0.2 ± 0.4 mm/year, p = 0.007). Conversely, a bicuspid aortic valve was not associated with more rapid aortic growth. The optimal imaging protocol comprises triennial imaging of aneurysms 40–49 mm in diameter and yearly imaging of those measuring 50–54 mm. This strategy is as accurate as annual follow-up, but reduces the number of imaging examinations by 29.9%.

Conclusions

In our population of patients with non-syndromic TAAs, we found aneurysm growth rates to be lower than those previously reported. Yearly imaging does not lead to changes in the management of small aneurysms. Thus, lower imaging frequencies might be a good alternative approach.

Bicuspid Aortic Valve: Morphology, Clinic, Diagnosis, Complications

Bicuspid aortic valve refers to common (0.5-2% of the population) congenital heart defects that are asymptomatic throughout life, with valve dysfunction and/or aortopathy (pathia- from Greek pathos disease), manifested by expansion, aneurysm or dissection of the vessel. The pathogenesis of the formation of a bicuspid valve is unknown, a genetic component is noted, since the defect develops as sporadic, familial, in combination with other congenital heart defects and with hereditary connective tissue disorders. Morphogenetic studies suggest that different phenotypes of bicuspid aortic valve can be considered as etiologically different diseases, with valve dysfunction or valve dysfunction and aortopathy. Aortic lesion is characterized by phenotypic heterogeneity due to genetic or hemodynamic features. Researchers are discussing the relationship between the phenotype of the bicuspid aortic valve and aortopathy to predict the course of the disease and select the optimal surgical treatment technique. Diagnosis of heart disease is based on the results of an echocardiographic study, magnetic resonance imaging. Surgical treatment is performed for significant hemodynamic disturbances resulting from insufficiency or stenosis of the aortic valve, in cases of infective endocarditis, the risk of which is high, with aneurysm or aortic dissection.

Is there an immunogenomic difference between thoracic and abdominal aortic aneurysms?

BACKGROUND AND AIM

Aortic aneurysms most commonly occur in the infra-renal and proximal thoracic regions. While generally asymptomatic, progressive aneurysmal dilation can become rapidly lethal when dissection or ruptures occurs, highlighting the need for more robust screening. Abdominal aortic aneurysm (AAA) is more prevalent compared to thoracic aortic aneurysm (TAA). The true incidence of TAA is underreported due to the absence of population screening and the silent nature of TAA. To achieve the optimum survival rate in aortic aneurysms, knowledge of natural course, genetic association, and surgical results are needed to be applied with adequate medical treatment and careful selection of patients for operation. The purpose of this paper is to provide a comprehensive review of the literature on natural history, immunology, and genetic differences between thoracic and AAAs.

METHOD

The literature was collected from OVID, SCOPUS, and PubMed.

RESULTS

(1) AAA expands faster than TAA. AAA expands at approximately 0.3-0.45 cm annually, depending on various factors (advancing age, diameter of aorta, smoking etc.). TAA expands up to 0.3 cm annually in a non-bicuspid aortic valve patient. (2) An increase in Matrix metallopeptidase 1, 2, 9, 12, 14 led to degrading extracellular matrix of the aortic vessel wall. This significantly contributed to the pathogenesis in AAA, whereas overactive Transforming growth factor-beta played a major role in the pathogenesis of TAA.

CONCLUSION

In the future, genetic testing may be the gold standard for tackling the geneticheterogeneity of aneurysms, therefore, identifying at-risk individuals developing TAA andAAA earlier.

Patterns of Surveillance Imaging for Incidentally Detected Ascending Aortic Aneurysms

BACKGROUND

Ascending aortic aneurysms (AsAA) remain a silent killer for which timely intervention and surveillance intervals are critical. Despite this, little is known about the follow-up care patients receive after incidental detection of an AsAA. We examined the pattern of surveillance and follow-up care for these high-risk patients.

METHODS

We identified patients at our institution with incidentally detected AsAAs (≥37 mm) between 2013 and 2016. We collected information on patients' aneurysms and clinical follow-up. Logistic regression models related aneurysm size and demographics to whether patients received follow-up imaging or referral.

RESULTS

From 2013 to 2016, 261 patients were identified to have incidentally detected AsAAs among the 21,336 computed tomography scans performed at our institution. The median aneurysm size was 4.2 cm (interquartile range, 4 to 4.4). Only 18 (6.9%) of the identified patients were referred to a cardiac surgeon for evaluation, and only 37.9% of the identified patients had a follow-up chest computed tomography scan within 1 year of detection; 34% had an echocardiogram. The median follow-up duration for the study was 5 years. Logistic regression models showed that aneurysm size and family history were significant predictors of whether a patient was referred to a cardiac surgeon (odds ratio 10.34; 95% confidence interval, 2.3 to 47.9), but not whether the patients received follow-up imaging.

CONCLUSIONS

Among 261 patients with incidentally detected AsAAs, only a third received any follow-up imaging within 1 year after detection, with very low clinical penetrance for expert referral. Surveillance of this high-risk patient population appears insufficient and may require standardization.

Analysis of ascending aortic diameter and long-term prognosis in patients with ascending aortic dissection

OBJECTIVES

This study was designed to review the ascending aortic diameter of patients undergoing surgery for AAD in China and its influence on prognosis.

METHODS

In the period between January 2018 and January 2020, 265 patients eligible for analysis of ascending aorta were included in this study. The maximum diameter of the ascending aorta was assessed using preoperative computed tomography (CT) scan for patients.

RESULTS

The mean diameter of the ascending aorta of the reference population was 48.16 ± 9.37 mm, and the percentage of subjects with an aorta <55 mm was 80.38%. In this study, we found that BMI, hypertension, and bicuspid aortic valve are the main factors affecting the widening of the ascending aorta, and the diameter of the ascending aorta in patients with AAD is negatively correlated with the patient's long-term prognosis. However, there is no significant difference in survival rates among patients with different ascending aortic diameter.

CONCLUSIONS

Ascending aortas with smaller diameter are also prone to dissection, most of which occur at a lower surgical threshold than recommended by current guidelines. Therefore, the diameter of ascending aorta cannot be used as an independent risk factor for high-risk patients with aortic dissection, but it can be used as an important indicator to evaluate the long-term prognosis of patients.

Thoracic aortic aneurysms in patients with heritable connective tissue disease

BACKGROUND

Patients with connective tissue diseases are at high lifetime risk of developing thoracic aortic aneurysms (TAAs) due to defects in extracellular matrix composition which compromise the structural integrity of the aortic wall. It is vital to identify and manage aneurysms early to prevent fatal complications such as dissection or rupture.

METHOD

This review synthesises information obtained from a thorough literature search regarding the pathophysiology of TAAs in those with heritable connective tissue diseases (HCTDs), the investigations for timely diagnosis and current operative strategies.

RESULTS

Major complications of open repair (OR) include pneumonia (32%), haemorrhage (31%) and tracheostomy (18%), with a minor risk of vocal cord paresis (9%). For thoracic endovascular aortic repair (TEVAR), high rates of endoleak were documented (38-66.6%). Reintervention rates for TEVAR are also high at 38-44%. Mortality rates were documented as 25% for open repair and vary from 14% to 44% for TEVAR.

CONCLUSION

OR remains the mainstay of surgical management. While TEVAR use is expanding, it remains the alternative choice due to concerns over endograft durability, limited long-term outcome data and the lack of high-quality evidence regarding its use in HCTD patients.

New indicators for systematic assessment of aortic morphology: a narrative review

In order to prevent the occurrence of aortic adverse events in ascending thoracic aortic aneurysm patients, preventive surgery is the sole option in case of large aneurysm. Identifying high-risk patients timely and accurately requires effective predictive indicators of aortic adverse events and accurate risk stratification thresholds. Absolute diameter measured after a single imaging examination, which has been used as the predictive indicator for decades, has been proved to be ineffective for risk stratification in moderately dilated aorta. Previously, new indicators combining absolute diameters with personalized parameters have been reported to show better predictive power of aortic adverse events than absolute diameters by correcting the effect of these parameters on the diameters. Meanwhile, combining three-dimensional parameters to formulate risk stratification thresholds not only may characterize the aortic risk morphology more precisely, but also predict aortic adverse events more accurately. These new indicators may provide more systematic assessment methods of patients’ risk, formulate more personalized intervention strategies for ascending thoracic aortic aneurysm patients, and also provide a basis for researchers to develop more accurate and effective risk thresholds. We also highlight that the algorithm obtained by combining multiple indicators may be a better choice compared with single indicator, but this still requires the support of more evidence. Due to the particularity of syndromic aortic disease, whether these new indicators can be used for its risk stratification is still uncertain. Therefore, the scope of this manuscript does not include this kind of disease.

Imaging Thoracic Aortic Aneurysm

High-quality aortic imaging plays a central role in the management of patients with thoracic aortic aneurysm. Computed tomography angiography and magnetic resonance angiography are the most commonly used techniques for thoracic aortic aneurysm diagnosis and imaging surveillance, with each having unique strengths and limitations that should be weighed when deciding patient-specific applications. To ensure optimal patient care, imagers must be familiar with potential sources of artifact and measurement error, and dedicate effort to ensure high-quality and reproducible aortic measurements are generated. This review summarizes the imaging evaluation and underlying pathology relevant to the diagnosis of thoracic aortic aneurysm.

Comparison of aortic remodelling after conservative treatment or thoracic endovascular repair in type B dissections

OBJECTIVES

Our aim was to compare aortic remodelling in type B dissections after thoracic endovascular aortic repair (TEVAR) or conservative treatment.

METHODS

We conducted a retrospective analysis of computed tomography (CT) data sets at dissection onset and at the last follow-up in a group with conservative (group A) and TEVAR treatment (group B). An additional analysis of the preoperative CT images was performed in patients from group A, who were converted to TEVAR during follow-up. Diameters and lengths of all aortic segments were measured and growth rates were calculated.

RESULTS

We included 74 patients: 50 patients in group A (follow-up time: 1625 ± 209 days) and 24 patients in group B (follow-up time: 554 ± 129 days). The mean aortic diameter growth rate was significantly higher in group A than in group B in the mid-descending aorta (A: +7 mm/year; B: -4 mm/year; P = 0.003). Length growth difference was only present in the abdominal aortic segment and was more pronounced in group A (+2 vs ±0 mm/year; P = 0.009). The conversion rate from conservative treatment to TEVAR was 36% (n = 18). A false lumen diameter of >22 mm at baseline was associated with a higher rate of conversion (P = 0.036). After conversion, the mean growth rate in the proximal descending and mid-descending aorta decreased from preoperative +11 and +18 mm/year to postoperative -9 and -14 mm/year, respectively (P < 0.001).

CONCLUSIONS

In acute type B dissections, TEVAR stops aortic enlargement in the thoracic aorta, but promotes distal dilatation compared to the conservative treatment group. After conversion to TEVAR in conservatively pretreated chronic type B dissections, a more pronounced diameter decrease in the descending aorta was observed than in patients treated in the acute phase.