Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: A multicenter comparative trial

A preliminary ex vivo diffusion tensor imaging study of distinct aortic morphologies

Changes in the microstructure of the aortic wall precede the progression of various aortic pathologies, including aneurysms and dissection. Current clinical decisions with regards to surgical planning and/or radiological intervention are guided by geometric features, such as aortic diameter, since clinical imaging lacks tissue microstructural information. The aim of this proof-of-concept work is to investigate a non-invasive imaging method, diffusion tensor imaging (DTI), in ex vivo aortic tissue to gain insights into the microstructure. This study examines healthy, aneurysm and a type B chronic dissection aortae, via DTI. DTI-derived metrics, such as the fractional anisotropy, mean diffusivity, helical angle and tractography, were examined in each morphology. The results from this work highlighted distinct differences in fractional anisotropy (healthy, 0.24 ± 0.008; aneurysmal, 0.19 ± 0.002; dissected, 0.13 ± 0.006) and a larger variation in the helical angle in the dissected aorta compared to healthy (39.28 ± 11.93° vs. 26.12 ± 4.60°, respectively). These differences were validated by histological characterisation. This study demonstrates the sensitivity of DTI to pathological changes in aortic tissue, highlighting the potential of this methodology to provide improved clinical insight.

Thirty-Day Outcomes of Endovascular Repair of Non-Ruptured Thoracic Aneurysms in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Thoracic Endovascular Aortic Repair (TEVAR) is the preferred treatment for thoracic aneurysms for eligible patients. Chronic obstructive pulmonary disease (COPD) is a common comorbidity that shares common inflammatory pathways with atherosclerosis, the major cause of thoracic aneurysms. However, surgical outcomes of TEVAR among patients with COPD have not been thoroughly investigated. This study aimed to assess the 30-day postoperative outcomes for COPD patients who have undergone TEVAR for non-ruptured thoracic aortic aneurysms, using data from a multi-institutional national registry.

METHODS

Patients who underwent TEVAR for non-ruptured thoracic aneurysms were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2022. A 1:1 propensity-score matching was used to match demographics, preoperative characteristics, and anesthesia between COPD and non-COPD patients. Thirty-day mortality and other postoperative outcomes were compared.

RESULTS

There were 525 (20.2%) COPD and 2,071 (79.8%) non-COPD patients who underwent TEVAR for the non-ruptured thoracic aneurysm. COPD was significantly more prevalent among patients with thoracic aneurysms compared to its incidence in the general population, and COPD patients also exhibited a higher burden of comorbidities. After 1:1 propensity-score matching, COPD and non-COPD patients had comparable 30-day mortality (5.7% vs 4.8%, p = 0.58). All other 30-day outcomes were comparable in COPD patients.

CONCLUSION

While COPD might be linked to the development of thoracic aneurysms through potentially shared pathophysiological pathways, COPD does not appear to be related to major adverse 30-day outcomes in TEVAR. Future studies should aim to explore the long-term outcomes in COPD patients undergoing TEVAR.Clinical ImpactCOPD was significantly more prevalent among patients with thoracic aneurysms compared to the general population, and COPD patients also exhibited a higher burden of comorbidities. However, after propensity-score matching, COPD patients demonstrated comparable risks across all 30-day outcomes. Therefore, while COPD might be linked to the development of thoracic aneurysms through potentially shared pathophysiological pathways, COPD does not appear to be related to major adverse 30-day outcomes in TEVAR.

Comparison of short-and long-term outcomes between endovascular and open repair for descending thoracic aortic aneurysm: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate and compare the efficacy of endovascular versus open repair for the treatment of patients with descending thoracic aortic aneurysm (DTAA).

METHODS

A systematic search of the PubMed, Embase, and Cochrane Library databases for relevant studies was performed. Outcome data, including postoperative mortality and morbidity, operative details, all-cause survival, freedom from aortic-related survival and freedom from aortic-related re-intervention, were independently extracted by two authors in a standardized way.

RESULTS

Twenty-nine studies comprising 49 972 patients (22 049 endovascular repair; 27 923 open repair) were included. Endovascular repair was associated with a significantly lower postoperative mortality rate [odd ratio (OR): 0.57, 95% confidence interval (CI): 0.45-0.72; I 2  = 72.58%] and morbidity. In terms of long-term survival, endovascular repair yielded better freedom from aortic-related survival [hazard ratio (HR): 0.71, 95% CI: 0.54-0.93, P = 0.012] but inferior freedom from aortic-related reintervention (HR: 2.10, 95% CI: 1.45-3.04, P < 0.001). Landmark analysis revealed that the open repair group experienced better all-cause survival beyond 16 months (HR: 1.64, 95% CI: 1.53-1.75, P < 0.001). In addition, in the subgroup of patients with intact DTAA, those who underwent open repair exhibited a higher rate of postoperative mortality (OR: 0.58, 95% CI: 0.38-0.88; I 2  = 83.34%) but had better all-cause survival beyond 7 months (HR: 1.72, 95% CI: 1.61-1.84, P < 0.001) than those who underwent endovascular repair.

CONCLUSION

Among patients treated for DTAA, endovascular repair was associated with better freedom from aortic-related survival, a lower risk for postoperative mortality and morbidity, and shorter lengths of intervention, intensive care unit stay, and hospital stay than those who underwent open repair. Open repair yielded significantly better long-term all-cause survival and freedom from aortic-related re-intervention than endovascular repair.

Thoracic vertebral body erosion due to a perianeurysmal outpouching lesion after thoracic endovascular aortic repair: a case report and literature review

BACKGROUND

The safety of endovascular treatment, such as thoracic endovascular aortic repair (TEVAR), for a descending thoracic aortic aneurysm has been well-established, with a reported low postoperative mortality rate but higher incidences of long-term complications such as endo-leakage, device failure, and aneurysm-related death. Based on this, we report the first case of massive thoracic vertebral body erosion due to a perianeurysmal outpouching lesion after TEVAR.

CASE PRESENTATION

A 77-year-old female with a history of TEVAR due to descending thoracic aortic arch aneurysm 4 years ago was referred from the cardiovascular clinic to the spine center. The patient presented with persisting back pain, which began 3 years after TEVAR and progressively worsened. Physical examination was notable for tenderness in the upper thoracic region without any neurological deficits. Computed tomography of the aorta and thoracic spine showed bony erosion into the T5-T7 vertebral bodies. Magnetic resonance imaging of the thoracic spine confirmed a perianeurysmal outpouching lesion eroding into the T5-T7 vertebral bodies due to pulsating pressure. We performed the posterior instrumented fusion from T3 to T9 at the thoracic spine and TEVAR at remnant endo-leakage lesions.

CONCLUSIONS

Since the progression of such a condition can have a catastrophic outcome, and because the treatment options vary, serial follow-up through an interdisciplinary approach is important in cases with a high index of suspicion of a perianeurysmal outpouching lesion.

Long-Term Outcomes and Late Complications of Thoracic Endovascular Aortic Repair Using the GORE TAG or Conformable GORE TAG

PURPOSE

Previous clinical studies have reported on the short- and mid-term prognoses of thoracic endovascular aortic repair (TEVAR) using the GORE thoracic aortic graft (TAG) or conformable GORE TAG. We evaluated the long-term prognoses of patients who underwent TEVAR using the GORE TAG or conformable GORE TAG in a real-world setting.

MATERIALS AND METHODS

This retrospective observational study analyzed the data of all consecutive patients aged 20 years or older who underwent TEVAR using either the GORE TAG or the conformable GORE TAG at a single center. The surgical criteria did not deviate from global standards. In principle, TEVAR was performed with the TAG or conformable thoracic aortic graft (CTAG) according to the manufacturer's instructions. The primary outcomes of this study were the 10-year overall survival rate and the rate of freedom from aorta-related deaths at 10 years.

RESULTS

Between January 2011 and December 2021, 331 patients underwent TEVAR, of whom 175 consecutive patients treated with TEVAR using either the GORE TAG or the conformable GORE TAG were enrolled. The mean age of the patients was 72.1 ± 9.3 years. In addition, the aneurysm and chronic dissection were 61.7% and 38.3%, respectively. Of all patients, 157 had a proximal landing zone ≥3, and 18 had a zone <3. The mean follow-up time was 46.5 ± 33.1 months. The 30-day mortality rate was 2.86%. The 3-, 5-, 7-, and 10-year overall survival rates were 76.9 ± 3.4%, 63.4 ± 4.1%, 55.9 ± 4.9%, and 42.4 ± 8.4%, respectively. The rate of freedom from aorta-related deaths at 3, 5, 7, and 9 years was 97.4 ± 1.3%, 95.0 ± 2.1%, 95.0 ± 2.1%, and 95.0 ± 2.1%, respectively. Late complications occurred in 23 (13.1%) patients. Endovascular re-intervention was performed because of endoleak, false lumen enlargement, or stent graft-induced new entry tear in 14 patients. Three patients required open conversion, and 6 were observed without re-intervention.

CONCLUSIONS

Thoracic endovascular aortic repair using the GORE TAG or conformable GORE TAG is a safe and effective procedure for the treatment of thoracic aortic aneurysms and aortic dissection.

CLINICAL IMPACT

Thoracic endovascular aortic repair using the GORE thoracic aortic graft (TAG) or conformable GORE TAG is a safe and effective procedure for the treatment of thoracic aortic aneurysms and aortic dissection. The 30-day mortality rate was 2.86%. During 10 years of follow-up, the overall survival rate was low; however, the risk of aorta-related deaths was also low. No significant differences in freedom from late complications and re-intervention are seen between the TAG and conformable thoracic aortic graft (CTAG) groups. Further investigations into the treatment of late complications are required.

Impact of aetiology on short- and long-term outcomes in open descending and thoracoabdominal aneurysm repair

OBJECTIVES

We analysed the impact of chronic type B aortic dissection (cTBAD) and degenerative aneurysm (DA) on the short- and long-term outcomes of patients undergoing open descending thoracic aortic aneurysm and thoracoabdominal aortic aneurysm repair.

METHODS

We performed a retrospective analysis of a prospectively maintained aortic database. From 1999 to 2023, 245 patients underwent open descending thoracic aortic aneurysm or thoracoabdominal aortic aneurysm repair. We compared preoperative comorbidities, postoperative complications and operative and long-term mortality for patients with cTBAD (120 patients, 49%) and DA (125 patients, 51%).

RESULTS

Patients with cTBAD were significantly younger, more likely to be male and less likely to have comorbidities including diabetes, chronic obstructive pulmonary disease and coronary artery disease. There were no statistically significant differences in the incidence of operative mortality between cTBAD (7.5%) and DA patients (11.2%) (P = 0.44). Survival at 1, 5, 10 and 15 years for cTBAD versus DA patients was 90% versus 76%, 79% versus 59%, 59% versus 42% and 50% versus 29%, respectively (P < 0.01); however, this lost statistical significance in the Cox regression (P = 0.86). Following multivariable analysis, older age, female gender, coronary artery disease, urgent or emergent procedure and descending thoracic aortic aneurysm were independent predictors of long-term outcomes.

CONCLUSIONS

There were no statistically significant differences in the incidence of postoperative complications, operative deaths and long-term survival between cTBAD and DA patients.

IRB NUMBER

(#20D.802), Obtained: 1/31/23.

16-year outcomes of blunt thoracic aortic injury treated with thoracic endovascular aortic repair: A single-institution experience

BACKGROUND

Blunt thoracic aortic injury (BTAI) is associated with considerable mortality and morbidity. Thoracic endovascular aortic repair (TEVAR) has essentially replaced open aortic repair (OAR) with superior outcome. The objective of this study was to evaluate the early and intermediate-term outcomes in patients sustaining BTAI treated with TEVAR, and to evaluate the prevalence and impact of left subclavian artery (LSA) coverage.

METHODS

This retrospective analysis includes patients undergoing TEVAR for BTAI between February 2006 and December 2022 at the Helsinki University Hospital, Finland. The primary endpoints were 30-day and 2-year mortality, technical success of stent-graft system deployment, and procedural and device-related complications. The secondary endpoints pertained to reintervention events: conversion to OAR, re-TEVAR, any endovascular/surgical reinterventions for optimal stent-graft function, or any reinterventions during follow-up.

RESULTS

A total of 38 consecutive BTAI patients treated with TEVAR were included in the analyses. Median patient age was 45.5 years (range, 15-79) and 66% were male. The median follow-up period was 39 months. Technical success was 100%, 30-day mortality was 0%, and 2-year mortality was 11% in the study cohort. Coverage of LSA without revascularization (13/18) resulted in one postoperative nondisabling stroke (1/13), no paraplegia, and one had ischemic left arm findings (1/13). Only one patient required reintervention (LSA embolization; 1/38).

CONCLUSION

In this institutional series, we provide further evidence in favor of TEVAR for BTAI treatment. We demonstrated that TEVAR is linked to highly favorable outcomes in the short and intermediate term, and coverage of LSA without revascularization was quite well tolerated.

Prognostic Impact of Pulmonary Diseases in 952 Patients with Thoracic and/or Abdominal Aortic Aneurysm

Background/Objectives: Pulmonary diseases are common in patients with thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA). Although high prevalences of chronic obstructive pulmonary disease and lung cancer (LC) are known, the prevalence of these and other pulmonary diseases regarding their relation to the outcome of TAA and/or AAA are not determined. Methods: Pulmonary diseases present at aortic aneurysm (AA) diagnosis and follow-up periods and cause of death of 952 patients with TAA, AAA, or TAA + AAA (including thoracoabdominal AA) treated at our institution in Japan were retrospectively analyzed. Cox regression analysis was used to investigate potential risk factors of mortality. Results: The mean patient age was 72.4 years, and the median follow-up was 4.92 years. At diagnosis, 528 (55.5%) patients had pulmonary diseases, including emphysema without interstitial lung disease (ILD) or LC, LC, idiopathic pulmonary fibrosis (IPF) without LC, non-IPF ILD without LC, and interstitial lung abnormalities (ILAs) without LC in 250, 85, 65, 15, and 58 patients, respectively. During follow-up, LC and acute exacerbation (AE) of IPF developed in 50 and 12 patients, respectively. In 213 patients who died, there were 45 (21.1%) aortic disease-related deaths. Other causes of death included LC (27.7%), cardiovascular events (9.4%), pneumonia (5.6%), and interstitial lung disease (4.7%). In a multivariate Cox regression hazard model, age; larger maximum aneurysm diameter; and coexisting LC, IPF, or concomitant cancer were associated with poor prognosis. Conclusions: In patients with AA, not only age and aneurysm diameter but also coexisting LC and IPF were prognostic factors for mortality.

The Clinical Impact of Thoracic Endovascular Aortic Repair in the Management of Thoracic Aortic Diseases

PURPOSE

Thoracic endovascular aortic repair (TEVAR) has been described to be superior to an open surgical approach, and previous studies have found superiority in TEVAR by reducing overall morbidity and mortality rates. This study aimed to describe the outcomes of TEVAR for patients with thoracic aortic disease at a high complexity.

MATERIALS AND METHODS

Descriptive study, developed by a retrospective review of a prospectively collected database. Patients aged above 18 years who underwent TEVAR between 2012 and 2022 were included. Patient demographics, perioperative data, surgical outcomes, morbidity, and mortality were described. Statistical and multivariate analyses were made. Statistical significance was reached when p values were <0.05.

RESULTS

A total of 66 patients were included. Male patients were 60.61% and the mean age was 69.24 years. Associated aortic diseases were aneurysms (68.18%), ulcer-related (4.55%), intramural-related hematoma (7.58%), trauma-related pathology (1.52%), and aortic dissection (30.30%). The mean hospital stay was 18.10 days, and intensive care unit was required for 98.48%. At 30 days, the mortality rate was 10.61% and the reintervention rate was 21.21%. Increased intraoperative blood loss (p=0.001) and male sex (p=0.04) showed statistical relationship with mortality. Underweight patients have 6.7 and 11.4 times more risk of complications and endoleak compared with higher body mass index values (p=0.04, 95% confidence interval [CI]=0.82-7.21) and (p=0.02, 95% CI=1.31-12.57), respectively.

CONCLUSION

Thoracic endovascular aortic repair seems to be a feasible option for patients with thoracic aortic pathologies, with adequate rates of mortality and morbidity. Underweight patients seem to have an increased risk of overall morbidity and increased risk for endoleak. Further prospective studies are needed to prove our results.

CLINICAL IMPACT

Obesity and BMI are widely studied in the surgical literature. According to our study, there is a paradox regarding the outcomes of patients treated with TEVAR in terms of postoperative complications and mortality related to the body mass index. And shouldn't be considered as a high-risk feature in terms of postoperative morbidity and mortality in this procedure.

Complications of thoracic endovascular aneurysm repair (TEVAR): A pictorial review

Thoracic endovascular aneurysm repair (TEVAR) has replaced open surgical repair as the treatment of choice for several aortic conditions. Despite its lower morbidity and mortality, several TEVAR-related complications can occur and some of which may necessitate surgical or endovascular re-intervention. The current article reviews common and rare complications of TEVAR procedure with emphasis on complications identifiable on cross-sectional imaging and potential pitfalls of pre-procedural planning.

Computed tomography angiography-guided analysis of morphologic properties of the thoracic aorta and arch branches among the adult population: A cross-sectional study

Background and Aims

Before performing any surgical or endovascular procedure, the anatomical classification of the patient is essential for treatment planning. Computed Tomographic Angiography (CTA) is a standard method to evaluate thoracic aortic anatomy and associated variations.

Methods

This cross-sectional, descriptive study was performed among adult participants without any peripheral vascular diseases undergoing thoracic CTA. Demographic data were collected along with factors retrieved from the patients CTA, such as the type of aortic arch, length, and diameter of ascending and descending aorta, the diameter of the main branches and the distance between branches, the angles by which the main arteries rise from their origins, and left anterior oblique angle of the aortic arch.

Results

164 patients, with a mean age of 57 ± 19.3 years, entered the study. 53 (33.8%) had a bovine arch, which was mostly observed among males. A decrease in the frequency of type I arch and also an increase in the frequency of type 2 and 3 arches was observed with the increase in age (p < 0.001). The BCT diameter had a direct association with both left common carotid artery diameter (r = 0.478, p < 0.001) and left subclavian artery diameter (r = 0.470, p < 0.001). The length of the descending aorta had a direct correlation (r = 0.294, p < 0.001) with the length of the ascending aorta.

Conclusion

Complex endovascular interventions are vital method in treating aorta, head, and neck pathologies. Accurate knowledge of thoracic aortic anatomy is becoming crucial for diagnosis and intervention planning.

Clinical efficacy of TEVAR utilizing fenestrated stent-grafts for zone 0 in an elderly frail patient with giant aortic arch aneurysm

Introduction and importance

Elderly and frail patients with thoracic aortic aneurysms (TAAs) near to origins of cervical arteries present facing challenges with aortic arch replacement with cardiopulmonary bypass, and traditional tube-type stent-grafts are also inadequate for transcatheter endovascular aortic repair (TEVAR). Thus, necessitating precise treatment with fenestrated stent-grafts from zone 0. This approach is crucial for achieving favorable postoperative outcomes without compromising activities of daily living (ADL).

Case presentations

An 85-year-old-man admitted to the hospital for treatment of a large TAA. While arch replacement is a definitive procedure, it is highly invasive, and the postoperative ADL are expected to be significantly lower than preoperative levels. Therefore, we performed a debranching TEVAR from Zone 0 with fenestrated stent-graft. The patient was discharged from the hospital on the 11th postoperative day.

Clinical discussion

In frail and elderly patients for whom conventional surgery may not be viable, TEVAR emerges as a preferred alternative. However, TEVAR of TAA proximal to the aortic arch continues to pose challenges, necessitating meticulous attention to the cervical branches in the intervention strategy. While surgical intervention in these patients necessitates careful consideration of its suitability, including the potential for postoperative enhancement in ADL, the use of fenestrated stent-grafts from Zone 0 emerges as one of the treatment modalities.

Conclusion

The authors present a very elderly case in which fenestrated stent-grafts were used to avoid aortic arch replacement for a large aortic arch aneurysm, resulting in a good postoperative course with no decline in ADL.

Successful open surgical treatment for persistent type II endoleak following thoracic endovascular aortic repair: a case report

BACKGROUND

The occurrence of type II endoleaks after endovascular repair of aortic aneurysm has gradually gained increasing attention. We present a case of a patient with an expanding aneurysm after thoracic endovascular aortic repair (TEVAR) for a type II endoleak, in which successful direct ligations of the intercostal artery were performed using a sac incision without cardiopulmonary bypass (CPB) or graft replacement.

CASE PRESENTATION

A 62-year-old male patient, previously treated with TEVAR for a descending thoracic aortic aneurysm, presented with ongoing chest discomfort. Based on the diagnosis of a growing aneurysm and type II endoleak, the patient was prepared for CPB and aortic cross-clamping, as a precautions against the possibility of a type I endoleak. A longitudinal opening of the thoracic aortic aneurysm sac was performed following left thoracotomy. Visual confirmation identified the T5 level intercostal artery as the source of the endoleak, and after confirming the absence of a type I endoleak, multiple ligations were applied to the intercostal artery. Follow-up computed tomography confirmed the absence of endoleaks or sac growth.

CONCLUSION

In a case involving TEVAR for a thoracic aortic aneurysm, open suture ligations were used to treat type II endoleaks without having to resort to CPB, resulting in successful outcomes.

Patterns of collateral arteries to the spinal cord after thoraco-abdominal aortic aneurysm repair

OBJECTIVES

Our goal was to evaluate postoperative patterns of collateral arteries to the spinal cord during occlusion of the segmental arteries supplying the artery of Adamkiewicz (AKA).

METHODS

Between April 2011 and December 2022, a total of 179 patients underwent thoraco-abdominal aortic aneurysm repair; 141 had an identifiable AKA on preoperative multidetector computed tomography scans, 40 underwent thoraco-abdominal aortic aneurysm replacement (TAAR) and 101 underwent thoracic endovascular aortic repair (TEVAR). New postoperative collateral blood pathways invisible on preoperative contrast-enhanced computed tomography scans were identified in 42 patients (10 patients who had TAAR vs 32 patients who had TEVAR) who underwent preoperative and postoperative multidetector computed tomography scanning for AKA identification.

RESULTS

The thoracodorsal and segmental arteries were the main collateral pathways in both groups. Th9-initiated collaterals were the most common. Collaterals from the internal thoracic artery were observed in the TEVAR group but not in the TAAR group. One patient in the TEVAR group experienced postoperative paraparesis, which was not observed in the TAAR group. Postoperative paraplegia was more common in the non-Th9-origin group, but this difference was not significant.

CONCLUSIONS

Thoracodorsal and segmental arteries may be important collateral pathways after TEVAR and TAAR. For thoracodorsal arteries, preserving the thoracodorsal muscle during the approach would be crucial; for segmental arteries, minimizing the area to be replaced or covered would be paramount. An AKA not initiated at the Th9 level poses a high risk of postoperative paraplegia.

Phase-specific survival after endovascular versus open surgical repair of descending thoracic aortic aneurysm

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) has gained preference over open surgical repair (OSR) as the intervention of choice for patients with descending thoracic aortic aneurysm (DTA). This study aimed to compare the outcomes of patients with DTA undergoing OSR and TEVAR with contemporary findings.

EVIDENCE ACQUISITION

A comprehensive search of MEDLINE and EMBASE databases was conducted to identify relevant randomized controlled trials or studies utilizing propensity-score analysis or reporting risk-adjusted outcomes. The search was performed up until March 2023.

EVIDENCE SYNTHESIS

Eight studies met the inclusion criteria, including 4 studies using propensity-score matching and four studies reporting risk-adjusted outcomes, comprising 14,873 patients with DTA undergoing OSR (N.=10,882) and TEVAR (N.=3991). Operative mortality was similar between the two interventions (odds ratio 0.92, 95% CI 0.70-1.21, P=0.57, I2=0%). However, overall long-term mortality was significantly higher after TEVAR compared to OSR (Hazard Ratio [HR] 1.30, 95% CI 1.05-1.59, P=0.01, I2=0%). Phase-specific analysis revealed comparable risks of mortality within 1 year and between one and two years after interventions, while the risk of mortality was significantly higher after TEVAR compared to OSR beyond two years (HR 1.77, 95% CI, 1.19-2.63, P=0.01. I2=0%).

CONCLUSIONS

This study demonstrated comparable operative mortality between OSR and TEVAR, but higher long-term mortality associated with TEVAR in patients with DTA. The phase-specific analysis highlighted the survival advantage of OSR beyond 2 years. These findings suggest a need for reconsidering OSR indications in the management of DTA.

Numerical simulation of the distal stent graft-induced new entry after TEVAR

The study aimed to investigate the mechanical factors for distal stent graft-induced new entry (dSINE) in aortic dissection patients and discussed these factors in conjunction with aortic morphology. Two patients (one dSINE and one non-dSINE), with the same age, gender, and type of implanted stent, were selected, then aortic morphological parameters were calculated. In addition, the stent material parameters used by the patients were also fitted. Simulations were performed based on the patient's aortic model and the stent graft used. The true lumen segment at the distal stent graft was designated as the "dSINE risk zone," and mechanical parameters (maximum principal strain, maximum principal stress) were computed. When approaching the area with higher mechanical parameters in the dSINE risk zone, dSINE patient exhibited higher values and growth rates in mechanical parameters compared to non-dSINE patient. Furthermore, dSINE patient also presented larger aortic taper ratio, stent oversizing ratio, and expansion mismatch ratio of the distal true lumen (EMRDTR). The larger mechanical parameters and growth rates in dSINE patient corresponded to a greater aortic taper ratio, stent oversizing ratio, and EMRDTR. The failure of dSINE prediction by the stent tortuosity index indicated that mechanical parameters were the fundamental reasons for dSINE development.

Thoracoabdominal aortic aneurysmectomy in the high-risk patient

OBJECTIVE

The study objective was to provide a review of outcomes and management strategies for high-risk scenarios in the open repair of thoracoabdominal aortic aneurysms.

METHODS

Series examining the open repair of thoracoabdominal aortic aneurysms were reviewed to identify well-described high-risk scenarios and summarize expected outcomes and management strategies in the current era.

RESULTS

The efforts of many have led to improved outcomes for patients undergoing the inherently challenging open repair of thoracoabdominal aortic pathologies. Several well-described high-risk scenarios include those related to preoperative comorbid conditions (preoperative pulmonary dysfunction, low ejection fraction, and renal dysfunction), anatomically high-risk cases (extent II repairs), and those with acute presentations (rupture, mycotic aneurysms, acute complicated type B aortic dissection). Several operative and perioperative techniques have been developed to mitigate the risk in these formidable cases.

CONCLUSIONS

Challenges remain for several high-risk scenarios in thoracoabdominal aortic aneurysm repair. Judicious patient selection, meticulous surgical, and critical care strategies have greatly decreased the risk for many high-risk patients.

Endovascular Repair in Blunt Thoracic Aortic Injury: A 10-Year Single Center Experience

BACKGROUND

Life-threatening blunt thoracic aortic injury (BTAI) typically occurs alongside multiple other traumatic injuries. Symptoms of BTAI can range from being asymptomatic in the case of intimal tears to becoming catastrophic in the case of uncontained aortic ruptures. The aim of this research was to examine the clinical outcomes for those who underwent thoracic endovascular aortic repair (TEVAR) in hospital settings.  Methods: A cross-sectional retrospective study was conducted using patient data that were extracted from Al-Noor Specialist Hospital, Makkah, Saudi Arabia, for the duration between January 2011 and December 2021. This study included data from all patients aged 18 and up who had been diagnosed with BTAI and had undergone TEVAR. The BTAI diagnoses were confirmed using CT scans. Logistic regression was utilized to identify predictors of patients' health status improvement and length of stay.

RESULTS

A total of 80 patients were involved. Around 50.0% (n=40) of the patients had grade 3 thoracic aortic injuries. The median duration of stay was 14.00 days (Interquartile range 21.00). Only one patient developed post-procedure complications (1.3%). Almost one-third (31.3%; n=25) of the patients required subclavian coverage. One patient developed intraoperative endoleak (1.3%). One patient developed an access site complication (1.3%). The mortality rate within 30 days of the operation was 1.3%. The vast majority of the patients (92.5%; n=74) showed improvement upon discharge from the hospital. The baseline patient characteristics and length of hospitalization had no effect on the improvement of patient status upon discharge or their length of stay (p>0.05).

CONCLUSION

Patients with BTAI have shown an excellent success rate with TEVAR and a low complication rate. Predictors of procedure success and length of stay need to be identified; however, this can't be done without larger-scale investigations. This can aid in the development of preventative measures that improve clinical outcomes for the patients.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

Animal Models, Pathogenesis, and Potential Treatment of Thoracic Aortic Aneurysm

Thoracic aortic aneurysm (TAA) has a prevalence of 0.16-0.34% and an incidence of 7.6 per 100,000 person-years, accounting for 1-2% of all deaths in Western countries. Currently, no effective pharmacological therapies have been identified to slow TAA development and prevent TAA rupture. Large TAAs are treated with open surgical repair and less invasive thoracic endovascular aortic repair, both of which have high perioperative mortality risk. Therefore, there is an urgent medical need to identify the cellular and molecular mechanisms underlying TAA development and rupture to develop new therapies. In this review, we summarize animal TAA models including recent developments in porcine and zebrafish models: porcine models can assess new therapeutic devices or intervention strategies in a large mammal and zebrafish models can employ large-scale small-molecule suppressor screening in microwells. The second part of the review covers current views of TAA pathogenesis, derived from recent studies using these animal models, with a focus on the roles of the transforming growth factor-beta (TGFβ) pathway and the vascular smooth muscle cell (VSMC)-elastin-contractile unit. The last part discusses TAA treatment options as they emerge from recent preclinical studies.

A hemodynamic study of blood flow models on various stent graft configurations during aorto-iliac reconstruction

PURPOSE

To compare the hemodynamic performance of three (Bottom Up non-ballet, Top-Down non-ballet, Top Down ballet) idealized stent graft configurations used during endovascular repair of abdominal aortic aneurysms, under the influence of various rheological models.

METHODS

Ten rheological models are assumed and a commercial finite volume solver is employed for the simulation of blood flow under realistic boundary conditions. An appropriate mesh convergence study is performed and five hemodynamic variables are computed: the time average wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), endothelial cell activation potential (ECAP) and displacement force (DF) for all three configurations.

RESULTS

The choice of blood flow model may affect results, but does not constitute a significant determinant on the overall performance of the assumed stent grafts. On the contrary, stent graft geometry has a major effect. Specifically, the Bottom Up non-ballet type is characterized by the least favorable performance presenting the lowest TAWSS and the highest OSI, RRT and ECAP values. On the other hand, the Top Down ballet type presents hemodynamic advantages yielding the highest TAWSS and lowest OSI, RRT and ECAP average values. Furthermore, the ballet type is characterized by the lowest DF, although differences observed are small and their clinical relevance uncertain.

CONCLUSIONS

The effect of the assumed rheological model on the overall performance of the grafts is not significant. It is thus relatively safe to claim that it is the type of stent graft that determines its overall performance rather than the adopted blood flow model.

Zone 2 Aortic Arch Repair With Single-Fenestrated Physician-Modified Endografts, at Least 3 Years of Follow-up

OBJECTIVE

The aim of this study is to report the efficiency and safety of single-fenestrated physician-modified endografts (PMEGs) in zone 2 aortic arch pathologies with at least 3 years of follow-up.

METHODS

All consecutive patients with a pathological aortic arch who underwent aortic repair combined with homemade single-fenestrated stent-graft from 2015 to 2020 were reviewed. The patients with a target vessel different from the left subclavian artery (LSA) were excluded.

RESULTS

A total of 63 patients were treated for a pathological arch in zone 2 with a single-fenestrated PMEG. 73% were male, and the mean age was 65 years old. 25% were treated for a degenerative aneurysm, 19% for a post dissection aneurysm and 24% for an acute type B dissection. 52% of the patients were treated as an emergency and half of those for an aortic rupture. The LSA fenestration was stented in 70%. During 30 days of follow-up, 2 strokes (3%) were reported, 6 patients (10%) died with 4 of those treated for aortic rupture and 1 had a retrograde aortic dissection. During at least 3 years of follow-up (median 49 months), no reintervention was needed for endoleaks, there was no stent fracture or stent migration. No patient died from an aortic cause. Subgroup analysis comparing the endovascular treatment for various aortic pathologies did not find significant differences in death rate or comorbidity including stroke. When comparing emergent and elective aortic repair, operating time was similar (64 vs 65 minutes), and the LSA fenestration was less frequently stented (52%) in the emergency group. There was no difference in stroke frequency. There was a higher rate of death in the emergency group at 30 days of follow-up, but no patient died from aortic cause in the long-term follow-up.

CONCLUSIONS

Aortic arch repair with single-fenestrated PMEGs for zone 2 pathological arch disease is associated with acceptable early and midterm major morbidity and mortality. It is suitable for emergency situations.

CLINICAL IMPACT

Single-fenestrated PMEG for the left subclavian artery is a safe and efficient option in the short and medium term for the treatment of the aortic arch in zone 2 with 98% technical success. It allows for aortic repair and subclavian artery revascularization in a single step for all patients. It is suitable for a range of main pathologies, including degenerative, dissection-related, isthmus rupture, and embolic pathologies. Additionally, it is always available and easily utilized in emergency cases.

Midterm outcomes of open repair versus endovascular descending thoracic aortic aneurysm repair

Objective

The study objective was to evaluate the midterm outcome of thoracic endovascular aortic repair compared with open repair in patients with descending thoracic aortic aneurysm.

Methods

From August 1993 to February 2023, 499 patients with descending thoracic aortic aneurysms underwent open repair (n = 221) or thoracic endovascular aortic repair (n = 278). Of these, 120 matched pairs were identified using propensity score matching based on age, sex, chronic lung disease, stroke, coronary artery disease, diabetes, ejection fraction, dialysis, peripheral vascular disease, prior cardiac surgery, connective tissue disease, and chronic dissection. Primary outcomes were postoperative paralysis, operative mortality, reoperation, and midterm survival.

Results

After matching, the preoperative demographics and comorbidities were balanced in both groups. Intraoperatively, open repair had a lower temperature (18 °C vs 36 °C) and more patients required blood products (66% vs 8%), P < .001. Postoperatively, patients undergoing thoracic endovascular aortic repair had fewer strokes (2.5% vs 9.2%; P = .03), less dialysis (0% vs 3.3%; P = .04), and shorter length of stay (5 days vs 12 days, P < .001), but similar lower-extremity paralysis (2.5% vs 2.5%, P = 1.00) compared with open repair. Furthermore, thoracic endovascular aortic repair had higher 7-year incidence of first reoperation (16.1% vs 3.6%, P < .001) but similar operative mortality (0.8% vs 4.2%; P = .10) and 10-year survival outcome (56%; 95% CI, 43-72 vs 58%; 95% CI, 49-68; P = .55) compared with open aortic repair. The hazard ratio was 0.93 (P = .78) for thoracic endovascular aortic repair for midterm mortality and 6.87 (P < .001) for reoperation.

Conclusions

Open repair could be the first option for patients with descending thoracic aortic aneurysms who were surgical candidates.

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.

Necrostatin-1 Attenuates Delayed Paraplegia after Transient Spinal Cord Ischemia in Rabbits by Inhibiting the Upregulation of Receptor-Interacting Protein Kinase 1 and 3

BACKGROUND

Delayed-onset paraplegia is a disastrous complication after thoracoabdominal aortic open surgery and thoracic endovascular aortic repair. Studies have revealed that transient spinal cord ischemia caused by temporary occlusion of the aorta induces delayed motor neuron death owing to apoptosis and necroptosis. Recently, necrostatin-1 (Nec-1), a necroptosis inhibitor, has been reported to reduce cerebral and myocardial infarction in rats or pigs. In this study, we investigated the efficacy of Nec-1 in delayed paraplegia after transient spinal cord ischemia in rabbits and assessed the expression of necroptosis- and apoptosis-related proteins in motor neurons.

METHODS

This study used rabbit transient spinal cord ischemia models using a balloon catheter. They were divided into a vehicle-treated group (n = 24), Nec-1-treated group (n = 24), and sham-controls (n = 6). In the Nec-1-treated group, 1 mg/kg of Nec-1 was intravascularly administered immediately before ischemia induction. Neurological function was assessed using the modified Tarlov score, and the spinal cord was removed 8 hr and 1, 2, and 7 days after reperfusion. Morphological changes were examined using hematoxylin and eosin staining. The expression levels of necroptosis-related proteins (receptor-interacting protein kinase [RIP] 1 and 3) and apoptosis-related proteins (Bax and caspase-8) were assessed using western blotting and histochemical analysis. We also performed double-fluorescence immunohistochemical studies of RIP1, RIP3, Bax, and caspase-8.

RESULTS

Neurological function significantly improved in the Nec-1-treated group compared with that in the vehicle-treated group 7 days after reperfusion (median 3 and 0, P = 0.025). Motor neurons observed 7 days after reperfusion were significantly decreased in both groups compared with the sham group (vehicle-treated, P < 0.001; Nec-1-treated, P < 0.001). However, significantly more motor neurons survived in the Nec-1-treated group than in the vehicle-treated group (P < 0.001). Western blot analysis revealed RIP1, RIP3, Bax, and caspase-8 upregulation 8 hr after reperfusion in the vehicle-treated group (RIP1, P = 0.001; RIP3, P = 0.045; Bax, P = 0.042; caspase-8, P = 0.047). In the Nec-1-treated group, the upregulation of RIP1 and RIP3 was not observed at any time point, whereas that of Bax and caspase-8 was observed 8 hr after reperfusion (Bax, P = 0.029; caspase-8, P = 0.021). Immunohistochemical study revealed the immunoreactivity of these proteins in motor neurons. Double-fluorescence immunohistochemistry revealed the induction of RIP1 and RIP3, and that of Bax and caspase-8, in the same motor neurons.

CONCLUSIONS

These data suggest that Nec-1 reduces delayed motor neuron death and attenuates delayed paraplegia after transient spinal cord ischemia in rabbits by selectively inhibiting necroptosis of motor neurons with minimal effect on their apoptosis.

Real-world comparative claims analysis of a novel single-branched aortic stent graft device versus thoracic endograft placement with extra-anatomic debranching/revascularization in zone 2 aortic disease

Background

Thoracic endovascular aortic repair (TEVAR) involving landing zone 2 can require extra-anatomic debranching (SR-TEVAR) to ensure left subclavian artery perfusion, resulting in increased costs. A single-branch device (Thoracic Branch Endoprosthesis [TBE], WL Gore, Flagstaff, AZ) provides a total endovascular solution. Comparative cost analysis of patients undergoing zone 2 TEVAR requiring left subclavian artery preservation with TBE versus SR-TEVAR is presented.

Methods

A single-center retrospective cost analysis was performed for aortic diseases requiring a zone 2 landing zone (TBE vs. SR-TEVAR) from 2014 to 2019. Facility charges were collected from the universal billing form UB-04 (form CMS 1450).

Results

Twenty-four patients were included in each arm. There were no significant differences in the overall mean procedural charges between the two groups: TBE, $209,736 ($57,761) vs. SR-TEVAR $209,025 ($93,943), P = 0.94. TBE resulted in reduced operating room charges ($36,849 [$8750] vs. $48,073 [$10,825], P = 0.02) and reduced intensive care unit and telemetry room charges, which did not reach statistical significance (P = 0.23 and 0.12, respectively). Device/implant charges were the primary cost driver in both groups. Charges associated with TBE were significantly higher: $105,525 ($36,137) vs. $51,605 ($31,326), P > 0.01.

Conclusions

TBE had similar overall procedural charges despite higher device/implant-related expenses and reduced facility resource utilization (lower operating room, intensive care unit, telemetry, and pharmacy charges).

Thoracoabdominal aortic aneurysm life-altering events following endovascular aortic repair in the Vascular Quality Initiative

OBJECTIVE

Endovascular aortic aneurysm repair has lower rates of postoperative mortality and morbidity when compared with open repair. However, endovascular repair still carries the risk of postoperative dialysis, paralysis, and stroke. This study examined the rates of postoperative mortality and morbidity stratified by type of endovascular aortic aneurysm repair.

METHODS

All patients who underwent endovascular aortic aneurysm repair in the Vascular Quality Initiative registry from January 2011 - May 2022 were identified. Patients were stratified by repair type: infrarenal endovascular aortic repair (EVAR), complex EVAR, thoracic endovascular aortic repair (TEVAR), extent I-III thoracoabdominal aortic aneurysm (TAAA) repair, or aortic arch repair. The primary outcome was postoperative thoracoabdominal aortic aneurysm life-altering events (TALE) across the different treatment groups. TALE was defined as a composite outcome of postoperative mortality, dialysis, paralysis, and/or stroke. Mixed effect logistic regression modeling was used to identify procedural and anatomic factors that were independently associated with TALE.

RESULTS

A total of 52,592 EVARs, 3,768 complex EVARs, 3,899 TEVARs, 1,139 extent I-III TAAA repairs, and 479 arch repairs were identified. TALE was observed in 1.2% of EVARs, 4.8% of complex EVARs, 6.0% of TEVARs, 10% of extent I-III TAAA repairs, and 14% of arch repairs. More proximal landing zone was associated with higher odds of TALE after complex EVAR (OR 1.9 [1.2-3.1]; p=.008), TEVAR (OR 2.2 [1.4-3.5]; p=.001), and extent I-III TAAA repair (OR 2.7 [1.5-4.9]; p=.001). Aortic diameter >65mm was associated with higher odds of TALE after infrarenal EVAR (OR 1.8 [1.4-2.3]; p<.001), complex EVAR (OR 1.6 [1.1-2.3]; p=.010), TEVAR (OR 2.7 [2.0-3.8]; p<.001), and arch repair (OR 2.4; [1.3-4.4]; p=.007). The use of parallel grafting technique (chimney/snorkel/periscope) during extent I-III TAAA repair was also associated with higher odds of TALE (OR 1.8 [1.1-3.2]; p=.032). Preoperative chronic kidney disease was also associated with higher odd of TALE after infrarenal EVAR (OR 4.3 [3.0-5.7]; p<.001), complex EVAR (OR 5.2 [3.3-8.2]; p<.001), TEVAR (OR 4.5 [2.8-7.1]; p<.001), and extent I-III TAAA repair (OR 3.2 [1.6-6.7]; p=.001).

CONCLUSION

While TALE was originally described for thoracoabdominal aortic aneurysm repairs, TALE may occur after complex EVAR, TEVAR, and arch repairs as well. Therefore, TALE and its component parts should be used to evaluate the efficacy of all aortic repairs and for preoperative counseling. Additionally, surgeons should be aware of anatomic and procedural characteristics that are associated with higher odds of TALE. The anticipated need for such interventions during aortic repair should be factored into preoperative risk assessment of patients.

Open surgical replacement of the descending aorta: single-center experience

Background

This study presents a single center's experience and analyzes clinical outcomes following elective open surgical descending aortic replacement.

Methods

Between January 2000 and August 2019, 96 patients with mean age 64 years (range, 49.5-71 years) (62.5% (n=60) male) underwent elective descending aortic replacement due to aneurysm (n=60) or chronic dissection (n=36). Marfan syndrome was present in 12 patients (12.5%).

Results

In-hospital mortality rate was 3.1% (n= 3. 2 in the aneurysm group, 1 in the dissection group). New-onset renal insufficiency postoperatively with (creatinine ≥ 2.5 mg/dl) manifested in 10 patients (10.8%). One patient (1%) suffered from stroke, and paraplegia developed in 1 pts (1%). The median follow-up time was 7 years (IQR: 2.5-13 years). The 5- and 10-year survival rates were 70.8% and 50.7% respectively. We did not observe any early or late prosthetic graft infection. The Cox proportional hazards regression analysis identified age (HR: 1.044, 95% CI: 1.009-1.080, p-value: 0.014), diabetes (HR: 2.544, 95% CI: 1.009-6.413, p-value: 0.048), and chronic obstructive pulmonary disease (COPD) (HR: 2.259, 95% CI: 1.044-4.890, p-value: 0.039) as risk factors for late mortality.

Conclusions

This study showed that the elective open surgical replacement of the descending aorta can be achieved with excellent outcomes in terms of perioperative mortality and morbidity. Prosthetic graft is not a problem with open surgical descending aortic replacement, even in the long term.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-022-01443-x.

Stroke Following Thoracic Endovascular Aortic Repair: Determinants, Short and Long Term Impact

We performed a contemporary assessment of clinical and radiographic factors of stroke after thoracic endovascular aortic repair (TEVAR). Patients undergoing TEVAR from 2006 to 2017 were identified. We assessed clinical and radiographic data, including preoperative head and neck computed tomography, Doppler ultrasonography, and intraoperative angiography. Our primary outcome was stroke after TEVAR. Four hundred seventy-nine patients underwent TEVAR, mean age 68.1 ± 19.5 years, 52.6% male. Indications for TEVAR included aneurysms (n = 238, 49.7%) or dissections (n = 152, 31.7%). Ishimaru landing zones were Zone 2 (n = 225, 47.0%), Zone 3 (n = 151, 31.5%), or Zone 4 (n = 103, 21.5%). Stroke occurred in 3.8% (n = 18) of patients, with 1.9% (8) major events (modified Rankin Scale >3). Pathophysiology was predominantly embolic (n = 14), and occurred in posterior (n = 6), anterior (n = 6), or combined circulation (n = 4), and in the left hemisphere (n = 10) or bilateral (n = 6). Univariate analysis suggested use of lumbar drain (33.3% versus 57.2%, P = 0.04), inability to revascularize the left subclavian artery (16.7% vs 5.2%, P = 0.04) and number of implanted components (2.5 ± 1.2 vs 2.0 ± 0.97, P = 0.03) were associated with stroke. Multivariable analysis identified number of implanted components (OR 1.7, 95%CI 1.17-2.67 P = 0.00) and inability to revascularize the left subclavian artery as independent predictors of stroke. Stroke was associated with a higher perioperative mortality (27.8% vs 3.9%, P < 0.01). Stroke after TEVAR is primarily embolic in nature and related to both anatomic and procedural factors. This may have important implications for device development in the era of endovascular arch repair.

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.

Single-center experience with thoracoabdominal aortic replacement in patients with Marfan syndrome

Objectives

Patients with Marfan syndrome are usually not suitable for endovascular repair of the thoracoabdominal aorta. This study was designed to analyze our center's experience with open surgical thoracoabdominal aortic replacement in Marfan patients.

Methods

This was a retrospective study with prospective follow-up. Between January 1995 and September 2021, a total of 648 patients underwent thoracoabdominal aortic replacement at our center. Of these, 60 had Marfan syndrome and were included in this study.

Results

The mean age was 39.5 ± 10.7 years, and 36 (60%) were male. Ten (17%) had aortic aneurysm, 4 (7%) acute/subacute dissection, and 46 (77%) chronic dissection. Patients presented with the following extent of aortic disease according to the Crawford classification: I-17 (28%), II-18 (30%), III-22 (37%), IV-2 (3%), and V-1 (2%). The mean cardiopulmonary bypass time was 173.9 ± 84.7 minutes. Four (7%) patients required stent graft extraction. Postoperatively, 5 (8%) patients required rethoracotomy and 6 (10%) tracheostomy. One (1.7%) patient had permanent paraplegia and 2 (3%) permanent paraparesis. Two (3%) patients had stroke. One (1.7%) patient was discharged with dialysis. The 30-day mortality was 3% (n = 2). Median follow-up time was 21.5 (range, 9.4-33.6) years. The 1-, 5-, and 10-year survival rate was 87%, 80%, and 68%, respectively. There were 16 aortic reinterventions in 9 patients during follow-up.

Conclusions

Thoracoabdominal aortic replacement remains a complex procedure but can be done extremely safely in Marfan patients. Perioperative mortality rates are very low, and the long-term outcomes are enduring. Because endovascular aortic repair is not recommended for patients with connective tissue disease, open surgery remains an important cornerstone of therapy.

Beta-blocker Use After Thoracic Endovascular Aortic Repair in Patients with Type B Aortic Dissection Is Associated with Improved Early Aortic Remodeling

OBJECTIVE

Beta-blockers are first-line anti-impulse therapy in patients presenting with acute type B aortic dissection (TBAD). However, little is understood about their impact after aortic repair. The aim of this study was to evaluate the role of postoperative beta-blocker use on outcomes of thoracic endovascular aortic repair (TEVAR) in TBAD.

METHODS

The Vascular Quality Initiative database was queried for all patients undergoing TEVAR for TBAD from 2012 to 2020. Aortic-related reintervention, all-cause mortality and effect of TEVAR on false lumen thrombosis of the treated aortic segment were assessed and compared between patients treated with and without beta-blocker postoperatively. Cox proportional hazards models were used to estimate the effect of beta-blocker therapies on outcomes.

RESULTS

1,114 patients undergoing TEVAR for TBAD were identified with a mean follow-up of 18±12 months. The mean age was 61.1±11.9 years, and 791 (71%) were male. 935 (84%) patients were maintained on beta-blocker at discharge and follow-up. Patients on beta-blocker were more likely to have an entry tear originating in zones 1-2 (22% vs 13%; P=.022). The prevalence of acute, elective and symptomatic AD, concurrent aneurysm, number of endografts used, distribution of the proximal and distal zones of dissection and operative time were comparable between the two cohorts. At 18-months, significantly more complete false lumen thrombosis (58 vs 47%; log-rank P=.018) was observed in patients on beta-blocker while the rates of aortic-related reinterventions (13% vs 9%; log-rank P=.396) and mortality (0.2% vs 0.7%; log-rank P=.401) were similar in patients with and without beta-blocker, respectively. Even after adjusting for clinical and anatomic factors, postoperative beta-blocker use was associated with increased complete false lumen thrombosis (HR 1.56; 95% CI: 1.10-2.21; P=.012) but did not affect mortality or aortic-related reintervention. A secondary analysis of beta-blocker use in acute versus chronic TBAD showed a higher rate of complete false lumen thrombosis in patients on beta-blocker in chronic TBAD (59% vs 38%; log-rank P=.038). In contrast, there was no difference in the rate of complete false lumen thrombosis in acute TBAD between the two cohorts (58% vs 51%; log-rank P=.158). When analyzed separately, postoperative ACE inhibitor use did not affect the rates of complete false lumen thrombosis, mortality and aortic-related reintervention.

CONCLUSIONS

Beta-blocker use was associated with promotion of complete false lumen in patients undergoing TEVAR for TBAD. In addition to its role in acute setting, anti-impulse control with beta-blocker appears to confer favorable aortic remodeling and may improve outcomes after TEVAR, particularly for chronic TBAD.

GORE® TAG® conformable thoracic stent graft for the treatment of descending aortic pathologies

Endovascular repair of the descending thoracic aorta has gained widespread acceptance as a primary treatment modality for thoracic aortic disease due to its minimally invasive approach and improved survival rates. GORE^® TAG^® Conformable Thoracic Stent Graft was designed for descending thoracic aortic aneurysms, penetrating ulcers, aortic transections and type B aortic dissections, which are accepted indications for endovascular therapy. The aim of this review is to summarize the clinical literature, focusing mainly on the publications that came from manufacturer's pre-market and post-market studies. Including the Global Registry for Endovascular Aortic Treatment (GREAT), sponsored by WL Gore & Associates (Flagstaff, AZ, USA), which is a large database of endovascular repair of various thoracic, abdominal and thoraco-abdominal aortic pathologies to identify and evaluate only those with isolated thoracic aortic pathology (arch and descending thoracic).

Endovascular stent grafting and open surgical replacement for chronic thoracic aortic aneurysms: a systematic review and prospective cohort study

Background

The management of chronic thoracic aortic aneurysms includes conservative management, watchful waiting, endovascular stent grafting and open surgical replacement. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) study investigates timing and intervention choice.

Objective

To describe pre- and post-intervention management of and outcomes for chronic thoracic aortic aneurysms.

Design

A systematic review of intervention effects; a Delphi study of 360 case scenarios based on aneurysm size, location, age, operative risk and connective tissue disorders; and a prospective cohort study of growth, clinical outcomes, costs and quality of life.

Setting

Thirty NHS vascular/cardiothoracic units.

Participants

Patients aged > 17 years who had existing or new aneurysms of ≥ 4 cm in diameter in the arch, descending or thoracoabdominal aorta.

Interventions

Endovascular stent grafting and open surgical replacement.

Main outcomes

Pre-intervention aneurysm growth, pre-/post-intervention survival, clinical events, readmissions and quality of life; and descriptive statistics for costs and quality-adjusted life-years over 12 months and value of information using a propensity score-matched subsample.

Results

The review identified five comparative cohort studies (endovascular stent grafting patients, n = 3955; open surgical replacement patients, n = 21,197). Pooled short-term all-cause mortality favoured endovascular stent grafting (odds ratio 0.71, 95% confidence interval 0.51 to 0.98; no heterogeneity). Data on survival beyond 30 days were mixed. Fewer short-term complications were reported with endovascular stent grafting. The Delphi study included 20 experts (13 centres). For patients with aneurysms of ≤ 6.0 cm in diameter, watchful waiting was preferred. For patients with aneurysms of > 6.0 cm, open surgical replacement was preferred in the arch, except for elderly or high-risk patients, and in the descending aorta if patients had connective tissue disorders. Otherwise endovascular stent grafting was preferred. Between 2014 and 2018, 886 patients were recruited (watchful waiting, n = 489; conservative management, n = 112; endovascular stent grafting, n = 150; open surgical replacement, n = 135). Pre-intervention death rate was 8.6% per patient-year; 49.6% of deaths were aneurysm related. Death rates were higher for women (hazard ratio 1.79, 95% confidence interval 1.25 to 2.57; p = 0.001) and older patients (age 61–70 years: hazard ratio 2.50, 95% confidence interval 0.76 to 5.43; age 71–80 years: hazard ratio 3.49, 95% confidence interval 1.26 to 9.66; age > 80 years: hazard ratio 7.01, 95% confidence interval 2.50 to 19.62; all compared with age < 60 years, p < 0.001) and per 1-cm increase in diameter (hazard ratio 1.90, 95% confidence interval 1.65 to 2.18; p = 0.001). The results were similar for aneurysm-related deaths. Decline per year in quality of life was greater for older patients (additional change –0.013 per decade increase in age, 95% confidence interval –0.019 to –0.007; p < 0.001) and smokers (additional change for ex-smokers compared with non-smokers 0.003, 95% confidence interval –0.026 to 0.032; additional change for current smokers compared with non-smokers –0.034, 95% confidence interval –0.057 to –0.01; p = 0.004). At the time of intervention, endovascular stent grafting patients were older (age difference 7.1 years; 95% confidence interval 4.7 to 9.5 years; p < 0.001) and more likely to be smokers (75.8% vs. 66.4%; p = 0.080), have valve disease (89.9% vs. 71.6%; p < 0.0001), have chronic obstructive pulmonary disease (21.3% vs. 13.3%; p = 0.087), be at New York Heart Association stage III/IV (22.3% vs. 16.0%; p = 0.217), have lower levels of haemoglobin (difference –6.8 g/l, 95% confidence interval –11.2 to –2.4 g/l; p = 0.003) and take statins (69.3% vs. 42.2%; p < 0.0001). Ten (6.7%) endovascular stent grafting and 15 (11.1%) open surgical replacement patients died within 30 days of the procedure (p = 0.2107). One-year overall survival was 82.5% (95% confidence interval 75.2% to 87.8%) after endovascular stent grafting and 79.3% (95% confidence interval 71.1% to 85.4%) after open surgical replacement. Variables affecting survival were aneurysm site, age, New York Heart Association stage and time waiting for procedure. For endovascular stent grafting, utility decreased slightly, by –0.017 (95% confidence interval –0.062 to 0.027), in the first 6 weeks. For open surgical replacement, there was a substantial decrease of –0.160 (95% confidence interval –0.199 to –0.121; p < 0.001) up to 6 weeks after the procedure. Over 12 months endovascular stent grafting was less costly, with higher quality-adjusted life-years. Formal economic analysis was unfeasible.

Limitations

The study was limited by small numbers of patients receiving interventions and because only 53% of patients were suitable for both interventions.

Conclusions

Small (4–6 cm) aneurysms require close observation. Larger (> 6 cm) aneurysms require intervention without delay. Endovascular stent grafting and open surgical replacement were successful for carefully selected patients, but cost comparisons were unfeasible. The choice of intervention is well established, but the timing of intervention remains challenging.

Future work

Further research should include an analysis of the risk factors for growth/rupture and long-term outcomes.

Trial registration

Current Controlled Trials ISRCTN04044627 and NCT02010892.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 6. See the NIHR Journals Library website for further project information.

Retrograde Superior Mesenteric Artery Stenting in Case of SMA Shuttering

This case describes a patient who underwent endovascular repair for an extent V thoracoabdominal aneurysm with planned coverage of the celiac artery. Following deployment of the stent graft, the superior mesenteric artery was shuttered, and the patient subsequently developed signs and symptoms of bowel ischemia. The patient underwent successful retrograde open superior mesenteric artery stenting with resolution of her symptoms. Although retrograde open mesenteric artery stenting (ROMS) has been primarily shown to be effective in acute mesenteric ischemia, this case demonstrates that ROMS can be used as a salvage option for shuttering during endovascular procedures.

Outcomes of Thoracic Endovascular Aortic Repair in Octogenarians

OBJECTIVE

The aim of this study is to compare outcomes between octogenarians and non-octogenarians undergoing thoracic endovascular aortic repair (TEVAR).

METHODS

Using the National Inpatient Sample database, we identified octogenarians (≥80 years) and non-octogenarians (<80 years) who had undergone thoracic endovascular aortic repair between 2012 and 2017. We compared patients' demographic, socioeconomic, comorbidity data between the two groups as well as the procedure indications and perioperative outcomes. A multivariable logistic regression analysis was conducted to evaluate the impact of advanced age (≥80 years) on the in-hospital mortality rates in patients who underwent TEVAR. This analysis was also performed for a separate cohort which included only patients who underwent TEVAR for ruptured thoracic aortic aneurysm.

RESULTS

A total of 4108 patients were included in our study; 3432 (83.5%) patients were <80 years (37.9% female; median age, 64 years; 34.3% non-white) and 676 (16.5%) patients were ≥80 years (50.7% female; median age, 83 years; 20.4% non-white). Non-ruptured thoracic aortic aneurysm was the most common indication for TEVAR in older patients (61.4%), whereas type B aortic dissection was the most common indication in younger patients (36.4%). In-hospital complications were comparable between the two groups except for respiratory complications that were higher in the younger patients (21.2% vs. 15.2%; P <.001). The multivariable analysis demonstrated that advanced age had no association with increased in-hospital mortality rates (adjusted odds ratio [aOR], 1.41; 95% confidence interval [CI], .97-2.05), However, in ruptured thoracic aortic aneurysm cohort, octogenarians had higher in-hospital mortality rates (aOR, 1.86; 95% CI, 1.04-3.32).

CONCLUSIONS

Octogenarians have acceptable rates of perioperative morbidity and mortality compared to the younger group and should be considered for TEVAR. Octogenarians are at higher risk for in-hospital mortality in the setting of ruptured thoracic aortic aneurysm, supporting the appropriateness of elective TEVAR in selected Octogenarians.

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.

IMPACT OF THORACIC ENDOVASCULAR AORTIC REPAIR TIMING ON AORTIC REMODELING IN ACUTE TYPE B AORTIC INTRAMURAL HEMATOMA

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) is increasingly utilized in the management of acute type B aortic intramural hematoma (TBIMH). Optimal timing for intervention has not been described. The aim of this study was to evaluate TEVAR timing on post-operative aortic remodeling.

METHODS

A retrospective chart review was performed on patients who underwent TEVAR for TBIMH from January 2008 to September 2018. Imaging was reviewed pre- and postoperatively. Primary data points included true lumen diameter (TLD) and total aortic diameter (TAD) at the site of maximal pathology. Primary endpoint was aortic remodeling evidenced by a TAD/TLD ratio closest to 1.0. Secondary outcome was occurrence of aortic-related adverse events and mortality (AREM): aortic rupture, aortic-related death, progression to dissection or need for aortic re-intervention within 12 months. Patients undergoing emergent TEVAR (within 24 hours, 'eTEVAR') were compared to the remainder - delayed TEVAR ('dTEVAR').

RESULTS

We analyzed 71 patients that underwent TEVAR FOR TBIMH; 25 underwent emergent TEVAR and 46 patients underwent dTEVAR (median: 5.5 days, range: 2-120 days). There were no differences in demographics and comorbidities and patients did not differ in presenting IMH thickness (12.6±3.1 mm vs. 11.3±4.1 mm, p=0.186) nor presenting TAD/TLD ratio (1.535±0.471 vs. 1.525±0.397, p=0.928) for eTEVAR and dTEVAR groups, respectively. eTEVAR patients had larger average presenting maximal descending aortic (DTA) diameter (45.8±14.3 mm vs. 38.2±7.5 mm, p=0.018) and higher incidence of penetrating aortic ulcer (PAU) on presenting CT angiography (52.0% vs 21.7%, p=0.033). Thirty day mortality was 2/25 (8.0%) for eTEVAR and 2/45 (4.4%) for dTEVAR (p=0.602). Postoperative aortic remodeling was more complete in the dTEVAR group (1.23±0.12 vs. 1.33±0.15, p=0.004). Case-control matching (controlling for presenting DTA diameter and PAU) on 30 patients still showed better aortic remodeling in the dTEVAR group (1.125±0.100 vs 1.348±0.42, p<0.001). The incidence of AREM was higher in the eTEVAR - 6/25 (24.0%) - group compared to the dTEVAR group - 2/46 (4.3%). At 12 months, freedom from AREM was higher in the dTEVAR group (95.7% vs. 76.0%, p=0.011). Postoperative TAD/TLD ratio was the best predictor for late aortic-related adverse events (AUROC=0.825, p=0.003).

CONCLUSION

TEVAR for acute type B IMH within 24 hours of admission is associated with lower aortic remodeling and higher occurrence of late aortic related adverse events and mortality. Delaying TEVAR when clinically possible could improve aortic remodeling and aortic-related outcomes.

Effectiveness of endovascular versus open surgical repair for thoracic aortic aneurysm: a systematic review and meta-analysis

INTRODUCTION

Since the approval, the TEVAR is widely used for the repair of thoracic aortic aneurysm. However, the long-term mortality and re-intervention rates compared to OSR are unclear. We aimed to compare the effectiveness of the thoracic endovascular aortic repair (TEVAR) with open surgical repair (OSR) specifically for thoracic aortic aneurysms.

EVIDENCE ACQUISITION

We conducted a comprehensive search in MEDLINE, PubMed, EMBASE, CINAHL, PROSPERO, Centre for Reviews and Dissemination, and the Cochrane Library up to November 2020. The main outcomes were early mortality, mid-to-long-term survival, and re-intervention. The quality of the evidence was assessed using the GRADE methodology. All analyses were performed using RevMan with the random effect model and Comprehensive Meta-Analysis software.

EVIDENCE SYNTHESIS

One systematic review and 15 individual studies were included. Pooled analysis showed that 30-day mortality, stroke, renal failure, and pulmonary complications were significantly lower in TEVAR vs. open surgery. The pooled rate of re-intervention significantly favored the OSR. The long-term survival and mortality favored TEVAR and OSR in one and two studies, respectively, but was non-significant in 7 analyzes.

CONCLUSIONS

Early clinical outcomes including the 30-day mortality, stroke, renal failure, and pulmonary complications significantly favored the TEVAR. However, the mid-to-long-term re-intervention rate favored the OSR and long-term survival was inconsistent among the studies. The quality of evidence was very low. More studies with longer follow-ups are needed. The use of TEVAR should be decided by taking into account other factors including patient characteristics and preferences, cost, and surgeon expertise.

Anticoagulation and Antiplatelet Medications Do Not Affect Aortic Remodeling after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection

OBJECTIVE

There is a lack of evidence regarding the effect of anticoagulation and antiplatelet medications on aortic remodeling for aortic dissection after endovascular repair. We investigated whether anticoagulation and antiplatelet medications affect aortic remodeling after thoracic endovascular aortic repair (TEVAR) for Type B aortic dissection (TBAD).

METHODS

Records of the Vascular Quality Initiative TEVAR registry (2012-2020) were reviewed. Procedures performed for TBAD were included. Aortic reintervention, false lumen thrombosis of the treated aorta and all-cause mortality at follow-up were compared between patients treated with and without anticoagulation medications. A secondary analysis was performed to assess the effect of antiplatelet therapy in patients not on anticoagulation. Cox proportional hazards models were used to estimate the effect of anticoagulation and antiplatelet therapies on outcomes.

RESULTS

1,210 patients (mean age, 60.7±12.2 years; 825 (68%) males) were identified with a mean follow-up of 21.2±15.7 months (range 1-94 months). 166 (14%) patients were on anticoagulation medications at discharge and at follow-up. Patients on anticoagulation were more likely to be older (mean age, 65.5 vs 60 years; P<.001) and Caucasian (69% vs 55%; P=.003), with higher proportions of coronary artery disease (10% vs 3%; P<.001), congestive heart failure (10% vs 2%; P<.001) and chronic obstructive pulmonary disease (15% vs 9%; P=.017). There were no differences in the mean preoperative thoracic aortic diameter or the number of endografts used. At 18-month, the rates of aortic reinterventions (8% vs 9% log-rank P=.873), complete false lumen thrombosis (52% vs 45%; P=.175) and mortality (2.5% vs 2.7%; P=.209) were similar in patients with and without anticoagulation, respectively. Controlling for covariates with the Cox regression method, anticoagulation use was not independently associated with a decreased rates of complete false lumen thrombosis (hazard ratio (HR) 0.74; 95% confidence interval (CI), 0.5-1.1; P=.132), increased need for aortic reinterventions (HR 1.02; 95% CI, 0.62-1.68; P=.934), and mortality (HR 1.25; 95% CI, 0.64-2.47; P=.514). On a secondary analysis, antiplatelet medications did not affect the rates of aortic reintervention, complete false lumen thrombosis and mortality.

CONCLUSIONS

Anticoagulation and antiplatelet medications do not appear to negatively influence the midterm endpoints of aortic reintervention or death in patients undergoing TEVAR for TBAD. Moreover, it did not impair complete false lumen thrombosis. Anticoagulation and antiplatelet medications do not adversely affect aortic remodeling and survival in this population at midterm.

Comparative evaluation of ballet-type and conventional stent graft configurations for endovascular aneurysm repair: A CFD analysis

PURPOSE:

Cross limb stent graft (SG) configuration technique for endovascular aneurysm repair (EVAR) is employed for splayed aortic bifurcations to avoid device kinking and smoothen cannulation. The present study investigates three types of stent graft (SG) configurations for endovascular aneurysm repair (EVAR) in abdominal aortic aneurysm. A computational fluid dynamic analysis was performed on the pulsatile non-Newtonian flow characteristics in three ideally modeled geometries of abdominal aortic (AA) SG configurations.

METHODS:

The three planar and crosslimb SG configurations were ideally modeled, namely, top-down nonballet-type, top-down ballet-type, and bottom-up nonballet-type configurations. In top-down SG configuration, most of the device is deployed in the main body in the vicinity of renal artery and the limbs are extended to the iliac artery. While in the bottom-up configuration, some of the SG device is deployed in the main body, the limbs are deployed in aortic bifurcation, and the extra stent graft of the main body is extended to the proximal aorta until the below of the renal artery. The effects of non-Newtonian pulsatile flow on the wall stresses and flow patterns of the three models were investigated and compared. Moreover, the average wall shear stress (AWSS), oscillatory shear stress index (OSI), absolute helicity, pressure distribution, graft displacement and flow visualization plots were analyzed.

RESULTS:

The top-down ballet-type showed less branch blockage effect than the top-down nonballet-type models. Furthermore, the top-down ballet-type configuration showed an increased tendency to sustain high WSS and higher helicity characteristics than that of the bottom-up and top-down non-ballet type configurations. However, displacement forces of the top-down ballet-type configuration were 40% and 9.6% higher than those of the bottom-up and top-down nonballet-type configurations, respectively.

CONCLUSIONS:

Some complications such as graft tearing, thrombus formation, limb disconnection during long term follow up periods might be relevant to hemodynamic characteristics according to the configurations of EVAR. Hence, the reported data required to be validated with the clinical results.

Outcomes of Open v. Endovascular Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms

BACKGROUND

Open repair is the standard of care for patients with descending thoracic and thoracoabdominal aortic aneurysms. Although effective, surgery carries a high risk of morbidity and mortality. Endovascular stent-grafts were introduced to treat these aneurysms in patients considered too high risk for open repair. Early results are promising, but later results are incompletely known. Therefore, we sought to compare short- and intermediate-term outcomes of open versus endovascular repair for these aneurysms.

METHODS

From 2000-2010, 1,053 patients underwent open (n=457) or endovascular (n=596) repair of descending thoracic and thoracoabdominal aortic aneurysms at Cleveland Clinic. To balance patient characteristics between these groups, propensity-score matching was performed, yielding 278 well-matched pairs (61% of possible pairs). Endpoints included short- and long-term outcomes.

RESULTS

In matched patients, compared with endovascular stenting, open repair achieved similar in-hospital mortality (n=23/8.3% vs n=21/7.6%, P=.8) and occurrence of paralysis and stroke (n=10/3.6% vs n=6/2.2%, P=.3), despite longer postoperative stay (median 11 vs 6 days), more dialysis-dependent acute renal failure (n=24/8.6% vs n=9/3.3%, P=.008), and prolonged ventilation (n=106/46% vs n=17/6.3%, P<.0001). Open repair resulted in better 10-year survival than endovascular repair (52% vs 33%, P<.0001), and aortic reintervention was less frequent (4% vs 21%, P<.0001). Despite a decrease in the first postoperative year, average aneurysm size did not recover to normal range after endovascular stenting.

CONCLUSIONS

Open repair of descending thoracic and thoracoabdominal aneurysms can achieve acceptable short-term outcomes with better intermediate-term outcomes than endovascular repair.

RETRACTED: Anesthesic and surgical guideline for the treatment of the thoraco-abdominal aorta. Consensus Document of the Spanish Societies of Anesthesia and Cardiovascular Surgery

Este artículo ha sido retirado por indicación del Editor Jefe de la revista, después de constatar que parte de su contenido había sido plagiado, sin mencionar la fuente original: European Heart Journal (2014) 35, 2873 926.: https://academic.oup.com/eurheartj/article/35/41/2873/407693#89325738 El autor de correspondencia ha sido informado de la decisión y está de acuerdo con la retirada del artículo. El Comité Editorial lamenta las molestias que esta decisión pueda ocasionar. Puede consultar la política de Elsevier sobre la retirada de artículos en https://www.elsevier.com/about/our-business/policies/article-withdrawal

Gimme' the Loop: Modifications to the Squid-Capture Technique for Laser-Fenestrated Thoracic Endografting

PURPOSE

Laser-fenestrated thoracic endovascular aortic repair (LfTEVAR) in the aortic arch with covering of the left subclavian artery (LSA) orifice is challenging. To optimize fenestration, the so-called squid-capture technique has been introduced. We present here a modification to the technique that may help improve time-efficiency and safety.

TECHNIQUE:

During the originally proposed squid-capture maneuver, the stent-graft is deployed in a preset snare wire loop, which is used to pull the stent graft toward the penetration device during in-situ fenestration. In preparation, the guidewire needs to be passed through the loop inside the aortic arch, which can be difficult and may predispose for embolic events. We propose here the creation of a "guidewire-through-snare-loop" configuration outside the body, which can then be reliably transferred into the aortic arch. The modified technique was successfully applied in a patient undergoing LfTEVAR for penetrating aortic ulcers.

CONCLUSION

The proposed modification may help facilitate the squid-capture technique for LfTEVAR while saving time and resources. Given that LfTEVAR is becoming more frequently used, it is important to ensure technical success and safety of the procedure.

Long-term survival after descending thoracic and thoracoabdominal aortic aneurysm repair

OBJECTIVE

Patients with descending thoracic aortic aneurysms (dTAA) or thoracoabdominal aortic aneurysms (TAAA) often have a variety of medical comorbidities. Those that are deemed acceptable for intervention undergo complicated repairs with good early outcomes. The purpose of this study was to identify variables that were associated with mortality over time.

METHODS

This was a retrospective review of a prospectively maintained database at our institution from 1983 to 2015. Patients were included if they underwent open or endovascular repair for dTAA or TAAA. Patients were excluded if they were intervened on for traumatic transections. The primary outcome for the study was long-term survival. Secondary outcomes included aortic-related mortality. We had mortality and survival data on all patients.

RESULTS

A total of 946 patients met our study criteria with a median follow-up of 102.8 months (interquartile range [IQR], 58.9-148.2 months). The median age of the cohort was 71 years (IQR, 63-77 years) with the majority of patients being male (58.1%). The extent of TAAA pathology was as follows: type I (14.2%), type II (21.2%), type III (17.1%), type IV (26.2%), and dTAA (21.2%). A total of 147 patients (15.5%) had a prior dissection. The median diameter of aneurysm was 6.4 cm (IQR, 6.0-7.0 cm). A total of 158 patients (16.7%) underwent endovascular repair over the study period. Variables associated with mortality over time were age, surgical era, acute pathology, dissection, preoperative creatinine, and type IV TAAAs. In addition, experiencing the following complications in the postoperative period was associated with mortality over time: neurological, cardiac, and pulmonary. Aortic-related mortality was 2.1% (n = 20) over the study period. Patients who underwent endovascular repair for acute conditions had better long-term survival when compared with open repair. However, there were no differences in long-term survival between open and endovascular repair for nonacute cases. In addition, repair in the more modern era was associated with improved survival.

CONCLUSIONS

TAAAs can be repaired with reasonable perioperative mortality rates. Once patients undergo repair of their aneurysm, aortic-related mortality remains low. The addition of endovascular options has dramatically changed management of patients with dTAA and TAAA. Further, endovascular repair was associated with decreased perioperative mortality and significantly increased long-term survival in acute patients. Patients undergoing TAAA repair are generally considered high risk and therefore require extensive long-term follow-up for management of their comorbidities and complications, because these are the main contributors to mortality over time.

Multiaxial pulsatile dynamics of the thoracic aorta and impact of thoracic endovascular repair

•

Altered motion of the thoracic aorta after thoracic endovascular aortic repair.

•

Geometric analysis with cardiac-gated computed tomography and computer modeling.

•

Decreased motion of the stented aorta and increased motion above the stented aorta.

•

Longitudinal curvature and diametric deformation affected by presence of endograft.

Purpose

The thoracic aorta is a highly mobile organ whose dynamics are altered by thoracic endovascular aorta repair (TEVAR). The aim of this study was to quantify cardiac pulsatility-induced multi-axial deformation of the thoracic aorta before and after descending aortic TEVAR.

Methods

Eleven TEVAR patients (8 males and 3 females, age 57–89) underwent retrospective cardiac-gated CT angiography before and after TEVAR. 3D geometric models of the thoracic aorta were constructed, and lumen centerlines, inner and outer surface curves, and cross-sections were extracted to measure aortic arclength, centerline, inner surface, and outer surface longitudinal curvatures, as well as cross-sectional effective diameter and eccentricity for the ascending and stented aortic portions.

Results

From pre- to post-TEVAR, arclength deformation was increased at the ascending aorta from 5.9 ± 3.1 % to 8.8 ± 4.4 % (P < 0.05), and decreased at the stented aorta from 7.5 ± 5.1 % to 2.7 ± 2.5 % (P < 0.05). Longitudinal curvature and diametric deformations were reduced at the stented aorta. Centerline curvature, inner surface curvature, and cross-sectional eccentricity deformations were increased at the distal ascending aorta.

Conclusions

Deformations were reduced in the stented thoracic aorta after TEVAR, but increased in the ascending aorta near the aortic arch, possibly as a compensatory mechanism to maintain overall thoracic compliance in the presence of reduced deformation in the stiffened stented aorta.

Systematic review of endovascular stent grafting versus open surgical repair for the elective treatment of arch/descending thoracic aortic aneurysms

OBJECTIVE

To review comparisons of the effectiveness of endovascular stent grafting (ESG) against open surgical repair (OSR) for treatment of chronic arch or descending thoracic aortic aneurysms (TAA).

DESIGN

Systematic review and meta-analysis DATA SOURCES: MEDLINE, EMBASE, CENTRAL, WHO International Clinical Trials Routine data collection, current controlled trials, clinical trials and the NIHR portfolio were searched from January 1994 to March 2020.

ELIGIBILITY CRITERIA FOR SELECTIVE STUDIES

All identified studies that compared ESG and OSR, including randomised controlled trials (RCTs), quasi-randomised and non-RCTs, comparative cohort studies and case-control studies matched on main outcomes were sought. Participants had to receive elective treatments for arch/descending (TAA). Studies were excluded where other thoracic aortic conditions (eg, rupture or dissection) were reported, unless results for patients receiving elective treatment for arch/descending TAA reported separately.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by one reviewer and checked by another. Risk of Bias was assessed using the ROBINS-I tool. Meta-analysis was conducted using random effects. Where meta-analysis not appropriate, results were reported narratively.

RESULTS

Five comparative cohort studies met inclusion criteria, reporting 3955 ESG and 21 197 OSR patients. Meta-analysis of unadjusted short-term (30 day) all-cause mortality favoured ESG (OR 0.75; 95% CI 0.55 to 1.03)). Heterogeneity identified between larger and smaller studies. Sensitivity analysis of four studies including only descending TAA showed no statistical significance (OR 0.73, 95% CI 0.45 to 1.18)), moderate heterogeneity. Meta-analysis of adjusted short-term all-cause mortality favoured ESG (OR 0.71, 95% CI 0.51 to 0.98)), no heterogeneity. Longer-term (beyond 30 days) survival from all-cause mortality favoured OSR in larger studies and ESG in smaller studies. Freedom from reintervention in the longer-term favoured OSR. Studies reporting short-term non-fatal complications suggest fewer events following ESG.

CONCLUSIONS

There is limited and increasingly dated evidence on the comparison of ESG and OSR for treatment of arch/descending TAA.

PROSPERO REGISTRATION NUMBER

CRD42017054565.