Trends in repair of intact and ruptured descending thoracic aortic aneurysms in the United States: A population-based analysis

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.

Short-term follow-up of proximal aorta remodeling after zone 2 thoracic endovascular aortic repair for acute type B aortic dissection

BACKGROUND

To evaluate the early remodeling of the proximal aorta in patients with acute type B aortic dissection (ATBAD) after zone 2 thoracic endovascular aortic repair (TEVAR).

METHODS

From January 2016 to May 2022, 53 ATBAD patients underwent zone 2 TEVAR were divided into two groups, the Castor single-branched stent-graft (CSS) group (n = 26) and the common stent-graft group (n = 27). Three-dimensional imaging created by computed tomography angiography was used to measure different parameters of the aorta, such as angulation, cross-sectional area (CSA), length and tortuosity. Early remodeling of the proximal aorta was evaluated by comparing geometric parameters of the proximal aorta before and 3 months after surgery.

RESULTS

In terms of angle, the postoperative angle of aortic arch to ascending aorta, descending aorta increased in all patients compared with that before surgery (all P < 0.05), while the angle of aortic arch to left subclavian artery increased after surgery only in the CSS group (P < 0.001); As for CSA, the CSA of distal aortic arch and true lumen increased (all P < 0.05), while the CSA of false lumen decreased in both groups after operation (all P < 0.05); Only in CSS group, the CSA of the ascending aorta, proximal aortic arch and total descending thoracic aorta decreased after surgery (all P < 0.05); In terms of length, the aortic arch prolonged after operation in both groups (P = 0.018 and P = 0.004, respectively). In addition, the ascending aorta tortuosity decreased in the CSS group after surgery (P = 0.011). There was no significant difference in the alterations of other aortic parameters after operation (P > 0.05).

CONCLUSIONS

The CSS implantation provided a more relatively safe and effective treatment for acute type B aortic dissection patients with unfavorable proximal landing zone. It can promote the earlier remodeling of the proximal aorta compared with the common stent-graft implantation after zone 2 TEVAR.

Endovascular treatment for life-threatening hemoptysis due to rupture of descending thoracic aortic aneurysm: A case series

INTRODUCTION AND IMPORTANCE

Aortic aneurysm is an uncommon but life-threatening cause of hemoptysis. Treatments include surgery and/or endovascular intervention, each with its own advantages and disadvantages. Endovascular intervention is associated with good early and medium-term outcomes.

CASE PRESENTATIONS

We report three cases of hemoptysis due to ruptured thoracic aortic aneurysm who underwent endovascular intervention. In all three cases, endovascular grafts were placed in the descending thoracic aorta, the number of grafts used was 1, the average time to stop hemoptysis was 4 to 5 days, and the length of hospital stay was between 6 and 8 days. No intravascular fistula, renal failure, prolonged mechanical ventilation and other major cardiovascular events were reported.

CLINICAL DISCUSSION

Endovascular treatment for descending TAA has been demonstrated to be safe and effective, particularly in emergencies in which patients presented with life-threatening hemoptysis, due to its rapid access to the aorta. In our experience at a tertiary hospital in southern Vietnam, the procedural time for a thoracic endovascular aortic repair is relatively brief and can last between 15 and 30 min. Thus, endovascular treatment for ruptured TAA can substantially improve patient prognosis, reduce mortality and complications.

CONCLUSION

The implementation of endovascular intervention can help improve prognosis, reduce mortality and complications in patients with hemoptysis due to ruptured thoracic aortic aneurysm.

Impact of ethnicity and race on outcomes after thoracic endovascular aortic repair

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) became the standard of care for treating Type B aortic dissections and descending thoracic aortic aneurysms. We aimed to describe the racial/ethnic differences in TEVAR utilization and outcomes.

METHODS

The National Inpatient Sample was reviewed for all TEVARs performed between 2010 and 2017 for Type B aortic dissection and descending thoracic aortic aneurysm (DTAA). We compared groups stratifying by their racial/ethnicity background in White, Black, Hispanic, and others. Mixed-effects logistic regression was performed to assess the relationship between race/ethnicity and the primary outcome, in-hospital mortality.

RESULTS

A total of 25,260 admissions for TEVAR during 2010-2017 were identified. Of those, 52.74% (n = 13,322) were performed for aneurysm and 47.2% (n = 11,938) were performed for Type B dissection. 68.1% were White, 19.6% were Black, 5.7% Hispanic, and 6.5% were classified as others. White patients were the oldest (median age 71 years; p < .001), with TEVAR being performed electively more often for aortic aneurysm (58.8% vs. 34% vs. 48.3% vs. 48.2%; p < .001). In contrast, TEVAR was more likely urgent or emergent for Type B dissection in Black patients (65.6% vs. 41.1% vs. 51.6% vs. 51.7%; p < .001). Finally, the Black population showed a relative increase in the incidence rate of TEVAR over time. The adjusted multivariable model showed that race/ethnicity was not associated with in-hospital mortality.

CONCLUSION

Although there is a differential distribution of thoracic indication and comorbidities between race/ethnicity in TEVAR, racial disparities do not appear to be associated with in-hospital mortality after adjusting for covariates.

A Novel Model of Tobacco Smoke-Mediated Aortic Injury

OBJECTIVE

Tobacco smoke exposure is a major risk factor for aortic aneurysm development. However, the initial aortic response to tobacco smoke, preceding aneurysm formation, is not well understood. We sought to create a model to determine the effect of solubilized tobacco smoke (STS) on the thoracic and abdominal aorta of mice as well as on cultured human aortic smooth muscle cells (HASMCs).

METHODS

Tobacco smoke was solubilized and delivered to mice via implanted osmotic minipumps. Twenty male C57BL/6 mice received STS or vehicle infusion. The descending thoracic, suprarenal abdominal, and infrarenal abdominal segments of the aorta were assessed for elastic lamellar damage, smooth muscle cell phenotype, and infiltration of inflammatory cells. Cultured HASMCs grown in media containing STS were compared to cells grown in standard media in order to verify our in vivo findings.

RESULTS

Tobacco smoke solution caused significantly more breaks in the elastic lamellae of the thoracic and abdominal aorta compared to control solution (P< .0001) without inciting an inflammatory infiltrate. Elastin breaks occurred more frequently in the abdominal aorta than the thoracic aorta (P < .01). Exposure to STS-induced aortic microdissections and downregulation of α-smooth muscle actin (α-SMA) by vascular smooth muscle cells (VSMCs). Treatment of cultured HASMCs with STS confirmed the decrease in α-SMA expression.

CONCLUSION

Delivery of STS via osmotic minipumps appears to be a promising model for investigating the early aortic response to tobacco smoke exposure. The initial effect of tobacco smoke exposure on the aorta is elastic lamellar damage and downregulation of (α-SMA) expression by VSMCs. Elastic lamellar damage occurs more frequently in the abdominal aorta than the thoracic aorta and does not seem to be mediated by the presence of macrophages or other inflammatory cells.

A Single-Center Experience With Total Percutaneous Implantation of a Low-Profile Thoracic Aortic Stent-Graft

PURPOSE

To evaluate the safety and effectiveness of total percutaneous implantation of the Zenith Alpha Thoracic (ZTA) endograft in the treatment of diseases of the descending thoracic aorta.

MATERIALS AND METHODS

A retrospective cohort study of 56 consecutive patients undergoing total percutaneous ZTA implantation between 2018 and 2020 was performed in a single center. Patients' demographics, clinical characteristics, anatomical parameters, operative details, device features, and postoperative outcomes were assessed. The primary endpoint was ongoing clinical success. A Cox regression model was used to determine the predictive factors of worse postoperative outcomes.

RESULTS

Eighty-three ZTA endografts were implanted in 35 men and 21 women with a mean age of 69±11 years for the treatment of 26 degenerative aneurysms, 15 type B dissections, and 8 penetrating ulcers, among others. Primary technical success was 100%, with a 30-day ongoing clinical success rate of 94.6%. The 1-year ongoing clinical success rate was 91.1% (51 patients), and freedoms from all-cause mortality, type 1 and 3 endoleaks, and any unplanned reintervention were, respectively, 95.3%, 91.4%, and 88.2% at 1 year. During follow-up, there was one case of surgical conversion for an aorto-esophageal fistula. On the contrary, neither aneurysmal rupture nor significant aneurysmal expansion was recorded. Repair of ruptured thoracic aorta and a high ratio of sheath outer diameter to external iliac artery diameter were found to be independently associated with worse outcomes, with adjusted odds ratios of 4.4 [1.5-15.3] and 4.9 [1.1-23.9], respectively.

CONCLUSION

The outcomes of total percutaneous implantation of ZTA endograft show excellent primary technical success and favorable midterm ongoing clinical success. Factors associated with worse outcomes include the repair of ruptured aorta and a high sheath to access vessel ratio.

Respiratory Failure after Open Descending Aortic Aneurysm Repair: Risk Factors and Outcomes

Purpose: This study was conducted to identify predictors of respiratory failure after open repair of descending thoracic aortic aneurysm (DTAA), and to identify any relationship between respiratory failure and long-term survival.

Methods: A total of 75 patients undergoing elective open DTAA repair at the Shiga University of Medical Science Hospital were included in the study. Univariate and multivariate logistic regression analyses were performed to assess the odds ratios for incident postoperative respiratory failure after open DTAA repair. Survival over time was estimated by the Kaplan–Meier method.

Results: Respiratory failure, defined as ventilation dependence for longer than 48 hours, occurred in 11 patients (14.7%). Independent predictors of respiratory failure after DTAA included prolonged operation time and reduced preoperative forced expiratory volume in 1 second/forced vital capacity × 100 (FEV₁%). In-hospital mortality was higher (p = 0.020) among patients with respiratory failure (18.2% of those who suffered respiratory failure) than among those without (0%). The survival rates at 8 years were significantly lower (p = 0.010) in the respiratory failure group (at 44.2%) than in the group without respiratory failure (at 89.0%).

Conclusion: Lower FEV₁% and longer operation time were risk factors of postoperative respiratory failure after open repair of DTAA, which in turn is associated with significantly reduced long-term survival.

Long-term stroke incidence in proximal thoracic aorta aneurysm survivors

BACKGROUND

Aneurysm of proximal thoracic aorta (pTAA) is an often indolent, yet fatal disease. Although advancements in aneurysmal repair techniques have increased long-term survival rates, studies have proven that there are increases in perioperative risk for stroke incidence after pTAA surgery. Conversely, there is little evidence regarding the long-term stroke incidence in pTAA individuals, which strongly influences the morbidity, mortality, and usage of antithrombotic agents.

METHODS

Using the Taiwan National Health Insurance Research Database, a nationwide population-based cohort, we recruited 3013 pTAA survivors hospitalized from 1 January 2000 to 31 December 2012. To ensure study cohort quality, only patients aged 20 years and above who underwent aneurysmal repair surgery are included. The control cohort is identified by matching background features (comorbidities, age, gender) at a 1:4 ratio through the use of frequency matching. The primary outcomes include incidence of ischemic stroke and intracranial hemorrhage one month after aneurysmal repair surgery.

RESULTS

The mortality of pTAA survivors is nearly twice of the matched controls despite aneurysmal repair (28.5 % vs. 15.2%, p < 0.001). Long-term follow-up of participants indicated that pTAA survivors had a higher risk for hemorrhage stroke (adjusted hazard ratio (aHR): 1.93; 95% confidence interval (CI): 1.47-2.53), but no significant increase in risk for ischemic stroke (aHR: 1.07; 95% CI: 0.92-1.25). Hemorrhagic stroke occurrence was found to be associated with age and diabetes mellitus. Comparison on hemorrhagic stroke subtypes between study and matched cohorts showed no statistical differences in intracerebral hemorrhage and subarachnoid hemorrhage.

CONCLUSIONS

Despite the advancement of aneurysmal repair surgery, this study suggests that pTAA patients may still face an increased risk of hemorrhage stroke. Further investigation is warranted to provide better long-term care for the pTAA population.

PET/CT Imaging in Soft Tissue Infection and Inflammation-An Update

Nuclear medicine procedures, including Ga-67 and labeled leucocyte SPECT/CT as well as PET/CT using 18F-FDG and recently Ga-68 tracers, have found extensive applications in the assessment of infectious and inflammatory processes in general and in soft tissues in particular. Recent published data focus on summarizing the available imaging information with the purpose of providing the referring clinicians with optimized evidence based results. Guidelines and/or recommendations of clinical societies have incorporated nuclear medicine tests (using both labeled leucocytes and FDG) in their suggested work-up for evaluation of infective endocarditis and in certain patients with suspected vascular graft infections. Joint guidelines of the European and American nuclear medicine societies include fever of unknown origin, sarcoidosis, and vasculitis among the major clinical indications that will benefit from nuclear medicine procedures, specifically from FDG PET/CT. Limitations and pitfalls for the use of radiotracers in assessment of infection and inflammation can be related to patient conditions (eg, diabetes mellitus), or to the biodistribution of a specific radiopharmaceutical. Limited presently available data on the use of functional and/or metabolic monitoring of response to infectious and inflammatory processes to treatment and with respect to the effect of drugs such as antibiotics and glucocorticoids on the imaging patterns of these patients need further confirmation.

Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study

OBJECTIVE

The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA).

METHODS

This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan-Meier estimator and multivariable Cox regression.

RESULTS

There were 140 patients (age [mean ± SD] 74.1 ± 8.8 years; 56% men; aneurysm size 64.8 ± 19 mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n = 20; 14.7%) was the most common complication, followed by paraplegia (n = 13; 9.6%) and major bleeding (n = 13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n = 31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0-132 months). The Kaplan-Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00-1.07; p = .046), history of stroke (HR 2.35; 95% CI 1.19-4.63; p = .014), previous aortic surgery (HR 2.11; 95% CI 1.15-3.87; p = .016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20-8.81; p = .001), stroke (HR 2.63; 95% CI 1.37-5.03; p = .004), and renal failure (HR 8.25; 95% CI 2.69-25.35; p = .001) were all associated with mortality.

CONCLUSIONS

This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.

Length of Stay after Thoracic Endovascular Aortic Repair Depends on Indication and Acuity

BACKGROUND

Length of stay (LOS) is a commonly used metric to optimize value in medical care. Although pathways have been developed for some procedures in vascular surgery to reduce LOS, they do not yet exist for thoracic endovascular aortic repair (TEVAR). The purpose of this study is to identify and define the risk factors for prolonged LOS in patients undergoing TEVAR to facilitate pathway development.

METHODS

We included TEVAR patients in the National Surgical Quality Improvement Program database from 2005 to 2015. Prolonged LOS was defined as LOS > 75th percentile of the overall cohort (11 days). Because initial analysis revealed the distinct clinical differences between dissection and aneurysm patients, further analysis was stratified by aortic pathology. Student's t-test and Chi-square tests were used to compare demographic and perioperative variables between dissection and aneurysm patients, respectively. Multivariable logistic regression was used to evaluate the predictors for prolonged LOS.

RESULTS

A total of 3,021 patients underwent TEVAR, with 858 patients (28.4%) undergoing TEVAR for dissection and 2,163 (71.6%) undergoing TEVAR for aneurysm. An initial analysis with logistic regression identified dissection indication (odds ratio [OR], 2.87; 95% confidence interval [CI], 1.1-7.3) as an independent predictor of prolonged LOS. Further analysis for prolonged LOS was subsequently performed separating dissection and aneurysm patients. Aneurysm patients were older (71.2 ± 11.7 vs. 63.1 ± 13.6 years, P < 0.001), more often Caucasian (76.8% vs. 61.8%, P < 0.001), and had more medical comorbidities (chronic obstructive pulmonary disease, cardiac history, diabetes, peripheral vascular disease, transient ischemic attack [TIA], P < 0.001). In contrast, dissection patients had higher American Society of Anesthesiology (ASA) classification score (58.5% had >3 ASA vs. 45.5%, P < 0.001), longer hospitalizations (10.2 ± 9.3 vs. 8.5 ± 10.4 days, P < 0.001), were more likely to have been transferred from another hospital or emergency room (58.4% vs. 48.3%, P < 0.001), and were more often emergent (32.4% vs. 15.4%, P < 0.001). In dissection patients, ASA classification score (OR, 1.49; 95% CI, 1.1-2.1) and dialysis (OR, 1.98; 95% CI, 1.0-3.9) were independent predictors for prolonged LOS. In aneurysm patients, dependent functional status (OR, 2.03; 95% CI, 1.4-2.8), diabetes (OR, 1.75; 95% CI, 1.1-2.8), cardiac history (OR, 1.37; 95% CI, 1.0-1.9), emergency status (OR, 1.98; 95% CI, 1.4-2.8), and dialysis (OR, 2.08; 95% CI, 1.2-3.7) predicted prolonged LOS. Postoperative complications including stroke/TIA; failure to wean from ventilator, sepsis, and pneumonia; and need for reoperation similarly increased LOS in both dissection and aneurysm patients.

CONCLUSIONS

Dissection and aneurysm patients undergoing TEVAR are comprised of different patient populations, with dissection patients more often enduring prolonged hospitalizations. In contrast, TEVAR performed for nonemergent aneurysm repair had the shortest LOS. These data support the development of separate pathways defined by indication and acuity for patients undergoing TEVAR.

The "3M" Approach to Cardiovascular Infections: Multimodality, Multitracers, and Multidisciplinary

Cardiovascular infections are associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient management, as early treatment improves the prognosis. The diagnosis cannot be made on the basis of a single symptom, sign, or diagnostic test. Rather, the diagnosis requires a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data, and imaging data. The application of multimodality imaging, including molecular imaging techniques, has improved the sensitivity to detect infections involving heart valves and vessels and implanted cardiovascular devices while also allowing for early detection of septic emboli and metastatic infections before these become clinically apparent. In this review, we describe data supporting the use of a Multimodality, Multitracer, and Multidisciplinary approach (the 3M approach) to cardiovascular infections. In particular, the role of white blood cell SPECT/CT and [¹⁸F]FDG PET/CT in most prevalent and clinically relevant cardiovascular infections will be discussed. In addition, the needs of advanced hybrid equipment, dedicated imaging acquisition protocols, specific expertise for image reading, and interpretation in this field are discussed, emphasizing the need for a specific reference framework within a Cardiovascular Multidisciplinary Team Approach to select the best test or combination of tests for each specific clinical situation.

Early outcomes of patients transferred with ruptured suprarenal aneurysm or dissection

Objective Despite centralisation of the provision of vascular care, not all areas in England and Wales are able to offer emergency treatment for patients with acute conditions affecting the aorta proximal to the renal arteries. While cardiothoracic centres have made network arrangements to coordinate care for the repair of type A dissections, a similar plan for vascular care is lacking. This study investigates early outcomes in patients with ruptured suprarenal aortic aneurysm or dissection (rSRAD) transferred to a specialist centre. Methods Retrospective observational study over a five-year period (2009-2014) assessing outcomes of patients with ruptured sRAD diagnosed at their local hospital and then transferred to a tertiary centre capable of offering such treatment. Results Fifty-two patients (median age 73 years, 32 male) with rSRAD were transferred and a further four died during transit. The mean distance of patient transfer was 35 miles (range 4-211 miles). One patient did not undergo intervention due to frailty and two died before reaching the operating theatre. A total of 23 patients underwent endovascular repair, 9 hybrid repair and 17 open surgery. Median follow-up was 12 months (range 1-43 months). Complications included paraplegia (n = 3), stroke (n = 2), type IA endoleak (n = 4); 30-day and in-hospital mortality were 16% and 27%. For patients discharged alive from hospital, one-year survival was 67%. Conclusions Although the number of patients with rSRAD is low and those who are transferred alive are a self-selecting group, this study suggests that transfer of such patients to a specialist vascular centre is associated with acceptable mortality rates following emergency complex aortic repair.

Risk Modeling to Optimize Patient Selection for Management of the Descending Thoracic Aortic Aneurysm

BACKGROUND

A single-institutional study comparing early and long-term outcomes of thoracic endovascular aortic repair (TEVAR) and open surgical repair (OSR) was performed to determine the appropriate treatment option for descending thoracic aortic aneurysm (DTAA).

METHODS

Between 2005 and 2014, 438 DTAA patients were treated (TEVAR, 88; OSR, 350). Acute dissection and traumatic injury were excluded. Perioperative and follow-up data were reviewed. Stratified analyses were conducted to identify patients most likely to benefit from TEVAR. A propensity score for TEVAR was developed by logistic regression, and predictive logistic and Cox regression models for death were adjusted for propensity score.

RESULTS

TEVAR patients were frequently older women with emergent status, chronic obstructive pulmonary disease, or coronary artery disease. TEVAR had similar immediate (0% vs 1%; p = 0.588) and delayed (5% vs 6%, p = 1.000) motor deficits and early mortality (6% vs 12%, p = 0.121) but lower dialysis (3% vs 18%, p < 0.001), respiratory failure (10% vs 34%, p < 0.001), and intensive care unit stay (2.0 vs 5.0 days, p < 0.001). Early mortality after TEVAR was lower in septuagenarians (3% vs 16%, p < 0.02), glomerular filtration rate of less than 60 mL/min (8% vs 32%, p < 0.049), chronic obstructive pulmonary disease (6% vs 21%, p < 0.02), defined as target population that had fourfold mortality reduction (p < 0.006) attributable to TEVAR. Propensity-adjusted predictors of early mortality predictors included OSR (odds ratio [OR], 4.3; p < 0.024), target population (OR, 7.7; p < 0.001), diabetes (OR, 3; p < 0.009), peripheral vascular disease (OR, 4.7; p < 0.001), and emergent status (OR, 4.6; p < 0.001). Propensity-adjusted determinants of survival were age, glomerular filtration rate of less than 60 mL/min, peripheral vascular disease, chronic obstructive pulmonary disease, and emergent status.

CONCLUSIONS

In older patients with significant comorbidities, TEVAR demonstrated superior results compared with OSR and may be preferable in this target population.

Late type III endoleak after thoracic endovascular aneurysm repair and previous infrarenal stent graft implantation - a case report and review of the literature

Thoracic endovascular aortic repair (TEVAR) effectively improved the results of thoracic aortic aneurysm treatment. TEVAR is a less invasive procedure that can be performed under local anesthesia with shorter hospital stay. The perioperative morbidity and mortality rates are lower for endovascular than open repair, but the rate of secondary interventions is higher for TEVAR. We report a case of an elderly man with synchronous abdominal and thoracic aortic aneurysms. A type III dangerous endoleak was recognized 3 years after TEVAR. It was successfully repaired during an endovascular procedure. There were no new endoleaks after 12 months of follow-up. TEVAR may be the only option of treatment for risky and elderly patients. However, postoperative monitoring is necessary to exclude different types of endoleaks. Most of them undergo effective endovascular repair.

The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has become an alternative to open repair for the treatment of ruptured thoracic aortic aneurysms (rTAAs). The aim of this study was to assess national trends in the use of TEVAR for the treatment of rTAA and to determine its impact on perioperative outcomes.

METHODS

Patients admitted with an rTAA between 1993 and 2012 were identified from the National Inpatient Sample. Patients were grouped in accordance with their treatment: TEVAR, open repair, or nonoperative treatment. The primary outcomes were treatment trends over time and in-hospital death. Secondary outcomes included perioperative complications and length of stay. Trend analyses were performed using the Cochran-Armitage test for trend, and adjusted mortality risks were established using multivariable logistic regression analysis.

RESULTS

A total of 12,399 patients were included, with 1622 (13%) undergoing TEVAR, 2808 (23%) undergoing open repair, and 7969 (64%) not undergoing surgical treatment. TEVAR has been increasingly used from 2% of total admissions in 2003-2004 to 43% in 2011-2012 (P < .001). Concurrently, there was a decline in the proportion of patients undergoing open repair (29% to 12%; P < .001) and nonoperative treatment (69% to 45%; P < .001). The proportion of patients undergoing surgical repair has increased for all age groups since 1993-1994 (P < .001 for all) but was most pronounced among those aged 80 years with a 7.5-fold increase. After TEVAR was introduced, procedural mortality decreased from 36% in 2003-2004 to 27% in 2011-2012 (P < .001); mortality among those undergoing nonoperative treatment remained stable between 63% and 60% (P = .167). Overall mortality after rTAA admission decreased from 55% to 42% (P < .001). Since 2005, mortality for open repair was 33% and 22% for TEVAR (P < .001). In adjusted analysis, open repair was associated with a twofold higher mortality than TEVAR (odds ratio, 2.0; 95% confidence interval, 1.7-2.5).

CONCLUSIONS

TEVAR has replaced open repair as primary surgical treatment for rTAA. The introduction of endovascular treatment appears to have broadened the eligibility of patients for surgical treatment, particularly among the elderly. Mortality after rTAA admission has declined since the introduction of TEVAR, which is the result of improved operative mortality as well as the increased proportion of patients undergoing surgical repair.

Female sex independently predicts mortality after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms

OBJECTIVE

Whereas sex differences in the pathogenesis, presentation, and outcomes of repair for abdominal aortic aneurysms are well studied, less is known about sex differences after thoracic endovascular aortic repair (TEVAR). The goal of this study was to evaluate the association between sex and morbidity and mortality after TEVAR.

METHODS

A retrospective review of all TEVARs in the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry from 2011 to 2015 was conducted, excluding those with dissection, trauma, and rupture. Statistical analysis was performed using the Fisher exact test and the Mann-Whitney U test for categorical and continuous variables. Multivariable logistic regression and Cox hazards modeling were used to account for differences in demographics, comorbidities, and aneurysm characteristics in 30-day mortality and long-term survival.

RESULTS

We identified 2574 patients (40% women) who underwent TEVAR. Women were older, were less likely to be white, and had smaller aortic diameters but larger aortic size indices (aortic diameter/body surface area). Women also had more chronic obstructive pulmonary disease but less coronary artery disease and fewer coronary interventions. Women were more likely to be symptomatic at presentation and subsequently to have a nonelective procedure. Women had higher estimated blood loss >500 mL (20% vs 17%; P = .04), were more likely to be transfused (29% vs 21%; P < .001), and more frequently underwent iliac access procedures (4.3% vs 2.1%; P < .01). Operative time and left subclavian intervention were similar. Postoperatively, women had increased median hospital (5 vs 4 days; P < .001) and intensive care unit (2.5 vs 2 days; P < .001) lengths of stay and were less likely to be discharged home (75% vs 86%; P < .001). Mortality was higher for women at 30 days (5.4% vs 3.3%; P < .01) and 1 year (9.8% vs 6.3%; P < .01). After adjusting for age, aortic size index, symptoms, and comorbidities, female sex remained independently predictive of 30-day mortality (odds ratio, 1.5; 95% confidence interval, 1.1-2.1, P < .01) and long-term mortality (hazard ratio, 1.3; 95% confidence interval, 1.03-1.6; P = .02).

CONCLUSIONS

Even after adjusting for differences in age and comorbidities, female patients have higher perioperative mortality and lower long-term survival after TEVAR. These findings, along with the rupture risk by sex, should be considered by clinicians in determining the timing of intervention.

Type 2 Diabetes Mellitus and Thoracic Aortic Aneurysm and Dissection: An Observational Population-Based Study in Spain From 2001 to 2012

To describe trends in the rates of discharge due to thoracic aortic aneurysm and dissection (TAAD) among patients with and without type 2 diabetes in Spain (2001-2012).We used national hospital discharge data to select all of the patients who were discharged from the hospital after TAAD. We focused our analysis on patients with TAAD in the primary diagnosis field. Discharges were grouped by diabetes status (diabetic or nondiabetic). Incidence was calculated overall and stratified by diabetes status. We divided the study period into 4 periods of 3 years each. We analyzed diagnostic and surgical procedures, length of stay, and in-hospital mortality.We identified 48,746 patients who were discharged with TAAD. The rates of discharge due to TAAD increased significantly in both diabetic patients (12.65 cases per 100,000 in 2001/2003 to 23.92 cases per 100,000 in 2010/2012) and nondiabetic patients (17.39 to 21.75, respectively). The incidence was higher among nondiabetic patients than diabetic patients in 3 of the 4 time periods.The percentage of patients who underwent thoracic endovascular aortic repair increased in both groups, whereas the percentage of patients who underwent open repair decreased. The frequency of hospitalization increased at a higher rate among diabetic patients (incidence rate ratio 1.14, 95% confidence interval [CI] 1.07-1.20) than among nondiabetic patients (incidence rate ratio 1.08, 95% CI 1.07-1.11). The in-hospital mortality was lower in diabetic patients than in nondiabetic patients (odds ratio 0.83, 95% CI 0.69-0.99).The incidence rates were higher in nondiabetic patients. Hospitalizations seemed to increase at a higher rate among diabetic patients. Diabetic patients had a significantly lower mortality, possibly because of earlier diagnoses, and improved and more readily available treatments.

Early Experiences with the Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm

BACKGROUND

The aim of this study was to report our early experiences with the endovascular repair of ruptured descending thoracic aortic aneurysms (rDTAAs), which are a rare and life-threatening condition.

METHODS

Among 42 patients who underwent thoracic endovascular aortic repair (TEVAR) between October 2010 and September 2015, five patients (11.9%) suffered an rDTAA.

RESULTS

The mean age was 72.4±5.1 years, and all patients were male. Hemoptysis and hemothorax were present in three (60%) and two (40%) patients, respectively. Hypovolemic shock was noted in three patients who underwent emergency operations. A hybrid operation was performed in three patients. The mean operative time was 269.8±72.3 minutes. The mean total length of aortic coverage was 186.0±49.2 mm. No 30-day mortality occurred. Stroke, delirium, and atrial fibrillation were observed in one patient each. Paraplegia did not occur. Endoleak was found in two patients (40%), one of whom underwent an early and successful reintervention. During the mean follow-up period of 16.8±14.8 months, two patients died; one cause of death was a persistent type 1 endoleak and the other cause was unknown.

CONCLUSION

TEVAR for rDTAA was associated with favorable early mortality and morbidity outcomes. However, early reintervention should be considered if persistent endoleak occurs.

[Aneurysms of the thoracic and thoracoabdominal aorta]

The incidence and operations of thoracic and thoracoabdominal aortic aneurysms have significantly increased. The indications for repair are considered to be a diameter of 6 cm or more and 5.5 cm for patient groups with increased risk of rupture. Complex open surgical repair is associated with significant mortality and complication rates. Total or hybrid endovascular repair seems to reduce early postoperative complications and mortality. The endovascular approach has evolved to be a good and predominant alternative to open repair of these aneurysms for older and high-risk patients as well as for aneurysms with optimal morphological suitability. Notwithstanding, at present a complete paradigm shift from open to endovascular repair for all patients, especially those with complex aneurysms, cannot yet be established.