Outcomes of thoracic endovascular aortic repair for chronic aortic dissections

STOP-Bang Questionnaire Is Associated With Aortic Remodeling in Patients With Acute Type B Aortic Dissection Undergoing Standard Thoracic Endovascular Aortic Repair

PURPOSE

To determine whether the STOP-Bang questionnaire, which is a tool for evaluating obstructive sleep apnea, is associated with aortic remodeling after thoracic endovascular aortic repair (TEVAR) in patients with type B aortic dissection (TBAD).

METHODS

Patients with TBAD who underwent standard TEVAR at our center from January 2015 to December 2020 were enrolled. For the included patients, we recorded baseline characteristics, comorbidities, preoperative computed tomographic angiography findings, procedure details, and complications. The STOP-Bang questionnaire was administered to each patient. Total scores comprised points for 4 yes/no questions and 4 clinical measurements. STOP-Bang ≥5 and STOP-Bang <5 groups were then created using the STOP-Bang total scores. We evaluated aortic remodeling 1 year after discharge and the reintervention rate, as well as false lumen complete thrombosis (FLCT) and non-FLCT length.

RESULTS

Fifty-five patients were enrolled in the study; STOP-Bang <5, n=36, and STOP-Bang ≥5, n=19. Compared with the STOP-Bang ≥5 group, the STOP-Bang <5 group achieved statistically significantly higher descending aorta positive aortic remodeling (PAR) rates in zones 3 to 5 (zone 3: p=0.002; zone 4: p=0.039; zone 5: p=0.023), higher total descending aorta-PAR rate (66.7% vs 36.8%, respectively; p=0.004), and lower reintervention rate (8.1% vs 38.9%, respectively; p=0.005). In the logistic regression analysis, STOP-Bang ≥5 had an odds ratio of 0.12 (95% confidence interval: 0.03-0.58; p=0.008). There was no significant difference in overall survival between the groups.

CONCLUSION

STOP-Bang questionnaire scores were associated with aortic remodeling after TEVAR in patients with TBAD. Increasing the frequency of surveillance after TEVAR might be beneficial in these patients.

CLINICAL IMPACT

We analysed aortic remodelling 1 year after thoracic endovascular aortic repair (TEVAR) in acute type B aortic dissection (TBAD) patients with STOP-Bang < 5 and STOP-Bang ≥ 5. Aortic remodelling was better, and the reintervention rate was higher in patients with STOP-Bang < 5 compared with patients with STOP-Bang ≥ 5. In patients with STOP-Bang ≥ 5, aortic remodelling was worse in zones 3-5 compared with zones 6-9. This study suggests that the STOP-Bang questionnaire results is associated with aortic remodelling after TEVAR in patients with TBAD.

Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection: Pre- and Postprocedural Imaging

Aortic dissection is a chronic disease that requires lifelong clinical and imaging surveillance, long after the acute event. Imaging has an important role in prognosis, timing of repair, device sizing, and monitoring for complications, especially in the endovascular therapy era. Important anatomic features at preprocedural imaging include the location of the primary intimal tear and aortic zonal and branch vessel involvement, which influence the treatment strategy. Challenges of repair in the chronic phase include a small true lumen in conjunction with a stiff intimal flap, complex anatomy, and retrograde perfusion from distal reentry tears. The role of thoracic endovascular aortic repair (TEVAR) remains controversial for treatment of chronic aortic dissection. Standard TEVAR is aimed at excluding the primary intimal tear to decrease false lumen perfusion, induce false lumen thrombosis, promote aortic remodeling, and prevent aortic growth. In addition to covering the primary intimal tear with an endograft, several adjunctive techniques have been developed to mitigate retrograde false lumen perfusion. These techniques are broadly categorized into false lumen obliteration and landing zone optimization strategies, such as the provisional extension to induce complete attachment (PETTICOAT), false lumen embolization, cheese-wire fenestration, and knickerbocker techniques. Familiarity with these techniques is important to recognize expected changes and complications at postintervention imaging. The authors detail imaging options, provide examples of simple and complex endovascular repairs of aortic dissections, and highlight complications that can be associated with various techniques. Online supplemental material is available for this article. ^©RSNA, 2022.

Reverse "cheese wire" fenestration for abdominal aortic dissection repair: a case report and literature review

Background

Aortic dissection is one of the most common emergency condition leading to internal organs or lower limb ischemia and aortic rupture. Herein, we described a reverse “cheese wire” endovascular fenestration repair (CWFER) in a patient with complicated abdominal aortic dissection which had never been reported.

Case presentation

A 62-year-old male presented abdominal tear-like pain and acute ischemia of the right lower extremity during the endovascular treatment of celiac trunk aneurysms. Computed tomography angiography (CTA) and digital subtraction angiography (DSA) showed abdominal aortic type B dissection with acute ischemia of the right lower extremity preoperatively. After a detailed preoperative examination, the patient then was performed a reverse CWFER. So far, the patient has been followed-up for 6 months, postoperative CTA demonstrated good stent-graft expansion and perfusion of bilateral common iliac arteries; also, no endoleak was detected.

Conclusions

The right iliac artery in this patient supplied by false lumen, which lead to acute ischemia of the right lower extremity, needed to be treated as an emergency and dealt with promptly. CWFER is a very high-risk treatment that requires the rich experience of vascular surgeon and accurate assessment of aortic dissection. After interventional treatment, the patient recovered uneventfully after 6 months’ follow-up.

Supplementary information

The online version contains supplementary material available at 10.1186/s12893-022-01581-4.

Methods and outcomes of endovascular false lumen embolization for thoracic aortic dissection

PURPOSE

To provide a contemporary review on endovascular false lumen (FL) embolization for thoracic aortic dissection (AD) and evaluate its early outcome.

METHODS

A systematic literature review on FL embolization for thoracic AD from January 2003 to December 2020 was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Each article was analyzed using a standardized protocol including predefined demographic characteristics, perioperative mortality and major complications.

RESULTS

A total of 29 papers with 229 patients were included into the analysis. The methods of FL occlusion used were: the Candy-Plug technique, the knickerbocker technique, the "cork in the bottleneck" technique and direct FL embolization with combination of stent-grafts, coils, onyx, plugs and glue. FL embolization procedure was performed in 79 patients (34.5%) with type A AD and 150 (65.5%) with type B AD. FL direct embolization was the most frequently used technique, and it was applied in 198 (86.5%) patients. Candy-plug, knickerbocker and "cork in the bottleneck" techniques were used in 26 (11.4%), 3 (1.3%) and 2 (0.9%) patients, respectively. Technical success was achieved in all patients except one (228/229, 99.6%) in which implantation of a stent to celiac trunk was not possible. There were four hospital deaths (1.7%). Neurological complications occurred in 6 patients (2.6%), including 4 (1.7%) spinal cord ischemia and 2 (0.9%) ischemic stroke. There were 1 (0.4%) iatrogenic retrograde dissection and 2 (0.9%) renal failure reported. The mean duration of follow-up was 16.5 months. There were 21 deaths (9.3%) during follow-up, and 8 (3.6%) were aorta-related. Thirty-three (14.7%) secondary intervention were performed. Five patients (2.2%) required open completion thoracoabdominal procedure incorporating the stent-graft into the repair. Complete FL thrombosis was observed in 181 (80.4%) patients, 34 (15.1%) had partial thrombosis, and 10 (4.4%) had FL progression.

CONCLUSIONS

FL embolization of the distal thoracic aorta is a promising technique in a group of patients to promote FL thrombosis and aortic remodeling in thoracic aorta.

Transfemoral transcatheter aortic valve implantation in a patient with chronic type B aortic dissection

A 70s woman with a history of open-heart surgery presented with severe aortic stenosis (AS). CT showed chronic type B aortic dissection (TBAD) between the distal aortic arch and the left common iliac artery. After careful consideration, we planned transfemoral (TF)-transcatheter aortic valve implantation (TAVI) using a 20-Fr long sheath to minimise number of contacts with the false lumen of the aorta. TAVI was performed under general anaesthesia, guided by transoesophageal echocardiography (TEE). A transcatheter aortic valve was successfully implanted. TEE immediately after valve implantation showed no remarkable changes in the descending thoracic aorta. Repeated postprocedural CT examinations showed no obvious changes in the aorta. The patient was stable without sequelae at the 12-month follow-up. This case demonstrates that TF-TAVI using a long sheath under TEE guidance can be a treatment option for patients with severe AS and chronic TBAD.

Surgical Strategy for Chronic Type B Dissecting Aortic Aneurysm to Prevent Aorta-Related Events

BACKGROUND

This study was aimed to evaluate the outcomes of performing open repair or thoracic endovascular aortic repair for chronic type B dissecting aortic aneurysm.

METHODS

From July 2004 to February 2019, 52 patients underwent surgery as open repair (n = 32) or endovascular repair (n = 20) for chronic type B dissecting aortic aneurysm. Replacement of the aorta was limited to the aneurysmal portion with or without reconstructing the visceral arteries or the segmental arteries. Stent grafts were deployed in the true lumen above the celiac artery to cover the primary entry for even DeBakey IIIb dissection.

RESULTS

Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. In the endovascular repair group, 3 patients died due to rupture of residual false lumen in the early, and late postoperative follow-up. The 5-year rate of freedom from all-cause death, aorta-related death, and aorta-related event were 84% ± 6%, 94% ± 3% and 84% ± 6%. The endovascular repair was independently associated with all-cause death (hazard ratio [HR], 5.7; confidence interval [CI], 1.02-31.6; P = 0.04) and aorta-related event (HR, 30.9; CI 4.9-195.0; P < 0.001). In the open group, postoperative residual aortic diameter was an independent predictor of aorta-related events, and the threshold was 41 mm.

CONCLUSIONS

Open repair remains a better option than simple endovascular repair alone in DeBakey IIIb dissection, but the distal un-resected aortic portion over 41 mm was associated with late aortic events.

TEVAR for complicated and uncomplicated type B aortic dissection-Systematic review and meta-analysis

BACKGROUND

Type B aortic dissection (TBAD), is defined as a dissection involving the aorta distal to left subclavian artery with the ascending aorta and the aortic arch not affected. TBAD is classified due to the time frame and presence of complications. Complicated TBAD (co-TBAD) patients have a greater mortality rate than uncomplicated TBAD (un-TBAD) and thoracic endovascular aortic repair (TEVAR) is considered the gold-standard intervention for these clinical challenges.

METHODS

We undertook a systematic review of the literature regarding TEVAR intervention in co-TBAD and un-TBAD. A comprehensive search was undertaken across four major databases and was evaluated and assessed until June 2020.

RESULTS

A total of 16,104 patients were included in the study (7772 patients co-TBAD and 8352 un-TBAD). A significantly higher proportion of comorbidities were seen in co-TBAD patients compared with un-TBAD. Acute dissection was more frequent in the co-TBAD group (73.55% vs. 66.91%), while chronic dissection was more common in un-TBAD patients (33.8% vs. 70.73%). Postprocedure stroke was higher in co-TBAD (5.85% vs. 3.92%; p < .01), while postprocedural renal failure was higher in un-TBAD patients (7.23 vs. 11.38%; p < .01). No difference was observed in in-hospital mortality however the 30 days mortality was higher in the co-TBAD group. One-year survival was higher in the uncomplicated group but this difference was not observed in the 5-year survival.

CONCLUSION

In our analysis we can appreciate that despite significantly higher comorbidities in the co-TBAD cohort, there was no difference in in-hospital mortality between the two groups and the 5-year survival did not have any difference.

Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs

OBJECTIVE

To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR).

METHODS

Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods.

RESULTS

Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m²), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m², previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004).

CONCLUSIONS

Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.

Endovascular Repair of Postdissection Aortic Aneurysms Using Physician-Modified Endografts

BACKGROUND

The purpose of this study was to report our experience and evaluate the technical and clinical outcomes of physician-modified endovascular aortic repair of chronic postdissection thoracoabdominal aortic aneurysms.

METHODS

A retrospective analysis of prospectively collected data of consecutive patients presenting with chronic postdissection aneurysms unfit for open surgery and treated by physician-modified stent grafts between January 2016 and December 2019 was conducted. Outcome data were collected retrospectively. Early outcomes included technical success, perioperative mortality, and major adverse events. Late outcomes included reintervention, false lumen thrombosis rate, aneurysm size regression, and survival.

RESULTS

Sixty-two patients (80.1% men with a mean age of 64 ± 9.9 years) were treated. The technical success was 98.3%. There was 1 (1.6%) death within 30 days. Perioperative major adverse events included respiratory failure (1.6%), spinal cord injury (0%), acute kidney injury (3.2%; 1 dialysis), bowel ischemia (1.6%), myocardial infarction (1.6%), and lower limb ischemia (1.6%). A reintervention was required in 6 (9.8%) patients. The false lumen thrombosis rates were 91.8% (n = 45 of 49) at 1-year follow-up. One patient died during follow-up from an aneurysm-related cause. The estimated overall survival rates were 98.4% and 96.8% at 6 months and 12 months, respectively.

CONCLUSIONS

The report confirmed the feasibility and safety of fenestrated and branched endovascular aortic repair in the setting of postdissection thoracoabdominal aortic aneurysms. Despite the associated perioperative risk and high probability of intended or unintended reintervention, the procedure could lead to favorable aortic remodeling.

Comparative Outcome Analysis of N-Butyl Cyanoacrylate Embolization of the False Lumen Versus Thoracic Endovascular Aortic Repair in Aortic Dissection

PURPOSE

To evaluate the feasibility, safety, and effectiveness of N-butyl cyanoacrylate (NBCA) embolization for the treatment of aortic dissection.

MATERIALS AND METHODS

In this single-center retrospective study conducted from February 2003 to June 2019, NBCA embolization of an aortic false lumen was attempted in 12 patients (median age, 59 y; range, 41-68 y) and thoracic endovascular aortic repair (TEVAR) was performed in 53 patients (median age, 59 y; range, 37-70 y) for aortic dissection with one or more indications of persisting pain, malperfusion, rupture or impending rupture, maximal aortic diameter ≥ 55 mm, and/or rapid aortic enlargement. The main exclusion criterion for embolization was the presence of fast blood flow in the aortic false lumen on aortography. The efficacy of NBCA embolization and TEVAR was compared by evaluating technical and clinical outcomes, repeat intervention-free survival (RFS), and overall survival (OS).

RESULTS

Technical success was achieved in 11 of the 12 patients treated with NBCA embolization (91.7%), and clinical success was achieved in 9 of these 11 (81.8%). No significant difference was found between embolization and TEVAR in clinical success rates (embolization, 81.8%; TEVAR, 84.9%; P = .409) or procedure-related complications (embolization, 1 patient [8.3%]; TEVAR, 4 patients [7.5%]; P = .701). In addition, embolization showed comparable 5-y RFS (embolization, 82.5% ± 9.3; TEVAR, 85.5% ± 4.8; P = .641) and 5-y OS (embolization, 100%; TEVAR, 95.4% ± 3.2; P = .744) rates to TEVAR.

CONCLUSIONS

NBCA embolization of the false lumen in aortic dissection seems to be a safe and effective treatment modality for the closure of false lumen in selected patients.

A multicenter "real-world" study of the valiant NAVION stent graft

BACKGROUND

The aim of the present study was to evaluate early results of thoracic endovascular aortic repair (TEVAR) using the Valiant Navion™ stent graft in a "real-world" scenario.

METHODS

All patients who underwent TEVAR with the Valiant Navion™ endograft between November 2018 and November 2019 were included in this retrospective multicenter study (six European centers). The primary endpoints were technical success, incidence of major adverse events (MAEs), access failure, deployment failure, deployment accuracy, and rate of intraoperative endoleaks (ELs).

RESULTS

One hundred-sixteen patients with varying thoracic aortic diseases were included. Eighteen patients (15.5%) were treated for an off-label condition. The technical success rate was 100%, without any access or deployment failures. The proximal and distal deployment accuracy rates were 99.1% and 97.4%, respectively. There were no intraoperative MAEs, including death. Two (1.7%) type Ib ELs were detected at the first postoperative CTA, all of which were in off-label procedures and related to the short length of the sealing neck. No type III ELs were detected. The median hospitalization time was 8 days (IQR 4-12), including a median intensive care unit stay of 1 day (IQR 1-2). The in-hospital mortality rate was 4.3%. At a median follow-up time of 98 days (IQR 39-187), there were no aortic-related mortalities or new onset of endoleaks.

CONCLUSION

Our initial experience with the Valiant Navion™ endograft in a wide variety of aortic diseases showed safe early outcomes, especially for on-label procedures.

Clinical and Morphologic Outcomes of Endovascular Repair for Subacute and Chronic Type B Aortic Dissection

BACKGROUND

The objective of the study was to assess long-term remodeling, survival, and reintervention outcomes after thoracic endovascular aortic repair (TEVAR) for subacute and chronic type B aortic dissection (TBAD).

METHODS

All patients who underwent TEVAR for subacute or chronic TBAD at a tertiary referral center between 1999 and 2015 were included in this cohort study. The primary outcome was aortic remodeling, and secondary outcomes included survival, rate of major complications, and reinterventions.

RESULTS

Fifty patients were included, with mean age of 62.4 years, 10 (20%) DeBakey type IIIA and 40 (80%) DeBakey type IIIB dissection; 45 standard TEVAR, 2 branched TEVAR, 3 TEVAR combined with fenestrated or branched EVAR. Indication for TEVAR was intact (n = 40) or ruptured (n = 1) postdissection aneurysm, hypoperfusion (n = 4), treatment-refractory pain (n = 2), or a combination (n = 3). Mean clinical follow-up was 76 months, and median radiological follow-up was 46 months. Thirty-day survival was 96%, stroke 4%, renal failure 0%, paraplegia 0%. Three- and five-year survival was 92% (95% confidence interval (CI) [79; 97]) and 77% (95% CI [61; 87]), respectively. Of 19 late deaths, 6 were confirmed aorta related. Five-year freedom from reintervention was 69% (95% CI [53-80]). Distal stent graft extension due to aortic dilatation composed most reinterventions. Mean maximal aortic diameter was 58.7 mm preoperatively and 51.9 mm on last follow-up (P = 0.003). On thoracic level, true lumen expanded (+10.0 mm, 95% CI [6.4; 13.6]) (P < 0.001) and false lumen decreased (-11.9 mm, 95% CI [-15.2; -8.5]) (P < 0.001) from baseline to the last computed tomography. In the abdominal aorta, true lumen diameter change was +3.1 mm (95% CI [1.4; 4.8]) (P = 0.001); false lumen diameter change was +1.0 mm (95% CI [-1.8; 3.8]) (P = 0.464).

CONCLUSIONS

TEVAR for subacute and chronic TBAD results in favorable remodeling of the thoracic but not the abdominal aorta. Five-year survival is almost 80%, but late aortic deaths still occur. Aortic dilatation distal to the treated segment requiring reintervention is common, emphasizing the importance of follow-up.

Late Aortic Expansion After Thoracic Endovascular Aortic Repair for Chronic DeBakey IIIb Dissection

BACKGROUND

The efficacy of thoracic endovascular aortic repair (TEVAR) for chronic DeBakey IIIb aortic dissection is still under discussion. This study was performed to investigate the incidence of and risk factors for late aortic expansion after TEVAR for chronic DeBakey IIIb aortic dissection.

METHODS

From March 2014 to April 2019, a total of 35 patients with chronic DeBakey IIIb aortic dissection underwent TEVAR in our institution. Risk factors for aortic expansion events were examined by stepwise Cox regression analysis. Aortic expansion events were defined as reintervention for expansion or aortic expansion of greater than 5 mm.

RESULTS

No operative death occurred, and the 2-year survival rate was 96.8%. The 1- and 2-year rates of freedom from reintervention were 87.8% and 80.2%, respectively. During follow-up, 11 patients had late aortic expansion events (4 with expansion of the thoracic aorta and 7 with expansion of the abdominal aorta). The 1- and 2-year rates of freedom from aortic expansion were 87.8% and 68.7%, respectively. Significant risk factors for expansion events were aortic dilation at the celiac level (hazard ratio [HR], 1.11; P = .015), saccular aneurysm formation of the false lumen (HR, 5.08; P = .049), and high number of residual large reentries (>5 mm) (HR, 2.78; P = .027).

CONCLUSIONS

In patients undergoing TEVAR for chronic DeBakey IIIb aortic dissection, late aortic expansion in both the thoracic and abdominal aorta remains an important issue. Aggressive additional intervention should be considered for high-risk patients with residual large reentries and aortic dilation at the celiac level.

Mid-Term Results of Frozen Elephant Trunk Technique for Chronic Aortic Dissection

Objective: In this study, we report our experience using the frozen elephant trunk (FET) technique for chronic aortic dissection. Methods: Between January 2011 and December 2017, 15 patients underwent total arch replacement (TAR) with the FET technique for chronic aortic dissection (CAD). Results: Hospital mortality was 6.7% (n=1). No patients experienced spinal cord injury. Distal stent-induced new entry (dSINE) occurred in the early postoperative period in one patient. There were four unplanned additional operations to manage dSINE. Five patients suffered from dSINE, and aortoesophageal fistula developed in three of them. Short insertion length of the FET and large angle between the distal edge of the FET and the descending aorta were significantly more common in the dSINE group than in the non-dSINE group. The cumulative survival rates at 1, 3, and 5 years were 93.3%, 93.3%, and 66.4%, respectively. The cumulative aortic event-free rates at 1, 2, and 3 years were 85.7%, 77.1%, and 52.9%, respectively. Conclusion: The FET technique for CAD provided good early results. Short insertion length of the FET, however, can induce dSINE, which requires an additional operation at mid-term. Thus, surgical indication of the FET technique for CAD must be discussed.

Association Between Extent of Stent-Graft Coverage and Thoracic Aortic Remodeling After Endovascular Repair of Type B Aortic Dissection

Purpose: To examine the association between the extent of stent-graft coverage and thoracic aortic expansion after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. Materials and Methods: A retrospective analysis was conducted of 201 patients (mean age 52.4±11.5 years; 178 men) with acute (135, 67.2%) or chronic (66, 32.8%) type B aortic dissection who underwent TEVAR at 4 medical centers. The mean stent-graft length was 157.1±33.3 mm. The percentage of stented descending aorta (PSDA) represented the extent of stent-graft coverage. After using restricted cubic smoothing spline plots to confirm the roughly linear relationship between PSDA and the risk of thoracic aortic expansion, patients were stratified into 2 groups on the median PSDA: the lower group (≤31.3%) and the higher group (>31.3%). Thoracic aortic expansion was defined as a ≥20% increase in the total thoracic aortic volume on the most recent postoperative computed tomography angiography scan compared with the preoperative measurement. The Kaplan-Meier method was used to estimate the cumulative freedom from thoracic aortic expansion after TEVAR; estimates are given with the 95% confidence interval (CI). A multivariable Cox proportional hazards model was used to analyze any independent association of the PSDA as a continuous or categorical variable with the risk of thoracic aortic expansion; results are presented as the hazard ratio (HR) and 95% CI. Results: No patients developed symptoms of spinal cord ischemia during hospitalization. Over a median 12.4 months of imaging follow-up, 34 (16.9%) patients developed thoracic aortic expansion. The estimate of freedom from thoracic aortic expansion at 12 months for the overall PSDA was 84.0% (95% CI 77.8% to 88.6%); between the groups, the freedom from thoracic aortic expansion estimate for the PSDA ≤31.3% group was significantly lower than in the higher group (p=0.032). Regression analysis showed no significant association between the risk of thoracic aortic expansion and the PSDA as a continuous variable (HR 0.97, 95% CI 0.91 to 1.03, p=0.288); however, analyzing the PSDA as a categorical variable indicated a significantly lower risk of thoracic aortic expansion for the PSDA >31.3% group (HR 0.46, 95% CI 0.22 to 0.95, p=0.036) after adjusting for a variety of demographic and anatomical characteristics. Conclusion: More extensive stent-graft coverage appears to improve thoracic aortic remodeling after TEVAR. However, the clinician should balance the benefit of extensive stent-graft coverage and its related risk of spinal cord ischemia.

Long-Term Outcomes of Open Surgery and Stent Graft Treatment in Patients Undergoing Repeat Thoracic Aortic Aneurysm Repair from Previous Anastomosis Site

Objective: The purpose of this study was to compare the long-term outcomes of open surgery and thoracic endovascular aortic repair (TEVAR) in patients undergoing repeat thoracic aortic repair from previous anastomosis site.

Methods: From January 2009 to December 2017, 68 patients needed repeat aortic surgery from previous anastomosis site. Twenty-three patients had dissected distal aorta and 45 patients had non-dissected distal aorta. Early and long-term outcomes of open surgery and TEVAR were compared in both groups.

Results: There were no significant differences in patient background between the two treatments in both groups. Open surgery was associated with longer intensive care unit stay, but there was no significant difference in in-hospital mortality in both groups. In patients with dissected distal aorta, there was no significant difference in long-term mortality (p=0.73). However, TEVAR was associated with higher risk of reintervention (p=0.038). In non-dissected distal aorta patients, acute kidney injury (p=0.002) and prolonged ventilation (p=0.032) were more often observed in open surgery. However, there were no significant differences in long-term mortality (p=0.23) and freedom from reintervention (p=0.13).

Conclusions: Long-term outcomes were similar between open surgery and TEVAR in both groups. However, TEVAR in patients with dissected distal aorta was associated with higher risk, for reintervention.

Surgical Outcomes And Postoperative Descending Aorta Morphologic Remodeling After Thoracic Endovascular Aortic Repair For Acute And Chronic Type B Aortic Dissection

Background

This study aims to investigate the descending aortic morphological alterations caused by pathological changes in acute and chronic Type B aortic dissection (TBAD) and morphological remodeling after thoracic endovascular aortic repair (TEVAR).

Patients and methods

From February 2012 to January 2016, 86 TBAD patients undergoing TEVAR were divided into an acute group (n=63) and a chronic group (n=23). The areas of the true, false and maximal lumen and descending aorta morphological parameters, including the taper ratio (TR), oversizing ratio (OR), mismatch ratio (MR), radius of curvature (RoC) and tortuosity index (TI), were evaluated. Follow-ups were performed postoperatively before discharge, at 1 and 6 months, and yearly thereafter.

Results

Before TEVAR, the TR (0.57 (0.49) vs 0.74 (0.60); P < 0.05), OR (2.75 ± 1.89 vs 3.96 ± 2.27; P < 0.05) and TI (1.22 (1.19) vs 1.41 ± 0.17; P < 0.05) were significantly higher in the chronic group than in the acute group. The TEVAR technical success rate was 100%. No differences were found in 30-day and >30-day mortality between the two groups. Pathology-specific devices, such as tapered stent grafts and distal bare stents, were used more frequently in the chronic group than in the acute group (47.8% vs 23.8%, P = 0.03; 43.5% vs 12.7%, P = 0.002, respectively). The OR and TI changes that occurred after TEVAR were significantly higher in the chronic group than in the acute group (1.80 ± 0.86 vs 2.98 ± 1.85, P = 0.028; 0.00 ± 0.09 vs 0.09 ± 0.10, P < 0.001, respectively).

Conclusion

TEVAR is a safe and effective therapy for acute and chronic TBAD. Compared to acute TBAD, chronic TBAD resulted in an adverse preoperative descending aorta morphology. Pathology-specific devices may be a feasible treatment option for endovascular repair of chronic TBAD. A larger series of cases with longer follow-up are needed to draw definitive conclusions.

The Role of Thoracic Endovascular Repair in Chronic Type B Aortic Dissection

Continued device improvements along with refined implantation techniques have revolutionize the use of thoracic endovascular repair for both aortic dissections and aneurysms. This is now considered standard of care for acute, complicated type B aortic dissection in patients with appropriate anatomy. However, the treatment of chronic, uncomplicated type B dissection continues to present challenges for the aortic surgeon, as the long-held dogma of medical management and surveillance for aneurysm degeneration has recently come into questions. We present evidence for a more thoughtful approach to management and intervention with thoracic endovascular repair in select patients with chronic, type B dissection.

Proposed classification of endoleaks after endovascular treatment of Stanford type-B aortic dissections

Objectives

Despite two decades of experience, no dedicated classification system exists to document and prognosticate patterns of endoleak encountered after endovascular therapy of type-B aortic dissection. This nomenclature gap has led to inconsistent management and underreporting of significant findings associated with adverse outcomes after endovascular treatment of type-B aortic dissection. Our goal was to propose a reproducible and prognostically relevant classification.

Methods

A multidisciplinary team of seven experienced open and endovascular aortic surgeons was assembled to provide consensus opinion. Extensive literature review was conducted. Deficiencies in the current classification approach of the various patterns of persistent filling of false lumen after endovascular therapy were identified.

Results

Our focus was to categorize high-risk and low-risk subgroups within endoleaks after endovascular treatment of type-B aortic dissection. In this classification, type-Ia endoleak refers to persistent filling of the false lumen in an antegrade manner. Causes include failure to cover the primary entry tear and sizing or technical related proximal seal failure. False lumen filling via distal entry tears is classified as type Ib endoleak, which is further sub-classified into b1 (major branch-related tears), and b2 (multiple small branches related tears). Retrograde ascending aortic dissection and stent graft-induced new entry were classified as type-I endoleaks (type-Ir and type-Is, respectively). Another focus was reclassification type-II endoleaks, with type-IIa endoleak referring to conventional retroleak from one or more posterior branches and type-IIx referring to retroleak from major branches (visceral or left subclavian arteries).

Conclusions

The majority of endoleaks after endovascular treatment of type-B aortic dissection are related to persistent or new filling of the false lumen. We propose a new false lumen-based classification schema for endoleaks occurring after endovascular therapy of type-B aortic dissection.

False lumen embolization in chronic aortic dissection promotes thoracic aortic remodeling at midterm follow-up

OBJECTIVE

Failure of thoracic endovascular aortic repair (TEVAR) in chronic aortic dissections can be partially explained by retrograde false lumen (FL) flow through distal re-entry tears. After implantation of a thoracic stent graft, FL thrombosis occurs in less than 50% of the cases. The objectives of this study were to describe the feasibility and outcomes of FL embolization in patients with chronic aortic dissections.

METHODS

Between June 2015 and January 2018, 27 patients (mean age, 61 ± 14 years) with chronic aortic dissection underwent FL embolization as an adjunct during or after TEVAR placement procedure. Indications for embolization were (1) symptomatic chronic aortic dissections with pain or rapid growth of aortic diameter (≥5 mm/y) requiring rapid exclusion of the aneurysm, (2) aneurysmal dilatation with persistent FL retrograde flow after TEVAR, and (3) large FL aneurysms (≥55 mm) that might lead to persistent retrograde flow. Twenty patients presented with type B chronic aortic dissections (74.1%) and seven presented a residual type A chronic aortic dissections (25.9%). Eight patients had a previous aortic arch replacement (29.6%). Six patients had previous repair with TEVAR (22.2%). The delay between the onset of dissection and the first endovascular repair was 47 months (range, 3-144). Spinal fluid drainage was used in 74.1% of cases (20/27 patients). Embolization devices included coils and vascular plugs.

RESULTS

The technical success rate was 100% (27/27). Complete spinal cord ischemia was observed in one patient (3.7%). There was one hospital death from pneumonia after zone 1 supra-aortic trunk debranching with TEVAR and embolization. After the index procedure, FL thrombosis was observed in 81.5% of patients (22/27) on late phase computed tomography angiography. Five patients required two or more embolization procedures, leading to a high rate of complete FL thrombosis (92.6%). One patient presented a type IB endoleak and one patient presented a type II endoleak. Radiologic follow-up was 20 ± 10 months. The maximum thoracic aortic diameter significantly decreased from 63 mm to 54 ± 10 mm (P < .001).

CONCLUSIONS

Embolization of the FL of chronic aortic dissections is technically feasible with a low morbidity rate. The FL thrombosis is observed in the majority of case and promotes favorable thoracic aortic remodeling. Longer follow-up is needed to confirm these good results on the thoracic aorta and this technique may, therefore, improve the results of TEVAR in chronic aortic dissections.

[Elimination of late endoleak after endovascular repair of a dissecting thoracoabdominal aortic aneurysm]

Described herein is a clinical case report regarding treatment of a 70-year-old male patient presenting with a late complication following endoprosthetic repair for a Stanford type B dissecting thoracic aortic aneurysm. The man was admitted to our hospital for persistent type IIb endoleak and an increased diameter of the aorta in its thoracic and thoracoabdominal portions. Two years previously, he had endured endoprosthetic repair of the thoracic aorta. The findings of computed tomography revealed negative dynamics manifesting as an increase in the diameter of the false channel of the arch and descending thoracic aorta with persistent type IIb endoleak. He was subjected to elimination of abdominal aortic dissection and type IIb endoleak with partial prosthetic repair of the descending thoracic portion of the aorta by means of prosthetic repair of the lower thoracic portion of the aorta between the stent graft and linear vascular Dacron prosthesis. The postoperative period was complicated by transient acute renal failure and paraparesis of the lower limbs. The patient was discharged on POD 14, with no endoleaks revealed on control computed tomography 3 months thereafter.

Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has become a mainstay of therapy for acute and chronic type B aortic dissection (TBAD). Dynamic aortic morphologic changes, untreated dissected aorta, and persistent false lumen perfusion have significant consequences for reintervention after TEVAR for TBAD. However, few reports contrast differences in secondary aortic intervention (SAI) after TEVAR for TBAD or describe their influence on mortality. This analysis examined incidence, timing, and types of SAI after TEVAR for acute and chronic TBAD and determined their impact on survival.

METHODS

All TEVAR procedures for acute and chronic TBAD (2005-2016) were retrospectively reviewed. Patients with staged (<30 days) or concomitant ascending aortic arch repair or replacement were excluded. Acuity was defined by symptom onset (0-30 days, acute; >30 days, chronic). SAI procedures were grouped into open (intended treatment zone or remote aortic site), major endovascular (TEVAR extension or endograft implanted at noncontiguous site), and minor endovascular (side branch or false lumen embolization) categories. Kaplan-Meier methodology was used to estimate freedom from SAI and survival. Cox proportional hazards were used to identify SAI predictors.

RESULTS

TEVAR for TBAD was performed in 258 patients (acute, 49% [n = 128]; chronic, 51% [n = 130]). Mean follow-up was 17 ± 22 months with an overall SAI rate of 27% (n = 70; acute, 22% [28]; chronic, 32% [42]; odds ratio, 1.7; 95% confidence interval, 0.9-2.9; P = .07]. Median time to SAI was significantly less after acute than after chronic dissection (0.7 [0-12] vs 7 [0-91] months; P < .001); however, freedom from SAI was not different (1-year: acute, 67% ± 4%, vs chronic, 68% ± 5%; 3-year: acute, 65% ± 7%, vs chronic, 52% ± 8%; P = .7). Types of SAI were similar (acute vs chronic: open, 61% vs 55% [P = .6]; major endovascular, 36% vs 38% [P = .8]; minor endovascular, 21% vs 21% [P = 1]). The open conversion rate (either partial or total endograft explantation: acute, 10% [13/128]; chronic, 15% [20/130]; P = .2) and incidence of retrograde dissection (acute, 6% [7/128]; chronic, 4% [5/130]; P = .5) were similar. There was no difference in survival for SAI patients (5-year: acute + SAI, 55% ± 9%, vs acute without SAI, 67% ± 8% [P = .3]; 5-year: chronic + SAI, 72% ± 6%, vs chronic without SAI, 72% ± 7% [P = .7]). Factors associated with SAI included younger age, acute dissection with larger maximal aortic diameter at presentation, Marfan syndrome, and use of arch vessel adjunctive procedures with the index TEVAR. Indication for the index TEVAR (aneurysm, malperfusion, rupture, and pain or hypertension) or remote preoperative history of proximal arch procedure was not predictive of SAI.

CONCLUSIONS

SAI after TEVAR for TBAD is common. Acute TBAD has a higher proportion of early SAI; however, chronic TBAD appears to have ongoing risk of remediation after the first postoperative year. SAI types are similar between groups, and the occurrence of aorta-related reintervention does not affect survival. Patients' features and anatomy predict need for SAI. These data should be taken into consideration for selection of patients, device design, and surveillance strategies after TEVAR for TBAD.

Techniques and outcomes of secondary endovascular repair for postdissection TAA/TAAA

Postdissection aortic aneurysms (PDAA) affect 20-40% of patients with aortic dissection. Open repair remains the first line therapy of PDAA, but is still associated with high mortality and morbidity rates. Endovascular repair is increasingly being used as a less invasive treatment option. Thoracic endovascular aneurysm repair (TEVAR) covering only the proximal entry tear has proven to be insufficient in most patients with chronic PDAA and has a limited role only for PDAA with distal sealing zone in the thoracic aorta. In PDAA extending to the thoracoabdominal aorta, a more complex repair is needed to achieve aneurysm exclusion. Fenestrated and branched stent-grafts have been used lately in some expert centres to treat PDAA of the thoracoabdominal aorta with good preliminary results despite the technical difficulties in these patients (narrow true lumen, stiff chronic dissection flap, target vessels that originate from the false lumen [FL]). A subset of patients with aneurysmal degeneration mainly in the descending thoracic aorta, can be treated with TEVAR landing proximal to the celiac artery along with adjuvant techniques such as coils, plugs, glue or "Candy-Plug" and "Knickerbocker" concepts to occlude the FL, preventing retrograde flow and reducing the pressure in the aneurysm. Other options that have been used in limited numbers of patients with PDAA include the PETTICOAT (provisional extension to induce complete attachment) and STABILISE (Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair) techniques. This article aims to review the outcomes of different endovascular techniques and strategies available for the repair of PDAA.