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

Aggressive Treatment Strategy at Index Thoracic Endovascular Aortic Surgery is Associated with Reduced Need for Short-Term Reintervention in Patients with Aortic Dissection

INTRODUCTION

Thoracic endovascular aortic surgery (TEVAR) is the modern standard of treatment for patients with Type B aortic dissection, however it is unclear how the initial length of treated aorta affects long-term outcomes. This study aims to elucidate risk factors for secondary intervention after TEVAR for aortic dissection, focusing on length of aortic treatment at index operation.

METHODS

A retrospective multihospital chart review was completed for patients treated between 2011 and 2022 who underwent TEVAR for aortic dissection with at least 1 year of post-TEVAR imaging and follow-up. Patient demographics and characteristics were analyzed. In this study, aortic zones treated only included those managed with a covered stent graft. The primary outcome measure was any need for secondary intervention.

RESULTS

A total of 151 patients were identified. Demographics included a mean age of 57 years, with 31.8% of the patients being female. Forty-three patients (28.5%) underwent secondary intervention after TEVAR, with a mean follow-up of 1.6 years. The most common indication for secondary intervention was aneurysmal degeneration of the residual false lumen (76%). There was a significant difference in the number of aortic zones treated in patients who did and did not require secondary intervention (2.3 ± 1 vs. 2.7 ± 1, P = 0.04). Additionally, patients with 3 or more aortic zones of treatment had a significant difference in the need for reintervention (32% secondary intervention versus 52% no secondary intervention, P = 0.02).

CONCLUSIONS

At least 3 zones of aortic treatment at index TEVAR is associated with a decreased need for overall reintervention. Modern treatment of acute and subacute type B dissection should stress an aggressive initial repair, balanced by the potential increased risk of spinal cord ischemia.

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.

Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection

BACKGROUND

Aortic dissection is the deadliest disease of the cardiovascular system. Type B aortic dissection accounts for 30%-60% of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair (TEVAR). However, patients are prone to various complications after surgery, with central nervous system injury being the most common, which seriously affects their prognosis and increases the risk of disability and death. Therefore, exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.

AIM

To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.

METHODS

We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022. The patients were categorized into injury (n = 159) and non-injury (n = 147) groups based on central nervous system injury following surgery. The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups. Multivariate logistic regression analysis was performed.

RESULTS

The Association between age, history of hypertension, blood pH value, surgery, mechanical ventilation, intensive care unit stay, postoperative recovery times on the first day after surgery, and arterial partial pressure of oxygen on the first day after surgery differed substantially (P < 0.05). Multivariate logistic regression analysis indicated that age, surgery time, history of hypertension, duration of mechanical ventilation, and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection (P < 0.05).

CONCLUSION

For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection, early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.

Incidence, Predictors, and Implications of Secondary Aortic Intervention Following Thoracic Endovascular Aortic Repair for Type B Dissection

BACKGROUND

Secondary aortic intervention (SAI) following thoracic endovascular aortic repair (TEVAR) is not uncommon. However, a satisfactory management system has not been established for these patients. We aimed to report our single-center experience with SAI after prior TEVAR for type B aortic dissection (TBAD).

METHODS

From January 2010 to May 2017, 860 eligible patients with TBAD underwent TEVAR. One hundred seven (12.4%) patients required SAI, either endovascularly (n=76) or surgically (n=31). The main indications for SAI were entry flow (n=58 [54.2%]), aneurysm expansion of the proximal or remote aorta (n=26 [24.3%]), retrograde type A aortic dissection (n=11 [10.3%]), distal stent-graft-induced new entry tear (n=6 [5.6%]), and stent migration (n=4 [3.7%]). The Kaplan-Meier curves were generated to determine the degree of freedom from SAI and the prognosis. Cox proportional hazards were used to screen for risk factors for SAI and poor prognosis.

RESULTS

The overall 30-day mortality rate after SAI was 4.7% (n=5): endovascular (n=2 [2.6%]) vs open surgery (n=3 [9.7%]; p=0.145). The cumulative survival rates with or without SAI were 86.3%±3.6% vs 95.7%±0.8% at 3 years and 82.0%±4.2% vs 92.2%±1.1% at 5 years, respectively (log-rank p<0.001). Although no significant difference in survival was observed, the incidence of SAI was significantly greater in patients who underwent TEVAR during the chronic phase (acute [11.6%] vs subacute [9.6%] vs chronic [27.8]; p<0.001). Multivariate regression analysis revealed that prior TEVAR in the chronic phase (hazard ratio [HR]=1.73, 95% confidence interval [CI]=1.03-2.90; p=0.039), maximum aortic diameter (HR=1.05, 95% CI=1.04-1.07; p<0.001), and arch involvement (HR=1.48, 95% CI=1.01-2.18; p=0.048) were predictors of the incidence of SAI. In addition, the maximum aortic diameter was demonstrated to be the only risk factor for prognosis after adjusting for confounding factors.

CONCLUSIONS

Thoracic endovascular aortic repair for chronic TBAD patients should be reconsidered. Open surgery is preferable for those with proximal progression, whereas endovascular treatment is more suitable for distal lesions. Close surveillance and timely reintervention after TEVAR, whether via endovascular techniques or open surgery, are necessary to prevent devastating complications.

CLINICAL IMPACT

The management of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR) is challenging. We summarized our single-center experience regarding secondary aortic intervention after TEVAR for TBAD. We found that TEVAR for chronic TBAD patients should be carefully evaulated, and open surgery is recommended for those with proximal progession, while endovascular treatment is more preferable for distal lesions.

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.

A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection

BACKGROUND

Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments.

METHODS

A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management.

RESULTS

RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001).

CONCLUSION

RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

The Caged Knickerbocker: A Novel Modification to Targeted False Lumen Management in Complex Aortic Dissection

INTRODUCTION

Targeted false lumen management has been described for complex presentations of aortic dissection. The "Knickerbocker" technique is often referenced and includes dilating a focal portion of an oversized endograft in the true lumen to purposefully rupture the false lumen septum, but at the expense of increased risk for visceral propagation and malperfusion. This case series describes a novel modification of the Knickerbocker technique by caging the distal end of the endograft prior to focal dilation.

METHODS

A retrospective chart review was conducted at a tertiary academic center from 2018-2020. Patients were included if they had a history or current presentation of aortic dissection and underwent a Caged Knickerbocker (CKB) repair. Data were collected to include demographics, indications for repair, technical success, perioperative outcomes, hospital course, mortality, and further aortic interventions.

RESULTS

Five patients were included in our evaluation. Four patients (80%) presented with chronic Type B aortic dissection (cTBAD) and concomitant aneurysmal degeneration of the thoracic aorta; 1 patient (20%) presented with an acute rupture secondary to cTBAD. Three patients (60%) had previous aortic repairs, 2 of which were for Type A Aortic Dissection that additionally required redo sternotomy and total arch replacement prior to CKB. CKB was technically successful in all cases with no peri-operative complications. Two (40%) patients required further aortic intervention due to aneurysmal degeneration.

CONCLUSION

Achieving complete false lumen thrombosis is a considerable challenge when managing complex aortic dissections. Our data demonstrate the technical feasibly and early successful outcomes with the CKB approach. Importantly, CKB facilitates future distal extension into the para-visceral aorta in cases of complex thoracoabdominal aortic aneurysms. Further research should focus on discerning individual patients who will benefit from targeted false lumen management and compare outcomes between different approaches.

Complications in Patients with Chronic Type B Aortic Dissection (cTBAD)-A Long-Term Analysis

Chronic type B aortic dissection (cTBAD) is a rare but challenging condition that requires individual treatment strategies. Especially the long-term therapy impacts prognosis. In this single-center retrospective study, we evaluated patients with cTBAD in our vascular outpatient clinic over 10 years. Follow-up consultations included contrast-enhanced, electrocardiogram-triggered, high-resolution CT angiography (CTA) covering the entire aorta. Evaluated characteristics went beyond demographic characteristics combining the treatment approach and the timing and occurrence of potential complications. We analyzed 133 patients in total (n = 92, 69.2% male) with cTBAD with a mean follow-up of 67.7 months. Most of them underwent invasive treatment (n = 102, 76.7%), the majority received thoracic endovascular aortic repair (TEVAR) (n = 82, 61.7%). A total of 80 patients (60.2%) had major complications, whereas over a third was free of complications even after 5 years. Most common complications were progress of dissection and endoleaks, aneurysms of true (TL) and false lumen (FL) were more common in the later time periods. The treatment of cTBAD in terms of timing, therapy approach, and complications is still challenging for the entire aortic team. Nevertheless, the early recognition of complications permits promising treatment options and highlights the importance of frequent follow-up examinations especially within the first years.

Reintervention after Thoracic Endovascular Aortic Repair of Uncomplicated Type B Aortic Dissection

BACKGROUND

Data are scarce regarding the incidence, reasons, potential risk factors, and long-term outcomes of reintervention after thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated type B aortic dissection (TBAD).

METHODS

Between January 2010 and December 2020, 238 patients with uncomplicated TBAD who received TEVAR were analyzed retrospectively. The clinical baseline data, aorta anatomy, dissection characteristics, and details of the TEVAR procedure were evaluated and compared. A competing-risk regression model was used to estimate the cumulative incidences of reintervention. The multivariate Cox model was used to identify the independent risk factors.

RESULTS

The mean follow-up time was 68.6 months. A total of 27 (11.3%) cases of reintervention were observed. The competing-risk analyses showed that the 1-, 3-, and 5-year cumulative incidences of reintervention were 5.07%, 7.08%, and 14.0%, respectively. Reasons for reintervention included endoleak (25.9%), aneurysmal dilation (22.2%), retrograde type A aortic dissection (18.5%), distal stent-graft-induced new entry and false lumen expansion (18.5%), and dissection progression and/or malperfusion (14.8%). Multivariable Cox analysis demonstrated that a larger initial maximal aortic diameter (Hazard ratio [HR], 1.75; 95% Confidence interval [CI], 1.13-2.69, p = 0.011) and increased proximal landing zone oversizing (HR, 1.07; 95% CI, 1.01-1.47, p = 0.033) were the significant risk factors for reintervention. Long-term survival rates were comparable between patients with or without reintervention (p = 0.915).

CONCLUSIONS

Reintervention after TEVAR in patients with uncomplicated TBAD is not uncommon. A larger initial maximal aortic diameter and excessive proximal landing zone oversizing are associated with the second intervention. Reintervention does not significantly affect long-term survival.

The Role of Multimodality Imaging Approach in Acute Aortic Syndromes: Diagnosis, Complications, and Clinical Management

Acute aortic syndromes are life-threatening conditions with high morbidity and mortality. The principal pathological feature is acute wall damage with possible evolution towards aortic rupture. Accurate and timely diagnosis is mandatory to avoid catastrophic consequences. Indeed, misdiagnosis with other conditions mimicking acute aortic syndromes is associated with premature death. In this view, cardiovascular imaging is necessary for the correct diagnosis and management. Echocardiography, computed tomography, magnetic resonance imaging, and aortography allow for diagnosis, guarantee immediate treatment, and detect associated complications. Multimodality imaging is essential in the diagnostic work-up to confirm or rule out acute aortic syndromes. The aim of this review is to highlight the contemporary evidence on the role of single cardiovascular imaging techniques and multimodality imaging in the diagnosis and management of acute aortic syndromes.

A Systematic Review on PETTICOAT and STABILISE Techniques for the Management of Complicated Acute Type B Aortic Dissection

Background

Extended downstream endovascular management has been applied in acute complicated type B aortic dissection (acTBAD), distally to standard thoracic endovascular aortic repair (TEVAR), using bare metal stents, with or without lamina disruption, using balloon inflation. The aim of this systematic review was to assess technical success, 30-day mortality, and mortality during follow-up in patients with acTBAD managed with the Provisional Extension To Induce Complete Attachment (PETTICOAT) or stent-assisted balloon-induced intimal disruption and relamination (STABILISE) technique.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement was followed. A search of the English literature, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, until 30th August 2022, was executed. Randomized controlled trials and observational studies (published between 2000-2022), with ≥ 5 patients, reporting on technical success, 30-day mortality and mortality during the available follow-up among patients that underwent PETTICOAT or STABILISE technique for acTBAD were eligible. The Newcastle-Ottawa Scale was applied to assess the risk of bias. Primary outcomes were technical success and 30-day mortality, and secondary outcome was mortality during the available follow-up.

Results

Thirteen studies were considered eligible, twelve in the quantitative analysis. In total, 418 patients with acTBAD managed with the PETTICOAT (83%) or STABILISE (17%) technique were included. Technical success ranged between 97-100%, 99% for the PETTICOAT and 100% for the STABILISE sub-cohort. Thirty-day mortality was estimated at 3.7% (12/321), 1.4% for the STABILISE and 4.4% for the PETTICOAT technique. All studies reported the mean available follow-up which was estimated at 20 months (range 3-168 months), 22 months (mean value) for the PETTICOAT and 17 months (mean value) for the STABILISE technique. Twenty-three patients died during follow-up, with an estimated mortality rate at 5.7% for the total cohort. The mortality during follow-up was 0% for the STABILISE and 7.0% for the PETTICOAT approach.

Conclusions

Both, the PETTICOAT and STABILISE techniques presented less than 4% perioperative mortality in patients with acTBAD with high technical success rate. The mid-term mortality rate was at 6%. However, the heterogeneity in the available studies' highlights the need for further prospective studies, including larger volume and longer follow-up.

Readmission after early thoracic endovascular aortic repair versus medical management of acute type B aortic dissection

BACKGROUND

The use of thoracic endovascular aortic repair (TEVAR) for the management of acute uncomplicated type B aortic dissection (TBAD) has increased. Although the results from early studies were promising, larger randomized trials evaluating TEVAR are lacking. It is also unclear where sufficient equipoise exists for such trials. In the present study, we evaluated the number of readmissions and unplanned operations after TEVAR vs those after medical management as the initial treatment of acute uncomplicated TBAD and the frequency of each treatment in this population.

METHODS

We performed a multi-institutional retrospective review of patients with acute TBAD from 2015 to 2020 with the 1-year outcomes available, excluding patients with prior aortic intervention or chronic, iatrogenic or traumatic etiologies. The primary exposure was TEVAR vs medical management at the index admission. The patient demographics, clinical presentation, and imaging findings were analyzed using bivariate and multivariate logistic regression for the primary outcomes of unplanned readmission and/or operation after the initial admission. The secondary outcomes were mortality, myocardial infarction, stroke, renal failure requiring dialysis, retrograde type A dissection, and length of stay. We hypothesized that the readmissions would be higher with medical management.

RESULTS

A total of 216 patients with TBAD (47 with complicated and 169 with uncomplicated) from two large academic centers were identified. Of the 169 patients with uncomplicated TBAD, 83 (49%) had been treated medically and 86 (51%) had undergone TEVAR at the initial admission. No differences were found in the demographics or high-risk imaging features at presentation. The medically managed patients had had higher rates of unplanned readmission (34% vs 9%; P = .0001) and operation (28% vs 8%; P = .0007) but shorter lengths of stay (6.3 vs 13.1 days; P < .0001). No differences were found in mortality, although the rate of myocardial infarction was higher in the medically managed group (10.8% vs 2.3%; P = .02). Although 28% of the medically managed patients had later required operation, they had had morbidity and mortality similar to those of patients who had undergone initial TEVAR. Initial medical management was associated with unplanned readmission (odds ratio, 8.3; P = .02) and the need for operation (odds ratio, 4.56; P = .006). No differences were found in the outcomes according to the involved aortic zones.

CONCLUSIONS

In the present study, medical management of acute uncomplicated TBAD was associated with higher rates of readmission and the need for unplanned operation compared with TEVAR. However, no differences were found in the 1-year mortality for the patients for whom medical management had failed. Because one half of the patients had undergone medical management and one half had undergone early TEVAR, this finding suggests clinical equipoise for the treatment of acute uncomplicated TBAD. Therefore, a larger randomized trial appears warranted to determine whether a clear benefit exists for early TEVAR.

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.

Physician-modified fenestrated endograft for postdissection thoracoabdominal aortic aneurysm following provisional extension to induce complete attachment and renal artery stenting

We have described a patient with a history of type A-11 dissection repair, who subsequently underwent thoracic endovascular aortic repair with distal bare metal dissection stents (provisional extension to induce complete attachment) and renal artery stenting for malperfusion. During the next 3 years, the thoracoabdominal aorta had continued to enlarge to 6.9 cm, despite false lumen embolization and thoracic endovascular aortic repair extension. Given the continued aortic enlargement, physician-modified fenestrated endovascular aortic repair was performed within the prior aortic and renal stents with successful aneurysm sealing. The results from the present case have illustrated that continued aneurysmal degeneration can occur after provisional extension to induce complete attachment and that subsequent physician-modified fenestrated endovascular aortic repair is feasible.

Retrograde ascending aortic dissection in the midterm period after thoracic endovascular aortic repair: a case report and literature review

Retrograde ascending aortic dissection (rAAD) is a catastrophic complication of thoracic endovascular aortic repair (TEVAR). A 56 year-old male patient who had undergone TEVAR for Stanford type B aortic dissection 6-month ago was admitted to our clinic with uncontrolled hypertension for the last twelve hours and history of a syncopal attack three days ago. Retrograde ascending aortic dissection was detected in computed tomography angiography. Ascending aorta and hemiarch replacement with a Dacron graft was safely performed via hypothermic circulatory arrest and antegrade cerebral perfusion for the treatment of rAAD after TEVAR.

Surgical Repair of Two Kinds of Type A Aortic Dissection After Thoracic Endovascular Aortic Repair

Background

Retrograde dissection is now recognized as an important complication following thoracic endovascular aortic repair (TEVAR). The purpose of this study is to describe two different situations of TAAD after TEVAR. We will introduce the surgical methods used to repair TAAD following TEVAR at our center, and evaluate its long-term prognosis.

Methods

Between January 2010 and October 2019, 50 patients who had previously received TEVAR treatment for TBAD were admitted to our center for repair of a type A aortic dissection. According to the patients’ CT angiographies and intra-operative findings, we identified two distinct groups: a retrograde group (stent-induced new aortic injury, with retrograde extension involving the ascending aorta) and an antegrade group (entry tear located in the aortic root, ascending aorta or the aortic arch, away from the edges of the stent grafts). The options for treatment of the proximal aorta were Bentall procedure (12/50, 24.0%) and ascending aorta replacement (38/50, 76.0%). All patients underwent total arch replacement (TAR) and frozen elephant trunk (FET) implantation. Survival over the follow-up period was evaluated with the Kaplan–Meier survival curve and the log-rank test.

Results

The median interval time from prior TEVAR to reoperation was 187 days (IQR: 30.0, 1375.0 days). 18.0% of TAAD after TEVAR did not have any obvious symptoms at the time of diagnosis, most of which were found on routine follow-up imaging. The patients in the retrograde group were younger than those in the antegrade group (44.0 ± 9.4 vs. 51.4 ± 10.5 years, P = 0.012). No significant differences in the incidence of post-operative complications or mortality were noted between the two groups. The mean follow-up time was 3 years. No late death or complications occurred after one year following surgery upon follow-up. The asymptomatic survival rate one year after surgery was 90.0%.

Conclusion

The TAR and FET technique was feasible and effective for complicated TAAD after TEVAR. The surgical success rate and long-term prognosis of patients undergoing the timely operation are satisfactory.

Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association

All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.

Aortic-related Readmission after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Patients: A Single-center Retrospective Study

OBJECTIVES

This study aimed to investigate the characteristics of and risk factors for aortic-related readmission after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

METHODS

Data from TBAD patients who underwent TEVAR from 2009-2018 at a Chinese tertiary center were retrospectively collected and analyzed. Enrolled patients were categorized into two groups according to whether aortic-related readmission occurred during follow-up, which was defined as hospitalization at least once after the initial procedure due to events that were related to or caused by aortic dissection or the initial procedure.

RESULTS

A total of 1 288 TBAD patients were enrolled, and 99 patients experienced aortic-related readmissions (7.7%), among whom chronic patients had the highest readmission rate (9.8%). The yearly proportion of readmission during the first year after initial procedure revealed a decreasing trend with a -9.7% annual percentage change. Seventy-one patients underwent reintervention (71.7%). Distal aneurysmal degeneration (43.7%) and distal stent graft-induced new entries (32.4%) were two major causes for reintervention. Fourteen patients in the reintervention subgroup underwent a second reintervention (19.7%). In-hospital mortality was 1.0% during the readmission and 14.3% during the second readmission. The overall survival was comparable between two groups (p=.93).

CONCLUSIONS

This study highlighted the importance of surveillance after initial procedure for TBAD patients with potential risk factors for aortic-related readmission, and the predisposition of patients with reintervention to multiple readmissions deserves attention.

Proximal true lumen collapse in a chronic type B aortic dissection patient: A case report

BACKGROUND

In the context of aortic dissection, increasing pressure within the newly formed false lumen can result in the progressive compression of the true aortic channel. However, true lumen collapse in chronic type B aortic dissection (cTBAD) patients is rare, with few clinical or experimental studies to date having explored the causes of such collapse.

CASE SUMMARY

In the present report, we describe a rare case of true-lumen collapse in an 83-year-old patient diagnosed with cTBAD, and we discuss potential therapeutic interventions for such cases. Following thoracic endovascular aortic repair (TEVAR), computed tomography angiography revealed satisfactory stent-graft positioning, no endoleakage, true lumen enlargement, thrombus formation in the false lumen, and slight enlargement of the true lumen distal to the stent-graft. Computational hemodynamic analyses indicated that the wall shear stress and pressure within the false lumen were significantly reduced following TEVAR.

CONCLUSION

TEVAR treatment of cTBAD patients suffering from proximal true lumen collapse can facilitate some degree of effective remodeling.

Secondary Interventions After TEVAR for Aortic Dissection

The goal of thoracic endograft placement in type B aortic dissection is to prevent aneurysmal degeneration and other complications. Although TEVAR is a highly effective tool for managing type B aortic dissection, many patients will require additional interventions. In this article, we present a case-based review of techniques for the management of persistent false lumen perfusion and stent-graft induced new entry tears after TEVAR for aortic dissection.

Endovascular therapies for Type B Aortic Dissection

Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, type B aortic dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as primary strategy is favored. However, there has been a recent paradigm shift in management of TBAD due to late aneurysmal degeneration of TBAD increasing morbidity and mortality at longer-term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.

Distal Aortic Remodeling after Type A Dissection Repair: An Ongoing Mirage

Remodeling is a commonly encountered term in the field of cardiothoracic surgery that is often used to describe various pathophysiological changes in the dimension, structure, and function of various cardiac chambers, including the aorta. Stanford type A or DeBakey type 1 aortic dissection (TAAD) is a perplexing pathologic condition that can present surgical teams with the need to navigate a maze of complex decision-making. Ascending or hemi-arch replacement leaves behind a significant amount of distal diseased aortic tissue, which might have a persistent false lumen or primary or secondary intimal tears (or communications between lumina), which can lead to dilatation of the aortic arch. Unfavorable aortic remodeling is a major cause of distal aortic deterioration after the index surgery. Cardiac surgeons are aware of post-surgical cardiac chamber remodeling, but the concept of distal aortic remodeling is still idealized. The contemporary literature from established aortic centers supports aggressive management of the residual aortic pathology during the index surgery, and with continuing technical advancements, endovascular stenting options are readily available for patients with TAAD or for complicated type B aortic dissection cases. This review discusses the pathophysiology and treatment options for favorable distal aortic remodeling, as well as its impact on mid- to long-term outcomes following TAAD repair.

The characteristics of distal tears affect false lumen thrombosis rate after thoracic endovascular aortic repair for acute type B dissection

OBJECTIVES

A low false lumen thrombosis rate (FLTR) is common in patients with type B aortic dissection after they have undergone thoracic endovascular aortic repair, which indicates a poor long-term prognosis. This study aimed to establish a quantitative linear regression model to predict false lumen (FL) thrombosis accurately using morphological parameters.

METHODS

In this retrospective study, we included 59 patients diagnosed with acute type B aortic dissection between 2014 and 2017. Morphological parameters were measured. Univariable and multivariable linear regression analyses were performed, and a linear regression model relating FLTR with the number of re-entry tears was proposed. Ten patients were further chosen to validate the linear relationship, and idealized aortic dissection models were adopted for haemodynamic analysis.

RESULTS

Only the total area and number of re-entry tears were negatively correlated with FL thrombosis (P < 0.001). Moreover, based on the univariable regression, the number of re-entry tears played a more crucial role in FLTR (R2 = 0.509 vs R2 = 0.298), and the linear relationship model was created as follows: thrombosis rate (%) = -11.25 × distal tear number + 105.24. This model was perfectly matched in 10 patients (concordance correlation coefficient = 0.880, P = 0.947). Moreover, when the total area of re-entry tears was constant, the net blood flow increased rapidly with an increase in the tear count.

CONCLUSIONS

The number of re-entry tears could be a crucial related factor of FL thrombosis; the larger the number of re-entry tears is, the lower the possibility of thrombosis is.

Adjunctive false lumen intervention for chronic aortic dissections is safe but offers unclear benefit

OBJECTIVE

Adjunctive false lumen embolization (FLE) with thoracic endovascular aortic repair (TEVAR) in patients with chronic aortic dissection is thought to induce FL thrombosis and favorable aortic remodeling. However, these data are derived from small single-institution experiences and the potential benefit of FLE remains unproven. In this study, we examined perioperative and midterm outcomes of patients with aortic dissection undergoing concomitant TEVAR and FLE.* METHODS: Patients 18 or older who underwent TEVAR for chronic aortic dissection with known FLE status in the Society for Vascular Surgery Vascular Quality Initiative database between January 2010 and February 2020 were included. Ruptured patients and emergent procedures were excluded. Patient characteristics, operative details and outcomes were analyzed by group: TEVAR with or without FLE. Primary outcomes were in-hospital post-operative complications and all-cause mortality. Secondary outcomes included follow-up mean maximum aortic diameter change, rates of false lumen thrombosis, re-intervention rates, and mortality.

RESULTS

884 patients were included: 46 had TEVAR/FLE and 838 had TEVAR alone. There was no significant difference between groups in terms of age, gender, comorbidities, prior aortic interventions, mean maximum pre-operative aortic diameter (5.1cm vs. 5.0cm, P=0.43), presentation symptomatology, or intervention indication. FLE was associated with significantly longer procedural times (178min vs. 146min, P=0.0002), increased contrast use (134mL vs. 113mL, P=0.02), and prolonged fluoroscopy time (34min vs. 21min, P<0.0001). However, FLE was not associated with a significant difference in post-operative complications (17.4% vs. 13.8%, P=0.51), length of stay (6.5 vs. 5.7 days, P=0.18), or in-hospital all-cause mortality (0% vs. 1.3%, P=1). In mid-term follow-up (median 15.5months, IQR 2.2-36.2 months), all-cause mortality trended lower, but was not significant (2.2% vs. 7.8%); and Kaplan-Meier analysis demonstrated no difference in overall survival between groups (P=0.23). By Cox regression analysis, post-operative complications had the strongest independent association with all-cause mortality (HR 2.65, 95% CI 1.56-4.5, P<0.001). In patients with available follow-up imaging and re-intervention status, mean aortic diameter change (n=337, -0.71cm vs. -0.69cm, P=0.64) and re-intervention rates (n=487, 10% vs. 11.4%, P=1) were similar.

CONCLUSIONS

Adjunctive FLE, despite increased procedural times, can be performed safely for patients with chronic dissection without significantly higher overall perioperative morbidity or mortality. TEVAR/FLE demonstrates trends for improved survival and increased rates of FL thrombosis in the treated thoracic segment; however, given the lack of evidence to suggest a significant reduction in re-intervention rates or induction of more favorable aortic remodeling compared to TEVAR alone, the overall utility of this technique in practice remains unclear. Further investigation is needed to determine the most appropriate role for FLE in managing chronic aortic dissections.

Burden and causes of readmissions following initial discharge after aortic syndromes

BACKGROUND

Aortic syndromes, including aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU), carry significant morbidity and mortality; few data exist regarding burden and causes of related rehospitalizations following initial discharge.

METHODS

The study was conducted using the Rochester Epidemiology Project. All adult residents (age ≥18 years) with an incident diagnosis of AD, IMH, and PAU (1995-2015) were identified from the Rochester Epidemiology Project using the International Classification of Diseases, Ninth Revision and Tenth Revision codes and Hospital Adaptation of the International Classification of Diseases, second edition, codes. Assessment of any-cause (aortic and cardiovascular), aorta-related, or cardiovascular-related readmissions was determined following date of hospital discharge or diagnosis date (ie, the index event).

RESULTS

A total of 117 patients of 130 cases of AD, IMH, and PAU included in the initial study population survived the index event and were evaluated. The median age of diagnosis was 74 years, and 70 (60%) were male. A total of 79 patients (68%) experienced at least one readmission. The median time to first any-cause, cardiovascular, and aortic readmission was 143, 861, and 171 days, respectively. The cumulative incidence of any-cause readmissions at 2, 4, and 10 years was 45%, 55%, and 69%, respectively. The cumulative incidence of cardiovascular readmissions at 2, 4, and 10 years was 15%, 20%, and 28%, respectively. The cumulative incidence of aortic readmissions at 2, 4, and 10 years was 38%, 46%, and 59%, respectively. Overall survival for the entire cohort at 2, 4, and 10 years was 84%, 75%, and 50%, respectively.

CONCLUSIONS

Readmissions following initial discharge after diagnosis of aortic syndrome are common and not different across specific disease types. Whereas aorta-related rehospitalizations occur in more than half of patients but tend to be earlier, cardiovascular-related rehospitalizations tend to happen later in about one-third of patients. This may suggest the need for early follow-up focused on aortic complications, whereas later follow-up should address cardiovascular events.

Technique-Based Evaluation of Clinical Outcomes and Aortic Remodelling Following TEVAR in Acute and Subacute Type B Aortic Dissection

INTRODUCTION

To evaluate the clinical outcomes and aortic remodelling rates following thoracic endovascular aortic repair (TEVAR) for acute or subacute type B aortic dissection (TBAD) based on technique.

MATERIAL AND METHODS

All TEVARs for acute/subacute TBAD between 01/01/2008 and 01/06/2020 were included. TEVARS were grouped by technique (TEVAR only, PETTICOAT and STABILISE). Aortic remodelling was assessed at three aortic levels on follow-up CT. Thirty-day technical/clinical success rates, re-intervention rates and complications were recorded.

RESULTS

A total of 29 patients were included. The median age was 55 years (31-82). The median duration from initial presentation to TEVAR was 7 days (0-84). Intra-procedural complications included one aortic rupture from balloon moulding in a STABILISE case. Thirty-day mortality, stroke, spinal cord ischaemia and visceral ischaemia were 3% (n = 1), 3% (n = 1), 3% (n = 1) and 3% (n = 1), respectively. (All occurred in acute TBAD.) Overall survival was 50.5 months (18-115). Median follow-up was 31 months (1-115). Six patients (21%) required re-intervention, with a median time of 5 months (5-46) from first TEVAR. Overall complete aortic remodelling rates were: 89% at the proximal descending thoracic aorta, 78% at the distal thoracic aorta and 50% at the infra-renal abdominal aorta. At the infra-renal aorta, the STABILISE group (n = 11) had a higher complete aortic remodelling rate (82%) compared to TEVAR alone (n = 12) (20%).

CONCLUSION

Endovascular intervention for acute and subacute TBAD is safe with a high rate of technical success. STABILISE results in higher aortic remodelling at the infra-renal aorta (82%) compared to TEVAR alone (20%) but risks aortic rupture from balloon moulding.

Ten-Year Clinical Characteristics and Early Outcomes of Type B Aortic Dissection Patients With Thoracic Endovascular Aortic Repair

OBJECTIVE/BACKGROUND

This study examined the 10-year hospitalization characteristics, economic patterns and early clinical outcomes of type B aortic dissection (TBAD) patients that underwent thoracic endovascular aortic repair (TEVAR) in one high-volume hospital in China.

METHODS

We performed a population-based retrospective analysis based on electronic medical record system data provided by Zhongshan Hospital Fudan University from 2009 to 2018.

RESULTS

We identified 1,367 cases of TBAD patients with TEVAR over the past decade. The total incidence of in-hospital complications was 7.6% (104 of 1,367), among which acute kidney injury (AKI) had the highest incidence (3.1%, 42 of 1,367). Aortic-related reintervention was performed in 7 patients (0.5%). The overall aortic-related in-hospital mortality rate was 2.7% (37 of 1,367) and had no significant time-varying trend (P = 0.2). Among these, 27% of in-hospital deaths were caused by retrograde type A dissection (RTAD). Chronic TBAD had a higher risk of in-hospital death versus acute TBAD, with a risk ratio of 2.69 (95% confidence interval [CI]: 1.19-6.09). Patients with hypertension (risk ratio 4.63, 95% CI: 1.38, 15.54) also had a higher in-hospital death risk. These 2 factors were also the predictive factors for the composite endpoint of in-hospital adverse events (risk ratio 2.17, 95% CI: 1.43, 3.29 and risk ratio 4.83, 95% CI: 1.90, 12.28, respectively), in addition to Marfan syndrome (risk ratio 4.05, 95% CI: 1.61, 10.19). The average length of hospitalization significantly declined during the past decade (annual percentage change -6.3%, 95% CI -8.2 to -4.3), and the stent-grafts (SGs) cost was the main expenditure of the total hospitalization costs.

CONCLUSION

Our study showed a favorable early outcome of TEVAR over the past decade. Greater attention should be paid to certain risk factors in order to reduce the in-hospital adverse events. SG expenditure is still the primary economic burden on Chinese TBAD patients.

The provisional extension to induce complete attachment technique is associated with abdominal aortic remodeling and reduces aorta-related adverse events after aortic dissection

OBJECTIVE

This study evaluated the efficacy of the provisional extension to induce complete attachment (PETTICOAT) technique for type B and postoperative residual type B aortic dissections compared with the conventional thoracic endovascular aortic repair (TEVAR) technique.

METHODS

In this retrospective study, we compared sequential aortic morphologic changes in consecutive patients with type B and postoperative residual type B aortic dissections treated with the PETTICOAT technique between January 2016 and December 2017 with patients treated with the conventional TEVAR between January 2013 and December 2015. Outcomes included aortic remodeling and aorta-related adverse events for 2 years postoperatively.

RESULTS

Forty-eight patients were included in this study (24 in the PETTICOAT group, 24 patients in the conventional TEVAR group). Although both groups showed aortic remodeling in the descending thoracic aorta, the PETTICOAT group developed significantly better aortic remodeling in the abdominal aorta compared with the conventional TEVAR group during the observation period. The PETTICOAT group had significantly fewer aorta-related adverse events compared with the conventional TEVAR group (8% vs 54%; P < .001). Aorta-related adverse events more commonly occurred in the poor remodeling group compared with in the good remodeling group (P = .001; hazard ratio, 8.32; 95% confidence interval, 2.26-30.64).

CONCLUSIONS

This study suggests that the PETTICOAT technique for aortic dissection may promote aortic remodeling and decrease the incidence of aorta-related adverse events. Additional studies are required to confirm these preliminary findings.

Remodeling, Reintervention, and Survival After Endovascular Repair of Chronic Type B Dissection

BACKGROUND

The efficacy of thoracic endovascular aortic repair (TEVAR) of chronic type B aortic dissection (cTBAD) is controversial. Only limited evidence describes temporal anatomic changes after TEVAR for cTBAD and their relationship to outcomes. We sought to investigate early aortic remodeling events after TEVAR for cTBAD with thoracic aneurysm and determine the association with reintervention and survival.

METHODS

Records from 95 cTBAD patients undergoing TEVAR from 2005 to 2017 were reviewed. Using 3-dimensional centerline analysis, anatomic phenotyping of the thoracoabdominal aorta was performed. Reverse aortic remodeling (RAR) was defined by a ≥5-mm reduction in maximal thoracic aortic diameter. Kaplan-Meier analysis estimated freedom from reintervention and survival.

RESULTS

Visceral segment dissection involvement was present in 89% of patients (n = 85), and the mean preoperative thoracic diameter was 63 mm (SD, 10). Complete thoracic false lumen thrombosis occurred in 71% of patients (n = 67), whereas abdominal false lumen thrombosis was documented in 60% (n = 57) by 6 months. RAR occurred in 41%. Aortic reintervention rate was 39% (n = 37). The 1- and 3-year freedom from reintervention was significantly higher in subjects experiencing early RAR (log-rank P = .02), but reintervention did not impact overall survival (log-rank P = .9). Similarly, overall survival was similar between patients with or without RAR (log-rank P = .4).

CONCLUSIONS

Early RAR is associated with decreased rates of reintervention; however, overall survival is not impacted by these changes. TEVAR for cTBAD results in a high rate of reintervention, which mandates vigilant surveillance protocols.

Mid-Term Outcomes of Complex Endografting for Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms

PURPOSE

To report early and mid-term results of post-aortic dissection thoracoabdominal aneurysms (pD-TAAA) treated by complex endografting in three tertiary referral hospitals.

MATERIALS AND METHODS

A review of all patients with pD-TAAA unfit for open surgery treated with complex endovascular repair from 2012 to 2018 was performed. Simple thoracic endografts (TEVAR) were excluded. Staged procedures in case of extensive aortic coverage were always planned.

RESULTS

In total, 21 patients (16 males, mean age 63 ± 10 years) with pD-TAAA underwent aortic repair by fenestrated or branched thoracoabdominal endografts for visceral vessels. Mean TAAA diameter was 61 ± 6.2 mm. Spinal cord drainage was performed in all patients. A staged approach was used in 12 (57%) cases. Technical success was achieved in 18 (86%) patients. No in-hospital deaths occurred. Two patients experienced transient post-procedural spinal cord ischemia. At 30 days, six type II endoleaks (29%), two type Ic endoleak (9.5%) and one type IIIc endoleak (5%) were reported. At a mean follow-up of 23 ± 13 months, no late aortic-related deaths occurred. Three patients underwent reintervention for type Ic and IIIc endoleaks. No visceral vessel occlusion was observed. Estimated freedom from reintervention at 12 and 24 months was 85.7 ± 0.7%. In 13 cases, TAAA diameter decreased at least 5 mm, while increased > 5 mm in only one case. Complete false lumen thrombosis was achieved in 18 patients (86%).

CONCLUSION

Complex endografting for pD-TAAA showed favorable mid-term results. Staged and carefully planned endovascular procedures may represent a safe and effective therapeutic option in patients deemed at high risk of open repair.

Preoperative distal aortic diameter is a significant predictor of late aorta-related events after endovascular repair for chronic type B aortic dissection

OBJECTIVES

Long-term therapeutic effects of thoracic endovascular aortic repair (TEVAR) for chronic type B aortic dissection remain controversial. This study aimed to evaluate the possible predictors of late aortic rupture and re-interventions after TEVAR.

METHODS

We retrospectively reviewed the operative outcomes of 40 patients who underwent TEVAR for chronic type B aortic dissection at Kyushu University Hospital. During a mean follow-up period of 39.2 months, we assessed aortic morphology via computed tomography and then employed a multivariable Cox regression analysis in an attempt to identify the predictors of late aorta-related events.

RESULTS

The early success rate of TEVAR was 100%. During the follow-up, however, three patients died from aortic rupture. Eight patients required aortic re-intervention, including thoraco-abdominal aortic graft replacement, repeated TEVAR, total arch replacement and EVAR. Multivariable Cox regression analysis revealed that the preoperative maximum distal aortic diameter was a significant predictor of late aorta-related events. The cutoff value of the distal aortic diameter was 40 mm. Freedom from aorta-related events was 94.6% at 1 year and 78.3% at 3 years. The survival rate was not significantly different despite the re-intervention.

CONCLUSIONS

TEVAR is an effective treatment for chronic type B dissection, with acceptable mid-term results. The preoperative distal aortic diameter is a significant risk factor for late aorta-related events. When the maximum distal aortic diameter is ≥ 40 mm, a therapeutic strategy should be developed taking into consideration the possible need for aortic re-intervention.

Staged Hybrid Single Lumen Reconstruction (TIGER) in Management of Chronic Symptomatic Complex Type B Aortic Dissection, Techniques, and Literature Review

BACKGROUND

Endovascular intervention for chronic symptomatic type B aortic dissection (CS-TBAD) induces aortic wall stress with negative hemodynamic cardiovascular consequences. CS-TBAD risks increased morbidity and mortality due to septum maturation with significant impact on false lumen modulation, and partial lumen thrombosis conveying the worst outcome. The aim of the TIGER technique is total aortic remodeling with true lumen expansion, false lumen regression and complete thrombosis, and stabilization of overall aortic diameter.

METHODS

We report 5 cases of aortic dissection with a mean follow-up of 16 months (6-28 months). All had aneurysmal dilation, with 3 having acute pan aortic dissection and 2 having CS-TBAD. All were managed by sTaged HybrId sinGle lumEn Reconstruction (TIGER). Our first approach was to create one single lumen from the supraceliac, infradiaphragmatic aorta to both common iliac arteries with open surgical patching of the visceral arteries; then, we performed a TEVAR 3 months later.

RESULTS

Three patients required a left subclavian artery chimney graft and one required bilateral subclavian to carotid artery transposition. No spinal drainage was required, and all patients had intraoperative transesophageal echo for wire guidance. We had no aortic rupture or retrograde type A dissection, and we experienced no renal, visceral, cardiac, pulmonary, or spinal complications. All patients, but one, went off their antihypertensive medication. All patients had normal estimated glomerular filtration rate postoperatively, and they all demonstrated accelerated aortic modulation.

CONCLUSIONS

TIGER was not only effective at the semiacute stage to initiate remodeling and prevent malperfusion, it also facilitated a straightforward TEVAR at stage 2, which was made easier by avoiding visceral branch stenting. Moreover, it decreased the length of aortic segment, which was stented, thereby avoiding critical shattering, branch dislodgment, and visceral compromise; spinal ischemia; and negative cardiovascular consequences.