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Han JY, James HI, Manesh M, Pyun AJ, Miranda E, Han SM. Hybrid approach to achieve secure distal seal zones during endovascular aortic repair in a patient with Marfan syndrome. J Vasc Surg Cases Innov Tech 2024; 10:101595. [PMID: 39282211 PMCID: PMC11401353 DOI: 10.1016/j.jvscit.2024.101595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 07/22/2024] [Indexed: 09/18/2024] Open
Abstract
This report details a hybrid approach for treatment of abdominal aortic aneurysm in a patient with Marfan syndrome (MFS). A 34-year-old patient with MFS and prior open thoracoabdominal aortic aneurysm repair underwent bilateral common iliac artery interposition graft repair and endovascular aortic repair. The bifurcated stent graft was implanted into the previous thoracoabdominal graft proximally and iliac interposition grafts distally. Postoperatively, the patient recovered uneventfully with sac regression to 4.5 cm through 2-year follow-up, without seal zone degeneration. This hybrid approach aimed to eliminate landing zone degeneration in patients with MFS undergoing endovascular repair.
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Affiliation(s)
- Jesse Y Han
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Herbert I James
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Michelle Manesh
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Elizabeth Miranda
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
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Amedi A, Meena RA, Garcia-Toca M, Ramos CR, Benarroch-Gampel J, H'Doubler PB, Duwayri Y, Leshnower BG, Rajani RR. Aggressive Treatment Strategy at Index Thoracic Endovascular Aortic Surgery is Associated with Reduced Need for Short-Term Reintervention in Patients with Aortic Dissection. Ann Vasc Surg 2024; 108:141-147. [PMID: 38942367 DOI: 10.1016/j.avsg.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/30/2024]
Abstract
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.
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Affiliation(s)
- Alan Amedi
- Emory University School of Medicine, Atlanta GA.
| | - Richard A Meena
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Manuel Garcia-Toca
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA
| | - Christopher R Ramos
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA
| | - James Benarroch-Gampel
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA
| | - Peter B H'Doubler
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Yazan Duwayri
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Bradley G Leshnower
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ravi R Rajani
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA
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Cha E, Eidt JF, Vasquez J. Variability in the Treatment of High-Risk Type B Aortic Dissection at a Single Center. Am J Cardiol 2024; 230:58-61. [PMID: 39209244 DOI: 10.1016/j.amjcard.2024.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/19/2024] [Accepted: 08/25/2024] [Indexed: 09/04/2024]
Abstract
Although there are established high-risk features in acute type B aortic dissection (TBAD), its management is variable. This study characterizes complicated, uncomplicated, and high-risk TBAD in addition to their management and outcomes to gain insight into the actual significance of these high-risk features and the reality of real-world practice in managing TBAD. A retrospective review of 62 patients was conducted. Patient demographics, management, and outcomes were characterized and evaluated with Pearson's χ2 test, Fisher's exact test, or analysis of variance. Of the 32 high-risk TBADs, 66% (n = 21) received endovascular repair, 31% (n = 10) were medically managed, and 3% (n = 1) received hybrid (open and endovascular) repair. Refractory hypertension and pain (52%, n = 11) were the most common high-risk features in patients with high-risk TBAD who received endovascular repair. A maximum aortic diameter of >40 mm (67%, n = 6) was the most common high-risk feature in patients who received medical management. The most prevalent high-risk feature for all treatment groups in the high-risk TBADs was an aortic diameter of >40 mm (n = 16; 50%). Adverse postoperative outcomes were highest in the high-risk and complicated groups with endoleak as the most common adverse outcome (high-risk 12.9%, complicated 13.6%). Of the 62 patients, 47% (n = 26) had follow-up since their admission with an average follow-up time of 69 ± 166 days. The significance of high-risk features in the management of high-risk TBAD remains unclear. This single-center experience with managing acute TBAD reveals the reality of inadequate follow-up that may be specific to this disease process. This highlights a need to direct more efforts to assess long-term outcomes after treatment.
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Affiliation(s)
- Erin Cha
- Texas A&M College of Medicine, College Station, Texas
| | - John F Eidt
- Vascular Surgery, Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas
| | - Javier Vasquez
- Vascular Surgery, Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas.
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Borghese O, Pisani A, Mastracci TM. Challenges in Diagnosis of Non-A Non-B Acute Aortic Dissection. Ann Vasc Surg 2024; 108:212-218. [PMID: 38960097 DOI: 10.1016/j.avsg.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Non-A non-B (NANB) aortic dissections are uncommon and frequently unrecognized diseases. However, their proper identification is crucial given the unpredictable behavior of the dissected aorta with potential mortality and increased morbidity. We investigate the accuracy of radiological computed tomography angiography (CTA) reports in the diagnosis of acute NANB and the risk related to delayed recognition or misdiagnosis. METHODS The pretreatment contrast CTA of all consecutive patients admitted with acute aortic dissection (AAD) in a University Hospital in London (UK) between January 2017 and May 2023 were reviewed to retrospectively verify the accuracy of CTA reports in the diagnosis of NANB AAD (B1-2D The risk related to the delayed diagnosis (morbidity, mortality, and hospital readmissions) were evaluated as secondary outcomes. The study was conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS Overall, 588 aortic CTAs were reviewed for a total of n = 393 (66.8%) type A AADs, n = 171 (29%) type B AADs and n = 25 (4.3%) NANB AADs (n = 16, 64% men, mean age 60.56, standard deviation ± 14.6 years). While no case of misdiagnosis was identified in Type A or B AAD groups, in NANBs only about a third of cases (n = 9, 36%) were immediately indicated as "NANB" (n = 2, 8%) or "B with retrograde extension into the arch" (n = 7, 28%), n = 8 cases (32%) were described generically as "arch dissections" (n = 6, 24%) or "type A and B" AAD (n = 2, 8%). The remaining 32% of patients received a diagnosis that did not include mention of the arch, as n = 6 (24%) cases were reported to be "type A″ and n = 2 (8%) to be "type B″ AADs. Despite the heterogeneity of terms used to describe NANB AAD, no case of cardiac tamponade, new onset malperfusion nor neurological complications were reported, and no sudden death nor home-discharge and readmission while waiting for the proper diagnosis. CONCLUSIONS The heterogeneity of terms used to describe NANB aortic dissection highlights the need for increased awareness, adoption of in guideline based classification systems, and further education to better understand and correctly address this challenging entity, minimizing misdiagnosis in ambiguous or difficult cases.
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Affiliation(s)
- Ottavia Borghese
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; PhD School Angio-Cardio-Thoracic Pathophysiology and Imaging, Sapienza University, Rome, Italy.
| | - Angelo Pisani
- PhD School Angio-Cardio-Thoracic Pathophysiology and Imaging, Sapienza University, Rome, Italy
| | - Tara Marie Mastracci
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; Department of Surgery and Interventional Sciences, University College London, London, UK
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Eidt JF, Gucwa AL, Cha E, Hohmann SE, Vasquez J. Emerging Trends in the Care of Type B Aortic Dissections. Am J Cardiol 2024; 230:62-71. [PMID: 39209243 DOI: 10.1016/j.amjcard.2024.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/02/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
Aortic dissection is the most common of the acute aortic syndromes. Acute aortic dissection remains a highly morbid and potentially lethal condition despite contemporary advances in medical and surgical care. Type B aortic dissection (TBAD) is classified as uncomplicated, uncomplicated with high-risk features, and complicated. The role of thoracic endovascular aortic repair (TEVAR) in uncomplicated TBAD remains uncertain and is the topic of ongoing clinical trials. In most complicated cases, TEVAR is effective at restoring visceral and extremity blood flow. TEVAR has also been shown to arrest hemorrhage in the setting of thoracic aortic rupture. TEVAR has been demonstrated to induce satisfactory remodeling in the covered segment of the thoracic aorta, but progressive enlargement of the visceral aorta has led to a variety of techniques designed to promote remodeling in the uncovered aortic segment. There is a need to better define high-risk features so that treatment can be tailored to specific clinical conditions.
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Affiliation(s)
- John F Eidt
- Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas.
| | | | - Erin Cha
- Texas A&M College of Medicine, College Station, Texas
| | - Steven E Hohmann
- Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas
| | - Javier Vasquez
- Baylor Scott and White Heart and Vascular Hospital, Dallas, Texas
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Borghese O, Sajiram S, Lee M, Olayiwola A, Adams B, Oo AY, Mastracci T, Lopez-Marco A. Frozen Elephant Trunk Procedure for Acute Type a Aortic Dissection: Analysis of Distal Aortic Remodeling According to the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS) Reporting Standard. Ann Vasc Surg 2024; 108:346-354. [PMID: 39009131 DOI: 10.1016/j.avsg.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND To investigate impact of frozen elephant trunk (FET) on long-term distal aortic remodeling in acute A aortic dissection (AAD) according to the latest recommended standards from the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS). METHODS Clinical data and imaging of patients who underwent FET to treat acute AAD over the last 8 years were retrospectively reviewed. Patients were included if a pre and postoperative computed angio tomographies at least 30 days from surgery was available for comparison. Contrasted postprocessed imaging were analyzed with Aquarius iNtuition (TeraRecon Inc., Foster City, CA, USA) to analyze long-term positive aortic remodeling, false lumen thrombosis, and aortic expansion according to the SVS or STS recommendations. Secondary endpoints were the rate of in-hospital and long-term mortality, spinal cord ischemia (SCI), and aortic-related reinterventions. RESULTS Out of 75 patients who underwent FET for type A AAD, n = 41 (54.6%) were included. Significant positive aortic remodeling was reported in Ishimaru zone 1-4 but not in visceral or infrarenal aorta (P < 0.001), and the overall rate of false lumen thrombosis was 95.1% (n = 39). Aortic expansion rates were as follows: 4.9% in zones 1-4, 8.3% in zones 5-6, and 15% in zone 7. The rates of in-hospital mortality and long-term mortality were 7.3% (n = 3) and 9.7% (n = 4), respectively. At a median follow-up of 11 months (range 1-141, reintervention rate was 17.1%. CONCLUSIONS We report positive aortic remodeling of the distal thoracic aorta in patients who underwent FET for acute AAD according to the SVS or STS reporting standards. The positive effect on the distal aorta is limited to the thoracic segments but not in the visceral aorta.
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Affiliation(s)
- Ottavia Borghese
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; PhD School Angio-Cardio-Thoracic Pathophysiology and Imaging, Sapienza University, Rome, Italy.
| | | | - Michelle Lee
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK
| | - Adeyemi Olayiwola
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK
| | - Benjamin Adams
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, London, UK
| | - Tara Mastracci
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; Department of Surgery and Interventional Sciences, University College London, London, UK
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, London, UK
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Kyriakou A, Ibrahim A, Oberhuber A. Intravascular Ultrasound Enhances the PETTICOAT Technique in Endovascular Therapy for Complicated Type B Aortic Dissection with Malperfusion Syndrome. Ann Vasc Surg 2024; 108:228-238. [PMID: 38964443 DOI: 10.1016/j.avsg.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 04/27/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND To present the value of intravascular ultrasound (IVUS) in diagnosis and treatment of complicated type B aortic dissection with malperfusion. Especially, the value of IVUS regarding the treatment strategy, reoperation rate, acute kidney injury, and false lumen thrombosis was investigated. METHODS Retrospective analysis of 25 type B aortic dissection cases with malperfusion treated with endovascular therapy from April 2019 to August 2022. In 17 cases, angiography and IVUS were applied during the operation (IVUS group), and in 8 cases, angiography was used without IVUS (control group) for final intraoperative control. IVUS was used to assess the true lumen collapse and to decide if additional bare stenting was necessary or not. Details from patients' charts and documentation from surgeries were analyzed. The endovascular technique included thoracic endovascular aortic repair with primary entry sealing and-if needed-bare stenting of the true lumen distal of the entry tears using the Provisional Extension To Induce Complete Attachment (PETTICOAT) technique. RESULTS All patients presented with pain localized mostly (48%) in thorax and abdomen. In all patients, the proximal entry tear of the dissection was covered using thoracic endovascular aortic repair. The PETTICOAT technique was applied in 13 cases (52%), whereas most combined procedures were applied in the IVUS group (12 compared to 1; P = 0.02). A total of 3 patients (1 in the control group, 12.5% and 2 in the IVUS group, 11.8%) underwent a bowel resection. Totally 8 patients (32%) underwent a reoperation in aorta (3 during the hospital stay). There were no statistical differences between IVUS and control group regarding the preoperative findings, the reoperation rates, and the postoperative complications. Five patients died (4 during the hospital stay); 1 in control and 4 in IVUS group; P = 0.53. The follow-up included a clinical and a computed tomography angiography examination. No statistically significant difference regarding occurrence and extension of false lumen thrombosis was observed between the 2 groups. CONCLUSIONS The IVUS and control groups showed no difference in survival rates. The use of IVUS extended the indication for PETTICOAT technique with statistically significant difference. A milder form of acute kidney injury presented in the IVUS group compared to the control group. In addition, a stronger correlation between IVUS and the avoidance of an aorta reoperation was observed, although it did not reach statistical significance.
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Affiliation(s)
- Andreas Kyriakou
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany.
| | - Abdulhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
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Zhang R, Sun L, Li Y, Li C, Zheng X, Hao Y. Risk factors for penetrating aortic ulcer progression. Ann Vasc Surg 2024:S0890-5096(24)00644-7. [PMID: 39419321 DOI: 10.1016/j.avsg.2024.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 08/09/2024] [Accepted: 08/29/2024] [Indexed: 10/19/2024]
Abstract
OBJECTIVES This study aimed to explore risk factors leading to asymptomatic penetrating aortic ulcer (PAU) progression. METHODS This retrospective study reviewed the clinical data of patients who were diagnosed with asymptomatic PAU through incidental imaging findings and underwent imaging follow-up between August 2018 and July 2022. Patients were grouped according to ulcer progression. The risk factors for PAU progression were also analyzed. RESULTS Among 60 patients with PAU, 32 (53.33%) experienced PAU progression. The mean follow-up time was 555.72±407.60 days. Although there was no statistically significant difference in cancer incidence between the PAU progression group and non-progression group (24 [75%] vs. 18 [64.28%], p=0.409), the difference in antineoplastic therapy use between the progression and non-progression groups was significant (19 [59.38%] vs. 7 [25.00%], p=0.010). There was no difference in the aortic diameter at the PAU (20.68±4.16 mm vs. 20.70±5.28 mm, p=0.990), PAU width (7.32±2.53 mm vs. 7.11±2.29 mm, p=0.741), and PAU depth (4.13±1.26 mm vs. 4.08±1.41 mm, p=0.880) between the two groups. In the progression group, the progression rates of aortic diameter at PAU, PAU width, and PAU depth were 2.16±4.28 mm/year, 5.91±14.49 mm/year and 2.87±5.87 mm/year, respectively. Binary logistic regression analysis showed that antineoplastic therapy was an independent predictor of PAU progression (p=0.017; OR, 4.144; 95% CI, 1.290-13.316). CONCLUSIONS Antineoplastic therapy may contribute to the progression of asymptomatic PAU in this retrospective study with small number of patients. Patients with asymptomatic PAU who are receiving or have completed antineoplastic therapy should be more vigilant regarding PAU progression.
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Affiliation(s)
- Rongjie Zhang
- Department of Vascular Surgery; Southwest Hospital; Army Medical University
| | - Long Sun
- Department of Vascular Surgery; Southwest Hospital; Army Medical University
| | - Yu Li
- Department of Vascular Surgery; Southwest Hospital; Army Medical University
| | - Chao Li
- Department of Vascular Surgery; Southwest Hospital; Army Medical University
| | - Xichuan Zheng
- Department of Vascular Surgery; Southwest Hospital; Army Medical University
| | - Yingxue Hao
- Department of Vascular Surgery; Southwest Hospital; Army Medical University.
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Gennai S, Leone N, Bartolotti LA, Andreoli F, Migliari M, Silingardi R. Comprehensive Learning Curve Analysis of a Long-Term Experience With Thoracic Endovascular Aneurysm Repair. J Endovasc Ther 2024; 31:901-909. [PMID: 36960843 DOI: 10.1177/15266028231161489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
PURPOSE To analyze the learning curve for thoracic endovascular aortic repair (TEVAR) in a single center over a period of 25 years. MATERIALS AND METHODS In total, 390 consecutive standard TEVAR procedures undertaken between 1996 and 2021 were included in a retrospective, observational, single-center study. Cumulative sum charts were elaborated for the entire center experience (primary outcome) as well as for the first and second implanting physicians. Data on procedural variables (contrast volume, operative and fluoroscopy time), 30-day major adverse events (MAEs) and clinical success, and endoleak and reintervention rates were secondary outcomes and subdivided into 4 quartiles of experience (Q1-Q4) or presented as first 2 versus latest 2 quartiles (Q1-Q2 vs Q3-Q4). RESULTS The mean follow-up was 4.3±4.0 years. The center's learning curve was achieved after 75 procedures, and it was similar for the first implanting physician. The surgeon coming thereafter had a significantly shorter curve (10 TEVARs). Comparing Q1-Q2 with Q3-Q4, 30-day MAEs (16.1 vs 11.3%, p=0.164), 30-day mortality (11.4% vs 3.6%, p=0.003), and intraoperative additional maneuvers (21.5% vs 13.3%, p=0.033) were reduced along with an improvement in clinical success (85.9% vs 90.3%, p=0.190). From Q1 to Q4, operative time (139.8±65.5 to 76.7±43.7 min, p=0.001), fluoroscopy time (15.1±8.8 to 7.1±5.1 min, p<0.001), and contrast volume (244.0±112.1 to 104.3±46.1 mL, p<0.001) showed a considerable reduction. Late endoleak and aortic-related mortality declined significantly from Q1-Q2 to Q3-Q4 (24.1% to 15.5%, p=0.033 and 18.6% vs 8.2%, p=0.006, respectively). Operative time (p=0.021), contrast volume (p=0.016), and fluoroscopy time (p=0.004) were independent risk factors for endoleak, causing a 1.3-fold risk increase for both each 60 minutes of additional operative time (p=0.021) and every 100 mL of additional contrast medium (p=0.016). Each 10-minute increase in fluoroscopy time determined a 1.4-fold risk increment (p=0.004). CONCLUSION The learning curve shortened significantly over time with non-negligible clinical outcome improvements, suggesting that specific endovascular training is mandatory to become an effective TEVAR performer. CLINICAL IMPACT For the first time in literature, the standard TEVAR's learning curve has been evaluated at a single vascular surgery center over a period of 25 years. The learning curve for the center and the first physician historically undertaking TEVAR was achieved at the 75th treated patient. The learning curve of the surgeons coming thereafter was significantly shorter (10 cases). This quarter-century demonstrated that intraoperative learning-related variables were associated with long-term clinical outcomes and all have improved over time. Centers approaching TEVAR for the first time and training program providers could use these data to aim to offer better clinical outcomes.
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Affiliation(s)
- Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Luigi Am Bartolotti
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Andreoli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Mattia Migliari
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Kim JK, Goh JH, Kim JB, Song JK, Yang DH, Kang JW, Kim SO, Koo HJ. Predictors of Late Adverse Events in Patients with Surgically Treated Type I Aortic Dissection. Eur J Vasc Endovasc Surg 2024; 68:444-453. [PMID: 38719137 DOI: 10.1016/j.ejvs.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 04/11/2024] [Accepted: 05/01/2024] [Indexed: 06/17/2024]
Abstract
OBJECTIVE Residual aortic dissection (AD) following DeBakey type I AD repair is associated with a high rate of adverse events that need additional intervention or surgery. This study aimed to identify clinical and early post-operative computed tomography angiography (CTA) imaging factors associated with adverse events in patients with type I AD after ascending aorta replacement. METHODS This single centre, retrospective cohort study included consecutive patients with type I AD who underwent ascending aorta replacement from January 2011 to December 2017 and post-operative CTA within three months. The primary outcome was AD related adverse events, defined as AD related death and re-operation due to aortic aneurysm or impending rupture. The location and size of the primary intimal tears, aortic diameter, and false lumen status were evaluated. Regression analyses were performed to identify factors associated with AD related adverse events. A decision tree model was used to classify patients as high or low risk. RESULTS Of 103 participants (55.43 ± 13.94 years; 49.5% male), 24 (23.3%) experienced AD related adverse events. In multivariable Cox regression analysis, connective tissue disease (hazard ratio [HR] 15.33; p < .001), maximum aortic diameter ≥ 40 mm (HR 4.90; p < .001), and multiple (three or more) intimal tears (HR 7.12; p < .001) were associated with AD related adverse events. The three year cumulative survival free from AD related events was lower in the high risk group with aortic diameter ≥ 40 mm and multiple intimal tears (41.7% vs. 90.9%; p < .001). CONCLUSION Early post-operative CTA findings indicating a maximum aortic diameter ≥ 40 mm and multiple intimal tears may predict a higher risk of adverse events. These findings suggest the need for careful monitoring and more vigilant management approaches in these cases.
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Affiliation(s)
- Jin Kyoung Kim
- Department of Thoracic and Cardiovascular Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Jung Hwan Goh
- University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Jae-Kwan Song
- Division of Cardiology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Joon-Won Kang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Hyun Jung Koo
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea.
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11
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He T, Bai J, Wu J, Liu Y, Qu L. Long-term outcomes of thoracic endovascular repair with quick fenestrater assisted in situ fenestration for type B aortic dissection. Vascular 2024; 32:937-945. [PMID: 37032595 DOI: 10.1177/17085381221140168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
OBJECTIVES To report the long-term outcomes of patients with type B aortic dissection (TBAD) treated with thoracic endovascular aortic repair (TEVAR) and quick fenestrated (QF)-assisted in situ fenestration (ISF). METHODS Between October 2017 and December 2018, 15 patients with TBAD requiring revascularization of the supra-aortic trunks underwent TEVAR with QF-assisted ISF at our institution. RESULTS Thirteen of the 15 patients were male, and the mean age was 52.87 ± 11.26. The technical success rate was 100%. Thirty-day mortality rate was 0. The median follow-up period was 41 months (range, 35-49). During follow-up, one non-aortic-related death was recorded, no fenestration lost its alignment, and no stroke or stent graft migration was observed. Two patients underwent another successful endovascular repair. One case of type Ib endoleak occurred 19 months postoperatively. This was caused by aortic progression distal to the stent graft. Another stent graft with a larger diameter was implanted in the descending aorta. One case of type Ic endoleak was observed 35 months postoperatively. The patient was diagnosed during the annual follow-up without any symptoms. Another bridging stent graft was implanted into the left subclavian artery distal to the already existing one, and the type Ic endoleak was successfully treated. CONCLUSIONS TEVAR with QF-assisted ISF may be an effective treatment for ISF in type B aortic dissection.
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Affiliation(s)
- Tianxiao He
- Division of Vascular Surgery, Department of General Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200001, China
| | - Jun Bai
- Division of Vascular Surgery, Department of General Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200001, China
| | - Jianjin Wu
- Division of Vascular Surgery, Department of General Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200001, China
| | - Yandong Liu
- Division of Vascular Surgery, Department of General Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200001, China
| | - Lefeng Qu
- Division of Vascular Surgery, Department of General Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200001, China
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12
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Ahmad W, Brunkwall J, Bunck AC, Dorweiler B, Mylonas S. Favorable Remodeling After TEVAR in Uncomplicated Acute and Subacute Type B Aortic Dissection in Comparison to Conservative Treatment: A Midterm Analysis. J Endovasc Ther 2024; 31:964-974. [PMID: 36891635 DOI: 10.1177/15266028231158971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period. MATERIALS AND METHODS Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints. RESULTS In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was -5 mm (interquartile range [IQR]=-28 to 8 mm), -11 mm (IQR=-53 to 10 mm), and 7 mm (IQR=-13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen. CONCLUSIONS Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling. CLINICAL IMPACT In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years.
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Affiliation(s)
- Wael Ahmad
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Alexander C Bunck
- Department of Radiology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
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13
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Öz T, Rantner B, Stana J, Stavroulakis K, Peterß S, Pichlmaier M, Fernandez Prendes C, Tsilimparis N. [Malperfusion after Aortic Dissection - Management and Techniques]. Zentralbl Chir 2024; 149:435-445. [PMID: 37327818 DOI: 10.1055/a-2058-9080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Malperfusion is a common complication of aortic dissection and further increases this deadly disease's mortality. An effective treatment strategy requires a timely diagnosis based on the clinical findings and the available instruments, understanding the disease's pathomechanism, recognising the therapy options recommended by the guidelines, and the diagnostic and therapeutic innovations of the area of research. The final treatment decision should be patient- and case-specific. In this work, we have considered malperfusion after aortic dissection, not only as a complication of aortic dissection but as a separate disease and summarise important information that can contribute to efficient therapy decisions in everyday clinical practice.
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Affiliation(s)
- Tugce Öz
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Barbara Rantner
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Jan Stana
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Konstantinos Stavroulakis
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Sven Peterß
- Abteilung für Herzchirurgie, University Hospital Munich, Munchen, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Standort Großhadern, Munchen, Deutschland
| | - Carlota Fernandez Prendes
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Ludwig-Maximilians-Universität München, München, Deutschland
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14
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Kozlov BN, Panfilov DS, Kim EB. Long-term outcomes of frozen elephant trunk for aortic dissection: a single-center experience. J Cardiothorac Surg 2024; 19:559. [PMID: 39354568 PMCID: PMC11443885 DOI: 10.1186/s13019-024-03074-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 09/15/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND To date a number of papers analysing outcomes of the frozen elephant trunk (FET) in acute aortic dissection has been published. However, there are limited comparative studies on long-term outcomes of FET in acute and chronic aortic dissection. The objective of the study was to analyze the long-term outcomes after FET procedure for aortic dissection (AD). METHODS Between March 2012 and December 2022, a total of 123 FET had been performed for thoracic aortic disease. Patients with aortic dissection (n = 97) were divided into 2 groups: acute (n = 32, 33%) and chronic aortic dissection (n = 65, 67%). Pre-, intra- and postoperative data were retrospectively collected from electronic patient's records, including follow-up data of the analyzed patients. RESULTS The incidence of stroke was 3.1%. The delirium rate was up to 9.3% in both groups with a prevalence in chronic aortic dissection (CAD) group without significant differences (P = 0.494). Paraplegia was diagnosed only in CAD patients (n = 2). Respiratory failure and the rate of renal replacement therapy were similar in the studied groups. Re-sternotomy was required in one (3.1%) patient with acute AD and 5 (7.7%) patients with chronic AD (P = 0.416). Overall 30-day mortality in the entire cohort, acute and chronic AD was 13 (13.4%), 7 (21.9%) and 6 (9.2%), respectively (P = 0.097). The overall survival rate at 60 months for the entire cohort, acute and chronic AD was 64.1 ± 5.9%, 62.3 ± 9.1%, 66.5 ± 7%, respectively (P = 0.265). Freedom from unintended distal aortic re-intervention at 60 months for the entire cohort of patients, acute and chronic AD was 74.2 ± 1.5%, 100%, 65.3 ± 2%, respectively (P = 0.355). CONCLUSIONS Our experience showed acceptable long-term outcomes after the FET procedure including mortality and re-intervention rate in patients with aortic dissection regardless of acuity of the dissection. TRIAL REGISTRATION The study has been registered in Australian and New Zealand Clinical Trial Registry (ACTRN 12618001329257) on August 7, 2018.
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Affiliation(s)
- Boris N Kozlov
- Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Tomsk, 634012, Russian Federation
| | - Dmitri S Panfilov
- Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Tomsk, 634012, Russian Federation
| | - Elena B Kim
- Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Tomsk, 634012, Russian Federation.
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15
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Betz T, Pfister K, Schierling W, Sachsamanis G, Kasprzak P, Oikonomou K. [Early Thoracic Endografting is Safe in Patients with Uncomplicated Type B Aortic Dissection]. Zentralbl Chir 2024; 149:428-434. [PMID: 37253376 DOI: 10.1055/a-2060-9864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
There are many publications dealing with treatment options for uncomplicated type B aortic dissection (TBAD). Early TEVAR (Thoracic Endovascular Aortic Repair) may improve aortic-specific survival and delay disease progression in the long-term. Especially in patients with uncomplicated TBAD and additional high-risk features, preemptive TEVAR may improve late outcomes.We conducted a retrospective analysis of all patients treated for TBAD in our hospital between February 2017 and September 2021. Comorbidities, intraoperative data, 30-day mortality and postprocedural complications were analysed.During the above-mentioned period, 61 patients (38 males, median age 63 years) with TBAD were treated. Six patients received best medical treatment (BMT). 55 patients were treated by TEVAR and BMT. 11 patients (20%) had complicated TBAD, 12 patients (22%) had uncomplicated TBAD with high-risk features and 32 patients (58%) had uncomplicated TBAD. Technical success was 100%. No patient with uncomplicated TBAD died within the first 30 postoperative days. One patient with uncomplicated TBAD had a stroke after TEVAR. Two reinterventions were performed on day 7 and day 9 after TEVAR.Patients with uncomplicated TBAD could be treated by early TEVAR, with a low rate of perioperative complications. In patients with uncomplicated TEVAR and high-risk features, early TEVAR with BMT should be considered as the treatment of choice.
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Affiliation(s)
- Thomas Betz
- Abteilung für Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Karin Pfister
- Abteilung für Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Wilma Schierling
- Abteilung für Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Georgios Sachsamanis
- Abteilung für Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Piotr Kasprzak
- Abteilung für Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Kyriakos Oikonomou
- Klinik für Gefäßchirurgie und Endovaskularchirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität Frankfurt am Main, Frankfurt am Main, Deutschland
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Cheng Z, Liu Y, Ma X. Comparative Analysis of Endovascular Repair of Single-Branched Stent-Graft and Hybrid Procedure for Patients With Type B Acute Aortic Dissection Involving the Left Subclavian Artery. J Endovasc Ther 2024; 31:892-900. [PMID: 36945730 DOI: 10.1177/15266028221149920] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE Thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) revascularization has been used in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone (PLZ). The outcomes of comparisons between TEVAR and hybrid procedure on patients with TBAD, with inadequate PLZ, are rarely reported. This study sought to compare and clarify the early and midterm outcomes between TEVAR and hybrid procedure in patients with TBAD, with inadequate PLZ. MATERIALS AND METHODS Between January 2019 and December 2021, 93 patients with TBAD, with inadequate PLZ, who underwent TEVAR or hybrid procedure, were retrospectively evaluated in Beijing Anzhen hospital. Demographics, comorbidities, preoperative imaging features, periprocedural details, and follow-up outcomes were analyzed. Survival was analyzed according to Kaplan-Meier method. RESULTS TEVAR procedures were performed on 41 patients (TEVAR group) and hybrid procedures on 52 patients (hybrid group). Early events, 30 day mortality, and all-cause mortality, were not significantly different between the 2 groups. However, patients receiving TEVAR had significantly shorter procedure time (p<0.001), hospital stay (p<0.001), and intensive care unit (ICU) stay (p=0.001) compared with those in the hybrid group. Patients receiving TEVAR had significantly lower midterm events (p=0.014) and re-intervention (p=0.015) compared with those in the hybrid group. CONCLUSION The study indicated that TEVAR with LSA revascularization for TBAD with inadequate PLZ is associated with a trend toward lower rates of midterm events, while the early and midterm mortalities were comparable with those in hybrid procedure. CLINICAL IMPACT This study is novel as it compared the outcomes between thoracic endovascular aortic repair (TEVAR) and hybrid procedure in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone, which has been rarely reported previously. We believe that our study makes a significant contribution to the literature because it is clinically relevant as it demonstrated that TEVAR with left subclavian artery (LSA) revascularization for TBAD with inadequate proximal landing zone is associated with a trend toward lower rates of mid-term events, while the early and mid-term mortalities were comparable with those in the hybrid procedure.
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Affiliation(s)
- Zhang Cheng
- Department of Interventional Diagnosis and Treatment, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongmin Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaohai Ma
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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17
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Roberts CS, McCullough KA. Pros and Cons of Classification Systems in Aortic Dissection. Am J Cardiol 2024:S0002-9149(24)00698-2. [PMID: 39357615 DOI: 10.1016/j.amjcard.2024.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 09/11/2024] [Accepted: 09/19/2024] [Indexed: 10/04/2024]
Affiliation(s)
- Charles S Roberts
- Department of Cardiac Surgery, Baylor University Medical Center, Dallas, Texas.
| | - Kyle A McCullough
- Department of Cardiovascular Research, Baylor Scott & White Research Institute, Plano, Texas
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18
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Trimarchi S, Mandigers TJ, Bissacco D, Nienaber C, Isselbacher EM, Evangelista A, Suzuki T, Bossone E, Pape LA, Januzzi JL, Harris KM, O'Gara PT, Gilon D, Hutchison S, Patel HJ, Woznicki EM, Montgomery D, Kline-Rogers E, Eagle KA. Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community. J Thorac Cardiovasc Surg 2024; 168:977-989.e24. [PMID: 37453718 DOI: 10.1016/j.jtcvs.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/21/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years. METHODS IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents. RESULTS Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index. CONCLUSIONS IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.
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Affiliation(s)
- Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
| | - Tim J Mandigers
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniele Bissacco
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Christoph Nienaber
- Department of Cardiology, Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, Imperial College, London, United Kingdom
| | - Eric M Isselbacher
- Cardiology Department, Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
| | - Arturo Evangelista
- Cardiology Department, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Toru Suzuki
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | | | - Linda A Pape
- Department of Medicine, University of Massachusetts Hospital, Worcester, Mass
| | - James L Januzzi
- Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Mass; Cardiology Division, Massachusetts General Hospital, Boston, Mass
| | - Kevin M Harris
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Patrick T O'Gara
- Department of Cardiology, Brigham & Women's Hospital, Boston, Mass
| | - Dan Gilon
- Department of Non-invasive Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Stuart Hutchison
- Department of Cardiac Sciences, University of Calgary Medical Centre, Calgary, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | | | | | | | - Kim A Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor, Mich
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19
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Roberts CS, McCullough KA. Intrapericardial (A) Versus Strictly Extrapericardial (B) Involvement in Aortic Dissection: A Practical Distinction. Am J Cardiol 2024:S0002-9149(24)00702-1. [PMID: 39342980 DOI: 10.1016/j.amjcard.2024.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Revised: 09/12/2024] [Accepted: 09/22/2024] [Indexed: 10/01/2024]
Affiliation(s)
- Charles S Roberts
- Department of Cardiac Surgery, Baylor University Medical Center, Dallas, Texas.
| | - Kyle A McCullough
- Department of Cardiovascular Research, Baylor Scott & White Research Institute, Plano, Texas
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20
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Wu Z, Lin J, Guo P, Cai F, Zhang J, Li W, Cai Y, Wu X, Wu Q, Dai Y, Hou X. Radiomics-Based Risk Assessment Correlates With Outcomes in Patients With Acute Type B Aortic Dissection Undergoing Thoracic Endovascular Repair. J Endovasc Ther 2024:15266028241275828. [PMID: 39287152 DOI: 10.1177/15266028241275828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
OBJECTIVES Our study aimed to investigate the correlations between radiomics-based assessment and outcomes, including positive aortic remodeling (PAR), reintervention for dissection at 1 year, and overall survival, in patients with Type B aortic dissection (TBAD) who underwent thoracic endovascular aortic repair (TEVAR). METHODS This was a single-center, retrospective, cohort study. The cohort comprised 104 patients who had undergone TEVAR of TBAD in our institution between January 2010 and October 2022. We segmented preoperative computed tomography (CT) images of the patients' descending aorta regions, then extracted a comprehensive set of radiomic features, including first-order features, shape features (2D and 3D), gray-level co-occurrence matrix (GLCM), gray-level size zone matrix, gray-level run length matrix, gray-level dependence matrix, neighborhood gray-tone difference matrix, from the regions of interest. Next, we selected radiomics features associated with total descending aorta positive aortic remodeling (TDA-PAR) and reintervention by least absolute shrinkage and selection operator (LASSO) regression and features associated with survival by LASSO-Cox regression. This enabled us to calculate radiomics-based risk scores for each patient. We then allocated the patients to high and low radiomics-based risk groups, the cutoff being the median score. We used 3 different models to validate the radiomics-based risk scores. RESULTS The patients' baseline characteristics did not differ between those who achieved TDA-PAR and those who did not. The radiomics-based risk scores were significantly and independently associated with all 3 outcomes. As to the impact of specific radiomics features, we found that GLSZM_SmallAreaLowGrayLevelEmphasis and shape_Maximum2DDiameterColumn had positive impacts on both reintervention and survival outcomes, whereas GLCM_Idmn positively affected survival but negatively affected reintervention. We found that radiomics-based risk for TDA-PAR correlated most significantly with zone 6 PAR. CONCLUSIONS Radiomics-based risk scores were significantly associated with the outcomes of TDA-PAR, reintervention, and overall survival. Radiomics has the potential to make significant contributions to prediction of outcomes in patients with TBAD undergoing TEVAR. CLINICAL IMPACT In this study of 104 patients with Type B aortic dissection, we demonstrated associations between radiomics-based risk and postoperative outcomes, including total descending aorta positive aortic remodeling, reintervention and survival. These findings highlight radiomics' potential as a tool for risk stratification and prognostication in acute Type B aortic dissection management.
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Affiliation(s)
- Zhiye Wu
- Trauma Center and Emergency Surgery Department, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jun Lin
- Trauma Center and Emergency Surgery Department, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Pingfan Guo
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Fanggang Cai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jinchi Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wanglong Li
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yihang Cai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xuemei Wu
- Department of Hepatology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Qiaoyi Wu
- Trauma Center and Emergency Surgery Department, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yiquan Dai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xinhuang Hou
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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21
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Karim F, Carlos Samayoa J, Spencer C, Narasimhan S, Hiremath G. Percutaneous Endovascular Stenting of an Acute Complicated Iatrogenic Type B Aortic Dissection in an Infant. JACC Case Rep 2024; 29:102494. [PMID: 39359500 PMCID: PMC11442176 DOI: 10.1016/j.jaccas.2024.102494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/16/2024] [Indexed: 10/04/2024]
Abstract
Thoracic endovascular aortic repair has emerged as a viable alternative for managing Sanford type B aortic dissection in adults. We report the first case of managing an acute and evolving communicating type B aortic dissection in an infant with endovascular aortic stenting.
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Affiliation(s)
- Farida Karim
- Division of Pediatric Cardiology, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Juan Carlos Samayoa
- Division of Pediatric Cardiology, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Celina Spencer
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Shanti Narasimhan
- Division of Pediatric Cardiology, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Gurumurthy Hiremath
- Division of Pediatric Cardiology, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
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Awiwi MO, Kandemirli VB, Kokash D, Hossain F, Gjoni M, Odisio E, Ocazionez D, Ferguson E, Hanna M, Duran C. Complications of thoracic endovascular aneurysm repair (TEVAR): A pictorial review. Curr Probl Diagn Radiol 2024; 53:648-661. [PMID: 38777715 DOI: 10.1067/j.cpradiol.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Thoracic endovascular aneurysm repair (TEVAR) has replaced open surgical repair as the treatment of choice for several aortic conditions. Despite its lower morbidity and mortality, several TEVAR-related complications can occur and some of which may necessitate surgical or endovascular re-intervention. The current article reviews common and rare complications of TEVAR procedure with emphasis on complications identifiable on cross-sectional imaging and potential pitfalls of pre-procedural planning.
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Affiliation(s)
- Muhammad O Awiwi
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA.
| | | | - Diana Kokash
- Division of Diagnostic Imaging, Dubai Academic Health Corporation, UAE
| | - Ferzana Hossain
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Migena Gjoni
- Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey
| | - Erika Odisio
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Daniel Ocazionez
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Emma Ferguson
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Mina Hanna
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
| | - Cihan Duran
- Division of Diagnostic Imaging, The University of Texas Health Science Center at Houston, Texas, USA
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23
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Marway PS, Campello Jorge CA, Tjahjadi N, Baker TJ, Mistelbauer G, Baeumler K, Hinostroza V, Higashigaito K, Mastrodicasa D, Masotti M, Nordsletten D, Patel HJ, Fleischmann D, Burris NS. Early three-dimensional growth in uncomplicated type B aortic dissection is associated with long-term outcomes. J Vasc Surg 2024:S0741-5214(24)01819-6. [PMID: 39222827 DOI: 10.1016/j.jvs.2024.08.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/22/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE Late adverse events (LAEs) are common among initially uncomplicated type B aortic dissection (uTBAD); however, identifying those patients at highest risk of LAEs remains a significant challenge. Early false lumen (FL) growth has been suggested to increase risk, but confident determination of growth is often hampered by error in two-dimensional clinical measurements. Semi-automated three-dimensional (3D) mapping of aortic growth, such as by vascular deformation mapping (VDM), can potentially overcome this limitation using computed tomography angiograms (CTA). We hypothesized that FL growth in the early pre-dissection phase by VDM can accurately predict LAEs. METHODS We performed a two-center retrospective study of patients with uTBAD, with paired CTAs in the acute (1-14 days) and subacute/early chronic (1-6 months) periods. VDM analysis was used to map 3D growth. Standard clinical CT measures (ie, aortic diameters, tear characteristics) were also collected. Multivariate analysis was conducted using a decision tree and Cox proportional hazards model. LAEs were defined as aneurysmal FL (>55 mm); rapid growth (>5 mm within 6 months); aorta-specific mortality, rupture, or re-dissection. RESULTS A total of 107 (69% male) patients with uTBAD initially met inclusion criteria with a median follow-up of 7.3 years (interquartile range [IQR], 4.7-9.9 years). LAEs occurred in 72 patients (67%) at 2.5 years (IQR, 0.7-4.8 years) after the initial event. A multivariate decision tree model identified VDM growth (>2.1 mm) and baseline diameter (>42.7 mm) as optimal predictors of LAEs (area under the receiver operating characteristic curve = 0.94), achieving an 87% accuracy (sensitivity of 93%, specificity of 76%) after leave-one-out validation. Guideline reported high-risk features were not significantly different between groups. CONCLUSIONS Early growth of the FL in uTBAD was the best tested indicator for LAEs and improves upon the current gold-standard of baseline diameter in selecting patients for early prophylactic thoracic endovascular aortic repair.
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Affiliation(s)
| | | | - Nicasius Tjahjadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Timothy J Baker
- Department of Radiology, University of Michigan, Ann Arbor, MI
| | | | | | | | | | - Domenico Mastrodicasa
- Department of Radiology, Stanford University, Stanford, CA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Maria Masotti
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - David Nordsletten
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
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24
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Gorgatti F, Nana P, Panuccio G, Rohlffs F, Torrealba JI, Kölbel T. Post-dissection Thoraco-abdominal Aortic Aneurysm Managed by Fenestrated or Branched Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2024; 68:325-334. [PMID: 38697255 DOI: 10.1016/j.ejvs.2024.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/27/2024] [Accepted: 04/28/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVE Fenestrated or branched endovascular aortic repair (F/B-EVAR) is a valuable treatment in patients with chronic post-dissection thoraco-abdominal aneurysm (PD-TAAA). This study aimed to analyse early and follow up outcomes of F/B-EVAR in these patients. METHODS Thirty day and follow up outcomes of consecutive patients with PD-TAAA treated with F/B-EVAR in a tertiary centre over eight years were analysed retrospectively. All patients presenting with PD-TAAA and managed with F/B-EVAR were eligible. A modified Crawford's classification system was used. Thirty day mortality and major adverse event (MAE) rates were analysed. Time to event data were estimated with Kaplan-Meier survival analysis. RESULTS Fifty five patients (80% men, mean age 63.7 ± 7.7 years) were included: 12 (22%) were managed urgently; 25 (46%) for chronic type B aortic dissection; and the remainder for residual type A aortic dissection. Of these patients, 88% had undergone previous thoracic endovascular aortic repair. Prophylactic cerebrospinal fluid drainage (CSFD) was used in 91%. Fifteen (27%) patients were treated with F-EVAR, nine (16%) with fenestrations and branches, and 31 (56%) with B-EVAR. False lumen adjunctive procedures were used in 56%. Technical success was achieved in 96% of patients. The thirty day mortality rate was 7% and MAE rate was 20%. Spinal cord injury (SCI) grades 1 - 3 and grade 3 rates were 13% and 2%, respectively. Mean follow up was 33.0 ± 18.4 months. Survival and freedom from unscheduled re-intervention were 86% (standard error [SE] 5%) and 55% (SE 8%) at 24 months, respectively. Freedom from target vessel stenosis and occlusion was higher in F-EVAR at the 12 month follow up (p = .006) compared with B-EVAR. CONCLUSION Fenestrated or branched endovascular repairs in patients with PD-TAAA showed high technical success, with acceptable early mortality and MAE rates. The SCI rate was > 10%, despite CSFD use and staged procedures. Almost a half of patients needed an unscheduled re-intervention within 24 months after F/B-EVAR.
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Affiliation(s)
- Filippo Gorgatti
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Petroula Nana
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany.
| | - Giuseppe Panuccio
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - José I Torrealba
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany
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25
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Vaddavalli VV, Wilkins PB, Schaller MS, Morrison JJ, Shuja F, Colglazier JJ, Mendes BC, Rasmussen TE, Kalra M, DeMartino RR. Natural history and long-term outcomes of medically managed Type B intramural hematoma. J Vasc Surg 2024; 80:648-655.e2. [PMID: 38904581 DOI: 10.1016/j.jvs.2024.04.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Type B intramural hematoma (IMH) is often managed medically, yet may progress to dissection, aneurysmal dilation, or rupture. The aim of this study was to report the natural history of medically managed Type B IMH, and factors associated with progression. METHODS We reviewed patients with medically managed Type B IMH between January 1995 to December 2022 at a single center. Any patients with immediate surgical or endovascular intervention were excluded. Demographic profiles, comorbidities, imaging, and follow-up details were reviewed. Patients were divided into two groups: Group 1 had isolated IMH, and Group 2 had IMH along with aneurysm or dissection at the time of presentation. On follow-up, progression was defined as degeneration to aneurysm/dissection or increase in the thickness of IMH in Group 1. In Group 2, progression was an increase in the size of aneurysm or development of new dissection. RESULTS Of 104 patients with Type B IMH during the study period, 92 were medically managed. The median age was 77 years, and 45 (48.9%) were females. Comorbidities included hypertension (83.7%), hypercholesterolemia (44.6%), and active smoking (47.8%). Mean Society for Vascular Surger comorbidity score was 6.3. Mean IMH thickness and aortic diameter at presentation were 8.9 mm and 38.3 mm, respectively. Median follow-up was 55 months. Overall survival at 1 year and 5 years was 85.8% and 61.9%, respectively. During follow-up, 19 patients (20.7%) required intervention, more common in Group 2 (Group 1, 8/66; 12.3% vs Group 2, 11/26; 42.3%; P = .001). This resulted in higher freedom from intervention in Group 1 at 1 year (93.5% vs 62.7%) and 5 years (87.5% vs 51.1%; P < .001). Indication for intervention was dissection (n = 4), aneurysm (n = 12), and progression of IMH (n = 3). In Group 1, progression was seen in 25 (37.9%), three (4.5%) remained stable, 29 (43.9%) had complete resolution of IMH, and nine patients were lost to follow-up. In Group 2, 11 patients (42.3%) had progression, seven (26.9%) remained stable, and eight were lost to follow-up. IMH thickness at presentation >7.2 mm is associated with both increased odds of progression (odds ratio, 3.3; 95% confidence interval, 1.2-11.1; P = .03) and intervention (odds ratio, 5.5; 95% confidence interval, 1.3-36.9; P = .03) during the follow-up. CONCLUSIONS Although many patients with Type B IMH managed medically stabilize or regress, progression or need for intervention can occur in up to 40% of cases. This is associated with the presence of aneurysm, dissection, and IMH thickness. Long-term follow-up is mandatory as late interventions occur, particularly for higher risk patients.
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Affiliation(s)
| | - Parvathi B Wilkins
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Melinda S Schaller
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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26
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Krebs JR, Filiberto AC, Fazzone B, Jacobs CR, Anderson EM, Shahid Z, Back M, Upchurch GR, Cooper M. Outcomes of Patients with Acute Type B Aortic Dissection and High-Risk Features. Ann Vasc Surg 2024; 106:99-107. [PMID: 38574807 DOI: 10.1016/j.avsg.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/19/2023] [Accepted: 01/09/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Recently the Society for Vascular Surgery (SVS) and Society for Thoracic Surgeons (STS) published contemporary guidelines clearly defining complicated versus uncomplicated acute type B aortic dissections (TBADs) with an additional high-risk grouping. Few studies have evaluated outcomes associated with "high-risk" TBADs. The objective of this study was to assess differences in demographics, clinical presentation, symptom onset, and outcomes in high-risk patients that underwent either thoracic endovascular aortic repair (TEVAR) or best medical management for acute TBAD compared to those with complicated and uncomplicated acute TBAD. METHODS Patients admitted with acute TBADs from a single academic medical center from October 2011 to March 2020 were analyzed. Per the STS/SVS 2020 guidelines, high risk was defined as refractory pain/hypertension, bloody pleural effusion, aortic diameter >4 cm, false lumen diameter >22 mm, radiographic malperfusion, and early readmission, and complicated was defined as ruptured/malperfusion presentation. Uncomplicated patients were those without malperfusion/rupture and without high-risk features. The primary end-point was inpatient mortality. Secondary end-points included complications, reintervention, and survival. RESULTS Of the 159 patients identified with acute TBAD, 63 (40%) met the high-risk criteria. In the high-risk cohort, 38 (60%) underwent TEVAR (HR-TEVAR), with refractory pain as the most common indication, while 25 (40%) were managed medically (HR-medical). Malperfusion or rupture was present in 63 (40%) patients (complicated TBAD (C-TBAD)), all of whom underwent TEVAR. An additional 33 patients had no high-risk features and were all managed medically (uncomplicated TBAD). There were no differences in age, body mass index, and race between groups. Among the 4 groups, there were variable distributions in sex, insurance status, and incidence of several baseline comorbidities including congestive heart failure, chronic obstructive pulmonary disease, and renal dysfunction (P < 0.05 for all). C-TBAD had increased length of stay (12, interquartile range [IQR] 9-22) compared to HR-TEVAR (11.5, IQR 7-15), HR-medical (6, IQR 5-8), and uncomplicated TBAD (7, IQR 5-10) (P < 0.01). C-TBAD had decreased days from admission to repair (0, IQR 0-2) compared to HR-TEVAR (3.5, IQR 1-8) (P < 0.01). C-TBAD patients had worse 3-year survival compared to other groups (log-rank P < 0.01), although when in-hospital mortality was excluded, survival was similar among groups (P = 0.37). Of patients initially managed medically, outpatient TEVAR was performed in 6 (24%) HR-medical and 4 (12%) uncomplicated patients, with no difference between rate of intervention between groups (P = 0.22). CONCLUSIONS High-risk features, as defined in updated SVS/STS guidelines, are common in patients presenting with acute TBAD. High-risk patients had acceptable outcomes when managed either surgically or medically. High-risk patients that underwent TEVAR had improved perioperative outcomes and mortality compared to those undergoing TEVAR for C-TBAD, a finding which may help guide preoperative risk stratification and patient counseling.
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Affiliation(s)
- Jonathan R Krebs
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Amanda C Filiberto
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Brian Fazzone
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Christopher R Jacobs
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Zain Shahid
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Martin Back
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Michol Cooper
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL.
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27
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Figueroa AV, Tanenbaum MT, Timaran CH, Oderich GS, Eagleton MJ, Schanzer A, Farber MA, Beck AW, Schneider DB, Gasper W, Sweet MP, Lee A, Cantor RS, Li X. Postdissection aortic aneurysm sac enlargement after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2024; 80:666-677.e1. [PMID: 38909915 DOI: 10.1016/j.jvs.2024.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVES Aneurysm sac changes after fenestrated-branched endovascular aneurysm repair (FBEVAR) for postdissection thoracoabdominal aortic aneurysms (PD-TAAs) are poorly understood. Partial thrombosis of the false lumen and endoleaks may impair sac regression. To characterize sac changes after FBEVAR for PD-TAAs, this study examined midterm results and predictors for sac enlargement. METHODS FBEVARs performed for PD-TAAs in 10 physician-sponsored investigational device exemption studies from 2008 to 2023 were analyzed. The maximum aortic aneurysm diameter was compared between the 30-day computed tomography angiogram and follow-up imaging studies. Aneurysm sac enlargement was defined as an increase in diameter of ≥5 mm. Kaplan-Meier curves and Cox regression were used to evaluate sac enlargement and midterm FBEVAR outcomes. RESULTS Among 3296 FBEVARs, 290 patients (72.4% male; median age, 68.4 years) were treated for PD-TAAs. Most aneurysms treated were extent II (72%) and III (12%). Mean aneurysm diameter was 66.5 ± 11.2 mm. Mortality at 30 days was 1.4%. At a mean follow-up of 2.9 ± 1.9 years, at least one follow-up imaging study revealed sac enlargement in 43 patients (15%), sac regression in 115 patients (40%), and neither enlargement nor regression in 137 (47%); 5 (2%) demonstrated both expansion and regression during follow-up. Freedom from aneurysm sac enlargement was 93%, 82%, and 80% at 1, 3, and 5 years, respectively. Overall, endoleaks were detected in 27 patients (63%) with sac enlargement and 143 patients (58%) without enlargement (P = .54). Sac enlargement was significantly more frequent among older patients (mean age at the index procedure, 70.2 ± 8.9 years vs 66.5 ± 11 years; P = .04) and those with type II endoleaks at 1 year (74% vs 52%; P = .031). Cox regression revealed age >70 years at baseline (hazard ratio [HR], 2.146; 95% confidence interval [CI], 1.167-3.944; P = .010) and presence of type II endoleak at 1 year (HR, 2.25; 95% CI, 1.07-4.79; P = .032) were independent predictors of sac enlargement. Patient survival was 92%, 81%, and 68% at 1, 3, and 5 years, respectively. Cumulative target vessel instability was 7%, and aneurysm-related mortality was 2% at 5 years. At least 42% of patients required secondary interventions. Sac enlargement did not affect patient survival. CONCLUSIONS Aneurysm sac enlargement occurs in 15% of patients after FBEVAR for PD-TAAs. Elderly patients (>70 years at baseline) and those with type II endoleaks at 1 year may need closer monitoring and secondary interventions to prevent sac enlargement. Despite sac enlargement in some patients, aneurysm-related mortality at 5 years remains low and overall survival was not associated with sac enlargement.
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Affiliation(s)
- Andres V Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mira T Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Gustavo S Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Memorial Hospital, Worcester, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Darren B Schneider
- Division of Vascular and Endovascular Surgery, University of Pennsylvania, Philadelphia, PA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Anthony Lee
- Division of Vascular Surgery, Boca Raton Regional Hospital, Boca Raton, FL
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28
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Shah A, Zulfiqar M, Yano M. Short segment linear "flaps" of the abdominal aorta: proposed mechanism of origin and evaluation of natural history via retrospective imaging review. Abdom Radiol (NY) 2024:10.1007/s00261-024-04531-1. [PMID: 39212684 DOI: 10.1007/s00261-024-04531-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 08/10/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Luminal linear findings (LLF) of the abdominal aorta are often called aortic "flaps," triggering concern for acute aortic syndrome. However, these "flaps" are unlikely to represent intimomedial dissection given isolation to the abdominal aorta, short length, and incidental discovery. We aim to characterize the etiology and stability of LLF. METHODS CT reports finalized January 2021-December 2022 were queried for terms "focal dissection," "dissection flap," "linear filling defect," and "linear flap." Patients were excluded for thoracoabdominal dissection, LLF in non-aortic vessel, no prior contrast-enhanced imaging, and less than 6 months between exams. Index exam reviewed for presence of LLF, atherosclerosis, and aortic caliber at LLF site. Prior exam assessed for aortic caliber and aortic findings at subsequent LLF site. Patients with unchanged LLF between exams were categorized "Stable" and patients with interval change "Dynamic." RESULTS Seven hundred and two cases identified. After exclusions, imaging from 70 patients reviewed; 1 excluded for no LLF. Stable Cohort of 39 patients had median follow-up 31 months (range 6-284 months). 87% of aortas were moderately/severely atherosclerotic (n = 16 moderate, n = 18 severe), while 69% were ectatic/aneurysmal (n = 27). Dynamic Cohort of 20 patients had median follow-up of 70 months (range 14-244 months). All were atherosclerotic and 80% were ectatic/aneurysmal compared to 25% ectatic/aneurysmal at prior imaging. Mural thrombus was present at the site of the future LLF in 17 of 20, thrombosed PAU in 1, and no focal findings in 2. CONCLUSION Short-segment LLFs within the abdominal aorta arise from prior mural thrombus and demonstrate long term stability. Clinically and radiographically indolent, LLFs should not be called dissection flaps.
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Affiliation(s)
- Amar Shah
- Department of Radiology, Mayo Clinic in Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Maria Zulfiqar
- Department of Radiology, Mayo Clinic in Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Motoyo Yano
- Department of Radiology, Mayo Clinic in Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
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29
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Chen JR, Shah VN, Pritting C, Nooromid M, Abai B, Plestis K. Like Father like Daughter: Surgical Redo Thoracoabdominal Aneurysm Repairs in a Family With Loeys-Dietz Syndrome. Vasc Endovascular Surg 2024:15385744241279139. [PMID: 39207942 DOI: 10.1177/15385744241279139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Loeys Dietz Syndrome (LDS) is an autosomal dominant connective tissue disorder resulting from a mutation in the transforming growth factor beta receptor (TGFBR) family of genes. It is commonly associated with the development of aortic aneurysms and dissections. We report the successful open surgical management of thoracoabdominal aneurysms in a father and daughter with Loeys-Dietz Syndrome after failed endovascular repair. The daughter required stent graft explantation, while the stent graft remained in the father. These cases highlight the importance of early genetic testing of both patients and first-degree family members in those with a strong history of aortic disease, even when there is a lack of typical connective tissue disorder associated physical exam findings and open surgical index operations.
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Affiliation(s)
- Joshua R Chen
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vishal N Shah
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Michael Nooromid
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Babak Abai
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Konstadinos Plestis
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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30
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Pu H, Peng T, Xu Z, Sun Q, Wang Z, Ma H, Fang S, Yang Y, Wu J, Wang R, Qiu P, Zhou J, Lu X. A morphological indicator for aortic dissection: fitting circle of the thoracic aorta. BMC Cardiovasc Disord 2024; 24:461. [PMID: 39198782 PMCID: PMC11351444 DOI: 10.1186/s12872-024-04130-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/19/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND This study aims to identify a morphological indicator of aortic dissection (AD) based on the geometrical characteristics of the thoracic aorta. METHODS We evaluated computed tomographic angiograms of 63 samples with AD (22 with type A AD, 41 with type B AD) and 71 healthy samples. Via centerline extraction and spatial transformation, the spatial entanglement of the aorta was minimized, and the expanded 2D aortic morphology was obtained. The 2D morphology of the thoracic aorta was fit to a circle. The applicability of the fitting circle method for identifying aortic dissection was verified by multivariable logistic regression analysis. RESULTS Via the 3D coordinate transformation algorithm, the optimal aortic view was obtained. On this view, the geometrical characteristics of the thoracic aortas of the healthy controls were similar to a portion of a circle (sum of residuals: 3502.45 ± 2566.71, variance: 86.23 ± 56.60), while that of AD samples had poorer similarity to the circle (sum of residuals: 5404.78 ± 3891.69, variance: 129.90 ± 90.09). This difference was significant (p < 0.001). A logistic regression model showed that increased deformation of the thoracic aorta was a significant indicator of aortic dissection (odds ratio: 1.35, p = 0.034). CONCLUSIONS The morphology of the healthy thoracic aorta could be fit to a circle, while that of the dissected aorta had poorer similarity to the circle. The statistics of the circle are an effective indicator of aortic deformation in AD. TRIAL REGISTRATION This study is registered in the Chinese Clinical Trial Registry (ChiCTR2000029219).
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Affiliation(s)
- Hongji Pu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Tao Peng
- School of Biomedical Engineering, Anhui Medical University, Meishan Road, Shushan District, Hefei, 230032, China
| | - Zhijue Xu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
- Key Laboratory of Systems Biomedicine (Ministry of Education), Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Qi Sun
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Zixin Wang
- School of Biomedical Engineering, Anhui Medical University, Meishan Road, Shushan District, Hefei, 230032, China
| | - Hui Ma
- School of Biomedical Engineering, Anhui Medical University, Meishan Road, Shushan District, Hefei, 230032, China
| | - Shu Fang
- School of Biomedical Engineering, Anhui Medical University, Meishan Road, Shushan District, Hefei, 230032, China
| | - Yang Yang
- Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Jie Wu
- Department of Vascular Surgery, Affiliated Hospital of Guizhou Medicine University, Guizhou, 550000, China
| | - Ruihua Wang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Peng Qiu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Jinhua Zhou
- School of Biomedical Engineering, Anhui Medical University, Meishan Road, Shushan District, Hefei, 230032, China.
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
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Li R, Luo Q, Green D, Huddleston S. Smaller Hospital Size is Associated With Higher Mortality in Stanford Type A Aortic Dissection. Vasc Endovascular Surg 2024:15385744241278839. [PMID: 39185819 DOI: 10.1177/15385744241278839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
BACKGROUND Stanford Type A Aortic Dissection (TAAD) is associated with high in-hospital mortality and the need for immediate surgical intervention. Larger hospital size may be associated with better patient care and surgical outcomes. This study aimed to examine the effect of hospital size on TAAD outcomes. METHOD Patients who underwent TAAD repair were identified in National Inpatient Sample (NIS) from Q4 2015-2020. NIS stratifies hospital size into small, medium, and large based on the number of hospital beds, geographical location, and the teaching status of the hospitals. Patients admitted to small/medium and large hospitals were stratified into two cohorts. Multivariable logistic regressions were performed to compare in-hospital outcomes, adjusted for demographics, comorbidity, primary payer status, and hospital characteristics including procedural volume. RESULTS There were 1106 and 3752 TAAD admitted to small/medium and large hospitals, respectively. Among patients admitted to small/medium hospitals, there was higher mortality (17.27% vs 14.37%, aOR = 1.32, P < 0.01), but shorter length of stay (P < 0.01) and lower cost (P = 0.03) compared to larger hospitals. There was no difference in morbidities. CONCLUSIONS Marked higher mortality is associated with admission to smaller hospitals among patients with TAAD, which may in turn decrease the average hospital stay and cost. Given that a significant percentage of patients are already being transferred out of the initial hospital and small/medium hospital is associated with higher mortality, centralization of care in centers of excellence may decrease the high mortality associated with TAAD.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Qianyun Luo
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Derrick Green
- Division of Vascular Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Minneapolis Veterans Administration Medical Center, Minneapolis, MN, USA
| | - Stephen Huddleston
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Chen Y, Ren J, Liu Z, Cui D, Wang S, Bi J, Dai X. Predictors for thoracic aortic growth in patients with type B aortic dissection after thoracic endovascular aortic repair. Vascular 2024:17085381241273233. [PMID: 39140232 DOI: 10.1177/17085381241273233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
OBJECTIVE To identify independent predictors of thoracic aortic growth in patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR). METHODS A retrospective analysis of the patients undergoing TEVAR for TBAD or intramural hematoma (IMH) from April 2014 to April 2023 was performed. The baseline morphological data of TBAD was established through computed tomography angiography (CTA) before discharge. Patients were divided into two groups based on aortic growth: growth and no growth. Aortic growth defined as an increase ≥5 mm in thoracic maximal aortic diameter during any serial follow-up CTA measurement. Logistic regression following propensity score matching (PSM) was used to identify independent predictors for aortic growth. Receiver operating characteristic curve and cutoff value of independent predictors were calculated. Linear regression was used to establish a correlation between anatomical variables and follow-up aortic diameter. RESULTS A total of 145 patients with TBAD (n = 122) or IMH (n = 23) undergoing TEVAR were included, with a male of 83.4% and a mean age of 56 ± 14.1 years. Patients in growth group and no growth group was 26 (17.9%) and 119 (80.1%), respectively. After using PSM method, matched regression analysis showed residual maximal tear diameter (OR = 0.889, 95% CI 0.830-0.952, p = 0.001) and follow-up aortic diameter (OR = 0.977, 95% CI 0.965-0.989, p < 0.001) were independent predictors for aortic growth. The cutoff value was 8.55 mm for residual tear diameter and 40.65 mm for follow-up maximal aortic diameter. The residual maximal tear diameter showed a linear correlation with follow-up aortic diameter (DW = 1.74, R2 = 6.2%, p = 0.033). CONCLUSIONS This study suggested that residual maximal tear diameter >8.55 mm and follow-up aortic diameter >40.65 mm could predict aortic growth in patients with TBAD undergoing TEVAR.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Precise Vascular Reconstruction and Organ Function Repair, Tianjin, China
- Department of Vascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianli Ren
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Cardiovascular Surgery, Yan'an University Affiliated Hospital, Yanan, China
| | - Zongwei Liu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Precise Vascular Reconstruction and Organ Function Repair, Tianjin, China
| | - Dongsheng Cui
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Precise Vascular Reconstruction and Organ Function Repair, Tianjin, China
| | - Shuaishuai Wang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Precise Vascular Reconstruction and Organ Function Repair, Tianjin, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Precise Vascular Reconstruction and Organ Function Repair, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Precise Vascular Reconstruction and Organ Function Repair, Tianjin, China
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Szeto WY, Fukuhara S, Fleischman F, Sultan I, Brinkman W, Arnaoutakis G, Takayama H, Eudailey K, Brinster D, Jassar A, DeRose J, Brown C, Farrington W, Moon MC. A novel hybrid prosthesis for open repair of acute DeBakey type I dissection with malperfusion: Early results from the PERSEVERE trial. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00677-9. [PMID: 39116932 DOI: 10.1016/j.jtcvs.2024.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/19/2024] [Accepted: 07/22/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Outcomes after hemiarch repair for acute DeBakey type I aortic dissection (ADTI) remain unfavorable, with high rates of major adverse events and negative aortic remodeling. The PERSEVERE study evaluates the safety and effectiveness of the AMDS Hybrid prosthesis, a novel bare metal stent, in patients presenting with preoperative malperfusion. METHODS PERSEVERE is a prospective single-arm investigational study conducted at 26 sites in the United States. Ninety-three patients underwent ADTI aortic dissection repair with AMDS implantation. The 30-day primary endpoints are a composite rate of 4 major adverse events and the rate of distal anastomotic new entry tears. The secondary endpoints include aortic remodeling. RESULTS Clinical malperfusion was documented in 76 patients (82%); only radiographic malperfusion, in 17 (18%). The median follow-up in the 93 patients was 5.6 months. Within 30 days, 9 patients died (9.7%), 10 patients (10.8%) experienced new disabling stroke, and 18 patients (19.4%) had new-onset renal failure requiring ≥1 dialysis treatment. There were no cases of myocardial infarction. The composite rate of major adverse events (27%) was lower than that reported in the reference cohort (58%). There were no distal anastomotic new entry tears. Technical success was achieved in 99% of patients. Early remodeling indicated total aortic diameter stability, true lumen expansion, and false lumen reduction in the treated aortic segment. CONCLUSIONS Early results show significant reductions in major adverse events and distal anastomotic new entry tears, successfully meeting both primary endpoints. The technical success rate was high. AMDS can be used safely in patients with ADTI dissection with malperfusion.
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Affiliation(s)
- Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa.
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Fernando Fleischman
- Department of Cardiothoracic Surgery, USC Cardiac and Vascular Institute, University of Southern California, Los Angeles, Calif
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - William Brinkman
- Department of Cardiothoracic Surgery, The Heart Hospital Baylor Scott & White Plano, Plano, Tex
| | - George Arnaoutakis
- Division of Cardiovascular and Thoracic Surgery, University of Texas, Austin, Tex
| | - Hiroo Takayama
- Division of Cardiac, Thoracic & Vascular Surgery, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY
| | - Kyle Eudailey
- Division of Cardiothoracic Surgery, University of Alabama Birmingham, Birmingham, Ala
| | - Derek Brinster
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital, New York, NY
| | - Arminder Jassar
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Joseph DeRose
- Division of Cardiothoracic Surgery, Montefiore-Einstein Heart Center, Bronx, NY
| | - Chase Brown
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Woodrow Farrington
- Division of Cardiothoracic Surgery, Emory University Hospital, Atlanta, Ga
| | - Michael C Moon
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Dittman JM, Benyakorn T, Mouawad NJ, Cao Z, Etafo J, Quiroga E, Starnes BW, Shalhub S. Complicated and Uncomplicated Isolated Abdominal Aortic Dissections Demonstrate Different Patient Characteristics and Outcomes. Ann Vasc Surg 2024; 105:29-37. [PMID: 38574811 DOI: 10.1016/j.avsg.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/20/2023] [Accepted: 01/07/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Isolated abdominal aortic dissection (IAAD) is a rare entity with poorly defined risk factors and wide variation in management. We set forth to compare patient characteristics, management, and outcomes of uncomplicated isolated abdominal aortic dissection (uIAAD) versus high risk and complicated isolated abdominal aortic dissection (hrcIAAD) to investigate whether these categories can be utilized to guide IAAD management and provide risk stratification for intervention. METHODS Retrospective chart review was performed to identify all patients with spontaneous IAAD at a tertiary health care system between 1996 and 2022. Demographics, comorbidities, factors relating to initial presentation including imaging findings, and dissection outcomes including long-term all-cause mortality and aortic-related mortality from time of dissection to final available record were abstracted. IAAD demonstrating rupture or malperfusion were designated as complicated, those with aortic diameter greater than 4 cm on presentation or refractory pain were designated as high risk, and the remainder was designated as uIAAD. All variables were compared between hrcIAAD and uIAAD using Fisher's exact test, unpaired t-test, and Mann-Whitney U-test as appropriate. RESULTS Over the study period, 74 patients presented with spontaneous IAAD (mean age 60 ± 16 years, 61% male) with postdissection follow-up records to an average of 6.8 ± 5.8 years. Of these, 76% presented with uIAAD versus 24% with hrcIAAD. hrcIAAD was diagnosed at a significantly younger age on average than uIAAD (52 ± 14 vs. 62 ± 16 years, P = 0.02), was less likely to present with concomitant hyperlipidemia (0% vs. 41%, P < 0.01), coronary artery disease (6% vs. 47%, P < 0.01), and prior smoking history (39% vs. 72%). hrcIAAD was more likely to present in patients with a genetic aortopathy (27% vs. 7%, P = 0.03). Hypertension was not significantly different between groups. Patients with hrcIAAD were significantly more likely to present with extension into iliac arteries compared to uIAAD (61% vs. 18%, P < 0.01). A much higher proportion of hrcIAAD required hospitalization compared to uIAAD (83% vs. 30%, P < 0.01) and operative intervention (67% vs. 7%, P < 0.01). While there was no significant difference in all-cause mortality between groups, there was a significant difference between aortic-related mortality which only occurred in those with hrcIAAD (28% vs. 0%, P < 0.01). CONCLUSIONS Comparison of long-term outcomes suggests that hrcIAAD is associated with increased hospitalization and need for operative intervention compared to uIAAD. Significant differences in atherosclerotic risk factors and proportions of connective tissue disease history between patients who present with hrcIAAD and uIAAD suggest that differences in underlying etiology are largely responsible for whether IAAD progresses towards rupture or has a more benign course and should be considered in risk stratification to guide more specific and targeted management of IAAD.
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Affiliation(s)
- James M Dittman
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Thoetphum Benyakorn
- Division of Vascular Surgery, Department of Surgery, Thammasat University, Pathum Thani, Thailand
| | - Nicolas J Mouawad
- Division of Vascular & Endovascular Surgery, Department of Surgery, McLaren Health System, Bay City, MI
| | - Zhanjiang Cao
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, Tsinghua University School of Clinical Medicine, Beijing, China
| | - Jasmin Etafo
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Sherene Shalhub
- Division of Vascular and Endovascular Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR.
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de Beaufort HWL, Vos JA, Heijmen RH. Initial Single-Center Experience With the Knickerbocker Technique During Thoracic Endovascular Aortic Repair to Block Retrograde False Lumen Flow in Patients With Type B Aortic Dissection. J Endovasc Ther 2024; 31:597-605. [PMID: 36342189 DOI: 10.1177/15266028221134889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Effectiveness of thoracic endovascular aortic repair in type B aortic dissection is impaired by persistent retrograde false lumen flow via distal re-entry tears. Controlled, stentgraft-assisted balloon dilatation of the true lumen at its lower end, or Knickerbocker technique, may block retrograde false lumen flow and consequently improve effectiveness by inducing immediate thrombosis along the entire descending thoracic aorta. MATERIALS AND METHODS A single-center retrospective analysis was performed for all consecutive patients with aortic dissection treated with the Knickerbocker technique to block retrograde false lumen flow. RESULTS Eleven patients were included for analysis. Intraoperative control angiography showed successful occlusion of the false lumen at the level of balloon dilatation in 9 out of 11 patients (82%). There was one perioperative mortality (9%), due to stroke. There were 2 early reinterventions, due to retroperitoneal bleeding and due to chyle leakage in the neck after left subclavian artery bypass. Median clinical follow-up duration was 6 (interquartile range [IQR] 2-11] months. There were 2 deaths during follow-up, one at 2 months after TEVAR from unknown cause of death, and one after 11 months due to rupture of an ascending aortic pseudoaneurysm. The Knickerbocker technique led to positive aortic remodeling. At 3 months follow-up, 100% of patients showed complete false lumen thrombosis in the thoracic aorta proximal to the level of balloon dilatation, with decreasing false lumen diameters (100%) and stable (44%) or decreasing (56%) total aortic diameters. In most patients, the false lumen distal to the stentgraft (i.e. at visceral level) remained patent (11% false lumen thrombosis rate), leading to ≥2 mm dilatation at this level (78% of patients) and in the infrarenal abdominal aorta (56% of patients) at 3 months postoperatively. No distal stent-graft-induced new entry tears were noticed during follow-up. CONCLUSION The Knickerbocker technique is feasible and effective, leading to positive aortic remodeling of the aorta covered by stentgraft in all of a small cohort of patients. CLINICAL IMPACT Persistent, retrograde false lumen perfusion from distal re-entries following thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection, may lead to progressive, aneurysmal dilatation. Controlled, stent graft-assisted balloon dilatation of the true lumen in the distal descending aorta (i.e. Knickerbocker technique) during TEVAR effectively excludes the false lumen from persistent flow resulting in positive aortic remodeling in our small cohort of patients, and hence potentially eliminates the risk of late post-dissection aneurysm formation in the descending thoracic aorta.
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Affiliation(s)
| | - Jan Albert Vos
- Department of Interventional Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, Radboud university medical center, Nijmegen, The Netherlands
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Cook IO, Green SY, Rebello KR, Zhang Q, Glover VA, Zea-Vera R, Moon MR, LeMaire SA, Coselli JS. Comparison of open thoracoabdominal repair for chronic aortic dissections and aneurysms. J Vasc Surg 2024; 80:323-335. [PMID: 38537876 DOI: 10.1016/j.jvs.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 03/14/2024] [Accepted: 03/19/2024] [Indexed: 04/23/2024]
Abstract
OBJECTIVE Aortic dissection is common in patients undergoing open surgical repair of thoracoabdominal aortic aneurysms (TAAAs). Most often, dissection is chronic and is associated with progressive aortic dilatation. Because contemporary outcomes in chronic dissection are not clearly understood, we compared patient characteristics and outcomes after open TAAA repair between patients with chronic dissection and those with non-dissection aneurysm. METHODS We retrospectively analyzed data from 3470 open TAAA repairs performed in a single practice. Operations were for non-dissection aneurysm in 2351 (67.8%) and chronic dissection in 1119 (32.2%). Outcomes included operative mortality and adverse events, a composite variable comprising operative death and persistent (present at discharge) stroke, paraplegia, paraparesis, and renal failure necessitating dialysis. Logistic regression identified predictors of operative mortality and adverse events. Time-to-event analyses examined survival, death, repair failure, subsequent progressive repair, and survival free of failure or subsequent repair. RESULTS Compared with patients with non-dissection aneurysm, those with chronic dissection were younger, had fewer atherosclerotic risk factors, and were more likely to have heritable thoracic aortic disease and undergo extent II repair. The operative mortality rate was 8.5% (n = 296) overall and was higher in non-dissection aneurysm patients (n = 217; 9.2%) than in chronic dissection patients (n = 79; 7.1%; P = .03). Adverse events were less frequent (P = .01) in patients with chronic dissection (n = 145; 13.0%), 22 (2.0%) of whom had persistent paraplegia. Chronic dissection was not predictive of operative mortality (P = .5) or adverse events (P = .6). Operative mortality and adverse events, respectively, were independently predicted by emergency repair (odds ratio [OR], 3.46 and 2.87), chronic kidney disease (OR, 1.74 and 1.81), extent II TAAA repair (OR, 1.44 and 1.73), increasing age (OR, 1.04/year and 1.04/year), and increasing aortic cross-clamp time (OR, 1.02/minutes and 1.02/minutes). Patients with chronic dissection had lower 10-year unadjusted mortality (42% vs 69%) but more frequent repair failure (5% vs 3%) and subsequent repair for progressive aortic disease (11% vs 5%) than patients with non-dissection aneurysm (P < .001); these differences were no longer statistically significant after adjustment. CONCLUSIONS Outcomes of open TAAA repair vary by aortic disease type. Emergency repairs and atherosclerotic diseases most commonly occur in patients with non-dissection aneurysm and independently predict operative mortality. Repair of chronic dissection is associated with low rates of adverse events, including operative mortality and persistent paraplegia, along with reasonable late survival and good durability. However, patients with chronic dissection tend to more commonly undergo subsequent repair to treat progressive aortic disease, which emphasizes the need for robust long-term imaging surveillance protocols.
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Affiliation(s)
- Ian O Cook
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Kimberly R Rebello
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Veronica A Glover
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Rodrigo Zea-Vera
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, TX; Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Research Institute and Heart & Vascular Institute, Geisinger, Danville, PA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, TX; Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX.
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Cho T, Uchida K, Yasuda S, Izubuchi R, Kaneko S, Minami T, Saito A. What is the Optimal Proximal Landing Zone of the Stent Graft in Treatment of Aortic Type B Dissection? Cardiovasc Intervent Radiol 2024; 47:1037-1044. [PMID: 38944660 DOI: 10.1007/s00270-024-03791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/14/2024] [Indexed: 07/01/2024]
Abstract
PURPOSE Retrograde type A aortic dissection (RTAD) represents a serious complication of endovascular treatment for type B aortic dissection (TBAD). To avoid RTAD, it is recommended to land the proximal end of the stent graft in a non-dissected aortic segment. In this study, we investigated whether landing in the dissection area increased the number of events at the proximal site. METHODS We conducted a retrospective review of endovascular treatments for TBAD at a single institution between 2009 and 2022. Patients were divided into two groups: group A, with a proximal landing zone entirely within the dissected area, and group B, with the proximal extent of the seal zone in the non-dissected area. We evaluated the occurrence of proximal events, including RTAD, and examined long-term outcomes to assess the validity of landing in the dissection area. RESULTS The study included eighty-nine patients who underwent endovascular treatment for TBAD. New intimal tears in the proximal landing site occurred in 3 cases (3.4%), with 1 case (2%) in group A and 2 cases (5.1%) in group B, showing no significant difference. Among the three cases, one (1.1%) in group B with zone 2 landing resulted in RTAD. At 60 months, the overall survival was 85%, and freedom from aorta-related mortality was 88%, with no significant difference between the groups. CONCLUSION Even if the proximal landing is in a dissected area, a treatment strategy performed in zone 3 without proximal landing in zone 2, seeking a non-dissected area, can still provide sufficient therapeutic effects. Level of Evidence 3 Retrospective single-center cohort analysis.
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Affiliation(s)
- Tomoki Cho
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan.
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Shota Yasuda
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Ryo Izubuchi
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Shotaro Kaneko
- Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Tomoyuki Minami
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Aya Saito
- Department of Surgery, Yokohama City University, Yokohama, Japan
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Aru RG, Holscher CM, Smith CW, Black JH. Endovascular fenestration and stenting for renovisceral malperfusion in a pediatric patient with type II Loeys-Dietz syndrome. J Vasc Surg Cases Innov Tech 2024; 10:101514. [PMID: 38989267 PMCID: PMC11234100 DOI: 10.1016/j.jvscit.2024.101514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/11/2024] [Indexed: 07/12/2024] Open
Abstract
A 16-year-old girl with Loeys-Dietz syndrome presented with an acute, complicated type B aortic dissection (AD) with mesenteric and right renal malperfusion owing to a dynamic obstruction. The anatomy of her AD and her genetic aortography were suboptimal for thoracic endovascular aortic repair. Given the concern for anticipated late aortic degeneration and the need for open aortic repair, she underwent successful transfemoral endovascular septal fenestration with stenting of the fenestration into the superior mesenteric artery and additional stenting of the right renal artery. Her renal failure and mesenteric angina resolved, and she was discharged home. Endovascular fenestration provides an elegant solution for AD-associated dynamic malperfusion of aortic branch vessels without compromising future open aortic repairs.
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Affiliation(s)
- Roberto G Aru
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Li R, Prastein D. Low Socioeconomic Status is Associated With Higher In-Hospital Mortality in Stanford Type A Aortic Dissection Repair: A Population Study of National Inpatient Sample From 2015 to 2020. J Surg Res 2024; 300:409-415. [PMID: 38851086 DOI: 10.1016/j.jss.2024.04.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Stanford Type A Aortic Dissection (TAAD) is characterized by a high in-hospital mortality rate and necessitates urgent surgical intervention. While socioeconomic status is known to influence health-care outcomes, its specific association with TAAD remains underexplored. This study aimed to investigate the population-based association between socioeconomic status with TAAD repair outcomes using a national registry. METHODS Patients who had TAAD repair were identified in National Inpatient Sample from Q4 2015-2020. National Inpatient Sample stratified estimated median household income of residents within a patient's ZIP code. Patients residing in neighborhoods of incomes in the lowest and highest quartiles were selected as the study cohorts. Multivariable logistic regressions were used to compare in-hospital outcomes, adjusted for demographics, comorbid conditions, hospital characteristics, primary payer status, and transfer status. RESULTS Compared to patients from high-income neighborhoods, patients in low-income communities had higher risks of mortality (adjusted odds ratio [aOR] 1.45, P = 0.01), acute kidney injury (aOR 1.225, P = 0.03), and infection (aOR 1.474, P = 0.02), as well as longer wait from admission to operation (24.96 ± 2.64 versus 18.00 ± 1.92 h, P = 0.03) and longer length of stay (15.06 ± 0.38 versus 13.80 ± 0.36 d, P = 0.01). In contrast, patients from low-income communities had less risk of hemorrhage/hematoma (aOR 0.691, P < 0.01) and lower total hospital charge (428,746 ± 10,658 versus 487,017 ± 16,770 US dollars, P < 0.01). CONCLUSIONS Evidence suggests patients from lower-income communities may have limited access to health care and treatment delays, leading to higher mortality and complications. The underlying reasons for these disparities in economically disadvantaged communities warrant further investigation, which could focus on health-care accessibility, timely detection of TAAD, and prompt transfers to specialized centers.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Deyanira Prastein
- The George Washington University School of Medicine and Health Sciences, Washington, DC
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Li G, Li J, Deng H, Wei X, Li N. Differences in In-Hospital and Follow-Up Outcomes Between Non-A Non-B Aortic Dissection and Type B Aortic Dissection Treated by Endovascular Based Treatment. Vasc Endovascular Surg 2024; 58:602-610. [PMID: 38649827 DOI: 10.1177/15385744241249293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVES Non-A non-B aortic dissection (AD) is a rare and life-threatening medical emergency, and it has been controversial whether it should be managed as type B aortic dissection (TBAD). The study aims to compare in-hospital and follow-up outcomes between patients with non-A non-B AD and those with TBAD treated by endovascular based treatment (EBT). METHODS From January 2017 to December 2021, 96 consecutive patients with non-A non-B AD met the inclusion criteria and underwent EBT. Patients with TBAD were matched to patients with non-A non-B AD at a 1:1 ratio using propensity score matching analysis to correct for baseline confounding factors. The primary endpoint was all-cause mortality. Aortic-related events were defined as dissection-related death, aortic rupture, retrograde type A aortic dissection, reintervention, and type Ia endoleak. RESULTS Patients with non-A non-B AD required more TEVAR-related adjunctive procedures compared to TBAD patients during EBT and they required a longer ICU length of stay (36.0 vs 24.0 hours, P < .05) as well as a longer hospitalization (8.0 vs 7.0 days, P < .05) after EBT. There was no statistical difference in overall survival after EBT for patients with TBAD and non-A non-B AD. However, compared to patients with TBAD, non-A non-B AD patients had a higher rate of reintervention and experienced more aortic-related late events during follow-up. CONCLUSION Patients with non-A non-B acute AD who are treated with EBT do not have higher in-hospital or follow-up mortality rates compared to patients with type B AD. However, there is an increased risk of reintervention and aortic-related late events after the intervention during follow-up.
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Affiliation(s)
- Gen Li
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Li
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongping Deng
- Department of Vascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiang Wei
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Na Li
- Division of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
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Xie LF, Lin XF, Wu QS, Xie YL, Zhang ZF, Qiu ZH, Chen LW. Risk prediction and prognostic analysis of post-implantation syndrome after thoracic endovascular aortic repair. Sci Rep 2024; 14:17376. [PMID: 39075074 PMCID: PMC11286741 DOI: 10.1038/s41598-024-65877-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/25/2024] [Indexed: 07/31/2024] Open
Abstract
This study aimed to establish a predictive model for the risk of post-thoracic endovascular aortic repair (TEVAR) post-implantation syndrome (PIS) in type B aortic dissection (TBAD) patients, assisting clinical physicians in early risk stratification and decision management for high-risk PIS patients. This study retrospectively analyzed the clinical data of 547 consecutive TBAD patients who underwent TEVAR treatment at our hospital. Feature variables were selected through LASSO regression and logistic regression analysis to construct a nomogram predictive model, and the model's performance was evaluated. The optimal cutoff value for the PIS risk nomogram score was calculated through receiver operating characteristic (ROC) curve analysis, further dividing patients into high-risk group (HRG) and low-risk group (LRG), and comparing the short to midterm postoperative outcomes between the two groups. In the end, a total of 158 cases (28.9%) experienced PIS. Through LASSO regression analysis and multivariable logistic regression analysis, variables including age, emergency surgery, operative time, contrast medium volume, and number of main prosthesis stents were selected to construct the nomogram predictive model. The model achieved an area under the curve (AUC) of 0.86 in the training set and 0.82 in the test set. Results from calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC) demonstrated that the predictive model exhibited good performance and clinical utility. Furthermore, after comparing the postoperative outcomes of HRG and LRG patients, we found that the incidence of postoperative PIS significantly increased in HRG patients. The duration of ICU stay and mechanical assistance time was prolonged, and the incidence of postoperative type II entry flow and acute kidney injury (AKI) was higher. The risk of aortic-related adverse events (ARAEs) and major adverse events (MAEs) at the first and twelfth months of follow-up also significantly increased. However, there was no significant difference in the mortality rate during hospitalization. This study established a nomogram model for predicting the risk of PIS in patients with TBAD undergoing TEVAR. It serves as a practical tool to assist clinicians in early risk stratification and decision-making management for patients.
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Affiliation(s)
- Lin-Feng Xie
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Xin-Fan Lin
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Qing-Song Wu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Yu-Ling Xie
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Zhao-Feng Zhang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Zhi-Huang Qiu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China.
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China.
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China.
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Ruiter Kanamori L, Tenorio ER, Babocs D, Savadi S, Baghbani-Oskouei A, Huang Y, Figueroa A, Tanenbaum M, Costa Filho JE, Baig M, Macedo TA, Timaran CH, Oderich GS. Indications, safety, and effectiveness of transcatheter electrosurgical septotomy during endovascular repair of aortic dissections. J Vasc Surg 2024:S0741-5214(24)01660-4. [PMID: 39074740 DOI: 10.1016/j.jvs.2024.07.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Endovascular repair of aortic dissections may be complicated by inadequate sealing zones, persistent false lumen perfusion, and limited space for catheter manipulation and target artery incorporation. The aim of this study was to describe the indications, technical success, and early outcomes of transcatheter electrosurgical septotomy (TES) during endovascular repair of aortic dissections. METHODS We reviewed the clinical data of consecutive patients treated by endovascular repair of aortic dissections with adjunctive TES in two centers between 2021 and 2023. End points were technical success, defined by successful septotomy without dislodgment of the lamella or target artery occlusion, and 30-day rates of major adverse events (MAEs). RESULTS Among 197 patients treated by endovascular repair for aortic dissections, 36 patients (18%) (median age, 61.5 years (interquartile range, 55.0-72.5 years; 83% male) underwent adjunctive TES for acute (n = 3 [8%]), subacute (n = 1 [3%]), or chronic postdissection aneurysms (n = 32 [89%]). Indications for TES were severe true lumen (TL) compression (≤16 mm) in 28 patients (78%), target vessel origin from false lumen in 19 (53%), creation of suitable landing zone in 12 (33%), and organ/limb malperfusion in four (11%). Endovascular repair included fenestrated-branched endovascular aortic repair (EVAR) in 18 patients (50%), thoracic EVAR/EVAR/PETTICOAT in 11 (31%), and arch branch repair in 7 (19%). All patients had dissections extending through zones 5 to 7, and 28 patients (78%) underwent TES across the renal-mesenteric segment. Technical success of TES was 92% (33/36) for all patients and 97% (32/33) among those with subacute or chronic postdissection aneurysms. There were three technical failures, including two patients with acute dissections with inadvertent superior mesenteric artery dissection in one patient and distal dislodgement of the dissection lamella in two patients. There were no arterial disruptions. The mean postseptotomy aortic lumen increased from 13.2 ± 4.8 mm to 28.4 ± 6.8 mm (P < .001). All 18 patients treated by fenestrated-branched EVAR had successful incorporation of 78 target arteries. There was one early death (3%) from stroke, and three patients (8%) had major adverse events. After a median follow-up of 8 months (interquartile range, 4.5-13.5 months), 13 patients (36%) had secondary interventions, and two (6%) died from non-aortic-related events. There were no other complications associated with TES. CONCLUSIONS TES is an adjunctive technique that may optimize sealing zones and luminal aortic diameter during endovascular repair of subacute and chronic postdissection. Although no arterial disruptions or target vessel loss occurred, patients with acute dissections are prone to technical failures related to dislodgement of the lamella.
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Affiliation(s)
- Lucas Ruiter Kanamori
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Emanuel R Tenorio
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Dora Babocs
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Ying Huang
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Andres Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mira Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jose Eduardo Costa Filho
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mirza Baig
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Thanila A Macedo
- Department of Diagnostic Radiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Gustavo S Oderich
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
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Li R, Prastein DJ. Peripheral artery disease is an independent risk factor for higher in-hospital mortality in Stanford type A aortic dissection repair. Vascular 2024:17085381241264726. [PMID: 39045849 DOI: 10.1177/17085381241264726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND Type A aortic dissection (TAAD) is an emergent condition that warrants immediate intervention. Peripheral artery disease (PAD) is a prevalent disease associated with worse outcomes in various cardiovascular procedures. However, it remains unclear whether PAD influences outcomes of TAAD repair. This study aimed to undertake a population-based analysis to assess impact of PAD on in-hospital outcomes following TAAD repair. METHODS Patients underwent TAAD repair were identified in National Inpatient Sample from Q4 2015 to 2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without PAD, adjusted for demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status. RESULTS 1525 patients with PAD and 2757 non-PAD patients underwent TAAD. PAD patients had higher mortality (18.62% vs 13.17%, aOR = 1.287, p = .01), AKI (51.41% vs 47.48%, aOR = 1.222, p < .01), infection (10.69% vs 8.02%, aOR = 1.269, p = .03), and vascular complication (7.28% vs 3.77%, aOR = 1.846, p < .01) but lower risks of pericardial complications (15.21% vs 19.95%, aOR = 0.696, p < .01). In addition, patients with PAD had longer time from admission to operation (1.29 ± 3.95 vs 0.70 ± 2.09 days, p < .01), longer LOS (14.92 ± 13.98 vs 13.41 ± 11.66 days, p = .01), and higher hospital charge (499,064 ± 519,405 vs 409,754 ± 405,663 US dollars, p < .01). CONCLUSION PAD was independently associated with worse outcome after TAAD repair. The elevated mortality rate could be attributed to the delay in surgery, which may be related to preoperative peripheral malperfusion syndrome that is common in PAD patients. A balance between preoperative management and immediate TAAD repair might be essential to prevent the increased mortality risk from treatment delays among PAD patients.
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Affiliation(s)
- Renxi Li
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Deyanira J Prastein
- Department of Surgery Hospital, The George Washington University, Washington, DC, USA
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Cao L, Zhang H, Guo W. Primary hyperparathyroidism and aortic dissection. J Vasc Surg 2024:S0741-5214(24)01646-X. [PMID: 39053784 DOI: 10.1016/j.jvs.2024.07.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 07/13/2024] [Accepted: 07/16/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China; Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China; Department of General Surgery, The 983rd Hospital of Joint Logistic Support Force of PLA, Tianjin, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China.
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Li R, Huddleston SJ, Prastein DJ. Alcohol use disorder is associated with a lower risk of in-hospital mortality in type A aortic dissection repair: a population-based study of National Inpatient Sample from 2015-2020. Alcohol Alcohol 2024; 59:agae061. [PMID: 39219176 DOI: 10.1093/alcalc/agae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 08/09/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND While alcohol consumption is implicated in the development of aortic dissection, the impact of alcohol use disorder (AUD) on the outcomes of type A aortic dissection (TAAD) repair is still largely unexplored. This study aimed to conduct a comprehensive, population-based analysis of effect of AUD on in-hospital outcomes following TAAD repair using National/Nationwide Inpatient Sample, the largest all-payer database in the United States. METHODS Patients undergoing TAAD repair were identified in National/Nationwide Inpatient Sample from Q4 2015-2020. Demographics, comorbidities, hospital characteristics, primary payer status, and transfer-in status between patients with and without AUD were matched by a 1:3 propensity-score matching. In-hospital outcomes were examined. RESULTS There were 220 patients with AUD who underwent TAAD repair. Meanwhile, 4062 non-AUD patients went under TAAD repair, where 646 of them were matched to all AUD patients. After propensity-score matching, AUD patients had a lower risk of in-hospital mortality (7.76% vs 13.31%, P = 0.03) while there was no difference in transfer-in status or time from admission to operation. However, patients with AUD had a higher rate of respiratory complications (27.40% vs 19.66%, P = 0.02) and a longer hospital length of stay (16.20 ± 11.61 vs 11.72 ± 1.69 days, P = 0.01). All other in-hospital outcomes were comparable between AUD and non-AUD patients. CONCLUSION AUD patients had a lower risk of in-hospital mortality but a higher rate of respiratory complications and a longer LOS. These findings can provide insights into preoperative risk stratification of these patients. Nonetheless, reasons underlying the lower mortality rate in AUD patients and their long-term prognosis require further investigation.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC 20052, USA
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, 420 Delaware St. SE, MMC 207, Minneapolis, MN 55455, USA
| | - Stephen J Huddleston
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, 420 Delaware St. SE, MMC 207, Minneapolis, MN 55455, USA
| | - Deyanira J Prastein
- The George Washington University Hospital, Department of Surgery, 2150 Pennsylvania Avenue NW #6B, Washington, DC 20037, USA
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Hari Y, Takagi H. Urgent Thoracic Endovascular Aortic Repair for Type-B 0,D Acute Aortic Dissection. Ann Vasc Surg 2024; 109:1-8. [PMID: 39025222 DOI: 10.1016/j.avsg.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/27/2024] [Accepted: 05/31/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The objective of the present study is to clarify safety and efficacy of thoracic endovascular aortic repair (TEVAR), excluding the primary entry in the descending aorta, for type-B0,D acute aortic dissection (TB0,DAAD) (so-called retrograde type-A acute aortic dissection). METHODS Forty-six patients with hyperacute-phase (within 2 days after the onset) type-A acute aortic dissection (TAAAD) and TB0,DAAD underwent urgent (on the admission or next day) intervention (TEVAR or conventional surgical aortic repair [CSAR]) for 2 years. Results of TEVAR for TB0,DAAD were compared with those of CSAR for TAAAD. Outcomes included 30-day mortality, aortic reintervention, and major complications (stroke and paraplegia/paraparesis). Details of TEVAR were also analyzed. RESULTS Seven patients with TB0,DAAD and 39 patients with TAAAD underwent respectively urgent TEVAR and CSAR. Aortic reintervention was significantly more frequent in the TEVAR than CSAR group (28.6% vs. 0%, P < 0.01). There was no difference in incidence of death and stroke between the TEVAR and CSAR group. All the 7 patients survived and 5 of the 7 (71.4%) patients were relieved of aortic reintervention for 30 days following TEVAR. One patient, however, underwent aortic arch replacement on postoperative day (POD) 1 owing to the patent and nonshrinking ascending false lumen (FL). The entry existed in the aortic arch. Another patient underwent ascending and transverse aortic replacement with frozen elephant trunk on POD13 due to proximal stent graft-induced new entry irrespective of the thrombosed and shrinking ascending FL. Because of the patent and nonshrinking ascending FL, 1 patient underwent additional TEVAR for the residual entry in the distal descending thoracic aorta on POD33 and subsequently ascending aortic replacement 4 months later. No entry was detected in the ascending or transverse aorta. The ascending FL in the other 4 patients was thrombosed early, shrinking gradually, and disappeared at last following TEVAR. CONCLUSIONS Urgent TEVAR for TB0,DAAD may be alternative to CSAR in selected cases. Accurate diagnosis of the primary entry location on preinterventional computed tomography scans for exclusion of the entry and cautious selection and delivery of a stent graft to prevent stent graft-induced new entry or endoleak are requisite for success of the procedure, remodeling of the FL, and satisfactory prognosis.
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Affiliation(s)
- Yosuke Hari
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan; Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan; Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan.
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Doering A, Nana P, Torrealba JI, Panuccio G, Trepte C, Chindris V, Kölbel T. Intra- and Early Post-Operative Factors Affecting Spinal Cord Ischemia in Patients Undergoing Fenestrated and Branched Endovascular Aortic Repair. J Clin Med 2024; 13:3978. [PMID: 38999542 PMCID: PMC11242175 DOI: 10.3390/jcm13133978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Spinal cord ischemia (SCI) is a severe complication after fenestrated/branched endovascular repair (f/bEVAR). The underlying causes of SCI are still under investigation. This study aimed to evaluate intra- and early post-operative parameters that may affect SCI evolution. Methods: A single-center retrospective analysis was conducted including SCI patients with complete anesthesiologic records (1 January 2011 to 31 December 2023). Values of intra-operative glucose, hemoglobin, lactate, activated clotting time (ACT), and the need for transfusion were collected. The cohort was compared to a matched cohort of non-SCI patients. Results: Fifty-one patients with SCI and complete anesthesiologic records were included (mean age: 69.8 ± 6.2 years; 39.2% male). Intra-operative glucose value < 110 mg/dL (AUC: 0.73; sensitivity 91%, specificity of 83%) and hemoglobin value > 8.5 mg/dL (AUC: 0.61; sensitivity 83%, specificity 78%) were protective for Grade 3 SCI. Twenty-three patients with SCI were matched to 23 patients without SCI. SCI patients presented significantly higher glucose levels intra-operatively (glucose mean value: SCI 150 ± 46 mg/dL vs. non-SCI: 122 ± 30 mg/dL, p = 0.005). ACT (SCI 259 ± 31 svs. non-SCI 288 ± 28 s, p = 0.001), volume input (SCI 4030 ± 1430 mL vs. non-SCI 3020 ± 113 mL, p = 0.009), and need for transfusion (SCI: 52.5% vs. 4.3%, p < 0.001) were related to SCI. Higher glucose levels were detected among patients with SCI, at 24 (SCI: 142 ± 30 mg/dL vs. non-SCI: 118 ± 26 mg/dL, p=0.004) and 48 h (SCI: 140 ± 29 mg/dL vs. non-SCI: 112 ± 20 mg/dL, p < 0.001) post-operatively. Conclusions: SCI is a multifactorial complication after f/bEVAR. Intra-operative and early post-operative glucose levels may be related to SCI evolution. Targeted glucose < 110 mg/dL may be protective for Grade 3 SCI.
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Affiliation(s)
| | - Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, 20251 Hamburg, Germany; (A.D.); (J.I.T.); (G.P.); (C.T.); (V.C.); (T.K.)
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48
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Shen Y, Wang J, Zhao J, Huang B, Weng C, Wang T. Development and Validation of a User Friendly Morphology Grading System (PATENT) Predicting Aortic Remodelling After Thoracic Endovascular Aortic Repair in High Risk Uncomplicated Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00568-9. [PMID: 38972631 DOI: 10.1016/j.ejvs.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/28/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE This study aimed to create a morphology grading system, solely based on 2D images from computed tomography angiography, to predict negative aortic remodelling (NAR) for patients with high risk uncomplicated type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). METHODS This single centre retrospective cohort study extracted and analysed consecutive patients diagnosed with high risk uncomplicated TBAD. Negative aortic remodelling was defined as an increase in the false lumen or total aortic diameter, or decrease in the true lumen diameter. The multivariable Cox regression model identified risk factors and a prediction model was created for two year freedom from NAR. A three category grading system, in which patients were classified into low, medium, and high risk groups, was further developed and internally validated. RESULTS Of 351 patients included, 99 (28%) developed NAR. The median age was 52 years (interquartile range 45, 62 years) and 56 (16%) were female. The rate of two year freedom from NAR was 71% (95% CI 65 - 77%). After the multivariable Cox regression analysis, Patent false lumen, Aberrant right subclavian artery, Taper ratio, abdominal circumferential Extent, coeliac artery or reNal artery involved, and four channel dissection (Three false lumens) remained independent predictors and were included in the PATENT grading system. The risk score was statistically significantly associated with NAR (HR 1.21; 95% CI 1.14 - 1.29; p < .001). The medium and high risk groups demonstrated a higher rate of NAR (medium risk, HR 2.82; 95% CI 1.57 - 5.01; p = .001; high risk, HR 4.39; 95% CI 2.58 - 7.48; p < .001). The grading system was characterised by robust discrimination with Harrell's C index of 0.68 (95% CI 0.63 - 0.75). CONCLUSION The PATENT grading system was characterised by good discrimination and calibration, which may serve as a clinician friendly tool to aid risk stratification for TBAD patients after TEVAR.
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Affiliation(s)
- Yinzhi Shen
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China; Department of Vascular Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jiarong Wang
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jichun Zhao
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Huang
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chengxin Weng
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tiehao Wang
- Division of Vascular Surgery, Department of General surgery, West China Hospital, Sichuan University, Chengdu, China.
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49
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Bissacco D, de Kort JF, Ramella A, Allievi S, Bellotti P, Casana R, Domanin M, Migliavacca F, Trimarchi S. Discussing on the Aortic Coverage in Type B Aortic Dissection Treatment: A Comprehensive Scoping Review. J Clin Med 2024; 13:3897. [PMID: 38999462 PMCID: PMC11242050 DOI: 10.3390/jcm13133897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/25/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVE The objective of this study is to investigate and address the question surrounding the determination of the optimal endograft length of coverage during TEVAR for type B aortic dissection (TBAD), with a particular emphasis on the distal landing zone (DLZ). DATA SOURCES MEDLINE, Scopus, and Web of Science databases were used. METHODS The PRISMA-ScR statement was followed. RESULTS Several variables can contribute to the length of coverage during TEVAR in TBAD patient. Baseline patient's characteristics, TBAD-related features, the type of endoprosthesis, and postoperative graft behaviour may contribute to the choice of coverage. CONCLUSIONS No robust data have been published regarding the optimal length of TEVAR. Therefore, reporting the percentage of covered aorta and improving computational studies should be valorised to improve postoperative outcomes.
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Affiliation(s)
- Daniele Bissacco
- Department of Clinical Sciences and Community Health, University of Milan, 20148 Milan, Italy
| | - Jasper F de Kort
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico di Milano, 20133 Milan, Italy
| | - Anna Ramella
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico di Milano, 20133 Milan, Italy
| | - Sara Allievi
- Department of Vascular Surgery, Santa Chiara Hospital, 38122 Trento, Italy
| | - Paolo Bellotti
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Renato Casana
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, 20145 Milan, Italy
| | - Maurizio Domanin
- Department of Clinical Sciences and Community Health, University of Milan, 20148 Milan, Italy
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Francesco Migliavacca
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico di Milano, 20133 Milan, Italy
| | - Santi Trimarchi
- Department of Clinical Sciences and Community Health, University of Milan, 20148 Milan, Italy
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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50
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Li R, Prastein D. Female patients have higher in-hospital mortality after type A aortic dissection repair: A population study from the national inpatient sample. World J Surg 2024; 48:1783-1790. [PMID: 38824464 DOI: 10.1002/wjs.12241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 05/27/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Stanford Type A Aortic Dissection (TAAD) is an emergent condition with high in-hospital mortality. Gender disparity in TAAD has been a topic of ongoing debate. This study aimed to conduct a population-based examination of gender disparities in short-term TAAD outcomes using the National/Nationwide Inpatient Sample (NIS) database, the largest all-payer database in the US. METHODS Patients undergoing TAAD repair were identified in NIS from the last quarter of 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between male and female patients, adjusted for demographics, comorbidities, hospital characteristics, primary payer status, and transfer status. RESULTS There were 1454 female and 2828 male patients identified who underwent TAAD repair. Female patients presented with TAAD were at a more advanced mean age (64.03 ± 13.81 vs. 58.28 ± 13.43 years, p < 0.01) and had greater comorbid burden. Compared to male patients, female patients had higher risks of in-hospital mortality (17.88% vs. 13.68%, adjusted odds ratio (aOR) = 1.266, p = 0.01). In addition, female patients had higher pericardial complications (20.29% vs. 17.22%, aOR = 1.227, p = 0.02), but lower acute kidney injury (AKI; 39.96% vs. 53.47%, aOR = 0.476, p < 0.01) and venous thromboembolism (VTE; 1.38% vs. 2.65%, aOR = 0.517, p = 0.01). Female patients had comparable time from admission to operation and transfer-in status, longer hospital stays, but fewer total hospital expenses. CONCLUSION Female patients were 1.27 times as likely to die in-hospital after TAAD repair but had less AKI and VTE. While there is no evidence suggesting delay in TAAD repair for female patients, the disparities might stem from other differences such as in care provided or intrinsic physiological variations.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Deyanira Prastein
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- The George Washington University School Hospital, Washington, District of Columbia, USA
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