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

Practice patterns of antiplatelet and anticoagulant therapy after fenestrated/branched endovascular aortic repair

OBJECTIVE

Antiplatelet and/or anticoagulant therapy are commonly prescribed after fenestrated/branched endovascular aortic repair (F/BEVAR). However, the optimal regimen remains unknown. We sought to characterize practice patterns and outcomes of antiplatelet and anticoagulant use in patients who underwent F/BEVAR.

METHODS

Consecutive patients enrolled (2012-2023) as part of the United States Aortic Research Consortium (US-ARC) from 10 independent physician-sponsored investigational device exemption studies were evaluated. The cohort was characterized by medication regimen on discharge from index F/BEVAR: (1) Aspirin alone OR P2Y12 alone (single-antiplatelet therapy [SAPT]); (2) Anticoagulant alone; (3) Aspirin + P2Y12 (dual-antiplatelet therapy [DAPT]); (4) Aspirin + anticoagulant OR P2Y12 + anticoagulant (SAPT + anticoagulant); (5) Aspirin + P2Y12 + anticoagulant (triple therapy [TT]); and (6) No therapy. Kaplan-Meier analysis and Cox proportional hazards modeling were used to compare 1-year outcomes including survival, target artery patency, freedom from bleeding complication, freedom from all reinterventions, and freedom from stent-specific reintervention.

RESULTS

Of the 1525 patients with complete exposure and outcome data, 49.6% were discharged on DAPT, 28.8% on SAPT, 13.6% on SAPT + anticoagulant, 3.2% on TT, 2.6% on anticoagulant alone, and 2.2% on no therapy. Discharge medication regimen was not associated with differences in 1-year survival, bleeding complications, composite reintervention rate, or stent-specific reintervention rate. However, there was a significant difference in 1-year target artery patency. On multivariable analysis comparing with SAPT, DAPT conferred a lower hazard of loss of target artery patency (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.27-0.84; P = .01). On sub-analyses of renal stents alone or visceral stents alone, DAPT no longer had a significantly lower hazard of loss of target artery patency (renal: HR, 0.66; 95% CI, 0.35-1.27; P = .22; visceral: HR, 0.31; 95% CI, 0.05-1.9; P = .21). Lastly, duration of DAPT therapy (1 month, 6 months, or 1 year) did not significantly affect target artery patency.

CONCLUSIONS

Practice patterns for antiplatelet and anticoagulant regimens after F/BEVAR vary widely across the US-ARC. There were no differences in bleeding complications, survival or reintervention rates among different regimens, but higher branch vessel patency was noted in the DAPT cohort. These data suggest there is a benefit in DAPT therapy. However, the generalizability of this finding is limited by the retrospective nature of this data, and the clinical significance of this finding is unclear, as there is no difference in survival, bleeding, or reintervention rates amongst the different regimens. Hence, an "optimal" regimen, including the duration of such regimen, could not be clearly discerned. This suggests equipoise for a randomized trial, nested within this cohort, to identify the most effective antiplatelet/anticoagulant regimen for the growing number of patients being treated globally with F/BEVAR.

Outcomes of thoracic endovascular aortic repair with physician-manufactured partial micropore stent grafts for aortic arch pathologies

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) has been used extensively in the management of thoracic aortic diseases. Numerous efforts have been made to enhance clinical outcomes through the use of stent grafts. This study aimed to investigate the effectiveness and safety of physician-manufactured partial micropore stent grafts (PSMGs) in TEVAR.

METHODS

Between December 2017 and June 2022, data were collected from 56 patients who underwent TEVAR using physician-manufactured PSMGs. The evaluation encompassed technical success, perioperative and follow-up morbidity and mortality, stroke incidence, and branch artery patency.

RESULTS

In this investigation, 56 patients received treatment with physician-manufactured PSMGs. Of these patients, 46 were male, with a mean age of 62.1 ± 11.2 years. Aortic pathologies comprised aortic dissection (n = 31 [55.4%]), aortic aneurysms (n = 10 [17.9%]), penetrating aortic ulcer (n = 8 [14.3%]), and intramural hematoma (n = 7 [12.5%]). During a median follow-up of 18 months (interquartile range, 13-25 months), the stroke rate, supra-aortic branch patency rate, and endoleak rate were 0%, 100%, and 7.1%, respectively. There were no occurrences of all-cause mortality, stroke, or the necessity for open conversion.

CONCLUSIONS

TEVAR with physician-manufactured PSMGs is a viable alternative for addressing aortic arch pathologies in proficient medical centers. The approach demonstrates favorable branch patency, a low complication rate, and minimal postoperative mortality.

Effect of autologous platelet-rich plasma on patients with acute type A aortic dissection underwent aortic arch replacement: A retrospective cohort study

BACKGROUND

Coagulopathy and massive bleeding are common complications of patients with Stanford type A acute aortic dissection repair, and patients with these complications require many transfusions. Autologous platelet-rich plasma (PRP) is widely used to reduce the need for blood products. In the present study, we aimed to investigate the effects of PRP on blood conservation and the postoperative conditions of patients who underwent aortic arch replacement.

METHODS

Patients with aortic dissection undergoing aortic arch replacement were included initially application In all, 837 patients were divided into the PRP and non-PRP groups according to PRP use, whereupon a propensity score match was performed. The data analyzed included patient basic information, intraoperative information, postoperative biochemical examinations, and CTA reports.

RESULTS

In total, 610 patients were finally included (305 patients per group). Groups were well balanced after matching. Compared to the non-PRP group, less cryoprecipitate was transfused in the PRP group (10.0 [7.5, 11.0] vs. 10.0 [10.0, 11.5], P = 0.021), while no differences were found in packed RBC, FFP, and platelets between the two groups. Also, the surgery variables showed no differences. After surgery, patients in the PRP group showed higher postoperative serum albumin (36.43±4.20 vs. 35.39±4.40 g/L, P = 0.004) and total protein levels (59.38±6.25 vs. 58.06±7.19 g/L, P = 0.019) than the non-PRP group, but no significant differences in the levels of ALT, AST, Scr, and BUN. CTA reports showed that the proportion of patients with pleural effusion was lower in the PRP group (76.66% vs. 83.99%, OR = 1.59, 95% CI: 1.04-2.45, P = 0.028), while the proportions of pericardial effusion were not significantly different.

CONCLUSIONS

PRP application in aortic arch replacement surgery reduced the transfusion of cryoprecipitate, increased the postoperative serum albumin and total protein levels, and reduced the incidence of pleural effusion. No effect of PRP application was found on other postoperative blood indicators and CTA reports.

The effect of postoperative anticoagulation on acute aortic dissection: a systematic review and meta-analysis

Background and aim

The evolution of the false lumen after the repair of acute aortic dissection has been linked to numerous adverse clinical outcomes, including increased late mortality and a higher risk of reoperation. Despite the widespread use of chronic anticoagulation in patients who have undergone repair for acute aortic dissection, the effects of this therapy on false lumen evolution and its subsequent consequences are yet to be fully understood. This meta-analysis aimed to investigate the impact of postoperative anticoagulation on patients with acute aortic dissection.

Methods

In PubMed, Cochrane Libraries, Embase, and Web of Science, we performed a systematic review of nonrandomized studies, comparing outcomes with postoperative anticoagulation vs. non-anticoagulation on aortic dissection. We investigated the status of false lumen (FL), aorta-related death, aortic reintervention, and perioperative stroke in aortic dissection patients with anticoagulation and non-anticoagulation.

Results

After screening 527 articles, seven non-randomized studies were selected, including a total of 2,122 patients with aortic dissection. Out of these patients, 496 received postoperative anticoagulation while 1,626 served as controls. Meta-analyses of 7 studies revealed significantly higher FL patency in Stanford type A aortic dissection (TAAD) postoperative anticoagulation with an OR of 1.82 (95% CI: 1.22 to 2.71; Z = 2.95; I²=0%; P = 0.93). Moreover, there was no statistically significant difference between the two groups in aorta-related death, aortic reintervention, and perioperative stroke with an OR of 1.31 (95% CI: 0.56 to 3.04; Z = 0.62; I² = 0%; P = 0.40), 0.98 (95% CI: 0.66 to 1.47; Z = 0.09; I² = 23%; P = 0.26), 1.73 (95% CI: 0.48 to 6.31; Z = 0.83; I² = 8%; P = 0.35), respectively.

Conclusions

Postoperative anticoagulation was associated with higher FL patency in Stanford type A aortic dissection patients. However, there was no significant difference between the anticoagulation and non-anticoagulation groups in terms of aorta-related death, aortic reintervention, and perioperative stroke.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Progression of Type B Intramural Hematoma Patients with Obstructive Sleep Apnea

OBJECTIVE

This study aimed to estimate the influence of obstructive sleep apnea (OSA) on type B intramural hematoma (IMHB) progression.

METHODS

All 127 patients received sleep evaluations and esophageal pressure measurements. Variables associated with aorta-related adverse events and mortality were summarized by logistic regression analysis and Cox proportional hazard models. Competing risk analysis of death was used to estimate aorta-related and non-aorta-related mortality.

RESULTS

The OSA group had a higher aorta-related adverse events rate (46% vs. 4%, P<0.001). The mean nighttime systolic pressure (OR, 1.24; 95% CI, 1.11-1.38, P<0.001) was associated with aorta-related adverse events during the acute phase. Thoracic endovascular aortic repair (TEVAR) (HR, 16.2; 95% CI, 7.68-34.22, P<0.001) and mean morning systolic pressure (HR, 1.43; 95% CI, 1.22-1.68, P<0.001) were associated with a higher rate of occurrence of aorta-related adverse events. The occurrence of OSA (HR, 3.19; 95% CI, 2.57-12.15, P<0.001) and mean morning systolic pressure (HR, 1.59; 95% CI, 1.27-2.01, P=0.002) were significantly associated with aorta-related mortality. Competing risk analysis revealed significantly higher aorta-related mortality in the OSA group (11.8% vs. 2.0%, P=0.0412). A neutrophil-to-lymphocyte ratio (NLR) of > 3.52 (specificity: 90.2%, sensitivity: 89.5%) and a mean platelet volume-to-platelet ratio (MPV/PLT) of > 0.049 (specificity: 98.0%, sensitivity: 98.7%) have diagnostic value for detecting OSA in IMHB.

CONCLUSIONS

OSA leads to a higher aorta-related adverse event rate and mortality in patients with IMHB. Variables associated with outcomes include TEVAR, mean morning/nighttime systolic pressure and OSA. The NLR and MPV/PLT ratios are valuable for detecting OSA in IMHB patients.