High intimal flap mobility assessed by intravascular ultrasound is associated with better short-term results after TEVAR in chronic aortic dissection

Early three-dimensional growth in uncomplicated type B aortic dissection is associated with long-term outcomes

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.

A novel technique for H-shaped reinforcement of double-barreled aorta in surgical treatment of chronic aortic dissection

Anastomosis of the prosthetic graft to the double-barreled aorta with intimal flap fenestration is a useful technique in surgery for chronic aortic dissection. Conversely, anastomosis to the false lumen's outer wall is prone to complications such as pseudoaneurysms, but little is known about the technique of reinforcing the double-barreled aorta. In this report, we describe a surgical case of chronic aortic dissection in which an H-shaped prosthetic graft was sutured to both aortic lumens, including the intimal flap, to prevent complications at the anastomosis site.

Comparative Effectiveness of Intravascular Ultrasound Versus Angiography in Abdominal and Thoracic Endovascular Aortic Repair: Systematic Review and Meta-Analysis

The effectiveness of intravascular ultrasound (IVUS) with angiography compared with angiography guidance alone in treating aortic conditions, such as dissections, aneurysms, and blunt traumatic injuries, remains unclear. This systematic review and meta-analysis evaluates the current literature for IVUS use during thoracic endovascular aortic repair (TEVAR) and abdominal endovascular aortic repair (EVAR). A comprehensive search of MEDLINE, EMBASE, and Cochrane CENTRAL databases was conducted in March 2024 adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing outcomes of TEVAR/EVAR with and without IVUS were identified. The outcomes of interest included contrast volume, fluoroscopy and procedural time, perioperative endoleak, and reinterventions and all-cause mortality during follow-up. Data with 95% confidence intervals (CIs) were extracted. Pooled analysis was performed using a random-effect model. Subgroup analysis was performed stratified by the condition being treated. Risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies. A total of 4,219 patients (n = 2,655 IVUS and n = 1,564 non-IVUS) from 9 observational studies were included. The IVUS group exhibited a reduction in contrast agent volume (weighted mean difference -34.65 mL, 95% CI -54.73 to -14.57) and fluoroscopy time (weighted mean difference -6.13 minutes, 95% CI -11.10 to -1.15), with no difference in procedural time. The perioperative type I and III endoleak occurrences were similar (risk ratio 2.36, 95% CI 0.55 to 10.11; risk ratio 0.72, 95% CI 0.09 to 5.77, respectively). Reintervention and mortality during follow-up were comparable (hazard ratio 0.80, 95% CI 0.33 to 1.97; hazard ratio 0.75, 95% CI 0.47 to 1.18, respectively). All the included studies had small risks of bias. In conclusion, this meta-analysis provides evidence that IVUS enables the safe deployment of TEVAR/EVAR with reduced contrast agent and radiation exposure.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

MR Angiography for Aortic Diseases

Aortic pathologic conditions represent diverse disorders, including aortic aneurysm, acute aortic syndrome, traumatic aortic injury, and atherosclerosis. Given the nonspecific clinical features, noninvasive imaging is critical in screening, diagnosis, management, and posttherapeutic surveillance. Of the commonly used imaging modalities, including ultrasound, computed tomography, and MR imaging, the final choice often depends on a combination of factors: acuity of clinical presentation, suspected underlying diagnosis, and institutional practice. Further research is needed to identify the potential clinical role and define appropriate use criteria for advanced MR applications such as four-dimenional flow to manage patients with aortic pathologic conditions.

Successful "PETTICOAT" procedure assisted by aortic angioscopy for complicated type B aortic dissection: Case report

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) is a useful treatment for acute type B aortic dissection (TBAD). A PETTICOAT (Provisional ExTension to Induce COmplete ATtachment) procedure can be an alternative surgical option for a patent false lumen. Non-obstructive aortic angioscopy is an attractive modality that can visualize the aortic intima for things such as entry or re-entry tears that are difficult to detect with computed tomography (CT). Herein, we describe a successful PETTICOAT procedure assisted by aortic angioscopy for subacute TBAD complicated by lower limb ischemia.

PRESENTATION OF CASE

A 63-year-old man who had been treated with conservative therapy for subacute TBAD had intermittent claudication. Enhanced CT revealed a primary entry tear at the distal arch, and the true lumen at the thoracoabdominal level was narrowed by the patent false lumen. Therefore, the PETTICOAT procedure was performed. The postoperative course was uneventful, with normalized lower limb pressure.

DISCUSSION

Although PETTICOAT procedure is effective for treating complicated TBAD, there is no consensus on where and how far the proximal stent graft or distal bare stent should be implanted. Non-obstructive aortic angioscopy during PETTICOAT is useful to detect and cover the entry and re-entry tears. The PETTICOAT procedure assisted by aortic angioscopy could contribute to determining the appropriate coverage range of the stent graft.

CONCLUSION

Aortic angioscopy could contribute to the surgical success of PETTICOAT procedure for complicated subacute TBAD.

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

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

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

The impact of dissection membrane motility on mid-term aortic remodelling after thoracic endovascular repair

OBJECTIVES

The aim of this study was to assess preoperative dissection flap motility and to evaluate its impact on the aortic remodelling and the development of distal stent-induced new entry after thoracic endovascular aneurysm repair (TEVAR)/frozen elephant trunk (FET).

METHODS

Patients with primary or residual type B dissections were included in a retrospective study with transoesophageal echocardiography analysis of the preoperative dissection flap motility assessed by the true lumen (TL) strain. Three-dimensional computing tomography centreline reconstructions before TEVAR/FET and during the follow-up were conducted to measure aortic remodelling: false lumen thrombosis, TL expansion and aortic diameters at 10 and 20 cm downstream the left subclavian artery, at the coeliac trunk and in the infrarenal aorta. All continuous variables are reported as median with first and third quartiles.

RESULTS

Fifty-six consecutive patients were treated with TEVAR (n = 45) or FET (n = 11) in the acute (n = 16), subacute (n = 16) and chronic (n = 24) dissection phase. At a median follow-up of 6 (3-12) months, they showed a favourable TL expansion in the descending aorta, significantly higher in the acute [+9 mm (5-12); P < 0.001] and subacute groups [+5 mm (3-8); P = 0.039] than in the chronic group [+2 mm (0-5)]. The dissection flap motility parameter TL strain was superior in the acute (P = 0.006) and subacute (P = 0.035) groups in comparison to the chronic group. The motile flap [TL strain >22.5% (median)] was associated with a higher TL expansion rate in the thoracic aorta (P = 0.009) and a comparable distal stent-induced new entry incidence (overall: 16%) in comparison to the immobile flap (P = 0.89).

CONCLUSIONS

The intraoperative assessment and the inclusion of the dissection flap motility parameters in the decision-making during TEVAR/FET may refine the distal endograft sizing for an improved remodelling of the TL.

An integrated fluid-structure interaction and thrombosis model for type B aortic dissection

False lumen thrombosis (FLT) in type B aortic dissection has been associated with the progression of dissection and treatment outcome. Existing computational models mostly assume rigid wall behavior which ignores the effect of flap motion on flow and thrombus formation within the FL. In this study, we have combined a fully coupled fluid-structure interaction (FSI) approach with a shear-driven thrombosis model described by a series of convection-diffusion reaction equations. The integrated FSI-thrombosis model has been applied to an idealized dissection geometry to investigate the interaction between vessel wall motion and growing thrombus. Our simulation results show that wall compliance and flap motion can influence the progression of FLT. The main difference between the rigid and FSI models is the continuous development of vortices near the tears caused by drastic flap motion up to 4.45 mm. Flap-induced high shear stress and shear rates around tears help to transport activated platelets further to the neighboring region, thus speeding up thrombus formation during the accelerated phase in the FSI models. Reducing flap mobility by increasing the Young's modulus of the flap slows down the thrombus growth. Compared to the rigid model, the predicted thrombus volume is 25% larger using the FSI-thrombosis model with a relatively mobile flap. Furthermore, our FSI-thrombosis model can capture the gradual effect of thrombus growth on the flow field, leading to flow obstruction in the FL, increased blood viscosity and reduced flap motion. This model is a step closer toward simulating realistic thrombus growth in aortic dissection, by taking into account the effect of intimal flap and vessel wall motion.

Initiating a New Era of Cardiovascular Diagnosis and Therapy in Acute Aortic Syndromes: The Mainz-Essen Experience (Part I)-Imaging and Biomarkers

Acute aortic syndromes (AAS) encompass a group of life-threatening medical conditions (acute aortic dissection [AAD], intramural hematoma, and penetrating aortic ulcer) with a common pathophysiological pathway. Due to overlapping symptoms and signs with other cardiovascular emergencies, the diagnosis remains challenging resulting in time delays and related increased in-hospital and long-term morbidity and mortality. The Cardiovascular Department of Johannes Gutenberg University in Mainz at West-German Heart Centre in Essen (Germany) first described (in 1984) AAD by transesophageal echocardiography, AAD diagnostic features, and furtherly explored the implementation of "invasive" imaging techniques, namely, intravascular ultrasound and intraluminal phased-array imaging. Furthermore, pioneer studies were undertaken on the biomarker and imaging interplay, namely, D-dimer and F-fluorodeoxyglucose positron emission tomography/computed tomography. We discuss the unique 35-year-long Mainz-Essen experience on the diagnostic and prognostic role of serological and imaging biomarkers in AAS.

[Innovations in the endovascular treatment of peripheral arterial disease]

The cooperation of physicians, engineers and other sciences results in a steady launching of effective tools for vascular treatment, which further support the dominating position of endovascular therapy in the field of PAD. Parallel to the treatment options, non-radiation based image guidance is another area, where innovation helps to reduce radiation burden for patient and staff members without losing procedural quality and despite a growing number of radiation based procedures. Meanwhile, the available portfolio of endovascular tools allows to treat every vessel segment with results comparable to or even better then open surgery. This survey presents new techniques, tools and recently published results from related trials, which will probably have further influence on PAD treatment in the coming years.

The effect of beta-blockers on hemodynamic parameters in patient-specific blood flow simulations of type-B aortic dissection: a virtual study

Aortic dissection (AD) is one of the fatal and complex conditions. Since there is a lack of a specific treatment guideline for type-B AD, a better understanding of patient-specific hemodynamics and therapy outcomes can potentially control the progression of the disease and aid in the clinical decision-making process. In this work, a patient-specific geometry of type-B AD is reconstructed from computed tomography images, and a numerical simulation using personalised computational fluid dynamics (CFD) with three-element Windkessel model boundary condition at each outlet is implemented. According to the physiological response of beta-blockers to the reduction of left ventricular contractions, three case studies with different heart rates are created. Several hemodynamic features, including time-averaged wall shear stress (TAWSS), highly oscillatory, low magnitude shear (HOLMES), and flow pattern are investigated and compared between each case. Results show that decreasing TAWSS, which is caused by the reduction of the velocity gradient, prevents vessel wall at entry tear from rupture. Additionally, with the increase in HOLMES value at distal false lumen, calcification and plaque formation in the moderate and regular-heart rate cases are successfully controlled. This work demonstrates how CFD methods with non-invasive hemodynamic metrics can be developed to predict the hemodynamic changes before medication or other invasive operations. These consequences can be a powerful framework for clinicians and surgical communities to improve their diagnostic and pre-procedural planning.

Dynamic Indicators That Impact the Outcomes of Thoracic Endovascular Aortic Repair in Complicated Type B Aortic Dissection

PURPOSE

To investigate dynamic variables obtained from retrospective computed tomography angiography for ability to predict thoracic endovascular aortic repair (TEVAR) outcomes in patients with complicated type B aortic dissection (cTBAD).

MATERIALS AND METHODS

Seventy-nine patients with cTBAD who received TEVAR from March 2009 to June 2018 were retrospectively enrolled. Relative true lumen area (r-TLA) was computed at the level of tracheal bifurcation every 5% of all R-R intervals. Parameters that reflect the state of intimal motion were evaluated, including difference between maximum and minimum r-TLA (D-TLA) and true lumen collapse. The endpoints comprised early (≤ 30 days) and late (> 30 days) outcomes after intervention.

RESULTS

Overall early mortality rate was 13.9% (11/79), and early adverse events rate was 24.1% (19/79). Patients who received TEVAR within 2 days of symptom onset demonstrated the worst outcomes. A longer time of r-TLA < 25% in 1 cardiac cycle (P = .049) and larger D-TLA (P < .001) were correlated to an increased early death. In addition, D-TLA was an independent predictor of early mortality. Area under the curve of D-TLA was 0.849 (95% confidence interval 0.730-0.967) for predicting early mortality and 0.742 (95% CI 0.611-0.873) for predicting early adverse events. Survival and event-free survival rates during follow-up were decreased in the D-TLA > 21.5% group compared with the D-TLA ≤ 21.5% group (all P < .001).

CONCLUSIONS

Larger D-TLA is correlated with worse postoperative outcomes and might be a crucial parameter for future risk stratification in patients with cTBAD.