EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ

Anesthetic Management for Proximal Aortic Repair

Surgical repair of the proximal aorta is a complex endeavor, requiring cardiopulmonary bypass (CPB) and often the use of hypothermic circulatory arrest (HCA). In addition to the normal considerations for patients undergoing cardiopulmonary bypass, additional challenges include cerebral and end-organ protection during periods of circulatory arrest. This review aims to provide an up-to-date, evidence-based review on anesthetic management for proximal aortic repair.

Successful Open Repair of a Thoracoabdominal Aortic Aneurysm After Multiple Failed Endovascular Treatments in a 22-Years-Old Individual With Loeys-Dietz Syndrome

Loeys-Dietz syndrome is a rare genetically triggered disease characterized by aortic involvement, predisposing individuals to aneurysm and dissection at young age. Open repair is considered the treatment of choice despite the fact that it is associated with significant morbidity and mortality rates. On the other hand, endovascular treatment may be also considered an acceptable option in specific cases such as emergency or in patients unfit for open surgery or when landing zones are within surgical grafts. We report the case of a thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR) in a 22-year-old male patient diagnosed with type 2 Loeys-Dietz syndrome, treated by means of a TAAA replacement with a 30-mm multi-branched "Coselli" aortic graft (Vascutek, Renfrewshire, Scotland, UK) after multiple previously interventions, including a thoracic endovascular aortic repair (TEVAR) and a custom made endograft for the visceral aorta.

Staged, hybrid approach by zone 2 arch replacement and completion thoracic endoprosthesis in retrograde acute type A aortic dissection

We describe a case of retrograde acute type A aortic dissection approached by a hybrid, staged approach consisting of a zone 2 arch replacement and completion thoracic endovascular aortic repair procedure combined with distal balloon-assisted stent graft dilatation to prevent retrograde false lumen flow. This technique may be an alternative and more complete when compared with a frozen elephant trunk procedure at onset. Additionally, favorable remodeling of the entire thoracic aorta is observed.

Critical Review of Guidelines for Type B Aortic Dissection

The management of type B aortic dissection is one of the most challenging and debated topics in contemporary cardiovascular surgery practice. Patients with acute or chronic dissection-related complications, face high morbidity and mortality if not treated promptly. For most patients requiring intervention, thoracic endovascular aortic repair (TEVAR) is considered the gold standard. However, both early and late TEVAR-related complications make decision-making complex, even for experienced clinicians. In many cases, optimal medical management with longitudinal imaging surveillance may be preferred. In response to these challenges, several societal guidelines have recently been published1-5 to provide evidence-based or expert consensus 'best practice' recommendations. Although these guidelines share many commonalities, they also highlight key unresolved clinical questions. For example, debates persist over the appropriate use of TEVAR for 'uncomplicated' TBAD, defining 'high-risk' criteria for uncomplicated presentations, and management of the false lumen, among other topics. Despite recent updates, a critical evaluation of the nuanced differences between these guidelines is lacking. Therefore, the purpose of this review is to compare current clinical practice guidelines, highlight their similarities and differences, and offer a comprehensive evaluation of the evidence surrounding management of TBAD. Moreover, this analysis will provide recommendations to address important knowledge gaps.

Impact of mild hypothermic circulatory arrest on surgical outcomes in acute type a aortic dissection patients: a single-centre study

BACKGROUND

As hypothermic circulatory arrest (HCA) is being more frequently induced in patients undergoing aortic arch surgery, its safety at different degrees has become a crucial area of study. The aim of this study was to assess the surgical outcomes of mild hypothermic circulatory arrest (MI-HCA) during aortic arch surgery.

METHODS

Acute type A aortic dissection (ATAAD) patients who underwent total arch replacement (TAR) and frozen elephant trunk (FET) surgery between January 2014 and December 2023 were enrolled in this study. The patients were divided into two groups according to the minimum nasopharyngeal temperature: the moderate hypothermic circulatory arrest (MHCA) group (20-28 °C) and the MI-HCA group (> 28 °C). The inverse probability of treatment weighting (IPTW) was used to balance differences in the baseline characteristics. Perioperative variables were analysed via pairwise comparisons, multivariable logistic regression, and subgroup forest plots to assess the impact of MI-HCA on surgical outcomes.

RESULTS

A total of 447 patients were included in this study, and the mean minimum nasopharyngeal temperature was 24.80 (23.98, 27.30) °C in the MHCA group and 30.10 (29.80, 30.70) °C in the MI-HCA group. The incidence of acute kidney injury (AKI) in the MI-HCA group was lower than that in the MHCA group (52% vs. 78%, p < 0.01). In the multivariable logistic regression analysis, MI-HCA was identified as an independent protective factor for AKI (OR = 0.354, 95% CI 0.177-0.689; p = 0.003). Additionally, compared with MHCA, MI-HCA was not associated with an increased incidence of stroke, spinal cord injury, or in-hospital mortality. After IPTW, the preoperative and intraoperative data of the patients were balanced, and the incidence of AKI in the MI-HCA group was still lower than that in the MHCA group (83.26% vs. 53.61%, p = 0.004). The subgroup forest plot also demonstrated that MI-HCA was a protective factor for postoperative AKI.

CONCLUSIONS

The surgical outcomes of MI-HCA in ATAAD patients were satisfactory. Compared with MHCA, MI-HCA provided sufficient protection for distal organs, the brain, and the spinal cord, with a significantly lower incidence of AKI. These results indicate that MI-HCA could be a better approach for ATAAD surgery.

Pre-emptive Endovascular Repair for Uncomplicated Type B Dissection - Is this an Option?

Type B aortic dissection (TBAD) primarily affects men aged 60-65, with hypertension in over 80% of cases. The gold standard for the treatment of uncomplicated acute TBAD is Best Medical Therapy (BMT), which focused on controlling blood pressure and heart rate. However, Thoracic Endovascular Aortic Repair (TEVAR) has gained attention over the years, especially for complicated TBAD cases, by covering the primary entry tear, lowering false lumen pressure, and promoting aortic remodeling. TBAD can be classified according to the onset of symptoms into acute, subacute and chronic stages, with different intervention implications at each stage. Studies such as the ADSORB and INSTEAD trials have shown the benefits of TEVAR over BMT, particularly in promoting aortic remodeling and reducing long-term aorta-related mortality. However, these trials noted no significant difference in immediate mortality. TEVAR timing is crucial, as early intervention in the acute phase can lead to higher complication rates due to higher intimal fragility. As a result, the subacute phase offers a balance, allowing beneficial remodeling with a lower complication rate.

Ascending aorta dilatation for pulmonary atresia with ventricular septal defect: a report of three adult cases

BACKGROUND

Patients with pulmonary atresia and ventricular septal defect (PA/VSD) are prone to progressive aortic dilation. However, there are relatively few reports of progressive development of aortic aneurysm or aortic dissection in adult patients who missed early corrective surgery.

PRESENTATION OF CASES

Case 1: A 38-year-old man with PA/VSD and a bicuspid aortic valve (BAV), underwent VSD repair, aortic valve replacement, and PA correction at age 21. Seventeen years after surgery, an aortic dissection occurred in the ascending aorta, which subsequently underwent the Bentall procedure. Case 2: A 33-year-old male with PA/VSD, and a Nakata index of 31.24 mm2/m2, underwent a central shunt surgery at age 17. Sixteen years after surgery, an aortic root aneurysm and ascending aortic dilatation (AAD) developed. Case 3: A 42-year-old female underwent corrective surgery for PA/VSD repair at age 14. Twenty-eight years after surgery, an AAD developed.

CONCLUSIONS

Adult patients with PA/VSD who miss the optimal age for surgery are more likely to develop dilatation of the ascending aorta and are at risk for aortic dissection. Therefore, long-term follow-up and monitoring is needed in this patient population.

Influence of false lumen status on systemic inflammatory response triggered by acute aortic dissection

We investigated the influence of false lumen (FL) status on the systemic inflammatory response triggered by acute aortic dissection (AAD) using cytokine profiling. The study included 44 patients with AAD. Patients were divided between those with a thrombosed FL (Group T, n = 21) and those with a non-thrombosed FL (Group P, n = 23). On-admission serum concentrations of 29 cytokines were compared between unmatched and propensity-score matched (n = 10 pairs) FL groups and a control group (non-ruptured thoracic aortic aneurysm, Group C, n = 20). Unmatched analysis showed 12 cytokines differed between groups and fell into three categories: Category A (increased expression in both FL groups: IL-6, IL-10, IL-15, G-CSF); Category B (increased expression only in Group P: IL-1Ra, IL-1β, IL-8, IL-12p70, GM-CSF); and Category C (others: IP-10, VEGF-A, eotaxin). The increases in Category A and Category B cytokines in Group T were attenuated, but not significantly, compared to their increases in Group P. Propensity-score matching analysis revealed a similar expression pattern with respect to all four Category A cytokines, four Category B cytokines (IL-1β, IL-1Ra, IL-12p70, and GM-CSF), and two Category C cytokines (IP-10 and VEGF-A). A robust inflammatory response occurs in patients with AAD, but the response is attenuated when the FL is thrombosed.

Factors associated with and outcomes of respiratory adverse events following thoracic endovascular aortic repair

OBJECTIVE

Respiratory adverse events (RAEs) after thoracic endovascular aortic repair (TEVAR) remain poorly characterized owing to the lack of comprehensive studies that identify individuals prone to these complications. This study aims to determine the incidence, factors associated with, and outcomes of RAEs after TEVAR.

METHODS

We identified patients in the Vascular Quality Initiative undergoing TEVAR isolated to zones 0 to 5 from 2010 to 2023 for nontraumatic pathologies. After determining the incidence of postoperative RAEs, we assessed baseline characteristics, pathology, procedural details, and postoperative complications stratified by respiratory complication status: none, pneumonia only, reintubation only, or both. We then examined preoperative and intraoperative variables independently associated with the development of postoperative RAEs using multivariable modified Poisson regression. Kaplan-Meier analysis and Cox proportional hazards regression models were used to determine associations between postoperative RAEs and 5-year survival adjusting for preoperative variables and other nonrespiratory postoperative complications in a separate model.

RESULTS

Of 10,708 patients, 8.3% had any RAE (pneumonia only, 2.1%; reintubation only, 4.8%; both, 1.4%). Patients with any RAE were more likely to present with aortic dissection (any respiratory complication, 46% vs no respiratory complication, 35%; P < .001), and be symptomatic (58% vs 48%; P < .001). Developing RAEs after TEVAR was associated with male sex (adjusted relative risk [aRR], 1.19; 95% confidence interval [CI], 1.01-1.41; P = .037), obesity (aRR, 1.31; 95% CI, 1.07-1.61; P = .009), morbid obesity (aRR, 1.68; 95% CI, 1.20-2.32; P = .002), renal dysfunction (aRR, estimated glomerular filtration rate 30-45, 1.45; 95% CI, 1.15-1.82; P = .002; estimated glomerular filtration rate <30/hemodialysis, 1.7; 95% CI, 1.37-2.11; P < .001), anemia (aRR, 1.31; 95% CI, 1.09-1.58; P = .003), aortic diameter >65 mm (aRR, 1.54; 95% CI, 1.25-1.89; P < .001), proximal disease in the aortic arch (aRR, 1.23; 95% CI, 1.03-1.48; P = .025) or ascending aorta (aRR, 1.61; 95% CI, 1.19-2.14; P = .002), acute aortic dissection (aRR, 2.13; 95% CI, 1.72-2.63; P < .001), ruptured presentation (aRR, 3.07; 95% CI, 2.43-3.87; P < .001), same-day surgical thoracic branch treatment (aRR, 1.51; 95% CI, 1.25-1.82; P < .001), chronic obstructive pulmonary disease on home oxygen (aRR, 1.58; 95% CI, 1.08-2.25; P = .014), limited self-care or bed-bound status (aRR, 2.12; 95% CI, 1.45-3.03; P < .001), and intraoperative transfusion (aRR, 1.88; 95% CI, 1.47-2.40; P < .001). Patients who developed postoperative RAEs had higher 30-day mortality (27% vs 4%; P < .001) and 5-year mortality than patients without respiratory complications (46% vs 20%; P < .001). After adjusting for preoperative and postoperative variables, the 5-year mortality was higher in patients who developed any postoperative RAE (adjusted hazard ratio [aHR], 1.8; 95% CI, 1.6, 2.1; P < .001), postoperative pneumonia only (aHR, 1.4; 95% CI, 1.0, 1.8; P = .046), reintubation only (aHR, 2.2; 95% CI, 1.8, 2.6; P < .001) or both (aHR, 1.5; 95% CI, 1.1, 2.0; P = .008).

CONCLUSIONS

RAEs after TEVAR are common, more likely to occur in male patients with obesity, renal dysfunction, anemia, chronic obstructive pulmonary disease on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, who received intraoperative transfusion, and are associated with a two-fold increase in 5-year mortality regardless of the development of other postoperative complications. Considering these factors in assessing the risks and benefits of TEVAR procedures, along with implementing customized postoperative care, can potentially improve clinical outcomes.

Rehabilitation Progress in Patients Following Surgery for Acute Stanford Type A Aortic Dissection Extending Beyond the Ascending Aorta

Background: The objective of this study was to assess the course of rehabilitation of patients hospitalized in the cardiac rehabilitation unit after surgery for acute Stanford type A aortic dissection, extending beyond the ascending aorta, and comparing these findings with those for patients who, after the same type of surgery, had no remaining dissection. The aim was to develop an optimal cardiac rehabilitation model for this patient population, given the lack of clear guidelines. Additionally, the study aimed to evaluate their one-year survival. Methods: The study included patients referred to the cardiac rehabilitation unit after surgery for acute Stanford type A aortic dissection extending beyond the ascending aorta (a total of 25 patients). The study group was compared with a cohort of patients (a total of 58) who underwent similar cardiac surgery. The main difference was the absence of residual aortic dissection. All patients were assessed on admission to the cardiac rehabilitation unit and at discharge using the 6-min walk test and the Tinetti test. All patients underwent 2-3 weeks of rehabilitation following the same protocol; however, the study group had significantly reduced exercise loads. Results: Patients in the study group were admitted to the cardiac rehabilitation unit in a significantly worse functional status compared to the comparison group, but the final assessment showed comparable results for the Tinetti test and the 6-min walk test. There were no differences in one-year survival between the two groups. Conclusions: Early postoperative cardiac rehabilitation in patients after acute aortic dissection significantly improves the functional status of this patient group, and is safe.

Correlation Between Intraoperative Near-infrared Spectroscopy Values and Neurologic Outcomes in Patients Undergoing Total Aortic Arch Replacement Using the Frozen Elephant Trunk Technique

OBJECTIVE

To correlate intraoperative near-infrared spectroscopy (NIRS) values with neurologic outcomes in patients undergoing total aortic arch replacement using the frozen elephant trunk (FET) technique.

DESIGN

Retrospective, single-center registry study using a two-way repeated-measures analysis of variance.

SETTING

Between November 2013 and December 2023, 427 patients were treated for acute and chronic aortic pathologies using the FET procedure.

PARTICIPANTS

A total of 166 patients with complete NIRS data at all predefined time points were included and retrospectively divided into two groups: patients diagnosed by experienced radiologists and clinicians with stroke and without stroke after FET.

MEASUREMENTS

Bilateral NIRS values were recorded continuously and at seven critical time points in each patient, and correlations were made between left- and right-sided NIRS values and stroke.

MAIN RESULTS

A total of 23 patients (13.9%) were diagnosed with stroke. There was a significantly higher in-hospital mortality in patients with stroke (21.7%) compared with patients without stroke (7.7%, p = 0.037). Left-sided regional cerebral oxygenation did not show significant difference in patients with versus without stroke (p = 0.550). Differences were detected in right-sided regional cerebral oxygenation trends (p < 0.001) and interhemisphere NIRS at specified time points (p = 0.009). The interaction, time × stroke, however, did not show significant results in any analysis (p > 0.05).

CONCLUSION

NIRS is a reliable tool to monitor intraoperative frontal lobe cerebral oxygen saturation. However, its use to predict postoperative stroke remains limited. Further refinements are needed to develop the technique into a prediction tool.

Aortic Outcome after Implementation of a Treatment Strategy for Type B Aortic Dissection Involving the Aortic Arch

OBJECTIVE

To evaluate the outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD)).

METHODS

This retrospective observational study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. All cases of NANB AAD (B 1-2 D) treated at our institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodeling were analyzed.

RESULTS

Among 519 cases of acute aortic syndrome, n = 22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n = 16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly 2 days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7 (31.8%) needed emergent operation for risks of impending aortic rupture or retrograde aortic dissection extension, and 4 (26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of false lumen thrombosis (100% vs 55.5%, P = 0.033), and a significant positive aortic remodeling in zone 3 (P < 0.001) and 4 (P = 0.038) were reported in operated versus medically managed patients.

CONCLUSIONS

The best treatment for NANB is not established. We advocate for medical stabilization with an operative approach that favors open surgery in the acute post dissection period, promotes aortic remodeling, and carries acceptable risk in centers where FET is performed routinely.

Are current follow-up intervals justified in patients with non-emergent aortic surgeries?

OBJECTIVES

Evidence for different surveillance protocols following aortic treatment is still lacking. The aim of this study was to analyse the clinical relevance of a first follow-up visit after 6 months.

METHODS

Between January 2018 and December 2019, 464 patients treated for non-emergent aortic pathologies were retrospectively analysed. The incidence of aortic events during follow-up (ie, death, reintervention, endoleaks, anastomotic/new aneurysms and diameter progression over time) was investigated. A discrete-time non-homogeneous Markov Chain Model was used to analyse the data and to arrive at the number of skipped 6-month follow-up visits needed to harm a patient.

RESULTS

After 6 months, 2 (1.77%) patients had died, 15 (15.31%) patients suffered from aortic events and a total of 4 (3.67%) patients had undergone reintervention after endovascular surgery, compared to 0 deaths, 2 (0.59%) patients with aortic events and 5 (1.48%) reinterventions after open surgery. In our Markov Chain Model, after 6 months, 4.75% of patients showed aortic events, received a reintervention or died. Sixty patients would need to skip their 6-month follow-up visit for one indication for reintervention to go unnoticed. Only 24 would need to skip it for one complication to go by unnoticed. This number is 55 after open surgery and 9 after endovascular surgery.

CONCLUSIONS

After elective endovascular or open aortic surgery without immediate in-hospital postoperative aortic events, the first follow-up visit after 6 months is important. Extending the first interval to longer time periods might lead to a considerable increase in missed aortic events. The cost and radiation exposure of frequent follow-ups must be balanced against the benefits of early preventative aortic interventions, warranting further research.

Management of Non-A Non-B Aortic Dissection: A Narrative Review

Non-A non-B aortic dissection remains a complex and controversial topic in cardiovascular management, eliciting varied approaches among cardiologists and surgeons. Due to the limited evidence surrounding this condition, existing guidelines are limited in the complexity of their recommendations. While most patients are initially managed medically, invasive treatment becomes necessary in a large proportion of patients. When surgery is considered, the most utilized techniques include the frozen elephant trunk procedure and endovascular repair strategies targeting the arch and descending thoracic aorta. This narrative review aims to synthesize current knowledge and clinical experiences, highlighting the challenges and evolving practices related to non-A non-B dissection management.

Quality of Life, Anxiety and Depression after Acute Type B Aortic Dissection

BACKGROUND

Type B aortic dissection (TBAD) is an acute cardiovascular emergency but also a condition warranting life-long surveillance. The long-term consequences on physical and mental well-being are largely unknown. The primary aim was to analyze self-reported Health-Related Quality of Life (HRQoL) and symptoms of anxiety and depression in patients with chronic TBAD. The secondary aim was to describe changes in physical and sexual activity following TBAD.

METHODS

This is a population-based cross-sectional survey study. All patients hospitalised with acute TBAD in Stockholm County 2017-2021, and alive on March 31, 2023, were invited to answer questionnaires on HRQoL (EQ-5D-5L, EQ VAS), anxiety (HADS-A), depression (HADS-D), physical activity (SED-GIH) and sexual activity (men: IIEF-5, women: FSFI-6).

RESULTS

Out of 88 invited TBAD patients, 49 (56%) participated. Median age was 72 years (IQR 62-81) and 41% were women. The median time from the acute event to the questionnaire response was 42 months (IQR 27-60). The mean EQ VAS score was 62. The largest negative impacts on the participants health status were seen in the "pain/discomfort" (66% of participants), "anxiety/depression" (53%) and "Mobility" (45%) domains. Based on the HADS questionnaire, 20% had a score indicating symptoms of depression, whereas 14% had a score indicating symptoms of anxiety. Overall, 69% reported a change in physical activity and 42% reported a change in sexual activity.

CONCLUSIONS

TBAD patients reported substantially reduced mental and physical well-being several years after the acute event. This new and important finding should be considered by health-care providers and in future follow-up protocols.

Impact of Open Surgical Descending Repair on Aortic Stiffness in an Ex Vivo Porcine Model

BACKGROUND

Previous studies have strongly suggested that stent-graft deployment and acute arch angulation increase aortic stiffness, the impact of surgical interposition grafting remains unclear. We investigated the impact of open surgery on aortic stiffness and compared this with stent-graft induced aortic stiffening, utilising an ex vivo model.

METHODS

Porcine thoracic aortas were connected to a mock circulatory loop. Baseline characteristics, proximal and distal flow curves (for PWV calculation), and blood pressures were recorded in a type I and III arch configuration. Subsequently, 10 cm proximal descending aorta was excised and replaced with Dacron® (IGK0018-40S). After surgery, all measurements were repeated in both arch configurations.

RESULTS

Fifteen aortas were prepared and attached to the circuit. After surgery, with both arch configurations, mean aortic PWV increased (Type I: 3.46 - 3.84 m/s (+10.7%),P < 0.001); Type III: 3.61 - 3.98 m/s (+10.4%),P = 0.001), systolic pressure remained stable (Type I: 121 - 124 mm Hg, P = 0.26; Type III: 124 - 124 mm Hg,P = 0.85), diastolic pressures decreased (Type I: 73 - 65 mm Hg,P < 0.001; Type III: 75 - 66 mm Hg,P < 0.001), and consequently mean arterial pressure decreased (Type I: 89 - 85 mm Hg,P = 0.020; Type III: 92 - 85 mm Hg,P = 0.001). The stable systolic pressure and decreased diastolic pressure, after surgery, led to an increased pulse pressure (Type I: 49 - 59 mm Hg,P < 0.001; Type III: 49 - 58 mm Hg; P < 0.001) CONCLUSIONS: Surgical interposition grafting of the proximal descending aorta increases aortic PWV, increases pulse pressure, and decreases diastolic blood pressure. These findings might be important for the long-term results of patients undergoing surgical treatment of aortic diseases.

Association between preoperative D-dimer with morphologic features and surgical outcomes of acute type A aortic dissection

OBJECTIVES

The association between preoperative D-dimer with morphologic features and surgical outcomes of acute type A aortic dissection is still unclear.

METHODS

430 acute type A aortic dissection patients who underwent total arch replacement and frozen elephant trunk in Beijing Anzhen Hospital of Capital Medical University between January 2016 and December 2020 were enrolled in the present study. Patients were divided into higher D-dimer (>2307 ng/ml) group and lower D-dimer (≤2307 ng/ml) group. We compared the extent of dissection and branch artery perfusion patterns between the 2 groups. The restricted cubic spline was performed to assess the association between D-dimer with the extent of dissection and major adverse events after surgery.

RESULTS

Among 430 patients, there were 45 (10.47%) in-hospital mortality and 156 (36.28%) major adverse events. Patients with higher D-dimer had bigger dissection extension length and false lumen perimeter in ascending aorta, thoracic descending aorta, diaphragmatic, coeliac trunk and renal artery level. For the branch artery perfusion patterns, patients with higher D-dimer had a higher proportion of malperfusion among the innominate artery, right renal artery and both side iliac arteries, a higher proportion of dissected intercostal artery/all intercostal arteries >0.5 (43.46% vs 29.63%, P = 0.003). The restricted cubic spline linear regression model revealed a nonlinear association between lnD-dimer with extension length and false lumen perimeter (all P for overall and P for nonlinearity <0.001 except false lumen perimeter in ascending aorta level). The restricted cubic spline logistic regression model revealed a linear association between lnD-dimer with major adverse events (P for overall <0.001, P for nonlinearity = 0.637). The association between lnD-dimer and major adverse events was still significant in the fully adjusted logistic regression model with computed tomography angiography characteristics [odds ratio (95% confidence interval) =1.388 (1.137, 1.695), P = 0.001].

CONCLUSIONS

Preoperative D-dimer strongly and positively correlates with the extent of dissection and major adverse events of acute type A aortic dissection after total arch replacement and frozen elephant trunk. D-dimer seems to be a supplement that indicates the severity of aortic dissection to aortic computed tomography angiography.

Anatomic feasibility of a novel modular triple-branched endograft for patients with aortic arch pathologies

OBJECTIVES

This study aimed to assess the anatomical feasibility of a novel modular triple-branched endograft for aortic arch diseases.

METHODS

A cross-sectional study was conducted on 314 patients with aortic arch pathologies treated at a single center from January 2018 to December 2023. Preoperative computed tomography angiography images were analyzed with three-dimensional reconstruction to quantify anatomical features. Feasibility was based on endograft anatomical criteria, and logistic regression identified risk factors for unsuitability.

RESULTS

Out of 132 patients included in the study, 67.4% were deemed anatomically suitable for the triple-branched device. A total of 36 (27.3%) patients were deemed inapplicable due to a large diameter of the proximal landing zone, 12 (9%) patients due to a small diameter of the left common carotid artery, and 1 (0.8%) patient due to a small diameter of the left subclavian artery. Logistic regression identified large proximal landing zone diameter and small left common carotid artery diameter were significant factors for unsuitability (p < 0.001 and p = 0.002, respectively).

CONCLUSIONS

The novel triple-branched endograft demonstrated promising anatomical feasibility in two-thirds of patients. However, anatomical constraints limited its applicability. Future device iterations should focus on accommodating a broader range of anatomical variations.

Ascending Geometry After Thoracic Endovascular Aortic Repair for Descending Aortic Dissection

BACKGROUND

This study aimed to assess geometry changes of the ascending aorta after thoracic endovascular aortic repair (TEVAR) for descending aortic dissection and identify potential risk factors for diameter and length change.

METHODS

Between April 2009 and July 2021, 102 patients were treated for acute descending aortic dissections (type B and non-A non-B) with TEVAR and were included in this analysis. Computed tomography angiographic scans were transferred to a dedicated imaging software and detailed aortic measurements (including length, diameter and area) were taken in multiplanar reconstruction postoperatively, after 6 months and annually thereafter.

RESULTS

Sixty-five (58%) patients were male, with a mean age of 66 (±11). Four (4%) patients were diagnosed with connective tissue disease. Before TEVAR, 79% of our patients were treated with a mean of 1.5 (±1.2) different classes of antihypertensive medications. This number rose to 98% after TEVAR and 2.7 (±1.0) different antihypertensive drugs. There was no significant change in length, diameter, cross-sectional area, or volume of the ascending aorta during the follow-up of 3 years after TEVAR. Body height was a negative predictor for mean ascending aortic diameter (P value = -0.013; B = -8.890) and mean aortic diameter at the level of the brachiocephalic trunk (P value = 0.039; B = -14.763).

CONCLUSIONS

Our data suggest no significant changes in the ascending aorta following TEVAR of the descending thoracic aorta during mid-term follow-up when under stringent blood pressure medication. Additionally, we did not find any modifiable risk factors for geometry parameter increase.

Apixaban removal during emergency surgery for type A acute aortic dissection: a prospective cohort study

BACKGROUND

Acute type A aortic dissection (ATAAD) has a high mortality, and acute aortic repair is the only curative treatment. In patients treated with factor Xa (FXa) inhibitors, the risk of severe disease-related complications such as cardiac tamponade and hemodynamic shock must be balanced against the potential for severe perioperative bleeding. The aim was to study intraoperative changes in plasma levels of the FXa inhibitor apixaban when using hemoadsorption during acute thoracic aortic repair.

MATERIALS AND METHODS

This is a single-center prospective cohort study. Eight apixaban-treated patients presenting with ATAAD underwent acute thoracic aortic repair with intraoperative hemoadsorption with CytoSorb. Apixaban concentrations were measured at the start of cardiopulmonary bypass (CPB) and after 5, 15, 30, 60, and 90 min of CPB, at CPB weaning, 30 min after CPB weaning and 24 h postoperatively, using ultraperformance liquid chromatography-mass spectrometry (UPLC-MS).

RESULTS

After 30 min of CPB with hemoadsorption, mean apixaban concentration (±SD) was reduced by 59% from 108 (±69) µg/l to 44 (±20) µg/l (P=0.009). There was a further reduction to 37 (±17) µg/l at CPB weaning (P=0.008). Apixaban concentration displayed an increase to 56 (±29) µg/l 24 h postoperatively (P=0.01). In-hospital mortality was 25%. The mean 24H chest tube drainage volume was 621 (±136) ml.

CONCLUSION

Intraoperative hemoadsorption lowers apixaban levels in patients undergoing emergency surgery for ATAAD. Further research is needed to determine its impact on perioperative bleeding complications and mortality.

Polytetrafluoroethylene Felt Inlay Neomedia and Tissue Glue Do Not Prevent Reoperation in Type A Aortic Dissection

Background/Objectives: Type A aortic dissection repair using Polytetrafluorethylene (PTFE) felt inlay and tissue glue has been proposed as a treatment modality. It remains unclear, if this method performs superiorly to tissue glue only. Methods: Between January 2011 and December 2015, 139 patients underwent surgical repair for type A aortic dissection, and 48 patients were excluded (n = 29 after receiving a composite graft, n = 18 in which no tissue glue was used, and n = 1 due to missing data). In the remaining patients, proximal aortic repair was performed either using PTFE felt inlay and tissue glue or tissue glue only. We analyzed the need for repeated surgery on the aorta during follow-up as a primary endpoint. The secondary endpoint was all-cause mortality at follow-up. Inverse probability of treatment weighting was used to balance the distribution of measured baseline covariates. Results: Sixty-six patients (73%) were treated with a tissue-glue-only approach-the Control Group. Twenty-five patients (27%) underwent proximal PTFE felt inlay and tissue glue-the Intervention Group. In the Intervention Group, 40% (n = 10) underwent reoperation due to re-dissection or pseudoaneurysm vs. 12% (n = 8) in the Control Group. The felt inlay increased the hazard of re-operation by 8.38 (1.63 to 43.0) after IPTW with death modeled as competing risk. Conclusions: Reoperation due to aortic complications was 10 times higher in patients treated with a combination of gluing and PTFE felt inlay vs. gluing only. These results are potentially caused by an interaction of PTFE, tissue glue, and aortic tissue.

Contemporary Single-Center Experience of Complete Aortic Arch Replacement Employing the Frozen Elephant Trunk Technique in Patients with Extensive Aortic Disease

Objective: This study aimed to examine contemporary results of the frozen elephant trunk (FET) procedure in an all-comers patient cohort. Methods: Between January 2017 and May 2024, a total of 132 consecutive patients with either aortic aneurysm (n = 32), acute aortic dissection (n = 32), or chronic aortic dissection (n = 68) underwent total aortic arch replacement employing the FET technique. In-hospital data were collected prospectively and included preoperative characteristics, intraoperative data, and follow-up results. Results: The median cardiopulmonary bypass time, cardiac ischemia time, and selective antegrade cerebral perfusion time were 180 (161-205), 89 (70-113), and 45 (38-54) min, respectively. Total 30-day mortality rate was 7.6% (n = 10). The rate of major postoperative neurological complications was 6.8% (n = 9) for perioperative stroke and 2.3% (n = 3) for permanent spinal cord injury. Five patients (3.8%) required hemofiltration at the time of discharge due to postoperative kidney injury. Rates of subsequent endovascular and open aortic repair following primary FET were 40.9% (n = 54) and 3.8% (n = 5), respectively. The median time to reintervention was 86 (30-439) days. The median follow-up time was 25 (8-52) months, and overall survival rates at 1, 2, and 3 years were 89%, 89%, and 87%, respectively. Conclusions: Our data are consistent with current reports, indicating that the FET technique is a valuable adjunct in treating extensive aortic arch pathologies. The procedure provides an increasingly safe and effective option for complete aortic arch replacement, even in patients requiring a redo procedure.

Aortic arch replacement in patients with previous repair of acute aortic dissection: a systematic review and meta-analysis

OBJECTIVES

Despite the popularity of the frozen elephant technique procedure in recent years, evidence is scarce regarding its utilization for aortic arch replacement following previous acute aortic dissection repair. In this systematic review and meta-analysis, we aimed to analyse clinical outcomes of aortic arch replacement in patients with previous repair of acute aortic dissection.

METHODS

A systematic literature search on PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science until March 2024 was performed for studies on open aortic arch replacement with or without frozen elephant technique procedure in adult patients after previous acute aortic dissection repair. Early and late postoperative mortality were primary, while postoperative complications were secondary outcomes of interest. Additionally, a meta-analysis was performed to pool the early and late postoperative mortality.

RESULTS

A total of 574 studies were identified, of which 9 studies including a total of 677 patients met the eligibility criteria. In-hospital or 30-day postoperative mortality and stroke were 0-17.5% and 0-7.7%, respectively. Duration of follow-up across all studies varied from 1.1 to 5.1 years. All-cause late mortality rate ranges from 5.9% to 30.5%. Aortic reintervention rate was 4.8-38.7%. The pooled early and late mortality rate were 8.7% [95% confidence interval (CI) 5.7-13%; I2 = 52%] and 24.9% (95% CI 19.5-31.1%; I2 = 54%), respectively.

CONCLUSIONS

Current evidence suggest that relatively younger patients with chronic post-dissection aneurysm or residual aortic dissection after acute aortic dissection repair can undergo an aortic arch replacement by a dedicated aortic team with acceptable mortality risk. However, postoperative neurological deficit remains an issue.

Ascending aortic length predicts adverse outcomes in type A intramural haematoma

OBJECTIVES

Ascending aortic length has recently been recognized as a novel predictor of adverse events in aortic diseases, but its prognostic value in type A intramural haematoma is unknown. We aimed to evaluate the association between ascending aortic length and outcomes in patients with type A intramural haematoma initially managed medically.

METHODS

We retrospectively analysed patients with acute type A intramural haematoma. Ascending aortic length was measured by computed tomography. The primary outcome was aortic progression, defined as aortic intervention or aortic-related death.

RESULTS

A total of 98 patients were enrolled. During a median follow-up of 2.6 years, aortic progression occurred in 27 patients (27.6%), i.e. 9 events per 100 patient-years. Patients with ascending aortic length ≥11 cm had significantly higher rates of aortic progression [54.2% (20.9 events per 100 patient-years) vs 18.9% (6.1 events per 100 patient-years), P = 0.001], surgical intervention (45.8% vs 12.2%, P = 0.001) and presence of ulcer-like projection (25.0% vs 2.7%, P = 0.002) compared to those with ascending aortic length <11 cm. Kaplan-Meier analysis demonstrated lower progression-free survival in the ascending aortic length ≥11 cm group (P = 0.0021). Ascending aortic length had a sensitivity of 61.9% and specificity of 77.8% for predicting aortic progression, with an area under the curve of 0.756 (95% confidence interval 0.649-0.862).

CONCLUSIONS

Ascending aortic elongation may identify a high-risk subgroup of acute type A intramural haematoma patients initially managed medically who could potentially benefit from early surgery. Ascending aortic length should be considered in the risk stratification and management of these patients.

Multicentre frozen elephant trunk technique experience as redo surgery to treat residual type A aortic dissections following ascending aortic replacement

OBJECTIVES

The goal of this project was to assess the efficacy of a reoperative frozen elephant trunk (FET) operation for treating residual type A aortic dissections.

METHODS

Between April 2015 and October 2023, a total of 237 patients underwent elective redo surgical aortic arch replacement via the FET technique to treat residual type A aortic dissection in 11 European aortic centres. Data were pooled and analysed retrospectively.

RESULTS

The time between an acute type A dissection repair to an FET implant was 5 years. More than half of all patients (54%) presented with an entry within the aortic arch, and 174 patients (73%) presented residual dissections of supra-aortic vessels. During FET repair, the axillary artery was cannulated in 181 patients (76%), whereas 83 patients (35%) underwent additional cardiac procedures including 39 root replacements (16%) and 15 coronary bypass procedures (6%). Zone 2 was the most common arch anastomosis site (n = 163, 69%), and bilateral antegrade cerebral perfusion was most frequent (n = 159, 67%). Fifteen patients (6%) died in-hospital. Age in years (P < 0.001, odds ratio: 1.069) proved to be predictive for overall mortality in our Cox regression model.

CONCLUSIONS

Elective redo surgical aortic arch replacement using the FET technique for treating residual type A aortic dissection following ascending aortic replacement revealed a favourable outcome. The decision to undertake stage two therapy of a residually dissected aortic arch should be made by an aortic team on a patient-by-patient basis.

Multicentre retrospective analysis of physician-modified fenestrated/inner-branched endovascular repair for complex aortic aneurysms

OBJECTIVES

In this multicentre retrospective observational study, we present the early outcomes of physician-modified fenestrated/inner-branched endovascular repair for pararenal and thoracoabdominal aortic aneurysms in patients at high risk for open surgical repair.

METHODS

We comprehensively reviewed the clinical data and outcomes of consecutive patients treated with physician-modified fenestrated/inner-branched endovascular repair for pararenal or thoracoabdominal aortic aneurysms at 6 centres between December 2020 and December 2021. Primary end-points included technical success, in-hospital mortality rates, major adverse events.

RESULTS

Seven and 31 patients (median age, 80.5 years) had pararenal and thoracoabdominal aortic aneurysms, respectively, involving 93 renal-mesenteric arteries incorporated through 10 fenestrations or 83 inner branches. Seven patients (18.4%) were treated non-elective conditions. The technical success rate was 89.5%. The median operative time was 334.5 min. Ten patients (26.3%) experienced major adverse events, including in-hospital mortality in 6 patients (15.8%), acute kidney injury in 3 patients (7.9%), respiratory failure in 3 patients (7.9%), bowel ischaemia in 1 patient (2.6%), stroke in 1 patient (2.6%) and paraplegia in 1 patient (2.6%). Among elective cases, in-hospital deaths occurred in 3 patients (9.7%), while in non-elective cases, the mortality rate was higher, with 3 patients (42.9%) succumbing. The median follow-up duration was 14 months.

CONCLUSIONS

Physician-modified fenestrated/inner-branched endovascular repair is a viable treatment for pararenal or thoracoabdominal aortic aneurysms in patients at high risk for open surgical repair. It provides customization without location constraints or production delays, but further validation is needed to ensure long-term reliability.

Simultaneous versus staged approach in transcatheter aortic valve implantation for severe stenosis and endovascular aortic repair for thoracic and abdominal aortic aneurysm

OBJECTIVES

Thoracic/abdominal aortic aneurysms and aortic stenosis may be concomitant diseases requiring both transcatheter aortic valve implantation (TAVI) and endovascular aneurysm repair (T/EVAR) in high-risk patients for surgical approaches, but temporal management is not clearly defined yet. The aim of the study was to analyse outcomes of simultaneous versus staged TAVI and T/EVAR.

METHODS

Retrospective observational multicentre study was performed on patients requiring TAVI and T/EVAR from 2016 to 2022. Patients were divided into 2 groups: 'Simultaneous group' if T/EVAR + TAVI were performed in the same procedure and 'Staged group' if T/EVAR and TAVI were performed in 2 steps, but within 3 months. Primary outcomes were technical success, 30-day mortality/major adverse events and follow-up survival. Secondary outcomes were procedural metrics and length of stay.

RESULTS

Forty-four cases were collected; 8 (18%) had T/EVAR and 36 (82%) had EVAR, respectively. Upon temporal determination, 25 (57%) and 19 (43%) were clustered in Simultaneous and Staged groups, respectively. In Staged group, median time between procedures was 72 (interquartile range-IQR: 57-87) days. Preoperative and intraoperative figures were similar. There was no difference in 30-day mortality (Simultaneous: 0/25 versus Staged: 1/19; P = 0.43). Pulmonary events (Simultaneous: 0/25 versus Staged: 5/19; P = 0.01) and need of postoperative cardiac pacemaker (Simultaneous: 2/25 versus Staged: 7/19; P = 0.02) were more frequent in Staged patients. The overall length of stay was lower in the Simultaneous group [Simultaneous: 7 (IQR: 6-8) versus Staged: 19 (IQR: 15-23) days; P = 0.001]. The median follow-up was 25 (IQR: 8-42) months and estimated 3-year survival was 73% with no difference between groups (Simultaneous: 82% versus Staged: 74%; P = 0.90).

CONCLUSIONS

Both Simultaneous or Staged T/EVAR and TAVI procedures are effective with satisfactory outcomes. Despite the small numbers, simultaneous repair seems to reduce length of stay and pulmonary complications, maintaining similar follow-up survival.

Transcatheter Aortic Valve Replacement Versus Surgical Aortic Valve Replacement in Bicuspid Aortic Valve Stenosis-We Need a Well-Designed Randomized Control Trial

Bicuspid aortic stenosis is a common pathology, typically seen in patients a decade younger than those with tricuspid valves. Surgical aortic valve replacement has been the mainstay treatment for bicuspid disease, especially considering the prevalence of concomitant aortic aneurysmal pathology. Transcatheter aortic valve replacement has shown equivalent results in bicuspid compared to tricuspid pathology in highly selected patient populations in single-arm registries and observational studies. For older patients with favorable bicuspid pathology, TAVR is reasonable. However, as younger patients with longer life expectancy are now being treated with TAVR, what is "best" is a question only answered by a well-designed randomized controlled trial. Herein, we describe the current evidence for treating bicuspid aortic stenosis and provide a framework for future trials. Yet, the question of equipoise remains, and who will we enroll?

Initial cannulation strategy impacts perioperative outcomes of acute type A dissection in high-volume centers

OBJECTIVE

We performed an intention-to-treat analysis of initial cannulation strategy to assess the impact on perioperative outcomes in acute type A dissection using multicenter data.

METHODS

All patients undergoing surgical repair of acute type A dissection from a multicenter national registry of 9 high-volume aortic centers were analyzed. Cannulation strategies included in the analysis were axillary, femoral, direct aortic, and innominate. Among 950 patients, we excluded those with chronic syndromes, type B dissections, and unknown initial cannulation strategy. Patients with multiple cannulation strategies were included if the sequence in which strategies were initiated was known. The final cohort consisted of 936 patients. Primary outcomes were stroke and death. Multivariable logistic regression was performed to adjust for baseline differences. P values represent Tukey's post hoc comparisons.

RESULTS

Among 936 patients, cannulation strategies in descending order included axillary (n = 502, 53%), femoral (n = 268, 29%), aortic (n = 104, 11%), and innominate (n = 59, 6%). Of these patients, 46 (5%) had a change in the initial cannulation strategy before initiating circulatory arrest, mainly for poor axillary flow or initial femoral cannulation for hemodynamic instability followed by axillary. Patients in the femoral group were younger (61.3 ± 13.8 years) than patients in the aortic group (66.4 ± 12.52 years, P = .01) and more likely to present with malperfusion (n = 123, 45.9%) compared with patients in the aortic, axillary, and innominate groups (P < .01). Patients in the femoral group also had the longest duration of cerebral ischemia (femoral: 16.9 ± 16 minutes, aortic: 11.5 ± 11.8 minutes; axillary: 4.41 ± 10.3 minutes; innominate: 2.53 ± 6 minutes, P < .01 for all vs femoral). Unadjusted risk of death, stroke, and prolonged ventilation was lowest in the axillary and innominate groups. Length of stay was also reduced in the innominate group. Multivariable regression demonstrated axillary (odds ratio [OR], 0.52; 0.36-0.75; P = .004) and innominate (OR, 0.19; 0.07-0.54; P = .009) cannulation to be associated with a significantly reduced risk of stroke. A nonsignificant indication of reduced death in patients receiving axillary cannulation remained (OR, 0.66; 0.45-0.96; P = .07).

CONCLUSIONS

In high-volume aortic centers, an initial cannulation strategy using axillary access is associated with reduced risk of stroke compared with femoral access. Axillary cannulation should be the preferred strategy in experienced centers if anatomy and stability allow.

Bicuspid Valve Aortopathy: Is It Reasonable to Define a Different Surgical Cutoff Based on Different Aortic Wall Mechanical Properties Compared to Those of the Tricuspid Valve?

BACKGROUND

In this study, we examined and compared ex vivo mechanical properties of aortic walls in patients with bicuspid (BAV) and tricuspid (TAV) aortic valve aortopathy to investigate if the anatomical peculiarities in the BAV group are related to an increased frailty of the aortic wall and, therefore, if a different surgical cutoff point for ascending aortic replacement could be reasonable in such patients.

METHODS

Ultimate stress tests were performed on fresh aortic wall specimens harvested during elective aortic surgery in BAV (n. 33) and TAV (n. 77) patients. Three mechanical parameters were evaluated at the failure point, under both longitudinal and circumferential forces: the peak strain (Pstr), peak stress (PS), and maximum elastic modulus (EM). The relationships between the three mechanical parameters and preoperative characteristics were evaluated, with a special focus on evaluating potential risk factors for severely impaired mechanical properties, cumulatively and comparatively (BAV vs. TAV groups).

RESULTS

The patient populations were inhomogeneous, as BAV patients reached surgical indication, according to the maximum aortic dilatation, at a younger age (58 ± 15 vs. 64 ± 13; p = 0.0294). The extent of the maximum aortic dilatation was, conversely, similar in the two groups (52 ± 4 vs. 54 ± 7; p = 0.2331), as well as the incidences of different phenotypes of aortic dilatation (with the ascending aorta phenotype being the most frequent in 81% and 66% of the BAV and TAV patients, respectively (p = 0.1134). Cumulatively, the mechanical properties of the aortic wall were influenced mainly by the orientation of the force applied, as both PS and EM were impaired under longitudinal stress. An age of >66 and a maximum dilatation of >52 mm were shown to predict severe Pstr reduction in the overall population. Comparative analysis revealed a trend of increased mechanical properties in the BAV group, regardless of the position, the force orientation, and the phenotype of the aortic dilatation.

CONCLUSIONS

BAV aortopathy is not correlated with impaired mechanical properties of the aortic wall as such. Different surgical cutoff points for BAV aortopathy, therefore, seem to be unjustified. An age of >66 and a maximum aortic dilatation of >52 mm, however, seem to significantly influence the mechanical properties of the aortic wall in both groups. These findings, therefore, could suggest the need for more accurate monitoring and evaluation in such conditions.

An analysis of early and long-term gender-related outcomes after thoracic endovascular aortic repair

OBJECTIVES

To evaluate gender-related outcomes during endovascular treatment of thoracic and thoraco-abdominal aortic diseases (TEVAR).

METHODS

Multicentre, retrospective, observational cohort study. All TEVARs between January 2005 and April 2023 were identified. Primary outcomes were 30-day mortality and cumulative survival. Secondary outcomes were vascular access complications, and freedom from TEVAR-related reintervention. Interventions performed in male patients were matched to females on the basis of a one-to-one coarsened exact matching.

RESULTS

We identified 151 males who were matched with 151 females. Mortality at 30 days was not statistically different between females and males (11.2% vs 11.2%; P = 1.0). At binary logistic regression analysis, duration of intervention (P = 0.001) and emergency TEVAR (P = 0.001) were associated with mortality at 30 days. Gender did not impact the access vessel complication rate [n = 6 (4.0%) vs n = 5 (3.3%); P = 1.0]. The median follow-up was 46 (interquartile range, 7-84) months with no difference between males and females [median 50 (11-95) vs 37.5 (3.5-71.2); P = 0.153]. Estimated survival was not statistically different between females and males [log-rank χ2 = 0.6, P = 0.442; 95% confidence interval (CI) 110.7-207.3]. At Cox's regression analysis, gender did not impact overall survival (hazard ratio 0.8; 95% CI 0.6-1.3; P = 0.450). Estimated freedom from TEVAR-related reinterventions was not statistically different between females and males (log-rank χ2 = 0.4, P = 0.837; 95% CI 187.8-219.3).

CONCLUSIONS

Female gender itself was not associated with worse 30-day mortality and late survival than males with similar access vessel complication as well as TEVAR-related reintervention rate.

Preliminary experience of the isolate left subclavian artery in-situ fenestration during 'zone 2' thoracic endovascular aortic repair

OBJECTIVES

To evaluate the results of isolated left subclavian artery in-situ fenestration (ISF) during 'zone 2' thoracic endovascular aortic repair (TEVAR) using a new adjustable needle puncturing device system.

METHODS

It is a multicentre, retrospective, physician-initiated cohort study of patients treated from 28 July 2021 to 3 April 2024. Inclusion criteria were isolate left subclavian artery revascularization for elective or urgent/emergent 'zone 2' TEVAR. The primary outcome was technical success and freedom from ISF TEVAR-related reintervention or endoleak.

RESULTS

We treated 50 patients: 28 (56.0%) atherosclerotic thoracic aneurysms, 12 (24.0%) type B aortic dissection and 10 (20.0%) penetrating aortic ulcers. Elective intervention was carried out in 46 (92.0%) cases. ISF was successful in all cases, with a procedural primary technical success in 47 (94.0%) cases. The median time of intervention was 184 min (interquartile range 135-220) with a median fenestration time of 20 min (interquartile range 13-35). Operative mortality did not occur. We observed 1 case of spinal cord ischaemia and 2 cases of bilateral posterior non-disabling stroke. Mortality at 30 days occurred in 1 (2.0%) patient (not aorta-related). The median follow-up was 4 months (interquartile range 1-12.25). Bridging stent graft patency was 100% with no ISF-related endoleak. ISF-related reintervention was never required.

CONCLUSIONS

ISF TEVAR using the Ankura™-II device with the self-centring adjustable needle system showed high technical success, promising stability and stable aortic-related outcomes. Owing to these results, it represents a safe and effective alternative for standard 'zone 2' TEVAR.

Disparities in mortality rates from aortic aneurysm and dissection by country-level income status and sex

Objective

To investigate the impact of national income level and sex on mortality trends from aortic aneurysm and dissection in addition to all aortic disease as a whole.

Methods

Using data from the World Health Organization mortality database, we conducted an analysis of mortality trends from aortic disease between 2000 and 2019, Countries were categorized into middle-income and high-income countries (MICs and HICs) on the basis of income level. Age-standardized and sex-specific age-standardized mortality rates per 100,000 persons, along with male-to-female mortality ratios, were calculated. Trends over the study period were analyzed using joinpoint regression.

Results

Our analysis comprised 29 MICs and 46 HICs, with an average population of 595 million and 1042 million during the observation period. During the observation period, age-standardized mortality rates from aortic disease decreased to 2.21 (2.17-2.25) and 2.28 (2.26-2.30) in MICs and HICs, respectively (average annual percentage change of -0.5% in MICs and -1.8% in HICs, P < .05 for both). However, mortality rates from aortic dissection increased in HICs from 2000 to 2019 (average annual percentage change of 1.3%, P < .001). Mortality from aortic disease, aortic dissection, and aortic aneurysm were male dominant in MICs and HICs but decreasing trends during the observation periods except for aortic dissection in MICs.

Conclusions

We present the contemporary and comprehensive analysis of global socioeconomic status and aortic diseases mortality. Although trends of mortality from aortic diseases are on the decline in both MICs and HICs, there is a striking increase in mortality for aortic dissection, specifically in HICs.

Temperature management in acute type A aortic dissection treatment: deep vs. moderate hypothermic circulatory arrest. Is colder better?

Introduction

The impact of different degrees of hypothermia in patients undergoing type A aortic dissection (TAAD) repair remains controversial. The purpose of this study was to compare the clinical outcomes of patients who received deep hypothermic circulatory arrest (DHCA) (<20°C) and those of patients who received moderate hypothermic circulatory arrest (MHCA) (20-28°C).

Methods

Between January 2011 and December 2020, 143 patients underwent surgical treatment for TAAD with CA and unilateral antegrade selective cerebral perfusion (uSCP). In this retrospective analysis, we evaluated the clinical outcomes of 143 individuals (103 who received DHCA vs. 40 who received MHCA). The primary outcome was the composite of major events (CMEs) including delirium, acute kidney injury (AKI), and in-hospital mortality. The secondary outcomes were overall mortality, bleeding, rethoracotomy, and length of intensive care unit (ICU) stay, among other things.

Results

Compared with the MHCA group, the DHCA group presented a greater incidence of postoperative complications, as follows: AKI (26 (25.2%) vs. 3 (7.5%), p = 0.020), delirium (23 (22.3%) vs. 2 (5%), p = 0.014), re-exploration rate (21 (20.4%) vs. 2 (5.0%), p = 0.024), and prolonged intensive care unit (ICU) stay (7.8 (4.4, 14.1) vs. 5.7 (2.4, 10) days, p = 0.019). The median cardiopulmonary bypass time (255 (210, 280) vs. 210 (190, 251) min, p = 0.010) and median cross-clamp time (140 (110, 180) vs. 125 (100, 160) min, p = 0.023) were significantly longer in the DHCA group. The German Registry for Acute Aortic Dissection Type A (GERAADA) score was significantly higher in the MHCA group (22.7 ± 9.1 vs. 19 ± 7.2, p = 0.012). The adjusted odds ratio for CME in the MHCA group was 0.78 (95% CI: 0.52-1.17, p = 0.001). The use of MHCA demonstrated a protective effect on reducing postoperative delirium (OR: 0.28, 95% CI: 0.14-0.46, p < 0.01) and postoperative AKI (OR: 0.29, 95% CI: 0.14-0.49, p < 0.01). Overall survival after two years did not differ between the two groups (log-rank, p = 0.16).

Conclusion

The principal findings of our study indicate that DHCA elevates the risk of postoperative AKI and delirium. As a result, the duration of hospitalization and intensive care unit stay was markedly extended. Consequently, MHCA should be favored over DHCA when the clinical circumstances permit, since DHCA remains a secure alternative in intricate dissection instances.

Long-Term Results and Quality of Life after Surgery for Acute Aortic Dissection Type A: Contemporary Single-Centre Experience

Background: Aortic dissection is still afflicted with significant morbidity and mortality. This research seeks to assess long-term outcomes and quality of life after emergency surgery for acute aortic dissection type A. Methods: A total of 413 patients were analysed, who had been operated upon between 2000 and 2016 at our centre. We compared our results of the early (2000-2007) versus late (2008-2016) period with regards to 30-day and follow-up mortality and need for reoperation, including risk factor analysis. Quality of life was assessed via the SF-36 survey. Results: Calculated perioperative risk by EuroSCORE increased significantly from early, 24.9%, to late, 38.0%, p < 0.001. Thirty-day rates of mortality decreased significantly from 26.7% to 17.4%, p = 0.03. Survival at 1-, 5-, and 10-years was 92.3% vs. 91.8% (p = 0.91), 75.2% vs. 81.0% (p = 0.29), and 53.4% vs. 69.7% (p = 0.04). Freedom from reoperation was comparable between groups at follow-up: 74.0% vs. 85.7%, p = 0.28. Quality of life was impaired. Conclusions: Despite more complex severity of disease and operative procedures, the results of surgery for type A aortic dissection improved significantly over time at 30-day and 10-year follow-up. Quality of life was significantly impaired compared to a healthy reference population.

Incidence and predictors of continued ascending aortic dilatation after TAVI in patients with bicuspid aortic stenosis

BACKGROUND

Patients undergoing transcatheter aortic valve implantation (TAVI) for bicuspid aortic stenosis (AS) frequently present with ascending aortic (AAo) dilatation which is left untreated. The objective of this study was to study the natural progression and underlying mechanisms of AAo dilatation after TAVI for bicuspid AS.

METHODS

Patients with a native bicuspid AS and a baseline AAo maximum diameter > 40 mm treated by TAVI and in whom post-TAVI computed tomography (CT) scans beyond 1 year were available were included. AAo dilatation was deemed to be either continuous (≥ 2 mm increase) or stable (< 2 mm increase or decrease). Uni- and multivariate logistic regression analysis was utilized in order to identify factors associated with continuous AAo dilatation post-TAVI.

RESULTS

A total of 61 patients with a mean AAo maximum diameter of 45.6 ± 3.9 mm at baseline were evaluated. At a median follow-up of 2.9 years, AAo dimensions remained stable in 85% of patients. Continuous AAo dilatation was observed in 15% of patients at a rate of 1.4 mm/year. Factors associated with continuous AAo dilatation were raphe length/annulus mean diameter ratio (OR 4.09, 95% CI [1.40-16.7], p = 0.022), TAV eccentricity at the leaflet outflow level (OR 2.11, 95%CI [1.12-4.53], p = 0.031) and maximum transprosthetic gradient (OR 1.30, 95%CI [0.99-1.73], p = 0.058).

CONCLUSIONS

Ascending aortic dilatation in patients undergoing TAVI for bicuspid AS remains stable in the majority of patients. Factors influencing TAV stent frame geometry and function were identified to be associated with continuous AAo dilatation after TAVI; this should be confirmed in future larger cohort studies.

Late diagnosis of Marfan syndrome is associated with unplanned aortic surgery and cardiovascular death

BACKGROUND

Marfan syndrome (MFS) guidelines recommend optimal pharmacologic therapy (OPT) and replacement of the ascending aorta (RAA) at 5.0 cm in diameter to prevent acute type A aortic dissection (ATAAD) and death. The effect of early MFS diagnosis and initiation of therapy on outcomes is not known. Therefore, we sought to evaluate the effect of age at MFS diagnosis and therapy initiation on delayed RAA and death.

METHODS

This retrospective observational cohort study with long-term follow-up included consecutive patients with MFS, pathogenic FBN1 variant, and regular visits to a European Reference Network Center. We considered MFS diagnosis at age ≥21 years late and OPT initiation at age <21 years early. Outcomes were delayed RAA with aneurysm diameter >5.0 cm or ATAAD and death from all causes. We used landmark design starting at age 21 years to determine associations with outcomes.

RESULTS

The study group consisted of 288 patients (45.1% male), including 169 patients with late diagnosis of MFS (58.7%) and 63 with early OPT (21.9%). During mean follow-up of 25 ± 14.7 years, 78 patients had delayed RAA, with 42 operations for ATAAD and 36 for aneurysms ≥5.0 cm. There were 33 deaths, including 11 deaths late after ATAAD. All deaths were cardiovascular. Late diagnosis, but not early OPT, showed univariate association with delayed RAA (P < .001) and death (P = .025). Multivariate Cox regression analysis confirmed late diagnosis as predictor of delayed RAA (hazard ratio, 8.01; 95% confidence interval, 2.52-25.45; P < .001) and death (hazard ratio, 4.68; 95% confidence interval, 1.17-18.80; P = .029).

CONCLUSIONS

Late diagnosis of MFS is associated with delayed surgery and death.

Prevalence and Influence of Genetic Variants on Follow-Up Results in Patients Surviving Thoracic Aortic Therapy

Background/Objective: To investigate the prevalence and effects of genetic variants (GVs) in survivors of thoracic aortic dissection/aneurysm repair. Methods: Patients aged 18-80 years who survived follow-up after cardiosurgical or endovascular repair of thoracic aortic aneurysm or dissection at a single tertiary center between 2008 and 2019 and underwent genetic testing were enrolled. The exclusion criteria were age >60 years, no offspring, and inflammatory- or trauma-related pathogenesis. Follow-up entailed computed tomography-angiography at 3 and 9 months and annually thereafter. All patients underwent genetic analyses of nine genes using next-generation sequencing. In cases of specific suspicion, the analysis was expanded to include 32 genes. Results: The study included 95 patients. The follow-up period was 3 ± 2.5 years. GVs were detected in 40% of patients. Correlation analysis according to primary diagnosis showed no significant correlation in disease persistence, progression, or in reintervention rates in aneurysm patients and a correlation of disease persistence with genetic variants according to variant class in dissection patients (p = 0.037). Correlation analysis according to follow-up CD finding revealed that patients with detected dissection, irrespective of original pathology, showed a strong correlation with genetic variants regarding disease progression and reintervention rates (p = 0.012 and p = 0.047, respectively). Conclusions: The prevalence of VUS is high in patients with aortic pathology. In patients with dissected aorta in the follow-up, irrespective of original pathology, genetic variants correlate with higher reintervention rates, warranting extended-spectrum genetic testing. The role of VUS may be greater than is currently known.

Outcome analysis of the surgical team in open surgical repair of intact abdominal aortic aneurysm surgery

OBJECTIVES

To analyze how the experience of the surgical team went to impact the outcomes after open surgical repair (OSR) of intact abdominal aortic aneurysms (AAAs).

METHODS

This is a single-center, observational cohort study with retrospective analysis of all OR for intact AAA performed between 1 January 2010 and 31 December 2022. The primary outcome was survival at 30 days and in follow-up, and a composite outcome of mortality and major complication. The secondary outcome was freedom from aorta-related reintervention. All outcomes were stratified according to the experience of the operating team (surgeons and anesthesiology).

RESULTS

We analyzed 103 (7.2%) patients: 97 (94.2%) males and 6 (5.8%) females. The mean age was 76 ± 8 years (range, 55-93). The best possible team composition was present in 52 (50.5%) interventions. The follow-up index was 0.82 ± 0.18 (range, 0.6-1.0). Mean follow-up duration was 59 ± 43 months (range, 0-158). We observed no differences between teams in major complications (best, 17.3% vs mixed, 21.6%; OR: 0.4, P = 0.622), 30 days mortality (best, 0% vs mixed, 5.9%; OR: 7.6, P = 0.118) and composite outcome (best, 11.5% vs mixed, 17.6%; OR: 0.8, P = 0.416). Cox regression analysis identified the best possible team as a protective factor against the need for reintervention (hazard ratio: 0.2; 95% confidence interval: 0.06-0.88, P = 0.032).

CONCLUSIONS

In our experience, OR of AAA yielded satisfactory results in terms of safety and efficacy independently of the team's experience. A more experienced team may protect against aorta-related reintervention.