Risk profile analysis of uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair: Laboratory and radiographic predictors

The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology

Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.

Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Traumatic Aortic Injury: A Systematic Review and Meta-Analysis

Blunt aortic injury is the second most prevalent cause of patient fatalities post-trauma, closely following head injuries as the leading cause. In recent years, thoracic endovascular aortic repair (TEVAR) has evidently improved survival rates and reduced complications in patients suffering from blunt traumatic aortic injury (BTAI) in comparison to open surgery and non-operative management. It is difficult to characterize the appropriate criteria for the timing of TEVAR, whether early or delayed for BTAI, considering the discrepancies related to timing. Electronic databases, including PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase, were searched through April 2023. The primary outcomes were short-term mortality and hospital and intensive care unit (ICU) stays. Time to TEVAR, acute respiratory distress syndrome, sepsis, deep vein thrombosis, delayed stroke, and renal failure were also evaluated. We included a total of seven studies, comprising 4177 patients who met the inclusion criteria. Short-term mortality was significantly higher in the early TEVAR group (RR: 1.86; 95% confidence interval (CI); (1.26-2.74); p<0.001; I2=33%). In contrast, the ICU length of stay was significantly shorter in the early group (mean difference: -2.82 days; 95% CI; (-4.09 - -1.56); p<0.0001; I2=55%). There was no significant difference between both groups in the presenting profile or postoperative complications. Patients undergoing delayed TEVAR had markedly lower mortality rates but a longer ICU stay. The need for future studies with more robust designs is imperative to investigate the factors influencing the timing of repair and the associated outcomes.

Ethnic & Sex Disparities in Type B Aortic Dissection Patients Undergoing Thoracic Endovascular Aortic Repair: An International Perspective

BACKGROUND

There has been a revolution in the management of type B aortic dissection (TBAD) over the last 2 decades due to the increasing development of endovascular techniques, with the prime example being thoracic endovascular aortic repair (TEVAR). However, many controversies concerning the use of TEVAR in TBAD exist. For instance, there is little available evidence suggesting any differences in demographics, disease characteristics, intervention technicalities, and clinical outcomes between males and females as well as different ethnicities when undergoing TEVAR for TBAD, both in the short and long term. Also, there is no risk prediction model/tool available. The objective of this international study is to describe and delineate the disparities between male and female patients of different ethnicities in terms of demographics, disease and interventional characteristics, and clinical outcomes.

METHODS

Over 17 years a total of 58 TBAD patients were admitted to 2 tertiary vascular centres and treated using TEVAR. Mortality, postoperative complications and reintervention data were recorded for the first 30 days after the procedure as well as during follow-up. Follow-up for all patients lasted until the study endpoint or until a patient's death. Data were analysed retrospectively using IBM SPSS statistical package 26 for Windows.

RESULTS

The mean age was similar between the 2 groups, with the majority of patients in both being Caucasian. More than half of the males had complicated TBAD, while the majority of females were classed as having uncomplicated disease. The most commonly utilized proximal and distal landing zone for the TEVAR stent graft was zone 2 and zone 4, respectively. The mean proximal stent diameter was significantly larger in males compared to females (P = 0.004). The difference in mean distal diameter between the 2 groups was insignificant (P = 0.721). The mean total stent coverage of the thoracic aorta was 251.3 mm in male patients compared to 291.2 mm in females (P = 0.203). A total of 32 patients underwent adjunctive procedures. Seven (17%) of the males had one or more postoperative complications compared to 2 (12%) females. Nine (22%) males underwent a reintervention procedure post TEVAR compared to only 1 (6%) female (P = 0.136). Overall, males had a mortality rate of 24% (n = 10) compared to 41% of females (n = 7) (P = 0.201). Estimated survival of males and females post TEVAR was 80.4 ± 9.6 months and 69.7 ± 14.4 months (P = 0.428). For the total population, the number of stent grafts was inversely correlated with mortality.

CONCLUSIONS

Despite the favourable clinical outcomes achieved by TEVAR in TBAD, there remains a grey area concerning its management. Thus, it is important to perform risk stratification of individual patients using their demographics and comorbidities, particularly scrutinizing patient sex and ethnic origin, when considering intervention for TBAD to achieve optimum results.

Cost analysis of thoracic endovascular aortic repair in type B aortic dissection: How much does quality cost?

BACKGROUND

Aortic dissection (AD) is a life-threatening medical emergency that affects an estimated 3-4 people per 100,000 annually, with 40% of cases classified as type B AD (TBAD). TBAD can be further classified as being complicated (co-TBAD) or uncomplicated (un-TBAD) based on the presence or absence of certain features such as malperfusion and rupture. TBAD can be managed conservatively with optimal medical therapy (OMT), or invasively with open surgical repair (OSR) or thoracic endovascular aortic repair (TEVAR), depending on several factors such as type of TBAD and its clinical acuity. The cost-effectiveness, or cost-benefit profile, of these strategies must be given equal consideration. However, TBAD studies featuring cost analyses are limited within the literature. This narrative review aims to address the gap in the literature on cost-effectiveness of TBAD treatments by providing an overview of cost analyses comparing OMT with TEVAR in un-TBAD and TEVAR with OSR in co-TBAD. Another aim is to provide a market analysis of the commercially available TEVAR devices.

METHODS

A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies.

RESULTS

Several TEVAR devices are available commercially on the global market costing $12,000-19,495. Nevertheless, the Terumo Aortic RELAY® stent graft seems to be the most cost-effective, yielding highly favourable clinical outcomes. Despite the higher initial cost of TEVAR, evidence in the literature strongly suggest that it is superior to OMT for un-TBAD on the long-term. In addition, TEVAR is well established in the literature as being gold-standard repair technique for co-TBAD, replacing OSR by offering a more optimal cost-benefit profile through lower costs and improved results.

CONCLUSIONS

The introduction of TEVAR has revolutionized the field of aortovascular surgery by offering a highly efficacious and long-term cost-effective treatment for TBAD.