Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial

A Multicenter Study of the Mid-term Outcomes of Patients with Uncomplicated Type B Aortic Dissection After Distal Porous Talos Stent-Graft Implantation

BACKGROUND

The Talos stent-graft has extended length to improve aortic remodeling, and distal porous design to decrease the rate of spinal cord ischemia (SCI). This study retrospectively analyzed its mid-term outcomes for uncomplicated type B aortic dissection in a multicenter study.

METHODS

The primary safety end point was 30-day major adverse events, including all-cause mortality, dissection-related mortality, conversion to open surgery, and device-related adverse events. The primary efficacy end point was treatment success at 12 months postoperation, defined as no technical failure or secondary dissection-related reintervention. The survival status of the patients was visualized using the Kaplan-Meier curve. Aortic growth was assessed at 4 levels, and SCI was evaluated at 12 months.

RESULTS

113 patients participated with a mean age of 54.4 (11.1) years and 71.7% (81/113) were male. The 30-day mortality was 0.9% (1/113), no conversions to open surgery or device-related adverse events were recorded. The 12-month treatment success rate was 99.1% (112/113), with no dissection-related reinterventions. There was no spinal cord or visceral ischemia at 12 months. At a median of 34 months follow-up, 9 further deaths were recorded and the 3-year survival rate was 91.7%. The percentage of aortic growth was 1.8% (2/111) at the tracheal bifurcation, 3.6% (4/111) below the left atrium, 6.0% (5/83) above the celiac artery, and 12.1% (9/74) below the lower renal artery. The total thrombosis rate of the false lumen at the stented segment was 80.5% (91/113).

CONCLUSIONS

The results showed satisfactory results of Talos stent-graft in terms of safety and efficacy. More data are needed to confirm the long-term performance.

The Evaluation of Outcomes after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection in Mainland China

BACKGROUND

To assess the mortality and outcomes after thoracic endovascular aortic repair (TEVAR) in patients with type B aortic dissection (TBAD) in mainland China, and to compare these outcomes with data from Western countries, while analyzing the potential reasons for differences among different countries.

METHODS

An extensive literature search spanning from January 1999 to October 2023 was conducted using PubMed, Cochrane Library, and Embase databases for studies on endovascular treatment for TBAD. This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data extraction and analysis followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Primary outcomes were in-hospital mortality and mid-term (< 5 years) mortality.

RESULTS

Based on 25 publications (3,080 patients), pooled estimate for in-hospital mortality was 2.2% (95% confidence interval, 1.6%-2.9%). Major perioperative complications included stroke (2.4% [1.8%-3.3%]), spinal cord ischemia (1.4% [1.0%-2.2%]), retrograde type A aortic dissection (1.2% [0.8%-1.8%]), type I endoleak (5.6% [3.6%-8.6%]), visceral ischemia (1.0% [0.5%-2.1%]), and acute renal failure (2.8% [2.0%-3.8%]). Mid-term mortality was 5.1% (3.6%-7.3%), and secondary intervention rate was 4.9% (4.0%-6.0%) with 1.7% (1.0%-2.9%) conversion rate to open surgery. In subgroup analysis based on uncomplicated TBAD, in-hospital and mid-term mortality was 0.5% (0.2%-1.5%) and 0.6% (0.2-1.7%), respectively. Compared with data from Western countries, mainland Chinese patients had a lower mortality.

CONCLUSIONS

In mainland China, the outcomes of endovascular treatment for TBAD are comparable to those of Western countries. The large number of patients undergoing TEVAR in mainland China and its good performance support the use of TEVAR in uncomplicated TBAD.

Effect of False Lumen Occlusion Treatment With AFX VELATM, Candy-Plug Technique for Chronic Aortic Dissection

INTRODUCTION

We sought to examine midterm results and remodeling effect of false-lumen occlusion treatment using AFX VELA in case of chronic dissection repair.

MATERIAL AND METHODS

From June 2019 to May 2022, we performed false lumen occlusion treatment using a modified Candy-Plug technique with AFX VELA on 8 chronic aortic dissection patients with a patent false lumen. We collected operative data, short-term clinical outcomes, mid-term clinical outcomes and imaging test results. We conducted follow-up examinations at postoperative, 6-month and 1-, 2- and 3-year intervals, including contrast-enhanced computed tomography to evaluate the diameter, false lumen thrombosis and any events.

RESULTS

The average time from the symptom onset to the thoracic endovascular repair was 81.5 (35-155) months. The aorta showed aneurysmal dilation with an average maximum short-axis diameter of 58.9 (41-91) mm. Two cases needed emergency surgery due to rupture and impending rupture. There were no postoperative deaths. Complete thrombosis within the false lumen was achieved in 6 cases (75%), but 2 cases had incomplete thrombosis, requiring additional treatment. The mean maximum diameter showed a significant decrease at 6 months, 1 year and 2 years postoperatively compared to preoperative measurements (P < .05).

CONCLUSION

We showed the results of false lumen occlusion treatment using the AFX VELA cuff. We observed favorable clinical outcomes and remodeling effects. While the long-term durability and efficacy of this technique in aortic remodeling will need to be monitored with further observation, the use of this cuff is considered a reliable approach to false lumen occlusion treatment.

Acute Type B Aortic Dissection: Insights From a Single-Center Retrospective Experience Over 12 Years

INTRODUCTION

The treatment of acute type B aortic dissection (ATBAD) is currently a challenge for vascular surgeons, because of the early morbidity and mortality rates and the high risk of late aortic events up to 50% at 5 years. This study presents the initial outcomes of ATBAD treatment using optimal medical therapy alone or combined with proximal entry tear stent-graft coverage. Additionally, it provides an analysis of the evolution of the aortic diameter and its clinical consequences during the chronic phase in each group.

MATERIALS AND METHODS

Conducted as a retrospective, single-center study, we enrolled all consecutive ATBAD patients (n=130) treated between 2008 and 2020. The primary analysis studies the entire patient cohort based on their initial management approach, namely, medical treatment alone for uncomplicated ATBAD (n=67) or combined with stent-graft entry tear coverage (n=63). We also conducted a subgroup analysis to investigate factors associated with disease progression in the medical management group.

RESULTS

Median follow-up was 29.5 months. During this time aneurysmal evolution was observed in: 42.4% of cases in the medical group compared with 21.8% in the stent-graft group, primarily affecting the thoracic aorta. The stent-graft group exhibited significant aortic remodeling, with a decrease in false lumen (FL) and thoracic aortic diameters. Initial aortic diameter ≥40 mm and FL ≥22 mm were independent risk factors for aneurysmal degeneration. Five-year survival was consistent at 76.1% in both groups.

CONCLUSION

This study confirms the safety and efficacy of stent-graft entry tear coverage for ATBAD. Initial thoracic endovascular aortic repair (TEVAR) appears to reduce late aortic events by promoting aortic remodeling. Considering TEVAR's safety and potential to prevent late aortic complications, it may be considered for uncomplicated ATBAD patients with an initial aortic diameter ≥40 mm or an FL ≥22 mm.

CLINICAL IMPACT

This study validates the efficacy and safety of using endovascular stent grafts to seal the proximal entry tear in cases of acute type B aortic dissections, compared to optimal medical therapy. Aortic remodelling significantly benefits from endovascular stent graft coverage of the proximal entry tear. Given the heightened risk of late aortic events observed in the medical therapy cohort, there appears to be a necessity for including endovascular interventions in the management of uncomplicated acute type B aortic dissections, particularly when aortic diameter is ≥40 mm and false lumen diameter is ≥22 mm.

Volumetric Analysis of Acute Uncomplicated Type B Aortic Dissection Using an Automated Deep Learning Aortic Zone Segmentation Model

INTRODUCTION

Machine learning techniques have shown excellent performance in 3D medical image analysis, but have not been applied to acute uncomplicated type B aortic dissection (auTBAD) utilizing SVS/STS-defined aortic zones. The purpose of this study was to establish a trained, automatic machine learning aortic zone segmentation model to facilitate performance of an aortic zone volumetric comparison between auTBAD patients based on rate of aortic growth.

METHODS

Patients with auTBAD and serial imaging were identified. For each patient, imaging characteristics from two CT scans were analyzed: (1) the baseline CTA at index admission, and (2) either the most recent surveillance CTA, or the most recent CTA prior to an aortic intervention. Patients were stratified into two comparative groups based on aortic growth: rapid growth (diameter increase ≥5mm/year) and no/slow growth (diameter increase <5mm/year). Deidentified images were imported into an open-source software package for medical image analysis and images were annotated based on SVS/STS criteria for aortic zones. Our model was trained using 4-fold cross-validation. The segmentation output was used to calculate aortic zone volumes from each imaging study.

RESULTS

Of 59 patients identified for inclusion, rapid growth was observed in 33 (56%) patients and no/slow growth was observed in 26 (44%) patients. There were no differences in baseline demographics, comorbidities, admission mean arterial pressure, number of discharge antihypertensives, or high-risk imaging characteristics between groups (p>0.05 for all). Median duration between baseline and interval CT was 1.07 years (IQR 0.38-2.57). Post-discharge aortic intervention was performed in 13 (22%) of patients at a mean of 1.5±1.2 years, with no difference between groups (p>0.05). Among all patients, the largest relative percent increases in zone volumes over time were found in zone 4 (13.9% IQR -6.82-35.1) and zone 5 (13.4% IQR -7.78-37.9). There were no differences in baseline zone volumes between groups (p>0.05 for all). Average Dice coefficient, a performance measure of the model output, was 0.73. Performance was best in zone 5 (0.84) and zone 9 (0.91).

CONCLUSIONS

We describe an automatic deep learning segmentation model incorporating SVS-defined aortic zones. The open-source, trained model demonstrates concordance to the manually segmented aortas with the strongest performance in zones 5 and 9, providing a framework for further clinical applications. In our limited sample, there were no differences in baseline aortic zone volumes between rapid growth and no/slow growth patients.

Trends in the incidence, surgical management and outcomes of type B aortic dissections in Australia over the last decade

OBJECTIVES

This study aims to investigate the incidence and in-hospital outcomes of surgical repair for type B aortic dissection (TBAD) in Australia.

METHODS

Data were obtained from the Australasian Vascular Audit (AVA) and the Australian Institute of Health and Welfare (AIHW). The former is a total practice audit mandated for all members of the Australian and New Zealand Society for Vascular Surgery (ANZSVS) while the latter is an independent government agency which records all healthcare data in Australia. All cases of TBAD which underwent surgical intervention (endovascular or open repair) between 2010 and 2019 were identified using prospectively recorded data from the AVA (New Zealand data was excluded). The primary outcomes were temporal trends in procedures and hospital mortality; secondary outcomes were complications and risk factors for mortality. All admissions and procedures for, and hospital deaths from, TBAD in Australia were identified in AIHW datasets using the relevant diagnosis and procedure codes, with age-standardized rates calculated for the period 2000-01 to 2018-19.

RESULTS

A total of 567 cases of TBAD underwent vascular surgical intervention (AVA data, Australia). Of these, 96.3% were treated by endovascular repair. There was an increase in the annual procedure number from 45 in 2010 to 88 in 2019. In-hospital mortality was 4.8% for endovascular repair and 19% for open repair (p = 0.021). From 2000-01 to 2018-19, the age-standardized procedure rates for TBAD (Australia) doubled, the proportion of admitted patients undergoing a procedure rose from 28% to 43%, and in-hospital deaths fell by 25%.

CONCLUSION

There has been an increasing incidence of vascular surgical intervention for TBAD in Australia. The majority of patients received endovascular therapy while the mortality from surgically managed TBAD appears to be falling.

Long-term outcomes of thoracic endovascular aortic repair for chronic Stanford type B aortic dissection

OBJECTIVES

The aim of this study was to report the long-term outcomes of proximal thoracic endovascular aortic repair (TEVAR) for chronic Stanford type B aortic dissection (cTBAD).

METHODS

We retrospectively analyzed the clinical data of 48 cases of patients with cTBAD who underwent proximal TEVAR in Zhongshan Hospital Fudan University from January 2010 to September 2013. The preoperative and postoperative imaging examinations, overall survival rate, aortic-related survival rate, and freedom from reintervention rate data were collected to evaluate aortic remodeling and clinical outcomes. The enrolled patients received follow-up at 1, 3, 6, and 12 months following treatment and annually thereafter.

RESULTS

A total of 48 patients (mean age, 58.3 ± 10.6 years; men:women, 40:8) were included, of which 38 cases (79.2%) were uncomplicated dissection and 10 cases (20.8%) were complicated. The mean follow-up time was 48.7 ± 40 months (1-120 months). The mean time interval from the initial procedure to reintervention was 50.6 ± 32.7 months (11-98 months). The following changes were observed at preoperative versus last follow-up timepoints. Descending aortic level: true lumen, 19.2 ± 7.01 mm vs. 36.9 ± 9.53 mm (p < 0.001); false lumen, 30.47 ± 15.89 mm vs. 19.16 ± 15.33 mm (p < 0.001); maximum diameter, 49.67 ± 13.96 mm vs. 56.66 ± 14.95 mm (p = 0.018). Diaphragm level: true lumen, 16.24 ± 5.41 mm vs. 24.41 ± 8.04 mm (p < 0.001); false lumen, 12.37 ± 11.49 mm vs. 14.92 ± 12.25 mm (p = 0.196); and maximum diameter, 34 ± 7.81 mm vs. 38.04 ± 7.7 mm (p < 0.001). The freedom from reintervention rate was 81% in 5 years and 50.6% in 10 years. The overall 10-years survival rate was 83% (6 of 48), and the aortic-related survival rate was 92.3% (3 of 48).

CONCLUSIONS

TEVAR is a safe and effective proximal repair intervention for cTBAD that can reliably induce the positive remodeling of the descending aorta.

Outcomes of post-implantation syndrome after endovascular repair for Stanford type B aortic dissection

OBJECTIVE

The aim of this study was to investigate the correlation between post-implantation syndrome (PIS) and long-term prognosis in patients with Stanford type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR).

METHODS

This retrospective study included 547 consecutive patients diagnosed with TBAD who underwent TEVAR at our institution between January 2014 and December 2019. Patients were categorized into two groups: the PIS group (patients with post-TEVAR PIS) and the non-PIS group (patients without post-TEVAR PIS). In-hospital and follow-up data were analyzed.

RESULTS

The incidence of PIS was 28.9% (158/547 patients). No baseline differences were observed between the PIS (n = 158) and the non-PIS (n = 389) groups. The proportion of emergency surgery in the PIS group was higher than that in the non-PIS group (44.9% vs 26.0%; P < .001), the operation time was longer (median, 65.0; interquartile range [IQR], 56.0-75.0 minutes vs 56.0; IQR, 45.0-66.0 minutes; P < .001), the volume of contrast medium used (median, 65.0; IQR, 56.0-75.0 mL vs 56.0; IQR, 45.0-66.0 mL; P < .001), and the average number of trunk stents (1.85 ± 0.4 vs 1.34 ± 0.5 pieces; P < .001) and branch stents (0.7 ± 0.7 vs 0.2 ± 0.5 pieces; P < .001) used were more in the PIS group than in the non-PIS group. The incidence of supra-aortic branch procedures was higher in the PIS group than in the non-PIS group. There was no significant difference in device-related complications (DRCs) or 30-day mortality between the two groups (2.5% vs 4.4%; P = .442 and 1.3% vs 1.3%; P = .688, respectively). Univariate and multivariable logistic regression analysis showed that emergency surgery, number of trunk stents >1, operation time >58.5 minutes, and contrast medium volume >75 mL were risk factors for PIS, and the odds ratios of emergency operation, number of trunk stents >1 piece, operation time >58.5 minutes, and contrast medium volume >75 mL were 2.526 (95% confidence interval [CI], 1.530-4.173), 4.651 (95% CI, 2.838-7.624), 3.577 (95% CI, 2.201-5.815), and 7.356 (95% CI, 4.111-13.160), respectively. Follow-up was completed in 98.5% (532/540) of the patients, with a median follow-up of 67 months (IQR, 50-86 months). There was no significant difference in survival between the PIS and non-PIS groups (12.4% vs 10.3%; P = .476) during follow-up. The incidences of DRCs (7.8% vs 11.6%; P = .200) and aortic false lumen thrombosis (75.8% vs 79.2%; P = .399) were comparable between the PIS and non-PIS groups. Univariate logistic regression analysis showed that PIS had no effect on long-term follow-up mortality, DRCs, entry flow, or aortic false lumen thrombosis rate.

CONCLUSIONS

PIS is relatively common after TEVAR and emergency surgery; number of trunk stents >1, operation time >58.5 minutes, and contrast medium volume >75 mL are of high predictive value for the assessment of PIS after TEVAR. However, PIS had little effect on early and late postoperative mortality or DRCs.

Extended thoracic endovascular aortic repair is optimal therapy in acute complicated type B dissection

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) represents optimal therapy for complicated acute type B aortic dissection (aTBAD). Persistent knowledge gaps remain, including the optimal length of aortic coverage, impact on distal aortic remodeling, and fate of the dissected abdominal aorta.

METHODS

Review of the Emory Aortic Database identified 92 patients who underwent TEVAR for complicated aTBAD from 2012 to 2018. Standard TEVAR covered aortic zones 3 and 4 (from the left subclavian to the mid-descending thoracic aorta). Extended TEVAR fully covered aortic zones 3 though 5 (from the left subclavian to the celiac artery). Long-term imaging, clinical follow-up, and overall and aortic-specific mortality were reviewed.

RESULTS

Extended TEVAR (n = 52) required a greater length of coverage vs standard TEVAR (n = 40) (240 ± 32 mm vs 183 ± 23 mm; P < .01). In-hospital mortality occurred in 5.4% of patients (7.7% vs 2.5%; P = .27) owing to mesenteric malperfusion (n = 3) or rupture (n = 2). The overall incidences of postoperative stroke, transient paraparesis, paraplegia, and dialysis were 5.4% (3.9% vs 7.5%; P = .38), 3.2% (5.8% vs 0%; P = .18), 0%, and 0% respectively, equivalent between groups. Follow-up was 96.6% complete to a mean of 6.1 years (interquartile range, 3.5-8.6 years). There were significantly higher rates of complete thrombosis or obliteration of the entire thoracic false lumen after Extended TEVAR (82.2% vs 51.5%; P = .04). Distal aortic reinterventions were less frequent after extended TEVAR (5.8% vs 20%; P = .04). Late aorta-specific survival was 98.1% after extended TEVAR vs 92.3% for standard TEVAR (P = .32).

CONCLUSIONS

Extended TEVAR for complicated aTBAD is safe, results in a high rate of total thoracic false lumen thrombosis/obliteration, and reduces distal reinterventions. Longer-term follow-up will be needed to demonstrate a survival benefit compared to limited aortic coverage.

Predictors of Late Adverse Events in Patients with Surgically Treated Type I Aortic Dissection

OBJECTIVE

Residual aortic dissection (AD) following DeBakey type I AD repair is associated with a high rate of adverse events that need additional intervention or surgery. This study aimed to identify clinical and early post-operative computed tomography (CT) imaging factors associated with adverse events in patients with type I AD after ascending aorta replacement.

METHODS

This single centre, retrospective cohort study included consecutive patients with type I AD who underwent ascending aorta replacement from January 2011 to December 2017 and post-operative CT within three months. The primary outcome was AD related adverse events, defined as AD related death and re-operation due to aortic aneurysm or impending rupture. The location and size of the primary intimal tears, aortic diameter, and false lumen status were evaluated. Regression analyses were performed to identify factors associated with AD related adverse events. A decision tree model was used to classify patients as high or low risk.

RESULTS

Of 103 participants (55.43 ± 13.94 years; 49.5% male), 24 (23.3%) experienced AD related adverse events. In multivariable Cox regression analysis, connective tissue disease (hazard ratio [HR] 15.33; p < .001), maximum aortic diameter ≥ 40 mm (HR 4.90; p < .001), and multiple (three or more) intimal tears (HR 7.12; p < .001) were associated with AD related adverse events. The three year cumulative survival free from AD related events was lower in the high risk group with aortic diameter ≥ 40 mm and multiple intimal tears (41.7% vs. 90.9%; p < .001).

CONCLUSION

Early post-operative CT findings indicating a maximum aortic diameter ≥ 40 mm and multiple intimal tears may predict a higher risk of adverse events. These findings suggest the need for careful monitoring and more vigilant management approaches in these cases.

Novel insights into thoracic endografts technology for prevention of distal stent-graft induced new entry (dSINE) following endovascular repair of type B aortic dissections: from bench to bedside

INTRODUCTION

Endovascular treatment of type B aortic dissections (TBAD) has currently acquired a primary therapeutic role when anatomically feasible. The main issue with thoracic endovascular aortic repair (TEVAR) for aortic dissection is the actual nature of the aortic wall, which is structurally compromised and more fragile. Indeed, a wealth of data have shown that TEVAR for TBAD will lead, in a substantial proportion of cases, to a device-related adverse event named distal stent-graft induced new entry (dSINE).

AREAS COVERED

Currently available aortic stent-grafts have not been specifically devised for the treatment of aortic dissection. A novel dissection specific stent-graft (DSSG) was developed, which is a custom-made device based on the Zenith Alpha Thoracic platform (Cook Medical). The DSSG has several unique properties that, in principle, make its use optimal in TBAD patients.

EXPERT OPINION

TEVAR in the setting of aortic dissections remains technically challenging. The occurrence of dSINE represents a unique complication in this scenario and may lead to high rates of aortic-related adverse events and need for secondary interventions. The use of a novel custom-made DSSG in the setting of chronic TBAD has been proven to be safe, feasible and effective. However, even this approach may fail to completely prevent dSINE formation.

Preemptive treatment in the acute and early subacute phase of uncomplicated type B aortic dissections with poor prognosis factors

Objective

Due to its favorable outcome regarding late morbidity and mortality, thoracic endovascular repair (TEVAR) is becoming more popular for uncomplicated type B aortic dissection (TBAD). This study aimed to compare preemptive endovascular treatment and optimal medical treatment (OMT) and OMT alone in patients presenting uncomplicated TBAD with predictors of aortic progression.

Design

Retrospective multicenter study.

Methods

We analyzed patients with uncomplicated TBAD and risk factors of progression in two French academic centers. Aortic events [defined as aortic-related (re)intervention or aortic-related death after initial hospitalization], postoperative complications, non-aortic events, and radiologic aortic progression and remodeling were recorded and analyzed. Analysis was performed on an intention-to-treat basis.

Results

Between 2011 and 2021, preemptive endovascular procedures at the acute and early subacute phase (<30 days) were performed on 24 patients (group 1) and OMT alone on 26 patients (group 2). With a mean follow-up of 38.08 ± 24.53 months, aortic events occurred in 20.83% of patients from group 1 and 61.54% of patients from group 2 (p < .001). No patient presented aortic-related death during follow-up. There were no differences in postoperative events (p = 1.00) and non-aortic events (p = 1.00). OMT patients had significantly more aneurysmal progression of the thoracic aorta (p < .001) and maximal aortic diameter (p < .001). Aortic remodeling was found in 91.67% of patients in group 1 and 42.31% of patients in group 2 (p < .001). A subgroup analysis of patients in group 1 showed that patients treated with preemptive TEVAR and STABILISE had reduced maximum aortic diameters at the 1-year (p = .010) and last follow-up (p = .030) compared to those in patients treated with preemptive TEVAR alone.

Conclusion

Preemptive treatment of uncomplicated TBAD with risk factors of progression reduces the risk of long-term aortic events. Over 60% of medically treated patients will require intervention during follow-up, with no benefit in terms of postoperative events. Even after surgical treatment, patients in the OMT group had significantly more aneurysmal progression, along with poorer aortic remodeling.

Efficacy of intentional undersized thoracic endovascular repair for Stanford type B aortic dissection

OBJECTIVE

Thoracic endovascular aneurysm repair (TEVAR) is widely used for the treatment of aortic dissection. Endograft oversizing is a risk factor for stent graft-induced new entry tears and retrograde type A aortic dissection. However, there is no clear consensus on the optimal graft size selection for Stanford type B acute or subacute aortic dissection (TBAD). Herein, we examined the safety and efficacy of TEVAR using an intentionally undersized endograft to treat TBAD.

METHODS

This retrospective chart review study included 82 patients who underwent TEVAR for acute or subacute Stanford TBAD between 2015 and 2022. We measured the true lumen diameter just distal to the subclavian artery and opted for a stent graft of the same diameter. In instances where deformation resulting from false lumen pressure displacement was pronounced, we measured the diameter at the site just proximal to the subclavian artery. Patients' characteristics, procedural, in-hospital, and follow-up data, and aortic remodeling were analyzed. The aortic diameter was analyzed using one-way analysis of variance followed by Dunnett's test. Survival and freedom from reintervention were estimated using Kaplan-Meier curves.

RESULTS

The follow-up rate was 98.4%. The mean age was 58.3 ± 12.3 years, and 76 were men (92.7%). The mean diameters of the stent graft and native proximal landing zone were 30.9 ± 3.2 mm and 30.8 ± 3.0 mm, respectively. The oversize rate of the stent graft in relation to the native proximal aortic diameter was 0.3% ± 4.7%. In-hospital mortality was observed in one patient, retrograde type A aortic dissection in one patient, distal stent graft-induced new entry tear in zero patients, and type 1a endoleak in 22 patients (26.8%). Type 1a endoleaks, characterized by antegrade false lumen blood flow originating from the primary entry, in 12 patients spontaneously disappeared within 1 year of follow-up. According to aortic remodeling, 59 patients (86.8%) achieved complete aortic remodeling at the aortic arch level and 51 (75.0%) at the eighth thoracic vertebral level. The diameters of the aortic arch and descending aorta were significantly reduced compared with the postoperative measurements (P <.001). Survival rates were 97.5% and 93.6% at 1 and 3 years, respectively. Freedom from reintervention was 84.7% and 84.7% at 1 and 3 years, respectively.

CONCLUSIONS

Intentionally undersized TEVAR was safe and achieved acceptable aortic remodeling despite a high rate of type 1a endoleaks. A type 1a endoleak was acceptable as it primarily diminished during the mid-term follow-up.

Long-term Outcomes of Endovascular Repair for Blunt Thoracic Aortic Injury: A 10 Year Multi-center Experience

OBJECTIVE

This study aimed to assess the long-term outcomes in patients treated by thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injuries (BTAI).

MATERIALS AND METHODS

From January 2010 to December 2019, this retrospective observational study was conducted at 3 centers, involving 62 consecutive BTAI patients who underwent TEVAR. Computed tomography angiography scans were planned to be conducted at 6 months post-procedure, and annually thereafter.

RESULTS

Technical success was achieved in all 62 procedures (100%), which included cases of dissection (n=35, 56.45%), pseudoaneurysm (n=20, 32.26%), and rupture (n=7, 11.29%). Mean injury severity score was 31.66±8.30. A total of 21 supra-arch branches were revascularized by chimney technique, with 12 cases involving the left subclavian artery (LSA) and 9 cases involving the left common carotid artery. In addition, 11 LSAs were covered during the procedure. The in-hospital mortality rate was 1.61% (n=1). The mean follow-up time was 86.82±30.58 months. The all-cause follow-up mortality rate was 3.28% (n=2). Stenosis or occlusion of 3 supra-arch branches (4.92%) was identified at follow-up, with 2 cases (3.28%) requiring re-intervention. No spinal cord ischemia, endoleak, or migration was observed.

CONCLUSIONS

Despite only including patients with long-term follow-up, this study confirms the long-term safety and effectiveness of TEVAR for BTAI. For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta.

CLINICAL IMPACT

This study confirms the long-term safety and effectiveness of endovascular treatment for blunt thoracic aortic injury (BTAI). For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. Through a remarkably extended follow-up period (86.82±30.58 months) conducted at multiple centers in China, this study confirms the long-term safety and effectiveness of endovascular treatment for BTAI.

Optimal Timing of Pre-emptive Thoracic Endovascular Aortic Repair in Uncomplicated Type B Aortic Dissection: A Network Meta-Analysis

BACKGROUND

This network meta-analysis compares outcomes of optimal medical therapy (OMT) and pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection at different phases of chronicity.

METHODS

MEDLINE and EMBASE were searched through November 2023. Pooled short-term outcomes (short-term mortality, perioperative complications) and long-term outcomes (all-cause mortality, aortic-related mortality, aortic re-intervention rates) were calculated.

RESULTS

Systematic review identified 17 studies (2 randomized controlled trials, 3 propensity score matching, and 2 inverse probability weighting). Subacute-phase intervention had lower short-term mortality than the acute-phase (hazard ratio [HR] [95% confidence interval [CI]]=0.60 [0.38-0.94], p=0.027). No significant differences were observed in aortic rupture and paraplegia. Acute-phase TEVAR had a higher stroke incidence than subacute-phase intervention (HR [95% CI]=2.63 [1.36-5.09], p=0.042), chronic (HR [95% CI]=2.5 [1.03-6.2], p=0.043), and OMT (HR [95% CI]=1.57 [1.12-2.18], p=0.008). Acute-phase TEVAR had higher long-term all-cause mortality than subacute-phase intervention (HR [95% CI]=1.34 [1.03-1.74], p=0.03). Optimal medical therapy had elevated long-term all-cause mortality compared with subacute-phase TEVAR (HR [95% CI]=1.67 [1.25-2.33], p<0.001) and increased long-term aortic-related mortality vs acute-phase (HR [95% CI]=2.08 [1.31-3.31], p=0.002) and subacute-phase (HR [95% CI]=2.6 [1.62-4.18], p<0.01) interventions. No significant differences were observed in aortic re-intervention rates.

CONCLUSIONS

Pre-emptive TEVAR may offer lower all-cause mortality and aortic-related mortality than OMT. Considering lower short-term mortality, perioperative stroke rate, and long-term mortality, our findings support pre-emptive TEVAR during the subacute phase.

CLINICAL IMPACT

The optimal timing of pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection remains uncertain. This network meta-analysis suggests that the subacute phase (14-90 days from symptom onset) emerges as the optimal timing for pre-emptive TEVAR. This window is associated with lower rates of short-term complications and higher long-term survival rates compared with alternative strategies.

Transcatheter electrosurgical septotomy technique for chronic postdissection aortic aneurysms

Aortic dissection often results in chronic aneurysmal degeneration due to progressive false lumen expansion. Thoracic endovascular aortic repair and other techniques of vessel incorporation such as fenestrated-branched or parallel grafts have been increasingly used to treat chronic postdissection aneurysms. True lumen compression or a vessel origin from the false lumen can present considerable technical challenges. In these cases, the limited true lumen space can result in inadequate stent graft expansion or restrict the ability to reposition the device or manipulate catheters. Reentrance techniques can be used selectively to assist with target vessel catheterization. Transcatheter electrosurgical septotomy is a novel technique that has evolved from the cardiology experience with transseptal or transcatheter aortic valve procedures. This technique has been applied in select patients with chronic dissection to create a proximal or distal landing zone, disrupt the septum in patients with an excessively compressed true lumen, or connect the true and false lumen in patients with vessels that have separate origins. In the present report, we summarize the indications and technical pitfalls of transcatheter electrosurgical septotomy in patients treated by endovascular repair for chronic postdissection aortic aneurysms.

Current perspectives in acute type B aortic dissections: a literature review

In this new millennial, endovascular strategies have revolutionized the treatment of acute type B aortic dissection (aTBAD). With reduced in-hospital mortality and good long-term outcomes TEVAR has become the gold standard for the treatment of complicated dissection and is gaining increasing support for its preventive applicability in some uncomplicated dissections. With this new paradigm came a shift of the treatment goal where just covering the entry tear is not enough and instead achieving long-term positive thoracoabdominal remodeling is needed. More extensive approaches with composite device designs (covered stent graft and bare metal stent) emerged to answer this aortic conundrum. At 5-year of follow-up, "Provisional ExTension To Induce COmplete Attachment technique" (PETTICOAT) and its evolution "Stent assisted balloon induced intimal disruption and relamination in aortic dissection repair" (STABILISE) seem to be safe techniques that can allow, when anatomically feasible, excellent aortic remodeling and, in some cases, even the healing of the dissection. Nevertheless, STABILISE results, although promising, are mostly based on small series and therefore need to be validated by analyzing medium-long-term results from the international registry. Given the plethora of new data and the disparity of expert opinions on the best treatment to adopt, in this review we aim to summarize the current knowledge on the results of these different strategies for acute TBAD.

Prognostic impact of oral anticoagulation therapy and atrial fibrillation in patients with type B acute aortic dissection

Background

The prognostic impact of atrial fibrillation (AF) and oral anticoagulation (OAC) therapy in patients with type B acute aortic dissection (AAD) remains unclear. Therefore, we investigated the prognostic impact of AF and OAC therapy in patients with type B AAD.

Methods

Consecutive patients diagnosed with AAD were included in this single-center, retrospective study. Patients with type B AAD were selected from the study population and divided into three groups: AF(+)/OAC(+), AF(+)/OAC(-), and AF(-)/OAC(-). The primary end point was major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, progressive aortic events, cerebral infarction, and organ malperfusion.

Results

In total, 139 patients diagnosed with type B AAD were analyzed. AF was observed in 27 patients (19%). Among them, 13 patients (9%) received OAC therapy for AF. MACCE occurred in 32 patients (23%) during the observation period: all-cause death in four patients, progressive aortic events in 24 patients, cerebral infarction events in two patients, and malperfusion events in two patients. The incidence of MACCE was higher in the AF(+)/OAC(+) group than in the AF(+)/OAC(-) group (hazard ratio[HR]: 3.875; 95% confidence interval [CI]: 1.153-17.496). In contrast, there was no significant difference in the incidence of MACCE between the AF(+)/OAC(-) and AF(-)/OAC(-) groups (HR: 1.001, 95% CI: 0.509-1.802).

Conclusion

Among patients with type B AAD, the use of OAC for AF was associated with a higher risk of MACCE.

Weekend Admission is Associated with Higher Kidney Failures after Thoracic Endovascular Aneurysm Repair for Stanford Type B Aortic Dissection

BACKGROUND

Weekend effect characterized by worse perioperative outcomes has been demonstrated in some surgery patients admitted on weekends, as opposed to weekdays. This study aimed to examine weekend effect on open surgical repair or thoracic endovascular aneurysm repair (TEVAR) for Stanford Type B Aortic Dissection (TBAD).

METHODS

Patients who underwent TBAD repair were identified in National/Nationwisde Inpatient Sample from Q4 2015-2020. Open surgery and TEVAR were examined separately. Multivariable analyses were performed comparing in-hospital perioperative outcomes of patients under weekday and weekend admission. Adjusted preoperative variables included sex, age, race, socioeconomic status, hospital characteristics, clinical symptoms, comorbidities, and elective/non-elective admission. Also, length of stay, days from admission to operation, and total hospital charge were compared.

RESULTS

Among patients who underwent open TBAD repair, 1321 were admitted on weekdays and 340 on weekends. Among patients who underwent TEVAR for TBAD, 2018 were admitted on weekdays and 440 wereadmitted on weekends. There was no difference in open repair outcomes between those admitted on weekdays vs weekends. In TEVAR, weekend admission was associated with higher post-procedural kidney failure (1.14% vs .20%, aOR = 4.11, P = .04) and superficial wound complications (2.73% vs 1.49%, aOR = 2.2, P = .03) but lower respiratory complications (5.80% vs 3.64%, aOR = .47, P = .01). Also, in TEVAR, weekend admission was associated with longer time from admission to operation (3.92 ± .27 vs 2.35 ± .09 days, P < .01).

CONCLUSIONS

Renal malperfusion was a common indication for TBAD repair. TBAD patients admitted over the weekend and underwent TEVAR had higher post-procedural kidney failure, which may be due to delayed diagnosis and treatment.

False lumen regurgitation fraction and energy loss in the aorta measured using four-dimensional flow MRI to predict expansion of acute uncomplicated type B aortic dissection: a prospective study

AIM

To assess the relationship between four-dimensional (4D)-flow-derived false lumen regurgitation fraction (FLRF) and energy loss (EL) percentage in the descending thoracic aorta (DTA) with the aortic growth rate in uncomplicated type B aortic dissection (uTBAD).

METHODS AND MATERIALS

In this prospective study performed on 15 patients with uTBAD, computed tomography (CT) angiography and 4D-flow magnetic resonance imaging (MRI) were performed at the initial presentation with follow-up CT at 2 years. 4D-flow parameters, including maximum peak systolic velocity (PSV), FLRF, and percentage of EL were measured using Circle CV42. The significance of these parameters for expansion (>3 mm/year) of aortic dissection was analysed.

RESULTS

Five patients had an enlarging aorta, while 10 had a stable aortic size. The Mann-Whitney U-test showed entry tear >10 mm (p=0.026), FLRF (7.6 ± 8.9 versus 64.8 ± 16.7%; p=0.002), EL in the DTA in (1.61 ± 1.99 versus 2.21 ± 0.32 μW/cm3; p=0.014) and percentage of EL in the DTA to overall energy loss from the ascending aorta to the DTA (37 ± 15% versus 66 ± 17%; p=0.005), having a statistically significant different expanding stable dissection. A positive significant Spearman correlation was noted with the aortic growth rate (in millimetres over 2 years) with FLRF (r=0.71, p=0.003), EL in the DTA (r=0.56, p=0.007), and percentage of EL in the DTA (r=0.62, p=0.003).

CONCLUSION

4D flow parameters, including FLRF and the percentage amount of EL in the DTA may help predict aortic growth at an early stage in uTBAD.

Hybrid noncovered open stents in repair of DeBakey type 1 acute aortic dissections

OBJECTIVES

The indications for use, evidence base and experience with the novel noncovered open hybrid surgical stents for acute type A aortic dissection repair for concurrent stabilization of the 'downstream' aorta remains limited. We review the evidence base and the development of these stents.

METHODS

Data were collected from Pubmed/Medline literature search to develop and review the evidence base for safety and efficacy of non-covered surgical stents. Existing guidelines for use and developments were reviewed.

RESULTS

A single randomized control trial and 4 single-centre studies were included in the review with a total worldwide experience of 241 patients. The deployment was easy and did not add significantly to the primary operation. The mortality and new stroke ranged from 6.3-18.7%. Safe and complete deployment was accomplished in 92-100%. There was no device-related reintervention. There was a significant improvement in malperfusion in over 90% of the cases with varying degrees of remodelling (60-90%) of the downstream aorta.

CONCLUSIONS

Open noncovered stent grafts represent a major technical advancement as an adjunct procedure for acute dissection repairs, e.g. hemiarch repair. It has potential for wider use by non-aortic surgeons due to simplicity of technique. Limited safety and efficacy data confirm the device to be safe, feasible and reproducible with potential for wider adoption. However, long-term trial and registry data are required before recommendations for standard use outside of high-volume experienced aortic centres.

Fenestrated Thoracic Endovascular Repair for Acute Type B Aortic Dissection with Isolated Left Vertebral Artery: A Case Report

Thoracic endovascular aortic repair (TEVAR) of acute uncomplicated type B aortic dissection (uTBAD) has been discussed for its potential to prevent future aortic events. We present a fenestrated TEVAR in the case of an 86-year-old man with acute uTBAD with an isolated left vertebral artery (ILVA). The ILVA originated from the distal side of the left subclavian artery, the left subclavian artery, and the intramural hematoma with an ulcer-like projection extended close to the left subclavian artery. We selected a fenestrated stent graft to achieve a proximal healthy landing. This case demonstrates that a fenestrated stent graft for acute uTBAD is useful for preserving arch vessels.

Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

A Monte Carlo Sensitivity Analysis for a Dimensionally Reduced-Order Model of the Aortic Dissection

PURPOSE

Aortic dissection is associated with a high mortality rate. Although computational approaches have shed light on many aspects of the disease, a sensitivity analysis is required to determine the significance of different factors. Because of its complex geometry and high computational expense, the three-dimensional (3D) fluid-structure interaction (FSI) simulation is not a suitable approach for sensitivity analysis.

METHODS

We performed a Monte Carlo simulation (MCS) to investigate the sensitivity of hemodynamic quantities to the lumped parameters of our zero-dimensional (0D) model with numerically calculated lumped parameters. We performed local and global analyses on the effect of the model parameters on important hemodynamic quantities.

RESULTS

The MCS showed that a larger lumped resistance value for the false lumen and the tears result in a higher retrograde flow rate in the false lumen (the coefficient of variation, [Formula: see text], the sensitivity [Formula: see text], Spearman's coefficient,[Formula: see text]). For the intraluminal pressure, our results show a significant role in the resistance and inertance of the true lumen (the coefficient of variation, [Formula: see text], the sensitivity [Formula: see text], and Spearman's coefficient,[Formula: see text] for the inertance of the true lumen).

CONCLUSION

This study highlights the necessity of comparing the results of the local and global sensitivity analyses to understand the significance of multiple lumped parameters. Because of the efficiency of the method, our approach is potentially useful to investigate and analyze medical planning.

STABILISE (Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair) Is Associated With Good Anatomical Results on the Distal Thoracoabdominal Aorta at 2 Years

PURPOSE

The aim of this comparative study was to evaluate the increased aortic diameter of the distal aorta after implementing the STABILISE technique in complicated type B aortic dissection (AD).

DESIGN

This is a comparative monocentric retrospective study.

MATERIALS AND METHODS

All patients who underwent an STABILISE procedure for complicated AD between 2018 and 2020 were included and compared with a historic cohort treated with thoracic endovascular aortic repair (TEVAR) alone. Aortic diameters were measured at 6 different levels on the thoracic and abdominal aorta. The primary end point was an increased aortic diameter at 1 and 2 years. The exclusion criterion was the absence of a computed tomography (CT) scan at 1 or 2 years.

RESULTS

A total of 55 patients were included: 24 in the TEVAR group and 31 in the STABILISE group. At the level of the stent graft, there was a decrease in aortic diameters in both groups without significant differences. At the level of the distal aorta, there was an increase in aortic diameters in both groups without significant differences. There were significantly more patients in the TEVAR group with an unfavorable increase in aortic diameter >5 mm of the distal aorta at 2 years than in the STABILISE group: 8 (33%) vs 1 (3%) (p=0.01). For chronic ADs, a significantly greater increase in aortic diameters of the distal aorta was observed in the STABILISE group.

CONCLUSIONS

The STABILISE technique is technically feasible and potentially leads to decreased longer re-intervention rates; indeed, more patients had an unfavorable increase in aortic diameter in the TEVAR group than in the STABILISE group at 2 years. The high rate of long-term distal aortic aneurysm progression and reintervention after TEVAR alone suggests that this option is not sufficient to definitively treat these complex patients.

CLINICAL IMPACT

This article reported the results of stent assisted balloon induced intimal disruption and relamination (STABILISE) with a follow-up at 2 years. This is the first comparative study between STABILISE, which has emerged as a new technique inducing aortic remodeling and therefore better long-term outcome, and the standard technique TEVAR alone. STABILISE technique is associated with good results on the distal aorta at 2 years with a rate of patient with unfavorable aortic diameter evolution greater in TEVAR group compared to STABILISE group and could improve the long-term results on the distal aorta by inducing extensive aortic remodeling.

Aortic Remodeling After Thoracic Endovascular Aortic Repair for Nonacute Uncomplicated Type B Aortic Dissection

BACKGROUND

Entry closure with thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD) results in aortic remodeling recently. This study aimed to evaluate the relationship between aortic diameter or timing of surgical intervention from onset and remodeling after TEVAR for uncomplicated nonacute TBAD.

METHODS

Between April 2014 and December 2021, 83 consecutive patients underwent TEVAR for TBAD at our center. Forty patients with subacute and chronic uncomplicated TBADs with a patent false lumen, who could be followed up for at least 6 months, were included in this study. Indications for TEVAR included aortic diameter enlargement and preemptive treatment to prevent future aneurysmal changes in patients at risk of aortic diameter enlargement. Aortic remodeling was accessed, and data between the remodeling and nonremodeling groups were compared.

RESULTS

The technical success rate was 97.5%, with a type Ia endoleak remaining in 1 patient. No operative or in-hospital mortality occurred. Paraparesis occurred in only 1 patient (2.5%). Follow-up was completed at a median of 53.5 months. Late death occurred in 3 cases, but there were no aortic-related deaths. Late aortic remodeling was achieved in 22 patients (55%). The preoperative maximum aortic diameter (PMAD) in the thoracic aortic region was 51.5 mm in the nonremodeling group, significantly larger than 42.5 mm in the remodeling group (P < 0.0001). The cutoff value of the PMAD for predicting aortic remodeling was 45 mm (area under the curve, 0.917; P = 0.028). The remodeling group had an earlier time from onset to intervention than the nonremodeling group, with a cutoff value of 6.3 months (area under the curve, 0.743; P = 0.021).

CONCLUSIONS

TEVAR for nonacute uncomplicated TBAD resulted in a late aortic remodeling rate of 55%. This study suggested that a PMAD of >45 mm or a period >6.3 months between dissection onset and surgery hinders aortic remodeling after TEVAR.

Disparities in Outcomes Between Sexes in Type B Aortic Dissection Patients Treated with TEVAR

BACKGROUND

To evaluate differences in presentation and outcomes between sexes in patients who underwent thoracic endovascular aortic repair for type B aortic dissection (TBAD).

METHODS

Between January 1, 2012 and January 1, 2017 186 patients underwent thoracic endovascular aortic repair for TBAD at a single institution. Men (n = 112) and women (n = 74) were compared based on presenting demographics, comorbidities, and postoperative complications. Primary outcomes were survival and need for reintervention.

RESULTS

Women were older (P = 0.04) and had a lower body mass index (P = 0.03). More women (F) presented with continued pain or refractory hypertension (51.0% F, 30.0% M), while more men (M) presented with acute complicated dissections (19.0% F, 39.0% M) (P = 0.008). At presentation, women had statistically higher relative rates of chronic obstructive pulmonary disease (P = 0.05), hyperlipidemia (P = 0.03), and smoking (P = 0.03). Significantly more women were on Medicare without Medicaid (55.0% F, 34.0% M), while men had private insurance (35.0% F, 13.0% M) (P = 0.005). There was no significant difference in blood pressure control at presentation, discharge, or at 30 days. When normalized by body surface area, women had larger ascending aortic diameters (19.2(3.10)F, 17.5(2.40)M, P = 0.0002), as well as proportionally larger true lumens at the left subclavian artery (14.9(2.90)F, 13.4(2.50)M, P = 0.0002), carina (12.6(5.80)F, 9.90(4.80)M, P = 0.0009), and celiac (10.5(4.50)F, 8.50(4.10)M, P = 0.006) levels, and at the largest point of dissection (11.6(6.50)F, 9.60(4.80)M, P = 0.04), as well as proportionately smaller false lumens at the carina (5.90(5.60)F, 9.30(6.10)M, P = 0.003). Despite not being statistically significant, women had lower rates of stroke (6.80% F, 8.00% M, P = 0.7) and acute kidney injury (5.40% F, 11.6% M, P = 0.2), as well fewer days in the intensive care unit (ICU) (3.20(4.30)F, 4.60(6.60)M, P = 0.2) and an overall shorter length of stay (6.80(6.70)F, 8.00(8.20)M, P = 0.5). Kaplan-Meier estimates for survival for women versus men were 96.0% vs. 92.0%, 90.0% vs. 79.0%, and 70.0% vs. 69.0% at 30 days, 1 year, and 3 years, respectively (P = 0.042). Kaplan-Meier estimates for freedom from reintervention for women versus men were 89.0% vs. 90.0%, 58.0% vs. 72.0%, and 48.0% vs. 58.0% at 30 days, 1 year, and 3 years, respectively (P = 0.13).

CONCLUSIONS

Women present with TBAD at an older age, have more comorbidities, lower socioeconomic status, and have larger ascending aortic diameters for their size. Despite having less severe dissections as evidenced by smaller false lumens and wider true lumens, it does not appear that this correlates with improved outcomes for women when compared to men. It appears that this is one of the few, if not only, aortic pathologies that result in comparable outcomes between sexes.

[Acute aortic syndrome]

Acute aortic syndrome embraces a group of heterogenous pathological entities involving the aortic wall with a common clinical profile. The current epidemiology, clinical presentation, diagnosis and treatment strategy are discussed in this review. Besides, the importance of multidisciplinary aortic teams, aortic centers and the implementation of an aortic code are emphasized.

Systemic immune-inflammation index predicts the clinical outcomes in patients with acute uncomplicated type-B aortic dissection undergoing optimal medical therapy

BACKGROUND

Optimal medical therapy (OMT) for uncomplicated type B aortic dissection (uTBAD) provides excellent short-term outcomes during follow up; however, its long-term therapeutic effectiveness is unsatisfactory. This study evaluated the predictive value of systemic immune-inflammation index (SII) for adverse events among patients with acute uTBAD undergoing OMT.

METHODS

We performed a retrospective analysis of a prospectively maintained database between 2013 and 2020. The primary end point in this study was composite outcomes including aortic intervention, all-cause mortality, retrograde type A aortic dissection (rTAAD) and aortic diameter growth > 5 mm. The patients were divided into high and low SII groups according to the optimal cut-off value of SII as determined using the receiver operating characteristic curve. Cox proportional hazards models were constructed to estimate the hazards ratios and identify the predictors of composite outcomes.

RESULTS

A total of 124 patients with acute uTBAD who underwent OMT were enrolled. One patient died during hospitalisation. At the end of a mean follow-up duration of 51 ± 23 months, 53 (43.1%) patients experienced composite outcomes, 15 patients (12.2%) died, 31 (25.2%) underwent aortic intervention, 21 (17.1%) exhibited diameter growth of > 5 mm, and 2 developed rTAAD. The patients were divided into low SII group (n = 78, 62.9%) and high SII group (n = 46, 37.1%) as per the optimal cut-off SII value of 1449. The incidence of composite outcomes in high SII group was significantly higher than that in low SII (28 [60.9%] vs. 26[33.3%], p < 0.01). Patients with high SII demonstrated significantly higher mortality rate than those with a low SII (11 [23.9%] vs. 5 [6.4%], respectively; p < 0.01). In addition, the high SII group had significantly higher rate of aortic-related reinterventions than the low SII group (16 [34.8%] vs. 15 [19.2%], p = 0.03). Multivariable Cox analyses showed that a high SII score was independently associated with composite outcomes rate (hazard ratio, 2.15; 95% confidence interval, 1.22-3.78; p < 0.01).

CONCLUSIONS

The long-term therapeutic effectiveness of OMT alone in patients with acute uTBAD is unsatisfactory. An SII > 1449 at the time of diagnosis is an independent predictor of OMT failure.

Treatment of Uncomplicated Type B Aortic Dissection: Optimal Medical Therapy vs TEVAR + Optimal Medical Therapy

Optimal Medical Therapy (OMT) has been the accepted mode of treatment for uncomplicated Type B Aortic Dissection (uTBAD). There is growing evidence that despite the short-term benefits of OMT, patients suffer deleterious consequences in the long-term with OMT alone. Thoracic Endovascular Aortic Repair (TEVAR) along with OMT has emerged as an alternative option for patients with uTBAD. This study evaluates the available literature for TEVAR + OMT as an alternative to OMT for treatment of uTBAD. In addition, issues related to TEVAR as a treatment for uTBAD are discussed.

Prognostic impact of early aortic volume changes at hospital discharge in patients with acute type B aortic dissection

BACKGROUND

Early prediction of aorta-related events is important for determining subsequent treatment strategies in patients with acute aortic dissection. However, most studies evaluated long-term aortic growth rates by annual assessment. The purpose of our study was to determine whether the in-hospital growth rate of aortic volume was associated with aorta-related events.

METHODS

We studied 116 patients with uncomplicated type B acute aortic dissection. We analyzed whether changes in aortic volume were associated with aorta-related events during a 5-year follow-up. According to the growth rate from admission to discharge, patients were divided into two groups: Increase >0 (aortic volume: n = 59, aortic diameter: n = 43) and Reduction ≤0 (aortic volume: n = 57, aortic diameter: n = 73) in maximum aortic diameter or aortic volume. The primary endpoint was the discriminative ability of the growth rate of aortic volume for aorta-related events.

RESULTS

According to the evaluation of aortic volume changes, the Increase group had significantly higher aorta-related event rates than those in the Reduction group (49.2 % vs. 3.5 %, respectively; p < 0.001). Receiver operating characteristics analysis showed that the growth rate of aortic volume had a clearly useful discrimination, with an area under the curve of 0.84, whereas the discriminative ability of the growth rate of maximum aortic diameter was poor (area under the curve: 0.53). Multivariate analysis showed that the growth rate of aortic volume from admission to discharge was an independent predictor of aorta-related events (hazard ratio, 26.3; 95 % confidence interval, 2.04-286.49; p = 0.001).

CONCLUSIONS

In-hospital evaluation of aortic volume was helpful to predict long-term aorta-related events in patients with uncomplicated type B acute aortic dissection.

Prevention of distal stent graft-induced new entry after endovascular repair for type B aortic dissection: A retrospective cohort study

OBJECTIVES

Distal stent graft-induced new entry (dSINE) can occur after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). In this study we aimed to compare the effectiveness of restrictive bare stent (RBS), tapered stent graft (TSG), and non-TSG in TEVAR in preventing dSINE after a midterm follow-up.

METHODS

This retrospective cohort study included patients with TBAD who underwent TEVAR (June 2010 to December 2018). The occurrence of dSINE during follow-up was examined. Predictors of dSINE were determined using Fine-Gray regression with death as the competing event. Survival was evaluated using Cox proportional hazards regression.

RESULTS

Finally, 364 patients were included: 111 with non-TSG TEVAR, 125 with TSG TEVAR, and 128 with TEVAR with RBS. After 54.5 months, incidences of dSINE in the 3 groups were 12.61%, 4.80%, and 1.56%, respectively (P = .002). On Fine-Gray regression adjusted for clinically relevant covariates, the expansion mismatch ratio (subdistribution hazard ratio, 1.09; 95% CI, 1.07-1.12; P < .001) and complete false lumen thrombosis (subdistribution hazard ratio, 0.35; 95% CI, 0.13-0.94; P = .037) were identified as predictors of dSINE. The Cox proportional hazards regression analysis revealed that dSINE was not only a risk factor for aortic-related mortality (hazard ratio, 17.90; 95% CI, 3.27-98.12; P = .001), but also a predominant risk factor for all-cause mortality (hazard ratio, 4.91; 95% CI, 1.66-14.52; P = .004).

CONCLUSIONS

dSINE can happen in TBAD patients who undergo TEVAR. Thus, long-term surveillance is crucial. TSG and RBS had lower expansion mismatch ratios, which might help prevent dSINE.

Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair (STABILISE): A Meta-Analysis of Early Outcomes

BACKGROUND

This meta-analysis aims to determine the early clinical outcomes and rate of complete false lumen obliteration associated with the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique in the management of aortic dissection.

METHODS

Electronic databases searches were performed on PubMed, Embase, and the Cochrane Library to identify studies reporting early outcomes of the STABILISE technique. In addition, we retrospectively analyzed all patients treated with the STABILISE technique for aortic dissection at our institution. The case series data were pooled with relevant studies to perform a meta-analysis of proportions using random-effects models.

RESULTS

One hundred and ninety two patients from 9 relevant studies were pooled with an additional 13 patients undergoing STABILISE at our institution over a 3-year period. Pooled in-hospital mortality rate was 6% [95% confidence interval (CI); 3%-10%, I2 = 0.00%] and the overall rate of intraoperative aortic rupture was 4% [95% CI; 2%-8%, I2 = 0.00%]. The rate of in-hospital reintervention was 8% [95% CI; 5%-14%, I2 = 13.37%]. Median follow-up ranged from 8 to 36 months. Pooled cumulative mortality at follow-up was 8% [95% CI; 4%-18%, I2 = 23.15%]. The overall rate of late reintervention was 11% [95% CI; 7%-17%, I2 = 0.00%]. Complete obliteration of the false lumen in the thoracic aorta was achieved in 93% of patients [95% CI; 84%-97%, I2 = 47.49%] and in the abdominal aorta in 86% of patients [95% CI; 79%-91%, I2 = 0.00%].

CONCLUSIONS

The STABILISE technique carries an acceptable operative safety profile with low in-hospital morbidity and mortality and excellent complete false lumen obliteration.

Hemodynamic Implications of STABILISE Technique for Aortic Dissection Repair

BACKGROUND

The stent-assisted balloon-induced intimal disruption and relamination (STABILISE) technique for treatment of type B dissection has shown promising clinical results at mid-term. Computational modeling is a way of noninvasively obtaining hemodynamic effects, such as pressure and wall shear stress, leading to a better understanding of potential benefits. Particular areas of interest are (1) the effect of intimal disruption and re-lamination and (2) the effect of the bare metal stent in the visceral aortic segment.

METHODS

Single-center prospective case series. Data from 5 consecutive locally performed cases of STABILISE technique were analyzed. Included cases were type B aortic dissection with or without prior de-branching. The STABILISE procedure had to be performed without 30-day major complications. Preoperative and postoperative imaging data for each patient were transferred to the biomedical engineering team. Each case was reconstructed, meshed, and simulated with computational fluid dynamics using patient-specific data (heart rate, blood pressure, height, and weight). Hemodynamic parameters were then extracted from the simulations.

RESULTS

In all cases, computational analysis showed for postoperative patients: (1) a drop in pressure difference between lumina and (2) lower wall shear stress effects, compared to their preoperative status. These observations were most pronounced in the visceral aortic segment.

CONCLUSIONS

Computational modeling shows favourable changes in the flow dynamics of type B dissection treated using the STABILISE technique. This may suggest protective effects of this technique for long-term aortic healing and cicatrization.

Thoracic Endovascular Aortic Repair on Zone 2 Landing for Uncomplicated Type B Aortic Dissection with Measurement of Intra-False Lumen Pressure

BACKGROUND

This study aimed to evaluate the midterm results of zone 2 thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) by measuring the intra-false lumen pressure (IFLP) during TEVAR.

METHODS

Fifteen patients (9 men; mean age, 57 years) who underwent zone 2 TEVAR for uncomplicated TBAD were reviewed. Delta systolic pressure (defined as the difference between systemic pressure and IFLP) was measured before and after primary entry closure, and aortic remodeling and thrombo-occlusion of the false lumen (FL) were evaluated 12 months after TEVAR at 5 different levels of the aorta.

RESULTS

Median duration from onset to TEVAR was 34 days. The left subclavian artery was preserved in 13 patients (87%) by using stent graft fenestration. Although 1 patient (6%) had a transient cerebral infarction, there were no severe TEVAR-related complications. Entry closure significantly reduced delta systolic pressure (mm Hg) compared to preoperative pressure at all levels (distal arch: -22.2 ± 10.8 vs. -5.2 ± 9.6; Th8: -20.1 ± 12.4 vs. -6.9 ± 7.2; Th10: -14.3 ± 14.6 vs. -4.7 ± 7.5; Th12: -14.4 ± 14.5 vs. -4.9 ± 7.8; L2: -14.5 ± 14.2 vs. -3.4 ± 6.9). The percentages of aortic remodeling with expansion of the true lumen (distal arch: 82%; Th8: 80%; Th10: 54%; Th12: 45%; L2: 50%) and complete false lumen thrombosis (distal arch: 100%; Th8: 100%; Th10: 67%; Th12: 11%; L2: 0%) were approximately consistent with the change in delta systolic pressure. During a follow-up of 41 months, distal stent-induced new entry occurred in 2 patients (13%) requiring secondary intervention; however, there were no cases of FL enlargement or aorta-related mortality.

CONCLUSIONS

Zone 2 TEVAR for uncomplicated TBAD may prevent TEVAR-related complications. Measuring IFLP could be a new predictive marker for assessing the extent of aortic remodeling.

Thoracic endovascular aortic repair for hyperacute, acute, subacute and chronic type B aortic dissection: Meta-analysis of reconstructed time-to-event data

Since the optimal timing for thoracic endovascular aortic repair (TEVAR) in the context of type B aortic dissections (TBAD) remains an open question, we performed a systematic review with meta-analysis to evaluate outcomes of TEVAR according to the phases of TBAD - hyperacute, acute, subacute and chronic. We carried out a pooled meta-analysis of time-to-event data extracted from studies published by June 2023 for the following outcomes: all-cause mortality, aortic-related mortality, and late aortic reinterventions. Thirteen studies met our eligibility criteria, comprising 4,793 patients (10.3 % hyperacute, 51.9 % acute, 25.9 % subacute, 11.9 % chronic). Considering the overall population, we observed a statistically significant difference between the groups (Log-rank test, P < 0.0001) and the main differences were found in the following comparisons: hyperacute versus acute (HR 1.61; 95 %CI 1.21-2.13; P = 0.001); hyperacute versus chronic (HR 1.70; 95 %CI 1.17-2.46; P = 0.005); subacute versus acute (HR 0.78; 95 %CI 0.63-0.98; P = 0.032). Considering the population with uncomplicated TBAD, we also observed a statistically significant difference for all-cause death between the groups (Log-rank test, P < 0.0001) and the main differences were found in the comparisons for subacute versus acute (HR 0.72; 95 %CI 0.58-0.88; P = 0.002). Furthermore, we observed statistically significant differences between the groups for aortic-related death (Log-rank test, P < 0.0001) and late aortic reintervention (Log-rank test, P < 0.0001), all favoring mostly the subacute phase as the optimal timing for TEVAR. In conclusion, there seems to be a timing-specific difference in the outcomes of TEVAR for TBAD pointing to the subacute phase as the optimal timing to achieve better long-term outcomes.

Non-A Non-B Acute Aortic Dissection: Is There Some Confusion in the Radiologist's Mind?

BACKGROUND

The aim of this study is to define and determine the rate of acute non-A-non-B aortic dissections, and to evaluate CT angiography findings and possible complications, as well as to discuss management strategies and currently available therapy. Non-A non-B type of aortic dissection is still a grey area in the radiologist's mind, such that it is not entirely clear what should be reported and completed in terms of this disease.

METHODS

A retrospective single-center study including 36 pre-treatment CT angiograms of consecutive patients (mean age: 61 years) between January 2012 and December 2022 with aortic dissection involving the aortic arch with/without the thoracic descending/abdominal aorta (type non-A non-B).

RESULTS

According to the dissection anatomy, we identified three modalities of spontaneous acute non-A-non-B anatomical configurations. Configuration 1 (n = 25) with descending-entry tear and retrograde arch extension (DTA entry). Configuration 2 (n = 4) with Arch entry tear and isolated arch involvement (Arch alone). Configuration 3 (n = 7) with Arch entry and anterograde descending (±abdominal) aorta involvement (Arch entry). CT angiogram findings, management, and treatment options are described.

CONCLUSIONS

Acute non-A non-B dissection represents an infrequent occurrence of aortic arch dissection (with or without involvement of the descending aorta) that does not extend to the ascending aorta. The complete understanding of its natural progression, distinct CT angiography subtypes, optimal management, and treatment strategies remains incomplete. Within our series, patients frequently exhibit a complex clinical course, often necessitating a more assertive approach to treatment compared to type B dissections.

Long-term survival and risk analysis of thoracic endovascular aortic repair for type B aortic dissection

To explore the safety and efficacy of thoracic endovascular aortic repair (TEVAR) in the treatment of patients with type B aortic dissection, and to evaluate the risk factors for long-term mortality. Our study retrospectively evaluated 729 patients with type B aortic dissection, who were divided into the thoracic endovascular aortic repair group and the optimal medical treatment group according to their treatment. In-hospital mortality, death within 30 days, and aortic-related mortality were lower in the thoracic endovascular aortic repair group than in the optimal medical treatment group (p < 0.05). The cumulative overall survival rates for the thoracic endovascular aortic repair group at 1 year, 5 years, and 10 years were 92.5%, 84.1%, and 73.5%, respectively. The Cox analysis found that TEVAR was beneficial in reducing mortality and that a vertical length of the dissection exceeding 150 mm was a risk factor for mortality.

A CT-based predictive model for stent-induced vessel damage: application to type B aortic dissection

OBJECTIVES

The distal stent-induced new entry (distal SINE) is a life-threatening device-related complication after thoracic endovascular aortic repair (TEVAR). However, risk factors for distal SINE are not fully determined, and prediction models are lacking. This study aimed to establish a predictive model for distal SINE based on the preoperative dataset.

METHODS

Two hundred and six patients with Stanford type B aortic dissection (TBAD) that experienced TEVAR were involved in this study. Among them, thirty patients developed distal SINE. Pre-TEVAR morphological parameters were measured based on the CT-reconstructed configurations. Virtual post-TEVAR morphological and mechanical parameters were computed via the virtual stenting algorithm (VSA). Two predictive models (PM-1 and PM-2) were developed and presented as nomograms to help risk evaluation of distal SINE. The performance of the proposed predictive models was evaluated and internal validation was conducted.

RESULTS

Machine-selected variables for PM-1 included key pre-TEVAR parameters, and those for PM-2 included key virtual post-TEVAR parameters. Both models showed good calibration in both development and validation subsamples, while PM-2 outperformed PM-1. The discrimination of PM-2 was better than PM-1 in the development subsample, with an optimism-corrected area under the curve (AUC) of 0.95 and 0.77, respectively. Application of PM-2 in the validation subsample presented good discrimination with an AUC of 0.9727. The decision curve demonstrated that PM-2 was clinically useful.

CONCLUSION

This study proposed a predictive model for distal SINE incorporating the CT-based VSA. This predictive model could efficiently predict the risk of distal SINE and thus might contribute to personalized intervention planning.

CLINICAL RELEVANCE STATEMENT

This study established a predictive model to evaluate the risk of distal SINE based on the pre-stenting CT dataset and planned device information. With an accurate VSA tool, the predictive model could help to improve the safety of the endovascular repair procedure.

KEY POINTS

• Clinically useful prediction models for distal stent-induced new entry are still lacking, and the safety of the stent implantation is hard to guarantee. • Our proposed predictive tool based on a virtual stenting algorithm supports different stenting planning rehearsals and real-time risk evaluation, guiding clinicians to optimize the presurgical plan when necessary. • The established prediction model provides accurate risk evaluation for vessel damage, improving the safety of the intervention procedure.

Editor's Choice - Trends in Management and Outcomes of Type B Aortic Dissection: A Report From the International Registry of Aortic Dissection

OBJECTIVE

To describe the trends in management and outcomes of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection.

METHODS

From 1996 - 2022, 3 908 patients were divided into similar sized quartiles (T1, T2, T3, and T4). In hospital outcomes were analysed for each quartile. Survival rates following admission were compared using Kaplan-Meier analyses with Mantel-Cox Log rank tests.

RESULTS

Endovascular treatment increased from 19.1% in T1 to 37.2% in T4 (ptrend < .001). Correspondingly, medical therapy decreased from 65.7% in T1 to 54.0% in T4 (ptrend < .001), and open surgery from 14.8% in T1 to 7.0% in T4 (ptrend < .001). In hospital mortality decreased in the overall cohort from 10.7% in T1 to 6.1% in T4 (ptrend < .001), as well as in medically, endovascularly and surgically treated patients (ptrend = .017, .033, and .011, respectively). Overall post-admission survival at three years increased (T1: 74.8% vs. T4: 77.3%; p = .006).

CONCLUSION

Considerable changes in the management of acute type B aortic dissection were observed over time, with a significant increase in the use of endovascular treatment and a corresponding reduction in open surgery and medical management. These changes were associated with a decreased overall in hospital and three year post-admission mortality rate among quartiles.

Novel repair of acute Stanford type B aortic dissection using combined endovascular graft and transfemoral replacement of vascular plug

We present successful treatment of dissected thoracoabdominal aorta using combined thoracic endovascular aortic repair and transfemoral replacement of Amplatzer™ vascular plug in a 38-year-old patient. Computed tomography angiography revealed a false lumen from the left subclavian artery to the left common iliac trunk, with re-entries connecting it to the true lumen of the aorta. We replaced the prosthetic endovascular graft just below the left subclavian artery to the top of the superior mesenteric artery. Amplatzer™ vascular plug was replaced below the diaphragm in a closed transfemoral procedure to prevent re-entry. The patient was discharged in good condition and 2 years postoperation imaging showed complete pseudoaneurysm closure.

Intramural hematoma in the proximal sealing zone of the thoracic endovascular aneurysm repair: frequency and safety in acute and subacute type B dissections

Introduction

To assess the outcomes after thoracic endovascular aneurysm repair (TEVAR) in the presence of intramural hematoma (IMH) in the proximal sealing zone.

Material and methods

Patient data were retrospectively extracted from the hospital records of patients treated with TEVAR for acute and chronic aortic dissection type B in one single center. The initial, preoperative, first postoperative, and last follow-up CT scans were evaluated in the aortic 3D multiplanar reformats and the centerline regarding IMH presence in the proximal sealing zone, anatomical preconditions, and the morphological TEVAR complications including migration and bird-beak. Groups with (IMH) and without IMH (no-IMH) were compared.

Results

Overall, 84 patients (IMH:42; no-IMH:42) were treated at the age of 63(55; 72) years, of whom 23/84 (27%), 34/84 (40%), and 27/84 (32%) were in the hyperacute, acute and subacute dissection phases, respectively. The bovine arch was found in 10/84(12%) and the type III arch was most common (43/84;51%). IMH maximum extent was found in zones 0, 1, 2, and 3 in 14/84 (17%), 17/84 (20%), 18/84 (21%), and 6/84 (7%), respectively. Sealing was achieved in zone II in 71/84 (85%) and LSA was revascularized in 66/84 (79%) of the overall cohort. Early mortality and paraplegia were 2/84 (2%) each; stroke rate was 3/84 (4%). During the 22 months median follow-up (22;4;43) no RTAD was observed. Migration ≥10 mm (IMH: 11/82; no-IMH: 10/82; P = 1.0) and bird-beaks (IMH: 10/82; no-IMH: 12/82; P = 0.8036) were comparable in both groups and accompanied by a low aorta related mortality (1/82) in both groups.

Conclusion

The presence of the IMH in the proximal TEVAR sealing zone is frequent and may not be relevant for the occurrence of the RTAD, stent-graft migration, or bird-beak formation.

Age-related difference in acute type B aortic dissection

OBJECTIVE

The objective is to compare the characteristics of clinical data, imaging data, and treatment methods of young and old patients with acute type B aortic dissection (ABAD).

METHODS

ABAD patients admitted to the Department of Vascular Surgery of the First Affiliated Hospital of Anhui Medical University from January 2012 to December 2018 were retrospectively reviewed. Patient demographics, such as gender, age, diabetes, hypertension, presenting symptoms, imaging characteristics, laboratory data on admission, hemodynamics on admission and in-hospital management, and mortality of different age groups were compared and analyzed. Categorical variables were compared using χ2 tests or Fisher's exact test. Continuous variables were compared using Student's t-test or Mann-Whitney U-test.

RESULTS

A total of 141 ABAD patients were included in this study. Old ABAD patients were more likely to have a prior history of hypertension (88.6% vs 70.4%, p = 0.037) and atherosclerosis (29.8% vs 7.4%, p = 0.016). In the young group, Marfan syndrome was significantly higher (14.8% vs 0.9%; p = 0.005). Compared with the old group, the number of distal tears in the young group was significantly higher (62.3% vs 39.5%, p = 0.027). The proportion of patients with malperfusion of lower limbs in the young group was significantly higher than that in the old group (22.2% vs 6.1%, p = 0.026). There was no significant difference in the treatment methods and in-hospital mortality between the two groups.

CONCLUSION

Compared with old ABAD patients, young ABAD patients had more distal tears and a higher proportion of lower limbs malperfusion.

Twenty years' experience of type B aortic dissections: a population-based national registry study from Finland

OBJECTIVES

The objective of this study was to investigate the incidence, treatment and survival of Stanford type B aortic dissection (BTAD) during 20 years in the Finnish population.

METHODS

Data collection was made from the Nationwide Care Register for Health Care, Finnish National Institute for Health and Welfare. All patients over 15 years of age with BTAD from 2000 to 2019 were included in the study. A data search of the Registry of Death Cause (Statistic Finland) was carried out to identify the date and cause of death.

RESULTS

There were 1742 cases of BTAD during the study period. BTAD represented 45.6% of all aortic dissections leading to hospital admission. Incidence for BTAD was 1.62 per 100 000 inhabitants per year. The median survival was 12.7 years [95% confidence interval (CI) 9.63-14.7], 12.4 years (95% CI 10.5-14.4) and 8.6 years (95% CI 7.5-9.7) for patients treated with thoracic endovascular aortic repair (TEVAR), surgery and medical treatment (MT), respectively. Survival was significantly better after TEVAR and surgery, compared to MT only (P < 0.001). Age-adjusted survival was significantly better after TEVAR compared to patients treated with MT or surgery (hazard ratio 0.578, 95% CI 0.420-0.794, P < 0.001). Aortic-related death was the most common cause of death in all groups (41%).

CONCLUSIONS

The incidence of BTAD seems to be similar in the Finnish population compared to other populational studies. Patients treated with TEVAR had significantly better survival compared to other patients. A high risk for late aortic-related death should be recognized in patients with BTAD.