Acute Type B Aortic Dissection: Does Aortic Arch Involvement Affect Management and Outcomes?: Insights From the International Registry of Acute Aortic Dissection (IRAD)

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Current knowledge and contemporary management of non-A non-B aortic dissections

Non-A non-B aortic dissection (AAD) is an infrequently documented condition, comprising of only a small proportion of all AADs. The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD, have led to an ongoing controversy around the topic. It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections, frequently leading to serious complications and thus mandating early intervention. Currently, the available treatment methods in the surgical armamentarium are conventional open, endovascular techniques and combined hybrid methods. The optimum approach is tailored in every individual case and may be determined by the dissection’s location, extent, the aortic diameter, the associated complications and the patient’s status. The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached. In an attempt to provide further insight into this perplexing entity, we performed a minireview of the literature, aiming to elucidate the epidemiology, clinical course and the optimal treatment modality.

Surgical treatment patterns and clinical outcomes of type B aortic dissection involving the aortic arch

OBJECTIVE

In the present report, we have described the outcomes of endovascular repair, hybrid arch repair, and open surgical repair for type B dissection involving the aortic arch (B_{1-2, D}).

METHODS

Cases of endovascular repair, hybrid arch repair, and open surgical repair performed between January 2015 and December 2019 for aortic dissection designated as B_{1-2, D} by the Society for Vascular Surgery/Society of Thoracic Surgeons classification were retrospectively analyzed. The primary end point was all-cause mortality at follow-up. The secondary end points included early mortality, early morbidities, and aortic-related late events. Kaplan-Meier curves were created to analyze survival from all-cause mortality and freedom from aortic-related late events in the endovascular, hybrid, and open groups. Propensity score matching and stratification (stratified by proximal dissection extension: B_{1, D} and B_{2, D}) were performed as sensitivity analyses to compare the outcomes among the three treatment patterns after controlling for major confounders.

RESULTS

The present study included 151 patients (men, 79.5%; mean age, 47.3 ± 10.5 years), with 72 (47.7%) in the endovascular group, 46 (30.5%) in the hybrid group, and 33 (21.8%) in the open group. No significant difference was noted in early mortality between the endovascular, hybrid, and open groups (1.4% vs 2.2% vs 3.0%; P = .791). The incidence of early endoleak was significantly greater (33.3% vs 13.0% vs 6.1%; P = .002) and the incidence of renal function deterioration was less (4.2% vs 26.1% vs 24.2%; P = .001) after endovascular repair vs hybrid arch repair and open surgery. After a median follow-up of 40.0 months (range, 0-84.0 months), no significant differences were found in all-cause mortality (5.6% vs 4.3% vs 3.0%; P = 1.0), aortic-related late events (16.7% vs 15.2% vs 12.1%; P = .834), or late endoleak (9.7% vs 4.3% vs 6.1%; P = .630) after endovascular, hybrid, and open surgery. The propensity score matching and stratification analyses displayed consistent outcomes for early mortality, all-cause mortality, and aortic-related late events among the three groups.

CONCLUSIONS

The mid- to long-term outcomes after endovascular repair, hybrid arch repair, and open surgical repair for type B dissection involving the aortic arch (B_{1-2, D}) were favorable and comparable in selected patients. Extensive experience and multidisciplinary teamwork are prerequisites for individualized strategies for repair of B_{1-2, D}.

Management and Outcomes of Non-A Non-B Aortic Dissection

OBJECTIVE

The results of best medical treatment (BMT), endovascular based treatment (EBT), and total arch replacement (TAR) with frozen elephant trunk (FET) treatment in a single centre experience were reported in non-A non-B aortic dissection patients.

METHODS

From January 2016 to May 2020, 215 consecutive patients with acute or subacute non-A non-B aortic dissection were enrolled. The primary endpoints were all cause death. Secondary endpoints included follow up adverse aortic event (AE), a composite of the outcomes of dissection related death, rupture, retrograde type A aortic dissection, stent graft induced new entry tear, secondary endoleak, and follow up re-intervention. Kaplan-Meier curves were used to evaluate associations between different treatments and outcomes.

RESULTS

Among the 215 dissection patients, 127 (59.1%) received EBT, 42 (19.5%) received TAR + FET, and the remaining 46 (21.4%) received BMT. Thirty day mortality was higher in patients receiving TAR + FET (7.1%) than in those treated with EBT (1.6%) or BMT (2.2%) (p = .12). However, after a median follow up of 39.1 (27.0 - 50.7) months, no additional death was recorded in the TAR + FET group, while nine (7.3%) patients died in the EBT group and 14 (31.8%) died in the BMT group (p < .001). Specifically, EBT and TAR + FET showed no significant difference in midterm mortality rate, follow up AE, and re-intervention for complicated or uncomplicated dissection patients involving zone 2. For patients with uncomplicated non-A non-B aortic dissection involving zone 2, EBT could profoundly decrease the mortality rate, follow up AE and re-intervention when compared with BMT (p < .010 for all), although this difference was not statistically significant between TAR + FET and BMT. No statistical comparison was performed in patients with zone 1 involvement because of the limited number of patients.

CONCLUSION

It was demonstrated that EBT or TAR + FET might be a viable strategy for non-A non-B aortic dissection patients.

Sex-related differences on the risks of in-hospital and late outcomes after acute aortic dissection: A nationwide population-based cohort study

Objective

The aim of this study is to evaluate the sex-related differences on the risks of perioperative and late outcomes for adult acute aortic dissection (AAD) patients following surgical management.

Methods and results

By using Taiwan National Health Insurance Research Database, totally 1,410 female and 3,432 male patients were identified to first-ever receive type A AAD open surgery or type B AAD stenting treatment from 2004 to 2013. We assessed the sex-related difference on outcomes, including in-hospital mortality, all-cause mortality, aortic death, redo aortic surgery, ischemic stroke, and depression during the follow-up period. The analysis was done separately for type A and type B surgeries.

Results

On average, female patients diagnosed with AAD were older than males. There was no significant sex difference of in-hospital mortality or all-cause mortality for both type A open and type B stent surgeries. The risk of redo aortic surgery was significantly greater in males than females (7.8% vs. 4%; unadjusted subdistribution hazard ratio [SHR] 0.51, 95% CI 0.38–0.69) for type A open surgery, but not for type B stent surgery. Noticeably, the risk of newly-diagnosed depression was significantly greater in females than males (8% vs. 5.1%; unadjusted SHR 1.6, 95% CI 1.24–2.06) for type A open surgery, but not for type B stent surgery.

Conclusions

No significant sex-related difference was found for the in-hospital mortality or accumulative all-cause mortality. However, there were more redo aortic surgeries for males and more postoperative depression for females in type A AAD population.

MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal

Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient’s management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replicable, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.

A New Aortic Arch Dissection Classification: The Fuwai Classification

Aims: We describe a new aortic arch dissection (AcD) classification, which we have called the Fuwai classification. We then compare the clinical characteristics and long-term prognoses of different classifications.

Methods: All AcD patients who underwent surgical procedures at Fuwai Hospital from 2010 to 2015 were included in the study. AcD procedures are divided into three types: Fuwai type Cp, Ct, and Cd. Type Cp is defined as the innominate artery or combined with the left carotid artery involved. Type Cd is defined as the left subclavian artery or combined with the left carotid artery involved. All other AcD surgeries are defined as type Ct. The Chi-square test was adopted for the pairwise comparison among the three types. Kaplan-Meier was used for the analysis of long-term survival and survival free of reoperation.

Results: In total, 1,063 AcD patients were enrolled from 2010 to 2015: 54 patients were type Cp, 832 were type Ct, and 177 were type Cd. The highest operation proportion of Cp, Ct and Cd were partial arch replacement, total arch replacement, and TEVAR. The surgical mortality in type Ct was higher compared to type Cd (Ct vs. Cd = 9.38 vs. 1.69%, p < 0.01) and type Cp (Ct vs. Cp = 9.38 vs. 1.85%, p = 0.06). There was no difference in surgical mortality of type Cp and Cd (p = 0.93). There were no significant differences in the long-term survival rates (p = 0.38) and free of aorta-related re-operations (p = 0.19).

Conclusion: The Fuwai classification is used to distinguish different AcDs. Different AcDs have different surgical mortality and use different operation methods, but they have similar long-term results.

Comparison of Open Repair vs. the One-Stage Hybrid Extra-Anatomic Technique for Distal Aortic Arch Disease Treatment: Mid-term Outcomes With a Risk-Adjusted Analysis

Objective: This study aims to compare the short- and mid-term outcomes of the stented elephant trunk (SET) procedure combined with supra-arch branch reconstruction and one-stage hybrid arch repair combined thoracic endovascular aortic repair (TEVAR) with extra-anatomic bypass in the management of distal arch disease.

Methods: From January 2009 to January 2019, 97 patients underwent one-stage hybrid arch repair combined with TEVAR with extra-anatomic bypass (HAR group), and 206 patients underwent the SET procedure with supra-arch branch reconstruction (SET group). We used inverse-probability-of treatment weighting (IPTW) to adjust baseline differences.

Results: Before IPTW adjustment, there was no significant difference in operative mortality between the two groups (5.2 vs. 1.0%, P = 0.064). The incidences of stroke, spinal cord injury (SCI), acute kidney injury (AKI), and endoleak also showed no significant differences (4.1 vs. 0.5%, P = 0.066; 2.1 vs. 1.5%, P = 1.000; 0 vs. 1.0%, P = 0.831; 6.2 vs. 1.9%, P = 0.113, respectively). After IPTW adjustment, the incidences of stroke, SCI, and AKI showed no significant differences between the two groups (1.8 vs. 1.1%, P = 0.138; 0.8 vs. 1.6%, P = 0.448; and 0 vs. 0.7%, P = 0.148, respectively). However, the HAR group tended to have higher operative mortality and incidence of endoleak than the SET group (12.4 vs. 1.3%, P = 0.01; 9.9 vs. 1.8%, P = 0.031, respectively). In the multivariate analysis, open repair decreased the risks of endoleak (odds ratio [OR], 0.171, 95% CI, 0.060–0.401; P < 0.001) and operative mortality (OR, 0.093, 95% CI, 0.027–0.238; P < 0.001). The overall survival and event-free survival of the HAR group were significantly lower than those of the SET group (P < 0.001).

Conclusion: One-stage hybrid arch repair combined TEVAR with extra-anatomic bypass and the SET procedure with supra-arch branch reconstruction both provided good postoperative treatment outcomes for distal arch disease. However, hybrid arch repair increased the risks of endoleak and operative mortality. The SET procedure provided better mid-term survival than hybrid arch repair without increasing operative mortality. Carefully selecting the indications for the procedure, while receiving close long-term follow-up, may improve the survival rate of patients undergoing hybrid arch repair.

Acute aortic dissection with entry tear at the aortic arch: long-term outcome

OBJECTIVES

The goal was to evaluate outcomes after conservative or surgical treatment of acute aortic arch dissections.

METHODS

Between January 2009 and December 2018, patients with a diagnosis of acute aortic dissection were analysed. Aortic arch aortic dissection was defined as a dissection with an isolated entry tear at the aortic arch with no involvement of the ascending aorta.

RESULTS

Aortic arch dissection was diagnosed in 31 patients (age 59 ± 11 years). Surgical intervention was performed in 13 (41.9%) cases. Overall in-hospital mortality was 3% (n = 1), and all deaths occurred in the conservative group (n = 1; 6%), whereas the overall stroke rate was 3% (n = 1), and all strokes occurred in the group treated surgically (n = 1; 8%). Surgical repair was necessary for the following conditions: end-organ malperfusion (n = 9; 69%), impending rupture (n = 3; 23%) and dilatation of the aorta with ongoing pain refractory to medical treatment (n = 1; 8%). Overall survival at the end of the follow-up period was 71%, with 77% in the surgical group and 63% in the conservative group (P = 0.91). Freedom from surgical intervention was 71%, with 82% in the surgical and 63% in the conservative group (P = 0.21), and freedom from a neurological event was 88%, with 89% versus 89% (P = 0.68) in the surgical and conservative groups, respectively.

CONCLUSIONS

Aortic arch dissection is a rare pathological condition that is one of the most challenging decision-making entities. Patients manifesting an uneventful course not requiring a surgical intervention during a hospital stay were at a higher risk for aorta-related intervention during the follow-up period. The treatment modality had no impact on survival or on the incidence of a neurological event.

Morphologic characteristics and endovascular management of acute type B dissection patients with superior mesenteric artery involvement

OBJECTIVE

Despite its association with static mesenteric malperfusion, the morphologic characteristics and optimal management of acute type B aortic dissection (ABAD) with superior mesenteric artery (SMA) involvement are poorly understood. We studied the associated risk factors and reported the outcomes of endovascular treatment.

METHODS

From May 2016 to May 2018, we examined 212 consecutive patients with ABAD in our center. Those with SMA involvement (SMAI) were included in the present study and divided into those with and without mesenteric malperfusion (MMP) according to the clinical findings. After thoracic endovascular aortic repair (TEVAR) with or without SMA revascularization, we compared the clinical data, imaging results, and outcomes for those with and without MMP.

RESULTS

Computed tomography angiography confirmed 44 cases of SMAI: 12 (27.3%) with MMP and 32 (72.7%) without MMP. The patients with MMP had presented more frequently with lower extremity malperfusion (33.3% vs 3.1%; P = .023) than had those without MMP, with an odds ratio of 14.15 (P = .047). Multivariate analysis showed that patients with a low true lumen (TL)/false lumen (FL) diameter ratio of the SMA (TL/FL-SMA <1) had a greater risk of developing MMP than those with a high TL/FL-SMA ratio of >1 (odds ratio, 8.49; 95% confidence interval, 1.24-58.26; P = .029). SMA TL thrombosis was a significant predictor of the requirement for additional SMA revascularization after TEVAR among patients with MMP (P = .045). During a mean 10-month follow-up period, complete FL thrombosis in the SMA was seen in 11 patients (25%; 33.3% with MMP vs 21.9% without MMP; P = .43). The overall mortality rate was 6.82% (16.7% in the MMP group and 3.1% in the non-MMP group; P = .09).

CONCLUSIONS

In the present study, limb ischemia and the TL/FL-SMA ratio were two independent predictors for the development of MMP in patients with ABAD and SMAI. We found that TEVAR can be safely performed for these patients, and SMA TL thrombosis predicted for the need for SMA revascularization.

Mid-Term Survival after Thoracic Endovascular Aortic Repair by Indication in the Medicare Population

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is indicated for treatment of aneurysms, dissections, and traumatic injury. We describe mid-term mortality and reintervention rates in Medicare beneficiaries undergoing TEVAR.

STUDY DESIGN

Patients who underwent TEVAR between 2006 and 2014 were identified by CPT codes in a 20% Medicare sample. Indication for aortic repair (aneurysm, dissection, trauma) was ascertained via ICD-9 codes. Follow-up was evaluated until 2015. Kaplan-Meier survival analysis and Cox regression were used to compare mortality, with reintervention and mortality rates expressed as a composite outcome in a hazard ratio with 95% confidence interval (hazard ratio [HR] 95% CI).

RESULTS

There were 3,095 patients who underwent TEVAR during the study period: 1,465 (47%) for aneurysm, 1,448 (47%) for dissection, and 182 (5.9%) for trauma. Mean patient age was 74.4 years, and 44.5% were female. Median follow-up was 2.7 years. The overall 30-day, 1-year, and 5-year, and 8-year survival rates were 93%, 78%, 49%, and 33%, respectively. Thirty-day mortality was highest in traumatic indications, but overall mortality was highest in patients undergoing TEVAR for aneurysm. Freedom from combined reintervention and mortality at 30 days, 1 year, 5 years, and 8 years was 89%, 73%, 43%, and 29%, respectively. Reintervention was highest in patients undergoing TEVAR for dissection (12.8%), followed by aneurysm (10.0%) and trauma (5.5%). Advanced age (HR 1.03 per year, 95% CI 1.02-1.03), congestive heart failure (CHF) (HR 1.48, 95% CI 1.33-1.65), dementia (HR 1.40, 95% CI 1.14-1.28), and rupture (HR 1.38, 95% CI 1.24-1.54) were associated with mortality.

CONCLUSIONS

Midterm survival is lower in patients who undergo TEVAR for dissection and aneurysm compared with trauma. Aneurysmal disease, advanced age, CHF, dementia, and aortic rupture are associated with mortality and reintervention in TEVAR.

Various Endoluminal Approaches Available for Treating Pathologies of the Aortic Arch

Open surgical repair of the aortic arch for degenerative aortic disease in an unfit patient is associated with significant morbidity and mortality. Endoluminal techniques have advanced over the last decade. Contemporary endovascular options including a hybrid approach (supra-aortic debranching and aortic stent graft), inner branched endograft, chimney stents, and scallop or fenestrated endografts are being used frequently as an alternative to open surgical arch repair. Understanding of the available endoluminal technology along with careful planning and effective teamwork is required to minimise complications associated with the endoluminal techniques, particularly neurological ones. Custom made techniques are superior to chimney or parallel technology in terms of their complications and durability. Integration of the protective devices such as embolic protection filters into stent design may reduce the risk of poor neurological sequelae. Long-term data are needed to assess the durability of these devices.

A New Clinically Driven Classification for Acute Aortic Dissection

Objectives: To report a new classification scheme for acute aortic dissection (AAD) that considers the aortic arch as a separate entity and integrates patterns of malperfusion syndrome (MPS). The proposed classification was evaluated retrospectively in a large population.

Materials and Methods: We retrospectively reviewed pre-therapy CT angiograms of 226 consecutive patients (mean ± SD age: 64 ± 12 years) with AAD. AADs were reclassified with a new classification scheme that included three aortic dissection types (A, involving at least the ascending aorta; B, involving exclusively the descending aorta; and C, involving the aortic arch with/without the descending aorta) and four malperfusion grades (0: no MPS; 1: dynamic MPS; 2: static MPS; 3: static and dynamic MPS). AAD features were assessed and correlated to patient outcomes.

Results: According to the new classification, we identified 152 type A dissections (92 A0, 11 A1, 38 A2, 11 A3); 50 type B (38 B0, 5 B1, 6 B2, 1 B3); and 24 type C (17 C0, 6 C2, 1 C3). Type C represented 11% of all AADs. MPS occurred in 39, 24, and 29% in type A, B, and C, respectively. Type C was treated with significantly more endovascular or hybrid interventions (37%) than in types A (3%) and B (20%) (p < 0.001).

Conclusion: The new AAD classification was feasible, and type C was easily identified (“non-A, non-B”). Preliminary findings supported the usefulness of this classification for the decision-making process and subsequent treatments.

Is the frozen elephant trunk technique justified for chronic type A aortic dissection in Marfan syndrome?

Background

Chronic type A aortic dissection (cTAAD) in Marfan syndrome (MFS) is rare. Surgical experience is limited and the role of frozen elephant trunk (FET) technique remains undefined. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and FET technique for cTAAD in MFS.

Methods

The clinical data of sixty-eight patients with MFS undergoing FET and TAR for cTAAD were analyzed.

Results

Mean age was 35.8±9.7 years and thirty-nine were male (57.4%). Operative mortality was 10.3% (7/68). Stroke occurred in one (1.5%), re-exploration for bleeding in five (7.3%), low cardiac output in four (5.9%), and acute renal failure in two (2.9%). Follow-up was complete in 100% (61/61) at mean 7.3±4.0 years. The false lumen was obliterated in 73.5% across FET and 50.0% in unstented descending aorta (DAo). Distal dilation occurred in twenty patients, six of whom underwent thoracoabdominal aortic replacement, one abdominal aortic replacement and one thoracic endovascular aortic repair (TEVAR). Late death occurred in five. At ten years, 59.8% were free from distal aortic dilation, and the incidences were 23.2% for death, 14.4% for distal reoperation, and 62.4% for reoperation-free survival. Predictors for operative mortality were extra-anatomic bypass [odds ratio (OR), 229.592; P=0.036], preoperative maximal size (DMax) of aortic sinuses (mm) (OR, 1.134; P=0.032) and cardiopulmonary bypass (CPB) time (minute) (OR, 1.061; P=0.041). Risk factors for aortic dilatation included patent false lumen at diaphragmatic hiatus [hazard ratio (HR), 5.374; P=0.008], preoperative DMax (mm) of proximal DAo (HR, 1.068; P=0.001) and renal arteries (HR, 1.102; P=0.005) which also predicted distal reoperation (HR, 1.149; P=0.001). The time from onset to operation (day) (HR, 1.002; P=0.004) and CPB time (minute) (HR, 1.032; P=0.036) predicted late death.

Conclusions

This study shows that the TAR and FET technique is a safe and durable approach to cTAAD in patients with MFS. The operation should be performed as early as possible to optimize clinical outcomes.

Endovascular management of chronic post-dissection aneurysms of the aortic arch

This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.

Homemade Fenestrated Stent-Grafts for Complete Endovascular Repair of Aortic Arch Dissections

Purpose: To evaluate outcomes of homemade fenestrated stent-grafts for complete endovascular aortic repair of aortic arch dissections. Materials and Methods: From July 2014 through September 2018, 35 patients (mean age 66±11 years; 25 men) underwent homemade fenestrated stent-graft repair of acute (n=16) or chronic (n=10) complicated type B aortic dissections (n=16) and dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections (n=9). Nineteen (54%) procedures were emergent. Results: Zone 2 single-fenestrated stent-grafts were used in 25 cases; the remaining 10 were double-fenestrated stent-grafts deployed in zone 0. Median time for stent-graft modification was 18 minutes (range 16–20). Technical success was achieved in all cases. An immediate distal type I endoleak was treated intraoperatively. Among the double-fenestrated stent-graft cases, the left subclavian artery fenestration could not be cannulated in 2 patients and revascularization was required. Partial coverage of the left common carotid artery necessitated placement of a covered stent in 3 cases. One (3%) patient had a stroke without permanent sequelae. Two type II endoleaks required additional covered stent placement at 5 and 7 days postoperatively, respectively. The 30-day mortality was 6% (2 patients with ruptured aortic arch aneurysm). During a mean follow-up of 17.6±13 months, there was no aortic rupture or retrograde dissection. One late type I endoleak was treated with additional proximal fenestrated stent-graft placement. One type II endoleak is currently under observation. One additional patient died (unrelated to the aorta); overall mortality was 9%. All supra-aortic trunks were patent. Conclusion: The use of homemade fenestrated stent-grafts for endovascular repair of aortic arch dissections is feasible and effective for total endovascular aortic arch repair. Durability concerns will need to be assessed in additional studies with long-term follow-up.

Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research

Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. The International Registry of Acute Aortic Dissection was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment. Since then, >7300 cases have been included from >51 sites in 12 countries. Although presenting symptoms and physical findings have not changed significantly over this period, the use of computed tomography in the diagnosis has increased, and more patients are managed with interventional procedures: surgery in type A AAD and endovascular therapy in type B AAD; with these changes in care, there has been a significant decrease in overall in-hospital mortality in type A AAD but not in type B AAD. Herein, we summarized the key lessons learned from this international registry of patients with AAD over the past 20 years.

Left ventricular remodeling in patients with acute type B aortic dissection after thoracic endovascular aortic repair: Short- and mid-term outcomes

BACKGROUND

Left ventricular (LV) remodeling remains unknown in patients with acute Type B aortic dissection (aTBAD) after thoracic endovascular aortic repair (TEVAR) during follow-up.

METHODS

Between May 2004 and January 2016, 163 consecutive patients (136 males, mean preoperative age: 51.06 ± 10.79 years) with aTBAD underwent TEVAR. A linear mixed model was used to evaluate risk factor influencing on LV remodeling and investigate longitudinal changes in LV thickness, diameter, volume, function and mass at preoperation, postoperation, short- and mid-term follow-up.

RESULTS

Median follow-up time was 48.0 months (quartiles 1-3, 31-84 months, maximum 147 months). LV thickness and mass followed a continuous downward trend over time. Interventricular septal thickness at end-diastole significantly decreased at mid-term follow-up (time, p < 0.001: preoperative 11.59 ± 0.14 mm vs mid-term 10.82 ± 0.15 mm, p < 0.001; postoperative 11.40 ± 0.14 mm vs mid-term 10.82 ± 0.15 mm, p = 0.006). LV posterior wall thickness at end-diastole was markedly reduced at mid-term follow-up (time, p < 0.001: preoperative 10.89 ± 0.11 mm vs mid-term 10.02 ± 0.11 mm, p < 0.001; postoperative 10.78 ± 0.13 mm vs mid-term 10.02 ± 0.11 mm, p < 0.001; short-term 10.56 ± 0.15 mm vs mid-term 10.02 ± 0.11 mm, p = 0.021). LV mass index markedly decreased during follow-up (time, p = 0.001: preoperative 129.60 ± 3.55 g/m² vs short-term 119.26 ± 3.19 g/m², p = 0.009; preoperative 129.60 ± 3.55 g/m² vs mid-term 115.79 ± 3.62 g/m², p = 0.003). LV function was improved, but not significantly so, during follow-up. Strict blood pressure control had no influence on LV remodeling. True lumen followed a continuous enlargement trend in terms of proximal thoracic aorta and celiac trunk level during follow-up.

CONCLUSIONS

TEVAR can reverse LV remodeling and LV hypertrophy in patients with aTBAD during follow-up.

SEALONE (Safety and Efficacy of Coronary Computed Tomography Angiography with Low Dose in Patients Visiting Emergency Room) trial: study protocol for a randomized controlled trial

Objective

Chest pain is one of the most common complaints in the emergency department (ED). Cardiac computed tomography angiography (CCTA) is a frequently used tool for the early triage of patients with low- to intermediate-risk acute chest pain. We present a study protocol for a multicenter prospective randomized controlled clinical trial testing the hypothesis that a low-dose CCTA protocol using prospective electrocardiogram (ECG)-triggering and limited-scan range can provide sufficient diagnostic safety for early triage of patients with acute chest pain.

Methods

The trial will include 681 younger adult (aged 20 to 55) patients visiting EDs of three academic hospitals for acute chest pain or equivalent symptoms who require further evaluation to rule out acute coronary syndrome. Participants will be randomly allocated to either low-dose or conventional CCTA protocol at a 2:1 ratio. The low-dose group will undergo CCTA with prospective ECG-triggering and restricted scan range from sub-carina to heart base. The conventional protocol group will undergo CCTA with retrospective ECG-gating covering the entire chest. Patient disposition is determined based on computed tomography findings and clinical progression and all patients are followed for a month. The primary objective is to prove that the chance of experiencing any hard event within 30 days after a negative low-dose CCTA is less than 1%. The secondary objectives are comparisons of the amount of radiation exposure, ED length of stay and overall cost.

Results and Conclusion

Our low-dose protocol is readily applicable to current multi-detector computed tomography devices. If this study proves its safety and efficacy, dose-reduction without purchasing of expensive newer devices would be possible.

Ascending aortic disease in a patient with Marfan Syndrome. Case report

La incidencia de síndrome de Marfan que ha sido reportada a nivel mundial es de 1 en 5000 casos, de los cuales aproximadamente el 80% o más desarrollan complicaciones cardiovasculares. La disección aórtica torácica aguda requiere una rotura en la íntima de la aorta, que forma parte del síndrome aórtico agudo. En la disección, la sangre pasa a través de la rotura y separa la íntima de la media o la adventicia, lo que crea una falsa luz intravascular. Un diagnóstico temprano incide directamente en las posibilidades de supervivencia, pues se trata de una  emergencia médica que puede llevar a la muerte, incluso con un tratamiento óptimo. Se presenta el caso de un hombre de 26 años con antecedente de síndrome de Marfan, dolor retro esternal lancinante, náusea, vómito, disnea de medianos esfuerzos que evolucionó a ortopnea, cianosis peribucal, soplo de insuficiencia aórtica y soplo sistólico mitral.Se realizaron estudios complementarios (radiografía de tórax, electrocardiograma, angiografía, tomografía, ecocardiograma) y se le diagnosticó disección de aorta ascendente tipo A Stanford, por lo que se decidió iniciar tratamiento quirúrgico mediante reemplazo de la raíz aórtica mediante prótesis compuesta y reconstrucción coronaria tipo Bentall y de Bono. En el procedimiento se presentó desestructuración de botón coronario derecho, por lo que fue necesario realizar puente venoso con hemoducto venoso de safena interno izquierdo. Se logró destete de circulación extra corpórea y luego se observó bajo gasto de carácter refractario (pese a soporte vasopresor a dosis máxima), fibrilación ventricular refractaria y asistolia; el paciente no mostró recuperación y falleció como consecuencia de un infarto agudo de miocardio transoperatorio. El tratamiento de la disección aórtica de aorta ascendente sigue siendo un desafío  terapéutico. El diagnóstico oportuno tiene relación directa con la esperanza de vida de quienes lo padecen, de ahí su importancia diagnóstica y su manejo.

Carotid Artery Dissection and Ischemic Stroke Originating from Localized Aortic Arch Dissection

Aortic dissection is an infrequent but important cause of acute ischemic stroke (AIS), and must not be overlooked because of a possible worse outcome, especially with the use of an intravenous recombinant tissue plasminogen activator. We report a case of left carotid artery dissection and AIS originating from localized aortic arch dissection, pathologically caused by cystic medial necrosis in the tunica media.

The new indication of TEVAR for uncomplicated type B aortic dissection

The classical therapeutic indication for type B aortic dissection is based on either medication or open surgery; medication therapy is recommended for relatively stable uncomplicated type B aortic dissection. With improvements in endovascular repair and the potential risk of disease progression, it is now necessary to evaluate the requirement for revision of the therapeutic choice of uncomplicated type B aortic dissection based on morphological features and time window. Data from 252 patients diagnosed as uncomplicated type B aortic dissection from 1992 to 2015 were analyzed retrospectively. Among these cases, 117 patients received medication therapy and 135 patients underwent endovascular repair. The 60-month survival rate in the endovascular group was higher than that in the medication group (92.3% vs 67.6%). According to the morphological evaluation, visceral artery involvement and false/true lumen ratios over 0.7 were strong risk factors for medical treatment alone. Increased surgical time and blood loss were found in patients treated in the chronic phase, compared with those who underwent endovascular repair within 14 days of the onset of symptoms. With improvements in aortic remodeling techniques, endovascular repair has been shown to improve long-term survival rates of patients with uncomplicated aortic dissection. Considering the potential risk of death, we recommend that patients with visceral artery involvement and a false/true lumen ratio over 0.7 should receive endovascular repair aggressively. Furthermore, delayed endovascular repair in the chronic phase does not improve the long-term outcome of uncomplicated type B aortic dissection.

Treatment of visceral malperfusion in acute type B aortic dissection by percutaneous endovascular fenestration using a stent, with additional stenting of the true lumen

Patients with acute type B aortic dissection (ABAD) are often treated medically. However, ABAD is a potentially serious emergency if complicated by acute organ ischemia. The therapeutic strategy for ABAD with visceral malperfusion remains controversial. Because emergent surgery has a high mortality rate, emergent endovascular treatment can be performed instead. We report a case of endovascular fenestration with stenting for visceral malperfusion in ABAD. One stent was inserted across the intimal flap to keep the fenestrated site open, and another stent was placed into the narrowed true lumen. This therapeutic strategy may be feasible for ABAD with acute malperfusion.

Best surgical option for arch extension of type B aortic dissection: the open approach

Arch extension of aortic dissection (AD) is reported to occur in 4-25% of patients presenting with acute type B AD. The DeBakey and Stanford classifications do not specifically account for this subset, however, recent studies have demonstrated that the prognosis of patients with arch extension in acute type B AD is virtually identical to that of others with type B AD. In this sense, it seems reasonable to extend the general management principles that are applied to classic acute type B AD even to patients with arch extension. This may be because even in patients with arch extension, most complications occur at locations distal to the arch, and therefore treatment of these patients is similar to that of complicated type B AD, namely thoracic endovascular aortic repair (TEVAR). Conversely, 10% of patients with acute type B AD and arch extension develop complications that are directly related to the arch pathology. This clinical scenario generally necessitates surgical arch repair through a sternotomy approach. The frozen elephant trunk technique combined with arch repair is a very reasonable option to treat this unique clinical entity that involves relatively distal locations of the aortic diseases. Combined arch and descending aorta replacement through thoracotomy is an alternative option particularly when the anatomical features of the target lesions are not suitable for a sternotomy approach or TEVAR. Nonetheless, the reported mortality associated with this approach has been exceedingly high. Hybrid arch repair is another consideration in treating these patients to reduce the treatment-related mortality and morbidity, especially when the arch pathology is limited to the distal part. Nevertheless, the safety and efficacy of this procedure in cases with more extensive arch involvement needs to be assessed in further studies in comparison with other treatment modalities.

Clinical features of acute aortic dissection from the Registry of Aortic Dissection in China

OBJECTIVE

To establish a systematic registry of aortic dissection in China, assess the clinical features of Chinese patients with acute aortic dissection (AAD), and compare our results with the data published by the International Registry of Acute Aortic Dissection (IRAD).

METHODS

We established the first Registry of Aortic Dissection in China (Sino-RAD) in 2011. Then we evaluated 1003 patients with AAD in Sino-RAD and compared our results with those reported by IRAD.

RESULTS

Compared with IRAD, the patients with AAD in Sino-RAD were significantly younger. Also, the ratio of male patients in Sino-RAD was significantly greater for the total cohort and the type A and B cohorts. The overall in-hospital mortality was 10.3% in Sino-RAD. For type A dissection, more patients in Sino-RAD received medical treatment and fewer received surgical treatment. The overall mortality, mortality of medical treatment, and mortality of surgical treatment was lower in Sino-RAD. In type B dissection, fewer patients in Sino-RAD received medical and surgical treatment and more received endovascular treatment.

CONCLUSIONS

The first Sino-RAD, including 15 large cardiovascular centers throughout China, was established. Our data were compared with those reported by IRAD. We found that, compared with Western populations, Chinese patients with AAD showed 6 differences, including earlier onset, more male patients, a low incidence of hypertension, a low incidence of chest pain, a high incidence of back pain, great differences in the choice of therapeutic strategies, and relatively low in-hospital mortality.

A Perspective on Natural History and Survival in Nonoperated Thoracic Aortic Aneurysm Patients

There are many questions that remain unanswered in the understanding of the natural history of thoracic aortic aneurysm (TAA). This review will critically appraise the current published evidence on the natural history of TAA in nonoperated patients and their present rates of survival.

Correlation between hemodynamic parameters and intra-arterial septum motion in DeBakey Type III aortic dissections using 2D pcMRI and 4D MRA

Outcome prediction in DeBakey Type III aortic dissections (AD) remains challenging. Large variations in AD morphology, physiology and treatment exist. A patient-specific approach towards a detailed understanding of the distinct features of each single case might be needed to account for this variation. In particular, an improved characterization of hemodynamic parameters in addition to geometrical quantities may yield deeper insight into this complex disease. Advances in cardiovascular magnetic resonance imaging (CMR) have resulted in pulse sequences that provide time-resolved information of blood velocities, aortic wall motion and, with the administration of exogenous intravenous contrast bolus, contrast passage timings. Here we provide a combined approach in a group of 10 AD patients using 2D phase contrast magnetic resonance imaging (2D pcMRI) and Time-resolved Angiography With Interleaved Stochastic Trajectories (TWIST) to quantify blood velocities, flow rates, maximum signal enhancement from exogenous contrast and time to maximum signal enhancement in the true lumen (TL) and false lumen (FL). The FL-TL dynamic pressure gradient was derived from 2D pcMRI velocity measurements. These hemodynamic parameters were correlated with dynamic parameters for the intra-arterial septum (IS) wall motion derived from 2D pcMRI. A strong positive correlation was found between the TL-FL dynamic pressure gradient and maximum IS extension (R=0.76) as well as with maximum IS contraction (R=-0.51) Taking the ratio of maximum extension to maximum contraction, the correlation increased to R= 0.81. The ratio of TL to FL volumetric flow rate showed a high correlation with the difference in FL-TL times to maximum enhancement (R=0.87) illustrating that higher flow in the TL will result in delayed contrast arrival in the FL and vice versa. Analogous, the TL to FL ratio of maximum enhancement correlated with the TL to FL ratio of the maximum volumetric flow rate (R=0.85). 2D pcMRI and 4D MRA in combination with exogenous intravenous contrast bolus allows characterization of hemodynamics in DeBakey type III AD. High correlations between IS wall motion, TL and FL pressure differences, flows and times to maximum enhancement were found. An extension of our analysis to follow-up imaging examinations are warranted to establish the potential for hemodynamic parameters determined with CMR as a marker for clinical outcome in longitudinal studies.

Preliminary findings in quantification of changes in septal motion during follow-up of type B aortic dissections

OBJECTIVE

To quantify longitudinal changes in intra-arterial septum (IS) motion with two-dimensional (2D) phase-contrast magnetic resonance imaging (2D pcMRI) in type B aortic dissections (AD) to improve the understanding of AD and its midterm development.

METHODS

From a database of 42 patients who underwent a dynamic magnetic resonance imaging (MRI) examination at the Acute Aortic Treatment Center of The Methodist DeBakey Heart & Vascular Center, 2D pcMRI image data was available from 10 patients with type B AD for both short-term (mean, 6.6 days; range, 1-10 days; n = 7) and midterm follow-up (mean, 155 days; range, 60-324; n = 5). IS motion was quantified as motion of IS boundary points averaged over the cardiac cycle. Relative change in IS motion was expressed as percent change compared with initial presentation. Maximum IS extension (true lumen [TL] expansion) and contraction (TL compression), IS fraction in phase with aortic flow and correlation of IS motion with aortic flow (IS compliance) were quantified.

RESULTS

IS motion at initial presentation was 0.68 ± 0.2 mm and was reduced at short-term (0.48 ± 0.3 mm; P = .07) and midterm (0.5 ± 0.2 mm; P = .1) follow-up. Trend in relative change of IS motion was variable during short-term follow-up: reduced in three subjects (-75% ± 6%) and elevated in four subjects (48% ± 23%). During midterm follow-up, relative change in IS motion was reduced in four subjects (28% ± 19%) and slightly elevated in one (6.2%). IS contraction decreased with follow-up while IS extension slightly increased. Fraction of IS moving in phase with aortic flow increased but IS compliance decreased, suggesting increasing IS stiffness.

CONCLUSIONS

Reduction of IS motion in AD is seen with short-term and midterm follow-up. Intersubject variability of this trend is high at short-term follow-up but low at midterm follow-up. Detailed analysis of IS motion parameters indicate reduction of IS contraction and IS compliance with time. This has potential implications for endovascular management of type B aortic dissections, as expansion of aortic stent grafts can be limited by a stiff IS.

Fever due to inflammation in acute aortic dissection: Description and proposals for diagnostic and therapeutic management

Few studies have investigated fever secondary to underlying acute aortic dissection. A retrospective analysis of 59 patients was carried out. Diagnostic criteria for fever secondary to underlying aortic dissection were defined. Five patients had a clinical presentation consistent with inflammatory fever due to acute aortic dissection. The main features were: fever occurred within the first 48 hours, the variability in body temperature was significantly less than with infectious fever (P=.015), episodes of fever did not affect the patient's general clinical condition, microbiological tests gave negative results, there was no response to empirical antimicrobial treatment, and fever disappeared within 24 hours in those treated with indomethacin. In conclusion, fever due to acute aortic dissection has distinct characteristics that enable it to be distinguished from infectious fever. Good management of this condition should not involve unnecessary diagnostic tests, the inappropriate use of antimicrobials, or a delay in applying the therapeutic measures necessary to treat the underlying aortic dissection.

Peak C-Reactive Protein Level Predicts Long-Term Outcomes in Type B Acute Aortic Dissection

Acute aortic dissection (AAD) is associated with an inflammatory reaction, as evidenced by elevated inflammatory markers, including C-reactive protein (CRP). The association between the peak CRP level and long-term outcomes in type B AAD has not been systematically investigated. The purpose of this study was to investigate whether the peak CRP level during admission predicts long-term outcomes in type B AAD. We conducted a clinical follow-up study of type B AAD. We divided the study population into 4 groups according to the tertiles of peak CRP levels (T1: 0.60 to 9.37 mg/dL; T2: 9.61 to 14.87 mg/dL; T3: 14.90 to 32.60 mg/dL; and unavailable peak CRP group). Multivariate Cox regression analysis was applied to investigate whether the tertiles of peak CRP predict adverse events even after adjusting for other variables. A total of 232 type B AAD patients were included in this analysis. The median follow-up period was 50 months. CRP reached its peak on day 4.5±1.7. Mean peak CRP values in T1, T2, and T3 were 6.4±2.4, 12.0±1.5, and 19.5±4.0 mg/dL, respectively. There were 65 events (39 deaths and 26 aortic events) during the follow-up. T3 and T2 (versus T1) were strong predictors of adverse events (T3: hazard ratio: 6.02 [95% CI: 2.44 to 14.87], P =0.0001; T2: hazard ratio: 3.25 [95% CI: 1.37 to 7.71], P =0.01) after controlling for all of the confounding factors. In conclusion, peak CRP is a strong predictor for adverse long-term events in patients with type B AAD.