The future of stenting in patients with type A aortic dissection: a systematic review

Endovascular Intervention for Aortic Dissection Is "Ascending"

Ascending aorta diseases represent an important cause of mortality worldwide. Notably, acute and chronic thoracic aorta pathologies have increased during the last years, but medical therapy does not seem to influence their natural history. Currently, although open surgery is the first choice of treatment, many patients are still rejected or have poor outcomes. In this scenario, endovascular treatment is raised as a valuable option. In this review we describe the limitations of conventional surgery and the state-of-art of endovascular ascending aorta repair.

ARISE: First-In-Human Evaluation of a Novel Stent Graft to Treat Ascending Aortic Dissection

BACKGROUND

Operative mortality for type A aortic dissection is still 10-20% at centers of excellence. Additionally, 10-20% are not considered as viable candidates for open surgical repair and not offered life-saving emergency surgery. ARISE is a multicenter investigation evaluating the novel GORE® Ascending Stent Graft (ASG; Flagstaff, AZ).

OBJECTIVE

The purpose of this study is to assess early feasibility of using these investigational devices to treat ascending aortic dissection.

METHODS

This a prospective, multicenter, non-randomized, single-arm study that enrolls patients at high surgical risk with appropriate anatomical requirements based on computed tomography imaging at 7 of 9 US sites. Devices are delivered transfemorally under fluoroscopic guidance. Primary endpoint is all-cause mortality at 30 days. Secondary endpoints include major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, 6 months, and 12 months.

RESULTS

Nineteen patients were enrolled with a mean age of 75.7 years (range 47-91) and 11 (57.9%) were female. Ten (52.6%) had DeBakey type I disease, and the rest were type II. Sixteen (84.2%) of the patients were acute. Patients were treated with safe access, (7/19 (36.8%) percutaneous, 10/19 (52.6%) transfemoral, 2/19 (10.5%) iliac conduit), delivery, and deployment completed in all cases. Median procedure time was 154 mins (range 52-392) and median contrast used was 111 mL (range 75-200). MACCE at 30 days occurred in 5 patients including mortality 3/19 (15.8%), disabling stroke in 1/19 (5.3%), and myocardial infarction in 1/19 (5.3%).

CONCLUSION

Results from the ARISE early feasibility study of a specific ascending stent graft device to treat ascending aortic dissection are promising.

A three-dimensional biomodel of type A aortic dissection for endovascular interventions

Thoracic endovascular aortic repair is widely used for type B aortic dissection. However, there is no favorable stent-graft for type A aortic dissection. A significant limitation for device development is the lack of an experimental model for type A aortic dissection. We developed a novel three-dimensional biomodel of type A aortic dissection for endovascular interventions. Based on Digital Imaging and Communication in Medicine data from the computed tomography image of a patient with a type A aortic dissection, a three-dimensional biomodel with a true lumen, a false lumen, and an entry tear located at the ascending aorta was created using laser stereolithography and subsequent vacuum casting. The biomodel was connected to a pulsatile mock circuit. We conducted four tests: an endurance test for clinical hemodynamics, wire insertion into the biomodel, rapid pacing, and simulation of stent-graft placement. The biomodel successfully simulated clinical hemodynamics; the target blood pressure and cardiac output were achieved. The guidewire crossed both true and false lumens via the entry tear. The pressure and flow dropped upon rapid pacing and recovered after it was stopped. This simulation biomodel detected decreased false luminal flow by stent-graft placement and detected residual leak. The three-dimensional biomodel of type A aortic dissection with a pulsatile mock circuit achieved target clinical hemodynamics, demonstrated feasibility for future use during the simulated endovascular procedure, and evaluated changes in the hemodynamics.

Case report: Diagnosis and emergency surgery on a young patient with extensive aortic dissection without any risk factors

Background

Type A aortic dissection is a very dangerous, fatal, and emergency condition for surgery. Acute aortic dissection is a rare condition, such that many patients will not survive without reconstructive surgery.

Case presentation

We present a case 24-year-old male who came with symptoms of shortness of breath and cough. The patient underwent ECG, chest radiology, and ultrasound, where the patient was found to have right pleural effusion while his ECG was normal. In the history taken from the patient, he had no underlying disease, no history of heart diseases in his family. For a better diagnosis, ETT and aortic CT angiography was performed on the patient which confirmed the evidence of dissection. Immediately after the diagnosis, necessary arrangements were made for open heart surgery and the patient was prepared for surgery. The patient was admitted in the cardiac surgery ICU for 5 days and his medication was carefully administered. After the conditions were stabilized, the patient was transferred to the post-cardiac surgery ICU ward. The patient was discharged from the hospital one week after the surgery and returned to the office as an OPD one week after his discharge.

Conclusion

Various risk factors can play a role in creating aortic dissection. Therefore, it is necessary to pay attention to patients’ history for achieving a quick and definitive diagnosis. Therefore, to control the complications of placing the cannula as well as the duration of the surgery, it is very important to reduce the duration of pumping on the patient and to be very careful during the cannula placement.

The Role of Thoracic Endovascular Aortic Repair (TEVAR) of Thoracic Aortic Diseases in Patients with Connective Tissue Disorders - A Literature Review

OBJECTIVE

To review the currently available literature to define the role of thoracic endovascular aortic repair (TEVAR) in patients with connective tissue disorders (CTD).

METHODS

A comprehensive electronic database search was performed in PubMed, SCOPUS, Embase, Google scholar, and OVID to identify all the articles that reported on outcomes of utilizing TEVAR in patients with CTD during elective and emergency settings. The search was not limited to time or language of the published study.

RESULTS

All the relevant studies have been summarized in its correspondence section. The outcomes were analyzed in narrative format. The role of TEVAR has been elaborated as per each study. Currently, there is limited large cohort size studies outlining the use of TEVAR in patients with CTD. The use of endovascular repair in patients with CTD is limited due to progressive aortic dilatations and high possibility of further reinterventions at later stage of life.

CONCLUSION

Open repair remains the gold standard method of intervention in young patients with progressive CTD, especially in the setting of acute type A aortic dissection. However, TEVAR can be sought as a reliable alternative in emergency setting of diseases involving the descending thoracic aorta; yet the long-term data needs to be published to support such practice.

Pregnancy and cardiac interventions: What are the optimal management options?

Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.

Thoracic Aortic Aneurysm Surgery in Marfan Patients: a Perspective from the UK

Objective

Cardiovascular complications in Marfan patients include progressive aortic root dilation which can precipitate acute aortic dissection, ruptured aorta, severe aortic regurgitation, or all the aforementioned. Such complications can be fatal and the cause of death prior to any surgical intervention. We set out to identify the Marfan population in England and Wales and present their surgical outcomes.

Methods

A total of 306 patients with Marfan syndrome who underwent aortic root surgery were identified between April 2007 and March 2013 from NICOR database. We examined the perioperative characteristics of such cohort along with in-hospital outcomes and survival.

Results

Root and ascending segment procedures on Marfan patients performed in 3.3% of the total cohort by NICOR root surgery patients. The median reported age was 40 years (IQR = 29-49 years) and 100 (32.7%) were female. Of the patients analysed, 17.3% were treated non-electively and 68.6% of them received concomitant valve procedure. The in-hospital mortality was 2.0%. Reoperation for bleeding was required in 8.2% of patients and 1.3% of them suffered a cerebrovascular accident (CVA). Mortality at 1 year was reported as 5.5%.

Conclusion

The outcomes of surgery on the root and ascending aorta in Marfan patients in the United Kingdom are satisfactory; however, the overall complexities of this patient population are not well understood and would benefit from further investigations.