Complicated Acute Type Research Articles

Is TEVAR with Full Petticoat Technique Effective for Complicated Acute Type B Dissection Cases?

Treatment by thoracic endovascular aortic repair (TEVAR) for type B dissection has improved outcomes. We tried the procedure named “Full Petticoat technique” in which the proximal entry tear was excluded with a covered stent and extended bare metal stents were placed to the aortic bifurcation for three complicated type B dissection cases with dynamic obstruction of the common iliac artery. Follow-up computed tomography revealed favorable aortic remodeling in which the true lumen was expanded. The short-term result of this procedure has shown acceptable aortic remodeling. The significance of this procedure is still unknown in the long term; hence long-term follow-up is necessary to completely understand the usefulness of this technique.

Graft Replacement of Kommerell Diverticulum and In Situ Aberrant Subclavian Artery Reconstruction

This study aimed to evaluate the early and long-term outcomes of graft replacement of Kommerell diverticulum and in situ reconstruction of aberrant subclavian arteries in adults. Seventeen patients, 6 symptomatic and 11 with right aortic arch, underwent open repair of Kommerell diverticulum from October 1999 to September 2017. Two of these patients underwent open surgical treatment of a ruptured aneurysm. Surgical indications were dilatation of Kommerell aneurysm (n= 9), the presence of a nondissecting aneurysm with Kommerell diverticulum (n= 6), acute type A aortic dissection (n= 1), and complicated acute type B aortic dissection (n= 1). Ten patients underwent total arch replacement and descending aorta replacement through a thoracotomy. Five patients underwent arch replacement and in situ reconstruction through a median sternotomy. All patients except 1 also underwent in situ reconstruction of their aberrant subclavian artery. In-hospital death occurred in 1 patient (5.9%), who underwent total arch replacement for a ruptured aneurysm. Permanent neurologic deficit did not occur in any patient, whereas transient neurologic deficit occurred in 2 patients (11.8%). Five- and 10-year survival rates were 85.2 ± 9.8% and 75.8 ± 12.5%, respectively. There was no symptom recurrence or stenosis of the reconstructed subclavian arteries. Early outcomes of graft replacement of Kommerell diverticulum and in situ aberrant subclavian artery reconstruction were acceptable. As for long-term outcomes, symptomatic improvement and an excellent patency rate among reconstructed aberrant subclavian arteries suggest that in situ surgical repair is an effective treatment option.

In Situ Laser Fenestration for Arch Branch Revascularization During Emergent Thoracic Endovascular Aortic Repair: Effective and Durable

Retrograde in situ laser fenestration of the left subclavian artery (LSA) or common carotid artery during emergent thoracic endovascular aortic repair (TEVAR) is an innovative method to revascularize arch branches for diverse thoracic aortic diseases. This study provides an update on our expanded experience with extended follow-up to determine the efficiency and durability of this technique. Patients who underwent TEVAR with aortic arch branch revascularization from 2009 through 2018 were retrospectively reviewed. After TEVAR, the endograft was deployed over a branch orifice, in situ retrograde laser fenestration was performed through retrograde access, and a balloon-expandable covered stent was deployed in the LSA or common carotid artery. Postoperative imaging with computed tomography angiography was performed to assess branch patency, endoleaks, and fenestration-related reinterventions. TEVAR with laser fenestration was successfully performed in 60 patients (38 men; mean age, 61 years) in an urgent or emergent setting for diverse thoracic aortic diseases including 16 ruptures. Seventeen had acute complicated type B aortic dissection, 15 had intramural hematoma, and 17 had chronic dissection. TEVAR was done in zone 0 in 2 patients, in zone 1 in 7 patients, and in zone 2 in 51 patients. A balloon-expandable covered stent was placed across the fenestration into 56 LSAs, 3 left coronary arteries, and 1 right coronary artery. Mean length of stay was 9 days. Mean follow-up was 2.44 years. In-hospital mortality was 8.3%. Stroke rate was 3.3% (2/60), and three had permanent paraplegia. Follow-up computed tomography angiography demonstrated 100% primary patency of branch stents. There was no type III endoleak, but three type IC endoleaks required early coiling (one) and late restenting (two) for a 5.45% fenestration-related major reintervention rate. In situ retrograde laser fenestration is a rapid, effective, and durable method to revascularize arch branches during emergent TEVAR. The high technical success, low fenestration-related morbidity and reintervention rate, and excellent branch stent patency support use of this versatile technique.

Late Aortic Remodeling after Endovascular Repair of Complicated Type B Aortic Dissection—TEVAR Protects Only the Covered Segment of Thoracic Aorta

TEVAR is the preferred way of treatment of complicated type B aortic dissection. The purpose of the study was to assess the impact of TEVAR on aortic remodeling in the thoracic and abdominal segment in long-term follow-up. Twenty-three patients with complicated type B aortic dissection were treated by TEVAR in years 2004-2012 in our department. Aortic remodeling was rated based on preoperative and final follow-up computed tomography angiography. Aorta was measured at the level of left bronchus, the diaphragm, celiac trunk, and the aorta below the renal arteries. Diameter of the aorta (da), total aortic area (taa), true lumen area (tla), and false lumen area (fla) were measured. Primary technical success was obtained in 100%. Primary clinical success rate was 82.6%. Early mortality was 13% (3 patients). Mean follow-up was 57.9months (26-123; standard deviation, ±30.5). All patients remain in the follow-up. Diameter of the aorta increased significantly only at the B level-from baseline 35,6mm to 40,5mm in the follow-up (P=0.005). Total aortic area (taa) was stable only at the A level but increased significantly at the B, C, and D levels. Area of the true lumen (tla) increased significantly at A, B, C, and D levels; area of false lumen (fla) decreased significantly at A and B levels, but the area of false lumen (fla) did not change at C and D levels. TEVAR for complicated acute aortic type B dissection is a safe and effective method of protecting thoracic aorta. The procedure was effective in majority of patients, and in 80% of the cases, there was no need for additional distal aortic coverage. The abdominal aorta is relatively stable over a long period of observation in complicated type B aortic dissection.

Bare Metal Stent Use in Type B Aortic Dissection May Offer Positive Remodeling for the Distal Aorta

Thoracic endovascular aortic repair is increasingly used in acute complicated type B aortic dissection. The objective of this study was to demonstrate evidenceof aortic remodeling by using a Proximal ExTension to Induce COmplete ATtachment (PETTICOAT) system in patients with acute complicated type B aortic dissections. From 2013 to 2016, 213 patients with type B aortic dissection were seen at our institution. A total of 33of those patients underwent thoracic endografting forcomplicated acute type B aortic dissection. Of these patients, 12 underwent standard thoracic endovascular aortic repair (standard group), and 21 had an additional bare metal stent distal to the covered endograft (PETTICOAT group). Aortic dimensions were measured on the basis of on three-dimensional computed tomographic scans on discharge and at 6 months. There were no differences in baseline characteristics between the standard group and the PETTICOAT group. At 6 months, both the PETTICOAT and standard groups had significant change in aortic diameter, true lumen diameter, and true lumen ratio throughout the thoracoabdominal aorta demonstrating positive remodeling. The change in true lumen ratio was significantly greater at the level of the celiac artery with the PETTICOAT system when compared with the standard group. The use of a PETTICOAT concept with an addition of a bare metal stent distal to the proximal thoracic endograft offers positive aortic remodeling in the thoracoabdominal aorta at 6 months.

Surgery for Acute Presentation of Thoracoabdominal Aortic Disease

Thoracoabdominal aortic aneurysms are most commonly asymptomatic until there is either an impending aortic catastrophe or one that has already occurred. While open surgery remains the gold-standard method for repair, modern technology has led to the development of less invasive endovascular devices and techniques. We provide an expert review of open and endovascular therapies for 3 highly lethal thoracoabdominal aortic emergencies in order to highlight expectations for both short- and long-term outcomes in an era of evolving technology and improvements in patient evaluation and postoperative care. Open repair of ruptured thoracoabdominal aortic aneurysms is associated with a dramatic increase in all postoperative complications, even in specialized aortic surgery centers. Mycotic thoracic aortic aneurysms are highly lethal if surgical treatment is not initiated quickly as they have a propensity toward rapid growth and fatal rupture. Thoracic endovascular aortic repair is well-suited for the treatment of acute complicated type B aortic dissection with outcomes superior to open repair in some centers. Acute aortic events associated with thoracoabdominal aneurysms represent technically challenging situations that require rapid diagnosis and treatment to avoid a fatal outcome. Endovascular techniques have evolved as a viable alternative therapy for acute complicated type B aortic dissection or as a bridge to more definitive repair in the setting of infection or rupture.

When Surgeons Create Their Own Tools!

In their paper, El Batti et al. proposed an experimental evaluation of endovascular fenestration scissors in an ovine model of aortic dissection.1El Batti S. Ben Abdallah I. Dufetelle E. Julia P. Menasche P. Alsac J.M. Experimental evaluation of endovascular fenestration scissors in an ovine model of aortic dissection.Eur J Vasc Endovasc Surg. 2018; 56: 373-380Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar This is a really interesting study that opens the doors to a new technique for treating patients and also for involving surgeons in creating the tools they actually need. The authors proposed a new device that may allow easier and safer endovascular fenestration than the usual technique that uses a sheath over two stiff wires to create a “scissor/fork” effect.2Alomran F. Alsac J.M. Distal endovascular fenestration inside thoracic exclusion: the DEFINITE technique for complicated acute type B dissections.Eur J Vasc Endovasc Surg. 2017; 53: 103Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Contrary to this “sheath over two wires,” they proposed a new innovative device consisting of “endo-scissors” comparable with those used in open surgery. Theoretically, endo-scissors should provide sharp cuts and avoid folding and tearing of the flap. It appears logical to compare both methods and prove the efficiency of the new device. More in depth preliminary in vitro tests could have been performed to evaluate the capabilities of the new device to cut materials of different thicknesses or densities and focus in vivo on the optimal device prototype. Moreover, it would have been very interesting to know the differences the authors may have noticed concerning ease of cutting, quality of cutting such as torn area or regular cut, as well as the ability to control the quality of the procedure under X-ray. The authors included in their study a haemodynamic evaluation of flap resection in the ovine dissection model they developed. Several models of aortic dissection have already been developed, but haemodynamic evaluation has been doubtful: dissection flaps were often unpredictable and inconsistent, either being very short in length or with undefined propagation and low reproducibility, in subsequent experiments.3Qing K.X. Chang Y.C. Lau S.F. Yiu W.K. Ting A.C. Cheng S.W. Ex-vivo haemodynamic models for the study of Stanford type B aortic dissection in isolated porcine aorta.Eur J Vasc Endovasc Surg. 2012; 44: 399-405Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar In their paper, El Batti et al. assessed the validity of the model using haemodynamic criteria, giving pressure values in both lumens and their change after fenestration. It may be criticised that the relatively short and small channel of dissection did not include visceral artery ostia, however, the model appeared to allow testing of endovascular fenestration scissors, even if it is unlike human pathology and does not allow valid conclusions concerning haemodynamic evaluation. In conclusion, this study is the perfect example of what should be a surgeon driven device to answer a clinical issue. The paper demonstrates how translational research and surgeon's involvement can lead to advances in our daily practice.4Vega de Ceniga M. Chakfé N. Back to the future.Eur J Vasc Endovasc Surg. 2018; 55: 453-454Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Experimental Evaluation of Endovascular Fenestration Scissors in an Ovine Model of Aortic DissectionEuropean Journal of Vascular and Endovascular SurgeryVol. 56Issue 3PreviewTo evaluate the experimental feasibility of endovascular fenestration using specific endovascular scissor prototypes in an ovine model of acute aortic dissection (AD). Full-Text PDF Open Archive

Temporal and Morphological Patterns Predict Outcome of Endovascular Repair in Acute Complicated Type B Aortic Dissection

The aim was to analyse early and late outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for acute or subacute non-traumatic type B aortic dissection (TBAD), with the particular aims of identifying prognostic morphological predictors, and to assess the magnitude of the impact of the timing of TEVAR. This was a retrospective, two centre, population based consecutive case series. The study group consisted of all the 53 patients undergoing TEVAR for complicated TBAD in Stockholm during the 12 year period 2004-2015. Demographic data, risk factors, operative, and outcome variables were registered and analysed. The CT scans were thoroughly retrospectively examined. Nearly half (24 patients; 45%) underwent TEVAR within 48h of the onset of the initial symptoms, another 20 within 2 weeks, and nine in the subacute phase (15-90 days). The median age was 63 years (range 32-88) and 20 patients (38%) were women. The 30 day mortality was 17% (nine patients). Eight of these nine patients were treated within the first 48h; urgent intervention (0-48h) was associated with increased mortality (crude OR 14.0; 95% CI 1.6-122). All the nine patients had a false lumen area (FLA) at the level of the tracheal bifurcation exceeding 50% of the aortic cross sectional area at that segment, a finding significantly associated with increased mortality (p=.04), with a 25% 30 day mortality if the FLA>50% (n=36) at that segment, but 0% if the FLA was <50%. Overall the one year survival was 79% and five year survival 65%. All the early deaths demonstrated a FLA >50% of the total aortic cross sectional area at the level of the tracheal bifurcation. Patients needing urgent TEVAR had markedly worse outcome. The first finding may become an additional tool for future risk stratification.

Severe Hypoglycemia (SH) and Diabetic Ketoacidosis (DKA) Hospitalization Rates—Twenty-Five Years in the Epidemiology of Diabetes Complications (EDC) Study

SH and DKA are common serious acute complications of type 1 diabetes (T1D), but whether rates have changed with recent improvements in diabetes management is not clear. We, thus examined data from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study of childhood onset T1D (mean age 28 and duration 19 years, n=658) to determine if the hospitalized rates of SH and DKA have changed over 25 years of follow-up. Participants reported hospitalizations at each biennial survey for the prior 5 years (1986-1988, 2012-2014) or prior 3 years (1996-1998, 2004-2006). Rates per 100 person years for SH and DKA were then calculated by dividing the total number of self-reported SH or DKA admissions by the total appropriate accumulated person years of reporting at each follow-up. Hospitalization rates for SH declined after 1996-1998 with a fall in HbA1c suggesting better overall management. The DKA hospitalization rate was consistent throughout the follow-up. The factors underlying these encouraging trends require further investigation and survival bias cannot be excluded. Disclosure G. Pambianco: None. T.J. Orchard: None.

A New Adjustable Puncture Device for In Situ Fenestration During Thoracic Endovascular Aortic Repair

Purpose: To describe a new adjustable puncture system for in situ fenestration in thoracic endovascular aortic repair (TEVAR). Technique: An adjustable puncture needle for use in conjunction with a steerable 8-F, 55-cm Fustar sheath is demonstrated in a 65-year-old man with acute complicated type B dissection involving the left subclavian artery (LSA). The puncture device features an inflatable balloon at the tip, a central lumen for 0.018-inch guidewires, and a 3-level puncture depth. After thoracic stent-graft deployment at zone 2, the needle/sheath combination was delivered from a left brachial artery access. The needle was adjusted perpendicular to the fabric of the stent-graft with the assistance of the steerable sheath. The balloon at the tip was inflated to center the needle, and the puncture depth was selected on the puncture needle system. Holding the sheath and puncture needle together, a hole was created in the graft fabric. The aperture was sequentially dilated to accommodate the mating stent selected to maintain perfusion to the LSA. This new device has been successfully applied in 6 patients treated with TEVAR for different arch pathologies. Conclusion: This new puncture device could assist in situ fenestration and improve the technical success rate.

Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome: Midterm outcomes and aortic remodeling

ObjectiveThe study objective was to assess the midterm outcomes and aortic remodeling in patients with Marfan syndrome with complicated acute type B aortic dissection treated with stent-assisted, balloon-induced intimal disruption and relamination. MethodsWe reviewed all patients treated with stent-assisted, balloon-induced intimal disruption and relamination for a complicated acute type B aortic dissection associated with Marfan syndrome according to the revised Ghent criteria. ResultsBetween 2015 and November 2017, 7 patients with Marfan syndrome underwent stent-assisted, balloon-induced intimal disruption and relamination for a complicated acute type B aortic dissection. The median age of patients was 47 years (range, 23-70). Four patients had a history of aortic root replacement. Technical success was achieved in 100%. Three patients required an adjunctive procedure for renal artery stenting (n = 2) and iliac artery stenting (n = 1). There was no in-hospital death, 30-day postoperative stroke, spinal cord ischemia, ischemic colitis, or renal failure requiring dialysis. At a median follow-up of 15 months (range, 7-28), 1 patient required aortic arch replacement for aneurysmal degeneration associated with a type Ia endoleak at 2 years, giving a late reintervention rate of 14%. There was no other secondary endoleak. The primary visceral patency rate was 100%. There were no all-cause deaths reported. At last computed tomography scan, all patients had complete aortic remodeling of the treated thoracoabdominal aorta. Distally, at the nonstented infrarenal aortoiliac level, 6 patients had persistent false lumen flow with stable aorto-iliac diameter in 5. One patient had iliac diameter growth (27 mm diameter at last computed tomography scan). ConclusionsStent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome is feasible, safe, and associated with an immediate and midterm persisting thoracoabdominal aortic remodeling.

Frozen Elephant Trunk for Acute Type B Dissection Involving the Distal Arch in the Hybrid Repair Era

Hybrid repair of complicated acute type B aortic dissection (ATBAD) with aortic arch involvement is associated with a high rate of endoleak, stroke, and retrograde aortic dissection. Optimal management of this lesion remains uncertain. In this hybrid repair era, surgical results of ATBAD with distal aortic arch involvement using a frozen elephant trunk procedure with transposition of the left subclavian artery (LSCA) to left common carotid artery (LCCA) is reported. From April 2011 to April 2016, 53 patients with complicated ATBAD with distal aortic arch involvement underwent a frozen elephant trunk procedure with LSCA-LCCA transposition. Preoperative organ malperfusion included renal ischemia in 10 subjects, renal infarction in 2, lower limb ischemia in 6, and visceral ischemia in5. There was no inhospital death. Continuous renal replacement therapy was required in 1 patient. Permanent neurologic injury was observed in 1 patient and temporary neurologic dysfunction in 1 patient. Ischemia of the lower limb and viscera was ameliorated after frozen elephant trunk implantation. During follow-up, thoracoabdominal aortic replacement was required in 1 patient, and the Wheat procedure in 1 other patient. The patency rate of the anastomotic sitebetween the LSCA and LCCA was 100%, and shrinkage of the descending aorta occurred in 90.4% of patients (47 of 52) as demonstrated by computed tomography. Open repair of ATBAD with distal aortic arch involvement using the frozen elephant trunk procedure with LSCA-LCCA transposition obtained satisfactory outcomes. Avoidance of complications using hybrid repair, good postoperative recovery, and a low prevalence of late reintervention were achieved. The satisfactory results favored this technique for this lesion in this hybrid repair era.

TCTAP C-182 Rescue Intervention After Three Days of Renal Ischemia Caused by Acute Complicated Type B Aortic Dissection

TCTAP C-182 Rescue Intervention After Three Days of Renal Ischemia Caused by Acute Complicated Type B Aortic Dissection

Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection.

Type B aortic dissection is a life-threatening acute aortic condition often with acute ischemic signs or symptoms. With initial management focusing on alleviating malperfusion and pain, and avoiding propagation of dissection or rupture both systolic blood and pulse pressure should be reduced initially by an aggressive medical approach. In the setting of persistent signs of complications endovascular strategies have replaced open surgery and led to a fourfold increase in early survival and better long-term outcomes. An electronic health database search was performed on articles published between January 2006 and July 2017. Publications were included in this review if (I) the index aortic pathology was type B aortic (distal) dissection; (II) when medical management, open surgical replacement or thoracic endovascular aortic repair were among those options; (III) when at least one of all basic outcome criteria such as survival, spinal cord ischemia and cerebrovascular accident was reported; (IV) when ≥15 serial patients were included. A total of 62 studies were eligible and analysed. Our manuscript has summarized data collected over 12 years on management specific outcomes in the setting of distal aortic dissection and provides an up-to-date interpretation of the published evidence. For complicated cases, treated acutely, the 30-day or in-hospital mortality was 7.3% when managed by endovascular means, whereas the pooled rate for 30-day or in-hospital mortality was 19.0% when subjected to open repair. For acute uncomplicated type B dissection usually treated with blood pressure lowering medications, the pooled 30-day or in-hospital mortality rate was 2.4%. Survival rates at 5 years averaged at 60% (40% mortality). Freedom from any aortic event ranged from 34.0% to 83.9%, underlining an inherent risk of progression and late complications. For chronic complicated type B dissection, the rates of stroke, paraplegia and operative mortality following endovascular repair ranged from 5% to 13%, 2% to 13% and 2 to 13%, respectively, while 5-year survival rates after open repair ranged from 60% to 90%. In chronic uncomplicated type B dissection almost 90% of patients survive initial hospitalization and were subjected to medical management with a 5-year survival of 50-80%. However, up to 20-55% of medically treated patients develop aneurysmal degeneration after 5 years with an unknown risk of rupture. Currently, the less invasive strategy of endovascular repair (as compared to open surgery) provides improved 30-day or in-hospital survival in the setting of complicated acute type B aortic dissection and may seek broad application. Open surgical aortic reconstruction should be left to experienced aortic centres if endovascular management is not an option.

TEVAR for Acute Complicated Type B Aortic Dissection

Thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of descending thoracic aortic aneurysms and has become the standard of care for treatment of type B aortic dissection complicated by organ malperfusion or rupture. Coverage of the primary intimal tear by the endograft eliminates antegrade false lumen perfusion and diverts all blood flow into the true lumen. This results in true lumen expansion and false lumen reduction and/or obliteration. In cases of dynamic malperfusion, TEVAR alone will resolve endorgan ischemia. Additional branch vessel stenting is required for cases of static malperfusion. A reproducible percutaneous method of TEVAR is described in which thoracic aortic stent grafting is performed from the left subclavian artery to the celiac artery with the use of intravascular ultrasound to repair acute type B aortic dissection. Salient technical aspects are described with illustrations demonstrating the key procedural steps.

Recent evolution in use and effectiveness in mainland China of thoracic endovascular aortic repair of type B aortic dissection

A meta-analysis was performed on 175 studies selected among those published in mainland China between 2008 and 2015 on thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (AD). Most TEVAR were performed in Shanghai, Beijing, Hubei and Guangdong in patients with mean age of 53.9 years, and acute (70%) or chronic (30%) type B AD. Procedural success rate was 99.1 ± 0.8%. Major complication rate was 1.7 ± 2.3%, with paraplegia in 0.4 ± 0.0%. Overall in-hospital mortality rate was 1.6 ± 0.9% with AD rupture in 30% (about 40% during first postoperative day); follow-up mortality rate was 2.3 ± 1.1%, with AD rupture in 39.2% (50% within first year). Compared with 2001–2007 data from China, there appeared to be improvement in rates of major complications, paraplegia and in-hospital mortality. Compared with 1999–2004 Western data, rates of procedural success, stroke, and paraplegia appeared similar, while those for major complications, in-hospital mortality, retrograde type A dissection and follow-up mortality appeared lower. Compared with more recent Western data (2006–2013) on acute complicated type B AD, stroke, paraplegia, in-hospital mortality and follow-up mortality appeared lower. Therefore, in mainland China, safety for TEVAR of type B AD appeared better between 2008 and 2015 than in previous periods in China or Western countries.

Management strategies in acute type B aortic intramural hematoma.

Intramural hematoma (IMH) is one of the acute aortic syndromes. IMH was originally noted as an 'aortic dissection without intimal tear.' It had been speculated that IMHs were caused by ruptured vasa vasorum in the aortic media and distinguished from classical aortic dissections. However, the majority of IMHs are now detected with an intimal defect using high-resolution computed tomography, which implies that IMHs may be a subset of aortic dissections with very limited flow in the false lumen. Management of IMHs had been controversial, but guidelines published in the early 2010 s recommend treating IMHs as classical aortic dissections: surgical repairs were indicated for type A IMHs; complicated acute type B IMHs were treated with endovascular or open repairs and uncomplicated type B IMHs were to be managed with antiimpulse therapy and close surveillance. To date, based on the favorable long-term outcomes of preemptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissections, early TEVAR for uncomplicated type B IMHs has been attempted. In this review, we describe the pathophysiology and management strategies for acute IMHs. IMHs have intimal tears or disruptions in 70-80%. Type B IMH should be managed with antiimpulse therapy, unless the patient has persistent pain or large ulcer-like projection.

How does descending aorta geometry change when it dissects?

Thoracic endovascular aortic repair is the treatment of choice in complicated acute type B aortic dissection. How to infer predissection aortic diameter is not well understood. Our aim was to delineate changes in descending aortic geometry due to dissection. Five tertiary centres reviewed their acute aortic dissection type B databases containing 802 patients. All patients who had undergone computed tomography angiography less than 2 years before and immediately after aortic dissection onset were included. We compared the aortic geometry before and after the dissection onset. Altogether 25 patients were included [median age 60 (first quartile 52, third quartile 72) years; 60% men]. In all except 1 patient, the maximum descending aortic diameter was less than 45 mm before aortic dissection onset. The largest increase in diameter induced by the dissection was observed in the proximal descending aorta 28.2 (25.1, 32.1) vs 34.6 (31.3, 39.1) mm (+6.4 mm; +23%; P < 0.001). The thoracic descending aortic length increased after the dissection onset [253.3 (229.3, 271.9) vs 261.3 (247.9, 285.4) mm; P = 0.003]. The predissection aortic diameter of the proximal thoracic descending aorta was 7.9 (5.2, 10.7) mm larger (P < 0.001) than the post-dissection area-derived true-lumen diameter and 2.5 (1.3, 6.1) mm larger than the maximum true-lumen diameter (P < 0.001). Type B aortic dissection increases the diameter, length and volume of the descending thoracic aorta. The predissection aortic diameter most closely resembles the post-dissection maximum diameter of the true lumen.

Clinical outcomes of aortic repair in young adult patients with ACTA2 mutations.

Actin, alpha-2, smooth muscle, aorta (ACTA2) mutations are one of the major causes of familial thoracic aortic aneurysms and dissections. The aim of this study was to review our clinical results of young adult patients with aortic disease caused by ACTA2 mutations. We reviewed the medical records of 251 patients (<50years old) who underwent surgery for thoracic aortic diseases between 2004 and 2014. Among them, nine patients (3.5%) had ACTA2 mutations. Their average age was 35years (range 22-47) and two patients (22.2%) were males. No patients fulfilled the diagnostic criteria for Marfan syndrome. Preoperative diagnoses included annulo-aortic ectasia (n=2), localized dissection of the sinus of Valsalva (n=2), acute type B aortic dissection (n=1), and chronic type B (n=4). Eight patients (88.9%) had hypertension. A thoracoabdominal aortic replacement was required in three patients who had descending replacement for residual chronic type B aortic dissection. A patient who had thoracic endovascular aortic repair for complicated acute type B aortic dissection showed no aortic dilatation for 7years after TEVAR. Histological results revealed cystic medial necrosis (CMN) in most cases (7/8; 87.5%). Surgical outcomes for patients with ACTA2 mutations were satisfactory. CMN was a major histological finding and family history of aortic event was detected in only half of the patients with ACTA2 mutations. Despite no characteristic physical findings besides hypertension, connective tissue disease including ACTA2 mutations should be considered for aortic dissection in young adult patients.

Homemade fenestrated stent-graft for thoracic endovascular aortic repair of zone 2 aortic lesions

ObjectiveThe aim of this retrospective analysis was to evaluate the outcomes of homemade fenestrated stent-grafts for thoracic endovascular aortic repair of zone 2 aortic lesions. MethodsFrom November 2013 to January 2017, 24 patients underwent thoracic endovascular aortic repair with left subclavian artery revascularization using a homemade fenestrated stent-graft to preserve the patency of the left subclavian artery. Elective cases accounted for 54% (n = 13) of the sample. Indications included acute complicated type B aortic dissection (n = 9), degenerative aneurysm (n = 9), penetrating aortic ulcer (n = 5), and intramural hematoma (n = 1). Routine postoperative follow-up imaging with computed tomography angiography was performed to assess thoracic endovascular aortic repair and left subclavian artery fenestration patency and endoleak. ResultsMedian duration for stent-graft modification was 16 minutes (range, 14-17 minutes). The technical success rate was 100%. One patient had a distal type I endoleak requiring additional stent-graft placement. One patient had partial coverage of the left common carotid artery requiring left common carotid artery stenting. One patient had a stroke without permanent sequelae (4.1%). Overall mortality was 0%. All left subclavian arteries were patent. Two type III endoleaks required additional left subclavian artery covered stent placement. One type II endoleak is currently observed. During a mean follow-up of 13.2 ± 2 months, there were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde dissection. ConclusionsThe use of a homemade fenestrated stent-graft for thoracic endovascular aortic repair of zone 2 aortic lesions is both feasible and effective for left subclavian artery revascularization during thoracic endovascular aortic repair involving a spectrum of thoracic aortic pathology. Durability concerns will need to be assessed in additional studies with long-term follow-up.