Acute Type B Aortic Dissection Research Articles

Type B Aortic Dissection in Marfan Patients after the David Procedure: Insights from Patient-Specific Simulation

ObjectiveAn elevated risk of acute type B aortic dissection (ATBAD) exists in Marfan syndrome (MFS) patients after the David procedure. This study explores hemodynamic changes in the descending aorta post-surgery. MethodsA single-center retrospective review identified 5 MFS patients who experienced ATBAD within 6 years post-David procedure, alongside 5 matched MFS patients without dissection >6 years post-surgery. Baseline and post-operative CT/MRI scans were analyzed for aortic geometry reconstruction. Computational fluid dynamics simulations evaluated pre- and post-operative hemodynamics. ResultsPatients with ATBAD showed lower blood flow velocities, increased vortices, and altered velocity profiles in the proximal descending aorta compared to controls. Pre-operatively, median Time-averaged wall shear stress (TAWSS) in the descending aorta was lower in ATBAD patients (Control: 1.76 [1.50, 2.83] Pa, Dissection: 1.16 [1.06, 1.30] Pa, p=0.047). Post-surgery, neither group had significant TAWSS changes (Dissection: p=0.69, Control: p=0.53). Localized analysis revealed surgery-induced TAWSS increases near the subclavian artery in the dissection group (range: +0.30 to +1.05 Pa, each comparison, p<0.05). No such changes were observed in controls. Oscillatory shear index (OSI) and Relative residence time (RRT) were higher in ATBAD patients pre- and post-surgery versus controls. ConclusionHemodynamics likely play a role in post-David procedure ATBAD. Further investigation into aortic geometry, hemodynamics, and post-operative ATBAD is vital for enhancing outcomes and refining surgical strategies in MFS patients.

Acute symptomatic isolated abdominal aortic dissection – Clinical characteristics, outcome and sex differences

ObjectivesAcute isolated abdominal aortic dissection (IAAD) is a rare condition and treatment recommendations are lacking. Most previous studies included both symptomatic and asymptomatic patients. The aims were to determine the proportion of IAAD among patients with acute type B aortic dissection (TBD) as well as to describe patient characteristics, radiological findings and frequency of early and late complications and to explore sex differences. MethodsThis was a retrospective cohort study including all patients hospitalized with acute symptomatic IAAD in Stockholm County during 2012-2021. ResultsA total of 277 patients with acute TBD were identified, of whom 10% (n=28/277) had acute IAAD. Median age was 56 years and 43% (n=12/28) were women. Hypertension was diagnosed in 46% (n=13/28) prior to admission. At onset, abdominal pain was the predominant complaint (93%, n=26/28) and 93% (n=26/28) were hypertensive on admission. The suprarenal aorta was involved in 39% (n=11/28) and at least one of the iliac arteries in 50% (n=14/28). All but one patient had uncomplicated IAAD (96%, n=27/28). One patient presented with aortic rupture, treated with open surgical repair. Among patients with primarily uncomplicated IAAD, 7% eventually developed chronic complications (n=2/27). Median maximum aortic diameter at 1-year follow-up was 21 mm (IQR 17-28). Only one patient had an aortic diameter exceeding 30 mm. None of the patients died during follow-up, median follow-up was 3.0 years (IQR 2-8). ConclusionsEarly and late complications are rare in patients with acute symptomatic IAAD and a conservative approach with antihypertensive treatment and surveillance in uncomplicated cases seems reasonable.

Spinal Cord Ischemia and Reinterventions Following thoracic endovascular repair for Acute Type B Aortic Dissections

ObjectiveThe technical aspects of thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), specifically the location of proximal seal zone (PSZ) (need to cover the left subclavian artery [LSA]), distal seal zone (DSZ) (length of aortic coverage), benefit of LSA revascularization, and prophylactic lumbar drainage are still debated. Each of these issues has potential benefits but also has known risks. This study aims to identify factors associated with reintervention and spinal cord ischemia (SCI) following TEVAR for acute TBAD with a zone 3 entry tear. MethodsThe Vascular Quality Initiative was queried for TEVARs performed for acute TBAD with zone 3 entry tear, zone 3 proximal zone of disease, treated with TEVAR extending between zone 2 and zone 5. The primary outcomes were SCI and related reintervention. Secondary outcomes were stroke, arm ischemia and retrograde type A dissection (RTAD). The exposure variables were PSZ 2 vs. 3, DSZ 4 vs. 5, prophylactic lumbar drain, and LSA revascularization. Univariate analyses were conducted with chi-square analysis and multivariable logistic regression was used to evaluate association with outcomes. ResultsOf 583 patients who met inclusion criteria, 266 had PSZ 2 and 317 had PSZ 3. On univariate analysis, PSZ 2 was associated with a higher rate of reintervention, but PSZ2 was not significant on multivariable analysis after accounting for age, sex, race, smoking, PSZ, DSZ, prophylactic lumbar drain and LSA patency. PSZ 2 was not associated with SCI, arm ischemia, or RTAD. PSZ 2 was associated with a trend towards a higher rate of stroke. DSZ 4 and DSZ 5 were performed in 161 and 422 TEVARs, respectively, and DSZ 5 was associated with a higher rate of SCI on univariate (3 [1.9%] vs. 39 [9.2%], P = .01) and multivariable (OR, 7.384, [95% CI, 2.193 – 24.867]; P = .001) analyses. Prophylactic lumbar drain placement was not statistically significantly associated with SCI, but lack of postoperative LSA patency was associated with SCI (OR 2.966, [95% CI, 1.016 – 8.656]; P = .05). ConclusionsThis study found that PSZ 2 was not associated with lower reinterventions or higher rates of SCI but trended towards a higher rate of stroke than PSZ 3. Additionally, DSZ 5 was strongly associated with SCI when compared with DSZ 4, highlighting the importance of limiting aortic coverage to coverage of the proximal entry tear when possible.

Outcomes of Patients with Acute Type B Aortic Dissection and High-Risk Features

BackgroundRecently the SVS and STS published contemporary guidelines clearly defining complicated vs uncomplicated acute type B aortic dissections (TBADs) with an additional high-risk grouping. Few studies have evaluated outcomes associated with “high-risk” TBADs. The objective of this study was to assess differences in demographics, clinical presentation, symptom onset, and outcomes in high-risk patients that underwent either thoracic endovascular aortic repair (TEVAR) or best medical management for acute TBAD compared to those with complicated and uncomplicated acute TBAD. MethodsPatients admitted with acute TBADs from a single academic medical center from 10/ 2011 to 3/2020 were analyzed. Per STS/SVS 2020 guidelines, high-risk was defined as refractory pain/hypertension, bloody pleural effusion, aortic diameter >4cm, false lumen diameter >22mm, radiographic malperfusion, early readmission, and complicated was defined as ruptured/malperfusion presentation. Uncomplicated patients were those without malperfusion/rupture and without high-risk features. The primary end-point was inpatient mortality. Secondary end-points included complications, re-intervention and survival. ResultsOf 159 patients identified with acute TBAD, 63 (40%) met high-risk criteria. In the high-risk cohort, 38 (60%) underwent TEVAR (HR-TEVAR), with refractory pain as the most common indication, while 25 (40%) were managed medically (HR-Medical). Malperfusion or rupture was present in 63 (40%) patients (C-TBAD), all of whom underwent TEVAR. An additional 33 patients had no high-risk features and were all managed medically (U-TBAD). There were no differences in age, BMI, and race between groups. Among the four groups, there were variable distributions in sex, insurance status, and incidence of several baseline comorbidities including CHF, COPD, and renal dysfunction (p<0.05 for all). C-TBAD had increased length of stay (12, IQR 9-22) compared to HR-TEVAR (11.5, IQR 7-15), HR-Medical (6, IQR 5-8), and U-TBAD (7, IQR 5-10) (p<0.01). C-TBAD had decreased days from admission to repair (0, IQR 0,2) compared to HR-TEVAR (3.5, IQR 1-8) (p<0.01). C-TBAD patients had worse 3-year survival compared to other groups (log-rank p<0.01), although when in-hospital mortality was excluded, survival was similar among groups (p=0.37).Of patients initially managed medically, outpatient TEVAR was performed in 6 (24%) HR-Medical and 4 (12%) uncomplicated patients, with no difference between rate of intervention between groups (p=0.22). ConclusionsHigh-risk features, as defined in updated SVS/STS guidelines, are common in patients presenting with acute TBAD. High-risk patients had acceptable outcomes when managed either surgically or medically. High-risk patients that underwent TEVAR had improved perioperative outcomes and mortality compared to those undergoing TEVAR for complicated TBAD, a finding which may help guide preoperative risk stratification and patient counseling.

Elongation of the proximal descending thoracic aorta and associated hemodynamics increase the risk of acute type B aortic dissection.

Acute type B aortic dissection (ATBAD) is a life-threatening aortic disease. However, little information is available on predicting and understanding of ATBAD. The study sought to explore the underlying mechanism of ATBAD by analyzing the morphological and hemodynamic characteristics related to aortic length. The length and tortuosity of the segment and the whole aorta in the ATBAD group (n= 163) and control group (n= 120) were measured. A fixed anatomic landmark from the distal of left subclavian artery (LSA) to the superior border of sixth thoracic vertebra was proposed as the proximal descending thoracic aorta (PDTA), and the dimensionless parameter, length ratio, was introduced to eliminate the individual differences. The significant morphological parameters were filtrated and the associations between parameters were investigated using statistical approaches. Furthermore, how aortic morphology influenced ATBAD was explored based on idealized aortic models and hemodynamic-related metrics. The PDTA length was significantly increased in the ATBAD group compared with the control group and had a strong positive correlation with the whole aortic length (r= 0.89). The length ratio (LR2) and tortuosity (T2) of PDTA in the ATBAD group were significantly increased (0.15 ± 0.02 vs 0.12 ± 0.02 and 1.73 ± 0.48 vs 1.50 ± 0.36; P< 0.001), and LR2 was positive correlation with T2 (r= 0.73). In receiver-operating curve analysis, the area under the curve was 0.835 for LR2 and 0.641 for T2. Low and oscillatory shear (LOS) was positive correlation with LR2, and the elevated LOS occurred in the distal of LSA. Elongation of PDTA is associated with ATBAD, and the length ratio is a novel predictor. Elongated PDTA induced more aggressive hemodynamic forces, and high LOS regions may correspond to the entry tear location. The synergy of the morphological variation and aggressive hemodynamics creates contributory conditions for ATBAD.

Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury.

Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI. Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD). We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43years (IQR, 29-58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90days (BTAI vs. TBAD; 13% vs. 29%; p < .001). We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.

Value of C-reactive protein/albumin ratio in predicting the development of preoperative oxygenation impairment in patients with Stanford type-B acute aortic dissection

ObjectivesWe aimed to assess the predicting value of C-reactive protein (CRP)/albumin ratio (CAR) in the development of Oxygenation impairment (OI) in the patients with Stanford type-B acute aortic dissection (AAD). MethodsThis study included 133 patients (age = 58.8 ± 12.0 years, median age = 61 years, Male/Female = 117/16) diagnosed as Stanford type-B AAD accompanied by hypertension from July 2012 to May 2020.Clinical data were retrospectively extracted from the database. The patients in this study were divided into OI group (oxygenation index ≤ 200) and non-OI group (oxygenation index > 200). Clinical characteristics in both groups were compared, and predicting value of CAR in the development of OI was assessed. ResultsPatients in OI group had higher peak body temperature (37.94 ± 0.62 vs. 37.67 ± 0.51 ℃, P =.010), higher levels of serum CRP (41.74 ± 27.71 vs 15.21 ± 19.66 mg/L, P =.000) and plasma B-type natriuretic peptide (292.14 ± 251.11 vs 179.80 ± 241.27 ng/L, P =.016), lower levels of albumin (34.00 ± 5.14 vs 37.72 ± 5.24 g/L, P =.000), and higher CAR (1.27 ± 0.89 vs 0.41 ± 0.53, P =.000). In multivariate regression analysis, CAR (odds ratio: 5.215, 95 % CI: 2.682; 10.137, P =.000) and the peak body temperature (odds ratio: 2.905, 95 % CI: 1.255; 6.724, P =.013) could significantly predict the OI development. The AUC for CAR was 0.831 (95 % CI: 0.756–0.907). An optimal cutoff value for CAR for predicting OI was ≥ 0.70, with a sensitivity of 67.5 % and a specificity of 88.2 %. ConclusionsCompared with CRP or albumin alone, the CAR might be a more accurate marker in predicting OI development in Stanford type-B AAD.

The application of 5E rehabilitation management mode in the nursing of patients with aortic dissection complicated by obstructive sleep apnea.

This study was designed to explore the effect of 5E rehabilitation mode (encouragement, education, exercise, employment, and evaluation)in patients with aortic dissection (AD) complicated by obstructive sleep apnea (OSA). Patients with Stanford type B AD (TBAD) complicated by OSA were admitted to Guangdong Provincial People's Hospital from January 2019 to December 2020. They were randomly divided into an experimental group and a control group. After discharge, patients in the control group were given routine nursing and follow-up education, whereas patients in the experimental group were given 5E rehabilitation management mode-based nursing and follow-up education. Upon the nursing intervention, the differences in polysomnography (PSG) parameters, medication adherence, quality of life, blood pressure, and heart rate of patients between the two groups were compared. Logistic regression analysis was performed to evaluate the risk factors for the occurrence of adverse aortic events. Atotal of 89 patients were enrolled, 49in the experimental group and 40 in the control group.After the intervention, the control of heart rate, systolic blood pressure, medication adherence, PSG parameters, and quality of life scores in the experimental group were significantly better than those in the control group (P<0.05). The incidence of adverse aortic events including aortic rupture and progressive aortic dilation in the experimental group was significantly lower than that in the control group (P < 0.05). Logistic regression analysis revealed that acute TBAD [odds ratio (OR) = 15.069; 95%confidence interval (CI), 1.738-130.652; P=0.014], history of chronic kidney disease (OR=10.342; 95%CI, 1.056-101.287; P=0.045), and apnea hypopnea index (AHI) ≥ 30 (OR=2.880; 95%CI, 1.081-9.51; P=0.036) were adverse factors affecting adverse aortic events; while 5E rehabilitation management mode (OR=0.063; 95%CI, 0.008-0.513; P=0.010) was a favorable factor for occurrence of adverse aortic events. The findings suggest that continuous nursing based on information carrier 5E rehabilitation management significantly enhanced medication adherence, improved patients' overall quality of life, and decreased the incidence of adverse aortic events in patientsTBAD patients and OSA.

Diameter changes of the thoracic aorta caused by acute type B aortic dissection.

The impact of type B acute aortic dissection (TBAAD) on historical pre-TBAAD diameters of the thoracic aorta is rarely reported. The aim of this study was to assess the extent of changes in aortic diameters induced by dissection, measured with a computed tomography (CT) scan obtained before and after TBAAD. Between January 2004 and December 2014, CT angiography of 50 non-Marfan patients with nonbicuspid aortic valves diagnosed with TBAAD were compared to historical CTs on file. The ascending aorta and proximal arch showed negligible change. The proximal, mid, and distal aorta diameters changed compared with predissected values (107.7 ± 4.8%, 109.3 ± 4.9%, and 105.7 ± 5.8%, respectively). Neither sex, false lumen status, or mural calcification, nor prior thoracoabdominal aortic ectasia, correlated with the diameter change. Age ≥80 years in the proximal descending aorta did correlate with the diameter change (110.7 ± 4.0% vs 106.1 ± 4.6% p = 0.01). Although identifying predicting factors for an aortic diameter increase all along with the thoracic aorta was still challenging, the degree of diameter change by aortic dissection was 105.7% to 109.3% in descending thoracic aorta, most prominent in middle descending aorta.

Age-related difference in acute type B aortic dissection.

The objective is to compare the characteristics of clinical data, imaging data, and treatment methods of young and old patients with acute type B aortic dissection (ABAD). ABAD patients admitted to the Department of Vascular Surgery of the First Affiliated Hospital of Anhui Medical University from January 2012 to December 2018 were retrospectively reviewed. Patient demographics, such as gender, age, diabetes, hypertension, presenting symptoms, imaging characteristics, laboratory data on admission, hemodynamics on admission and in-hospital management, and mortality of different age groups were compared and analyzed. Categorical variables were compared using χ2 tests or Fisher's exact test. Continuous variables were compared using Student's t-test or Mann-Whitney U-test. A total of 141 ABAD patients were included in this study. Old ABAD patients were more likely to have a prior history of hypertension (88.6% vs 70.4%, p = 0.037) and atherosclerosis (29.8% vs 7.4%, p = 0.016). In the young group, Marfan syndrome was significantly higher (14.8% vs 0.9%; p = 0.005). Compared with the old group, the number of distal tears in the young group was significantly higher (62.3% vs 39.5%, p = 0.027). The proportion of patients with malperfusion of lower limbs in the young group was significantly higher than that in the old group (22.2% vs 6.1%, p = 0.026). There was no significant difference in the treatment methods and in-hospital mortality between the two groups. Compared with old ABAD patients, young ABAD patients had more distal tears and a higher proportion of lower limbs malperfusion.

Early and mid-term results of endovascular repair for type B aortic dissections: A single tertiary center experience

Aim: The utility of thoracic endovascular aortic repair (TEVAR) in Type B Aortic dissections (TBAD) continues to advance at a growing rate. The purpose of this research was to investigate our management strategy and early-mid-term outcomes of endovascular procedures for TBAD, in a single tertiary center. Material and Methods: Sixty-six eligible TBAD patients (2 hyperacute complicated, 12 acute complicated and 52 uncomplicated) were enrolled in this single-center, retrospective cohort study between January 2016 and January 2023. The endpoints of the study were technical success, early and late morbidity and mortality, reinterventions throughout the follow-up period, as well as late open conversion. Results: Technical success was achieved in all cases. Early mortality was seen in only 3 patients (4.5%). Only patients with one hyperacute and two acute complicated TBAD (cTBAD) had early death. There was one late mortality in an acute cTBAD patient, who developed retrograde type A dissection two months after TEVAR. The median follow-up period was 26.1±13.7 months. Six reinterventions were performed for extension of dissection or covering the entries distally (9.1%). No endoleak, graft infection or migration were observed. Open surgical repair was performed; however, the patient did not survive. Conclusion: Early results of TEVAR in elective TBAD is trouble-free. Carrying the patients to the subacute phase seems to be the most suitable timing for TEVAR. Anti-stimulus and anti-hypertensive treatment with surveillance programme is mandatory for this patient cohort. Pre-emptive TEVAR has satisfactory results; however, long-term results are mandatory for further recommendations.

Short-term follow-up of proximal aorta remodeling after zone 2 thoracic endovascular aortic repair for acute type B aortic dissection

BackgroundTo evaluate the early remodeling of the proximal aorta in patients with acute type B aortic dissection (ATBAD) after zone 2 thoracic endovascular aortic repair (TEVAR). MethodsFrom January 2016 to May 2022, 53 ATBAD patients underwent zone 2 TEVAR were divided into two groups, the Castor single-branched stent-graft (CSS) group (n = 26) and the common stent-graft group (n = 27). Three-dimensional imaging created by computed tomography angiography was used to measure different parameters of the aorta, such as angulation, cross-sectional area (CSA), length and tortuosity. Early remodeling of the proximal aorta was evaluated by comparing geometric parameters of the proximal aorta before and 3 months after surgery. ResultsIn terms of angle, the postoperative angle of aortic arch to ascending aorta, descending aorta increased in all patients compared with that before surgery (all P < 0.05), while the angle of aortic arch to left subclavian artery increased after surgery only in the CSS group (P < 0.001); As for CSA, the CSA of distal aortic arch and true lumen increased (all P < 0.05), while the CSA of false lumen decreased in both groups after operation (all P < 0.05); Only in CSS group, the CSA of the ascending aorta, proximal aortic arch and total descending thoracic aorta decreased after surgery (all P < 0.05); In terms of length, the aortic arch prolonged after operation in both groups (P = 0.018 and P = 0.004, respectively). In addition, the ascending aorta tortuosity decreased in the CSS group after surgery (P = 0.011). There was no significant difference in the alterations of other aortic parameters after operation (P > 0.05). ConclusionsThe CSS implantation provided a more relatively safe and effective treatment for acute type B aortic dissection patients with unfavorable proximal landing zone. It can promote the earlier remodeling of the proximal aorta compared with the common stent-graft implantation after zone 2 TEVAR.

[Management of acute type B aortic dissection: treatment and follow-up].

Aortic dissection is a life-threatening condition caused by a tear in the tunica intima which creates a false lumen into the aortic wall. Acute type B aortic dissection (TBAD) is defined by the presence of the entry tear in the aorta distal to the left subclavian artery, without ascending aorta and arch involvement, and accounts for 25-40% of all aortic dissections. Optimal medical therapy (OMT), focused on blood pressure and heart rate control, remains the gold standard treatment, especially for patients with uncomplicated TBAD, while complicated dissections require surgical therapy. Recent studies have shown that a considerable number of patients treated only with OMT develop late aorta-related complications that increase morbidity and mortality, as well as the need for surgical intervention. During the last decades, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is safe and effective in the treatment of TBAD, both complicated and uncomplicated, with improved long-term survival outcomes and aortic remodeling in combination with OMT compared to OMT alone. However, in cases of acute uncomplicated TBAD the optimal timing for TEVAR is not entirely clarified and there is lack of long-term evidence. Therefore, the role of pre-emptive TEVAR for these patients is still uncertain and the management of acute uncomplicated TBAD remains challenging.

[Analysis of risk factors associated with acute Stanford type B aortic dissection complicated with pleural effusion and observation of the curative effect after intracavitary repair].

Objective: To investigate the risk factors of acute Stanford type B aortic dissection (TBAD) complicated with pleural effusion (PE) and the short-term and long-term outcomes of thoracic endovascular aortic repair (TEVAR). Methods: A case-control study. The clinical and imaging data of 1 083 patients with acute TBAD admitted to the General Hospital of Northern Theater Command from April 2002 to December 2020 were retrospectively analyzed, including 211 cases with pleural effusion and 872 cases without pleural effusion. The baseline analysis of the two groups of patients was performed. The risk factors associated with pleural effusion were analyzed by binary logistic regression, and the results were expressed as odds ratio (OR) and 95% confidence interval (CI). According to the quantity of pleural effusion, they were simultaneously divided into small pleural effusion group and medium large pleural effusion group, to compare the short-term and long-term effects of TEVAR patients with different amounts of pleural effusion. Results: The incidence of pericardial effusion (17.5% vs. 3.8%, P<0.001), anemia (21.3% vs. 12.5%, P=0.001), aortic spiral tear (49.8% vs. 37.8%, P=0.002), dissection tear over diaphragm (57.8% vs. 48.1%, P=0.011), serum creatinine [85 (69, 111) vs. 81 (67, 100) μmol/L, P=0.011] and white blood cell levels[(11.3±4.2)×109/L vs. (10.3±4.2)×109/L, P=0.002] in acute TBAD pleural effusion group were significantly higher than those in non-pleural effusion group, and the hemoglobin level was significantly lower than that in non-pleural effusion group [(128±20) vs. (133±17) g/L, P<0.05]. Logistic stepwise regression analysis showed that pericardial effusion (OR=5.038,95%CI 2.962-8.568,P<0.001), anemia (OR=2.047,95%CI 1.361-3.079,P=0.001), spiral tear (OR=1.551,95%CI 1.030-2.336, P=0.002) and elevated white blood cell (OR=1.059,95%CI 1.011-1.102, P=0.005) were independent risk factors for TBAD complicated with pleural effusion. The incidences of all-cause death (4/19 vs. 1.5% vs. 0.9%, P<0.001), aortogenic death (4/19 vs. 0.7% vs. 0.7%, P<0.001) and aortic related adverse events (4/19 vs. 1.5% vs. 1.1%, P<0.001) in patients with large pleural effusion during TEVAR operation were significantly higher than those in patients with small pleural effusion and those without pleural effusion, and the differences were statistically significant. At 1 month follow-up after TEVAR, the incidence of all-cause death (4/16 vs. 3.3% vs. 1.6%, P<0.001), aortogenic death (4/16 vs. 0.8% vs.0.7%, P<0.001), aorta related adverse events (4/16 vs. 4.1% vs. 4.7%, P=0.013) and overall clinical adverse events (4/16 vs.9.8% vs. 6.7%, P=0.014) in the medium and large thoracic group were significantly higher than those in the small pleural effusion group and no pleural effusion group, and the differences were statistically significant. At 1 year follow-up after TEVAR, the incidence of all-cause death (4/15 vs. 4.9% vs. 3.9%, P=0.004), aortogenic death (4/15 vs.2.5% vs. 2.1%, P<0.001), aorta related adverse events (5/15 vs. 11.5% vs. 9.4%, P=0.012) and overall clinical adverse events (5/15 vs. 18.9% vs. 13.1%, P=0.029) in the medium and large thoracic group were significantly higher than those in the small pleural effusion group and no pleural effusion group, and the differences were statistically significant. Conclusions: Single center data showed that pericardial effusion, anemia, spiral tear and elevated white blood cell were independent risk factors for acute TBAD complicated with pleural effusion; the early (1 month) and long-term (1 year) rates of all-cause death, aortic mortality, aortic adverse events and overall clinical adverse events were significantly higher in TBAD patients with moderate pleural effusion after TEVAR, and moderate and large pleural effusion was an independent risk factor for near and long-term aortic related adverse events after TEVAR surgery.

High Serum VE-Cadherin and Vinculin Concentrations Are Markers of the Disruption of Vascular Integrity during Type B Acute Aortic Dissection.

In the present study, we measured the serum vascular endothelial cadherin (VEC) and vinculin (Vcn) concentrations in patients with type B acute aortic dissection (TBAD) to evaluate their diagnostic value for this condition. A total of 100 patients with TBAD and 90 matched controls were included in the study. The serum concentrations of VEC and Vcn were measured using enzyme-linked immunosorbent assays. The serum VEC and Vcn concentrations were significantly higher in participants with TBAD than in healthy controls. Compared with patients with acute myocardial infarction (AMI), the serum concentrations of VEC and Vcn in patients with TBAD were higher, and the Vcn showed significant difference, with statistical significance. Receiver operating characteristic analysis generated areas under the curves for VEC and Vcn that were diagnostic for TBAD (0.599 and 0.655, respectively). The optimal cut-off values were 3.975 ng/μL and 128.1 pg/mL, the sensitivities were 43.0% and 35.0%, and the specificities were 73.3% and 90.0%, respectively. In addition, the use of a combination of serum VEC and Vcn increased the AUC to 0.661, with a sensitivity of 33.0% and a specificity of 93.33%. A high serum Vcn concentration was associated with a higher risk of visceral malperfusion in participants with TBAD (odds ratio (OR) = 1.007, 95% confidence interval [CI]: 1.001-1.013, p = 0.014). In participants with refractory pain, the adjusted OR for the serum VEC concentration increased to 1.172 (95% CI: 1.010-1.361; p = 0.036), compared with participants without refractory pain. This study is the first to show the diagnostic value of serum VEC and Vcn for AAD and their relationships with the clinical characteristics of patients with TBAD. Thus, VEC and Vcn are potential serum markers of TBAD.

Optimal Timing of Thoracic Endovascular Aortic Repair for Late Remodeling in Acute Type B Dissection

BackgroundTo determine the optimal timing of thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), we investigated the relationship between the timing of TEVAR after onset and late aortic remodeling. MethodsBetween March 2015 and August 2020, 48 patients with TBAD (39 men [81.2%]; aged 61.0 ± 10.6 years) underwent TEVAR in the acute phase (within 14 days; n = 23), subacute phase (15-90 days; n = 13), or chronic phase (>90 days; n = 12). These 3 groups were compared in terms of the true lumen (TL) area ratios, calculated by dividing the TL area by the aortic lumen area on the computed tomography image at 1 week, 1 year, 2 years, and 3 years after TEVAR. ResultsAt the distal-end level of the TEVAR stent, there were significant negative correlations between TEVAR timing and TL area ratio, and the cutoff value for the most effective TEVAR timing for late aortic remodeling was 14 and 8 days on the receiver operating characteristic curves with a TL area ratio of ≥80% at 1 year and 3 years after TEVAR, respectively. ConclusionsIn patients with acute TBAD, acute phase TEVAR (within 14 days after onset) may be an optimal strategy to obtain sufficient aortic remodeling for a long-term postoperative period.

Deep learning-aided extraction of outer aortic surface from CT angiography scans of patients with Stanford type B aortic dissection

BackgroundGuidelines recommend that aortic dimension measurements in aortic dissection should include the aortic wall. This study aimed to evaluate two-dimensional (2D)- and three-dimensional (3D)-based deep learning approaches for extraction of outer aortic surface in computed tomography angiography (CTA) scans of Stanford type B aortic dissection (TBAD) patients and assess the speed of different whole aorta (WA) segmentation approaches.MethodsA total of 240 patients diagnosed with TBAD between January 2007 and December 2019 were retrospectively reviewed for this study; 206 CTA scans from 206 patients with acute, subacute, or chronic TBAD acquired with various scanners in multiple different hospital units were included. Ground truth (GT) WAs for 80 scans were segmented by a radiologist using an open-source software. The remaining 126 GT WAs were generated via semi-automatic segmentation process in which an ensemble of 3D convolutional neural networks (CNNs) aided the radiologist. Using 136 scans for training, 30 for validation, and 40 for testing, 2D and 3D CNNs were trained to automatically segment WA. Main evaluation metrics for outer surface extraction and segmentation accuracy were normalized surface Dice (NSD) and Dice coefficient score (DCS), respectively.Results2D CNN outperformed 3D CNN in NSD score (0.92 versus 0.90, p = 0.009), and both CNNs had equal DCS (0.96 versus 0.96, p = 0.110). Manual and semi-automatic segmentation times of one CTA scan were approximately 1 and 0.5 h, respectively.ConclusionsBoth CNNs segmented WA with high DCS, but based on NSD, better accuracy may be required before clinical application. CNN-based semi-automatic segmentation methods can expedite the generation of GTs.Relevance statementDeep learning can speeds up the creation of ground truth segmentations. CNNs can extract the outer aortic surface in patients with type B aortic dissection.Key points• 2D and 3D convolutional neural networks (CNNs) can extract the outer aortic surface accurately.• Equal Dice coefficient score (0.96) was reached with 2D and 3D CNNs.• Deep learning can expedite the creation of ground truth segmentations.Graphical

Late Referral and Patient Transfer is Associated with Worse Outcomes for Patients Presenting with Initially Uncomplicated Type B Aortic Dissections

Acute type B aortic dissections (TBADs) can become complicated at any time point, necessitating surgical repair. We sought to investigate the effect of interhospital transfer on the development of delayed complications in acute type B aortic dissection (dcTBAD). All patients who presented with acute TBAD to a tertiary aortic center from 2015 to 2019 were analyzed. Patients were divided into initially complicated type B aortic dissection (icTBAD) (0-24hours from symptom onset), dcTBAD (25hours to 14days), and uncomplicated type B aortic dissection (ucTBAD) groups. Criteria for complicated dissection were aortic rupture, malperfusion, or rapid aortic growth. Demographics, patient history, the timing of presentation, imaging findings, and clinical outcomes were compared between groups. Of 120 acute TBADs included, 27 (22%) were initially complicated (aortic rupture, n=9; malperfusion, n=18). Twenty-one (18%) developed delayed complications (aortic rupture, n=3; malperfusion, n=14; rapid growth, n=4) at a median of 7.0 [4.0, 9.0] days from symptom onset. Seventy-two (60%) remained uncomplicated. Overall, 111 (93%) presented as transfers from outside hospitals (icTBAD, n=25; dcTBAD, n=21; ucTBAD, n=65). Of those, dcTBADs were more likely to have a prolonged delay between presentation to the outside hospital and referral to the tertiary center compared to ucTBADs (median=1.00 [0.0, 5.0] days delayed vs. 0.00 [0.0, 0.0] days delayed; P<0.001). Initially uncomplicated patients referred for transfer ≥24hours from presentation went on to develop dcTBAD more often than those transferred in <24hours (73% vs 13%; P<0.001). Of dcTBADs, 38% had no high-risk features on initial imaging. Patients with dcTBAD had significantly longer length of stay (median=12 vs 7days; P=0.006). In-hospital mortality was significantly higher in dcTBADs than ucTBADs (9.5% vs 0%; P=0.047). In-hospital mortality was not significantly different between dcTBADs and icTBADs (9.5% vs. 11%; P>0.05). The incidence and consequence of dcTBADsare not insignificant. Late referral and transfer to a tertiary aortic center (≥24hours from initial presentation) was associated with dcTBADsrequiring surgical intervention. The development of dcTBADwas associated with increased length of stay and increased in-hospital mortality.

Postoperative acute kidney injury after thoracic endovascular aortic repair for acute type B aortic dissection

BackgroundThoracic endovascular aortic repair (TEVAR) has evolved as the standard for treating complicated acute type B aortic dissection (ATBAD). Acute kidney injury (AKI) is a common complication in critically ill patients and is commonly observed in patients with ATBAD. The purpose of the study was to characterize AKI after TEVAR. MethodsAll patients who underwent TEVAR for ATBAD from 2011 through 2021 were identified using the International Registry of Acute Aortic Dissection. The primary end point was AKI. A generalized linear model analysis was performed to identify a factor associated with postoperative AKI. ResultsA total of 630 patients presented with ATBAD and underwent TEVAR. The indication for TEVAR was complicated ATBAD in 64.3%, high-risk uncomplicated ATBAD in 27.6%, and uncomplicated ATBAD in 8.1%. Of 630 patients, 102 (16.2%) developed postoperative AKI (AKI group) and 528 patients (83.8%) did not (non-AKI group). The most common indication for TEVAR was malperfusion (37.5%). In-hospital mortality was significantly higher in the AKI group (18.6% vs 4%; P < .001). Postoperatively, cerebrovascular accident, spinal cord ischemia, limb ischemia, and prolonged ventilation were more commonly observed in the AKI group. The expected mortality was similar at 2 years between the two groups (P = .51). Overall, the preoperative AKI was observed in 95 (15.7%) in the entire cohort consisting of 60 (64.5%) in the AKI group and 35 (6.8%) in the non-AKI group. A history of CKD (odds ratio, 4.6; 95% confidence interval, 1.5-14.1; P = .01) and preoperative AKI (odds ratio, 24.1; 95% confidence interval, 10.6-55.0; P < .001) were independently associated with postoperative AKI. ConclusionsThe incidence of postoperative AKI was 16.2% in patients undergoing TEVAR for ATBAD. Patients with postoperative AKI had a higher rate of in-hospital morbidities and mortality than those without. A history of CKD and preoperative AKI were independently associated with postoperative AKI.

Acute Complicated Type B Aortic Dissection: Do Alternative Strategies Versus Central Aortic Repair Make Sense?

Current guidelines dictate emergency repair for an acute complicated type B aortic dissection (TBAD). Surgical approaches for the treatment of acute complicated TBAD can be divided into open and endovascular. The endovascular approach is further divided into central aortic repair and alternative endovascular techniques. Central repair includes endoluminal aortic stent graft repair, such as thoracic endovascular aortic aneurysm repair and provisional extension to induce complete attachment, extended provisional extension to induce complete attachment and stent-assisted balloon-induced intimal disruption and re-lamination in aortic dissection repair techniques. Alternative endovascular techniques include reno-visceral stenting, endovascular aortic membrane fenestration and targeted false lumen thrombosis. This review discusses and compares the various endovascular approaches to repair of acute complicated TBAD, focusing on central versus alternative endovascular techniques. We also discuss indications for technique selection, focusing on the acute management of complicated TBAD.