Aortic Length Research Articles

Ascending aortic length predicts adverse outcomes in type a intramural hematoma.

Ascending aortic length has recently been recognized as a novel predictor of adverse events in aortic diseases, but its prognostic value in type A intramural haematoma is unknown. We aimed to evaluate the association between ascending aortic length and outcomes in patients with type A intramural haematoma initially managed medically. We retrospectively analyzed patients with acute type A intramural haematoma. Ascending aortic length was measured by computed tomography. The primary outcome was aortic progression, defined as aortic intervention or aortic-related death. A total of 98 patients were enrolled. During a median follow-up of 2.6 years, aortic progression occurred in 27 patients (27.6%), ie, 9 events per 100 patient-years). Patients with ascending aortic length ≥11 cm had significantly higher rates of aortic progression (54.2% [20.9 events per 100 patient-years] vs 18.9% [6.1 events per 100 patient-years], p = 0.001), surgical intervention (45.8% vs 12.2%, p = 0.001), and presence of ulcer-like projection (25.0% vs 2.7%, p = 0.002) compared to those with ascending aortic length <11 cm. Kaplan-Meier analysis demonstrated lower progression-free survival in the ascending aortic length ≥11 cm group (p = 0.0021). Ascending aortic length had a sensitivity of 61.9% and specificity of 77.8% for predicting aortic progression, with an area under the curve of 0.756 (95% confidence interval: 0.649-0.862). Ascending aortic elongation may identify a high-risk subgroup of acute type A intramural haematoma patients initially managed medically who could potentially benefit from early surgery. Ascending aortic length should be considered in the risk stratification and management of these patients.

Relationship of body height to thoracic aortic length: implications for sex differences and normative values

Abstract Introduction The scaling of organ to body size is highly variable and can affect organ function in individuals of different sizes. Despite the relationship between aortic length and body size, to our knowledge, its scaling relationship has not been assessed. We assessed the allometric relationship between thoracic aortic length and body height and generated normative data for this important structural parameter. Methods Using a convolutional neural network (U-Net) we segmented the thoracic aorta among 49,282 UKBB participants who underwent magnetic resonance imaging. To define normal allometric relationships, we included a highly selected subgroup (n=3,856) without cardiovascular risk factors or prevalent cardiovascular disease. Allometric relations were estimated using sex-adjusted log-log models. Results The mean thoracic aorta centerline length was 31.68 (SD=2.50) cm. Males exhibited longer thoracic aortas than females (32.93 vs. 31.15 cm; P&amp;lt;0.0001). In log-log models, body height accounted for 13.4% of the population variability in thoracic aortic length (R2=0.134; P&amp;lt;0.0001). The allometric power relating thoracic aortic length to body height was highly sublinear (power point estimate=0.44; 95% CI:0.37, 0.50). Sex was a predictor of thoracic aortic length (β=0.02; 95%CI=0.014, 0.029; P&amp;lt;0.0001), indicating that for any given body height, females had slightly shorter thoracic aortas compared to males. Among males, the 5th, 25th, 50th, 75th and 95th percentiles of allometrically scaled aortic length were 2.69, 3.20, 3.36, 3.53, and 3.96, respectively. Among females, the corresponding percentiles were 2.69, 3.11, 3.29, 3.46, 4.01. Conclusions The thoracic aorta exhibits a highly sublinear length relationship with body height, suggesting that disproportionate length relationships at the extremes of body height may have an important impact on pulsatile hemodynamics. Females exhibit slightly shorter thoracic aortas than males even after accounting for body height in an allometric fashion.aorta length vs height

Genome wide association studies on three-dimensional aortic geometric indices measured with magnetic resonance imaging

Abstract Introduction To date, three-dimensional properties of the aorta have not been comprehensively quantified in a population level dataset, nor has there been a genome-wide association study (GWAS) to identify significant single nucleotide polymorphisms (SNPs) associated with geometric properties of the aorta. Methods We segmented the thoracic aorta of 48,045 subjects in the UK Biobank using a U-Net convolutional neural network. We then computed geometric measurements (centerline length, arch height, arch width, arch height-width ratio, curvature, and mean, minimum and maximum diameter) across six subsegments of the aorta. Centerline length was allometrically indexed to body height. Using generalized linear models, we performed GWAS on each geometric phenotype adjusted for the following covariates: (1) age, (2) sex, and (3) ten genetic principal components. SNPs with a minor allele frequency &amp;lt; 0.05 were excluded. We performed LD-based clumping with an r2 threshold of 0.001 to identify significant loci and used LDSC to compute the genetic heritability of each geometric phenotype. Results After performing LD clumping, we identified 457 significant(P&amp;lt;5e-8) SNPs across 36 aortic geometric parameters. GWAS-based heritability analyses showed a mean heritability of 13.8 (9.9) % across all aortic geometric parameters, with all intercepts being close to 1, suggesting minimal genomic inflation. Maximum aorta diameter exhibited the highest observed heritability of 34.5 (3.0) %. Allometric centerline length showed a heritability of 13.6 (1.5) %. Similarly, arch height and width showed heritability of 14.6 (1.5) %, and 13.64 (1.5) % respectively. Aortic curvature showed limited heritability at 8.54 (1.2) %, with arch curvature being further reduced to 7.6 (1.20) %. Conclusion To our knowledge, this was the first study that investigated the genetic architecture of aortic centerline length, aortic curvature, and aortic tortuosity. These results suggest that aortic remodeling associated with aging and pathological conditions has important genetic contributions. SNPs associated with aortic geometry may identify therapeutic targets to prevent aortic remodeling, which should be the focus of future work.significant_snpsheritability

Ventilation Dependency after Cardiac Operation for Infective Endocarditis: Risk Factors and Focus on Preoperative Aortic Regurgitation

Introduction: The investigation was to elucidate predictors of ventilation dependency after cardiac operation for infective endocarditis. Methods: Patients with infective endocarditis undergoing cardiac operation were retrospectively investigated. Mechanical ventilation &gt;72 hours was defined as ventilation dependency after cardiac operation. Results: 896 patients with infective endocarditis who underwent cardiac operation were assigned to group of mechanical ventilation ≤72 h (n = 704) and &gt;72 h (n = 192). Multivariate analyses identified age, interval from symptoms to operation, vegetation size, aortic occlusion length, pump length, intensive care unit (ICU) retention length, serum creatinine before and 24 h after surgery, preoperative and postoperative left ventricular end diastolic dimension (LVEDD), preoperative aortic regurgitation and packed red blood cells to be associated with ventilation dependency after cardiac operation; ventilation dependency is significantly related to prolonged ICU stay (&gt;3 d), 1- and 5-year mortality after cardiac operation. All-time mortality (45.3% versus 5.6%, p &lt; 0.001) of mechanical ventilation &gt;72 h group was higher than that of mechanical ventilation ≤72 h group. A significant positive correlation exists between preoperative aortic regurgitation and ventilation dependency after cardiac operation. A value of preoperative aortic regurgitation &gt;5.25 cm2 was 100% sensitive and 64.6% specific for the diagnosis of ventilation dependency after cardiac operation. Conclusions: We found modifiable risk factors of ventilation dependency after cardiac operation including interval from symptoms to operation, vegetation size, aortic occlusion length, pump length, ICU retention length, serum creatinine before and 24 h after operation, preoperative and postoperative LVEDD, preoperative aortic regurgitation and packed red blood cells and optimization of pre-, peri-, and postoperative factors that can reduce incidence of ventilation dependency, contributing to better short- and long-term outcomes.

Anatomical analysis of the abdominal aorta in a South African sample: influence of age and sex.

The anatomy of the abdominal aorta (AA) varies with age and sex; however, limited studies exist from South Africa. Given the increased incidence of endovascular treatment of the AA, reference values are relevant for interventionalists for improving the safety of endovascular procedures. Therefore, the study aimed to determine the lengths, diameters and tortuosity of the AA and their association with age and sex in a South African sample. After ethical approval, 97 computed tomography angiography (CTA) scans from an adult sample (54 male and 43 female), mean age 48.5 ± 17.2 years were analysed. The aortic length was measured from the origin of the coeliac trunk to the bifurcation point of the AA. The lumen diameters of the aorta were measured at three landmarks. Tortuosity of the AA was quantified with the tortuosity index and its prevalence was determined. The AA was longer in males and showed a significant weak positive correlation with age. The mean diameters of the AA were larger in males and had a significant strong positive correlation with age in both sexes (p < .001). There was a strong positive correlation between age and tortuosity in both sexes (p < .001). The prevalence of a tortuous c-shaped-curve phenotype was 8.2%, with a 7:1 male-to-female ratio. The dimensions and tortuosity differed between sexes and varied significantly with age. These findings may contribute towards reference values in the South African setting, inform patient selection and complement decision-making of endovascular treatment strategies.

Baseline Diameter Does Not Predict Growth Rate in a Presurgical Ascending Thoracic Aortic Aneurysm Population.

Patients with ascending thoracic aortic aneurysm are recommended to undergo routine imaging surveillance. Although maximal diameter is the primary metric of disease severity, recent American College of Cardiology/American Heart Association guidelines emphasize the importance of aortic growth in determining surgical candidacy and risk. As diameter increases, it is assumed that aortic growth rate accelerates because of increased wall tension; however, this relationship is poorly studied. We aim to investigate the relationship between ascending thoracic aortic aneurysm diameter and growth rate using vascular deformation mapping, a validated technique for 3-dimensional growth mapping with submillimeter accuracy. We retrospectively identified adult patients with ascending aortic dilation (≥4.0 cm) and serial gated computed tomography angiograms separated by ≥2 years, excluding confirmed heritable thoracic aortic disease. Ascending growth rate was defined as 90th percentile radial wall deformation by vascular deformation mapping. Maximal diameter measurements were derived from the baseline computed tomography angiogram, and aortic length and body size-adjusted indexes were calculated. Among 258 included patients (63.2% men; age of 63 years [interquartile range, 55-69 years]), mean±SD baseline diameter was 46.3±3.6 mm and median growth rate was 0.21 mm/year (interquartile range, 0.13-0.38 mm/year). No correlation was noted between growth rate and baseline diameter (r=0.02, P=0.74) or other aortic size metrics. On multivariate analysis, age was independently predictive of growth rate (β=-0.007, P=0.021), alongside weight (β=0.003, P=0.016) and the presence of moderate or severe aortic valve insufficiency (β=0.146, P=0.049). Maximal aortic diameter is not predictive of aortic growth rate, in this contemporary cohort of patients with sizes under current surgical thresholds (<55 mm).

Anatomical Feasibility of Endobentall Strategies for Management of Acute type A Aortic Dissection.

This study assesses the feasibility of acute type A dissections treatment with a dedicated aortic root endograft concept and introduces a new aortic classification. Acute type A aortic dissection (ATAAD) remains a catastrophic aortic condition with perioperative mortality ranging from 12% and 20%. Total Aortic root endovascular repair, "Endobentall concept", has been explored as an alternative but only documented on case report. Imaging study of all consecutive patients treated in three French centers were achieved. The study introduces an adapted aortic classification to report entry tear locations. Measurements included aortic annulus mensuration, coronary height, and several aortic lengths. Two treatment concepts were described "fenestrated Endobentall" and "branched Endobentall". Patients were eligible to the "fenestrated endobentall" design if their aortic root dimensions fitted the Edwards Sapien® and Corevalve Medtronic® instruction for use. Eligibility for the "branched Endobentall" required meeting the criteria for a "fenestrated Endobentall" and having a left coronary main stem length exceeding 5mm. "Branched Endobentall" was mandatory when the entry was located in the aortic root. A total of 250 CT scans for acute type A aortic dissection were reviewed, 116 were finally included for analysis. The primary entry tear was found in the aortic root in 9% of patients, and in 31% of cases, it was located within the first centimeter distal to the sinotubular junction (STJ). 63.7% of the patients were eligible for an Endobentall procedure, even 73.3% when considering extended criterion. Fenestrated Endobentall accounted for 2/3 of cases. In our study, 63.7% of patients with aortic type A dissections are deemed eligible to an "Endobentall repair", increasing to 73.3% when considering extended anatomical criteria.

Feasibility of endovascular aortic arch repair after hemiarch replacement for acute type A aortic dissection

ObjectiveWe assessed the treatment feasibility of 4 investigational arch endografts currently available in the United States, for patients who have undergone hemiarch replacement for an acute DeBakey I dissection. MethodsWe evaluated 71 consecutive patients for suitability for treatment with the Cook Medical Zenith Arch Branched Device, Gore TAG Thoracic Branch Endoprosthesis, Terumo Bolton Relay Dual Branch Device, and Endospan Nexus Aortic Arch Stent Graft System. Proximal landing zone anatomy was evaluated on postoperative computed tomography angiography using 3-dimensional imaging software and compared against each manufacturer recommended sizing criteria. ResultsTwenty-one patients (29.6%) were deemed unsuitable for branched endograft due to mechanical aortic valve, connective tissue disorder, and extension of dissection into the brachiocephalic trunk (BCT). Forty-one percent were excluded from all devices; 8.5% were candidates for only 1 device, 24% for 2, 4% for 3, and 23% for all 4 devices. Reasons for exclusion included ascending aortic/neck diameter being too large/small, insufficient ascending aorta length, insufficient BCT length, and BCT size being too large. Both patient-related factors (BCT diameter/length, dissection into BCT, and connective tissue disorder) and technical factors (mechanical aortic valve, ascending aorta graft length/diameter) influenced candidacy. ConclusionsDespite the availability of multiple branched endovascular devices, a significant number of patients may be unsuitable for subsequent endoarch repair. Awareness of anatomic inclusion criteria for arch endografts and modification of surgical technique for creation of a suitable landing zone at the initial operation may increase the likelihood of successful endovascular repair in the future.

Early results from the pivotal trial substudy of the GORE EXCLUDER conformable endoprosthesis in angulated necks

ObjectiveTo report the investigational device exemption study 1-year clinical outcomes of the high neck angulation (HNA) substudy of the GORE EXCLUDER Conformable AAA Endoprosthesis (EXCC) for treatment of infrarenal abdominal aortic aneurysms (AAAs). MethodsThis study is a prospective, multicenter clinical trial conducted in the United States and included core laboratory assessment of imaging and independent event adjudication. Anatomical criteria for enrollment in the HNA substudy included infrarenal aortic neck angulation >60° and ≤90° with aortic neck length ≥10 mm. Primary safety end points included estimated blood loss of >1000 mL, death, stroke, myocardial infarction, bowel ischemia, paraplegia, respiratory failure, renal failure, and thromboembolic events. Primary effectiveness end points included technical success, absence from type I and III endoleaks, migration (≥10 mm), sac enlargement (≥5 mm), sac rupture, and conversion to open repair. ResultsBetween January 2018 and February 2022, 95 patients were enrolled in the HNA substudy across 35 sites. Of the 95 patients, 71 (74.7%) were male and the cohort average age was 74.4 years. The mean infrarenal proximal aortic neck angle was 71.6° and the mean AAA size was 62.9 mm. Overall technical success was achieved in 93 patients (97.9%). Freedom from a primary safety end point through 30 days was 96.7%; 3 (3.3%) patients had an estimated blood loss of >1000 mL. Freedom from the primary effectiveness at 12 months was achieved in 94.8%. Four patients (4.3%) had a type IA endoleak; intervention after the procedure was not required and no subsequent interventions or sac enlargement were noted in these patients. At 12 months, 29 patients (39.7%) experienced a type II endoleak and 1 (1.3%) patient experienced AAA sac expansion of ≥5 mm. Through 12 months, 1 patient (1.3%) had a conversion to open surgical repair. There were no aneurysm-related deaths, ruptures, or migration through 12 months. ConclusionsThe investigational device exemption study demonstrates safety and effectiveness of the GORE EXCLUDER Conformable AAA Endoprosthesis device in AAA with highly angulated necks (>60° and ≤90°) are preserved at the 12-month follow-up.

A Prevention Protocol Reduces Spinal Cord Ischemia in Patients Undergoing Branched/Fenestrated Endovascular Aortic Repair

ObjectivesSpinal cord ischemia (SCI) is a devastating complication that is associated with thoracoabdominal aortic repair, with higher risk associated with increased aortic coverage length, making patients undergoing branched/fenestrated endovascular repair(B/FEVAR) particularly vulnerable. A bundled SCI prevention protocol was previously reported to reduce SCI rates when compared to a historic cohort in a single-center study. Therefore, this analysis aims to further validate and update outcomes associated with the protocol given the routine implementation of this strategy at two institutions (University of Florida [UF] and the University of Alabama at Birmingham [UAB]) since inception. MethodsComponents of the SCI prevention protocol include selective cerebrospinal fluid (CSF) drainage, specified blood pressure parameters, transfusion goals, and selective pharmacologic adjuncts (naloxone, steroids). This protocol was routinely implemented in May 2015. Patients undergoing B/FEVAR from May 2015-December 2022 constituted the post-protocol cohort(n=402) and were compared to the pre-protocol cohort (n=160, January 2010-April 2015). The primary outcome was SCI incidence and subgroup analysis was conducted among patients deemed to be high-risk (Crawford extent I- III thoracoabdominal aneurysms (TAAA) dissection-related disease, prior aortic repair, coverage proximal to zone 5). Survival analysis was performed using Kaplan-Meier methodology. ResultsThe pre- and post-protocol cohorts were demographically similar, though more post-protocol patients were American Society of Anesthesiology(ASA) class IV (86.1% vs. 55.0%; p<0.001). TAAA was the most common indication in both groups. CSF drain placement was more common in the post-protocol group, particularly among high-risk patients. SCI occurred in 15.9% of pre-protocol patients versus 3.0% of post-protocol patients(p<0.001). In high-risk patients, the pre- and post-protocol cohort SCI incidence was 23.2% vs. 5.0%, respectively (p<0.001). 30-day mortality was decreased in the post-protocol cohort (6.3% vs. 2.2%, p=0.02). Although the post-protocol group had a trend toward improved 1-year survival, this was not statistically significant (84.4% vs. 88.3%, log-rank p=0.35). Among SCI patients, one-year mortality was 28% and 33.3% in the pre- and post-protocol groups, respectively(p=0.46). ConclusionImplementation of a bundled SCI prevention protocol significantly reduces SCI rates in B/FEVAR patients, which has now been validated at two institutions, with the most significant reductions occurring among high-risk patients. Although the overall one-year mortality difference was not significantly different between the cohorts, the high mortality rates among SCI patients highlights the importance of preventative measures.

Computed tomography angiography-guided analysis of morphologic properties of the thoracic aorta and arch branches among the adult population: A cross-sectional study.

Before performing any surgical or endovascular procedure, the anatomical classification of the patient is essential for treatment planning. Computed Tomographic Angiography (CTA) is a standard method to evaluate thoracic aortic anatomy and associated variations. This cross-sectional, descriptive study was performed among adult participants without any peripheral vascular diseases undergoing thoracic CTA. Demographic data were collected along with factors retrieved from the patients CTA, such as the type of aortic arch, length, and diameter of ascending and descending aorta, the diameter of the main branches and the distance between branches, the angles by which the main arteries rise from their origins, and left anterior oblique angle of the aortic arch. 164 patients, with a mean age of 57 ± 19.3 years, entered the study. 53 (33.8%) had a bovine arch, which was mostly observed among males. A decrease in the frequency of type I arch and also an increase in the frequency of type 2 and 3 arches was observed with the increase in age (p < 0.001). The BCT diameter had a direct association with both left common carotid artery diameter (r = 0.478, p < 0.001) and left subclavian artery diameter (r = 0.470, p < 0.001). The length of the descending aorta had a direct correlation (r = 0.294, p < 0.001) with the length of the ascending aorta. Complex endovascular interventions are vital method in treating aorta, head, and neck pathologies. Accurate knowledge of thoracic aortic anatomy is becoming crucial for diagnosis and intervention planning.

Comparison of vortex formation in expanded and curved aortic sinuses: The effect of sinus curvature

Aortic valve disease is a significant health issue. Research on the effects of aortic sinus geometry and aortic valve motion during a heartbeat is imperative, as numerous valvular diseases are associated with blood flow near the heart valve. Changes in the internal space of the sinus and the formation of blood clots have been reported after the implantation of a transcatheter aortic valve, an artificial heart valve. Although the sinus shape and leaflet motion significantly affect the hemodynamic characteristics and platelet aggregation, the blood flow behaviors near the heart valve associated with clot formation have not been fully elucidated. This study conducted in vitro experiments to investigate the flow behavior near an aortic sinus model based on the sinus shape. Additionally, hemodynamic changes associated with variations in the aortic sinus geometry and leaflet length within an aortic sinus model under pulsatile-flow conditions were elucidated. In a curved sinus model, a large single vortex formed near the center of the sinus region. Meanwhile, the center of the vortex in the sinus region shifted during a cycle in an expanded sinus model. Furthermore, a small vortex remained where the leaflet was initiated, thus increasing the likelihood of thrombus formation. Thus, the curved sinus model is advantageous for preventing material accumulation by maintaining a large vortex structure. The experimental results confirmed that the aortic sinus shape and leaflet length affect the likelihood of thrombus formation inside the aortic sinus.

Scoring system to predict mid-term adverse events after elective thoracic endovascular aortic repair

ObjectiveTo develop and validate a scoring system to predict mid-term adverse events after elective thoracic endovascular aortic repair (TEVAR). MethodsIn this multicenter retrospective observational cohort study, 350 patients who underwent elective TEVAR for thoracic aortic disease between January 2008 and December 2021 were analyzed. The primary outcome was the first adverse event occurring within 5 years of the initial TEVAR, which included death during the initial hospitalization, perioperative neurologic complication, stent graft–induced new entry, dissection, rupture, graft infection, and reintervention related to the initial TEVAR. The scoring system was developed using the regression coefficients of the Fine-Gray subdistribution hazard model. Its performance was evaluated using the area under the receiver operating characteristic curve (AUC) for competing risk analysis and internally validated by cross-validation. ResultsEighty-two patients experienced at least 1 adverse event within 5 years of the initial TEVAR. The 5-year cumulative incidence of adverse events was 26% (95% confidence interval, 21%-31%). Female sex, comorbidity score, use of anticoagulants, preoperative aortic diameter at the diaphragm level, proximal oversizing ratio, aortic coverage length, and hybrid procedure were included in the scoring system. The AUC of the scoring system in the internal validation was 0.748 (standard error, 0.009). When the scoring system was validated in patients with intact thoracic aortic aneurysm only, the AUC was 0.780 (standard error, 0.012). ConclusionsAlthough external validation is needed, our scoring system may be useful for decision making, especially in patients with an intact thoracic aortic aneurysm.

Extended aortic coverage in thoracic aortic endovascular repair is not associated with spinal cord ischemia

ObjectiveSpinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains a debilitating complication, occurring in 10% of patients. Studies have shown that extended aortic coverage is a risk factor for SCI. This study evaluates whether extended aortic length coverage is a significant risk factor for SCI. MethodsThis study retrospectively reviewed 277 consecutive patients who underwent TEVAR successfully between 2006 and 2021 at a single institution. The patients were classified into 2 groups: ≥205 mm and <205 mm of thoracic aortic coverage. Analysis of variance was used to compare these variables and associated aortic coverage between the 2 groups. Univariable logistical regression was used to compare SCI and associated factors. ResultsOf the 269 patients who underwent successful TEVAR, 127 (47.2%) had ≥205 mm and 142 (52.8%) had <205 mm of aorta coverage. Patients with ≥205 mm of thoracic aorta coverage were more likely to be smokers (P < .01) and to have a history of previous stroke (P < .05). Patients with extended coverage were more likely to receive a preoperative lumbar drain (LD) (P < .01). Extended aortic coverage was not associated with a higher risk of SCI compared to standard aortic coverage (4.7% vs 4.2%; P = .84). Extended aortic coverage with or without a preoperative LD did not have an association with SCI (P = .91). Type II endoleaks were seen more in extended aortic coverage (P < .01). ConclusionsExtended aortic coverage (compared with the standard approach) was not associated with a higher risk of SCI; however, this may have been mitigated by a higher prevalence of prophylactic lumbar drainage in this population.

An Expert Delphi Consensus on Risk Factors for Adverse Events After Endovascular Aortic Aneurysm Repair: Tier 1 Study From the International RIsk Stratification in EVAR (IRIS-EVAR) Working Group.

Tier 1 of the International RIsk Stratification in EndoVascular Aneurysm Repair (IRIS-EVAR) project aimed to identify important risk factors for adverse events following endovascular aneurysm repair (EVAR). Initially, the steering committee proposed a number of risk factors for adverse events following EVAR. A Delphi consensus was performed as expert panelists were presented with risk factors and provided the opportunity to propose additional risk factors during the process. Experts in EVAR completed an online survey via 3 structured rounds. The first round opened in July 2022, and the third round closed in December 2022. Panelists rated risk factors using a 4-point Likert scale. Consensus was defined as >70% of participants agreeing/strongly agreeing or disagreeing/strongly disagreeing with a statement in each round. Thirty-five panelists from 12 countries completed the 3 rounds of surveys. Of a total of 64 individual risk factors assessed by the panelists, 37 (58%) had consensus that they were important for adverse events following EVAR. Risk factors were stratified in 4 domains: 14 (38%) were related to preoperative anatomy, 3 (8%) related to the aortic device selection, 8 (22%) related to the procedure performance, and 12 (32%) related to postoperative surveillance. Factors with the highest consensus in each domain were as follows: proximal aortic neck length <15 mm (98% consensus), anatomy non-compliant with instructions for use (94% consensus), length of achieved proximal aortic neck post implantation <10 mm (98% consensus), and non-satisfactory seal at landing or overlapping zones/sac expansion/kink or stenosis (100% consensus each), respectively. Clinically important risk factors for adverse events after EVAR were identified via expert consensus. These factors will be used to develop an expert consensus-informed risk stratification and surveillance strategies. This is the first study to apply an in-depth Delphi methodology to achieve an expert consensus on risk factors for adverse events after endovascular aneurysm repair (EVAR). Important risk factors were stratified in 4 domains: preoperative anatomy (14 factors), aortic device (3 factors), EVAR procedure (8 factors), and postoperative surveillance (12 factors). This study will potentially influence future clinical practice by providing evidence informed by experts regarding predictors of adverse events following EVAR that can be taken into account during decision making and developing post-EVAR surveillance strategies. These findings will inform a risk stratification tool for everyday use by vascular surgeons.

Temporal evolution of ascending aortic aneurysm wall stress predicts all-cause mortality.

Diameter-based risk stratification for elective repair of ascending aortic aneurysm fails to prevent type A dissection in many patients. Aneurysm wall stresses may contribute to risk prediction; however, rates of wall stress change over time are poorly understood. Our objective was to examine aneurysm wall stress changes over 3-5 years and subsequent all-cause mortality. Male veterans with <5.5 cm ascending aortic aneurysms and computed tomography at baseline and 3- to 5-year follow-up underwent three-dimensional aneurysm model construction. Peak circumferential and longitudinal wall stresses at systole were calculated using finite element analysis. Temporal trends were assessed by mixed-effects modelling. Changes in aortic wall stresses, diameter and length over time were evaluated as predictors of subsequent 3-year all-cause mortality by Cox proportional hazards modelling. Sixty-two male veterans were included in the study. Yearly changes in geometric and biomechanical measures were 0.12 mm/year (95% confidence interval, 0.04-0.20) for aortic diameter, 0.41 mm/year (0.12-0.71) for aortic length, 1.19 kPa/year -5.94 to 8.33) for peak circumferential stress, and 0.48 kPa/year (-3.89 to 4.84) for peak longitudinal stress. Yearly change in peak circumferential stress was significantly associated with hazard of death-hazard ratio for peak circumferential stress growth per 10 kPa/year, 1.27 (95% CI, 1.02-1.60; P = 0.037); hazard ratio for peak circumferential stress growth ≥ 32 kPa/year, 8.47 (95% CI, 2.42-30; P < 0.001). In this population of nonsurgical aneurysm patients, large temporal changes in peak circumferential stress, but not aortic diameter or length, was associated with all-cause mortality. Biomechanical stress and stress changes over time may be beneficial as additional risk factors for elective surgery in small aneurysms.

Extensive Calcification Involving the Entire Length of Aorta: A Rare Presentation of Porcelain Aorta

Extensive Calcification Involving the Entire Length of Aorta: A Rare Presentation of Porcelain Aorta

Predictive Factors for Iliac Limb Occlusions After Endovascular Abdominal Aneurysm Repair: Determined from Aortoiliac Anatomy, Endovascular Procedures, and Aneurysmal Remodeling.

Iliac limb occlusion (ILO) is a serious complication of endovascular abdominal aneurysm repair (EVAR). This study aimed to identify predictive factors for ILO derived from aortoiliac morphology, endovascular procedure-related parameters, and aneurysmal remodeling characteristics. Patient demographics, pre-EVAR anatomical characteristics of the aneurysm, endovascular procedure details, and post-EVAR aneurysmal remodeling outcomes were analyzed and compared using univariate analysis. Statistically significant factors were subsequently subjected to Cox regression and Kaplan-Meier analyses. Between January 2013 and April 2022, 66 patients were included in this study. Fourteen patients presented with ILO and were compared with 52 control patients with patent endograft limb over at least 1-year of follow-up. The tortuosity indices of the common iliac artery (CIA) and endograft iliac limb to vessel oversizing were significantly larger in the ILO group than in the patent endograft limb group. The CIA index of tortuosity ≥1.08, and endograft iliac limb to vessel oversizing ≥18.8% were independent predictors for ILO. During the follow-up of all patients, the proximal aortic neck and CIA diameters increased, aneurysm sac diameter decreased, and aortic neck and aortic length increased. The aortoiliac length increased over time in patients with patent endograft limb but not in patients with ILO. A change in the lowest renal artery-left iliac bifurcation distance ≦0.07 mm increased the risk of ILO. ILO is predisposed to occur when the CIA index of tortuosity ≥1.08 and endograft iliac limb to vessel oversizing ≥18.8% are present. Significant aortoiliac remodeling, including proximal aortic neck dilatation, neck straightening, aneurysmal sac regression, iliac artery enlargement, and aortic lengthening, occurs after EVAR. Aortoiliac elongation was observed in patients with patent endograft limb, but not in patients with ILO. ILO was associated with a change in the lowest renal artery-left iliac bifurcation from the postoperative measurements ≦ 0.07 mm.

Age affects vascular morphology and predictiveness of anatomical landmarks for aortic zones in trauma patients: implications for resuscitative endovascular balloon occlusion of the aorta.

Understanding the vascular morphology is fundamental for resuscitative endovascular balloon occlusion of the aorta. This study aimed to evaluate the effect of aging on length and diameter of aorta and iliac arteries in trauma patients, and to investigate the predictiveness of anatomical landmarks for aortic zones. A total of 235 patients in a regional trauma center registry from September 1, 2018, to January 3, 2024, participated in the study. Reconstruction of computed tomography was applied to the torso area. The marginal diameter and length of aorta and iliac arteries were measured. Anatomical landmark distances and aortic marginal lengths were compared. The length and diameter of aorta and iliac arteries increased with age, and a tortuous and enlarged morphology was observed in older patients. There was a good regression between age and diameter of the aorta. Neither the jugular notch, the xiphisternal joint, nor the umbilicus could reliably represent specific margins of aortic zones. The distance between the mid-sternum and femoral artery (427 ± 25 to 442 ± 25mm for right, and 425 ± 28 to 440 ± 26mm for left) was predictive for zone 1 in all groups. The distance between the lower one-third junction of the xiphisternum to the umbilicus and femoral artery (232 ± 19 to 240 ± 17mm for right, and 229 ± 20 to 237 ± 19mm for left) was predictive for zone 3 aorta. Aging increases the length and diameter of aorta and iliac arteries, with a tortuous and enlarged morphology in geriatric populations. The mid-sternum and the lower one-third junction of the xiphisternum to the umbilicus were predictive landmarks for zone 1 and zone 3, respectively.

Marfan and Loeys-Dietz aortic phenotype: A potential tool for diagnosis and management

ObjectiveIn heritable aortic diseases, different vascular involvement may occur with potential variable implications in aortic dilation/dissection risk. This study aimed to analyze the aortic anatomy of individuals with Marfan syndrome and Loeys-Dietz syndrome to identify possible morphological differences. MethodsComputed tomography and magnetic resonance imaging of the thoracoabdominal aorta from the proximal supra-aortic vessels to the femoral bifurcation level of 114 patients with Marfan and Loeys-Dietz syndromes and 20 matched control subjects were examined. Aortic diameters, areas, length, and tortuosity were measured in different aortic segments using specific vessel analysis software. ResultsPatients with Marfan syndrome showed a higher prevalence of ascending aorta and aortic root dilation (P = .011), larger and longer aortic roots (P = .013) with pear-shaped phenotype, larger isthmus/descending aorta diameter ratio (P = .015), and larger suprarenal aorta and iliac arteries. Patients with Loeys-Dietz syndrome showed longer indexed segments and a significantly longer arch (P = .006) with type 2/3 arch prevalence (P = .097). Measurement ratios analysis provided cut-off values (aortic root to ascending aorta length/aortic root diameter, aortic root/sinotubular junction, aortic root/ascending aorta diameter) differentiating patients with Marfan syndrome from patients with Loeys-Dietz syndrome, even in the early stage of the disease. ConclusionsBoth syndromes show peculiar anatomic patterns at different aortic levels irrespective of aortic dilation and disease severity. These features may represent the expression of different genetic mutations on aortic development, with a potential impact on prognosis and possibly contributing to better management of the diseases. The systematic adoption of whole body imaging with magnetic resonance or computed tomography should always be considered, because they allow a complete vascular assessment with practical indicators of differential diagnosis.