Aortic-related Death Research Articles

Use of Secondary Iliac Branch Devices after Previous Endovascular Abdominal and Thoraco-Abdominal Aortic Aneurysm Repair

To assess the safety and effectiveness of iliac branch devices (IBDs), as secondary procedure, for the treatment of type Ib endoleak or evolution of iliac artery disease after prior endovascular aortic repair (EVAR) for thoraco-abdominal (TAAAs) or abdominal aortic aneurysms (AAAs). A multicentre observational study of three European centres. The study included 75 patients (age 71 ± 9 years, 96% men) with previous EVAR (n= 64, 85%) or fenestrated or branched (FB) EVAR (n= 11, 15%). Overall, 88 IBDs were implanted to treat aneurysmal iliac artery evolution in 40 (53%) and type Ib endoleak in 35 (47%) cases, respectively. Thirteen (17%) patients received bilateral IBDs. Internal iliac artery (IIA) catheterisation was done through a transaxillary access (n= 82, 93%) or up and over (n= 6, 7%) technique. The primary endpoint was technical success. Secondary endpoints were 30 day major adverse event, early and long term freedom from re-intervention and target vessel instability. All procedures were technically successful (100%). During hospitalisation, there were four (5%) major adverse events and three (4%) early re-interventions, but no death, stroke, or damage to previous endografts. The median follow up was 47 (interquartile range 42) months, and the five year survival rate was 78 ± 6% with no aortic related death. Cox's regression analysis showed pre-operative renal function impairment (hazard ratio [HR] 3.4; 95% confidence interval [CI] 1.1 - 10.1; p= .033), and primary TAAA repair (HR 6.1; 95% CI 1.6-22.3; p= .006) as independent factors for long term mortality. Freedom from re-interventions was 85 ± 4% at five years with 11 (12%) cases (five endoleaks, four IBD thromboses, two stenoses). IIA instability was reported in three (3%) limbs and freedom from IIA instability was 95 ± 3% after 60 months. Secondary IBD after EVAR is a safe and effective procedure with high technical success and low complication rates. The technique of choice to revascularise the IIA seems not to affect early and follow up results. Long term durability of IBD repair is acceptable with low rates of IIA re-intervention.

Thoracic Endovascular Aortic Repair versus Optimal Medical Treatment in Patients with Type B Intramural Hematoma: A Meta-Analysis.

We intended to study the effect of thoracic endovascular aortic repair (TEVAR) and optimal medical treatment (OMT) on type B intramural hematoma (BIMH). We searched PubMed, EMbase, Cochrane Library, and China National Knowledge Infrastructure databases that compared TEVAR and OMT in patients with BIMH. Two authors independently assessed the risk of bias using the Newcastle-Ottawa Scale. The rate ratio (RR) and 95% confidence interval were used to calculate the outcome. The primary endpoints were aortic-related death and regression/resolution. Secondary endpoints were all-cause death, progression to dissection, and secondary intervention. Eight observational studies were included in the analysis. TEVAR reduced aortic-related death (RR 0.22, 95% CI 0.08-0.56, P = 0.002, I² = 24%) and promoted hematoma regression/resolution (RR 1.48, 95% CI 1.05-2.10, P <0.05, I² = 71%) compared to OMT. Moreover, TEVAR was associated with a reduction in progression to dissection (RR 0.32, 95% CI 0.13-0.81, P <0.02, I² = 39%) and secondary intervention (RR 0.18, 95% CI 0.09-0.37, P <0.00001, I² = 38%) compared to OMT. However, all-cause death has no significant difference between the two groups (RR 0.45, 95% CI 0.17-1.19, P = 0.11, I² = 58%). The results of this meta-analysis suggested that TEVAR is an effective treatment for BIMH, which can delay the progression of intramural hematoma and promotes regression/resolution. More research about indications of TEVAR is still needed.

Midterm Results of Thoracic Endovascular Aortic Repair with Reentry Closure for Chronic Type B Aortic Dissection with Aneurysmal Dilatation.

Objectives: This study aims to discuss the midterm results of thoracic endovascular aortic repair (TEVAR) with reentry closure for chronic type B aortic dissection (CTBAD). Materials and Methods: This retrospective study analyzed 13 patients with CTBAD who underwent TEVAR with reentry closure between July 2014 and December 2020. We evaluated the false lumen (FL) cross-sectional area using computed tomography images of the descending aorta at the level of the bronchial bifurcation, Valsalva sinus, celiac artery, and infrarenal abdominal aorta pre- and postoperation. The study endpoints were technical and clinical success rates, freedom from additional aortic reintervention or surgery, and survival. Results: Technical success was obtained in 12 patients (92.3%) with no hospital mortality and neurological complications. The postoperative observation period was 49.2±21.5 months. The clinical success rate was 76.9% (10 cases), and a postoperative reduction of the FL cross-sectional area was obtained in 53.8% of patients. The 5-year overall survival rate was 64.8% with no aortic-related deaths while the 5-year freedom from additional aortic surgery rate was 66.7%. Conclusions: TEVAR with reentry closure suggests preventing FL dilatation or rupture in CTBAD, but the revision of our devices and further research with more patients and longer follow-up periods are required.

Traumatic blunt thoracic aortic injury: a 10-year single-center retrospective analysis

BackgroundApproximately 80% of patients with blunt thoracic aortic injury (BTAI) die before reaching the hospital. Most people who survive the initial injury eventually die without appropriate treatment. This study analyzed and reported the treatment strategy of a single center for BTAI in the last 10 years and the early and middle clinical results.MethodsThis retrospective study included patients diagnosed with BTAI at Xijing Hospital from 2013 to 2022. All inpatients with BTAI aged ≥ 18 years were included in this study. The clinical data, imaging findings, and follow-up results were retrospectively collected and analyzed. The Kaplan–Meier curve and multivariate logistic regression were used to compare survivors and nonsurvivors.ResultsA total of 72 patients (57% men) were diagnosed with BTAI, with a mean age of 54.2 ± 9.1 years. The injury severity score was 24.3 ± 18, with Grade I BTAI1 (1.4%), Grade II 17 (23.6%), Grade III 52 (72.2%), and Grade IV 2 (2.8%) aortic injuries. Traffic accidents were the main cause of BTAI in 32 patients (44.4%). Most patients had trauma, 37 had rib fractures (51.4%), Sixty patients (83.3%) underwent thoracic endovascular aortic repair (TEVAR) surgery, eight (11.1%) underwent conservative treatment, and only four (5.6%) underwent open surgery. The overall hospitalization mortality was 12.5%. In multivariate logistic regression, elevated creatinine levels (P = 0.041) and high Glasgow coma scale (GCS) score (P = 0.004) were the predictors of hospital mortality. The median follow-up period was 57 (28–87) months. During the follow-up period, all-cause mortality was 5.6% and no aortic-related deaths were reported. Three patients (4.2%) needed secondary surgery and two of them underwent endovascular repair.ConclusionAlthough TEVAR surgery may be associated with intra- or postoperative dissection rupture or serious complications in the treatment of Grade III BTAI, the incidence rate was only 8.9%. Nevertheless, TEVAR surgery remains a safe and feasible approach for the treatment of Grade II or III BTAI, and surgical treatment should be considered first,. A high GCS score and elevated creatinine levels in the emergency department were closely associated with hospital mortality. Younger patients need long-term follow-up after TEVAR.

Effectiveness and Minimal-Invasiveness of Zone 0 Landing Thoracic Endovascular Aortic Repair Using Branched Endograft.

Background: Zone 0 landing thoracic endovascular aortic repair (TEVAR) for the treatment of aortic arch diseases has become a topic of interest. This study aimed to verify whether branced TEVAR (bTEVAR) is an effective and a more minimally invasive treatment by comparing the outcomes of bTEVAR and hybrid TEVAR (hTEVAR) in landing zone 0. Methods: This retrospective, single-center, observational cohort study included 54 patients (bTEVAR, n = 25; hTEVAR, n = 29; median age, 78 years; median follow-up period, 5.4 years) from October 2012 to June 2018. The logistic Euro-SCORE was significantly higher in the bTEVAR group than in the hTEVAR group (38% vs. 21%, p < 0.001). Results: There was no significant difference the in-hospital mortality between the bTEVAR and hTEVAR groups (0% vs. 3.4%, p = 1.00). The operative time (220 vs. 279 min, p < 0.001) and length of hospital stay (12 vs. 17 days, p = 0.013) were significantly shorter in the bTEVAR group than in the hTEVAR group. The 7-year free rates of aorta-related deaths (bTEVAR [95.5%] vs. hTEVAR [86.9%], Log-rankp = 0.390) and aortic reintervention (bTEVAR [86.3%] vs. hTEVAR [86.9%], Log-rankp = 0.638) were not significantly different. Conclusions: The early and mid-term outcomes in both groups were satisfactory. bTEVAR might be superior to hTEVAR in that it is less invasive. Therefore, bTEVAR may be considered an effective and a more minimally invasive treatment for high-risk patients.

Fenestrated/branched endovascular aortic repair using unilateral femoral access in patients with iliac occlusive disease

ObjectiveFenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging owing to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease. MethodsWe performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with unilateral iliofemoral occlusive disease were included in the analysis. All patients had one patent iliac artery that was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (stroke, spinal cord injury, dialysis or decrease in the glomerular filtration rate of more than 50%, bowel ischemia, myocardial infarction, or respiratory failure), primary iliac patency, and freedom from reinterventions. ResultsThere were 959 patients treated with F/BEVAR. Of these, 15 patients (1.56%; mean age, 74 years; 80% male) had occluded iliac arteries and 1 patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (n = 8) or juxtarenal abdominal aortic aneurysm (n = 7). Brachial access was used in 14 of the 15 patients and preloaded systems in 7 of the 15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were seven physician-modified endovascular grafts, seven custom-made devices, and one off-the-shelf device used. Thirteen patients (87%) had distal seal using aortouni-iliac stent grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in two patients and six patients had a prior FCB. Technical success was 100%. There were no intraoperative complications or early lower extremity ischemic complications, and all FCB were preserved. There was one mortality (7%) within 30 days owing to retrograde type A dissection. Major adverse events occurred in 20% of patients. The median follow-up was 12 months (range, 0-85 months). Two patients (13%) required three reinterventions. One patient required proximal stent graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an aortouni-iliac graft (21 months) and thrombolysis of that extension (50 months). At last follow-up, all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no r-intervention. The overall survival rate was 60%, without aortic-related deaths. ConclusionsAlthough challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications, but satisfactory outcomes.

Five-year outcomes of physician-modified endografts for repair of complex abdominal and thoracoabdominal aortic aneurysms

ObjectiveThere is paucity of data on the durability of physician modified endografts (PMEGs) for complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) despite widespread use. The aim of this study was to evaluate and compare the early and long-term outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) for CAAAs and TAAAs using PMEGs. MethodsWe reviewed clinical data and outcomes of patients treated by FB-EVAR using PMEGs for CAAAs (defined as short-neck infrarenal, juxtarenal, and pararenal AAAs) and TAAAs between 2007 and 2019. All patients were treated by a dedicated team with extensive manufactured device experience. Endpoints included 30-day mortality and major adverse events, patient survival and freedom from aortic-related mortality (ARM), freedom from secondary intervention, target artery (TA) patency, and freedom from TA endoleak and TA instability. ResultsOf 645 patients undergoing FB-EVAR, 156 patients (24%) treated with PMEG (121 males; mean age, 75 ± 8 years) were included. There were 89 CAAAs, 33 extent IV TAAAs and 34 extent I to III TAAAs. A total of 452 renal-mesenteric targets (3.1 ± 1.0 vessels/patient) were incorporated. Patients with TAAAs had significantly (P < .05) larger aneurysms (73 ± 11 vs 68 ± 14 mm), more TAs incorporated (3.4 ± 0.9 vs 2.8 ± 1.0), and more often had previous aortic repair (54% vs 27%). Technical success was higher in patients treated for CAAAs (99% vs 91%; P = .04). Thirty-day and/or in-hospital mortality was 5.7% and was significantly lower for CAAAs compared with TAAAs (2% vs 10%; P = .04), with three of nine early mortalities (33%) among patients treated emergently. After a mean follow-up of 49 ± 38 months, there were 12 aortic-related deaths (7.6%), including nine early deaths (5.7%) from perioperative complications and three late deaths (1.9%) from rupture. At 5 years, patient survival was 41%. Patients treated for CAAAs had higher 5-year freedom from ARM (P = .016), TA instability (P = .05), TA endoleak (P = .01), and TA secondary interventions (P = .05) with a higher, but non-significant, freedom from sac enlargement ≥5 mm (P = .11). Primary and secondary TA patency was 91% ± 2% and 99% ± 1%, respectively. Sac regression ≥5 mm occurred in 67 patients (43%) and was associated with increased survival (hazard ratio, 0.54; 95% confidence interval, 0.37-0.80) compared with those without sac regression. ConclusionsFB-EVAR using PMEGs was performed with acceptable long-term outcomes. Overall patient survival was low due to significant underlying comorbidities. Patients treated for CAAAs had higher freedom from ARM, TA instability, TA endoleak, TA secondary interventions, and a trend towards higher freedom from sac enlargement compared with patients treated for TAAAs. Sac regression was associated with improved patient survival.

Outcomes of patients with aortic vascular graft and endograft infections initially contra-indicated for complete graft explantation.

Complete excision in patients with aortic vascular graft and endograft infections (VGEIs) is a significant undertaking, and many patients never undergo definitive treatment. Knowing their fate is important to be able to assess the risks of graft excision vs alternative strategies. This study analyzed their life expectancy and sepsis-free survival. VGEIs were diagnosed according to the Aortic Graft Infection (MAGIC) criteria, and patients turned down for graft removal from November 2006 to December 2020 were included. Primary endpoints were aortic-related and sepsis-free survival estimated using the Kaplan-Meier method. A Cox proportional hazards regression analysis was used to compute the hazard ratio (HR) and 95% confidence interval (CI) as estimates of survival without sepsis. Seventy-four patients were included, with a median age of 71years (range, 63-79years). The index aortic repair was either open (n= 33; 44.6%), endovascular (n= 19; 25.7%), or hybrid (n= 22; 29.7%). Causative organisms were identified in 56 patients (75.7%). At presentation, 26 patients (35.1%) required salvage surgery, open (n= 22; 29.7%) or endovascular (n= 8; 10.8%), and 17 radiological drainage (23.0%). During follow-up, eight required drainage and 11 (14.9%) graft removal (five complete). Infectious complications included pseudoaneurysms (n= 14; 18.9%), rupture (n= 9; 12.2%), gastro-intestinal bleeding (n= 13; 17.6%), septic embolisms (n= 4; 5.4%), and thrombosis (n= 12; 16.2%). In-hospital mortality was 20.3% (n= 15), freedom from aortic-related death and overall survival was 77.1% (95% CI, 65.2%-85.3%) and 70.4% (95% CI, 58.3%-79.7%) at 1year, and 61.7% (95% CI, 46.1%-74.0%) and 43.1% (95% CI, 29.2%-56.3%) at 5years. Sepsis recurrence occurred in 37 patients (50.0%). Seven (16.3%) developed acquired antimicrobial resistance. Malnutrition (HR, 3.3; 95% CI, 1.4-7.6; P= .005), hemorrhagic shock at presentation (HR, 2.9; 95% CI, 1.0-8.2; P= .048), aorto-enteric fistulae (HR, 3.3; 95% CI, 1.3-8.4; P= .011), fungal coinfection (HR, 3.5; 95% CI, 1.2-11.5; P= .030), and infection with resistant micro-organisms (HR, 3.1; 95% CI, 1.1-8.3; P= .023) were significantly associated with worse survival without sepsis. In-hospital and aortic-related mortality were significant, but with salvage surgery and antibiotic therapy, the median survival was 3years. Sepsis recurrence remained frequent, and further procedures were needed. These outcomes should be considered when graft excision is proposed. Known predictors of adverse outcomes should become important points for discussion in multidisciplinary team meetings.

Sex-based differences in patients undergoing thoracic endovascular aortic repair for acute complicated type B dissection

Sex-based differences in outcomes for patients undergoing degenerative aortic aneurysm repair have been well described, with female patients having worse early and long-term outcomes compared with male patients. However, differences between men and women after thoracic endovascular aortic repair (TEVAR) of acute complicated type B aortic dissection (TBAD) have not been well characterized. Therefore, the objective of the present study was to assess the sex-based differences in clinical presentation, time to repair, morbidity, and mortality for patients undergoing TEVAR for TBAD. All TEVAR procedures performed for acute complicated TBAD from a single academic medical center from August 2005 to January 2020 were analyzed. The clinical presentation, time to repair, and outcomes were compared by sex. The primary outcome was 30-day mortality. The secondary outcomes were in-hospital complications, reintervention, aorta-related death, and out of hospital survival. The predictors of mortality, including sex, were determined using multivariable logistic regression. A total of 159 patients (38 women [24%]) were included in the analysis. No sex-based differences were found in clinical presentation or comorbidity prevalence between the female and male patients. The female patients had had a longer overall time from initial symptom onset to TEVAR (female patients: median, 3.5days [interquartile range (IQR), 1-10days]; male patients: median, 1day [IQR, 1-3]; P= .007). However, no differences were found in the time to repair after admission to the academic medical center (female patients: median, 1day [IQR, 0-5days]; male patients: median, 1day [IQR, 0-3]; P= .176). No differences were found in the unadjusted aortic-related, in-hospital, or 30-day death between the female and male patients. Similarly, the risk-adjusted analysis revealed that sex was not associated with adverse outcomes. The 1- and 5-year freedom from aortic-related mortality were 82%± 4% and 87%± 6% and 79%± 4% and 80%± 8% for the men and women, respectively. We found no differences between the female and male patients with acute complicated TBAD who had undergone TEVAR in the clinical presentation or comorbidities. The female patients had undergone TEVAR after a longerduration of symptoms, but this was not associated with sex-based differences in early or late morbidity or mortality.

The Comparison between Frozen Elephant Trunk Technique and Conventional Total Arch Replacement, a Single-center Study

Objective: The advantage of the frozen elephant trunk technique (FET) is treating the aortic pathology extending from the aortic arch to the descending aorta in a one-stage operation. This study aimed to determine the early and long-term outcomes of total arch replacement with the frozen elephant trunk technique compared to conventional total arch replacement (cTAR).&#x0D; Materials and Methods: This study was a single-center, retrospective cohort study. Patients who underwent aortic arch replacement between January 2009 and December 2020 were enrolled and divided into two groups. 32 patients underwent the FET and 47 patients underwent cTAR. Outcomes and survival analysis were compared.&#x0D; Results: The 5-year survival for FET and cTAR were 87.27% and 82.55% and the aortic-related mortality was not significantly different (HR 0.97, 95%CI 0.22-0.43). Aortic re-intervention was significantly lower in the FET group accounting for 3.57%, while there was 39.1% in the cTAR group. FET significantly reduced aortic re-intervention compared with cTAR (HR 0.09, 95%CI 0.01-0.81). There were no differences in the incidence of stroke between the two groups. However, FET patients had significantly increased risks of paraplegia by 21% when compared to cTAR (Risk difference +0.21, 95%CI 0.02-0.40)&#x0D; Conclusions: The FET technique had comparable early outcomes in terms of mortality, renal function, postoperative bleeding, and recurrent laryngeal nerve injury. Even though FET had a significant risk of postoperative paraplegia, FET reduced the aortic re-intervention rate without increasing aortic-related death.

Volume Analysis to Predict the Long-Term Evolution of Residual Aortic Dissection after Type A Repair.

Background: The aim of this study was to evaluate the aortic diameter and volume during the first year after a type A repair to predict the long-term prognosis of a residual aortic dissection (RAD). Methods: All patients treated in our center for an acute type A dissection with a RAD and follow-up > 3 years were included. We defined two groups: group 1 with dissection-related events (defined as an aneurysmal evolution, distal reintervention, or aortic-related death) and group 2 without dissection-related events. The aortic diameters and volume analysis were evaluated on three postoperative CT scans: pre-discharge (T1), 3–6 months (T2) and 1 year (T3). Results: Between 2009 and 2016, 54 patients were included. Following a mean follow-up of 75.4 months (SD 31.5), the rate of dissection-related events was 62.9% (34/54). The total aortic diameters of the descending thoracic aorta were greater in group 1 at T1, T2 and T3, with greater diameters in the FL (p < 0.01). The aortic diameter evolution at 3 months was not predictive of long-term dissection-related events. The total thoracic aortic volume was significantly greater in group 1 at T1 (p < 0.01), T2 (p < 0.01), and T3 (p < 0.01). At 3 months, the increase in the FL volume was significantly greater in group 1 (p < 0.01) and was predictive for long-term dissection-related events. Conclusion: This study shows that an initial CT scan volume analysis coupled with another at 3 months is predictive for the long-term evolution in a RAD. Based on this finding, more aggressive treatment could be given at an earlier stage.

Noncommunicating acute type A aortic dissection in elderly patients: Surgery versus medical management.

Our goal was to evaluate the surgical and conservative outcomes of acute type A aortic dissection with a thrombosed false lumen of the ascending aorta in elderly patients. Patients older than 75 years with acute type A aortic dissection admitted to our hospital from October 2011 to December 2020 were reviewed retrospectively, including those with the noncommunicating type without malperfusion and low physical capacity prehospitalization. Sixty-six patients were enrolled consecutively in the medical (M, n = 30) and surgical (S, n = 36) groups. The ascending aorta was the most replaced section in the S group (78%). Groups did not differ significantly in hospital deaths and in intensive care unit and hospital stays. Two patients (7%) underwent surgery and 3 (10%) underwent redissection in the M group. No significant difference existed between the groups in the decline of physical performance during hospitalization. Seven patients in the M group (24%) had aorta-related events in the late period as opposed to none in the S group (P=0.003). Survival rates after 4 years were 78.3% and 71.4% in the S and M groups, respectively (P=0.154). The cumulative incidence of overall reintervention due to an aortic event was significantly higher in the M group; however, the 2 groups did not differ significantly in overall aorta-related deaths. Surgical outcomes of noncommunicating acute type A aortic dissection in elderly patients were favorable. There was no significant difference in maintaining physical function at discharge, and the medical group had a significantly higher overall aortic event rate than the surgical group.

Long-Term Results of Complex Abdominal Aortic Aneurysm Open Repair.

This study investigated the long-term outcomes of patients treated with open surgical repair for complex abdominal aortic aneurysms (c-AAAs). A total of 119 patients with c-AAAs undergoing repair between January 2010 and June 2016 in a high-volume aortic center were included. The long-term imaging follow-up consisted of yearly abdominal ultrasound examinations and 5-year computed tomography angiography. At a median follow-up of 76 months (IQR 38 months), forty-three deaths (37%) and three (2.5%) aortic-related deaths were observed. Long-term chronic renal decline was observed in fifty (43.8%) patients, significantly correlated with post-operative acute kidney injury. During the follow-up, five reinterventions (4.3%) were performed. The present study suggests that open c-AAA repair can be performed with acceptable operative risk with durable results. To achieve the best possible long-term outcome, the open surgery repair of complex AAA should be performed in high-volume aortic centers and tailored to the patient.

Procedure and Aortic Remodeling Effects of Entry Closure with Stentgraft for Type B Aortic Dissection: Comparison between the Patients with Narrow True Lumen and Those with Aneurysmal Dilated False Lumen.

Objectives: Appropriateness of device selection, procedure protocol and aortic remodeling effects of entry closure (TEVAR) with stent-graft (SG) for patent false lumen type B aortic dissection (TBAD) were compared between the patients with narrow true lumen (narrow group) and those with aneurysmal dilated false lumen (aneurysmal group).Methods: Twenty-six patients with narrow true lumen (narrow group) and 20 patients with aneurysmal false lumen (aneurysmal group) were included in this study. In narrow group, straight SG was implanted from Zone 3 regardless the distance between the left subclavian artery and entry. In aneurysmal group, straight or taped SG was implanted with proximal landing zone length 20 mm or more. Thoracic aortic anatomy was evaluated by CT and aortic remodeling was defined as true lumen diameter ≥50% of the aortic diameter and occlusion of false lumen. Aorta related death, retrograde type A aortic dissection (RTAD), stentgraft induced new entry (SINE) and aortic maximum diameter enlargement 5 mm or more (aortic expansion) were included in the aortic event.Results: There was no procedure related complication in narrow group and 1 patient died due to aortic rupture in aneurysmal group, Type Ia endoleak by enhanced CT 7 days after TEVAR was detected in one patient in each group. Achievement of aortic remodeling was significantly better in narrow group. Aortic event occurred in only one patient in narrow group, in whom aortic expansion was observed. In aneurysmal group, aortic event occurred 12 patients (60%) and 2 RTAD, 5 SINE, and 8 aorta expansion were observed. Aortic event free rate was significantly better in narrow group.Conclusion: TEVAR procedure for the TBAD patients with narrow true lumen seemed to be appropriate, however, different TEVAR procedure or additional procedures would be required for those with aneurysmal dilated false lumen to obtain favorable outcomes. (This is secondary publication from Jpn J Vasc Surg 2021; 30: 347–357.)

A SiMplified bARe-Wire Target Vessel (SMART) Technique for Fenestrated Endovascular Aortic Repair

Purpose: The aim of this study was to present a new technique for fenestrated endovascular aortic aneurysm repair (FEVAR) and to review its preliminary results. The SiMplified bARe-wire Target vessel (SMART) technique for FEVAR aims to simplify the procedure by avoiding guiding sheaths into visceral arteries during the main graft deployment. Materials and Methods: The SMART technique requires a 12 to 16Fr contralateral introducer, depending on number of fenestrations—compared with standard 18 to 22Fr for 3 to 4 FEVAR—to achieve target vessel catheterization and stenting during FEVAR by avoiding the use of parallel 6 to 7Fr guiding sheaths into each visceral vessel. Fenestrations are sequentially catheterized, assisted by a steerable sheath. A Rosen wire is maintained in each fenestration, with a single sheath parked in the final target vessel while releasing the fenestrated graft. Data on patients treated for pararenal or thoracoabdominal aortic aneurysms with FEVAR, adopting the SMART technique, were retrospectively reviewed. End points were technical success, intraprocedural variables, 90-day mortality, major adverse events (MAEs), and target vessel patency. Results: From May 2018 to December 2020, 57 consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. Median total procedure time and total fluoroscopy time were 223 (196–271) minutes and 81 (71–94) minutes, respectively. Primary technical success was 96.4% (55/57). No misalignment occurred from graft deployment. The total number of fenestrations was 169, including 54 left and 53 right renal arteries, 43 superior mesenteric arteries and 18 celiac trunks (3.0±0.9 vessels/patient), with target vessel technical success of 98.2%. During the first 90 days, there were no deaths (0%). The MAEs included acute kidney injury (AKI) in 3 patients (5%) with no new dialysis onset, respiratory failure requiring prolonged ventilation in 2 patients (4%), myocardial ischemia in 1 patient (2%), but no lower limb ischemia, stroke, or spinal cord ischemia (SCI) occurred. After a mean follow-up of 14±10 months, there was 1 aortic-related death. Primary and assisted primary target vessel patency was 94.6%±1.8 and 97.0%±1.3% respectively. Conclusions: The SMART technique proved to be a safe alternative to standard FEVARs, with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity. Clinical Impact This study evalautes the outcome of fenestrated endovascular aortic repair (FEVAR) procedures at Uppsala university hospital using a simplified bare-wire Target vessel (SMART) technique. The SMART technique requires a smaller contralateral introducer compared to standard 18-22Fr for 3-4 FEVAR to achieve target vessel catetherization and stenting. Fifty-seven consecutive patients were treated for pararenal or thoracoabdominal aortic aneurysms. The SMART technique proved to be a safe alternative to standard FEVARs with excellent technical result and acceptable target vessel patency at mid-term, while reducing the risk for introducer-induced lower limb ischemia, related complications, and morbidity.

Zone 0 thoracic endovascular aortic repair in high risk patients: A retrospective case series.

To report our experience applying endovascular stent graft repair to treat ascending aortic diseases in high-risk patients and to evaluate the safety and feasibility of this approach. Patients with comorbid conditions or older age are not suitable for open procedures but may be considered suitable for ascending endovascular repair. Eleven high-risk patients received zone 0 thoracic endovascular aortic repair from September 2014 to May 2020. All patients were followed up until death or December 2021. Primary outcomes were in-hospital and long-term all-cause mortality as well as in-hospital and long-term aorta-related mortality. The mean follow-up duration of all patients was 35.78 months. The cohort comprised of three pathology subgroups: penetrating atherosclerotic ulcer (PAU) (n =6), acute dissection (AD) (n = 3), and chronic dissecting aneurysm (CDA) (n = 2). The in-hospital all-cause mortality rates were 0%, 33.33% and 0% for PAU, AD, and CDA groups, respectively. Long-term all-cause mortality were 33.33%, 33.33%, and 50% for PAU, AD, and CDA groups, respectively. There was only one in-hospital death related to acute aortic dissection, and no long-term aorta-related deaths occurred during the study period. During the follow-up time, the majority of patients had good remodeling of ascending aorta, slow progression in cases with endoleak, and no aorta-related mortality. Ascending endovascular aortic repair appears to be a safe and feasible procedure for emergent aortic repair in carefully selected patients with prohibitive surgical risk who are not candidates for open procedures.

Late outcomes of the frozen elephant trunk technique for acute and chronic aortic dissection: the angle change of the FROZENIX by "spring-back" force.

To evaluate the outcomes of total arch replacement using the frozen elephant trunk technique with a FROZENIX® J Graft for patients with either acute or chronic aortic dissection, and to evaluate the late-phase outcomes. Between January 2015 and December 2020, we used the frozen elephant trunk technique in 47 patients with acute aortic dissection and 12 patients with chronic aortic dissection. The primary endpoints were 30-day mortality, late aorta-related death and late aortic events. The secondary endpoints included early surgical complications and any aortic events (e.g. stent graft-induced new entry, frozen elephant trunk angle change). In the acute group, there were no aorta-related deaths, although 13 patients (27.7%) experienced an aortic event; stent graft-induced new entry occurred in 6 patients (12.8%). In the chronic group, 1 patient (9.1%) experienced aorta-related death, and 9 (81.8%) experienced an aortic event; stent graft-induced new entry occurred in 4 patients (36.4%). During the late phase after surgery, there was a significant increase in the frozen elephant trunk angle in both groups. In the AAD group, both the FET angle and spring-back angle were significantly enlarged in the late phase. There were no significant differences between groups in the degree of angle change, the overall survival, or aortic event-free survival. Total arch replacement using the frozen elephant trunk technique affords good early-stage results for both acute and chronic aortic dissection. During follow-up, careful monitoring for aortic events and appropriate therapeutic interventions are required. If surgeons are to use this device, they must have a thorough understanding of its spring back force and other features.

Predictors of Intervention in Acute Type B Aortic Penetrating Ulcer and Intramural Hematoma

We aimed to investigate predictors of intervention of acute type B aortic penetrating ulcer (PAU) and intramural hematoma (IMH). We conducted a retrospective chart review of all patients admitted for acute type B PAU or IMH in a tertiary referral hospital. Indications to intervention were "complicated" (rupture, impending rupture, malperfusion) or "high risk for unfavorable outcome" (refractory hypertension and/or pain despite best medical treatment, morphologic aortic evolution, transition to a new aortic syndrome, or increase in IMH/PAU depth >5 mm) during the acute/subacute phase. The primary outcomes were overall mortality, aortic-related mortality, and freedom from intervention. Time-dependent outcomes were estimated with Kaplan-Meier curves. Cox proportional hazards models were used to identify predictors of intervention and mortality. There were 54 acute aortic syndromes, 37 PAUs and 17 IMHs. Mean age was 69 ± 14 years and 33 patients (62.2%) were male. Six (11.5%) patients had complicated aortic syndromes and underwent urgent repair. Two (3.7%) additional patients developed an impending rupture during the acute phase. Eleven (21.1%) patients were classified as at "high risk" during the initial hospitalization. Overall, 22 (40.7%) patients required an aortic intervention during the initial admission (n=16, 72.7% during the acute phase; n=6, 27.3% during the subacute phase). In-hospital mortality was 5.5% (1 PAU and 2 IMH), and was aorta-related in all cases. For IMH, disease extension in >3 aortic zones (HR 1.94, 95%CI 1.17-32.6; p=0.038) and presence of ulcer-like projections (ULPs) (HR 1.23, 95%CI 1.02-9.41; p=0.042) were associated with the need for intervention. There were no aortic-related deaths or intervention during the chronic phase. PAU width >20 mm (HR 1.68, 95%CI 1.07-16.08; p=0.014), PAU depth >15 mm (HR 6.74, 95%CI 1.31-34.18; p=021), PAU depth/total aortic diameter >0.3 (HR 4.31, 95%CI 1.17-20.32; p=0.043), and location at the level of the paravisceral aorta (HR 2.24, 95%CI 1.23-4.70; p=0.035) were significantly associated with need for intervention. Six additional (16.2%) PAUs required intervention during the chronic phase owing to PAU growth. Maximum aortic diameter >35 mm was significantly associated with intervention (HR 1.45, 95%CI 1.00-2.32; p=0.037). Acute symptomatic type B IMHs and PAUs are characterized by a high risk of complications during the first month from presentation. Morphologic features associated with intervention were IMH with ULPs or extension in more than 3 aortic zones, as well as PAUs with depth>15 mm, width >20 mm, or depth/aortic diameter ratio>0.3. A strict follow-up protocol or consideration for early intervention within 30 days from presentation should be taken into account for these high-risk patients. During the chronic phase imaging follow-up is particularly important for PAUs in order to identify progression to saccular aneurysms.

Endovascular plugs to occlude proximal entries in chronic aortic dissection.

OBJECTIVESPatients with expanding chronic aortic dissection and patent proximal entries are sometimes poor candidates for open surgery or TEVAR. Occlusion of proximal entries with endovascular plugs has previously been suggested in selected patients, but clinical results over time are unknown. This study analyses aortic remodelling and clinical outcome after proximal entry occlusion.METHODSBetween 2007 and 2016, 14 patients, with expanding chronic aortic dissection, considered poor candidates for standard treatment, were treated with endovascular plugs in proximal entries located in the arch (n = 6) or descending aorta (n = 8). The Amplatzer™ Vascular Plug II was used for entries 4 mm and the Amplatzer™ Septal Occluder or Amplatzer™ Muscular VSD Occluder for entries 5–16 mm. Patients were followed for 0.5–13 years (median 7.3) with clinical visits and computed tomography. Diameters and cross-sectional areas along the aorta were measured.RESULTSOcclusion of proximal entries was achieved in 10/14 patients (71%), including 4 patients with an adjunctive reintervention needed for complete seal in the segment. Unchanged or reduced maximum thoracic aortic diameter was observed in all 10 patients with successful occlusion. In 4 patients, proximal occlusion was not achieved and early conversion to FET (n = 1), FET/TEVAR (n = 2) or TEVAR (n = 1) was performed. Two aorta-related deaths occurred during follow-up, both after early conversion.CONCLUSIONSEndovascular occlusion of proximal dissection entries of expanding chronic aortic dissections can induce favourable aortic remodelling and may be considered in selected patients with expanding chronic aortic dissection who are poor candidates for open surgery or stent graft repair.

Aortic Remodeling After Stepwise External Wrapping for Type A Acute Aortic Dissection

BackgroundThe optimal repair technique for type A acute aortic dissection is graft replacement; however, the treatment approach in high-risk patients remains controversial or suboptimal. MethodsWe have retrospectively analyzed a cohort of high-risk patients who were admitted to our center for type A acute aortic dissection and who were treated by a new surgical approach using artificial grafts (stepwise external wrapping) between January 2016 and January 2020. The primary endpoints included inhospital mortality and survival during follow-up. Secondary endpoints included the assessment of aortic remodeling after ascending aorta wrapping. ResultsAmong the 134 patients admitted for type A acute aortic dissection, 43 patients underwent stepwise external wrapping. The mean patient age was 79.1 ± 6.8 years. The new standard European System for Cardiac Operative Risk Evaluation score was 64% ± 12%. There was one hospital death (2.3%). There were two major complications of persistent cerebral disorder (4.6%). Minor complications included temporary neurologic disorder (2.3%) and renal failure (2.3%). The intensive care unit and hospital stays were 2.8 ± 1.0 days and 11.7 ± 2.5 days, respectively. The follow-up survival rate was 95.3% ± 6.2% and 91% ± 10.2% at 1 and 3 years, respectively, after surgery. There was no aortic-related death during follow-up. At 1 year after surgery, complete remodeling of the ascending aorta was obtained in 30 patients (85.7%), and 5 patients (14.3%) showed partial remodeling. ConclusionsOur stepwise external wrapping technique was associated with excellent outcomes for high-risk patients with type A acute aortic dissection.