Aortic-related Death Research Articles

Thrombocytopenia as a preoperative risk assessment tool in patients with type B aortic dissection after thoracic endovascular aortic repair

Abstract Background Postoperative thrombocytopenia has been reported to be correlated with adverse events, but the prognostic value of baseline thrombocytopenia is unclear. This study was undertaken to evaluate the relationship between preoperative thrombocytopenia and adverse outcomes in patients with type B aortic dissection who underwent thoracic endovascular aortic repair (TEVAR). Methods A total of 825 patients with acute and sub-acute type B aortic dissection undergoing were TEVAR at a multidisciplinary aortic center were enrolled between January 2010 and December 2017. Patients were stratified on the basis of presence (n=149) or absence (n=676) of thrombocytopenia (platelet count, <150x109/L), according to preprocedural platelet counts. The primary outcome of interest was in-hospital mortality. Secondary outcomes of interest was long-term death. Results In the enrolled cohort, thrombocytopenia occurred in 149 (18.1%) patients. Patients with thrombocytopenia were older, were more commonly acute stage of TBAD, higher D-dimer level and had higher rates of abdominal vessel involvement and pericardial effusion. During the hospitalization period, 26 patients (3.2%) died, which was significantly higher in the thrombocytopenic group (8.1% versus 2.1%; P=0.001) Multivariate analyses revealed that thrombocytopenia was independently associated with in-hospital mortality (Table). During long-term follow-up (median duration 44.2 months), A total of 62 deaths were reported after discharge, including 40 (64.5%) aortic-related and unknown deaths, of which 12 and 50 patients for thrombocytopenia and non-thrombocytopenia group, respectively. Kaplan-Meier estimated rates of long-term all-cause mortality were higher for thrombocytopenia (log-rank test, P=0.014). Similar results were observed in a subset of aortic-related death (P=0.004) as well as aortic-related and unknown death (P=0.006), not non-aortic related death (P=0.878) (Figure 1). Conclusion Platelet counts, as simple and inexpensive indexes, were reliable to be used as a preoperative risk assessment tool for patients with type B aortic dissection undergoing thoracic endovascular aortic repair. Figure 1. Long-term Mortality Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): This research was supported by grant DFJH201807 from High-level Hospital Construction Project of Guangdong Provincial People's Hospital.

Distal Remodeling After Operations for Extensive Acute Aortic Dissection

The clinical predictors of distal aortic remodeling (DAR) after various procedures for extensive acute aortic dissection are not fully understood. From 2008 to 2018, a total of 122 candidates with extensive acute type A and B aortic dissections survived operations of total arch replacement plus frozen elephant trunk (n= 36), ascending aortic replacement plus supraaortic debranching plus retrograde stenting (hybrid procedure; n= 25), and total endovascular repair (n= 61). We assessed DAR at 4 thoracoabdominal aortic levels based on true lumen expansion, false lumen patency, maximal aortic area, and the blood supply of major branches. Univariate and multivariate logistic and mixed-effect models were performed to delineate patterns and risks for DAR at midterm follow-up. At 3.9 years, 13 aorta-related adverse events (10.7%; including 3 aortic-related deaths [2.5%]) and 8 aortic reinterventions (6.6%) occurred. Follow-up computed tomography angiography was performed in all patients at 3.3 years (interquartile range, 2.7-4.4 years). The degree of DAR, which was relatively independent among aortic levels, was maximal at the pulmonary bifurcation level (90.2% complete false lumen thrombosis) and decreased along the distal aorta. Analyses of longitudinal data indicated that baseline overall false lumen patency was the only available factor to predict DAR at all 4 aortic levels. Dissection type, surgical technique, implant size, and medication did not sufficiently influence DAR at midterm follow-up. After distinct operations for extensive acute aortic dissection, DAR beyond the stent graft coverage is a local anatomical behavior independent of dissection type or proximal management.

Prevalence and progression of aortic dilatation in adult patients with Turner syndrome: a cohort study.

Turner syndrome (TS) is a rare disorder affecting 1/2500 female newborn. Aortic dilatation (AD) and aortic dissection represent a major concern in TS. The aims of our study were to describe the aortic root growth, potential aortic dilatation (AD) risk factors and cardiovascular outcomes in a cohort of patients with TS. Among 204 adult patients included, 197 were studied using a standardized 1.5 Tesla MRI protocol. AD was defined as an aortic diameter ≥20 mm/m2 at the Valsalva sinuses and/or at the ascending aorta, when indexed to body surface area. At baseline, AD was present in 81/197 (41.1%) and 32/197 (16.2%) of patients, at the levels of Valsalva and ascending aorta, respectively. The aortic Valsalva diameter was larger in patients treated for thyroiditis (P < 0.001). Potential risk factors of AD were aging (P < 0.001) and the presence of bicuspid aortic valve (BAV) (P = 0.002). The hazard ratio (HR) of AD occurrence in the presence of BAV was 2.2 (95% CI: 1.33-3.71). After a median follow-up period of 5.1 years (n = 143), AD was present in 58/143 (40.6%) and 25/143 (17.5%) of patients at the levels of Valsalva and ascending aorta, respectively. The median aortic growth of the Valsalva sinuses remained stable. At the ascending aorta, it increased by 0.14 ± 0.61 mm/year. Only one aortic-related death was observed. AD is common in adult patients with TS. However, our results are rather reassuring, as the median aortic diameters remained stable after 5.1 years and few aortic events were observed.

One-Year Single-Center Results of the Multilayer Flow Modulator Stents for the Treatment of Type B Aortic Dissection

Purpose To report a single-center series of patients with type B aortic dissection treated with the Multilayer Flow Modulator (MFM). Materials and Methods Over a 36-month period, 23 patients (median age 53 years; 20 men) with complicated type B aortic dissections (2 acute, 5 subacute, and 16 chronic) were treated with the MFM. Primary endpoints of rupture or dissection-related death, overall mortality, and reintervention were evaluated using the Kaplan-Meier method; estimates for freedom from the endpoints are reported with the 95% confidence interval (CI). Secondary outcomes included technical success, adverse events, and aortic remodeling. Clinical and imaging data were collected preoperatively, directly postoperatively, and annually to 36 months for analysis using computational fluid dynamics (CFD). Results Initial technical success was 91.3%. The estimates of the endpoints at 12 months were 100% for freedom from rupture or aortic-related death, 95.7% for freedom from overall mortality, and 91.3% for freedom from reintervention. No device-related neurological or systemic complications occurred, and no additional reinterventions were needed during follow-up. A total of 144 branches overstented by the MFM remained patent. Morphologic analysis of the aortic dissection showed progressive true lumen volume increase (75.9%, p<0.001) with concomitant false lumen volume decrease (42.8%, p<0.001); the CFD analyses showed increased laminar flow. Conclusion In the current series, the MFM provided a safe and feasible treatment option for complicated acute, subacute, and chronic type B aortic dissections, with high technical success, low mortality, and active aortic remodeling. Further studies should elucidate the long-term safety of the MFM and its effectiveness in a larger patient cohort.

Repair of residual aortic dissections with frozen elephant trunk technique

In this study, we present our mid-term results of reoperation with the frozen elephant trunk procedure due to patent false lumen-related complications in patients previously undergoing supracoronary aortic repair for acute type A aortic dissection. Between January 2013 and September 2018, a total of 23 patients (17 males, 6 females; mean age 51.5±9.7 years; range, 30 to 67 years) who underwent ascending aortic replacement due to type A aortic dissection and, later, frozen elephant trunk procedure for residual distal dissection were included. For diagnostic purposes and follow-up, computed tomography angiography was performed in all patients, and both re-entry and aortic diameters were evaluated. Echocardiography was used to evaluate cardiac function and valve pathologies. The Ishimaru zone 0 (n=11, 47.8%), Ishimaru zone 1 (n=1, 4.3%), Ishimaru zone 2 (n=4, 17.4%), and Ishimaru zone 3 (n=7, 30.4%) were used for frozen elephant trunk stent graft fixation. The mean duration of cardiopulmonary bypass and antegrade selective cerebral perfusion was 223.9±71.2 min and 88.9±60.3 min, respectively. In-hospital mortality was 13%, while there was one (4.3%) aortic-related death and four (17.4%) re-interventions during follow-up. Early repair should be considered in the presence of persistent dissections due to alarmingly high mortality rates of reoperations. Reoperation with the frozen elephant trunk procedure has acceptable results and the decision of the procedure to be performed should be based on preoperative risk factors of the patient.

Stepwise external wrapping procedure for type A intramural hematoma.

The optimal treatment for Stanford type A acute intramural hematoma remains controversial, especially in elderly or high-risk patients. We have developed a new surgical approach using artificial grafts (stepwise external wrapping) for high-risk patients. The aim of this study is to report our results using the stepwise external wrapping procedure in the treatment of high-risk patients with type A intramural hematoma. Among the 129 patients admitted for type A intramural hematoma between January 2016 and January 2020, 49 patients underwent stepwise external wrapping. The mean patient age was 78±7years. The new standard European system for cardiac operative risk evaluation II was 54%±23%. The mean overall operation and cardiopulmonary bypass times were 96±13minutes and 35±10minutes, respectively. There were no hospital deaths. Two cases of temporary neurologic disorder, 1 case of renal failure, and 2 cases of wound infection occurred during the postoperative period. The intensive care unit and hospital stays were 2±1days and 10±3days, respectively. The thickness of intramural hematoma that had been the target of the stepwise external wrapping procedure decreased significantly from 18.0±10.7mm preoperatively to 5.2±4.4mm at 3months after surgery (P<.05). The follow-up survival was 97.7%±4.4 % at 1year after surgery and 89.8%±11.4% at 3years after surgery. There was no aortic-related death during follow-up. Our stepwise external wrapping is a feasible alternative to conventional graft replacement for high-risk patients with type A intramural hematoma. The early and midterm outcomes of the procedure were satisfactory, but further careful follow-up is needed.

Late Outcome after Surgery for Type-A Aortic Dissection.

The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316–12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193–10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067–9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.

Mid-Term Outcomes of Complex Endografting for Chronic Post-Dissection Thoracoabdominal Aortic Aneurysms.

To report early and mid-term results of post-aortic dissection thoracoabdominal aneurysms (pD-TAAA) treated by complex endografting in three tertiary referral hospitals. A review of all patients with pD-TAAA unfit for open surgery treated with complex endovascular repair from 2012 to 2018 was performed. Simple thoracic endografts (TEVAR) were excluded. Staged procedures in case of extensive aortic coverage were always planned. In total, 21 patients (16 males, mean age 63 ± 10years) with pD-TAAA underwent aortic repair by fenestrated or branched thoracoabdominal endografts for visceral vessels. Mean TAAA diameter was 61 ± 6.2mm. Spinal cord drainage was performed in all patients. A staged approach was used in 12 (57%) cases. Technical success was achieved in 18 (86%) patients. No in-hospital deaths occurred. Two patients experienced transient post-procedural spinal cord ischemia. At 30days, six type II endoleaks (29%), two type Ic endoleak (9.5%) and one type IIIc endoleak (5%) were reported. At a mean follow-up of 23 ± 13months, no late aortic-related deaths occurred. Three patients underwent reintervention for type Ic and IIIc endoleaks. No visceral vessel occlusion was observed. Estimated freedom from reintervention at 12 and 24months was 85.7 ± 0.7%. In 13 cases, TAAA diameter decreased at least 5mm, while increased > 5mm in only one case. Complete false lumen thrombosis was achieved in 18 patients (86%). Complex endografting for pD-TAAA showed favorable mid-term results. Staged and carefully planned endovascular procedures may represent a safe and effective therapeutic option in patients deemed at high risk of open repair.

Results of frozen elephant trunk from the international E-vita Open registry.

Over the years, frozen elephant trunk (FET) has become the treatment of choice for multisegmental thoracic aortic disease. This multicenter study presents the evolution of FET results using the E-vita Open hybrid graft with respect to institutional experience and time. The data of International E-vita Open registry were studied according to the institutional experience of the participating centers (high- versus low-volume centers) and according to the evolution of FET treatment during time (1st period, 2005-2011 versus 2nd period, 2012-2018). Overall, 1,165 patients were enrolled in the study with a wide variety of multisegmental thoracic aortic pathologies and aortic emergencies. Participating centers determined their own surgical protocol. The overall 30-day mortality was 12%. Short- and long-term survival were higher in high- versus low-volume centers (P=0.048 and P=0.013, respectively). In the 2nd time period, cerebral complications were reduced significantly (P=0.015). Incidence of permanent spinal cord-related symptoms was reduced to 3% in the 2nd time period, but did not reach statistical significance. Hypothermic circulatory arrest time (P<0.001) and incidence of postoperative temporary renal replacement therapy (P=0.008) were significantly reduced in the 2nd time period. Ten-year survival and freedom from aortic-related death rates were 46.6% and 85.7%, respectively, for the entire group. The freedom from distal aortic re-interventions for a new or progressive residual aortic disease was 76.0%. Evolution of FET arch repair techniques with the E-vita Open graft and increasing institutional experience were associated with improved results. Progression of residual aortic disease makes close follow-up with aortic imaging mandatory in such patients.

Frozen elephant trunk with straight vascular prosthesis: single-center experience with a review of current trends.

We aim to reflect on our experience utilizing the frozen elephant trunk (FET) and straight vascular prostheses. Three hundred patients from 2005 to 2018 were identified from our prospectively collected data stratifying the patients who underwent aortic surgery including the arch and distal aortic stream. We examined the pre-operative and operative characteristics of these patients along with in-hospital outcomes and follow-up survival. Continuous and categorical variables were analyzed using two-sided unpaired t-test and Fischer's Exact test, respectively. Kaplan Meier analysis was used to evaluate survival. Three hundred patients (mean age 59) underwent one stage surgery utilizing our FET for acute type A aortic dissection (ATAAD, 55%), chronic aortic dissection (CAD, 23%) and thoracic aortic aneurysm (TAA, 22%). 30-day mortality was 12%, highest amongst the ATAAD group (12.8%). Neurological deficit stratified into permanent stoke and paraplegia was 7% and 2% respectively. Freedom from aortic related death at 10 years was 91%. Survival probability at 5 years for ATAAD, CAD & TAA was 91%, 98% and 92% respectively. Freedom from reintervention in ATAAD proximal repair vs. FET was 68% vs. 87% at 5 years and 48% vs. 74% at 10 years respectively. Patients were separated according to distal anastomosis level in zone 2 (Z2, 237) and zone 3 (Z3, 105). Conceptual zone 2 versus zone 3 aortic arch replacement survival analysis at 5 years was Z2 - 75% vs Z3 - 60% (P=0.034); and at 8 years was Z2 - 74% vs. Z3 - 52% (P=0.018). Frozen elephant trunk using EVITA Hybrid Open Plus stent graft and other devices in the family of device technology attain optimal outcomes to treat complex thoracic aortic lesions in elective and non-elective settings.

Aortic Wall Enhancement Detected by Contrast Computed Tomography Scan Predicts Aortic Remodeling after Conservative Therapy for Acute Uncomplicated Type B Dissection

The Investigation of Stent Grafts in Aortic Dissection with extended length of follow-up trial showed that pre-emptive thoracic endovascular aneurysm repair (TEVAR) for the uncomplicated type B dissection (TBAD) in the subacute phase promotes aortic remodeling and avoids aortic-related death 5 years after onset. However, there are some patients with complete aortic remodeling (CAR) with optimal medical treatment (OMT) and severe complications after TEVAR such as retrograde type A dissection. Therefore, which patients should undergo pre-emptive TEVAR and optimal surgical timing are still under debate. We reported that aortic wall enhancement (AWE) after endovascular aneurysm repair for abdominal aortic aneurysm was associated with sac shrinkage. However, there is no report about the relationship between AWE and aortic dissection. Herein, we evaluated the relationship between AWE and acute TBAD. From March 2012 to May 2018, consecutive patients with acute TBAD were retrospectively collected. We retrospectively analyzed 35 patients with acute TBAD who were treated with OMT and without pre-emptive TEVAR in the subacute phase. AWE was defined as an increase of more than 20 Hounsfield units in mean computed tomography (CT) values, comparing images in delayed contrast-enhanced scans with those in plain scans evaluated within 3months from onset. The measurement points were all slices including the wall of the false lumen. The patients with traumatic dissection, type A dissection, acute complicated type B dissection, chronic (>12weeks) dissection, and those lost to follow-up within 3months from onset were excluded. The primary end point was spontaneous CAR under OMT, as determined by the latest contrast-enhanced CT scan. The median follow-up period from onset was 86weeks and there were 25 cases (71.4%) with AWE. Under OMT, CAR was observed in 20 patients (57.1%); this was significantly associated with abdominal branch dissection (6/15 [40%] vs. 2/20 [10%], P=0.050), number of tears more than 2 at onset (11/15 [73%] vs. 4/20 [20%], P=0.003), multiple tears at 1month after onset (9/15 [60%] vs. 4/20 [20%], P=0.020), maximal false lumen diameter at 1month after onset (14 vs. 8mm, P=0.025), and AWE within 3months of onset (7/15 [47%] vs. 18/20 [90%], P=0.010). Multivariate analysis demonstrated a significant difference with multiple tears at onset (P=0.014) and AWE within 3months of onset (P=0.047). AWE was associated with CAR under OMT for acute TBAD which is out of indication of pre-emptive TEVAR. Presence of AWE may be useful in predicting prognosis of TBAD.

Long-Term Outcome of Chimney Technique Using a Balloon-Expandable Bare-Metal Stent to Preserve Supra-Arch Branches in Type B Aortic Dissection.

This study was performed to investigate the long-term effect of chimney technique using balloon-expandable bare-metal stents (BMSs) to preserve the supra-arch branches in type B aortic dissection (TBAD). Fifty patients with TBAD treated by thoracic endovascular aortic repair with the chimney technique (chTEVAR) using balloon-expandable BMSs from July 2009 to December 2013 were retrospectively assessed. Follow-up computed tomography angiography was performed to assess the postoperative outcomes. The primary end point was a persistent type Ia endoleak (ELIa). The secondary endpoints were chimney stent (CS)-based complications (stenosis, occlusion, fracture, or transposition), all-cause mortality, reintervention, and stroke. Fifty supra-arch branches (left common carotid artery, n = 11; left subclavian artery, n = 39) were preserved via the chimney technique with 50 balloon-expandable BMSs. The technical success rate was 100%. An immediate ELIa was discovered in 9 (18%) patients. The median survival duration during follow-up was 77.3 months. Five (10%) patients had a persistent ELIa; 3 of these patients had an immediate ELIa. Asymptomatic CS-based complications were found in 3 (6%) patients. The all-cause mortality rate was 8% (4/50); 2 deaths were aortic-related deaths. Five (10%) patients underwent a reintervention. During the estimated 36-month survival period, the survival rate, the rate of freedom from persistent ELIa, and the rate of freedom from reintervention were 93.87%, 89.48%, and 95.56%, respectively. The long-term outcomes showed that chTEVAR using balloon-expandable BMSs was safe and feasible for preservation of the supra-arch branches. Evaluation of more patients with a longer follow-up period is needed.

Determining the Optimal Proximal Landing Zone for TEVAR in the Aortic Arch: Comparing the Occurrence of the Bird-Beak Phenomenon in Zone 0 vs Zones 1 and 2

Purpose: To identify the optimal proximal landing zone for thoracic aortic endovascular repair (TEVAR) of aortic arch pathologies so as to avoid the bird-beak phenomenon that leads to type Ia endoleak. Materials and Methods: A retrospective single-center review was conducted of 164 patients (mean age 70.3±10.8 years, range 29–93; 127 men) who underwent repairs of the aortic arch using hybrid TEVAR from April 2008 to March 2017. The patients were divided into 2 groups according to the proximal landing zone: 43 zone 0 patients (26.2%) had total debranching TEVAR (n=18) or total endovascular aortic repair (n=25) while 121 patients (73.8%) had TEVAR landing in zones 1 (n=41) or 2 (n=80). Bird-beak configurations, endoleaks, and stent migrations were assessed on the postoperative and latest computed tomography angiography (CTA) scans. Overall survival and freedom from the bird-beak configuration, aorta-related death, and aortic events were estimated using the Kaplan-Meier method. Hazard ratios (HR) were calculated with the 95% confidence interval (CI). Results: All procedures were successful, without any 30-day mortality. There were 3 early complications (1.8%; all strokes) and 10 early endoleaks (6.1%; no type Ia). On the first postoperative CTA, 42 patients (25.6%) had a bird-beak configuration. The zone 0 patients had significantly fewer (p<0.001), shorter (p<0.004), and less angulated (p<0.001) bird-beak configurations than in zones 1–2. The mean follow-up period was 4.2 years (range 0.5–8.8). There were 18 late deaths (11.0%); only one was related to the aorta (rupture due to a type Ib endoleak in a zone 0 patient). The 5-year freedom from aorta-related death was not significantly different between groups (zone 0: 96.9% vs zones 1–2: 100%, p=0.080). On the latest CTA, 51 (31.0%) patients had a bird-beak configuration; of those, 22 (13.4%) showed >3-mm progression. The freedom from bird-beak configuration estimate was significantly higher in the zone 0 group (95.4%) vs zones 1–2 (57.8%; HR 0.10, 95% CI 0.02 to 0.31, p<0.001). There were 9 late endoleaks (4 type Ia; none in the zone 0 group). The rate of stent-graft migration was significantly lower in the zone 0 group (2.3% vs 14.1% in zones 1–2, p=0.035). Conclusion: Early and most late results in zone 0 TEVAR were equal to those in zones 1 and 2; however, there were no late type Ia endoleaks and fewer bird-beak configurations associated with zone 0 TEVAR, which suggests that zone 0 landing is advantageous for preventing these complications.

Early and long-term results of total arch replacement with the frozen elephant trunk technique for acute type A aortic dissection.

We evaluated the operative and long-term outcomes of the frozen elephant trunk (FET) technique for acute type A aortic dissection. This study evaluated 426 consecutive patients who underwent aortic repair for acute type A aortic dissection from June 2007 to December 2018 at our centre. Of these, 139 patients underwent total arch replacement with FET (FET group), and 287 underwent other procedures (no FET group). Ninety-two patients in the FET group were matched to 92 patients in the no FET group by using propensity score matching analysis. Thirty-day mortality and neurological dysfunction were not significantly different between the FET and no FET groups (1.4% vs 2.4%, P = 0.50 and 5.0% vs 6.3%, P = 0.61, respectively). Long-term survival was better in the FET group than in the no FET group (P = 0.008). Freedom from distal thoracic reintervention was similar in the FET and no FET groups (P = 0.74). In the propensity-matched patients, freedom from aortic-related death was better in the FET group than in the no FET group (P = 0.044). Operative outcomes showed no significant difference between the 2 groups. FET contributes to better long-term survival in patients with acute type A aortic dissection.

Prognostic value of clinical and morphologic findings in patients with type B aortic intramural hematoma

BackgroundAortic intramural hematoma (IMH) is a subset of acute aortic syndrome, and its prognosis may differ between races. This study aimed to study the prognosis of Chinese type B IMH patients and to find out risk factors.MethodsA total of 71 type B IMH patients with or without penetrating atherosclerosis ulcer (PAU) administrated in our center between September 2013 and October 2017 were retrospectively studied. Both clinical and imaging data were collected and analyzed. The primary end point was aorta-related death, and the secondary end point was progression, which was defined as enlargement of aorta, increased aortic wall thickness, and aortic dissection or aneurysm formation. Kaplan-Meier survival analysis and Cox regression analysis were used for prognostic analysis.ResultsAmong these 71 patients, 21 had simple type B IMH, when 50 had type B IMH in association with PAU. Twenty-five patients received optimal medical therapy (OMT) alone, while 46 patients received surgery and OMT. The mean follow-up time was 27.5 ± 13.5 months. For type B IMH patients, association with PAU indicated poor prognosis and required more intensive management (HR = 16.68, 1.96~141.87), while maximum aortic diameter (MAD) was an independent risk factor (HR = 1.096, 1.016~1.182). For patients with PAU-IMH, MAD was an independent risk factor (HR = 1.04, 1.021~1.194), while surgical treatment was independent protective factor (HR = 0.172, 0.042~0.696).ConclusionAssociation with PAU and MAD were independent risk factors for type B IMH patients. Surgery may improve the outcomes for type B IMH in association with PAU.

One-Year Results From the SURPASS Observational Registry of the CTAG Stent-Graft With the Active Control System

Purpose: To report the outcomes from the observational SURPASS registry, which was created to assess the performance of the Conformable TAG (CTAG) stent-graft with the Active Control System (ACS) in patients undergoing thoracic endovascular aortic repair (TEVAR) in a real-world setting. Materials and Methods: The SURPASS registry (ClinicalTrials.gov; identifier NCT03286400) was an observational, prospective, single-arm, post-market, international study that enrolled patients undergoing TEVAR using the CTAG with ACS for both acute and chronic thoracic aortic disease between October 2017 and July 2018. The CTAG with ACS features 2-stage deployment of the stent-graft and an optional angulation mechanism that modifies only the proximal end of the stent-graft. During the observation period, 127 patients (mean age 67.1±12.1 years, range 27–86; 92 men) were enrolled and treated for an array of aortic pathologies, including chronic and acute lesions and 4 ruptured descending thoracic aneurysms. The primary outcome of this study was technical success; secondary outcomes were clinical success and major adverse events at 30 days and 12 months. The numbers of 2-stage device deployments and applications of the angulation mechanism were recorded, along with the reasons for use. Results: Technical success of the TEVAR was 97.6% owing to unintentional partial coverage of supra-aortic branches in 3 cases (the vessels were patent on imaging). The stent-graft was repositioned at its intermediate diameter in 79 patients (62.2%), and the angulation feature was applied in 64 cases (50.4%), mainly to improve proximal wall apposition and orthogonality in the aorta. The desired effect was achieved in 60 cases (93.8%). There was no device compression, bird-beak configuration, fracture, or graft occlusion. The 30-day and 12-month clinical success rates were 97.6% and 92.9%, respectively. There were 3 aorta-related deaths at 30 days and a further 3 at 12 months. Fatalities were due to a retrograde type A dissection (0.8%), paraplegia, bowel ischemia, sepsis in the setting of a mycotic aneurysm, aneurysm rupture post aortoesophageal fistula, and multiorgan dysfunction syndrome. Three endoleaks (2 type Ia and 1 type III) required reintervention. Conclusion: In the SURPASS registry, the use of the CTAG device with ACS showed promising outcomes despite the challenging pathologies. The new delivery system enables a controlled staged delivery with in situ adjustments during positioning, facilitating the treatment of complex aortic disease.

Results of ascending aortic and arch replacement for type A aortic dissection

ObjectiveThe outcomes of emergency surgery for type A acute aortic dissection have improved. However, ascending aortic replacement sometimes leads to dilatation of the distal aorta. The present study reviewed our outcomes of ascending aortic replacement and total arch replacement in patients with type A acute aortic dissection. MethodsA total of 253 patients with type A acute aortic dissection underwent a central repair operation. Our standard technique was ascending aortic replacement. Total arch replacement was performed only when entry existed in the major curvature of the aortic arch and the proximal descending aorta. A total of 169 patients (67%) underwent ascending aortic replacement, and 84 patients (33%) underwent total arch replacement. Hospital death due to initial surgery, dilatation of the distal aorta greater than 5 cm, new occurrence of aortic dissection, any distal aortic surgery, and aortic-related deaths were defined as distal aortic events. ResultsThe mortality was 7.1% in the ascending aortic replacement group and 6.0% in the total arch replacement group. Postoperative computed tomography was performed in 162 patients in the ascending aortic replacement group. The false lumen of the residual aortic arch had thrombosed and healed in 94 patients (58%) and remained present in 68 patients (42%). The distal aortic event-free rate in the ascending aortic replacement group decreased from 74% at 5 years to 51% at 9 years, and the rate in the total arch replacement group was 83% at 5 to 9 years (P < .01). For the ascending aortic replacement group, more patients with a dissected arch had a distal aortic event compared with patients with a healed arch (P < .01). ConclusionsTotal arch replacement was associated with fewer distal aortic events. We may expand the indications for total arch replacement in stable patients.

Short- and long-term outcomes in isolated penetrating aortic ulcer disease

BackgroundThe optimum management of isolated penetrating aortic ulceration (PAU), with no associated intramural hematoma or aortic dissection is not clear. We evaluate the short- and long-term outcomes in isolated PAU to better inform management strategies. MethodsWe conducted a retrospective review of 43 consecutive patients (mean age, 72.2 years; 26 men) with isolated PAU (excluding intramural hematoma/aortic dissection) managed at a single tertiary vascular unit between November 2007 and April 2019. Twenty-one percent had PAU of the arch, 62% of the thoracic aorta, and 17% of the abdominal aorta. Conservative and surgical groups were analyzed separately. Primary outcomes included mortality, PAU progression, and interventional complications. ResultsInitially, 67% of patients (29/43) were managed conservatively; they had significantly smaller PAU neck widths (P = .04), PAU depths (P = .004), and lower rates of associated aneurysmal change (P = .004) compared with those initially requiring surgery. Four patients (4/29) initially managed conservatively eventually required surgical management at a mean time interval of 49.75 months (range, 9.03-104.33 months) primarily owing to aneurysmal degeneration. Initially, 33% of patients (14/43) underwent surgical management; 7 of the 14 procedures were urgent. Of the 18 patients, 17 eventually managed with surgical intervention had an endovascular repair; 2 of the 17 endovascular cases involved supra-aortic debranching, six used scalloped, fenestrated, or chimney stents. The overall long-term mortality was 30% (mean follow-up, 48 months; range, 0-136 months) with no significant difference between the conservatively and surgically managed groups (P = .98). No aortic-related deaths were documented during follow-up in those managed conservatively. There was no in-hospital mortality after surgical repair. Of these 18 patients, two required reintervention within 30 days for type I or III endoleaks. Among the 18 patients, seven died during follow-up (mean survival, 90.24 months; range, 66.48-113.88) with 1 of the 18 having a confirmed aortic-related death. ConclusionsIsolated, asymptomatic, small PAUs may be safely managed conservatively with regular surveillance. Those with high-risk features or aneurysmal progression require complex strategies for successful treatment with acceptable long-term survival.

Medical therapy in type B aortic intramural hematoma is associated with a high failure rate

ObjectiveIntramural hematoma (IMH) is on the spectrum of acute aortic syndrome, but optimal management is poorly understood. The aim of this study was to evaluate outcomes of patients with type B IMH (TBIMH) after best medical therapy (BMT) and to assess for risk factors associated with failure of BMT. MethodsThis is a single-institution retrospective chart review of all patients with TBIMH between January 2008 and December 2017. Failure of BMT was defined as any of the following end points: aortic rupture, aorta-related death, aortic enlargement to at least 55 mm or growth of >10 mm within 12 months, or need for surgical aortic intervention for failed BMT. ResultsWe identified 92 patients, of whom 25 received emergent thoracic endovascular aortic repair; 67 patients were initially managed with BMT, and of these, 32 underwent thoracic endovascular aortic repair within 14 days for early BMT failure. Two additional patients had early BMT failure; one died of aortic rupture due to retrograde type A dissection, and one patient was advised to undergo repair but did not comply and was lost to follow-up. Fourteen patients (20.9%) received endovascular therapy for late failure of BMT after the initial hospitalization. Medical management was successful in 19 patients (28.4%), although 5 patients had aortic enlargement but below the threshold for elective repair (maximal aortic diameter of 55 mm). On univariate analysis, presenting IMH thickness and growth of IMH thickness were risk factors for BMT failure. On multivariate analysis, presenting IMH thickness was the sole predictive risk factor for medical therapy failure (odds ratio, 1.083; 95% confidence interval, 1.021-1.149; P = .008), with an odds ratio of 6.810 (95% confidence interval, 1.921-24.146; P = .002) with a presenting IMH thickness of ≥8.0 mm, which was the calculated IMH thickness cutoff value with highest sensitivity and specificity to predict failure of BMT (area under the receiver operating characteristic curve = 0.795; P = .001; J = 0.62). ConclusionsBMT for TBIMH is associated with a high failure rate and need for interventions. IMH thickness on admission is the most reliable factor to predict failure of BMT.

The Role of Macrophages in Aortic Dissection.

Aortic dissection (AD) is a fatal disease that accounts for a large proportion of aortic-related deaths and has an incidence of about 3–4 per 100,000 individuals every year. Recent studies have found that inflammation plays an important role in the development of AD, and that macrophages are the hub of inflammation in the aortic wall. Aortic samples from AD patients reveal a large amount of macrophage infiltration. The sites of macrophage infiltration and activity vary throughout the different stages of AD, with involvement even in the tissue repair phase of AD. Angiotensin II has been shown to be an important factor in the stimulation of macrophage activity. Stimulated macrophages can secrete metalloproteinases, inflammatory factors and other substances to cause matrix destruction, smooth muscle cell apoptosis, neovascularization and more, all of which destroy the aortic wall structure. At the same time, there are a number of factors that regulate macrophages to reduce the formation of AD and induce the repair of torn aortic tissues. The aim of this review is to take a close look at the roles of macrophages throughout the course of AD disease.