Aorta-related Events Research Articles

Outer Media Thickness at False Lumen and Secondary Aortic Dilatation After Acute Aortic Dissection

BackgroundThis study measured the outer media thickness (OMT) at the false lumen by using microscopic images of specimens collected intraoperatively and assessed the impact of OMT on secondary dilatation of the downstream aorta. MethodsOf 238 patients undergoing surgical procedures for acute type A dissection between 2007 and 2016, 129 patients fulfilled the inclusion criteria for this study: DeBakey type I dissection with a patent false lumen, histopathologic examination of full-thickness aortic wall, and at least 1 follow-up computed tomographic scan at more than 3 months after surgical procedures. On average, 5.1 scans were obtained per patient, and median follow-up was 4.3 years. ResultsConsiderable variation was observed in OMT (median, 0.21 mm; range, 0.04-0.51 mm). The aortic diameter growth rate was inversely correlated with the OMT, and in the lowest tertile of OMT the aortic diameter dilated significantly faster in the first year than later and faster than in the other tertiles. Multivariable Fine-Gray analysis, with death as the competing risk, identified OMT as an independent variable for aortic-related events. Patients with OMT of 0.04 to 0.15 mm had a 3.54-fold higher risk of aortic-related events and those with 0.16 to 0.31 mm had a 1.56-fold higher risk of aortic-related events than did patients with OMT of 0.32 to 0.51 mm. Multivariable Cox regression analyses revealed OMT of 0.04 to 0.15 mm as an independent variable for all-cause mortality. ConclusionsIn patients with DeBakey type I aortic dissection with a patent false lumen, the growth rate of the distal residual dissecting aorta was inversely correlated with the OMT. The risk of aortic-related events was significantly higher in patients with OMT of 0.04 to 0.15 mm.

Journal of Vascular Surgery – January 2022 Audiovisual Summary

Hi! I am Peter Gloviczki from Mayo Clinic, Editor-In-Chief of the Journal of Vascular Surgery (JVS). We hope you found peace and happiness during the Holidays and you and your family are healthy and safe. I am happy to introduce four excellent papers we published in the 2022 January issue of the JVS. They are freely available to read or full-text download for the next 2 months. Our first article is the Editors’ Choice and our CME article this month, entitled “The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction,” by Dr Kakra Hughes and colleagues from Maryland and Washington, D.C.1Hughes K. Olufajo O.A. Wright K. Roby D.H. Fryer C.S. Wright J.L. et al.The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction.J Vasc Surg. 2022; 75: 172-180Google Scholar In this multicenter retrospective study, outcomes of lower extremity revascularizations for peripheral artery disease in over 131,000 patients were determined using the Nationwide Readmissions Database. Compared to patients in the lowest quartile of median household income (MHI), those in the highest quartile had lower rates of amputation and less readmissions. However, subsequent revascularization and mortality rates were similar across the groups. The authors concluded that a lower socioeconomic status was associated with worse outcomes and that improving results of lower extremity arterial reconstructions may involve addressing socioeconomic disparities. The next article I would like to introduce is titled “A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections,” written by Dr Tomaz Mesar and colleagues from Norfolk, Virginia.2Mesar T. Alie-Cusson F.S. Rathore A. Dexter D.J. Stokes G.K. Panneton J.M. A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections.J Vasc Surg. 2022; 75: 40-48Google Scholar In this single-center retrospective study, 83 patients underwent thoracic endovascular aortic repair (TEVAR) for complicated acute type B aortic dissection. The proximal landing zone was zone 2 in 48 and zone 3 in 35 patients. At 36 months those with zone 3 TEVAR needed significantly more aortic reinterventions and this group also had significantly lower freedom from aortic related events. These data suggest that these patients may benefit from a more aggressive proximal landing zone even if left subclavian revascularization has to be performed. The third article you should all read is entitled “Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta.”3Li J. Xia L. Ma M. Feng X. Wei X. Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta.J Vasc Surg. 2022; 75: 58-66Google Scholar This paper was written by Dr Jiangtao Li and colleagues from Wuhan, China. Out of 135 patients with acute intramural hematoma of the ascending aorta that extended into the descending thoracic aorta, 104 patients underwent TEVAR of the descending thoracic aorta and 31 were treated with medical therapy (MT) alone. Those who had TEVAR had higher freedom from adverse aorta related events and they also had a significantly better survival rate than those who had medical therapy. In the MT group, patients with renal insufficiency had most adverse aorta related events. The final article this month is on “The natural history of large abdominal aortic aneurysms in patients without timely repair,” written by Dr Elizabeth Lancaster and co-authors from San Francisco, Oakland, Pasadena, and South San Francisco, California.4Lancaster E.M. Gologorsky R. Hull M.M. Okuhn S. Solomon M.D. Avins A.L. et al.The natural history of large abdominal aortic aneurysms in patients without timely repair.J Vasc Surg. 2022; 75: 113-121Google Scholar Of 3248 patients with large aneurysms, 2215 (68%) patients underwent repair and 1033 (32%) did not undergo repair. The 3-year cumulative incidence of rupture was 3.4% for initial AAA size 5.0 to 5.4 cm (women only), 2.2% for 5.5 to 6.0 cm, 6.0% for 6.1 to 7.0 cm, and 18.4% for >7.0 cm. Women with AAA size 6.1 to 7.0 cm had a 12.8% incidence of rupture, while it was only 4.5% for men. In this large cohort, annual rupture rates for large AAAs were lower than previously reported, with possible increased risk in women. These were just four of the many excellent papers we published in the January issue of the JVS. Please read our journals, follow us on social media and send us great manuscripts for publication. We wish you and your family a Happy New Year! Thank you for watching and see you next time for the highlights of the February issue of the Journal of Vascular Surgery. The video accompanying this article may be found online at www.jvascsurg.org. https://www.jvascsurg.org/cms/asset/3f089146-0e7e-4ffd-87a7-6ddf476c6fa6/mmc1.mp4Loading ... Download .mp4 (264.52 MB) Help with .mp4 files Video

Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta.

The optimal treatment of intramural hematoma (IMH) involving the ascending aorta remains controversial. This study aimed to analyze the results of the management of patients with acute IMH involving the ascending aorta and extending into the descending thoracic aorta, to compare outcomes of descending thoracic endovascular aortic repair (TEVAR) with that of medical therapy (MT), and to assess the risk factors associated with adverse aortic events. We retrospectively analyzed all patients diagnosed with acute IMH involving the ascending aorta and extending into the descending thoracic aorta from January 2012 to December 2019. The primary end points during follow-up were aortic disease-related death and adverse aorta-related events that required surgical or endovascular treatment, such as aortic rupture, the progression of aortic disease, or endoleak. We identified a total of 135 patients with acute IMH involving the ascending aorta and extending into the descending thoracic aorta, of whom 104 underwent descending TEVAR (group 1) and 31 were managed with MT (group 2). Freedom from adverse aorta-related events at 1, 3, and 5years was significantly higher for patients who underwent descending TEVAR compared with those managed with MT (89.2%, 88.2%, and 84.0% vs 74.2%, 74.2%, and 74.2%, respectively; P= .026). The 1-, 3-, and 5-year survival rates for patients in the descending TEVAR group was 100%, 100%, and 100%, respectively, which was significantly higher than the survival of the MT group: 93.5%, 93.5%, and 81.9%, respectively (P= .002). On a univariate analysis among patients receiving MT, those who suffered adverse aorta-related events showed a higher prevalence of renal insufficiency (55.6% vs 9.1%; P= .003). In MT patients, multivariate analysis showed that renal insufficiency was the only independent risk factor associated with adverse aorta-related events (hazard ratio, 8.691; 95% confidence interval, 2.056-36.737; P= .003). Based on our study, compared with MT, descending TEVAR might be the more favorable treatment for patients with IMH involving the ascending aorta and extending into the descending thoracic aorta. Patients with renal insufficiency are more likely to experience adverse aorta-related events, which implies the need for subsequent intervention or an increased risk of mortality. The risk factor would be helpful for clinical decision-making.

Uncomplicated type A intramural hematoma with extension to the descending thoracic aorta is best treated by thoracic endovascular aneurysm repair in most patients.

Uncomplicated type A intramural hematoma with extension to the descending thoracic aorta is best treated by thoracic endovascular aneurysm repair in most patients.

Surgical Strategy for Chronic Type B Dissecting Aortic Aneurysm to Prevent Aorta-Related Events

This study was aimed to evaluate the outcomes of performing open repair or thoracic endovascular aortic repair for chronic type B dissecting aortic aneurysm. From July 2004 to February 2019, 52 patients underwent surgery as open repair (n = 32) or endovascular repair (n = 20) for chronic type B dissecting aortic aneurysm. Replacement of the aorta was limited to the aneurysmal portion with or without reconstructing the visceral arteries or the segmental arteries. Stent grafts were deployed in the true lumen above the celiac artery to cover the primary entry for even DeBakey IIIb dissection. Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. In the endovascular repair group, 3 patients died due to rupture of residual false lumen in the early, and late postoperative follow-up. The 5-year rate of freedom from all-cause death, aorta-related death, and aorta-related event were 84% ± 6%, 94% ± 3% and 84% ± 6%. The endovascular repair was independently associated with all-cause death (hazard ratio [HR], 5.7; confidence interval [CI], 1.02-31.6; P=0.04) and aorta-related event (HR, 30.9; CI 4.9-195.0; P < 0.001). In the open group, postoperative residual aortic diameter was an independent predictor of aorta-related events, and the threshold was 41 mm. Open repair remains a better option than simple endovascular repair alone in DeBakey IIIb dissection, but the distal un-resected aortic portion over 41 mm was associated with late aortic events.

Influence of measurement and sizing techniques in thoracic endovascular aortic repair on outcome in acute complicated type B aortic dissections.

OBJECTIVESThoracic endovascular aortic repair (TEVAR) is the first-line therapy in acute complicated type B aortic dissections (cTBAD). Nevertheless, no evidence-based consensus on the optimal measurement technique and sizing for TEVAR in cTBAD exists. The aim was to evaluate how different measurement and sizing techniques for TEVAR affect long-term outcomes.METHODSRetrospective analysis investigating the association between sizing and postoperative results after TEVAR in patients with cTBAD, treated between January 2003 and December 2020. Diameter measurements were performed perpendicular to a centreline in pre-interventional Computed tomography angiographies. Oversizing was determined by measuring aortic diameter in zone 2 of the aortic arch in relation to the implanted stent graft, and categorized into 2 sizing groups (≤10% and >10%). The primary outcome was freedom from aortic-related events. Secondary outcomes included mortality and a comparison of 3 alternative measurement techniques considering the estimated pre-dissection diameter.RESULTSFifty-seven patients (median age 69, interquartile range 59.6–78.2 years) were included. Stent graft oversizing by ≤10% showed a trend towards fewer aortic-related events hazard ratio 0.455 (95% confidence interval 0.128–1.624, P = 0.225).The 3 measurement techniques using the pre-dissection aortic diameter differed by a mean of 1.7–4.0 mm with a variability of up to 8.4 mm. In none of the 57 patients, the same stent graft would have been chosen based on the different measurement techniques using an oversizing ≤10%.CONCLUSIONSTEVAR oversizing of ≤10% in patients with cTBAD might reduce aortic-related events up to 50%. Consensus on measurement techniques of the pre-dissection aortic diameter and stent graft sizing is of paramount importance.

Mid-term Patency of the Great Saphenous Bypass to Aorta vs. Non-aortic Arteries in Stanford Type A Aortic Dissection Surgery With Concomitant CABG.

Background: Stanford type A aortic dissection (STAAD) is often associated with coronary artery problems requiring coronary artery bypass grafting (CABG). However, the prognosis of different proximal graft locations remains unclear.Methods: From May 2015 to April 2020, 62 patients with acute STAAD who underwent aortic surgery concomitant with CABG were enrolled in our study. Aortic bypass was defined as connecting the proximal end of the vein bridge to the artificial aorta (SVG-AO); non-aortic bypass was defined as connecting the proximal end of the vein bridge to a non-aorta vessel, including left subclavian artery, left common carotid artery, and right brachiocephalic artery (non-SVG-AO). We compared early- and mid-term results between patients in the above two groups. Early results included death and bleeding, and mid-term results graft patency, aortic-related events, and bleeding. Grafts were evaluated by post-operative coronary computed tomography angiography. According to the Fitzgibbon classification, grade A (graft stenosis <50%) is considered a patent graft. Univariate and multivariate analyses were performed to assess differences between aortic and non-aortic bypass in STAAD.Results: SVG-AO and non-SVG-AO were performed in 15 and 47 patients, respectively. There was no significant difference in death (log-rank test, p = 0.426) or bleeding (p = 0.766) between the two groups in the short term. One year of follow-up was completed in 37 patients (eight in the SVG-AO group and 29 in the non-SVG-AO group), among which 14/15 (93.3%) grafts were patent in the SVG-AO group and 32/33 (97.0%) grafts in the non-SVG-AO at 1 week, without a significant difference (p = 0.532). At 3 months, 12/13 (92.3%) grafts were patent in the SVG-AO group and 16/32 (50.0%) grafts in the non-SVG-AO, with a significant difference (p = 0.015), and 12/13 (92.3%) grafts in the SVG-AO group and 15/32 (46.9%) grafts in the non-SVG-AO group were patents, with a significant difference. Multivariate analysis showed proximal aortic bypass and dual anticoagulation to be protective factors for the 1-year patency of grafts.Conclusion: In patients requiring aortic dissection surgery with concomitant CABG, no differencess' between SVG-AO and SVG-non-AO in early outcomes were detected, but SVG-AO may have higher mid-term patency.

A Population-Based Study of the Incidence and Natural History of Degenerative Thoracic Aortic Aneurysms

ObjectiveTo investigate the incidence and natural history of degenerative thoracic aortic aneurysms (TAAs) and compare results between ascending (aTAAs) and descending TAAs (dTAAs). Patients and MethodsThis population-based cohort study used the Rochester Epidemiology Project database from January 1, 1995, through December 31, 2015. Patients were classified as the aTAA or dTAA group. ResultsOf 238 Olmsted County residents studied, 131 (55.0%) were women; 154 (64.7%) were in the aTAA group, and 84 (35.3%) were in the dTAA group. Median age was 77.0 years (interquartile range, 69.1-83.8 years). The overall age- and sex-adjusted incidence rate was 13.8 per 100,000 person-years (95% CI, 12.1 to 15.6) and varied from 9.9 in 1995 to 1999 to 19.0 in 2005 to 2009. It was 9.0 (95% CI, 7.5 to 10.4) for the aTAA and 4.9 (95% CI, 3.8 to 5.9) for the dTAA group. Overall 5-year survival was 62.5%, lower than the expected survival of 73.7% for the US 2010 census population (P<.001). The 5-year survival was 42.9% for the aTAA and 73.4% for the dTAA group (P<.001). On multivariable analysis, advanced age and smoking status were associated with all-cause mortality. The 5-year estimate of freedom from an aortic-related event was 80.0%, lower for dTAAs (67.8%) than for aTAAs (85.2%; P<.001). Maximal aortic diameter and dTAAs were associated with aortic-related events. ConclusionThe incidence of TAAs was stable from 1995 to 2015 and mortality for those with TAAs remains higher than for the general population. Older age and smoking status were associated with overall mortality, whereas larger aneurysms and dTAAs were associated with aortic-related events.

Focal Intimal Disruption Size at Multidetector CT and Disease Progression in Type B Aortic Intramural Hematoma.

Background Recent imaging techniques show that patients with aortic intramural hematoma (IMH) have various sizes of focal intimal disruptions (FIDs) that may affect clinical outcomes. Purpose To evaluate the relationship between size of FIDs detected at multidetector CT and disease progression in patients with type B IMH. Materials and Methods This retrospective study analyzed consecutive patients with type B IMH who underwent multidetector CT at admission within 24 hours after symptom onset from January 2011 to March 2017. FID was defined as a focal contrast material-filled pouch projecting outside of the aorta lumen with a communicating orifice greater than 3 mm. Large FID was defined as an FID of at least 10 mm in length and width and at least 5 mm in depth. Aorta-related events were defined as a composite of aortic rupture, surgical or endovascular aortic repair, progressive aortic enlargement, and development of aortic dissection. Results Seventy-six patients (mean age, 72 years ± 11 [standard deviation]; 54 men) were evaluated. Fifty patients (66%; 50 of 76) had 91 FIDs. Twenty-eight patients had large FIDs and 22 patients had small FIDs. Aorta-related events occurred in 15 of 28 patients with large FIDs, two of 22 patients with small FIDs, and four of 26 patients with no FID. Patients with large FIDs showed lower aorta-related event-free survival rates than did patients with small FIDs or no FID (small FIDS, 63% ± 10 vs 90% ± 7 at 3 years, respectively [P = .001]; and no FIDS, 63% ± 10 vs 84% ± 7 at 3 years, respectively [P = .005]). Multivariable analysis showed that a maximum aortic diameter of at least 40 mm (hazard ratio, 4.8; 95% CI: 1.8, 12.6; P = .001) and large FID (hazard ratio, 3.2; 95% CI: 1.1, 8.9; P = .03) were the independent predictors of aorta-related events. Conclusion A large portion of patients with B-intramural hematoma (IMH) had focal intimal disruption (FID) detected at CT at admission. Large FIDs were associated with disease progression of IMH. © RSNA, 2021 See also the editorial by Raptis and Braverman in this issue. Online supplemental material is available for this article.

Prognostic value of estimated glomerular filtration rate and presence of proteinuria in type B aortic intramural hematoma.

BackgroundAlthough aggressive medical treatment is recommended in patients with type B aortic intramural hematoma (IMH), a variety of aortic events can occur during the later period. For early identification of these patients, the present study was aimed at evaluating the prognostic validity of estimated glomerular filtration rate (eGFR) and the presence of proteinuria in type B aortic IMH.MethodsData of 61 patients with type B IMH in Peking University People’s Hospital from January 2008 to December 2018 were retrospectively collected. The serum creatinine level and urine protein levels were measured at admission. And eGFR were calculated by the CKD-EPI equation. Adverse aortic-related events were defined as a composite of satisfaction of criteria for surgical conversion (with or without actual surgical intervention) and death from aortic rupture.ResultsInitial eGFR was significantly different between patients with adverse aortic-related events and those without (P=0.003). On multivariate analysis, eGFR <90 mL/min/1.73 m2 (OR, 8.726; 95% CI: 1.711–46.144; P=0.009) and ULP (OR, 17.516; 95% CI: 3.322–92.258; P=0.001) were independent predictors of adverse aorta-related events. Furthermore, eGFR <90 mL/min/1.73 m2 and proteinuria (+) (OR, 8.344; P=0.030) had significantly greater rates of aortic-related events. In addition, eGFR <90 mL/min/1.73 m2 and proteinuria (+) had incremental prognostic value (C-statistic, 0.860, P=0.039) compared with ulcer-like projection (C-statistic, 0.815) alone.ConclusionsInitial eGFR and presence of proteinuria were able to provide incremental prognostic information in addition to ulcer-like projection in patients with type B aortic IMH.

Abstract 13675: Impact of Antithrombotic Therapy on Clinical Outcomes in Patients With Type B Acute Aortic Syndrome

Introduction: In type B acute aortic syndrome (B-AAS), degree of false lumen thrombosis is known to affect clinical outcome. Antithrombotic therapy might have impact on prognosis through affecting false lumen thrombosis.We aimed to assess the impact of antithrombotic therapy on clinical outcomes in patients with B-AAS. Methods: A total of 429 patients with acute B-AAS admitted to our hospital and discharged alive were retrospectively analyzed. The primary outcome was aorta-related adverse events, defined as a composite of aorta-related death, aortic rupture, surgical or endovascular aortic repair and progressive aortic dilation. Results: Of the 429 patients, 72 patients (17 %) were discharged with antithrombotic therapy and 357 (83 %) without antithrombotic therapy. 254 patients (59 %) presented with intramural hematoma with complete thrombosis of false lumen, and 175 (41 %) presented with classic aortic dissection. Reasons for prescription were coronary artery disease (n=25), cerebral ischemia (n=17) and others (n=30). In the antithrombotic group, patients were significantly older than no-antithrombotic group (73 ± 13 vs 67 ± 13 years, P= 0.001) and had more comorbidities such as dyslipidemia (40 % vs 26 %, P= 0.011), diabetes mellitus (22 % vs 11 %, P= 0.007) and coronary artery disease (36 % vs 5 %, P&lt; 0.001). During a mean follow-up of 4.8 ± 5.2 years, 37 patients (51 %) in the antithrombotic group and 98 patients (27 %) in the no-antithrombotic group had a primary outcome event. Event-free survival rate among antithrombotic versus no-antithrombotic group was 36 % vs 73 % at 5 years (P&lt; 0.001). Multivariate Cox regression analysis adjusted for age, sex, comorbidity and medication revealed that antithrombotic therapy was a significant risk factor for aorta-related adverse events (hazard ratio 2.08, 95% confidence interval 1.247-3.463; P= 0.005). Conclusion: In B-AAS, antithrombotic therapy was associated with an increased risk of aorta-related events. For patients with indispensable need of antithrombotic therapy, careful follow-up should be provided.

Risk stratification of ulcer-like projections in patients with acute type B aortic intramural hematoma

Abstract Background Acute type B aortic intramural hematoma (IMH) with ulcer-like projections (ULP) is associated with various adverse aortic-related events (AAE) and recommended for preventive endovascular repair as alternative. However, we have no therapeutic criterion on which to decide preventive treatment. Objectives The purpose of this study was to determine the prognostic value and risk stratification of ULP in patients with acute type B IMH for proper treatment. Methods A retrospective study was conducted on 61 consecutive patients with acute type B IMH and with present of ULP from January 2015 to December 2018 in our center. All patients were treated medically initially and CT scans were performed on admission and during follow-up period. Results During a median follow-up of 4.5 months (range, 0.3 to 49.8 months) from onset, 36 patients (59.0%) had composites of adverse aortic events, including 1 patient died for aortic rupture, 6 patients converted to endovascular repair, 6 progressed into aortic dissection, and 28 developed to aortic enlargement. A cutoff value to estimate risk is 6.0 mm for maximal ULP width (72.2% sensitivity and 84.0% specificity) and 4.0 mm for maximal ULP depth (94.4% sensitivity and 52.0% specificity). Patients with widest (P=0.005) or deepest ULP (P=0.019) in aortic arch and proximal descending thoracic aorta had significant poorer aorta-related event-free survival rates. On multivariate analysis, maximal ULP width ≥6.0 mm [hazard ratio (HR) = 2.569, 95% confidence interval (CI):1.157 to 5.705, P=0.020], maximal ULP depth ≥4.0 mm (HR=5.198, 95% CI: 1.154 to 23.420, P=0.032) and widest ULP in aortic arch and proximal descending thoracic aorta (HR=2.363, 95% CI: 1.012 to 5.517, P=0.047) were independently associated with AAE. ULP with both risk location (widest ULP in aortic arch and proximal descending thoracic aorta) and size (maximal ULP width ≥6.0 mm) were significantly associated with a poorer aortic-related event-free survival rate than others (both P&amp;lt;0.001). Conclusions Maximal ULP width ≥6.0 mm, maximal ULP depth ≥4.0 mm and widest ULP in aortic arch and proximal descending thoracic aorta are predictive for progression of acute type B aortic intramural hematoma. For patients with ULP in both risk location and size, preventive endovascular treatment should be considered. Figure 1 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.

Sex-related outcomes after open type IV thoracoabdominal aortic aneurysm repair

ObjectiveAlthough outcomes after infrarenal abdominal aortic aneurysm surgery are worse in women, sex-specific differences in outcomes after open type IV thoracoabdominal aortic aneurysm (TAAA) surgery are undefined. The goal of this study was to define sex-based disparities in short- and long-term outcomes after open type IV TAAA surgery. MethodsAll open type IV TAAA repairs performed during 27 years were evaluated using a single institutional database. Charts were retrospectively evaluated for major adverse events (in-hospital death, other major in-hospital complication) and long-term complications (graft- and aortic-related events and death). Univariate analyses were performed using the Fisher’s exact test for categorical variables and Wilcoxon rank-sum testing for continuous variables. Logistic multivariable regression was used for the in-hospital end points death and major complication, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. ResultsDuring the 27-year study period, 234 patients had an open type IV TAAA repair; 85 were female and 149 were male. There were 26 (17.5%) men and 16 (18.8%) women who suffered a major in-hospital complication/death. There were eight (3.4%) in-hospital deaths, all occurring in men. Unadjusted survival at 5 years was 67.9% for women and 58.4% for men. Multivariable analyses revealed no sex-based difference in combined major in-hospital events and death (female: odds ratio [OR], 1.8; confidence interval [CI], 0.83-4.0; P = .13) or any complication (OR, 1.0; CI, 0.55-1.8; P = .99). However, women were less likely than men to be discharged to home (OR, 0.28; CI, 0.13-0.60; P = .001) and had decreased survival compared with men after discharge (hazard ratio, 2.1; CI, 1.2-3.5; P = .008). ConclusionsNo sex-based differences were found for the in-hospital outcomes of death or major complication after open type IV TAAA repair. However, women are less likely than men to be discharged home. Among those who survive the index operation, female sex portends decreased survival following discharge after repair.

Prediction of adverse events in patients with initially medically treated type A intramural hematoma

BackgroundPrior studies provided limited data regarding natural history of initially medically treated type A intramural hematoma (IMH). ObjectivesTo develop predictive models for adverse aorta-related events in patients with type A IMH. MethodsWe performed a retrospective pooled analysis of individual patient data, including baseline clinical and CT characteristics. All patients enrolled were followed up for adverse aorta-related events, defined as a composite of aortic disease-related death and the presence of aortic complications that required aortic invasive treatment. ResultsA total of 172 patients (52.9% men) were included, with a mean age of 61.1 ± 11.2 years. During a median follow-up time of 770.5 (45.3–1695.8) days, 60 patients (34.9%) experienced adverse aorta-related events. In Cox regression model for predicting adverse aorta-related events, hypertension (HR = 3.78, p = .067), MAD (HR = 1.05, p = .018), presence of ULP (HR = 2.43, p = .002) and pericardial effusion (HR = 1.65, p = .061) were independently associated with adverse aorta-related events. A majority of the adverse aorta-related events (n = 46, 76.7%) occurred within acute and subacute phase (90 days) of IMH. In predictive model for 90 days aortic events, MAD≥50.7 mm (OR = 2.79, p = .006) and presence of ULP (OR = 3.20, p = .002) were independent predictors. C statistic of the predictive model were 0.71 (p < .001). ConclusionsPredictive models including baseline clinical and CT characteristics as predictors allow for accurate estimation of risk of adverse aorta-related events in patients with type A IMH. The proposed predictive models are helpful for risk estimates and decision making.

MODERATE AORTIC ENLARGEMENT IN TWO WEEKS OF ONSET IS THE SIGNIFICANT PREDICTOR FOR AORTA-RELATED ADVERSE EVENTS IN PATIENTS WITH TYPE B AORTIC DISSECTION

Predicting the risk factors for future aorta-related adverse events in patients with uncomplicated acute type B aortic dissection (TBAD) is crucial to determine a therapeutic strategy including preemptive thoracic endovascular aortic repair (TEVAR). Although moderate aortic enlargement in 2 weeks of

Management of acute type A intramural hematoma: upfront surgery or individualized approach? A retrospective analysis and meta-analysis.

BackgroundManagement of acute type A intramural hematoma (IMH) is a controversial topic. In our study, we aim to analyze the survival outcomes in local patients with acute type A IMH and a meta-analysis on survival in type A IMH treated medically versus surgically was performed.MethodsFrom 2014 to 2019, 65 patients with acute type A IMH were selected for analysis. Primary outcome of interest was 1 year all cause survival. The rate of aortic-related events in the medical group was evaluated. PubMed and Embase were searched for meta-analysis.ResultsThe mean age of our cohort was 61.7±9.7 years. Of the 65 patients, 40% had emergency operation. Overall 1-year survival was 96.9%. The 1-year survival was 94.9% for the medical group. 46.2% of the medical group required aortic intervention at a mean duration of 191±168 days. Maximal aortic diameter (MAD) ≥45 mm was predictive of aortic-related events in the medical group (OR: 7.0; 95% CI, 1.7–29.4; P=0.008). For the meta-analysis, 21 studies were identified, and 900 patients were included. Emergent surgery was associated with improved survival in type A IMH (OR: 0.76; 95% CI, 0.29–1.97, P=0.58; I2=27%).ConclusionsThe 1-year survival after type A IMH was promising, regardless of approach. The conservative-first approach was found to be safe & feasible, and upfront surgery remained the management of choice in general. Patients with MAD ≥45 mm was associated with subsequent aortic intervention in the medical-first group.

Preoperative distal aortic diameter is a significant predictor of late aorta-related events after endovascular repair for chronic type B aortic dissection.

Long-term therapeutic effects of thoracic endovascular aortic repair (TEVAR) for chronic type B aortic dissection remain controversial. This study aimed to evaluate the possible predictors of late aortic rupture and re-interventions after TEVAR. We retrospectively reviewed the operative outcomes of 40 patients who underwent TEVAR for chronic type B aortic dissection at Kyushu University Hospital. During a mean follow-up period of 39.2months, we assessed aortic morphology via computed tomography and then employed a multivariable Cox regression analysis in an attempt to identify the predictors of late aorta-related events. The early success rate of TEVAR was 100%. During the follow-up, however, three patients died from aortic rupture. Eight patients required aortic re-intervention, including thoraco-abdominal aortic graft replacement, repeated TEVAR, total arch replacement and EVAR. Multivariable Cox regression analysis revealed that the preoperative maximum distal aortic diameter was a significant predictor of late aorta-related events. The cutoff value of the distal aortic diameter was 40mm. Freedom from aorta-related events was 94.6% at 1year and 78.3% at 3years. The survival rate was not significantly different despite the re-intervention. TEVAR is an effective treatment for chronic type B dissection, with acceptable mid-term results. The preoperative distal aortic diameter is a significant risk factor for late aorta-related events. When the maximum distal aortic diameter is ≥ 40mm, a therapeutic strategy should be developed taking into consideration the possible need for aortic re-intervention.

The surgical management of retrograde type A aortic dissection after thoracic endovascular aortic repair.

Our goal was to review the surgical treatment of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) in our centre. From January 2014 to April 2018, 22 patients with RTAD after TEVAR were operated on in our centre. The mean age at operation was 52.0 ± 8.0 years old. The median interval between the primary TEVAR procedure and RTAD was 4.6 months (range 0-120 months). The postoperative mortality and morbidity rates were calculated to evaluate the early and long-term results. Twenty patients received total arch replacement with the frozen elephant trunk technique and 2 patients received total arch replacement alone. The mean cardiopulmonary bypass time, aortic cross-clamp time and selective cerebral perfusion time were 172.4 ± 39.3, 100.1 ± 30.3 and 19.7 ± 10.5 min, respectively. The incidence of major adverse events was 18.6% (4/22), including stroke in 1 patient, myocardial dysfunction in 1 patient and renal failure necessitating dialysis in 3 patients. Death within 30 days was 13.6% (3/22 patients). The follow-up data were available for all 19 survivors. The mean follow-up period was 32.2 ± 16.2 months (range 10-62 months). No deaths or aortic-related events occurred during the follow-up period. Total arch replacement with or without the frozen elephant trunk technique was suitable for the management of RTAD after TEVAR, with acceptable early and long-term results.

The futility of surveillance for old and small aneurysms

ObjectiveWe investigated the yield of ultrasound surveillance for small abdominal aortic aneurysms (AAAs) in patients older than 80 years compared with a younger population for detecting AAA growth reaching the threshold size for repair. Secondary objectives included analysis of the incidence of AAA repair and the cost-benefit of surveillance. MethodsA retrospective cohort study was performed of all patients undergoing AAA surveillance in Ottawa between 2007 and 2015. Patients were dichotomized by enrollment age (<80 years vs ≥80 years) and stratified by enrollment AAA size. Cohorts were cross-referenced with the Ottawa surgical database, leveraging the common health region to ensure complete data capture. The threshold size for repair was sex specific (female, 5.0 cm; male, 5.5 cm). Factors influencing AAA growth rate were assessed with a general linear multiple mixed model. Analyses with Cox proportional hazards models with competing risk for mortality assessed aorta-related events, and cost-benefit was analyzed by referencing Ontario billing codes. ResultsA total of 1231 patients underwent serial ultrasound surveillance, of whom 500 were older than 80 years at some point during the study period. The mean AAA growth rate was 1.63 mm/y (95% confidence interval [CI], 1.54-1.71). Old age and small enrollment aneurysm size were significantly protective against AAA growth. Overall, 357 (29%) patients reached the AAA size threshold for repair, and 272 (22%) underwent AAA repair. Patients older than 80 years were less likely to reach the AAA threshold size for repair compared with their younger counterparts (adjusted hazard ratio, 0.77; 95% CI, 0.61-0.97). Of the 357 patients whose AAA reached the threshold size for repair, octogenarians were substantially less likely to undergo elective AAA repair (adjusted hazard ratio, 0.34; 95% CI, 0.24-0.47). Repair of ruptured AAA was rare (0.8%), and age differences were insignificant. For every octogenarian with an enrollment AAA size between 3.0 and 3.9 cm who ultimately received elective AAA repair, 51 patients were enrolled in surveillance without elective repair. This corresponded to an estimated $33,139 in ultrasound fees. ConclusionsSurveillance of most patients with small AAA is appropriate. However, patients older than 80 years were significantly less likely than their younger counterparts to experience aortic growth reaching the threshold size for repair. Furthermore, in the unlikely event of AAA growth, patients older than 80 years were substantially less likely to undergo repair. These results suggest that in the context of patient-specific health and wishes, surveillance of AAAs <4 cm in octogenarians is costly and unlikely to be beneficial.

P1448 Thoracic aorta and circulating transforming growth factor-b in marfan syndrome and marfanoid habitus

Abstract Purpose Current understanding of the pathogenesis of thoracic aortic aneurysm (TAA) in Marfan syndrome (MS) focuses upon abnormal activity of the transforming growth factor beta (TGF-β) signalling pathway. Circulating TGF-β predicts cardiovascular events in patients with MS and is elevated in the entire spectrum of aortic syndromes. Marfanoid habitus (MH) patients not meeting the MS criteria (TAA, ectopia lentis, family history), but share the same skeletal features and are the part of the Marfan continuum. Our aim was to evaluate the possible role of elevated TGF-β level in the aortic dilatation at mid-term follow-up in Marfanoid habitus patients. Methods 33 consecutive patients with a presumptive clinical diagnosis of Marfan syndrome were referred to Almazov centre and enrolled in our observational, prospective, single-center study. Nine of them (mean age 27.9 ± 9.3) fulfilled diagnosis of MS according to revised Ghent criteria. 24 subjects (mean age 21.8 ± 3.4) with skeletal features of Marfanoid habitus have had no major findings of MS. Proximal aortic segments were visualized in the parasternal long-axis and suprasternal views. Concentration of TGF-β1 and TGF-β2 in serum was determined using a test system Human Platinum ELISA. End points analyzed during 5 years of follow-up were mortality, aortic-related events, and aortic dimension changes. Results During 122 person-years of the follow-up (median 5.1 years) no deaths or aortic-related events occurred in Marfanoid habitus patients. TGF-β1 and TGF-β2 serum levels were elevated in patients with Marfanoid habitus (14.2 ± 27.6 and 2.1 ± 1.7 ng/ml, respectively) but were lower than in MS group (44.6 ± 47.3 ng/ml, p = 0.03 and 2.7 ± 1.7 ng/ml, p = 0.39, respectively). A high TGF-β1 serum level (cutoff &amp;gt;14.75 ng/ml, provided by the manufacturer of our TGF-β assay) was detected in 44% and TGF-β2 (&amp;gt;2.0 ng/ml) in majority patients (67%) of the MS group. In Marfanoid habitus group we found a high TGF-β1 serum level only in 4 (17%) patients and TGF-β2 in 9 (38%) patients. Aortic diameter at the sinuses of Valsalva and Z-score were significantly lower in Marfanoid habitus group (29.2 ± 2.8 mm and 1.56 ± 0.93) than in MS patients (43.1 ± 15.1 mm, p = 0.0007 and 6.86 ± 5.83, p = 0.004) at the beginning of study and significantly increased during the follow-up (31.3 ± 2.9 mm and 1,69 ± 0,15, p &amp;lt; 0.001 for both). There was no correlation between TGF-β level and aortic dimensions in patients with MS and marfanoid habitus. Conclusion In young adults with Marfanoid habitus and the current absence of ascending aortic aneurysm we found the increased TGF-β level and aortic root enlargement during the follow-up. High TGF-β serum level may contribute to the excessive progression of aortic dilatation later over mid-to-late aging and requires further investigation to establish its role in the aortic aneurysm pathogenesis.