Change In Aortic Diameter Research Articles

Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection

Many patients with aortic dissection develop Crawford extent I or II thoracoabdominal aortic aneurysms (TAAA). Because open repair is associated with a high morbidity and mortality, hybrid approaches to TAAA repair are emerging. In this study, we evaluated the midterm outcomes and aortic remodeling of a hybrid technique that combines proximal thoracic endovascular aneurysm repair (TEVAR), followed by staged distal open thoracoabdominal repair for patients with Crawford extent I or II TAAAs secondary to chronic aortic dissection. We identified 19 patients with Crawford extent I (n = 1) or extent II (n = 18) TAAAs secondary to chronic aortic dissection who underwent a staged hybrid repair from 2007 to 2014 at our institution. Nine patients had previous open ascending aortic surgery for type I aortic dissection. Stage 1 TEVAR was performed via percutaneous (n = 8), femoral cutdown (n = 8), or iliac exposure (n = 3). The left subclavian artery was covered in nine patients and revascularized in eight patients using carotid-subclavian bypass (n = 7) or laser fenestration (n = 1). Stage 2 open repair was performed a median of 18 weeks later with partial cardiopulmonary bypass via left femoral arterial and venous cannulation for visceral and lower body perfusion. The open thoracoabdominal graft was anastomosed proximally in an end to end fashion with the endograft. We then assessed surgical morbidity and mortality, midterm survival, and freedom from reintervention. Aortic remodeling was measured and change in maximum aortic and false lumen diameter at last follow-up (median, 3 years) from baseline was assessed. There were no deaths, strokes, or chronic renal failure in this cohort. After stage 1 TEVAR, three patients required repeat intervention for endoleak (type Ia, n = 1; type Ib, n = 1; type II, n = 1) before open repair. After stage 2 open repair, there was a single delayed permanent paralysis 2 weeks after discharge. At a median 3-year follow-up (range, 6 months-6.2 years), there were no deaths, neurologic events, endoleaks, or TAAA reinterventions. Complete false lumen thrombosis occurred in 100% of the patients, with maximum false lumen diameter decreasing from 34.3 ± 15.3 mm to 13.2 ± 12.0 mm (P < .01) and total aortic diameter decreasing from 60.2 ± 9.0 mm to 49.4 ± 9.6 mm (P < .01). Staged hybrid TAAA repair, using a combination of proximal TEVAR with open distal repair, can be performed using established endovascular skills and technology coupled with traditional open aortic surgical techniques, with low surgical morbidity and mortality. In the midterm, staged hybrid TAAA repair was associated favorable survival, aortic remodeling, and freedom from reintervention.

Segmental Aortic Stiffness in Children and Young Adults With Connective Tissue Disorders: Relationships With Age, Aortic Size, Rate of Dilation, and Surgical Root Replacement.

Aortic diameter is an imperfect predictor of aortic complications in connective tissue disorders (CTDs). Novel indicators of vascular phenotype severity such as aortic stiffness and vertebral tortuosity index have been proposed. We assessed the relation between aortic stiffness by cardiac MRI, surgical root replacement, and rates of aortic root dilation in children and young adults with CTDs. Retrospective analysis of cardiac MRI data on children and young adults with a CTD was performed to derive aortic stiffness measures (strain, distensibility, and β-stiffness index) at the aortic root, ascending aorta, and descending aorta. Vertebral tortuosity index was calculated as previously described. Rate of aortic root dilation before cardiac MRI was calculated as change in echocardiographic aortic root diameter z score per year. In 83 CTD patients (median age, 24 years; range, 1-55; 17% <18 years of age; 60% male), ascending aorta distensibility was reduced in comparison with published normative values: median z score, -1.93 (range, -8.7 to 1.3; P<0.0001 versus normals). Over a median follow-up period of 2.7 years, there were no aortic dissections or deaths, but 16 of 83 (19%) patients underwent surgical aortic root replacement. In multivariable analysis, lower aortic root strain (P=0.05) and higher vertebral tortuosity index (P=0.01) were independently associated with aortic root replacement. Lower ascending aorta strain (P=0.02) was associated with a higher rate of aortic root dilation. Higher aortic stiffness is associated with higher rates of surgical aortic replacement and aortic root dilation in children and young adults with CTDs.

Aortic neck enlargement after endovascular aneurysm repair using balloon-expandable versus self-expanding endografts

This study evaluated changes in aortic neck diameter after endovascular aneurysm repair (EVAR) using a balloon-expandable stent (BES) endograft compared with a commercially available self-expanding stent (SES) endograft. We hypothesized that forces applied to the aortic neck by SES endografts may induce aortic neck enlargement over time and that such enlargement may not occur in aneurysm patients treated with a device that does not use a proximal SES. This was a retrospective quantitative computed tomography (CT) image analysis of patients treated with the Nellix (Endologix, Irvine, Calif) BES (n = 49) or the Endurant II (Medtronic, Minneapolis, Minn) SES (n = 56) endograft from 2008 to 2010. Patients with preimplant, postimplant, and at least 1-year serial CT scans underwent quantitative morphometric assessment by two independent vascular radiologists blinded to the outcome results. Changes in the infrarenal neck over time were compared with the suprarenal aorta for each patient. Follow-up extended to 4.8 years for the BES and to 4.6 years for the SES, with no significant difference in median follow-up time (34 months for BESs and 24 months for SESs; P = .06). There were no differences in preimplant neck diameter (25.2 ± 0.9 mm vs 25.7 ± 1.1 mm; P = .54) or length (27.7 ± 3.7 mm vs 23.6 ± 3.7 mm; P = .12) between BESs and SESs at baseline. After implantation, neck diameter increased by 1.1 ± 0.5 mm in BES patients and 2.6 ± 0.5 mm in SES patients (P = .07) compared with the preoperative diameter. At 3 years, neck diameter increased by 0.5 ± 0.9 mm in BES patients and by 3.8 ± 1.0 mm in SES patients (P = .0002) compared with the first postoperative CT scan. The annual postimplant rate of increase in the infrarenal neck diameter was fivefold greater in SES patients (1.1 ± 0.1 mm/y) than in BES patients (0.22 ± 0.04 mm/y; P < .0001). There were no significant differences in the diameter of the suprarenal aorta at baseline or at 3 years and no differences in the annual rate of change in suprarenal aortic diameter between BES and SES endografts. EVAR using SES endografts resulted in progressive infrarenal aortic neck enlargement, whereas EVAR using BES endografts resulted in no neck enlargement over time. These data suggest that infrarenal neck enlargement after EVAR with SES endografts is likely related to the force exerted by SES elements rather than disease progression in the infrarenal neck.

PC18. Long-Term Outcomes Following Open Juxtarenal Abdominal Aortic Aneurysm Repair: Degeneration of Remnant Aorta and Need for Reintervention

The fate of remnant aneurysmal or ectatic aortic segments and the need for reintervention following open juxtarenal abdominal aortic aneurysm (JRAA) repair remains undefined. The aim of this study was to assess long-term outcomes of open JRAA repair with emphasis on morphological changes of remnant proximal aortic tissue to facilitate selection of patients who would benefit from initial fenestrated endovascular repair (FEVAR). Data from consecutive patients who underwent elective open JRAA repair from January 2001 to August 2010 were retrospectively analyzed. Demographics, preoperative risk factors, reintervention, and mortality were evaluated. Aortic diameter changes were evaluated in patients with available postoperative computed tomography (CT) scans. Outer aortic diameter measurements were performed at four levels: renal (RA), suprarenal (SRA), supramesenteric (SMA) and supraceliac (CA). There were 161 patients (125 men, 36 women) with a mean age of 73.5 years (range, 55-93 years). Risk factors included coronary artery disease in 61%, renal insufficiency (serum creatinine >1.5 mg/dL) in 30%, and pulmonary disease in 56%. Mean Society for Vascular Surgery risk score was 9.2 ± 4.7. The proximal anastomosis was sewn to normal aorta (< 30 mm) in 79 patients and to ectatic aorta (≥30 mm) in 72 patients. Thirty-day mortality was 0. Median clinical follow-up was 7.2 years (range, 4 days-14 years). Seventy patients died during follow-up, and one aortic reintervention was performed. On Kaplan-Meier analysis, survival free of reintervention in the entire cohort at 1, 3, and 5 years was 96%, 92%, and 92%; overall survival was 89%, 79%, and 28% at 3, 5, and 10 years (Fig). Seventy patients had postoperative CT scans. On imaging follow-up at a mean of 30 months, average aortic growth was 0.6 ± 1.6 mm at RA, 1.3 ± 2.1 mm at SRA, 1.4 ± 1.8 mm at SMA, and 1.5 ± 2.7 mm at CA. No significant difference in growth was found in patients with anastomoses sewn to remnant normal vs ectatic aorta (0.2 ± 1.9 mm vs 0.3 ± 0.9 mm, P = .1). Growth of remnant paravisceral aortic segments following open JRAA repair is slow, and only a minority of patients require reintervention during their lifetime. Based on these results, patients should be selected for initial FEVAR based on medical comorbidities and not ectasia of the paravisceral aorta. Open JRAA repair remains a durable procedure.

Randomized clinical trial of mast cell inhibition in patients with a medium-sized abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is thought to develop as a result of inflammatory processes in the aortic wall. In particular, mast cells are believed to play a central role. The AORTA trial was undertaken to investigate whether the mast cell inhibitor, pemirolast, could retard the growth of medium-sized AAAs. In preclinical and clinical trials, pemirolast has been shown to inhibit antigen-induced allergic reactions. Inclusion criteria for the trial were patients with an AAA of 39-49 mm in diameter on ultrasound imaging. Among exclusion criteria were previous aortic surgery, diabetes mellitus, and severe concomitant disease with a life expectancy of less than 2 years. Included patients were treated with 10, 25 or 40 mg pemirolast, or matching placebo for 52 weeks. The primary endpoint was change in aortic diameter as measured from leading edge adventitia at the anterior wall to leading edge adventitia at the posterior wall in systole. All ultrasound scans were read in a central imaging laboratory. Some 326 patients (mean age 70·8 years; 88·0 per cent men) were included in the trial. The overall mean growth rate was 2·42 mm during the 12-month study. There was no statistically significant difference in growth between patients receiving placebo and those in the three dose groups of pemirolast. Similarly, there were no differences in adverse events. Treatment with pemirolast did not retard the growth of medium-sized AAAs. NCT01354184 (https://www.clinicaltrials.gov).

Echocardiograpic Evaluation of Short-term Outcome of Patent Ductus Arteriosus Closure using Amplatzer Occluder Device

Objective: To compare clinical and echocardiographic data before and after transcatheter closure of patent ductusarteriosus (PDA) with occluder device. Methods: The study population consisted of 30 children with PDA who were subjected to history taking and clinical examination to detect symptoms and signs suggestive of significant shunting. Doppler, two-dimensional echocardiography studies with measurement of mitral inflow velocities in early and late diastole (E and A wave), early and late diastolic mitral annular velocity (E and A) by DTI, Tei index, and standard chamber dimensions. All children were studied before and 3 months after percutaneous closure of PDA that done using the Amplatzer device. Results: Transcatheter closure of PDA produced marked improvement of patients’ symptoms and signs postclosure, significant reduction in heart rate and respiratory rate while there was no significant change in blood pressure or temperature. Also there was significant reduction in LV systolic and diastolic dimensions and volumes, LV ejection fraction, left atrial diameter, E wave, A wave, E wave and A wave while there was significant increase in LV Tei index and no significant change in aortic root diameter, E/A or E/E. Conclusion: Haemodynamic effects of PDA and changes in LV dimensions and function caused by it are reversible after transcatheter closure of PDA.

Abstract 18498: Description of Aortic Root Growth and Outcomes in a Cohort of Pediatric Patients with Loeys-Dietz Syndrome

Background: Loeys Dietz Syndrome (LDS) is associated with rapid aortic dilation and aortic dissection, but data on children with LDS are limited. The goal of this study is to describe aortic root growth and outcomes in children with LDS. Methods: Patients with LDS were identified from an institutional database. Data regarding genetic mutation, medications, aortic root dimensions by transthoracic echocardiography (TTE), aortic dissection and surgical intervention were collected. For those with &gt;2 TTEs 1 year apart, rate of change in z-score was calculated using linear regression. TTEs performed after aortic surgery were excluded. We examined if variables were associated with rate of aortic root growth. Results: Of 16 patients, 8 were female. Five had a TGFBR1 and 9 had a TGFBR2 mutation; 2 patients did not have genetic data available. Median aortic root Z-score at diagnosis was 3.5 (range 0.5-25.4). Fifteen patients were on medication (2 beta-blocker (BB), 5 angiotensin receptor blocker (ARB), 5 BB+ARB, and 3 with past use of both). Four patients underwent prophylactic root replacement at ages 3.3, 6.7, 8.7, and 9.4 years at root dimensions 3.2, 6.5, 4.0, and 4.1 cm respectively. One patient had a Type A dissection at age 15y after prior root replacement and underwent repeat surgery. Another underwent heart transplant at 6.9 years old after prior root replacement. Ten patients had serial TTE data. Median change in aortic root diameter and Z-score was 0.11cm/year and 0.1/year respectively. Mean change in z-score per year for those on on BB was -0.1± (range -1.2 to 0.7), ARB 0.5 (range 0.1 to 1.1) and both 0.0 (range -0.2 to 0.2, p=NS). No variables studied were associated with faster aortic growth. Conclusions: Degree of aortic root dilation and rate of aortic root growth is highly variable in children with LDS, although factors associated more aggressive disease are unclear. The high proportion of patients with adverse outcomes including aortic dissection and surgery is concerning.

Abstract 12138: Angiotensin Blockade Reduces Aortic Dilatation in Patients With Marfan Syndrome: A Meta-Analysis

Introduction: Recently few studies evaluated the effects of ACE/ARB in patients with Marfan syndrome. However, as majority of the studies were small and mainly pilot studies, conclusive evidence of benefit with ACE/ARB in this scenario is still pending. The objective of the present meta-analysis was to evaluate the effect of ACE/ARB on the progression of aortic root dilatation in patients with Marfan syndrome. Hypothesis: Treatment with ACE/ARBs is effective for the prevention of aortic-root enlargement in patients with Marfan syndrome. Methods: We searched PubMed, EMBASE, and Cochrane Central Register of Clinical Trials from the inception to April 30, 2013. The main outcome of the present analysis was the change in aortic root diameter with ACE/ABR therapy compared to control. The random effects model of DerSimonian and Laird was used. Results: Four studies were included in the final analysis; three studies were randomized trial and one was observation study. ACE/ARB significantly reduced enlargement of aortic root diameters compared to control; mean difference of -0.97 (95% confidence interval, -1.42 to -0.52; P&lt;0.0001). Consistent benefit of ACE/ARB was observed in all sub-group and sensitivity analyses; against beta blocker, against placebo, in adult patients, with only ARB, analysis with the results from only RCTs. Conclusions: This is the first meta-analysis indicating a beneficial effect of ACE/ARB treatment on aortic root dilatation in patients with Marfan Syndrome. Current evidence supports the use of ARB, specially losartan for this indication.

How Does the Ascending Aorta Geometry Change When It Dissects?

The purpose of this study is to delineate changes in aortic geometry and diameter due to dissection. Aortic diameter is the major criterion for elective ascending aortic replacement for dilated ascending aortas to prevent aortic dissection. However, recommendations are made on the basis of clinical experience and observation of diameters of previously dissected aortas. Six tertiary centers on 2 continents reviewed their acute aortic dissection type A databases, which contained 1,821 patients. Included were all non-Marfan patients with nonbicuspid aortic valves who had undergone computed tomography angiography <2 years before and within 12 h after aortic dissection onset. Aortic geometry before and after dissection onset were compared. Altogether, 63 patients were included (27 spontaneous and 36 retrograde dissections, median age 68 [57; 77] years; 54% were men). In all but 1 patient, maximum ascending aortic diameter was <55 mm before aortic dissection onset. The largest increase in diameter and volume induced by the dissection were observed in the ascending aorta (40.1 [36.6; 45.3] mm vs. 52.9 [46.1; 58.6] mm, +12.8 mm; p < 0.001; 124.0 [90.8; 162.5] cm(3) vs. 171.0 [147.0; 197.0] cm(3), +47 cm(3); p < 0.001). Mean aortic arch diameter increased from 39.8 (30.5; 42.6) mm to 46.4 (42.0; 51.6) mm (+6.6 mm; p < 0.001) and descending thoracic aorta diameter from 31.2 (27.0; 33.3) mm to 34.9 (30.9; 39.5) mm (+3.7 mm; p < 0.001). Changes in thoracic aorta geometry were similar for spontaneous and retrograde etiology. Geometry of the thoracic aorta is affected by aortic dissection, leading to an increase in diameter that is most pronounced in the ascending aorta. Both spontaneous and retrograde dissection result in similar aortic geometry changes.

Angiotensin-Induced Abdominal Aortic Aneurysms in Hypercholesterolemic Mice: Role of Serum Cholesterol and Temporal Effects of Exposure

ObjectiveUnderstanding variations in size and pattern of development of angiotensin II (Ang II)-induced abdominal aortic aneurysms (AAA) may inform translational research strategies. Thus, we sought insight into the temporal evolution of AAA in apolipoprotein (apo)E−/− mice.ApproachA cohort of mice underwent a 4-week pump-mediated infusion of saline (n = 23) or 1500 ng/kg/min of Ang II (n = 85) and AAA development was tracked via in vivo ultrasound imaging. We adjusted for hemodynamic covariates in the regression models for AAA occurrence in relation to time.ResultsThe overall effect of time was statistically significant (p<0.001). Compared to day 7 of AngII infusion, there was no decrease in the log odds of AAA occurrence by day 14 (−0.234, p = 0.65), but compared to day 21 and 28, the log odds decreased by 9.07 (p<0.001) and 2.35 (p = 0.04), respectively. Hemodynamic parameters were not predictive of change in aortic diameter (Δ) (SBP, p = 0.66; DBP, p = 0.66). Mean total cholesterol (TC) was higher among mice with large versus small AAA (601 vs. 422 mg/ml, p<0.0001), and the difference was due to LDL. AngII exposure was associated with 0.43 mm (95% CI, 0.27 to 0.61, p<0.0001) increase in aortic diameter; and a 100 mg/dl increase in mean final cholesterol level was associated with a 12% (95% CI, 5.68 to 18.23, p<0.0001) increase in aortic diameter. Baseline cholesterol was not associated with change in aortic diameter (p = 0.86).ConclusionsThese are the first formal estimates of a consistent pattern of Ang II-induced AAA development. The odds of AAA occurrence diminish after the second week of Ang II infusion, and TC is independently associated with AAA size.

Comparison of thoracic aortic diameter changes after endograft placement in patients with traumatic and aneurysmal disease

The purpose of this study was to evaluate acute changes in aortic size before and after endograft placement for traumatic injury and aneurysmal disease. We hypothesize that there are inherent differences between trauma and aneurysm populations undergoing thoracic endovascular aortic repair (TEVAR) and that these factors may affect device choice and sizing for each group. This retrospective study evaluated the existing digital imaging of traumatic injury and aneurysmal patients enrolled in the 0802 and 0803 multi-site trials that received the GORE Conformable TAG thoracic device. Pre- and post-treatment imaging was available for 70 traumatic injury and 54 aneurysmal patients. Post-treatment imaging was defined as being complete within 30 days of treatment. A standardized protocol was used to complete measurements of the proximal and distal maximum neck diameters through the use of the orthogonal view before imaging and at 30-day imaging. The resultant changes in diameter for each group were analyzed by means of t-tests. Mean increases in proximal (3.0 mm vs 2.0 mm; P < .05) and distal neck diameters (2.9 mm vs 0.7 mm; P < .01) after TEVAR are significantly greater in traumatic injury patients than in aneurysm patients between pretreatment and 30-day imaging. In both study populations, smaller pretreatment aortic neck diameters showed a larger change in neck diameter than did larger pretreatment aortic diameters. Aneurysm patients were oversized significantly more than were trauma patients at the proximal neck (9.1% vs 4.5%; P < .05). However, at the distal neck, the trauma patients were oversized more than were the aneurysm patients (17.5% vs 13.6%; P = .06). A strong correlation was found between the percentage of oversizing and change in the distal neck diameter after TEVAR in both patient groups. The results suggest that there are differences between trauma and aneurysm populations. Careful device selection may contribute to the avoidance of complications related to both undersized and oversized devices. Short-term analysis shows that TEVAR can be successfully accomplished in both trauma and aneurysm groups over a wide sizing range. Further data regarding long-term device complications are needed to better characterize this relationship.

Comparison of thoracic aortic diameter changes after endograft placement in patients with traumatic and aneurysmal disease

Comparison of thoracic aortic diameter changes after endograft placement in patients with traumatic and aneurysmal disease

Preoperative Infra- and Suprarenal Aortic Pulsatile Distension is Comparable between Relatively Young and Older Patients with an Abdominal Aortic Aneurysm

Young healthy individuals have a large aortic pulsatile distension during the cardiac cycle. In patients with an abdominal aortic aneurysm (AAA), aortic distension during the cardiac cycle is associated with stent graft migration. However, whether the pulsatile distension is larger in relatively young patients with an AAA compared to older AAA patients is unknown. This study investigated whether preoperative pulsatile aneurysm neck distension is related to age. From our database of endovascular aneurysm repair (EVAR), we selected 25 consecutive male patients ≤65 years of age (group 1) and 25 consecutive patients >65 years of age (group 2). All patients had a preoperative electrocardiogram-triggered computed tomography angiography scan consisting of 8 phases. Aortic area and diameter changes per heartbeat were measured at 2 levels: (A) 3 cm above and (B) 1 cm below the most distal renal artery. In group 1 compared to group 2, distension during the cardiac cycle at level A was 1.6 ± 0.4 versus 1.5 ± 0.4 mm (P = 0.62), and the aortic area increase was 45.4 ± 19.6 versus 41.7 ± 20.8 mm(2) (P = 0.52). Aortic distension at level B was 1.4 ± 0.3 versus 1.5 ± 0.4 mm (P = 0.79), and the area increase was 35.5 ± 12.0 versus 35.0 ± 15.5 mm(2) (P = 0.90). Preoperative pulsatile aneurysm neck distension did not differ between younger and older patients; therefore, we do not expect young patients to have more pulsatile distension-related complications after EVAR.

Thoracic Aortic Diameter Changes After Endograft Placement: Comparison of Traumatic and Aneurysmal Disease

Thoracic Aortic Diameter Changes After Endograft Placement: Comparison of Traumatic and Aneurysmal Disease

FRI0237 Outcome of aortic involvement in giant cell arteritis (GCA) after 1-year follow-up: Prospective study using computed tompography angiography (CTA)

BackgroundA prospective study of 40 patients with newly diagnosed, biopsy-proven GCA patients disclosed CTA signs of aortitis in 65% of patients1. The involvement by segments was as follows: ascending aorta...

Abstract 240: Serum Cholesterol and Angiotensin-Induced Abdominal Aortic Aneurysm in Hypercholesterolemic Mice

Background Although hyperlipidemia is known to augment the incidence of abdominal aortic aneurysms (AAA) in the AngII-induced model of apolipoprotein E -/- mice, its relationship to AAA size is unknown. Therefore, we evaluated the relationship between total cholesterol concentration (TC) and change (delta) in aortic diameter. Methods TC was measured in 36 male mice that underwent a 4-week infusion period with saline (n=9) or AngII (1500 ng/kg/min; n=27), along with serial measurements of pulse rate (PR), and pulse (PP), mean arterial (MAP), systolic (SBP) and diastolic (DBP) pressure. A linear mixed effect model was used to assess the relationship between all hemodynamic parameters and delta. Nonparametric and linear regression methods were used to evaluate TC in relation to delta. Results TC did not differ between AngII and control mice (Figure, bottom left) (p=0.18). The burden of atherosclerosis was greater among AngII-exposed mice versus control, but did not differ by presence or size of AAA (Figure, bottom right). None of the hemodynamic parameters were predictive of delta (SBP, p = 0.66; DBP, p = 0.66; MAP, p = 0.55; PP, p = 0.66; and PR, p = 0.39). Mean TC was higher among mice with large versus small AAA (552.6 vs. 393.5 mg/ ml, p&lt;0.05; Figure, top right). The nonparametric smoothing line (Figure, top left) suggests a first order relationship between delta and TC (p for trend &lt; 0.001). AngII (ß = 0.48, p &lt; 0.001) and TC (ß = 0.0015, p = 0.003) were independent predictors in the linear model for delta. Conclusions Our findings suggest that TC is incrementally associated with AAA size. These findings may have potential clinical relevance for risk assessment in AAA patients. Figure

Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration

The Food and Drug Administration has approved devices for endovascular management of thoracic endovascular aortic aneurysm repair (TEVAR); however, limited data exist describing the outcomes of TEVAR for aneurysms attributable to chronic type B aortic dissection (cTBAD). This study was undertaken to determine the results of endovascular treatment of cTBAD with aneurysmal degeneration. A retrospective analysis of all patients treated for cTBAD with aneurysmal degeneration at the University of Florida from 2004 to 2011 was performed. Computed tomograms with centerline reconstruction were analyzed to determine change in aortic diameter, relative proportions of aortic treatment lengths, and false lumen perfusion status. Reintervention and mortality were estimated using life-tables. Cox regression analysis was completed to predict mortality. Eighty patients underwent TEVAR for aneurysm due to cTBAD (mean age [± standard deviation], 60 ± 13 years [male, 87.5%; n = 70]; median follow-up, 26 [range, 1-74] months). Median time from diagnosis of TBAD to TEVAR was 16 (range, 1-72) months. Prior aortic root/arch replacement had been performed in 29% (n = 23) at a median interval of 28.5 (range, 0.5-312) months. Mean preoperative aneurysm diameter was 62.0 ± 9.9 mm. In 75% (n = 60) of cases, coverage was proximal to zone 3, and 24% (n = 19) underwent carotid-subclavian bypass or other arch debranching procedure. Spinal drains were used in 78% (pre-op 71%, n = 57; post-op 6%, n = 5). Length of stay was 6.5 ± 4.7 days with a composite morbidity of 26% and in-hospital mortality of 2.5% (n = 2). Overall neurologic event rate was 17% (spinal cord ischemia 10% [n = 8], with a permanent deficit observed in 6.2% [n = 5]; stroke 7.5%). Aneurysm diameter reduced or stabilized in 65%. The false lumen thrombosed completely within the thoracic aorta in 52%, and reintervention within the treated aortic segment was required in 16% (n = 13).One- and 3-year freedom from reintervention (with 95% confidence interval [CI]) was 80% (range, 68%-88%) and 70% (range, 57%-80%), respectively. Survival at 1 and 5 years was 89% (range, 80%-94%) and 70% (range, 55%-81%) and was not significantly different among patients requiring reintervention or experiencing favorable aortic remodeling. Multivariable analysis identified coronary artery disease (hazard ratio [HR], 6.4; 95% CI, 2.3-17.7; P < .005), prior infrarenal aortic surgery (HR, 8.6; 95% CI, 2.3-31.7; P = .001), and congestive heart failure (HR, 11.9; 95% CI, 1.9-73.8; P = .008) as independent risk factors for mortality. Hyperlipidemia was found to be protective (HR, 0.2; 95% CI, 0.05-0.6; P = .004). No significant difference in predictors of mortality were found between patients who underwent reintervention vs those who did not (P = .2). TEVAR for cTBAD with aneurysmal degeneration can be performed safely but spinal cord ischemia rates may be higher than previously reported. Liberal use of procedural adjuncts to reduce this complication, such as spinal drainage, is recommended. Reintervention is common, but long-term survival does not appear to be impacted by remediation.

A prospective, randomized, placebo-controlled, double-blind, multicenter study of the effects of irbesartan on aortic dilatation in Marfan syndrome (AIMS trial): study protocol

BackgroundCardiovascular complications are the leading cause of mortality and morbidity in Marfan syndrome (MFS), a dominantly inherited disorder caused by mutations in the gene that encodes fibrillin-1. There are approximately 18,000 patients in the UK with MFS. Current treatment includes careful follow-up, beta blockers, and prophylactic surgical intervention; however, there is no known treatment which effectively prevents the rate of aortic dilatation in MFS. Preclinical, neonatal, and pediatric studies have indicated that angiotensin receptor blockers (ARBs) may reduce the rate of aortic dilatation. This trial will investigate the effects of irbesartan on aortic dilatation in Marfan syndrome.Methods/DesignThe Aortic Irbesartan Marfan Study (AIMS) is an investigator-led, prospective, randomized, placebo-controlled, double-blind, phase III, multicenter trial. Currently, 26 centers in the UK will recruit 490 clinically confirmed MFS patients (aged ≥6 to ≤40 years) using the revised Ghent diagnostic criteria. Patients will be randomized to irbesartan or placebo. Aortic root dilatation will be measured by transthoracic echocardiography at baseline and annually thereafter. The primary outcome is the absolute change in aortic root diameter per year measured by echocardiography. The follow-up period will be a minimum of 36 months with an expected mean follow-up period of 48 months.DiscussionThis is the first clinical trial to evaluate the ARB irbesartan versus placebo in reducing the rate of aortic root dilatation in MFS. Not only will this provide useful information on the safety and efficacy of ARBs in MFS, it will also provide a rationale basis for potentially lifesaving therapy for MFS patients.Trial registrationISRCTN, 90011794

Toward Uniformity in Reporting of Thoracic Aortic Diameter

Toward Uniformity in Reporting of Thoracic Aortic Diameter

Novel Mechanism of Aortic Aneurysm Development in Mice Associated With Smoking and Leukocytes

The purpose of this study was to evaluate potential mechanisms promoting abdominal aortic aneurysm development with tobacco smoke (TS) exposure. Experiments used the elastase perfusion model of abdominal aortic aneurysms with smoke-free controls. The effect of TS exposure was evaluated in C57/Bl6 mice, after broad-spectrum matrix metalloproteinase inhibition with doxycycline and in mice deficient in matrix metalloproteinase-9, matrix metalloproteinase-12, Cathepsin-S, and Neutrophil Elastase. Preparations of washed marrow, spleen, and peripheral blood leukocytes were transferred to smoke-free mice from 6-week TS-exposed mice or smoke-free mice. All mice were euthanized 14 days after elastase perfusion, and the percentage of change in aortic diameter (%Δ aortic diameter) was calculated. Electron microscopy of aortic tissue from animals exposed to TS without elastase exposure did not demonstrate any ultrastructural changes. Neither doxycycline nor any specific elastase deficiency was effective at preventing an increase in %Δ aortic diameter in TS-exposed animals. Smoke exposure for 6 weeks increased the %Δ aortic diameter after a smoke-free interval of up to 6 weeks before elastase perfusion. Leukocyte preparations from TS-exposed mice localized to abdominal aortic aneurysms and increased the %Δ aortic diameter in smoke-free mice. The effect of TS on the development of abdominal aortic aneurysms is not dependent on the activity of elastolytic enzymes and persists for long periods despite cessation of TS. Alterations in leukocyte response to aortic injury appear to mediate this effect.