Aortic Dissection Patients Research Articles

Abstract 4120105: Meta-Analysis of Outcomes in Patients Developing Acute Kidney Injury Following Thoracic Endovascular Aortic Repair for Stanford Type B Aortic Dissection

Background and Aims: Thoracic endovascular aortic repair (TEVAR) is warranted in patients with Stanford Type-B aortic dissection who are at an increased risk of aneurysm rupture and enlargement. While studies indicate that development of post-operative acute kidney injury (AKI) (with incidence rate varying from 1.5% to 34%) may potentially worsen outcomes and increased mortality, the specific role of AKI in the postoperative period for patients undergoing TEVAR for Stanford Type-B aortic dissection remains understudied and unclear. Our meta-analysis aims to contribute valuable insights into this aspect. Methods: A comprehensive literature search spanning major bibliographic databases was conducted to retrieve studies comparing outcomes in Stanford Type-B aortic dissection patients undergoing TEVAR who developed AKI postoperatively versus those who did not. Our outcomes of interest included the risk of in-hospital mortality, stroke, and requirement for dialysis. Relative risks (RRs) were pooled from all studies using DerSimonian and Laird random-effects models in the ‘meta’ package of R software (Version: 2023.12.1+402). Statistical significance was set at p <0.05. Results: Three studies were included with 1091 patients (234 in the AKI group and 857 in the non-AKI group). The development of AKI was associated with a significantly higher risk of in-hospital mortality [RR: 5.31; 95% CI: 3.10, 9.08; p<0.0001; I 2 =0%], a higher risk of stroke [RR: 2.33; 95% CI: 1.30, 4.17; p=0.0046; I 2 =0%], and an increased risk of requiring dialysis [RR: 18.43; 95% CI: 3.35, 101.46; p=0.0008; I 2 =0%] (Figure 1). No heterogeneity was observed between the studies (Figure 1 and 2). Conclusion: The development of AKI after TEVAR in patients with Stanford Type-B aortic dissection is associated with an increased risk of in-hospital mortality, stroke, and dialysis requirement. Hence, further research into early recognition of the risk factors associated with the development of AKI after TEVAR is warranted, along with determining its effects in longer follow-up durations.

Thirty-day outcomes of endovascular repair of Stanford type B aortic dissection in patients with chronic obstructive pulmonary disease.

Thoracic Endovascular Aortic Repair (TEVAR) has revolutionized the surgical treatment for Stanford type B aortic dissection (TBAD). While chronic obstructive pulmonary disease (COPD) is associated with worse outcomes in major surgeries, the specific outcomes of TEVAR in patients with COPD have not been extensively explored. This study aimed to evaluate the 30-day postoperative outcomes of COPD patients undergoing TEVAR for TBAD utilizing data from a multi-institutional national registry. Patients who underwent TEVAR for TBAD were identified in the ACS-NSQIP database from 2005 to 2022. A 1:3 propensity-score matching was used to match demographics and preoperative characteristics between patients with and without COPD. Thirty-day postoperative outcomes were compared. There were 172 (9.56%) and 1628 (90.44%) COPD and non-COPD patients who underwent TEVAR for TBAD, respectively. Patients with COPD had a higher comorbidity burden. After the propensity-score matching, all 172 COPD patients were matched to 440 non-COPD patients. COPD and non-COPD patients had comparable mortality rates (10.12% vs 6.82%, p = .18). However, COPD patients had a higher risk of pulmonary complications (20.83% vs 13.18%, p = .02). All other 30-day outcomes were similar between the two groups. COPD patients had 58.04% higher pulmonary complications while all other 30-day outcomes were comparable to their non-COPD counterparts. Therefore, close monitoring and timely intervention for pulmonary complications in COPD patients can be important after TEVAR for TBAD. Future studies should investigate long-term outcomes among these COPD patients.

Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with sleep apnea syndrome

Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with sleep apnea syndrome

The introduction of a dedicated cardiology clinic including a clinical scientist led pathway for women with turner's syndrome

Abstract Background There are more than 15,000 women living with Turner’s Syndrome (TS) in the UK, over 700 of whom are cared for within our linked Endocrinology services. Mortality is predominantly related to cardiovascular disease therefore close cardiology review with a focus on aortopathy is essential (1). However appropriate surveillance is challenging with growing pressures on all aortopathy services across the United Kingdom. Purpose To audit our current practise according to current international guidelines (2) and seek methods to improve the pathway for our growing population of TS patients including the feasibility of a Clinical Scientist led clinic, aiming to improve capacity and efficiency of our service. Methods A quality improvement project was conducted over a three-year period, piloting a dedicated clinical scientist-led clinic under close Cardiology Consultant supervision. Patients selected were deemed lower risk for cardiovascular complications according to American Heart Association (AHA) recommendations (2) (figure 1). Follow-up intervals of patients under both consultant-led and clinical scientist led pathways were analysed. Results Among a total of 226 patients analysed, 103 (46%) fell into the lowest risk category and therefore deemed suitable for prospective Clinical Scientist led pathway (figure 2). Analysis of all patients demonstrated that 60% had appropriate follow-up intervals according to guidelines, while 37% were too short and 3% were too long. A five-year projection indicated a consequential 96 unnecessary additional appointments for patients that were being seen too frequently. Further analysis showed that the time frame for follow up was too short in 25% of patients seen in the clinical scientist led clinic compared to 41% in the Consultant-led clinic. There were no aortic dissections in patients under surveillance during this period. In the last 10 years 1 patient on the waiting list for surgery (having presented with a type B dissection but requiring workup for liver cirrhosis) had a retrograde type A dissection (indexed aortic root dimension 2.4cm/m²). No other adverse events were recorded. Conclusion Auditing our service revealed safe management and improved adherence to guidelines in the clinical scientist-led clinic, identifying opportunities to optimize follow-up and enable physicians to focus upon high-risk patients. This pilot demonstrates the feasibility of a clinical scientist-led clinic in managing low risk TS patients, suggesting scalability to other conditions involving aortopathy to address capacity issues and improve pathways.

Monocytes perturbation implicated in the association of stress hyperglycemia with postoperative poor prognosis in non-diabetic patients with Stanford type-A acute aortic dissection

ObjectivesThe study aimed to investigate the interaction of intraoperative stress hyperglycemia with monocyte functions and their impact on major adverse events (MAEs) in acute aortic dissection (AAD) patients who underwent open repair surgery.MethodsA total of 321 adults who underwent open surgery for AAD at two tertiary medical centers in China were enrolled in the study. The primary endpoint was defined as the incidence and characteristics of perioperative stress hyperglycemia. The secondary endpoints included the incidence of postoperative MAEs, postoperative monocyte counts and inflammatory cytokine expression. Multi-logistic, linear regression and receiver operating characteristic (ROC) curve analyses were used to establish relationships between intraoperative time-weighted average glucose (TWAG), day-one postoperative monocyte counts, serum inflammatory cytokines and postoperative outcomes. In addition, in vitro experiments were conducted to evaluate changes in the inflammatory features of monocytes under high glucose conditions.ResultsIntraoperative hyperglycemia, as indicated by a TWAG level over 142 mg/dL, was associated with elevated postoperative monocyte counts and inflammatory cytokines, which correlated with extended intensive care unit (ICU) stays and worsened outcomes. In vitro, high glucose treatment induced mitochondrial impairment in monocytes, increased the release of inflammatory cytokines and the proportion of classical monocytes from AAD patients.ConclusionsIntraoperative stress hyperglycemia, in combination with day-one postoperative monocyte counts, were clinically significant for predicting adverse outcomes in AAD patients undergoing open repair surgery. Elevated glucose concentrations shaped the inflammatory features of monocytes in AAD by impairing mitochondrial functions.Graphical abstractHigh glucose-driven mitochondrial functional impairment mediates a more pronounced monocytic inflammatory state in Stanford type-A AAD.

Impact of Surgery Timing and Malperfusion on Acute Type A Aortic Dissection Outcomes.

To determine the impact of symptom-to-surgery time on mortality in acute type A aortic dissection (ATAAD) patients, with and without malperfusion. A retrospective analysis of 288 ATAAD patients was conducted. Patients were separated into the early (≤ 10 h) and late (> 10 h) groups by symptom-to-surgery time. Data on characteristics, surgery, and complications were compared, and multivariable logistic regression determined mortality risk factors. Mortality rates did not significantly differ between early and late groups. Age (OR 1.09, 95% CI 1.05-1.13, p<0.001), ECMO use (OR 10.73, 95% CI 2.51-45.87, p=0.001), and malperfusion (OR 6.83, 95% CI 2.84-16.45, p<0.001) predicted operative death. Subgroup analysis showed cerebral (OR 3.20, 95% CI 1.11-9.26, p=0.031), cardiac (OR 5.89, 95% CI 1.32-26.31, p=0.020), and limb (OR 6.20, 95% CI 1.75-22.05, p=0.005) malperfusion as predictors of operative death. One (OR 6.30, 95% CI 2.39-16.61, p<0.001), two (OR 12.79, 95% CI 2.74-59.81, p=0.001), and three (OR 46.99, 95% CI 7.61-288.94, p<0.001) organs malperfusion, together with Penn B (OR 7.96, 95% CI 3.04-20.81, p<0.001) and Penn B-C (OR 12.50, 95% CI 2.65-58.87, p=0.001) classifications predict operative mortality. Survival analysis revealed significant differences between malperfusion and no malperfusion (34% vs. 9%, p<0.001) but not between late and early (14% vs. 21%, p=0.132) groups. Malperfusion remained an essential predictor of operative (OR 7.06 95% CI 3.11-17.19, p<0.001) and mid-term mortality (OR 3.38 95% CI 1.97-5.77, p<0.001) in subgroup analysis. Preoperative malperfusion status, rather than symptom-to-surgery time, significantly impacts both operative and mid-term mortality in ATAAD patients.

Aortic arch anatomical differences in male type B aortic dissection patients vs. healthy male individuals

BackgroundUnderstanding the distinct anatomical differences between patients with type B aortic dissection (TBAD) and control patients (CPs) can enhance our knowledge of normal and pathological aortic dimensions. This study aimed to deepen our knowledge of these dimensions by measuring and comparing the anatomical indices of the aortic arch in male patients with TBAD and non-TBAD male patients.MethodsIn this cross-sectional observational study, 62 TBAD patients (TBADPs) and 43 CPs were assessed. Using a fit centerline approach, we identified three pivotal anatomical landmarks: Point A, Point B, and Point C. These landmarks represented intersections of the aortic arch with the brachiocephalic trunk, left common carotid artery, and left subclavian artery, respectively. These points defined Zones 1, 2, and 3, which collectively span the entire proximal aorta from the proximal end of the aortic valve to Point C. Our analyses compared key anatomical indices such as diameter of the circumscribed circle (Dcirc), ellipticity, curvature, tortuosity between TBADP and CP at critical points and regions.ResultsTBADPs showed a more circular cross-sectional shape at Points A, B and C, as indicated by reduced values of Dcirc_A (P = 0.031), ellipticity_A (P = 0.034) and ellipticity_B (P = 0.048), together with a significant decrease in Dcirc_C (P = 0.015) and ellipticity_C (P = 0.007). The aortic arch in TBADPs showed enhanced tortuosity in Zone 1 (p = 0.002) and extended elongation in Zone 3 (p = 0.001).ConclusionsThe study found that the aortic arch in male TBAD patients is more circular near its primary branches, has greater tortuosity in Zone 1, and is longer in Zone 3 compared to male control patients.

Identifying HIF1A and HGF as two hub genes in aortic dissection and function analysis by integrating RNA sequencing and single-cell RNA sequencing data.

Aortic dissection (AD) is a severe aortic disease with high mortality, and its pathogenesis remains elusive. To explore the regulatory mechanisms of AD, we integrated public RNA sequencing (RNA-seq) and single-cell RNA sequencing (scRNA-seq) datasets to screen the hub genes of AD and further analyzed their functions, which may provide references to the diagnosis and treatment of AD. Four AD-related datasets were obtained from the Gene Expression Omnibus (GEO) database. Weighted gene co-expression network analysis and differential expression analysis were applied to identify overlapping genes in dataset GSE153434. Protein-protein interaction (PPI) network was constructed based on overlapping genes. Five methods (closeness, degree, EPC, MCC, and MNN) were used to pick hub genes. The receiver operating characteristic curve was used to evaluate the diagnostic efficiency of the hub genes in extra datasets GSE98770 and GSE52093. scRNA-seq dataset GSE213740 was used to explore the expression and function of the hub genes at the single-cell level. Quantitative real-time polymerase chain reaction was used to verify the expression of hub genes in beta-aminopropionitrile (BAPN)-induced mouse thoracic aortic aneurysm and dissection (TAAD) model. A total of 71 overlapping genes were screened by intersecting the significant genes in the pink module and the differentially expressed genes. A PPI network with 45 nodes and 74 edges was generated, and five top hub genes (HIF1A, HGF, HMOX1, ITGA5, and ITGB3) were identified. All the hub genes had area under the curve values above 0.55. scRNA-seq data analysis showed that HIF1A was significantly upregulated in macrophages and HGF was significantly upregulated in vascular smooth muscle cells (SMCs) of the ascending aortas in AD patients. HIF1A may transcriptionally regulate multiple downstream target genes involving inflammation (TLR2, ALOX5AP, and MIF), glycolysis (ENO1, LDHA, and GAPDH), tissue remodeling (PLAU), and angiogenesis (SERPIN and VEGFA). HGF may participate in the signaling among SMCs, fibroblasts, and endothelial cells through binding to different receptors (MET, EGFR, IGF1R, and KDR). The mRNA expression of Hif1a, Hgf, and their target genes, including Alox5ap, Serpine1, Tlr2, Plau, Egfr, and Igf1r, was significantly upregulated in aortic tissues of BAPN-treated mice. By integrating RNA-seq and scRNA-seq data, we identified HIF1A and HGF as two hub genes with good diagnostic efficiency for AD. HIF1A in macrophages may promote AD formation by promoting inflammation, glycolysis, tissue remodeling, and angiogenesis, and HGF may mediate signaling among SMCs, fibroblasts, and endothelial cells in the development of AD.

Methylprednisolone for acute type A aortic dissection patients undergoing total arch replacement: Design and rationale of the Medal trial

BackgroundThe mortality and morbidity of emergency total aortic arch replacement (TAAR) for acute type A aortic dissection (ATAAD) is high, which is partly due to the excessively activated systemic inflammatory response. Methylprednisolone, an anti-inflammatory agent, might suppress the systemic inflammatory response and lead to improved outcomes. However, the protective effects of methylprednisolone on TAAR for ATAAD were not clarified. The usage and dosage varied in different centers across the world. Methods and resultsThe Medal trial is a prospective, multicenter, randomized, double-blind, placebo-controlled, parallel-group trial to evaluate whether 500 mg methylprednisolone IV before cardiopulmonary bypass could reduce the incidence of postoperative major organ injury, compared to placebo. Adult patients with the diagnosis with ATAAD, awaiting emergency total aortic arch replacement with hypothermic circulatory arrest and selective cerebral perfusion will be included in the trial. A total of 340 eligible subjects from nine large cardiovascular centers will be randomized in a 1:1 ratio to recieve 500mg methylprednislone or placebo before cardiopulmonary bypass. The primary outcome is postoperative major adverse outcome [defined as all-cause death or postoperative neurological deficit or KDIGO II -III acute kidney injury or respiratory syndrome (tracheal intubation> 72 hours, tracheostomy or re-intubation) until postoperative day 30 or patient discharge]. The study has received approval from the local Ethics Committees of the nine participating centers, and enrolled its first subject in June 24, 2022. As of September 5,2024, 323 subjects have been enrolled. Results of the Medal trial will be published once data collection and analysis have been completed. ConclusionsThe Medal trial will determine the effectiveness of 500 mg methylprednisolone on the outcomes of patients with ATAAD undergoing TAAR. RegistrationURL https://www.chictr.org.cn/searchprojEN.html (Chinese Clinical Trial Registry). Unique identifier: ChiCTR2200059286

Machine Learning Model for Predicting Risk Factors of Prolonged Length of Hospital Stay in Patients with Aortic Dissection: a Retrospective Clinical Study.

The length of hospital stay (LOS) is crucial for assessing medical service quality. This study aimed to develop machine learning models for predicting risk factors of prolonged LOS in patients with aortic dissection (AD). The data of 516 AD patients were obtained from the hospital's medical system, with 111 patients in the prolonged LOS (> 30days) group based on three quarters of the LOS in the entire cohort. Given the screened variables and prediction models, the XGBoost model demonstrated superior predictive performance in identifying prolonged LOS, due to the highest area under the receiver operating characteristic curve, sensitivity, and F1-score in both subsets. The SHapley Additive exPlanation analysis indicated that high density lipoprotein cholesterol, alanine transaminase, systolic blood pressure, percentage of lymphocyte, and operation time were the top five risk factors associated with prolonged LOS. These findings have a guiding value for the clinical management of patients with AD.

Quantitative Electroencephalography Monitoring in Type A Aortic Dissection Surgery: A Clinical Case Review and Prospective Applications.

This review explores advanced methods for assessing perioperative cerebral function in Type A aortic dissection (TAAD) patients, with a focus on quantitative electroencephalography (QEEG). It highlights the critical issue of cerebral malperfusion, which is associated with higher mortality and poor prognosis during the perioperative phase in TAAD patients. The review centers on the utilization of QEEG as a pivotal tool for the extensive monitoring of brain function at various stages: preoperatively, intraoperatively, and postoperatively. It elaborates on the foundational principles of QEEG, including the mathematical and computational analysis of electroencephalographic signals, enriched with intuitive graphical representations of cerebral functional states. QEEG is presented as an innovative approach for the real-time, noninvasive, and reliable assessment of cerebral function. The review details the application of QEEG in monitoring conditions such as preoperative cerebral malperfusion, intraoperative deep hypothermic circulatory arrest, and postoperative recovery of cerebral function in patients undergoing TAAD treatment. Although QEEG is still in an exploratory phase for TAAD patients, it has shown efficacy in other domains, suggesting its potential in multimodal brain function monitoring. However, its broader application requires further research and technological advancements.

Development and external validation of a novel modality for rapid recognition of aortic dissection based on peripheral pulse oximetry waveforms.

Aortic dissection (AD) is a life-threatening cardiovascular emergency that is often misdiagnosed as other chest pain conditions. Physiologically, AD may cause abnormalities in peripheral blood flow, which can be detected using pulse oximetry waveforms. This study aimed to assess the feasibility of identifying AD based on pulse oximetry waveforms and to highlight the key waveform features that play a crucial role in this diagnostic method. This prospective study employed high-risk chest pain cohorts from two emergency departments. The initial cohort was enriched with AD patients (n=258, 47% AD) for model development, while the second cohort consisted of chest pain patients awaiting angiography (n=71, 25% AD) and was used for external validation. Pulse oximetry waveforms from the four extremities were collected for each patient. After data preprocessing, a recognition model based on the random forest algorithm was trained using patients' gender, age, and waveform difference features extracted from the pulse oximetry waveforms. The performance of the model was evaluated using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA). The importance of features was also assessed using Shapley Value and Gini importance. The model demonstrated strong performance in identifying AD in both the training and external validation sets. In the training set, the model achieved an area under the ROC curve of 0.979 (95% CI: 0.961-0.990), sensitivity of 0.918 (95% CI: 0.873-0.955), specificity of 0.949 (95% CI: 0.912-0.985), and accuracy of 0.933 (95% CI: 0.904-0.959). In the external validation set, the model attained an area under the ROC curve of 0.855 (95% CI: 0.720-0.965), sensitivity of 0.889 (95% CI: 0.722-1.000), specificity of 0.698 (95% CI: 0.566-0.812), and accuracy of 0.794 (95% CI: 0.672-0.878). Decision curve analysis (DCA) further showed that the model provided a substantial net benefit for identifying AD. The median mean and median variance of the four limbs' signals were the most influential features in the recognition model. This study demonstrated the feasibility and strong performance of identifying AD based on peripheral pulse oximetry waveforms in high-risk chest pain populations in the emergency setting. The findings also provided valuable insights for future human fluid dynamics simulations to elucidate the impact of AD on blood flow in greater detail.

Short-term outcomes of mild (≥30 ℃) vs. moderate hypothermic circulatory arrest in aortic arch surgery.

Hypothermia and antegrade cerebral perfusion (ACP) strategies in open aortic arch surgery (AAS) have improved significantly. The significance of the gradual temperature rise to mild hypothermia is quite apparent, however, its safety remains a challenge. Therefore, our objective was to explore the safety and efficacy of mild hypothermic circulatory arrest (Mi-HCA, ≥30 ℃). This retrospective cohort study enrolled in a total of 372 patients, and was performed at the Beijing Anzhen Hospital between January 2017 and November 2022. Among the 372 patients, 81 received AAS at ≥30 ℃, and the remaining 291 received the same at 22-29.9 ℃. Most acute type A aortic dissection (ATAAD) patients received total arch replacement (TAR) and frozen elephant trunk (FET) operation. Mi-HCA patients exhibited strongly augmented systemic temperature (26.19±1.63 vs. 31.40±0.79 ℃, P<0.01). The surgical, cardiopulmonary bypass (CPB), cross-clamp, circulatory arrest, and ACP durations were drastically diminished among Mi-HCA patients (all P<0.01). Moreover, the major adverse events (MAEs) incidence of Mi-HCA patients was significantly decreased (25.43% vs. 14.81%, P<0.05). Simultaneously, the Mi-HCA strategy also exhibited enhanced protection of blood cells, as well as myocardial and hepatic function. Nevertheless, multivariate logistic regression analysis revealed that Mi-HCA strategy (≥30 ℃) was not a stand-alone risk factor for MAEs following AAS. The short-term outcomes and safety of Mi-HCA, in combination with ACP, in AAS are satisfactory. Additionally, relative to the traditional moderate hypothermic circulatory arrest (MHCA) approach, it can substantially decrease operation duration while improving patient clinical outcomes.

Acute type A aortic dissection in patients with non-prior cardiac surgery vs. prior cardiac surgery: a systematic review and meta-analysis.

Patients with prior cardiac surgery undergoing acute type A aortic dissection (ATAAD) are thought to have worse clinical outcomes as compared to the patients without prior cardiac surgery. To compare the safety and efficacy of ATAAD in patients with prior cardiac surgery. We systematically searched PubMed, Cochrane Library and Google Scholar from database inception until April 2024. We included nine studies which consisted of a population of 524 in the prior surgery group and 5,249 in the non-prior surgery group. Our primary outcome was mortality. Secondary outcomes included reoperation for bleeding, myocardial infarction, stroke, renal failure, sternal wound infection, cardiopulmonary bypass (CPB) time, cross-clamp time, hospital stay, and ICU stay. Our pooled estimate shows a significantly lower rate of mortality in the non-prior cardiac surgery group compared to the prior cardiac surgery group (RR = 0.60, 95% CI = 0.48-0.74). Among the secondary outcomes, the rate of reoperation for bleeding was significantly lower in the non-prior cardiac surgery group (RR = 0.66, 95% CI = 0.50-0.88). Additionally, the non-prior cardiac surgery group had significantly shorter CPB time (MD = -31.06, 95% CI = -52.20 to -9.93) and cross-clamp time (MD = -21.95, 95% CI = -42.65 to -1.24). All other secondary outcomes were statistically insignificant. Patients with prior cardiac surgery have a higher mortality rate as compared to patients who have not undergone cardiac surgery previously. Patients with prior cardiac surgery have higher mortality and longer CPB and cross-clamp times. Tailored strategies are needed to improve outcomes in this high-risk group.

Risk prediction of postoperative permanent stroke in acute type A aortic dissection patients with severe common carotid artery stenosis using brain CT perfusion

Rationale and objectivesTo explore the feasibility and predictive utility for neurological outcomes of brain computed tomography perfusion (CTP) for surgically treated acute type A aortic dissection patients with severe common carotid artery stenosis. Materials and methodsConsecutive acute type A aortic dissection patients with severe common carotid artery stenosis undergoing preoperative brain computed tomography perfusion and surgery at our center were examined in retrospect. Brain perfusion was assessed using parameters including cerebral blood flow, cerebral blood volume, mean transmit time, time to maximum, penumbra volume and infarct core volume. Univariable and multivariable regression analyses were performed to identify clinical and imaging predictors associated with postoperative permanent stroke. ResultsOut of 44 patients included, 19 patients (43.2 %) presented with postoperative permanent stroke. Univariable analysis revealed that internal carotid artery dissection, cerebral blood flow of the affected side, cerebral blood volume of the affected side, and penumbra volume were implicated in postoperative permanent stroke. Multivariable analysis further showed that cerebral blood flow of the affected side was an independent indicator of a permanent stroke following surgery (odds ratio: 0.820, 95 % confidence interval: 0.684–0.982; p = 0.012). The area under the receiver operating characteristic curve was 0.867 (95 % confidence interval: 0.764–0.970), and the optimal cut-off value was 45.6mL/100 mL/min. ConclusionCerebral blood flow of the affected side was an independent indicator of permanent stroke following surgery in acute type A aortic dissection patients with severe common carotid artery stenosis. Brain CTP could be a helpful modality for quantitative evaluation of cerebral malperfusion and neurological prognostication.

Systematic Review and Meta-Analysis With Reconstructed Time-To-Event Data of Frozen Elephant Trunk and Conventional Aortic Repair.

Frozen elephant trunk (FET) has gained popularity since its inception. Nevertheless, the optimal approach for managing aortic arch pathologies remains subject of debate. This meta-analysis compared outcomes between patients undergoing FET and those undergoing conventional aortic repair. Systematic searches were conducted up to February 2024. Pooled results of short and long-term outcomes were computed. A systematic review identified 21 non-randomized studies encompassing 3240 patients. Short-term mortality was lower in FET recipients than in those undergoing conventional repair (OR [95% CI] = 0.58 [0.44-0.78], P < .01). Postoperative paraplegia incidence was higher in the FET cohort (OR = 1.85 [1.02-3.34], P = .04), while subgroup analysis showed no difference between the two groups in patients with acute aortic dissection. Long-term all-cause mortality was lower among FET recipients. Subgroup analysis showed FET was associated with reduced all-cause mortality (HR = 0.55 [0.39-0.79], P < .01) and aortic re-intervention (HR = 0.62 [0.39-0.99], P = .05) in acute aortic dissection patients. This meta-analysis underscores the favorable association between the utilization of FET and improved short and long-term outcomes compared with conventional repair, while paraplegia incidence was higher in the FET group. FET appears to offer superior benefits, particularly evident in patients with acute aortic dissection.

A comparison between direct true lumen versus conventional cannulation for management of acute type- aortic dissection patients.

Objective: To compare the postoperative outcomes while using direct true lumen approach versus conventional cannulation approach in management of acute type-A aortic dissection patients. Study Design: Randomized Clinical Trial. Setting: Department of Vascular Surgery, Combined Military Hospital, Rawalpindi. Period: 1st June 2022 to 31st December 2022. Methods: A total of 22 patients age more than 18 years who presented in CMH Emergency Department with acute type A aortic dissection were included in this study. In group A (11 patients) were managed with direct true lumen cannulation while in group B (11 patients) were managed with conventional (axillary/femoral) cannulation. In both groups intra-operative parameters like procedure time, mean time of cardiopulmonary bypass, cross clamp and circulatory arrest time were measured. In both groups, outcome was measured in terms of occurrence of multi-organ failure, acute kidney injury, arrhythmias on ECG and in-hospital mortality. Data was analyzed using SPSS 26. Results: Mean age of our patients were 43.36±2.16yrs in group A while 43.36±2.94yrs in group B. Male gender predominates in both groups (gp A- 81.8% &amp; gp B-90.9%). We found no difference of statistical significance between two groups in terms of various intra-operative parameters like mean duration of procedure in group A was 428.15min and in group B was 427.36 min. Similarly mean circulatory arrest time was 31 min in group A and 29.09 min in group B. Patients in “direct true lumen cannulation” group had significantly shorter duration of intubation. In terms of post-operative outcomes, multi-organ failure occurred in 1 (9.09%) patient in group A while it occurred in 3(27.27%) patients in group B. In hospital mortality occurred in 2(18%) patients in group A as compared to 4(36%) in group B. So better results were observed in “direct true lumen cannulation” group as compared to “conventional (axillary/femoral) cannulation” group. Conclusion: In our study, acute type-A aortic dissection patients who had undergone direct true lumen cannulation during operative management showed better post-operative outcomes.

Unraveling phenotypic heterogeneity in stanford type B aortic dissection patients through machine learning clustering analysis of cardiovascular CT imaging

ObjectiveAortic dissection remains a life-threatening condition necessitating accurate diagnosis and timely intervention. This study aimed to investigate phenotypic heterogeneity in patients with Stanford type B aortic dissection (TBAD) through machine learning clustering analysis of cardiovascular computed tomography (CT) imaging. MethodsElectronic medical records were collected to extract demographic and clinical features of patients with TBAD. Exclusion criteria ensured homogeneity and clinical relevance of the TBAD cohort. Controls were selected on the basis of age, comorbidity status, and imaging availability. Aortic morphological parameters were extracted from CT angiography and subjected to K-means clustering analysis to identify distinct phenotypes. ResultsClustering analysis revealed three phenotypes of patients with TBAD with significant correlations with population characteristics and dissection rates. This pioneering study used CT-based three-dimensional reconstruction to classify high-risk individuals, demonstrating the potential of machine learning in enhancing diagnostic accuracy and personalized treatment strategies. Recent advancements in machine learning have garnered attention in cardiovascular imaging, particularly in aortic dissection research. These studies leverage various imaging modalities to extract valuable features and information from cardiovascular images, paving the way for more personalized interventions. ConclusionThis study provides insights into the phenotypic heterogeneity of patients with TBAD using machine learning clustering analysis of cardiovascular CT imaging. The identified phenotypes exhibit correlations with population characteristics and dissection rates, highlighting the potential of machine learning in risk stratification and personalized management of aortic dissection. Further research in this field holds promise for improving diagnostic accuracy and treatment outcomes in patients with aortic dissection.

Surgical strategy and long-term outcomes of dissected carotid artery with false lumen thrombus in acute type A aortic dissection.

Optimal management of involved common carotid artery (CCA) with false-lumen thrombus remains unclear in aortic dissection patients. We aim to investigate outcomes and compare different surgical strategies. This is a retrospective cohort study and the institutional database of acute type A aortic dissection was reviewed. The patients with CCA involvement and extended false-lumen thrombus were enrolled and grouped according to the management of CCA: extra-thoracic carotid artery replacement (CAR) and reconstruction in situ (RIS). Multivariate logistic regression analysis was used to investigate the effect of management on neurological outcomes. Kaplan-Meier method was used for survival analysis and log-rank test was used to compare the difference on survival rate. From March 2011 to December 2019, 68 patients were enrolled (24 in the CAR group and 44 in the RIS group). The overall operative mortality was 7.4% (5 patients) and 21 patients had the incidence of postoperative neurological deficit was (30.9%). The rates of main postoperative complications were similar between the two groups. Twenty-five (56.8%) patients in the RIS group had residual false-lumen thrombus at discharge. In multivariate analysis, CAR was the only independent protective factor of postoperative neurological deficit [odds ratio (OR) =0.03, 95% confidence interval (CI): 0.0-0.61, P=0.02] and age was the only risk factor (OR =1.34, 95% CI: 1.11-1.62, P=0.002). The median follow-up time was 40 (interquartile range, 24-69) months and some of the patients received imaging follow-up. The overall survival rates at 5 and 10 years were 95.8%, and 95.8% in the CAR group and 84.1%, and 76.4% in the RIS group, with no significant difference (P=0.22). No cerebrovascular accident and reintervention occurred and 20 (90.9%) patients with residual false-lumen thrombus had reabsorption of thrombus during the follow-up period. CAR was a thorough technique and could protect patients from postoperative neurological deficit than RIS. Patients in either group could have a satisfying long-term prognosis after surviving from perioperative period. Most patients had reabsorption of residual false-lumen thrombus after anticoagulant therapy.

Risk prediction and prognostic analysis of post-implantation syndrome after thoracic endovascular aortic repair

This study aimed to establish a predictive model for the risk of post-thoracic endovascular aortic repair (TEVAR) post-implantation syndrome (PIS) in type B aortic dissection (TBAD) patients, assisting clinical physicians in early risk stratification and decision management for high-risk PIS patients. This study retrospectively analyzed the clinical data of 547 consecutive TBAD patients who underwent TEVAR treatment at our hospital. Feature variables were selected through LASSO regression and logistic regression analysis to construct a nomogram predictive model, and the model's performance was evaluated. The optimal cutoff value for the PIS risk nomogram score was calculated through receiver operating characteristic (ROC) curve analysis, further dividing patients into high-risk group (HRG) and low-risk group (LRG), and comparing the short to midterm postoperative outcomes between the two groups. In the end, a total of 158 cases (28.9%) experienced PIS. Through LASSO regression analysis and multivariable logistic regression analysis, variables including age, emergency surgery, operative time, contrast medium volume, and number of main prosthesis stents were selected to construct the nomogram predictive model. The model achieved an area under the curve (AUC) of 0.86 in the training set and 0.82 in the test set. Results from calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC) demonstrated that the predictive model exhibited good performance and clinical utility. Furthermore, after comparing the postoperative outcomes of HRG and LRG patients, we found that the incidence of postoperative PIS significantly increased in HRG patients. The duration of ICU stay and mechanical assistance time was prolonged, and the incidence of postoperative type II entry flow and acute kidney injury (AKI) was higher. The risk of aortic-related adverse events (ARAEs) and major adverse events (MAEs) at the first and twelfth months of follow-up also significantly increased. However, there was no significant difference in the mortality rate during hospitalization. This study established a nomogram model for predicting the risk of PIS in patients with TBAD undergoing TEVAR. It serves as a practical tool to assist clinicians in early risk stratification and decision-making management for patients.