Aortic Injury Research Articles

Interim Analysis of an Ongoing Study Evaluating Preventive Aortic Stent Graft Implantation Prior to Major Thoracic Tumor Resection and a Review of the Literature

Abstract Introduction There is limited data in the literature on the use of thoracic aortic stent graft implantation (TEVAR) to facilitate en-bloc resection of tumors that have invaded the aortic wall. After TEVAR, extended resections can be performed, avoiding aortic wall replacement or catastrophic situations such as life-threatening bleeding from aortic injury. Aims The aim of this interim analysis was to demonstrate the feasibility of TEVAR without increased risk of perioperative morbidity and mortality. Methods A retro- and prospective data analysis was performed including all consecutive patients with suspicious aortic wall infiltration on preoperative imaging, who received a TEVAR implantation prior to resection of thoracic malignancy between 1/2008 and 12/2022. In addition, a literature review was conducted. Results Thirteen patients (median age 67 years, range 23-75, 62% female) have been treated at our institution so far. Nine patients received neoadjuvant therapy. In all patients it was possible to implant the stent graft with sufficient overlap at the level of the tumor mass. In 69% the proximal landing zone was located in aortic zone 3 to 4. No postoperative endograft related morbidity, especially no spinal cord ischemia, no stroke, no postoperative bleeding or access site complications, as well as no dissection or aortic rupture was observed. In nine patients, aortic wall infiltration was confirmed intraoperatively, and a partial non-circumferential resection of the aortic wall was necessary. The 30-day mortality rate was 15% (one case) due to respiratory failure and ARDS as well as postoperative empyema. Eight patients died during a median follow up of 11 month (0.7-94). Conclusions In this, to the best of our knowledge, largest analysis to date, the results of previous smaller series were confirmed. Aortic stent grafting prior to thoracic tumor resection allows extensive resections while maintaining low morbidity and a low 30-day mortality risk.

De novo acute type B aortic dissection in two patients with previous infrarenal endovascular aortic aneurysm repair with EndoAnchors

<h2>Abstract</h2> Acute aortic dissections in the immediate postoperative period following endovascular abdominal aortic aneurysm repair (EVAR) have been linked to technical factors such as excessive endograft oversizing or aortic wall injuries during the procedure, whereas dissections that occur later are more likely to be de novo. Regardless of their etiology, aortic dissections can extend in the abdominal aorta, causing collapsing and occlusion of the endograft with devastating complications. There have been no reports of aortic dissections in EVAR patients in whom endoanchors were used. We present two cases of de novo type B aortic dissection (TBAD) after EVAR with entry tears in the descending thoracic aorta. Interestingly in both of our cases the dissection flap appeared to stop abruptly at the site of endograft fixation with the endo-anchors, suggesting that end-anchors might prevent propagation of aortic dissections beyond the endoanchor fixation level and thus protect the EVAR from collapsing.

Thoracic Aortic Arch Repair and Debranching in Thoracic Endovascular Aortic Repair Stent Migration

Thoracic endovascular aortic repair is a common reparative approach to aortic injury. Common long-term complications include endo-leak and stent migration. However, in some patients, an aortic arch repair with debranching may reduce the risk of further endo-leakage and migration. This poster presentation aimed to outline a novel approach to an open thoracic endovascular aortic repair (TEVAR) stent migration with an aortic arch repair with debranching utilising a 20-mm Gelweave straight graft anastomosed end-to-end.

Sex Differences in Blunt Traumatic Aortic Injury from the Aortic Trauma Foundation Global Registry

Trauma is the leading cause of death in people younger than 45 years, and blunt traumatic aortic injury (BTAI) is the second leading cause of death after blunt trauma. There have been reports on variations in physiological response to trauma between men and women, as well as sex/gender disparities in aortic disease outcomes, but there is a gap in the literature on sex differences in patients with traumatic aortic injury. The Aortic Trauma Foundation international prospective multicenter registry was used to examine sex differences in traumatic aortic injury characteristics, management, and outcomes from 2016 to 2022. Data were analyzed by contingency table, stratified and multivariable regression. There were 781 patients with BTAI and complete injury grade information, of whom 182 patients (23%) were female. The mean age was 43.4 ± 18 years, and women were significantly older than men (48 ± 18.6 vs 42.3 ± 17.6 years, P < .0001). A total of 464 patients (59%) underwent thoracic endovascular aortic repair with no significant difference between men (61%, 364 of 599) and women (55%, 100 of 182). Injury severity score and Glasgow coma scores did not differ between women and men. Women more often had pelvic fracture (41% vs 30%, P < .004), splenic injury (31% vs 23%, P < .05), renal injury (22% vs 14%, P < .02), sacral spine fracture (12% vs 6%, P < .02), and sternal fracture (17% vs 10%, P < .02), but these injury patterns were not associated with higher grade aortic injuries. There were no sex differences in the distribution of aortic injury grade. In-hospital mortality was 12%, and aortic-related mortality was 4% for the entire cohort, with no differences between men and women. The presence of sternal fracture appeared to predict higher aortic mortality in women (10% with sternal fracture vs 2% without, P = .05) but not in men (9% with sternal fracture vs 10% without P = .9). There is no difference in mortality between men and women with BTAI. Women with BTAI presented more frequently with intra-abdominal and pelvic injuries, and sternal fractures appear to predict a higher mortality in women with BTAI.

Timing Is Everything: Delaying Endovascular Repair of Blunt Thoracic Aortic Injuries Is Safe and Appropriate

Timing Is Everything: Delaying Endovascular Repair of Blunt Thoracic Aortic Injuries Is Safe and Appropriate

Delayed Repair is Associated With Lower Stroke Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

Delayed Repair is Associated With Lower Stroke Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

Trends in Management and Perioperative Outcomes of Blunt Thoracic Aortic Injury Over the past Decade

Trends in Management and Perioperative Outcomes of Blunt Thoracic Aortic Injury Over the past Decade

Postoperative Complications in Emergent vs Non-emergent Thoracic Endovascular Aortic Repair in Blunt Thoracic Aortic Injuries From the Aortic Trauma Foundation Global Registry

Postoperative Complications in Emergent vs Non-emergent Thoracic Endovascular Aortic Repair in Blunt Thoracic Aortic Injuries From the Aortic Trauma Foundation Global Registry

In-silico investigations of haemodynamic parameters for a blunt thoracic aortic injury case

Accounting for 1.5% of thoracic trauma, blunt thoracic aortic injury (BTAI) is a rare disease with a high mortality rate that nowadays is treated mostly via thoracic endovascular aortic repair (TEVAR). Personalised computational models based on fluid–solid interaction (FSI) principals not only support clinical researchers in studying virtual therapy response, but also are capable of predicting eventual outcomes. The present work studies the variation of key haemodynamic parameters in a clinical case of BTAI after successful TEVAR, using a two-way FSI model. The three-dimensional (3D) patient-specific geometries of the patient were coupled with three-element Windkessel model for both prior and post intervention cases, forcing a correct prediction of blood flow over each section. Results showed significant improvement in velocity and pressure distribution after stenting. High oscillatory, low magnitude shear (HOLMES) regions require careful examination in future follow-ups, since thrombus formation was confirmed in some previously clinically reported cases of BTAI treated with TEVAR. The strength of swirling flows along aorta was also damped after stent deployment. Highlighting the importance of haemodynamic parameters in case-specific therapies. In future studies, compromising motion of aortic wall due to excessive cost of FSI simulations can be considered and should be based on the objectives of studies to achieve a more clinical-friendly patient-specific CFD model

The Impact of Annual Surgeon Volume on Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

The Impact of Annual Surgeon Volume on Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

Predicting Mortality in Blunt Abdominal Aortic Trauma- a Novel Approach Utilizing Neural Networks

The aim of this study was to develop an accurate neural network (NN)-based approach to predict in-hospital mortality in patients who sustain blunt traumatic aortic injury (BTAI). Secondary objectives include identifying factors that may play a contributory role in mortality. The 2019 National Trauma Data Bank (NTDB) was queried for International Classification of Diseases, Tenth Edition (ICD-10) codes corresponding to blunt abdominal aortic trauma. Patients with no signs of life upon presentation were excluded from this study. A total of 113 patients were used to train a NN using the following input variables: age, sex, Injury Severity Scale (ISS), presenting Glasgow Coma Scale (GCS), packed red blood cells (RBCs) used in the first 4 hours of presentation, and presenting systolic blood pressure (SBP). The primary outcome of our study was the area under the receiver-operator characteristics curve (AUC), sensitivity, and specificity of our NN with secondary outcomes including the normalized importance ratio of variables used to train the NN. The NN accurately predicted mortality in patients who sustained BTAI with an AUC of 0.93 (Fig), sensitivity of 72%, and specificity of 89%. There were no significant differences in age between the mortality and survival cohorts. There was a higher prevalence of males in the mortality group in addition to a higher ISS, lower GCS, increased number of packed RBCs in the first 4 hours of presentation and a lower presenting SBP. Our NN found transfusion requirements to be the most predictive of mortality followed by ISS. A NN-based approach can accurately predict mortality in BTAI. Additionally, transfusions requirements within the first 4 hours and presenting ISS were found to have the highest predictive value. Furthermore, NN can be utilized as an innovative predictive adjunct in the management of critical trauma.

Experience of vascular injuries at a military hospital in Korea.

Vascular injuries require immediate surgical treatment with standard vascular techniques. We aimed to identify pitfalls in vascular surgery for trauma team optimization and to suggest recommendations for trauma and vascular surgeons. We reviewed 28 victims and analyzed the patterns of injuries, methods of repair, and outcomes. Ten patients had torso injuries, among whom three thoracic aorta injuries were repaired with thoracic endovascular aortic repair, one left hepatic artery pseudoaneurysm with embolization, and two inferior vena cava with venorrhaphy, three iliac arteries with patch angioplasty or embolization, and three common femoral arteries with bypass surgery or arterioplasty. Four patients had upper extremity injuries, among whom one brachial artery and vein was repaired with bypass surgery after temporary intravascular shunt perfusion, two radial arteries were repaired with anastomoses, and one ulnar artery was repaired with ligation. One radial artery under tension was occluded. Fourteen patients had lower extremity injuries, among whom one superficial femoral artery and vein was repaired with bypass and concomitant ligation of the deep femoral artery and vein, three superficial femoral arteries were repaired with bypass (two concomitant femoral veins with bypass or anastomosis), one deep femoral artery with embolization, two popliteal arteries with bypass or anastomosis, four infrapopliteal transected arteries, one arteriovenous fistula with ligation, and one pseudoaneurysm with bypass. However, one superficial femoral artery and all femoral veins were occluded. One leg replantation failed. There are potential complications of vascular access during resuscitative endovascular balloon occlusion of the aorta procedures. Vascular repair should be performed without tension or spasm. Preservation of the harvested vein in papaverine solution and blood while using a temporary intravascular shunt is a method of eliminating spasms.

Endovascular treatment of a traumatic thoracic pseudo-aneurysm in a pediatric patient: a case report with review of literature

Blunt aortic injury (BAI) as a result of thoracic trauma is a rare entity in the adult and pediatric population. The endovascular approach has been the preferred method of management over operative repair in adults. However, data on pediatrics is limited to case reports and case series with no long-term follow-up. There are no current guidelines for management in the pediatric population. We are reporting a successful repair of a traumatic thoracic aortic aneurysm in a 13 year old boy with covered stents, with a review of relevant literature.

Same Treatment, Same Outcome, Even In The Long-Term Observation?

Sex-Related Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic InjuryEuropean Journal of Vascular and Endovascular SurgeryPreviewCurrent literature suggests that thoracic endovascular aortic repair (TEVAR) in older patients with aortic aneurysms results in higher peri-operative mortality and lower long term survival in females compared with males. However, sex-related outcomes in younger patients with blunt thoracic aortic injury (BTAI) undergoing TEVAR remain unknown. This study examined the association between sex and outcomes after TEVAR for BTAI. Full-Text PDF

Benzo[a]pyrene and a high-fat diet induce aortic injury and promote low-density lipoprotein accumulation in the endothelium

Benzo[a]pyrene (BaP) is a ubiquitous environmental pollutant which mainly exposed though diet. High-fat diet (HFD) can induce atherosclerosis, as can BaP. Unhealthy dietary habits lead to high intake of both BaP and lipids. However, the combined effect of BaP and HFD on atherosclerosis and lipid accumulation in the arterial wall, the initial stage of atherosclerosis, is unclear. In this study, C57BL/6 J mice were subchronically exposed to BaP and a HFD, and the mechanism of lipid accumulation was investigated in EA.hy926 and HEK293 cells. Results showed that BaP and HFD increased blood lipids and damaged aortic wall synergistically. Meanwhile, LDL enhanced the toxicity of BaP, and BaP promoted the production of reactive oxygen species and malonaldehyde in EA.hy926 cells, which aggravated LDL-induced cell injury. Moreover, BaP and HFD/LDL induced LDL accumulation in the aortic wall of C57BL/6 J mice/EA.hy926, and the mechanism was by activating AHR/ARNT heterodimer to combine with the scavenger receptor BⅠ (SR-BⅠ) and activin receptor-like kinase 1 (ALK1) promoter regions to transcriptional upregulate its expression, which enhanced the uptake of LDL, and promoting the production of AGEs to inhibit reverse cholesterol transport by SR-BI. BaP and lipid synergistically promoted aortic and endothelial damage, and the health risk of their combined intake should be paid attention to.

Endovascular Repair of Traumatic Infrarenal Aortic Injury in an 8-Year-Old.

The patient is an 8 year-old male presenting to outside facility following high-speed motor vehicle collision in which he was a restrained passenger. CT imaging at that time demonstrated a traumatic infrarenal aortic pseudoaneurysm, extensive pneumoperitoneum and free fluid, and an unstable L2 vertebral body fracture. He underwent exploratory laparotomy with small bowel resection prior to transfer. The patient was left in discontinuity and temporary closed. Vascular surgery was consulted upon arrival to tertiary care children's hospital. The decision was made to proceed with emergent endovascular repair. An aortogram confirmed the location of the aortic disruption well below the renal arteries, superior to the bifurcation. An 11 mm × 5 cm Viabahn covered stent was placed across the injury with adequate proximal and distal seal. This is a case of seatbelt-related pediatric infrarenal aortic injury in the setting of polytrauma. Endovascular repair was pursued in this damage-control setting.

LB-4 | First-in-human experience with a novel (low profile, high flow) percutaneous ventricular assist device

Current FDA approved pVAD devices have large profiles (e.g. > 14F) and are associated with high rates of morbidity (e.g. vascular complications). At maximum flow rates (i.e. RPMs), these devices are fraught with high rates of hemolysis. The Supira 10F system was designed and developed to address these limitations. 6 patients underwent high risk PCI with the use of a novel Supira 10F system as part of an IRB approved FIH protocol. The device is an expandable axial flow 21 Fr pump in its nominal state and is sheathed to 10F for delivery and removal. In its nominal state, the device provides continuous unloading throughout the cardiac cycle. The system is delivered via rapid exchange ("RX") over a pre-established LV rail wire. Once positioned trans-valvular, the guidewire is removed and the axial pump is initiated. PCI was then performed to each of the 6 patients per local practices. Following PCI, the device is removed and hemostasis achieved. The primary outcomes was a composite endpoint of procedural and safety assessment. Procedural success was defined as: safe implantation of device, hemodynamic support during the PCI, and successful withdrawal of the device. Safety assessment was defined as freedom from device-related major adverse events (MAE), including vascular complications (access and central), aortic valve injury, mitral valve injury, and systemic embolization. Baseline demographics of the enrolled patients consist of age 58±9 yrs, 83% male, and a BMI 30±2. Comorbid conditions consisted of prior MI (66%), DM (50%), tobacco use (50%) and pulmonary hypertension (50%). The EF ranged from 30-60% with at least 2 vessels treated in 66% of the patients. The device support time ranged from 42 - 96 minutes. Procedural success was 100% and none of the patients in this early series experienced device related adverse events peri-procedurally. There was no early indicators of clinically significant hemolysis. Herein we present our initial FIH experience with a novel expandable low profile and high flow Supira 10F system which addresses limitations of current FDA approved devices. In this early experience the device was safe and allowed for successful completion of high risk PCI.

Homeobox A9 is a novel mediator of vascular smooth muscle cell phenotypic switching and proliferation by regulating methyl-CpG binding protein 2

Aberrant proliferation and phenotypic switching of vascular smooth muscle cells (VSMCs) are considered to be the main pathological processes of atherosclerotic plaque formation. Methyl-CpG binding protein 2 (MECP2) affects cell differentiation via modulating VSMC-specific gene expression and acts as a driver for the development of atherosclerosis (AS). Here, we aimed to elucidate the role of homeobox A9 (HOXA9) on aberrant VSMCs upon injury or AS, and whether HOXA9-mediated VSMC injury was associated with MECP2. Adeno-associated virus serotype 8-mediated knockdown of HOXA9 rescued aortic pathological injury of apolipoprotein E-deficient (ApoE−/−) mice fed a high-fat diet (HFD), characterized by the reduction of lipid accumulation and foam cell formation. Further in vitro evidence suggested that proliferation and migration of primary mouse VSMCs (mVSMCs) stimulated by oxidized low-density lipoprotein (ox-LDL) were inhibited after HOXA9 silencing. In addition, HOXA9 silencing blocked VSMC phenotypic switching from contractile to a pathological synthetic state. HOXA9 overexpression caused opposite alterations in ox-LDL-stimulated mVSMCs. Mechanistically, MECP2 was transcriptionally activated by HOXA9. Forced expression of MECP2 impaired the anti-proliferation, anti-migration, and phenotypic switching abilities of HOXA9 silencing in VSMCs upon ox-LDL stimulation. Collectively, our findings reveal that the role of HOXA9 in pathological vascular remodeling may attribute to transcriptional regulation of MECP2.

Septal Myectomy Outcomes in Children and Adolescents With Obstructive Hypertrophic Cardiomyopathy

BackgroundLittle data exist regarding characteristics and outcomes of pediatric patients undergoing septal myectomy. We evaluated this in a large referral population. MethodsSeptal myectomy was performed in 199 consecutive patients aged ≤18 years with obstructive hypertrophic cardiomyopathy from January 1, 1976, to June 30, 2021. ResultsMedian age was 13 years (interquartile range [IQR], 8-15 years). Left ventricular myectomy approaches included transaortic (163 of 198 [82%]), transapical (16 of 198 [8%]), and combined (19 of 198 [10%]). Right ventricular interventions included myectomy (13 of 199 [7%]) and patch reconstruction of the outflow tract (15 of 199 [8%]). Maximum left ventricular outflow tract gradients decreased after myectomy (prebypass: 50 mm Hg [IQR, 31-73 mm Hg] vs postbypass: 4 mm Hg [IQR, 0-9 mm Hg], P < .001), and this was sustained long-term (5 mm Hg [IQR, 5-10 mm Hg] at 10 years). Iatrogenic aortic and mitral valve injuries occurred in 13 of 199 (7%) and 1 of 199 (1%), respectively; however, all were successfully repaired. Operative mortality was 2 of 199 (1%). The cumulative incidence of redo myectomy was low, at 5.8% at 5 and 8.3% at 10 years. Redo myectomy patients had higher maximum left ventricular outflow tract gradients on echocardiography at predischarge and 1 year and were younger at the index operation (8 years [IQR, 2.5-10 years] vs 13 years [IQR, 9-16 years], P < .001). Overall survival at 10 years was 90%, relative to 47% in a previously reported pediatric nonoperative cohort. ConclusionsPediatric septal myectomy provides safe, effective, and durable relief of ventricular outflow tract obstruction. Iatrogenic valve injury remains a low but nonnegligible risk. Recurrent obstruction requiring redo myectomy is infrequent and can be identified early. Long-term survival in this pediatric septal myectomy cohort appears to fare better than pediatric hypertrophic cardiomyopathy cohorts managed nonoperatively.

Moxibustion of 45 ℃ at "Zusanli" (ST36) improves vascular endothelial oxidative stress in hyperlipidemia rats

To explore the antioxidant effect of moxibustion on vascular endothelial function and the under-lying mechanism. Forty male SD rats were randomly divided into blank, model, moxibustion and endothelial nitric oxide synthase (eNOS) inhibitor groups, with 10 rats in each group. Hyperlipidemia rat model was established by high fat diet for 8 weeks. Rats in the moxibustion group received 45 ℃ moxibustion at "Zusanli" (ST36) for 10 min once daily for consecutive 4 weeks. Rats in the eNOS inhibitor group received intraperitoneal injection of eNOS inhibitor L-NAME (1 mg/100 g) at the same time of moxibustion intervention. The morphology of abdominal aorta endothelium was observed by HE staining. Lipid deposition in abdominal aorta was observed by oil red O staining. The contents of total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) in serum and reactive oxygen species (ROS), nitric oxide (NO), superoxide dismutase (SOD), oxidized LDL lipoprotein (ox-LDL), endothelin-1 (ET-1), eNOS, malondialdehyde (MDA) in serum and abdominal aorta were determined by ELISA. The expression of eNOS in abdominal aorta was detected by immunofluorescence. HE staining of the abdominal aorta showed no significant pathological abnormality in the blank group; the endovascular cortex was rough, and the inner, media and outer membrane were rough in the model group; the nucleus and surrounding tissue structure were clear and the vascular wall was smooth in the moxibustion group; abdominal aorta texture was rough in the eNOS inhibitor group. Compared with the blank group, the area of oil red O staining in abdominal aorta increased (P<0.05); the contents of serum TC, TG and LDL-C increased (P<0.01, P<0.05) while HDL-C decreased (P<0.05); the contents of ET-1 in serum and abdominal aorta were increased (P<0.01, P<0.05) while the contents of NO and eNOS were decreased (P<0.05, P<0.001); the contents of ROS, ox-LDL and MDA in serum and abdominal aorta were increased (P<0.001, P<0.01, P<0.000 1) while the content of SOD in abdominal aorta was decreased (P<0.000 1); the expression level of eNOS in abdominal aorta was decreased (P<0.05) in the model group. Compared with the model group, the area of oil red O staining in abdominal aorta decreased (P<0.05); the contents of TC, TG and LDL-C in serum decreased (P<0.05) while HDL-C increased (P<0.05); the contents of ET-1 in serum and abdominal aorta were decreased (P<0.01, P<0.05) while the contents of NO and eNOS in abdominal aorta were increased (P<0.001, P<0.01); the contents of ROS and MDA in serum and abdominal aorta were decreased (P<0.001, P<0.01, P<0.05), the content of ox-LDL was decreased (P<0.01) and the content of SOD was increased (P<0.000 1) in abdominal aorta; the expression level of eNOS in abdominal aorta was increased (P<0.05) in the moxibustion group. Compared with the moxibustion group, the contents of serum TC, LDL-C and MDA in the eNOS inhibitor group were increased (P<0.05); the contents of ET-1, ROS, ox-LDL and MDA in abdominal aorta were increased (P<0.05), the contents of NO, eNOS and SOD were decreased (P<0.05); the expression level of eNOS in abdominal aorta was decreased (P<0.05). 45 ℃ moxibustion at ST36 can protect and repair vascular endothelial injury in abdominal aorta of hyperlipidemia rats and improve the oxidative stress of vascular endothelium.