Aortic Intervention Research Articles

Ascending aortic length predicts adverse outcomes in type a intramural hematoma.

Ascending aortic length has recently been recognized as a novel predictor of adverse events in aortic diseases, but its prognostic value in type A intramural haematoma is unknown. We aimed to evaluate the association between ascending aortic length and outcomes in patients with type A intramural haematoma initially managed medically. We retrospectively analyzed patients with acute type A intramural haematoma. Ascending aortic length was measured by computed tomography. The primary outcome was aortic progression, defined as aortic intervention or aortic-related death. A total of 98 patients were enrolled. During a median follow-up of 2.6 years, aortic progression occurred in 27 patients (27.6%), ie, 9 events per 100 patient-years). Patients with ascending aortic length ≥11 cm had significantly higher rates of aortic progression (54.2% [20.9 events per 100 patient-years] vs 18.9% [6.1 events per 100 patient-years], p = 0.001), surgical intervention (45.8% vs 12.2%, p = 0.001), and presence of ulcer-like projection (25.0% vs 2.7%, p = 0.002) compared to those with ascending aortic length <11 cm. Kaplan-Meier analysis demonstrated lower progression-free survival in the ascending aortic length ≥11 cm group (p = 0.0021). Ascending aortic length had a sensitivity of 61.9% and specificity of 77.8% for predicting aortic progression, with an area under the curve of 0.756 (95% confidence interval: 0.649-0.862). Ascending aortic elongation may identify a high-risk subgroup of acute type A intramural haematoma patients initially managed medically who could potentially benefit from early surgery. Ascending aortic length should be considered in the risk stratification and management of these patients.

Distal ascending aortic dilatation portends a near 2-fold greater risk of cardiovascular mortality than proximal enlargement: results from 120,000 patients in a nationwide echocardiographic database

Abstract Background The management of thoracic aortic dilatation is clinically challenging and acute aortic dissection (AD) is under-recognised as a primary cause of death. Despite the majority of AD occurring in non-severely dilated aortas, absolute aortic diameter remains the most utilised criterion for adjudging preventative surgical correction. In order to improve outcomes and guide management, greater prognostic understanding is needed. Purpose We examined a nationwide echocardiographic dataset linked to mortality outcomes to determine how ascending thoracic aortic dilatation and its site affects cardiovascular disease (CVD) mortality over time. Methods The National Echocardiography Database Australia (NEDA) was examined for aortic dimensions at the sinuses of Valsalva (SoV), sinotubular junction (STJ) and ascending aorta (AscAo) in patients who had undertaken &amp;gt;1 echocardiographic study. Following separation of those who had undergone corrective aortic surgery, patients were stratified according to absolute aortic diameters and grouped as normal (&amp;lt;4cm), mild (4.0-4.5cm), moderate (4.5-5cm) and severely (&amp;gt;5cm) dilated at the prescribed thoracic aortic sites. Mortality data was then linked from the National Death Index (NDI). Results 398,905 echocardiographs from 121,115 patients with a mean age of 62.6±16.2 years were included. At the time of mortality data linkage, 38,681 (32%) had died, of whom 13,292 (34%) died from CVD causes and only 276 (0.007%) had aortic dissection recorded as their primary cause of death. Severe aortic dilatation at any site increased the likelihood of 10-year CVD mortality (29% vs. 15% in those with normal diameters; HR 3.00; CI 1.60-5.63; p&amp;lt;0.0001), with an incremental increase in the probability of CVD death when moving from the proximal to distal ascending aorta; 10-year CVD mortality at the SoV 26% (HR 1.93; CI 1.29-2.87; p&amp;lt;0.001), STJ 39% (HR 2.82; CI 1.64-4.86; p&amp;lt;0.001) and AscAo 44% (HR 4.74; CI 2.46-9.13; p&amp;lt;0.001) respectively (Figure 1). When examining those patients who had undergone corrective aortic surgery, the likelihood of 10-year CVD mortality was comparable to the population with normal aortic diameters (17 vs. 15%, HR 1.1; CI 0.9-1.36; p=0.3) (Figure 2). Conclusion Severe aortic dilatation increases the probability of 10-year cardiovascular mortality. Interestingly, there is an incremental increase in the likelihood of CVD mortality when moving from the proximal to distal ascending aorta, with severe AscAo dilatation conferring a near 2-fold greater risk of CVD mortality compared with severe SoV aneurysms. Additionally, surgical aortic intervention nearly normalises survival probability to the population with healthy aortic diameters. These results identify new considerations for prognostication, risk stratification and surgical guidance of aortic repair.CVD mortality by aortic dilatationCVD mortality after aortic intervention

Gender-related differences in the timing of intervention for aortic stenosis: focus on cardiac damage

Abstract Background and aim: There is an increasing awareness of gender-related differences in the management of cardiovascular diseases. Our aim was to assess whether cardiac damage prior to intervention for severe aortic stenosis (AS) differs according to gender. Methods Retrospective analysis of a prospective cohort of patients with AS who underwent surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) in a tertiary care center from 2017 to 2022. Echocardiographic parameters prior to surgery were collected, and patients were classified into categories of a cardiac damage staging system. (1) Several echocardiographic variables according to gender were evaluated. Results 869 patients were included, of which 350 underwent TAVR and 519 were treated with SAVR. Females represented 52.4% (n=272) of TAVR patients and 37.7% (n=132) of SAVR patients. In the echocardiogram performed before the intervention, both in the TAVR and the SAVR cohort, female patients had worse diastolic function (significantly higher values of E/e’), and greater involvement of pulmonary vasculature damage (significantly higher pulmonary artery systolic pressure and worse right ventricular-arterial coupling (Table-Figure 1). When applying an available cardiac damage staging system (1), we documented that women were treated at a statistically significant more advanced stage compared to men (Figure 2). Conclusions There are gender-related differences in the timing of aortic stenosis intervention, both with TAVR and SAVR. Women are operated on at a more advanced stage of cardiac damage, particularly regarding the parameters of diastolic function and right-side damage. These findings should be taken into account to improve intervention timing and outcomes, especially for women.Table-Figure 1Figure 2

Sex differences in aortic prognosis in Marfan patients, a retrospective longitudinal study from the REPAG registry

Abstract Introduction Previous studies(1-4) have suggested a more favourable aortic outcome among women with Marfan syndrome (MFS), although the precise underlying mechanism remains not completely understood. In this retrospective longitudinal study, we aim to evaluate sex differences in aortic events in a large cohort of Marfan patients seen in 11 tertiary centres in Spain. Methods Patients with diagnosis of Marfan syndrome (MFS) were included. Data on aortic events (AE) including elective aortic surgeries, acute aortic syndrome or death were incorporated. Survival free of the combined endpoint of death or first aortic event (elective aortic surgery or acute aortic syndrome) was compared between male and female by the Kaplan-Meier curves, log-rank test and subsequent Cox regression analysis. Results A total of 442 patients with MFS where included, 48.2% female and 56.2% index cases. Although systemic score and proband proportion was not different between both sexes, the diagnosis was earlier in males (p=0.01) (Table). Furthermore, among adult patients, males exhibited greater height, weight, and body surface area (BSA). Absolute aortic root diameter at baseline was greater in males, but not BSA-indexed diameters or z-scores. Combined endpoint of death or aortic event was observed in 192 patients (120 male, 72 female, p=&amp;lt;0.00001). Female sex had better survival free of the combined endpoint in a multivariable Cox analysis (HR 0.41 95% CI=0.30–0.55) with a mean survival free of the combined endpoint of 41.3yrs in male and 61.4 years in females (p&amp;lt;0.0001) (Figure).Although a higher proportion of elective aortic interventions as first event was observed in males (66.7% vs 52.8%), the proportion of type A dissections was similar between both sexes (26.7 vs 26.4%) with increased frequency of type B dissections in females as first aortic event (4.2 vs 15.3%) (p=0.026) Conclusions Male patients with MFS present higher aortic root diameters but similar BSA-indexed and zscores than females. Survival free of first aortic event or death is reduced in male with MFS, with greater frequency of elective aortic intervention. Although this last is driven by absolute aortic diameter, no increase on type A dissection was observed in women. These findings might suggest a potentially less aggressive manifestation of proximal aortic disease in women with MFS.Table:Comparison male and female Marfan

The Carbon Footprint of the Vascular Surgery Operating Room

ObjectiveClimate change is the single greatest threat to global human health, contributing to changes in disease patterns, water and food insecurity, vulnerability in shelter and human settlements, climatic volatility, and population growth and migration. Healthcare generates between 8 - 10% of all greenhouse gas emissions. Surgical care accounts for a significant proportion due to equipment and drug use, sterility requirements, and life support systems. There are currently minimal data describing this carbon consumption. The purpose of this study was to determine the carbon utilization of common vascular interventions and to identify variables associated with increased carbon utilization. MethodsWe conducted an observational study of all elective and urgent vascular surgery procedures performed at our institution in a two-month period in 2023. All waste generated was weighed and cataloged per hospital waste practices. Additional characteristics of the procedures were also collected. Carbon utilization was determined by applying DEFRA greenhouse gas life-cycle conversion factors to the mean waste produced. These factors take into account greenhouse gas emissions generated in the initial production and eventual disposal. Variables associated with increased carbon production were evaluated by linear regression models with log-transformed outcomes. Results59 procedures were included. Complex endovascular aortic procedures were the most carbon intensive (69.35kg CO2), equivalent to driving a medium-sized vehicle 369 kilometers. Dialysis access procedures (11.5kg CO2) and minor amputations (10.6kg CO2) were the least carbon intensive. Open surgical bypasses (28.4kg CO2) and cerebrovascular procedures (20.3kg CO2) produced a moderate amount of carbon. Endovascular interventions were 50% more carbon intensive than open interventions (95% CI: 28%, 77%; p <0.01). Aortic interventions were 63% more carbon intensive than non-aortic interventions (95% CI: 28%, 109%; p<0.01). In both models, there was nearly a half percent increase in carbon generated for each minute of additional operating time (p<0.01). Blood loss was not consistently associated with carbon utilization. ConclusionsClimate change is a major threat to human health. The environmental impact of day-to-day surgery is rarely considered but clearly significant. Larger procedures are associated with increased carbon utilization, particularly if they are endovascular or aortic. The duration of the case is also associated with increased utilization. Further work should be done to identify additional variables and opportunities for carbon reduction.

Feasibility of Intraoperative 3-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Aortic Valve Replacement: A Prospective Observational Pilot Study

To assess the feasibility of intraoperative 3-dimensional speckle-tracking-based myocardial deformation analysis for evaluation of twist, torsion, and strain using speckle tracking, and to investigate the immediate changes in these parameters after aortic valve replacement. Prospective observational study SETTING: Single-center study at a tertiary academic cardiac center PARTICIPANTS: Forty-nine patients undergoing minimally invasive surgical aortic valve replacement INTERVENTIONS: Acquisition of full-volume images of the left ventricle after induction of anesthesia and at the end of surgery using transesophageal echocardiography (TEE), and analysis of the datasets using 3D speckle-tracking-based myocardial deformation analysis (Tomtec Arena). Of the 49 complete volume datasets, 30 (61%) had quality sufficient for speckle tracking. No significant differences were observed between the examinations in terms of ejection fraction (EF) (p = 0.177), global longitudinal strain (GLS) (p = 0.276), circumferential strain (CS) (p = 0.238), twist (p = 0.970), or torsion (p = 0.417). 3D speckle-tracking-based myocardial deformation analysis from intraoperative TEE datasets is feasible in >60% of patients with aortic valve stenosis. There were no statistically significant differences in GLS, CS, twist, or torsion between the intraoperative examinations.

National registry insights on genetic aortopathies and thoracic endovascular aortic interventions: Presented at the 51st Annual Symposium of the Society for Clinical Vascular Surgery, Scottsdale, AZ, March 16-20, 2024.

National registry insights on genetic aortopathies and thoracic endovascular aortic interventions: Presented at the 51st Annual Symposium of the Society for Clinical Vascular Surgery, Scottsdale, AZ, March 16-20, 2024.

A National Survey of Interventional Radiology Trainees on Peripheral and Aortic Endovascular Training.

The development of technical skills in peripheral and aortic endovascular intervention is an essential part of interventional radiology (IR) training. Access to endovascular training remains contentious, with IR and vascular surgery (VS) trainees competing for opportunities. The Collaborative Peripheral and Aortic Endovascular Training Survey (CPAETS) aimed to evaluate IR trainees' experiences, expectations, and barriers to endovascular training. CPAETS was a joint survey between the British Society of Interventional Radiology and the Rouleaux Club (UK Vascular Trainees' Association), open for 12 weeks and distributed to UK-based IR and VS trainees. This article focuses on IR trainee responses. Thirty-two responses were received from IR trainees across England, Scotland and Wales. Overall, 59% of respondents were satisfied with their endovascular training. IR trainees reported less regular hands-on experience of aortic endovascular procedures (50%) compared to peripheral endovascular procedures (93%). Consequently fewer trainees (65%) felt confident in achieving the necessary aortic endovascular competencies by the end of their training, compared to peripheral procedures (89%). Limited exposure to aortic endovascular procedures resulted in reduced confidence levels in performing aortic intervention as compared to peripheral procedures. Potential solutions to bridge some of these IR training gaps include greater pre-operative and post-operative presence, the use of simulators and IR fellowships to ensure adequate training opportunities. This article provides a snapshot of the current gaps in IR endovascular training in the UK, with insight into solutions that can enable trainees to develop clinical and technical competencies required for IR consultant practice.

Comparative study of acute kidney injury in pararenal aortic aneurysm: open surgical versus endovascular repair.

Pararenal abdominal aortic aneurysms (PR-AAA), constituting around 15%-20% of AAA patients, are defined as having no neck between the aneurysm and the renal arteries. Due to an insufficient sealing zone, open surgical repair (OSR) is the gold standard, while EVAR is reserved for those unfit for surgery. Renal outcomes disturb long-term survival, and they have massive socioeconomic and quality of life implications, especially if patients require dialysis. This study aims to elucidate any difference between EVAR and OSR of PR-AAA, excluding suprarenal aneurysms, with specific emphasis on renal dysfunction over the short and long term. An existing database of PR-AAA between 2002 and 2023 was used to glean information regarding the therapeutic option used. Renal events were defined by the RIFLE criteria. Out of 1,563 aortic interventions, we identified 179 PR-AAA, of which 99 high-risk patients had an aortic neck of less than 10 mm with complete follow-up. We excluded patients with fenestrated EVAR (FEVAR), branched EVAR (BEVAR), or chimney EVAR (Ch-EVAR) and any patients requiring visceral artery reimplantation. In total, 63 patients underwent EVAR, and 36 required OSR. 17.46% of patients who underwent EVAR experienced acute kidney injury (AKI) compared with 36.11% of the OSR group (P = 0.037). The mean post-op creatinine for OSR was 109.88 µmol/L, and for EVAR was 127.06 µmol/L (P = 0.192). The mean difference between long-term (9-12 years) creatinine values in OSR was 14.29 µmol/L (P = 0.191), and the mean difference for EVAR was 25.05 µmol/L (P = 0.024). Furthermore, 27.8% of OSR patients who underwent Left Renal Vein Division and Ligation (LRVDL) experienced an AKI, while 50% who did not undergo LRVDL experienced an AKI (P = 0.382). Thirty-day morbidity in the EVAR group (20.97%) was significantly lower than in the OSR group (42.62%) (P = 0.022). Moreover, 3.17% in EVAR group and 7.14% in OSR group had aneurysm-related mortality (P = 0.584). The rate of renal events for OSR is higher, while the rate of endovascular renal events was lower. Our study shows that PR-AAA undergoing OSR may benefit from endovascular repair.

SP7.11 - Long term mortality risk factors for patients that underwent a Carotid surgery

Abstract Aims Carotid endarterectomy is the gold standard intervention to reduce carotid stenosis induced embolic cerebrovascular events. Current literature lacks long-term large sample analysis for post-carotid surgery mortality risks. The aim of this study was to determine long term all-cause mortality after carotid surgery. Method Single centre 10-year retrospective observational study of CEA mortality evaluating pre, intra and post-operative factors between 2010 and 2020. The data was manually extracted from the hospital’s database. Odds ratios and mortality rates were calculated and adjusted for age by adapting linear regression. Results 970 patients’ data were identified with an average follow up of 6.65 ±3.37 years for an average mortality rate of 31.9%. There was a non-significant (p&amp;gt;0.05) age adjusted odd of survival between gender (aOR 1.81 ±0.298) elective admission (aOR 0.932 ±0.321) and symptomatic patients (aOR 1.274 ±0.47). There was a significantly (p&amp;gt;0.05) decreased chance of survival for current smokers (aOR 0.433 ±0.54) and patients on ACE/ARB (aOR 0.516 ±0.091). On the other hand, single (aOR 2.934 ±0.531) and dual anti-platelet (aOR 4.964 ±0.286) showed a significant (p&amp;gt;0.05) protective effect. The 5-year age-adjusted death rate was elevated for all patients at 1.42. Conclusion The results highlight the smoking cessation, DAPT and appropriate prophylaxis remain important factors in increasing survival odds post carotid surgery. 30% mortality at 5 years is similar to those after Aortic interventions in these arteriopathic patients with extensive co morbidities.

Aortic arch registry of type a aortic dissection (AoArch) - rationale, design and definition criteria

BackgroundType A acute aortic dissection (TAAAD) is a deadly condition that demands immediate surgery, because it involves a critically. The mortality and morbidity associated with it are significant, and it is vital that the patient’s conditions and treatment strategies are fully understood to ensure the appropriate management of TAAAD. This study aims to ascertain whether hemiarch repair (HAR) versus extended arch repair (EAR) with or without descending aortic intervention results in better perioperative and late outcomes for patients with TAAAD.MethodsFour leading centers of cardiac surgery from two European countries have joined forces to create a groundbreaking multicenter observational registry (AoArch). This study was approved by the institutional review board (IRB 202201173). We conducted a retrospective review (NCT 0591263) of our prospectively maintained database for patients who underwent operative repair of DeBakey type I or type II dissection from January 1, 2005 to March 2024 (NCT 05927090). We will analyze how patient co-morbidities, referral conditions, and surgical strategies involving hemi-arch repair (HAR) and extended arch repair (EAR) impact early and late adverse events. We have developed a procedure urgency algorithm based on the severity of preoperative hemodynamic conditions and malperfusion due to TAAAD, and we will use it to assess the primary clinical outcomes: in-hospital mortality, late mortality, and reoperations on the aorta. We will define secondary outcomes as permanent neurologic deficit, the need for new dialysis, respiratory failure, a composite of major adverse events (myocardial infarction, cerebrovascular accidents, the need for dialysis, or the need for tracheostomy), and a composite of major adverse pulmonary events (intubation over 48 h, pneumonia, reintubation, tracheostomy), and reoperation due to bleeding.DiscussionThis multicenter registry will definitively determine the prognostic significance of critical preoperative conditions and the efficacy of extended arch interventions and hemiarch repair in reducing the risk of early adverse events after surgery for TAAAD. This registry will provide insights into the long-term durability of different strategies of surgical repair for TAAAD.

Elective root replacement increases the risk of type B dissection in patients with Marfan syndrome

ObjectiveMarfan syndrome is a genetic disorder with increased risk of aortic dissection. Currently, type A aortic dissection risk is mitigated by aortic root replacement with Dacron. It is unclear if root replacement increases the risk of distal aortic disease given the noncompliant nature of Dacron. MethodsAll adult patients with a diagnosis of Marfan syndrome at a single academic center, excluding those with history of dissection or concomitant arch repair, were studied (n = 322). Student t test or Wilcoxon Mann–Whitney test was used for continuous variables; chi-square or Fisher exact test was used for categorical variables. Propensity matching used age, sex, hypertension, race, body mass index, family history of Marfan syndrome, and genetic mutational class. Differences in freedom from type B aortic dissection were determined using the log-rank test. ResultsA total of 124 patients underwent root replacement compared with 198 patients with no prior aortic surgery. Median follow-up time was 9.90 years. Male sex, weight, and hypertension prevalence were higher in the root replacement group (P < .05). Distribution of fibrillin-1 mutations was homogenous (P > .9). Type B aortic dissection frequency in the root replacement group was higher (21% [n = 20] vs 4.2% [n = 4], P < .001). Aortic-related mortality was higher in the root replacement group (11% [n = 14] vs 3.5% [n = 7], P < .01). Distal aortic intervention frequency was higher in the root replacement group (P = .009). ConclusionsPatients with Marfan syndrome who undergo elective aortic root replacement appear to have a higher incidence of subsequent type B aortic dissection, independent of other risk factors. Careful consideration must be made to the management of the distal aorta in patients with Marfan syndrome who undergo root replacement.

Abstract Mo050: Fluoroquinolones and the Risk of Aortic Aneurysm or Aortic Dissection: Evidence From a Nationwide Nested Case-Control Study Paralleled With Matched Experimental Models

Background and Aims: Fluoroquinolones (FQ) have been linked to aortic aneurysms and dissections (AA/AD), resulting in an official warning. However, recent large-scale epidemiological studies have reported lack of FQ-AA/AD association. This study aimed to scrutinize FQ-AA/AD risk by implementing a combined epidemiological and experimental approach. Methods: Danish nationwide registers (2003-2021) were used for a nested case-control analysis. FQ-AA/AD risk was evaluated in a main and high-risk FDA cohort. Further, mortality and aortic interventions linked to FQ were investigated in patients with aortic disease. Additionally, ciprofloxacin (100 mg/kg/day, 2x2 weeks) was administered to wild-type, hypertensive or Marfan mice. Aortic diameters and pulse wave velocity (PWV) were measured longitudinally to investigate aortic remodelling. Results: The main cohort comprised 5.10 million individuals with 58,919 cases and 1,767,510 sampled controls. Compared with amoxicillin exposure. FQ exposure was not associated with increased AA/AD risk (30-day hazard ratios (HR) 1.00 [95% confidence intervals (CI): 0.74-1.34]; 90-day HR 1.07 [CI 0.94-1.22]; 1-year HR 0.95 [0.90-1.01]). In a high-risk cohort, there was no FQ-AA/AD association (30-day HR 0.83 [0.61-1.12]; 90-day HR 0.99 [0.86-1.15]; 1-year HR 0.97 [0.90-1.05]). In patients with aortic disease, FQ were not associated with increased aortic interventions or mortality (30-day HR 0.98 [0.79-1.22]; 90-day HR 1.06 [0.95-1.19]). Additionally, ciprofloxacin did not affect aortic diameters or PWV in wild type, hypertensive, and Marfan mice, while differences between models proved the sensitivity of the methodology. Conclusion: The data clearly do not support the current precautions and warnings pertaining to risks of aortopathies and FQ should not be discouraged when clinically indicated.

Safety of adjuvant open axillary access during complex thoracoabdominal aortic endovascular procedures.

Endovascular treatment of aortic diseases with complex anatomy may require an additional upper extremity arterial access (like axillary access) for support during aortic navigation and allowing the use of larger sheaths for thoracoabdominal antegrade access. The objective of this study is to evaluate the safety of the open axillary approach as adjuvant access in complex thoracoabdominal aortic endovascular interventions. A monocentric retrospective study was performed, including all patients with a complex aortic endovascular procedure (fEVAR, bEVAR, chEVAR or TEVAR), elective or urgent, with open surgical exposure of the axillary artery as adjuvant access, between 2012 and 2022. Demographic data, diagnosis and urgency criteria, type of aortic intervention, size of axillary sheath, use of through-and-through maneuver, and features by computed tomography angiography (CTA) of the axillary artery and aortic arch were recorded. The appearance of local and aortic postoperative complications were described, and possible prognostic factors were analyzed. Forty-eight patients (38 men) were included, median age 78 years (range 50-87), 33 with intact thoracoabdominal aneurysms, eight previous EVAR endoleaks and seven aortic aneurysm ruptures. 28 fEVAR/bEVAR, 17 chEVAR and three TEVAR procedures with axillary access were performed. Left infraclavicular axillary access was the most common approach (94%), along with a 12 French (F) median sheath (range 7-20). Eight (16.7%) local complications were identified: three bleedings, one hematoma, three focal dissections in the subclavian artery, and one brachial embolism, all successfully resolved. The only factor related to local complications was small axillary diameter (median 10.7 vs. 14.6 mm; P<0.001), a subclavian/sheath ratio less than one was associated to more local complications (P=0.02). Regarding aortic complications, two (4.1%) type B asymptomatic aortic dissections with left juxta-subclavian tear were found, attributed to local manipulation, occurring only in urgent procedures (P=0.032). The use of open axillary access as an adjuvant approach in complex aortic endovascular surgery, although it is very useful and usually safe, can be associated with subclavian or even aortic complications (not reported until now), especially in cases with small subclavian diameters and urgent cases.

Descending Thoracic and Thoracoabdominal Aortic Aneurysm Repairs: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

BackgroundContemporary national outcomes of open and endovascular aortic repair for descending thoracic aortic aneurysms (DTAAs) and thoracoabdominal aortic aneurysms (TAAAs) are unclear. This study evaluated this issue by using The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD). MethodsFrom July 1, 2017 to June 30, 2022, study investigators identified 3522 adults who underwent planned DTAA repair (open, 328; endovascular, 1895) or TAAA repair (open, 870; endovascular, 429), after excluding ascending aorta or aortic arch aneurysms (zone 0, 1, or 2), interventions with a proximal extent in zone 0 or zone 1, juxtarenal or infrarenal aortic interventions, hybrid procedures, aortic trauma, and aortic infection. ResultsMost DTAA interventions (85.2%) were endovascular repairs, whereas most TAAA interventions were open repairs (66.9%). For DTAA interventions, the operative mortality, permanent stroke rate, and rate of spinal cord injury were 4.2%, 3.8%, and 2.4% for endovascular repairs and 9.2%, 8.5%, and 4.6% for open repairs, respectively (all P < .05). For TAAA interventions, the operative mortality, permanent stroke rate, and rate of spinal cord injury were 6.5%, 2.1%, and 3.0% for endovascular repairs and 11.7%, 6.0%, and 12.2% for open repairs, respectively (all P < .05). Increasing annual open TAAA repair volume was associated with lower odds of experiencing the composite of operative mortality, permanent stroke, or spinal cord injury. ConclusionsOn the basis of STS ACSD data, endovascular repair was the predominant approach for treating DTAA, whereas most patients undergoing TAAA interventions had an open surgical repair. Outcome differences between open and endovascular approaches may be related to patient selection. Increasing center experience with open TAAA repair is associated with improved outcomes.

Single-Center Experience on the Elective Hybrid Combination of Single Perclose + Angio-Seal VIP 8F Compared With Standard Dual Perclose During Percutaneous Endovascular Aortic Aneurysm Repair.

This single-center study aimed to assess patients who underwent intentional percutaneous endovascular aortic aneurysm repair (pEVAR) with Hybrid Technique combining a single Perclose (Abbott, Abbott Park, Illinois) Suture-Mediated Closure Device + single Angio-Seal VIP 8F (Terumo, Tokyo, Japan) and compare outcomes with the standard Dual Perclose technique. Materials and Methods: Consecutive elective pEVAR patients treated from November 2022 to November 2023, with healthy femoral accesses and introducer sheaths ≤20 French (F) outer diameter, were included. Coin-toss randomization determined whether a combination of single Perclose Device + single Angio-Seal VIP 8F (Hybrid Technique) or the standard double Perclose Devices (Dual Perclose) was used. In Hybrid Technique, a single Perclose device was positioned at 12 o'clock; a single Angio-Seal VIP 8F was placed after sheaths removal. Dual Perclose followed standard procedure. Primary endpoints included immediate hemostasis, sheath diameter differences, access conversion rate, technical success, and cost analysis. The study involved 60 pEVAR patients (median age=78, interquartile range [IQR]=72-85 years) within the inclusion criteria. In 14 (24%) cases, only 1 femoral access was studied. There were 106 pEVAR accesses, with 58 (54.7%) in the Hybrid Technique group and 48 (45.3%) in the Dual Perclose group. Both groups exhibited homogeneity in pre-operative characteristics and sheath diameter (Hybrid Technique-16F vs Dual Perclose-18F; p=0.202). Immediate hemostasis was achieved in 100% of the Hybrid Technique group vs 87.5% for the Dual Perclose group (p=0.006). Surgical access conversion was unnecessary. Technical success was 100%, with all 6 femoral bleeding cases after Dual Perclose resolved endovascularly, using additional devices. Cost analysis showed a median cost of 330 euros (IQR=0) for the Hybrid Technique group vs 384 euros (IQR=360-456) for the Dual Perclose group (p<0.001). Thirty-day mortality was 3%, in 2 fragile patients, without access-related complications. Multivariate analysis identified Dual Perclose access (odds ratio [OR]=35.6; 95% confidence interval [CI]=18.3-36.8; p<0.001) and obesity (OR=19.7; 95% CI=1.4-23.9.5; p<0.001) as independent risk factors for immediate hemostasis failure. Median follow-up was 134 days (IQR=41-227), with 1 Hybrid Technique case (2%) successfully treated with thrombin injection for a small femoral pseudoaneurysm after 62 days. The elective Hybrid Technique with combination of single Perclose Device + single Angio-Seal VIP 8F during pEVAR in selected patients appears to be non-inferior to the standard Dual Perclose procedure. It demonstrates a positive trend in reducing immediate hemostasis failure and costs. Both procedures achieved technical success and avoiding surgical access conversions. This study introduces a novel elective hybrid technique combining a single Perclose device with a single Angio-Seal VIP 8Fr for percutaneous endovascular abdominal aortic interventions. Results for hybrid technique showed 100% technical success and efficient immediate hemostasis, while costing less than standard dual Perclose procedure. Both procedures did not require surgical conversions. Despite being a single-center study, it demonstrates potential benefits of the intentional application of this hybrid technique towards minimally invasiveness. Obesity and dual Perclose technique were identified as independent risk factors for hemostasis failure, reaffirming the hybrid technique procedure's efficacy as well as and non-inferiority to standard procedure.

Early outcomes of total arch replacement in the treatment of aortic dissection

Abstract: Overview: Aortic dissection are severe pathologies with high mortality and complication rates post-surgery despite significant advancements in both diagnosis and surgical treatment. Aortic arch replacement surgery is a classic and highly effective treatment method at Cho Ray Hospital. Objectives: Describe clinical, paraclinical characteristics, postoperative results, general complications and early hospital mortality. Methods: Descriptive cross sectional study. Results: 102 patients underwent aortic arch replacement surgery due to aortic dissection. Males predominated at 72.5%. The male:female ratio was 2.5:1. The average age was 56.45 ± 11.79 years. A history of hypertension was present in 81.4% of cases. Most patients with aortic dissection were admitted in an acute condition, accounting for 95%. Patients with type A aortic dissection accounted for 87.3%, with the entry tear in the ascending aorta at 27.5%. Isolated aortic arch replacement was performed in 46.1% of patients, while 53.9% underwent aortic arch replacement with frozen elephant trunk technique. 7 patients required aortic root replacement, 7 needed aortic valve surgery, and 10 required CABG. Most patients were cooled to 25 degrees C with cerebral perfusion to three branches. Ascending aorta cannulation was established in 45.2% of cases. The average cardiopulmonary bypass time was 257.7 minutes, with selective cerebral perfusion time at 115.9 minutes and lower body circulatory arrest time averaging 57.2 minutes. Postoperative neurological complications occurred in 10.8%, and the rate of renal failure requiring dialysis was 17.8%. The mortality rate was 9.6%. Longer cardiopulmonary bypass times and body temperatures above 25 degrees significantly increased the rate of postoperative renal failure requiring dialysis. Patients with postoperative renal failure requiring dialysis had a statistically significant increase in postoperative mortality rates. Aortic root intervention surgery combined with arch replacement did not affect the rate of postoperative complications. Aortic arch replacement with frozen elephant trunk technique did not affect cardiopulmonary bypass time, clamping time, or the rate of postoperative complications. Conclusions: Total arch replacement at Cho Ray Hospital initially showed a safe and effective with acceptable mortality rate.

Carbon dioxide cone-beam computed tomography for the technical assessment of endovascular aortic intervention

Cone-beam computed tomography (CBCT) is widely used for the technical assessment of standard and complex endovascular aortic interventions. Use of iodinated contrast in CBCT imaging might provide useful additional information; however, this also increases the procedural contrast dose, which may cause renal function deterioration, and the radiation exposure. We describe the technique and feasibility of carbon-dioxide (CO2)-enhanced CBCT for the technical assessment of standard and complex endovascular aortic repair. In our experience CO2-CBCT had no related adverse events and provided satisfactory imaging quality to assess endograft integrity, vessels patency, and was safely performed in case of severe chronic renal insufficiency.

Adverse Events in Open Surgical vs. Ultrasound-Guided Percutaneous Brachial Access for Endovascular Interventions.

Background: Advances in endovascular interventions have made endovascular approaches the first option for treating peripheral arterial diseases. Although radial artery access is commonly used for coronary procedures, the common femoral artery remains the most frequent site for endovascular treatments due to better ergonomics and proven technical success. Meanwhile, data on using upper extremity access via the brachial artery during complex endovascular aortic interventions are lacking. This study aimed to compare the incidence of access site complications between ultrasound-guided percutaneous brachial access (UPA) and open surgical incisional brachial access (OSA) in the management of peripheral arterial diseases. Methods: Patients who underwent treatment for peripheral arterial and aortic disease using brachial access from 2019 to 2023 were included in this study. The primary endpoint was the complication rate at the access site 30 days postoperatively. Access-related complications included bleeding requiring re-exploration, acute upper limb ischemia, thrombosis, pseudoaneurysm, arteriovenous fistula, and nerve injury associated with the brachial access. Results: Brachial access was performed on 485 patients (UPA, n = 320; OSA, n = 165). The mean operation time was 164.5 ± 45.4 min for the percutaneous procedure and 289.2 ± 79.4 min for the cutdown procedure (p = 0.003). Postprocedural hematoma occurred in 15 patients in the UPA group and 2 patients in the OSA group (p = 0.004). Thromboembolic events were observed in 9 patients in the percutaneous group and 3 patients in the OSA group. Reoperation was required for 23 patients in the percutaneous group and 8 patients in the cutdown group. Conclusions: The findings indicate that patients undergoing endovascular arterial interventions have a higher rate of brachial access complications in the UPA group compared to the OSA group.

Age-Based Outcomes After Surgical Aortic Valve Replacement With Bioprosthetic Versus Mechanical Valves

Recommendations for prosthesis type in older patients who underwent surgical aortic valve replacement (SAVR) are established, albeit undervalidated. The purpose of this study is to compare outcomes after bioprosthetic versus mechanical SAVR across various age groups. This was a retrospective study using an institutional SAVR database. All patients who underwent isolated SAVR were compared across valve types and age strata (<65 years, 65 to 75 years, >75 years). Patients who underwent concomitant operations, aortic root interventions, or previous aortic valve replacement were excluded. Objective survival and aortic valve reinterventions were compared. Kaplan-Meier survival estimation and multivariate regression were performed. A total of 1,847 patients underwent SAVR from 2010 to 2023. A total of 1,452 patients (78.6%) received bioprosthetic valves, whereas 395 (21.4%) received mechanical valves. Of those who received bioprosthetic valves, 349 (24.0%) were aged <65 years, 627 (43.2%) were 65 to 75 years, and 476 (32.8%%) were older than 75 years. For patients who received mechanical valves, 308 (78.0%) were aged <65 years, 84 (21.3%) were between 65 and 75 years, and 3 (0.7%) were >75 years. The median follow-up in the total cohort was 6.2 (2.6 to 8.9) years. No statistically significant differences were observed in early-term Kaplan-Meier survival estimates between SAVR valve types in all age groups. However, the cumulative incidence estimates of aortic valve reintervention were significantly higher in patients aged under 65 years who received bioprosthetic than those who received mechanical valves, with 5-year reintervention rates of 5.8% and 3.1%, respectively (p = 0.002). On competing risk analysis for valve reintervention, bioprosthetic valves were significantly associated with an increased hazard of aortic valve reintervention (hazard ratio 3.35, 95% confidence interval 1.73 to 6.49, p <0.001). In conclusion, SAVR with bioprosthetic valves (particularly, in patients aged <65 years) was comparable in survival to mechanical valve SAVR but significantly associated with increased valve reintervention rates.