Aortic Length Research Articles

Influence of body height on aortic systolic pressure augmentation and wave reflection in childhood.

The enhanced wave reflection in small children is a well-known phenomenon. It is explained on the basis of differences in the body height and the timing of wave reflection. This hypothesis still has not been proved directly. The aim of our study was to determine the reference values of aortic augmentation index (Aix(ao)) and the simultaneously measured return time of the systolic pulse wave (RT) in relation to the body height to test this hypothesis. Aix(ao) and RT were measured by Arteriograph in a healthy population aged 3-18 years (n = 4619, 2489 males). The Aix(ao) decreased with increasing age in boys from 18.6 ± 8.4% to 4.7 ± 4.3% and in girls from 22.3 ± 9.2% to 8.1 ± 5.1%, whereas the RT increased from 115.5 ± 16.3 ms to 166.7 ± 20.8 ms in boys and from 106.7 ± 21.9 ms to 158.1 ± 15.5 ms in girls. These changes were constant during childhood, but they slowed down after the onset of puberty. Because aortic pulse wave velocity (PWV(ao)) measured in the same population was unchanged during childhood, the increase of RT can only be explained by the increase of aortic length due to growth. In the puberty PWV(ao) starts increasing indicating that RT (Aix(ao)) does not follow the increase (decrease) of aortic length proportionally.

Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair

Spinal cord ischemia (SCI) is a devastating but potentially preventable complication of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to determine what factors predict SCI after TEVAR. All TEVAR procedures at a single institution were reviewed for patient characteristics, prior aortic repair history, aortic centerline of flow analysis, and procedural characteristics. SCI was defined as any lower extremity neurologic deficit that was not attributable to an intracranial process or peripheral neuropathy. Forty-three patient and procedural variables were evaluated individually for association with SCI. Those with the strongest relationships to SCI (P < .1) were included in a multivariable logistic regression model, and a stepwise variable elimination algorithm was bootstrapped to derive a best subset of predictors from this model. From 2002 to 2013, 741 patients underwent TEVAR for various indications, and 68 (9.2%) developed SCI (permanent: n = 38; 5.1%). Because of the lack of adequate imaging for centerline analysis, 586 patients (any SCI, n = 43; 7.4%) were subsequently analyzed. Patients experiencing SCI after TEVAR were older (SCI, 72 ± 11 years; no SCI, 65 ± 15 years; P < .0001) and had significantly higher rates of multiple cardiovascular risk factors. The stepwise selection procedure identified five variables as the most important predictors of SCI: age (odds ratio [OR] multiplies by 1.3 per 10 years; 95% confidence interval [CI], 0.9-1.8, P = .06), aortic coverage length (OR multiplies by 1.3 per 5 cm; CI, 1.1-1.6; P = .002), chronic obstructive pulmonary disease (OR, 1.9; CI, 0.9-4.1; P = .1), chronic renal insufficiency (creatinine concentration ≥ 1.6 mg/dL; OR, 1.9; CI, 0.8-4.2; P = .1), and hypertension (defined as chart history or medication; OR, 6.4; CI, 2.6-18; P < .0001). A logistic regression model with just these five covariates had excellent discrimination (area under the receiver operating characteristic curve = .83) and calibration (χ(2) = 9.8; P = .28). This analysis generated a simple model that reliably predicts SCI after TEVAR. This clinical tool can assist decision-making about when to proceed with TEVAR, guide discussions about intervention risk, and help determine when maneuvers to mitigate SCI risk should be implemented.

Aortic Arch Morphology and Aortic Length in Patients with Dissection, Traumatic, and Aneurysmal Disease

This study assessed aortic arch morphology and aortic length in patients with dissection, traumatic injury, and aneurysm undergoing thoracic endovascular aortic repair and identified characteristics specific to the different pathologies. We retrospectively evaluated the aortic arch morphology and aortic length of 210 patients (49 dissection, 99 traumatic injury, 62 aneurysm) enrolled in three trials who received the conformable Gore TAG thoracic endoprosthesis. The mean age was 43 ± 19.6 years for trauma patients, 57 ± 11.7 years for dissection patients, and 72 ± 9.6 years for aneurysm patients. A standardized protocol was used to measure aortic arch diameter, length, and take-off angle, and clock-face orientation of branch vessels. Differences in arch anatomy and length were assessed using analysis of variance and independent t-tests. Of the 210 arches evaluated, 22% had arch vessel common trunk configurations. The Table contains highlights of comprehensive measurements. The aortic diameter and the distance from the left main coronary to the left common carotid were greater in dissection patients than in trauma or aneurysm patients (P < .05). The distances from the branch vessels to the celiac artery were greater in dissection and aneurysm patients than in trauma patients (P < .05). Aortic diameter was greater in aneurysm patients compared with trauma patients (P < .05). The take-off angle of the innominate, left common carotid, and left subclavian were greater, between 19% and 36%, in trauma patients than in dissection and aneurysm patients (P < .05). Clock-face orientation of the arch vessels varied between pathologies. Arch anatomy has significant morphologic differences when comparing aortic pathologies. Describing these differences in a large sample of patients is beneficial for device designs and patient selection that plays a critical role in outcomes.TableHighlights of aortic arch measurements in patients with dissection, traumatic, and aneurysmal diseaseMeasurement/studyMeanSDP valueANOVAAortic diameter (mm) 20 mm distal to LMC Trauma30.54.5<.0001 Dissection38.44.8 Aneurysm36.54.9Distance (mm) from LMC to LCC<.0001Trauma103.816.7Dissection126.516.2Aneurysm116.618.4 IA to CA<.0001Trauma244.723.6Dissection280.531.1Aneurysm306.340.1 LCC to CA<.0001Trauma238.422.5Dissection27429Aneurysm298.335.3 CA to LRA0.07Trauma34.712Dissection39.714Aneurysm3912.6Take-off angle at IA, °<.0001 Trauma72.520.5 Dissection56.616 Aneurysm53.916.5Take-off angle at LCC, °<.0001 Trauma64.616.5 Dissection51.613.5 Aneurysm51.411.6Clock position of IA<.0001 Trauma12:3929’ Dissection12:1131’ Aneurysm12:2630’Clock position of LCC<.0001 Trauma12:0421’ Dissection11:4725’ Aneurysm11:5821’ANOVA, Analysis of variance; CA, celiac artery; IA, innominate artery; LCC, left common carotid; LMC, left main coronary; LRA, left radial artery; SD, standard deviation. Open table in a new tab

Examination of factors in type I endoleak development after thoracic endovascular repair

The objective of this study was to assess the effects of operative indication, anatomy, and stent graft on type I endoleak occurrence after thoracic endovascular aortic repair. A retrospective review was conducted of patients admitted for thoracic endovascular aortic repair between 2007 and 2013. All computed tomography angiography imaging was analyzed for the presence of endoleak and measurement of diameters and lengths. Variables studied included underlying disease, emergency, achieved aortic neck length, difference between proximal and distal neck diameters, landing zone 2, and stent graft characteristics (diameter, number, type of device, oversizing degree, and covered aorta length). The study population involved 84 patients (mean age, 56 years; range, 17-94 years) who were treated for thoracic aortic aneurysm (TAA) (n = 29; 34.5%), traumatic aortic rupture (n = 27; 32%), type B aortic dissection (n = 19; 22.5%), intramural hematoma (n = 2; 2%), penetrating aortic ulcer (n = 5; 6%), and aortoesophageal fistula (n = 2; 2%). Of these, 60 patients (71.5%) were treated emergently and 24 (28.5%) electively. Primary type I endoleak was noted in eight patients (9.5%), of which two resolved spontaneously. After a mean follow-up of 32 months (range, 3-76 months), secondary type I endoleak was detected in four patients (4.5%). All of them occurred after emergent TAA treatment. Comparison between emergent and elective groups revealed no significant differences in neck length (19.5 mm vs 26.5 mm; P = .197), oversizing degree (11.1% vs 10.9%; P = .811), or endoleak rates (13.3% vs 8.3%; P = .518). Hemorrhagic shock was not predictive of endoleak (P = .483). Cox regression analysis of the different anatomic and stent graft-related factors revealed short proximal landing zone as the unique independent predictor of type I endoleak (hazard ratio, 0.89; 95% confidence interval, 0.81-0.99; P = .032). Endoleak risk seems not to be increased by an emergency setting. However, the relatively high rate of late endoleak observed after emergent TAA repair advocates for close follow-up, contrary to traumatic aortic rupture. Furthermore, regardless of the pathologic process, a longer proximal landing zone is likely to guarantee early and late success.

Standard endovascular treatment of abdominal aortic aneurysms in patients with very short proximal necks using the Endurant stent graft

This study evaluated and compared the midterm results of endovascular aortic aneurysm repair with the Endurant (Medtronic Inc, Santa Rosa, Calif) stent graft system in off-label use in patients with short (<10 mm) proximal aortic necks and in patients treated according to device-specific instructions for use. This was a case-control (2:1) single-center retrospective analysis of prospectively collected data performed between September 2008 and December 2012. Analysis identified 19 elective patients with short (<10 mm) proximal necks and mild angulations (≤45°) treated with the Endurant stent graft and 38 patients matched for age, sex, and aneurysm diameter with proximal aortic necks ≥10 mm in length who met the instructions for use. End points included technical and clinical success and freedom from any secondary intervention, any type of endoleak, and aneurysm-related death. The short-neck group was a mean ± standard deviation age of 71.7 ± 8.9 years, 84% were men, and their mean infrarenal aortic neck length was 6.1 ± 1.2 mm. Mean suprarenal and infrarenal angles were 110° ± 10.4° and 170° ± 15.4°, respectively. Aortic neck diameters were similar between the groups (26.6 ± 3.8 vs 25.7 ± 3.7 mm; P = .36). Primary technical success was achieved in all cases. Off-label patients were more likely to require additional proximal cuff deployment to successfully obtain a seal (21% vs 3%; P = .04). The two patient groups were similar in rates of perioperative mortality, morbidity, and complications. Mean follow-up of 24 ± 12 months revealed no differences in clinical success, freedom from reintervention, and aneurysm-related death. No type I endoleaks were observed in either group during the follow-up period. The Endurant stent graft system applied off-label in patients with very short aneurysm necks (<10 mm) with mild angulation showed acceptable treatment results. These midterm results might suggest its use in carefully selected patients with very short neck anatomy. Long-term data are needed to verify the observed durability of the Endurant stent graft.

Safety and effectiveness of the INCRAFT AAA Stent Graft for endovascular repair of abdominal aortic aneurysms

This study evaluated the 2-year safety and effectiveness of the European First-in-Human INNOVATION trial for the INCRAFT AAA Stent Graft system (Cordis Corp, Bridgewater, NJ), an ultra-low-profile device for the treatment of abdominal aortic aneurysms. From March 2010 to June 2011, the INNOVATION prospective multicenter trial involving six centers in Europe enrolled and treated 60 asymptomatic patients (95% male; mean age, 74.4 ± 6.9 years) with the INCRAFT System. Main inclusion criteria included proximal aortic neck length of 15 mm or more with a diameter up to 27 mm; distal iliac landing zones with a length greater than 10 mm and a diameter between 9 and 18 mm; and aortic bifurcation >18 mm in diameter and access vessels large enough to accept the 14F outer diameter of the delivery system. The primary end point was technical success at 1 month; 2-year safety end points included the absence of device- or procedure-related major adverse events, absence of type I or III endoleaks, and maintenance of device integrity through 2 years of follow-up. Study oversight was provided by a Data Safety Monitoring Board with event adjudication by a Clinical Events Committee and imaging analysis by an independent core laboratory. Of 60 successfully treated patients, two did not come back for their 1-month evaluation but remained enrolled in the study; 56 were evaluated at 1 year and 52 at 2 years. Of the 58 patients, 56 met the 1-month primary safety and effectiveness end point (97%; 95% confidence interval, 88%-100%). All patients were free from aneurysm enlargement through 2 years. There were no type I or III endoleaks at the 2-year time point. All-cause mortality at 2 years was 11.5%, and no death was device or procedure related. In total, three patients required a postprocedure intervention, two to repair a type I endoleak and one for limb occlusion. Core laboratory evaluation of the postoperative imaging studies documented absence of endograft migration and stent fractures in all patients. The INCRAFT AAA Stent Graft System provides a durable solution for patients with abdominal aortic aneurysms, with a low frequency of device-related events through 2 years of follow-up.

Increased aortic pulse wave velocity in obese children

OBJECTIVES Obesity may start in childhood and obese children are more likely to grow up to be obese adults. Atherosclerosis is one of the most important complications of obesity. Pulse wave velocity (PWV), a noninvasive measure of arterial stiffness, is accepted to be an indicator of subclinical atherosclerosis. The aim of the study was to determine PWV in obese children. STUDY DESIGN The study included 30 obese (12 boys, 18 girls; mean age 13 ± 2 years) and 30 lean children (13 boys, 17 girls; mean age 12.5 ± 1.7 years). Weight and height were measured and obesity was defined as body mass index (BMI) of greater than the 95th percentile for age. All the subjects underwent echocardiographic evaluation and blood samples were obtained. Pulse-wave velocity was calculated using the following equation: PWV (m/sec) = height-based aortic length (cm)/(100xtransit time [sec]). The latter was measured as the difference in the time of onset of two flows at the diaphragm and the aortic valve. RESULTS Obese subjects had significantly higher blood pressure levels compared to the control group (p<0.001). The two groups were similar with respect to fasting glucose, hemoglobin, serum creatinine, and lipid levels. Among echocardiographic parameters, left ventricular end-diastolic dimension, interventricular septum thickness, posterior wall thickness, left ventricular mass index, left atrium dimension, and aortic root dimension were significantly increased in obese subjects compared to controls (p<0.01). Obese children had significantly higher PWV values than the controls (4.0 ± 0.8 vs. 3.3 ± 0.7 m/sec, p<0.001). A positive significant correlation was found between PWV and BMI (r=0.391, p=0.002). CONCLUSION Our findings show that aortic PWV is increased in obese children, suggesting that obesity may cause subclinical atherosclerosis even at early ages.

Prognostic Implications of Initial Echocardiographic Findings in Adolescents and Adults with Supracristal Ventricular Septal Defects

Although surgery is recommended for pediatric patients with supracristal ventricular septal defects (sVSDs) to prevent progression of aortic regurgitation (AR), outcomes in adolescents and adults with sVSDs are not known. In this retrospective observational study, clinical data without surgery were obtained in 60 patients with sVSDs (group 1; mean age, 36 ± 13 years), 120 age- and defect size-matched patients with perimembranous ventricular septal defects (group 2), and 52 patients with sVSDs who underwent surgery (group 3; mean age, 32 ± 11 years). Aortic sinus wall prolapse (38% vs 3%, P < .0001) and moderate to severe AR (7% vs 0%, P= .012) were more frequently observed in group 1 than in group 2. Five, three, and two patients in group 1 had surgery during follow-up because of rupture of the aneurysm of the sinus of Valsalva, endocarditis, and heart failure, respectively. Group 1 had a lower 12-year clinical event-free (surgery and endocarditis) rate (76 ± 9% vs 94 ± 4%, P= .031) but an equivalent overall survival rate (100% vs 94 ± 3%, P= .143) compared with group 2. Patients with maximal prolapsing aortic sinus wall length > 7 mm showed a higher frequency of aneurysm of the sinus of Valsalva rupture than those with no prolapse or maximal prolapsing length ≤7mm (80% [four of five] vs 2% [one of 55], P< .001). The event-free and overall survival rates were comparable between groups 1 and 3, with equivalent 10-year AR progression-free survival rates (94 ± 5% vs 91± 5%, P= .301). Aneurysm of the sinus of Valsalva rupture, rather than AR progression, was the main clinical event. Watchful monitoring of patients with high-risk echocardiographic features may be a rational option.

RR10. Adverse Outcomes Associated With Bleeding Complications in Thoracoabdominal Aortic Aneurysm Repair

Predictors of any SCI were age (odds ratio [OR], multiplies 1.3 per 10 years; 95% confidence interval [CI] 0.9-1.8; P 1⁄4 .06), aortic coverage length (OR multiplies 1.3 per 5 cm; 95% CI, 1.1-1.6; P 1⁄4 .002), chronic pulmonary disease (OR, 1.9; 95% CI, 0.9-4; P 1⁄4 .1), chronic renal insufficiency (creatinine $1.6; OR, 1.9; 95% CI, 0.8-4.2; P 1⁄4 .1), and hypertension (chart history and/or medication; OR, 6.4; 95% CI, 2.6-18; P < .0001). The final model included age, aortic coverage length, and hypertension with excellent discrimination (area under the curve 1⁄4 .84) and calibration (c 1⁄4 9.8; P 1⁄4 .28; Fig). Conclusions: This analysis yielded a simple model that reliably predicts SCI after TEVAR. This clinical tool can assist decision making regarding when to proceed with TEVAR, guide discussions about intervention risk, and help determine when maneuvers to mitigate SCI risk should be implemented.

Bicuspid aortic valves: Diagnostic accuracy of standard axial 64-slice chest CT compared to aortic valve image plane ECG-gated cardiac CT

ObjectivesTo assess the diagnostic accuracy of standard axial 64-slice chest CT compared to aortic valve image plane ECG-gated cardiac CT for bicuspid aortic valves. Materials and methodsThe standard axial chest CT scans of 20 patients with known bicuspid aortic valves were blindly, randomly analyzed for (i) the appearance of the valve cusps, (ii) the largest aortic sinus area, (iii) the longest aortic cusp length, (iv) the thickest aortic valve cusp and (v) valve calcification. A second blinded reader independently analyzed the appearance of the valve cusps. Forty-two age- and sex-matched patients with known tricuspid aortic valves were used as controls. Retrospectively ECG-gated cardiac CT multiphase reconstructions of the aortic valve were used as the gold-standard. ResultsFourteen (21%) scans were scored as unevaluable (7 bicuspid, 7 tricuspid). Of the remainder, there were 13 evaluable bicuspid valves, ten of which showed an aortic valve line sign, while the remaining three showed a normal Mercedes-Benz appearance owing to fused valve cusps. The 35 evaluable tricuspid aortic valves all showed a normal Mercedes-Benz appearance (P=0.001). Kappa analysis=0.62 indicating good interobserver agreement for the aortic valve cusp appearance. Aortic sinus areas, aortic cusp lengths and aortic cusp thicknesses of ≥3.8cm2, 3.2cm and 1.6mm respectively on standard axial chest CT best distinguished bicuspid from tricuspid aortic valves (P<0.0001 for all). Of evaluable scans, the sensitivity, specificity, positive and negative predictive values of standard axial chest CT in diagnosing bicuspid aortic valves was 77% (CI 0.54–1.0), 100%, 100% and 70% respectively. ConclusionThe aortic valve is evaluable in approximately 80% of standard chest 64-slice CT scans. Bicuspid aortic valves may be diagnosed on evaluable scans with good diagnostic accuracy. An aortic valve line sign, enlarged aortic sinuses and elongated, thickened valve cusps are specific CT features.

Safety of Chronic Anticoagulation Therapy After Endovascular Abdominal Aneurysm Repair (EVAR)

Current data supporting the effect of anticoagulation drug use on aneurysm sealing and the durability of endovascular abdominal aneurysm repair (EVAR) are conflicting. This study assessed the safety of chronic anticoagulation therapy after EVAR. Records of 1409 consecutive patients having elective EVAR during 1997-2011 who were prospectively followed were reviewed. Survival, reintervention, conversion, and endoleak rates were analyzed in patients with and without chronic anticoagulants. Cox proportional hazards models were used to estimate the effect of anticoagulation therapy on outcomes. One-hundred and three (7.3%) patients were on chronic anticoagulation drugs (80 on vitamin K antagonists) at the time of EVAR. An additional 46 patients started on anticoagulants after repair were identified. Patients on chronic anticoagulation therapy at repair (mean age 73.6 years; 91 males) had more frequent cardiac disease (74.8% vs. 44.2%; p < 00001), but no other differences in demographic and major baseline comorbidities with respect to the others. At baseline, mean abdominal aortic aneurysm (AAA) diameter was 56.43 mm vs. 54.65 mm (p = .076) and aortic neck length 26.54 mm vs. 25.21 mm (p = .26) in patients with and without anticoagulants, respectively. At 5 years, freedom from endoleak rates were 55.5% vs. 69.9% (p < .0001), and freedom from reintervention/conversion rates were 69.4% vs. 82.4% (p < .0001) in patients with (including those with delayed drug use) and without chronic anticoagulants, respectively. Controlling for covariates with the Cox regression method, at a mean follow-up of 64.3 ± 45.2 months after EVAR, use of anticoagulation drugs was independently associated with an increased risk of endoleak (odds ratio, OR 1.6; 95% confidence interval, CI: 1.23-2.07; p < .0001) and reintervention or late conversion rates (OR 1.8; 95% CI: 1.31-2.48; p < .0001). The safety of anticoagulation therapy after EVAR is debatable. Chronic anticoagulation drug use risks exposure to a poor long-term outcome. A critical and balanced decision-making approach should be applied to patients with AAA and cardiac disease who may require prolonged anticoagulation treatment.

Endovascular repair of traumatic thoracic aortic rupture: a single centre experience

Thoracic aortic rupture is usually the result of a sudden deceleration caused by a traffic accident, fall or some other misfortune. Before the endovascular era, there was only one treatment option: open repair, burdened by high morbidity and significant mortality. Now, we have the ability to treat it with a stent graft. The advantages of this method include avoiding a thoracotomy or aorta cross-clamping and their associated complications. To present our experience and results of endovascular treatment of thoracic aortic ruptures. Since 1998, we have performed endovascular treatment for aortic lesions in 1,598 patients. From this group, the indication for stent graft implantation in 31 patients was a traumatic aortic rupture or pseudoaneurysm caused by an injury. All patients had a history of blunt chest trauma. The sequence of injury treatment depended on the severity of each. In all but two patients, the first was an aortic stent graft implantation. The length of thoracic aorta covered ranged from 100-200 mm (mean 123 mm). We did not use any method of spinal cord ischaemia protection. Final angiography showed complete exclusion of the aortic disruption in all patients. All but one operation was successful. One patient died intraoperatively due to concomitant injuries. After the operation, none of the patients had signs of spinal cord ischaemia or any other complications through a follow-up period ranging from 12 to 96 months (mean 40 months). Our experience with traumatic thoracic aortic ruptures suggests that endovascular treatment should be the method of choice, especially in unstable multi-trauma patients. However, long-term studies are required to assess the durability of this technique after many years.

Influence of Oversizing on Outcome in Thoracic Endovascular Aortic Repair

To investigate the influence of stent-graft oversizing on device-related complications after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA). The study cohort was composed of patients enrolled in 4 clinical trials of the TAG thoracic stent-graft. A total of 337 TAA patients (222 men; mean age 72 years) treated in these trials had sufficient data for analysis of oversizing and post-procedure mortality and complications, such as endoleak, migration, rupture, and reinterventions. Mean oversizing at the proximal landing zone was 14.6% (range -3.4% to 39.7%). Patients were stratified based on the percentage of oversizing: <10% (n=85, group 1), 10%-20% (n=188, group 2), and >20% (n=64, group 3). Patients in group 1 had significantly larger preoperative proximal aortic diameters (32.6 vs. 31.3 vs. 28.2 mm, respectively; p<0.001) and neck lengths (6.9 vs. 5.8 vs. 5.2 cm (p=0.035). Overall, type I endoleak was the most frequent complication during the first 30 days of follow-up (35, 10.4%), but the incidences did not differ among the 3 groups (10.6% vs. 11.2% vs. 7.8%, respectively; p=0.809). Over a mean follow-up of 41.8±20.7 months, there were no significant differences in the occurrence of device-related complications among the groups, though the incidence of type I endoleaks was lower in group 2 (9.4% vs. 3.2% vs. 7.8%, respectively; p=0.073). Cox proportional hazards modeling showed no difference in the time to type I endoleak among oversizing groups [group 1 vs. 2: HR 1.24, 95% CI 0.65 to 2.36 (p=0.509) and group 3 vs. 2: HR 1.24, 95% CI 0.60 to 2.60 (p=0.562)]. The percentage of oversizing did not significantly affect the incidence of device-related complications after TEVAR for TAA. Although oversizing may enhance the radial force and help maintain a good proximal seal, additional oversizing seemed not to improve the overall outcome in this analysis. The current guidelines regarding stent-graft oversizing for TAA seem appropriate, though the correct percentage remains to be determined.

Abstract 18390: Aortic Pulse Wave Velocity Measurement by Doppler Technique During Transesophageal Echocardiography Examination: A Feasible and Reproducible Method

Introduction: Aortic pulse wave velocity (aPWV) is the gold-standard measure of arterial stiffness. In daily practice, the carotid-femoral PWV (cfPWV) is widely used for arterial stiffness assessment. PWV is calculated by dividing traveled distance by transit time. But, the inaccuracy of distance measurement and the approximation of the true aortic length which change with age may influence the absolute value of cfPWV. Making the assumption that the flow wave of continuous spectral Doppler corresponds to the real pulse wave, aPWV can be directly measured in the aorta by transesophageal echography (TEE). The aim of this study is to evaluate whether aPWV measured by Doppler technique during TEE is easily feasible and to analyse the reproducibility of the technique. Methods: Doppler images were obtained from the TEE examination of the thoracic aorta in 44 patients undergoing elective cardiac surgery. From a random choice of 194 acquisitions, a total of 100 images were analyzed offline by two different investigators in two separated periods to measure the transit time according to the two tangents method. Results: The Bland-Altman plots illustrate that there is no significant difference nor bias between the two readings made by one observer and neither for the mean of the observations made by separated observers. Intra-observer reproducibility of the Doppler measurements was high ( Intra Class Correlation (ICC) = 0.98 and 0.96). Agreement between observer was also good (ICC=0.98). Conclusions: These data demonstrate that Doppler technique during TEE is a feasible and reproducible method to calculate aPWV.

An Analysis of Variables Affecting Aortic Neck Length with Implications for Fenestrated Endovascular Repair of Abdominal Aortic Aneurysm

A major factor in the selection of patients for endovascular aneurysm repair (EVAR) is the character of the aortic neck, and studies suggest that many patients are treated outside of the instructions for use (IFU) criteria. By analyzing aortic neck morphology, we hope to identify factors that may influence decision making about the use of fenestrated endografts as an alternative to extending the neck limitations of traditional endografts. A retrospective analysis was completed on 111 patients who underwent computed tomography angiography (CTA) scans between May 1, 2009 and January 3, 2011 for the evaluation of abdominal aortic aneurysm (AAA). Individual characteristics of neck and aneurysm morphology were analyzed to establish whether certain factors determined suitability for EVAR with traditional nonfenestrated endografts. In considering augmented neck lengths (ANL), anatomic measurements of distance from the start of aortic dilatation to the lowest renal artery (LRA) and highest renal artery (HRA) were analyzed. Measurements were analyzed using Stata software (version 11.2; StataCorp, College Station, TX). There were 86 men and 25 women in the patient population, with an average age of 72.9 years. In 46 patients, the proximal neck length was <15 mm, with 26 patients having neck lengths <10 mm. There was a negative relationship between AAA maximum diameter and proximal neck length (rs = -0.2237; P = 0.018), indicating that as aneurysm size increases, proximal neck length decreases. There was a significant correlation between proximal neck length and proximal neck diameter (rs = -0.2585; P = 0.006) and between proximal neck length and angle (rs = -0.2355; P = 0.013), and between proximal neck diameter and right iliac maximum diameter (rs = 0.2329; P = 0.014). Using fenestration to place an endograft above the LRA would create an ANL of >15 mm in 20 of 40 patients with aortic necks deemed too short to be eligible for EVAR using conventional infrarenal graft positioning. Extending the graft above the HRA would create an ANL of >15 mm in 36 of 40 patients. In this study, 41% of patients presented with neck lengths outside that of the traditional IFU for most aortic endografts. While there was wide variation from patient to patient, there was a general correlation between increasing AAA size and aneurysms that have shorter, wider, and more angulated proximal necks. Fenestration of even 1 renal artery could substantially increase the ANL. Additional study is warranted to determine if an increase in ANL in patients with otherwise short necks will positively impact long-term EVAR outcomes.

Distribution of Abdominal Aortic Calcium by Computed Tomography: Impact of Analysis Method on Quantitative Calcium Score

Abdominal aortic calcification (AAC) can be quantified using computed tomography (CT), but imaging planesare prescribed based on bony landmarks, so that individual variation between the landmark and the aortoiliac junction can result in variable aortic coverage. In the Framingham CT substudy, we scanned a 15-cm (Z-direction) abdominal segment cranial to the S1 vertebral body. We sought to determine the range and distribution of length of aorta scanned and the distribution of AAC within the abdominal aorta and to compare burden of AAC measured from fixed-length segments versus AAC from all slices cranial to the aortoiliac bifurcation. AAC was quantified by modified Agatston score (AS) in 100 Framingham Heart Study participants (60±13years old, 51 men). We compared the AS measured from 5-cm and 8-cm segments with the ASALL (total visualized aorta). Of 100, 73 participants had AAC >0. The total length of aorta imaged was ≥8cm in 84% of participants. Qualitatively, 5-cm and 8-cm segments correctly identified 96% and 99%, respectively, of participants as having or not having AAC. Quantitatively, AS8cm was within 20% of ASALL in four-fifths and within 30% of ASALL in nine-tenths of participants. AS5cm more severely underestimated ASALL. The use of S1 as the caudal imaging landmark in a 15-cm slab yields ≥8cm aortic coverage in most adults. Both 5-cm and 8-cm analysis strategies are comparable to analyzing the total visualized abdominal aorta for prevalent AAC, but only 8-cm segment analysis yields quantitatively similar measures of AAC.

Carotid–femoral pulse wave velocity in obese children and adolescents: The potential bias of tape distance measuring

BackgroundThe recommendation for carotid–femoral pulse wave velocity (cfPWV) is to use a calliper to measure the aortic length as a straight line. In adults, it has been shown that tape follows the body contours potentially making the distance longer – ultimately a higher cfPWV – interpreted as a higher aortic stiffness. Our objective was to investigate to what extent a tape measurement is influenced by abdominal obesity in children and adolescents. MethodsIn a cross-sectional design, 100 obese patients with age 10–18 years were compared to 50 healthy control individuals. CfPWV was measured by applanation tonometry. The aortic length was determined with tape and a calliper (distance-tape and distance-calliper). The bias of the tape measurements was calculated as distance-tape minus distance-calliper. ResultsThe bias of the tape measurements (mean ± SD) was significant in both the obese (Δ 14.6 ± 11.2 mm, P < 0.0001) and the control group (Δ 5.7 ± 5.8 mm, P < 0.0001), and showed a linear relationship with waist-height ratio in the obese group (obese: β = 96.9, CI: 75.3–118.5, P < 0.0001). Likewise, cfPWV was significantly higher when tape was used for the distance measurements in both groups (P values <0.0001). In multiple regression, however, cfPWV for both tape and calliper were significantly lower in the obese compared to the control group (P values <0.01). ConclusionsThe bias of the tape measurements was related to the degree of abdominal obesity. Our results emphasize the importance of the use of a calliper when evaluating cfPWV in obese children and adolescents.

Change of Aortic Length After Closing-Opening Wedge Osteotomy for Patients With Ankylosing Spondylitis With Thoracolumbar Kyphosis

A computed tomographic study. To investigate the change in aortic length in patients with ankylosing spondylitis (AS) with thoracolumbar kyphosis after closing-opening wedge osteotomy (COWO). Several previous studies reported that COWO can effectively correct severe thoracolumbar kyphosis caused by AS. However, one disadvantage of COWO is elongation of the aorta, which increases the risk of aortic injury. To date, no studies have analyzed the alteration in aortic length in patients with AS undergoing COWO for thoracolumbar kyphosis. A total of 21 consecutive patients with AS with a mean age of 38.9 years undergoing COWO for the correction of thoracolumbar kyphosis were retrospectively studied. Radiographical measurements included global kyphosis, thoracic kyphosis, lumbar lordosis, angle of fusion levels, local kyphosis, and anterior height of the osteotomized vertebra. The computed tomographic scans of the spine were used to measure the aortic diameter (at the site of the osteotomy) and length (the length between the superior endplate of the upper instrumented vertebra and the inferior endplate of L4). The aortic length increased by an average of 2.2 cm postoperatively. Significant changes in global kyphosis, local kyphosis, angle of fusion levels, lumbar lordosis, anterior height of the osteotomized vertebra, and aortic diameter at the site of the osteotomy were observed (P < 0.01). Significant correlation was noted between aortic length and changes in global kyphosis (r = 0.525, P = 0.015), local kyphosis (r = 0.654, P = 0.001), angle of fusion levels (r = 0.634, P = 0.002), and lumbar lordosis (r = 0.538, P = 0.012). Aortic lengthening after COWO for correction of kyphosis was quantitatively confirmed by this study. Spine surgeons should be aware of the potential risk for the development of aortic injury in patients with AS undergoing COWO for the correction of thoracolumbar kyphosis. 4.

Cohort-Comparison of Thoracic Endovascular Aortic Repair with Open Thoracic Aortic Repair Using Modern End-Organ Preservation Strategies

Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. In an effort to create a more level assessment, we compared our outcomes of TEVAR with modern open thoracic aortic repair (OTAR) controls. A retrospective review of a prospective database of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest (HCA) was used in all OTAR patients. Both groups underwent cerebrospinal fluid (CSF) drain placement when feasible. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for 1-year survival estimates. Subgroup analysis was performed using length of aortic stent graft coverage or length of aortic replacement. During the study period (2002-2013), 81 patients underwent TEVAR and 61 underwent OTAR with median follow-up of 23.7 months (interquartile range, 6.7-55.1) and 36.4 months (interquartile range, 9.6-60.2), respectively. TEVAR patients had significantly lower 30-day mortality (2.5% vs 13.1%; P = .02) and fewer complications including pneumonia (P = .01) and rebleeding (P = .03). However, there was no difference in permanent spinal cord ischemia (SCI) (1% vs 2%; P = .9) or estimated 1-year survival (P = .9). Among OTAR patients, HCA tended to have higher 30-day mortality (16% vs 7%, P = .43). Cox regression revealed that advanced age and higher baseline creatinine levels were associated with greater hazard of 1-year mortality; TEVAR and CSF drain placement were protective of 1-year survival. For patients with <20 cm of aortic stent graft or aortic graft replacement, there was no difference in 30-day mortality (P = .07) or permanent SCI (TEVAR n = 0, 0% vs OTAR n = 1, 2%; P = .9). For those with ≥20 cm of aortic stent graft or replacement, there was no difference in 30-day mortality (P = .9) or permanent SCI (TEVAR n = 1, 2% vs OTAR n = 0, 0%; P = .9). TEVAR continues to show improved perioperative outcomes with decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the advent of routine end-organ preservation during OTAR, SCI can be safely reduced to comparable levels with those of TEVAR. Length of aortic stent graft coverage or length of surgical graft replacement does not significantly impact outcomes.

Comparison of Accuracy of Aortic Root Annulus Assessment With Cardiac Magnetic Resonance Versus Echocardiography and Multidetector Computed Tomography in Patients Referred for Transcatheter Aortic Valve Implantation

The evaluation of the aortic root in patients referred for transcatheter aortic valve implantation is crucial. The aim of the present study was to compare the accuracy of cardiac magnetic resonance (CMR) evaluation of the aortic annulus (AoA) with transthoracic and transesophageal echocardiography and multidetector computed tomography (MDCT) in patients referred for transcatheter aortic valve implantation. In 50 patients, maximum diameter, minimum diameter and AoA, length of the left coronary, right coronary, and noncoronary aortic leaflets, degree (grades 1 to 4) of aortic leaflet calcification, and distance between AoA and coronary artery ostia were assessed. AoA maximum diameter, minimum diameter, and area by CMR were 26.4 ± 2.8mm, 20.6 ± 2.3mm, 449.8 ± 86.2mm(2), respectively. The length of left coronary, right coronary, and noncoronary leaflets by CMR were 13.9 ± 2.2, 13.3 ± 2.1, and 13.4 ± 1.8mm, respectively, whereas the score of aortic leaflet calcifications was 2.9 ± 0.8. Finally, the distances between AoA and left main and right coronary artery ostia were 16.1 ± 2.8 and 16.1 ± 4.4 mm, respectively. Regarding AoA area, transthoracic and transesophageal echocardiography showed an underestimation (p <0.01), with a moderate agreement (r: 0.5 and 0.6, respectively, p <0.01) compared with CMR. No differences and excellent correlation were observed between CMR and MDCT for all parameters (r: 0.9, p <0.01), except for aortic leaflet calcifications that were underestimated by CMR. In conclusion, aortic root assessment with CMR including AoA size, aortic leaflet length, and coronary artery ostia height is accurate compared with MDCT. CMR may be a valid imaging alternative in patients unsuitable for MDCT.