Chronic Aortic Dissection Research Articles

Conservative management for type A chronic thoracic aortic dissection on a patient with Marfan Syndrome, "when surgery can't be done": a case report from the rural hospital

Conservative management for type A chronic thoracic aortic dissection on a patient with Marfan Syndrome, "when surgery can't be done": a case report from the rural hospital

Intramural hematoma in the proximal sealing zone of the thoracic endovascular aneurysm repair: frequency and safety in acute and subacute type B dissections.

To assess the outcomes after thoracic endovascular aneurysm repair (TEVAR) in the presence of intramural hematoma (IMH) in the proximal sealing zone. Patient data were retrospectively extracted from the hospital records of patients treated with TEVAR for acute and chronic aortic dissection type B in one single center. The initial, preoperative, first postoperative, and last follow-up CT scans were evaluated in the aortic 3D multiplanar reformats and the centerline regarding IMH presence in the proximal sealing zone, anatomical preconditions, and the morphological TEVAR complications including migration and bird-beak. Groups with (IMH) and without IMH (no-IMH) were compared. Overall, 84 patients (IMH:42; no-IMH:42) were treated at the age of 63(55; 72) years, of whom 23/84 (27%), 34/84 (40%), and 27/84 (32%) were in the hyperacute, acute and subacute dissection phases, respectively. The bovine arch was found in 10/84(12%) and the type III arch was most common (43/84;51%). IMH maximum extent was found in zones 0, 1, 2, and 3 in 14/84 (17%), 17/84 (20%), 18/84 (21%), and 6/84 (7%), respectively. Sealing was achieved in zone II in 71/84 (85%) and LSA was revascularized in 66/84 (79%) of the overall cohort. Early mortality and paraplegia were 2/84 (2%) each; stroke rate was 3/84 (4%). During the 22 months median follow-up (22;4;43) no RTAD was observed. Migration ≥10 mm (IMH: 11/82; no-IMH: 10/82; P = 1.0) and bird-beaks (IMH: 10/82; no-IMH: 12/82; P = 0.8036) were comparable in both groups and accompanied by a low aorta related mortality (1/82) in both groups. The presence of the IMH in the proximal TEVAR sealing zone is frequent and may not be relevant for the occurrence of the RTAD, stent-graft migration, or bird-beak formation.

Abstract 13284: New Elastic Fiber Formation by Non-Smooth Muscle Lineage Cells During the Progression of Aortic Dissections

Introduction: Aortic dissection (AD) is a life-threatening vascular disease displaying the disruption of the extracellular matrix (ECM). Elastic fibers are a major component of ECM and confer structural integrity to the aortic wall. Normally, elastic fibers are minimally synthesized in adulthood. However, it remains unknown whether and how elastic fibers are synthesized following ADs. Methods and Results: AD was induced by administration of β-aminopropionitrile (BAPN, 0.5% wt/vol) to male C57BL/6J mice at 4 weeks of age. Thoracic aortas were collected after 4 or 12 weeks of BAPN administration. False lumen formation with fresh hematomas was observed at 4 weeks of BAPN administration, indicating development of acute ADs. The false lumen developed striking remodeling at 12 weeks, suggesting progression to the chronic phase. RT-qPCR revealed that mRNA abundance of tropoelastin, a precursor of elastic fibers, was increased significantly at the chronic phase of ADs, but not at the acute phase. Tropoelastin mRNA was observed primarily in the vascular wall of the false lumen, as evidenced by in situ hybridization. Of interest, elastic fibers were formed in the wall of the false lumen in chronic ADs. These data suggest that elastic fibers were newly synthesized during the progression of ADs. Immunostaining revealed that the walls of true and false lumens of chronic ADs were mainly composed of cells expressing both αSMA (encoding by Acta2 ) and MYH11, common markers for smooth muscle cells (SMCs). However, in a lineage tracing study, the walls of the false lumen of chronic ADs were negative for the Acta2 lineage, suggesting that cells in the wall of the false lumen were derived from a non-SMC lineage but acquired SMC properties during AD progression. Bulk RNA sequencing identified the increased abundance of 2,799 genes in chronic ADs and 102 transcription factors were predicted to regulate these genes. Among them, JunB was the most abundant molecule that can be aligned in the promotor region of tropoelastin. Of note, JunB was expressed adjacent to both αSMA-positive cells and new elastic fibers in the dissected aortas. Conclusion: ADs exhibit vascular remodeling with newly elastic fiber formation by non-SMC lineage cells during the disease progression.

Emergency and Compassionate Use of a Novel Ascending Endograft for Ascending and Arch Aortic Pathology.

Patients with complicated ascending aortic pathology, including patients with acute type A aortic dissection may be at extreme risk for open repair. Thoracic endovascular aortic repair (TEVAR), infrequently used for the ascending aorta, may be considered an alternative in this setting. We describe early results for emergency and compassionate (E&C) use of a novel endograft, specifically designed for use to treat pathology of the ascending aorta. This case series evaluated 19 patients (mean age, 68.84±13.12 years; 57.9% female) treated with ascending TEVAR for acute and chronic acute (4), subacute (1), or chronic (1) aortic dissection or pseudoaneurysm (13). Six of the 19 patients (31.5%) were treated under compassionate use and 13 patients (68.4%) were treated under the emergency use exemption. Ten patients (52.6%) received additional devices to extend treatment into the arch and descending aorta. Device delivery was achieved in all patients (100%). Thirty-day mortality and stroke occurred in 3 patients (15.8%) and in 1 patient (5.3%), respectively. In 1 patient (5.3%), with an Unanticipated Adverse Device Event, the aorta ruptured when the endograft eroded into the adventitial portion of dissection site at the posterior aspect of the ascending wall. Devices were explanted in 2 patients (10.5%), 353 and 610 days after the index procedure, respectively. Six patients had endoleaks (31.6%), including type I (n=2, 10.5%), type II endoleaks (n=3, 15.8%), and indeterminate endoleak (n=1, 5.3%). Delivery and deployment of a novel ascending thoracic stent graft with or without an additional branched arch extension is feasible in patients with complex anatomy and pathology, including acute aortic dissection and pseudoaneurysm. Additional experience with this novel device will further refine the patient population most suitable for endovascular ascending aortic repair for these pathologies. This study describes a novel stent graft specifically designed for treatment of ascending aortic pathology, including acute type A dissection. The patients described in this series constituted a group outside the formal US FDA sponsored clinical trial, and were those accepted as part of an emergency and compassionate use basis.

Acute-on-Chronic Aortic Dissection: Management and Outcomes of the Unstable “Triple-Lumen” Aorta

BackgroundThe impact of acute aortic dissection of the chronically dissected distal aorta is unknown. This study sought to describe the incidence and characteristics of the triple-lumen aortic dissection and its impact on survival. MethodsFrom 2010 to 2021, a query of a single-institution aortic database identified 1149 patients with chronic distal aortic dissection. Thirty-three (2.9%) patients with at least 3 distinct lumens and 2 separate “primary” intimal tears were identified by analysis of contrast-enhanced cross-sectional imaging. Triple-lumen patients were exactly matched with a cohort of double-lumen patients on a 1:1 ratio using 5 preoperative variables, and outcomes between the groups were assessed. ResultsThe median age at time of initial dissection in patients with a triple-lumen dissection was 46 years. Initial dissection was a type A in 33% and a type B in 67% of patients. The median time from initial dissection to triple-lumen diagnosis was 4.2 years. On diagnosis of the triple-lumen aorta, 85% of patients required urgent aortic repair for rapid growth (36%), aortic diameter ≥55 mm (30%), malperfusion (6%), intractable pain (6%), and rupture/type A (6%). Thirty-day mortality after triple lumen dissection was 12%. ConclusionsAcute-on-chronic distal dissection resulting in a triple-lumen aorta should be classified as a “complicated” type B dissection as these patients typically have large aneurysms and a high incidence of rapid false lumen expansion requiring urgent surgical repair.

Endovascular treatment of chronic type b dissection at dong nai general hospital: A case report

Introduction: Chronic type B aortic dissection is a disease that can lead to false lumaen dilatation, which carries a risk of aortic rupture and sudden death. Endovascular intervention to treat this disease has been carried out at major centers in Vietnam. We report 1 case of endovascular intervention for chronic type B aortic dissection at Dong Nai General Hospital.[1]
 Case report: A 76-year-old male patient was admitted to the hospital because of incidentally finding of mediastinum dilatation on chest x ray. The patient had a history of severe retrosternal chest pain radiating to the back 3 months before admission. Computed tomography showed chronic type B dissection, primary entry point diameter of 16.3 mm, maximum aortic diameter of 46.6 x 47.7 mm. The patient underwent endovascular intervention, a 40 x 36 x 150 mm Medtronic Valiant Captivia graft was used, half of the left subclavian artery was covered. The results were good, the false lumen was partially thrombosed. The patient was discharged from the hospital in a stable condition 4 days after the intervention.
 Conclusion: Endovascular intervention for chronic aortic dissection at Dong Nai General Hospital can be applied safely. The implementation of this technique would benefit local patients and promote the development of the hospital.

Clinical Outcomes and Factors Associated With Aortic Shrinkage After Thoracic Endovascular Aortic Repair for Aneurysmal Chronic Aortic Dissection.

The effectiveness of thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection (AD) with aneurysmal degeneration remains controversial. We retrospectively investigated clinical outcomes and assessed predictors of aortic shrinkage after TEVAR for chronic aneurysmal AD. Between January 2010 and December 2021, 70 patients with double-barrel-type chronic AD were enrolled. Major intimal tears in thoracic aorta were covered by stent graft. Early and late clinical outcomes, and diameter change of downstream aorta during follow-up period were reviewed. Subsequently, factors associated with aortic shrinkage were assessed by logistic regression analysis. Mean age was 63 (interquartile range [IQR]: 54-68) years, 54 (80%) men, median duration from AD onset was 4 (IQR: 1-10) years, and maximum aortic diameter was 53 (IQR: 49-58) mm. Supra-aortic debranching procedure was required in 57 (81%) patients. Early aorta-related death occurred in 2 (3%) patients. Both stroke and spinal cord ischemia occurred in 1 (2%) patient. Five-year freedom rates from aorta-related death and reintervention were 96% and 51%, respectively. Sixty-four patients underwent follow-up computed tomography (84%) 1 year after TEVAR, with 33 (52%) achieving aortic shrinkage. In multivariable analysis, duration from AD onset (per year) (odds ratio [OR]: 0.82, 0.70-0.97; p=0.017) and maximum aortic-diameter ratio between aortic arch and descending aorta (per 0.1) (morphologic index; OR: 1.34, 1.04-1.74; p=0.023) were independent aortic shrinkage predictors. Thoracic endovascular aortic repair for chronic AD with aneurysmal degeneration achieved satisfactory survival outcomes, but with a considerable reintervention rate. Duration from AD onset and preoperative aortic morphology could affect post-TEVAR aortic shrinkage. Earlier intervention could lead to better aortic shrinkage. Thoracic endovascular aortic repair for chronic aortic dissection with aneurysmal degeneration showed low incidence of early and late aorta-related death. By contrast, aortic shrinkage rate was low with high incidence of reintervention to the residual downstream aorta. According to the assessment of preoperative variables, chronicity and aortic morphology could predict postoperative aortic shrinkage.

Extra-anatomical left common carotid and subclavian artery bypass followed by aortic arch replacement with frozen elephant trunk

BackgroundTotal arch replacement (TAR) using a frozen elephant trunk (FET) allows for simultaneous treatment of the aortic arch and descending aortic pathology via median sternotomy. In addition, an extra-anatomical bypass performed between the left common carotid artery (CCA) and subclavian artery (SCA) prior to TAR allowed further proximalisation of the FET prosthesis, facilitated distal anastomosis of the TAR and spared the demanding left subclavian artery (LSA) anastomosis in the deep thorax. We investigated the efficacy of this debranching-first technique, followed by TAR using a frozen elephant trunk, as a two-stage operation for extensive thoracic aortic aneurysms in high-risk patients.MethodsForty-nine consecutive patients with diffuse degenerative aneurysms from the aortic arch to the descending aorta or chronic aortic dissection who underwent left common carotid to subclavian artery bypass followed by TAR using a frozen elephant trunk and subsequent thoracic endovascular aortic repair between 2016 and 2021 were analysed. The baseline characteristics and clinical outcomes were assessed. The estimated overall survival, 5-year aortic event-free survival, and aortic reintervention rates were analysed.ResultsThe average European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 4.7 ± 2.5. The operative mortality rate was 4.1%, with no paraplegia events. The estimated 5-year overall survival, cumulative aortic-related mortality rates were 76.8% and 2%, respectively. The estimated 5-year overall cumulative aortic reintervention rate, including the intended intervention, was 31.3%. The estimated 5-year cumulative rate of non-intended reintervention was 4.5%.ConclusionsThe assessed technique enables a less technically demanding surgery with reasonable outcomes. The estimated 5-year aortic event-free survival and reintervention rates were acceptable, suggesting that multiple stages of alternative open and endovascular interventions, such as this technique, may reduce the morbidity and mortality rates of high-risk patients with diffuse thoracic aortic aneurysm.UMIN-CTR (University hospital Medical Information Network-Clinical Trial Registry)https://center6.umin.ac.jp/cgi-open-bin/ctr_e/index.cgiClinical registration number: UMIN000051531

Branched stented anastomosis frozen elephant trunk repair: Early results from a physician-sponsored investigational device exemption study

BackgroundMultisegment thoracic aortic disease typically requires total aortic arch replacement, affects a heterogenous population, and carries a high risk even at centers of excellence. Risk has been associated with the duration of operation and complexity of repair. A novel branched stented anastomosis frozen elephant trunk repair (B-SAFER) technique has been developed at our center and is currently being studied as a physician-sponsored investigation device exemption (PS-IDE). ObjectiveThis study aimed to assess the early safety of using this investigational technique to treat the proximal aorta in subjects with aortic disease involving multiple segments. MethodsThis prospective, single center, nonrandomized study enrolled patients undergoing B-SAFER for acute aortic syndrome (n = 73), aortic aneurysm with chronic aortic dissection (n = 68), degenerative aortic aneurysm (n = 33), or congenital aortic arch disease (n = 4). Devices are delivered antegrade under hypothermic circulatory arrest, and the arch reconstruction is performed as a single anastomosis single stent (SASS; n = 70), single anastomosis multiple stent (SAMA; n = 68), multiple anastomosis single stent (MASS; n = 21), or multiple anastomosis multiple stent (MAMS; n = 16) reconstruction. The primary safety endpoints were operative mortality, disabling stroke, and paraparesis/paralysis. ResultsBetween May 27, 2021, and December 31, 2022, 178 patients underwent B-SAFER in the configurations and for the indications as described above. The median patient age was 65 years (range, 21 to 85 years), and 52 (29%) were female. The median cardiopulmonary bypass time was 188 minutes (interquartile range [IQR], 155 to 226 minutes), and 97% of the patients underwent repair with antegrade brain perfusion for a median of 46 minutes (IQR, 38 to 61 minutes). Operative mortality occurred in 10 patients (5.6%, including 6 [8.2%] with acute dissection, 2 [2.9%] with chronic dissection, 2 [6.1%] with degenerative aneurysm, and 0 with a congenital disorder), disabling stroke in 5 patients (2.9%), and paraparesis in 1 patient. Other serious complications included respiratory failure (n = 20; 11.4%) and acute kidney injury (n = 18; 10%). Thirty-two patients (18%) had undergone second-stage repairs (28 endovascular and 4 open), with 1 operative mortality after that procedure due to distal rupture. Estimated survival was 95% at 30 days, 88% at 90 days, 84% at 6 months, and 79% at 1 year. One-year survival differed by indication (72% for acute dissection, 91% for chronic dissection, 71% for degenerative aneurysm, and 100% for congenital disorders). Conclusions:The B-SAFER technique for total arch replacement in a complex cohort of patients with various indications for surgery is a safe and reproducible operation, as demonstrated by the early results from a very inclusive PS-IDE study. Further follow-up and analysis will help refine the technique. Novel devices to perform this procedure should be developed.

Chronic Residual Aortic Dissection after Type A Aortic Dissection Repair: 7-year Results

BACKGROUND: Residual Type B aortic dissection (RTBAD) after Type A aortic dissection (TAAD) repair is a serious disease that requires reintervention. Thoracic endovascular aortic repair (TEVAR) for RTBAD after TAAD repair is an acceptable choice for this problem. AIM: This study aimed to investigate the outcomes of extended coverage of the descending thoracic aorta by TEVAR for RTBAD after TAAD repair. METHODS: This was a retrospective study. From November 2017 to August 2022, 12 patients were enrolled in this study. Patients underwent extended TEVAR for residual chronic Type B aortic dissection after TAAD repair. Data were collected from 12 patients in this period, and detailed patient characteristics were analyzed before, early after, and periodically after procedure. At the same time, we tried to develop an algorithm for this group of the patients. RESULTS: TEVAR consisted of isolated TEVARs (n = 12). The mean time from TAAD repair to TEVAR was 27 ± 33 months (2–86 months). Technical success of TEVAR was 100%. The distal ends of the stent grafts were T 8 (eight cases), T 9 (four cases). The average length of hospital stay after TEVAR was 3.41 day (2–5 days). There were no surgical/hospital deaths or complications. The average postoperative follow-up period was 26.75 months (22–34) without death or reintervention. CONCLUSION: The short-term outcomes of extended TEVAR for residual chronic Type B aortic dissection after TAAD repair were acceptable without major adverse aortic events. By careful systematic evaluation of the patients, coverage of the descending thoracic aorta may prevent aortic events, but middle-and long-term results should be clarified.

Emergency transfemoral valve-in-valve transcatheter aortic valve implantation in patient with chronic typeA aortic dissection.

Emergency transfemoral valve-in-valve transcatheter aortic valve implantation in patient with chronic typeA aortic dissection.

Safety and Efficacy of Inner Branched Stent-Graft in the Treatment of Aortic Arch Disease: A Systematic Review.

To provide a descriptive overview on the contemporary outcomes of thoracic endovascular arch repair with inner branched endoprosthesis (bTEVAR) for the treatment of aortic arch pathologies. A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Pre-defined search terms were used to interrogate PubMed and OVID Medline databases from January 1999 to July 2022. Patient characteristics, indication for treatment, procedural data, mortality rates, postoperative complications, and reintervention rate during follow-up were evaluated. Nineteen articles were included, encompassing a total of 618 patients who received bTEVAR, most of which were double-branched (63.9%, n=395). The main indication for treatment was aneurysm secondary to chronic aortic dissection (38.8%, n=240/618) with a mean maximum diameter of 58.3±11.4 mm. Pooled mean technical success rate was 97.4±4.4% (95% confidence interval [CI]=95.1%-99.5%); 2 and 3 patients required conversion to chimney technique and open repair, respectively. Among the pooled rates of early complications, postoperative stroke was the highest (10.5%; 95% CI=6.8%-14.3%). Thirty-day and in-hospital mortality rate was 5.5% (95% CI=2.6%-9.7%). Forty patients (6.5%; 95% CI=2.5%-9.5%) required early reintervention. During a mean follow-up of 20.7±13.5 months, the mortality rate was 18.2% (n=108/593; 95% CI=8.6%-20.6%) where 12 (11.1%) were aortic-related. Pooled late reintervention rate was 9.6% (95% CI=4.8%-14.3%). Comparison of demographics and outcomes found no significant difference between single and double bTEVAR. Branched thoracic endovascular aortic repair is a promising approach for aortic arch pathologies with a high technical success rate despite a steep learning curve. However, contemporary outcomes reflect that postoperative stroke remains the predominant concern. Further experience and long-term follow-up are required to sufficiently elucidate the safety and durability of bTEVAR in the management of aortic pathologies for high-risk patients. This systematic review summarized the contemporary outcomes of thoracic endovascular aortic repair with different inner branched stent-grafts for the management of aortic arch pathologies. Pooled results from nineteen studies with 618 patients demonstrated a high technical success rate and an acceptable mortality rate. However, postoperative stroke remains the major concern. Long-term follow-up is needed to evaluate its durability.

Automated cross-sectional view selection in CT angiography of aortic dissections with uncertainty awareness and retrospective clinical annotations

Surveillance imaging of patients with chronic aortic diseases, such as aneurysms and dissections, relies on obtaining and comparing cross-sectional diameter measurements along the aorta at predefined aortic landmarks, over time. The orientation of the cross-sectional measuring planes at each landmark is currently defined manually by highly trained operators. Centerline-based approaches are unreliable in patients with chronic aortic dissection, because of the asymmetric flow channels, differences in contrast opacification, and presence of mural thrombus, making centerline computations or measurements difficult to generate and reproduce. In this work, we present three alternative approaches – INS, MCDS, MCDbS – based on convolutional neural networks and uncertainty quantification methods to predict the orientation (ϕ,θ) of such cross-sectional planes. For the monitoring of chronic aortic dissections, we show how a dataset of 162 CTA volumes with overall 3273 imperfect manual annotations routinely collected in a clinic can be efficiently used to accomplish this task, despite the presence of non-negligible interoperator variabilities in terms of mean absolute error (MAE) and 95% limits of agreement (LOA). We show how, despite the large limits of agreement in the training data, the trained model provides faster and more reproducible results than either an expert user or a centerline method. The remaining disagreement lies within the variability produced by three independent expert annotators and matches the current state of the art, providing a similar error, but in a fraction of the time.

Computational fluid dynamics-based prediction of aortic aneurysm rupture in a patient with chronic aortic dissection

BackgroundThe indication of additional aortic arch surgery for residual aortic dissection remains controversial as some patients experience aneurysm rupture at a smaller diameter of 55 mm.MethodAn 84-year-old woman, who underwent total arch replacement for chronic dissection, developed rupture of a residual aneurysm of with a diameter of 48 mm. Computational fluid dynamics simulated pressure and wall shear stress comparing pre- and post-total arch replacement.ResultsAfter total arch replacement, false lumen pressure in the distal aortic arch increased (pre, 138.5 mmHg; post, 148.2 mmHg). Wall shear stress also increased in the distal aortic arch (pre, 10.5 Pa; post, 16.9 Pa).ConclusionComputational fluid dynamics could retrospectively predict a significant postoperative increase in false lumen pressure and wall shear stress of chronic dissections after total arch replacement, potentially leading to aneurysm rupture.

Recurrent aneurysm 11 years after thoracoabdominal aortic replacement due to recanalization of intercostal arteries of the wrapping native aorta in Marfan syndrome: a case report

BackgroundPersistent blood flow is common in aortic aneurysms following endovascular repair. However, the recanalization of thrombosed intercostal arteries after open aortic repair is rare. We report a case of aortic aneurysm recurrence 11 years after thoracoabdominal aortic replacement resulting from recanalization of the intercostal arteries like a type II endoleak in a patient with Marfan syndrome.Case presentationA 50-year-old woman with Marfan syndrome presented with left-sided back pain after meals. She underwent abdominal aortic replacement at 35 years of age, distal aortic arch and thoracoabdominal aortic replacement for type B chronic aortic dissection at 38 years of age, and aortic root to the remnant arch replacement with a mechanical valve conduit for type A acute aortic dissection at 43 years of age, which resulted in complete replacement of the entire aorta with prosthetic grafts. The patient has been taking warfarin since then. The prothrombin time-international normalized ratio levels were controlled almost within the range of 1.5–2.5 during the follow-up period, but it was elevated up to 3.4 at 1 month before she felt back pain and kept high at 4.2 on admission. Enhanced computed tomography (CT) revealed an aneurysm between the descending graft and the remaining native aortic wall, compressing the esophagus. However, there were no abnormal findings on the CT performed 10 months prior to admission. Surgery revealed that the orifices of the intercostal arteries were patent with backflow. We closed the patent intercostal arteries using nonabsorbable sutures. The patient’s postoperative course was uneventful, and the CT performed 1 year later showed no aneurysmal recurrence.ConclusionsHere, we describe a rare case of recurrent aortic aneurysm long term after graft replacement due to recanalization of the intercostal arteries of the remaining aortic wall. Our findings suggest that closing all orifices of the intercostal arteries during aortic repair, regardless of backflow, could prevent delayed reopening; systemic anticoagulation after aortic replacement may be a risk factor for recanalization, and that postoperative periodic CT follow-up is essential, especially in patients receiving anticoagulant therapy.

Descending Aortic Replacement with Third-Part Left Axillary Artery Graft Perfusion

We introduce a unique perfusion method for open descending aortic repair through a left thoracotomy. Perfusion from femoral artery cannulation is generally adopted in descending aortic replacement surgery. However, in cases with shaggy or partially thrombosed chronic aortic dissection, retrograde perfusion alone has a high risk of embolization and alternative perfusion methods should be considered. Our perfusion method from the third part of the left axillary artery graft is safe, simple, and useful for avoiding postoperative cerebral complications. In the present study, we report the advantages and challenges of this graft-interposed perfusion via the distal left axillary artery for descending aortic replacement.

A Case of Chronic Aortic Dissection in Malagasy Patient Suspected of Turner Syndrome

The association between aortic dissection and Turner syndrome has been described in the literature as rare. We report a case of a Stanford type-A chronic aortic dissection in a woman suspected of Turner syndrom. Our goal is to recall the association between these two diseases for early detection and follow-up.

Long-Term Results with 187 Frozen Elephant Trunk Procedures.

The frozen elephant trunk (FET) technique is an established therapeutic option in the treatment of complex aortic diseases. We report our long-term clinical outcomes after FET repair. A total of 187 consecutive patients underwent FET repair at our department between 8/2005 and 3/2023. Indications included acute and chronic aortic dissections and thoracic aneurysms. Endpoints included operative morbidity and mortality, long-term survival, and the need for reinterventions. Operative mortality, spinal cord injury and permanent stroke rates were: 9.6%, 2.7% and 10.2%, respectively. At five years, overall survival was 69.9 ± 3.9% and freedom from aortic-related death was 82.5 ± 3.0%, whereas at ten years, overall survival was 53.0 ± 5.5% and freedom from aortic-related death was 75.8 ± 4.8%. Sixty-one reinterventions on the thoracic aorta were necessary. Freedom from secondary interventions at ten years was 44.7 ± 6.4% overall (63.1 ± 10.0% for acute dissections, 40.8 ± 10.3% for chronic dissections and 28.9 ± 13.1% for aneurysms, respectively). The high reintervention rate for chronic dissections and for aneurysms is related to the pre-existing aortic pathology. Late aortic growth of untreated segments with potentially fatal outcome occurs even after ten years, so careful annual follow-up is mandatory in this patient cohort.

False lumen flow dynamics and partial thrombosis in patients with chronic aortic dissection of the descending aorta: a 4D flow CMR study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation, and Universities Background Partial thrombosis of the false lumen (FL) in patients with chronic aortic dissection (AD) of the descending aorta has recently been associated with poor outcomes (1). However, four-dimensional phase-contrast cardiovascular magnetic resonance (4D flow CMR) studies analyzing flow dynamics and biomechanics in the FL and their relationship with partial thrombosis are lacking. Purpose This study aimed to compare FL flow dynamics and biomechanics between patients with non- and partially-thrombosed FL. Methods Patients with a chronic (>3 months after the acute event), non-thrombosed or partially-thrombosed FL in the descending aorta after an AD underwent an imaging follow-up including a magnetic resonance angiography (MRA) and a 4D flow CMR study. FL thrombosis was quantified as the ratio of thrombus volume and FL volume on MRA. Forward systolic and diastolic flow, and wall shear stress (WSS) were calculated at 8 equidistant planes covering the FL descending aorta from the pulmonary bifurcation to the diaphragmatic level, and averaged values were used (1,2). Maximum kinetic energy (KE), maximum acceleration and flow stasis were quantified in a volume covering the same region of the descending aorta (1). Aortic stiffness in the FL was assessed in terms of pulse wave velocity (PWV), which was calculated from the third supraortic trunk to the diaphragmatic level (3). Results Sixty-five patients with a complete imaging protocol were included in the study. The FL was non thrombosed in 34 patients and partially thrombosed in 31 patients, which presented with the 21 ± 13 % of the FL volume occupied by thrombus. Demographics and clinical data, and flow dynamic and biomechanical parameters of these patients are shown in Table 1. Partial thrombosis of the false lumen was associated with a reduction in the amount and energy of flow in the FL (reduced forward systolic flow, KE and acceleration (Figure 1B-D, respectively)), and a more stagnated flow in the FL (increased flow stasis (Figure 1E)). Axial WSS showed a tendency to be lower in the partial-thrombosis group compared to the no-thrombosis group (Figure 1F), while PWV were similar in both of them. Conclusion In patients with chronic AD of the descending aorta, false lumen axial wall shear stress, kinetic energy, and flow acceleration and stasis proved to be the main discriminators between no and partial thrombosis of the false lumen.

Fracture and embolization of a metal stent after a frozen elephant trunk procedure.

The Frozenix J graft open stent graft has been available since 2014 in Japan. This stent is widely used for the frozen elephant trunk technique in many institutions, mainly for cases of acute type A aortic dissection and also for cases of a true aneurysm and chronic aortic dissection. We treated a rare case in which the metal wires of the Frozenix J graft were broken and embolized to the periphery half a year after being implanted.