Complicated Acute Type B Aortic Dissection Research Articles

Postoperative acute kidney injury after thoracic endovascular aortic repair for acute type B aortic dissection

BackgroundThoracic endovascular aortic repair (TEVAR) has evolved as the standard for treating complicated acute type B aortic dissection (ATBAD). Acute kidney injury (AKI) is a common complication in critically ill patients and is commonly observed in patients with ATBAD. The purpose of the study was to characterize AKI after TEVAR. MethodsAll patients who underwent TEVAR for ATBAD from 2011 through 2021 were identified using the International Registry of Acute Aortic Dissection. The primary end point was AKI. A generalized linear model analysis was performed to identify a factor associated with postoperative AKI. ResultsA total of 630 patients presented with ATBAD and underwent TEVAR. The indication for TEVAR was complicated ATBAD in 64.3%, high-risk uncomplicated ATBAD in 27.6%, and uncomplicated ATBAD in 8.1%. Of 630 patients, 102 (16.2%) developed postoperative AKI (AKI group) and 528 patients (83.8%) did not (non-AKI group). The most common indication for TEVAR was malperfusion (37.5%). In-hospital mortality was significantly higher in the AKI group (18.6% vs 4%; P < .001). Postoperatively, cerebrovascular accident, spinal cord ischemia, limb ischemia, and prolonged ventilation were more commonly observed in the AKI group. The expected mortality was similar at 2 years between the two groups (P = .51). Overall, the preoperative AKI was observed in 95 (15.7%) in the entire cohort consisting of 60 (64.5%) in the AKI group and 35 (6.8%) in the non-AKI group. A history of CKD (odds ratio, 4.6; 95% confidence interval, 1.5-14.1; P = .01) and preoperative AKI (odds ratio, 24.1; 95% confidence interval, 10.6-55.0; P < .001) were independently associated with postoperative AKI. ConclusionsThe incidence of postoperative AKI was 16.2% in patients undergoing TEVAR for ATBAD. Patients with postoperative AKI had a higher rate of in-hospital morbidities and mortality than those without. A history of CKD and preoperative AKI were independently associated with postoperative AKI.

Abstract 12150: Acute Type B Aortic Dissection a 15-Year, Single-Center Experience

Introduction: Treatment of acute type B aortic dissection (ATBAD) has evolved with the use of endovascular technology. This study evaluates the short and long-term outcomes of patients with ATBAD over a 15-year period. Methods: A retrospective review identified patients with ATBAD at our institution between 2006 and 2020. Patients were analyzed based on presentation status (complicated vs. uncomplicated) and treatment. Complicated ATBAD (cATBAD) included malperfusion of any vascular bed, intractable pain, rupture, or rapid expansion. Postoperative outcomes were evaluated within the initial 30 days after diagnosis when managed medically or within thirty days of surgical intervention. Descriptive statistics was performed to assess short-term outcomes. Kaplan-Meier survival was performed to assess long-term mortality. Results: A total of 296 patients presented with ATBAD in the study period. Out of those, 121 patients presented with cATBAD, while 175 patients presented with uncomplicated ATBAD (uATBAD). Out of the cATBAD group, 89 were treated with TEVAR, and 32 were treated with medication only. The cATBAD group was younger than the uCTBAD group (62.0 vs. 65.2, p=0.05). Early mortality was more common in cATBAD than uATBAD (9.9% vs 2.3%, p=0.013). When comparing cATBAD who underwent TEVAR vs conservative medical management, early mortality was higher in the medication only group (12.5% vs 9.0% p = 0.013). Permanent paraplegia occurred in 1.1% (1/89)of patients undergoing TEVAR. Kaplan-Meier survival analysis demonstrated no significant difference in long-term mortality between the cATBAD and uATBAD groups (Logrank p = 0.23). Among the uATBAD patients, 10.3% (18/175) required future intervention for type B dissection (12 TEVAR, 6 open). Among the TEVAR patients, 20.2% (18/89) required re-operations (11 endovascular repairs, 7 open). Conclusions: ATBAD is associated with significant morbidity and mortality, especially in the setting of a complicated presentation. While uATBAD is associated with better short-term outcomes, the diminishing difference in long-term outcome between cATBAD and uATBAD calls for reevaluation of our indications for intervention and may suggest that the remodeling associated with TEVAR could have long term benefit.

Central arch reconstruction and thoracic endovascular aortic repair for complicated acute type B aortic dissection with aberrant right subclavian artery.

Aberrant right subclavian artery (ARSA) is a rare anatomic variant in which the right subclavian artery originates distal to the left subclavian artery (LSA) and crosses the midline in a retroesophageal course before assuming its right subclavicular position. Patients with acute type B aortic dissection (ATBAD) and ARSA pose a unique challenge due to the absence of an appropriate proximal landing zone for thoracic endovascular aortic repair (TEVAR) without covering both subclavian arteries. In this case series, 2 different hybrid techniques of central 4-vessel arch reconstruction with TEVAR are described to treat 4 patients with complicated ATBAD and ARSA.

FT11. The Optimal Aortic Diameter for Risk of Late Aortic Events in Uncomplicated Stanford Type B Aortic Dissection

The initial treatment of uncomplicated acute type B aortic dissection (ATBAD) has previously been mainly medication. Almost half of patients require aortic surgery in the chronic phase. The initial aortic diameter is a risk factor for late aortic events in patients with uncomplicated ATBAD. However, the cutoff value remains controversial, 40 mm or 45 mm. We evaluated the optimal aortic diameter for risk of late aortic events in patients with uncomplicated ATBAD. We conducted a retrospective cohort study reviewing 175 consecutive patients who underwent initial treatment for uncomplicated ATBAD between October 2004 and May 2017. We excluded 47 patients with complicated ATBAD (rupture, impending rupture, malperfusion). The follow-up rate was 95.4%, with a mean follow-up of 43.8 ± 36.4 months. The largest diameters of the minor and major axes were measured on computed tomography at admission and before discharge. All causes of mortality, late aortic events, and operation and indication for operation for dissected aorta were assessed with the Kaplan-Meier method. Logistic regression was used to examine whether aortic diameter is useful in predicting late aortic events. Cox regression was carried out to assess the prognostic effect of aortic diameter after allowing significant covariates, and receiver operating characteristic analyses were used to determine test reliability. In-hospital mortality was one (0.6%). Long-term mortality was 26 (14.9%). There were 42 patients (24.1%) who underwent late operation for dissected aorta, and 26 patients (14.9%) refused late operation despite a dissected aneurysm of 55 mm or saccular aneurysm. The rate of freedom from these aortic events was 73.5%, 61.2%, and 53.9% at 1 year, 3 years, and 5 years. Receiver operating characteristic analyses showed cutoff values at admission of 40 mm for minor axis diameter with sensitivity of 72.1% and specificity of 83.2% (area under the curve [AUC], 0.81; P < .001) and 41 mm for major axis diameter (AUC, 0.80; P < 0.001); cutoff values before discharge were 39 mm for minor axis diameter (AUC, 0.83; P < .001) and 42 mm for major axis diameter (AUC, 0.85; P < 0.001). After adjustment for other covariates (age, sex, ulcerlike projection, and larger false lumen diameter), minor axis aortic diameter at admission of 40 mm was an independent risk factor of late aortic events (hazard ratio, 4.55, 95% confidence interval, 2.58-8.32; P < .001). We identify minor axis diameter of 40 mm on computed tomography at admission as the optimal aortic diameter for prediction of late aortic events.

Frozen Elephant Trunk for Acute Type B Dissection Involving the Distal Arch in the Hybrid Repair Era

Hybrid repair of complicated acute type B aortic dissection (ATBAD) with aortic arch involvement is associated with a high rate of endoleak, stroke, and retrograde aortic dissection. Optimal management of this lesion remains uncertain. In this hybrid repair era, surgical results of ATBAD with distal aortic arch involvement using a frozen elephant trunk procedure with transposition of the left subclavian artery (LSCA) to left common carotid artery (LCCA) is reported. From April 2011 to April 2016, 53 patients with complicated ATBAD with distal aortic arch involvement underwent a frozen elephant trunk procedure with LSCA-LCCA transposition. Preoperative organ malperfusion included renal ischemia in 10 subjects, renal infarction in 2, lower limb ischemia in 6, and visceral ischemia in5. There was no inhospital death. Continuous renal replacement therapy was required in 1 patient. Permanent neurologic injury was observed in 1 patient and temporary neurologic dysfunction in 1 patient. Ischemia of the lower limb and viscera was ameliorated after frozen elephant trunk implantation. During follow-up, thoracoabdominal aortic replacement was required in 1 patient, and the Wheat procedure in 1 other patient. The patency rate of the anastomotic sitebetween the LSCA and LCCA was 100%, and shrinkage of the descending aorta occurred in 90.4% of patients (47 of 52) as demonstrated by computed tomography. Open repair of ATBAD with distal aortic arch involvement using the frozen elephant trunk procedure with LSCA-LCCA transposition obtained satisfactory outcomes. Avoidance of complications using hybrid repair, good postoperative recovery, and a low prevalence of late reintervention were achieved. The satisfactory results favored this technique for this lesion in this hybrid repair era.

Invited commentary

The preceding manuscript by Ding et al describes a hybrid procedure for the management of an acute type B aortic dissection in 16 patients with an aberrant right subclavian artery (ARScA). Although this particular clinical situation may be encountered infrequently, some of the management strategies may prove useful in the management of other pathologies associated with an ARScA, that is, a Kommerell diverticulum. Although open management of arch pathologies involving an ARScA are manageable, sternotomies with cardiopulmonary bypass, likely requiring circulatory arrest and some means of cerebral protection, certainly pose at least the potential for major morbidity. In this series, using thoracic endografting and extra-anatomic bypass, a satisfactory clinical outcome was accomplished with no perioperative deaths, strokes, or spinal cord ischemic events, Although 12 of 16 patients are described as having complicated acute TBAD, only 3 patients required an urgent repair within the first 7 days after the dissection; the majority were treated electively between 8 and 30 days after the dissection. My major concerns include the following:A.The incidence of acute type A aortic dissection, which indeed occurred in a single patient treated in the 8- to 30-day interval.B.Enlargement of Kommerell diverticula, which were present in 2 patients, and further enlargement was not noted during a median follow-up of 33 months.C.Systemic perfusion of the proximal ARScA, which could produce a type II endoleak. This leak did occur in a single patient, who required an Amplatzer plug occlusion of the ARScA orifice in the late follow-up.D.Two extra-anatomic bypass grafts occluded in the late follow-up, but were asymptomatic. Interestingly, two early type I endoleaks spontaneously closed. I congratulate the authors for their fine work, confirming that, often, “less may be more.” The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Outcomes of hybrid procedure for type B aortic dissection with an aberrant right subclavian arteryJournal of Vascular SurgeryVol. 67Issue 3PreviewTo report our single-center experience of the hybrid procedure for type B aortic dissection (TBAD) with an aberrant right subclavian artery (ARSA) and the early to midterm outcomes in these patients. Full-Text PDF Open Archive

Treatment solution: treatment of choice in a case of haemodynamic instability after endovascular repair of a complicated acute type-B aortic dissection.

Treatment solution: treatment of choice in a case of haemodynamic instability after endovascular repair of a complicated acute type-B aortic dissection.

Commentary on ‘Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection’

Objectives The purpose of this retrospective cohort study was to determine the early and long-term mortality and morbidity as well as to reveal risk factors influencing the long-term prognosis in patients with complicated acute type B aortic dissection (CABAD) undergoing open surgical suprarenal aortic fenestration (OSSAF). Methods Fifty-two patients with CABAD, defined as (impending) rupture, acute enlargement of the false lumen, malperfusion, and/or unrelenting back pain or uncontrollable hypertension despite maximum medical therapy were treated with by surgical repair between 2002 and 2008. Ten patients with (impending) rupture had aortic graft replacement, while 42 (33 men, mean age 55 ± 11 years) had OSSAF. Follow up visits were scheduled at 1, 3–6 and 12 months after the surgery and annually thereafter. Clinical examination and computed tomography angiography findings were investigated at baseline and at subsequent visits. Results The indications for OSSAF were acute enlargement of the false lumen in four (10%), malperfusion in 17 (40%) (11 lower extremity [26%], 6 visceral [14%]), and unrelenting back pain or uncontrollable hypertension in 21 cases (50%). The 30 day mortality was 21.4% (2 multiple organ failure, 2 heart failure, 3 pneumonia, 1 intestinal necrosis, 1 major hemorrhage). The mean follow up was 84 ± 40 months. The 5 year survival was 70.6%. Eight patients (19%) died during the follow up period (6 aortic ruptures, 2 myocardial infarctions). None of the patients became paraplegic after the surgery. Further surgery or stenting was indicated in nine cases (21%). Conclusions OSSAF has been performed with an acceptable early mortality and low paraplegia rate, but late mortality is frequently related to aortic rupture. Stentgraft coverage of the primary entry tear decreases late aortic related deaths, but suprarenal fenestration remains an option for cases not suitable for endovascular techniques.

Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection

The purpose of this retrospective cohort study was to determine the early and long-term mortality and morbidity as well as to reveal risk factors influencing the long-term prognosis in patients with complicated acute type B aortic dissection (CABAD) undergoing open surgical suprarenal aortic fenestration (OSSAF). Fifty-two patients with CABAD, defined as (impending) rupture, acute enlargement of the false lumen, malperfusion, and/or unrelenting back pain or uncontrollable hypertension despite maximum medical therapy were treated with by surgical repair between 2002 and 2008. Ten patients with (impending) rupture had aortic graft replacement, while 42 (33 men, mean age 55±11 years) had OSSAF. Follow up visits were scheduled at 1, 3-6 and 12 months after the surgery and annually thereafter. Clinical examination and computed tomography angiography findings were investigated at baseline and at subsequent visits. The indications for OSSAF were acute enlargement of the false lumen in four (10%), malperfusion in 17 (40%) (11 lower extremity [26%], 6 visceral [14%]), and unrelenting back pain or uncontrollable hypertension in 21 cases (50%). The 30 day mortality was 21.4% (2 multiple organ failure, 2 heart failure, 3 pneumonia, 1 intestinal necrosis, 1 major hemorrhage). The mean follow up was 84±40 months. The 5 year survival was 70.6%. Eight patients (19%) died during the follow up period (6 aortic ruptures, 2 myocardial infarctions). None of the patients became paraplegic after the surgery. Further surgery or stenting was indicated in nine cases (21%). OSSAF has been performed with an acceptable early mortality and low paraplegia rate, but late mortality is frequently related to aortic rupture. Stentgraft coverage of the primary entry tear decreases late aortic related deaths, but suprarenal fenestration remains an option for cases not suitable for endovascular techniques.

Open fenestration for complicated acute aortic B dissection.

Acute type B aortic dissection (ABAD) is a serious cardiovascular emergency in which morbidity and mortality are often related to the presence of complications at clinical presentation. Visceral, renal, and limb ischemia occur in up to 30% of patients with ABAD and are associated with higher in-hospital mortality. The aim of the open fenestration is to resolve the malperfusion by creating a single aortic lumen at the suprarenal or infrarenal level. This surgical procedure is less invasive than total aortic replacement, thus not requiring extracorporeal support and allowing preservation of the intercostal arteries, which results in decreased risk of paraplegia. Surgical aortic fenestration represents an effective and durable option for treating ischemic complications of ABAD, particularly for patients with no aortic dilatation. In the current endovascular era, this open technique serves as an alternative option in case of contraindications or failure of endovascular management of complicated ABAD.

Part One: For the Motion. Level 1 Evidence is Necessary Comparing TEVAR and Medical Management of Uncomplicated Type B Aortic Dissection

Part One: For the Motion. Level 1 Evidence is Necessary Comparing TEVAR and Medical Management of Uncomplicated Type B Aortic Dissection

Endovascular Repair of Complicated Acute Type-B Aortic Dissection with Stentgraft: Early and Mid-term Results

Endovascular Repair of Complicated Acute Type-B Aortic Dissection with Stentgraft: Early and Mid-term Results

Endovascular Repair of Complicated Acute Type-B Aortic Dissection with Stentgraft: Early and Mid-term Results

Endovascular Repair of Complicated Acute Type-B Aortic Dissection with Stentgraft: Early and Mid-term Results

Endovascular Repair of Complicated Acute Type-B Aortic Dissection with Stentgraft: Early and Mid-term Results

Objectives To analyse the experience of a single centre and evaluate the early and mid-term results of endovascular repair of complicated acute type B aortic dissection with stentgrafts. Method From July 2002 to January 2009, 45 patients (12 women, 33 men) with complicated acute type B aortic dissection (mean age, 42.6 years; range, 31–47 years) were treated with Thoracic Endovascular Aortic Repair (TEVAR). Indications for treatment included rupture in 6(13%), hemathorax with impending rupture in 27(60%), malperfusion syndrome in 11 (22%), and transient paraplegia in one patient (2.2%). Five kinds of commercially available thoracic stentgrafts were used. Follow up was 100% during a period of 13 months (range, 1–36 months). Results Technical success (coverage of the primary tear site) was achieved in all 45 patients(100%) including deliberate partial or total coverage of the LSA in 7 patients (15.6%). The 30-day and in-hospital mortality was 4.4% including one late rupture case. Overall survival was 95.6% at 1 and 3-years’ follow-up. None of the patients with malperfusion required adjunct distal stents All hemothoces resolved within 3 months including 5 patient required thoracentesis and one had tube thoracostomy. And 7 patients required temporary dialysis In-hospital complications occurred in 26.7% of patients and re-intervention was required in one patient and no patient had postoperative paraplegia Postoperative CT angiography showed 25 patients (58.1%) with complete thrombosis of the false lumen and re-expansion of the true lumen. Conclusions Endovascular repair of complicated acute type B aortic dissection with stentgraft is proven to be a technically feasible and effective in this relatively difficult patient cohort, The short and mid-term efficacy are persuasive, however, the long-term efficacy needs to be evaluated further.

Long-term outcomes of surgical aortic fenestration for complicated acute type B aortic dissections

Surgical aortic fenestration has been used for treating ischemic complications of acute type B aortic dissection (ABAD). In the current endovascular era, surgical aortic fenestration may serve as an alternative for these patients after percutaneous failure. The purpose of this study is to describe our surgical suprarenal and infrarenal aortic fenestration technique, and to report the long-term outcomes of this approach in the management of complicated ABAD. We retrospectively analyzed the in-hospital and long-term outcomes of 18 patients treated with either suprarenal (n = 10) or infrarenal surgical fenestration (n = 8) for complicated ABAD between 1988 and 2002. Suprarenal fenestration was performed through a thoracoabdominal incision in the 10th intercostal space, whereas patients treated with infrarenal fenestration underwent a midline laparotomy. A longitudinal aortotomy was performed and the true and false lumens were identified, followed by a wide resection of the intimal membrane. Median age was 60 years (range, 48-82 years) and 89% (n = 16) were male. The in-hospital mortality was 22% (n = 4), which included two deaths after suprarenal fenestration and two deaths after infrarenal fenestration. In the remaining patients, full visceral, renal, and lower extremity function was recovered, except for 1 patient with paraplegia at admission in which the neurologic deficit was permanent. Median follow-up of the surviving patients was 10.0 years (interquartile range, 12.5; range, 0.5-20 years). During follow-up, none of the patients developed renal or visceral ischemia, or ischemic complications to the lower extremities, and no significant dilatations of the treated aortic segments were noted. Three of 14 patients with ABAD who were discharged alive expired during the follow-up period due to causes unrelated to the surgical procedure. Surgical aortic fenestration represents an effective and durable option for treating ischemic complications of ABAD. Actually, this conservative surgical technique may serve as the alternative treatment in case of contraindications or failure of endovascular management of complicated ABAD.