True Lumen Diameter Research Articles

Long-Term Outcomes of PETTICOAT Technique-Assisted Thoracic Endovascular Aortic Repair for the Treatment of Acute and Subacute Complicated Type B Aortic Dissection.

To evaluate the long-term outcomes of the provisional extension to induce complete attachment technique (PETTICOAT) for the treatment of acute and subacute complicated type B aortic dissection (TBAD). We retrospectively collected and analyzed the clinical data of patients with acute and subacute TBAD who were treated using the PETTICOAT technique at our center between March 2014 and March 2023. The primary endpoint was all-cause mortality; secondary endpoints were a composite of complications, such as entry flow, stent-graft-induced new entry (SINE), and re-intervention. The technical success was 92% (46/50). The perioperative mortality was 2% (1/50), and the procedure-related re-intervention was also 2% (1/50). The mean follow-up time was (74.9±33.9) months. The mortality was 4.1% (2/49). The incidence of aortic-related complications was 8.2% (4/49), including new entry flow, 2 retrograde type A aortic dissections, and 1 distal stent graft-induced new entry SINE. The procedure-related re-intervention rate was 4.1% (2/49). After 5 years of follow-up, the total aortic diameter at the renal artery level was reduced from that at the third year of follow-up but was still significantly larger than preoperatively (26.9±6.6 mm vs. 24.1±4.2 mm, p=0.013). While at the covered stent, bare stent, stentless, and celiac artery (CA) levels, the total aortic diameters did not change significantly compared with preoperative values, whereas true lumen (TL) diameters and TL ratios were maintained at obviously higher levels than preoperative. The rate of complete thrombosis of false lumen in the thoracic aortic segment was significantly higher than that in the abdominal aortic segment (79.6% vs 30.6%, p=0.0001). The results indicated that the PETTICOAT technique is safe and effective and could promote positive remodeling of the aorta from the level of the covered stent to the CA. Remodeling of the distal abdominal aorta may fluctuate and requires close follow-up review. The long-term results from our center suggest that the PETTICOAT technique promotes positive remodeling of the aorta from the level of the covered stent to the CA; whereas this advantage does not seem to be significant in the more distal segment of the abdominal aorta, mainly at the level of RA and distal. Therefore, further procedures may be required for aortic dissection of the abdominal segment. In addition, aortic remodeling may fluctuate to some extent during the follow-up period, especially in the abdominal visceral region, so close follow-up review is quite important, and prompt re-intervention is required if necessary.

Morphology of true lumen and surgical outcomes of acute type A aortic dissection repair with superior mesenteric artery malperfusion

BackgroundAcute type A aortic dissection (ATAD) can cause visceral malperfusion. Central aortic repair may resolve malperfusion, but some require further intervention. This study aimed to review outcomes after ATAD presenting with visceral malperfusion and to evaluate the predictive value of true lumen (TL) morphologies in preoperative computed tomography scan for persistent superior mesenteric artery (SMA) ischemia after central repair. MethodsOpen surgical repair of ATAD performed between 2008 and 2023 at our institution was reviewed retrospectively. Patients with central repair first approach were included for analysis. Patients with inadequate computed tomography scan data to assess luminal morphology were excluded. TL morphology was reviewed at the diaphragm level and categorized as concave or convex. The malperfusion pattern, static vs dynamic, was assessed at SMA orifices. Data were analyzed using a contingency table and parametric and nonparametric methods. ResultsA total of 543 open ATAD repairs were performed. Of these, 263 patients were eligible under the inclusion criteria and, subsequently, analyzed. The mean age was 57±14, and 83 (31%) patients were female. SMA malperfusion developed in 42 (16%) of the 263 patients, including 26 patients with dynamic obstruction, 6 patients with static obstruction, and 10 patients with dynamic and static obstruction. Regarding dissection flap morphology, 78 patients (30%) exhibited concave morphology, while 185 patients (70%) had convex morphology. TL diameter was significantly larger in convex than concave (concave: 6 mm vs convex: 16 mm; P < .0001). The prevalence of clinically significant SMA malperfusion was higher in concave-shaped TL (concave 41% vs convex 5%; P < .0001). Dynamic SMA obstruction was more frequently observed in the concave group (concave 72% vs convex 30%; P < .001). However, significantly more patients with convex-shaped TL required bowel resection than concave (concave 13% vs convex 70%; P < .001). The operative mortality was higher in the convex group, although statistically insignificant (concave 19% vs convex 50%; P = .0059). ConclusionsCentral repair first strategy could resolve more than 80% of SMA malperfusion in ATAD when the TL is concave-shaped at the level of the diaphragm. Convex-shaped TL morphology was associated with less incidence of SMA malperfusion but was more frequently associated with static obstruction and higher incidence of bowel resection. The morphology evaluation of the TL at the diaphragm level may be simple and beneficial for surgical planning for ATAD presenting with SMA malperfusion.

Is TEVAR an Effective Approach to Prevent Complications after Surgery for Aortic Dissection Type A? A Systematic Review.

Introduction: A residual false lumen after treatment for Aortic Dissection type A (AD) has been associated with early complications, such as A malperfusion or rupture and mid-term or delayed complications, such as aneurysm formation or dissection expansion. Thoracic Endovascular Aortic Repair (TEVAR) is considered an effective solution by several surgical teams to prevent future complications. In this systematic review, all published data regarding the implementation of TEVAR after previous treatment for AD were collected in order to investigate indications, methods, clinical outcomes and aortic remodeling in these patients. Methods: The aim of this study was to investigate the indications, the methods and the efficacy of TEVAR usage after surgical treatment of AD. Data for this study were collected from four widely used medical databases (MEDLINE, SCIENCE DIRECT, GOOGLE SCHOLAR, OVID). All the results for each database were recorded and were analyzed with a systematic method. Techniques and clinical outcomes were investigated. Aortic remodeling was evaluated based on the following parameters in these studies: aortic diameter, true lumen diameter, false lumen diameter, false lumen thrombosis and false lumen patency. Results: The results obtained from the search among all databases comprised 1410 articles and of these articles 9 were included in the review. The majority of the studies were retrospective (seven out of nine studies), while no study was randomized. The total number of patients was 157 and 133 of them (84.7% of patients) were treated with TEVAR in zone 3 without extension below the diaphragm intraoperatively. Among 142 patients, the calculated mortality rate was 12.7% (18 of 142 patients), with 2.8% (4 of 142 patients) presenting with stroke. The percentage of patients with total or partial thrombosis combined was 65.9% (62 patients in a population of 92). The reintervention rate was 18.7%. Conclusions: TEVAR after AD surgery is an approach usually chosen in clinical practice, but the criteria of its usage are uncertain. This method is safe and enhances aortic remodeling with an acceptable reintervention rate. Definite guidelines in this field should be created in order to delineate whether TEVAR after AD surgery is beneficial as a preventive measure to aorta-related complications and to decide under which criteria this approach should be chosen.

Analysis of the effect and safety of lumen reshaping after endovascular repair of Stanford B type aortic dissection at different intervention times

Objective: To Compare the effects and safety of lumen reshaping after thoracic endovascular aortic repair (TEVAR) for Stanford B type aortic dissection (AD) at different intervention times. Methods: A retrospective analysis was conducted on the clinical data of 189 patients with Stanford type B aortic dissection treated with TEVAR at the Affiliated Hospital of Chengde Medical College from January 2016 to December 2020.Based on the time from onset to surgery, patients were divided into an early intervention group (≤14 days, n=127) and a delayed intervention group (>14 days, n=62).The diameters of the total aorta, true lumen and false lumen at different times and planes (S1 plane: at the bifurcation of the pulmonary artery; S2 plane: at the lower edge of the left atrium; S3 plane: at the upper edge of the celiac trunk) post-surgery were compared between the two groups, and the rate of change in diameters of true and false lumens across these planes was calculated. The patients were followed until December 1st, 2023, and the median follow-up time was 45(40, 49) months. The postoperative complications and survival of the two groups were compared. Results: The early intervention group comprised 86 men and 41 women, with an average age of (58.3±10.7) years. The delayed intervention group included 41 men and 21 women, with an average age of (58.5±9.2) years. Both groups had an operation success rate of 100%. Six months post-surgery, the early intervention group had an expansion rate of the true lumen diameter at planes S2 and S3 of 40.1%(25.5%, 56.1%) and 5.3%(-2.5%, 15.8%), respectively, which was superior to the delayed intervention group's 18.5%(10.6%, 39.8%) and 1.0%(-8.2%, 9.6%) (both P<0.05).The early intervention group had a reduction rate of the false lumen diameter at planes S1, S2, and S3 of -56.2%(-61.3%, -48.8%), -70.4%(-81.8%, -56.6%), and -5.4%(-17.4%, 0.1%), respectively, better than the delayed intervention group's -44.2%(-53.7%, -38.3%), -49.0%(-57.6%, -35.8%), and -3.1%(-6.7%, 1.8%) (all P<0.05).At plane S1, the true lumen diameter of patients in both groups showed an increasing trend over 36 months post-surgery, while the false lumen diameter showed a decreasing trend (both P<0.05).At plane S2, the true lumen diameter of patients in the early intervention group exhibited an increasing trend over 36 months post-surgery, and the false lumen diameter exhibited a decreasing trend (both P<0.05).At plane S3, the total aortic diameter of patients in the delayed intervention group showed a slight increasing trend over 36 months post-surgery (P<0.05).The overall survival time were 45.0 months (95%CI: 42.9-47.1) for patients in the early intervention group and 46.0 months (95%CI: 43.5-48.5) for those in the delayed intervention group, with no statistically significant difference observed (P>0.05).The incidence rates of complications such as aortic rupture, retrograde Type A dissection, new distal endograft dissection, endoleak, paraplegia, and others showed no statistically significant difference between the two groups (all P>0.05), with no cases of stent migration or deformation observed. Conclusion: Early intervention for Stanford type B aortic dissection provides a better aortic remodeling outcome than delayed intervention, with similar safety.

Efficacy of intentional undersized thoracic endovascular repair for Stanford type B aortic dissection

ObjectiveThoracic endovascular aneurysm repair (TEVAR) is widely used for the treatment of aortic dissection. Endograft oversizing is a risk factor for stent graft-induced new entry tears and retrograde type A aortic dissection. However, there is no clear consensus on the optimal graft size selection for Stanford type B acute or subacute aortic dissection (TBAD). Herein, we examined the safety and efficacy of TEVAR using an intentionally undersized endograft to treat TBAD. MethodsThis retrospective chart review study included 82 patients who underwent TEVAR for acute or subacute Stanford TBAD between 2015 and 2022. We measured the true lumen diameter just distal to the subclavian artery and opted for a stent graft of the same diameter. In instances where deformation resulting from false lumen pressure displacement was pronounced, we measured the diameter at the site just proximal to the subclavian artery. Patients’ characteristics, procedural, in-hospital, and follow-up data, and aortic remodeling were analyzed. The aortic diameter was analyzed using one-way analysis of variance followed by Dunnett’s test. Survival and freedom from reintervention were estimated using Kaplan-Meier curves. ResultsThe follow-up rate was 98.4%. The mean age was 58.3 ± 12.3 years, and 76 were men (92.7%). The mean diameters of the stent graft and native proximal landing zone were 30.9 ± 3.2 mm and 30.8 ± 3.0 mm, respectively. The oversize rate of the stent graft in relation to the native proximal aortic diameter was 0.3% ± 4.7%. In-hospital mortality was observed in one patient, retrograde type A aortic dissection in one patient, distal stent graft-induced new entry tear in zero patients, and type 1a endoleak in 22 patients (26.8%). Type 1a endoleaks, characterized by antegrade false lumen blood flow originating from the primary entry, in 12 patients spontaneously disappeared within 1 year of follow-up. According to aortic remodeling, 59 patients (86.8%) achieved complete aortic remodeling at the aortic arch level and 51 (75.0%) at the eighth thoracic vertebral level. The diameters of the aortic arch and descending aorta were significantly reduced compared with the postoperative measurements (P <.001). Survival rates were 97.5% and 93.6% at 1 and 3 years, respectively. Freedom from reintervention was 84.7% and 84.7% at 1 and 3 years, respectively. ConclusionsIntentionally undersized TEVAR was safe and achieved acceptable aortic remodeling despite a high rate of type 1a endoleaks. A type 1a endoleak was acceptable as it primarily diminished during the mid-term follow-up.

A new minimal invasive technique with in-situ stent-graft fenestration for type A aortic dissection

BackgroundAortic surgery successfully improves the prognosis of patients with type A aortic dissection. However, total arch replacement and reconstruction remain challenging. This study presents a new surgical modality, the in-situ stent-graft fenestration (ISSF) technique, for simplifying aortic arch reconstruction and assesses its short-term efficacy and safety in patients with type A aortic dissection. MethodsData from 177 patients with type A aortic dissection who underwent aortic arch reconstruction were retrospectively analyzed. Sun's procedure was performed in 90 patients and ISSF was performed in the other 87. ResultsThe in-hospital mortality rate was 7.8% in the Sun's procedure group and 3.4% in the ISSF group (p = 0.357). Compared to the Sun's procedure group, the ISSF group had significantly shorter surgical duration, cardiopulmonary bypass time, circulatory arrest time, mechanical ventilation time, and aortic cross-clamp time (p < 0.05). Additionally, intraoperative blood loss was lower in the ISSF group than in the Sun's procedure group (p < 0.05). Patients who underwent ISSF also had a lower incidence of postoperative complications, including lung injury, renal failure, peripheral nerve injury, and chylothorax, than those who underwent Sun's procedure (p < 0.05). During the 6-month follow-up period after surgery, both groups showed significant improvements in the true lumen diameter of the descending thoracic aorta post-operation compared with the pre-operation measurements; meanwhile, the false lumen diameter decreased (p < 0.05). ConclusionsThe ISSF technique appears to be an effective and safe alternative to conventional surgical procedures for patients with type A aortic dissection, with the potential to simplify the procedure, shorten the operation time, and yield satisfactory operative results. However, further investigation is needed to determine its long-term benefits.

Visceral Aorta Electrocautery Septotomy to Allow Branched Endovascular Aortic Repair in Ruptured Chronic Post-Dissection Thoraco-Abdominal Aneurysm.

Endovascular repair of chronic post-dissection thoraco-abdominal aortic aneurysms (PD-TAAA) presents specific technical challenges due to the presence of chronic septum. Small true lumen diameter and false lumen visceral vessel origin can make branched endograft prohibitive. Septotomy may allow to overcome these challenges in cases of high complex anatomy. We describe the application of electrocautery septotomy to the visceral aorta segment to deploy an off-the-shelf branched endograft in a chronic PD-TAAA rupture with true lumen collapse. Electrocautery septotomy can be an effective adjunctive technique to facilitate branched endograft, overcoming technical challenges associated with the endovascular treatment of chronic PD-TAAA. Electrocautery septotomy is an adjunctive technique that can facilitate endovascular treatment of post-dissection thoraco-abdominal aneurysm. By creating a common lumen, this technique might reduce the number of re-interventions associated with PD-TAAA endovascular exclusion.

Clinical outcomes and aortic remodeling after Castor single-branched stent-graft implantation for type B aortic dissections involving left subclavian artery.

The left subclavian artery (LSA) can be intentionally covered by a stent graft to acquire adequate landing zones for a proximal entry tear near the LSA during thoracic endovascular aortic repair (TEVAR). The Castor single-branched stent graft is designed to treat type B aortic dissection (TBAD) to retain the LSA during TEVAR. This study investigates clinical outcomes, aortic remodeling, and abdominal aortic perfusion patterns after TEVAR with the novel Castor device. From November 2020 to June 2023, 29 patients with TBAD involving the LSA were treated with the Castor single-branched stent graft. In-hospital clinical outcome and aortic computed tomography angiography (CTA) data were analyzed. CTA was performed preoperatively and at follow-up to observe stent morphology; branch patency; endoleak; change in true lumen (TL), false lumen (FL), and transaortic diameters; and abdominal aortic branch perfusion pattern. The technical success rate was 96.6%. One failure was that the branch section did not completely enter the LSA and the main body migrated distally. No in-hospital mortality, paraplegia, or stroke occurred. During follow-up, one type Ib endoleak, four distal new entry tears, and one recurrent type A dissection arose from a new entry tear at the ascending aorta, no stent migration was observed, and the branch patency rate was 100%. At the thoracic aorta, TL diameters significantly increased, FL diameters markedly decreased, and FL was partially or completely thrombosed in most patients at follow-up. At the abdominal aorta, we observed 33.3% of TL growth and 66.7% of TL stabilization or shrinkage. The initial TL ratio at iliac bifurcation negatively predicted abdominal TL growth after TEVAR with a cutoff of 21.0%. Of the 102 abdominal aortic branches, 94.1% of the branches showed no change in perfusion pattern, 3.9% of the branches had an increased TL perfusion, and 2.0% of the branches had an increased FL contribution. The Castor unibody single-branched stent graft offers an efficient endovascular treatment for TBAD involving the LSA. TEVAR with the Castor device effectively induced thoracic FL thrombosis and thoracic TL enlargement and resulted in abdominal TL growth when the initial TL ratio at iliac bifurcation is less than 21.0%. Abdominal aortic branch perfusion patterns remain relatively stable after TEVAR with the Castor stent graft.

Evidence-based frozen elephant trunk practice: a narrative review.

The frozen elephant trunk (FET) allows a single-stage repair of complex arch pathologies due to its stented and non-stented hybrid prosthesis (HP) features. FET inherently has its own related complications including distal stent graft-induced new entry (dSINE), failure of aortic remodelling, endoleak, reintervention, and kinking of the stent. The aim of this narrative review is to discuss the latest evidence regarding the postoperative clinical outcomes of the FET procedure. Another aim is to provide an overview of results achieved using different FET devices on the global arch prostheses market. A comprehensive literature search was conducted using multiple electronic databases to identify and extract the relevant data and information. This review found that the literature reported a 5-12% mortality rate post-FET, with varying figures depending on the prosthesis type. Between 0-18.2% of patients developed dSINE, while 0.1-28% developed endoleak. Reintervention occurred in 0-28% of patients and the incidence of kinking has been quoted between 0-8% in the literature. Reporting aortic remodelling rates was challenging due to the lack of standardisation and various measurements reported; however, all studies included in this review reported relative increase in true lumen diameter, reduction in the false lumen diameter, and/or false lumen thrombosis. In conclusion, FET can achieve a favourable postoperative profile in terms of survival, complications and aortic remodelling, and remains the gold-standard treatment for thoracic aortic pathologies implicating the arch and descending thoracic aorta.

The Role of Endovascular Repair Timing in Uncomplicated Acute Type B Intramural Hematoma Management

With favorable results of thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated acute type B intramural hematoma (uTBIMH), TEVAR is increasingly utilized in the management of patients with uTBIMH. However, optimal timing for intervention has not been decided. This study aimed to compare the efficacy of acute and delayed TEVAR in patients with uTBIMH. We included patients with uTBIMH who underwent TEVAR between October 2014 and December 2021. The participants were divided into the acute TEVAR (aTEVAR) and delayed TEVAR (dTEVAR) groups. We analyzed the total aortic diameter (TAD)/true lumen diameter (TLD) ratio on computed tomography angiography (CTA) and aortic-related adverse events and all-cause mortality (AREM). We included 34 individuals with uTBIMH, among which 20 underwent aTEVAR and 14 underwent dTEVAR. We observed no significant differences in baseline characteristics between both groups. However, compared with the aTEVAR group, better aortic remodeling was achieved in the dTEVAR group before discharge (1.32±0.11 vs. 1.21±0.09, P=0.005) and at the 1-year follow-up (1.18±0.09 vs. 1.10±0.04, P=0.034). Although the 30-day and 1-year follow-up outcomes of AREM were not significantly different, the Kaplan-Meier analysis showed that AREM incidence in the dTEVAR group was significantly lower than that in the aTEVAR group (85.7% for dTEVAR vs. 65.0% for aTEVAR, log-rank P=0.20). Moreover, subgroup analysis revealed a significant difference in the TAD/TLD ratio between the aTEVAR and dTEVAR groups in individuals without a focal intimal disruption (1.33±0.11 vs. 1.17±0.09, P=0.008). For individuals with uTBIMH, delaying TEVAR by>7days improved aortic remodeling and lowered the incidence of early AREM. Additionally, the absence of focal intimal disruption on preoperative CTA supports delayed intervention.

Standing the test of time: total aortic remodeling 13 years after TEVAR for acute type B aortic dissection

Long-term outcome after thoracic endovascular aortic repair (TEVAR) of acute type B aortic dissection (aTBAD) is still underreported in current literature. This case report shows persistence of aortic remodeling without secondary complication or need of reintervention 13 years after TEVAR. A 45-year-old woman was referred to the emergency room with aTBAD. Due to early diameter progression in combination with therapy-refractory pain and uncontrolled hypertension, TEVAR was performed. Hereafter, the patient showed complete remodeling of the descending thoracic aorta without persistent false lumen perfusion in this segment and with stable true and false lumen diameter in the untreated abdominal segment for a 13-year period. No aortic-related reintervention was needed. With contemporary devices and adapted therapy, TEVAR seems able to treat complex thoracic disease. Long-term follow-up (FU) is mandatory to monitor the efficacy and durability of endovascular treatment in aortic disease.

3D Printing-Assisted versus Conventional Extracorporeal Fenestration Tevar for Stanford Type B Arteries Dissection with Undesirable Proximal Anchoring Zone: Efficacy Analysis

Background: To compare the outcomes of two Thoracic Endovascular Aortic Repair (TEVAR) techniques of Left Subclavian Artery (LSA) reconstruction for Stanford Type B Aortic Dissection (TBAD) patients with undesirable proximal anchoring zone. Methods: We retrospectively reviewed 57 patients with TBAD who underwent either three dimensional (3D)-printing-assisted extracorporeal fenestration (n = 32) or conventional extracorporeal fenestration (n = 25) from December 2021 to January 2023. We compared their demographic characteristics, operative time, technical success rate, complication rate, secondary intervention rate, mortality rate, and aortic remodeling. Results: Compared with the conventional group, the 3D-printing-assisted group had a significantly shorter operative time (147.84 ± 33.94 min vs. 223.40 ± 65.93 min, p &lt; 0.001), a significantly lower rate of immediate endoleak (3.1% vs. 24%, p = 0.048) and a significantly higher rate of true lumen diameter expansion in the stent-graft segment (all p &lt; 0.05), but a significantly longer stent graft modification time (37.63 ± 2.99 min vs. 28.4 ± 2.12 min, p &lt; 0.001). There were no significant differences in other outcomes between the two groups (p &gt; 0.05). The degree of false lumen thrombosis was higher in the stent-graft segment than in the non-stent-graft segment in both groups and the difference was statistically significant (X2 = 5.390, 4.878; p = 0.02, 0.027). Conclusions: Both techniques are safe and effective for TBAD with an undesirable proximal landing zone. The 3D-printing-assisted extracorporeal fenestration TEVAR technique has advantages in operative time, endoleak risk, and aortic remodeling, while the traditional extracorporeal fenestration TEVAR technique has advantages in stent modification.

Preoperative diameters of aorta influence the remodeling after surgery for type A aortic dissection.

Although current research revealed the preoperative diameter of the aorta is related to aortic remodeling, prognosis should consider the true lumen (TL) and false lumen (FL) respectively too. The cohort of this retrospective analysis included 161 type A aortic dissection (TAAD) patients who underwent surgery at a single institution from September 1, 2017, to September 1, 2018. Computed tomography angiography (CTA) images were reviewed to assess changes of the diameters of the TL, FL and total aorta at the levels of the stented segment, distal end of the stent, celiac trunk, and below the renal artery. During the study period, positive remodeling was observed in 33 (20.5%) patients. The probability of negative remodeling far from the stent segment was greater than the aorta close to the stent. Only the TL diameter was associated with each levels' changes and underwent significant change (P<0.05). Multivariate analysis identified aortic regurgitation as a risk factor for remodeling in the distal end of the stent. The maximum diameter of the FL was the only risk factor related to the remodeling type (odds ratio =0.10; 95% confidence interval: 0.01-0.51), a maximum diameter of the FL of >1.28 cm was associated with a higher probability of negative remodeling after surgery (specificity =0.994; sensitivity =0.571; area under the receiver operating characteristic curve =0.76). The TL and FL diameters on preoperative CTA images can be used to assess the risk of negative remodeling after surgery.

Aortic Remodeling Following Hybrid Arch Repair for Complex Arch and Proximal Descending Thoracic Aortopathies

Hybrid aortic arch repair involves debranching of the great vessels to create a zone 0 proximal landing zone for simultaneous or staged thoracic endovascular aortic repair (TEVAR) as a less invasive therapy for complex arch and descending thoracic aortopathies. Data on thoracoabdominal aortic remodeling following hybrid arch repair remains scarce. We aimed to evaluate short-term remodeling of the thoracoabdominal aorta following hybrid arch repair. All patients (n = 38) undergoing hybrid arch repair with planned zones 0 to 5 TEVAR from January 2020 to March 2022 were retrospectively reviewed. Computed tomography angiography scans preoperatively, after TEVAR, and at the 3- to 6-month follow-up were analyzed for thoracoabdominal aorta remodeling. Aortic true lumen diameter (TLD) for dissections and full lumen diameter for aneurysms were recorded at 12 anatomical levels: left subclavian artery, tracheal carina, left inferior pulmonary vein, inferior left atrium, diaphragm, celiac trunk, superior mesenteric artery, renal arteries, aortic bifurcation, and common iliac arteries. Visceral vessel origin from true/false lumen and extent of false lumen thrombosis were assessed. Mean change in aortic TLD was calculated at every level and paired-samples t test was used to compare means. Of 38 patients, 37 had follow-up imaging at a mean duration of 6 months (mean age, 57.9 ± 10.0 years; 30 males [78.9%]) and one (2.6%) mortality (Table). Four (10.5%) presented with aneurysms (0, 3), 26 (68.4%) with type A aortic dissection (0, 3), and 8 (21.1%) with type B aortic dissection (1, 10). In aneurysm patients (n = 4), there was one postoperative death (2.6%) due to cardiac arrest before staged TEVAR; the remaining three had stable aneurysm sacs without endoleak at last follow-up. For dissection patients, at a mean follow-up of 6 months, there was significant increase in the mean TLD at each level (P < .05), except zones 9 and 10. The largest increase in mean TLD was observed at the left subclavian artery (+5.19 mm; 95% confidence interval [CI], 2.63-7.76), tracheal carina (+6.78 mm; 95% CI, 3.04-10.53), and lower left atrium (+4.49 mm; 95% CI, 2.01-6.97). The left renal artery was the most common vessel originating from the false lumen (14 [36.8%] pre- and post-TEVAR); followed by the right renal artery (7 [18.4%] pre-TEVAR and 5 [13.2%] post-TEVAR). Visceral perfusion remained intact following TEVAR in all patients. False lumen thrombosis to distal zone 5 was observed in 100% of the dissection patients. Hybrid arch repair with zone 0 to 5 TEVAR provides adequate aneurysm exclusion and positive aortic remodeling down to zone 8 in the short term with improved TLD and high rate of false lumen thrombosis. When involved, zones 9 to 11 may require adjunctive or alternative branched or fenestrated strategies for total aortic remodeling and complete false lumen obliteration.TableSummary of included patients and measurements at various anatomic levelsVariableNo. of patients (%); n = 38Patient characteristics Age, years57.9 ± 10.0 Male30 (78.9) Diabetes mellitus11 (28.9) Hypertension35 (92.1) Dyslipidemia19 (50.0) Cerebrovascular disease4 (10.5) Dialysis1 (2.6) Chronic obstructive pulmonary disease7 (18.4) Smoking history22 (57.9) Prior coronary artery bypass grafting3 (7.9) Aortic aneurysm4 (10.5) Type A aortic dissection26 (68.4) Type B aortic dissection8 (21.1) Prior valve surgery10 (26.3) Mortality1 (2.6)Aortic remodeling dataLevelPreoperative true lumen measurements, mmPost-TEVAR true lumen measurements (mean follow-up 6 months), mmRemodeling over mean follow-up of 6 monthsMinMaxMean ± SDVessel origin from false lumenFalse lumen partial thrombosisFalse lumen full thrombosisMinMaxMean ± SDVessel origin from false lumenFalse lumen partial thrombosisFalse lumen full thrombosisMean Change (95% CI) [% change]P valueLeft subclavian artery11.248.322.25 ± 8.83---15.938.427.44 ± 5.33---5.19 (2.63-7.76) [+23.3%].001*Carina3.460.919.78 ± 11.05---3.340.126.59 ± 7.28---6.78 (3.04-10.53) [+34.3%].001*LIPV6.567.317.45 ± 10.61---7.93623.16 ± 6.31---4.27 (0.85-7.69) [+24.5%].016*Left atrium4.966.216.89 ± 11.03---5.461.221.33 ± 9.30---4.49 (2.01-6.97) [+26.6%].001*Diaphragm6.634.715.75 ± 7.15---6.549.119.03 ± 8.22---3.28 (1.53-5.04) [+20.9%].001*Celiac trunk2.828.113.92 ± 6.574 (10.5)25 (65.8)0 (0.0)5.928.915.49 ± 6.204 (10.5)14 (36.8)2 (5.3)2.57 (0.86-4.27) [+18.4%].005*SMA3.427.113.77 ± 5.963 (7.9)24 (63.2)0 (0.0)6.330.114.94 ± 5.673 (7.9)17 (44.7)1 (2.6)1.17 (0.20-2.15) [+8.5%].020*RRA3.126.313.08 ± 6.147 (18.4)24 (63.2)0 (0.0)6.728.614.46 ± 5.645 (13.2)13 (34.2)1 (2.6)1.38 (0.18-2.58) [+10.6%].025*LRA3.130.712.78 ± 6.4714 (36.8)22 (57.9)0 (0.0)6.328.613.80 ± 5.4614 (36.8)13 (34.2)2 (5.3)1.02 (0.02-2.02) [+8.0%].046*Aortic bifurcation7.328.114.06 ± 5.83---7.830.114.45 ± 4.99---0.39 (−0.83 – 1.62) [+2.8%].518RCIA3.517.510.82 ± 3.76---2.717.710.44 ± 3.46---−0.38 (−1.36 – 0.61) [-3.5%].443LCIA3.315.610.28 ± 3.72---3.616.410.67 ± 3.63---0.28 (−0.29 – 0.86) [+2.8%].317LCIA, left common iliac artery; LIPV, left inferior pulmonary vein; LSCA, left subclavian artery; RRA, right renal artery; LRA, left renal artery; RCIA, right common iliac artery; SD, standard deviation SMA, superior mesenteric artery; TEVAR, thoracic endovascular aortic repair. 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Bare Stent Fracture After TEVAR With the Modified Restrictive Bare Stent (RBS) Technique in Type B Aortic Dissections.

The aim was to assess the mid-term aortic remodeling and bare-metal stent (BMS) integrity of the restricted bare stent (RBS) technique reconstruction in aortic dissections. This retrospective cohort study included prospectively collected patients treated with the modified RBS technique between 2017 and 2020. The preoperative, postoperative, and last follow-up computed tomographic (CT) scans were analyzed in the centerline at the mid-descending, celiac trunk (CeT), and the mid-abdominal levels for false lumen (FL) patency, aortic diameter, and true lumen (TL) diameter changes. Bare-metal stent integrity was assessed in the 3-dimensional multiplanar reformats. The median follow-up of the cohort (n=17) was 26 (11, 45) months. The procedure was mainly performed with the Relay NBS endograft (15/17; 88%) + E-XL BMS (17/17; 100%). Postoperative mortality, paraplegia, stroke, renovisceral vessel loss, and type I and III endoleaks were not observed. BMS fractured in 6 patients (6/17; 36%), damaged the dissection flap in 4/17 (24%), and led to the reperfusion of the FL and re-interventions with TEVAR (4/17; 24%). Two patients without FL reperfusion showed stable CT follow-ups 13 and 17 months after the fracture diagnosis. The TL expansion was seen at all landmarks and peaked in the thoracic aorta (+10; 6, 15; p<0.001). The FL thrombosis after modified RBS was only relevant in the thoracic aorta (p<0.001) and at CeT (p=0.003). The aortic diameter was stable in the thoracic aorta and increased at distal landmarks (CeT [+5; 1, 10; p=0.001]; mid-abdominal [+3; 1, 5; p=0.004]). The modified RBS technique could not stop aortic growth below the diaphragm and prevent new membrane rupture due to the fractures of the BMS and consecutive flap damage with the reperfusion of the FL. The treatment of complicated type B aortic dissections with TEVAR has become a standard. Particularly, patients with true lumen collapse and malperfusion may benefit from a more aggressive treatment strategy including proximal TEVAR and distal bare-metal stent implantation to re-open the true lumen and to prevent distal stent-induced new entry. However, this study reports the challenges of this approach with a high rate of bare-metal stent fractures during the follow-up. The fractures that occurred at the site of vertical nitinol bridges led to the dissection membrane ruptures and the reperfusion of the false lumen with consecutive dilatation. A close follow-up is mandatory to detect this complication and to treat the patients with TEVAR extension.

Application of "Fabulous" stent system to improve aortic remodeling after TEVAR for type B aortic dissection.

Application of "Fabulous" stent system to improve aortic remodeling after TEVAR for type B aortic dissection.

Favorable Remodeling After TEVAR in Uncomplicated Acute and Subacute Type B Aortic Dissection in Comparison to Conservative Treatment: A Midterm Analysis

Purpose: The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period. Materials and Methods: Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints. Results: In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was −5 mm (interquartile range [IQR]=−28 to 8 mm), –11 mm (IQR=−53 to 10 mm), and 7 mm (IQR=−13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen. Conclusions: Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling. Clinical Impact In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years.

Morphological parameters affecting false lumen thrombosis following type B aortic dissection: a systematic study based on simulations of idealized models

Type B aortic dissection (TBAD) carries a high risk of complications, particularly with a partially thrombosed or patent false lumen (FL). Therefore, uncovering the risk factors leading to FL thrombosis is crucial to identify high-risk patients. Although studies have shown that morphological parameters of the dissected aorta are related to FL thrombosis, often conflicting results have been reported. We show that recent models of thrombus evolution in combination with sensitivity analysis methods can provide valuable insights into how combinations of morphological parameters affect the prospect of FL thrombosis. Based on clinical data, an idealized geometry of a TBAD is generated and parameterized. After implementing the thrombus model in computational fluid dynamics simulations, a global sensitivity analysis for selected morphological parameters is performed. We then introduce dimensionless morphological parameters to scale the results to individual patients. The sensitivity analysis demonstrates that the most sensitive parameters influencing FL thrombosis are the FL diameter and the size and location of intimal tears. A higher risk of partial thrombosis is observed when the FL diameter is larger than the true lumen diameter. Reducing the ratio of the distal to proximal tear size increases the risk of FL patency. In summary, these parameters play a dominant role in classifying morphologies into patent, partially thrombosed, and fully thrombosed FL. In this study, we point out the predictive role of morphological parameters for FL thrombosis in TBAD and show that the results are in good agreement with available clinical studies.

Factors Affecting False Lumen Thrombosis In Type B Aortic Dissection.

Complete thrombosis of the false lumen facilitates remodeling of type B aortic dissection (TBAD). Morphological characteristics affect thrombosis in the false lumen. Discuss the factors present before admission that influence false lumen thrombosis in patients with TBAD. We studied 282 patients diagnosed with TBAD in our hospital between January 2008 and December 2017. We divided the subjects into a thrombotic group and a non-thrombotic group based on whether any thrombus was detectable in the false lumen. We analyzed the differences between the two groups with respect to clinical data, the vertical length of the dissection, and the diameter of the aorta. P values < 0.05 were considered statistically significantly different. Significant differences between the thrombotic group and non-thrombotic group were found with respect to age (53.92 ± 11.40 vs. 50.36 ± 10.71, p = 0.009) and proportion of patients with renal insufficiency (7.83% vs. 16.38%, p = 0.026). In zones 3-9, the true lumen diameter of the thrombotic group was significantly larger than in the non-thrombotic group (p < 0.05). Binary logistic regression analysis showed that true lumen diameter in zone 5 and renal insufficiency were independent predictors of false lumen thrombosis. Age and renal function were associated with thrombosis in the false lumen. Potentially, the difference between the diameter of the true lumen diameter and that of the false lumen may influence the thrombosis of the false lumen.

Case-Control Study of 3D Morphology in Isolated Mesenteric Artery Dissection.

Isolated mesenteric artery dissection (IMAD) is uncommon and has not been investigated in detail. This study aimed to accurately identify the morphological differences of IMAD patients with control individuals using a detailed 3D volumetric analysis. In this retrospective case-control study, cases were patients with acute symptomatic IMAD treated in a French intestinal stroke center between January 2016 and November 2019. Case-control matching was (1:3) by age, gender, and body mass index (BMI). The semi-automatic morphological analysis of the mesenteric artery included volumetric measurements of the true and false lumen size, the centerline curvature and the 3D aortomesenteric angles. Seventeen IMAD cases (mean age 56 ± 4years, 94% men) were matched with 51 controls. The mean overall lumen (OL) volume was higher in IMAD patients as compared to controls (+ 64%, p < 0.001). In the same way, the mean OL cross-sectional area and diameters were higher in IMAD patients: + 77% for OL area (< 0.001) and + 34% for OL diameters (< 0.001). Meanwhile, no significant difference was found in terms of true lumen (TL) volume (p = 0.16) or cross-sectional area (p = 0.30) between IMAD patients and controls, whereas the mean TL diameter was lower in the IMAD group (p < 0.05). Patients with acute mesenteric ischemia had a lower [TL/OL volume] ratio (45% vs. 59%, p < 0.05) and longer dissections (63mm vs. 48mm, p < 0.01). The 3D aortomesenteric angle was significantly higher in IMAD patients at both 2cm (p < 0.01) and 4cm (p < 0.05) from the ostium. Using an original 3D semi-automated analysis, this study shows that IMAD induces significant morphological changes compared to control individuals: a larger aortomesenteric 3D angle, an increased overall volume and area. IMAD patients with acute mesenteric ischemia presented with a more severe morphological profile.