Dissection In Patients Research Articles

A Comparison of the Clinical Outcomes of Thoracic Endovascular Repair for Acute Type B Aortic Dissection with Multichanneled and Double-Channeled Morphology

In this study, we aim to investigate the clinical features and outcomes of multichanneled aortic dissection (MCAD) and double-channeled aortic dissection (DCAD) in acute type B aortic dissection (TBAD) patients who underwent thoracic endovascular aortic repair (TEVAR).In total, 479 consecutive acute TBAD patients treated with TEVAR from April 2002 to May 2020 were retrospectively enrolled in this study. The MCAD group was defined as those of multichanneled morphology by initial computed tomography angiography (CTA) (n = 61), whereas the DCAD group was defined as those with double-channeled morphology by initial CTA (n = 418). The clinical and morphological characteristics and short-term and long-term adverse events (30-day and > 30 days) were recorded and evaluated.No significant differences were noted between the 2 groups as regards demographics, comorbidity profiles, or initial feature of CTA. The incidence of true lumen compression was found to be significantly lower in the MCAD group compared with the DCAD group (8.2% versus 20.8%, P < 0.05). During the 65.37 ± 40.06 months of follow-up, there were no statistically significant differences in terms of 30-day mortality or the incidence of early adverse events between the 2 groups. The incidence rates of 5-year cumulative freedom from all-cause mortality and 5-year cumulative freedom from AD-related mortality were not significantly different between the MCAD and DCAD groups, whereas the 5-year cumulative freedom from adverse events were lower in the MCAD group compared to DCAD group (51.1% versus 72.5%, P < 0.05). In multivariate Cox regression models, only age > 60 years, pleural effusion, branch involvement, and length of the stent were independent predictors of mortality, whereas age > 60 years, pulse, pleural effusion, true lumen compression, widest diameter of the descending aorta, branch involvement, and length of stent were independent predictors of adverse aortic events.No significant difference was noted between the MCAD and DCAD groups in the 5-year mortality following, whereas patients with MCAD were found to have significantly lower AD-related events than patients with DCAD in long-term follow-up.

Omission of axillary lymph node dissection in patients with ypN+ breast cancer after neoadjuvant chemotherapy: A retrospective multicenter study (KROG 21-06)

BackgroundWe evaluated the impact of omitting axillary lymph node dissection (ALND) on oncological outcomes in breast cancer patients with residual nodal disease after neoadjuvant chemotherapy (NAC). MethodsThe medical records of patients who underwent NAC followed by surgical resection and had residual nodal disease were retrospectively reviewed. In total, 1273 patients from 12 institutions were included; all underwent postoperative radiotherapy. Axillary surgery consisted of ALND in 1103 patients (86.6%) and sentinel lymph node biopsy (SLNBx) alone in 170 (13.4%). Univariate and multivariate analyses of disease-free survival (DFS) and overall survival (OS) were performed before and after propensity score matching (PSM). ResultsThe median follow-up was 75.3 months (range, 2.5–182.7). Axillary recurrence rates were 4.8% in the ALND group (n = 53) and 4.7% in the SLNBx group (n = 8). Before PSM, univariate analysis indicated that the 5-year OS rate was inferior in the ALND group compared to the SLNBx group (86.6% vs. 93.3%, respectively; P = 0.002); multivariate analysis did not show a difference between groups (P = 0.325). After PSM, 258 and 136 patients were included in the ALND and SLNBx groups, respectively. There were no significant differences between the ALND and SLNBx groups in DFS (5-year rate, 75.8% vs. 76.9%, respectively; P = 0.406) or OS (5-year rate, 88.7% vs. 93.1%, respectively; P = 0.083). ConclusionsSLNBx alone did not compromise oncological outcomes in patients with residual nodal disease after NAC. The omission of ALND might be a possible option for axillary management in patients treated with NAC and postoperative radiotherapy.

Thyroid hormone, cortisol, interleukin-2, and procalcitonin regulate postoperative delirium in acute type A aortic dissection patients

BackgroundWe assessed the relationships between levels of preoperative thyroid hormone (TH), cortisol, interleukin-2 (IL-2), and procalcitonin (PCT) and postoperative delirium (POD) in acute type A aortic dissection (ATAAD) patients receiving modified triple-branched stent-graft (MTBSG) implant surgeries.MethodsATAAD patients received MTBSG implant surgeries in our hospital between February 2019 and December 2020 were recruited. We separated them into a POD and non-POD cohort and employed univariable and multivariable regression analysis to establish independent correlations between preoperative THs, cortisol, IL-2, and PCT and POD. In addition, we conducted stratification analyses to examine the link between pre-surgical THs and POD in normal TSH and lower TSH subgroups.ResultsPOD occurred in 78 of 224 patients (34.8%). POD patients exhibited markedly reduced preoperative free triiodothyronine (FT3) (P = 0.008) and free thyroxine (FT4) (P = 0.023) levels, while remarkably enhanced preoperative cortisol (P < 0.001), IL-2 (P < 0.001), and PCT (P < 0.001) levels. Based on multivariate regression analysis, reduced preoperative FT3 (P = 0.032), as well as augmented preoperative IL-2 (P = 0.001), cortisol (P < 0.001), and PCT (P = 0.016) were strong stand-alone risk factors for POD. Moreover, subgroup analysis found the association between FT3 (P = 0.029), FT4 (P = 0.042) and POD was both significant in patients with normal TSH levels.ConclusionsReduced preoperative FT3 and elevated preoperative cortisol, IL-2, and PCT were strong indicators of POD in ATAAD patients. Hence, we recommend that the thyroid function, cortisol, PCT, and IL-2 should be evaluated prior to surgery in ATAAD patients.

A retrospective study of thoracic endovascular aortic repair timing in patients with uncomplicated type B dissection who have a smoking history.

To determine the optimal timing of thoracic endovascular aortic repair (TEVAR) for patients with uncomplicated type B dissections who have a smoking history. Data from 308 consecutive patients with uncomplicated type B dissections, who have a smoking history and onset-to-TEVAR time within 90 days, were analyzed. The patients were divided into two groups: Acute and subacute phases. Univariate and multivariate regression analyses were performed. Smooth curve fitting and threshold analysis were performed to characterize the relationship between the onset-to-TEVAR time and follow-up deaths. There were no significant differences between the two groups. Smooth curve fitting and threshold effect analysis showed that if early TEVAR was performed within 9.4 days from onset, there was better long-term survival and there was no significant difference after 9.4 days. By studying the relationship between onset-to-TEVAR time and all-cause mortality, we found that early TEVAR may have a lower all-cause mortality rate during follow-up in uncomplicated type B dissection patients who have a smoking history and within 90 days from onset.

Individualized exercise prescription and cardiac rehabilitation following a spontaneous coronary artery dissection or aortic dissection.

Prescribed aerobic-based exercise training is a low-risk fundamental component of cardiac rehabilitation (CR). Secondary prevention therapeutic strategies following a spontaneous coronary artery dissection (SCAD) or aortic dissection (AD) should include CR. Current exercise guidance for post-dissection patients recommends fundamental training components including target heart rate zones are not warranted. Omitting fundamental elements from exercise prescriptions risks safety and makes it challenging for both clinicians and patients to understand and implement recommendations in real-world practice. We review the principles of exercise prescription for CR, focusing on translating guidelines and evidence from well-studied high-risk CR populations to support the recommendation that exercise testing and individualized exercise prescription are important for patients following a dissection. When patients self-perceive exercise intensity there is a tendency to underestimate intensities within metabolic domains that should be strictly avoided during routine exercise training following a dissection. However, exercise testing associated with CR enrolment has gained support and has not been linked to adverse events in optimally medicated post-dissection patients. Graded heart rate and blood pressure responses recorded throughout exercise testing provide key information for developing an exercise prescription. An exercise prescription that is reflective of medical history, medications, and cardiorespiratory fitness optimizes patient safety and yields improvements in blood pressure control and cardiorespiratory fitness, among other benefits. This clinical practice and education article demonstrates how to develop and manage a CR exercise prescription for post-acute dissection patients that can be safe and effective for maintaining blood pressure control and improving cardiorespiratory fitness pre-post CR.

Survival impact of the number of lymph nodes dissection in patients receiving neoadjuvant chemotherapy for esophageal squamous cell carcinoma.

This study aimed to investigate the survival impact of the number of lymph nodes dissection (LND) in patients receiving neoadjuvant chemotherapy (NCT) for esophageal squamous cell carcinoma (ESCC). We retrospectively analyzed the clinical pathological data and survival of 407 ESCC patients who underwent esophagectomy after NCT between January 2015 and December 2016. The relationship between the number of LNDs and 5-year overall survival (OS) or disease-free survival (DFS) was plotted by using restricted cubic spline analysis. A Cox proportional hazards regression model was used to identify prognostic factors of OS and DFS. We observed an obvious non-linear relationship between LND and the hazard ratios (HRs) for OS (P = 0.0015) and DFS (P < 0.001) of all the patients. In the multivariate analysis of OS and DFS, the number of LNDs (greater than 28 and less than 46) had a significant protective effect on survival (OS: HR: 0.61, 95% CI: 0.42-0.88, P = 0.007; DFS: HR: 0.50, 95% CI: 0.36-0.70, P < 0.001). For patients with nodal metastases, it was also an independent prognostic factor for OS (HR, 0.56, 95% CI, 0.35-0.90, P = 0.017) and DFS (HR, 0.42, 95% CI, 0.28-0.65, P < 0.001). Some degree of lymphadenectomy after NCT was beneficial in improving 5-year OS and DFS for ESCC patients with nodal metastases. For patients with nodal negativity, more extended lymphadenectomy did not improve patient survival.

Efficacy and Safety of Exercise Testing and Rehabilitation for Aortic Dissection Patients: A SCOPING REVIEW.

Although physical exercise has established benefits for long-term cardiovascular health, concern regarding further aortic events has limited the evidence for exercise among aortic dissection (AD) patients. The objective was to perform a scoping review of the current concepts and gaps in the literature regarding the benefit and safety of cardiovascular testing and rehabilitation among post-AD patients. A scoping review of the literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Eligibility criteria included any studies with AD in relation to exercise rehabilitation or testing and physical or mental health. Electronic databases were queried for relevant studies (last queried, November 1, 2021). Six observational studies were included with a total of 381 patients with AD, all of whom underwent surgical intervention. Study heterogeneity prevented data synthesis and a formal systematic review, although four dominant themes emerged: cardiovascular-related outcomes, aorta-related outcomes, quality of life (QoL), and serious adverse events. Patients with AD have reduced baseline physical capacity and QoL. Rehabilitation programs may increase both physical status and QoL. Rates of serious adverse rates are minimal yet poorly defined. Within the context of apparent benefits from cardiovascular testing and rehabilitation for patients with AD who have undergone intervention, this scoping review highlights the need for increased comparative research specific to exercise among patients with AD and outcomes such as mortality and reinterventions.

Nanocarbon or indocyanine green: Which is superior for gasless transaxillary endoscopic thyroidectomy to protect the parathyroid gland?

Damage to the parathyroid glands remains a frequent complication after thyroidectomy, often resulting in hypoparathyroidism. Accordingly, identifying the parathyroid glands during thyroid surgical procedures is indispensable to prevent accidental surgical removal. The participants were randomly divided into three groups (indocyanine green [ICG], nanocarbon [NC], and control group). To identify and protect parathyroid glands during neck lymph node dissection in patients with thyroid cancer, IG was intravenously administered to the ICG group, whereas the NC group received an intra-thyroid injection of the NC suspension before dissection. IG was intravenously administered to each group after dissection. Subsequently, we analyzed surgical outcomes, including operative time, number of lymph nodes, serum calcium, and number of parathyroid glands. We included 30 patients who underwent gasless transaxillary endoscopic thyroidectomy for thyroid cancer. Based on our findings, a greater number of parathyroid glands (P < 0.01) and higher postoperative parathyroid hormone (PTH) levels were detected in the NC and ICG groups than those in the control group (P < 0.01). The number of parathyroid glands and postoperative PTH levels in the NC group were higher than those in the ICG group (P < 0.01). Gasless transaxillary endoscopic thyroidectomy with NC and ICG for thyroid cancer could effectively protect the parathyroid gland and afford satisfactory clinical efficacy. NC could offer an advantage over ICG for protecting the parathyroid gland.

Phase 2 Single-arm Trial of Primary Retroperitoneal Lymph Node Dissection in Patients with Seminomatous Testicular Germ Cell Tumors with Clinical Stage IIA/B (PRIMETEST)

BackgroundPrimary retroperitoneal lymph node dissection (RPLND) for clinical stage (CS) IIA/B seminoma without adjuvant treatment is an experimental treatment to avoid radiotherapy- or chemotherapy-related toxicity from standard treatment. ObjectiveThe PRIMETEST trial aimed to prospectively evaluate the oncological efficacy and surgical safety of primary RPLND. Design, setting, and participantsPRIMETEST is a single-arm, single-center prospective phase 2 trial. Patients with seminoma, unilateral retroperitoneal lymph node metastases <5 cm, and human chorionic gonadotropin levels <5 mU/ml were included. Patients with CS IIA/B seminoma at initial diagnosis, and recurrence under active surveillance or following adjuvant carboplatin for CS I disease were eligible. Outcome measurements and statistical analysisUnilateral open or robot-assisted primary RPLND was performed. The primary endpoint of the study was progression-free survival (PFS) after 36 mo. The trial was considered positive if <30% of patients experienced a recurrence. Results and limitationsBetween 2016 and 2021, 33 patients were accrued (nine with primary CS IIA/B, 19 recurrences during active surveillance, and five recurrences following adjuvant carboplatin). Thirteen and 20 patients had CS IIA and IIB, respectively. Open and robot-assisted RPLND procedures were performed in 14 (42%) and 19 (58%) patients, respectively. After a median follow-up of 32 mo (interquartile range 23–46), ten recurrences were detected (30%, 95% confidence interval: 16–49%); thus, the primary endpoint was not met. Infield recurrences occurred in three of ten patients. The current analysis of risk factors could not identify the predictors of recurrence. Three of 33 patients (9%) presented with pN0. ConclusionsThe PRIMETEST trial did not meet its primary endpoint. Nevertheless, PFS of 70% after a median follow-up of 32 mo suggests this approach to be of interest for highly selected patients. Selection criteria, however, need to be defined and validated in a larger prospective cohort of patients. Until then, surgery alone for the treatment of patients with CS IIA/B seminoma cannot be recommended outside of a clinical trial setting. Patient summaryIn this study, we investigated primary surgery as an alternative to conventional treatment (chemotherapy or radiation therapy) in patients with metastatic seminoma. The primary objective of the study, to prevent at least 30% of patients from recurrence, was not met. However, certain patients may benefit from this approach and thereby avoid chemotherapy or radiation therapy. Predictive factors need to be analyzed to better select patients for this surgery-only approach.

Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection

BackgroundAcute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details. MethodsPatients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI. ResultsA total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001). ConclusionsAKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.

Abstract 11121: In-Hospital Outcomes of Aortic Dissection in Patients With Substance Use Disorder

Introduction: Substance Use Disorder (SUD) is a chronic relapsing disease emanating from the uncontrolled use of drugs despite devastating physical, neurologic and psychological consequences. Studies have proven an association of SUD with a variety of life-threatening cardiac conditions. Aortic dissection (AD) is an acute condition caused by a tear in the inner layer of the aorta and requires immediate intervention. Our study aimed to ascertain the in-hospital outcomes of patients with substance use disorders presenting with Aortic dissection using a national representative sample. Methods: This was a retrospective study done using the 2016-2019 National inpatient sample, ICD 10 codes were used to identify individuals who were admitted for aortic dissection who were further categorized into two groups based on a history of SUD or not. Multivariate analysis was used to control for confounders and assess in-hospital mortality and other hospital outcomes. Results: A total of 63,380 patients were admitted for Aortic dissection during the study period. 26% (16,775) of the population sample had active abuse of at least 1 substance. AD was identified in a younger age group with SUD vs those without SUD with a mean age of 57. vs 65 years respectively. 68% of patients with SUD were found to be males with the predominant race being white (56%). A higher proportion of SUD patients had co-morbid Hypertension (60%) and smoked Cigarette (92%). Comparing both groups, there was no statistical difference in in-hospital mortality (AOR 1.06, 95% CI 0.88-1.26, p=0.50). However, there was a higher risk of acute coronary syndrome (AOR 1.77, 95% CI 1.20-2.40, p= 0.01), Cardiogenic shock (AOR 1.26, 95% CI 1.01-1.57, p&lt; 0.001) and Embolic stroke (AOR 1.33, 95% CI 1.05-1.67, p=0.019) in the SUD group. We also observed no difference in the mean length of stay (adjusted coefficient 0.456, 95% CI 0.049- 0.96, p=0.077) or the mean of total hospital charges (adjusted coefficient 3882, 95% CI -10548.17- 18313.79, p= 0.60) in both groups. Conclusions: We observed that in hospitalized patients with AD, SUD is not associated with an increased risk of in-hospital mortality, however, there is a significantly increased risk of cardiogenic shock, coronary syndrome, and embolic stroke.

Abstract 14451: Mechanistic Classification and Outcomes of Isolated Aortic Regurgitation in a Contemporary Cohort of Patients

Introduction: Aortic valve regurgitation (AR) is due to leaflet disease and/or dilatation of the functional aortic annulus complex. Understanding the mechanism(s) of AR informs surgical planning of valve and aorta repair. In this study we aimed to examine the etiologies, mechanisms, and outcomes of isolated pure native severe AR in a contemporary consecutive cohort of patients. Methods: From our institutional echocardiography database, we identified all patients with native moderate-to-severe (3+) or severe (4+) AR between 2014-2019. Patients with infective endocarditis, aortic dissection, or other concomitant valve disease were excluded. AR was classified using the El-Khoury classification: Type I-normal leaflet motion (Ia = ascending aorta and sinotubular junction dilatation, Ib = aortic root dilation, Ic = aortic annular dilation), Type II-leaflet prolapse, and Type III-leaflet restriction. Valve anatomy and clinical outcomes were also extracted. Results: A total of 560 patients with at least moderate-to-severe (3+) AR were identified, 270 were excluded (92 patients for endocarditis, 152 patients for concomitant valvulopathy, 23 patients for acute aortic dissection, and 11 patients for other reasons), and 282 patients (77.3% male) were included. The most common mechanism was Type II (leaflet prolapse), idenfied in 98 (35%) patients. Multiple mechanisms of AR were identified in 164 (58%) patients. The most common combination was Type Ib (aortic root dilation) and Type II (leaflet prolapse) seen in 45 (27%) patients. Ninety-nine (35%) patients had a bicuspid aortic valve (BAV). Follow-up was available for 275 patients (98%) with a median duration of 4.7±2.4 years. Of the 158 (57%) patients who underwent surgical intervention, valve repair was performed in 77 patients (49%) and valve replacement in 80 (51%) patients. Valve intervention was more common in women (70%) than in men (54%). Conclusion: In a large contemporary cohort of patients with at least moderate to severe (3+) isolated pure native AR, Type II (leaflet prolapse) was the most common mechanism, however multiple mechanisms are present in most AR patients. Aortic valve repair now accounts for almost half of the surgical interventions for isolated AR in our center.

Distal Aortic Progression After Hemiarch, Zones 1-3 Arch Replacement in Acute Type A Aortic Dissection

BackgroundThere is debate regarding aortic arch repair extent for acute type A aortic dissection (ATAAD) patients. MethodsFrom 1996 to 2021, 756 ATAAD patients underwent open arch replacement. The cohort was divided into hemiarch (n = 481), zone 1 (n = 65), zone 2 (n = 148), and zone 3 (n = 62) arch replacement groups. Cross-group comparison of aortic growth was modeled using data from interval postoperative computed tomography or magnetic resonance imaging of the distal aorta. ResultsDemographics were not significantly different except the hemiarch group had more coronary artery disease and less stroke. Intraoperatively, zones 1, 2, and 3 had greater cardiopulmonary bypass, cross-clamp, and hypothermic circulatory arrest times and required more intraoperative blood transfusion than the hemiarch group. Perioperative outcomes were similar among groups except zone 3 had more reoperation for bleeding. Ten-year cumulative incidence of reoperation was hemiarch, 16.7%; zone 1, 16.3%; zone 2, 21.5%; and zone 3, 17.6% (P = .70). Ten-year survival was similar: hemiarch, 66%; zone 1, 60.3%; zone 2, 68.0%); and zone 3 66.1% (P = .20). Aortic arch, descending aorta, and abdominal aorta growth rates were not significantly different among groups over 10 years. In the whole cohort, the growth rate over time for aortic arch was 0.38 mm per year (P < .001), descending aorta 0.84 mm per year (P < .001), and abdominal aorta 0.69 mm per year (P < .001). ConclusionsThere was no significant difference in long-term survival, distal aorta growth, or reoperation rate for distal aortic aneurysm after hemiarch or zones 1, 2, or 3 arch replacement. Patient-specific arch replacement strategies may be used rather than defaulting to aggressive arch replacement for all ATAAD patients.

Abstract 14579: Predictors of In-Hospital Mortality in Coronary Artery Dissection Patients: An Insight From the National Inpatient Sample Database

Background: There is a paucity of data on predictors of mortality in all-cause coronary artery dissection patients. The purpose was to study the baseline characteristics, associated co-morbidities, and in-hospital mortality in coronary artery dissection patients using the Healthcare Cost and Utilization Project National Inpatient Sample database. Methods: The Healthcare Cost and Utilization Project administrative longitudinal database contains encounter-level information on inpatient stays, emergency department visits, and ambulatory surgery in all U.S. hospitals. We performed a cross-sectional analysis on 25005 patients diagnosed with coronary artery dissection during hospitalization from January 2016 to December 2018. The primary outcome was in-hospital mortality. Results: Of the total patient population, 25005 patients were found to have coronary artery dissection. All patients with ages ≥ 18 were included in the study (24980). The observed overall in-hospital mortality was 6.0% (1498 patients out of 24980). The higher mortality was observed in age group &gt;80 years when compared to the age group &lt;40 years (adjusted odds ratio: 8.5; 95% confidence interval: 5.7 to 12.4; p-value &lt; 0.01). Patients with peripheral vascular disease (adjusted odds ratio: 2.0; 95% confidence interval: 1.7 to 2.3; p-value &lt; 0.01) and cardiogenic shock (adjusted odds ratio: 10.8; 95% confidence interval: 9.5 to 12.2; p-value &lt; 0.01) showed higher mortality (Table 1,2). Conclusion: To the best of our knowledge, this is the largest population-based study investigating the predictors of in-hospital mortality in all-cause coronary artery dissection patients. Our analysis showed higher mortality with increasing age and in patients who developed cardiogenic shock and those with peripheral vascular disease.

Abstract 15236: A Systematic Review of the Quality of Life (QOL) Assessment Tools Used in Aortic Dissection in the Context of Survivorship

Introduction: The term 'survivorship' describes the therapeutic, functional, psychosocial, and financial experience of living with a chronic condition.This term acknowledges the fact that a patient’s life can be radically altered overnight because of their disease and treatment, but also designates patients as ‘survivors’, having overcome the acute phase (‘acute survivorship’) and now needing to live with, through and beyond their condition (‘extended survivorship’ and ‘permanent survivorship’). The aim of this systematic review was to identify the most frequently used quality of life (QOL) assessment tools and to determine how closely these align to the concept of 'survivorship'. Methods: A systematic literature review was conducted according to PRISMA guidelines. Embase, Medline and the Cochrane Library were electronically searched till January 2022 for studies reporting on QOL in aortic dissection patients. Observational studies and case series studies were included. Due to the degree of heterogeneity existing between the studies, a meta-analysis was not conduced. Study quality was assessed using the Agency for Healthcare Research and Quality (ARHQ) methodology checklist. Results: A total of 27 studies were included, encompassing 32 QOL tools. The most common QOL tool utilised was the SF-36, across 11 studies. Only one qualitative study investigated patient perspectives of living with aortic dissection. Overall, QOL was found to be poor in aortic dissection survivors. All identified QOL tools demonstrated a poor alignment with the survivorship domains. Included studies displayed a moderate to high risk of bias, having small sample sizes and an insufficient follow-up period. Conclusion: This review highlights the absence of an aortic dissection specific QOL tool. All QOL tools identified failed to encompass the breadth of survivorship domains, with a lack of studies focusing on the patients’ perspective. Further research is urgently required to gain an insight into the quality of life of patients who have survived an aortic dissection, and to develop an aortic dissection specific QOL tool, underpinned by the survivorship domains.

Potential metabolomic biomarkers for the identification and diagnosis of type A acute aortic dissection in patients with hypertension

Most patients with acute aortic dissection (AAD) have a history of hypertension. Diagnosis of AAD in patients with hypertension at an early stage is complicated and challenging. This study aimed to explore the distinctive metabolic changes in plasma samples of AAD patients with hypertension and patients with hypertension only and provide early identification and diagnosis of AAD in patients with hypertension. We collected blood samples from 20 patients with type A AAD and hypertension admitted to the emergency department and physically examined other 20 patients with hypertension as controls. The plasma metabolomic profiles of these patients were determined using untargeted metabolomics with ultra-high-performance liquid chromatography-quadrupole time-of-flight mass spectrometry. A total of 38 metabolites that differed between the AAD and hypertension groups were screened. In the positive ion mode, 12 metabolites were different between the two groups, and in the negative ion mode, 26 metabolites were different. Among the 26 different metabolites detected by the negative ion mode, 21 were significantly upregulated and five were downregulated in patients with AAD compared to patients with hypertension. Moreover, five metabolites were upregulated and seven were significantly downregulated in patients with AAD compared to those with hypertension, as detected by the positive ion mode. The metabolites differentially expressed in AAD were mainly involved in lipid metabolism (fatty acid biosynthesis, biosynthesis of unsaturated fatty acids, and linoleic acid metabolism), carbohydrate metabolism (galactose, fructose, and mannose metabolisms), and membrane transport (ATP-binding cassette transporters). Interestingly, plasma hydrocortisone and dimethylglycine concentrations were significantly increased in patients with type A AAD, with the highest area under the curve value (AUC = 0.9325 or 0.9200, respectively) tested by the receiver operating characteristic curve analysis. This study provides possible metabolic markers for the early clinical diagnosis of AAD in patients with hypertension.

Circulating biomarker-based risk stratifications individualize arch repair strategy of acute Type A aortic dissection via the XGBoosting algorithm.

The incremental usefulness of circulating biomarkers from different pathological pathways for predicting mortality has not been evaluated in acute Type A aortic dissection (ATAAD) patients. We aim to develop a risk prediction model and investigate the impact of arch repair strategy on mortality based on distinct risk stratifications. A total of 3771 ATAAD patients who underwent aortic surgery retrospectively included were randomly divided into training and testing cohorts at a ratio of 7:3 for the development and validation of the risk model based on multiple circulating biomarkers and conventional clinical factors. Extreme gradient boosting was used to generate the risk models. Subgroup analyses were performed by risk stratifications (low vs. middle-high risk) and arch repair strategies (proximal vs. extensive arch repair). Addition of multiple biomarkers to a model with conventional factors fitted an ABC risk model consisting of platelet-leucocyte ratio, mean arterial pressure, albumin, age, creatinine, creatine kinase-MB, haemoglobin, lactate, left ventricular end-diastolic dimension, urea nitrogen, and aspartate aminotransferase, with adequate discrimination ability {area under the receiver operating characteristic curve (AUROC): 0.930 [95% confidence interval (CI) 0.906-0.954] and 0.954, 95% CI (0.930-0.977) in the derivation and validation cohort, respectively}. Compared with proximal arch repair, the extensive repair was associated with similar mortality risk among patients at low risk [odds ratio (OR) 1.838, 95% CI (0.559-6.038); P = 0.316], but associated with higher mortality risk among patients at middle-high risk [OR 2.007, 95% CI (1.460-2.757); P < 0.0001]. In ATAAD patients, the simultaneous addition of circulating biomarkers of inflammatory, cardiac, hepatic, renal, and metabolic abnormalities substantially improved risk stratification and individualized arch repair strategy.

Complications of Extended Pelvic Lymph Node Dissection in Patients Undergoing Minimally Invasive Radical Prostatectomy: Analysis and Risk Factors.

Background The knowledge of risk factors and complications related to extended pelvic lymph node dissection (ePLND) during radical prostatectomy can help selecting patients who will benefit the most with lymph node dissection concomitant to radical prostatectomy. Materials and Methods Retrospective cohort evaluating 135 patients with PC, with a high risk for lymph node metastasis, submitted to ePLND by a single surgeon between 2013 and 2019, performed either by the laparoscopic or laparoscopic robot-assisted approach. Data related to complications were properly recorded using the Martin's criteria and were classified by the Satava and Clavien–Dindo–Strasberg methods. Logistic regression was used to determine predictors of complications related to ePLND. Results The mean number of lymph nodes removed was 10.2 ± 4.9, and in 28.2%, they were positive for metastasis. There were five intraoperative complications (4%), all in patients operated by laparoscopic approach. There were nine severe postoperative complications (7.3%), four of which occurred after postoperative day 30. Three patients (2.4%) had thromboembolic complications and five patients (4.0%) had lymphocele that required treatment. There was a correlation between the American Society of Anesthesiologists (ASA) physical status classification and postoperative complications (p=0.06), but it was not possible to identify statistically significant predictors. Conclusion ePLND during radical prostatectomy has a low rate of intraoperative complications and may change prostate cancer staging. Postoperative complications, especially venous thromboembolism and lymphocele, need to be monitored even in the late postoperative period.

Machine Learning for the Prediction of Lymph Node Metastasis in Patients with Prostate Cancer

<h3>Purpose/Objective(s)</h3> Many tools are used to predict the probability of lymph node involvement (LNI) in patients with prostate cancer before radical prostatectomy (RP) and to select patients for lymph node dissection. Our goal was to externally validate common prediction tools and to create a machine learning model for the prediction of LNI in patients with prostate cancer referred for RP. <h3>Materials/Methods</h3> Patients treated at two academic institutions between 1990 and 2020 with RP followed by pelvic lymph node dissection were included. We trained a gradient boosted tree on data from one institution and the model was validated on the other dataset. Variables incorporated into the model are patient's age, percentage of cores positive on biopsy, Gleason scores, preoperative PSA, and clinical T-stage (cT). The area under curve of the receiver operator characteristic curve (AUC) served as the performance metric. We further compared our model's performance to that of established nomograms, namely the Roach formula, the online Memorial Sloan Kettering Center (MSKCC) nomogram, and the 2012 Briganti nomogram. <h3>Results</h3> The combined dataset consisted of 19,090 patients with median age of 65, median PSA at diagnosis of 7.60 ng/mL, and median percentage of positive cores at biopsy of 44%. 14,252 patients (74.6%) had a Gleason score (GS) of 7, and 4,841 (25.4%) had a GS of ≥ 8. Most patients (18,570 or 97.3%) had cT-stage ≤cT2 disease, and 523 (2.7%) had cT3-4 disease. 3,058 patients (16%) were found to have lymph node involvement. The external validation dataset had 1,093 patients, with 10.7% having lymph node positive disease. After training and on external validation, the AUC of our model was 0.79 (CI: 0.7465-0.83), compared to 0.69 (0.64-0.7455), 0.73 (0.6813-0.7742), and 0.74 (0.6931 - 0.7914) when using the Roach formula, MSKCC nomogram, and Briganti 2012 nomogram, respectively. Furthermore, our model's improved performance was statistically significant, with p-value <0.05 when comparing its AUC to that of all other models. <h3>Conclusion</h3> Our machine learning model can be used to estimate an individual patient's risk of LNI and serves as an additional tool with improved performance compared to established prediction models.

Intraoperative ultrasound: "Alternative eye" in lymph nodal dissection in non-small cell lung cancer.

Staging of the mediastinum lymph nodes involvement in patients with non-small cell lung cancer (NSCLC) is an important prognostic factor determining the most appropriate multimodality treatment plan. The objective of this study is to assess ultrasound characteristics of mediastinal lymph nodes metastasis and effectiveness of intraoperative ultrasound-guided mediastinal nodal dissection in patients with resected NSCLC. All patients undergoing video-assisted thoracoscopic surgery lobectomy and pulmonary lymphadenectomy from November 2020 to March 2022 at the thoracic surgery department of the Vanvitelli University of Naples underwent intraoperative ultrasound-guided mediastinal lymph nodal dissection. This study evaluates whether individual B-mode features and a compounding thereof can be used to accurately and reproducibly predict lymph node malignancy. Intraoperative ultrasound, during systematic mediastinal lymph node dissection, is helpful in preventing lesion to mediastinal structures. Pathological nodal sonographic characteristics are round shape, short-axis diameter, echogenicity, margin, the absence or presence of coagulation necrosis sign, and the absence or presence of central hilar structure, increased color Doppler flow, the absence or presence of calcification, and nodal conglomeration. Operating time was not substantially prolonged. The procedure is simple, safe and highly accurate. Ultrasonic techniques allow surgeons to detect the relationship between lymph nodes and surrounding large blood vessels during biopsy, improving the safety and simplicity of the operation, increasing the number of harvested lymph nodes, and reducing the risk of intraoperative injury; it is a fast, easily reproducible, and inexpensive method.