Endovascular Repair Of Acute Type Research Articles

The association between sex and outcomes after thoracic endovascular repair for acute type B aortic dissection

ObjectivePrior literature has found worse outcomes for female patients after endovascular repair of abdominal aortic aneurysm and mixed findings after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm. However, the influence of sex on outcomes after TEVAR for acute type B aortic dissection (aTBAD) is not fully elucidated. MethodsWe identified patients who underwent TEVAR for aTBAD (<30 days) in the Vascular Quality Initiative from 2014 to 2022. We excluded patients with an entry tear or stent seal within the ascending aorta or aortic arch and patients with an unknown proximal tear location. Included patients were stratified by biological sex, and we analyzed perioperative outcomes and 5-year mortality with multivariable logistic regression and Cox regression analysis, respectively. Furthermore, we analyzed adjusted variables for interaction with female sex. ResultsWe included 1626 patients, 33% of whom were female. At presentation, female patients were significantly older (65 [interquartile range: 54, 75] years vs 56 [interquartile range: 49, 68] years; P = .01). Regarding indications for repair, female patients had higher rates of pain (85% vs 80%; P = .02) and lower rates of malperfusion (23% vs 35%; P < .001), specifically mesenteric, renal, and lower limb malperfusion. Female patients had a lower proportion of proximal repairs in zone 2 (39% vs 48%; P < .01). After TEVAR for aTBAD, female sex was associated with comparable odds of perioperative mortality to males (8.1 vs 9.2%; adjusted odds ratio [aOR]: 0.79 [95% confidence interval (CI): 0.51-1.20]). Regarding perioperative complications, female sex was associated with lower odds for cardiac complications (2.3% vs 4.7%; aOR: 0.52 [95% CI: 0.26-0.97]), but all other complications were comparable between sexes. Compared with male sex, female sex was associated with similar risk for 5-year mortality (26% vs 23%; adjusted hazard ratio: 1.01 [95% CI: 0.77-1.32]). On testing variables for interaction with sex, female sex was associated with lower perioperative and 5-year mortality at older ages relative to males (aOR: 0.96 [0.93-0.99] | adjusted hazard ratio: 0.97 [0.95-0.99]) and higher odds of perioperative mortality when mesenteric malperfusion was present (OR: 2.71 [1.04-6.96]). ConclusionsFemale patients were older, less likely to have complicated dissection, and had more distal proximal landing zones. After TEVAR for aTBAD, female sex was associated with similar perioperative and 5-year mortality to male sex, but lower odds of in-hospital cardiac complications. Interaction analysis showed that females were at additional risk for perioperative mortality when mesenteric ischemia was present. These data suggest that TEVAR for aTBAD overall has a similar safety profile in females as it does for males.

Spinal cord ischemia and reinterventions following thoracic endovascular repair for acute type B aortic dissections

ObjectiveThe technical aspects of thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), specifically the location of proximal seal zone (PSZ) (need to cover the left subclavian artery [LSA]), distal seal zone (DSZ) (length of aortic coverage), benefit of LSA revascularization, and prophylactic lumbar drainage are still debated. Each of these issues has potential benefits but also has known risks. This study aims to identify factors associated with reintervention and spinal cord ischemia (SCI) following TEVAR for acute TBAD with a zone 3 entry tear. MethodsThe Vascular Quality Initiative was queried for TEVARs performed for acute TBAD with zone 3 entry tear, zone 3 proximal zone of disease, treated with TEVAR extending between zone 2 and zone 5. The primary outcomes were SCI and related reintervention. Secondary outcomes were stroke, arm ischemia, and retrograde type A dissection (RTAD). The exposure variables were PSZ 2 vs 3, DSZ 4 vs 5, prophylactic lumbar drain, and LSA revascularization. Univariate analyses were conducted with χ2 analysis, and multivariable logistic regression was used to evaluate association with outcomes. ResultsOf 583 patients who met inclusion criteria, 266 had PSZ 2 and 317 had PSZ 3. On univariate analysis, PSZ 2 was associated with a higher rate of reintervention, but PSZ2 was not significant on multivariable analysis after accounting for age, sex, race, smoking, PSZ, DSZ, prophylactic lumbar drain, and LSA patency. PSZ 2 was not associated with SCI, arm ischemia, or RTAD. PSZ 2 was associated with a trend towards a higher rate of stroke. DSZ 4 and DSZ 5 were performed in 161 and 422 TEVARs, respectively, and DSZ 5 was associated with a higher rate of SCI on univariate (3 [1.9%] vs 39 [9.2%]; P = .01) and multivariable (odds ratio, 7.384; 95% confidence interval, 2.193-24.867; P = .001) analyses. Prophylactic lumbar drain placement was not statistically significantly associated with SCI, but lack of postoperative LSA patency was associated with SCI (odds ratio, 2.966; 95% confidence interval, 1.016-8.656; P = .05). ConclusionsThis study found that PSZ 2 was not associated with lower reinterventions or higher rates of SCI but trended towards a higher rate of stroke than PSZ 3. Additionally, DSZ 5 was strongly associated with SCI when compared with DSZ 4, highlighting the importance of limiting aortic coverage to coverage of the proximal entry tear when possible.

Endovascular repair of acute type B aortic dissection: Main complications during 30 postoperative days

Introduction: Diseases of the aorta are moving towards less invasive approaches, with Thoracic Endovascular Repair (TEVAR) standing out. TEVAR is already a well-known intervention with clear benefits over conventional surgery. In addition to the benefits of this type of procedure, it is also necessary to recognize the main postoperative complications related to this approach. The aim of this study was to identify the main complications in the first 30 days after procedure in patients undergoing TEVAR, as well as to assess the main comorbidities that contribute to the development of complications.

Aortic intimal intussusception induced by stent-graft during endovascular repair of acute type B aortic dissection.

Aortic intimal intussusception induced by stent-graft during endovascular repair of acute type B aortic dissection.

Left subclavian artery revascularization is associated with less neurologic injury after endovascular repair of acute type B aortic dissection

ObjectiveThe aim of this study was to analyze patients with acute type B aortic dissection (aTBAD) requiring thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage to determine whether LSA revascularization decreased the risk of neurologic complications. MethodsThe national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with aortic aneurysms or aortic ruptures were excluded from the analysis. Patients were divided into two groups according to whether their LSA was revascularized (prior to or during TEVAR) or not. Univariate followed by multivariate analysis was used to account for possible confounders and evaluate the association of LSA revascularization with the primary outcome of neurologic injury (stroke or spinal cord ischemia). ResultsAmong patients who had TEVAR for aTBAD, 501 patients had the LSA covered. The LSA was revascularized prior to or concomitant with TEVAR in 28% of these patients (n = 139). Average age was 57 years, and 73% (n = 366) were male. Neurologic injury developed in 88 patients (18%). On univariate analysis, patients who had their LSA revascularized were significantly less likely to develop neurologic injury (10% vs 20%; P < .01). This association persisted after accounting for potential confounders (odds ratio, 0.4; P = .02). No significant difference was seen when comparing 30-day or 1-year mortality between patients who had LSA revascularization and those who did not. Follow-up averaged 1.9 years (range, 0-8.1 years). Long-term survival did not differ between the two groups on Kaplan-Meier analysis. ConclusionsIn this study of patients with aTBAD who underwent LSA coverage during TEVAR, the addition of a LSA revascularization procedure was associated with a significantly lower incidence of neurological injury including spinal cord ischemia and/or stroke.

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.

Association Between Preoperative Monocyte to High-Density Lipoprotein Ratio on In-hospital and Long-Term Mortality in Patients Undergoing Endovascular Repair for Acute Type B Aortic Dissection.

Aims: The monocyte to high-density lipoprotein ratio (MHR), a novel marker of inflammation and cardiovascular events, has recently been found to facilitate the diagnosis of acute aortic dissection. This study aimed to assess the association of preoperative MHR with in-hospital and long-term mortality after thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD).Methods: We retrospectively evaluated 637 patients with acute TBAD who underwent TEVAR from a prospectively maintained database. Multivariable logistic and cox regression analyses were conducted to assess the relationship between preoperative MHR and in-hospital as well as long-term mortality. For clinical use, MHR was modeled as a continuous variable and a categorical variable with the optimal cutoff evaluated by receiver operator characteristic curve for long-term mortality. Propensity score matching was used to diminish baseline differences and subgroups analyses were conducted to assess the robustness of the results.Results: Twenty-one (3.3%) patients died during hospitalization and 52 deaths (8.4%) were documented after a median follow-up of 48.1 months. The optimal cutoff value was 1.13 selected according to the receiver operator characteristic curve (sensitivity 78.8%; specificity 58.9%). Multivariate analyses showed that MHR was independently associated with either in-hospital death [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.16-3.85, P = 0.015] or long-term mortality [hazard ratio (HR) 1.78, 95% CI 1.31-2.41, P < 0.001). As a categorical variable, MHR > 1.13 remained an independent predictor of in-hospital death (OR 4.53, 95% CI 1.44-14.30, P = 0.010) and long-term mortality (HR 4.16, 95% CI 2.13-8.10, P < 0.001). Propensity score analyses demonstrated similar results for both in-hospital death and long-term mortality. The association was further confirmed by subgroup analyses.Conclusions: MHR might be useful for identifying patients at high risk of in-hospital and long-term mortality, which could be integrated into risk stratification strategies for acute TBAD patients undergoing TEVAR.

Journal of Vascular Surgery – January 2022 Audiovisual Summary

Hi! I am Peter Gloviczki from Mayo Clinic, Editor-In-Chief of the Journal of Vascular Surgery (JVS). We hope you found peace and happiness during the Holidays and you and your family are healthy and safe. I am happy to introduce four excellent papers we published in the 2022 January issue of the JVS. They are freely available to read or full-text download for the next 2 months. Our first article is the Editors’ Choice and our CME article this month, entitled “The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction,” by Dr Kakra Hughes and colleagues from Maryland and Washington, D.C.1Hughes K. Olufajo O.A. Wright K. Roby D.H. Fryer C.S. Wright J.L. et al.The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction.J Vasc Surg. 2022; 75: 172-180Google Scholar In this multicenter retrospective study, outcomes of lower extremity revascularizations for peripheral artery disease in over 131,000 patients were determined using the Nationwide Readmissions Database. Compared to patients in the lowest quartile of median household income (MHI), those in the highest quartile had lower rates of amputation and less readmissions. However, subsequent revascularization and mortality rates were similar across the groups. The authors concluded that a lower socioeconomic status was associated with worse outcomes and that improving results of lower extremity arterial reconstructions may involve addressing socioeconomic disparities. The next article I would like to introduce is titled “A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections,” written by Dr Tomaz Mesar and colleagues from Norfolk, Virginia.2Mesar T. Alie-Cusson F.S. Rathore A. Dexter D.J. Stokes G.K. Panneton J.M. A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections.J Vasc Surg. 2022; 75: 40-48Google Scholar In this single-center retrospective study, 83 patients underwent thoracic endovascular aortic repair (TEVAR) for complicated acute type B aortic dissection. The proximal landing zone was zone 2 in 48 and zone 3 in 35 patients. At 36 months those with zone 3 TEVAR needed significantly more aortic reinterventions and this group also had significantly lower freedom from aortic related events. These data suggest that these patients may benefit from a more aggressive proximal landing zone even if left subclavian revascularization has to be performed. The third article you should all read is entitled “Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta.”3Li J. Xia L. Ma M. Feng X. Wei X. Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta.J Vasc Surg. 2022; 75: 58-66Google Scholar This paper was written by Dr Jiangtao Li and colleagues from Wuhan, China. Out of 135 patients with acute intramural hematoma of the ascending aorta that extended into the descending thoracic aorta, 104 patients underwent TEVAR of the descending thoracic aorta and 31 were treated with medical therapy (MT) alone. Those who had TEVAR had higher freedom from adverse aorta related events and they also had a significantly better survival rate than those who had medical therapy. In the MT group, patients with renal insufficiency had most adverse aorta related events. The final article this month is on “The natural history of large abdominal aortic aneurysms in patients without timely repair,” written by Dr Elizabeth Lancaster and co-authors from San Francisco, Oakland, Pasadena, and South San Francisco, California.4Lancaster E.M. Gologorsky R. Hull M.M. Okuhn S. Solomon M.D. Avins A.L. et al.The natural history of large abdominal aortic aneurysms in patients without timely repair.J Vasc Surg. 2022; 75: 113-121Google Scholar Of 3248 patients with large aneurysms, 2215 (68%) patients underwent repair and 1033 (32%) did not undergo repair. The 3-year cumulative incidence of rupture was 3.4% for initial AAA size 5.0 to 5.4 cm (women only), 2.2% for 5.5 to 6.0 cm, 6.0% for 6.1 to 7.0 cm, and 18.4% for >7.0 cm. Women with AAA size 6.1 to 7.0 cm had a 12.8% incidence of rupture, while it was only 4.5% for men. In this large cohort, annual rupture rates for large AAAs were lower than previously reported, with possible increased risk in women. These were just four of the many excellent papers we published in the January issue of the JVS. Please read our journals, follow us on social media and send us great manuscripts for publication. We wish you and your family a Happy New Year! Thank you for watching and see you next time for the highlights of the February issue of the Journal of Vascular Surgery. The video accompanying this article may be found online at www.jvascsurg.org. https://www.jvascsurg.org/cms/asset/3f089146-0e7e-4ffd-87a7-6ddf476c6fa6/mmc1.mp4Loading ... Download .mp4 (264.52 MB) Help with .mp4 files Video

A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections.

Thoracic endovascular aortic repair (TEVAR) has become first-line therapy for complicated acute type B aortic dissection (aTBAD). However, the strategy for optimal proximal landing zone remains to be determined. We compared early outcomes and late aortic-related adverse events in patients undergoing TEVAR for complicated aTBAD with endograft deployment in proximal landing zone 2 vs3. We performed a retrospective chart review of adult patients undergoing TEVAR for complicated aTBAD within 6weeks of diagnosis from January 2008 to December 2018. We excluded patients with connective tissue disorders and prior type A repair. Patients were divided into landing zone 2 TEVAR (Z2T) and zone 3 TEVAR (Z3T) groups. Z2 patients were divided between left subclavian artery (LSA) revascularization (Z2R) vs LSA coverage without revascularization (Z2C). Groups were compared for the need for aortic reintervention within 36months of initial admission and freedom from aortic-related adverse events and mortality (AREM), defined as the need for aortic reintervention, aortic-related death, or rupture. Eighty-three patients underwent TEVAR for complicated aTBAD within a mean of 4.1± 7.8days; 89.5% of patients had less than 2cm of healthy proximal descending thoracic aorta. The landing zone was Z3T in 35 patients and 48 underwent Z2T: 10 Z2C and 38 Z2R. There were no differences between Z2T and Z3T in time from diagnosis to TEVAR, demographics, comorbidities, and diameter aortic measurements. The 30-day survival was 87.8%-89.5% for Z2R, 88.6% for Z3, and 80.0% for Z2C (P= .610). The postoperative spinal cord ischemia rate was 3.7%-2.7% for Z2R, 0% for Z3T, and 20.0% for Z2C (P= .012). The postoperative thoracic aortic rupture was 2.2% in Z2 and 0 in Z3. The need for aortic reintervention at 36months after TEVAR was lower for Z2T (10.4%) vs Z3T (31.4%; P= .025). Freedom from AREM at 36months was higher in Z2T vs Z3T (87.5% vs 68.6%; P= .048). The freedom from proximal reintervention was higher in Z2T (95.8%) compared with Z3T (80.0%; P= .019). Z3T deployment was predictive for AREM (odd ratio, 3.648; 95% confidence interval, 1.161-11.465; P= .027) and need for proximal reintervention (odds ratio, 5.542; 95% confidence interval, 1.062-28.927; P= .042). Most patients with aTBAD have less than 2cm of proximal healthy descending thoracic aorta. In patients treated for complicated aTBAD, Z2T is associated with a lower need for aortic reintervention and aortic-related adverse events than Z3T. Patients may benefit from a more aggressive proximal landing zone with similar perioperative morbidity when Z2T is done with LSA revascularization.

Remodeling of Aortic Configuration and Abdominal Aortic Branch Perfusion After Endovascular Repair of Acute Type B Aortic Dissection: A Computed Tomographic Angiography Follow-Up.

Background: Thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) induces false lumen (FL) thrombosis, promotes favorable aortic remodeling, and makes an impact on abdominal aortic branch perfusion patterns. However, little is known about the long-term fate of aortic remodeling and abdominal aortic branch perfusion after TEVAR for TBAD and the effect of FL thrombosis status on these changes.Materials and methods: Between January 2014 and May 2021, 59 enrolled patients with acute TBAD were treated with TEVAR and had post-operative or follow-up images. Pre-operative, post-operative, and latest follow-up CT angiography (CTA) data were analyzed for the largest diameter of true lumen (TL), FL, and transaorta and for the FL thrombosis status on the stented thoracic aorta, unstented thoracic aorta, and abdominal aorta. Abdominal aorta perfusion patterns were characterized.Results: The mean follow-up period was 17.1 months. In the stented thoracic aorta, average TL diameters increased, average FL diameters decreased, and average transaortic diameters did not change; 82.6% of the patients had either a stable or shrinking transaortic size and 87% of the patients achieved total FL thrombosis. In the unstented thoracic aorta, average TL diameters increased, transaortic growth and no changes occurred in 39.1 and 45.7% of the patients, respectively, and complete FL thrombosis was present in 50% of the patients. In the abdominal aorta, average FL and transaortic diameters increased, aorta was expanded in 52.2% of the patients, and FL remained patent in 65.2% of the patients. Of the 354 branches, 37 branches (10.5%) exhibited changes in perfusion patterns, 22 branches (6.2%) demonstrated an increased TL perfusion, and 15 branches (4.2%) had an increased FL contribution. Compared with patent or partially thrombosed FL, complete FL thrombosis was accompanied by a bigger decrease in FL diameters, a larger increase in TL diameters, and a higher percentage of abdominal branch TL perfusion.Conclusions: In majority of the patients, TEVAR stabilized the size of the stented thoracic aorta, namely TL expansion and FL obliteration. However, abdominal aortic FL remained patent FL, and it was expanded with the resultant transaortic growth over a long follow-up period. Abdominal aortic branch perfusion patterns remained largely stable after TEVAR. The failure to achieve FL thrombosis negatively affects the remodeling of a contagious abdominal aortic dissection.

Endovascular Repair for Acute Type B Aortic Dissection With Unfavorable Proximal Landing Zone

BackgroundThe study aimed to compare the safety and effectiveness between fenestrated technique with or without chimney stent and single-branched stent graft for isolated left subclavian artery revascularization during endovascular repair of acute type B aortic dissection with unfavorable proximal landing zone. MethodsFrom January 2016 to December 2019, 65 acute type B aortic dissection patients with unfavorable proximal landing zone were treated with either the fenestrated technique (n = 34, group A) or single-branched stent graft (n = 31, group B). Type I endoleak, retrograde type A dissection, stroke, left subclavian artery patency, 30-day mortality, and aortic remodeling were systematically recorded and retrospectively analyzed. ResultsTechnical success rates for groups A and group B were 94.12% and 100%, respectively. Left subclavian artery primary patency was achieved for all enrolled patients. The incidence of type I endoleak, retrograde type A dissection, stroke, and 30-day mortality was 5.9%, 5.9%, 2.9%, and 2.9% in group A, respectively, but none were encountered in group B. Left subclavian artery occlusion was observed in 3 patients in group A and 2 patients in group B during a mean follow-up of 16.18 ± 2.08 months and 15.19 ± 2.68 months, respectively. After the procedure, significant aortic remodeling was detected in both groups during follow-up. ConclusionsBoth techniques are feasible and safe for isolated left subclavian artery revascularization during endovascular repair for acute type B aortic dissection. Apart from the associated perioperative risks of complications and mortality for the fenestrated technique, both procedures contributed to favorable aortic remodeling.

Effect of proximal fixation length on complications after endovascular repair of type B aortic dissection

ObjectiveWe evaluated the effect of the achieved proximal seal length on the outcomes after endovascular repair of acute type B aortic dissection (aTBAD). MethodsA post hoc analysis was performed using data from two prospective, multicenter investigational studies of the Zenith Dissection Endovascular System (STABLE I and II). Patients treated for aTBAD within 14 days of symptom onset were included if complete preoperative and postoperative imaging data were available for review. The patients were divided into four groups according to the length of the achieved proximal seal according to the centerline imaging findings: ≥20 mm, ≥10 to <20 mm, ≥0 to <10 mm, and <0 mm. The outcomes stratified by the achieved proximal seal length were evaluated. All imaging findings were based on core laboratory analysis. ResultsA total of 110 patients were included in the present analysis; 51 were from STABLE I and 59 from STABLE II. Although the study protocol criteria required a ≥20 mm length of nondissected aorta distal to the left common carotid artery to serve as a proximal seal zone, an achieved proximal seal length of ≥20 mm was observed in only 19 of the 110 patients (17.3%) according to the location of stent-graft placement. After a mean follow-up duration of 41.6 ± 21 months, the cumulative rate of the composite device outcome (ie, proximal entry flow, retrograde dissection, transaortic growth, and stent-graft migration) was lowest in patients with an achieved proximal seal length of ≥20 mm (15.8%; 3 of 19). The cumulative rate increased as the seal length decreased (32.0% [8 of 25], 55.6% [20 of 36], and 60.0% [18 of 30] with a proximal seal length of ≥10 to <20 mm, ≥0 to <10 mm, and <0 mm, respectively; P < .01, Cochran-Armitage trend test). ConclusionsA clear inverse relationship was found between the proximal seal length achieved and associated adverse outcomes. This finding underscores the importance of landing the stent-graft in healthy, nondissected aorta to minimize the risk of complications and provide a durable repair in patients with aTBAD.

Provisional extension to induce complete attachment of an endovascular repair for acute type A aortic dissection with visceral malperfusion

Provisional extension to induce complete attachment of an endovascular repair for acute type A aortic dissection with visceral malperfusion

Percutaneous endovascular repair of acute type A intramural hematoma of the ascending aorta

Percutaneous endovascular repair of acute type A intramural hematoma of the ascending aorta

Experience of stent-graft repair in acute ascending aortic syndromes.

Endovascular repair is an alternative to surgical treatment for ascending aortic syndromes for those at high risk. We present our experience of endovascular repair for acute type A aortic dissections and intramural hematomas and discuss the outcomes. From January 2015 to May 2018, six patients diagnosed with acute type A aortic dissections or type A intramural hematoma underwent endovascular procedures in our hospital. The mean age of the patients was 58 ± 16 years, and the median follow-up was 11 months. The entry tear occurred in the ascending aorta in two patients (2 of 6) and the proximal descending aorta in four patients (4 of 6). All of the devices were delivered through the common femoral artery. One was converted to open surgery (1 of 6), one suffered mortality (1 of 6), one had a neurological deficit irrelevant to the procedure, and one had postoperative renal failure. Four patients (4 of 6, 66.7%) had regression of false lumens in the ascending aorta. None of the cases required late reinterventions. We concluded that endovascular repair may be an option for retrograde type A aortic dissections, but it may prove problematic when the entry tear is within the proximal half of the ascending aorta. Rigorous patient selection is crucial, lifelong imaging surveillance is necessary, and improving ascending aorta-specific devices may improve outcomes.

RS08. Inadequate Proximal Seal Length Predicts Complications After Endovascular Repair of Acute Type B Aortic Dissection

RS08. Inadequate Proximal Seal Length Predicts Complications After Endovascular Repair of Acute Type B Aortic Dissection

Importance of accurately locating the entry site for endovascular treatment of retrograde Type A acute aortic dissection.

The aim of this study was to evaluate the diagnostic possibilities of accurately locating the entry site in acute retrograde Type A aortic dissection and the results of the corresponding endovascular treatments. Among 100 patients who underwent surgery for the treatment of spontaneous acute Type A aortic dissection between 2012 and June 2017, all but 1 patient had preoperative computed tomographic angiography. A total of 8 retrograde extensions originated from the descending aorta, in which 6 of them were diagnosed correctly using radiological imaging. The surgical team was unable to properly diagnose the entry site using radiological imaging in only 1 patient, and no preoperative computed tomographic-angiographic scans were available for 1 other patient. In the latter case, the retrograde dissection was diagnosed intraoperatively and confirmed by postoperative computed tomographic angiography. In 5 patients, a tear-oriented endovascular repair was performed based on preoperative radiological findings. In the remaining 3 patients, conventional surgery of the proximal aorta was performed because of the clinical situation (e.g. aortic insufficiency, pericardial effusion) and/or diagnostic uncertainty. One patient subsequently underwent an endograft successfully. All patients survived surgery and were alive at the last follow-up; however, complete remodelling of the thoracic aorta was evident in only patients with endovascular repair. Tear-oriented endovascular repair of acute Type A aortic dissection originating from the descending aorta seems to be a valuable and durable therapeutic option. However, the determination of the entry site in the descending aorta is a prerequisite for this type of treatment. Therefore, the surgical team should consider a diagnostics based on modern, sophisticated radiological methods.

Sandwich Technique for Endovascular Repair of Acute Type A Aortic Dissection

Overview: To describe a new endovascular procedure for acute type A aortic dissection (TAAD) repair. Methods: Between 2013 and 2016, 12 patients (average age 54±9.6 years; 10 men) with acute TAAD (mean EURO score 11.4%±3.2%, range 5–17) and unfit for surgery underwent thoracic endovascular aortic repair (TEVAR) with 2 periscope grafts to preserve blood supply to supra-aortic branches plus bypass grafting as needed. If the ascending aorta was dilated to >40 mm, sternotomy was performed to wrap the ascending aorta and reduce its diameter to accommodate the aortic stent-grafts. Results: All patients were successfully treated. Seven patients required bypass grafting, and most of the patients had periscope grafts to the innominate/right common carotid artery and left common carotid artery; only 3 patients had the left subclavian artery preserved. All patients exhibited good hemodynamics and normal pressures after the procedure. The mean procedure time and blood loss were 4.5±1.0 hours and 217±111.5 mL, respectively. Two patients treated emergently died shortly after surgery from multiorgan failure. The average follow-up duration was 17±14.5 months (range 2–42) in the 10 survivors. The remaining patients recovered and none experienced stent-graft thrombosis, stroke, or peripheral artery embolism during follow-up. Conclusion: A procedure that combines sandwich/periscope grafting with TEVAR, wrapping of the aorta, and supra-arch bypass grafting can be used to treat patients with acute TAAD.

Thoracic endovascular repair for acute type A aortic dissection: operative technique.

Acute type A aortic dissection is a potentially lethal condition which requires immediate diagnostic and therapeutic intervention. Open surgical repair remains the standard of care as survival rates continue to improve in the modern surgical era. Unfortunately, up to twenty percent of patients are denied surgical therapy because they are deemed medically unfit to undergo open repair. The application of thoracic endovascular aortic repair (TEVAR) has changed the treatment paradigm for aortic disease involving the descending thoracic aorta and may be a viable rescue option for patients with type A dissection who are not eligible for open surgical repair. New endovascular devices and advanced image-guided procedures are continually evolving. This article summarizes the pathology of aortic dissection and focuses on currently available endovascular solutions for transapical and transfemoral stent graft deployment for acute aortic dissection involving the ascending aorta for selected patients who are ineligible for open surgical repair.

Outcomes and Morphologic Changes of Immediate Type Ia Endoleak following Endovascular Repair of Acute Type B Aortic Dissection

The clinical significance of immediate type Ia endoleaks after thoracic endovascular aortic repair (TEVAR) for aneurysms has been described in detail. However, this phenomenon is still controversial in TEVAR patients treated for acute type B aortic dissection. A single-institution study was conducted in 81 prospectively evaluated patients treated between January 2012 and June 2012 for acute type B aortic dissection. Preoperative and postoperative computed tomography angiography (CTA) images were analyzed using 3-dimensional reconstruction to measure the areas and indices of the true lumen, false lumen, and total aorta in the proximal, middle, and distal descending thoracic aorta. Data were analyzed and compared between the 2 groups of patients, with and without immediate type Ia endoleaks. The average follow-up period was 12 months (range 10-13 months) after the procedure. TEVAR was successfully performed in all patients (mean age 53 years; 86% men). Thirty-six of the 81 patients were diagnosed with complicated type B dissection, including persistent pain (19/36, 52.7%), refractory hypertension (4/36, 11.1%), and end-organ ischemia (13/36, 36.1%). Of all the patients, 37 (45.7%) were diagnosed with immediate type Ia endoleaks. The differences between the 30-day and 1-year all-cause mortality rates between the 2 groups were nonsignificant (13.5% vs. 2.2%, P = 0.08; 16.2% vs. 4.5%, P = 0.13). No stroke or paraplegia occurred during the follow-up. Reintervention was performed in 2 patients for delayed type I endoleaks in the group without immediate type Ia endoleaks. Pre- and postoperative CTA images were available for analysis in 54 patients. Among them, 24 patients had type Ia endoleaks. Patients with immediate type Ia endoleaks had a significantly larger preoperative distal false lumen area (498 ± 274 vs. 284 ± 213 mm(2), P = 0.02) and a larger distal aortic area (759 ± 275 vs. 624 ± 185 mm(2), P = 0.03). The 1-year follow-up CTA demonstrated significantly smaller true lumen indices and larger false lumen areas and false lumen indices in the proximal, middle, and distal sections in patients with immediate type Ia endoleaks. Differences in the postoperative morphological changes of the whole descending thoracic aorta were significant between the 2 groups, with the maximum area and the proximal, middle, and distal regions involved. The occurrence of endoleaks and the rates of postoperative false lumen thrombosis throughout the length of stent grafts were not significant at 1-year follow-up. The majority of immediate type Ia endoleaks following TEVAR in acute type B aortic dissections could seal spontaneously, without additional procedures needed. However, the appearance of such complications could be a risk factor of poorer aortic remodeling. Careful surveillance is recommended more frequently in patients with immediate type Ia endoleaks.