Patent False Lumen Research Articles

Fate of dissected arch vessels by adventitial inversion technique for acute type A aortic dissection repair.

OBJECTIVESThe adventitial inversion technique is used widely for aortic reconstruction for acute type A aortic dissection, as it easily controls the bleeding at anastomotic sites and closes the patent false lumen. However, this technique for arch vessel reconstruction has not been previously reported. Therefore, we applied the adventitial inversion technique for dissected arch vessel reconstruction to close the patent false lumen.METHODSAmong 57 consecutive patients who underwent emergency surgical treatment for acute type A aortic dissection from July 2006 to July 2012, the adventitial inversion technique for the dissected arch vessels was performed in 26 patients (42 arch vessel stumps). The patency and morphologic change of the false lumen of the arch vessels were evaluated using contrast-enhanced computed tomography.RESULTSOverall, 2 hospital deaths were recorded, and the hospital mortality rate was 4%. No postoperative cerebral strokes and reoperations due to bleeding occurred. Follow-up by contrast-enhanced computed tomography was completed in 24 patients (37 stumps) with a mean duration of 99 ± 35 months. The postoperative closure rate of the false lumen after adventitial inversion was 86%, which was higher than when adventitial inversion was not used. No adverse events including stroke occurred during follow-up period.CONCLUSIONSThis technique facilitates the closure of the false lumen of dissected arch vessels and might improve clinical outcomes.

False Lumen Flow Assessment by Magnetic Resonance Imaging and Long-Term Outcomes in Uncomplicated Aortic Dissection

BackgroundDespite the absence of clinical complications after an acute aortic dissection (AD) with persistent patent false lumen (FL), a high risk for clinical events may persist. ObjectivesThe aim of this study was to assess the natural evolution of noncomplicated AD and ascertain whether different FL flow patterns by magnetic resonance imaging (MRI) have independent prognostic value for AD-related events beyond established morphologic parameters. MethodsOne hundred thirty-one consecutive patients, 78 with surgically treated type A dissections and 53 with medically treated type B dissections, were followed up prospectively after acute AD with persistent patent FL in the descending aorta. Maximum aortic diameter, true lumen compression, entry tear, and partial FL thrombosis by computed tomography were assessed. Systolic antegrade true lumen and FL flow volumes and diastolic antegrade and retrograde flows were analyzed by MRI during the first year after AD. ResultsAfter a median follow-up period of 8.0 years (IQR: 4.6-10.9 years), 43 patients presented aorta-related events (25 died and 18 required endovascular treatment). FL systolic antegrade flow ≥30% with respect to total systolic antegrade flow and retrograde diastolic flow ≥80% with respect to total diastolic FL flow were predictors of aortic events. In multivariate analysis, aortic diameter >45 mm (HR: 2.91), type B dissection (HR: 2.44), and MRI flow pattern (HR: 16.87) were independent predictors of AD-related events. ConclusionsHigh systolic antegrade flow volume in the FL with significant diastolic retrograde flow assessed by MRI and aortic diameter >45 mm identify patients with higher risk for complications in whom more aggressive management would be indicated.

P41 ORAL ANTICOAGULATION AFTER REPAIR OF ACUTE TYPE A AORTIC DISSECTION: A REAL RISK ON LONG–TERM?

Abstract Objective To analyse the effects of chronic oral anticoagulation on long–term outcomes after repair of type A acute aortic dissection and its influence on false lumen fate. Methods We studied 188 patients (median age 62 years; 74% males) who had repair of type A aortic dissection; patients receiving postoperative chronic oral anticoagulation (n = 59) were compared to those on antiplatelet therapy alone (n = 129). Results Median age was similar: 60 (18–79 years) vs 64 years (22–86) (p = 0.11); patients on anticoagulants were more frequently males (88% vs 67%, p = 0.003). After a median follow–up of 8.4 years (2 months to 30 years) 58 patients died, 18 for aortic–related causes, and 37 underwent aortic reintervention. After multivariable adjustment, anticoagulation showed no significant effect on long–term survival (HR 0.85, 95% CI 0.41–1.76; p = 0.66) neither on risk of reintervention (HR 0.55, 95% CI 0.27–1.15; p = 0.11). Analysis of 127 postoperative computed tomography scans showed a patent false lumen in 53% of anticoagulated vs 38% of not anticoagulated patients (p = 0.09); partially thrombosed in 8% vs 28% (p = 0.01) and thrombosed in 39% vs 34% (p = 0.63). In patients with a control computed tomography there were 6 late aortic–related deaths, 1 among patients anticoagulated and 5 in those who were not. Conclusions Chronic anticoagulation after repair of type A acute aortic dissection favours persistent late false lumen patency which is not a risk factor for late mortality or reoperation. Chronic anticoagulation can be administered safely to patients with repaired type A acute aortic dissection regardless of its specific indication.

Successful Aortic Remodeling Through the Candy-Plug Technique for Chronic Type B Aortic Dissection.

To describe the efficiency of the candy-plug technique using an Excluder aortic extender and obtain optimal aortic remodeling. A 46-year-old male patient had a history of acute type B aortic dissection and progressive dilation of the descending aorta (53mm diameter) with a patent false lumen. He was treated with the candy-plug technique, using an Excluder aortic extender of 32-45mm was placed and a 16-mm Amplatzer Vascular Plug II. No technical complications were observed in the patient. Good aortic remodeling was observed after 6months, CT showed complete thrombosis of the false lumen and reduction of the maximum perpendicular diameter of the descending aorta from 53 to 47mm. The diameter of the other proximal zones of the descending aorta was 45-47mm, and the Excluder aortic extender changed into an elliptical shape. This is the first report of good aortic remodeling with an elliptical shape by performing the candy-plug technique. The candy-plug technique using an Excluder aortic extender is an improved method for occluding the false lumen as it provides improved aortic remodeling. The 2 indications for this surgery are limited. A large entry point in the descending abdominal aorta that is more peripheral than the candy-plug position must be visible on contrast-enhanced CT and the false lumen is not too large. We consider candy-plug placement in the true lumen central to the TEVAR to avoid occluding the artery of Adamkiewicz, since we have to avoid the thrombosis of the peripheral false lumen where a candy-plug was placed. Since it is unclear whether long-term results are satisfactory, we must continue to study chronic aortic type B dissection.

Outer Media Thickness at False Lumen and Secondary Aortic Dilatation After Acute Aortic Dissection

BackgroundThis study measured the outer media thickness (OMT) at the false lumen by using microscopic images of specimens collected intraoperatively and assessed the impact of OMT on secondary dilatation of the downstream aorta. MethodsOf 238 patients undergoing surgical procedures for acute type A dissection between 2007 and 2016, 129 patients fulfilled the inclusion criteria for this study: DeBakey type I dissection with a patent false lumen, histopathologic examination of full-thickness aortic wall, and at least 1 follow-up computed tomographic scan at more than 3 months after surgical procedures. On average, 5.1 scans were obtained per patient, and median follow-up was 4.3 years. ResultsConsiderable variation was observed in OMT (median, 0.21 mm; range, 0.04-0.51 mm). The aortic diameter growth rate was inversely correlated with the OMT, and in the lowest tertile of OMT the aortic diameter dilated significantly faster in the first year than later and faster than in the other tertiles. Multivariable Fine-Gray analysis, with death as the competing risk, identified OMT as an independent variable for aortic-related events. Patients with OMT of 0.04 to 0.15 mm had a 3.54-fold higher risk of aortic-related events and those with 0.16 to 0.31 mm had a 1.56-fold higher risk of aortic-related events than did patients with OMT of 0.32 to 0.51 mm. Multivariable Cox regression analyses revealed OMT of 0.04 to 0.15 mm as an independent variable for all-cause mortality. ConclusionsIn patients with DeBakey type I aortic dissection with a patent false lumen, the growth rate of the distal residual dissecting aorta was inversely correlated with the OMT. The risk of aortic-related events was significantly higher in patients with OMT of 0.04 to 0.15 mm.

Can preoperative features predict residual false lumen remodelling after tear-oriented limited resection for acute type I dissection?

Our goal was to identify the preoperative findings in computed tomography correlated with the postoperative changes of the false lumen (FL) remaining in the descending thoracic aorta following tear-oriented surgery for acute type I dissection. Patients who underwent ascending +/- partial arch replacement, with available preoperative and postoperative late (>1 year) CT scans, were included. Preoperative cross-sectional parameters were measured by the semi-automated centreline method at the level of the anastomosis. The parameters of the patients who presented positive remodelling of the proximal descending thoracic aorta were compared with those of the patients who did not in the late images. Among the included 101 patients, positive remodelling of the proximal descending thoracic aorta was observed in 46.5%, of which 76.6% extended downwards to the middle descending thoracic aorta. In the univariable analysis, an FL area ratio <50% (P < 0.001), a circumferential ratio of dissection <50% (P = 0.028), an FL width <20 mm (P = 0.008) at the distal anastomotic zone and not leaving residual arch branches having patent false lumens (P = 0.005) correlated with positive remodelling. The number of fulfilled above-mentioned features revealed a better correlation, which was stronger in patients without Marfan syndrome and in those older than 50 years. The cross-sectional extent of dissection at the presumed distal anastomotic zone is associated with descending thoracic aorta positive remodelling following tear-oriented replacement for acute type I aortic dissection. Considering the anatomical features in determining the extent of aortic replacement, some of the non-Marfan elderly patients can be spared from aggressive total arch replacement with the frozen elephant trunk technique.

Ratio of the false lumen to the true lumen is associated with long-term prognosis after surgical repair of acute type A aortic dissection

ObjectivesThe aim of this study was to assess potential predictors of aortic events after an emergency surgery for acute type A aortic dissection, especially paying attention to the findings of computed tomography (CT) performed immediately after the surgery. MethodsBetween January 2001 and December 2015, 72 patients, who were diagnosed as having Stanford type A acute aortic dissection with a patent false lumen in the descending thoracic aorta, survived the emergency operation, and had postoperative CT scan data, were included in this study (mean follow-up, 8.2 ± 3.8 years; range 0.8-17.4 years). From the CT scan data, the diameter of the false lumen (FL-D) and true lumen (TL-D) were measured, and the FL-D:TL-D ratio was calculated. Long-term outcomes of the FL-D > TL-D group (n = 30) and the FL-D < TL-D group (n = 42) were compared. ResultsIn the late follow-up, 17 aortic events in the downstream aorta were observed. The FL-D:TL-D ratio (P = .01) was an adjusted risk of aortic events in multivariable analysis. The rates of freedom from aortic events at 5 and 9 years were superior in the FL-D < TL-D group than in the FL-D > TL-D group (92.0% and 88.6% vs 81% and 60.7%; log rank P < .05). ConclusionsOur results suggest that the false lumen:true lumen ratio predicts long-term prognosis after surgical repair of acute type A aortic dissection.

Numerical modeling of residual type B aortic dissection: longitudinal analysis of favorable and unfavorable evolution.

Residual type B aortic dissection was numerically investigated to highlight the contribution of biomechanical parameters to the pathology's evolution. Patient-specific geometries from cases involving both favorable and unfavorable evolution were modeled to assess their hemodynamic features. This original approach was supported by a longitudinal study confirming the association between morphological changes, hemodynamic features, adverse clinical outcomes, and CT-angioscan observations on the same patient. Comparing one patient with unfavorable evolution with one with favorable one, we identify potential biomechanical indicators predictive of unfavorable evolution: (i) a patent false lumen with a flow rate above 50% of inlet flow rate; (ii) high wall shear stress above 18 Pa at entry tears, and above 10 Pa at some regions of the false lumen wall; (iii) low time-averaged wall shear stress in distal false lumen below 0.5 Pa; (iv) vortical structure dynamics. Although these comparisons could only be conducted on 2 patients and need to be confirmed by a larger number of cases, our findings point to these hemodynamic markers as possible candidates for early evaluation of the pathology's evolution towards an unfavorable scenario. Graphical Abstract Correlation between hemodynamics index and thrombus initiation for unfavorable case. ET2 and ET3 are entry tear numbers 2 and 3 respectively. WSS is wall shear stress. TAWSS is time average shear stress.

False lumen rotational flow and aortic stiffness are associated with aortic growth rate in patients with chronic aortic dissection of the descending aorta: a 4D flow cardiovascular magnetic resonance study

BackgroundPatency of the false lumen in chronic aortic dissection (AD) is associated with aortic dilation and long-term aortic events. However, predictors of adverse outcomes in this population are limited. The aim of this study was to evaluate the relationship between aortic growth rate and false lumen flow dynamics and biomechanics in patients with chronic, patent AD.MethodsPatients with a chronic AD with patent false lumen in the descending aorta and no genetic connective tissue disorder underwent an imaging follow-up including a contrast-enhanced 4D flow cardiovascular magnetic resonance (CMR) protocol and two consecutive computed tomography angiograms (CTA) acquired at least 1 year apart. A comprehensive analysis of anatomical features (including thrombus quantification), and false lumen flow dynamics and biomechanics (pulse wave velocity) was performed.ResultsFifty-four consecutive patients with a chronic, patent false lumen in the descending aorta were included (35 surgically-treated type A AD with residual tear and 19 medically-treated type B AD). Median follow-up was 40 months. The in-plane rotational flow, pulse wave velocity and the percentage of thrombus in the false lumen were positively related to aortic growth rate (p = 0.006, 0.017, and 0.037, respectively), whereas wall shear stress showed a trend for a positive association (p = 0.060). These results were found irrespectively of the type of AD.ConclusionsIn patients with chronic AD and patent false lumen of the descending aorta, rotational flow, pulse wave velocity and wall shear stress are positively related to aortic growth rate, and should be implemented in the follow-up algorithm of these patients. Further prospective studies are needed to confirm if the assessment of these parameters helps to identify patients at higher risk of adverse clinical events.

Predictors of hypoxemia in type-B acute aortic syndrome: a retrospective study

Acute aortic syndrome (AAS) can be life-threatening owing to a variety of complications, and it is managed in the intensive care unit (ICU). Although Stanford type-B AAS may involve hypoxemia, its predictors are not yet clearly understood. We studied clinical factors and imaging parameters for predicting hypoxemia after the onset of type-B AAS. We retrospectively analyzed patients diagnosed with type-B AAS in our hospital between January 2012 and April 2020. We defined hypoxemia as PaO2/FiO2 ≤ 200 within 7 days after AAS onset and used logistic regression analysis to evaluate prognostic factors for hypoxemia. We analyzed 224 consecutive patients (140 males, mean age 70 ± 14 years) from a total cohort of 267 patients. Among these, 53 (23.7%) had hypoxemia. The hypoxemia group had longer ICU and hospital stays compared with the non-hypoxemia group (median 20 vs. 16 days, respectively; p = 0.039 and median 7 vs. 5 days, respectively; p < 0.001). Male sex (odds ratio [OR] 2.87; 95% confidence interval [CI] 1.24–6.63; p = 0.014), obesity (OR 2.36; 95% CI 1.13–4.97; p = 0.023), patent false lumen (OR 2.33; 95% CI 1.09–4.99; p = 0.029), and high D-dimer level (OR 1.01; 95% CI 1.00–1.02; p = 0.047) were independently associated with hypoxemia by multivariate logistic analysis. This study showed a significant difference in duration of ICU and hospital stays between patients with and without hypoxemia. Furthermore, male sex, obesity, patent false lumen, and high D-dimer level may be significantly associated with hypoxemia in patients with type-B AAS.

Differences in the Area of Proximal and Distal Entry Tears at CT Angiography Predict Long-term Clinical Outcomes in Aortic Dissection.

To identify entry tear variables that are related to adverse clinical events by using CT angiography (CTA) performed during the subacute phase of aortic dissection. In this prospective study conducted from January 2000 to December 2013, participants with an aortic dissection with a patent false lumen and no comorbidities underwent CTA during the subacute phase. Participants were followed up for a survival analysis to assess the time to an adverse aortic event (AAE). The maximum aortic diameter (MAD), proximal and distal tear areas and difference between these areas, and partial false-lumen thrombosis were assessed by using Cox regression for adverse events. Seventy-two participants (mean age, 55 years ± 12 [standard deviation]; 55 men) were evaluated: 47 were surgically treated (type A aortic dissection) and 25 were medically treated (type B aortic dissection). Twenty-two participants had an AAE manifest during follow-up (9.22 years ± 5.78): There were 18 elective surgeries for aneurysmal degeneration, two emergent surgeries for acute aortic syndrome, and two aortic condition-related deaths. A categorical model composed of genetic aortic disease (GAD) (hazard ratio [HR], 3.4 [95% CI: 1.2, 9.9]; P = .02), MAD greater than 45 mm (HR, 6.1 [95% CI: 2.4, 15.8]; P < .001), and tear dominance (HR, 5.2 [95% CI: 2.1, 13]; P < .001), defined as an absolute tear area difference of greater than 1.2 cm2, was used to stratify participants into three risk groups: low, without any risk factors (57% [41 of 72] and 7% [three of 41] had events); intermediate, with one risk factor (31% [22 of 72] and 50% [11 of 22] had events); and high, with two or more risk factors (13% [nine of 72] and 89% [eight of nine] had events; log rank P < .001). Tear dominance demonstrated at CTA performed in the subacute phase of aortic dissection was related to long-term adverse events. Participants without GAD, dominant tears, or MAD greater than 45 mm had conditions that were safely managed with optimal medical treatment and imaging follow-up.Keywords: CT Angiography, Vascular, Aorta, Dissection Supplemental material is available for this article. © RSNA, 2021See also commentary by Fleischmann and Burris in this issue.

Abstract 10987: Effect of False Lumen Status on Systemic Inflammatory Response Induced by Acute Aortic Dissection

Introduction: Acute aortic dissection (AAD) frequently induces a systemic inflammatory reaction. However, the influence of dissection morphology on immune response remains to be elucidated. Hypothesis: False lumen (FL) status influences peripheral blood cytokine expression in patients with AAD. Methods: Serum concentrations of 29 cytokines were measured on admission (within 48 hours of symptom onset) in 44 patients with AAD. None were suffering shock or aortic rupture and none had an autoimmune or hematologic disease. The 44 patients were divided into 2 groups based on FL patency: those with a thrombosed FL (Group T [n=21]: median age, 76 years) and those with a partially thrombosed or fully patent FL (Group P [n=23]: median age, 61 years). Stanford classes did not differ between these groups (Group T: type A, n=7; type B, n=14 vs. Group P: type A, n=14; type B, n=9) (p=0.068). Laboratory values, including cytokine concentrations, were compared between these groups and a control group (Group C—patients with a non-ruptured atherosclerotic thoracic aortic aneurysm—n=20]: median age, 75 years) by Mann-Whitney test, with multiple comparisons subjected to Bonferroni correction. Results: Leukocyte counts (x10e3/μL) were increased in both groups (Group T: 9.5 [7.7, 11.7]; Group P: 14.0 [10.4, 18.0] vs. Group C: 5.8 [5.0. 7.1]) (both p&lt;0.001), but CRP concentrations (mg/dL) were not (0.51 [0.15, 3.3], p=0.077 and 0.38 [0.10, 2.7], p=0.165 vs. 0.2 [0.1, 0.21]). D-dimer concentrations (μg/mL) were increased in Group P (28.8 [8.6, 108], p&lt;0.001) but not in Group T (2.9 [1.5, 5.3], p=0.87) (vs. Group C: 2.5 [1.4, 4.9]). Seventeen cytokines [IFNγ, IL-2, IL-4, IL-17α, TNFα, etc.] did not differ significantly between the 2 AAD groups; 12 did differ significantly. The differentially expressed cytokines fell into 3 hierarchical clusters: cluster A (increased expression in both groups [G-CSF, IL-6, IL-10, IL-15]), cluster B (increased expression only in Group P [GM-CSF, IL-1Ra, IL-1b, IL-8, IL-12p70, IP-10], and cluster C (increased expression only in Group T [IL-5, VEGF]). Conclusions: A robust inflammatory response occurs regardless of FL status, but the response is somewhat attenuated in patients with a thrombosed FL vs. those with a patent FL.

Deep Learning-Based 3D Segmentation of True Lumen, False Lumen, and False Lumen Thrombosis in Type-B Aortic Dissection.

Patients with initially uncomplicated typeB aortic dissection (uTBAD) remain at high risk for developing late complications. Identification of morphologic features for improving risk stratification of these patients requires automated segmentation of computed tomography angiography (CTA) images. We developed three segmentation models utilizing a 3D residual U-Net for segmentation of the true lumen (TL), false lumen (FL), and false lumen thrombosis (FLT). Model 1 segments all labels at once, whereas model 2 segments them sequentially. Best results for TL and FL segmentation were achieved by model 2, with median (interquartiles) Dice similarity coefficients (DSC) of 0.85 (0.77-0.88) and 0.84 (0.82-0.87), respectively. For FLT segmentation, model 1 was superior to model 2, with median (interquartiles) DSCs of 0.63 (0.40-0.78). To purely test the performance of the network to segment FLT, a third model segmented FLT starting from the manually segmented FL, resulting in median (interquartiles) DSCs of 0.99 (0.98-0.99) and 0.85 (0.73-0.94) for patent FL and FLT, respectively. While the ambiguous appearance of FLT on imaging remains a significant limitation for accurate segmentation, our pipeline has the potential to help in segmentation of aortic lumina and thrombosis in uTBAD patients.Clinical relevance- Most predictors of aortic dissection (AD) degeneration are identified through anatomical modeling, which is currently prohibitive in clinical settings due to the timeintense human interaction. False lumen thrombosis, which often develops in patients with type B AD, has proven to show significant prognostic value for predicting late adverse events. Our automated segmentation algorithm offers the potential of personalized treatment for AD patients, leading to an increase in long-term survival.

Chronic thoracoabdominal aortic dissection: endovascular options to obliterate the false lumen.

Persistent false lumen patency in chronic thoracoabdominal aortic dissections after thoracic endovascular aortic repair (TEVAR) contributes to negative aortic remodeling. We have previously described the evolution of various endovascular techniques to treat persistent false lumen perfusion including false lumen embolization. Objectives of this study are to describe endovascular techniques to obliterate the false lumen and present updated outcomes in a recent series of patients undergoing false lumen embolization for chronic aortic dissection. From January 2018 to May 2021, 17 patients with chronic dissection underwent false lumen embolization with coils, iliac plugs, and nitinol plugs. This was often in conjunction with or following TEVAR and balloon fracture fenestration. Mean follow-up 354±324 days. After false lumen embolization there was no mortality, stroke, spinal cord ischemia, or visceral and limb ischemia. No patients required dialysis, though 1 (5.9%) did experience acute kidney injury. There was 1 (5.9%) patient that required endovascular re-intervention on the thoracoabdominal aorta. No patients underwent subsequent open surgical repair. TEVAR with adjunctive false lumen embolization and balloon fracture fenestration are techniques to obliterate retrograde flow into the false lumen of chronic thoracoabdominal aortic dissections in appropriately selected patients.

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.

The effect of postoperative anticoagulation on false lumen patency after surgery for acute type A aortic dissection

BackgroundPatent false lumen has been shown to have a negative impact on prognosis after surgery for acute type A aortic dissection (ATAAD). We aimed to assess the effect of postoperative anticoagulation on false lumen patency and clinical outcomes in relation to false lumen status.MethodsPostoperative computed tomographies of 156 patients undergoing ATAAD DeBakey type I surgery were retrospectively evaluated for false lumen patency. The patients were divided into groups determined by anticoagulation treatment at discharge. Uni- and multivariable logistic regression was used for analysing the effect of anticoagulation on the false lumen, and Kaplan–Meier estimates were used to assess the association of a patent false lumen with the incidence of reoperation and long-term survival.ResultsA patent false lumen was present in 81% of the patients. Postoperative anticoagulants were not associated with a patent false lumen (p = 0.48) in univariable analysis. In multivariable analysis, both hemiarch replacement (OR 0.15, CI95% 0.05–0.49, p = 0.001) and the use of betablockers had a protective effect (OR 0.29, CI95% 0.10–0.85, p = 0.023). The Kaplan–Meier estimates for survival and the composite endpoint of survival and freedom from distal reintervention indicated no difference in outcome between patients in regard to anticoagulation treatment (survival p = 0.43, composite p = 0.82) or false lumen status (survival p = 0.21, composite p = 0.09).ConclusionThis study could not show negative effects from the postoperative use of anticoagulants on false lumen status, nor that false lumen patency was associated with poorer prognosis. A hemiarch procedure was shown to be associated with reduced risk of false lumen patency.

Outcomes of Endovascular Therapy for Stanford Type B Aortic Dissection in Patients With Marfan Syndrome

A single-center, retrospective review was performed between January 2009 and December 2019. A total of 26 patients with Marfan syndrome (MFS) underwent thoracic endovascular aorta repair (TEVAR) for Stanford type B aortic dissection (TBAD). The mean age was 38 years (range, 24-64 years). In-hospital mortality was 0%. The cumulative survival rate was 88% at 5 years and 83% at 10 years. Freedom from reintervention was 83% at 5 years and 50% at 10 years. Patients with a thrombosed false lumen (FL) along the length of the stent graft had a significantly higher cumulative survival rate and freedom from reintervention than patients with patent FL. TEVAR can be performed safely and effectively for TBAD in patients with MFS. Perioperative mortality and morbidity were low. Lifelong follow-up is mandatory to prevent aortic rupture. Patients with a patent FL were at high risk of late death.

Do oral anticoagulants impact outcomes and false lumen patency after repair of acute type A aortic dissection?

ObjectiveThe study objective was to analyze the effects of chronic oral anticoagulation on long-term outcomes after repair of type A acute aortic dissection and its influence on false lumen fate. MethodsWe studied 188 patients (median age, 62 years; 74% were male) who underwent repair of type A aortic dissection; patients receiving postoperative chronic oral anticoagulation (n = 59) were compared with those receiving antiplatelet therapy alone (n = 129). ResultsMedian age was similar: 60 years (18-79 years; OAC group) versus 64 years (22-86; no-OAC group) (P = .11); patients taking anticoagulants were more frequently male (88% vs 67%, P = .003). After a median follow-up of 8.4 years (2 months to 30 years), 58 patients died, 18 of aortic-related causes, and 37 patients underwent aortic reintervention. After multivariable adjustment, anticoagulation showed no significant effect on long-term survival (hazard ratio, 0.85; 95% confidence interval, 0.41-1.76; P = .66) or risk of reintervention (hazard ratio, 0.55; 95% confidence interval, 0.27-1.15; P = .11). Analysis of 127 postoperative computed tomography scans showed a patent false lumen in 53% of anticoagulated patients versus 38% of nonanticoagulated patients (P = .09): partially thrombosed in 8% versus 28% (P = .01) and thrombosed in 39% versus 34% (P = .63), respectively. In patients with a control computed tomography, there were 6 late aortic-related deaths, 1 among anticoagulated patients and 5 in those who were not. ConclusionsChronic anticoagulation after repair of type A acute aortic dissection favors persistent late false lumen patency, which is not a risk factor for late mortality or reoperation. Chronic anticoagulation can be administered safely to patients with repaired type A acute aortic dissection regardless of its specific indication.

Potential of unenhanced computed tomography as a screening tool for acute aortic syndromes.

Contrast-enhanced computed tomography (CE-CT) is the gold standard for diagnosing acute aortic syndromes (AAS). Unenhanced computed tomography (unenhanced-CT) also provides specific findings for AAS; however, its diagnostic ability is not well discussed. This study aims to evaluate the potential of unenhanced-CT as an AAS screening tool. We retrospectively examined AAS patients who visited our hospital between 2011 and 2021 to validate the diagnostic value of unenhanced-CT alone and along with the aortic dissection detection risk score (ADD-RS) plus D-dimer. Acute aortic syndrome was assessed as detectable using unenhanced-CT with any of the following findings: pericardial haemorrhage, high-attenuation haematoma, and displacement of intimal calcification or a flap. Of the 316 AAS cases, 292 (92%) were detectable with unenhanced-CT. Twenty-four (8%) cases undetectable with unenhanced-CT involved younger patients [median (interquartile range), 45 (42-51) years vs. 72 (63-80) years, P < 0.001] and patients more frequently complicated with a patent false lumen (79% vs. 42%, P < 0.001). Acute aortic syndrome-detection rate with unenhanced-CT increased with age, reaching 98% (276/282) in those ≥50 years of age and 100% (121/121) in those ≥75 years of age. With the ADD-RS plus D-dimer, there was only one AAS case undetectable with unenhanced-CT among patients ≥50 years of age, except for cases with the ADD-RS ≥1 plus D-dimer levels of ≥0.5 μg/mL. Acute aortic syndromes in younger patients and patients with a patent false lumen could be misdiagnosed with unenhanced-CT alone. The combination of the ADD-RS plus D-dimer and unenhanced-CT could minimize AAS misdiagnosis while avoiding over-testing with CE-CT.

Aortic remodelling and false lumen changes after the frozen elephant trunk technique using the thoraflex hybrid stented graft for aortic dissection

BackgroundDespite the marked improvement in the aortic dissection repair techniques, residual dissected aorta with a patent false lumen remains an issue. So, the aim of our study is to observe the effect of inserting the Thoraflex Hybrid Graft on the aortic diameters in patients with type A aortic dissection involving the arch and descending aorta. Patients with type I aortic dissection who had aortic dissection repair using the Thoraflex Hybrid Graft in University Hospitals Birmingham were studied. Radiological assessment with computed tomography of the aorta was done at the level of the diaphragm to measure the true lumen, false lumen and total aortic diameters. Significance of change of diameters at early post-operative as compared to the pre-operative period was analysed.ResultsEight cases were done in the acute setting, while 14 cases were done in the chronic setting. The ratio of true lumen to the total aortic diameter has significantly increased in the follow-up period as compared to the pre-operative period (P = 0.031). Whereas false lumen to total aortic diameter ratio has significantly decreased (P = 0.024). Subgroup analysis revealed that these changes were not significantly altered by whether the dissection was acute or chronic.ConclusionsThe Thoraflex Hybrid Graft will induce positive aortic remodelling with expansion of true lumen and will diminish the false lumen. But we could not find a significant difference between acute or chronic cases due to small sample size.