Patent False Lumen Research Articles

Outflow Through Aortic Side Branches Drives False Lumen Patency in Type B Aortic Dissection.

Objective: Thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) aims to induce false lumen (FL) thrombosis by sealing intimal tears between the true (TL) and the FL, and blocking the inflow into the FL. Incomplete thrombosis of the FL is correlated with poor clinical outcome. We hypothesize that the number of major and minor branches arising from the FL affects FL patency and may negatively influence TEVAR induced FL thrombosis.Methods: Computed tomography (CT)-scans from 89 patients diagnosed with TBAD [best medical treatment (BMT) n = 52, TEVAR n = 37] from two high-volume vascular surgery centers were analyzed retrospectively. Analysis included evaluation of the FL patency status, the number, location and size of intimal tears, and the presence of minor and major side branches originating from the FL. Multiple regression analysis was conducted to evaluate obtained parameters as predictors for FL thrombosis status.Results: In univariate analysis, the strongest correlation for FL patency was found for the number of major (R = 0.79) and minor (R = 0.86) side branches originating from the FL. When applying a multiple linear regression model, the number of major (normalized beta 0.37; P < 0.001) and minor (normalized beta 0.41; P < 0.01) side branches arising from the FL were valid predictors for the axial length of the patent and non-patent FL, and additionally determined the length of the patent FL at 12-month follow-up in patients that underwent TEVAR.Conclusions: Our data suggest that the number of minor side branches that originate from the FL in TBAD is an important determinant of FL patency, to a greater degree than previously assumed.

Predictors of adverse events in uncomplicated type B aortic dissection: a systematic review with meta-analysis.

Thoracic endovascular aortic repair (TEVAR) has been selectively used for uncomplicated acute type B aortic dissection (TBAD); however, not all cases will benefit from TEVAR. A search for high risk clinical and radiographic predictors for complications is ongoing. This systematic review and meta-analysis aimed to identify predictors of major adverse events during follow-up of uncomplicated TBAD, in order to identify who might benefit from elective TEVAR. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) Statement. 16 studies were included in a qualitative synthesis and 10 in the meta-analysis. Several risk factors associated to major adverse events have been described, including: 1) aortic diameter ≥40 mm; 2) greater false lumen diameter (>22 mm); 3) patent false lumen; 4) primary entry tear >10 mm; and 5) greater number of false lumen vessels origin. Quantitative synthesis identified an aortic diameter ≥40 mm significantly associated with major adverse events (HR=3.56; P<0.00001). Reporting of false lumen status, aortic diameters and growth, and demographic data was not always congruent with the most recent recommendations by Society for Vascular Surgery and Society of Thoracic Surgeons, published in 2020. Acute and subacute patients with uncomplicated TBAD presenting with an aortic diameter ≥40 mm and solely treated with BMT have an increased hazard of developing major adverse events (HR), making them potential candidates for TEVAR. Remaining risk factors analysed have weaker evidence.

Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with Marfan syndrome

ObjectiveTo evaluate the mid-term outcomes of thoracic endovascular aorta repair (TEVAR) for Stanford type B aortic dissection (TBAD) in patients with Marfan syndrome (MFS). MethodsBetween January 2009 and December 2019, patients with MFS who underwent TEVAR for TBAD were enrolled. Demographic data, preoperative and perioperative clinical profiles, and follow-up data were collected and analyzed. The cumulative survival and freedom from reintervention rates were calculated with Kaplan-Meier analysis. ResultsA total of 26 patients were enrolled. The mean age was 38.5 ± 10.7 (range, 24-64 years). The in-hospital mortality was 0. The cumulative survival rate was 88.1% (95% confidence interval [CI], 67.5%-98.5%) at 5 years and 82.9% (95% CI, 60.2%-93.3%) at 10 years. Patients with a thrombosed false lumen (FL) along the length of the stent had a significantly higher cumulative survival rate (P < .05) and freedom from reintervention (P = .01) than patients with patent FL. The freedom from reintervention was 83.4% (95% CI, 61.4% to 93.4%) at 5 years and 50.3% (95% CI, 21.4%-97.3%) at 10 years. There was no significant difference freedom from reintervention in freedom from reintervention between patients with and those without a previous aortic root procedure (P = .46). ConclusionsTEVAR can be performed safely and effectively for TBAD in patients with MFS. Perioperative mortality and morbidity were low; however, lifelong close follow-up in the clinic and imaging are mandatory to prevent aortic rupture. Patients with a patent FL were at high risk of late death.

Aortic dissection diagnosed on stroke computed tomography protocol: a case report

BackgroundAortic dissection is one of the causes of stroke. Because cerebral infarction with aortic dissection is a contraindication to intravenous recombinant tissue plasminogen activator (rt-PA) therapy, exclusion of aortic dissection is necessary prior to its administration. However, imaging takes time to provide a diagnosis, possibly causing delays in surgical treatment.Case presentationA 65-year-old Japanese female patient was transported to the hospital for a suspected stroke, with back pain and left upper and lower extremity palsy which occurred while eating. Upon arrival at the hospital, the left lower limb paralysis had improved, but the left upper limb paralysis remained. Right back pain had also developed. A plain head computed tomography (CT) scan performed 110 minutes after onset showed no acute bleeding or infarction. Subsequent CT perfusion (CTP) showed acute perfusion disturbance in the right hemisphere without infarction, known as ischemic penumbra. The four-dimensional maximum-intensity projection image reconstructed from CTP showed a delayed enhancement at the right internal carotid and right middle cerebral arteries compared to the contralateral side, suggesting a proximal vascular lesion. Contrast helical CT from the neck to abdomen revealed an acute aortic dissection of Stanford type A with false lumen patency. The dissection extended to the proximal right common carotid artery. The patient underwent an emergency total arch replacement and open stent graft. After recovering well, the patient was ambulatory upon discharge from the hospital. The combination of plain head CT, CTP, and helical CT scan from the neck to abdomen enabled us to evaluate for stroke and aortic dissection within a short amount of time, allowing for early therapeutic intervention.ConclusionsWhen acute stroke is suspected due to neurological deficits, plain head CT is the first choice for imaging diagnosis. The addition of cervical CT angiography can reliably exclude stroke due to aortic dissection. CTP can identify ischemic penumbra, which cannot be diagnosed by plain head CT or diffusion-weighted magnetic resonance imaging. These combined stroke CT protocols helped us avoid missing an aortic dissection.

Limited vs. extended repair for acute type I aortic dissection: long-term outcomes over a decade in Beijing Anzhen Hospital.

Limited vs. extended repair for acute type I aortic dissection: long-term outcomes over a decade in Beijing Anzhen Hospital.

Flow density of computed tomography aortography for predicting early unfavorable aortic remodeling after TEVAR in type IIIb aortic dissection

ObjectivePatients diagnosed of DeBakey type III aortic dissection with partial thrombosis of false lumen (FL) have a higher mortality rate. However, IIIb dissections with full patent FL tend to exhibit a partially thrombosed FL quickly after thoracic endovascular aortic repair (TEVAR); thus, we investigated survival and aortic remodeling in this population. MethodsWe reviewed computed tomography aortograms (CTAs) of 123 patients with TEVAR-treated IIIb aortic dissections from July 2006 to June 2015; contrast density of CTAs represented intraluminal flow. Patients were selected to fit in 2 groups of FL in term of FL contrast density: low flow (LF) group (non-opacification in the midway of FL) and high flow (HF) group (full patent FL). ResultsSurgical mortality was 10.3% in the HF group and 4.5% in the LF group (n = 61; LF = 22; HF = 39). 3 patients in the HF group suffered from lethal aortic rupture in 10 days postoperatively. The HF group showed significant increase in maximal diameter, and had larger thoracic (+4.00 ± 2.68 vs −1.16 ± 3.42 mm, P < .001) aortic diameter expansion from preoperation to one week postoperation. Both groups exhibited significant favorable thoracic TL expansion and maximal aortic diameter shrinkage in postoperative one week to one year. However, HF group displayed less thoracic aortic FL regression (−70.9 ± 83.5 vs −113.9 ± 95.0 cm3, P = .1) and TL expansion (+14.5 ± 27.2 vs +36.8 ± 28.3 cm3, P = .008) when compared to LF group. ConclusionsPreoperative HF in the FL has an unfavorable effect on thoracic aortic diameter in one week post-TEVAR. This might increase the risk of aortic rupture.

Preservation of the Aortic Root During Type A Aortic Dissection Surgery: An Effective Strategy?

Background Management of the aortic root during acute Type A aortic dissection (TAAD) repair remains controversial in term of long-term evolution and reoperation. The aim of this study was to assess the long-term outcomes of the aortic root after conservative management during primary surgery. Methods One hundred sixty-four consecutive patients were included in this monocentric retrospective study. The primary endpoint was reoperation on the aortic root during long-term follow-up. Forty-six patients had aortic root replacement (ARR) and 118 had supracoronary aortic replacement (SCR). The 10-year survival, occurrence of significant aortic regurgitation, and radiologic aortic root dilatation in each group were assessed during follow-up. Results Patients from ARR group were younger than those from SCR group ( p < 0.0001). Median follow-ups of ARR group and SCR group are 4.4 (interquartile range [IR]: 2.6–8.3) and 6.15 (IR: 2.8–10.53) years, respectively. Reoperation of the aortic root during long-term follow-up was similar in both groups (ARR group: 5.1%, SCR group: 3.3%, p = 0.636). The 10-year survivals of ARR and SCR groups were 64.8 ± 12.3% and 46.3 ± 5.8% ( p = 0.012), respectively. Long-term significant aortic regurgitation occurred in one patient (1.7%) and seven patients (7.6%) of the ARR and SCR groups ( p = 0.176), respectively. Radiologic aortic root diameters in the SCR group were similar between postoperative period and follow-up studies ( p = 0.58). Reoperation on the distal aorta ( p = 0.012) and patent radiologic false lumen of the descending aorta ( p = 0.043) were independent risk factors of late death. Conclusion SCR is an effective technique for primary TAAD surgery and does not increase the rate of late reoperation on the aortic root.

Long-term fate of aortic branches in patients with aortic dissection

ObjectiveLate morbidity and mortality related to aortic branches in patients with aortic dissection (AD) have not been well described. We investigated the fate of aortic branches in a population cohort of patients with newly diagnosed AD. MethodsWe used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, Minnesota, residents with a diagnosis of AD from 1995 to 2015. Only patients with >30 days of available follow-up imaging studies were included in the present analysis. The primary outcome was freedom from any branch-related event (any intervention, aneurysm, malperfusion, rupture, or death occurring after the acute phase >14 days). The secondary outcome was the diameter change in the aortic branches. Univariate and multivariable Cox proportional hazards models were used to identify the predictors of branch-related events. Univariate and multivariate linear regression models were used to assess the aortic branch growth rate. ResultsOf 77 total incident AD cases, 58 patients who had survived and had imaging follow-up studies available were included, 28 (48%) with type A and 30 (52%) with type B AD. The presentation was acute in 39 patients (67%), 6 (10%) of whom had had branch malperfusion. Of 177 aortic branches involved by the AD, 81 (46%) had arisen from the true lumen, 33 (19%) from the false lumen, and 63 (36%) from both. After the acute phase, freedom from any branch-related event at 15 years was 48% (95% confidence interval [CI], 32%-70%). A total of 31 branch-related events had occurred in 19 patients within 15 years, including 12 interventions (76% freedom; 95% CI, 63%-92%), 10 aneurysms (67% freedom; 95% CI, 50%-90%), 8 cases of malperfusion (76% freedom; 95% CI, 61%-94%), and 1 rupture (94% freedom; 95% CI, 84%-100%). No branch-related deaths had occurred. Type B AD (hazard ratio [HR], 3.5; 95% CI, 1.1-10.8; P = .033), patency of the aortic false lumen (HR, 6.8; 95% CI, 1.1-42.2; P = .038), and malperfusion syndrome at presentation (HR, 6.0; 95% CI, 1.3-28.6; P = .023) were predictors of late aortic branch-related events. The overall growth rate of aortic branches was 1.3 ± 3.0 mm annually. Patency of the aortic false lumen, initial branch diameter, and Marfan syndrome were significantly associated with diameter increase. ConclusionsIn patients with AD, aortic branch involvement was responsible for significant long-term morbidity, without any related mortality. Type B AD, patency of the aortic false lumen, and malperfusion syndrome at presentation resulted in a greater risk of branch events during the long-term follow-up. Dilatation of the aortic branches was observed in one third of cases during follow-up, especially in the case of a patent aortic false lumen or the presence of Marfan syndrome.

Full PETTICOAT in acute type B aortic dissection with patent false lumen may offer positive remodeling for the distal aorta.

The provisional extension to induce complete attachment (PETTICOAT) technique is a unique thoracic endovascular aortic repair (TEVAR) for aortic dissection, which consists of proximal descending aortic endografting plus distal bare-metal stenting. This study aimed to investigate the efficacy of the PETTICOAT technique in patients with acute-sub-acute complicated type B aortic dissections. In particular, we compared the remodeling effect of full PETTICOAT covering down to the abdominal aorta with that of simple entry closure. In this retrospective pre-post study, we compared the clinical course of consecutive patients undergoing TEVAR with the PETTICOAT technique in which proximal entry tear was excluded with a covered stent, and extension bare stents were placed down to the abdominal segment for acute-sub-acute complicated type B aortic dissections, between 2015 and 2017, with a control group treated with TEVAR with entry closure between 2011 and 2015. Outcomes included the aortic remodeling rate and the aortic diameter up to 1year after surgery. Subjects consisted of 47 patients (21 in full PETTICOAT group, 26 in the simple entry closure group). The remodeling rate of the abdominal aorta in the full PETTICOAT group was significantly higher than in the simple entry closure group (p < 0.05), while that of the thoracic aorta was comparable between the two groups. This study suggests that the full PETTICOAT technique achieves better aortic remodeling compared to entry closure alone, and might lead to less reintervention.

The frozen elephant trunk technique for acute retrograde type A aortic dissection: preliminary results.

Our goal was to determine the early and midterm outcomes after total arch replacement with the frozen elephant trunk (FET) technique compared to those of the conventional elephant trunk (ET) technique for acute retrograde type A aortic dissection. Between 2012 and 2019, a total of 49 patients had total arch replacement for acute retrograde type A aortic dissection. Patients were divided into the conventional ET (n = 17) and FET (n = 32) groups. The false lumen status was evaluated using enhanced computed tomography (CT) 1 week postoperatively. The diameter of the downstream aorta was evaluated annually using CT. The median follow-up period was 29 months. Preoperative data and neurological complications were not significantly different in the 2 groups. The diameter and length of the ET prosthesis were significantly larger and longer in the FET group. The overall early mortality rate was 10.2% (5/49) with no differences between the 2 groups. The mean follow-up period was significantly longer in the conventional ET group. The rates of freedom from aortic events at 3 years were significantly lower in the FET group. At the level of the distal arch, postoperative false lumen patency was significantly lower and the follow-up aortic diameter was significantly smaller in the FET group. The FET technique facilitates false lumen thrombosis and aortic remodelling at the distal arch level, with fewer adverse aortic events during the follow-up period with acceptable early outcomes; however, these findings are exploratory and require investigation.

Distal Remodeling After Operations for Extensive Acute Aortic Dissection

The clinical predictors of distal aortic remodeling (DAR) after various procedures for extensive acute aortic dissection are not fully understood. From 2008 to 2018, a total of 122 candidates with extensive acute type A and B aortic dissections survived operations of total arch replacement plus frozen elephant trunk (n= 36), ascending aortic replacement plus supraaortic debranching plus retrograde stenting (hybrid procedure; n= 25), and total endovascular repair (n= 61). We assessed DAR at 4 thoracoabdominal aortic levels based on true lumen expansion, false lumen patency, maximal aortic area, and the blood supply of major branches. Univariate and multivariate logistic and mixed-effect models were performed to delineate patterns and risks for DAR at midterm follow-up. At 3.9 years, 13 aorta-related adverse events (10.7%; including 3 aortic-related deaths [2.5%]) and 8 aortic reinterventions (6.6%) occurred. Follow-up computed tomography angiography was performed in all patients at 3.3 years (interquartile range, 2.7-4.4 years). The degree of DAR, which was relatively independent among aortic levels, was maximal at the pulmonary bifurcation level (90.2% complete false lumen thrombosis) and decreased along the distal aorta. Analyses of longitudinal data indicated that baseline overall false lumen patency was the only available factor to predict DAR at all 4 aortic levels. Dissection type, surgical technique, implant size, and medication did not sufficiently influence DAR at midterm follow-up. After distinct operations for extensive acute aortic dissection, DAR beyond the stent graft coverage is a local anatomical behavior independent of dissection type or proximal management.

Simple Surveillance Is Not So Simple

The fate of the distal aorta is largely unknown after acute type A repair. In this issue of The Annals of Thoracic Surgery, the study by Ismaguilova and colleagues1Ismaguilova A. Martufi G. Gregory A.J. et al.Multidimensional analysis of descending aortic growth after acute type A aortic dissection.Ann Thorac Surg. 2021; 111: 615-622Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar identified a group of 40 patients who had undergone type A dissection repair (DeBakey I/II) with adequate postoperative computed tomography scan angiography imaging. Using 3-dimensional (3D) reconstructions and a centerline, the diameters of these aortas were measured at 100 points along the aorta from the subclavian to the renals. These diameters were then tracked over time with the aid of a 3D nonlinear growth model. This study found that the distal aorta grew considerably after DeBakey type I repair, whereas after DeBakey type II repair the aorta did not. The largest diameter of the aorta grew much slower than the that of the fastest growing segment (type 1: 0.6 versus 3.8 mm/y; type 2: 0.03 versus 1.8 mm/y). The aorta at the maximum diameter grew at about the same rate in both DeBakey groups, whereas the DeBakey type I group had a higher rate of growth at the fastest growing slice of aorta. This area typically did not correlate with the original area of maximum diameter. Another, similar study by Martufi and colleagues2Martufi G. Auer M. Roy J. et al.Multidimensional growth measurements of abdominal aortic aneurysms.J Vasc Surg. 2013; 58: 748-755Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar analyzed abdominal aortic aneurysms using similar centerline measurements and software and came to similar conclusions. Other studies found that abdominal aortic growth is more exponential in nature,3Hirose Y. Hamada S. Takamiya M. Predicting the growth of aortic aneurysms: a comparison of linear vs exponential models.Angiology. 1995; 46: 413-419Crossref PubMed Scopus (35) Google Scholar and that it also occurs in an irregular,4Vega de Céniga M. Gómez R. Estallo L. et al.Analysis of expansion patterns in 4-4.9 cm abdominal aortic aneurysms.Ann Vasc Surg. 2008; 22: 37-44Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar “staccato” fashion.5Kurvers H. Veith F.J. Lipsitz E.C. et al.Discontinuous, staccato growth of abdominal aortic aneurysms.J Am Coll Surg. 2004; 199: 709-715Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar This rebuts a few older studies suggesting that the aorta undergoes slow, linear growth over time. Halstead and colleagues6Halstead J.C. Meier M. Etz C. et al.The fate of the distal aorta after repair of acute type A aortic dissection.J Thorac Cardiovasc Surg. 2007; 133: 127-135Abstract Full Text Full Text PDF PubMed Scopus (236) Google Scholar made this conclusion based on follow-up of 89 patients after undergoing type A repair (median growth: 1.0 mm/y). They found that a patent false lumen and larger initial size were associated with faster expansion (1.2 versus 0.8 mm/y). More recent studies make this analysis of progressing aortic diameters seem crude, even though Halstead and coworkers used segmental analysis and linear modeling. However, this older study had incomplete computed tomography follow-up and probably underestimated aneurysm growth. The only data they had for comparison were decades old7Haverich A. Miller D.C. Scott W.C. et al.Acute and chronic aortic dissections—determinants of long-term outcome for operative survivors.Circulation. 1985; 72: II22-II34PubMed Google Scholar and probably no longer useful. We must commend the authors for arguing, probably correctly, that one cannot simply examine the widest part of the remaining aorta at follow-up and be complacent. As our imaging methods move toward 3D rendering, our analysis of the aorta after surgery must evolve as well (especially after a patient survives a type A dissection). Changes in the aortic diameter are likely an interplay among regional geometry, flow dynamics, and local inflammatory or genetic changes. It would have been interesting to see how false lumen patency influenced the findings and affected all of these diameters, but that would have been exceedingly complex. Unfortunately, the lack of clinical data for these patients makes this more of a mathematical imaging study. We have no idea what these small changes in aortic size mean clinically. With a larger sample size and more clinical data, we may be able to predict stability versus degeneration better. Multidimensional Analysis of Descending Aortic Growth After Acute Type A Aortic DissectionThe Annals of Thoracic SurgeryVol. 111Issue 2PreviewAfter repair of acute type A aortic dissection, typical geometric variables of conventional aortic surveillance focus on maximum diameter and its rate of growth, potentially missing important geometric changes elsewhere. We determined additional information provided by a semiautomated, 3-dimensional (3D), nonlinear growth model of the descending thoracic aorta after repair of type A aortic dissection. Full-Text PDF

The Number of Preoperative Abdominal False Lumen–perfused Small Branches Is Related to Abdominal Aortic Remodeling after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection

Abdominal aortic enlargement (AAE) is a commonly seen complication after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). This study assessed the relationship between preoperative abdominal false lumen-perfused small branches (pre-AFLSBs) and risk of AAE after TEVAR for TBAD extending through the abdominal aorta. One hundred and eighty-four patients with TBAD who had been treated by TEVAR at 4 hospitals in China were stratified in accordance with median pre-AFLSBs: ≤8 (group A) and >8 (group B). AAE was defined as ≥20% increase in abdominal total aortic volume, measured using imaging software featuring centerline analysis, on most recent postoperative computed tomography angiography relative to preoperative examination. Multivariable Cox proportional hazard regression was used to evaluate the relationship between the number of pre-AFLSBs and the risk of AAE after TEVAR. At median 12.4months imaging follow-up, AAE was present in 65 patients at higher cumulative rate (log-rank test P<0.001) in group B, which had more frequent partially thrombosed or patent abdominal false lumen than group A at 6-12months (P<0.01) and 12-24months (P=0.03) of follow-up. In a multivariable Cox proportional hazard regression model, the number of pre-AFLSBs was independently associated with risk of AAE after TEVAR (hazard ratio [for one increase], 1.10; 95% confidence interval, 1.00-1.21; P=0.04) after adjustment for age, gender, dissection chronicity, Society for Vascular Surgery risk score, preoperative maximum descending aortic diameter, false lumen status of the abdominal aorta, numbers of false lumen-perfused visceral arteries, abdominal intimal larger tears, and preoperative abdominal intimal small tears, and dissection length and descending aortic length ratio. The number of pre-AFLSBs was positively associated with the risk of AAE after TEVAR for TBAD extending through the abdominal aorta.

Unusual, Radical Treatment of Type A Aortic Dissection: A Case Report.

Type A aortic dissection, according to Stanford classification, is a surgical emergency with high morbidity and carries 56% of in-hospital mortality when surgical intervention is not performed. The surgical mortality at 30 days is 10 to 20%. The therapeutic goals are to replace the diseased ascending aorta and to treat or to monitor the distal aortic patent false lumen. When the dissection involves the aortic root and the architecture of aortic valve is normal, the surgical techniques used could be multiple: reinforce the aortic root and spare the native aortic valve or replace the aortic valve and the aortic root. The Florida sleeve technique has been developed to treat the aortic aneurysm, sparing the aortic valve in patients with connective tissue disease. Some case reports have described the use of this technique to treat an acute aortic dissection. In the following case, we present a single stage repair of the ascending aorta, aortic arch, and proximal intrathoracic aorta in a patient with Type A aortic dissection through the contemporaneous use of two techniques: Florida sleeve and Vascutek “Thoraflex” hybrid prosthesis. The use of these two techniques allows the repair/replacement of the proximal intrathoracic aorta, the sparing of the native aortic valve, the employment of a hybrid prosthesis to replace the supraortic vessels, and the creation of a descending aortic landing zone for later, distal intervention.

The surgical management of acute type A aortic dissection: Current options and future trends.

Acute type A aortic dissection (ATAAD) is a catastrophic condition that can be fatal if not treated immediately. We sought to examine the literature and identify evidence behind each method of surgical intervention. A comprehensive electronic literature search was done to identify the articles that reported outcomes and discussed surgical techniques in ATAAD. No limits were placed on timing or type of the articles; all results are summarized in a narrative manner within each relevant section. Different units have different approaches for extensive ATAAD; experienced and high-volume units tend to perform aortic root and total-arch replacement, whereas others tend to perform only hemiarch replacement. The evidence shows no significant differences in long-term outcomes. Frozen elephant trunk and endovascular repair play key roles in managing the rest of the aortic dissection that involve the thoracic aorta, and the evidence evolve with their impact on false lumen patency. The management of ATAAD is tailored by individual surgeons and unit experience to save lives. Future directions for reducing mortality depend on effective early recognition and accessibility to centralized specialist centers with experience in a wide range of surgical techniques.

Early outcomes with a hybrid technique for repair of a non-A non-B aortic dissection

ObjectiveThis study reports the early outcomes of patients with acute non-A non-B aortic dissection that involved the aortic arch but not the ascending aorta. MethodsFrom January 2013 to December 2018, 825 patients presented with aortic dissection. Of these, 28 patients with non-A non-B dissection (classified as dissection extending into the aortic arch with entry between the left common carotid artery and the left subclavian arteries) underwent a novel hybrid surgery. Self modified stent-grafts (Micropart Corp, Shanghai, China) were implanted via median sternotomy. Clinical presentation, postoperative data, and early outcomes were recorded. ResultsAll patients underwent an emergency operation. There were no in-hospital mortalities, reexplorations for hemorrhage, reports of paraplegia, cerebral infarctions, endoleaks, or left subclavian artery occlusions. No blood products were required during or after the operations. During the early follow-up at 39.12 ± 15.04 months (6.0-74.0 months), 1 patient was lost to follow-up, and 1 patient died suddenly. Computed tomography angiography showed false lumen patency persisted in the aortic arch and descending aorta without any symptoms. The 6-month computed tomography angiography showed significantly smaller distal aortic arch diameters (31.94 ± 6.95 mm) and descending aorta diameters (34.84 ± 4.15 mm) than measured preoperatively (36.76 ± 4.15 mm and 37.31 ± 4.7 mm, respectively). No paraplegia, cerebral infarction, upper limb ischemia, or left subclavian artery ischemia events were reported. ConclusionsOur inclusion aortic arch technique is a safe, effective, and simple treatment for non-A non-B aortic dissections that can avoid endoleaks, requires no blood products, and has satisfactory early outcomes.

The Long-term Fate of Aortic Branches in Patients With Aortic Dissection

ABSTRACT Objective Late morbidity and mortality related to aortic branches in patients with aortic dissection (AD) are not well described. We aimed to investigate the fate of aortic branches in a population cohort of patients with newly diagnosed AD. Methods We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN, residents diagnosed with AD from 1995 to 2015. Only patients with >30 days of available follow-up imaging were included in the analysis. The primary outcome was freedom from any branch-related event (any intervention, aneurysm, malperfusion, rupture, or death occurring after the acute phase >14 days). Secondary outcome was the diameter change of the aortic branches. Univariate and multivariable Cox proportional hazards models were used to identify predictors of branch-related events; univariate and multivariate linear regression models were used to assess aortic branches growth rate. Results Of 77 total incident AD cases, 58 patients who survived with imaging follow-up were included, 28 (48%) with type A and 30 (52%) with type B AD. The presentation was acute in 39 (67%) cases; 6 (10%) had branch malperfusion. Of 177 aortic branches involved by the AD, 81 (46%) arose from the true lumen, 33 (19%) from the false lumen, 63 (36%) from both. After the acute phase, freedom from any branch-related event at 15 years was 48% (95%CI 32-70). Thirty-one branch-related events occurred in 19 patients over 15 years: 12 interventions (76% freedom, 95%CI 63-92), 10 aneurysms (67% freedom, 95%CI 50-90), 8 malperfusions (76% freedom, 95%CI 61-94) and 1 rupture (94% freedom, 95%CI 84-100). There were no branch-related deaths. Type B AD (HR 3.5, 95%CI 1.1-10.8; P=.033), patency of the aortic false lumen (HR 6.8, 95% CI 1.1-42.2; P=.038) and malperfusion syndrome at presentation (HR 6.0, 95% CI 1.3-28.6; P=.023) were predictors of late aortic branches-related events. Overall growth rate of aortic branches was 1.3±3.0 mm/year. Patency of the aortic false lumen, initial branch diameter, and Marfan syndrome were significantly associated with diameter increase. Conclusions In patients with AD, aortic branch involvement was responsible for a significant long-term morbidity, without any related mortality. Type B AD, patency of the aortic false lumen, or malperfusion syndrome at presentation had a higher risk of branch events during the long-term follow-up. Dilatation of the aortic branches was observed in one third of cases during follow-up, in particular in case of a patent aortic false lumen or Marfan syndrome.

Serum Ceruloplasmin Is the Candidate Predictive Biomarker for Acute Aortic Dissection and Is Related to Thrombosed False Lumen: a Propensity Score-Matched Observational Case-Control Study.

Acute aortic dissection (AAD), one of the fatal diseases observed at the department of vascular surgery, is associated with a great mortality rate at the early stage. Ceruloplasmin (CP) is the plasma protein that functions as a copper transporter. The current retrospective research was carried out to assess CP contents and to examine the possible part in diagnosing patients with AAD. In addition, propensity score matching (PSM) was also utilized for reducing the bias in case screening as well as the clinical confounders. Using PSM, this study included 85 pairs of AAD cases (Stanford A and B dissection) and matched controls, and their CP levels were also detected through enzyme-linked immunosorbent assay (ELISA). Additionally, the relative clinical data were extracted from participants included in this study. After PSM adjustment for clinical variables, including gender, age, body mass index (BMI), heart ratio (HR), smoking, hypertension, diabetes mellitus, coronary heart disease (CHD), and stroke, the serum CP contents among AAD cases were remarkably increased compared with those among the normal subjects. Besides, the CP contents showed independent association with the AAD risk. Typically, the CP level was significantly positively correlated with platelet (R = 0.329) or C-reactive protein (R = 0.340) level. Meanwhile, the area under the receiver operating characteristic (ROC) curve (AUC) was 0.929 when CP was used to diagnose AAD, and the best threshold value was 36.82mg/dL. Serum CP content significantly increased in cases with thrombosed false lumen (FL) relative to those in patent FL cases. Results of logistic regression analysis suggested that a greater CP content indicated an increased thrombosed FL risk (OR = 1.11; 95% CI: 1.01-1.23; P = 0.040). Findings in this study suggest that serum ceruloplasmin contents evidently increased among acute aortic dissection cases. CP shows close correlation with the inflammatory factors among AAD cases. Further, CP may serve as the candidate biomarker to diagnose AAD and to identify an increased risk of thrombosed false lumen.

Is the frozen elephant trunk technique justified for chronic type A aortic dissection in Marfan syndrome?

Chronic type A aortic dissection (cTAAD) in Marfan syndrome (MFS) is rare. Surgical experience is limited and the role of frozen elephant trunk (FET) technique remains undefined. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and FET technique for cTAAD in MFS. The clinical data of sixty-eight patients with MFS undergoing FET and TAR for cTAAD were analyzed. Mean age was 35.8±9.7 years and thirty-nine were male (57.4%). Operative mortality was 10.3% (7/68). Stroke occurred in one (1.5%), re-exploration for bleeding in five (7.3%), low cardiac output in four (5.9%), and acute renal failure in two (2.9%). Follow-up was complete in 100% (61/61) at mean 7.3±4.0 years. The false lumen was obliterated in 73.5% across FET and 50.0% in unstented descending aorta (DAo). Distal dilation occurred in twenty patients, six of whom underwent thoracoabdominal aortic replacement, one abdominal aortic replacement and one thoracic endovascular aortic repair (TEVAR). Late death occurred in five. At ten years, 59.8% were free from distal aortic dilation, and the incidences were 23.2% for death, 14.4% for distal reoperation, and 62.4% for reoperation-free survival. Predictors for operative mortality were extra-anatomic bypass [odds ratio (OR), 229.592; P=0.036], preoperative maximal size (DMax) of aortic sinuses (mm) (OR, 1.134; P=0.032) and cardiopulmonary bypass (CPB) time (minute) (OR, 1.061; P=0.041). Risk factors for aortic dilatation included patent false lumen at diaphragmatic hiatus [hazard ratio (HR), 5.374; P=0.008], preoperative DMax (mm) of proximal DAo (HR, 1.068; P=0.001) and renal arteries (HR, 1.102; P=0.005) which also predicted distal reoperation (HR, 1.149; P=0.001). The time from onset to operation (day) (HR, 1.002; P=0.004) and CPB time (minute) (HR, 1.032; P=0.036) predicted late death. This study shows that the TAR and FET technique is a safe and durable approach to cTAAD in patients with MFS. The operation should be performed as early as possible to optimize clinical outcomes.

Anatomical aspects and feasibility of endovascular repair for chronic post-dissection arch and thoracoabdominal aortic aneurysms.

Aortic dissection is a complex pathology that carries significant morbidity and mortality if not treated in a timely fashion. While the open repair remains the gold standard treatment for patients with acute type A dissection, ascending aortic replacement is associated with high incidence of arch and descending thoracic aorta residual false lumen patency and aneurysmal degeneration. Multiple approaches have been used over the decades to address aneurysmal degeneration in the arch and thoracoabdominal aorta. This article summarizes anatomical requirements for total endovascular repair of aortic arch and TAAAs using fenestrated and branched endografts.