Indications For Thoracic Endovascular Aortic Repair Research Articles

Clinical Outcomes of Celiac Artery Coverage vs Preservation During Thoracic Endovascular Aortic Repair

Adequate proximal and distal seal zones are necessary for successful Thoracic Endovascular Aortic Repair (TEVAR). Often, the achievement of an adequate distal seal zone requires celiac artery (CA) coverage by endograft with or without preservation of CA blood flow. The outcomes of CA coverage without its flow preservation were studied only in small case series. This study aims to determine the difference in outcomes between CA coverage with vs without preservation of CA blood flow during TEVAR using a multi-institutional national database. Vascular Quality Initiative (VQI) was reviewed for all TEVAR patients distally landing in Zone 6. The cohort was divided into TEVAR with vs without CA flow preservation. Demographic, clinical, and perioperative characteristics, as well as post-operative mortality, morbidities, and complications, were compared between the groups. Univariate and multivariate regression analyses were performed. Out of 25,549 reviewed patients, 772 had a distal landing in zone 6, 212 of which (27.5%) had TEVAR without CA flow preservation, whereas 560 (72.5%) underwent TEVAR with CA flow preservation. Indications for TEVAR were: aneurysm in 431 (55.8%), dissection in 247 (32.0%), or other in 94 (12.2%) cases. Patients who underwent TEVAR without CA flow preservation had statistically significantly higher rates of 30-day mortality (11.3% vs 5.9%, p=0.010), 30-day disease/treatment-related mortality (8.0% vs 4.3%, p=0.039), as well as a tendency of increased intestinal ischemia requiring intervention (1.9% vs 0.5%, p=0.077). After adjusting for potential confounders, CA coverage without flow preservation was associated with more than a two-fold increase in the overall 30-day mortality (OR: 2.83, 95%CI: 1.35-5.92, p=0.006) and 30-day disease/treatment-related mortality (OR: 2.72, 95%CI: 1.11-6.72, p=0.029). In a sub-group analysis based on disease pathology, these results persisted only in the aneurysm group (30-day mortality (OR: 2.36, 95%CI: 1.01-5.48, p=0.047), 30-day disease/treatment-related mortality (OR: 2.88, 95%CI: 1.08-7.67, p=0.034)), whereas there was no significant association between CA flow preservation status and the endpoints in the dissection subgroup (30-day mortality (OR: 1.16, 95%CI: 0.22-6.05, p=0.856), 30-day disease/treatment-related mortality (OR: 0.90, 95%CI: 0.16-5.19, p=0.911)). CA coverage during TEVAR without preservation of its blood flow is associated with significantly higher mortality in patients with aortic aneurysm, but not dissection. In patients with aortic aneurysm CA flow should be preserved during TEVAR whenever feasible, whereas in patients with dissection, it may be safe to cover CA without preservation of its flow. Prospective studies should be done to confirm these findings and compare the open vs endovascular revascularization techniques on outcomes.

Six Years' Experience With a Novel Dissection-Specific Stent-Graft to Prevent Distal Stent-Graft-Induced New Entry.

Thoracic endovascular aortic repair (TEVAR) in chronic dissection is associated with a risk for distal stent-graft-induced new entry (dSINE) in up to a quarter of cases. We assess the mid-term outcome of a novel dissection-specific stent-graft (DSSG), which is a custom-made device based on the Cook Alpha platform, with a modified graft design and a distal endovascular elephant trunk without any supporting stent to reduce the radial force on the dissection membrane at the distal landing zone. A retrospective single-center study of chronic dissection patients at high risk of dSINE who received an elective endovascular repair with DSSG from January 2017 to June 2023. The primary outcome is Kaplan-Meier (KM) estimated freedom from dSINE during follow-up. Secondary outcomes included technical success, aortic remodeling, and anatomical evaluation of the distal landing zone in cases with dSINE during follow-up versus those without. Thirty patients (24 males) with a median age of 66 years [range=31-78] underwent elective TEVAR with the DSSG. The majority, n=27 (90%), had previous aortic repair; 7 (23%) had established connective tissue disease, and 6 (20%) had established dSINE after previous stent-graft implantation as an indication for TEVAR. Technical success was achieved in n=29 (97%). Median follow-up was 38.5 months (4.3-76.4), and KM estimated freedom from dSINE at 1 and 3 years was 95.6% (SE 0.043) and 89% (SE 0.081), respectively Four cases developed dSINE during follow-up. The median distance from the distal stent-graft to the coeliac trunk was 74mm (range=18-123) in the dSINE group versus 26mm (range=0-74) in the non-dSINE group (p=0.049). Median proximal tangential aortic angulation in the distal landing zone was 38.5° (range=26°-50°) in the dSINE group compared to 21° (range=3-61°) in the non-dSINE group (p=0.052). The Use of a novel DSSG with low radial force for TEVAR in the setting of chronic dissection is safe and feasible, with remodeling outcomes comparable with standard TEVAR. The reduced distal radial force in the DSSG does not eliminate the risk for dSINE over time, with new entries occurring, particularly in cases where the distal landing zone is in a tortuous aortic segment and not close to the coeliac trunk. Using the novel dissection-specific stent-graft with reduced radial force is safe and feasible but does not completely eliminate the risk of dSINE occurring over time. The exact positioning of the distal stent-graft in a straight aortic segment, close to the coeliac trunk, may be of importance to further mitigate the risk.

Complementary Thoracic Endovascular Aortic Repair (TEVAR) after Frozen Elephant Trunk for Residual Type A Aortic Dissection: Perioperative and Mid-Term Outcomes.

Objectives: The aim of this retrospective study was to evaluate the results of complementary TEVAR following the frozen elephant trunk (FET) procedure for patients with residual type A aortic dissection (rTAAD) in terms of technical feasibility, safety and mid-term outcomes. Methods: This was a retrospective single-centre analysis of patients who received TEVAR after FET for rTAAD from January 2012 up to December 2021. The primary endpoint was technical success. Safety parameters included 30-day/in-hospital morbidity and mortality. Furthermore, mid-term clinical and morphological outcomes were evaluated. Results: Among 587 TEVAR procedures, 60 patients (11 with connective tissue disorders) who received TEVAR after FET for rTAAD were identified. The median interval between FET and TEVAR was 28.5 months. Indications for TEVAR after FET were true lumen collapse distal to FET prosthesis (n = 7), dSINE (n = 2), planned completion (n = 13) and aortic diameter progression (n = 38). In forty-seven patients, TEVAR was performed in an elective setting; eight and six patients were operated on in an urgent or emergency setting, respectively. All TEVAR procedures were successfully completed. The 30-day mortality and spinal cord ischemia rates were 1.7%. During a median follow-up of 37 months, two further patients died. Nine patients had to undergo a further aortic intervention: fenestrated stent-graft (n = 3) or open repair of the infrarenal abdominal aorta (n = 6). Conclusions: Complementary TEVAR following FET for rTAAD showed excellent technical success and low perioperative risk, supporting the feasibility and safety of this strategy. Despite the favourable mid-term survival, certain patients might require a further aortic procedure.

Five-year sex-related outcomes of thoracic endovascular aortic repair in the Global Registry for Endovascular Aortic Treatment

ObjectiveThe impact of sex on outcomes of thoracic endovascular aortic repair (TEVAR) represents an area of increased interest over the last decade, and long-term data are lacking. The aim of the present study was to investigate sex-related differences in long-term outcomes after TEVAR using real-world data from the Global Registry for Endovascular Aortic Treatment. MethodsData were obtained retrospectively after querying the multicenter, sponsored Global Registry for Endovascular Aortic Treatment. Patients treated with TEVAR between December 2010 and January 2021 were selected regardless of the type of thoracic aortic disease. The primary outcome was sex-specific all-cause mortality at 5 years and maximum follow-up. Secondary outcomes were sex-specific all-cause mortality at 30 days and 1 year, and aorta-related mortality, major adverse cardiac events, neurological complications, and device-related complications or reinterventions at 30 days, 1 year, 5 years, and maximum follow-up. ResultsA total of 805 patients were analyzed; 535 (66.5%) were males. Females were older (median, 66 years [interquartile range (IQR), 57-75 years] vs 69 years [IQR, 59-78 years], P < .001). Males had more frequently a history of coronary artery bypass grafting and renal insufficiency (8.7% vs 3.7% [P = .010] and 22.4% vs 11.6% [P < .001]). The median follow-up was 3.46 years (IQR, 1.49-4.99 years) for males and 3.18 years (IQR, 1.29-4.86 years) for females. Indications for TEVAR were mostly descending thoracic aortic aneurysms (n = 307 [38.1%]) type B aortic dissections (n = 250 [31.1%]) or others (n = 248 [30.8%]). Freedom from 5-year all-cause mortality was similar for males and females (67% [95% CI, 62.1-72.2] vs 65.9% [95% CI, 58.5-74.2]; P = .847), and there were no differences in secondary outcomes. Multivariable Cox regression showed females to have lower all-cause mortality rates; however, this difference did not reach statistical significance (hazard ratio, 0.97; 95% CI, 0.72-1.30; P = .834). Additional subgroup analyses based on the indication for TEVAR did not identify differences between both sexes for the primary and secondary outcomes except more endoleak type II in females with complicated type B aortic dissection (1.8% vs 12.1%; P = .023). ConclusionsThe present analysis suggests that long-term outcomes of TEVAR performed irrespective of the type of aortic disease are similar for males and females. Further studies are needed to clarify existing controversies regarding the impact of sex on outcomes of TEVAR.

Long-Term Thoracic Endovascular Repair Follow-Up from 1999 to 2019: A Single-Center Experience

Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990s and long-term follow-up studies are warranted in current guidelines. Patients undergoing TEVAR were consecutively included from 1999 to 2019. Thoracic aortic disease includes thoracic aortic aneurysms, aortic dissection, traumatic rupture, penetrating aortic ulcer (PAU), and intramural hematoma (IMH). Our prospective database recorded baseline characteristics, endoleak or aneurysm growth, and death. Patients were included at the time of treatment and censored at death or first reintervention depending on the analysis. Primary end point was all-cause death; secondary end point was reintervention. Survival and failure analyses were done using STATA IC 16.0 and truncated at 15years of follow-up. Two hundred and fifty six patients were included and 63% were men. Their mean age at intervention was 66.2±14.5years and they were followed for a mean of 5.2±4.5years. Indications for TEVAR were acute aortic syndrome in 40.6%, chronic aortic disease in 44.5%, and traumatic rupture in 14.8%. Technical success was seen in 94.1% of the operations, and the left subclavian artery was covered in 27.7%. A 30-day mortality rate was 21.2% (22/104) and 1.75% (2/114) (P<0.001) for urgent and elective patients, respectively. Twelve patients (4.7%) died within 24hr of treatment. Overall, long-term mortality recorded 112 (43.8%) deaths, 29 patients had reinterventions (11.3 %, 95% confidence interval: 7.7-15.9), and aneurysms accounted for 62.1% of all reinterventions. Twenty four (82.8%) reinterventions occurred within the first 5years. This long-term follow-up study shows excess mortality in patients treated for acute aortic syndrome compared to chronic aortic disease, within the first 30days; this difference diminishes at the end of follow-up. Most endoleaks occur within the first 5 years, although new endoleaks continue to develop decades after in previous endoleak-free patients calling for lifelong surveillance.

Outcomes of great vessel debranching to facilitate thoracic endovascular aortic repair

ObjectiveWith the expanding application of endovascular technology, the need to deploy into zone 0 has been encountered on occasion. In the present study, we evaluated the outcomes of great vessel debranching (GVD) as a method of extending the proximal landing zone to facilitate thoracic endovascular aortic repair (TEVAR). MethodsWe performed a single-center retrospective review of all patients who had undergone GVD followed by TEVAR between May 2013 and December 2020. The primary outcome was primary patency of all targeted vessels, with all-cause perioperative mortality as a secondary outcome. Kaplan-Meier analysis was used to account for censoring of mortality and primary patency. The extent of hybrid aortic repairs was characterized into type I (GVD plus TEVAR without ascending aorta or aortic arch reconstruction, type II (GVD plus TEVAR with ascending aorta reconstruction), and type III (GVD plus TEVAR with ascending aorta and aortic arch reconstruction with an elephant trunk (soft [surgical] or frozen [endovascular]]). ResultsA total of 42 patients (23 men [54.8%]; mean age, 62.2 ± 11.2 years) had undergone GVD, with 122 vessels revascularized (42 innominate, 42 left common carotid, and 38 left subclavian arteries). The indication for TEVAR was aneurysmal degeneration from aortic dissection in 32 patients (76.2%), a thoracic aneurysm in 9 patients (21.4%), and a perforated aortic ulcer in 1 patient (2.4%). The median duration between GVD and TEVAR was 82 days. The mean follow-up period was 25.7 ± 23.5 months. Type I repair was performed in 4, type II in 16, and type III in 22 patients. The perioperative mortality, stroke, and paraplegia rates were 9.5%, 7.1%, and 2.4%, respectively. Neither the extent of repair (P = .80) nor a history of aortic repair (P = .90) was associated with early mortality. Of the 38 patients who had survived the perioperative period, 6 had died >30 days postoperatively. At 36 months, the survival estimate was 68.6% (95% confidence interval, 45.7%-83.4%). The overall primary patency of the innominate artery, left common carotid artery, and left subclavian artery was 100%, 89.5%, and 94.1%, respectively. The primary-assisted patency rate was 100% for all the vessels. ConclusionsWe found GVD to be a safe and effective method of extending the proximal landing zone into zone 0 with outstanding primary patency rates. Further studies are required to confirm the safety and longer term durability for these patients.

Abstract 12937: Sex Differences on Clinical Outcomes After Thoracic Endovascular Aortic Repair

Introduction: Thoracic endovascular aortic repair (TEVAR) has been increasingly utilized for the treatment of descending thoracic aortic aneurysms and dissections. Further research is warranted to understand outcomes of TEVAR in various populations. Hypothesis: Sex will not influence outcomes after nonelective TEVAR. Methods: This was an observational study from the Nationwide Readmissions Database analyzing men (n=3903) and women (n=2691) with aortic aneurysm or Type B aortic dissection who underwent nonelective TEVAR from 2010-2017. Appropriate trend weighting was used to generate national estimates. International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes were used to identify patients with thoracic aortic aneurysms or dissections who underwent TEVAR. 30-day and 90-day readmissions, in-hospital mortality, postoperative complications, and cost were compared between the two groups. Mixed model logistic regression was used to determine predictors of readmission, treating each participating hospital as a random effect. Results: The study population consisted of 6594 patients (3903 men, 2691 women) who underwent nonelective TEVAR. In-hospital mortality was 9.3% (n=613) and was not significantly different between groups (9.85% in men vs 8.50% in women, p=0.06). Of the remaining 5981 patients, women were more likely than men to be older, to have chronic pulmonary disease, and to have aneurysm rather than dissection as their indication for TEVAR. Women were less likely to have chronic kidney disease. Postoperatively, women were less likely to develop respiratory failure (9.41% vs 11.75%), acute kidney injury (17.93% vs 33.87%), and mesenteric ischemia (2.63% vs 4.36%). On multivariable regression, female sex was not associated with an increased risk of readmission at 30 days (OR 1.04, 95% CI 0.87-1.25, p=0.67) or 90 days (OR 1.06, 95% CI 0.90-1.25, p=0.48) as compared to male sex. Conclusions: Sex was not an independent predictor of 30-day and 90-day readmissions after nonelective TEVAR. While males had higher rates of complications such as acute kidney injury and mesenteric ischemia, mortality did not differ significantly between the two groups.

Outcomes of Thoracic Endovascular Aortic Repair in Octogenarians.

The aim of this study is to compare outcomes between octogenarians and non-octogenarians undergoing thoracic endovascular aortic repair (TEVAR). Using the National Inpatient Sample database, we identified octogenarians (≥80years) and non-octogenarians (<80years) who had undergone thoracic endovascular aortic repair between 2012 and 2017. We compared patients' demographic, socioeconomic, comorbidity data between the two groups as well as the procedure indications and perioperative outcomes. A multivariable logistic regression analysis was conducted to evaluate the impact of advanced age (≥80years) on the in-hospital mortality rates in patients who underwent TEVAR. This analysis was also performed for a separate cohort which included only patients who underwent TEVAR for ruptured thoracic aortic aneurysm. A total of 4108 patients were included in our study; 3432 (83.5%) patients were <80years (37.9% female; median age, 64years; 34.3% non-white) and 676 (16.5%) patients were ≥80 years (50.7% female; median age, 83 years; 20.4% non-white). Non-ruptured thoracic aortic aneurysm was the most common indication for TEVAR in older patients (61.4%), whereas type B aortic dissection was the most common indication in younger patients (36.4%). In-hospital complications were comparable between the two groups except for respiratory complications that were higher in the younger patients (21.2% vs. 15.2%; P <.001). The multivariable analysis demonstrated that advanced age had no association with increased in-hospital mortality rates (adjusted odds ratio [aOR], 1.41; 95% confidence interval [CI], .97-2.05), However, in ruptured thoracic aortic aneurysm cohort, octogenarians had higher in-hospital mortality rates (aOR, 1.86; 95% CI, 1.04-3.32). Octogenarians have acceptable rates of perioperative morbidity and mortality compared to the younger group and should be considered for TEVAR. Octogenarians are at higher risk for in-hospital mortality in the setting of ruptured thoracic aortic aneurysm, supporting the appropriateness of elective TEVAR in selected Octogenarians.

A 10-Year Single-Center Experience With the GORE TAG Conformable Thoracic Stent Graft in the Treatment of Thoracic Aortic Disease

Objective: The aim of this study was to report 10-year real-world single-center experience with the GORE TAG conformable thoracic aortic graft (CTAG), focusing on rupture-free survival, aortic-related reintervention, and device-related complications during midterm and long-term follow-up (FU). Methods: This retrospective study analyzes results of thoracic endovascular aortic repair (TEVAR) performed between January 2009 and December 2018. Out of 419 TEVAR procedures within this period, 194 patients (male 57.2%, 111/194), with a mean age of 65 ± 13 years, were treated with the CTAG device. Indication for TEVAR was a thoracic aortic aneurysm in 24.7% (48/194), type B aortic dissection in 32.5% (63/194), penetrating aortic ulcer 15.5% (30/194), and miscellaneous 27.3% (53/194). Emergently were operated 43.8% (85/194) patients. Median follow-up (FU) including computed tomography imaging was 43.5 months (Q1-Q3: 8.6–67.0) and was completed in 91.2% (177/194) of patients. Results: Overall survival rates were 75.8% (95% confidence interval [CI] = [0.76–0.70]) and 56.6% (95% CI = [0.57–0.50]) at 12 and 60 months, respectively. Cumulative incidence for aortic rupture was 11.9% (95% CI = [0.07–0.17]) at 60 and 90 months, respectively. Cumulative incidence for aortic-related reintervention was 27.5% (95% CI = [0.21–0.34]) at 60 and 90 months. Cumulative incidence for migration was 2.8% (95% CI = [0.004–0.05]) and 3.9% (95% CI = [0.007–0.07]) at 60 and 90 months, respectively. New endograft infections or material fatigue were not observed. Conclusions: The herein reported 10-year real-world single-center experience with the CTAG observed favorable long-term outcome. Thus, the device demonstrates appropriate persistent safety, efficacy, and clinical durability up to long-term FU in the treatment of diverse thoracic aortic pathologies.

Therapeutic window for obtaining favorable remodeling after thoracic endovascular aortic repair of type B aortic dissection

ObjectiveThe purpose of the present study was to determine the most appropriate timing for thoracic endovascular aortic repair (TEVAR) of type B aortic dissection (TBAD) in terms of remodeling of the aorta. MethodsA total of 41 patients who had undergone TEVAR for the treatment of aortic dissection were included in the present study. The patients were divided into two groups: those who had undergone TEVAR in the acute or subacute phase (group A) and those who had undergone TEVAR in the chronic phase (group B). The indications for TEVAR as the treatment of TBAD were the presence of aortic rupture or malperfusion of the aortic branches, a maximum aortic diameter of ≥40 mm on the initial diagnostic computed tomography scan, and/or expansion of the aorta of ≥5 mm within 3 months for acute and subacute TBAD. The indication was a maximum aortic diameter of ≥50 mm or expansion of the aorta of ≥5 mm within 1 year for chronic TBAD. The diameters of the aorta, true lumen, and false lumen were measured at the level of the most dilated part of the descending aorta (level M) and at the diaphragm (level D) on the computed tomography scan obtained before TEVAR and at the 2-year follow-up examination. ResultsThe median interval between TEVAR and the onset of TBAD was 0.2 month (interquartile range, 0.03-0.7 month) in group A (n = 21) and 32 months (interquartile range, 4.7-35.2 months) in group B (n = 20). Except for the aortic diameter at level D in group B, favorable remodeling was obtained at both levels in both groups. The diameter change ratio of the aorta at level D was significantly greater in group A than in group B (P = .02). Receiver operating characteristic curve analysis of the interval for a significant decrease in the aortic diameter at level D yielded 4.2 months as the optimal threshold for performing TEVAR (area under the curve, 0.859; 95% confidence interval, 0.7-1.0). ConclusionsTEVAR for TBAD will result in favorable outcomes, irrespective of the timing of the procedure. However, it might be more effective to perform TEVAR within 4.2 months of the onset of TBAD, provided that the TEVAR procedure can be performed safely.

Outcome after acute und subacute TEVAR in uncomplicated type B aortic dissection

Abstract Objective In the past years, a paradigm shift from best medical therapy to early thoracic endovascular aortic repair (TEVAR) has been observed in the treatment of uncomplicated type B aortic dissection (uTBAD). We aimed to analyze outcomes after TEVAR in the acute and subacute phase of uTBAD, focusing on aortic remodeling. Methods Retrospective analysis of consecutive patients who underwent TEVAR for acute or subacute uTBAD in two tertiary referral centers from 2008 – 2017. Two assessors per center reviewed computed tomography scans of each patient at presentation, at one year and at the last follow-up using post-processing software. Results Forty-nine patients were treated with TEVAR for uTBAD. The indication for TEVAR was the presence of multiple morphologic predictors of adverse aortic outcome. The most common predictors were a false lumen diameter of &amp;gt; = 22mm in 76% of patients, a primary entry tear of &amp;gt; = 10mm in 69% and a total aortic diameter of &amp;gt; = 40mm in 67%. There were no in-hospital deaths and no deaths at 1 year. The median follow-up was 40.6 months. Three-year cumulative survival was 94 % (46/49). Fourteen secondary interventions were performed in 10 patients (20 %) after a median of 4.2 months. TEVAR lead to remodeling of the descending thoracic aorta with a median reduction of the total aortic diameter of 4.5 mm within one year and stable diameters after three years. The median maximum false lumen diameter diminished from 26 mm to 15 mm in one year (at 3 years: 14.8 mm). Conclusion In this cohort of selected patients with uTBAD and multiple morphologic predictors of worse aortic outcome, elective acute or subacute TEVAR was associated with a low mortality and positive aortic remodeling in the mid-term follow-up.

Outcomes of Great Vessel Debranching to Facilitate Thoracic Endovascular Aortic Repair

With the expanding application of endovascular technology, the need to deploy into zone 0 has been encountered on occasion. This study evaluated the outcomes of great vessel debranching (GVD) as a method of extending proximal landing zone to facilitate thoracic endovascular aortic repair (TEVAR). A single-center retrospective review of all patients who underwent GVD followed by TEVAR between May 2013 and May 2020 was conducted. The primary outcome was primary patency of all targeted vessels, with mortality as a secondary outcome. Kaplan-Meier analysis was used to account for censoring in estimates of mortality and primary patency. There were 38 patients (20 men; mean age, 65 ± 14 years) who underwent GVD, with 110 vessels revascularized (38 innominate, 37 left common carotid, and 35 left subclavian; Table). Indications for TEVAR were type A dissection in 16 patients, type B dissection with aneurysmal degeneration in 12, thoracic aneurysm in 9, and perforated aortic ulcer in 1. Median duration between GVD and TEVAR was 38 days. Mean follow-up was 1.5 ± 1.8 years. Perioperative mortality, stroke, and paraplegia rates were 5.3%, 5.3%, and 2.6%, respectively. During the perioperative period, three endoleaks were identified, two of which required reintervention. Late deaths through 2 years occurred in five patients. Survival estimates were 82.1% and 77.8% at 1 year and 2 years, respectively. Overall primary patency was 96.8% through 2 years as a result of one-vessel occlusion at 18 months postoperatively. GVD is a safe and effective means of extending proximal landing zone and thereby facilitating TEVAR with an outstanding primary patency rate. Longer follow-up analysis is needed to determine late risk of graft-related complications and mortality in these patients.TableMethod of great vessel debranching (GVD)Ascending aorta-based bypassReimplantationCross-cervical bypassCarotid-subclavian bypassSubclavian transpositionInnominate308N/AN/AN/ALeft common carotid2791N/AN/ALeft subclavian108133N/A, Not applicable. Open table in a new tab

Clinical and Morphologic Outcomes of Endovascular Repair for Subacute and Chronic Type B Aortic Dissection

The objective of the study was to assess long-term remodeling, survival, and reintervention outcomes after thoracic endovascular aortic repair (TEVAR) for subacute and chronic type B aortic dissection (TBAD). All patients who underwent TEVAR for subacute or chronic TBAD at a tertiary referral center between 1999 and 2015 were included in this cohort study. The primary outcome was aortic remodeling, and secondary outcomes included survival, rate of major complications, and reinterventions. Fifty patients were included, with mean age of 62.4years, 10 (20%) DeBakey type IIIA and 40 (80%) DeBakey type IIIB dissection; 45 standard TEVAR, 2 branched TEVAR, 3 TEVAR combined with fenestrated or branched EVAR. Indication for TEVAR was intact (n=40) or ruptured (n=1) postdissection aneurysm, hypoperfusion (n=4), treatment-refractory pain (n=2), or a combination (n=3). Mean clinical follow-up was 76months, and median radiological follow-up was 46months. Thirty-day survival was 96%, stroke 4%, renal failure 0%, paraplegia 0%. Three- and five-year survival was 92% (95% confidence interval (CI) [79; 97]) and 77% (95% CI [61; 87]), respectively. Of 19 late deaths, 6 were confirmed aorta related. Five-year freedom from reintervention was 69% (95% CI [53-80]). Distal stent graft extension due to aortic dilatation composed most reinterventions. Mean maximal aortic diameter was 58.7mm preoperatively and 51.9mm on last follow-up (P=0.003). On thoracic level, true lumen expanded (+10.0mm, 95% CI [6.4; 13.6]) (P<0.001) and false lumen decreased (-11.9mm, 95% CI [-15.2; -8.5]) (P<0.001) from baseline to the last computed tomography. In the abdominal aorta, true lumen diameter change was +3.1mm (95% CI [1.4; 4.8]) (P=0.001); false lumen diameter change was +1.0mm (95% CI [-1.8; 3.8]) (P=0.464). TEVAR for subacute and chronic TBAD results in favorable remodeling of the thoracic but not the abdominal aorta. Five-year survival is almost 80%, but late aortic deaths still occur. Aortic dilatation distal to the treated segment requiring reintervention is common, emphasizing the importance of follow-up.

Predictors of 30-day readmission and resource utilization after thoracic endovascular aortic repair.

The introduction and expansion of thoracic endovascular aortic repair (TEVAR) have revolutionized the treatment of a variety of thoracic aortic diseases. We sought to evaluate the incidence, causes, predictors and costs associated with 30-day readmission after TEVAR in a nationally representative cohort. Adult patients undergoing isolated TEVAR were identified in the National Readmissions Database from 2010 to 2014. Hospital costs were estimated by converting individual hospital charge data adjusted to 2014 consumer price indices. Multivariable logistic regression was utilized to determine hospital- and patient-level factors associated with readmissions. A total of 24983 TEVARs were noted during the study period; the average age of the patients was 65 ± 16 years; 40% were women. The most common indication was an intact thoracic aneurysm (43.5%), followed by aortic dissection (30.5%). The average cost of the index admission was $63644 ± $52312; the average hospital stay was 11 ± 14 days; the index mortality rate was 6.7%. Readmissions within 30 days occurred in 17.4% of patients. Indications for readmission were varied; the most common aetiologies were cardiac (17.8%), infectious (16.0%) and pulmonary (12.1%). On multivariable analysis, the strongest predictor of readmission was the diagnosis, with a ruptured thoraco-abdominal aneurysm having the highest readmission burden (adjusted odds ratio 2.23, 1.17-4.24; P = 0.015). Notably, hospital volume did not predict index hospital length of stay, costs or 30-day readmissions (all P > 0.10). Annual TEVAR volume was not associated with any of the outcomes assessed. Rather, indication for TEVAR was the strongest predictor for many outcomes. As TEVAR becomes increasingly utilized, a focus on cardiac and vascular diseases may reduce readmissions and improve quality of care.

Outcome comparison of thoracic endovascular aortic repair performed outside versus inside proximal landing zone length recommendation

ObjectiveSuccess of thoracic endovascular aortic repair (TEVAR) relies heavily on the proximal landing zone (PLZ) sealing. Most instructions for use of thoracic endografts recommend a PLZ length of at least 2 cm. Because of the complex aortic anatomic features, TEVAR landing in zone 1 to zone 3 may not meet this requirement. The aim of this study was to examine whether 2-cm PLZ nonadherence was related to adverse outcomes after TEVAR. MethodsA retrospective review was performed of patients who underwent zone 1, zone 2, and zone 3 landing TEVAR at a single institution between November 2013 and October 2018. Preoperative and postoperative computed tomography angiography images were analyzed using three-dimensional reconstruction. The patients were categorized into two groups: PLZ ≥2 cm (adherence group) and PLZ <2 cm (nonadherence group). Collected data included patient and anatomic characteristics. Primary outcomes were type IA endoleak, retrograde dissection, and graft migration. ResultsThe cohort comprised 63 patients (18 in the adherence group and 45 in the nonadherence group) with a mean age of 53.3 ± 20.6 years. Indications for TEVAR were blunt thoracic aortic injury (65.1%), thoracic aneurysm (23.8%), penetrating ulcer (9.5%), and type B dissection (1.6%). Mean PLZ length was significantly shorter for the nonadherence group (8 ± 7 mm for the nonadherence group vs 34 ± 15 mm for the adherence group; P < .0001). PLZ location (2 zone 1, 15 zone 2, 46 zone 3) and oversizing (19.4% ± 8.3% for the adherence group; 20.3% ± 10.2% for the nonadherence group; P = .7) were similar between the groups. The mean PLZ aortic diameter of the adherence group was significantly larger than that of the nonadherence group (29 ± 5 mm for the adherence group; 25 ± 5 mm for the nonadherence group; P = .004). Mean follow-up time was 126.7 days (range, 0-644 days) for the adherence group and 233.8 days (range, 0-1750 days) for the nonadherence group (P = .2). During the study period, no primary outcome was observed in the adherence group, whereas 12 adverse events occurred in 10 patients in the nonadherence group (type IA endoleak, n = 10; graft migration, n = 1; retrograde dissection, n = 1). Of 10 type IA endoleaks, five were immediate (4 resolved spontaneously, 1 remained persistent) and five were delayed (1 resolved spontaneously, 1 remained persistent, 1 ruptured causing death, 2 required total arch replacement). ConclusionsAchieving recommended sealing zone of 2-cm centerline length is paramount to avoid device-related adverse outcomes. We recommend careful surveillance in patients undergoing urgent TEVAR with <2-cm PLZ.

Endovascular Treatment of Descending Thoracic Aortic Pathology: Results of the Regis-TEVAR Study

Endovascular techniques have become an essential tool for treatment of thoracic aortic pathology. The objective of this study was to analyze indications and results of thoracic endovascular aortic repair (TEVAR) in vascular surgery units, through a retrospective and multicentric national registry called Regis-TEVAR. From 2012 to 2016, a total of 287 patients from 11 vascular surgery units, treated urgently and electively, were recruited consecutively. The primary variables analyzed are mortality, survival, and reintervention rate. The following indications for TEVAR were also analyzed: aortic dissections, thoracic aneurysms, traumatisms, and intramural hematomas or penetrating ulcers, as well as results and postoperative complications in accordance with each indication. Of the 287 TEVAR performed (239 men, mean age 64.1±14.1years), 155 were because of aortic aneurysm (54%), 90 because of type B aortic dissection (31.4%), 36 because of traumatic aortic rupture (12.5%), and 6 because of penetrating ulcers or intramural hematomas (2.1%). Overall mortality at 30days was 11.5% (18.5% in urgent and 5.3% in elective), being higher in dissections (13.3%). The median actuarial survival was 73% at 4years. The stroke rate was 3.1%, and the rate of spinal cord ischemia was 4.9%. Aortic reoperations were necessary in 23 patients (8.1%). This registry provides complete and reliable information on real clinical practice of TEVAR in Spain, with results similar to international series of open surgery. In accordance with these data, TEVAR can be performed with acceptable morbidity and mortality and with low rates of postoperative complications.

Anatomic suitability for “off-the-shelf” thoracic single side-branched endograft in patients with type B aortic dissection

ObjectiveTreatment of type B aortic dissections with thoracic endovascular aortic repair (TEVAR) has been adopted in many centers with the goal of covering the proximal entry tear. Coverage of the left subclavian artery (LSCA) is commonly required to achieve a dissection-free proximal seal zone. A novel thoracic single side-branched (TSSB) endograft device offers a potential off-the-shelf option to achieve total endovascular incorporation of LSCA during zone 2 TEVAR. The aim of this study was to determine what percentage of patients with type B aortic dissection who require zone 2 TEVAR meet the anatomical requirements for this device. MethodsAll consecutive patients undergoing TEVAR for type B aortic dissections at a single institution from 2006 to 2016 were evaluated. Three-dimensional centerline reconstruction of preoperative computed tomography angiography was performed to identify the diameter of the aorta, distances between branch vessels, diameter of the target branch vessel, and location of the primary entry tear. Only patients who met criteria for zone 2 TEVAR were included in the analysis. The primary outcome was percentage of patients that meet all anatomical requirements for TSSB. Individual criteria were evaluated independently, and results were stratified by dissection chronicity. ResultsEighty-seven patients who underwent TEVAR for Stanford type B aortic dissections were reviewed. Fifty-seven (66%) would have required zone 2 TEVAR. Indications for TEVAR were malperfusion (12), aneurysm (15), persistent pain (22), rupture (3), uncontrolled hypertension (5), and other (3). Mean follow-up was 19 months (range, 1-72 months). Only 16 of the 57 patients (28%) met all the requirements for anatomic suitability. The primary contributor was that only 49% of patients had sufficient length between arch branches to prevent coverage of a proximal branch. ConclusionsAlthough the new TSSB device can allow for a more proximal seal zone and eliminate the need for open aortic arch debranching, only 28% of patients with type B dissection who required zone 2 TEVAR met all the anatomic requirements for this device. Future devices will need to account for the short distance between the left carotid and LSCA to be more broadly applicable.

IP257. Percutaneous Femoral Access Associated With Reduced Resource Use After Thoracic Endovascular Aortic Repair for Trauma

Thoracic endovascular aortic repair (TEVAR) has become the more common repair modality for traumatic aortic injury in the past few decades. The Society for Vascular Surgery guidelines for the management of aortic injury recommend open femoral access for endovascular repair. However, there is limited literature evaluating percutaneous femoral access in TEVAR for trauma. The objective of this study was to evaluate outcomes after percutaneous access for trauma TEVAR. A retrospective review of the prospectively maintained Vascular Quality Initiative thoracic endovascular repair module from 2008 to 2017 was evaluated. Patients listed as having traumatic disease as the indication for TEVAR were included. Patients were grouped into two cohorts based on access type: open and percutaneous. Intention-to-treat analysis was performed for patients who had failed percutaneous access and were converted to open access. Patients in each cohort were stratified on the basis of a dichotomized injury severity score (1-3, moderate; 4-6, severe). Primary end points were access site outcomes and resource use. Secondary outcomes included composite complication profile. There were 402 patients included in the study, with 122 in the open group and 280 in the percutaneous group. The demographics between the groups demonstrate a significantly higher proportion of white race in the moderate injury percutaneous group (66% ± 54.1% vs 195% ± 69.6%; P = .003; Table I). Access site outcomes are not different between groups for either injury severity. There is a significantly reduced operative time in the percutaneous group for both severity levels (P = .006 and P = .03, respectively) as well as decreased length of stay in the moderate severity percutaneous group (P = .009; Table II). A decreased vasopressor requirement is also seen in the severely injured percutaneous group (P = .001). Overall complications are not significantly different between groups. This is the first study to evaluate outcomes after percutaneous access for trauma TEVAR. These data demonstrate reduced resource use for patients undergoing percutaneous access with similar access site and overall complications compared with open femoral access. These data validate the safety of percutaneous access for TEVAR after traumatic aortic injury.Table IPatients' demographicsISS class 1-3ISS class 4-6Open access (n = 50)±SE or %Percutaneous access (n = 112)±SE or %P valueOpen access (n = 72)±SE or %Percutaneous access (n = 168)±SE or %P valueDemographics Age, years40.12.2844.31.83.17843.42.1342.51.40.722 Male3774.07970.5.7094765.312172.0.356 White2244.07667.9.0034461.111970.8.174 BMI, kg/m229.41.1828.90.62.70228.70.8528.00.53.466 AIG2.80.0972.70.079.6222.90.1082.90.62.711 GCS score12.460.5712.720.39.70410.680.5910.460.40.763AIG, Aortic injury grade; BMI, body mass index; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; SE, standard error. Open table in a new tab Table IIComparison of outcomes and resource useISS class 1-3ISS class 4-6Open access (n = 50)±SE or %Percutaneous access (n = 112)±SE or %P valueOpen access (n = 72)±SE or %Percutaneous access (n = 168)±SE or %P valueResource use OR time, minutes106.310.9778.54.50.017122.910.9096.76.30.050 Total LOS, days17.31.8012.50.88.01624.84.2521.11.54.303 ICU LOS, days6.50.837.10.63.61511.61.3211.61.02.993 Reintervention00.032.7.55311.421.21.000 Vasopressors36.065.41.0001723.6127.1.001Complication CNS12.032.71.00045.663.6.492 Cardiac24.076.3.722912.5148.3.342 Death24.021.8.5881115.3127.1.058Access site Hematoma00.000.0.00000.031.81.000 Site occlusion00.000.0.00000.010.61.000 SSI00.000.0.00000.021.21.000CNS, Central nervous system; ICU, intensive care unit; ISS, Injury Severity Score; LOS, length of stay; OR, operating room; SE, standard error; SSI, surgical site infection. Open table in a new tab

Thoracic endovascular stent graft repair for ascending aortic diseases

ObjectivesWe describe the preliminary results of thoracic endovascular aortic repair (TEVAR) in a group of patients with ascending aortic disease from the Global Registry for Endovascular Aortic Treatment (GREAT). MethodsWe identified TEVAR performed for diseases truly originating from the ascending aorta. Between July 2011 and May 2015, 5014 patients were enrolled; six (0.12%) were identified and included in the analysis. One further patient was withdrawn from the study due to lack of a signed consent form. Patients having a “zone 0” proximal landing zone reported for their TEVAR without the presence of an ascending aortic disease were not included. Reinterventions of previous open and endovascular repair were also excluded. ResultsThree males and three females were treated. Mean age was 69 years ± 10 years (range, 58-83 years). Indication for TEVAR was atherosclerotic aneurysm (n = 4; ruptured, n = 1), complicated type A dissection (n = 1, rupture), and pseudoaneurysm (n = 1). Mean maximum aortic lesion diameter was 60 mm 14 (range, 39-77 mm). Urgent intervention was performed in three (50%) cases. Primary clinical success was 100%. There was no TEVAR-related in-hospital mortality. Open conversion was never required. Complication such as cerebrovascular accidents, valve impairment, or myocardial infarction did not occur. All patients were discharged home alive. No patient was lost at a median follow-up of 26 months (range, 16-72 months). During the follow-up, no patient died and ongoing primary clinical success was maintained in all patients. Reintervention was never required; endoleaks, migrations, fractures, or ruptures were not observed. ConclusionsPreliminary “real-world” experience of ascending TEVAR shows satisfactory outcomes at short-term follow-up. Although concerns remain for “off-label” use of standard devices, TEVAR-related complications were not observed. Longer follow-up data are expected to confirm durability of these results.

Anatomic Suitability for Standard, “Off-the-Shelf” Thoracic Single Side-Branched Endograft in Patients With Type B Aortic Dissection

Treatment of type B aortic dissections with thoracic endovascular aortic repair (TEVAR) has been adopted in many centers with the goal of covering the proximal entry tear. Coverage of the left subclavian artery is commonly required to achieve a dissection-free proximal seal zone. A novel thoracic single side-branched (TSSB) endograft offers a potential off-the-shelf option to achieve total endovascular incorporation of the left subclavian artery during zone 2 TEVAR. The aim of this study was to determine what percentage of patients with type B aortic dissection who require zone 2 TEVAR meet the anatomic requirements for this device. All consecutive patients undergoing TEVAR for type B aortic dissections at a single institution from 2006 to 2016 were evaluated. Three-dimensional centerline reconstruction of preoperative computed tomography angiography was performed to identify the diameter of the aorta, distances between branch vessels, diameter of the target branch vessel, and location of the primary entry tear. Only patients who required zone 2 TEVAR were included in the analysis. The primary outcome was percentage of patients who met all anatomic requirements for the TSSB endograft. The specific requirements leading to nonsuitability were also calculated. Eighty-seven patients who underwent TEVAR for type B aortic dissection were reviewed; 57 of 87 would have required zone 2 TEVAR. Indications for TEVAR were malperfusion (12), aneurysm (15), persistent pain (22), rupture (3), uncontrolled hypertension (5), and other (3). Mean follow-up was 19 months (range, 1-72 months). Only 17 patients (30%) met all the requirements for anatomic suitability (Fig). The reasons for failing anatomic suitability were covered stent graft length proximal to the branch portal (61%), aortic diameter at the proximal seal zone (11%), left subclavian diameter (16%), left subclavian length to its first branch (14%), and access vessel diameter (40%). Although the standard TSSB endograft can allow a more proximal seal zone and eliminate the need for open aortic arch debranching, only 30% of patients with type B dissection who require zone 2 TEVAR meet all the anatomic requirements for this device. The most common reason for failure of anatomic suitability is the proximity of the left carotid to the left subclavian origin.