Initial Aortic Diameter Research Articles

Acute Type B Aortic Dissection: Insights From a Single-Center Retrospective Experience Over 12 Years.

The treatment of acute type B aortic dissection (ATBAD) is currently a challenge for vascular surgeons, because of the early morbidity and mortality rates and the high risk of late aortic events up to 50% at 5 years. This study presents the initial outcomes of ATBAD treatment using optimal medical therapy alone or combined with proximal entry tear stent-graft coverage. Additionally, it provides an analysis of the evolution of the aortic diameter and its clinical consequences during the chronic phase in each group. Conducted as a retrospective, single-center study, we enrolled all consecutive ATBAD patients (n=130) treated between 2008 and 2020. The primary analysis studies the entire patient cohort based on their initial management approach, namely, medical treatment alone for uncomplicated ATBAD (n=67) or combined with stent-graft entry tear coverage (n=63). We also conducted a subgroup analysis to investigate factors associated with disease progression in the medical management group. Median follow-up was 29.5 months. During this time aneurysmal evolution was observed in: 42.4% of cases in the medical group compared with 21.8% in the stent-graft group, primarily affecting the thoracic aorta. The stent-graft group exhibited significant aortic remodeling, with a decrease in false lumen (FL) and thoracic aortic diameters. Initial aortic diameter ≥40 mm and FL ≥22 mm were independent risk factors for aneurysmal degeneration. Five-year survival was consistent at 76.1% in both groups. This study confirms the safety and efficacy of stent-graft entry tear coverage for ATBAD. Initial thoracic endovascular aortic repair (TEVAR) appears to reduce late aortic events by promoting aortic remodeling. Considering TEVAR's safety and potential to prevent late aortic complications, it may be considered for uncomplicated ATBAD patients with an initial aortic diameter ≥40 mm or an FL ≥22 mm. This study validates the efficacy and safety of using endovascular stent grafts to seal the proximal entry tear in cases of acute type B aortic dissections, compared to optimal medical therapy. Aortic remodelling significantly benefits from endovascular stent graft coverage of the proximal entry tear. Given the heightened risk of late aortic events observed in the medical therapy cohort, there appears to be a necessity for including endovascular interventions in the management of uncomplicated acute type B aortic dissections, particularly when aortic diameter is ≥40 mm and false lumen diameter is ≥22 mm.

Impact of Initial Aortic Diameter on Mortality in Acute Type B Aortic Dissection

Impact of Initial Aortic Diameter on Mortality in Acute Type B Aortic Dissection

Features and outcomes of focal intimal disruption in acute type B intramural haematoma.

A focal intimal disruption (FID) is a risk factor for adverse aorta-related events in patients with acute type B intramural haematoma. This study evaluated the impact of FIDs on overall survival with a selective intervention strategy for large or growing FIDs. Additionally, this study evaluated the risk factors associated with the growth of FIDs. This retrospective study included all consecutive patients admitted for acute type B intramural haematomas between November 2004 and April 2021. The primary outcome was overall survival. The secondary outcome was the cumulative incidence of composite aortic events and the growth of FIDs. The latter was calculated on centreline-reconstructed computed tomography images. A total of 105 patients were included. A total of 106 FIDs were identified in 73 patients (73/105, 69.5%). The 1- and 5-year cumulative incidence rates of composite aortic events were 36.2% and 39.2%, respectively. The 1- and 5-year overall survival was 93.3% and 81.5%, respectively. Initial maximal aortic diameter and large FIDs during acute phase were significant risk factors for composite aortic events, but not risk factors for overall survival. The early appearance interval of an FID was a significant risk factor for growth of an FID. With a selective intervention strategy for large or growing FIDs, the presence of large FIDs during the acute phase does not affect overall survival. The early appearance interval was associated with the growth of FIDs.

Reintervention after Thoracic Endovascular Aortic Repair of Uncomplicated Type B Aortic Dissection

Data are scarce regarding the incidence, reasons, potential risk factors, and long-term outcomes of reintervention after thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated type B aortic dissection (TBAD). Between January 2010 and December 2020, 238 patients with uncomplicated TBAD who received TEVAR were analyzed retrospectively. The clinical baseline data, aorta anatomy, dissection characteristics, and details of the TEVAR procedure were evaluated and compared. A competing-risk regression model was used to estimate the cumulative incidences of reintervention. The multivariate Cox model was used to identify the independent risk factors. The mean follow-up time was 68.6 months. A total of 27 (11.3%) cases of reintervention were observed. The competing-risk analyses showed that the 1-, 3-, and 5-year cumulative incidences of reintervention were 5.07%, 7.08%, and 14.0%, respectively. Reasons for reintervention included endoleak (25.9%), aneurysmal dilation (22.2%), retrograde type A aortic dissection (18.5%), distal stent-graft-induced new entry and false lumen expansion (18.5%), and dissection progression and/or malperfusion (14.8%). Multivariable Cox analysis demonstrated that a larger initial maximal aortic diameter (Hazard ratio [HR], 1.75; 95% Confidence interval [CI], 1.13-2.69, p = 0.011) and increased proximal landing zone oversizing (HR, 1.07; 95% CI, 1.01-1.47, p = 0.033) were the significant risk factors for reintervention. Long-term survival rates were comparable between patients with or without reintervention (p = 0.915). Reintervention after TEVAR in patients with uncomplicated TBAD is not uncommon. A larger initial maximal aortic diameter and excessive proximal landing zone oversizing are associated with the second intervention. Reintervention does not significantly affect long-term survival.

Radiation and Chemotherapy are Associated with Altered Aortic Aneurysm Growth in Patients with Cancer: Impact of Synchronous Cancer and Aortic Aneurysm

The purpose of this study was to assess the associations between malignancy, therapeutic regimens, and aorto-iliac aneurysm (i.e., abdominal aortic aneurysm [AAA]) growth rates. A retrospective single centre analysis identified patients with an AAA plus cancer. Patients who had two or more computed tomography angiograms over six months or more and additional malignancy were included. Clinical data and aneurysm diameters were analysed. AAA growth under cancer therapy (chemotherapy or radiation) was compared with a non-cancer AAA control cohort and to meta-analysis data. Statistics included t tests and a linear regression model with correction for initial aortic diameter and type of treatment. From 2003 to 2020, 217 patients (median age 70 years; 92% male) with 246 aneurysms (58.8% AAA) and 238 malignancies were identified. Prostate (26.7%) and lung (15.7%) cancer were most frequently seen. One hundred and fifty-seven patients (72.3%) received chemotherapy, 105 patients (48.4%) radiation, and 79 (36.4%) both. Annual AAA growth (mean ± standard deviation) was not statistically significantly different for cancer and non-cancer patients (2.0 ± 2.3 vs. 2.8 ± 2.1 mm/year; p= .20). However, subgroup analyses revealed that radiation was associated with a statistically significantly reduced mean aneurysm growth rate compared with cancer patients without radiation (1.1 ± 1.3 vs. 1.6 ± 2.1 mm/year; p= .046) and to the non-cancer control cohort (1.7 ± 1.9 vs. 2.8 ± 2.1 mm/year; p= .007). Administration of antimetabolites resulted in statistically significantly increased AAA growth (+ 0.9 mm/year; p= .011), while topoisomerase inhibitors (- 0.8 mm/year; p= .17) and anti-androgens (- 0.5 mm/year; p= .27) showed a possible trend for reduced growth. Similar observations were noted for iliac aneurysms (n= 85). Additionally, the effects persisted for chemotherapy combinations (2.6 ± 1.4 substances/patient). Patients with cancer and concomitant aortic aneurysms may require intensified monitoring when undergoing specific therapies, such as antimetabolite treatment, as they may experience an increased aneurysm growth rate. Radiation may be associated with reduced aneurysm growth.

Penetrating aortic ulcer and aortic intramural hematoma: Treatment strategy.

The indication, timing, and choice of the treatment modality for penetrating aortic ulcers (PAUs) and intramural hematoma (IMH) are frequently challenging. This article reviews these pathologies and their relation to aortic dissection and proposes a diagnostic and treatment algorithm. A review of literature on diagnosis and treatment of PAU and IMH was conducted. The PubMed database was searched using the terms "penetrating aortic ulcer" and "aortic intramural hematoma". Articles were reviewed and the studies involving diagnosis and management of PAU and IMH were included. We subsequently proposed a management algorithm for PAU and IMH based on available evidence. PAU and IMH are distinct entities from aortic dissection, although they carry a significant risk of progression into dissection, aneurysm, and rupture. PAU and IMH originating in zone 0 of the aorta generally require surgical treatment. When the origin is beyond zone 0, a trial of medical therapy is recommended. Progression of disease on imaging studies, persistent uncontrolled pain, and certain high-risk features warrant surgery. High-risk features signaling risk of disease progression include PAU with IMH, PAU depth more than 10mm, PAU diameter more than 20mm, IMH thickness more than 10mm, and maximum initial aortic diameter more than 40mm. High-quality evidence regarding the treatment of PAU and IMH is lacking. These entities can have a malignant course when they are present with associated symptoms and/or when they have associated high-risk features on imaging. An aggressive surgical approach is necessary in that group of patients.

Accuracy of Point-of-Care Ultrasound in Follow Up Abdominal Aortic Aneurysm Imaging.

Point-of-care ultrasound (POCUS) has been reported as a valuable tool for bedside diagnoses of abdominal Aortic Aneurysms (AAA). However, no data exist regarding POCUS in measuring follow-up AAA diameter studies in patients with existing AAAs. The purpose of this study was to determine the variability of aortic measurements performed by a non-physician using POCUS vs standard of care (SOC) measurements by a registered vascular technologist or an abdominal/pelvic CT scan. A prospective observational ultrasound study was performed from 1/1/2019 to 3/31/2021 on patients with a diagnosis of an AAA (≥3.0cm). A research coordinator (non-physician) underwent a 3-hour training session in ultrasound operation and basic human anatomy to measure AAA diameter. The maximum aortic diameter was documented and compared to measurements obtained by SOC ultrasonography or CT scan. The POCUS and SOC ultrasounds were separated by no more than 90 days. Clinical risk factors including age, race, body mass index, coronary artery disease, hypertension, peripheral vascular disease, cerebrovascular disease, diabetes, and current smoking were also collected. Eighty-one patients (mean age: 73.6 ± 5.8years, body mass index: 29.5 ± 6.2kg/m2) were being followed in a vascular clinic and underwent both a POCUS and SOC ultrasounds. One indeterminant study was reported in identifying an AAA diagnosis, due to an overlying colostomy. The average follow-up time from initial screening aortic diameter to POCUS was 4.4 ± 3.7years. Overall average aortic diameter measurements obtained were 4.1 ± .9cm for POCUS and 4.0 ± .9cm for SOC (P = NS). Average difference in aortic measurement for POCUS and SOC was -.1 ± .3cm. POCUS is an accurate method to follow AAA diameter in patients. POCUS could improve patient follow up with AAA diameter measurements, streamline care and reduce overall burden for both patients and Radiology Departments in assessing follow up AAA diameters.

The risk of rupture and abdominal aortic aneurysm morphology: A computational study.

Prediction of rupture and optimal timing for abdominal aortic aneurysm (AAA) surgical intervention remain wanting even after decades of clinical, histological, and numerical research. Although studies estimating rupture from AAA geometrical features from CT imaging showed some promising results, they are still not being used in practice. Patient-specific numerical stress analysis introduced too many assumptions about wall structure for the related rupture potential index (RPI) to be considered reliable. Growth and remodeling (G&R) numerical models eliminate some of these assumptions and thus might have the most potential to calculate mural stresses and RPI and increase our understanding of rupture. To recognize numerical models as trustworthy, it is necessary to validate the computed results with results derived from imaging. Elastin degradation function is one of the main factors that determine idealized aneurysm sac shape. Using a hundred different combinations of variables defining AAA geometry or influences AAA stability (elastin degradation function parameters, collagen mechanics, and initial healthy aortic diameters), we investigated the relationship between AAA morphology and RPI and compared numerical results with clinical findings. Good agreement of numerical results with clinical expectations from the literature gives us confidence in the validity of the numerical model. We show that aneurysm morphology significantly influences the stability of aneurysms. Additionally, we propose new parameters, geometrical rupture potential index (GRPI) and normalized aneurysm length (NAL), that might predict rupture of aneurysms without thrombus better than currently used criteria (i.e., maximum diameter and growth rate). These parameters can be computed quickly, without the tedious processing of CT images.

Predictors of Long-Term Aortic Growth and Disease Progression in Patients with Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer

We aimed to identify predictors of long-term aortic diameter change and disease progression in a population cohort of patients with newly diagnosed aortic dissection (AD), intramural hematoma (IMH), or penetrating aortic ulcer (PAU). We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN-USA, residents diagnosed with AD, IMH, and PAU (1995-2015). The endpoints were aortic diameter change, freedom from clinical disease progression (any related intervention, aortic aneurysm, new aortic syndrome, rupture or death) and disease resolution (complete spontaneous radiological disappear). Linear regression was used to assess aortic growth rate; predictors of disease progression were identified with Cox proportional hazards. Of 133 incident cases, 46 ADs, 12 IMHs, and 28 PAUs with sufficient imaging data were included. Overall median follow-up was 8.1 years. Aortic diameter increase occurred in 40 ADs (87%, median 1.0 mm/year), 5 IMHs (42%, median 0.2 mm/year) and 14 PAUs (50%, median 0.4 mm/year). Symptomatic presentation (P=0.045), connective tissue disorders (P=0.005), and initial aortic diameter >42 mm (P=0.013) were associated with AD growth rate. PAU depth >9 mm (P=0.047) and female sex (P=0.013) were associated with aortic growth rate in PAUs and IMHs. At 10 years, freedom from disease progression was 22% (95% CI 12-41) for ADs, 44% (95% CI 22-92) for IMHs, and 46% (95% CI 27-78) for PAUs. DeBakey I/IIIB AD (HR 3.09; P=0.038), initial IMH aortic diameter (HR 1.4; P=0.037) and PAU depth >10 mm (HR 3.92; P=0.018) were associated with disease progression. No AD spontaneously resolved; resolution rate at 10 years was 22% (95% CI 0-45) for IMHs and 11% (95% CI 0-23) for PAUs. Aortic growth and clinical disease progression are observed in most patients with aortic syndromes, while spontaneous resolution is uncommon. Predictors of aortic growth and disease progression may be used to tailor appropriate follow-up and eventual early intervention.

Results of a prospective follow-up study after type A aortic dissection repair: a high rate of distal aneurysmal evolution and reinterventions.

We investigated the anatomical evolution of residual aortic dissection after type A repair and factors associated with poor prognosis at a high-volume aortic centre. Between 2017 and 2019, all type A aortic dissections were included for prospective follow-up. Patients without follow-up computed tomography (CT) scan available for radiological analysis and patients without residual aortic dissection were excluded from this study. The primary end point was a composite end point defined as dissection-related events including aneurysmal evolution (increased diameter > 5 mm/year), aortic reintervention for malperfusion syndrome, aortic diameter >55 mm, rapid aortic growth >10 mm/year or aortic rupture and death. The secondary end points were risk factors for dissection-related events and reintervention analysis. All immediate and last postoperative CT scans were analysed. Among 104 patients, after a mean follow-up of 20.4 months (8-41), the risk of dissection-related events was 46.1% (48/104) and the risk of distal reintervention was 17.3% (18/104). Marfan syndrome (P < 0.01), aortic bicuspid valve (P = 0.038), innominate artery debranching (P = 0.025), short aortic cross-clamp time (P = 0.011), initial aortic diameter >40 mm (P < 0.01) and absence of resection of the primary entry tear (P = 0.015) were associated with an increased risk of dissection-related events or reintervention during follow-up. Residual aortic dissection is a serious disease requiring close follow-up at an expert centre. This study shows higher reintervention and aneurysmal development rates than currently published. To improve long-term outcomes, the early demographic and anatomic poor prognostic factors identified may be used for more aggressive treatment at an early phase.

Comparative study on clinical efficacy of different methods for the treatment of intramural aortic hematoma

To explore the difference of curative effect between different treatment modalities, in order to provide reference for the treatment of aortic intramural hematoma (IMH). 168 patients with aortic intramural hematoma diagnosed and treated from January 2010 to July 2020 were selected in the Second Affiliated Hospital of Nanchang University. Among them, 48 patients were diagnosed with Stanford A aortic intramural hematoma and 120 were diagnosed with Stanford B aortic intramural hematoma. According to the therapeutic methods, patients were divided into conservative treatment group and endovascular treatment group (TEVAR). For endovascular treatment group, according to the different timing of surgery, can be divided into acute phase group (onset within 72 h) and non-acute phase group (time of onset > 72 h).The clinical data and follow-up data were collected and analyzed by variance analysis and χ2 test. There were 168 patients diagnosed with aortic intramural hematoma 39 of them were (81.25%) Stanford A aortic intramural hematoma patients with pleural or pericardial effusion. For patient with Stanford A aortic intramural hematoma, endovascular treatment was performed in 15 patients (31.2%), and 33 cases (68.8%) for conservative treatment. The average follow-up (24.9 ± 13.9) was months. There were 120 patients with Stanford type B aortic intramural hematoma (71.4%), 60 patients received endovascular treatment (50%), and 60 patients (50%) received conservative treatment, with an average follow-up of (27.8 ± 14.6) months. For Stanford A type aortic intramural hematoma patients when the maximum aortic diameter ≥ 50 mm or hematoma thickness ≥ 11 mm, with high morbidity and mortality, positive endovascular treatment can reduce complications and death. For patients with Stanford type B aortic intramural hematoma, when the maximum aortic diameter ≥ 40 mm or hematoma thickness ≥ 10 mm, with high morbidity and mortality, positive endovascular treatment can reduce complications and death. Both Stanford type A and B aortic intramural hematoma patients could benefit from the endovascular treatment when the initial maximum aortic diameter is ≥ 50 mm or the hematoma thickness is ≥ 11 mm.

Sex-Based Differences Among Experimental Swine Abdominal Aortic aneurysms

BackgroundFemale sex protects against abdominal aortic aneurysms (AAAs); however, the mechanisms behind these sex-based differences remain unknown. The purpose of this study was to explore the role of sex and sex hormones in AAA formation among swine. Materials and methodsUsing a previous validated model, infrarenal AAA were surgically created in uncastrated male (n = 8), female (n = 5), and castrated male (n = 4) swine. Aortic dilation was measured on postoperative day 28 during the terminal procedure and compared to initial aortic diameter measured during the index procedure. Tissue was analyzed for immunohistochemistry, cytokine array, gelatin zymography, serum 17β-estradiol, and testosterone assay. ResultsUncastrated males had significantly larger maximal aortic dilation compared to castrated males (113.5% ± 11.4% versus 38.1% ± 4.5%, P = 0.0012). Females had significantly higher mean aortic dilation compared to castrated males (96.2% ± 7.5% versus 38.1% ± 4.5%, P = 0.0004). Aortic diameters between females and uncastrated males were not significantly different on day 28. Female swine had significantly higher concentrations of 17β-estradiol compared with uncastrated males (1590 ± 873.3 ng/mL versus 95.2 ± 2.3 ng/mL, P = 0.047), with no significant difference between females and castrated males. Uncastrated male AAA demonstrated significantly more elastin degradation compared with female and castrated males (P = 0.01 and <0 .01, respectively). No differences existed for T-cells or smooth muscle cells between groups. Multiple proinflammatory cytokines were elevated within uncastrated male aortic walls compared to females and castrated males. ConclusionsSex hormones, specifically 17β-estradiol and testosterone, influence experimental swine AAA formation as demonstrated by increased aneurysm size, collagen turnover, and elastolysis in uncastrated males in processes reflective of human disease.

Predictive Factors of Operative Need in Medically Managed Type B Aortic Dissections

Aneurysmal degeneration of medically managed type B aortic dissection (TBAD) can be a life-threatening condition. Preventive thoracic endovascular aorta repair (TEVAR) in patients at risk could potentially be beneficial. The aim of this study was to examine the predictors for late aneurysmal dilatation after TBAD. A retrospective study was conducted on 82 patients with medically managed acute TBAD for a minimum of 14days. Relevant demographic, biochemical, and radiographic variables at presentation were studied. The aortic dissection risk calculator tool developed by Sailer etal., predicting the risk of adverse events after aortic dissection based on demographic and radiographic variables at presentation, was tested retrospectively. With a median follow-up of 36months (range 13-68), 25 (30.5%) patients underwent surgery (92% TEVAR). A larger initial aortic and false lumen diameter as well as a greater distal extension of the dissection was associated with higher need for surgery (respectively, P=0.003, P=0.004, and P=0.001). We observed higher growth rates of maximum aortic diameter in patients with a greater distal extension of the dissection, larger false lumen diameters and false lumen outflow, and entry tears located at the inner aortic arch (respectively, P=0.001, P=0.005, P=0.001 and P=0.014). No significant correlations could be found for the risks provided by the calculator tool. The initial maximum aortic diameter of TBAD is a key predictor for aortic growth. Furthermore, the distal extension of the dissection also seems to play an important role in late aneurysmal degeneration. However, we were not able to confirm the added value of the risk calculator tool in our study group.

Predictors of Long-term Aortic Growth and Disease Progression in Patients With Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer

The objective was to investigate predictors of long-term aortic diameter change and disease progression in a population cohort of patients with newly diagnosed aortic dissection (AD), intramural hematoma (IMH), or penetrating aortic ulcer (PAU). We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, Minnesota, residents diagnosed with AD, IMH, and PAU (1995-2015). Only patients with at least two available imaging studies were included. The primary outcome was aortic diameter change. Secondary outcomes were freedom from disease progression (defined by any related intervention, aortic aneurysm, new aortic syndrome, rupture, or death) and disease resolution (defined by complete spontaneous radiologic disappearance). Linear regression models were used to assess aortic growth rate; Cox proportional hazards models were used to identify predictors of disease progression or resolution. Of 133 total incident cases, 46 ADs, 12 IMHs, and 28 PAUs with sufficient imaging data were included in the analysis. Overall median follow-up was 8.1 years. Aortic diameter increase was seen in 40 ADs (87%; median 1.0 mm/y), 5 IMHs (42%; median, 0.2 mm/y), and 14 PAUs (50%; median, 0.4 mm/y) during follow-up. A symptomatic presentation (P = .045), connective tissue disorders (P = .005), and initial maximum aortic diameter >42 mm (P = .013) were significant predictors of aortic growth rate for AD. Female sex (P = .013) and initial PAU depth >9 mm (P = .047) were significantly associated with growth rate in PAUs. No predictors of aortic growth rate were identified for IMHs. At 10 years, freedom from disease progression was 22% (95% confidence interval [CI], 12-41) for ADs, 44% (95% CI, 22-92) for IMHs, and 46% (95% CI, 27-78) for PAUs; most events occurred within 5 years (n = 34 [73%]), 9 (17%) after 5 to 10 years, and 5 (9%) >10 years from the diagnosis. Initial maximum aortic diameter was a significant predictor of IMH progression (hazard ratio, 1.4; 95% CI, 1.0-1.9; P = .037); no progression predictors were identified for ADs and PAUs. No AD spontaneously resolved; mortality-free resolution rate at 10 years was 22% (95% CI, 0-45) for IMHs and 11% (95% CI, 0-23) for PAUs. There were no predictors of disease resolution. Aortic growth is observed in most patients with AD, IMH, or PAU. Disease progression is frequent and may occur also after 10 years from the initial diagnosis, whereas a spontaneous resolution is uncommon. Follow-up imaging, particularly early after aortic events, is important in these patients. High-risk predictors of aortic growth rate and disease progression should be used to additionally tailor appropriate aortic follow-up.

Concomitant Wrapping of a Moderately Dilated Ascending Aorta during Aortic Valve Replacement: Postoperative Remodeling of a Distinctive Aorta.

PurposeThe long-term outcomes of aortic wrapping in patients with ascending aortic aneurysms, which are rare, but can be fatal, remain poorly understood. This retrospective study analyzed the outcomes of aortic diameter, including aortic root, ascending aorta, and proximal arch diameters, after aortic wrapping during aortic valve replacement surgery.Materials and MethodsNinety-six patients with ascending aortic dilation of 40–55 mm who underwent aortic wrapping during aortic valve replacement were selected for this study. Aortic diameter was measured at three levels perioperatively and at follow-up (median time of 9.1±4.2 years). A linear mixed-effects model was used to analyze aortic diameter expansion.ResultsFreedom from adverse aortic events (aortic dissection or rupture, reoperation, or sudden death) at 10 years was 97.9%. No significant dilation at the level of the sinuses of Valsalva (0.069 mm/year, p=0.524) or ascending aorta (0.152 mm/year, p=0.124) was observed. Significant dilation occurred at the proximal aortic arch (0.343 mm/year, p=0.006). Subgroup analysis with a multivariable linear mixed model identified initial ascending aortic diameter to be a significant predictor of proximal arch dilation (p=0.032). Receiver operating characteristic curve analysis revealed that the cut-off for the prediction of proximal arch redilation was an initial mid-ascending aortic diameter of 47.0 mm (area under the curve 0.747, 90% confidence interval 0.613–0.881, p=0.023).ConclusionAortic wrapping could be considered as a safe and long-term therapeutic option. Redilation of the proximal arch should be carefully observed during long-term follow-up.

Factors Predicting Aneurysmal Degeneration of Medically Managed Type B Aortic Dissections

Introduction: Aneurysmal degeneration of medically managed type B aortic dissection (TBAD) can be a life-threatening condition. Preventive thoracic endovascular aorta repair (TEVAR) in patients at risk could potentially be beneficial. A number of predictive factors for aneurysmal degeneration of medically managed type B aortic dissections have already been described in literature. However, no study yet has revised these risk factors coupled to the aortic dissection risk tool (Stanford Aortic Dissection Risk Calculator) developed by Sailer et al 1 The objectives of this study is to examine the predictors for late aneurysmal dilatation after TBAD. Methods: A retrospective study was conducted on 100 patients initially treated medically for acute TBAD. Relevant demographic, biochemical and radiographic variables at presentation were studied. The aortic dissection risk calculator tool developed by Sailer et al.1, predicting the risk of adverse events after aortic dissection based on demographic and radiographic variables at presentation, was tested retrospectively. Results: With a median follow-up of 36 months (range 13-76), 43 patients underwent surgery (72.1% TEVAR). A larger initial aortic and false lumen diameter as well as a greater distal extension of the dissection was associated with higher need for surgery (respectively, p=0.004, p=0.020 and p=0.003). A more specific predictor for TEVAR was an initial aortic diameter above 40mm (p=0.024). Higher growth rates of the maximum aortic diameter were observed with a greater distal extension of the dissection, larger false lumen diameters and false lumen outflow, and entry tears located at the inner aortic arch (respectively, p=0.002, p=0.011, p=0.046 and p=0.027). No significant correlations were found for the absolute and relative risks provided by the calculator tool. Conclusion: The initial maximum aortic diameter of the aortic dissection is a key predictor for aortic growth. Furthermore, the distal extension of the aortic dissection also seems to play an important role in late aneurysmal degeneration. However, we were not able to confirm the added value of the risk calculator tool in general practice. A prospective study is needed with more uniform data collection and follow-up imaging. Disclosure: Nothing to disclose

The Initial Aortic Diameter as the Predictors of Aortic Events in Uncomplicated Type B Aortic Dissection

Introduction: Several past studies investigated to detect the risk factors of late aortic events for patients with uncomplicated acute Type B aortic dissection. The initial aortic diameter was reported as a risk factor for late aortic events. However, it remains controversial about the cut off values; 40mm or 45mm. We evaluate the optimal initial aortic diameter for a risk factor. Methods: We conducted a retrospective cohort study reviewing 216 consecutive patients underwent initial treatment for uncomplicated acute type B aortic dissection between 2004 and 2018. We excluded 50 complicated cases (rupture, impending rupture and malperfusion). We evaluated the incidences of aortic events (operation for dissected aorta or operative indication for dissected aorta) after initial therapy. Follow up rates was 90.7% with median follow-up of 42 months. The largest minor and major axes diameters were measured on computed tomography at admission, before discharge. Logistic regression was used to examine whether aortic diameter was useful in predicting late aortic events. Cox regression was carried out to assess the prognostic effect of aortic diameter after allowing for significant covariates and receiver operating characteristic (ROC) analyses were used to determine test reliability. Moreover, patients were categorized into 3 groups based on the largest minor axis aortic diameter at admission; 40mm > Group A, 45mm > Group B ≥ 40mm, Group C ≥ 45mm, and Kaplan-Meier analyses detected the incidences of aortic events among these three groups. Results: In hospital mortality was 1 (0.5%). Long-term mortality was 40 (18.6%). Aortic events were 82 (38.1%). ROC analyses showed the cut-off values 40mm of minor axis diameter at initial CT (Area under the curve, 0.77, p< 0.01). In the multivariate analysis, risk factors of aortic events were initial aortic diameter ≥ 40mm (HR 4.21, 95% CI 2.54-6.98, p< 0.01), the false lumen diameter > the true lumen diameter (HR 3.73, 95%CI 1.88-7.41, p< 0.01), ulcer like projection (HR 1.83, 95%CI 1.04-3.22, p=0.04) and age ≥ 70 (HR 2.01, 95%CI 1.22-3.33, p= 0.01) were shown to be independent risk factors of late aortic events. The 3-years incidences rates of aortic events were 22.3% in Group A, 47.5% in Group B, and 87.9% in Group C, respectively (p< 0.01). Conclusion: We identify the optimal aortic diameter for predictor of aortic events was 40mm at admission. The larger initial aortic diameter, the more likely patients were to experience aortic events. We should closely monitor them and consider intervention at appropriate time. Disclosure: Nothing to disclose

Dissection Thoracic Aneurysm After Type A Surgical Repair: “Kick-Off registry”

Introduction - The success of aortic dissection surgery depends upon complete resection of the primary intimal tear with attempted obliteration of the false lumen; in this concept the major goal for acute type A aortic dissection (AAAD) after surgical aortic replacement is to have a living patient.” This motto is always the directive for the cardiac-surgeon. However, the extent of the “A” dissection and surgical management could lead to “chronic dissection B”; which may eventually require additional treatments during follow-up. The traditional approach of open distal anastomosis is associated with high rates of persistent false lumen patency which exposes the patient to the formation of complex thoraco-abdominal dissection aneurysms. Kick-Off is a registry which evaluates the results of “cardiac-surgery” performed on patients with AAAD, in acute phase as well as during follow-up (the need of intervention surgery or endovascular aortic repair for dissection thoracic aneurysm > 55 mm). Methods - Between January 2010 and December 2017, in Santa Maria Hospital - Terni data concerning acute type A aortic dissection was collected in a registry: “Kick-Off Registry”. Urgent admissions with the diagnosis of acute A dissection were selected. Surgical outcomes were evaluated in terms of operative mortality and morbidity. Furthermore the development of thoracic dissection aneurysm was analysed, during follow-up. The following anatomic conditions like entry tear (patent / non patent); entry tear localization (inner or external), diameter of entry tear (major or minor 10 mm); initial aortic diameter (major or minor 40 mm), false lumen thrombosis (yes or not), shape of true lumen (elliptical or circular) and type of dissecton (linear or spiral) were taken into consideration. Moreover the type of surgical approach was evaluated. Statistical analyses were carried out using SPSS statistics version 22. Results - 196 patients underwent emergency repair for AAAD using a standard approach. 66% patients required replacement of the dissected ascending aorta, 27% required an emiarch replacement and 7% required total aortic root replacement. The mean age was 65.7 (146 male – 50 female). Median-follow-up was 29 months. Overall operative mortality was 21%. Multivariate analysis revealed that older age, stroke and malperfusion increased the risk of operative death. During follow-up the overall need for any kind of intervention (surgery, TEVAR or Hybrid intervention) was 19%. In multivariate analysis (Cox regression) a patent primary entry tear (P<0.05), initial diameter (superior to 40 mm - P<0.05)were predictors of thoraco-abdominal dissection aneurysm superior to 55 mm. Multivariate analysis showed that the type of required repair (emiarch replacement) was the primary factor associated with the development of dissection aneurysm (P<0.001). Conclusion - The anatomic conditions of AAAD and an unsuitable surgical strategy could bring about the development of thoraco-abdominal dissection aneurysm. The “Kick-Off” registry is helpful to understand the mechanisms that lead to dissection aneurysm; in the future we hope to categorization the risk patients for aneurysm disease. Furthermore, treatment options in acute phase and suggest preventive strategies to reduce the occurrence of this dissection aneurysm to a minimum would be define.

It is Safe to Follow Patients with Medically Treated Type B Aortic Dissections

Introduction - Type B aortic dissection (TABD) is a potentially life threatening disease and early endovascular treatment in uncomplicated cases has been reported. Urgent intervention is necessary in 1/3 of the cases for vascular complications. The promising short-term results of endovascular surgery seem to support the use of stent graft implantation in uncomplicated cases to prevent late aortic complications. Our aim was to analyse the results of late aorta related mortality in medically treated patients and to identify the factors that lead to late aortic interventions. Methods - Consecutive patients presented with acute uncomplicated TBAD in a tertiary care university centre were included in the study. The study period was 10 years (2006-2015). The data were analysed retrospectively. Initial and follow-up CT angiographic images were studied to measure maximal initial and follow-up aortic diameter and the change of the degree of false lumen thrombosis. Statistical methods: univariate analysis and life table calculations. Results - There were 43 patients (74% men), the average age at admission was 62.8 years. The mean follow-up time was 37.2 months. Seven patients (16.28%) had aortic surgery later (4 stent graft implantations, 2 open prosthetic graft implantations and 1 open thoracoabdominal aortic refenestration). Two patients (4.65%) had percutaneous interventions of aortic branches (1 renal artery stent implantation and 1 balloon angioplasty. None of the patients who required late surgery died in 30 days after admission. One patient (2.33%) died during follow up, related to a new dissection (surgery was not performed). CT angiography on admission showed completely patent false lumen in 83.3% of the cases, partial thrombosis was detected in 10% and complete thrombosis in 6.7%.During follow-up of the medically treated patients, the false lumen remained patent in 66.7%, 12.5% had partial thrombosis and 20.8% were thrombosed completely. The patients who required surgery later had patent false lumen in 16.7%, partial thrombosis in 50% and total thrombosis in 33.3%. The average maximum aortic diameter on admission was 41.34 mm (SD: 9.13) with no difference between the cohorts continue to have medical treatment or late surgery (p=0.89). The average increase of aortic diameter was 6.83 mm (SD: 5.31) in the group required surgery later and 5.71 mm (SD: 5.49) in patients without late surgery. The difference was not significant (p=0.16). Conclusion - Based on our low late aorta related mortality in patients treated medically for uncomplicated TABD, we consider the conservative approach and close follow-up (aggressive blood pressure control and serial images) to be a safe strategy in this cohort and we do not recommend early surgery. No death occured following elective late aortic intervention. The changes of the false lumen thrombosis had no relationship to late mortality and aortic intervention.

Risk of developing an abdominal aortic aneurysm after ectatic aorta detection from initial screening

ObjectiveCurrent abdominal aortic aneurysm (AAA) surveillance guidelines lack any follow-up recommendations after initial abdominal aortic screening diameter of less than 3.0 cm. Some reports have demonstrated patients with late AAA formation and late ruptures after initial ultrasound screening detection of patients with an aortic diameter of 2.5 to 2.9 cm (ectatic aorta). The purpose of this study was to determine ectatic aorta prevalence, AAA development, rupture risk, and risk factor profile in patients with detected ectatic aortas in a AAA screening program. MethodsA retrospective chart review of all patients screened for AAA from January 1, 2007, to December 31, 2016, within a regional health care system was conducted. Screening criteria were men 65 to 75 years of age that smoked a minimum of 100 cigarettes in their lifetime. An ectatic aorta was defined as a maximum aortic diameter from 2.5 to 2.9 cm. An AAA was defined as an aortic diameter of 3 cm or greater. Patients screened with ectatic aortas who had subsequent follow-up imaging of the aorta with a minimum of 1-year follow-up were analyzed for associated clinical and cardiovascular risk factors. All data were collected through December 3,/2018. A logistic regression of statistically significant variables from univariate and χ2 analyses were performed to identify risks associated with the development of AAA from an initially diagnosed ectatic aorta. A Cox proportional hazard model was used to assess survival data. A P value of less than .05 was considered statistically significant. ResultsFrom a screening pool of 19,649 patients, 3205 (16.3%) with a mean age of 72.1 ± 5.3 years were identified to have an ectatic aorta from January 1, 2007, to December 31, 2016. The average screening ectatic aortic diameter was 2.6 ± 0.1 cm. There were 672 patients (21.0%) with a mean age of 73.0 ± 5.7 years who received subsequent imaging for other clinical indications and 193 of these patients (28.7%) with ectatic aortas developed an AAA from the last follow-up scan (4.2 ± 2.5 years). The average observation length of all patients was 6.4 ± 2.9 years. No ruptures were reported, but 27.8% of deaths were of unknown cause. One patient had aortic growth to 5.5 cm or greater (0.15%). Larger initial screening diameter (P < .01), presence of chronic obstructive pulmonary disease (P < .01), and active smoking (P = .01) were associated with AAA development. ConclusionsPatients with diagnosed ectatic aortas from screening who are active smokers or have chronic obstructive pulmonary disease are likely to develop an AAA.