Initial Thoracic Endovascular Aortic Repair Research Articles

Deep learning-based radiomics of computed tomography angiography to predict adverse events after initial endovascular repair for acute uncomplicated Stanford type B aortic dissection

PurposeThis study aimed to construct a predictive model integrating deep learning-derived radiomic features from computed tomography angiography (CTA) and clinical biomarkers to forecast postoperative adverse events (AEs) in patients with acute uncomplicated Stanford type B aortic dissection (uTBAD) undergoing initial thoracic endovascular aortic repair (TEVAR). MethodsWe retrospectively evaluated 369 patients treated with TEVAR for acute uTBAD from January 2015 to December 2022. A three-dimensional (3D) deep convolutional neural network (CNN) automated radiomic feature extraction from CTA images. Feature selection, using Analysis of Variance (ANOVA) and the Least Absolute Shrinkage and Selection Operator (LASSO) algorithms, refined a radiomic score (Rad-Score). This score, alongside clinical parameters, was modelled via Extreme Gradient Boosting (XGBoost) analysis. Model calibration was assessed by calibration curves. ResultsThe integration of the Rad-Score with clinical factors including albumin and C-reactive protein levels moderately enhanced predictive efficiency, exhibiting an area under the curve (AUC) of 1.000 (95%CI, 1.000–1.000) in the training cohort and 0.990 (95%CI, 0.966–1.000) in the internal validation cohort. In an independent validation cohort from another hospital, the combined model yielded an AUC of 0.985 (95%CI, 0.965–1.000), with an accuracy, precision, sensitivity, and specificity of 0.92, 0.92, 0.94, and 0.91, respectively. ConclusionsThe synergistic application of deep learning-based radiomics from CTA and clinical indicators holds promise for anticipating AEs post-initial thoracic endovascular aortic repair in patients with acute uTBAD. The clinical utility of the constructed combined model, offering prognostic foresight during follow-up, has been substantiated.

Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury.

Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

Early and midterm outcomes of fenestrated and branched endovascular aortic repair in thoracoabdominal aneurysms types I through III

BackgroundFenestrated and branched endovascular aortic repair (F/BEVAR) of thoracoabdominal aortic aneurysms (TAAAs) has shown high technical success and low early mortality rates. Aneurysm extent has been reported as a factor affecting outcomes. This study aimed to assess the early and midterm follow-up outcomes of patients managed by F/BEVAR for types I through III TAAAs. MethodsA single-center retrospective analysis was conducted, including data from consecutive, elective and urgent (symptomatic and ruptured cases), patients treated for types I through III TAAAs, between October 1, 2011, and October 1, 2022, using F/BEVAR. Degenerative and postdissection TAAAs were included. Patients received prophylactic cerebrospinal fluid drainage (CSFD), except those under therapeutic anticoagulation, those who were hemodynamically unstable, or those with failed CSFD application. When an initial thoracic endovascular aortic repair was performed, as part of a staged procedure, no CSFD was used. Later stages and nonstaged procedures were performed under CSFD. Thirty-day mortality and major adverse events (MAEs) were analyzed. Kaplan-Meier estimates were used for follow-up outcomes. ResultsF/BEVAR for types I through III TAAAs was performed in 209 patients (56.9% males; mean age, 69.6 ± 3.2 years; mean aneurysm diameter, 65.2 ± 6.2 mm); 29.2% type I, 57.9% type II, and 12.9% type III. Urgent repair was performed in 26.7% of patients (56 cases; 23 ruptured and 33 symptomatic cases) and 153 were treated electively. Thirty-two patients (15.3%) were classified as American Society of Anesthesiologists (ASA) class IV. CSFD was used in 91% and staged thoracic endovascular aortic repair was performed in 51.2% of patients. Technical success was 93.8% (96.7% in elective vs 94.6% in urgent cases; P = .92). Thirty-day mortality was 11.0% (4.6% in elective vs 28.5% in urgent cases; P < .001) and MAEs were recorded in 17.2% of cases (7.8% in elective vs 42.8% in urgent cases; P < .001). Spinal cord ischemia rate was 20.5% (17.6% in elective vs 28.7% in urgent cases; P = .08), whereas 2.9% of patients presented paraplegia (1.3% in elective and 7.1% in urgent cases; P = .03). The mean follow-up was 16 ± 5 months. Survival was 75.0% (standard error, 4.0%) and freedom from reintervention was 73.3% (standard error, 4.4%) at 36 months. ASA IV and urgent repair were detected as independent factors related to early mortality and MAE, whereas ruptured aneurysm status was related to spinal cord ischemia evolution. ConclusionsEndovascular repair for types I through III TAAAs provides encouraging early outcomes in terms of mortality, MAE, and paraplegia, especially in an elective setting. Setting of repair and baseline ASA score should be taken into consideration during decision-making.

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

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

Intimal tear closure by false lumen stent graft placement for postdissection thoracoabdominal aortic aneurysm

We report a false lumen (FL) stent graft technique to close the intimal tears at the visceral segment for a postdissection thoracoabdominal aneurysm after initial thoracic endovascular aortic repair. Following endovascular abdominal aortic repair, a stent graft was deployed in the FL, overlapping the main bodies from both previous repairs just after a bare metal stent was implanted in the FL proximal to the target lesion to prevent overdilation. A reentry tear at the iliac level was intentionally preserved to protect spinal cord perfusion and develop a collateral network and will be closed in the future staged procedure.

Thoracic Endovascular Aortic Repair vs Medical Therapy Alone for Uncomplicated Acute Type B Aortic Dissection

It remains controversial if thoracic endovascular aortic repair (TEVAR) or optimal medical therapy (OMT) should be the standard of care for uncomplicated type B aortic dissection (uTBAD). We evaluate our institutional experience to compare the outcomes of TEVAR vs OMT as primary treatment for uTBAD. Data were analyzed to compare early and late outcomes of 219 patients (135 men; 61.6%) with uTBAD who were triaged to OMT in 162 and TEVAR in 57 over 3 decades. Mean age was 64.5 ± 12.7 and 63.5 ± 15.9 years (P = .630) in the TEVAR and OMT groups, respectively. TEVAR group had significantly higher incidences of hypertension (87.8% vs 40.1; P < .001), smoking (63.2% vs 38.3%; P = .002), dyslipidemia (47.4% vs 16.7%; P < .001), chronic kidney disease (17.5% vs 6.2%; P = .016), and prior stroke/transient ischemic attack (14% vs 4.9%; P = .035). After TEVAR, neither death nor paraplegia occurred, while seven patients developed acute kidney injury not requiring hemodialysis (12.3%), and one sustained stroke (1.8%). In-hospital/30-day mortality was 0% with TEVAR vs 16% (26/162) with OMT (P < .001). Follow-up was 100% (193/193) at a median of 5.8 years (mean, 7.8; interquartile range [IQR], 2.0-12.3). In OMT group, 70 patients died at median 5.2 years (IQR, 2.0-8.8 years), and 72 underwent intervention at median 85 days (IQR, 0.01-1.2 years), including open descending repair in 60, TEVAR in 9, abdominal aortic repair in 2, and arch repair in 1. Following intervention, 40 died at median 1.8 years (IQR, 0.02-6.3 years). In TEVAR group, 18 underwent reintervention at median 48.5 days (IQR, 29-101 days), including 11 redo-TEVAR, 3 EVARs, 1 hemiarch, and 3 others; all were alive at latest follow-up except 1 expiring at 6.9 months postreintervention. At 3 months, 1 year, and 3 years following treatment, survival rates were significantly higher in TEVAR vs OMT patients (100% vs 83.2 ± 2.9%; 94.4 ± 3.1 vs 77.0 ± 3.3%; and 91.8 ± 4.0% vs 67.9 ± 3.7%) (P = .002, Fig 1); the respective freedom from (re)intervention were 75.4 ± 5.7% vs 72.7 ± 3.6%, 68.0 ± 6.2% vs 64.2 ± 3.9%, and 68.0 ± 6.2% vs 53.0 ± 4.2% (P = .198) in TEVAR vs OMT groups. After (re)intervention, the group with initial TEVAR had improved survival (94.4 ± 5.4% up to 3 years) compared to OMT patients (76.4 ± 5.0 at 1 year, 65.3 ± 5.6% at 3 years) (P = .039) (Fig 2). In the management of uTBAD, patients receiving initial OMT showed lower survival and required more intervention, while initial TEVAR achieved significantly higher survival up to 3 years, even after reintervention. These results argue favorably for the use of TEVAR as the primary treatment of choice for uTBAD.Fig 2Survival after (re)intervention, Kaplan-Meier survival curve comparing survival postsurgical (re)intervention after initial treatment by either thoracic endovascular aortic repair (TEVAR) or medical therapy up to 3 years after treatment. Log-rank P = .039.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Open Versus Endovascular Left Subclavian Artery Revascularization Outcomes in Thoracic Endovascular Aortic Repair: A National Study

Left subclavian artery (LSA) revascularization is recommended in patients undergoing elective thoracic endovascular aortic repair (TEVAR) with LSA coverage. However, the outcomes of open vs endovascular techniques for LSA revascularization remain poorly studied due to lack of high-quality evidence. The aim of this study is to use a large national database to compare the effects of open vs endovascular LSA revascularization for LSA coverage during TEVAR on the perioperative outcomes of stroke, arm ischemia (AI), spinal cord ischemia (SCI), 30-day mortality, and reintervention. Patients who had undergone LSA revascularization for LSA coverage in the Vascular Quality Initiative TEVAR database between 2011 and 2022 were identified. Patients with no coverage of the LSA, no LSA revascularization after LSA coverage, conversion to open repair, proximal disease > zone 5, distal zone disease < zone 3, and genetic history of connective tissue disease were excluded. We divided our cohort into two groups: open and endovascular revascularization of LSA. Open LSA revascularization was defined as treatment with surgical bypass. Endovascular LSA revascularization was defined as treatment with stent, stent graft, chimney, scallop, stented scallop, fenestration, stented fenestration, fenestrated branch, side-arm branch, and iliac device. Outcomes were perioperative stroke, AI, SCI, 30-day mortality, and reintervention. A total of 3052 patients met our inclusion criteria. There were 2396 (78.5%) patients in the open LSA revascularization group and 656 (21.5%) patients in the endovascular LSA revascularization group. The results are summarized in the Table. When compared with open LSA revascularization, endovascular LSA revascularization showed no significant difference in the risk of stroke (adjusted odds ratio [aOR]: 1.1, 95% confidence interval [CI]: 0.8-1.5; P = .498), AI (aOR: 1.5, 95% CI: 0.7-3.1; P = .273), SCI (aOR: 0.7, 95% CI: 0.3-1.5; P = .337), and 30-day mortality (aOR: 1.3, 95% CI: 0.8-2.0; P = .254). Furthermore, there was no significant difference in the risk of reintervention (aOR: 0.7, 95% CI: 0.4-1.2; P = .166). In this analysis of Vascular Quality Initiative data, both open and endovascular LSA revascularization for LSA coverage during TEVAR were equally effective and durable with no significant difference in outcomes of stroke, AI, SCI, 30-day mortality, and reintervention. Thus, endovascular LSA revascularization is a viable alternative to open LSA revascularization that could reduce the need for staged carotid-subclavian bypass or transposition procedures. Further studies are warranted to compare the long-term outcomes of open vs endovascular LSA revascularization, in addition to comparing the outcomes of specific endovascular techniques to each other.TableMultivariate logistic regression of stroke, arm ischemia (AI), spinal cord ischemia (SCI), 30-day mortality, and reintervention outcomesOutcomeEndovascular LSA revascularization vs open LSA revascularizationaOR (95% CI) (reference = open LSA revascularization)P valueStroke1.1 (0.8-1.5).498AI1.5 (0.7-3.1).273SCI0.7 (0.3-1.5).33730-day mortality1.3 (0.8-2.0).254Reintervention0.7 (0.4-1.2).166aOR, adjusted odds ratio; CI, confidence interval; LSA, left subclavian artery. Open table in a new tab

Readmission after early thoracic endovascular aortic repair versus medical management of acute type B aortic dissection

BackgroundThe use of thoracic endovascular aortic repair (TEVAR) for the management of acute uncomplicated type B aortic dissection (TBAD) has increased. Although the results from early studies were promising, larger randomized trials evaluating TEVAR are lacking. It is also unclear where sufficient equipoise exists for such trials. In the present study, we evaluated the number of readmissions and unplanned operations after TEVAR vs those after medical management as the initial treatment of acute uncomplicated TBAD and the frequency of each treatment in this population. MethodsWe performed a multi-institutional retrospective review of patients with acute TBAD from 2015 to 2020 with the 1-year outcomes available, excluding patients with prior aortic intervention or chronic, iatrogenic or traumatic etiologies. The primary exposure was TEVAR vs medical management at the index admission. The patient demographics, clinical presentation, and imaging findings were analyzed using bivariate and multivariate logistic regression for the primary outcomes of unplanned readmission and/or operation after the initial admission. The secondary outcomes were mortality, myocardial infarction, stroke, renal failure requiring dialysis, retrograde type A dissection, and length of stay. We hypothesized that the readmissions would be higher with medical management. ResultsA total of 216 patients with TBAD (47 with complicated and 169 with uncomplicated) from two large academic centers were identified. Of the 169 patients with uncomplicated TBAD, 83 (49%) had been treated medically and 86 (51%) had undergone TEVAR at the initial admission. No differences were found in the demographics or high-risk imaging features at presentation. The medically managed patients had had higher rates of unplanned readmission (34% vs 9%; P = .0001) and operation (28% vs 8%; P = .0007) but shorter lengths of stay (6.3 vs 13.1 days; P < .0001). No differences were found in mortality, although the rate of myocardial infarction was higher in the medically managed group (10.8% vs 2.3%; P = .02). Although 28% of the medically managed patients had later required operation, they had had morbidity and mortality similar to those of patients who had undergone initial TEVAR. Initial medical management was associated with unplanned readmission (odds ratio, 8.3; P = .02) and the need for operation (odds ratio, 4.56; P = .006). No differences were found in the outcomes according to the involved aortic zones. ConclusionsIn the present study, medical management of acute uncomplicated TBAD was associated with higher rates of readmission and the need for unplanned operation compared with TEVAR. However, no differences were found in the 1-year mortality for the patients for whom medical management had failed. Because one half of the patients had undergone medical management and one half had undergone early TEVAR, this finding suggests clinical equipoise for the treatment of acute uncomplicated TBAD. Therefore, a larger randomized trial appears warranted to determine whether a clear benefit exists for early TEVAR.

The optimal length of aortic coverage during index thoracic endovascular aortic repair for dissection remains unclear

Endovascular repair of uncomplicated type B aortic dissection (TBAD) continues to become more prevalent. In the accompanying paper, Xiang et al1 assess risk factors for distal stent-graft-induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR). As all aortic surgeons are aware, aortic dissection is a chronic disease condition, much like diabetes or heart failure; it requires technically thoughtful interventions followed by lifelong surveillance and maintenance therapy. This study is an important contribution in our understanding of how the techniques employed at initial TEVAR may affect long-term aortic remodeling and the need for additional procedures.

Abstract 9499: Clinical Outcomes With Initial Thoracic Endovascular Aortic Repair versus Initial Medical Therapy for Acute Uncomplicated Type B Aortic Dissection in the United States

Introduction: Thoracic endovascular aortic repair (TEVAR) has increasingly been used for uncomplicated type B aortic dissection (uTBAD) despite limited supporting data. We compared outcomes after a strategy of initial TEVAR vs. initial medical therapy in patients with uTBAD. Methods: Index acute uTBAD admissions from 2011-2018 were identified using 100% Medicare inpatient claims. Initial TEVAR was defined as TEVAR within 30 days of admission. Complicated and non-acute TBAD were excluded. Outcomes included survival, cardiovascular hospitalizations, aorta-related and repeat aorta-related hospitalizations, and aortic interventions. Propensity score inverse probability weighting (IPW) was used to reduce the effects of treatment selection bias in the data. The primary analyses were landmarked at 30 days to avoid survival time bias; a sensitivity analysis used TEVAR status as a time-dependent variable to account for deaths in the first 30 days. Results: Of 7,105 patients with eligible index admissions for acute uTBAD, 1,140 (16.0%) underwent initial TEVAR. Receipt of initial TEVAR was significant associated with geographic region, non-Medicaid dual eligibility, and institutional TEVAR volume as well as certain comorbidities. After IPW, mortality was similar for the two strategies out to 5 years (HR 0.95, 95% CI 0.85 to 1.06), while aorta related hospitalizations were modestly increased with the TEVAR strategy (HR 1.12, 95% CI 0.99 to 1.27). In the sensitivity analysis including deaths within the first 30 days, initial TEVAR was associated with lower mortality over a period of 1 year (aHR 0.86, 95%CI 0.74-0.997, p=.045), 2 years (aHR 0.85, 95%CI 0.75-0.96, p=.01), and 5 years (aHR 0.87, 95%CI 0.79-0.97, p=.008). Conclusions: We found that a significant minority of uTBAD patients undergo initial TEVAR, which may be associated with lower risk of mortality when deaths within the first 30 days are included. These outcomes, and the reasons why some patients receive initial TEVAR while others do not, remain incompletely characterized. These findings, along with factors related to anatomy, peri-procedural complications, adequacy of medical therapy, patient preferences, and cost effectiveness, need to be assessed in a prospective trial in the US population.

Initial Thoracic Endovascular Aortic Repair vs Medical Therapy for Acute Uncomplicated Type B Aortic Dissection

Thoracic endovascular aortic repair (TEVAR) has increasingly been used for uncomplicated type B aortic dissection (uTBAD) despite limited supporting data. To assess whether initial TEVAR following uTBAD is associated with reduced mortality or morbidity compared with medical therapy alone. This cohort study included Centers for Medicare & Medicaid Services inpatient claims data for adults aged 65 years or older with index admissions for acute uTBAD from January 1, 2011, to December 31, 2018, with follow-up available through December 31, 2019. Initial TEVAR was defined as TEVAR within 30 days of admission for acute uTBAD. Outcomes included all-cause mortality, cardiovascular hospitalizations, aorta-related and repeated aorta-related hospitalizations, and aortic interventions associated with initial TEVAR vs medical therapy. Propensity score inverse probability weighting was used. Of 7105 patients with eligible index admissions for acute uTBAD, 1140 (16.0%) underwent initial TEVAR (623 [54.6%] female; median age, 74 years [IQR, 68-80 years]) and 5965 (84.0%) did not undergo TEVAR (3344 [56.1%] female; median age, 76 years [IQR, 69-83 years]). Receipt of TEVAR was associated with region (vs South; Midwest: adjusted odds ratio [aOR], 0.66 [95% CI, 0.53-0.81]; P < .001; Northeast: aOR, 0.63 [95% CI, 0.50-0.79]; P < .001), Medicaid dual eligibility (aOR, 0.76; 95% CI, 0.63-0.91; P = .003), hypertension (aOR, 1.26; 95% CI, 1.03-1.54; P = .03), peripheral vascular disease (aOR, 1.24; 95% CI, 1.02-1.49; P = .03), and year of admission (2012, 2013, 2014, and 2015 were associated with greater odds of TEVAR compared with 2011). After inverse probability weighting, mortality was similar for the 2 strategies up to 5 years (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06), as were aorta-related hospitalizations (HR, 1.12; 95% CI, 0.99-1.27), aortic interventions (HR, 1.01; 95% CI, 0.84-1.20), and cardiovascular hospitalizations (HR, 1.05; 95% CI, 0.93-1.20). In a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality over a period of 1 year (adjusted HR [aHR], 0.86; 95% CI, 0.75-0.99; P = .03), 2 years (aHR, 0.85; 95% CI, 0.75-0.96; P = .008), and 5 years (aHR, 0.87; 95% CI, 0.80-0.96; P = .004). In this study, 16.0% of patients underwent initial TEVAR within 30 days of uTBAD, and receipt of initial TEVAR was associated with hypertension, peripheral vascular disease, region, Medicaid dual eligibility, and year of admission. Initial TEVAR was not associated with improved mortality or reduced hospitalizations or aortic interventions over a period of 5 years, but in a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality. These findings, along with cost-effectiveness and quality of life, should be assessed in a prospective trial in the US population.

Hybrid Approaches for Aortic Disease–Our Experience

Despite significant technological advancements in endovascular aortic repair, the aortic arch remains a challenge due to anatomic complexity including arch angulation and morphology as well as the location of brachiocephalic vessels in relation to landing zones. Total endovascular solutions are in development and being studied, in the meantime, hybrid thoracic endovascular aortic repair (TEVAR) is a viable alternative to traditional open total arch replacement. A retrospective case series was performed reviewing outcomes of 71 patients who underwent hybrid TEVAR in the aortic arch over the past 12years at our facility. Major morbidity in the first 30days post procedure was experienced by 3 patients (15.7%) and included one patient with stroke (n=1), and another who experienced paraplegia and pulmonary complications (n=1). There was one in-hospital death as a result of respiratory failure in a patient with multiple underlying comorbidities including chronic obstructive pulmonary disease on postoperative day 5 resulting in a 30-day mortality of 5.2%. After a mean follow-up of 30months, the overall mortality remained 5.2%. Major morbidity occurred in one patient who developed retrograde type A dissection. There was no stenosis of bypass grafts identified on follow-up imaging. Endoleak was identified in 2 patients. One patient experienced persistent retrograde perfusion of the false lumen with interval aneurysmal degeneration which was managed with an Amplatz vascular plug at 120months following the initial hybrid TEVAR (5.2%). Single-stage hybrid TEVAR in the aortic arch is technically feasible with a good mid-term survival and a long-term freedom from reintervention.

Left Subclavian Artery Revascularization May Not Influence the Incidence of Spinal Cord Ischemia in Elective Thoracic Endovascular Aortic Aneurysm Repair

To analyze whether left subclavian artery (LSA) revascularization in patients undergoing elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) is associated with decreased spinal cord ischemia (SCI). The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with acute aortic dissections or aortic ruptures were excluded from the analysis. Only patients undergoing elective TEVAR for TAA and had their LSA covered during the procedure were included. Patients were divided into two groups according to their LSA revascularization (before or during TEVAR). A descriptive analysis was done to evaluate the change in frequency of LSA revascularization over the study interval. Univariate analysis was done to compare preoperative and intraoperative variables, and primary outcomes of SCI and cerebral stroke between the two groups. Among patients who had elective TEVAR for TAA, 669 patients had the LSA covered. The LSA was revascularized in 67% of these patients (n = 446). The incidence of LSA revascularization increased over the study period (Fig 1) (P < .001). Average age was 69 years, and 65% (n = 433) were male. Demographics and past medical history are summarized in Table I. Spinal cord ischemia developed in 20 patients (3%), and cerebral stroke in 29 patients (4%). No significant difference was seen when comparing postoperative SCI, cerebral stroke, 30-day or 1-year mortality between patients who had LSA revascularization and those who did not (Table II). Long-term survival did not differ between the two groups on Kaplan-Meier analysis (Fig 2). In patients with TAA undergoing elective TEVAR with LSA coverage, an increasing percentage of patients underwent preoperative or concomitant LSA revascularization over the course of the study—81% in 2021. In this study, LSA revascularization, however, did not aff5ct the incidence of postoperative SCI, cerebral stroke, or short or long-term mortality. In conclusion, LSA revascularization did not protect against SCI and may carry its own morbidity in elective TAAs requiring LSA coverage. More detailed studies are needed to help define the role of LSA revascularization in this setting.TableComparison of baseline characteristics, comorbidities, intraoperative variables, and postoperative outcomes between patients who had left subclavian artery (LSA) revascularization and those who did notOverall (n = 669)LSA nonrevascularized (n = 223)LSA revascularized (n = 446)P valueBaseline characteristics Age, years, mean (SD)69 (11)70 (11)69 (11).48 Gender, No. (%).69Male433 (65)142 (64)291 (65)Female236 (35)81 (36)155 (35) Race, No. (%).41African American115 (17)39 (18)76 (17)White474 (71)164 (74)310 (70)Others80 (12)20 (9)60 (14) BMI, mean (SD)28.4 (6.7)28.1 (6.8)28.5 (6.7).45 Smoking status, No. (%).94Never171 (26)59 (27)112 (25)Prior343 (51)113 (51)230 (52)Current154 (23)51 (23)103 (23)Medical History CVD, No. (%)81 (12)31 (14)50 (11).31 CAD, No. (%)111 (17)43 (19)68 (15).19 Congestive heart failure, No. (%)93 (14)33 (15)60 (13).63 COPD, No. (%)193 (29)73 (33)120 (27).12 Hypertension, No. (%)608 (91)199 (89)409 (92).22 Diabetes, No. (%)97 (14)38 (17)59 (13).19 Prior aortic surgery, No. (%)279 (42)103 (46)176 (40).10 Prior aneurysm repair, No. (%)226 (34)82 (36)145 (32).50Intraoperative variables Contrast volume, mL, mean (SD)118 (73)115 (72)120 (73).41 EBL, mL, mean (SD)243 (448)228 (399)251.2 (470).01 Fluoro time, minutes, mean (SD)23.2 (20.3)22.6 (23.0)23.5 (18.9).061 Procedure time, minutes, mean (SD)176 (100)158 (111)186 (94)<.01 Spinal drain placement, No. (%).38None343 (51.4%)111 (49.8%)232 (52.3%)Prophylactic311 (46.6%)106 (47.5%)205 (46.2%)Postoperative11 (1.6%)6 (2.7%)5 (1.1%)Outcomes Spinal cord ischemia, No. (%)20 (3)8 (4)12 (3).52 Cerebral stroke, No. (%)29 (4)9 (4)20 (5).79 30-Day mortality, No. (%)26 (4)5 (2)21 (5).12 1-Year mortality, No. (%)65 (10)21 (9)44 (10).85COPD, Chronic obstructive pulmonary disease; CVD, cerebrovascular disease; EBL, estimated blood loss; PCI, percutaneous coronary interventions; SD, standard deviation. Open table in a new tab Fig 2Kaplan-Meier curves comparing long-term survival between patients who underwent left subclavian artery (LSA) revascularization and those who did not.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Left Subclavian Artery Coverage is Not Associated with Neurological Deficits in Trauma Patients Undergoing Thoracic Endovascular Repair

Endovascular repair of the thoracic aorta (TEVAR) outcomes have been studied with an interest in complications related to left subclavian artery (LSA) coverage in patients with atherosclerotic pathologies; however, specific data on the management of the LSA in a trauma population are lacking. The objective of this study is to evaluate outcomes following TEVAR for traumatic aortic injury based on LSA coverage. The Vascular Quality Initiative thoracic endovascular aortic repair module (2010-2017) was analyzed. Patients were included if they had a traumatic aortic injury requiring TEVAR. Patients were placed in 2 groups based on coverage of the LSA. Patients were propensity score matched and the primary outcomes were cerebrovascular symptoms and spinal cord ischemia. Additional clinical and resource utilization outcomes were analyzed. Four hundred and fifty one patients were included in the analysis. There were 268 patients in the LSA not-covered group and 183 patients in the LSA covered group. The mean aortic injury grade was 2.88±0.056 vs. 2.88±0.049 in the covered versus not-covered group (P=0.957). Glasgow coma scale and injury severity score were not different between the groups. There was no difference between groups for cerebrovascular symptoms or spinal cord ischemia, 1.4% vs. 2.8%, P=0.684 and 0% vs. 2.1%, P=0.247, after propensity score matching. Significant differences in access site complications and resource utilization were identified between groups. This is the largest series to evaluate complications based on LSA coverage following TEVAR in trauma patients. Our data demonstrate that coverage of the LSA during TEVAR following blunt trauma is associated with no difference in central nervous system outcomes. As such, LSA revascularization strategies, while possible, are not directly supported by these data and should be individualized based on each patient's specific clinical scenario.

Retrograde type A dissection in the Vascular Quality Initiative thoracic endovascular aortic repair for dissection postapproval project: Presented at the Forty-fifth Annual Meeting of the Southern Association for Vascular Surgery (Virtual), Scottsdale, Ariz, January 27-30, 2021.

Background Retrograde dissection (RD) can be a serious complication after thoracic endovascular aortic repair (TEVAR), with retrograde type A dissection (RTAD) particularly life-threatening. Prior studies have suggested that treatment timing, anatomic characteristics, device selection, and procedural conduct of TEVAR performed for type B aortic dissection could mitigate the occurrence of RD. The Vascular Quality Initiative TEVAR for Dissection Registry is an ongoing project meant to satisfy Food and Drug Administration requirements for postmarket approval surveillance of the Gore conformable TAG thoracic endoprosthesis (W.L.

Surgical Treatment of Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair.

Data are scarce regarding retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR). This study aimed to investigate the clinical characteristics and surgical treatment outcomes of patients who developed RTAD after TEVAR.From January 2015 to January 2020, 25 consecutive patients (aged 52 ± 11.69 years) of RTAD after TEVAR received open surgery. All patients received total arch replacement (TAR) with the frozen elephant trunk (FET). The proximal part of the TEVAR stent was removed using a wire scissor. The distal part of the TEVAR stent in the descending aorta was preserved. Data of 50 random patients of type A aortic dissection without prior TEVAR were collected during the same period. We compared the perioperative and midterm follow-up outcomes between patients with prior TEVAR and patients without prior TEVAR.The mean cardiopulmonary bypass time, aortic cross-clamp time, and deep hypothermic circulatory arrest time were 173.7 ± 44.1, 109.5 ± 31.4, and 21.6 ± 6.8 minutes in the RTAD group, respectively. These times are similar to those of the no-RTAD group. The median interval between the initial TEVAR procedure and RTAD was 8.5 months (range, 0-72 months). New entry tears that were induced by the proximal end of the TEVAR stent were found in 23 (92%) patients of the RTAD group. There were no significant differences in major adverse events and overall survival between the two groups.TAR with the FET technique was feasible for the treatment of RTAD after TEVAR, with acceptable early and midterm results.

Retrograde type A dissection in the Vascular Quality Initiative thoracic endovascular aortic repair for dissection postapproval project

BackgroundRetrograde dissection (RD) can be a serious complication after thoracic endovascular aortic repair (TEVAR), with retrograde type A dissection (RTAD) particularly life-threatening. Prior studies have suggested that treatment timing, anatomic characteristics, device selection, and procedural conduct of TEVAR performed for type B aortic dissection could mitigate the occurrence of RD. The Vascular Quality Initiative TEVAR for Dissection Registry is an ongoing project meant to satisfy Food and Drug Administration requirements for postmarket approval surveillance of the Gore conformable TAG thoracic endoprosthesis (W.L. Gore & Associates, Flagstaff, Ariz), Medtronic Valiant thoracic stent graft (Medtronic, Santa Rosa, Calif), and Cook Medical dissection devices (Cook Medical, Bloomington, Ind) and provides a unique source of evaluation for RTAD in a prospectively collected real-world registry. MethodsA total of 588 consecutive patients at 49 institutions had undergone TEVAR for acute (<30 days; n = 336) and chronic (≥30 days; n = 252) type B aortic dissection were included. The occurrence of RD as reported by the participating centers and de-identified source documents were reviewed and confirmed independently by two of us (A.W.B. and G.W.). The demographics, procedural and device data, and anatomic considerations were evaluated, and the devices were grouped in a de-identified manner as Gore, Medtronic, and other. ResultsThe mean follow-up was 889 days (median, 658 days), and 408 patients had completed follow-up data available for >1 year. A total of 19 patients with RD (3.2%) were identified, 9 of whom had been treated for acute and 10 for chronic dissection, a 2.7% and 4.0% incidence, respectively (P = .48, acute vs chronic). Of the 19 RD cases, 15 were RTAD, 6 after treatment of acute and 9 after treatment of chronic dissection, a 1.8% and 3.6% incidence, respectively (P = .19, acute vs chronic). Five cases of RD had occurred intraoperatively (four of which were RTAD). The median time to RD and RTAD was 62 and 69 days, respectively (range, 0 to 1600 days). Of the 15 patients with RTAD, 12 had undergone surgical repair and 2 had not undergone repair; the treatment of one was unknown. The overall mortality was 33.3% (5 of 15). The factors associated with RTAD included more extensive dissection (mean, 5.6 zones without RTAD vs 8.5 zones with RTAD; P = .001), female sex (28.3% female without RTAD vs 53.3% with RTAD; P = .04), and non-White race (62.7% White without RTAD vs 33.3% White with RTAD; P = .05). Mean oversizing was not significantly different for those without RTAD compared with that for those with RTAD (14.0% vs 14.2%; P = .92). The device type was anonymized in this project; however, we found no significant differences between the Gore, Medtronic, and all other devices. ConclusionsThe rate of RD in the present real-world postapproval project was consistent with that from previously reported studies, including highly controlled pivotal studies. Device type was not predictive of RD, and the newly identified risk factors for RTAD include more extensive dissection and a trend toward a greater risk for female sex and non-White race.

Spot Stenting Combined With False Lumen Endovascular Occlusive Repair for Post-dissection Abdominal Aortic Aneurysm

Purpose: To introduce a new spot stenting, combined with a false lumen endovascular occlusive repair (SS-FLEVOR) technique for treating post-dissection abdominal aortic aneurysms. Technique: This technique is demonstrated in a 74-year-old man who received an initial thoracic endovascular aortic repair 7 years ago and suffered from distal aortic expansion during the follow-up session. All the tears located more than 15 mm away from the orifice of visceral arteries were excluded by spot stenting in the aortic true lumen. Then, a compliant stent-graft was implanted in the false lumen to seal the tears near the visceral arteries orifice from the outside. In addition, coils were deployed to block the potential backflow from the intercostal arteries and to induce false lumen thrombosis. Moreover, visceral arteries originated from false lumen were repaired by covered-stents implanted from the true lumen. The distal iliac arteries were sealed either with iliac extensions or cover-stents. This new technique has been applied in 5 patients, resulting in 100% technical success and encouraging intermediate outcomes. Conclusion: SS-FLEVOR is a feasible and safe technique to promote false lumen thrombosis in selected cases.

Anticoagulation and antiplatelet medications do not affect aortic remodeling after thoracic endovascular aortic repair for type B aortic dissection

ObjectiveThere is a lack of evidence regarding the effect of anticoagulation and antiplatelet medications on aortic remodeling for aortic dissection after endovascular repair. We investigated whether anticoagulation and antiplatelet medications affect aortic remodeling after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). MethodsRecords of the Vascular Quality Initiative TEVAR registry (2012-2020) were reviewed. Procedures performed for TBAD were included. Aortic reintervention, false lumen thrombosis of the treated aorta, and all-cause mortality at follow-up were compared between patients treated with and without anticoagulation medications. A secondary analysis was performed to assess the effect of antiplatelet therapy in patients not on anticoagulation. Cox proportional hazards models were used to estimate the effect of anticoagulation and antiplatelet therapies on outcomes. ResultsA total of 1210 patients (mean age, 60.7 ± 12.2 years; 825 males [68%]) were identified with a mean follow-up of 21.2 ± 15.7 months (range, 1-94 months). One hundred sixty-six patients (14%) were on anticoagulation medications at discharge and at follow-up. Patients on anticoagulation were more likely to be older (mean age, 65.5 vs 60 years; P < .001) and Caucasian (69% vs 55%; P = .003), with higher proportions of coronary artery disease (10% vs 3%; P < .001), congestive heart failure (10% vs 2%; P < .001), and chronic obstructive pulmonary disease (15% vs 9%; P = .017). There were no differences in the mean preoperative thoracic aortic diameter or the number of endografts used. At 18 months, the rates of aortic reinterventions (8% vs 9%; log-rank P = .873), complete false lumen thrombosis (52% vs 45%; P = .175), and mortality (2.5% vs 2.7%; P = .209) were similar in patients with and without anticoagulation, respectively. Controlling for covariates with the Cox regression method, anticoagulation use was not independently associated with a decreased rates of complete false lumen thrombosis (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.5-1.1; P = .132), increased need for aortic reinterventions (HR, 1.02; 95% CI, 0.62-1.68; P = .934), and mortality (HR, 1.25; 95% CI, 0.64-2.47; P = .514). On a secondary analysis, antiplatelet medications did not affect the rates of aortic reintervention, complete false lumen thrombosis, and mortality. ConclusionsAnticoagulation and antiplatelet medications do not appear to negatively influence the midterm endpoints of aortic reintervention or death in patients undergoing TEVAR for TBAD. Moreover, it did not impair complete false lumen thrombosis. Anticoagulation and antiplatelet medications do not adversely affect aortic remodeling and survival in this population at midterm.

Long-term outcomes of the conformable TAG thoracic endoprosthesis in a prospective multicenter trial

BackgroundThe Gore conformable TAG thoracic endoprosthesis (CTAG) was engineered to enhance conformability in the thoracic aorta and has demonstrated greater deployment accuracy and wall apposition than the original TAG device. The Food and Drug Administration approved the CTAG in 2011 based on the 1-year results of the pivotal trial for the CTAG device. In the present report, we have documented the outcomes for those patients through 5 years. MethodsThe CTAG aneurysm study was a prospective, multicenter trial that assessed the safety and effectiveness of the CTAG device as treatment of descending thoracic aortic aneurysms. Follow-up imaging assessments consisted of radiographs and computed tomography at annual intervals through 5 years. A core imaging laboratory was used to assess the aneurysm size, device integrity, and endoleaks. ResultsA total of 66 patients were enrolled (51 pivotal arm patients and 15 continued access patients) from October 2009 through September 2011. The baseline characteristics, procedural characteristics, and outcomes through 2 years were reported previously. Through 5 years, five patients (7.6%) had required device-related reintervention (one type Ia endoleak or contained rupture of the descending thoracic aorta, one type Ib endoleak, two indeterminate endoleaks, and one thoracic aortic pseudoaneurysm). Four patients (6.1%) had died of aneurysm-related causes, with one death occurring within 30 days of the index procedure. A total of 24 patients (36.3%) had died during the 5-year study period. Seven patients (10.6%) had experienced stroke or transient ischemic attack through 5 years, with one early stroke (postoperative day 28). Prosthesis or intercomponent migration was observed in six patients (9.1%) through 5 years; however, no patient had developed a type III junctional endoleak. No stent-graft fracture or compression was observed through 5 years. At 5 years, 14 patients (50.0%) showed sac regression, 5 (17.9%) showed sac expansion, and 9 (32.1%) showed sac stability using on a 5-mm threshold for change. ConclusionsThoracic endovascular aortic repair with the CTAG device was associated with low rates of aneurysm-related mortality and reintervention through 5 years. Proximal endoleak was rare, and most patients showed sac regression or stability at 5 years after the initial thoracic endovascular aortic repair.