Length Of Dissection Research Articles

Similar Midterm Clinical Outcomes and Aortic Remodeling in Bifurcated and Straight Aortic Stent Grafts Used to Treat Isolated Abdominal Aortic Dissection

Purpose: The optimal treatment for isolated abdominal aortic dissection (IAAD) is currently unknown. We compared the effects of straight and bifurcated aortic stent grafts on postoperative aortic remodeling in patients with IAAD. Materials and Methods: From February 2012 to December 2019, 57 patients with IAAD were treated using endovascular methods, including either a bifurcated or a straight aortic stent graft. The clinical features, risk factors, computed tomography angiograms, midterm follow-up results, and aortic remodeling of these patients were reviewed and analyzed. Results: In total, 44 (77%) patients were treated with a bifurcated graft and 13 (23%) patients were treated with a straight graft. Patients treated with straight grafts had fewer common iliac arteries involved (38% vs 73%, p=0.023), the dissection length was shorter (76.3 ± 40.0 vs 116.2 ± 56.7 mm, p=0.011), and the preoperative aortic diameter (26.0 ± 5.6 vs 35.2 ± 12.1 mm) and the false lumen diameter (13.1 ± 5.2 vs 21.2 ± 11.3 mm) were smaller. During the procedure, there were 3 (5.3%) type I endoleaks, 1 (1.8%) surgical conversion and 1 (1.8%) partial renal artery coverage without perioperative mortality. Patients with straight grafts had shorter operative time (96.5 ± 24.4 vs 144.2 ± 49.0 minutes, p<0.0001). The median follow-up duration was 37.6 ± 21.0 (range = 3–89) months with 1 (1.8%) aortic-related death. Type A aortic dissection occurred in 1 (1.8%) patient. New descending aortic dissection occurred in 3 (5.3%) patients, and 1 patient advanced to type A aortic dissection 3 months later. Two (3.5%) patients had limb occlusion. There was no significant difference in aortic remodeling, survival, and freedom from all adverse events between the 2 treatment strategies. Conclusions: Endovascular treatment provides a safe, minimally invasive treatment for IAAD in midterm follow-up. Compression of the true lumen at the aortic bifurcation is the main concern after treatment with a bifurcated graft. Straight grafts are an excellent alternative for some patients, with the benefit of reduced procedural time, effective aortic remodeling, and excellent clinical prognosis. More experience is needed to offer clear recommendations for making treatment decisions as well as determine long-term effectiveness and durability.

The potential role of diffusion weighted imaging in the diagnosis of early carotid and vertebral artery dissection

PurposeTo investigate the role of the diffusion weighted imaging (DWI) in the acute dissection of internal carotid artery (ICA) and vertebral artery (VA) and assessing the length of intramural hematoma (IMH), caused by dissection.MethodsWe analyzed 28 patients presenting with a dissection of the ICA and/or VA with respect to the presence of high signal intensity areas on DWI suggestive of dissection and 20 control subjects without arterial dissection, some with and some without atherosclerotic lesions. ICA or VA dissection was defined by clinical and imaging, computed tomography angiography (CTA), MR angiography (MRA), and digital subtraction angiography (DSA) findings. The length of DWI hyperintensity was compared to length of the occlusion or stenosis on the angiographic examination.ResultsIn 28 patients, 30 dissected arteries were analyzed. Time intervals from the onset of the first clinical symptoms to the radiological evaluation ranged from 1.5 h to 42 days. In 28 (93%) of the dissections, a high signal intensity of the affected artery was present on DWI. The measurement of the dissection length on DWI compared to DSA showed a mean deviation of 2.7 mm and a standard deviation of 3.7 mm.ConclusionDWI is a highly sensitive and valuable pulse sequence for the detection of dissected cervical arteries even in the first hours after symptom onset. In contrast to CTA and MRA, DWI can be a potential tool for a reliable measurement of the dissection length.

Comparison of Angiographic Dissection Classification Systems in the Femoropopliteal Arteries Using IVUS Validation and Reliability Testing

Purpose: Objective assessment of dissection severity is difficult. Recognition of this has led to the creation of classification systems. This study investigated the performance of the National Heart Lung and Blood Institute (NHLBI) and Kobayashi systems at differentiating severity of femoropopliteal dissection using intravascular ultrasound (IVUS) as the reference standard. Comparison between the 2 systems and the inter- and intra-observer reliability were also investigated. Materials and Methods: Angiographic and IVUS imaging was assessed in 51 cases sourced from a RCT investigating the use of IVUS in femoropopliteal disease. A total of 2 readers independently scored the angiography images according to NHLBI and Kobayashi dissection classification systems and a consensus score was obtained for each system in each case. The NHLBI classification was condensed into 3 grades of dissection to allow comparison between systems. Dissection length, dissection arc, minimum lumen area, and lumen area stenosis were obtained from the IVUS imaging. IVUS parameters were compared between grades of severity for both systems. Agreement in grading between the systems was assessed and IVUS parameters for each level of dissection severity were compared between systems. Inter and intra-observer agreement tested for each system. Results: Dissection was present on IVUS in 92.2% (47/51) of cases and angiography identified 78.7% (37/47) of these. No difference was present in any IVUS parameters between mild and severe dissections with either classification system. No difference in IVUS findings was present for the same grades of dissection between systems. The 2 systems agreed on severity grade in 47 of 51 cases. The inter-observer agreement was for NHLBI was k=0.549 and k=0.627 for Kobayashi. Intra-observer agreement for NHLBI was k=0.633 and k=0.633 and for Kobayashi was k=0.657 and k=0.297. Conclusion: The lack of difference in IVUS parameters between mild and severe dissection for the NHLBI and Kobayashi systems raises doubts about their ability to effectively differentiate dissection severity. Weak to moderate reliability suggests that variability in interpreting dissection may be higher than acceptable. IVUS imaging is more sensitive for detecting dissection than angiography and research is required to establish the value of adding IVUS to dissection classification systems.

Can extended upper pole ureterectomy prevent ureteral stump syndrome after proximal approach for duplex kidneys?

ABSTRACTIntroduction:Symptomatic duplex kidneys usually present with recurrent urinary tract infection due to ureteral obstruction (megaureter, ureterocele or ectopic ureter) and/or vesicoureteral reflux. Upper-pole nephrectomy is a widely accepted procedure to correct symptomatic duplex systems with poor functioning moieties, also known as upper or proximal approach. The distal ureteral stump syndrome (DUSS) can be a late complication of this approach. There is no consensus upon the length of ureteral dissection and the better approach to symptomatic disease in duplex systems, so we aim to identify if extended ureteral dissection can prevent DUSS in top-down approach.Materials and Methods:Forty-four consecutive patients with symptomatic duplex system were retrospectively classified into two groups: those with limited ureteral excision after heminephrectomy (HN) (group-1) and those with extended ureterectomy after HN (group-2). Patients were followed-up for at least 36 months regarding outcomes of distal ureteral stump.Results:Overall complication was 20%. A total of 8 patients required unplanned further surgery in Group-1 (30%) whereas only 1 patient required unplanned surgery in group 2 (6%) (p=0.07). Subgroup analysis showed that Group-1 presented more DUSS requiring surgery during follow-up than group-2 (p=0.04). Factors possibly affecting complications incidence (such as ureterocele or ectopic ureter) did not differ between groups (p=0.72 and p=0.78).Conclusion:Upper pole nephrectomy should be performed with extended distal ureteral dissection to prevent ureteral stump complications.

Sand cover enhances rill formation under laboratory rainfall simulation

Soil erosion was severe in the wind-water erosion crisscross region of the northern Loess Plateau of China, where aeolian sand cover may enhance water erosion. In order to evaluate the effects of sand cover on runoff, soil loss and rill information, a series of rainfall simulation experiments was conducted in two contrasting treatments. One is a bare loess soil slope serving as a control, and another is a sand-covered loess slope (namely sand cover treatment). Nine simulated rains, 60 min each, were applied to each treatment in duplicates. The results showed that the runoff generation mechanism changed from infiltration-excess runoff in the control to subsurface saturation-excess runoff in the sand cover treatment. The runoff initiation was delayed about three folds in the sand cover treatment as compared to the control. Total runoff volumes and total soil loss in the sand cover treatment in each event were 1.1–1.2 times and 1.9–9.3 times those in the control treatment. A paired t-test showed that the runoff rates were greater in sand cover than in control in all events except for the last run at P < 0.05. The soil loss rates were greater in sand cover than in control for all events except the first rain at P < 0.05. Measured total rill length, width, and degree of rill dissection in the sand cover treatment were much greater than those in the control. The rill erosion of sand cover slope was dominated by the shallow and wider rills, while loess slope was dominated by the narrow and deeper rills. The results clearly indicated that a sand layer overlying a less pervious loess soil facilitated return flow and thus accelerated rill formation and development. This finding is in line with the common understanding that return flow in layered soil can promote rill formation and cause severe rill erosion, which is also important to understand the effect of wind-blown sand cover on water erosion in the wind-water erosion crisscross region.

Association of Postangioplasty Femoropopliteal Dissections With Outcomes After Drug-Coated Balloon Angioplasty in the Femoropopliteal Arteries

Purpose: Balloon angioplasty for the treatment of femoropopliteal lesions is often complicated by postangioplasty dissections. While dissections are known to affect patency and reintervention after balloon angioplasty, the association between dissections and major adverse limb event (MALE) after drug-coated balloon (DCB) angioplasty remains uncertain. Thus, the postangioplasty dissection and bailout stenting patterns were investigated. Materials and Methods: This was a single-center retrospective study enrolling patients with de novo femoropopliteal lesions treated with DCB with/without stenting. Postangioplasty target vessel dissection was graded based to the coronary artery classification grades A-F, with grade C-F considered “severe.” Cox regression analysis was performed to examine the association of dissection severity with outcomes during 2-year follow up, among nonstented cases. Results: In 85.3% of the cases (N=203/238) a postangioplasty dissection was observed. The average dissection length was 55.57 mm (SD 36.71 mm), with 1 dissection present in 91.8% (N=180/196) and 2 or more dissections present in 8.2% (N=16/196). Dissection severity was grade A (19.8%), B (20.6%), C (23.1%), D (10.9%), E (10.1%), and F (0.8%). Bailout stenting was required in 40.4% of the patients, being more prevalent among grade C and grade E cases. Among 142 nonstented cases, dissections were present in 85.2%. A total of 75 (52.8%) of these dissections were grade A and B, while 46 (32.4%) were grade C to F. Among nonstented cases, grade C (hazard ratio [HR] 5.83; 95% CI 1.25 to 27.31; p=0.025) and grade D (HR 6.32; 95% CI 1.39 to 28.86; p=0.017) vs grade A dissections were associated with a higher risk for 2-year MALE. Multivariate analysis adjusting for several lesion characteristics demonstrated a statistically significant higher risk for 2-year MALE among the severe dissection group (HR 2.94; 95% CI 1.27 to 6.79; p = 0.012). Interestingly, the risks of limb loss (HR 1.30; 95% CI 0.22 to 7.79; p=0.774) and repeat revascularization (HR 0.95; 95% CI 0.40 to 2.26; p=0.905) during follow-up were similar between the 2 groups. Conclusion: This study indicated that nonstented moderate and severe postangioplasty dissections after DCB angioplasty were associated with higher risk for MALE. Future studies are needed to validate our results and determine other dissection characteristics (eg, total dissection length, lumen area, total number of dissections) that may affect the efficacy of DCB.

Evaluation of isolated abdominal visceral artery dissection with multi-scale spiral computed tomography: a retrospective case series

BackgroundTo evaluate the role of multi-slice spiral computed tomography (MSCT) angiography in the diagnosis of spontaneous isolated visceral artery dissection (SIVAD).MethodsTwenty-seven patients with abdominal SIVAD were included in the study. The MSCT scans of the patients were subjected to various post-processing techniques to visualize the visceral artery wall. Clinical features including arterial dissection, thrombosis, dissection length, true/false lumen, and complications were recorded.ResultsType I, IIa, and IIb SIVADs were observed in 11, 6, and 10 patients, respectively. Superior mesenteric artery (SMA) dissection was the most common (n = 16), followed by abdominal aortic dissection (n = 6), splenic artery dissection (n = 2), renal artery dissection (n = 2), and splenic artery dissection (n = 1). One patient with SMA dissection suffered small intestine ischemia, 1 with splenic artery dissection had splenic infarction, and 1 patient with left renal artery dissection experienced renal infarction. The false lumen was bigger than the true lumen in 20 patients, with 9 patients having thrombus. The true lumen was bigger than the false lumen in 7 patients.ConclusionsMSCT angiography is a valuable technique in the diagnosis and treatment of patients with SIVAD. Patients with abdominal pain suspected due to SIVAD should be examined with MSCT angiography for early detection of SIVAD.

Clinical features and management strategy of symptomatic spontaneous isolated celiac artery dissection

The aim of this study was to evaluate the clinical features and management strategy for patients with symptomatic spontaneous isolated celiac artery dissection (SICAD). In this retrospective study, consecutive patients with symptomatic SICAD from two institutions were included. The demographics, clinical manifestations, comorbidities, imaging findings and treatment strategy selection were obtained from the medical records. The general epidemiological data, treatment regimens and clinical and follow-up outcomes were analysed. Patients were divided into the conservative treatment group (group A, n = 26) and endovascular treatment group (group B, n = 11). Of these 37 patients, extent of dissection in both groups included only celiac trunk (61.54%% vs. 18.18%, p = 0.03), common hepatic artery (CHA) and splenic artery (SA) (3.85%% vs. 54.55%, p = 0.001), CHA (7.69% vs. 18.18%, p = 0.57), SA (23.08% vs. 9.09, p = 0.65) and left gastric artery (LGA) (3.85% vs. 54.55%, p = 0.99). Of note, the extension of the lesion in group A was shorter than that in group B. In addition, there were significantly more type IIb in group A than in group B (42.31% vs. 9.09%, p = 0.06) and the mean length of dissection in group A was 42.3 ± 54.71 mm which was significantly shorter than that in the group B 58.45 ± 3.71 mm (p =0.04). During a median follow-up of 11.5 months, the 1, 3, 6 and 12 month follow-ups were completed in 100% (37/37), 100% (37/37), 94.59% (35/37) and 91.19% (34/37) of patients, respectively. The cumulative rate of persistent disease stability in patients with endovascular treatment group was higher than in that conservative treatment group at the 3, 6, 9 and 12 months (50% vs. 16.67%, p = 0.001; 80% vs. 37.5%, p =0.03; 100% vs. 62.5%, p = 0.012;100% vs. 91.67%, p = 0.02 respectively). Most symptomatic SICAD have a tendency to persistent disease stability after conservative treatment. Risk factors for failed conservative treatment were length of dissection and branch involvement. Furthermore, endovascular treatment was associated with a high technical success and persistent disease stability rate, which might be reserved for patients with failed conservative treatment.

Comparison of the internal thoracic artery flow dissected by video endoscopy or conventional technique.

ABSTRACTPurpose:To compare the blood flow in the internal thoracic artery when dissected endoscopically in a conventional manner, in addition to develop a reliable experimental training model for the surgical team.Methods:Paired experimental study. Ten pigs were operated and had both internal thoracic arteries dissected, the right with a conventional technique and the left by video endoscopy. The main outcomes to be studied were flow, length, and time of dissection of each vessel.Results:Blood flow measurements were performed with mean heart rate of 100 ± 16 bpm and mean arterial pressure of 89.7 ± 13 mm Hg. The mean blood flow of endoscopic dissection of the internal thoracic artery was 170.2 ± 66.3 mL/min and by direct view was 180.8 ± 70.5 (p = 0.26). Thus, there was no statistically significant difference between the flows, showing no inferiority between the methods.Conclusions:The minimally invasive dissection of the internal thoracic artery was shown to be not inferior to the dissection by open technique in relation to the blood flow in the present experimental model. In addition, the model that we replicated was shown to be adequate for the development of the learning curve and improvement of the endoscopic abilities.

Detecting isolated superior mesenteric artery dissection with computed tomography

Aim: Isolated superior mesenteric artery (SMA) dissection without associated aortic dissection is a rare entity. The aim of the study is to evaluate its incidence, and multidetector computed tomography (MDCT) and computed tomography angiography (CTA) findings, as well as show the clinical importance of this condition, which should be diagnosed and treated urgently. Methods: Images of all patients who underwent contrast enhanced CTA or MDCT scan from July 2017 to July 2020 at our radiology department were examined retrospectively. A total of 600 CTA and 14000 contrast enhanced MDCT scans (14600 CT) were evaluated. Only the cases with isolated SMA dissections without aortic involvement, who had arterial phases on contrast enhanced MDCT images, were included. Aortic dissection cases with SMA involvement, and non-contrast MDCT images were excluded. Age, gender, symptoms, presence of thrombosis or bowel ischemia were noted. Average extension of dissection and distance from origin were measured. Results: Ten patients (7 M, 3 F), aged between 48-66 years (mean: 57 years), had isolated SMA dissection. The mean distance of dissection from origin and mean extension were 1.9 cm and 3.4 cm, respectively. Patients were treated with conservative anticoagulation therapy. Follow-up CTA or MDCT showed normal SMA without evidence of dissection in 5 patients, decreased extension and length of dissection in 3 patients and no significant difference in 2 patients. Conclusion: Isolated SMA dissection is a rare but important cause of abdominal pain. Early diagnosis allows correct treatment. CT is a useful noninvasive method for diagnosis and anticoagulation therapy is successful.

Primary Conservative Therapy for Symptomatic Isolated Mesenteric Artery Dissection with Severely Compressed True Lumen or Large Dissecting Aneurysm

PurposeTo investigate the safety and effectiveness of primary conservative therapy for patients with symptomatic isolated mesenteric artery dissection (IMAD) with a severely compressed true lumen and/or a large dissecting aneurysm. Materials and MethodsA total of 35 consecutive patients (all men; median age, 53 y) with symptomatic IMAD with a severely compressed true lumen and/or a large dissecting aneurysm but without intestinal necrosis or arterial rupture who were treated with primary conservative therapy between November 2018 and February 2020 were assessed. A severely compressed true lumen was defined as luminal stenosis > 70%. A large dissecting aneurysm was defined as dissecting aneurysm diameter ≥ 1.5 times larger than the normal mesenteric artery diameter. ResultsThere was a strong positive relationship among abdominal pain, degree of luminal stenosis, and length of dissection (R = 0.811; P < .001). Conservative treatment was successful in all patients. Abdominal pain was eliminated within 4.7 d ± 4.8 (range, 2–31 d) in all patients, within 3.6 d ± 1.2 (range, 2–6) in the 31 patients with minor or moderate abdominal pain, and within 13.3 d ± 11.9 (range, 6–31 d) in the 4 patients with severe abdominal pain. Complete or partial remodeling of the mesenteric artery was achieved in 6 (17.1%) and 29 (82.9%) patients, respectively, during 8.6 mo ± 4.3 of follow-up. ConclusionsPrimary conservative therapy can be used safely and effectively in patients with symptomatic IMAD with a severely compressed true lumen and/or a large dissecting aneurysm but without intestinal necrosis or arterial rupture.

Tracing: A Simple Interpretation Method for the DIEP Flap CT Angiography to Help Operative Decision-making.

SummaryCT angiography (CTA) is an established technique that allows preoperative planning in DIEP flap reconstruction. However, innovative technological developments with extensive amounts of information require processing of data. It also requires user knowledge to interpret findings. Descriptions by radiologists are many times disappointingly limited to caliber and exit points of the perforator from the rectus fascia. Many DIEP flap surgeons similarly fail to utilize the CTA to its full extent. This is likely due to information overload. By tracing the DIEA on the CTA on a computer screen, using an ordinary ballpoint pen and a white sheet of paper, the surgeon can create a stylistic map of the dissectional-path of the DIEA. The map illustrates unusual branching patterns, perforator caliber and location, interconnections between individual perforators (or lack thereof), length of intramuscular dissection, and also rectus abdominis muscle intersections. The mapping can help in the choice of perforator(s) and may also speed up decision-making during surgical dissection. A penciled map also eases a round-table discussion, if multiple surgeons are involved in the operation. The map can also easily be brought to the operating room for guidance. Tracing is a user-friendly, time-efficient, intuitive, low-cost, and low-tech method that generates data that are easy to interpret, easy to share, and easy to discuss with other surgeons. The method is also not dependent on a radiologist for interpretation.

Anterior Tibial Artery and Its Clinical Importance in the Posterolateral Approach to the Tibial Plateau: An Angiographic Study on 219 Lower Limbs.

The anterior tibial artery (ATA) is the most critical anatomical structure at risk at the distal border of the posterolateral approach to the tibial plateau. This study aimed to use available lower extremity digital subtraction angiography (DSA) images to determine the distal safe limit of this approach by measuring the distance from the tibial joint line to the ATA where it pierces the interosseous membrane. Tibial plateau mediolateral width (TP-ML-W) and the perpendicular distances from the ATA to the tibial joint line and fibular head were measured on DSA images in 219 lower extremities. To normalize the distances according to the tibial dimensions, each distance was divided by the TP-ML-W, and a ratio was obtained. Popliteal artery branching pattern was categorized according to the classification proposed by Kim et al. Comparative analysis between right and left extremities, genders, and anatomical variations were performed. There were 102 male and 26 female subjects with a mean age of 60.7 ± 15.7 years (range, 17-92 years). Ninety-one subjects had bilateral lower extremity DSA; thus, a total of 219 extremities were analyzed. The TP-ML-W was wider in male (78.3 ± 7.0) than female (70.5 ± 7.3) subjects (p = 0.001). The ATA coursed through the interosseous membrane at 50.9 ± 6.9 mm (range, 37.4-70.2 mm) distal to the tibial plateau joint line, and it was 66.5 ± 7.2% of the TP-ML-W. The ATA coursed through the interosseous membrane at 36.5 ± 6.0 mm (range, 21.9-53.8 mm) distal to the fibular head, and it was 47.7 ± 6.6% of the TP-ML-W. All measured variables were similar between the regular branching pattern of the popliteal artery (type 1A) and other observed variations among male subjects. The safe length of dissection in the posterolateral approach is average 66.5% (range, 45.7-86.7%) of the TP-ML-W. This ratio is valid for both genders. The use of a ratio instead of a distance, which is subject to personal variations, seems to be more logical and practical for planning this surgery, but the wide range should still not be ignored.

Safety and efficacy of peroral endoscopic myotomy with standard myotomy versus short myotomy for treatment-naïve patients with type II achalasia: a prospective randomized trial

Peroral endoscopic myotomy (POEM) has emerged as an effective endoscopic treatment modality for achalasia. However, there is no consensus regarding the length of muscle bundle dissection during POEM. The most commonly used approach is standard myotomy (about 10 cm). We herein compared the outcomes between standard myotomy versus short myotomy for the management of treatment-naïve patients with type II achalasia. This was a prospective, single-center, randomized trial in China. Previously untreated adults with a clinical diagnosis of type II achalasia, confirmed by manometric testing, were enrolled between February 2018 and February 2019. Patients were randomly assigned to POEM with standard myotomy or short myotomy. Clinical data on demographic characteristics, operative parameters, pre- and postoperative Eckardt scores, esophageal manometry results, 24-hour pH test, and adverse events were recorded and compared between the 2 groups. Of 100 randomized patients, 94 underwent treatment (48 in the standard myotomy group and 46 in the short myotomy group), and 91 (97%) completed the study. POEM was successfully accomplished in most patients (97.8%). The primary outcome of treatment success occurred in 45 of 48 patients (93.8%) in the standard myotomy group versus 44 of 46 (95.7%) in the short myotomy group, with no statistically significant difference between the 2 groups (P= .520). There were no significant between-group differences in postoperative esophageal manometry, Eckardt score, diameter of the esophageal lumen, quality of life, procedure-related adverse events, or reflux esophagitis (P > .05). Postoperative abnormal esophageal acid exposure occurred more often in the standard myotomy group than in the short myotomy group (21/48 patients [43.8%] vs 11/46 patients [23.9%], P= .042). Meanwhile, the short myotomy group showed a significant reduction in total procedure time compared with the standard myotomy group (31.2 ± 15.3 minutes vs 45.6 ± 16.2 minutes, respectively, P< .05). Among treatment-naïve patients with type II achalasia, standard and short POEM were comparable in terms of providing treatment efficacy and improving quality of life at 1 year, whereas short POEM is technically simpler to perform and requires less procedure time. Moreover, the short POEM approach resulted in fewer cases of postoperative abnormal esophageal acid exposure. (Clinical trial registration number: ChiCTR1800014989.).

Management of Symptomatic Spontaneous Isolated Superior Mesenteric Artery Dissection: A Single Centre Experience with Mid Term Follow Up

This study aimed to report a single centre management experience and mid term outcomes for symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD). This was a retrospective observational study. Between 1 August 2012, and 30 June 2018, consecutive patients with symptomatic SISMAD were included. Patient demographics, clinical symptoms, comorbidities, risk factors, and dissection characteristics were obtained. The treatment regimens and clinical and follow up outcomes were reviewed and analysed. A chi square test, Fisher's exact test, or one way analysis of variance was used to compare variables between the groups. Binary logistic regression was used to determine predictive factors for failed conservative treatment. The cumulative rate of complete dissection remodelling was calculated using a Kaplan-Meier curve. Sixty-two patients (mean age, 56.0±9.3 years) were included. Patients at risk of intestinal ischaemia or dissecting aneurysm rupture were considered to be high risk patients (Group 1, n=16) and received primary endovascular treatment. The remaining patients were considered low risk (Group 2, n=46) and received primary conservative treatment. Symptom relief was observed in 82.6% of patients in Group 2. Finally, failed conservative treatment was observed in 50% of the low risk patients. Dissection length ≥50mm was an independent risk factor for failed conservative treatment (p=.019; OR 4.68, 95% CI 1.29-16.98). During a median follow up of 30.5 months (interquartile range, 17.5, 58.3), patients with stents had a higher complete dissection remodelling rate than those without stents. This study found that conservative treatment showed satisfactory symptom resolution for low risk SISMAD patients. Endovascular stenting was associated with a high technical success and dissection remodelling rate. This treatment modality might be reserved for patients with high risk SISMAD or failed conservative treatment. In addition, a dissection length ≥50mm was a risk factor for failed conservative treatment.

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

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

Increased Epicardial Adipose Tissue is Associated with the Extent of Aortic Dissection

BackgroundEpicardial adipose tissue (EAT) is a biologically active organ that has endocrine and paracrine functions. Endothelial dysfunction, systemic, and local inflammatory response, due to bio-active molecules produced by EAT, may affect aortic dissection propagation and extent. We investigated the association between EAT thickness and the extent of aortic dissection.MethodsWe retrospectively enrolled 78 patients with aortic dissection diagnosed by thoracoabdominal Computerized Tomography (CT). EAT was measured from the thickest part of the perpendicular plane between the pericardium and free wall of the right ventricle using CT. Aortic dissection length was measured from the beginning to the end of the dissection flap at sagittal images.ResultsWe included 78 patients with the mean age of 63.9 ± 11.7 and 57 (73.5%) patients were male. Dissection length was correlated positively with EAT (r = 0.409, p < 0.001), body mass index (r = 0.408, p = 0.018), and admission systolic blood pressure (r = 0.830, p = 0.026) whereas an inverse correlation existed between age and dissection length (r = −0.318, p = 0.005). Multivariate analysis identified age and EAT as independent predictors of dissection length.ConclusionIncreased EAT was independently associated with the extent of aortic dissection. We think that either paracrine and endocrine functions of EAT might have contributed to the extent of aortic dissection.

Mid-term outcomes of symptomatic isolated superior mesenteric artery dissection with endovascular management.

The clinical outcomes, safety, and efficacy of endovascular management are explored for symptomatic isolated superior mesenteric artery dissection (ISMAD). In this retrospective study, 51 consecutive patients with symptomatic ISMAD received endovascular management from three institutions between January 2011 and December 2019.These patients were categorized into group A (endovascular treatment was used as the first-line therapy) and group B(endovascular treatment was used as the second-line therapy). The general epidemiological data, clinical manifestations, first-episode symptoms, treatment process, imaging findings, follow-up outcomes were analyzed from the medical records. A total of 51 patients with endovascular management were collected in this study. Significant differences were observed between the two groups with respect to the course (150 h vs. 57 h; p < 0.001), intestinal ischemia (26.32% vs. 6,25%; p = 0.04) and dissection length (45.26 ± 13.78 mm vs. 63.37 ± 12.73 mm; p < 0.001). Technical success rate was 90.2% (46/51). There was significant difference in the MOD (42.27 ± 23.41 min vs. 76.63 ± 28.62 min p < 0.001), MPSRT (4.67 ± 2.65 h vs. 7.32 ± 2.49 h, p = 0.02), LOS (9.52 ± 3.72 days vs. 11.86 ± 4.13 days; p = 0.01) between the two groups. The bleeding complication rate was 7.84% (one patient in group A and three patients in group B). A total of 48 (94.12%, 48/51) patients were followed up for a median of 36.51 months (range, 4-87 months). Positive events of the SMA were achieved in 81.25% (39/48), and negative events of the SMA were achieved in 18.75% (8/48) based on the follow-up contrast-enhanced CT scan. Endovascular management of symptomatic ISMAD has a high technical success rate and efficient at controlling symptoms. Furthermore, as more positive events occur, endovascular management should be encouraged early when pain persists after conservative management or there are signs of disease progression.

Outcomes and radiographic findings of symptomatic isolated mesenteric artery dissection with conservative management.

The aim of this study was to evaluate the computed tomography follow-up outcomes and radiographic findings of symptomatic isolated mesenteric artery dissection (IMAD) after conservative management. In this retrospective study, 130 consecutive patients with symptomatic IMAD from three institutions were enrolled from January 2011 to December 2019. The general epidemiological data, clinical manifestations, first-episode symptoms, imaging findings, and treatment strategy selection were analyzed from the medical records. Among 130 patients diagnosed with symptomatic IMAD, positive remodeling of the SMA was achieved in 75.38% (98/130), and negative remodeling of the SMA was achieved in 24.62% (32/130). In the positive remodeling group, complete remodeling was achieved 39.23% (51/130) (type I 6 patients, type IIa 10 patients, type IIb 35 patients), in which type IIb was the most (p = 0.004). Moreover, of the 32 patients in whom negative remodeling of the SMA was achieved, significant differences were observed between the type IIa with respect to dissecting aneurysm formation (p = 0.04).Of the seven factors analyzed with a logistic regression model identified three factors significantly associated with negative remodeling: length of dissection (Waldχ2 13.331; OR 6.945; 95% CI 2.762-10.498; p = 0.014), true lumen residual diameter (TLRD) (Waldχ2 9.626; OR 7.85; 95% CI 1.892-19.063; p = 0.022), and branch involvement (Waldχ2 11.812; OR 7.247; 95% CI 1.245-14.830; p = 0.011). The prognosis of most symptomatic IMAD has a tendency to positive remodeling after conservative management, in which the initial type IIb classification is common. In contrast, risk factors for negative remodeling were type IIa, length of dissection, TLRD, and branch involvement. Patients with these morphological characteristics may not benefit from conservative management.

Minimal dissection of posterior wall of rectum reduces rectal prolapse in laparoscopic assisted anorectal pull-through

PurposeTo determine if minimal dissection of the posterior wall of rectum can reduce rectal prolapse after laparoscopic assisted anorectal pull-through (LAARP) in male anorectal malformation (ARM) with rectourethral fistula. MethodsEighty-six male patients with ARM who underwent LAARP in our center between 2007 and 2018 were retrospectively analyzed. There were 45 cases of prostatic urethral fistula, 24 bulbar urethral fistulas, and 15 bladder neck fistulas. Two patients had no fistula. To prevent rectal prolapses, we markedly shortened the length of posterior rectal dissection from mid-2016. Dissection of posterior wall of rectum was performed minimally around the level of the fistula and the dissected portion of the posterior rectum was significantly shorter than the previous cases. For comparative analysis, patients were divided into two groups (before and after application of minimal dissection of posterior wall of rectum): Group A, from 2007 to mid-2016 and Group B, from mid-2016 to 2018. ResultsThere were 60 patients in Group A and 26 patients in Group B. Demographic characteristics were not significantly different between the two groups. The median follow-up duration was 52.4 months for Group A and 26.9 months for Group B. Group B had lower incidence of rectal prolapse (11.5%) than Group A (68.3%) (p < 0.001). Upon our subgroup analysis based on types of fistula, patients with recto-prostatic urethral fistula and recto-bulbar urethral fistula showed significant reduction in the incidence of rectal prolapse (both p < 0.001). However, patients with recto-bladder neck fistula showed no statistical significance (p = 0.264). ConclusionMinimal dissection of the posterior wall of rectum can reduce rectal prolapse in LAARP. Level of evidenceIII. Retrospective Comparative Treatment Study