Open Thoracic Aortic Repair Research Articles

Thoracic Endovascular Aortic Repair for Aortic Aneurysm Is Safe in Patients With Chronic Kidney Disease, but at a Cost

The advent of thoracic endovascular aortic repair (TEVAR) has resulted in improved morbidity and mortality for patients compared with open thoracic aortic repair. Yet it remains unclear how chronic kidney disease (CKD) affects TEVAR outcomes. The paucity of data on CKD patients can be rectified using the robust vascular-specific Vascular Quality Initiative. This study's goal was to identify adverse outcomes associated with CKD stage including postoperative 30-day outcomes and 1-year survival after TEVAR for aortic aneurysm.

National Trends of Thoracic Endovascular Aortic Repair versus Open Thoracic Aortic Repair in Pediatric Blunt Thoracic Aortic Injury

Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment modality in adult patients with BTAI, but its use in pediatrics is currently not supported by device manufacturers and lacks United States Food and Drug Administration approval. We hypothesized that there would also be an increased use of TEVAR in the pediatric population, thus conferring a lower risk of mortality compared with open thoracic aortic repair (OTAR). The National Trauma Data Bank (2007-2015) was queried for patients ≤17 years with BTAI. The primary outcomes were the incidences of TEVAR and OTAR. Secondary outcome was risk of mortality in those undergoing intervention. A multivariable logistic regression model was used to determine the risk of mortality in OTAR versus TEVAR. We identified 650 pediatric BTAI patients with 159 (24.5%) undergoing intervention. Of these, 124 underwent TEVAR (78.0%) and 35 (22.0%) underwent OTAR. The rate of TEVAR steadily increased from 2007 to 2015 (15.4% vs. 27.1%, P<0.001). Patients receiving OTAR and TEVAR had a similar injury severity score and rate of hypotension on admission (P>0.05). Compared with OTAR, TEVAR patients had a higher rate of any traumatic brain injury (TBI) (63.7% vs. 37.1%, P=0.005) and shorter hospital and intensive care unit length of stay (LOS) (16.4 vs. 21.4days, P=0.02; 10.1 vs. 12.2days, P=0.01). TEVAR and OTAR, even when stratified by≤14 years and 15-17 years, had no difference in risk for mortality (odds ratio 1.20, confidence interval 0.29-5.01, P=0.80). The rate of TEVAR in pediatric BTAI nearly doubled from 2007 to 2015. Compared with OTAR, TEVAR was associated with a shorter hospital LOS despite a higher rate of TBI. There was no difference in risk for mortality between TEVAR and OTAR. Longitudinal studies to determine the long-term efficacy and complication rates, including reintervention, development of endoleak, and/or need for further operations, are needed as this technology is being rapidly adopted for pediatric trauma patients.

Editor's Choice – Open Thoracic and Thoraco-abdominal Aortic Repair After Prior Endovascular Therapy

The aim was to present current results of open thoracic and thoraco-abdominal aortic repair as secondary procedure after prior endovascular therapy. This was a retrospective cross border single centre study. From 2006 to July 2017 45 open thoracic aortic (TAA) or thoraco-abdominal aortic aneurysm (TAAA) operations were performed on 44 patients (median age 58 [15-80] years) as secondary surgery after previous endovascular therapy comprising TEVAR (n=38; 86%), EVAR (n=3; 7%), fenestrated EVAR (n=1; 2%) and TEVAR plus EVAR (n=1; 2%). Eleven patients (25%) had had previous open aortic surgery at the secondary surgery site. Indications for TAA(A) repair were Type I endoleak (n=10; 23%), post-dissection aneurysm progression due to persisting false lumen perfusion (n=8; 18%), proximal/distal disease progression (n=16; 36%), device fracture/dislocation (n=4; 9%), infection (n=5; 11%), and initial endograft misplacement (n=1; 2%). The operations included descending thoracic aortic repair (n=13, 29%), TAAA Type I (n=4; 9%), Type II (n=5; 11%), Type III (n=13; 29%), Type IV (n=7; 16%), and Type V repair (n=3; 7%) with simultaneous arch repair in 18% (n=8). The median time to secondary surgery was 36 (2-168) months. The median follow up was 39 (3-118) months. In hospital mortality was 20% (n=9) due to intra-operative aneurysm rupture, pneumonia induced sepsis, hemorrhagic cerebellar infarction, mesenteric ischaemia, broncho-esophageal fistula, and multiorgan failure (1/9) as well as haemorrhage (3/9). Estimated survival was 73% at 1 year and 71% overall. The most frequent complications were pneumonia (n=19; 43%), bleeding requiring revision (n=11; 25%) and sepsis (n=14; 32%). Transient dialysis was required in 32% (n=14), permanent dialysis in 6% (n=2). Permanent spinal cord deficit (paraparesis) occurred in 6% (n=2). Estimated freedom from aortic re-intervention was 86%. Open TAA(A) repair as a secondary procedure after previous endovascular aortic therapy is an important treatment option even in the endovascular era. It represents a durable treatment that can produce respectable outcomes. Yet the peri-operative morbidity and mortality are relevant and a specialised team and infrastructure are mandatory for these complex procedures. Therefore, centralisation is required.

Impact of Surgical Stroke on the Early and Late Outcomes After Thoracic Aortic Operations

Thoracic aortic operations still remain associated with substantial risks of death and neurologic injury. This study investigated the impact of surgical stroke on the early and late outcomes, focusing on the physical status and quality of life (QOL). From 1986 to 2008, 500 patients (aged 63 ± 13 years) underwent open thoracic aortic repair for root and ascending (31%), arch (39%), extended arch (10%), and descending and thoracoabdominal (19%) aneurysms. Brain protection consisted of retrograde cerebral perfusion (52%), antegrade cerebral perfusion (29%), and simple deep hypothermic circulatory arrest (19%). Surgical stroke was defined as a neurologic deficit persisting more than 72 hours after the operation. QOL was assessed with the Short-Form 36 Health Survey Questionnaire 5.9 ± 4.2 years after the operation. Stroke occurred in 10.3% of patients. Hospital mortality was 21% in the stroke group and 2.7% in the nonstroke group (p < 0.001). At hospital discharge, 76% of survivors in the stroke group had permanent neurologic deficits (PNDs), with sustained tracheostomy in 39%, tube feeding in 46%, and gastrostomy in 14%, and 89% required transfer to other facilities. PND was an independent risk factor for late death (hazard ratio, 2.29; 95% confidence interval, 1.04 to 4.62; p= 0.041) in a multivariate analysis. The physical component of the QOL score was worse in the PND group (51% vs 100%; p= 0.039), whereas the mental component was similar in both groups (14% vs 14%). Surgical stroke is associated with high hospital mortality and PNDs that decrease late survival and the physical component score of the QOL survey.

Cohort Comparison of Thoracic Endovascular Aortic Repair with Open Thoracic Aortic Repair Using Modern End-Organ Preservation Strategies

Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. To create a more level assessment, we compared our outcomes of elective TEVAR with modern open thoracic aortic repair (OTAR) controls. A retrospective review of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest was used in all OTAR patients. Cerebrospinal fluid drain placement was attempted in all patients. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for survival estimates. The main outcome was mortality. Secondary outcomes included postoperative spinal cord ischemia (SCI) or stroke, and any persistent neurologic deficit 30 days following the operation. During the study period, 62 patients underwent TEVAR and 56 underwent OTAR with median follow-up of 23.7 months and 36.4 months, respectively. No difference existed between the TEVAR and OTAR with respect to overall neurologic complications (8.1% vs. 12.5%, P = 0.55) as well as any residual neurologic deficit at 30 days (0% vs. 5.4%, P = 0.10). TEVAR patients had fewer complications including pneumonia (P = 0.02), rebleeding (P = 0.02), and acute kidney injury (P = 0.001). There was no difference in 30-day mortality (1.6% vs. 8.9%, P = 0.10), 1-year mortality (12.2% vs. 14%, P = 0.80), or 5-year mortality (53.9% vs. 44%, P = 0.48) between TEVAR and OTAR, respectively. TEVAR continues to show improved perioperative outcomes with a trend toward decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the routine use of end-organ preservation strategies during OTAR, neurologic deficits, particularly SCI, can be safely reduced to comparable levels with those of TEVAR and 1-year all-cause mortality rates are similar between the groups. These OTAR results may serve as a benchmark as TEVAR is increasingly applied for other aortic pathologies, such as chronic dissection, wherein long-term efficacy is not proven.

Cohort-Comparison of Thoracic Endovascular Aortic Repair with Open Thoracic Aortic Repair Using Modern End-Organ Preservation Strategies

Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. In an effort to create a more level assessment, we compared our outcomes of TEVAR with modern open thoracic aortic repair (OTAR) controls. A retrospective review of a prospective database of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest (HCA) was used in all OTAR patients. Both groups underwent cerebrospinal fluid (CSF) drain placement when feasible. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for 1-year survival estimates. Subgroup analysis was performed using length of aortic stent graft coverage or length of aortic replacement. During the study period (2002-2013), 81 patients underwent TEVAR and 61 underwent OTAR with median follow-up of 23.7 months (interquartile range, 6.7-55.1) and 36.4 months (interquartile range, 9.6-60.2), respectively. TEVAR patients had significantly lower 30-day mortality (2.5% vs 13.1%; P = .02) and fewer complications including pneumonia (P = .01) and rebleeding (P = .03). However, there was no difference in permanent spinal cord ischemia (SCI) (1% vs 2%; P = .9) or estimated 1-year survival (P = .9). Among OTAR patients, HCA tended to have higher 30-day mortality (16% vs 7%, P = .43). Cox regression revealed that advanced age and higher baseline creatinine levels were associated with greater hazard of 1-year mortality; TEVAR and CSF drain placement were protective of 1-year survival. For patients with <20 cm of aortic stent graft or aortic graft replacement, there was no difference in 30-day mortality (P = .07) or permanent SCI (TEVAR n = 0, 0% vs OTAR n = 1, 2%; P = .9). For those with ≥20 cm of aortic stent graft or replacement, there was no difference in 30-day mortality (P = .9) or permanent SCI (TEVAR n = 1, 2% vs OTAR n = 0, 0%; P = .9). TEVAR continues to show improved perioperative outcomes with decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the advent of routine end-organ preservation during OTAR, SCI can be safely reduced to comparable levels with those of TEVAR. Length of aortic stent graft coverage or length of surgical graft replacement does not significantly impact outcomes.

Association of race and socioeconomic status with the use of endovascular repair to treat thoracic aortic diseases

Descending thoracic aortic diseases may be treated with either open thoracic aortic repair or thoracic endovascular aortic repair (TEVAR). Previous studies have demonstrated that race and socioeconomic status (SES) affect access to care and treatment allocation in vascular surgery. We hypothesized that racial minorities and lower SES patients have decreased propensity to have their thoracic aortic disease treated with TEVAR. Weighted discharge records for patients who underwent either open thoracic aortic repair or TEVAR between 2005 and 2008 were evaluated using the Nationwide Inpatient Sample. Patient records were stratified by therapeutic intervention (open repair vs TEVAR). Differences in baseline comorbidities, race, and SES were compared. To account for the effects of comorbidities and other factors, hierarchical logistic regression modeling was used to determine the likelihood for TEVAR performance based on differences in patients' race and SES. A total of 60,784 thoracic repairs were analyzed, the majority (79.4%) of which were open repairs. The most common race was white (78.2%), followed by black (9.1%), Hispanic (5.7%), Asian or Pacific Islander (2.9%), and Native American (0.7%). Patients were divided into quartiles according to SES with 20.6% of patients in the lowest SES quartile, 24.3% in the second quartile, 26.4% in the third quartile, and 28.8% in the highest SES quartile. Indications for treatment were similar for both treatment groups. After adjusting for multiple patient and hospital factors, race and SES were significantly associated with treatment modality for thoracic aortic disease. Black, Hispanic, and Native American populations had increased adjusted odds ratios of TEVAR performance compared with white patients. Similarly, lower SES correlated with increased use of TEVAR. Contrary to our initial hypothesis, racial minorities (Black, Hispanic, and Native American) and patients with lower median household incomes have a greater association with the performance for TEVAR after accounting for patient comorbid disease, indication for treatment, payer status, and hospital volume. These results indicate that traditional racial disparities do not persist in TEVAR allocation.

Spinal screw penetration of the aorta

Aortic injury is a complication of spinal instrumentation with treatment challenges, especially with hardware infection. We present two cases of spinal screws penetrating the descending thoracic aorta (DTA). Case 1 had pain after T6-T7 fusion with screw penetration of the DTA causing pseudoaneurysm. Case 2 had perforation of the DTA by a T4 screw with infected pseudoaneurysm. Neither was an endovascular candidate and both underwent open repair. Although endovascular approaches have benefits in aortic aneurysm repair, the techniques of open thoracic aortic repair remain relevant.

Long-Term Comparison of Thoracic Endovascular Aortic Repair (TEVAR) to Open Surgery for the Treatment of Thoracic Aortic Aneurysms

Conclusions: Thoracic endovascular aortic repair (TEVAR) is a safe and effective treatment for thoracic aortic aneurysms. TEVAR provides improved perioperative results and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysms initially decrease in diameter and then stabilize over time. Summary: Early clinical results with TEVAR have generally shown a trend toward better perioperative survival and less major perioperative complications than open thoracic aortic aneurysm repair. The early results of the pivotal trials used to gain approval of the Gore TAG, Medtronic Talent, and Cook Zenith TX2 stent grafts provided highly favorable midterm data for stent grafts. Longer-term data are still desirable, however. The authors investigated long-term survival and freedom from aortic complications in patients enrolled in five U.S. Food and Drug Administration investigational device exemption studies of TEVAR grafts from a single center and compared them with a group of open control patients with similar anatomic features. Demographic, clinical, and radiographic parameters were collected prospectively from patients enrolled in trials assessing the Gore TAG (55), Medtronic Talent (36), and Cook TX2 (15) devices. Outcomes in patients treated with these stent grafts were compared with 45 contemporaneous open controls. From 1995 to 2007, there were 106 patients enrolled in TEVAR trials at the hospital of the University of Pennsylvania and 45 open controls. TEVAR patients were older and had more comorbidities, including diabetes and renal failure. TEVAR patients had 2.3 ± 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P = .1) and paralysis/paraparesis (3.9% TEAVR, 7.1% open; P = .2) did not differ in the open vs TEVAR patients. Prolonged intubation >24 hours was more common in the open controls (9% TEVAR, 24% open; P = .002). Overall survival at 8 to 10 years was ∼40% and was similar between groups (log-rank P = .5). Predictors of late mortality included age, diabetes, chronic renal failure, and chronic obstructive coronary disease. Use of TEVAR vs open surgery did not influence mortality (hazard ratio, 0.9; 95% confidence interval, 0.4-1.6). At 5 years in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention of the treated segment was 85% in TEVAR patients at 10 years. Comment: The article highlights the fact that compared with the number of patients in whom TEVAR has been performed, the number of patients with long term follow-up is still relatively small. (The University of Pennsylvania group has reported >500 TEVAR procedures in other articles.) In the discussion after the article, Dr Craig Miller from Stanford indicates that he is concerned that “the entire thoracic field is being ‘dumbed down’ as the TEVAR era evolved.” One can easily extrapolate Dr Miller's concerned to all endovascular techniques “dumbing down” all of vascular surgery. In the long run, however, outcomes rather than nostalgia will drive practice patterns in the treatment of vascular disease.

Nationwide trends and regional/hospital variations in open versus endovascular repair of thoracoabdominal aortic aneurysms

Thoracic endovascular aortic repair (TEVAR) has been gaining popularity for the treatment of thoracoabdominal aortic aneurysm (TAAA). We used a nonvoluntary database to examine national trends and regional/hospital variations in the use of TEVAR and open thoracic aortic repair (OTAR) for TAAA. From the 2005-2008 Nationwide Inpatient Sample database, we identified all patients with the diagnosis of TAAA who were treated with TEVAR or OTAR. Rates of these procedures were compared between years, across geographic regions, and between hospitals of various bed sizes. Over the study period, the rate of OTAR remained relatively stable (range, 7.5/100 patients in 2005 to 10.1/100 patients in 2008; P = .26), whereas the rate of TEVAR increased dramatically (range, 1.4/100 patients in 2005 to 6.3/100 patients in 2008; P < .0001). In 2008, 29% (211) of all TEVAR procedures and 11% (130) of all OTAR procedures were performed in western regions of the United States (P = .03). Additionally, 13% (95) of all TEVAR procedures and 3% (35) of all OTAR procedures were performed in smaller hospitals (P < .0001). The use of TEVAR for TAAA repair increased significantly over the study period, whereas OTAR rates remained relatively stable. Our findings suggest that more patients who were otherwise not surgical candidates or did not have traditional surgical indications for OTAR were treated with TEVAR, most commonly in regions or hospitals where OTAR is less often performed. Given the complexity of TAAA cases, these results may have significant implications for patient safety in the current era of heightened health care scrutiny.

Long-term comparison of thoracic endovascular aortic repair (TEVAR) to open surgery for the treatment of thoracic aortic aneurysms

Thoracic endovascular aortic repair (TEVAR) has become a widely established treatment for a variety of thoracic aortic pathologic diseases despite limited long-term data to support its use. We compared the long-term outcomes of TEVAR with the 3 commercially available stents grafts for thoracic aortic aneurysms to results in control subjects undergoing open surgery. Demographic, clinical radiographic parameters were collected prospectively on patients enrolled in trials assessing the Gore TAG (55), Medtronic Talent (36) and Cook TX2 (15) devices. Outcomes were compared with 45 contemporaneous open controls. Detailed clinical and radiographic information was available for analysis. Standard univariate, survival, and regression methods were used. During the study period (1995-2007) 106 patients were enrolled in TEVAR trials and there were 45 open controls. TEVAR patients were older and had significantly more comorbidities including diabetes and renal failure. TEVAR patients had 2.3 ± 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P = .1), paralysis/paraparesis (3.9% TEVAR, 7.1% open; P = .2), and prolonged intubation more than 24 hours (9% TEVAR, 24% open; P = .02) tended to be more common in the open controls. Overall survival at 10 years was similar between groups (log rank P = .5). Multivariate predictors of late mortality included age, chronic obstructive pulmonary disease, diabetes, and chronic renal failure. Use of TEVAR versus open surgery did not influence mortality (hazard ratio, 0.9 95% confidence interval, 0.4-1.6). Over 5 years of radiographic follow-up in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention on the treated segment was 85% in TEVAR patients at 10 years. TEVAR is a safe and effective procedure to treat thoracic aortic aneurysms with improved perioperative and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysm diameters initially decrease and then stabilize over time.

Thoracic Aortic Trauma: Outcomes and Hospital Resource Utilization after Endovascular and Open Repair

Thoracic endovascular aortic repair (TEVAR) has evolved as a treatment option for the management of thoracic aortic trauma as an alternative to open thoracic aortic repair (OTAR). Population-level outcomes are not known and were evaluated. Secondary data analysis of the 2005-2006 Nationwide Inpatient Sample data was performed, and 1,561 patients with thoracic aortic injury (mean age 44.8 +/- 18.8 years; men 77.2%) were identified. Of these, 510 underwent emergent surgical intervention: 240 OTAR (47%) and 270 TEVAR (53%). Males were more likely to undergo any surgery (77.2% vs 22.8%; p = .03). Hospital mortality after OTAR was greater compared to TEVAR (14.61% vs 7.43%; p = .009). OTAR patients were more likely to have pulmonary complications (37.8% vs 21.65; p < .0001) but were less likely to have stroke (2.1% vs 5.8%; p = .03) compared to TEVAR patients. After adjustment, OTAR patients remained more likely to die compared to TEVAR patients (OR 11.5; 95% CI 4.0-33.2). Hospital length of stay and hospital cost were significantly greater for OTAR than for TEVAR. An increase in patients with thoracic aortic injury undergoing repair was found (23.0% vs 40.3%; p < .0002). In trauma, TEVAR was associated with decreased hospital mortality, hospital use, and pulmonary complications but increased rates of stroke. Further implementation of TEVAR for management of thoracic aortic trauma may improve future outcomes and reduce hospital resource use.

Open Thoracic Aortic Repair for Dysphagia in Patients with Kommerell's Diverticulum and Right-Sided Aortic Arch with Aberrant Left Subclavian Artery

Kommerell's diverticulum of an aberrant left subclavian artery associated with a right-sided aortic arch is a rare congenital aortic anomaly. This communication reports two cases of this congenital anomaly leading to severe dysphagia. Both cases were successfully repaired with a staged open approach rather than an endovascular approach, which would not have addressed the presenting symptom of dysphagia.

Initial Results of a Thoracic Aortic Endovascular Program: Safer in High-Risk Patients

Results are presented from our single-institutional experience with thoracic endovascular aortic repair to confirm that it is safe in patients with significant comorbidities. A retrospective review of all patients undergoing endovascular or open thoracic aortic repair at our institution since 2002 was performed. Main outcome measures included clinical presentation, demographics, preoperative risk factors, operative details, and clinical outcomes. The endovascular group included 37 patients (22 males), whereas the open group included 19 patients (eight males). Eight patients per group were treated emergently for trauma or rupture (22% and 42%, respectively; p=0.11). Endovascular patients were significantly older with more comorbid conditions (p<0.05). However, the overall perioperative complication rate was similar in the two groups (32.4% and 31.6%, respectively). Postoperative renal failure occurred only in four open patients (21.1% vs. 0%, p < 0.05). Operative time, ventilator days, and total length of stay were also greater for open patients (p<0.05). There was one death in the endovascular group and three in the open group (2.7% and 15.8%, respectively; p=0.07). Endovascular patients had shorter operative time and length of stay, fewer ventilator days and intensive care unit days, and fewer transfusions. Although the endovascular patients were significantly older with more comorbidities, the complication rate was similar to the open group. Also, there was a trend toward lower mortality in the endovascular group (p=0.07). Endovascular repair is the procedure of choice for treating the descending thoracic aorta in high-risk patients even in the emergent setting.

Outcomes and survival in surgical treatment of the descending thoracic aorta with acute dissection

Conclusion: Open replacement of the descending thoracic aorta or thoracoabdominal aorta for acute type B dissection carries substantial morbidity and mortality rates. Summary: In a large majority of cases, acute type B aortic dissection is managed medically with a favorable outcome. Certainly, aortic rupture in the setting of acute type B dissection is an indication for emergency intervention. Some centers also used continued pain or a large diameter aortic dissection as an indication for urgent repair. In this article the authors describe the results of open urgent or emergency repair of the descending thoracic aorta or the thoracoabdominal aorta for acute dissection in 76 consecutive patients (72% male). The patients were acquired during a 16-year period from 1989 to 2004 and therefore represent a relatively small component of patients treated for thoracic dissection at this center during that time. The average age of the patients who underwent surgery for acute type B aortic dissection was 64.1 ± 12.2 years (range, 36-86 years), and 22% presented with rupture. A variety of surgical adjuncts were used without a specific protocol, including hypothermic circulatory arrest in eight patients and left carotid bypass in 15. Spinal fluid drainage was used in only five patients. Aortic clamp time was 38.4 ± 17.3 minutes. One patient died intraoperatively. The overall 30-day operative mortality was 22.4%. Paraplegia occurred in 6.6%, and hemodialysis was required in 19.7%, with about half of these patients requiring permanent hemodialysis. Cardiac complications occurred in 43.4%, and 10 patients had prolonged respirator dependence necessitating tracheostomy. The hospital stay was 26.0 ± 29.7 days. Rupture was not associated with an increased risk of operative mortality or perioperative complication. Comment: The article highlights why it is best to avoid an operation in acute type B dissections. Even in a center with acknowledged expertise in thoracic aortic surgery, mortality is high and morbidity is also very high. Because mortality and morbidity rates were the same for patients with and without rupture, it is important to reassess indications for emergency or urgent open thoracic aortic repair in patients with acute type B dissection. We need better natural history data to know whether continued pain predicts rupture or if a larger initial diameter of the dissection predicts actual rupture. One can also see this article as providing justification for endovascular repair of ruptured or severely symptomatic acute type B dissections. Given the results here, most centers are likely to do better with endovascular repair rather than open repair of an acute type B dissection.

Clinical competence statement on thoracic endovascular aortic repair (TEVAR)—multispecialty consensus recommendations: A Report of the SVS/SIR/SCAI/SVMB Writing Committee to Develop a Clinical Competence Standard for TEVAR

Clinical competence statement on thoracic endovascular aortic repair (TEVAR)—multispecialty consensus recommendations: A Report of the SVS/SIR/SCAI/SVMB Writing Committee to Develop a Clinical Competence Standard for TEVAR