Thoracic Aneurysm Research Articles

Gene Commonality in Arterial Circuits Throughout the Body.

The common genetic underpinnings of thoracic aortic aneurysms and aneurysms and dissections of several other major arterial circuits have been described in the literature. These include thoracic and abdominal aortic aneurysms, thoracic and intracranial aneurysms, thoracic aortic aneurysms, and spontaneous coronary artery dissections. In this study, we provide a unified report of these observations and investigate any genetic commonality between the above four arterial circulations.

Abstract 4138322: Do branched stent grafts for dissecting aortic aneurysms really improve long-term outcomes?

Backgrounds: We have previously used a handmade branched stent graft (SG) to treat thoracic aortic aneurysms. In this study, we examined the long-term results of treatment for dissecting thoracic aortic aneurysms. Methods: Between 2004 and 2014, we treated 28 patients with dissecting thoracic aneurysms using the branched SGs. Results: The mean age was 65 ± 14 years; 17 were over 70, and 22 were male. The mean time from the onset of dissection was 5.7 ± 6.3 years; 6 were operated within one year. The mean aneurysm diameter was 59 ± 8 mm. All dissecting aneurysms were located after zone 3. SG branches were one in 24 cases, two in 2, and three in 2. Twenty-two were treated for entry closure and distal landing in the true lumen. Six with limited dissecting aneurysms were treated for entry closure and distal landing in a non-dissected lumen. The cause of perioperative death was pneumonia in 1. The mean follow-up was 8.3 ± 5.3 years. Entry closure was achieved at 86%, branch patency was 94%, and aneurysm diameter was reduced by an average of 5 ± 14%. There were 6 aneurysm-related deaths. Two were aneurysm ruptures, and each of the 4 was additional operative death, sudden death, SMA occlusion, and type A dissection. The aneurysm-related mortality was 26% at eight years; there was no difference between under 70 and over 70 years old. The cumulative risk of additional procedures was 57% at eight years, and the risk was higher in those over 70 than those under 70 (p<0.05). Thirteen required additional procedures, and 5 required multiple. In detail, re-TEVAR to distal SINE was in 7, re-TEVAR for aneurysm enlargement due to residual false lumen was in 1, re-TEVAR for type 1a endoleak (EL) was in 4, open repair was in 3, stenting for stenosis of true lumen in iliac artery was in 1, stenting for SG branches were in 2, and embolization of the left subclavian artery after re-TEVAR was in 1. Details of open repair were partial arch and thoracic descending replacement for type 1a EL in 1, ascending and partial arch replacement for type 1a EL followed by partial arch and thoracoabdominal replacement in 1, partial arch and thoracoabdominal replacement for distal SINE and aneurysm enlargement in 1. Conclusion: The branched SG for dissecting thoracic aneurysms successfully achieved the initial goal of entry closure, which concept is promising, but requires careful observation for appropriate additional procedures.

Abstract 4137735: Chronic Oxidative Stress Induces Hypertension and Abdominal Aortic Aneurysm in Chemogenetic Mice Model

Background: Aortic aneurysms account for ~10,000 deaths annually in the USA. Oxidative stress is implicated in both abdominal (AAA) and thoracic (TAA) aneurysm formation, but the mechanisms are incompletely understood. We used a chemogenetic approach to modulate oxidative stress in the vascular wall by creating a transgenic mouse (DAAO-TG Tie2 ) that expresses yeast D-amino acid oxidase (DAAO) driven by the endothelial Tie2 promoter. DAAO generates the reactive oxygen species hydrogen peroxide from D-amino acids. Vascular tissues contain L-amino acids, so yeast DAAO is quiescent until DAAO-TG Tie2 mice are provided with D-amino acids. Here we characterize the cellular and molecular consequences of vascular oxidative stress in DAAO-TG Tie2 mice. Hypothesis: Chronic oxidative stress in the vascular wall causes arterial dysfunction. Aim: To characterize the phenotype of DAAO-TG Tie2 mice after oxidative stress induction in vascular endothelium. To identify the mechanisms whereby vascular oxidative stress causes arterial dysfunction and hypertension. Methods: Systolic blood pressure and aortic sonography were measured weekly in D-alanine-fed DAAO-TG Tie2 . Proteomic analyses were used to identify mechanistic targets, which were validated using biochemical and immunohistochemical methods. Results: D-alanine-fed DAAO-TG Tie2 mice develop systolic hypertension and abdominal but not thoracic aortic aneurysms; treated mice die in >3 months with burst abdominal aortic aneurysms. Transgene expression is similar in abdominal and thoracic endothelium. Levels of oxidative stress markers (oxidized proteins, lipid, and DNA) were similar in thoracic and abdominal aorta. Proteomic analyses established phenotypic switching in abdominal but not thoracic aorta, and also revealed activation of the oxidant-activated kinase ASK1 and of the MAP kinase cascade in abdominal but not thoracic aorta. Immunoblot analyses showed a marked decrease in JNK1 phosphorylation by phosphatase DUSP3 and an increase in vascular KLF4, leading to phenotypic switching of contractile to synthetic VSMCs. Conclusion: Chronic chemogenetic oxidative stress induces hypertension and abdominal aortic aneurysm formation caused by KLF4-dependent VSMC phenotypic switching.

Abstract 4118766: Lower Winter and Higher Summer Temperatures Increase the Risk of Hospitalization With Aortic Aneurysm or Aortic Dissection

Background: Seasonal variation in aortic dissection incidence are well-documented. This study utilized a high-resolution surface temperature model and state-specific administrative medical data to investigate the relationship between long-term exposure to winter and summer temperature averages and hospitalization rates for aortic aneurysm or dissection. Methods: Using data from the 2000-2016 State Inpatient Databases (SID), 265,795 hospitalizations with a principal diagnosis of aortic aneurysm or dissection for residents of 19 U.S. states were identified via ICD-9 and 10 codes. Daily surface temperature data, extracted from Oak Ridge National Laboratory’s Daymet weather model on a 1-km grid, were aggregated to zip codes to match SID's spatial resolution. Linear regressions, adjusted for demographics, comorbidities (including hypertension, hyperlipidemia, atherosclerosis, smoking, and genetic disorders), air pollution, and neighborhood socioeconomic status, estimated absolute changes in annual hospitalization rates associated with variations in winter and summer temperature averages. Nonlinear exposure-effect relationships were assessed using penalized cubic splines with at most nine degrees of freedom. Results: Each Celsius degree decrease in winter and increase in summer was associated with 19.0 (95% CI: 17.5, 20.8, p<0.001) and 10.4 (95% CI: 8.0, 12.7, p<0.001) additional hospitalizations per one million person-years, respectively. These statistically significant associations were consistent across subgroups, including thoracic vs. abdominal and aneurysm vs. dissection. Further analysis revealed that cooler-than-average winter temperatures consistently correlated with increased hospitalization rates for overall aortic aneurysms or dissections and their subtypes. Conclusion: Colder winter and hotter summer temperatures significantly increase the risk of hospitalization for aortic aneurysm or dissection. This emphasizes the importance of understanding how environmental factors contribute to aortic disease.

Genetically proxied liability to migraine and risk of intracranial aneurysm and subarachnoid hemorrhage.

Observational studies have reported inconsistent relationships between migraine and the risk of intracranial aneurysm and subarachnoid hemorrhage (SAH). To determine whether genetic liability to migraine is associated with risk of intracranial aneurysm and aneurysmal SAH. This study was designed as a two-sample Mendelian randomization (MR) analysis. Genetic associations with migraine were obtained from a large-scale meta-analysis of five population and clinic-based genome-wide association studies of migraine (102,084 cases and 771,257 controls of European ancestry). Genetic associations with intracranial aneurysm and SAH were obtained from a meta-analysis of 22 population-based genome-wide association studies (7495 cases and 71,934 controls of European ancestry). Findings were corroborated by sensitivity analyses and replicated in an independent sample of combined cases of intracranial aneurysm and SAH (3529 cases and 234,948 controls of Asian ancestry from the Biobank Japan and China Kadoorie Biobanks). In secondary analyses, we investigated the outcomes of extracranial aneurysm in the FinnGen and UK Biobank cohorts (up to 7466 combined cases of thoracic and abdominal aortic aneurysm). Genetic liability to migraine was associated with increased risk of the combined outcome of unruptured intracranial aneurysm and SAH (odds ratio [OR] of outcome per doubling in migraine liability 1.19, 95% confidence interval [CI] 1.06-1.35; p = 0.005). This finding was replicated in an independent sample (OR 1.15, 95% CI 1.02-1.30; p = 0.027), and there were similar associations across the component outcomes of unruptured intracranial aneurysm (OR 1.20, 95% CI 1.01-1.42; p = 0.035) and SAH (OR 1.18, 95% 1.04-1.33; p = 0.008). These findings were consistent in sensitivity analyses robust to violations of the MR assumptions. In reverse MR analyses, genetic liability to intracranial aneurysm was not associated with migraine (OR 1.03, 95% CI 0.99-1.07; p = 0.141). In a secondary analysis, there were similar associations of genetic liability to migraine with all forms of aortic aneurysm (OR for combined thoracic and aortic aneurysm 1.18, 95% CI 1.10-1.27; p = 8.49 × 10-6). Genetic liability to migraine was associated with increased risk of intracranial and extracranial aneurysms, supporting a causal relationship between liability to migraine and these traits. Further work is needed to identify the biological mechanisms and clinical relevance of these findings.

Mapping 18F-FDG PET uptake in the aortic wall and thrombus

Abstract Background Positron Emission Tomography (PET) uptake allows for the assessment of molecular activity, being 18F-FDG uptake indicative of glucose metabolism. PET uptake is commonly quantified manually by drawing regions of interest, which is subjective, poorly-reproducible and may miss relevant information. Purpose To develop and test an image analysis method to quantify and map 18F-FDG uptake on the whole aortic wall and thrombus. Methods PET-MRI was acquired in patients with thoracic or abdominal aortic aneurysms. The aorta was semi-automatically segmented in the MR angiography using 3DSlicer, generating a surface mesh that was expanded by 3 mm inward and outward. PET uptake was interpolated over this volume with a uniform spatial resolution of 1 mm. By means of 9 reference points, the aortic wall was discretized into 52 (thoracic) or 80 (thoraco-abdominal) standardized regions (i.e. wall patches). For each aortic patch and for the whole thrombus volume, the target to background Ratio (TBR) was calculated by dividing the uptake by a reference uptake in the left atrium. Two observers segmented the aorta and thrombus, located the anatomical reference points and quantified TBR. Inter-observer agreement for segmentation and aortic wall discretization was evaluated in terms of the 95% Hausdorff Distance (HD) and Dice Score Coefficient (DSC), while both median and 95% TBR in each region were tested via intra-class correlation coefficient (absolute value, single measure). Results Data from 20 patients with thoracic or abdominal aneurysms were analysed, 10 of them presented thrombus. The reproducibility of the segmentation of the aorta (median HD 3.16 IQR [2.42 - 3.94] mm, DSC 0.90 [0.89 - 0.92]) and of the thrombus (HD 4.87 [3.51 - 8.45] mm, DSC 0.85 [0.80 - 0.87]) were excellent. The inter-observer agreement in the localization of reference points was good (HD 5.10 [3.29 - 8.73] mm), resulting in excellent overlapping of the standardized aortic wall patches (HD 3.80 [2.44 - 5.08] mm). Inter-observer agreement of median and 95% TBR in each aortic patch were excellent (ICC of 0.90 and 0.93, respectively, Figure 1), with minimal bias (Figure 2). Similarly, excellent interobserver reproducibility was observed for median and 95% TBR in the thrombus (ICC of 0.97 and 0.96, respectively, Figure 2). Conclusions A robust and reproducible image analysis method to map PET uptake along the aortic wall was developed, extending the possibilities to study aortic diseases molecular activity and its association with local aortic characteristics.

Increased risk for thoracic and abdominal aortic aneurysm in the relatives of abdominal aorta aneurysm patients

Abstract Introduction Genetic susceptibilities in aneurysm genes are risk factors for developing aneurysms of the aorta. This translates to a high aneurysm prevalence in relatives of aortic aneurysm patients. For relatives of abdominal aorta aneurysm (AAA) patients, guidelines recommend abdominal ultrasound screening for early detection and management, while for relatives of thoracic aorta aneurysm patients (TAA), transthoracic ultrasound of the ascending aorta and aortic root is recommended. Neither of these guidelines are designed to detect aneurysms in the whole aorta. The incidence of TAA in relatives of AAA index-patients is unknown and may determine whether abdominal ultrasound screening is sufficient for relatives of AAA patients or whether whole aorta screening should be recommended. Furthermore, focused screening of high risk relatives of aneurysm patients may improve the yield of aneurysm detection now that population frequencies are declining. Methods Whole aorta non-contrast CTs of relatives of AAA index-patients were collected retrospectively in a tertiary referral (2016 to 2021). Family history and DNA testing of AAA index-patients were used to classify relatives into high genetic risk (familial disease and/or pathogenic/likely pathogenic variant (P/LP) in an aneurysm gene) or unknown genetic risk (no familial disease or no P/LP detected). TAA were defined as ascending diameters ≥ 45mm or descending diameters ≥ 40mm. Thoracic aortic dilatations (TAD) were defined as ascending diameters of 40-45 mm or descending diameters of 35-40 mm. Abdominal diameters ≥30mm were classified as AAA and diameters between 25-29 mm as abdominal dilatations (AAD). References 1-3. Results CT scans (n=301 relatives, 47% male, age 58(50-65)) showed 34% aortic aneurysms and/or dilatations versus 14% in the general population (age adjusted, p<0.001). TAA was 28-times more frequent (2%, p<0001) and AAA 3 times more frequent (8%, p<0.001) than in the general population. Thoracic and abdominal dilatations occurred in 18% and 17% of relatives. Overall, males were 4 times more likely to have an aneurysm than females (p<0.05). Aneurysms and dilatations occurred at the same rate in relatives with or without a family history or a P/LP in an aneurysm gene. These results endorse total aorta screening for relatives of all AAA patients rather than restricting screening to the abdominal aorta. Conclusions Relatives of AAA patients had a high risk for thoracic and abdominal aneurysms as well as dilatations. This indicates that imaging of the whole aorta will improve early detection of aortic aneurysms in relatives both with and without a family history of aneurysms.

Conservative Management of mild symptomatic descending thoracic aneurysm – A case report with 1year follow-up

Background: The thoracic aorta is made up of the ascending, descending, aortic arch, and aortic root. An aneurysm forms when the artery's usual diameter increases by fifty percent. Thoracic aneurysms affect 10 of every 100,000 elderly adults and are less common than their abdominal counterparts. Patients with thoracic aortic aneurysms (TAAs) rarely experience symptoms, and 95% of TAA patients are asymptomatic. Case history: A 47-year-old male patient who had a medical history of hypertension, dyslipidemia, and smoking. During the first visit, the patient presented with two months of dull back pain. The patient's blood pressure was 180/110 mm of Hg. Our initial assessment involved taking an X-ray and an echocardiography of the patient's chest. The data from his echocardiography and chest reveals that he has a thoracic aneurysm. After a confirmatory CT scan, the diagnosis of thoracic aortic aneurysm was made. Conclusion: In our case report, conservative method was successful in the management of a mild symptomatic descending thoracic aorta aneurysm. However, the size, growth pace, and underlying cause of an aortic aneurysm might all affect whether doctors recommend surgery to repair it. If an aneurysm ruptures or dissects, immediate surgery may be required. J Shaheed Suhrawardy Med Coll 2023; 15(1): 87-90

Women Experience Higher Rates of Mortality Following Thoracic Endovascular Aneurysm Repair

ObjectivesThoracic endovascular aortic repair (TEVAR) and complex endovascular thoraco-abdominal aneurysm repair (cEVAR) has been increasingly adopted in the treatment of thoracic and thoracoabdominal aorta aneurysms, offering a less invasive approach for patients with appropriate anatomy. Women usually present with smaller aortic diameter. However, they usually have greater aneurysm growth rates. How sex can affect postoperative and short-term outcomes after TEVAR is not well reported. The aim of this study was to assess outcomes in female versus male patients undergoing TEVAR for treatment of thoracic and thoracoabdominal aneurysms in a Medicare-linked database. MethodsWe retrospectively reviewed patients undergoing TEVAR for thoracic and thoracoabdominal aneurysm repair in the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database from 2003 to 2018. Patients were divided into males and females. Patients presented with ruptured aneurysm were excluded from the analysis. Postoperative outcomes included in-hospital stroke, myocardial infarction (MI), spinal cord ischemia, and 30-day mortality. One-year outcomes included mortality, aneurysmal rupture, and reintervention. Postoperative outcomes were assessed using multivariable logistic regression analysis and one-year outcomes were evaluated using Kaplan Meier Survival and Cox regression analyses. ResultsA total of 3,058 males and 1,843 females were available for the analysis. Female patients had smaller median aortic diameter, were more likely to be black, with chronic obstructive pulmonary disease, and chronic kidney disease, and to be symptomatic on presentation. Male patients were more likely to be on preoperative medications such as aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, P2Y12 antagonists, and anticoagulants. After adjusting for potential confounders, female gender was associated with double the risk of in-hospital stroke (OR: 2.3, 95%CI ((1.5-3.7), P<0.001) and 80% increase in 30-day mortality (OR: 1.8, 95%CI (1.3-2.6), P=0.001). At one year, female gender was associated with a higher risk of mortality (HR: 1.2, 95%CI (1.05-1.4), P=0.011). There was a trend towards higher risk of reintervention (HR: 1.2, 95%CI (0.97-1.6), P=0.079). ConclusionsMortality after TEVAR seems to be higher in female patients at 30 days and up to one year of follow-up. Female patients also face a two times higher risk of in-hospital stroke. Future studies with a larger female population should aim to identify and potentially ameliorate the factors associated with these unfavorable outcomes in females.

Aortic Aneurysm with and without Dissection and Concomitant Atherosclerosis-Differences in a Retrospective Study.

Thoracic aortic aneurysm is a latent disease with a high risk of death. Today, as data are accumulating, an estimation of the differences in thoracic aneurysm in men and women of different age groups is required. The present study evaluated the type of atherosclerotic aortic lesions in males and females at different ages regarding the presence or absence of aortic dissection. A retrospective analysis of clinical and morphological data of 43 patients with thoracic aortic aneurysm was carried out. Patients were divided into groups based on the presence or absence of thoracic aneurysm dissection. Our results of a comparative analysis of the age of study participants showed that patients with aneurysm dissection were younger than patients without dissection. In the subgroup of patients with aortic dissection, the mean age was 50.6 years old, and in patients without aortic dissection, the mean age was 55.0 years old. When conducting a frequency analysis using Fisher's exact test, it was found that in men and women aneurysm dissection was not associated with atherosclerotic lesions of the aorta. In women and men, aneurysm dissection was not associated with stage of atherosclerotic lesions of the aorta regardless of age; no statistically significant differences were found between the groups with and without aneurysm dissection (p > 0.05). Dissection of the thoracic aneurysm developed in the absence of severe atherosclerosis of the thoracic aorta. Only 18.6% men and women possessed atherosclerotic plaques of types IV and V.

Whole aorta imaging shows increased risk for thoracic aortic aneurysms and dilatations in relatives of abdominal aortic aneurysm patients

ObjectiveFor relatives of abdominal aortic aneurysm (AAA) patients, guidelines recommend abdominal imaging aimed at early detection and management of AAA, and do not include screening for thoracic aortic aneurysms (TAA). We aimed to investigate if TAA occur in undiagnosed relatives of AAA patients without a known genetic susceptibility for aneurysms, similar to families with identified genetic susceptibilities for aneurysms like in Marfan and Loeys-Dietz syndrome, where both AAA and TAA occur. MethodsRelatives of AAA patients were invited for non-contrast whole aorta CT screening. Systematic measurements of the CT scans were used to detect aneurysms and dilatations. Classification into familial and non-familial was based on reported family histories. In addition, aneurysm gene panel testing of AAA index cases was used for the classification of high vs unknown genetic risk (high genetic risk: familial aneurysm or a (likely) pathogenic variant (P/LP) in an aneurysm gene; unknown genetic risk: no family history or P/LP). ResultsWhole aorta imaging of 301 relatives of 115 abdominal aortic aneurysm index-patients with non-contrast CT scans showed a 28-fold increase in thoracic aortic aneurysms in relatives (1.7%, p<0.001 versus the age adjusted population) and a high frequency of thoracic dilatations in 18% of the relatives. Thoracic aneurysms and dilatations in relatives occurred even when index patients were unaware of familial aneurysms. AAA was increased in the relatives compared to the age adjusted population (8%, p<0.001). ConclusionsAn increased risk for thoracic aneurysms and dilatations was detected by whole aorta imaging of relatives of AAA index patients, even when index patients were unaware of familial aneurysms.These results indicate -still unknown- shared genetic susceptibilities for thoracic and abdominal aneurysms. Therefore, imaging of the whole aorta of relatives of all abdominal aneurysm patients, will improve early detection of aortic aneurysms in relatives of all AAA patients.

Open aneurysmorraphy following branched and fenestrated endovascular repair of complex thoracic aneurysms

ObjectiveWe present a review of our hybrid management (endovascular + open surgery) of large thoracic aortic aneurysms (>80 mm). The strategy comprises a primary endovascular repair using thoracic endovascular aortic repair (TEVAR), and/or fenestrated and branched endografts (FBEVAR), followed by open thoracotomy and aneurysmorraphy, specifically without the need for aortic cross-clamping. MethodsWe performed a retrospective review of all patients who had undergone aneurysmorraphy via thoracotomy following TEVAR and FBEVAR in two high-volume aortic centers between December 2017 and March 2024. We performed aneurysmorraphy in two clinical situations: (1) in the setting of a planned staged treatment, shortly after TEVAR or FBEVAR in young patients with aneurysm diameter >100 mm; and (2) as a secondary intervention during follow-up for patients with persistent sac enlargement and aneurysm diameters >80 mm. The primary end points were 30-day survival and aneurysm-related mortality during follow-up. Secondary endpoints were sac size evolution, perioperative and postoperative complications, freedom from further reintervention, and late aortic complications. ResultsTwelve patients underwent aneurysmorraphy following TEVAR and/or FBEVAR during the study period. Mean patient age was 60 ± 12 years, and the mean sac diameter before thoracotomy was 101 ± 25 mm. Endovascular embolization of intercostal arteries prior to aneurysmorraphy was performed in four patients. The 30-day survival rate was 100%. During the mean follow up period of 21 months, two patients died—one of COVID and another of intra-cerebral hemorrhage. No aneurysm-related mortality occurred, and sac regression was achieved in all patients except one experiencing aortic growth below the aneurysmorraphy. ConclusionsThis study demonstrates that thoracic aneurysmorraphy performed after TEVAR and FBEVAR for complex thoracic aneurysms is a safe and effective technique. This procedure allows the eradication of endoleaks and an immediate sac volume reduction, which prevents aorta-bronchial or esophageal fistulation and secures the endovascular repair; the reduction of the aneurysm mass effect restores normal lung parenchyma expansion. This hybrid management strategy drastically reduces the morbidity associated with standard open surgery performed for thoracic endograft explantation.

ID: 334000 Treatment of Post Thoracotomy Pain in a Patient with T6 Paraplegia after Thoracic Aneurysm Repair

ID: 334000 Treatment of Post Thoracotomy Pain in a Patient with T6 Paraplegia after Thoracic Aneurysm Repair

469 - Pre and postnatal imaging of thoracic aneurysm: the Case of a delicate balance between maternal and child health outcomes for a personalized care

469 - Pre and postnatal imaging of thoracic aneurysm: the Case of a delicate balance between maternal and child health outcomes for a personalized care

Thoracic Endovascular Aortic Repair and Endovascular Aneurysm Repair Approaches for Managing Aortic Pathologies: A Retrospective Cohort Study.

Background/Objectives: Since thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR) are increasingly utilized, examining their outcomes and safety in real-world scenarios is crucial. This study investigated the management and outcomes of TEVAR and EVAR as alternatives to traditional open surgical repair for managing aortic pathologies. Methods: This was a retrospective cohort study. We analyzed the data from 59 consecutive patients who underwent TEVAR or EVAR between 2015 and 2022 at a single tertiary care center. The primary outcome was survival, and secondary outcomes were complications assessment, including re-intervention and occurrence of endoleaks. Results: TEVAR accounted for 47.5% of cases (n = 28), while EVAR comprised 52.5% (n = 31). Patients were mostly 61-70 years old (23.7%) and male (91.5%). Surgery indications differed, with aneurysmal repair being the prevalent indication for EVAR (90.3%, n = 28) and trauma being the main indication for TEVAR (67.9%, n = 19). Regarding the primary outcome, 11 patients (18.6%) died for various reasons; of those, 2 patients (3.4%) were determined to have died from vascular-related issues. Most patients (81.4%, n = 48) did not experience intraoperative complications. The most common intraoperative complications were endoleaks and access failure, each affecting 5.1% (n = 3) of patients. Re-intervention was necessary in 16.9% (n = 10) of cases, with endoleaks being the major indication (60%). Emergency intervention was more frequent in the TEVAR group (p = 0.013), resulting in significantly longer hospitalization (p = 0.012). Conclusions: Despite limitations, our analysis indicates a good safety profile with high success rates and a low incidence of adverse health outcomes and mortality in TEVAR/EVAR procedures. Nevertheless, the results emphasize the ongoing concern of endograft leaks, necessitating re-interventions.

Preliminary experience of the isolate left subclavian artery in-situ fenestration during 'zone 2' thoracic endovascular aortic repair.

To evaluate the results of isolated left subclavian artery in-situ fenestration (ISF) during 'zone 2' thoracic endovascular aortic repair (TEVAR) using a new adjustable needle puncturing device system. It is a multicentre, retrospective, physician-initiated cohort study of patients treated from 28 July 2021 to 3 April 2024. Inclusion criteria were isolate left subclavian artery revascularization for elective or urgent/emergent 'zone 2' TEVAR. The primary outcome was technical success and freedom from ISF TEVAR-related reintervention or endoleak. We treated 50 patients: 28 (56.0%) atherosclerotic thoracic aneurysms, 12 (24.0%) type B aortic dissection and 10 (20.0%) penetrating aortic ulcers. Elective intervention was carried out in 46 (92.0%) cases. ISF was successful in all cases, with a procedural primary technical success in 47 (94.0%) cases. The median time of intervention was 184 min (interquartile range 135-220) with a median fenestration time of 20 min (interquartile range 13-35). Operative mortality did not occur. We observed 1 case of spinal cord ischaemia and 2 cases of bilateral posterior non-disabling stroke. Mortality at 30 days occurred in 1 (2.0%) patient (not aorta-related). The median follow-up was 4 months (interquartile range 1-12.25). Bridging stent graft patency was 100% with no ISF-related endoleak. ISF-related reintervention was never required. ISF TEVAR using the Ankura™-II device with the self-centring adjustable needle system showed high technical success, promising stability and stable aortic-related outcomes. Owing to these results, it represents a safe and effective alternative for standard 'zone 2' TEVAR.

Surgical management of giant cell arteritis of the proximal aorta

ObjectiveGiant cell arteritis (GCA) may present as proximal aortic pathology requiring surgical intervention. We present our experience with surgical management of GCA in patients presenting with proximal aortic disease. MethodsFrom January 1993 to May 2020, 184 adult patients were diagnosed with GCA on histopathology after undergoing cardiac surgery. Survival was estimated with Kaplan-Meier method. Reoperation rates were estimated with cumulative incidence accounting for competing risks of death. ResultsThe most common indication for surgery was ascending aortic aneurysm (n = 179, 97.3%). Stroke occurred in 6 (3.3%), pneumonia in 8 (4.4%), and dialysis in 3 (1.6%) patients. Multivariable analysis found advanced age (hazard ratio [HR], 1.054; 95% confidence interval [CI], 1.026-1.082, P < .001), recent heart failure (HR, 1.890; 95% CI, 1.016-3.516, P = .04), peripheral vascular disease (HR, 2.229; 95% CI, 1.458-3.624, P < .001), and cerebrovascular disease (HR, 1.762; 95% CI, 1.035-3.000, P = .03) as predictors of late mortality. Median follow-up was 13.7 years, and 30-day mortality was 1.5%. Nineteen patients underwent 24 aortic reinterventions including aortic arch reconstruction (n = 4), descending thoracic aorta aneurysm repair (n = 8), thoracoabdominal aortic aneurysm repair (n = 11), and pseudoaneurysm repair (n = 1). Rate of reintervention on the aorta was 3.9% (95% CI, 1.9%-8.1%), 7.1% (95% CI, 4.1%-12.3%), 12.8% (95% CI, 8.3%-19.6%), and 12.8% (95% CI, 8.3%-19.6%) at 1, 5, 10, and 15 years, respectively. ConclusionsSurgery in patients with GCA can be performed with acceptable early and late outcomes. Advancing age, heart failure, peripheral vascular disease, and cerebrovascular disease are risk factors for worse survival. Postoperative surveillance is important as need for aortic reintervention is not uncommon.

Optimal size of Frozenix for true thoracic aneurysms: is downsizing an option?

During total arch replacement (TAR) using frozen elephant trunk (FET) technique with Frozenix for true thoracic aortic aneurysm (tTAA), oversized FET tends to be chosen similar to the endovascular devise selection. However, the oversized FET is considered a risk factor for intimal injury. The appropriate size selection of FET remains insufficiently understood. Between October 2014 and March 2022, a total of 49 patients underwent TAR using Frozenix for tTAA. Out of 49 patients, four patients planned to staged surgery were excluded, 19 patients were operated on with an undersized Frozenix compared with the descending aorta (undersized FET group) and in 26 patients an equal or oversized Frozenix was used (oversized FET group). Clinical outcomes and postoperative diameter changes were investigated. In-hospital mortality was 0%. The mean diameter of Frozenix and the descending aorta was 30.7mm and 28.8mm, respectively, in the oversized FET group, and 26.7mm and 30.1mm in the undersized FET group. Postoperative computed tomography (CT) demonstrated no endoleaks not only in the oversized FET group but also in the undersized FET group. CT also revealed that undersized FET had expanded more than the original diameter in all cases except for two, with an average of 2.47 ± 1.53mm. Additionally, the descending aorta covered with Frozenix shrank in 10 patients (53%). Postoperative adverse aortic events were not observed. Undersized Frozenix tightly fit the descending aorta and resulted in complete sealing without endoleaks. Oversized FET is not strictly necessary considering the size-related adverse complications.

366. MINIMALLY INVASIVE MANAGEMENT OF AORTO-OESOPHAGEAL FISTULA: THORACIC ENDOVASCULAR AORTIC REPAIR AND THORACOSCOPIC ASSISTED OESOPHAGECTOMY WITH DELAYED GASTRIC CONDUIT RECONSTRUCTION

Abstract Background Development of aorto-oesophageal fistula (AOF) within the context of thoracic aortic aneurysm is rare and carries a high mortality rate. Here we present two cases detailing the successful management of AOF. Methods A 58 year old male presented with haematemesis. CT angiogram demonstrated fistulation between a mycotic aneurysmal thoracic aorta and the oesophagus. He underwent Thoracic Endovascular Aneurysm Repair (TEVAR). This was followed by thoracoscopic assisted oesophagectomy (TAO) and delayed gastric conduit reconstruction. A 49 year old female presented with massive haematemesis. CT angiogram demonstrated a calcified thoracic aneurysmal sac. This was managed with TEVAR. Subsequent investigations revealed mediastinitis, stent graft infection and AOF. This was managed with TAO and delayed gastric conduit reconstruction. Results Gastric conduit reconstruction achieved an excellent functional result in both patients. Ongoing Aortic CT surveillance has revealed satisfactory appearances with no current plans for further vascular intervention. Both patients have returned to full employment. Conclusions TEVAR should be used as the initial bridging intervention to stabilise haemodynamically unstable patients with AOF. Subsequent oesophageal resection can be safely performed using a minimally invasive approach with subsequent retro-sternal reconstruction using a gastric conduit. CT follow up demonstrate no ongoing issues with the implanted aortic stents

768. ENDOSCOPIC MANAGEMENT OF COMPLEX THORACIC AORTA ANEURYSMAL SAC AND ENDOGRAFT INFECTION ASSOCIATED WITH AORTOESOPHAGEAL FISTULA

Abstract Background Aortoesophageal fistula (AEF) is a rare but life-threatening condition. Secondary AEF is a complex pathology occurring after thoracic aorta surgery with prosthetic graft, with an incidence of 1.6%. However, this is likely to rise with the increasing number of thoracic endovascular aortic repair (TEVAR) being performed. Management of secondary AEF is more challenging due to presence of adhesions in the pleural space, co-existing endograft infection and poor physiology of this group of patients. Definitive surgery carries high mortality rate and not all patients are suitable candidates. We review a case of secondary AEF with thoracic endograft infection managed non-operatively. Methods Our patient is a 70 years old man with a background of Stanford type A aortic dissection managed with ascending aorta and hemi-arch replacement with Dacron graft. Six years later, he had frozen elephant trunk reconstruction due to aneurysmal dilatation. Three months later, he underwent TEVAR for descending thoracic aorta aneurysm. Post-operation, he was diagnosed with Flavonifractor plautii bactaeremia secondary to infected aneurysmal sac and aortic stent graft and was initiated on antimicrobial therapy. During this time patient also developed recurrent episodes of haemoptysis. Bronchoscopy excluded an aortobronchial fistula and Oesophago-gastro-duodenoscopy (OGD) confirmed AEF at 25 cm from incisors. Results After discussion with a multidisciplinary team and patient, endoscopic management was chosen over surgery. Initial endoscopic closure of AEF with over-the-scope-clip appeared satisfactory but repeat OGD showed recurrence of new AEF which was partially closed with clips. Repeat imaging showed worsening mediastinal infection with larger gas-containing cavity. OGD was repeated with contrast demonstrating fistulous connection between the oesophagus and aneurysmal sac. A 7-French 4 cm double pigtail (DPT) stent was deployed into the sac under fluoroscopy to allow for trans-oesophageal drainage. Repeat imaging showed improvement in infection (Figure 1). Patient underwent endoscopic exchange of DPT stent 2 months after the initial insertion. Conclusion Definitive surgery for secondary AEF includes drainage of infection, explantation of infected endograft and aortic and oesophageal reconstruction. Oesophagectomy is preferred over primary repair of oesophageal defect. Not all patients will be suitable candidates for radical surgery and a non-operative approach may be required. Our patient likely has dense pleural and mediastinal adhesions from previous surgeries and thus, repeat surgery will be more challenging with increased risk of complications. However, if his mediastinal infection fails to resolve despite a period of DPT stent drainage, definitive surgery involving McKeown minimally invasive oesophagectomy with substernal gastric pull up would be required. Figure 1: Image A shows a large cavity with air and coalescent locules (arrow) prior to insertion of DPT stent. Image B shows a collapsed cavity (arrow) after DPT stent insertion.