Thoracic Aneurysm Research Articles

Uncomplicated type A intramural hematoma with extension to the descending thoracic aorta is best treated by thoracic endovascular aneurysm repair in most patients.

Uncomplicated type A intramural hematoma with extension to the descending thoracic aorta is best treated by thoracic endovascular aneurysm repair in most patients.

Parallel grafts and physician modified endografts for endovascular repair of the aortic arch.

Aortic arch aneurysms are a challenging clinical problem especially in high-risk patients. Open aortic arch replacement, even in the best of centers, carries significant risk of stroke or death in this high-risk population. Many high-risk patients are deemed inoperable and not offered repair. Branched and fenestrated thoracic endografts are currently undergoing clinical trials in the United States but are not yet commercially available. Many elderly and frail patients have significant brachiocephalic occlusive disease or anatomy excluding them for consideration for such clinical trials. These patients also present with acute aortic syndromes requiring urgent or emergent repair and are unable to participate in clinical trials due to the time required to have such devices available. Alternative endovascular therapies, including parallel stent grafts (including Chimneys, Snorkels and Periscopes) and physician modified thoracic endografts, have been used to treat such high-risk patients combined with commercially available thoracic endovascular aneurysm repair (TEVAR) devices. This paper aims to review the techniques and current reported outcomes from parallel stent grafts and physician modified devices used to treat high risk patients undergoing repair for aortic arch pathologies.

Single Stem Visceral Debranching for Complex Aortic Disease

ObjectiveThe treatment of complex aortic disease has been described with various retrograde visceral bypass techniques. An original technique with a single stem retrograde visceral graft (SSRVG) is presented.MethodsThis was a single centre retrospective study including 16 patients between 2015 and 2019. Patients were treated for aortic dissection (AD; type A and acute or chronic type B), thoraco-abdominal aortic aneurysms (TAAAs), and visceral occlusive disease. Surgery consisted of visceral vessel debranching from the native infrarenal aorta or from an aortic graft. In the case of AD, surgical fenestration was performed. Additional thoracic endovascular aneurysm repair (TEVAR) completed the treatment when indicated, during the same procedure or later. Patient outcomes and reconstruction patency were studied.ResultsThe mean patient age was 64 years (median 68 ± 12.6). Ten (62%) patients were treated for AD, three (19%) for TAAA, and three (19%) for occlusive disease. Sixty-nine target vessels were debranched with this SSRVG technique. Aortic surgical fenestration was performed in eight cases and TEVAR in four. During their hospital stay, three (19%) TAAA patients died, seven cases of renal insufficiency (44%), four cases of pneumonia (25%), and three colonic ischaemia cases (19%) were noted. After a mean follow up of 21 months, no other deaths occurred. All vessels (except two inferior mesenteric arteries) were patent and no endoleak was noted.ConclusionThe SSRVG technique can be offered in various complex aortic diseases. The use of a single graft is feasible and reduces the volume of multiple branch assembly in the retroperitoneal space. The observed patency rate is high.

Selection of the Approach Route on TEVAR Based on Abdominal Aortic 3D-CT in Patient with an Infected Thoracic Aneurysm with Porcelain Aorta

Selection of the Approach Route on TEVAR Based on Abdominal Aortic 3D-CT in Patient with an Infected Thoracic Aneurysm with Porcelain Aorta

Total Aortic Arch Replacements With a 4 Branched Frozen Elephant Trunk (FET) Graft in Acute Aortic Dissection (DeBakey type I)

Total Aortic Arch Replacements With a 4 Branched Frozen Elephant Trunk (FET) Graft in Acute Aortic Dissection (DeBakey type I)

Endoleak outcomes with different stent-graft generations in a 25-years thoracic endovascular aortic repair experience.

To compare endoleak outcomes after thoracic endovascular aneurysm repair (TEVAR) with different stent-graft generations into long-term follow-up. retrospective, observational, and single-center cohort study. TEVAR procedures performed between November 1995 and December 2020 were analyzed. The primary endpoint of this study was the freedom from endoleak (type I/III) in four stent-graft generations during the follow-up period. The first generation (GEN1) included: Vanguard; AneuRx and Talent; Stentor; Excluder; Endologix; EndoFit. The second generation (GEN2) included: TAG and TX. The third (GEN3) included: Relay Plus; Valiant Captivia; Zenith Alpha and custom-made. The fourth (GEN4) included: Relay Pro; Conformable C-TAG; Navion; E-Vita; Najuta; Nexus; standard and custom-made thoraco-abdominal devices. Nonaortic and aorta-related survival was considered as secondary outcome. A total of 509 TEVAR were included with a 44.3 ± 42.5months mean follow-up. Freedom from endoleak at 5years was 65.6%, 61.4%, 76.2%, and 69.1% for GEN1, GEN2, GEN3, and GEN4, respectively (p = 0.368). The first two generations demonstrated a higher endoleak rate when compared with the two most recent ones (27.2 vs 18.2%, respectively; p = 0.043). GEN1 was an independent risk factor (p = 0.014) and GEN4 was an independent protective factor (p = 0.001) for endoleak. GEN1 was found to be a risk factor for type-Ia endoleak (p = 0.059). GEN4 demonstrated a protective association regarding type-Ib endoleak (p = 0.012). Overall survival was 75.3%, 44.4%, 27.2%, and 17.6% at 1, 5, 10, and 15years, respectively. Survival distinguished as non-related versus aortic-related was 86.7% vs 23.5%, 52.7% vs 9.8%, 32.9% vs 2.0%, 21.2% vs 0% at 1, 5, 10, and 15years, respectively (p< 0.000). Endoleak occurred in a non-negligible percentage of TEVAR patients. A significant reduction of endoleak incidence over evolving stent-grafts generations was registered. Newer stent-graft generations demonstrated better long-term endoleak. Data about long-term outcomes require ongoing updates to prove both the reliability and the durability of newer stent-graft generations.

Efficiency of hybrid surgical treatment of the aortic arch and descending thoracic aorta aneurysm

OBJECTIVE. Assessment of the mid-term results after various types of debranching in hybrid surgery of the aortic arch and descending thoracic aorta.METHODS AND MATERIALS. 47 patients with various pathologies of the aortic arch and descending thoracic aorta were operated on. Six of them suffered from type IIIa dissection and 26 from type IIIb dissection according to DeBakey classification, 15 patients had true aortic aneurysms. The following interventions were performed: total aortic arch debranching (n=5), cross subclavian-subclavian-left-common carotid (n=14) or cross carotid-carotid-subclavian bypass (n=7); subclavian-carotid transposition or bypass (n=12); Chimney technique for the aortic arch aneurysm (n=8); in situ fenestration of the endoprosthesis (n=1). Elective surgery was performed in 32 patients, emergency in 15.RESULTS. Technical success achieved in 100 %. The overall hospital mortality rate was 10.6 % (n=5), elective surgery mortality rate was 9.3 % (n=3), in emergency cases - 13.3 % (n=2). Causes of mortality: stroke (n=1), multiple organ failure after prosthetic ascending aorta due to retrograde dissection after stent graft implantation (n=1), pneumonia (n=1), acute myocardial infarction (n=1), profuse bleeding (n=1). Cumulative survival rate was 87.5 % over 5 years, freedom from reinterventions - 89.1 %. During the first year of observation, 3 patients underwent stent graft replacement of the descending thoracic aorta due to formation of a dissection below the primary stent graft (n=1), open prosthesis of the ascending aorta due to it retrograde dissection (n=1), endofixation of the stent graft with embolization of the false lumen (n=1).CONCLUSION. Hybrid surgery on the aortic arch and the descending thoracic aorta is safe and effective treatment. Regular follow-up and timely treatment of complications in the long term after hybrid or endovascular interventions are necessary to improve long-term results.

Early Result of TEVAR for Thoracic Aortic Aneurysm: An Experience in Ramathibodi Hospital

Background: Traditional treatment of patients with thoracic aortic aneurysms is open surgical graft replacement. At present, thoracic endovascular aortic repair (TEVAR) is an alternative option for treat patients who have high surgical risk. The authors retrospectively reviewed result of TEVAR in patients diagnosed with thoracic aortic aneurysm in Ramathibodi Hospital in 5 years, especially mortality, postoperative morbidity. Objective: To evaluate a results of TEVAR for thoracic aortic aneurysm and to identify post-operative complication. Material and Methods: The authors reviewed data from patients who were diagnosed with thoracic aortic aneurysm and underwent TEVAR procedure at Ramathibodi Hospital from 1 January 2014 to 31 December 2018. Baseline characteristics and post procedural imaging were collected and analyzed. Univariate analysis was used to identify risks associated with endoleak. Survival and reintervention rate were estimated using Kaplan-Meier methodology and between groups comparison was analyzed using the log rank test. Results: Total 33 patients were included in the analysis, with a mean age of 68.57 years. There were 7 patients with endo leak (21.21%). Endo leak was more common in male (6 out of 7, 85.70%). Renal failure occurred in only 1 patient from all (3.00%). Stroke and/or paraplegia was found in 1 patient (3%) and respiratory complication in 5 patients (15.10%). Two patients in non endoleak group died (6.1% of all). No incidence of graft migration and distal sine (stent induced new entry tear). Operative time was found to be associated with risk for developing endo leak (p-value=0.015, 95% CI 1.00 to 1.03). Conclusion: TEVAR procedure for thoracic aortic aneurysm in Ramathibodi Hospital has low in mortality and postoperative complications. However, longer operative time is associated with an increased risk in endoleak in TEVAR procedure. Keywords: Thoracic aneurysm; Thoracic endovascular aortic repair; TEVAR

Safety and Effectiveness of TEVAR in Native Proximal Landing Zone 2 for Chronic Type B Aortic Dissection in Patients With Genetic Aortic Syndrome

Objectives The aim of this study is to report the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) in a native proximal landing zone (PLZ) 2 for chronic type B aortic dissection (TBAD) patients with genetic aortic syndrome (GAS). Methods A retrospective review of a single center database to identify patients with GAS treated with TEVAR in native PLZ 2 for chronic TBAD and thoracic false lumen aneurysm between February 2012 and February 2018 was undertaken. Results In total, 31 patients with GAS (24 Marfan syndrome [MFS], 5 Loeys-Dietz syndrome [LDS], and 2 vascular Ehlers-Danlos syndrome [vEDS]) were treated by endovascular repair. Nineteen patients were treated by TEVAR as index procedures with 8 patients (5 females, mean age = 55, range = 36–79 years old) receiving TEVAR in native PLZ 2. Left subclavian artery (LSA) perfusion was preserved in all 8 patients: by left common carotid artery-LSA bypass in 6 patients, chimney stenting of the LSA in 1 patient, and partial coverage of LSA ostium in 1 patient. Technical success was achieved in all patients (100%). There was no 30 day mortality (0%). The 30 day morbidity (0%) was free from major complications. The median follow-up was 40 months (range = 7–79). One patient died due to non-aortic-related cause. Native PLZ 2 was free from complications in MFS patients (5/8). Two patients with LDS developed type Ia endoleak with aneurysmal progression. One patient was treated by proximal extension with a double inner branched arch stent-graft landing in the replaced ascending aorta. The other one was treated with frozen elephant trunk. Conclusion Thoracic endovascular aortic repair in native PLZ 2 was safe and effective with no early or midterm PLZ complications in patients with MFS with chronic TBAD in this limited series. Native PLZ 2 is not safe in patients with LDS and should only be used in emergencies as a bridging to open repair.

Double Barreled Graft (Chimney) as a Strategy to Preserve Supraortic Branches in Contained Ruptured Thoracic Aneurysm Thoraco Endovascular Aortic Aneurysmal Repair- A Case Report

Out of many strategies that are used to treat aortic arch disease, including open surgery, branched techniques, and hybrid repair with Thoracic Endovascular Aortic Aneurysmal Repair (TEVAR) and supra-aortic branch reconstruction and fenestration, Thoracic Endovascular Aortic Aneurysmal Repair (TEVAR) incorporating chimney is frequently used in unstable and morbid patients not suitable for other procedures. We describe here a case of contained rupture of a thoracic aortic aneurysm, which was treated with TEVAR incorporating a double chimney to the left common carotid and left subclavian arteries. There was an uncomplicated course of the procedure with complete coverage of aneurysm with stent-graft and open aortic arch vessels when followed up to 6 months. There were no complications noted as well. In this case we took the precaution to upsize the stent-graft by 20% to 30% also for adequate coverage of aneurysm we had to adopt to the chimney technique. To prevent complications like gutter and endoleaks, the kissing technique was used during deployment. In addition, there was adequate coverage of chimney-grafts with adequate proximal projection.

Physician-Modified Endografts Versus Chimney/Snorkel for Ruptured and Symptomatic Juxtarenal and Paravisceral Aneurysms in the Vascular Quality Initiative

Ruptured and symptomatic juxtarenal and paravisceral aneurysms present technical challenges during endovascular repair. We sought to compare physician modification and fenestrated (PMEG) versus chimney/periscope/snorkel (CHIMPS) repair techniques for the treatment of ruptured and symptomatic paravisceral and juxtarenal aortic aneurysms (r/sPJAA). Patients in the thoracic and complex endovascular aneurysm module of the Vascular Quality Initiative (VQI) national registry undergoing CHIMPS and PMEG for r/sPJAA were included. Patients who underwent thoracic aneurysm repair with only celiac intervention or who had coverage or occlusion only of one renal or visceral branch vessel were excluded. One-year mortality was the primary outcome. Secondary outcomes included peri- and postoperative endoleak, hospital and ICU length of stay, reintervention, and other local and systemic complications. A total of 81 CHIMPS and 47 PMEG patients were identified. Patients undergoing PMEG were more frequently symptomatic, had a history of CHF and were taking aspirin, statin and P2Y12 antiplatelet medications. Patients undergoing CHIMPS presented more frequently with rupture. There was no significant survival advantage for CHIMPS over PMEG patients (P=0.5). There were no apparent long-term differences in the numbers of endoleaks or in the rates of subsequent reinterventions between the two groups. It does not appear that the procedure type (CHIMPS versus PMEG) is associated with postoperative survival in patients with r/sPJAA. Not surprisingly, survival is associated with postoperative complications, particularly myocardial infarction and intestinal ischemia. Further research should evaluate reasons for failure to rescue from and the impact of postoperative complications on the postoperative survival after endovascular repair of r/sPJAA.

Satralizumab, Novel Interleukine-6 Inhibitor for Preventing Descending Thoracic Aorta Aneurysm Development.

Descending thoracic aorta aneurysm (dTAA) has increasing incidence and, if left untreated, could lead to death. There is not any study of satralizumab treatment for preventing dTAA formation and progression. Forty male 10-week-old Rattus norvegicus were enrolled in the experiment. They were divided into four equal groups: dTAA treated with saline (dTAA-P) and dTAA treated with satralizumab (dTAA-S). One of the control groups was treated with saline (C-P), and the other was treated with satralizumab (C-S). Satralizumab and saline were used once every 2 weeks, subcutaneously 120 mg for 4 weeks. dTA diameter was measured at days 0, 3, 7, 14, 21, and 28. IL-6 level was measured on the 7th day that showed significantly increased IL-6 serum level in dTAA-P rats compared to C-P. Maximal dTA diameter (%MAD) was obtained at day 14, which was scientifically matched to the aorta aneurysm definition (>50% increase in diameter). From the seventh day, a significant difference in %MAD was observed between dTAA-P and dTAA-S groups. However, the %MAD of these two groups was significantly higher than control groups till the end of the 28th day. Using an IL-6 inhibitor agent to prevent dTAA formation and progression showed promising results. It suggests that using the IL-6 inhibitors in susceptible persons can be considered a lifesaving therapeutic approach.

Abstract 17228: Not Just Another Knick In The Wall: An Unusual Case Of Multiple Arterial Aneurysms

Case Presentation: 47-year-old Liberian woman with a history of latent TB and no prior cardiac history presented with dyspnea, palpitations, and weight loss. She had fevers, tachycardia, and cervical lymphadenopathy. Cardiac exam showed widened pulse pressure, systolic and diastolic murmur, and features of heart failure. TTE showed dilated left ventricle with preserved ejection fraction, aortic root aneurysm compressing left atrium, severe aortic and mitral regurgitation, and moderate pericardial effusion with no tamponade. CT angiogram of neck, chest and abdomen showed right subclavian artery mycotic aneurysm, large left supraclavicular lymphadenopathy, multiple aortic arch, and descending thoracic aorta mycotic aneurysms. She underwent emergent surgical intervention. Intraoperative TEE revealed rupture of aortic root aneurysm into left ventricular outflow tract causing a fistula, perforated anterior mitral leaflet, and distortion of the left atrial wall. She underwent mitral and aortic tissue valve replacement, aortic root replacement, and a pericardial patch repair of the left atrial wall. Subsequently, she underwent right subclavian artery aneurysm resection, right carotid axillary bypass, and vertebral artery reimplantation. Aortic valve pathology was suggestive of endocarditis with negative cultures. Lymph node biopsy revealed non-necrotizing granulomatous inflammation with no evidence of acid-fast bacilli, fungi, and malignancy. Autoimmune workup was negative. A PET CT showed post-surgical inflammatory changes with no evidence of malignancy. Discussion: We describe an unusual case of multiple large arterial aneurysms causing severe valvular insufficiency requiring emergent surgical intervention. The patient underwent extensive workup which was unrevealing. She was treated for subacute bacterial endocarditis and suspected Bechet’s disease. Thus, the quest for a definitive diagnosis continues to elude us.

Abstract 9487: Sildenafil (Viagra) Aggravates the Development of Experimental Abdominal Aortic Aneurysm

Introduction: PDE5 plays a critical role in vascular smooth muscle cell (SMC) contraction by hydrolyzing 3’,5’ cyclic monophosphate (cGMP) and antagonizing cGMP-dependent protein kinase I (PKGI)-mediated vascular relaxation. SMC contractile dysfunction is implicated in the pathogenesis of aortic aneurysm (AA). PDE5 inhibitors, such as Sildenafil, have been used clinically for treating erectile dysfunction (Viagra) and pulmonary hypertension (Revatio), through promoting SMC relaxation via elevating cGMP. However, it has been reported that PDE5 expression is reduced in human thoracic aneurysms and Viagra usage is associated with human aneurysm rupture or aortic dissection in several case reports. Objective: We aim to investigate the effect of sildenafil in the development of experimental abdominal aortic aneurysm (AAA), the most common form of AA that mainly occurs in elderly male. Methods and Results: AAA was induced in C57BL/6J mouse by periaortic elastase in combination with 3-aminopropionitrile fumarate salt (BAPN) treatment to block elastin/collagen formation. Immunofluorescent staining showed decreased PDE5 expression in mouse AAA. The effect of Sildenafil was examined on pre-existing moderate AAA by providing in drinking water for 28 days. We found that Sildenafil significantly aggravated aneurysmal wall dilation and elastin degradation. Mechanistically, the effect of Sildenafil on the signaling of SMC contraction and PKGI activation were examined in the medial lesion area of AAA. Immunofluorescent staining revealed that Sildenafil significantly decreased the phosphorylation of myosin light chain 2 (MLC2) at Ser19 in AAA, a biochemical marker of SMC contraction. Proximity ligation assay (PLA) revealed an increase of cGMP-PKGI interaction by Sildenafil, an indication of PKGI activation. Conclusions: Chronic Sildenafil treatment aggravated experimental AAA development and elastin degradation by dysregulating contractile signaling in SMCs. Our findings may raise caution of clinical usage of Viagra in aneurysmal patients.

The impact of dissection membrane motility on mid-term aortic remodelling after thoracic endovascular repair.

The aim of this study was to assess preoperative dissection flap motility and to evaluate its impact on the aortic remodelling and the development of distal stent-induced new entry after thoracic endovascular aneurysm repair (TEVAR)/frozen elephant trunk (FET). Patients with primary or residual type B dissections were included in a retrospective study with transoesophageal echocardiography analysis of the preoperative dissection flap motility assessed by the true lumen (TL) strain. Three-dimensional computing tomography centreline reconstructions before TEVAR/FET and during the follow-up were conducted to measure aortic remodelling: false lumen thrombosis, TL expansion and aortic diameters at 10 and 20 cm downstream the left subclavian artery, at the coeliac trunk and in the infrarenal aorta. All continuous variables are reported as median with first and third quartiles. Fifty-six consecutive patients were treated with TEVAR (n = 45) or FET (n = 11) in the acute (n = 16), subacute (n = 16) and chronic (n = 24) dissection phase. At a median follow-up of 6 (3-12) months, they showed a favourable TL expansion in the descending aorta, significantly higher in the acute [+9 mm (5-12); P < 0.001] and subacute groups [+5 mm (3-8); P = 0.039] than in the chronic group [+2 mm (0-5)]. The dissection flap motility parameter TL strain was superior in the acute (P = 0.006) and subacute (P = 0.035) groups in comparison to the chronic group. The motile flap [TL strain >22.5% (median)] was associated with a higher TL expansion rate in the thoracic aorta (P = 0.009) and a comparable distal stent-induced new entry incidence (overall: 16%) in comparison to the immobile flap (P = 0.89). The intraoperative assessment and the inclusion of the dissection flap motility parameters in the decision-making during TEVAR/FET may refine the distal endograft sizing for an improved remodelling of the TL.

EP.WE.690PPI Prescribing in Vascular Discharges

Abstract Aims Aspirin and clopidogrel are ubiquitously seen in prescriptions of most attendees to hospitals, especially those being admitted to a vascular unit. Most, if not all, are on at least one anti-platelet agent, and some are on dual antiplatelets (DAPA) or an anticoagulant. These increase the risk for upper gastrointestinal (UGI) bleeds, which lead to significant morbidity and mortality. In order to prevent this, proton pump inhibitors (PPIs) are recommended to be prescribed for patients with increased risk of UGI bleeds. Our aim for this audit was to evaluate the prescription of PPIs in vascular patients discharged from a major vascular hub. Methods Data was collected from a prospectively maintained database of consecutive primary vascular discharges between 01/09/2020 and 31/09/2020. Results 87 patients discharged in this period (71% Male, Median age 72 (22-92) yrs). 26% of admissions accounted for Diabetic foot infection management, 25% for Critical Limb Ischaemia management and 20% for Thoracic or Aortic Aneurysm management. 70% of patients were discharged with either a single or DAPA. 94% of patients met the NICE guideline for requirement for a PPI. 49% of those patients were not discharged with a PPI. Of the patients who should have been prescribed a PPI on discharge, 5% suffered UGI bleeds in the follow up period (2/42). Conclusions PPIs are often not prescribed when discharging vascular patients, most of whom are high risk for having UGI bleeds. We will re-audit this after education and protocols have been implemented.

EP.WE.173A Ticking Time Bomb – incidental finding of a giant thoracoabdominal aneurysm

Abstract Background Giant aortic aneurysm is a rare clinical entity. They may present with typical features of chest pain, or most feared complications with dissection and rupture. However, an asymptomatic and unruptured giant thoracic aneurysm is extremely rare with only two case reports in the literature. Case presentation An 80-year-old lady admitted to a local district general hospital with a 5-day history of productive cough with shivers. She tested positive for COVID-19 on admission. Diagnostic workup demonstrated an incidental finding of a giant TAAA. Her case was referred to a tertiary hospital for vascular Multidisciplinary Team (MDT) discussion and planning. It was decided that for her to have pre-operative assessment and MDT discussion after her recovery from infection to have definitive management of the TAAA. The patient is currently being managed supportively in hospital. Discussion According to National Institute for Health and Care Excellence (NICE), asymptomatic and 5.5 cm or larger aneurysm should be considered for repair. The case should be discussed in terms of the overall balance of benefits and risks with repair and conservative management, based on the current status of health and the expected future health. In this case, it was deemed that the risk of proceeding with repair at present outweighed the benefits. Conclusion This case describes a rare incidental finding of a giant TAAA. It emphasises the importance of MDT approach to direct and achieve appropriate management for a complex TAAA. Care treatment prioritisation, surgical planning and full complement expertise are required in complex cases such as this.

Complications after thoracic endovascular aortic repair for ruptured thoracic aortic aneurysms remain high compared with elective repair

ObjectiveThoracic endovascular aortic repair (TEVAR) for ruptured thoracic aortic aneurysms is associated with increased perioperative mortality and morbidity compared with intact repair. The purpose of our study was to evaluate the factors associated with the presentation of ruptured aneurysms and adverse outcomes after repair. MethodsThe Vascular Quality Initiative (VQI) registry was queried (2010-2020) to identify patients who had undergone TEVAR for ruptured and intact thoracic aortic aneurysms. The primary outcome was to identify the factors associated with ruptured thoracic aortic aneurysms. The secondary outcomes included perioperative mortality and morbidity, 5-year survival, and the identification of factors associated with adverse outcomes after TEVAR. ResultsOf the 3039 patients identified with a thoracic aortic aneurysm, 2806 (92%) had undergone repair for an intact aneurysm and 233 (8%) had undergone repair for a ruptured aneurysm. Chronic kidney disease was associated with a greater odds of a presentation with a ruptured aneurysm (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.0-4.9; P < .001). The factors associated with a lower odds of rupture included prior aortic aneurysm repair (OR, 0.71; 95% CI, 0.49-0.97; P = .05), prior smoker (OR, 0.36; 95% CI, 0.24-0.53; P < .001), preoperative beta-blocker therapy (OR, 0.57; 95% CI, 0.41-0.80; P = .001), and preoperative statin therapy (OR, 0.68; 95% CI, 0.49-0.94; P = .020). TEVAR for ruptured thoracic aortic aneurysms was associated with higher perioperative mortality (rupture vs intact, 27% vs 4.6%; OR, 6.6; 95% CI 4.3-10; P < .001) and the composite outcome of mortality, new dialysis, paralysis, and stroke (38% vs 9.5%; OR, 5.1; 95% CI, 3.5-7.4; P < .001). The 5-year survival was significantly lower after TEVAR for ruptured thoracic aortic aneurysms (50% vs 76%; P < .001; hazard ratio, 0.39; 95% CI, 0.29-0.52; P < .001). Preoperative statin therapy was associated with higher 5-year survival (hazard ratio, 1.3; 95% CI, 1.0-1.6; P = .021). ConclusionsTEVAR for ruptured thoracic aortic aneurysms results in increased perioperative mortality and morbidity and lower 5-year survival compared with TEVAR for intact aneurysms. Patients with prior aortic aneurysm repair, prior smoking, and preoperative beta-blocker or statin therapy were less likely to present with ruptured thoracic aneurysms. This correlation might be attributed to increased exposure to cardiovascular healthcare providers and, thus, subsequently increased screening and surveillance, allowing for elective repair of thoracic aortic aneurysms.

A Proposal to Evaluate Proximal and Distal Arch Endovascular Repairs Separately

We congratulate the authors on a remarkable report1 – more than 4 000 aortic arch presentations over four years, 12.5% (n = 513) managed using surgeon modified arch thoracic endovascular aneurysm repair (TEVAR)/fenestrated endovascular aneurysm repair (FEVAR) with impressive early and midterm results. It echoes a similar, but smaller, recent publication.2

Recurrent Aortobronchial Fistula after Endovascular Stenting for Infected Pseudoaneurysm of the Proximal Descending Thoracic Aorta: Case Report

Aortobronchial fistula (ABF) induced by an infected pseudoaneurysm of the thoracic aorta is a life-threatening condition. As surgical treatment is associated with significant mortality and morbidity, thoracic endovascular aneurysm repair (TEVAR) may be an alternative for the treatment of ABF. However, the long-term durability of this intervention is largely unknown and the recurrence of ABF is a potential complication. We experienced a case of recurrent ABF after stent grafting as an early procedure for an infected pseudoaneurysm of the thoracic aorta. Remnant ABF, bronchial and/or aortic wall erosion, vasa vasorum connected with ABF, and recurrent local inflammation of the thin aortic wall around ABF might cause recurrent hemoptysis. As a result, we suggest that TEVAR should be considered as a bridge therapy for the initial treatment of ABF resulting from an infected pseudoaneurysm, and that several options, such as second-stage surgery, should be considered to prevent the recurrence of ABF.