Thoracic Aneurysm Research Articles

Abstract 12986: Aorta Gene: Polygenic Prediction Improves Detection of Thoracic Aortic Aneurysm

Introduction: Thoracic aortic disease is an important cause of morbidity and mortality in the US, and aortic diameter is a heritable contributor to risk. Question: Could a polygenic prediction of ascending aortic diameter improve detection of aortic aneurysm? Methods: We used deep learning to measure ascending thoracic aortic diameter in 56,556 UK Biobank participants and conducted a genome-wide association study (GWAS) in 39,524. We built a 1.1-million SNP polygenic score using PRScs . In 4,896 non-GWAS participants (“training set”), we built linear models from clinical variables and the polygenic score (“AORTA Gene”) and simpler comparators. The models were assessed in the remaining 4,962 unrelated UK Biobank participants with imaging (“test set”). The models were externally validated in All Of Us participants over the age of 40. Results: In the test set, the AORTA Gene model explained 39.9% (95% CI 37.8-42.0%) of the variance in thoracic aortic diameter compared to 29.2% for the clinical model (95% CI 27.1-31.4%). For diameter ≥ 4cm, the area under the receiver operating characteristic curve (AUROC) was 0.834 for AORTA Gene, superior to the clinical model (0.765, P=7.3E-10). Thresholding at the top 10% of the score, AORTA Gene had a sensitivity of 52% and a specificity of 91.2% (F1: 0.197) for detecting the 113 participants with diameter ≥ 4. For the clinical score, the respective values were 36.3%, 90.9%, and 0.137. In 610 All Of Us participants with genetic data and aortic measurements, the AORTA Gene model had a correlation of 0.591 (95% CI 0.537-0.640) with aortic diameter vs 0.538 (95% CI 0.479-0.592) for the clinical model (P=2.2E-13 against a null hypothesis of the genetics being uninformative beyond clinical factors). It had an AUROC of 0.827 for identifying diameter ≥4cm vs 0.791 for the clinical model (P=7.8E-03). AORTA Gene also had a higher AUROC for prevalent thoracic aneurysm diagnoses (0.760 vs 0.739 for the clinical score, N=1,904 cases, P=2.4E-16) and incident diagnoses (0.748 vs 0.729, N=1,632 events, P=9.5E-10). Conclusions: Genetic information improved prediction of thoracic aortic diameter and aneurysm when added to clinical risk factors. Larger and more diverse samples will be needed to develop more powerful scores.

Transcarotid thoracic endovascular aortic repair for rupture of the aortic isthmus due to high energy blunt trauma: A case report

Introduction: Blunt thoracic aortic injury (BTAI) is associated with very high mortality, and managing currently favors thoracic endovascular aneurysm repair (TEVAR) if feasible, especially BTAI due to high energy force, where patients usually suffer from polytrauma, which requires rapid discover and treat spontaneously. However, a remarkable group of patients is contraindicated for the transfemoral route- the established first-line approach in endovascular interventions of the aorta. Here, we report a successful case in which the carotid artery was used to perform TEVAR. Case presentation: A young female was transferred to our emergency department after injuries sustained by falling from the fifth floor. Her vital signs were stable on admission. Pan CT scan revealed multiple injuries: A grade III injury of the aortic isthmus, a grade III liver injury without active bleeding, and fracture of the sternum, multiple ribs, T12-L1 vertebral body, and pelvic ring. However, her hemodynamics became unstable, and we decided to perform an urgent endovascular repair. During preparations for TEVAR, we found that the diameter at the proximal landing zone was 17.1mm, so it cannot be accommodated by any of the available thoracic endograft devices. Under the emergency condition, we decide to perform TEVAR by abdominal aortic device and access via the carotid to suit the device's length. After inpatient rehabilitation, she was discharged without neurologic sequelae. Conclusion: Transcarotid TEVAR is feasible and could be considered as an alternative approach in some specific patients with BTAI.

Strategies for prevention of spinal cord ischemia in the management of thoracic and thoracoabdominal aneurysms

Spinal cord ischemia (SCI) is undoubtedly the most devastating adverse event that occurs after either a thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA) repair. While open surgery techniques and minimally invasive endovascular options are now available for treating complex anatomy aortic aneurysms, spinal cord ischemia still occurs to a greater extent than desirable. Multiple risk factors have been associated with this adverse event, such as advanced age, perioperative hypotension, extent of the repair, and ligation of multiple intercostal and lumbar arteries during the surgical repair. The present literature review aims to analyze the contributing risk factors for SCI in the context of aortic surgery, explore the most relevant strategies for preventing postoperative SCI, and discuss the current management strategy when this complication occurs.

Current Medicare reimbursement for complex endovascular aortic repair is inadequate based on results from a multi-institutional cost analysis

ObjectiveComplex endovascular juxta-, para- and suprarenal abdominal aortic aneurysm repair (comEVAR) is frequently accomplished with commercially available fenestrated (FEVAR) devices or off-label use of aortoiliac devices with parallel branch stents (chEVAR). We sought to evaluate the implantable vascular device costs incurred with these procedures as compared with standard Medicare reimbursement to determine the financial viability of comEVAR in the modern era. MethodsFive geographically distinct institutions with high-volume, complex aortic centers were included. Implantable aortoiliac and branch stent device cost data from 25 consecutive, recent, comEVAR in the treatment of juxta-, para-, and suprarenal aortic aneurysms at each center were analyzed. Cases of rupture, thoracic aneurysms, reinterventions, and physician-modified EVAR were excluded, as were ancillary costs from nonimplantable equipment. Data from all institutions were combined and stratified into an overall cost group and two, individual cost groups: FEVAR or chEVAR. These groups were compared, and each respective group was then compared with weighted Medicare reimbursement for Diagnosis-Related Group codes 268/269. Median device costs were obtained from an independent purchasing consortium of >3000 medical centers, yielding true median cost-to-institution data rather than speculative, administrative projections or estimates. ResultsA total of 125 cases were analyzed: 70 FEVAR and 53 chEVAR. Two cases of combined FEVAR/chEVAR were included in total cost analysis, but excluded from direct FEVAR vs chEVAR comparison. Median Medicare reimbursement was calculated as $35,755 per case. Combined average implantable device cost for all analyzed cases was $28,470 per case, or 80% of the median reimbursement ($28,470/$35,755). Average FEVAR device cost per case ($26,499) was significantly lower than average chEVAR cost per case ($32,122; P < .002). Device cost was 74% ($26,499/$35,755) of total reimbursement for FEVAR and 90% ($32,122/$35,755) for chEVAR. ConclusionsResults from this multi-institutional analysis show that implantable device cost alone represents the vast majority of weighted total Medicare reimbursement per case with comEVAR, and that chEVAR is significantly more costly than FEVAR. Inadequate Medicare reimbursement for these cases puts high-volume, high-complexity aortic centers at a distinct financial disadvantage. In the interest of optimizing patient care, these data suggest a reconsideration of previously established, outdated, Diagnosis-Related Group coding and Medicare reimbursement for comEVAR.

Transvenous Access for Emergent Thoracic and Thoracoabdominal Aortic Aneurysm Repair in Patients Without Femoral Access.

To describe the technique of transvenous access for emergent endovascular repair of thoracic and thoracoabdominal aneurysms exemplified with 2 cases. Transvenous access to the aorta is described as an alternative access method to deliver aortic endografts in emergency situations. A 68-year-old female patient with severely compromised iliac and subclavian artery access was treated for a ruptured extent V thoraco-abdominal aortic aneurysm with a t-Branch (Cook Medical, Bjaeverskov, Denmark) delivered through a transcaval access. To avoid severe aortocaval shunting a balloon-expandable covered stent was deployed through a carotid access due to severe bilateral subclavian ostial stenosis. A 71-year-old man with an acute type B aortic dissection and bilateral narrow long-segment stenting of the iliac arteries was treated with a physician-modified thoracic endovascular aortic repair using an arteriovenous fenestration created at the level of the common iliac artery. We describe the access creation by fenestration using a transseptal needle. Transvenous access for thoracic and thoraco-abdominal aortic aneurysm repair is safe and feasible in selected emergent cases. A transvenous approach may be helpful in selected patients when an endovascular repair needs to be performed but no arterial femoral access is available. This approach proved to be feasible even with large-bore introducer sheaths, taking its place in the armamentarium of the vascular surgeon for emergent complex endovascular aortic repairs.

Spinal cord injury after open and endovascular repair of descending thoracic aneurysm and thoracoabdominal aortic aneurysm: an updated systematic review and meta-analysis.

Spinal cord injury (SCI) is a rare but severe complication after open or endovascular repair of descending thoracic aneurysms (DTAs) or thoracoabdominal aortic aneurysms (TAAAs). This meta-analysis aims to provide a comprehensive assessment of SCI rates and factors associated with SCI. A systematic literature search was performed in September 2022 looking for studies on open and/or endovascular repair of DTA and/or TAAA published after 2018, to update the results of our previously published meta-analysis. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, 30-day and in-hospital mortality, follow-up mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications. Data were pooled as proportions using inverse-variance weighting. A total of 239 studies (71 new studies and 168 from our previous meta-analysis) and 61,962 patients were included. The overall pooled rate of permanent SCI was 3.3% [95% confidence interval (CI), 2.9-3.8%]. Open repair was associated with a permanent SCI rate of 4.0% (95% CI, 3.3-4.8%), and endovascular repair was associated with a permanent SCI rate of 2.9% (95% CI, 2.4-3.5%). Permanent SCI was 2.0% (95% CI, 1.2-3.3%) after DTA repair, and 4.7% (95% CI, 3.9-5.6%) after TAAA repair; permanent SCI rate was 3.8% (95% CI, 2.9-5.0%) for Crawford extent I, 13.4% (95% CI, 9.0-19.5%) for extent II, 7.1% (95% CI, 5.7-8.9%) for extent III, 2.3% (95% CI, 1.6-3.5%) for extent IV, and 6.7% (95% CI, 1.7-23.1%) for extent V TAAA aneurysms. The pooled rate of CSF drain related complications was 1.9% (95% CI, 0.8-4.7%) for severe, 0.4% (95% CI, 0.0-4.0%) for moderate, and 1.8% (95% CI, 0.6-5.6%) for minor complications. Permanent SCI occurs after both endovascular and open DTA or TAAA repairs. Open repairs and TAAA repairs have higher risk of SCI compared with endovascular or DTA repairs. In particular, extent II aneurysms present the highest overall risk of SCI.

Clinical presentation, outcomes, and threshold for repair by sex in degenerative saccular vs fusiform aneurysms in the descending thoracic aorta

ObjectiveSaccular-shaped thoracic aortic aneurysms (TAAs) are often treated at smaller diameters compared with fusiform TAAs, despite a lack of strong clinical evidence to support this practice. The aim of this study was to examine differences in presentation, treatment, and outcomes between saccular TAAs and fusiform TAAs in the descending thoracic aorta. We also examined the need for sex-specific treatment thresholds for TAAs. MethodsAll Vascular Quality Initiative (VQI) patients undergoing thoracic endovascular aneurysm repair (TEVAR) for degenerative TAAs in the descending thoracic aorta from 2012 through 2022 were reviewed. Patients were stratified by urgency: emergent/urgent vs elective repairs (ruptured/symptomatic). Demographics, comorbidities, anatomical/procedural characteristics, and outcomes for fusiform TAAs and saccular TAAs were compared. Cumulative distribution curves were used to plot the proportion of patients who underwent emergent/urgent repair according to sex-stratified aortic diameter. ResultsAmong 655 emergent/urgent TEVARs, 37% were performed for saccular TAAs, whereas among 1352 elective TEVARs, 35% had saccular TAA morphology. Compared with fusiform TAAs, saccular TAAs more frequently underwent emergent/urgent (ruptured/symptomatic) TEVAR below the repair threshold in both females (<50 mm: 38% vs 10%; relative risk, 3.39; 95% confidence interval [CI], 2.04-5.70; P < .001), and males (<55 mm: 47% vs 21%; relative risk, 2.26; 95% CI, 1.60-3.18; P < .001). Moreover, among patients with emergent/urgent fusiform TAAs, females presented at smaller diameters compared with males, whereas there was no difference in preoperative aneurysm diameter among patients with saccular TAAs. Regarding outcomes, emergent/urgent treated saccular TAAs had similar postoperative outcomes and 5-year mortality compared with fusiform TAAs. Nevertheless, in the elective cohort, patients with saccular TAAs had similar postoperative mortality compared with those with fusiform TAAs, but a lower rate of postoperative spinal cord ischemia (0.7% vs 3.2%; P = .010). Furthermore, patients with saccular TAAs had a higher rate of 5-year mortality compared with their fusiform counterparts (23% vs 17%; hazard ratio, 1.53; 95% CI, 1.12-2.10; P = .010). ConclusionsPatients with saccular TAAs underwent emergent/urgent TEVAR at smaller diameters than those with fusiform TAAs, supporting current clinical practice guideline recommendations that saccular TAAs warrant treatment at smaller diameters. Furthermore, these data support a sex-specific treatment threshold for patients with fusiform TAAs, but not for those with saccular TAAs. Although there were no differences in outcomes following TEVAR between morphologies in the emergent/urgent cohort, patients with saccular TAAs who were treated electively were associated with higher 5-year mortality compared with those with fusiform TAAs.

Open and endovascular reinterventions after Candy Plug false lumen embolization of type B aortic dissection

ObjectiveIn the majority of patients with chronic type B aortic dissection, there is persistent retrograde flow in the false lumen (FL) through distal re-entry tears. Among several endovascular techniques proposed for FL management, the “Candy Plug” (CP) technique has gained acceptance with good early results. The aim of this study is to report the types and outcomes of open and endovascular reinterventions and identify mechanisms of procedure failure as well as other causes for reinterventions. MethodsAll patients with type B aortic dissection submitted to thoracic endovascular aneurysm repair and CP implantation for FL embolization from January 2016 to December 2022 at our institution were included in this study. The preoperative, intraoperative, and postoperative data of the primary intervention and secondary reinterventions, when performed, were prospectively collected and retrospectively analyzed. Preoperative and postoperative computed tomography angiography were also analyzed. ResultsDuring the study period, 33 patients were submitted to thoracic endovascular aneurysm repair and CP implantation. Twenty-three patients (69.7%) showed thoracic FL complete thrombosis with aortic stability or positive remodeling at a mean follow-up of 45 ± 23.1 months. Ten patients (30.3%) underwent aortic reinterventions (male, n = 9; mean age, 60.5 ± 7.6 years). Of these 10 patients, in four patients, complete thrombosis of the FL was never achieved, leading to ongoing perfusion of the FL, defined as “primary failure.” The other six patients underwent reinterventions for different causes: two patients, after initial sealing, showed a progressive enlargement of the abdominal FL leading to distal degeneration. One patient showed proximal degeneration, two patients showed a type II thoracoabdominal aortic aneurysm and CP implantation was used as a planned procedure to reduce the extent of the surgical procedure, and one patient had recurrent, intractable back pain despite complete thrombosis of the FL. Reinterventions were open in five cases and endovascular in five. One in-hospital death (postoperative day 27) after a type II thoracoabdominal aortic aneurysm open repair was recorded. In addition, two cases of delayed spinal cord ischemia after open reintervention were recorded: one resulting in permanent paraplegia and one transitory with complete recovery. ConclusionsThe CP technique was safe and effective; however, a significant rate of aortic-related reintervention was observed. Several mechanisms led to reinterventions either in terms of “primary failure” of the CP or subsequent aneurysmal degeneration. Complex reinterventions were often necessary, with a high rate of major complications in case of open repair. Life-long and closer surveillance might be required in these patients.

Anesthesia management of patients undergoing thoracic endovascular aortic repair: A retrospective analysis of single center.

Thoracic endovascular aortic repair (TEVAR) is a new alternative surgical treatment for aortic pathologies, which is more minimally invasive. The aim of current study was to summarize the single-center experience of general anesthesia for patients undergoing TEVAR. In adult patients undergoing surgery for congenital heart disease, the strategy of "fast-track" anesthesia with early extubation in theater is associated with a shorter intensive care unit (ICU) stay, and lower health-care-related costs. Fast-track anesthesia has not been assessed in patients under TEVAR. Adult patients who received general anesthesia for TEVAR in our center from January 2020 to December 2020 were included. Baseline characteristics, airway management, anesthetic techniques and major complications were collected. A total of 204 (171 male, mean age 58.1 ± 11.5 years) patients met inclusion criteria for this study. The distribution of pathologies included 29 descending thoracic aneurysms, 87 type B dissections, and 88 intramural hematoma/perforating aortic ulcer. Etomidate was the induction agent in 190 (93.1%) patients, compared with propofol in 16 (7.8%). Cisatracurium was the muscle relaxant in 201 (98.5%), compared with rocuronium in 3 (1.5%). Midazolam (benzodiazepines) was given to 124 (60.8%) patients during anesthesia induction. General anesthesia was maintained with sevoflurane in 85.3% (174) patients, dexmedetomidine in 201 (98.5%) and propofol in 204 (100%). Postoperative length of stay (LOS) in the hospital was 6.0 (5.0-7.8) days. LOS in the ICU was 23.0 (20.0-27.8) hours. Overall neurologic event rate was 2.0% (n = 4) (spinal cord ischemia 1.5% [n = 3]; stroke 0.5% [n = 1]). After matching, patients who received "fast-track" anesthesia had a shorter LOS in ICUs (21.0 [18.0-24.0] vs 24.0 [20.0-44.0] hours; P = .005), and a shorter postoperative LOS in hospital (5.0 [4.0-7.0] vs 6.0 [5.0-8.0] days; P = .001). There were no in-hospital deaths. Fast-track anesthesia is feasible and safe in patients underwent TEVAR. This management strategy is associated with shorter LOS of ICU and total postoperative hospital stays. An early extubation strategy should be implemented for hemodynamically stable patients.

Long-Term Results with 187 Frozen Elephant Trunk Procedures.

The frozen elephant trunk (FET) technique is an established therapeutic option in the treatment of complex aortic diseases. We report our long-term clinical outcomes after FET repair. A total of 187 consecutive patients underwent FET repair at our department between 8/2005 and 3/2023. Indications included acute and chronic aortic dissections and thoracic aneurysms. Endpoints included operative morbidity and mortality, long-term survival, and the need for reinterventions. Operative mortality, spinal cord injury and permanent stroke rates were: 9.6%, 2.7% and 10.2%, respectively. At five years, overall survival was 69.9 ± 3.9% and freedom from aortic-related death was 82.5 ± 3.0%, whereas at ten years, overall survival was 53.0 ± 5.5% and freedom from aortic-related death was 75.8 ± 4.8%. Sixty-one reinterventions on the thoracic aorta were necessary. Freedom from secondary interventions at ten years was 44.7 ± 6.4% overall (63.1 ± 10.0% for acute dissections, 40.8 ± 10.3% for chronic dissections and 28.9 ± 13.1% for aneurysms, respectively). The high reintervention rate for chronic dissections and for aneurysms is related to the pre-existing aortic pathology. Late aortic growth of untreated segments with potentially fatal outcome occurs even after ten years, so careful annual follow-up is mandatory in this patient cohort.

Gender-related differences in aortic diameters: why do we use the same cutoff?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patient’s body size and gender are major determinants of aortic dimensions. Even though female gender is associated with smaller aortic dimensions, surgery indication for thoracic aorta aneurysms is still based mainly on absolute diameters without considering gender. Therefore, if 4 cm is the number which allows us to discriminate aortic dilation in women is still controversial. Objective to compare the upper limit of normal (ULN) and Z score between genders in the population of the MATEAR Study (prospective nationwide multicenter registry in Argentina) and to determine the usefulness and fairness of the guideline’s recommendations about aortic diameters in women. Methods It was a prospective nationwide registry (53 centers). We included 1,000 healthy adult individuals (mean age: 38.3±12.7 years) being 553 women (56.7% Caucasian, 38.3% Native Americans). Echocardiograms were performed in all patients measuring aortic dimensions at 6 levels following the current standard recommendations: aortic annulus, aortic sinuses, sinotubular junction (STJ), proximal ascending aorta, aortic arch, and proximal descending aorta. Absolute diameters and indexed diameters by body surface area and height were compared between men and women, as well as the estimated ULN in order to analyze discrepancies of the recommended ULN (4cm) in female individuals. Results Table 1 shows the baseline characteristics of the study population by gender. The mean age was similar in both sexes (39.1±13.4 years in women and 37.2±12.3 years in men). Women had lower values in all anthropometric parameters, they were 13 cm shorter than men, and had lower left ventricular diameters, ventricular mass, septal thickness and medium blood pressure. The aortic measures at the six levels revealed that women had lower absolute aortic diameters in all aortic segments. However, when the indexed parameters were analyzed in the aortic root and STJ, women presented lower height indexed diameters but higher BSA/indexed diameters (Table 2 and Figure 1). Regarding the Z score evaluation, we found that the recommended ULN (4 cm) was higher in women than men, with a Z score equivalent to 3.61 and 2.34 respectively. Moreover, in our registry 3.62 cm was the ULN in women which corresponded to a Z score of 2.5. Conclusions As was suggested in previous studies aortic diameter indexed by height or BSA appear to be the most appropriate measurements for considering aortic dilatation. In our registry, women showed lower absolute aortic diameters in all segments placing the recommended ULN of 4cm as a misguided value for considering aortic dilatation in women. Therefore, gender should always be taken into account when defining aortic dilatation.

Common Designs of Custom-Made Fenestrated Arch Devices and Applicability of an Off-the-Shelf Design.

To analyze device designs, similarities and overlaps of custom-made fenestrated arch endografts intended for mid/distal arch thoracic endovascular aortic repair. A multicenter cross-sectional study analyzing custom-made anonymized graft plans was performed. Graft plans were included from a cohort of mid/distal aortic arch repairs using custom-made fenestrated aortic endografts treated at 8 centers. Grafts targeting >2 arteries were excluded. No patient/clinical data were analyzed. A descriptive analysis was performed followed by an analysis of overlap of the designs to reach a common design in which the greatest number of grafts would overlap. One hundred thirty-one graft plans were included. All grafts were custom-made grafts from the COOK Medical Fenestrated arch platform. Ninety-four (71.8%) had a scallop-and-single-fenestration design, 33 (25.2%) had a single fenestration and 4 (4.3%) a single scallop. For analysis purposes, these latter 4 grafts were excluded. Two main graft plans (Plans 1 and 2) were proposed after analysis with similar configuration (1 scallop with 30 mm width, 20 mm height, 12:00 position; 1 preloaded fenestration with 8 mm diameter, 26 mm from the top of the graft and 12:00 position; tapered, with a 193 mm length and 32 mm distal diameter) but with 2 different proximal diameters of 38 mm (Plan 1) and 44 mm (Plan 2), reaching an overall feasibility of 85.8% (n=109), being 47.2% (n=60) and 38.6% (n=49) for each design, respectively. The degree of overlap between the studied fenestrated and/or scalloped thoracic endovascular aneurysm repair (TEVAR) graft designs was high. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility. In a multicenter study analyzing 127 fenestrated aortic arch endograft plans from 9 aortic centers, we found that the degree of overlap between the studied fenestrated and/or scalloped arch graft designs was high and that 2 proposed graft designs would be theoretically applicable in 85.8% of cases. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility.

Device profile of EndoAnchors for aortic stent graft implantation: overview of their safety and efficacy

ABSTRACT Introduction Endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) are established techniques to treat abdominal aortic aneurysms (AAA) and thoracic aortic aneurysms (TAA). However, there are limitations when challenging proximal neck anatomy is present. Heli-FX EndoAnchors have been used in addition to EVAR and TEVAR to improve proximal sealing of a stent-graft, but there are limited data available on their outcomes, safety, and efficacy. Areas Covered The properties and development of Heli-FX EndoAnchors are evaluated. The evidence of various clinical outcomes, safety, and efficacy is interrogated with the augmented use of Heli-FX EndoAnchors with EVAR or TEVAR. Expert Opinion Challenging proximal neck anatomy can be problematic during EVAR or TEVAR. EndoAnchors may be part of the solution – used either prophylactically or therapeutically. The safety and efficacy databases are building but long-term data are still not available for this device and there remains inadequate data to support its routine use. Judicious patient selection is still needed.

Thoracic aneurysm and dissection gene variants increase the risk of aortic-related adverse events in early-onset isolated Stanford type B aortic dissection after endovascular aortic repair.

Researches on Marfan syndrome and Ehlers-Danlos syndrome leading to early-onset aortic dissection (AD) emphasize the importance of gene variants, but the genetic pathogenesis, clinical characteristics and outcomes of early-onset isolated Stanford type B aortic dissection (iTBAD) patients remain unclear and need to be further elucidated. Isolated type B AD patients with an onset age of less than 50 years were enrolled in this study. Whole exome sequencing (WES) was performed to detect 11 known thoracic aortic aneurysm and dissection (TAAD) gene variants. Clinical characteristics and outcomes were compared between patients with and without gene variants. Multivariate Cox regression analysis was performed to identify independent risk factors for aortic-related adverse events (ARAEs) after endovascular aortic repair. A total of 37 patients were included. Ten patients carried 10 variants in five TAAD genes, four of whom carried pathogenic or likely pathogenic variants. Compared to patients without the variants, patients with variants had a lower incidence of hypertension (50.0% vs. 88.9%, P=0.021), a higher incidence of other vascular abnormalities (60.0% vs. 18.5%, P=0.038), all-cause mortality (40.0% vs. 3.7%, P=0.014) and aortic related mortality (30.0% vs. 3.7%, P=0.052). Multivariate analysis confirmed the presence of TAAD gene variants as the only independent risk factor for ARAEs [hazard ratio (HR) =4.00; 95% confidence interval (CI): 1.26-12.74; P=0.019]. Routine genetic testing is necessary for early-onset iTBAD patients. Individuals with a high risk of ARAEs can be identified by detecting TAAD gene variants, which is important for risk stratification and proper management.

EFFICACITY OF COMBINATION ACID ACETYLSALICYLIC AND GLUCOCORTICOID IN TAKAYASU ATERITIS TREATMENT: A CASE CLINIC TAKAYASU ARTERITIS IN VIET NAM

Objective: This brings up the potential of medical management for patients who are diagnosed with Takayasu arteritis, instead of using invasive methods such as aortic stent placement or operations. Design and method: A young female 14 years old was diagnosed with Takayasu arteritis. Initial symptoms include fever, loss of appetite, weight loss, muscle pain, followed by palpitations and abdominal pain, and loose stools. The test showed an increased hypersensitive C-reactive protein level (CRPhs: 28.7 mg/L). Computed tomography angiography (CTA) chest with contrast shows two segments of thoracic aneurysms involving descending aorta, the aortic diameter of the superior and inferior segment aneurysms is #1.6-1.8 cm, #2x 2.1cm, respectively, and the length is #2.5cm, # 3.2cm, respectively. According to the American College Rheumatology 1994, we classified this patient as type III. The patient was treated with corticosteroid therapy consisting of: prednisolone at an initial dose of 20 mg/day, reduced to a dose of 10 mg/day at month 3, and reduced to a dose of 5 mg/day after 6 months until now. In addition, we also added low-dose aspirin (81mg/day), ACE inhibitors, and beta-blockers to increase the effectiveness of treatment Results: After 3 months, Hs-CRP levels returned to normal (from 28.7 mg/L to 1.23 mg/L) and remained below the 3 mg/L thresholds during the next 15 months. After 12 months of combined treatment with corticosteroids and aspirin as described above, the patient's aortic diameter had returned to almost normal on CTA. After that, we have reduced the patient's corticosteroid dose (prednisolone 5 mg/day) and are going to finish the treatment after 18 months. Conclusions: This successful case high value on the role of pharmacological therapy in cases of Takayasu arteritis. It also brings up a debate regarding the concept of surgery required in cases of Takayasu arteritis complicated with dilatation, aneurysm, or stenosis. The combination of glucocorticoid therapy with aspirin can reduce the cost of treatment as well as avoids the side effects of the combination of glucocorticoid with immunosuppressive drugs. This opens up great treatment opportunities for Takayasu arteritis patients in low-economic countries like Vietnam.

Thoracic aneurysm endovascular repair of extremely tortuous aorta in neonatal Marfan syndrome patient with major scoliosis

Thoracic aneurysm endovascular repair of extremely tortuous aorta in neonatal Marfan syndrome patient with major scoliosis

Effectiveness of Proximal Landing Zone 1 and 2 Thoracic Endovascular Aortic Repair for Type B Aortic Dissection by Comparing Outcomes With Thoracic Arch Aneurysm.

Hybrid thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is a minimally invasive procedure with improved results. This study aimed to clarify the effectiveness and expand the possibilities of zone 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. This retrospective, single-center, observational cohort study included 213 patients (TBAD, n=69; thoracic arch aneurysm [TAA], n=144; median age, 72 years; median follow-up period, 6 years) from May 2008 to February 2020. The following conditions were satisfied before performing zone 1 and 2 landing TEVAR: TBAD; proximal landing zone (LZ): diameter <37 mm, length >15 mm, and nondissection area, proximal stent-graft: size ≤40 mm and oversizing rate: 10% to 20%, and TAA; proximal LZ: diameter ≤42 mm and length >15 mm, proximal stent-graft: size ≤46 mm and oversizing rate: 10% to 20%. Of the 69 patients in the TBAD group, 34 (49.3%) had patent false lumen (PFL), and 35 (50.7%) had false lumen partial thrombosis (FLPT), including ulcer-like projections. Emergency procedures were performed in 33 (15.5%) patients. There were no significant differences in the in-hospital mortality (TBAD: 1.5% vs TAA: 0.7%, p=0.544) or the in-hospital aortic complications (TBAD: n=1 vs TAA: n=5, p=0.666). Retrograde type A dissection was not observed in the TBAD group. The aortic event-free rates at 10 years were 89.7% (95% confidence interval [CI]: 78.7%-95.3%) and 87.9% (95% CI: 80.3%-92.8%) in the TBAD and TAA groups, respectively (log-rank p=0.636). In the TBAD group, the early and late outcomes were not significantly different between the PFL and FLPT groups. Satisfactory early and long-term results were obtained with zone 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD. This study aimed to clarify the effectiveness and expand the possibilities of zones 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. Satisfactory early and long-term results in the TBAD and thoracic arch aneurysm (TAA) groups were obtained with zones 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD.

Outcome of surgical repair for aortic coarctation with coexisting descending aortic aneurysm in adult patients

Objective: To evaluate the efficacy of surgical treatment of aortic coarctation combined with descending aortic aneurysm in adult patients. Methods: This is a retrospective cohort study. Adult patients with aortic coarctation who were hospitalized in Beijing Anzhen Hospital from January 2015 to April 2019 were enrolled. The aortic coarctation was diagnosed by aortic CT angiography, and the included patients were divided into the combined descending aortic aneurysm group and the uncomplicated descending aortic aneurysm group based on descending aortic diameter. General clinical data and surgery-related data were collected from the included patients, and death and complications were recorded at 30 days after surgery, and upper limb systolic blood pressure was measured in all patients at discharge. Patients were followed up after discharge by outpatient visit or telephone call for their survival and the occurrence of repeat interventions and adverse events, which included death, cerebrovascular events, transient ischemic attack, myocardial infarction, hypertension, postoperative restenosis, and other cardiovascular-related interventions. Results: A total of 107 patients with aortic coarctation aged (34.1±15.2) years were included, and 68 (63.6%) were males. There were 16 cases in the combined descending aortic aneurysm group and 91 cases in the uncomplicated descending aortic aneurysm group. In the combined descending aortic aneurysm group, 6 cases (6/16) underwent artificial vessel bypass, 4 cases (4/16) underwent thoracic aortic artificial vessel replacement, 4 cases (4/16) underwent aortic arch replacement+elephant trunk procedure, and 2 cases (2/16) underwent thoracic endovascular aneurysm repair. There was no statistically significant difference between the two groups in the choice of surgical approach (all P>0.05). In the combined descending aortic aneurysm group at 30 days after surgery, one case underwent re-thoracotomy surgery, one case developed incomplete paraplegia of the lower extremity, and one case died; and the differences in the incidence of endpoint events at 30 days after surgery were similar between the two groups (P>0.05). Systolic blood pressure in the upper extremity at discharge was significantly lower in both groups compared with the preoperative period (in the combined descending aortic aneurysm group: (127.3±16.3) mmHg vs. (140.9±16.3) mmHg, P=0.030, 1 mmHg=0.133 kPa; in the uncomplicated descending aortic aneurysm group: (120.7±13.2) mmHg vs. (151.8±26.3) mmHg, P=0.001). The follow-up time was 3.5 (3.1, 4.4) years. There were no new deaths in the combined descending aortic aneurysm group, no transient ischemic attack, myocardial infarction or re-thoracotomy surgery, and one patient (1/15) suffered cerebral infarction and 10 patients (10/15) were diagnosed with hypertension. The differences in the occurrence of endpoint events during postoperative follow-up were similar between the two groups (P>0.05). Conclusion: In experienced centers, long-term prognosis of patients with aortic coarctation combined with descending aortic aneurysm is satisfactory post surgical intervention.

Aneurysm Size Is Associated with Increased Morbidity and Mortality in Patient Undergoing Thoracic Endovascular Aneurysm Repair for Degenerative Aneurysms

Prior studies have shown larger aneurysm sizes predictive of worse outcomes following abdominal aortic aneurysms. This study aimed to evaluate whether maximal aortic diameter affects outcomes after thoracic endovascular aneurysm repair (TEVAR) of thoracic aortic aneurysm (TAA). Clinical data of patients undergoing TEVAR for non-ruptured-asymptomatic TAAs was extracted from the Vascular Quality Initiative (2012-2022). Patients were stratified into size groups according to TAA diameter: small ≤ 5.5 cm; 5.5 cm < medium ≤ 6.5 cm; and large > 6.5 cm. Inverse probability weights (IPW) were calculated and used to balance the groups’ clinical characteristics. The small group was used as a reference point for comparing outcomes. The primary end points were all-cause mortality and thoracoabdominal life-altering events (TALE)—a composite of stroke, death, paraplegia, and dialysis. Secondary end points included procedural complication rates. We included706 small, 795 medium, and 385 large patients in the final analysis. TALE rates were statistically higher in the medium vs small (P < .01: 18% vs 11%) and large vs small (P < .001: 21% vs 11%) groups, but not in the large vs medium group. Kaplan-Meier analysis showed a significant 8-year survival difference (P < .001: 85% small vs 71% medium vs 70% large). Regression models adjusted for clinical characteristics showed higher odds of TALE in the medium (odds ratio, 1.8; 95% confidence interval [CI], 1.2-2.7; P < .05) and large (odds ratio, 2.1; 95% CI, 1.4-3.3; P < .001) vs small groups. Hazard analysis showed a higher risk of 8-year mortality in all intergroup comparisons (large vs small hazard ratio, 1.9; 95% CI, 1.4-2.8; P < .001). Increases in maximal aortic diameter are associated with worse early and late outcomes following TEVAR for TAA. The incidence of TALE and the long-term risk of mortality increases as a function of the TAA size category; therefore, early TAA repair with TEVAR should be considered at 5.5 cm in suitable-risk patients with appropriate anatomy.

Aneurysm Size Is Associated with Increased Morbidity and Mortality in Patient Undergoing Thoracic Endovascular Aneurysm Repair for Elective Type B Dissection

Although aneurysm size has been categorized as a strong predictor of aortic dissection, its specific effect on the treatment of such complications has not been elucidated. As result, this study aimed to evaluate whether maximal aortic diameter affects outcomes after thoracic endovascular aneurysm repair (TEVAR) of type B dissection. Clinical data of patients undergoing TEVAR for elective type B dissections was extracted from the Vascular Quality Initiative (2012-2022). Patients were stratified into size groups according to aneurysm diameter: small ≤5.5 cm; 5.5 cm < medium ≤ 6.5 cm; and large > 6.5 cm. Inverse probability weights were calculated and used to balance the groups’ clinical characteristics. The small group was used as a reference point for comparing outcomes. The primary end points were all-cause mortality and thoracoabdominal life-altering events (TALE)—a composite of stroke, death, paraplegia, and dialysis. Secondary end points included major adverse cardiac events (MACE), a composite of stroke, myocardial infarction (MI), new dysrhythmia, chronic heart failure, major adverse limb events, leg amputation, embolization, spinal ischemia, and others. There were 1788 small, 667 medium, and 341 large patients included in the final analysis. TALE rates were statistically higher in the large vs small (P < .01: 24.3% vs 16.2%) and large vs medium groups (P < .001: 24.3% vs 15.9%) but not in the large vs small group (Table). The large vs small group also had a higher incidence of spinal ischemia, respiratory complications, MACE, and perioperative mortality. Although the Kaplan-Meier analysis did not show a statistically significant 8-year survival difference, it illustrated a clinically meaningful survival difference (P = .053: 77.0% small vs 74.2% medium vs 67.8% large). Logistic regression models adjusted for unbalanced characteristics showed higher odds of TALE in the large vs small (odds ratio, [OR] 2.2; 95% confidence interval [CI], 1.4-3.3; P < .001) and large vs medium groups (OR, 1.69; 95% CI, 1.2-2.5; P < .05). The large vs small group also demonstrated higher odds of spinal ischemia, respiratory complications, MACE, and perioperative mortality. Hazard analysis showed increased risk of 8-year mortality in the large vs small (hazard ratio, 1.8; 95% CI, 1.1-2.8; P < .05) and large vs medium groups (hazard ratio, 1.5; 95% CI, 1.1-2.1; P < .05). Larger maximum aortic diameters are associated with worse outcomes following TEVAR for type B dissections. The incidence of TALE and the long-term risk of mortality increases at the 6.5 cm size category; therefore, elective type B dissection repair with TEVAR should be considered at aortic diameters of 6.5 cm or greater in suitable-risk patients with appropriate anatomy.TableAdjusted logistic regression on outcomes of interestOutcomesSmall vs mediumSmall vs largeMedium vs largeSpinal ischemia at discharge1.4(0.38-5.24)NS3.5(1.12-10.73)aP < .052.5(0.82-7.37)NSRespiratory complication1.5(0.80-2.69)NS2.2(1.21-4.01)aP < .051.0(0.86-2.63)NSMACE1.9(1.09-3.39)aP < .052.1(1.15-3.72)aP < .051.1(0.68-1.71)NSTALE1.3(0.84-1.96)NS2.2(1.42-3.29)bP < .051.7(1.16-2.44)aP < .05Perioperative mortality1.9(0.95-3.97)NS2.6(1.31-5.14)aP < .051.3(0.69-2.61)NSMACE, Major adverse cardiac events; NS, nonsignificant; TALE, thoracoabdominal life-altering events. Values are odds ratios (95% confidence intervals).aP < .05, bP < .001. Open table in a new tab