Thoracic Aortic Aneurysm Repair Research Articles

Using Machine Learning to Predict Outcomes Following Thoracic and Complex Endovascular Aortic Aneurysm Repair

Using Machine Learning to Predict Outcomes Following Thoracic and Complex Endovascular Aortic Aneurysm Repair

Effective Strategies for Managing Sudden Hemoptysis Caused by Aorto-Bronchial Fistula during Cardiopulmonary Bypass: A Case Report

Aorto-bronchial fistula (ABF) is a rare but life-threatening complication that can occur after thoracic endovascular aortic repair (TEVAR). The ABF clinical diagnosis can be challenging due to its insidious symptoms and potential for misdiagnosis. Managing endobronchial hemoptysis caused by ABF during cardiopulmonary bypass (CPB) is challenging due to limited clinical experience. We present a case of a patient who was previously treated with TEVAR for a thoracic aortic dissection and endovascular abdominal aortic aneurysm repair for an abdominal aortic aneurysm. The patient was admitted with intermittent hemoptysis over 1 year and chest pain for 3 days. Aortic computed tomography angiography (CTA) showed a recurrent dissection of the aortic arch. We encountered endotracheal hemoptysis during total arch replacement combined with a stented frozen elephant trunk under CPB. Due to the patient's prior history of TEVAR, the ABF was eventually diagnosed during the procedure; however, with the implementation of a series of measures, we were able to successfully resuscitate the patient. The literature suggests that this may be an exceedingly rare case of ABF successfully treated during CPB. Currently, there are no established clinical guidelines or consensus for the diagnosis and treatment of ABF after TEVAR due to the lack of case reports with extensive data. Timely identification of the bleeding bronchus, early activation of blood cell salvage, early neutralization of heparin activity, and timely resection of the diseased lobe are key to treating patients with ABF during CPB.

Clinical impact of proximal fixation augmentation using the Najuta thoracic fenestrated stent graft during endovascular treatment for distal aortic arch aneurysm

ObjectivePrevention of late type 1a endoleaks is the main concern in thoracic endovascular aortic aneurysm repair (TEVAR) for thoracic aortic aneurysm (TAA). Since 2017, we have performed zone 0 TEVAR with proximal fixation augmentation using a Najuta thoracic fenestrated stent graft in addition to zone 2 TEVAR for distal arch aneurysms. We report the early-midterm outcomes of TEVAR performed using this strategy. MethodsThis single-center retrospective study enrolled 386 cases of TEVAR for thoracic aortic disease between January 2013 and December 2020. Patients with TAA treated by TEVAR landing at zone 2 was referred to as the Standard group (S group), whereas those treated by TEVAR landing at zone 0 using a Najuta fenestrated stent graft in addition to zone 2 TEVAR was referred to as the Augmentation group (A group). We retrospectively compared the clinical outcomes between the two groups. The primary endpoint was secondary intervention for postoperative type1a endoleaks. Secondary endpoints were technical success, aneurysm-related death (ARD), and major adverse events (MAEs) including stroke, paraplegia, endoleaks, and secondary interventions. ResultsWe performed TEVAR in 41 and 30 cases in the S and A groups, respectively. The mean aneurysm sizes in the S and A group were 54.5 and 57.3 mm (p=0.23), and the proximal neck lengths were 16.8 and 17.4 mm (p = 0.65), respectively. The anatomical characteristics appeared to be similar in both groups. The technical success rate in both groups was 100%. Three cases in the S group had MAEs, including two stroke and one brachial artery pseudoaneurysm; whereas, 2 cases had MAEs in the A group, including one stroke and one paraplegia. There was no 30-day mortality or retrograde type A dissection in both groups. The mean observation periods in the S and A groups were 46 (1–123) and 35 (1–73) months, respectively. At 36 and 60 months post-procedure, the freedom from ARD was 97.6% and 97.6% in the S group, 100.0% and 100.0% in the A group (p=0.39); and the freedom from re-intervention for type1a endoleaks was 79.2% and 65.2% in the S group, 100.0% and 100.0% in the A group (p = 0.0087 < 0.05). A statistically significant reduction in re-intervention for type1a endoleaks was observed in the A group. ConclusionsProximal fixation augmentation using the Najuta fenestrated stent graft during TEVAR for distal arch aneurysm is effective in preventing the postoperative late type 1a endoleaks.

Long-term results of etiology-based thoracic endovascular aortic repair: a single-center experience.

The use of thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) and Stanford type B aortic dissection (TBAD) has been increasing; however, in terms of etiology, the differences of long term after TEVAR outcomes remain unexplored. Thus, we investigated etiology-specific long-term results of TEVAR for TAA and TBAD. A total of 421 TEVAR procedures were performed at our institution from July 2007 to December 2021; 249 TAA cases and 172 TBAD cases were included. Traumatic aortic dissection and aortic injury cases were excluded. The mean observation duration was 5.7years. The overall 30-day mortality rate was 1.4% (n = 6), with 1.2% (n = 3) in the TAA group and 1.7% (n = 3) in the TBAD group. The overall incidence of postoperative stroke was 0.9% (n = 4), with 1.2% (n = 3) and 0.6% (n = 1) in the TAA and TBAD groups, respectively (p = 0.90). Paraplegia developed in 1.7% (n = 7) of patients, with 2.4% (n = 6) in the TAA group and 0.6% (n = 1) in the TBAD group. Freedom from aortic-related death was not significantly different between the two etiologies; however, thoracic reintervention was more common in the TBAD group (p = 0.003), with endoleak being the most common indication for reintervention. Additionally, retrograde type A aortic dissection occurred in four TBAD cases, while migration occurred in three TAA cases. The perioperative results of TEVAR for TAA and TBAD were satisfactory. The long-term results were unfavorable owing to the occurrence of etiology-specific and common complications. In terms of the high frequency of reintervention, the long-term complications associated with TEVAR are etiology specific.

Suture-Based Vascular Closure Versus Surgical Closure of Large Bore Arteriotomies: A Real-World Experience.

With the introduction of transcatheter aortic valve implantation (TAVI), endovascular abdominal aortic aneurysm repair (EVAR), thoracic endovascular aortic aneurysm repair (TEVAR), and frequent use ofleft ventricular assist devices in complicated percutaneous coronary interventions, the use of large bore arterial access has become a necessity. In the index study, we compared the percutaneous closure of large arteriotomies with open surgical (OS) closure. It was a prospective study in which we compared the technical success and vascular complication rate associated with the use of a suture-based vascular closure device (VCD): Perclose ProGlide(PP) with that of OS closure. The study was carried out at Command Hospital Air Force,Bengaluru, India, from January 1, 2016, toDecember 31, 2020. The inclusion criteria were any percutaneous intervention involving large bore arterial access (≥12 French (F) sheath). The exclusion criteria were any condition where a persistent need for vascular access at the end of the procedure was required. We noted the baseline characteristicsand type of anesthesia for all patients. The primary outcome was technical success and major vascular complications, which included major local site bleeding: Bleeding Academic Research Consortium (BARC) 3 or more, failed hemostasis requiring a second intervention, and acute vessel occlusion. Total time taken for the procedure (TTP), time to ambulation (TTA), and time to discharge post-procedure (TTD) were noted for each patient. The secondary outcomes were any bleeding other than major, local hematoma sized >5 cm at 24 hours, pseudo aneurysm formation at 30 days, and acute limb ischemia at 30 days. A total of 120 patients (PP: 60 (males: 54, females: 6), OS: 60 (males: 50, females: 10)) were included in this study.The mean age of patients was comparable in both groups (PP: 71.8 ± 9.62 years and OS: 71.0 ± 7.76 years, p-value: 0.63). Total large arteriotomies (mean size: 18.03F ± 3.34) closed were 184 (PP: 90, OS: 94). The procedures performed were EVAR: 64 (PP: 30, OS: 34), TAVI: 38 (PP: 21, OS: 17), and TEVAR: 18 (PP: 9, OS: 9). All patients in PP group received dual ProGlide with preclose technique. All TEVAR procedures (total arteriotomies: 18) required a vascular sheath of ≥ 24F.There was no statistical difference between the mean size of sheaths used in the two groups. The technical success (PP: 95.55%, OS: 97.87%, 95% CI: -5.78%-10.98%, p-value: 0.48) and rate of major complications were similar in both groups. Three patients in the PP group who had failed hemostasis with two ProGlides were successfully managed with one additional Angioseal (6F) each.The occurrence of hematoma sized larger than 5 cm was significantly more in the PP group compared to the OS group (PP: 7 (7.78%), OS: 0 (0%), p-value: 0.006). While GA was used for all patients who underwent vascular closure with OS, only eight patients (13.33%) in the PP group required GA. The TTP, TTA, and TTD were significantly lower in the PP group as compared to the OS group. The percutaneous closure of large bore arteriotomies with suture-based VCDs is equally effective and is not associated with increased major vascular complications. In fact, the TTP, TTA, and TTD are significantly lower in the PP group which can translate to better patient comfort and lower costs.

Prevalence of Genetic Variants and Deep Phenotyping in Patients with Thoracic Aortic Aneurysm and Dissection: A Cross-Sectional Single-Centre Cohort Study.

There is a paucity of evidence on people with thoracic aortic aneurysm and dissection. We aimed to determine the prevalence of genetic variants and their associations with phenotypes. In this cross-sectional single-centre cohort study of consecutive patients who underwent endovascular or open-surgical repair of thoracic aortic aneurysm and dissection, genetic analysis was performed using four-stage Next Generation Sequencing, and findings were confirmed with Sanger sequencing. We collected personal and family history on comorbidities, clinical examination, anthropometrics, skeletal deformities, joint function, and ophthalmological measures. Cardiovascular risk and phenotype scores were calculated. Ninety-five patients were eligible (mean age 54 ± 9 years, 70% males, 56% aortic dissection). One-fifth had a family history of aortic disease. Furthermore, 95% and 54% had a phenotype score of ≤5 and ≤2, respectively. There were no significant differences in the distribution of phenotype characteristics according to age, sex, aortic pathology, or performed invasive procedures. Genetic variants of uncertain significance were detected in 40% of patients, with classic mutations comprising 18% of all variants. We observed no significant association with cardiovascular and phenotype scores but with higher joint function scores (p = 0.015). Genetic variants are highly present in clinically relevant aortic pathologies. Variants appear to play a larger role than previously described. The different variants do not correlate with specific phenotypes, age, pathology, sex, or family history.

Significance of isolated postoperative atrial fibrillation in thoracic aortic aneurysm repair

ObjectiveAlthough postoperative atrial fibrillation has been shown to be associated with worse survival after thoracic aortic surgery, its effect on outcomes independently from other postoperative complications is not well understood. MethodsThis is a single-center retrospective study of patients who underwent open thoracic aortic aneurysm repair between March 2005 and March 2021. Postoperative atrial fibrillation was defined as new-onset atrial fibrillation that developed during the index hospital stay. Patients with preoperative atrial fibrillation were excluded. Postoperative major complications included reoperation for bleeding, respiratory failure, acute renal failure, and stroke. Variables associated with postoperative atrial fibrillation were analyzed with multivariable regression. Survival of patients without major complications was compared between patients without atrial fibrillation and patients with postoperative atrial fibrillation after propensity score matching for baseline and intraoperative characteristics. ResultsOf 1454 patients, 520 (35.8%) were observed to have postoperative atrial fibrillation. Patients with postoperative atrial fibrillation had a higher rate of postoperative major complications than those without atrial fibrillation (20.2% vs 12.2%, P < .001). Ten-year survival was 82.0% in patients with postoperative atrial fibrillation and 87.0% in patients without atrial fibrillation (P = .008). In the cohort of patients without complications, 10-year survival was similar between patients with and without postoperative atrial fibrillation after propensity score matching (83.6% vs 83.8%, P = .75). ConclusionsPostoperative atrial fibrillation is common after open proximal thoracic aortic aneurysm repair. Although development of major postoperative complications is associated with postoperative atrial fibrillation and decreased long-term survival, isolated postoperative atrial fibrillation does not appear to influence long-term survival.

Costs of endovascular and open repair of thoracic aortic aneurysms.

Repair of thoracic aortic aneurysms with either endovascular repair (TEVAR) or open surgical repair (OSR) represents major surgery, is costly and associated with significant complications. The aim of this study was to establish accurate costs of delivering TEVAR and OSR in a cohort of UK NHS patients suitable for open and endovascular treatment for the whole treatment pathway from admission and to discharge and 12-month follow-up. A prospective study of UK NHS patients from 30 NHS vascular/cardiothoracic units in England aged ≥18, with distal arch/descending thoracic aortic aneurysms (CTAA) was undertaken. A multicentre prospective cost analysis of patients (recruited March 2014-July 2018, follow-up until July 2019) undergoing TEVAR or OSR was performed. Patients deemed suitable for open or endovascular repair were included in this study. A micro-costing approach was adopted. Some 115 patients having undergone TEVAR and 35 patients with OSR were identified. The mean (s.d.) cost of a TEVAR procedure was higher £26 536 (£9877) versus OSR £17 239 (£8043). Postoperative costs until discharge were lower for TEVAR £7484 (£7848) versus OSR £28 636 (£23 083). Therefore, total NHS costs from admission to discharge were lower for TEVAR £34 020 (£14 301), versus OSR £45 875 (£43 023). However, mean NHS costs for 12 months following the procedure were slightly higher for the TEVAR £5206 (£11 585) versus OSR £5039 (£11 994). Surgical procedure costs were higher for TEVAR due to device costs. Total in-hospital costs were higher for OSR due to longer hospital and critical care stay. Follow-up costs over 12 months were slightly higher for TEVAR due to hospital readmissions.

The Impact of Serum Interleukin-4, Interleukin-10, Interleukin-17a, and Interleukin-22 Levels on the Development of Sporadic Ascending Aortic Aneurysms

Introduction: Aortic aneurysms are chronic diseases associated with inflammatory/immunological mechanisms. Interleukins (ILs) with pro-inflammatory and anti-inflammatory activities are shown to be related to the development of aortic damage. In this context, this study aims to evaluate the serum IL-4, IL-10, IL-17A, and IL-22 in patients with sporadic thoracic ascending aortic aneurysms. Patients and Methods: The population of this prospective study consisted of all consecutive patients with sporadic ascending aortic aneurysms who underwent thoracic aortic aneurysm repair between November 2019 and September 2022. In the end, 29 patients (the patient group) and 19 healthy voluntary participants without aortic pathology (the control group) were included in the study. The study’s primary outcome was the differences in serum IL levels between the groups. Results: The patient group was significantly older than the control group (p= 0.042). Significantly higher neutrophil-to-lymphocyte ratio (NLR) values were detected in the patient group (p= 0.031). The median IL10 (p= 0.001), IL-17A (p&lt; 0.001), and IL-4 (p&lt; 0.001) levels were significantly lower in the patient group than in the control group. There were no significant correlations between serum IL levels and the aneurysm diameter (p&gt; 0.05). On the other hand, there were moderate correlations between IL-10 and IL-17A (r= 0.409, p= 0.038), IL-10 and IL-22 (r= 0.464, p= 0.017), and IL-17A and IL-4 (r= 0.496, p= 0.006). NLR ≥1.95 was found to be an independent risk factor for sporadic ascending aortic aneurysms [Odds Ratio (OR)= 4.53, 95% confidence interval (CI)= 1.12-21.17, p= 0.040]. Conclusion: IL-10, IL-17A, and IL-4 were significantly lower in patients with sporadic ascending aortic aneurysms larger than 55 mm. NLR was an independent risk factor for sporadic ascending aortic aneurysms. The diameter of the aneurysm was not correlated with ILs. There were positive correlations between IL-10, IL-17A, and IL-4 levels.

The revascularization of the left subclavian artery with a cross over axilloaxillary bypass for the hybrid repair of thoracic aortic aneurysms

The revascularization of the left subclavian artery with a cross over axilloaxillary bypass for the hybrid repair of thoracic aortic aneurysms

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.

Discussion to: Midterm outcomes of open repair versus endovascular descending thoracic aortic aneurysm repair

Discussion to: Midterm outcomes of open repair versus endovascular descending thoracic aortic aneurysm repair

Outcomes of open repair for descending thoracic and thoracoabdominal aortic aneurysm in recent 10 years: experience of a high-volume centre in Korea.

Although recent studies and guidelines suggest the preferred outcomes after surgical repair of thoracic aortic aneurysm (TAA) and thoracoabdominal aortic aneurysm (TAAA), published results are limited to those from high-volume hospitals and based on old data gathered before optimal management was established. Here, we analysed our outcomes over the previous 10 years from cases of open TAA and TAAA repair to offer updated and real-world results of those complex procedures performed in a high-volume centre. From November 2013 to April 2022, 212 consecutive adult patients who underwent open TAA and TAAA repair were enrolled. We analysed early and late outcomes after surgery, including postoperative complications and mortality. There were 154 (73%) men, and the median age at surgery was 61 years. Intraoperative death occurred in 1 patient due to uncontrolled bleeding. Nine patients (4%) died during follow-up, and the survival estimates at 5 years were 94 ± 3% and 95 ± 3% after descending TAA and TAAA repair, respectively. Ten patients (4%) suffered from spinal cord ischaemic injury (9 with paraplegia and 1 with paresthesia), but permanent paraplegia persisted in only 1 case. We report very low postoperative complication rates and excellent early and late survival rates after open TAA and TAAA repair from our recent 10-year data analysis. These findings may assist when choosing treatment options for these complicated diseases.

Midterm outcomes of open repair versus endovascular descending thoracic aortic aneurysm repair

ObjectiveThe study objective was to evaluate the midterm outcome of thoracic endovascular aortic repair compared with open repair in patients with descending thoracic aortic aneurysm. MethodsFrom August 1993 to February 2023, 499 patients with descending thoracic aortic aneurysms underwent open repair (n = 221) or thoracic endovascular aortic repair (n = 278). Of these, 120 matched pairs were identified using propensity score matching based on age, sex, chronic lung disease, stroke, coronary artery disease, diabetes, ejection fraction, dialysis, peripheral vascular disease, prior cardiac surgery, connective tissue disease, and chronic dissection. Primary outcomes were postoperative paralysis, operative mortality, reoperation, and midterm survival. ResultsAfter matching, the preoperative demographics and comorbidities were balanced in both groups. Intraoperatively, open repair had a lower temperature (18 °C vs 36 °C) and more patients required blood products (66% vs 8%), P < .001. Postoperatively, patients undergoing thoracic endovascular aortic repair had fewer strokes (2.5% vs 9.2%; P = .03), less dialysis (0% vs 3.3%; P = .04), and shorter length of stay (5 days vs 12 days, P < .001), but similar lower-extremity paralysis (2.5% vs 2.5%, P = 1.00) compared with open repair. Furthermore, thoracic endovascular aortic repair had higher 7-year incidence of first reoperation (16.1% vs 3.6%, P < .001) but similar operative mortality (0.8% vs 4.2%; P = .10) and 10-year survival outcome (56%; 95% CI, 43-72 vs 58%; 95% CI, 49-68; P = .55) compared with open aortic repair. The hazard ratio was 0.93 (P = .78) for thoracic endovascular aortic repair for midterm mortality and 6.87 (P < .001) for reoperation. ConclusionsOpen repair could be the first option for patients with descending thoracic aortic aneurysms who were surgical candidates.

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.

Impact of preoperative identification of the artery of Adamkiewicz on spinal cord injury after descending aortic and thoracoabdominal aortic repair.

Some recent reports have demonstrated that preoperative Adamkiewicz artery (AKA) identification and its targeted reconstruction has provided satisfactory outcomes with respect to spinal cord protection. This paper investigates the impact of preoperative identification of the AKA on reducing the incidence of spinal cord injury (SCI) in open repair (OR) and endovascular repair (EVR) of descending thoracic aortic (dTA) and thoracoabdominal aortic aneurysm (TAA) repair. The clinical data of patients with dTA and TAA treated between 2011 and 2022 were investigated. A total of 256 patients comprising of 201 males and 55 females, with a mean age of 72.1±10.0 years, were included. OR was used in 102 patients and EVR in 154 patients whose distal landing zone was below T8, all of which needed preoperative identification of the AKA. The AKA was identified in 207 (80.9%) patients, and was located in the level between T8 and T12 in 81.2%. In OR, the responsible arteries, including the identified AKA, were promptly reconstructed in 66 (64.7%) patients. In EVR, 65 (42.2%) patients had the AKA covered by an endovascular prosthesis. Deaths prior to 30 days occurred in seven (2.7%, four in OR and three in EVR) patients. In OR, SCI occurred in six (5.9%) patients including three (2.9%) with paraplegia and three (2.9%) with paraparesis, whereas in EVR ten (6.5%) patients had SCI, including two (1.3%) with paraplegia and eight (5.2%) with paraparesis. The incidence of SCI was significantly higher in patients with the AKA covered than those without it covered [13.8% (9 of 65) vs. 1.1% (1 of 89); P=0.002], whereas no significant differences were found between patients with or without the AKA reconstructed. Preoperative identification of the AKA was useful enough to determine treatment strategies with less likelihood of SCI in both OR and EVR for dTA and TAA pathologies.

941 A Systematic Review of Surgical Intervention Criteria for Thoracic Aortic Aneurysms

Abstract Aim Elective surgical repair of thoracic aortic aneurysms (TAAs) is the only treatment that prevents dissection or rupture. Current guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology, recommend an aortic diameter threshold of 5.5cm for surgical intervention of TAAs. Recent studies have questioned the efficacy of current guidelines as they highlighted that the majority of dissections occur before reaching the threshold. This review aims to determine if an aortic diameter of 5.5cm is an appropriate threshold for prophylactic surgical repair of non-syndromic ascending TAAs. Method A search of Ovid MEDLINE and Pubmed databases was performed. Search terms included “ascending thoracic aortic aneurysm”, “ATAA”, “aortic diameter” and “aortic size paradox”. Non-English papers, animal studies and case reports were excluded. Reference lists from each article were assessed for further literature which met the inclusion criteria. Results 22 studies were included. Four themes emerged from these papers which support lowering the threshold for prophylactic surgery: quantifying the changes in aortic diameter that occur during dissection, the discovery of the aortic size paradox, the identification of a new hinge point, and the improved safety of modern surgery. Regardless of this evidence, it appears to be unjustified to lower the threshold based on relative risk calculations. Conclusions Despite current guidelines, the use of aortic diameter as a risk assessment tool for TAAs is inadequate. Multiple studies have shown the ineffectiveness of a 5.5cm threshold, suggesting revision of current surgical guidelines is warranted.

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.

Sandwich thoracic branch endoprosthesis technique for endovascular repair of thoracic aortic aneurysm with aberrant right subclavian artery

Subclavian artery coverage is frequently required to achieve an adequate proximal seal during thoracic endovascular aortic repair. The thoracic branch endoprosthesis (TBE; W.L. Gore & Associates) is the first U.S. Food and Drug Administration–approved branched device for thoracic endovascular aortic repair, designed for left subclavian artery incorporation. However, anatomic suitability of the TBE has been shown to be limited. In the present report, we describe a novel technique using the TBE in a sandwich periscope configuration to allow for emergent repair of a ruptured thoracic aortic aneurysm with a highly angulated proximal seal zone and aberrant right subclavian artery.

Neuromonitoring for descending thoracic and thoracoabdominal aortic aneurysm repair.

Neuromonitoring for descending thoracic and thoracoabdominal aortic aneurysm repair.