Thoracic Endovascular Aortic Repair For Type B Aortic Dissection Research Articles

Incidence, Predictors, and Implications of Secondary Aortic Intervention Following Thoracic Endovascular Aortic Repair for Type B Dissection.

Secondary aortic intervention (SAI) following thoracic endovascular aortic repair (TEVAR) is not uncommon. However, a satisfactory management system has not been established for these patients. We aimed to report our single-center experience with SAI after prior TEVAR for type B aortic dissection (TBAD). From January 2010 to May 2017, 860 eligible patients with TBAD underwent TEVAR. One hundred seven (12.4%) patients required SAI, either endovascularly (n=76) or surgically (n=31). The main indications for SAI were entry flow (n=58 [54.2%]), aneurysm expansion of the proximal or remote aorta (n=26 [24.3%]), retrograde type A aortic dissection (n=11 [10.3%]), distal stent-graft-induced new entry tear (n=6 [5.6%]), and stent migration (n=4 [3.7%]). The Kaplan-Meier curves were generated to determine the degree of freedom from SAI and the prognosis. Cox proportional hazards were used to screen for risk factors for SAI and poor prognosis. The overall 30-day mortality rate after SAI was 4.7% (n=5): endovascular (n=2 [2.6%]) vs open surgery (n=3 [9.7%]; p=0.145). The cumulative survival rates with or without SAI were 86.3%±3.6% vs 95.7%±0.8% at 3 years and 82.0%±4.2% vs 92.2%±1.1% at 5 years, respectively (log-rank p<0.001). Although no significant difference in survival was observed, the incidence of SAI was significantly greater in patients who underwent TEVAR during the chronic phase (acute [11.6%] vs subacute [9.6%] vs chronic [27.8]; p<0.001). Multivariate regression analysis revealed that prior TEVAR in the chronic phase (hazard ratio [HR]=1.73, 95% confidence interval [CI]=1.03-2.90; p=0.039), maximum aortic diameter (HR=1.05, 95% CI=1.04-1.07; p<0.001), and arch involvement (HR=1.48, 95% CI=1.01-2.18; p=0.048) were predictors of the incidence of SAI. In addition, the maximum aortic diameter was demonstrated to be the only risk factor for prognosis after adjusting for confounding factors. Thoracic endovascular aortic repair for chronic TBAD patients should be reconsidered. Open surgery is preferable for those with proximal progression, whereas endovascular treatment is more suitable for distal lesions. Close surveillance and timely reintervention after TEVAR, whether via endovascular techniques or open surgery, are necessary to prevent devastating complications. The management of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR) is challenging. We summarized our single-center experience regarding secondary aortic intervention after TEVAR for TBAD. We found that TEVAR for chronic TBAD patients should be carefully evaulated, and open surgery is recommended for those with proximal progession, while endovascular treatment is more preferable for distal lesions.

5-Year Outcomes of Endovascular Treatment for Aortic Dissection From the Global Registry for Endovascular Aortic Treatment

Global Registry for Endovascular Aortic Treatment (GREAT) is an International prospective multicenter registry collecting real-world data on performance of W. L. Gore (Flagstaff, AZ) aortic endografts. The purpose is to analyze long term outcomes/patient survival and device performance in patients undergoing thoracic endovascular aortic repair (TEVAR) for acute/chronic and complicated/uncomplicated Type B aortic dissection (TBAD). From August 2010 to October 2016, 5014 patients were enrolled in the GREAT registry. The study population were patients treated with TEVAR for TBAD through 5-year follow-up (day 0-2006). The primary outcomes for this analysis were all-cause and aortic-related mortality, stroke, aortic rupture, endoleaks, migration, fracture, compression, and any reintervention through 5-years. 265 patients were identified. Mean age was 60.9 ± 11.9 years [range, 19-84 years; 211 (79.6%) males]. Devices used were GORE® TAG® and Conformable GORE® TAG® Thoracic Endoprosthesis (TAG/CTAG) (W.L. Gore, Flagstaff, AZ). 228 patients (86.0%) underwent primary endovascular treatment [144 (54.3%) off-label]. 22 (8.3%) underwent reintervention after prior endovascular procedure, 15 (5.7%) underwent reintervention after prior open procedure. Kaplan-Meier estimated freedom from all-cause mortality at 5 years was 71.1%. Freedom from aortic-related mortality through 5 years was 95.8%. There was no significant difference in freedom from all-cause mortality during the follow-up period in complicated or uncomplicated disease. At 30 days and through 5 years respectively for all following outcomes, aortic rupture rate was 1.1% (n=3) and 1.9% (n=5). Stroke rate was 1.1% (n=3) and 4.2% (n=11). Spinal cord ischemic event rate was 1.5% (n=4) and 2.6% (n=7). Re-interventions were required in 6.4% (n=17) and 21.1% (n=56) of patients. Need for conversion to open repair was 0.4% (n=1) and 2.6% (n=7). Additional graft placement was required in 3 patients (1.1%) and 16 patients (6.0%). Endoleak rate at 30 days was 3.4% [n=9; Type IA (n=1; 0.4%), Type IB (n=4; 1.5%), Type II (n=1; 0.4%), Type III (n=1; 0.4%) and unspecified (n=4; 1.6%)]. Through 5 years, endoleak rate was 12.1% [n=32; Type IA (n=7; 2.6%), Type IB (n=10; 3.8%), Type II (n=9; 3.4%), Type III (n=2; 0.8%) and unspecified (n-12, 4.5%)]. There were no cases of stent migration, compression or fracture through 5 years. Results at 5-year follow-up demonstrate that the use of TAG/CTAG can be supported in treatment of TBAD (acute, chronic, complicated and uncomplicated). These data demonstrate strong device durability, beneficial patient outcomes, and support for treatment of thoracic aortic dissection with an endovascular approach. Complete 10-year follow-up in GREAT as planned will be advantageous.

Initial experience with a modified "candy-plug" technique for false lumen embolization in chronic type B aortic dissection.

Persistent distal false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) can lead to aneurysmal degeneration and an increased risk of rupture. We have presented our initial experience using a modified "candy-plug" (CP) technique for FL embolization. From February 2021 to July 2022, we treated six patients using the modified CP technique. All the patients had undergone prior or simultaneous TEVAR for chronic TBAD with persistent FL perfusion and aneurysm expansion. Bilateral common femoral artery access was obtained, and intravascular ultrasound was used to confirm wire access in the true lumen (TL) and FL. A conformable TAG device (W.L. Gore & Associates, Flagstaff, AZ) was used in four cases and an Excluder aortic cuff (W.L. Gore & Associates) in two cases. The device was modified by placing a constraining "napkin-ring" suture through the middle segment of the device. Femoral sheaths were placed in the TL and FL. A standard TL TEVAR extension was performed at the level of the celiac artery (zone 5). Next, the CP device was advanced and deployed in the FL, distally aligning it with the TL device. An appropriately sized Amplatzer II plug (Abbot Vascular, Santa Clara, CA) was then deployed in the constrained segment of the modified stent graft. Completion angiography was performed to confirm successful FL embolization. Technical success was defined as successful deployment of the CP device in the FL. The technical success rate was 100% (six of six patients). Clinical success was defined as the cessation of aneurysm growth on follow-up computed tomography angiography. No 30-day mortality, myocardial infarction, stroke, spinal cord ischemia, access site complications, or aortic-related reinterventions occurred. Surveillance imaging at a mean follow-up of 10months confirmed clinical success (stable aneurysm size or shrinkage) for all five patients with follow-up data available. The modified CP embolization technique is a promising solution for persistent distal FL perfusion after TEVAR for TBAD. Further investigation is required to determine the long-term durability of this technique as an adjunct to TEVAR to promote aortic remodeling.

Endovascular therapy for Stanford B aortic dissection for patients with Marfan Syndrome: systematic review and meta-analysis.

The role of thoracic endovascular aortic repair (TEVAR) in patients with Marfan Syndrome with Stanford type B aortic dissection (TBAD) remains under debate. MEDLINE and EMBASE were searched through December 2021 to identify studies that investigated outcomes in MFS patients with TBAD who underwent TEVAR. Data regarding patient characteristics, perioperative and late outcomes were extracted. Twelve studies were identified including 120 patients. The mean age was 40.2 years (95% confidence interval [CI], 36.8-43.6). 40.4% (95% CI: 10.8-70.0) of cases were performed emergently. 76.2% (95% CI: 64.6-87.8) of patients had a history of previous aortic surgery. In-hospital mortality was 3.7% (95% CI: 0.6-6.8). Primary endoleak occurred in 15.2% (95% CI: 8.6-21.8), which was comprised of type 1 (9.3% [95% CI: 3.9-14.6]) and type 2 (7.1% [95% CI: 2.3-12.0]) endoleaks. During mean follow-up period of 37.4 months (95% CI: 24.1-50.7), secondary endoleak was reported in 14.1% (95% CI: 7.1-21.1), which was comprised of type 1 (7.4% [95% CI: 2.4-12.5]) and type 2 (4.0% [95% CI: 0.3-7.7]) endoleak. Repeat TEVAR was performed in 15.5% (95% CI: 9.3-21.8) and open aortic surgery in 18.6% (95% CI: 9.6-27.5). Long-term mortality was 11.9% (95% CI: 6.5-17.3). Our analysis showed that TEVAR for TBAD in patients with MFS has low perioperative morbidity and mortality but was associated with a high rate of late reintervention. This treatment option should be limited to emergent cases and to patients deemed unsuitable for open repair. Lifelong follow-up with imaging is mandatory in this population.

Prognosis and Risk Factors of Stroke After Thoracic Endovascular Aortic Repair for Stanford Type B Aortic Dissection.

Background: Stroke is a severe complication of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). Our aim is to identify predictors of stroke after TEVAR.Methods: From February 2016 to February 2019, 445 patients with TBAD who underwent TEVAR were retrospectively analyzed. Univariate and multivariate analyses were performed to identify predictors of stroke after TEVAR.Results: The total incidence of stroke was 11.5%, with transient neurological dysfunction (TND) of 10.6% and permanent neurological dysfunction (PND) of 0.9%. The average age of the patients was 53.0 ± 3.2 years, and the male/female ratio was 1.17. Univariate analysis suggested that age, body mass index (BMI), diabetes mellitus, chronic obstructive pulmonary disease (COPD), the urgency of repair, type of anesthesia, and left subclavian artery (LSCA) processing were potential risks factors of stroke after TEVAR. Multiple logistic regression identified that LSCA coverage (OR = 5.920, 95% CI: 2.077–16.878), diabetes mellitus (OR = 3.036, 95% CI: 1.025–8.995), and general anesthesia (OR = 2.498, 95% CI: 1.002–6.229) were independent predictors of stroke after TEVAR.Conclusions: Left subclavian artery (LSCA) coverage, diabetes mellitus, and general anesthesia were independent risk factors of stroke after TEVAR for TBAD.

Remodeling of Aortic Configuration and Abdominal Aortic Branch Perfusion After Endovascular Repair of Acute Type B Aortic Dissection: A Computed Tomographic Angiography Follow-Up.

Background: Thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) induces false lumen (FL) thrombosis, promotes favorable aortic remodeling, and makes an impact on abdominal aortic branch perfusion patterns. However, little is known about the long-term fate of aortic remodeling and abdominal aortic branch perfusion after TEVAR for TBAD and the effect of FL thrombosis status on these changes.Materials and methods: Between January 2014 and May 2021, 59 enrolled patients with acute TBAD were treated with TEVAR and had post-operative or follow-up images. Pre-operative, post-operative, and latest follow-up CT angiography (CTA) data were analyzed for the largest diameter of true lumen (TL), FL, and transaorta and for the FL thrombosis status on the stented thoracic aorta, unstented thoracic aorta, and abdominal aorta. Abdominal aorta perfusion patterns were characterized.Results: The mean follow-up period was 17.1 months. In the stented thoracic aorta, average TL diameters increased, average FL diameters decreased, and average transaortic diameters did not change; 82.6% of the patients had either a stable or shrinking transaortic size and 87% of the patients achieved total FL thrombosis. In the unstented thoracic aorta, average TL diameters increased, transaortic growth and no changes occurred in 39.1 and 45.7% of the patients, respectively, and complete FL thrombosis was present in 50% of the patients. In the abdominal aorta, average FL and transaortic diameters increased, aorta was expanded in 52.2% of the patients, and FL remained patent in 65.2% of the patients. Of the 354 branches, 37 branches (10.5%) exhibited changes in perfusion patterns, 22 branches (6.2%) demonstrated an increased TL perfusion, and 15 branches (4.2%) had an increased FL contribution. Compared with patent or partially thrombosed FL, complete FL thrombosis was accompanied by a bigger decrease in FL diameters, a larger increase in TL diameters, and a higher percentage of abdominal branch TL perfusion.Conclusions: In majority of the patients, TEVAR stabilized the size of the stented thoracic aorta, namely TL expansion and FL obliteration. However, abdominal aortic FL remained patent FL, and it was expanded with the resultant transaortic growth over a long follow-up period. Abdominal aortic branch perfusion patterns remained largely stable after TEVAR. The failure to achieve FL thrombosis negatively affects the remodeling of a contagious abdominal aortic dissection.

Impact of High-Risk Features and Timing of Repair for Acute Type B Aortic Dissections

The new Society for Vascular Surgery reporting standards for type B aortic dissection (TBAD) categorize clinical presentations of aortic dissection into uncomplicated, high-risk features (HRFs) and complicated groups. Although it is accepted that complicated dissections require immediate repair, the optimal timing of repair for those with HRFs has yet to be established. We aimed to identify the ideal timing of thoracic endovascular aortic repair (TEVAR) for HRFs and the outcomes associated with specific HRFs. The Vascular Quality Initiative was queried for TEVARs performed for acute and subacute TBAD with HRFs from 2014 to 2020. Rupture, malperfusion, and uncomplicated cases were excluded. HRFs were defined per the Society for Vascular Surgery guidelines as refractory hypertension, pain, and rapid aneurysm expansion or aneurysm size >40 mm. The primary outcomes were in-hospital or 30-day mortality and 1-year survival, with primary exposure variables of the interval (in days) from symptoms to repair and the number of HRFs. The secondary outcomes were spinal cord ischemia, myocardial infarction, stroke, and retrograde type A dissection. Of the 1100 patients who met the inclusion criteria, 811 had one HRF, 249 had two, and 40 had three. No significant differences were found in the primary or secondary outcomes according to the number of HRFs. Of the 1100 patients, 309 had undergone repair at 0 to 2 days, 262 at 3 to 6 days, 270 at 7 to 14 days, and 259 at ≥15 days. TEVAR performed at ≥15 days was independently associated with lower in-hospital and 30-day mortality (odds ratio, 0.38; P = .0388) and improved 1-year survival. Postoperative stroke was associated with earlier repair (0-2 days). No association was found between the timing of repair with myocardial infarction, spinal cord ischemia, retrograde type A dissection, or reintervention (Tables I and II). TEVAR for TBAD with HRFs delayed for ≥15 days from symptom onset was associated with improved survival, supporting the theory that it is best to delay TEVAR to the subacute phase. Additionally, TEVAR delayed ≥3 days was associated with a decrease in stroke. The presence of more than one HRF was not associated with worse outcomes. Because the classification of HRF is relatively new and without guidelines regarding repair, the present results highlight the risks of early intervention for patients with HRFs and suggest that these patients will benefit from at least a short stabilization period before TEVAR.Table IUnivariate analysis of impact of timing and HRFs on outcomes after TEVARVariableResultsP valueHRF1 (n = 811)2 (n = 249)3 (n = 40)NA Spinal cord ischemia42 (5.2)8 (3.2)3 (7.5).32 Myocardial infarction15 (1.9)1 (0.4)1 (2.5).17 Stroke49 (6)11 (4.4)2 (5).61 Retrograde type A dissection14 (1.7)4 (1.6)0 (0).99Interval to repair, days0-2 (n = 309)3-6 (n = 262)7-14 (n = 270)≥15 (n = 259) Spinal cord ischemia22 (7.1)8 (3.1)11 (4.1)12 (4.6).12 Myocardial infarction5 (1.6)4 (1.5)4 (1.5)4 (1.5).99 Stroke34 (11)11 (4.2)11 (4.1)6 (2.3)< .0001 Retrograde type A dissection4 (1.3)5 (1.9)3 (1.1)6 (2.3).69HRF, High-risk feature; TEVAR, thoracic endovascular aortic repair.Data presented as number (%).Boldface P values represent statistical significance. Open table in a new tab Table IIMultivariate analysis of impact of operative timing and HRFs on outcomesVariableRelated reinterventionIn-hospital/30-day mortalityOR95% CIP valueOR95% CIP valueInterval to repair 0-2 DaysRefRef 3-6 Days0.7440.38-1.455.38711.0150.499-2.063.9674 7-14 Days0.740.38-1.442.37690.4650.199-1.083.076 ≥15 Days0.5580.272-1.142.11040.380.152-0.951.0388HRFs 1RefRef 20.9840.54-1.79.9571.7250.9-3.307.1005 30.9310.21-4.121.92451.7890.465-6.876.3972CI, Confidence interval; HRF, high-risk feature; OR, odds ratio; Ref, reference.Boldface P values represent statistical significance. Open table in a new tab

Hospitalization Cost and In-hospital Outcomes Following Type B Thoracic Aortic Dissection Repair

Several studies have reported lower mortality and morbidity after thoracic endovascular aortic repair (TEVAR) when compared to open surgical repair (OSR) in the treatment of type B aortic dissection (TbAD). However, there are few studies in the literature on the cost of both treatment options. Thus, the aim of this study is to focus on in-hospital outcomes and cost associated with TbAD repair procedures in a national database in the United States. A retrospective review of the Premier Healthcare Database (PHD) between June 2009 and March 2015 was performed. ICD-9-CM codes were used to identify patients who underwent OSR or TEVAR for TbAD. Endpoints included in-hospital adverse events, in-hospital mortality and hospitalization cost. Logistic regression models and generalized linear models were used to assess the impact of treatment type on the main outcomes. Out of 1752 patients with TbAD, 54.3% underwent OSR and 45.7% underwent TEVAR. Patients in the TEVAR group were older [median age, 64 (IQR 54-73) vs. 59 (IQR 49-70), P < 1] and more likely to have preexisting comorbidities. IAE rates were 78.6% for the OSR group compared to 43.1% for the TEVAR group, P < 0.001. Patients in the OSR group showed significantly higher in-hospital mortality (15.3% vs. 5.9%, P < 0.001). After adjusting for potential confounders, OSR was associated with a 5-fold increase in IAE [aOR(95%CI): 4.8 (3.8-6.1), P < 0.001] and a 3-fold increase in in-hospital mortality [aOR(95%CI): 3.3 (2.1-5.1), P < 0.001]. In regards to charges related to the hospital stay, total cost was significantly higher among patients undergoing OSR $53,371 ($39,029-$80,471) vs. TEVAR $45,311 ($31,479-$67,960), P < 0.001. The present study shows that TEVAR presents an advantage in terms of morbidity, mortality and cost when compared to OSR in the treatment of TbAD. However, long-term cost-effectiveness of both procedures remains unknown. Further research is warranted to see whether the superiority of TEVAR is maintained over time.

Influence of TEVAR on blood pressure in subacute type B aortic dissection (TBAD) patients with refractory and non-refractory arterial hypertension

Aim of this study was to compare the modifications of systemic blood pressure in patients with subacute type b aortic dissection (TBAD) and refractory (rHTN) and non-refractory arterial hypertension (N-rHTN) treated by thoracic endovascular aortic repair (TEVAR). Patients were divided into two groups, rHTN defined as blood pressure >140/90 mmHg with ≥5 antihypertensive drugs and patients with N-rHTN. Primary endpoint was the variation of mean systolic, diastolic and overall pressure (MSP, MDP and MAP) before and after antihypertensive treatment or TEVAR. Secondary endpoints were the 30-days mortality. Fifty-seven patients were included in this study. Of the 44 Patients of the TEVAR group 21 were included in the N-rHTN group. The MSP before and after surgery for the N-rHTN group was 130 (±10 SD) and 111 (±22 SD) mmHg, P=0.01. In the rHTN group 164 (±17 SD) and 118 (±17 SD) mmHg (P=0.01). The reduction of MSP was greater in the rHTN group (P=0.01). The MAP before and after the TEVAR for the N-rHTN group was 90 (±10 SD) and 74 (±12 SD) mmHg (P=0.01), in the rHTN group 111 (±14 SD) and 70 (±9 SD) mmHg (P=0.01). The overall mortality rate group was 2.2% (1/44). TEVAR for TBAD appears to positively affect blood pressure in patients with rHTN and N-rHTN.

Risk factors and early outcomes of acute renal injury after thoracic aortic endograft repair for type B aortic dissection.

BackgroundThoracic endovascular aortic repair (TEVAR) has become an emerging treatment modality for acute type B aortic dissection (TBAD) patients in recent years. The risk factors and impacts of acute kidney injury (AKI) after percutaneous TEVAR, however, have not been widely established.MethodsWe retrospectively studied the clinical records of 305 consecutive patients who admitted to our institution and had TEVAR for TBAD between December 2009 and June 2013. The patients were routinely monitored for their renal functions preoperatively until 7 days after TEVAR. The Kidney Disease Improving Global Guidelines (KDIGO) criteria were used for AKI.ResultsOf the total 305 consecutive patients, 84 (27.5%) developed AKI after TEVAR, comprising 66 (21.6%) patients in KDIGO stage 1, 6 (2.0%) patients in stage 2 and 12 (3.9%) patients in stage 3. From the logistic regression analysis, systolic blood pressure (SBP) on admission >140 mmHg (odds ratio [OR], 2.288; 95% CI, 1.319–3.969) and supra-aortic branches graft bypass hybrid surgery (OR, 3.228; 95% CI, 1.526–6.831) were independent risk factors for AKI after TEVAR. Local anesthesia tended to be a protective factor (OR, 0.563; 95% CI, 0.316–1.001). The preoperative renal function, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or statin administration, volume of contrast agent, range of TBAD and false lumen involving renal artery were not associated with post-operation AKI. The in-hospital mortality and major adverse events were markedly increased with the occurrence of AKI (7.1% vs 0.9%, P=0.006; 14.3% vs 3.2%, P<0.001, respectively).ConclusionsTEVAR for TBAD has a high incidence of AKI, which is associated with worse in-hospital outcomes. SBP on admission and supra-aortic branches graft bypass hybrid surgery were the most significant risk factors. Renopreventive measures should be considered in high-risk patients.