Thoracic Endovascular Aortic Repair Group Research Articles

Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury.

Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injuries (BTAI) requiring intervention. Data suggests that low grade BTAI (Grade 1 [intimal tears] or Grade 2 [intramural hematoma]) will resolve spontaneously if treated with non operative management (NOM) alone. There has been no comparison specifically between the use of NOM vs. TEVAR for low grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. Retrospective analysis of all patients with a low grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilatory days. 880 patients with BTAI were enrolled. Of the 269 patients with low grade BTAI, 218 (81%) were treated with NOM alone (81% Grade I, 19% Grade II), while 51 (19%) underwent a TEVAR (20% Grade I, 80% Grade II). There was no difference in demographics or mechanism of injury in low grade BTAI patients who underwent NOM vs. TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs. 18%, p=0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p=0.06). Hospital and ICU length of stay, and ventilator days were not different between the two groups. NOM alone is safe and appropriate management for low grade BTAIs, with lower mortality and decreased rates of complications when compared to routine initial TEVAR.

STABILISE (Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair) Is Associated With Good Anatomical Results on the Distal Thoracoabdominal Aorta at 2 Years.

The aim of this comparative study was to evaluate the increased aortic diameter of the distal aorta after implementing the STABILISE technique in complicated type B aortic dissection (AD). This is a comparative monocentric retrospective study. All patients who underwent an STABILISE procedure for complicated AD between 2018 and 2020 were included and compared with a historic cohort treated with thoracic endovascular aortic repair (TEVAR) alone. Aortic diameters were measured at 6 different levels on the thoracic and abdominal aorta. The primary end point was an increased aortic diameter at 1 and 2 years. The exclusion criterion was the absence of a computed tomography (CT) scan at 1 or 2 years. A total of 55 patients were included: 24 in the TEVAR group and 31 in the STABILISE group. At the level of the stent graft, there was a decrease in aortic diameters in both groups without significant differences. At the level of the distal aorta, there was an increase in aortic diameters in both groups without significant differences. There were significantly more patients in the TEVAR group with an unfavorable increase in aortic diameter >5 mm of the distal aorta at 2 years than in the STABILISE group: 8 (33%) vs 1 (3%) (p=0.01). For chronic ADs, a significantly greater increase in aortic diameters of the distal aorta was observed in the STABILISE group. The STABILISE technique is technically feasible and potentially leads to decreased longer re-intervention rates; indeed, more patients had an unfavorable increase in aortic diameter in the TEVAR group than in the STABILISE group at 2 years. The high rate of long-term distal aortic aneurysm progression and reintervention after TEVAR alone suggests that this option is not sufficient to definitively treat these complex patients. This article reported the results of stent assisted balloon induced intimal disruption and relamination (STABILISE) with a follow-up at 2 years. This is the first comparative study between STABILISE, which has emerged as a new technique inducing aortic remodeling and therefore better long-term outcome, and the standard technique TEVAR alone. STABILISE technique is associated with good results on the distal aorta at 2 years with a rate of patient with unfavorable aortic diameter evolution greater in TEVAR group compared to STABILISE group and could improve the long-term results on the distal aorta by inducing extensive aortic remodeling.

Open Versus Zone 0/1 Endovascular Aortic Repair for Arch Aneurysm: A Propensity Score-Matched Study from the National Clinical Database in Japan

Although open surgical repair (OSR) is the gold standard for treating arch aneurysms, thoracic endovascular aortic repair (TEVAR) may be a less invasive alternative. However, it remains unclear which of the 2 methods yields better outcomes. In this study, we compared the perioperative outcomes of both procedures for arch aneurysms using a nationwide surgical database. Data of patients who underwent elective aortic repair for true arch aneurysms were extracted from the National Clinical Database of Japan. Patients who underwent OSR and Zone 0/1 TEVAR were matched in a 1:1 ratio using propensity scores and their mortality and morbidity rates were compared. A total of 2,815 and 1,125 patients underwent OSR and Zone 0/1 TEVAR, respectively. After propensity score matching, 1,058 patients were included in both groups. Compared with OSR, Zone 0/1 TEVAR was associated with a significantly higher incidence of stroke (5.8 vs. 10.0%, P<0.001) and paraplegia/paraparesis (1.6 vs. 4.4%, P<0.001). However, there were no significant differences in the 30-day and operative mortality rates between the 2 groups (2.2 vs. 2.7% and 4.5 vs. 5.4%, respectively). In the Zone 0/1 TEVAR group, postoperative computed tomography was performed in 92.4% of patients, and types I and III endoleaks were identified in 6.4% and 1.1% of patients, respectively. Zone 0/1 TEVAR has higher incidences of stroke and paraplegia/paraparesis than OSR, with a risk of postoperative endoleaks. Resolving these problems is the key for expanding the application of Zone 0/1 TEVAR and in the meantime OSR remains the gold standard for surgically fit patients.

Abstract 13161: Efficacy of Thoracic Endovascular Aortic Repair versus Best Medical Therapy in Treatment of Type B Aortic Dissection: A Meta-Analysis

Background and aim: Techniques in endovascular therapy have evolved offering a promising alternative to medical therapy alone in Type B aortic dissections (TBADs). The aim of this meta-analysis is to compare mortality and overall complications in thoracic endovascular aortic repair (TEVAR) with best medical therapy (BMT) in patients with TBADs. Methods: We included any randomized control trials, case controls, prospective or retrospective cohort and cross sectional studies that compared TEVAR versus BMT for the treatment of type B aortic dissection. Multiple electronic databases were searched to identify relevant articles including PubMed, Scopus, and Web of Science. Review Manager (RevMan) software, version 5.4 was used to perform the analysis. Results: A total of 1966 studies were screened with 32 studies included. Thirty-two cohort studies including 150836 patients (19512 TEVAR and 131324 BMT) were included. TEVAR was associated with a significantly lower 30-day mortality rate compared to BMT (RR= 0.79, CI= 0.63, 0.99, P = 0.04) notably in patients ≥ 65 years of age (RR=0.78, CI=0.64, 0.95, P=0.01). TEVAR group had a statistically significant prolonged length of hospital (MD= 3.42, CI= 1.69, 5.13, P = 0.0001), and ICU stay (MD= 3.18, CI= 1.48, 4.89, P = 0.0003) compared to BMT. BMT was associated with increased overall complications (RR= 1.50, CI= 1.20, 1.86, P = 0.0003) and stroke (RR= 1.52, CI= 1.29, 1.79, P &lt; 0.00001). No statistically significant difference in late mortality (1, 3, and 5 year), intervention-related (acute renal failure, spinal cord ischemia, myocardial infarction, respiratory failure, and sepsis), was noted between both groups. Conclusion: In patients with TBAD, TEVAR was associated with a decreased risk of 30-day mortality rate and overall complications compared to BMT. More randomized control trials are needed to support our findings.

Long-term survival and risk analysis of thoracic endovascular aortic repair for type B aortic dissection

To explore the safety and efficacy of thoracic endovascular aortic repair (TEVAR) in the treatment of patients with type B aortic dissection, and to evaluate the risk factors for long-term mortality. Our study retrospectively evaluated 729 patients with type B aortic dissection, who were divided into the thoracic endovascular aortic repair group and the optimal medical treatment group according to their treatment. In-hospital mortality, death within 30days, and aortic-related mortality were lower in the thoracic endovascular aortic repair group than in the optimal medical treatment group (p<0.05). The cumulative overall survival rates for the thoracic endovascular aortic repair group at 1 year, 5 years, and 10 years were 92.5%, 84.1%, and 73.5%, respectively. The Cox analysis found that TEVAR was beneficial in reducing mortality and that a vertical length of the dissection exceeding 150mm was a risk factor for mortality.

The impact of urgency of repair on outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury

ObjectiveCurrent societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI. MethodsPatients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes. ResultsOf 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission. ConclusionsPatients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.

The Role of Endovascular Repair Timing in Uncomplicated Acute Type B Intramural Hematoma Management

With favorable results of thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated acute type B intramural hematoma (uTBIMH), TEVAR is increasingly utilized in the management of patients with uTBIMH. However, optimal timing for intervention has not been decided. This study aimed to compare the efficacy of acute and delayed TEVAR in patients with uTBIMH. We included patients with uTBIMH who underwent TEVAR between October 2014 and December 2021. The participants were divided into the acute TEVAR (aTEVAR) and delayed TEVAR (dTEVAR) groups. We analyzed the total aortic diameter (TAD)/true lumen diameter (TLD) ratio on computed tomography angiography (CTA) and aortic-related adverse events and all-cause mortality (AREM). We included 34 individuals with uTBIMH, among which 20 underwent aTEVAR and 14 underwent dTEVAR. We observed no significant differences in baseline characteristics between both groups. However, compared with the aTEVAR group, better aortic remodeling was achieved in the dTEVAR group before discharge (1.32±0.11 vs. 1.21±0.09, P=0.005) and at the 1-year follow-up (1.18±0.09 vs. 1.10±0.04, P=0.034). Although the 30-day and 1-year follow-up outcomes of AREM were not significantly different, the Kaplan-Meier analysis showed that AREM incidence in the dTEVAR group was significantly lower than that in the aTEVAR group (85.7% for dTEVAR vs. 65.0% for aTEVAR, log-rank P=0.20). Moreover, subgroup analysis revealed a significant difference in the TAD/TLD ratio between the aTEVAR and dTEVAR groups in individuals without a focal intimal disruption (1.33±0.11 vs. 1.17±0.09, P=0.008). For individuals with uTBIMH, delaying TEVAR by>7days improved aortic remodeling and lowered the incidence of early AREM. Additionally, the absence of focal intimal disruption on preoperative CTA supports delayed intervention.

Thoracic Endovascular Aortic Repair Versus Open Surgery for Stanford Type B Aortic Dissection: A Meta-Analysis and Systematic Review.

Thoracic endovascular aortic repair is a relatively new technique relative to open surgery, and our aim was to assess whether there is a difference in the risk of common postoperative complications between thoracic endovascular aortic repair and open surgery. The PubMed, Web of Science, and Cochrane library were systematically searched for trials comparing thoracic endovascular aortic repair and open surgical repair from January 2000 to September 2022. Primary outcome was death, other outcomes included common associated complications. Data were combined using risk ratio or standardized mean difference with 95% confidence interval. Funnel plot and egger's test were used for assessing publication bias. The study protocol was registered prospectively with PROSPERO (CRD42022372324). This trial included 11 controlled clinical studies with 3667 patients. Thoracic endovascular aortic repair had lower risk of death (risk ratio [RR], 0.59; 95% CI, 0.49 to 0.73; p < 0.00001; I2 = 0), dialysis (RR, 0.55; 95% CI, 0.47 to 0.65; p < 0.00001; I2 = 37%), stroke (RR, 0.71; 95% CI, 0.51 to 0.98; p = 0.03; I2 = 40%), bleeding (RR, 0.44; 95% CI, 0.23 to 0.83; p = 0.01; I2 = 56%), and respiratory complications (RR, 0.67; 95% CI, 0.60 to 0.76; p < 0.00001; I2 = 37%) compared with open surgical repair. In addition, the length of hospital stay was shorter in the thoracic endovascular aortic repair group (SMD, -0.84; 95% CI, -1.30 to -0.38; p = 0.0003; I2 = 80%). Thoracic endovascular aortic repair has significant advantages over open surgical repair, in terms of postoperative complications and survival in Stanford type B aortic dissection patients.

Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Traumatic Aortic Injury: A Systematic Review and Meta-Analysis.

Blunt aortic injury is the second most prevalent cause of patient fatalities post-trauma, closely following head injuries as the leading cause. In recent years, thoracic endovascular aortic repair (TEVAR) has evidently improved survival rates and reduced complications in patients suffering from blunt traumatic aortic injury (BTAI) in comparison to open surgery and non-operative management. It is difficult to characterize the appropriate criteria for the timing of TEVAR, whether early or delayed for BTAI, considering the discrepancies related to timing. Electronic databases, including PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase, were searched through April 2023. The primary outcomes were short-term mortality and hospital and intensive care unit (ICU) stays. Time to TEVAR, acute respiratory distress syndrome, sepsis, deep vein thrombosis, delayed stroke, and renal failure were also evaluated. We included a total of seven studies, comprising 4177 patients who met the inclusion criteria. Short-term mortality was significantly higher in the early TEVAR group (RR: 1.86; 95% confidence interval (CI); (1.26-2.74); p<0.001; I2=33%). In contrast, the ICU length of stay was significantly shorter in the early group (mean difference: -2.82 days; 95% CI; (-4.09 - -1.56); p<0.0001; I2=55%). There was no significant difference between both groups in the presenting profile or postoperative complications. Patients undergoing delayed TEVAR had markedly lower mortality rates but a longer ICU stay. The need for future studies with more robust designs is imperative to investigate the factors influencing the timing of repair and the associated outcomes.

Thoracic Endovascular Aortic Repair vs Medical Therapy Alone for Uncomplicated Acute Type B Aortic Dissection

It remains controversial if thoracic endovascular aortic repair (TEVAR) or optimal medical therapy (OMT) should be the standard of care for uncomplicated type B aortic dissection (uTBAD). We evaluate our institutional experience to compare the outcomes of TEVAR vs OMT as primary treatment for uTBAD. Data were analyzed to compare early and late outcomes of 219 patients (135 men; 61.6%) with uTBAD who were triaged to OMT in 162 and TEVAR in 57 over 3 decades. Mean age was 64.5 ± 12.7 and 63.5 ± 15.9 years (P = .630) in the TEVAR and OMT groups, respectively. TEVAR group had significantly higher incidences of hypertension (87.8% vs 40.1; P < .001), smoking (63.2% vs 38.3%; P = .002), dyslipidemia (47.4% vs 16.7%; P < .001), chronic kidney disease (17.5% vs 6.2%; P = .016), and prior stroke/transient ischemic attack (14% vs 4.9%; P = .035). After TEVAR, neither death nor paraplegia occurred, while seven patients developed acute kidney injury not requiring hemodialysis (12.3%), and one sustained stroke (1.8%). In-hospital/30-day mortality was 0% with TEVAR vs 16% (26/162) with OMT (P < .001). Follow-up was 100% (193/193) at a median of 5.8 years (mean, 7.8; interquartile range [IQR], 2.0-12.3). In OMT group, 70 patients died at median 5.2 years (IQR, 2.0-8.8 years), and 72 underwent intervention at median 85 days (IQR, 0.01-1.2 years), including open descending repair in 60, TEVAR in 9, abdominal aortic repair in 2, and arch repair in 1. Following intervention, 40 died at median 1.8 years (IQR, 0.02-6.3 years). In TEVAR group, 18 underwent reintervention at median 48.5 days (IQR, 29-101 days), including 11 redo-TEVAR, 3 EVARs, 1 hemiarch, and 3 others; all were alive at latest follow-up except 1 expiring at 6.9 months postreintervention. At 3 months, 1 year, and 3 years following treatment, survival rates were significantly higher in TEVAR vs OMT patients (100% vs 83.2 ± 2.9%; 94.4 ± 3.1 vs 77.0 ± 3.3%; and 91.8 ± 4.0% vs 67.9 ± 3.7%) (P = .002, Fig 1); the respective freedom from (re)intervention were 75.4 ± 5.7% vs 72.7 ± 3.6%, 68.0 ± 6.2% vs 64.2 ± 3.9%, and 68.0 ± 6.2% vs 53.0 ± 4.2% (P = .198) in TEVAR vs OMT groups. After (re)intervention, the group with initial TEVAR had improved survival (94.4 ± 5.4% up to 3 years) compared to OMT patients (76.4 ± 5.0 at 1 year, 65.3 ± 5.6% at 3 years) (P = .039) (Fig 2). In the management of uTBAD, patients receiving initial OMT showed lower survival and required more intervention, while initial TEVAR achieved significantly higher survival up to 3 years, even after reintervention. These results argue favorably for the use of TEVAR as the primary treatment of choice for uTBAD.Fig 2Survival after (re)intervention, Kaplan-Meier survival curve comparing survival postsurgical (re)intervention after initial treatment by either thoracic endovascular aortic repair (TEVAR) or medical therapy up to 3 years after treatment. Log-rank P = .039.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Application of "Fabulous" stent system to improve aortic remodeling after TEVAR for type B aortic dissection.

It is known that the Proximal Extension To Induce Complete Attachment (PETTICOAT) technique improves the distal aortic remodeling compared with standard thoracic endovascular aortic repair (TEVAR). [ 1, 2] However, the only available Zenith Dissection Endovascular System (Cook Medical Inc., Bloomington, Ind, USA) has several limitations, including only two sizes (36 mm and 46 mm) and an one-taper design, which may not be suitable for the complex morphology of dissection at distal aorta, particular for the east Asian population. Thus, our center designed the new "Fabulous" stent system and acheieved better early curative effect. Our center designed "Fabulous" stent system based on the conception of PETTICOAT technique. It included the proximal covered stent-graft and the distal bare stent component, which were designed to include 13 models to adapt various anatomical characteristics (the diameter of stent-graft and bare stent ranged between 20–44 mm and 16–40 mm, respectively). The deployment of proximal stent-graft was similar to the standard TEVAR; the distal bare stent was placed above the level of the celiac artery orifice with 3–4 cm overlapping with the proximal stent-graft. To further assess whether the "Fabulous" stent system was associated with better aortic remodeling versus standard TEVAR alone, we conducted a comparative study between the group with "Fabulous" stent system and with standard stent-grafts at 1-year follow-up. The study was approved by the relevant ethics committee (unique protocol ID: WQ1601). All patients enrolled provided written informed consent. The "Fabulous" stent system group was a prospective single-arm study conducted at multicenter between December 2017 and October 2019 comprised of 134 type B aortic dissection (TBAD) patients, [ 3] and 159 TBAD patients receiving standard TEVAR from multicenter during the same period were included in control group. Two groups have the consistent inclusion and exclusion criteria, and Inverse Probability Treatment Weighting (IPTW) was used to balance baseline characteristics and analyze the outcomes [Supplementary Table 1, https://links.lww.com/CM9/B504]. There was no significant difference in the rate of endoleak between the two groups, but all patients in "Fabulous" group have no reintervention and stent graft-induced new entry (SINE). The possible reason might be that the high and low wave with semi-suturing and flexibility design ensured that the bare stent component had good plasticity and adapted well to the aorta, reducing the risk of SINE. To assess aortic remolding, the distal aorta was divided into two segments: (segment 1) the thoracic aorta from distal end of the stent graft to the celiac trunk which contained the bare stent; (segment 2) from the celiac trunk to the lower renal artery. Patients in "Fabulous" group had better outcomes of true lumen (TL) expansion and false lumen (FL) diminution than those in the standard TEVAR group in the segment 1(22.95 ± 5.55 mm vs. 18.99 ± 6.12 mm, P = 0.001, minimum diameter of TL; 9.06 ± 12.27 mm vs. 25.20 ± 12.65 mm, P <0.001, maximum diameter of FL). As for the outcomes of the segment 2, "Fabulous" group further demonstrated better outcomes of TL expansion and FL diminution than standard TEVAR therapy (16.97 ± 5.01 mm vs. 15.23 ± 4.76 mm, P = 0.025, TL diameter; 11.53 ± 8.87 mm vs. 18.14 ± 10.10 mm, P <0.001, FL diameter). To better showed the changes of distal aortic remodeling of pre-operation and 1-year follow-up between the two groups, line graphs were made to compare the differences. In the segment 1, "Fabulous" group had better trend of TL expansion and FL regression than the standard TEVAR group (8.98 ± 0.91 mm ["Fabulous" group] vs. 5.84 ± 0.79 mm [standard TEVAR group], P <0.001, change of minimum diameter of TL; –20.9 ± 1.67 mm ["Fabulous" group] vs. –4.96 ± 1.46 mm [standard TEVAR group], P <0.001, change of maximum diameter of FL), and "Fabulous" group decreased the total aortic lumen area (7.36 ± 3.17 mm 2 [1-year follow-up] vs. 8.58 ± 2.62 mm 2 [pre-operation], P <0.001, total aortic lumen area). As for the outcomes in the segment 2, "Fabulous" group still showed better trend of TL diameter expansion than standard TEVAR group (2.71 ± 0.42 mm ["Fabulous" group] vs. 2.54 ± 0.4 mm [standard TEVAR group], P <0.001) and no obvious trend of total aortic lumen area expansion (6.32 ± 2.47 mm 2 [1-year follow-up] vs. 6.21 ± 1.66 mm 2 [pre-operation], P = 0.510, total aortic lumen area) [ Figure 1A]. In the aspect of FL thrombosis, patients in "Fabulous" group had better trend of FL thrombosis than those in standard TEVAR group at segment 1 [ Figure 1B].Figure 1: The comparison of aortic remodeling between "Fabulous" and standard TEVAR. (A) Line graph of aortic diameter changes at the segment 1 and 2 between the standard TEVAR and "Fabulous" groups. (B) The change rate of FL thrombosis at segment 1. FL: False lumen; TEVAR: Thoracic endovascular aortic repair; TL: Ture lumen.Compared with Zenith Dissection Endovascular System, although patients in Study for the Treatment of complicated Type B Aortic Dissection using Endoluminal repair (STABLE) trials benefitted from the PETTICOAT technique in terms of promoting distal FL thrombosis and TL expansion at 1-year follow-up, the diameter of abdominal aorta exhibited significant overall increase both in the SI and II trials. [ 4, 5] On the contrary, no obvious distal aortic enlargement was observed in our "Fabulous" group (6.32 ± 2.47 mm 2 [1-year follow-up] vs. 6.21 ± 1.66 mm 2 [pre-operation], P = 0.510, total aortic lumen area in segment 2). The potential reasons might be listed as follows: Firstly, the supporting section of bare stent was knitted with monofilament nitinol wire to ensure bearing certain radial compression; secondly, the connecting section of bare stent was knitted with multiple nitinol wire to ensure that the stent had good flexibility and conformability; thirdly, the multi-taper design feature with a 15–30% rate of oversizing, which was less than that of the Zenith Dissection Endovascular system, could adapt to the different situations better. The features of bare stent design in "Fabulous" stent system gained better TL remodeling without obvious distal aortic expansion. In summary, the application of "Fabulous" stent system had better outcomes of distal aortic remodeling than standard TEVAR, while did not increase the incidence of complications. It could adapt to the Asian populations' vascular anatomy better and still needed large and long-term follow-up to test its efficiency. Funding This study was supported by grants from the National Science Foundation of China (No.81970412); Shanghai Municipal Science and Technology Commission Innovation Fund (No.22S31904800); Fujian Province Health Science and Technology Fund (No.2021GGB030); Shanghai Municipal Science and Technology Commission Innovation Fund (No.18441902400); National Clinical Research Center for Interventional Medicine Fund (No.2021-004); Shanghai Municipal Health Commission (No.20214Y0474); Xiamen Municipal Health Science And Technology Program Fund (No. 3502Z20194034); and Fudan Zhangjiang Clinical Medicine Innovation Fund (No. KP7202115)Foundation:. Conflicts of interest None.

Early Thoracic Endovascular Aortic Repair of Uncomplicated Type B Thoracic Aortic Dissection: An Aorta Team Approach.

Although uncomplicated Type B aortic dissection (uTBAD) is traditionally treated with optimal medical therapy (OMT) as per guidelines, recent studies, performed primarily in interventional radiology or surgical operating rooms, suggest superiority of thoracic endovascular aortic repair (TEVAR) over OMT due to recent advancements in endovascular technologies. We report a large, single-center, case control study of TEVAR versus OMT in this population, undertaken solely in a cardiac catheterization laboratory (CCL) with a cardiologist and surgeon. We aimed to determine if TEVAR for uTBAD results in better outcomes compared with OMT. This was a retrospective chart review of all patients with uTBAD during the last 13 years, with 46 cases (TEVAR group) and 56 controls (OMT group). In the TEVAR group, the procedure duration of 2.5 hours resulted in 100% procedural success for stent placement, with 63% undergoing protective left subclavian artery bypass, 0% mortality or stroke, and a lower readmission rate (1 vs. 2%; p = 0.04 in early TEVAR cases), but a longer length of stay (12.9 vs. 8.5 days: p = 0.006). The risk of all-cause long-term mortality was markedly reduced in the TEVAR group (RR = 0.38; p = 0.01), irrespective of early (<14 days) versus late intervention. On follow-up computed tomography imaging, the false lumen stabilized or decreased in 85% of cases, irrespective of intervention timing. TEVAR performed solely in the CCL is safe and effective, with lower all-cause mortality than OMT. These data, in collaboration with previous data on TEVAR in different settings, call for consideration of an update of practice guidelines.

Role of initial medical treatment and effectiveness of thoracic endovascular aortic repair for acute type A aortic dissection with thrombosed false lumen.

The optimal treatment for acute type A aortic dissection (AAAD) with thrombosed false lumen (T-FL) of the ascending aorta remains controversial. The goal of this study was to evaluate clinical outcomes of initial medical treatment (IMT) and the effectiveness of thoracic endovascular aortic repair (TEVAR) for AAAD with T-FL. We retrospectively analysed 60 patients with AAAD with T-FL. Emergency aortic repair was performed in 33 patients, and IMT was selected in 27 uncomplicated patients with ascending aortic diameter < 50 mm and ascending T-FL thickness ≤ 10 mm. Among the 27 patients who received IMT, 14 had intramural haematomas at admission; however, new ulcer-like projections appeared in 7 (50%) during hospitalization. Before discharge, 12 (44%) were given medical treatment only, and 15 (56%) required delayed aortic repair including TEVAR in 8 and open repair in 7. The median interval from onset to delayed repair was 9 days, and significantly more patients received TEVAR compared to those receiving emergency repair (53% vs 21%; P = 0.043). Between the TEVAR (n = 15) and the open repair (n = 33) groups, 1 (7%) 30-day death occurred in the TEVAR group, whereas no in-hospital deaths occurred in the open repair group. During the median follow-up time of 24.8 months, no aorta-related death was observed, and there were no statistically significant differences in the rate of freedom from aortic events (TEVAR: 92.8%/3 years vs open repair: 88.4%/3 years; P = 0.871). Our management, using a combination of emergency aortic repair, IMT and delayed aortic repair for AAAD with T-FL, achieved favourable clinical outcomes. Among the selected Japanese patients, IMT with repeated multidetector computed tomography could detect a new intimal tear that could be closed by TEVAR in some cases. Using EVAR for this pathology resulted in acceptable early and midterm outcomes. Further investigations are required to validate the safety and efficacy of this management procedure.

Comparative Analysis of Endovascular Repair of Single-Branched Stent-Graft and Hybrid Procedure for Patients With Type B Acute Aortic Dissection Involving the Left Subclavian Artery.

Thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) revascularization has been used in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone (PLZ). The outcomes of comparisons between TEVAR and hybrid procedure on patients with TBAD, with inadequate PLZ, are rarely reported. This study sought to compare and clarify the early and midterm outcomes between TEVAR and hybrid procedure in patients with TBAD, with inadequate PLZ. Between January 2019 and December 2021, 93 patients with TBAD, with inadequate PLZ, who underwent TEVAR or hybrid procedure, were retrospectively evaluated in Beijing Anzhen hospital. Demographics, comorbidities, preoperative imaging features, periprocedural details, and follow-up outcomes were analyzed. Survival was analyzed according to Kaplan-Meier method. TEVAR procedures were performed on 41 patients (TEVAR group) and hybrid procedures on 52 patients (hybrid group). Early events, 30 day mortality, and all-cause mortality, were not significantly different between the 2 groups. However, patients receiving TEVAR had significantly shorter procedure time (p<0.001), hospital stay (p<0.001), and intensive care unit (ICU) stay (p=0.001) compared with those in the hybrid group. Patients receiving TEVAR had significantly lower midterm events (p=0.014) and re-intervention (p=0.015) compared with those in the hybrid group. The study indicated that TEVAR with LSA revascularization for TBAD with inadequate PLZ is associated with a trend toward lower rates of midterm events, while the early and midterm mortalities were comparable with those in hybrid procedure. This study is novel as it compared the outcomes between thoracic endovascular aortic repair (TEVAR) and hybrid procedure in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone, which has been rarely reported previously. We believe that our study makes a significant contribution to the literature because it is clinically relevant as it demonstrated that TEVAR with left subclavian artery (LSA) revascularization for TBAD with inadequate proximal landing zone is associated with a trend toward lower rates of mid-term events, while the early and mid-term mortalities were comparable with those in the hybrid procedure.

Favorable Remodeling After TEVAR in Uncomplicated Acute and Subacute Type B Aortic Dissection in Comparison to Conservative Treatment: A Midterm Analysis.

The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period. Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints. In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was -5 mm (interquartile range [IQR]=-28 to 8 mm), -11 mm (IQR=-53 to 10 mm), and 7 mm (IQR=-13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen. Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling. In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years.

Clinical characteristics and outcomes of Stanford type B aortic intramural hematoma: A single centre experience.

To compare the clinical characteristics of Stanford type B aortic intramural hematoma (IMH) and Stanford type B aortic dissection (AD), and to identify the differences between thoracic endovascular aortic repair (TEVAR) and medical management (MM) in the Stanford type B IMH patients. A retrospective observational study was conducted in patients treated between January 2015 and December 2016. The clinical characteristics and CT images of patients with type B IMH and type B AD were compared, and the clinical characteristics and CT images of patients in the type B IMH group who were treated with TEVAR and MM were compared. A total of 176 patients were included in this study, including 62 patients of type B IMH and 114 patients of type B AD. Five patients died in the IMH group and three in the AD group. The proximal hematoma or entry tear in both groups was mainly located in the descending aorta, and the proportion of the iliac artery involved in the AD group was significantly higher than that in the IMH group (31.6% vs. 8.1% P < 0.05). There were 50 MM patients and 12 TEVAR patients in the IMH group. No death occurred in the TEVAR group, while five patients in the MM group died. Seven patients in the MM group had disease progression vs. 12 in the TEVAR group (P < 0.05). The patients in the TEVAR group had more intima lesions than those in the MM group (83.3% vs. 30.0%, P < 0.05). TEVAR group involved more iliac artery hematoma than MM group (33.3% vs. 2.0%, P < 0.05). The maximum thickness of hematoma in TEVAR group was 14.9 ± 3.4 mm, which was significantly larger than that of MM group (10.2 ± 2.8 mm) (P < 0.05). In the diagnosis of IMH, patients' symptoms and high-risk signs of CTA should be paid attention to. TEVAR therapy should be actively considered on the basis of effective medical management when there are intima lesions (ULP/PAU), increased aortic diameter and hematoma thickness, extensive hematoma involvement, and pleural effusion.

Impact of thoracic endovascular aortic repair timing on outcomes after uncomplicated type B aortic dissection in the Society for Vascular Surgery Vascular Quality Initiative postapproval project for dissection

ObjectiveThe timing of thoracic endovascular aortic repair (TEVAR) after the onset of uncomplicated acute type B aortic dissection (uTBAD) remains controversial. The objective of this study was to evaluate the Society for Vascular Surgery Vascular Quality Initiative (VQI) postapproval study (VQI PAS) data for the impact of TEVAR timing for uTBAD on early and late outcomes, including mortality, procedural complications, and long-term reintervention. MethodsThe VQI PAS used for this analysis includes a total of 606 patients. Patients with uTBAD (defined as those without rupture or malperfusion) exclusive of cases categorized as emergent (N = 206) were divided into groups defined by the Society for Vascular Surgery/Society of Thoracic Surgeons reporting guidelines based on the timing of treatment after the onset of dissection: within 24 hours (N = 8), 1 to 14 days (N = 121), and 15 to 90 days (N = 77). Univariate and multivariable analysis were used to determine differences between timing groups for postoperative mortality, in-hospital complications, and reintervention. ResultsDemographics and comorbid conditions were very similar across the 3 TEVAR timing groups. Notable differences included a higher prevalence of baseline elevated creatinine (>1.8 mg/dL)/chronic end-stage renal disease and designation as “urgent” in the <24-hour group, as well as a higher rate of preoperative β-blocker therapy in the 1- to 14-day group. Postoperative stroke, congestive heart failure, and renal ischemia were more common in the <24-hour group without an increase in mortality. Unadjusted 30-day mortality across groups was lowest in the early TEVAR group (0%, 3.3%, and 5.2%; P = .68), as was 1-year mortality (0%, 8.3%, and 18.2%; P = .06), although not statistically different at any time point. Reintervention out to 3 years was not different between the groups. Multivariable analysis demonstrated the need for a postoperative therapeutic lumbar drain to be the only a predictive risk factor for mortality (hazard ratio = 7.595, 95% confidence interval: 1.730-33.337, P = .007). When further subdivided into patients treated 1 to 7 days or 8 to 14 days after dissection, findings were similar. ConclusionsPatients with uTBAD treated within 24 hours were unusual (N = 8), too small for valid statistical comparison, and likely represent a high-risk subgroup, which is manifested in a higher risk of complications. Although there was a trend toward improved survival in the acute (1- to 14-day) phase, outcomes did not differ compared with the subacute (15- to 90-day) phase with relation to early mortality, postoperative complications, or 1-year survival. These data suggest that the proper selection of patients for early TEVAR can result in equivalent survival and early outcomes.

Surgical and endovascular repair for type B aortic dissections with mesenteric malperfusion syndrome: A systematic review of in-hospital mortality

ObjectivesMesenteric malperfusion is a feared complication of aortic dissection, with high mortality. The purpose of this study was to systematically review in-hospital mortality (IHM) of endovascular and surgical management of acute and chronic Stanford type B aortic dissections (TBAD) complicated by mesenteric malperfusion (MesMP). MethodsA systematic search of English language articles was conducted in relevant databases. Data on patient demographics, procedure details, and survival outcomes were collected. Reports were classified by type of intervention performed. Studies that failed to report patient-level outcomes based on specific intervention performed or IHM were excluded. Retrospective chart review of previously published data from a single institution was also performed to further identify cases of TBAD that were managed endovascularly. The Fisher exact test was performed to determine statistical significance. ResultsIn total, 37 articles were suitable for inclusion in this systematic review, which yielded 149 patients with a median age 55.0 years (interquartile range, 46.5-65 years) and 79% being male. Overall, in-hospital mortality was 12.8% (19/149) and was similar between endovascular and open surgical interventions (13% vs 11%, P = .99). Among endovascular strategies, IHM was greater, although not statistically significant in the thoracic endovascular aortic repair group compared with the fenestration/stenting without thoracic endovascular aortic repair group (24% vs 11%, P = .15). ConclusionsMultiple strategies exist for the management of TBAD with MesMP; however, a majority of cases were managed endovascularly. Despite advances in therapies, mortality remains high at 13%.

The Role of Surgical and Endovascular Repair of Blunt Traumatic Aortic Injury in the Modern Era: A Single-Center Experience.

Objective:To evaluate the efficacy of chest x-ray (CXR) in blunt traumatic aortic injury (BTAI) as a primary imaging tool in trauma patients. Methods:We retrospectively reviewed our hospital records for blunt thoracic aortic injury patients who had a therapeutic intervention from January 2015 to February 2021. Patients’ characteristics, initial chest x-rays, and computed tomography (CT) scan were extracted and re-evaluated.Results: Eighteen patients matched the criteria of our research. The mean age and the injury severity score (ISS) was 29.8±11.2 and 38.4±14.4, respectively. Seven patients (38.9%) underwent thoracic endovascular aortic repair (TEVAR), and 11 (61.1%) had open surgery. The TEVAR group had significantly lower mean intensive care unit stay days (6.6±3.9 vs. 10.8±6.9 in open aortic repair (OAR), p<0.05). The percentile of patients requiring blood transfusion was significantly lower in the TEVAR group (57% vs. 100% in OAR, p<0.05). Mediastinal widening (66.7%) was the most common finding during the evaluation of initial chest x-rays. Interestingly, 22.2% of the initial x-rays were not remarkable for BTAI.Conclusion:TEVAR is an advantageous choice in the management of BTAI. However, open aortic repair is the optimal decision in certain situations. It is suggested that the Interventional management of the BTAI must be performed by experienced vascular surgeons in a medical center capable of both OAR and TEVAR.

Thoracic Endovascular Aortic Repair of Highly Tapered Type B Aortic Dissection with Proximal Tapered Stent Grafts and Distal Restrictive Stent Grafts

This study evaluated aortic remodeling in highly tapered type B aortic dissection (TBAD) patients who underwent thoracic endovascular aortic repair (TEVAR) with a proximal tapered stent graft plus a distal restrictive stent graft to maximize thoracic coverage while avoiding distal excessive oversizing. Thirty-four patients presenting with highly tapered TABD were randomized to restricted TEVAR (r-TEVAR) and standard TEVAR groups. Highly tapered TBAD was defined as the maximal diameter of the true lumen at proximal and distal thoracic aorta landing zone tapers greater than 8mm or taper ratio greater than 20%. Patients in the r-TEVAR group underwent proximal tapered stent grafts plus distal restrictive stent grafts, to match the taper ratio of the descending thoracic aorta (DTA) and extend the length of stent coverage. Patients in the standard TEVAR group underwent proximal tapered stent grafts implantation without distal restrictive stent grafts. Aortic remodeling was estimated by computed tomography angiography (CTA) during the follow-up. In total, 16 patients underwent r-TEVAR, and 18 patients underwent standard TEVAR. The taper ratio of the stent graft matched the DTA in the r-TEVAR group (24.7±3.4% vs. 27.3±4.2%, P=0.068), but did not match that in the standard TEVAR group (13.5±3.3% vs. 30.5±9.6%, P<0.001). The length of stent graft coverage in the r-TEVAR group was longer than that in the standard TEVAR group (220.4±21.1mm vs. 175.3±17.8mm, P<0.001). Compared with the standard TEVAR group, the r-TEVAR group had better complete remodeling of the DTA at 6months (40% vs. 5.6%, P=0.03), 12months (60% vs. 16.7%, P=0.027), and 24months (78.6% vs. 41.2%, P=0.036) after the operation. There was no difference in the cumulative survival rate between the r-TEVAR and standard TEVAR groups (P=0.166). The r-TEVAR with overlapping proximal tapered stent grafts and distal restrictive stent grafts can match the taper of highly tapered TABD, extend the length of stent graft coverage, and lead to better remodeling of the DTA than standard TEVAR.