Thoracoabdominal Aorta Research Articles

Open repair of chronic type B aortic dissection

: Open repair of descending thoracic and thoracoabdominal aortic aneurysms in the setting of chronic aortic dissection is a complex procedure that requires a thorough understanding of the physiology of aortic dissection and cardiopulmonary bypass, efficient reperfusion of vital organs and meticulous surgical technique. Open surgery on the descending thoracic or thoracoabdominal aorta is high risk and has been associated with significant morbidity and mortality. Alternatively, endovascular repair of chronic distal aortic dissection using the currently available thoracic endovascular devices is less invasive and can have low mortality. However, reintervention is quite common, the durability of the repair is questionable and aortic remodeling is uncommon in the abdominal aorta. Endovascular repair is not likely to be durable in the young patient with a genetically triggered or familial aortopathy. For these reasons, we believe that open repair of chronic distal aortic dissection is the definitive and durable solution in the appropriately selected patient. We have a greater than 20-year experience using deep hypothermia and circulatory arrest for repair of complex thoracic and thoracoabdominal aortic aneurysms. Morbidity and mortality in our hands using this perfusion technique in chronic distal aortic dissection is comparable to endovascular procedures with rates of mortality 3.6%, permanent neurological deficit 2.6%, permanent requirement for hemodialysis 0% and cerebrovascular accident 1%. The following article describes, in detail, the intraoperative technique and postoperative management of patients who are suitable for descending thoracic or thoracoabdominal aortic aneurysm repair of chronic distal aortic dissection with deep hypothermia and circulatory arrest.

Aortic Complications Related to Mycobacterium bovis after Intravesical Bacille Calmette-Guérin Therapy - a Systematic Review

Aortic complications after intravesical Bacillus Calmette-Guérin (BCG) application are a rare complication of the treatment of non-muscle invasive bladder cancer. The aim of this systematic review was to perform a descriptive analysis of previously published studies and to discuss the particular challenges of diagnosis and treatment of this rare complication. A literature search was performed in PubMed (1949-2021) and Web of Science (1900-2021) using the search terms "mycobacterium" OR "bovis" OR "BCG" AND "aorta" OR "aneurysm". In a staged review process, publications with the following inclusion criteria were included in data analysis: original paper, full-text availability in English or German and aortic complication after intravesical BCG instillation. We focused on the analysis of BCG-specific medical history data as well as treatment strategies in relation to patient outcome and the occurrence of graft infections during follow-up. A total of 60 individual cases were described in 55 published articles. BCG-induced mycotic aortic aneurysms can occur in all segments of the thoracoabdominal aorta, but the infrarenal aortic segment was most commonly affected (65% of cases). The most common configuration was saccular outpouchings (65%). Concomitant infections in other tissues were typical (65%). Patients with mycotic aneurysm presented with or without consecutive aortic rupture in 28% and 63%, respectively. Diagnosis was based on a combination of pathological and microbiological examinations. A common treatment algorithm was surgical infection treatment (85%) and antitubercular therapy (83%). Performed simultaneously, they resulted in a long-term survival of 81%. Graft infection after initial aortic repair with alloplastic material (n=40) developed in ten patients (25%) during follow-up. Diagnosis of mycotic aneurysms or vascular complications after intravesical BCG application is exceptionally challenging and a high level of suspicion is required. Diagnosis is based on obtaining sample material of affected regions and the combination of patient's history, clinical presentation and pathological or microbiological examinations. Currently, no consensus guideline for optimal medical treatment options of aortic complications secondary to BCG instillation exists. The combination of surgical treatment and supportive antitubercular therapy seems to achieve the best results. Since the risk of prosthetic infection after the use of alloplastic materials remains high (25%), we strongly suggest evaluating autologous or allogenic aortic replacement during initial aortic repair.

UNUSUAL PRESENTATION OF AORTIC DISSECTION WITH RIGHT CALF PAIN

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: The incidence rate of acute type A aortic dissection is between 2.1 and 16.3 per 100,000 persons per year. Over 90% of patients with acute aortic dissection present with chest or back pain. In the case of an acute dissection, mortality can be almost 50% within the first 48 hours of symptom onset, 21 to 49% of the patients with aortic dissection die before reaching the hospital. Therefore, prompt diagnosis and treatment is imperative for survival. Aortic dissection can be easily missed in the settings of atypical presentation. We are presenting a case of a 48-year-old male who presented with right calf pain as a symptom of acute aortic dissection. CASE PRESENTATION: The patient is a 48 year old male with no known medical history presented with chief complain of right calf pain. He woke up from his sleep due to severe throbbing pain in his right calf that radiated to the calf with associated paresthesia. He denied recent trauma, prolonged period of immobilization, recent travel, known history of Baker's cyst, insect bites or exertion. Upon further questioning, the patient did report chronic back pain. Vitally, his blood pressure was elevated at 216/126 with no significant difference between both arms, no tachycardic, and not hypoxic. Clinically, his right lower calf is swollen with tortuous vein, not tense. Distal pulses are palpable with a sensory deficit at the dorsum of the right foot. Laboratory studies were only significant of a D-dimer of 32,279. Due to the elevated D-dimer, CTA chest and abdominal CT Aorta/Iliofemoral angiography was obtained that revealed an acute Stanford type A dissection of the thoracoabdominal aorta, large fusiform dissecting aneurysm of the distal abdominal aorta extending into bilateral common iliac arteries with absent distal runoff enhancement to the right foot, indicative of critical limb ischemia. An esmolol drip was quickly started and transferred to high-level care facility for an emergent surgical procedure. DISCUSSION: Our patient presented with an acute right leg pain that prompted us to get a D-dimer to further evaluate for an acute deep venous thrombosis. An elevated D-dimer has been found to have 96.7% sensitivity for aortic dissection, the significantly elevated d-dimer levels prompted an emergent CTA of the chest and abdomen for evaluation of dissection. This case was not considered "text book," since patient did not complain of the typical "tearing" chest pain radiating to the back to be concerned aortic dissection. CONCLUSIONS: Aortic dissection is a life-threatening disease, immediate evaluation can save a patient's life. Since many of these cases are often missed due to atypical presentation, it is imperative to develop awareness regarding the various ways an acute aortic dissection can disguise itself as. This case elucidates the importance of critical limb ischemia and a significantly elevated D-dimer due to an acute aortic dissection. REFERENCE #1: Inga H. Melvinsdottir, Sigrun H. Lund, Bjarni A. Agnarsson, Kristinn Sigvaldason, Tomas Gudbjartsson, Arnar Geirsson, The incidence and mortality of acute thoracic aortic dissection: results from a whole nation study, European Journal of Cardio-Thoracic Surgery, Volume 50, Issue 6, December 2016, Pages 1111–1117, https://doi.org/10.1093/ejcts/ezw235 REFERENCE #2: Wundram, M., Falk, V., Eulert-Grehn, JJ. et al. Incidence of acute type A aortic dissection in emergency departments. Sci Rep 10, 7434 (2020). https://doi.org/10.1038/s41598-020-64299-4 DISCLOSURES: No relevant relationships by Mary Dickow, source=Web Response No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Verisha Khanam, source=Web Response No relevant relationships by Sarwan Kumar, source=Web Response

Outcomes and Reintervention After Repair of Type I Aortic Dissection

After emergency surgery for ascending aortic dissection, patients frequently have residual dissection of the thoracic or thoracoabdominal aorta that mandates lifelong surveillance and management. We examined the outcomes for these patients according to the extent of aortic reconstruction at the index repair.

High-Pitch Photon-Counting Detector Computed Tomography Angiography of the Aorta: Intraindividual Comparison to Energy-Integrating Detector Computed Tomography at Equal Radiation Dose.

The aims of this study were to determine the objective and subjective image quality of high-pitch computed tomography (CT) angiography of the aorta in clinical dual-source photon-counting detector CT (PCD-CT) and to compare the image quality to conventional dual-source energy-integrating detector CT (EID-CT) in the same patients at equal radiation dose. Patients with prior CT angiography of the thoracoabdominal aorta acquired on third-generation dual-source EID-CT in the high-pitch mode and with automatic tube voltage selection (ATVS, reference tube voltage 100 kV) were included. Follow-up imaging was performed on a first-generation, clinical dual-source PCD-CT scanner in the high-pitch and multienergy (QuantumPlus) mode at 120 kV using the same contrast media protocol as with EID-CT. Radiation doses between scans were matched by adapting the tube current of PCD-CT. Polychromatic images for both EID-CT and PCD-CT (called T3D) and virtual monoenergetic images at 40, 45, 50, and 55 keV for PCD-CT were reconstructed. Computed tomography attenuation was measured in the aorta; noise was defined as the standard deviation of attenuation; contrast-to-noise ratio (CNR) was calculated. Subjective image quality (noise, vessel attenuation, vessel sharpness, and overall quality) was rated by 2 blinded, independent radiologists. Forty patients were included (mean age, 63 years; 8 women; mean body mass index [BMI], 26 kg/m2). There was no significant difference in BMI, effective diameter, or radiation dose between scans (all P's > 0.05). The ATVS in EID-CT selected 70, 80, 90, 100, 110, and 120 kV in 2, 14, 14, 7, 2, and 1 patients, respectively. Mean CNR was 17 ± 8 for EID-CT and 22 ± 7, 20 ± 6, 18 ± 5, 16 ± 5, and 12 ± 4 for PCD-CT at 40, 45, 50, 55 keV, and T3D, respectively. Contrast-to-noise ratio was significantly higher for 40 and 45 keV of PCD-CT as compared with EID-CT (both P's < 0.05). The linear regression model (adjusted R2, 0.38; P < 0.001) revealed that PCD-CT reconstruction (P < 0.001), BMI group (P = 0.007), and kV of the EID-CT scan (P = 0.01) were significantly associated with CNR difference, with an increase by 34% with PCD-CT for overweight as compared with normal weight patients. Subjective image quality reading revealed slight differences between readers for subjective vessel attenuation and sharpness, whereas subjective noise was rated significantly higher for 40 and 45 keV (P < 0.001) and overall quality similar (P > 0.05) between scans. High-pitch PCD-CT angiography of the aorta with VMI at 40 and 45 keV resulted in significantly increased CNR compared with EID-CT with ATVS at matched radiation dose. The CNR gain of PCD-CT increased in overweight patients. Taking into account the subjective analysis, VMI at 45 to 50 keV is proposed as the best trade-off between objective and subjective image quality.

Short Term Outcomes of Distal Extended EndoVascular Aortic Repair (DEEVAR) Petticoat in Acute and Subacute Complicated Type B Aortic Dissection

The aim of this study was to evaluate the peri-operative and short term results of institutional experience with the Distal Extended EndoVascular Aortic Repair PETTICOAT (DEEVAR PETTICOAT) procedure. This was a single centre, observational study. From January 2015 to December 2019, 53 patients were admitted to the institution for treatment of acute and subacute complicated type B aortic dissection. Among them, data on 16 patients deemed suitable for a PETTICOAT procedure extended at infrarenal and iliac level by means of a bifurcated endograft were prospectively collected. Patients with persistent pain, visceral or lower limb malperfusion, true lumen collapse, and distal extension with computed tomography angiography (CTA) evidence of entry tears in the infrarenal or iliac zone were included. A CTA scan was performed in all patients at the baseline, before hospital discharge and then at six and 12 months post-operatively to assess aortic remodelling. Complete aortic remodelling was defined as stable aortic size (maximum enlargement < 5 mm) with complete true lumen re-expansion and complete false lumen exclusion or disappearance. Technical success was obtained in all patients. One patient (7%) had intra-operative infrarenal aortic rupture during balloon dilation of the distal end of the bare stent, successfully treated by deployment of a bifurcated endograft. Additional covered stenting of the visceral arteries was necessary in nine patients (56%) and malperfusion resolved immediately in all cases. There were no spinal cord ischaemia or other peri-procedural complications, and no post-operative death, stroke, paraplegia/paraparesis, or acute renal failure was observed. Follow up ranged from one month to 24 months (median 7.5 months). One patient (7%) with a history of drug abuse died from sepsis. At the last CTA check, all patients showed complete remodelling of the thoraco-abdominal aorta and iliac arteries without vessel enlargement. The present findings suggest that the DEEVAR PETTICOAT procedure provides effective sealing of all distal tears without increased risk of major peri-procedural complications. Further studies with larger number of patients and longer follow up are needed to confirm the safety and durability of this technique.

The first case of renal artery prosthetics using a vascular stent graft during renovisceral debranching

The article demonstrates the first clinical case of using the vascular stent graft in renal artery prosthetics in the framework of hybrid treatment of a patient with Stanford B type aortic dissection with renovisceral debranching and subsequent aortic endoprosthetics. Currently available approaches to nephropothecation in prosthetics of renal arteries, surgical technique for using the graft, and the features and advantages of its use are described. The place of this new technique in the surgery of thoracoabdominal aorta is discussed.

The current status and prospect of catheter-based treatment of ascending aorta and aortic root diseases

In recent years, the endovascular procedures has considerably evolved in concepts, technologies, materials and devices on cardiovascular surgery, and influenced the development and the future direction of cardiovascular surgery technology. Endovascular aorta repair is well recognized as the optimal therapy for patients presenting with acute or chronic pathology of distal aortic arch, descending aorta and thoraco-abdominal aorta. The use of catheter-based endovascular repair in the ascending aorta pathology including aneurysms, pseudoaneurysms, penetrating aortic ulcers and acute or chronic Stanford type A aortic dissection has been concerned and reported. Comparing to the open surgical procedures for ascending aorta and aortic root disease with high perioperative mortality and morbidity, the catheter-based endovascular repair has minimally invasive, expanding the alternative treatment of ascending aorta disease, especially for patients with high-risk profiles. However, due to the complex anatomy and functional properties, materials and devices, the use of this technique in ascending aorta and aortic root is still questionable. In addition, the long-term and reliable clinical research results is still inadequate, and the safety and effectiveness need further research.

Delivery system release during transcatheter aortic valve implantation in extreme thoracoabdominal aorta tortuosity and bicuspid aortic valve: Case report

Delivery system release during transcatheter aortic valve implantation in extreme thoracoabdominal aorta tortuosity and bicuspid aortic valve: Case report

The protective effects of topiramate on intestinal injury induced with infrarenal aortic occlusion via oxidative stress and apoptosis

ABSTRACT Purpose: Prolonged surgical procedures and some clinical conditions such as surgeries of thoracoabdominal aorta, mesenteric ischemia, cardiopulmonary bypass, strangulated hernias and neonatal necrotizing enterocolitis may cause decreased perfusion and injury of relevant organs and tissues. After reperfusion, injuries may get worse, leading to ischemia–reperfusion (I/R) injury. Reperfusion following arterial clamping allows oxygen to ischemic tissues and produce injury by multiple mechanisms, including neutrophilic infiltration, intracellular adhesion molecules, and generation of reactive oxygen radicals. In this study with the analysis of SOD, MDA and Caspase-3 levels, we aimed to investigate the effect of topiramate on the outcome of I/R occured after abdominal aorta clamping on rats. Materials and Methods: Totaly 24 Sprague–Dawley male rats were randomly divided into three experimental groups; the control group (n = 8), I/R (n = 8) and I/R+ topiramate (n = 8). Topiramate (100 mg/kg/day); 50 mg/kg (single dose) was administered intraperitoneally after being diluted with saline 5 days before I/R. Results: The intestinal tissue of the ischemia group displayed hemorrhage, Crypts of Lieberkuhn degeneration, ulceration, vascular congestion and edematous fields as a result of aortic occlusion. We also observed that MDA levels and Caspase-3 positivity increased and SOD levels decreased in the small intestine. However, topiramate administration decreased Crypts of Lieberkuhn degeneration, ulceration, vascular congestion and edematous fields, Caspase-3 positivity, and MDA levels. Conclusion: Our findings suggest that topiramate is effective against aortic occlusion-induced intestinal injury by reducing oxidative stress and apoptosis.

False lumen enhancement characteristics on computed tomography angiography predict risk of aneurysm formation in acute type B aortic dissection.

Differential luminal enhancement [between true lumen (TL) and false lumen (FL)] results from differential flow patterns, most likely due to outflow restriction in the FL. We aimed to assess the impact of differential luminal enhancement at baseline computed tomography angiography on the risk of adverse events in patients with acute type B aortic dissection (TBAD). Baseline computed tomography angiographies of patients with acute TBAD between 2007 and 2016 (n = 48) were analysed using three-dimensional software at multiple sites along the descending thoraco-abdominal aorta. At each location, we measured contrast density in TL and FL [Houndsfield unit (HU)], maximal diameter (cm) and circumferential FL extent (°). Outcome data were collected via retrospective chart review. Multivariable logistic regression models were employed to determine the independent risk of TL-FL differential luminal enhancement on aneurysm formation (maximal diameter ≥55 mm) and medical treatment failure. Patients were predominately male (75%) and 52.8±12.9 years at diagnosis. The mean follow-up was 5.9±2.6 years, and 42% (n = 20/48) patients were diagnosed with thoraco-abdominal aortic aneurysm. The baseline absolute difference between FL and TL contrast density measured at 2 cm distal to primary entry tear (TL-FLabs-Tear) was significantly higher among patients who developed aneurysm (26 HU, IQR: 15-53 vs 13 HU, IQR: 4-24, P = 0.001). Aneurysm development during follow-up was predicted by TL-FLabs-Tear (odds ratio 1.07, P = 0.012) and baseline maximal aortic diameter (odds ratio 1.90, P < 0.001). High (≥18 HU) differential luminal enhancement was associated with lower rates of aneurysm-free survival and higher rates of medical treatment failure. Differential luminal enhancement may be a novel predictor of aneurysm formation among patients with acute TBAD.

Comparative evaluation of visceral and renal protection methods during thoracoabdominal aortic repair (Experience of Russian Surgery Research Center named after B.V. Petrovsky)

The objective: to compare the effectiveness of visceral and renal protection methods during thoracoabdominal aortic (TAA) repair: left atrial-femoral bypass (LAFB) and cardiopulmonary bypass (CPB) in conjunction with selective perfusion (SP) of these organs.Subjects: 81 patients who underwent TAA repair were enrolled in retrospective analysis: LAFB was used in 29 patients (Group 1), CPB and SP ‒ in 52 patients (Group 2).Results. In Group 2, there were lower intraoperative blood loss volume (1,500 ml vs 4,200 ml, p &lt; 0.001), significantly lower levels of direct bilirubin, blood creatinine, blood alpha-amylase in postoperative period, significantly shorter duration of hospital stay, ICU stay and duration of mechanical ventilation. Also in this group, there were lower incidence of multiple organ dysfunction (11.5% vs 37.9%, p = 0.005), stroke (0 vs 10.3%, p = 0.043), lower need for requirement (3.8% vs 20.7%, p = 0.022) and mortality (3.8% vs 27.6%, p = 0.003).Conclusion: During TAA repair, CPB in conjunction with selective visceral and renal perfusion is more beneficial for organ protection as compared with LAFB.

Immediate outcomes of simultaneous and step-by-step reconstruction of aortic dissection: a single-center study

The aim. To evaluate the immediate outcomes after complete single-stage or step-by-step reconstruction of the primary and secondary distal aortic dissection using implantation of bare metal stents in the thoracoabdominal aorta.Materials and methods. A prospective study was performed involving 21 patients (19 male) with aortic dissection: 8 had secondary distal dissection (group 1) and 13 had primary distal dissection (group 2). In all patients, indications for intervention were signs of malperfusion in one or more vascular regions. The following factors were evaluated: 30-day survival after surgery, causes of fatal outcomes, frequency and characteristics of non-fatal complications.Results. The average age in group 1 was 43.0 ± 3.1 years, in group 2: 56.0 ± 3.9 years (p &lt; 0.05). The most common cause of dissection in group 1 was connective tissue dysplasia, in group 2 – atherosclerosis in combination with arterial hypertension (p &lt; 0.05). In group 1, 1 (13%) lethal outcome was registered, in group 2 – 4 (31%), the difference between the groups was not significant. Lethal complications were: multiple organ failure, stent implantation in the false aortic canal, aortic rupture, and thrombosis of the superior mesenteric artery. Non-fatal complications developed in group 1 in 3 (38%), in group 2 – in 3 (23%) patients, the difference between the groups is not significant. Among the non-lethal complications, malperfusion of the upper and lower extremities was diagnosed, requiring stent placement, prosthetics or bypass surgery; cerebrospinal circulation disorder, acute cerebrovascular accident, multiple organ failure, conservatively treated.Conclusion. The survival rate for 30 days after a complete single-stage or step-by-step reconstruction of the primary and secondary distal aortic dissection using implantation of bare metal stents in the thoracoabdominal aorta is 76%, the frequency of non – fatal complications is 28%.

ATHEROGRIPPE – Effect of two influenza vaccines on the development of atherosclerosis in ApoE−/− mice

The scientific interest in influenza vaccine and its cardiovascular protection continues to grow. Clinical data are progressively reinforcing a vaccine-specific effect, an “infection-independent” action, underlined by an immunomodulatory effect. However, there is a lack of biological data to justify influenza vaccination as an athero-protective measure. We aimed to study the effect of Influenza vaccination on atherosclerotic plaque development in apoE(−/−) mice. Thirty-six apoE−/− mice, aged 6 months and fed nonatherogenic chow, were randomized into three groups ( n = 12, 6 males and 6 females). Mice were immunized subcutaneously and boosted once 3 weeks later with Influenza vaccine (60 μg/0.5 mL Vaxigrip®, Sanofi-Aventis) or a solution of 4 soluble recombinant hemagglutinins (HA)(60 μg/0.5 mL) or with phosphate buffered saline. After 3 weeks, mices were started on high fat diet for 12 weeks. Blood samples were collected from submandibular veins before and after each immunisation. At termination, animals were euthanized and aortic sinus, brachiocephalic trunk and thoraco-abdominal aorta were removed from each animal and preserved.Circulating autoantibodies IgG and IgM against native apoB-100 were quantified by an in-house ELISA in plasma samples. Animals vaccinated with 60 μg/0.5 mL Vaxigrip® and recombinant solution showed a better overall aging phenotype. ApoE−/−vaccinated mice showed macroscopically smaller plaques on large arteries (aorta and brachiocephalic trunk) (quantification in progress) compared to control mice (treated only with saline solution). Similarly, vaccinated mices were found to have lower levels of IgM native ApoB100 autoantibodies compared to control group. These results indicate that vaccination against Influenza may protect against the development of CVD by promoting smaller and stable atherosclerotic plaques and by inducing atheroprotective immune responses.

Incidence of spinal cord ischemia according to the patency of reimplanted segmental arteries during thoracoabdominal aortic replacement.

This study aimed to investigate the impact of segmental artery reimplantation and its patency on spinal cord ischemia (SCI) in thoracoabdominal aorta replacement. For 193 patients who underwent early postoperative computed tomographic (CT) angiography after thoracoabdominal aorta replacement, the technique of segmental artery reimplantation, their patency, and postoperative SCI were retrospectively investigated. The early patency rate of reimplanted segmental artery was 83.3% (210 of 252), as 13 were taken down intraoperatively and 42 were not visualized in the postoperative CT angiography. The patency rate differed according to the reimplantation technique: 93.6% (131/140) for en bloc patch, 95.6% (43/45) for small individual patch, and 53.7% (36/67) for graft interposition. SCI occurred in 13 (6.3%) patients, 4 of whom (2.0%) remained paraplegic permanently. SCI was significantly more frequent (P=0.044) in the patients in whom segmental artery reimplantation was not successful (take-down or occlusion, 6/37=16.2%) than in those who had all segmental arteries sacrificed intentionally (2/64=3.1%) and those who showed patency of all reimplanted segmental arteries (5/92=5.4%). Especially, there was no permanent paraplegia in the last group. Failure of intended segmental artery reimplantation was a significant risk factor of postoperative SCI in logistic regression analysis (P=0.012; odds ratio 4.65, 95% confidence interval 1.41-15.36). During thoracoabdominal aorta replacement, attention should be paid to the segmental artery reimplantation technique, which affects the risk of occlusion or intraoperative take-down and thereby may have impact on postoperative SCI.

STABILISE Technique for Treatment of Type B Aortic Dissection: A Literature Review

Endovascular techniques are currently the treatment of choice for complicated type B aortic dissection (cTBAD). Among them is the STABILISE technique, the goal of which is to achieve, in a single surgical session, immediate remodelling of the thoraco-abdominal aorta with consequent obliteration of the false lumen through re-apposition of the dissection flap to the outer layers of the aorta. This is a relatively recent technique, with few published series. Therefore, this review aimed to systematise the information to date on this technique of increasing importance in the treatment of acute type B aortic dissections. Keywords: Aortic dissection, Endovascular, PETTICOAT, STABILISE, TEVARFigure 1Schematic representation of the STABILISE technique. (A) Type B aortic dissection with compression of the true lumen (TL) by the false lumen (FL). (B) Residual flow in the false lumen after implantation of the proximal endoprosthesis and bare metal stent (PETTICOAT technique). (C) Intimal re-apposition after ballooning of the distal endoprosthesis and stent with obliteration of the false lumen (STABILISE technique).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Figure 1Schematic representation of the STABILISE technique. (A) Type B aortic dissection with compression of the true lumen (TL) by the false lumen (FL). (B) Residual flow in the false lumen after implantation of the proximal endoprosthesis and bare metal stent (PETTICOAT technique). (C) Intimal re-apposition after ballooning of the distal endoprosthesis and stent with obliteration of the false lumen (STABILISE technique).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Treatment of thoracoabdominal aortic aneurysm by prosthetic vessel replacement under left heart bypass.

Thoracoabdominal aortic aneurysm (TAAA) prosthetic vessel replacement is one of the most complex operations in the field of cardiovascular surgery. The key to success of this operation is to prevent and avoid ischemia of important organs while repairing TAAA. This study aims to summarize and analyze the effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA. Data of 15 patients with TAAA who underwent prosthetic vessel replacement under left heart bypass in Xiangya Hospital of Central South University were retrospectively analyzed. According to Crawford classification, there were 2 cases of type I, 8 cases of type II, 3 cases of type III, and 2 cases of type V. There were 14 cases of selective operation and 1 case of emergency operation. All operations were performed under left heart bypass, and cerebrospinal fluid drainage was performed before operation. Left heart bypass was established by intubation of left inferior pulmonary vein and distal abdominal aorta or left femoral artery. The thoracoabdominal aorta was replaced segment by segment. After aortic dissection, the kidneys were perfused with cold crystalloid renal protective solution, and the celiac trunk and superior mesenteric artery were perfused with warm blood. One patient with TAAA after aortic dissection of type A died. During the operation, straight blood vessels were used to repair TAAA, and the celiac artery branches were trimmed into island shape and anastomosed with prosthetic vessels. After the operation, massive bleeding occurred at the anastomotic stoma, then anaphylactic reaction occurred during massive blood transfusion, resulting in death. One patient suffered from paraplegia due to ischemic injury of spinal cord. The other patients recovered well and were discharged. The postoperative ventilation time was (16.5±13.8) h and the postoperative hospital stay was (10±4) d. The amount of red blood cell transfusion was (13±9) U. The patients were followed up for 2 months to 2 years, and the recovery was satisfactory. The effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA is good, which is worthy of clinical promotion.

Automated tube voltage selection and adapted contrast media injection protocols in CT angiography of the thoracoabdominal aorta

PurposeThe aim was to assess the image quality (IQ) in computed tomography angiography (CTA) of the thoracoabdominal aorta utilizing automated tube voltage selection (ATVS) with a subsequently adapted contrast media (CM) injection protocol.Materials and methodsA total of 104 consecutive patients referred for CTA of the thoracoabdominal aorta were included. Scans were acquired on a 3rd-generation DSCT using ATVS with a quality reference tube voltage and current of 100 kV and 150 mAs. CM protocols were adapted to kV settings by modifying iodine delivery rate (IDR) whilst maintaining an identical injection time (13.3 s): 0.9 gI/s (70 kV), 1.0 gI/s (80 kV), 1.1 gI/s (90 kV) 1.2 gI/s (100 kV). Both objective (attenuation, contrast-to-noise and signal-to-noise) and subjective (4-point Likert scale: 1 = poor/2 = sufficient/3 = good/4 = excellent) IQ were assessed.ResultsATVS assigned a 70 kV (n = 88) and 90 kV (n = 16) protocol in most patients. Fewer patients were assigned to an 80 kV (n = 4) and 100 kV (n = 1) protocol, these protocols were, therefore, excluded from further analysis. Attenuation on all designated levels of the thoracoabdominal aorta was diagnostic in 99.0% of the scans; 87/88 scans (98.9%) in the 70 kV group and in 16/16 (100%) in the 90 kV group. Overall mean attenuation was 349 ± 72HU for 70 kV and 310 ± 43HU for 90 kV. Subjective IQ was diagnostic in all scans. Overall effective radiation dose for 70 kV and 90 kV was 1.8 ± 0.2 mSv and 3.4 ± 0.7 mSv, respectively.ConclusionsAdaptation of CM injection protocols (IDR) to ATVS in CTA of the aorta—scanned with 70 kV and 90 kV—is feasible and results in diagnostic image quality.

Surgical treatment for thoracoabdominal aorta pathology

Material and Methods . A total of 29 patients with thoracoabdominal aortic pathology were operated in the Sukhanov Federal Center of Cardiovascular Surgery from January, 2016 to December, 2020. Among these patients, 19 patients had thoracoabdominal aortic aneurysm, six patients had type III aortic dissection, and four patients had corrected type I aortic dissection. The average age of patients was 58 ± 12 years and ranged from 29 to 73 years. To minimize the time of ischemia in visceral organs, we developed and implemented in clinical practice a new method for thoracoabdominal aorta reconstruction. The operations began with a distal bypass of the iliac arteries followed by a consecutive debranching of the left renal artery, superior mesenteric artery, and celiac trunk in the presence of natural blood circulation without clamping the aorta. The left ventricular bypass (pulmonary vein – branch of the prosthesis) was connected and aorta was clamped and opened only at the stage of prosthetic repair of the right renal arteries and intercostal arteries. The last step was a proximal anastomosis at the level of aortic isthmus. Results . The rate of total postoperative mortality was 13.7% (four patients). Acute kidney injury requiring renal replacement therapy was detected in 10.3% of cases. Spinal complications such as temporal paraplegia were observed in two patients (6.9%). Respiratory failure was detected in four patients (13.7%). Bleeding requiring reoperation occurred in one patient (3.4%). Conclusion . The proposed new method for a surgical reconstruction of the thoracoabdominal aorta allowed to decrease aortic cross-clamp time, cardio-pulmonary bypass duration, and ischemia of the visceral organs and spinal cord, which directly contributed to the improvement of surgical treatment results in this category of severely ill patients.

False lumen pressure estimation in type B aortic dissection using 4D flow cardiovascular magnetic resonance: comparisons with aortic growth

BackgroundChronic type B aortic dissection (TBAD) is associated with poor long-term outcome, and accurate risk stratification tools remain lacking. Pressurization of the false lumen (FL) has been recognized as central in promoting aortic growth. Several surrogate imaging-based metrics have been proposed to assess FL hemodynamics; however, their relationship to enlarging aortic dimensions remains unclear. We investigated the association between aortic growth and three cardiovascular magnetic resonance (CMR)-derived metrics of FL pressurization: false lumen ejection fraction (FLEF), maximum systolic deceleration rate (MSDR), and FL relative pressure (FL ΔPmax).MethodsCMR/CMR angiography was performed in 12 patients with chronic dissection of the descending thoracoabdominal aorta, including contrast-enhanced CMR angiography and time-resolved three-dimensional phase-contrast CMR (4D Flow CMR). Aortic growth rate was calculated as the change in maximal aortic diameter between baseline and follow-up imaging studies over the time interval, with patients categorized as having either ‘stable’ (< 3 mm/year) or ‘enlarging’ (≥ 3 mm/year) growth. Three metrics relating to FL pressurization were defined as: (1) FLEF: the ratio between retrograde and antegrade flow at the TBAD entry tear, (2) MSDR: the absolute difference between maximum and minimum systolic acceleration in the proximal FL, and (3) FL ΔPmax: the difference in absolute pressure between aortic root and distal FL.ResultsFLEF was higher in enlarging TBAD (49.0 ± 17.9% vs. 10.0 ± 11.9%, p = 0.002), whereas FL ΔPmax was lower (32.2 ± 10.8 vs. 57.2 ± 12.5 mmHg/m, p = 0.017). MSDR and conventional anatomic variables did not differ significantly between groups. FLEF showed positive (r = 0.78, p = 0.003) correlation with aortic growth rate whereas FL ΔPmax showed negative correlation (r = − 0.64, p = 0.026). FLEF and FL ΔPmax remained as independent predictors of aortic growth rate after adjusting for baseline aortic diameter.ConclusionComparative analysis of three 4D flow CMR metrics of TBAD FL pressurization demonstrated that those that focusing on retrograde flow (FLEF) and relative pressure (FL ΔPmax) independently correlated with growth and differentiated patients with enlarging and stable descending aortic dissections. These results emphasize the highly variable nature of aortic hemodynamics in TBAD patients, and suggest that 4D Flow CMR derived metrics of FL pressurization may be useful to separate patients at highest and lowest risk for progressive aortic growth and complications.