To Thoracic Endovascular Aortic Repair Research Articles

The Rate of Postoperative Complications in Complicated Acute, and Subacute Type B Aortic Dissections after TEVAR vs. PETTICOAT Procedures: Systematic Review and Meta-Analysis.

Background and Objectives: Provisional extension to induce complete attachment (PETTICOAT) is suggested as being associated with a lower incidence of aorta-related events and fewer reinterventions compared to thoracic endovascular aortic repair (TEVAR) in patients with complicated acute, and subacute type B aortic dissections. Materials and Methods: This article is a systematic review and meta-analysis following the PRISMA guidelines. The Medline, PubMed, Embase, and Cochrane databases were searched, starting on 21 February 2022 and ending on 22 June 2022, to identify studies that investigated the rate of postoperative complications in patients treated with the PETTICOAT compared to the TEVAR. A random effects meta-analysis was performed. Of 2350 studies, 5 studies involving 360 patients were included: 143 patients after the PETTICOAT procedure and 217 after the TEVAR. Results: The meta-analysis of all studies showed that the rate of secondary endovascular reinterventions was smaller in patients treated with the PETTICOAT (n = 3 studies; OR, 0.30; 95% CI, 0.10 to 0.94; p = 0.04). The results of other postoperative complications (30-day mortality, mortality during follow-up, paraplegia, stroke, and occurrence of endoleak) were lower in the PETTICOAT group but were not statistically significant. The rate of postoperative renal failure was lower in patients treated with the TEVAR (n = 4; OR, 1.08; 95% CI, 0.46 to 2.51; p = 0.86). Conclusion: This meta-analysis suggests that the PETTICOAT procedure is related to the lower rate of secondary endovascular reinterventions for complicated acute, and subacute type B aortic dissections.

Retrograde type A aortic dissection during or after thoracic endovascular aortic repair: a single center 16-year experience.

This article aims to investigate the incidence rate of retrograde type A aortic dissection (RTAD) and the risk factors of RTAD in relation to thoracic endovascular aortic repair (TEVAR). Patients with thoracic aortic disease who underwent TEVAR at Henan Provincial People's Hospital from January 2004 to December 2019 were enrolled in the present research. The risk factors associated with RTAD following TEVAR using univariate and multiple logistic regression analyses. During the study period, A total of 1,688 TEVAR patients were included in this study, and of these, 1,592 cases were included in the type B aortic dissection (TBAD) group, and 96 cases were included in the non-TBAD group. There were 1,230 cases of aortic dissection and 362 cases of aortic intramural hematoma and/or penetrating ulcer in the TBAD group. The non-TBAD group included 68 cases of thoracic aortic aneurysm, 21 cases of thoracic aortic pseudoaneurysm, and seven cases of congenital aortic coarctation. The overall incidence rate of RTAD was 1.1% (18/1,688) in patients, all of which occurred in the TBAD group. The cohort comprised 18 RTAD patients with an average age of 56.78, consisting of 13 males and 5 females. Among them, 13 individuals exhibited hypertension. Ten instances happened within the TEVAR perioperative period, including two cases during the surgery, six cases occurred within three months, two cases occurred after one year, and the longest interval was 72 months following TEVAR. TEVAR was successfully implemented in 17 patients, while the operation technique was temporarily altered in one case. The new entry position for RTAD was identified as the proximal region of the stent graft (SG) in 13 patients, while in five cases, the entry site was more than 2 cm away from the proximal region of the SG. 17 cases were at the greater curvature of the aorta, and one case was at the lesser curvature. Multivariate logistic regression analysis revealed that the SG oversizing ratio is a relevant risk factor for RTAD. However, ascending aortic diameter, aortic arch type, SG type, and anchored region were not directly related to the occurrence of RTAD. RTAD is a rare yet catastrophic complication. It could occur both during the procedure, early and late postoperative periods. Maintaining an appropriate SG oversizing ratio is crucial to minimize the risk of RTAD.

Rule of four: an anatomic and value-based approach to stent-graft inventory for blunt thoracic aortic injury.

As blunt thoracic aortic injury (BTAI) treatment has shifted from open to thoracic endovascular aortic repair (TEVAR), logistical challenges exist in creating and maintaining inventories of appropriately sized stent-grafts, including storage demands, shelf-life management and cost. We hypothesized that most injured aortas can be successfully repaired with a narrow range of stent-graft sizes and present a value-based anatomic approach to optimizing inventory. CT-scans of all patients with BTAI admitted to our Level I trauma center from Apr2010-Dec2018 were reviewed. Patients with anatomy incompatible with TEVAR were excluded. For each patient, after aortic sizing a set of two stent-grafts most likely to be utilized was selected from a list of twenty commercially available GORE conformable TAG endografts based on manufacturer instructions. Stent-graft sizes were then ranked based on the number of cases they would be suitable for. MATLAB was utilized to determine the combinations of stent-grafts which would cover the most patients. Twenty-eight patients with BTAI were identified and three were excluded based on iliac diameter. Most patients were male (68%), mean age 42.3 ± 20.2years, mean ISS 37.0 ± 9.8. Overall mortality was 25%. Of the 20 available stent-graft options, a combination of four stent-grafts would successfully treat 100% of the patients in this series. Based on actual CT-scan aortic measurements, we demonstrated that an inventory of four sent-graft sizes was sufficient to treat 100% of patients with BTAI. These data can be utilized as a value-based anatomic approach to aortic stent-graft institutional inventory creation and maintenance.

Aorto-esophageal fistula secondary after thoracic endovascular aortic repair.

Aortoesophageal fistula (AEF) secondary to thoracic endovascular aortic repair (TEVAR) is a rare clinical entity that poses a threat to life as it causes massive digestive bleeding, and it is estimated that 60% of patients who suffer from it could die within within 6 months of the onset of their symptoms. It requires a high clinical suspicion to establish an early multidisciplinary surgical treatment. We present the cases of two patients diagnosed with aortoesophageal fistulas after TEVAR in the last 5 years (January 2018-December 2022) while reviewing the existing scientific literature on the matter.

A Rare Case of an Ascending Aorta and Aortic Arch Aneurysm with an Aberrant Right Common Carotid Artery

Ascending aortic aneurysms are asymptomatic and are usually discovered as an incidental finding on chest imaging. However, larger aneurysms can present with symptoms resulting from compression of surrounding structures including the trachea, bronchi, and the esophagus which can result in hoarseness, cough chest pain or back pain. The presence of an aortic arch anomaly, specifically an aberrant right common carotid artery, in a background of an aortic arch aneurysm is extremely rare with a worldwide incidence of <1%. They are usually asymptomatic but can result to catastrophic life threatening events and pose significant challenges to surgical or endovascular treatment. This is a case of a 63-year old Filipino male who presented with a sudden onset of dull back pain radiating to the left anterior chest. Workup revealed an ascending and aortic arch aneurysm with an aberrant right common carotid artery arising directly from the transverse aorta. Surgical aortic arch debranching was done to repair the aberrant vessels prior to Thoracic Endovascular Aortic Repair (TEVAR) wherein a custom-made Thoracic Valiant graft was deployed on the aneurysm. The patient was discharged on the 4th day after TEVAR without any complaints of dyspnea, back pain nor chest pain with no neurologic and visceral organ dysfunction. This case has emphasized that knowledge on the anatomy of the aortic arch is imperative in planning out thoracic surgery and endovascular interventions especially on rare anatomic anomalies such as seen in this case. Keywords aortic aneurysm, aberrant right common carotid artery, TEVAR

Intraoperative Stent-Graft-Induced Aortic Intimal Intussusception During TEVAR for Type B Aortic Dissection

Background: Aortic intimal intussusception is well described in the natural progression of type A aortic dissection. Only 3 cases of aortic intimal intussusception were reported to be related to thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection. In our study, we are reporting a rare but potentially fatal complication, the intraoperative stent-graft (SG)-induced aortic intimal intussusception (ISAII); this study reports a series of endovascular repair for ISAII cases. By presenting the ISAII definition, the diagnostic steps to rule out or to identify the condition, and the techniques to resolve it, we intended to raise the awareness of this severe complication, so that physicians can adapt to overcome the complications while performing TEVAR. Materials and Methods: ISAII was defined as the partial or circumferential disruption of the distal intimal flap as an intraoperative complication of endovascular treatment. From January 2014 to June 2020, 1,096 patients underwent TEVAR for Stanford type B aortic dissection at our hospital. Among them, 14 ISAII complications were witnessed. All these patients underwent endovascular repair for ISAII lesions, and their data were extracted for analysis. Results: The ISAII lesions were classified into 3 types according to their location in different aortic segments: type I, ISAII was limited within the intended SG coverage segment; type II, ISAII occurred after SG introduction or deployment, and the detached intimal flap extended beyond the intended SG coverage segment but did not affect the abdominal aortic visceral branches; type III, ISAII occurred during SG introduction or deployment, and the detached intimal flap descended to the abdominal aortic segment with visceral branches. Our results showed ISAII as a rare complication with an incidence of 1.28% (14/1096), and endovascular repair for all types of ISAII is an effective treatment. With a mean follow-up of 27.36 months (range 5–71 months), all the ISAII lesions were stable, and all the major aortic branches, SGs, and bare stents were patent. Conclusions: The management of this potentially devastating intraoperative complication relies on accurate diagnosis and prompt management. Our results suggested that endovascular repair for ISAII is effective and durable for correcting this complication. Graphical

Timing and Outcome of Endovascular Repair for Uncomplicated Type B Aortic Dissection

This study aimed to determine the effect of intervention timing, from symptom onset to thoracic endovascular aortic repair (TEVAR), on early and late outcomes in high risk patients with uncomplicated type B aortic dissection (uTBAD). The study retrospectively evaluated 267 uTBAD patients with high risk radiographic features who underwent pre-emptive TEVAR during the acute and subacute periods. Demographics, comorbidities, pre-operative imaging features, peri-procedural details, and follow up outcomes were analysed. Among the 267 pre-emptive TEVARs for high risk uTBAD, 130 were performed in the acute phase (1-14 days); and 137 in the subacute phase (15-90 days), from initial presentation. The mean age was 55.9 ± 11.0 years and 222 (83.1%) were men. The 30 day mortality rate in the acute group was five times higher than that in the subacute group (3.8% vs. 0.7%), although without statistically significant difference (p= .11). No statistically significant difference in 30 day outcomes (aortic rupture, retrograde type A dissection [RTAD], immediate type Ia endoleak, stroke, spinal cord ischaemia, and re-intervention) was noted (p > .05 for each). Of note, aortic rupture, RTAD, and disabling stroke were observed only in the acute group. Multivariable logistic analyses showed that intervention timing was not associated with 30 day outcomes. The median clinical follow up was 48.2 ± 25.9 months (range 1 - 106 months). There were no significant differences in all cause mortality, dissection related death, late intervention, or aortic related late events among timing cohorts (p > .05 for each). Furthermore, aortic remodelling, by analysing the flow status of the false lumen and evaluation of aortic diameters, either at the thoracic aorta level or the abdominal aorta level, was similar between the two groups. Multivariable Cox analyses showed that intervention timing was not associated with late outcomes. The present study indicates that TEVAR for high risk uTBAD in the acute phase was associated with a trend toward higher rates of early complications, while the long term outcomes were comparable with those of the subacute phase.

Thoracic Endovascular Aortic Repair in the Setting of Compromised Distal Landing Zones

The short-term and intermediate-term outcomes of two distinct approaches to thoracic endovascular aortic repair (TEVAR) for descending aortic aneurysms in patients with compromised distal landing zones are reported. Fifty-one patients (38 female, average age 72 ± 9 years) underwent 55 TEVARs (2008 to 2018) for aneurysmal disease. Inclusion criteria consisted of TEVAR in a compromised distal landing zone, defined as follows: diameter 3.5 cm or greater; cross-sectional thrombus 50% or greater; or 25% or greater circumferential mural calcification in the 2 cm supraceliac aorta; or tortuosity index of 1.1 or more over the 10 cm supraceliac aorta. Treatment cohorts were (1) TEVAR alone (n= 29), and (2) TEVAR with adjunct consisting of visceral snorkel graft with distal stent extension (n= 20) or EndoAnchors (Medtronic, Minneapolis, MN [n= 6]). Perioperative complication rate was 20%. Thirty-day mortality was 5% including one access-site related intraoperative death and one postoperative death from embolic mesenteric ischemia. Median clinical follow-up was 2.2 years. Intermediate-term outcomes include type 1B endoleaks, 35%; 0.5 cm or more per year maximal aortic diameter growth, 9%; reintervention, 15%; and all-cause mortality, 25%. The distal landing zone diameter increased by 0.3 cm per year in the TEVAR alone cohort; however, it decreased by 0.1 cm per year in the adjunct cohort ( P= .04). Thoracic endovascular aortic repair is a viable alternative for the treatment of thoracoabdominal aortic aneurysms in patients with compromised distal landing zones, although these patients may benefit significantly from the development of branched thoracoabdominal devices. In the interim, the use of TEVAR adjuncts may limit progressive degeneration of the distal landing zone in this patient population.

Improved Remodeling With TEVAR and Distal Bare-Metal Stent in Acute Complicated Type B Dissection

The ASSIST (A multicentre Study in Survivors of type B aortic dissection undergoing Stenting) study compared both 1-year outcomes and evolution of true and false lumen (eg, remodeling) in patients with complicated type B aortic dissection subjected to thoracic endovascular aortic repair (TEVAR) with distal true lumen scaffolding by self-expanding nitinol open stent in comparison with TEVAR alone. The ASSIST study was a multicenter prospective single-arm study comparing clinical and imaging data from 39 consecutive patients (59.4 ± 13 years of age) who received TEVAR and the JOTEC E-XL open stent with data from matched control subjects treated with TEVAR alone based on 1:1 propensity score matching. Clinical data were collected by an independent Contract Research Organization (CRO) and computed tomography images were subjected to blinded core-lab analysis. There were no differences in baseline demographics, clinical profiles, morphological data, procedural details, and in-hospital and 1-year outcomes between groups. Differences emerged with regard to evolution of both true lumen distal to stent graft, false lumen over the entire length of dissection, and remodeling (P < .001). At 1 year, TEVAR with the E-XL stent revealed false lumen thrombosis at the level of celiac trunk in 53.8% vs 17.9% with TEVAR alone (P= .004). Kaplan-Meier survival analysis indicated favorable clinical outcomes with the additional E-XL stent. TEVAR for acute complicated type B aortic dissection proved to be safe and promoted remodeling of the stent grafted thoracic aorta. Additional scaffolding of the true lumen distal to TEVAR with a self-expanding stent supported distal true lumen expansion, false lumen regression, and thrombosis, with evidence of improved distal remodeling at 1 year.

TAA 1. The Role of Heparin in Endovascular Repair of Blunt Thoracic Aortic Injury

Early diagnosis and treatment are essential to improve survival of patients with blunt thoracic aortic injury (BTAI). Often, aortic surgical intervention may be delayed because of increased risk of bleeding with heparin, particularly in polytrauma victims. We believe that surgical delay may be remedied by proceeding without heparinization. This study reviewed the outcome of patients subjected to thoracic endovascular aortic repair (TEVAR) under full, low-dose, and no intraoperative systemic heparinization. There were 77 cases of confirmed BTAI identified and retrospectively analyzed at a high-volume urban trauma center during a period of 15 years (March 2003-September 2017). Patients were stratified into three groups on the basis of the intraoperative use of heparin during TEVAR as follows: full heparin (FH), low-dose heparin (LH), and no heparin (NH). Baseline characteristics including the patients' demographics, diagnostic laboratory data and imaging studies, operative reports, postoperative complications, embolic and bleeding outcomes, and mortality data were reviewed. Of the 77 total patients who underwent TEVAR for BTAI, 42 patients received FH, 18 received LH, and 17 had no use of systemic heparin. There was no significant difference in age, sex, body mass index, or smoking history. The most common mechanism of injury was motor vehicle collision. Grade 3 (pseudoaneurysm) was the predominant type of BTAI (FH, 69.0%; LH, 61.1%; NH, 76.5%; P = .23). The mean interval between admission and repair was three times longer in the FH group than in the NH group (FH, 2.33 days; NH, 0.76 day; P = .091). The mean time in the intensive care unit was shorter in the NH group vs the FH group (15 days vs 26.21 days; P = .025). Thromboembolic and bleeding outcomes and mortality rates were comparable in all three groups; 57 patients continued follow-up for a mean time of 30.99 months. Our study shows no statistically significant difference in outcomes between the heparinized and nonheparinized groups. The primary benefit of the NH group is seen in time to repair. Although not statistically significant, the mean time to repair was three times longer in the FH group. Patients in the NH group also benefited from prompt intervention and treatment. Therefore, intraoperative heparinization in critically ill patients with BTAI undergoing TEVAR remains at the surgeon's discretion, although the lack of heparinization appears to be a safe and potentially faster alternative, particularly in the polytrauma patient.

Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs

ObjectiveTo review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR). MethodsBetween February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods. ResultsThirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m2, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004). ConclusionsOpen surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.

The role of heparin in endovascular repair of blunt thoracic aortic injury

ObjectiveEarly diagnosis and treatment are essential to improve survival of patients with blunt thoracic aortic injury (BTAI). Often, aortic surgical intervention may be delayed because of increased risk of bleeding with heparin, particularly in polytrauma victims. We believe that surgical delay may be remedied by proceeding without heparinization. This study reviewed the outcome of patients subjected to thoracic endovascular aortic repair (TEVAR) under full, low-dose, and no intraoperative systemic heparinization. MethodsThere were 77 cases of confirmed BTAI identified and retrospectively analyzed at a high-volume urban trauma center during a period of 15 years (March 2003-September 2017). Patients were stratified into three groups on the basis of the intraoperative use of heparin during TEVAR, as follows: full heparin (FH), low-dose heparin (LH), and no heparin (NH). Baseline characteristics including the patients' demographics, diagnostic laboratory data and imaging studies, operative reports, postoperative complications, embolic and bleeding outcomes, and mortality data were reviewed. ResultsOf the 77 total patients who underwent TEVAR for BTAI, 42 patients received full-dose heparinization, 18 received low-dose heparin, and 17 had no use of systemic heparin. There was no significant difference in age, sex, body mass index, or smoking history. The most common mechanism of injury was motor vehicle collision. Grade 3 (pseudoaneurysm) was the predominant type of BTAI (FH, 69.0%; LH, 61.1%; NH, 76.5%; P = .23). The mean interval between admission and repair was three times longer in the FH group than in the NH group (FH, 2.33 days; NH, 0.76 day; P = .091). The mean time in the intensive care unit was shorter in the NH group vs the FH group (15 days vs 26.21 days; P = .025). Thromboembolic and bleeding outcomes and mortality rates were comparable in all three groups; 57 patients continued follow-up for a mean time of 30.99 months. ConclusionsOur study shows no statistically significant difference in outcomes between the heparinized and nonheparinized groups. The primary benefit of the NH group is seen in time to repair. Although not statistically significant, the mean time to repair was three times longer in the FH group. Patients in the NH group also benefited from prompt intervention and treatment. Therefore, intraoperative heparinization in critically ill patients with BTAI undergoing TEVAR remains at the surgeon's discretion, although the lack of heparinization appears to be a safe and potentially faster alternative, particularly in the polytrauma patient.

Advances in Treatment and Long-term Survival in Patients with Descending Thoracic Aortic Aneurysms Treated at a Single Tertiary Center from 1984 to 2014

We report long-term survival in open surgical and endovascular patients treated for descending thoracic aortic aneurysms (TAAs) at a single tertiary center from 1984 to 2014 to study the impact of transition to thoracic endovascular aortic repair (TEVAR) for TAA repair. Using a prospectively maintained registry, all patients (n=202) having open or endovascular repair (TEVAR) of descending TAAs were studied. Date of last contact or death was obtained on all patients from hospital records, Social Security Death Database, and verified online records. Survival curves were computed and compared by age, preoperative variables, surgical approach, and hospital complications. Proportional hazards models were used for multivariate analysis of survival. In total, 28% had dissection, 41.6% presented acutely, 68.8% had TEVAR, and 31.1% had open surgery. Spinal cord injury (SCI) occurred in 0.5% and stroke in 1%. Operative mortality (5.9%) was associated with acuity, respiratory failure, open approach, and age. One-year survival in all patients was 83.7%. One-year mortality was associated with acuity, open surgery, respiratory failure, hospital complications, and coronary artery bypass surgery (CABG). Five-year survival was 60.4% and not associated with other variables. One-year survival was 76% in open patients and 87% in TEVAR patients. When operative mortality was excluded, 1-year survival was 89% and 5-year survival was 64.2% and there was no difference in long-term survival between TEVAR and open surgery. One-year mortality was associated with CABG and hospital complications. No variables were associated with 5-year survival. Ten-year survival was 35% and predicted only by age at operation. Operative mortality was higher in open surgery than TEVAR, but after 30days, long-term survival was the same. Eighty-nine percent of patients were alive 1 year after surgery and 64% were alive 5 years after surgery. Low SCI contributed to longer survival.

Differences in Aortic Diameter Measurements with Intravascular Ultrasound and Computed Tomography After Blunt Traumatic Aortic Injury

Intravascular ultrasound (IVUS) has been recommended as an adjunct to thoracic endovascular aortic repair (TEVAR) as computed tomography (CT) in injured patients may inaccurately determine the true aortic diameter. We hypothesize that CT and IVUS offer discordant measurements of aortic diameter in trauma patients and that each modality may result in different graft size estimates for TEVAR. Patients treated by TEVAR for blunt aortic injury from June 2011 to 2016 were reviewed. Cases where IVUS was not used and those without complete CT and IVUS images were excluded. Three-dimensional reconstructions were used to derive centerline diameters of the aorta, proximal and distal to the injury. IVUS diameters were taken from the flow lumen, not including the aortic wall itself. Measurements were made by an investigator blinded to the graft implanted. Descriptive statistics were used to compare patients with concordant diameter (group 1) with patients with discordant diameters (group 2). A total of 24 blunt thoracic aortic injuries were repaired with TEVAR during the study period; complete data were available for 16. The mean age of the patients was 43 (±18), and 12 of the patients were men. The median time from injury to CT was 2.5hr (0.9-8.5) and to TEVAR was 18 (3-48) hr. Stent graft diameter for implantation based on CT and IVUS imaging was the same in 5 cases (group 1). In 11 cases, the graft diameter for implantation based on IVUS was differently sized compared with that determined by CT (group 2). Ten diameters were 1 size larger, and 1 diameter was 1 size smaller by IVUS. There were no significant differences in the mean lowest systolic blood pressure (98 vs. 92, P=0.53), median fluid resuscitation in the first 24hr (4.9 vs. 5.0L, P=0.97), or median 24-hr transfusion requirements (130 vs. 1311mL, P=0.11) between the groups 1 and 2, respectively. In group 2, the graft size chosen for surgery correlated more with measurements obtained from the CT than from IVUS (9 vs. 2). The TEVAR has become the standard therapy for blunt aortic injury, despite a dearth of long-term outcome data. The preoperative CT frequently underestimates aortic diameter compared with intraoperative IVUS. The implications of placing thoracic endografts and whether excessive oversizing results in long-term aortic dilation need to be the focus of long-term studies in these relatively young patients.

Influence of Timing After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection

This study aimed to analyze the influence of the timing of intervention from presentation of symptoms to thoracic endovascular aortic repair (TEVAR) and its relation to major complications. Data were collected from the Japan Adult Cardiovascular Surgery Database. We retrospectively analyzed the data of 680 patients who underwent TEVAR for acute and subacute type B dissection between January 2008 and January2013. Thoracic endovascular aortic repair for type B dissection was performed in 680 patients: 295 repairs were performed within 24 hours of presentation of symptoms (hyperacute); 97 between 24 hours and 14 days (acute); and 288 between 14 days and 6 weeks (subacute). Hyperacute patients more frequently had immediate life-threatening complications from type B dissection such as rupture or malperfusion than did acute or subacute patients (41.0% [121 of 295] versus 7.2% [7 of 97] versus 4.2% [12 of 288]; p < 0.001; and 17.3% [51 of 295] versus 8.3% [8 of 97] versus 5.6% [16 of 288]; p < 0.001, respectively). Operative mortality and severe complications including aortic dissection were more common among hyperacute patients (11.9% [35 of 295] versus 0% [0 of 97] versus 1.7% [5 of 288]; p < 0.001; and 32.5% [96 of 295] versus 10.3% [10 of 97] versus 8.3% [24 of 288]; p < 0.001, respectively) and did not differ significantly between acute and subacute patients (p= 0.191 and p= 0.553, respectively). Although TEVAR performed for aortic dissection within 24 hours of presentation of symptoms was associated with worse outcomes, TEVAR performed between 24 hours and 14 days, as compared with TEVAR between 14 days and 6 weeks, does not appear to increase the risk of perioperative complications.

Thoracic endovascular repair in management of traumatic aortic dissection. A 10 years experience

BackgroundResults of surgery in descending aortic dissection is usually not safe. Recently after introducing the thoracic endovascular stents the outcome marvelously improved. Our objective was to evaluate the results of our 10 years experience of using the endovascular stents in trauma patients. MethodsIn Saudi German Hospital in Madinah Munawarah, from 2007 to 2016 13, cases of traumatic aortic dissection were subjected to thoracic endovascular aortic repair (TEVAR). All cases were victims of blunt trauma in road traffic accidents (RTAs). All had descending thoracic aortic dissection just after the left subclavian artery. Medtronic TEVAR was used in all cases. The data of those patients were collected and revised. CT angio, echocardiography and abdominal ultrasonography were the main tools in the diagnosis. ResultsAll cases were males, middle aged, victims of RTAs and all were associated with other injuries.12 cases survived, one died due to major head injury. The survived cases had no paraplegia either before or after stenting. No intra-thoracic bleeding occurred after the procedure. All cases had no coronary artery or valvular involvement. All cases had good landing zones most were within the range of 2 cms or even more. There was no mortality or morbidity related to the procedure. ConclusionsThe TEVAR is a reliable, safe, convenient and with less complications than the surgical management for traumatic aortic dissection. No incidence of paraplegia was encountered. It is mandatory in all cases presented in RTAs to be surveyed for traumatic aortic dissection.

Differences in Aortic Diameter Measurements With Intravascular Ultrasound and Computed Tomography After Blunt Traumatic Aortic Injury

Background Intravascular ultrasound (IVUS) has been recommended as an adjunct to thoracic endovascular aortic repair (TEVAR) as computed tomography (CT) in injured patients may inaccurately determine the true aortic diameter. We hypothesize that CT and IVUS offer discordant measurements of aortic diameter in trauma patients and that each modality may result in different graft size estimates for TEVAR. Methods Patients treated by TEVAR for blunt aortic injury from June 2011 to 2016 were reviewed. Cases where IVUS was not used and those without complete CT and IVUS images were excluded. Three-dimensional reconstructions were used to derive centerline diameters of the aorta, proximal and distal to the injury. IVUS diameters were taken from the flow lumen, not including the aortic wall itself. Measurements were made by an investigator blinded to the graft implanted. Descriptive statistics were used to compare patients with concordant diameter (group 1) with patients with discordant diameters (group 2). Results A total of 24 blunt thoracic aortic injuries were repaired with TEVAR during the study period; complete data were available for 16. The mean age of the patients was 43 (±18), and 12 of the patients were men. The median time from injury to CT was 2.5 hr (0.9–8.5) and to TEVAR was 18 (3–48) hr. Stent graft diameter for implantation based on CT and IVUS imaging was the same in 5 cases (group 1). In 11 cases, the graft diameter for implantation based on IVUS was differently sized compared with that determined by CT (group 2). Ten diameters were 1 size larger, and 1 diameter was 1 size smaller by IVUS. There were no significant differences in the mean lowest systolic blood pressure (98 vs. 92, P = 0.53), median fluid resuscitation in the first 24 hr (4.9 vs. 5.0 L, P = 0.97), or median 24-hr transfusion requirements (130 vs. 1311 mL, P = 0.11) between the groups 1 and 2, respectively. In group 2, the graft size chosen for surgery correlated more with measurements obtained from the CT than from IVUS (9 vs. 2). Conclusions The TEVAR has become the standard therapy for blunt aortic injury, despite a dearth of long-term outcome data. The preoperative CT frequently underestimates aortic diameter compared with intraoperative IVUS. The implications of placing thoracic endografts and whether excessive oversizing results in long-term aortic dilation need to be the focus of long-term studies in these relatively young patients.

Repair of Complicated Chronic Type B Dissection with Distal Aortic Arch Involvement Using Left Subclavian Artery Transposition with Implantation of a Stented Elephant Trunk.

Background Optimal management of complicated chronic type B dissection with involvement of the distal aortic arch is controversial. Late complications related to thoracic endovascular aortic repair (TEVAR) are much more common than those using open aortic surgery. We reviewed our experience of left subclavian artery (LSCA) transposition with implantation of a stented elephant trunk for complicated chronic type B dissection with involvement of the distal aortic arch. Materials and Methods From January 2011 to June 2015, 20 patients with complicated chronic type B dissection with involvement of the distal aortic arch underwent LSCA transposition with implantation of a stented elephant trunk via a median sternotomy under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion (SACP). Preoperative renal dysfunction was observed in three patients, left heart failure in one patient, and spinal cord ischemia in one patient. Results There was one (5.0%, 1/20) in-hospital death. All but one patient required mechanical ventilation for < 24 hours. Mean duration of mechanical ventilation and mean duration of stay in the intensive care unit was 16 ± 4 and 35 ± 16 hours, respectively. No severe complications occurred. There was one death because of unknown cause during follow-up. One case received thoracoabdominal aortic replacement 9 months after surgery. Conclusion Acceptable surgical outcomes were obtained using LSCA transposition with implantation of a stented elephant trunk. This method is an alternative to TEVAR for complicated chronic type B dissection with involvement of the distal aortic arch.

Modified Petticoat Technique with Pre-placement of a Distal Bare Stent Improves Early Aortic Remodeling After Complicated Acute Stanford Type B Aortic Dissection

This study evaluates the safety and efficacy of pre-placement of a distal bare stent as an adjunct to thoracic endovascular aortic repair (TEVAR) in the setting of complicated acute Stanford type B aortic dissection (cTBAD). The records of all patients diagnosed with cTBAD at the institution between 2010 and 2013 were reviewed. Indications for the pre-placement of a distal bare stent included symptomatic malperfusion and/or radiological evidence of true lumen collapse. Computed tomography angiography was performed post-operatively to assess aortic remodeling. 148 patients were treated for cTBAD: 113 patients (76.4%) were treated with standard TEVAR and 35 (23.6%) were treated by combined proximal TEVAR with pre-placement of an adjunctive distal bare stent. Primary technical success was 95.9%. The 30 day mortality rate was 4.1% and was not different between groups. The 30 day morbidity included transient renal failure (10.1%), endoleak (7.4%), and paraplegia (2.7%), and was not different between groups. The mean follow up was 10 months (range 2-12 months). No late stent complications were observed; patients with an adjunctive bare stent had less distal re-dissection (0% vs 15%; P = .01) and fewer endovascular re-interventions (5.7% vs 20.4%; P = .04). At 1 year, patients treated with TEVAR and an adjunctive distal bare stent had increased true lumen volume (166 vs 110 mL; P = .022), decreased false lumen volume (60 vs 90 mL; P = .043), and increased complete false lumen thrombosis in the thoracic (76.5% vs 29.5%; P < .001) and abdominal (20.6% vs 3.8%; P = .002) segments. Combined pre-placement of a distal bare stent as an adjunct to proximal TEVAR to treat cTBAD restricts oversizing of the distal stent graft, reducing the potential for distal true lumen collapse and visceral malperfusion, and improving remodeling of the dissected thoracic aorta. Long-term follow up and prospective studies are needed to assess the overall effectiveness of this treatment strategy.

Modified Petticoat Technique with Pre-placement of a Distal Bare Stent Improves Early Aortic Remodeling after Complicated Acute Stanford Type B Aortic Dissection

This study evaluates the safety and efficacy of pre-placement of a distal bare stent as an adjunct to thoracic endovascular aortic repair (TEVAR) in the setting of complicated acute Stanford type B aortic dissection (cTBAD). The records of all patients diagnosed with cTBAD at the institution between 2010 and 2013 were reviewed. Indications for the pre-placement of a distal bare stent included symptomatic malperfusion and/or radiological evidence of true lumen collapse. Computed tomography angiography was performed post-operatively to assess aortic remodeling. 148 patients were treated for cTBAD: 113 patients (76.4%) were treated with standard TEVAR and 35 (23.6%) were treated by combined proximal TEVAR with pre-placement of an adjunctive distal bare stent. Primary technical success was 95.9%. The 30 day mortality rate was 4.1% and was not different between groups. The 30 day morbidity included transient renal failure (10.1%), endoleak (7.4%), and paraplegia (2.7%), and was not different between groups. The mean follow up was 10 months (range 2-12 months). No late stent complications were observed; patients with an adjunctive bare stent had less distal re-dissection (0% vs. 15%; p = .01) and fewer endovascular re-interventions (5.7% vs. 20.4%; p = .04). At 1 year, patients treated with TEVAR and an adjunctive distal bare stent had increased true lumen volume (166 vs. 110 mL; p = .022), decreased false lumen volume (60 vs. 90 mL; p = .043), and increased complete false lumen thrombosis in the thoracic (76.5% vs. 29.5%; p < .001) and abdominal (20.6% vs. 3.8%; p = .002) segments. Combined pre-placement of a distal bare stent as an adjunct to proximal TEVAR to treat cTBAD restricts oversizing of the distal stent graft, reducing the potential for distal true lumen collapse and visceral malperfusion, and improving remodeling of the dissected thoracic aorta. Long-term follow up and prospective studies are needed to assess the overall effectiveness of this treatment strategy.