Treatment Of Aortic Dissection Research Articles

Aortic dissection induced by vascular endothelial growth factor inhibitors.

Vascular endothelial growth factor (VEGF) contributes to angiogenesis and vasculogenesis. The occurrence and progression of tumors are accompanied by angiogenesis. Vascular endothelial growth factor inhibitors (VEGFI) have been used in anti-tumor treatment. However, aortic dissection (AD) is one of the VEGFI-associated adverse reactions with cute onset, rapid progression, and high case fatality rate. We collected case reports of VEGFI related to aortic dissection in PubMed and CNKI (China National Knowledge Infrastructure) from inception to 28 April 2022. Seventeen case reports were selected. The medication included sunitinib, sorafenib, pazopanib, axitinib, apatinib, anlotinib, bevacizumab, and ramucirumab. This review discusses the pathology, risk factors, diagnosis, and treatment of AD. Vascular endothelial growth factor inhibitors are related to aortic dissection. Although current literature lacks clear statistical evidence on the population, we offer points to encourage further confirmation of the best methods of care for these patients.

Semi-supervised aortic dissections segmentation: A time-dependent weighted feedback fusion framework.

The segmentation of true lumen (TL) and false lumen (FL) plays an important role in the diagnosis and treatment of aortic dissection (AD). Although the deep learning methods have achieved remarkable performance for this task, a large number of labeled data are required for training. In order to alleviate the burden of doctors' labeling, in this paper, a novel time-dependent weighted feedback fusion based semi-supervised aortic dissections segmentation framework is proposed by effectively leveraging the unlabeled data. A feedback network is additionally extended to encode the predicted output from the backbone network into high-level feature space, which is then fused with the original feature information of the image to fix previous potential mistakes, thereby segmentation accuracy is improved iteratively. To utilize both labeled data and unlabeled data, the fused feature space flows into the network again to generate the second feedback and make sure consistency with the previous one. The utilization of image feature space provides better robustness and accuracy for the proposed structure. Experiments show that our method outperforms five existing state-of-the-art semi-supervised segmentation methods on both a type-B AD dataset and a public dataset.

Lack of Access to Primary Care Reduces Survival Following Aortic Dissection

Optimal medical management is critical for the long-term treatment of aortic dissections (AD) to prevent complications and improve survival. Medical management is known to be influenced by various social determinants of health (SDOH), including health insurance, social support, distance to the hospital, and primary care provider (PCP) access. This study was designed to determine the relative impact of these different geographic and SDOH factors on the long-term survival of patients after diagnosis and treatment for acute AD. We retrospectively analyzed patients presenting to a single academic tertiary medical center for surgical and medical management of acute AD (types A and B) from January 2010 to December 2020. Data were collected regarding patient demographics, perioperative hospital course, and SDOH factors such as home/social status, primary and secondary insurance status, PCP access following surgery, distance to the hospital, and 2020 Area Deprivation Ondex scores. Cox proportional hazards regression models were used to estimate the risk-adjusted association between SDOH variables and mortality following acute AD. We identified 124 patients who presented with an acute AD during the study period (25% type A, 25% type B, and 50% with both type A and B components), who were predominantly male (68%) with a mean age of 60 years. Patients resided a median distance of 30.2 miles from the medical center, 18% lived alone, and 9% were uninsured. Roughly one-half of the cohort (52%) was documented to have access to a PCP, and patients with a PCP were significantly more likely to be maintained on antihypertensive (anti-HTN) medication therapy during follow-up (Fig 1). The most common anti-HTN agents were angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (56%), followed by beta-blockers (44%), and calcium channel blockers (26%). Over a median follow-up of 14.6 months, 43 patients (35%) died, with reduced survival observed among patients with no PCP access (Fig 2). In risk-adjusted models, increasing age, no PCP access, and lack of insurance were all found to be independent predictors of mortality following acute AD. Further, uninsured patients with no-PCP access or medication use had the highest risk for mortality (hazard ratio, 27.6; 95% confidence interval, 8.95-85.23; P < .001). Lack of access to a PCP and anti-HTN therapy following acute AD significantly increases the risk of short- and long-term mortality. These findings are independent of how far patients live from the hospital or other SDOH factors, highlighting the importance of community outreach programs to maintain medical management for uninsured AD patients.Fig 2Kaplan-Meier survival curves following acute aortic dissection, stratified by whether patients had access to a primary care provider (PCP).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract 589: A Fluid Structure Interaction Workflow For Studying Aortic Dissections

Introduction: After diagnosis and treatment of aortic dissections, there is the potential for future complications such as the growth or rupture of pre-existing aneurysms or further dissection of the aorta. This susceptibility to future complications is what we refer to as “aortic fragility”. Current computational models of aortic dissection rely upon computational fluid dynamics (CFD) or finite element analysis (FEA); however, there are limitations to using either method alone. Using a healthy patient aorta as our control case, we developed a novel method of coupling CFD with FEA in a fluid surface interaction (FSI) model for studying aortic dissection. Methods: We developed this FSI model by first segmenting aortas from CT scans to generate patient-specific models. With these meshes, we used a cardiac cycle fluid velocity profile to perform CFD and extracted static pressure values on the aortic wall at systole and diastole. We applied these pressures to our FEA model as the mechanical load driving wall deformation. Results: We successfully completed the CFD portion of our FSI simulation with results consistent with our expectations. Velocity data at the ascending and descending aorta, branches and arch correctly reflect our input cardiac cycle velocity profile. Histograms of static pressure values on the aortic wall at systole and diastole show that the mean systolic pressure is greater than the mean diastolic pressure, thus reflecting our expectations. Heat maps of this data reveal the aortic arch and branches to be areas of highest pressure, with pressure gradually decreasing in the distal aorta. Conclusion: With our healthy aorta control, we have successfully validated the CFD component of our FSI model. Our methods improve upon previous models by coupling CFD with FEA, allowing the use of realistic pressure loads derived from fluid analysis. We plan to further improve by validating the FEA component of our model and applying our methodology to dissection geometries. With this FSI workflow, we hope to more accurately model and predict the deformation patterns of aortic dissection in fragile aortas.

Endovascular Treatment of Complex Aortic Dissection. A Single Center 5 Years' Experience with 36 Patients.

We present an analysis that compares aortic morphological and clinical outcomes of 36 patients, all treated with endovascular uncovered stents implantation preceded or not by stent-graft implantation, or surgical treatment in the context of complex treatment of type A or type B aortic dissection. Between 2014 and 05/2018 our team treated 36 patients with acute aortic dissection and end-organ ischemia due to true lumen compression. All clinical and periprocedural data were obtained prospectively, followed by a retrospective analysis. The case series aim is to show induction of aortic remodeling by depressurization of the false lumen and increasing the size of the true lumen by non-covered stents implantation in the aorta and its affected side branches. Secondary endpoints were survival, branch patency, true lumen and false lumen size evolution. Results from the diameter of both lumens measured by computed tomography angiography (CTA) before and at least 1 year after the treatment showed statistically significant differences, patent stents, as well as symptomatic improvement in all patients. Both aorta-related and general mortality in this complex group of patients was 0%. The concept of redirection of flow in aortic dissection with non-covered stents was safe, led to positive aorta remodeling and resulted in excellent survival rate.

The evolution of management of type B aortic dissection in a series of 100 consecutive cases in a tertiary center

Introduction and ObjectivesManagement of aortic dissection is rapidly evolving. The present study aims to assess paradigm shifts in type B aortic dissection (TBAD) treatment modalities and their outcomes according to clinical presentation and type of treatment. We also aim to assess the impact of endovascular technology in TBAD management in order to define organizational strategies to provide an integrated cardiovascular approach. MethodsWe performed a retrospective review with descriptive analysis of the last 100 consecutive patients with TBAD admitted to the Vascular Surgery Department of Centro Hospitalar Universitário Lisboa Norte over a 16-year period. Results were stratified according to treatment modality and stage of the disease. The study was further divided into two time periods, 2003–2010 and 2011–2019, respectively before and after the introduction of a dedicated endovascular program for aortic dissections. ResultsA total of 100 patients (83% male; mean age 60 years) were included, of whom 59 were admitted in the acute stage (50.8% with complicated dissections). The other 41 patients were admitted for chronic dissections, most of them for surgical treatment of aneurysmal degeneration. Temporal analysis demonstrated an increase in the number of patients operated for aortic dissection, mainly due to an increase in chronic patients (33.3% in 2003–2010 vs. 64.4% in 2011–2019) and a clear shift toward endovascular treatment from 2015 onward. Overall in-hospital mortality was 14% and was significantly higher in the chronic phase (acute 5.1% vs. chronic 26.8%; OR 5.30, 95% CI 1.71–16.39; p=0.003) and in patients with aneurysmal degeneration, regardless of the temporal phase. Only one death was recorded in the endovascular group. ConclusionManagement of TABD carried an overall mortality of 14% during a 16-year period, but the appropriate use of endovascular technology has substantially reduced in-hospital mortality.

The Choice of Tactics for Surgical Treatment of Acute De Bakey Type I Aortic Dissection in a Multidisciplinary Surgical Hospital

BACKGROUND Acute proximal aortic dissection (Stanford type A) remains the most common fatal pathology of the thoracic aorta. Despite the improvement of surgical technologies, hospital mortality after emergency surgical interventions is 17–25%, in complicated cases it can reach 80–90%.AIM OF STUDY Description of the perioperative treatment tactics adopted at the N.V. Sklifosovsky Research Institute for Emergency Medicine as well as the evolution of approaches that make it possible to obtain satisfactory hospital and long-term results in the treatment of aortic dissection.MATERIAL AND METHODS the study included 278 patients operated on from 2015 to 2021 in the acute stage of aortic dissection (less than 48 hours from the moment of manifestation of the disease). The operated patients were divided into two groups, depending on the presence of complicated forms: group A, 102 patients with uncomplicated course of the disease; group B, 176 patients with complicated course of the disease. Additionally, patients were divided depending on the level of distal reconstruction performed: group I, 83 patients, surgery was limited to prosthetics of the ascending aorta, without removing the clamp; group II, 137 patients who underwent hemi-arch surgery; group III, 58 patients, with distal reconstruction involving the aortic arch.RESULTS Total hospital mortality was 28.1%: 25.3% in group I, 29.1% in group II, 29.3% in group III. In the group of uncomplicated dissection, postoperative mortality was 18.6%, while in the group of complicated dissection it was 33.5%.CONCLUSION An integrated multidisciplinary approach with the formation of an “aortic team”, an individual approach to surgery, depending on the anatomy of the dissection and the clinical status of the patient, will improve the results of the treatment of acute aortic dissection, as the most severe and multiple organ pathology of the aorta.FINDING 1. Hospital mortality of complicated forms of dissection remains significantly higher — 33.5% versus 18.5% of uncomplicated course. 2. The most optimal method of distal reconstruction in patients with the peracute stage of dissection is an open anastomosis with the aorta using the “hemi-arch” technique. 3. If it is necessary to extend the surgical intervention on the aortic arch, a distal anastomosis in areas 0, 1, 2 with the possibility of a subsequent endovascular stage is the priority.

Development of innovative system of universal stent graft for endovascular treatment of aneurysm and aortic displacement in various locations

This study presents the technology of developing a universal stent graft for endovascular treatment of aneurysms and aortic dissection of various localizations, without considering the vessel diameter. A self-expanding nitinol stent was used as the frame of the main trunk of the stent graft. During the study, several variants of the aortic linear graft were manufactured and tested. The optimal stiffness and diameter of the nitinol wire were selected based on the results. When creating a bifurcation module, special attention was paid to simplifying the positioning and intravascular assembly of the structure. Implantable modules have been developed for the prosthetics of the main branches of the aorta. Dacron, optimal in terms of fiber structure, was chosen as the material of the woven shell of the graft. Linear extensibility, compactness of the pile, and tensile strength during fenestration were evaluated. To determine the heparin-controlled surgical porosity, experimental samples of stent grafts were tested on a stand simulating arterial blood flow. The wall material of the developed device had a heparin-controlled surgical porosity of 50150 mL/min/cm2 at 120 mm Hg with the possibility of maintaining a controlled endolic. The graft wall created a pressure gradient of no more than 3 mm Hg, and the flow velocity indicators were quite sufficient for adequate perfusion of vital organs. After the inactivation of heparin, blood permeability became zero. The implantation technique of the developed product was implemented on a silicone aortic phantom simulating aneurysm expansion with and without dissection. The phantom contour was filled with a solution simulating the rheological properties of native blood. Pulsating blood flow was simulated using a perfusion pump. Under X-ray control, a stent graft was installed on five large biological samples (sheep). Implantation was performed in the aortic arch with prosthetics of the brachiocephalic trunk and the suprarenal aorta with prosthetics of the visceral branches. With the experiment, we hope that the result will allow us to minimally invasively help patients suffering from aneurysms of any localization.

Cocaine user with chest pain.

A 52-year-old male presented to the emergency department with a past medical history of active cocaine use and a chief complaint of chest pain that radiated to the back. Physical exam revealed a well-appearing, comfortable male with normal cardiac sounds, regular rate and rhythm, bilateral equal pulses in all four extremities, and intact motor and sensation in the extremities. A bedside ultrasound was performed and revealed an ascending aorta dissection (Figure 1 and Video 1). This was confirmed on intraoperative transesophageal echocardiogram that demonstrated the proximity of the aortic dissection flap to the aortic valve (Figure 2). Computed tomography angiography (CTA) of the chest confirmed the diagnosis of Stanford A (type 1) aortic dissection extending from the supravalvular region to the level of the renal arteries. The patient was placed on nicardipine and esmolol drips and cardiothoracic surgery was emergently consulted. The patient underwent surgery where he had an intraoperative transesophageal echocardiogram, stenting of the aortic root, ascending aorta, and descending aorta. He recovered from his surgery and was ultimately discharged to home. Aortic dissection is a relatively rare disease with an estimated global death rate of 2.78 per 100,000.1 The diagnosis is typically made with CTA of the chest. Thoracic aortic dissection is classified into two categories: Stanford type A that involves the proximal ascending aorta before the left subclavian and Stanford type B that involves the aorta only distal to the left subclavian.2 The treatment of aortic dissection includes blood pressure and heart rate reduction. Early surgical consultation is important because type A aortic dissection is a true surgical emergency.

Rapid detection of two markers of acute aortic dissection based on a lateral flow assay of hollow CdTe/CdS nanospheres

Acute aortic dissection (AAD) is an emergency disease with a high mortality rate, and its characteristics is variable clinical symptoms, complex pathology, high misdiagnosis rate, leading to its frequent confusion with other chest pains of myocardial infarction and chronic emphysema in clinic; Therefore, early diagnosis and treatment of acute aortic dissection is the key to reduce its mortality and improve the prognosis of patients., and timely & rapid diagnosis is crucial for successful treatment. Conventional methods (such as PCR, MRI, and ELISA) cannot be implemented as a rapid point-of-care (POC) test for ADD. Highly fluorescent hollow CdTe/CdS nanospheres (NSs) with the inside size of ∼240 nm and shell thickness of ∼19 nm were prepared via the hydrothermal method, and three color NSs with green, yellow and red fluorescence of wavelength of 535 nm, 580 nm, and 620 nm, respectively, were obtained by changing the preparation temperature. Immunochromatographic (ICG) assay were developed with the prepared yellow CdTe/CdS NSs for the sensitive and qualitative detection of high mobility group box protein B1 (HMGB1). Visual limit of detection of ICG for HMGB1 antigen was 3.13 ng/mL within 15 min, lower than that of normal ELISA. Furthermore, a multichannel lateral flow assays (mLFA) was developed with green and yellow CdTe/CdS NSs for the simultaneous, specific, sensitive, and qualitative detection of HMGB1 and soluble growth stimulating gene 2 (sST2), and visual limits of detection of HMGB1 and sST2 in mLFA were 10 ng/mL and 1.25 ng/mL, respectively. This mLFA of CdTe/CdS NSs with two marker-antibodies first facilitates its application of POC in the early diagnosis on AAD.

One year follow-up outcomes of endovascular treatment for aortic dissection with a partial micropore stent graft in which fixation of the stent is done in zone 0: A pivotal trial first in human

ObjectiveThis study aimed to verify the efficacy and safety of the treatment for patients diagnosed with DeBakey type I and type III thoracic aortic dissections using a partial micropore stent graft. MethodsWe conducted a retrospective analysis of 32 patients who suffered from thoracic aortic dissection and underwent endovascular repair using a partial micropore stent graft at our center between December 2018 and January 2020. ResultsThe technical success rate for 32 patients was 100 %, while no 30-day mortality was observed. In the 30 patients finished follow-ups, 30 (mean: 1 per patient) micropore stents were implanted, while the openings of 90 (mean: 3 per patient) aortic arch branches were covered by the stents. After more than 12 months follow-up, 26 (86.7 %) of the 30 patients presented with a complete thrombosis in the false lumen, and 4 (13.3 %) patients presented with a partial thrombosis in the false lumen. All 90 aortic arch branches were patent. No aortic arch branch artery stenosis or occlusion was observed. ConclusionsThe outcomes obtained during 12 months of follow-up suggested that performing endovascular repair for thoracic aortic dissection patients with a partial micropore stent graft is safe and effective, maintaining the patency of aortic arch branch vessels.

Treatment and referral experiences of patients with type A aortic dissection and their families: a qualitative study

ObjectivesThis study aimed to analyse the experiences and feelings of patients with type A aortic dissection (TAAD) and their families during the medical treatment and referral process, investigate the entire...

Percutaneous Coronary Intervention as a Bridge Therapy for Aortic Dissection Related Bilateral Coronary Malperfusion: A Case Report.

Dealing with coronary arteries caused by aortic dissection remains a great challenge in the treatment of aortic dissection. Here, we present the case of a 57-year-old woman, who initially detected chest pain, and electrocardiography showed ST-elevation myocardial infarction. After the primary percutaneous coronary intervention, aortic dissection was accidentally detected. She then received central repair and had a satisfactory outcome. We proved that percutaneous coronary intervention as a bridge therapy for aortic dissection-related coronary malperfusion might be efficient.

Endovascular Treatment of Chronic Aneurysmal Aortic Dissection: In Search of Effective Repairs

Management of aneurysms in the setting of chronic Type B aortic dissections still represents one area that leaves much to be desired. As the authors and others have pointed out, 20–50% of dissection patients will have aneurysmal degeneration with up to 40% of medically managed patients requiring an intervention and two-thirds of those due to aneurysmal degeneration. 1 Durham C.A. Aranson N.J. Ergul E.A. et al. Aneurysmal degeneration of the thoracoabdominal aorta after medical management of type B aortic dissection. J Vasc Surg. 2015; 62: 900-906 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Traditional open surgery is not an easy feat for both the patient and operator with high complication rates. 2 Conrad M.F. Crawford R.S. Davison J.K. et al. Thoracoabdominal aneurysm repair: a 20-year perspective. Ann Thorac Surg. 2007; 83: S856-S861 Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar Much effort has been spent searching for an acceptable endovascular solution to this problem but these suffer from both a lack of the necessary technology and the technically demanding nature of the case. Many of the challenges to endovascular treatment stem from the dual lumens, multiple entry points, lack of distal seal zones, and difficult access and angles to the visceral vessels. 3 Kuzniar M.K. Wanhainen A. Tegler G. et al. Endovascular treatment of chronic aortic dissection with fenestrated and branched stent grafts. J Vasc Surg. 2021; 73: 1573-1582 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Treatment of thoracoabdominal aortic aneurysmal degeneration following aortic dissections at a single surgical center using a physician-assembled branched endovascular stent graftAnnals of Vascular SurgeryPreviewAneurysmal degeneration of aortic dissection portends significant morbidity and mortality consequences in the subacute and chronic phases of aortic dissection. This paper describes the use of a multi-branched stent graft system for the treatment of thoracoabdominal aneurysmal degeneration of dissections with visceral segment involvement and reports upon the 30-day and one-year outcomes for the first 18 patients treated with this design configuration. Full-Text PDF

Approach to aortic dissection in light of the American College of Cardiology (ACC) and American Heart Association (AHA) 2022 Guidelines

The blood necessary for sustaining life passes into the aorta through the pump function of the left ventricle and is distributed to the systemic arterial bed via the aorta and its branches. In an average lifetime, about 200 million liters of blood, the basis of life, are delivered to the organs via the aorta and its branches Acute Aortic Syndromes, especially Aortic Dissection, can impair this vital function of the aorta. Aortic Dissection (AD) is not one of the most common diseases encountered by physicians in daily clinical practice, but it is frequently associated with life threatening complications. It has a high mortality rate of 1% to 2%/h if it is not diagnosed quickly and appropriate treatment is not started immediately. However, this diagnosis is not always easy to make. The main reason for this is the lack of a very specific symptom that would allow physicians, especially emergency physicians, cardiologists and cardiovascular surgeons, who encounter AD more frequently, to easily suspect AD and its course with nonspecific symptoms. In this review, we will evaluate new developments in the diagnosis and treatment of AD in the light of the American College of Cardiology (ACC) and American Heart Association (AHA) 2022.

Diagnosis and treatment of aortic dissection. Literature review

Diagnosis and treatment of aortic dissection. Literature review

Early results of direct true lumen cannulation (samurai technique) in aortic dissection surgery

Aim: The aim of this study was to evaluate and compare the clinical outcomes of Direct True Lumen Cannulation (Samurai Technique), axillary artery cannulation and femoral artery cannulation techniques used in aortic dissection surgery. Materials and methods: The data of 124 patients who underwent surgical treatment for acute aortic dissection between February 2018 and December 2022 were analyzed rectospectively. Patients were divided into Group 1 (samurai technique cannulation group) and Group 2 (axillary and femoral cannulation group). Results: When the results were analyzed, preoperative personal and clinical characteristics were found to be similar between the groups. In the inoperative period, the time from skin incision to CPB, hypothermic circulatory arrest time, and time for cooling were shorter in group 1. While there were no cannulation-related complications in group 1, axillary artery dissection developed in two patients in group 2. No significant difference was observed between the groups in postoperative results. Conclusion: Although there were similar results in the groups in the preoperative and postoperative periods, the more positive results in the surgery show that cannulation with the samurai technique is a preferable method.

Large distal tear of aortic dissection

BACKGROUND: The traditional treatment for aortic dissections (ADs) is a proximal repair of AD, but the long-term prognosis of residual distal dissection is unsatisfactory. The distal aortic intimal tear of distal aortic segmental enlargement (DASE) is evaluated via its size, with risk assessment, and assessed its risk, which will provide clinicians with diagnosis and treatment direction. METHODS: We analyzed 419 ADs patients who underwent radiographic examination of the aorta between September 1999 and May 2014. We recorded the area of the aortic intimal tear and divided it into two groups (75 patients in DASE group and 344 patients in non-DASE group). Logistics regression analysis or natural logarithm transformation was used to explore the potential risk of remaining distal tears to DASE, while the Logistic multiple regress equations were used to find out the independent risk factors. RESULTS: The postoperative large tear was defined as short diameter ≥5.0 mm. The independent risk factors of DASE are as follows: Short diameter of postoperative tears (odds ratios [ORs], 1.10;95% confidence interval [CI], 1.02–1.19; P &lt; 0.0120); short diameter of the first tear after operation (OR, 1.12; 95% CI, 1.00–1.26; P &lt; 0.0580) and the existence of large tears (OR, 1.13; 95% CI, 1.01–1.26; P &lt; 0.0298). CONCLUSIONS: Our findings suggest that the size of the remaining tears and the existence of large tears are the key risk factors for patients with DASE. Patients with large remaining tears should be supervised regularly and treated timely.

Progressive aortic enlargement in medically managed acute type B aortic dissections with visceral aortic involvement.

Aortic remodeling of the thoracic aorta has been studied in patients treated with medical or endovascular therapy for the treatment of acute aortic dissections; however, particular attention has not yet focused on identifying specific growth patterns and rates across all aortic zones. Additionally, previous studies have not delineated between dissections with and without visceral aortic involvement, and we hypothesize that these two cohorts may exhibit distinct differences. The aim of this study is to investigate aortic behavior over time in medically managed acute Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) type B dissections with visceral aortic involvement and identify potential associations of subsequent aortic behavior with clinical outcomes. A single-center retrospective review was performed of all patients between 2010 and 2020 with acute SVS/STS type B aortic dissections with visceral aortic involvement that were not surgically managed. Short-axis centerline measurements of the true/false lumen and total aortic diameter (TAD) were taken at standardized locations relative to aortic anatomy within each aortic zone, including nondissected zones. Measurements were taken at the time of diagnosis and at six subsequent yearly intervals. Diameter changes over time were evaluated using repeated measures mixed models linear growth analysis. Aortic enlargement was classified by growth in TAD ≥5mm in either the thoracic (thoracic segment enlargement [TSE], zone 0-4) or visceral segments (visceral segment enlargement [VSE], zone 5-9). A total of 78 patients were identified with a median length of follow-up of 3.3years (interquartile range [IQR], 1.3-6.6years). Follow-up past 5years was seen in 31% of the cohort. For the entire cohort, mean thoracic growth in TAD was 2.0± 2.0mm/year, and visceral growth in TAD was 2.5± 2.4mm/year. TSE was observed in 65% of patients, with a median time until onset of 0.8years (IQR, 0.4-2.3years). VSE was observed in 57% of the cohort, with a median time until onset of 1.6years (IQR, 0.9-3.3years). Repeat measures mixed models linear growth analysis identified significant predictable linear growth in all aortic zones except for the nondissected zones 0-2. Odds for TSE are significantly increased in patients with known genetically triggered aortic conditions (odds ratio [OR], 2; 95% confidence interval [CI], 1.8-4.5; P= .044) and in cases where the dissection entry tear was in either zone 1 or 2 (OR, 4.8; 95% CI, 1.2-8.4; P= .044). In adjusted regression analysis, odds for intervention in the thoracic aorta were significantly increased in patients with rapid TSE in zone 3 (OR, 3.6; 95% CI, 1.1-8.4; P= .045). Similarly, odds for intervention targeting the visceral aortic segment were significantly increased in patients with zone 9 VSE (OR, 9.3; 95% CI, 1.1-13.3; P= .014). Odds for 5-year all-cause mortality were significantly increased in cases with large thoracic aneurysms (OR, 6.1; 95% CI, 1.1-14.9; P= .042). Aortic enlargement was present in the majority of patients with medically managed acute SVS/STS Type B aortic dissections with visceral aortic involvement, with analysis demonstrating predictable linear growth in all dissected zones. Patients with aortic enlargement demonstrated higher gross changes in diameter in addition to higher yearly rates of change compared with all comers. Odds for enlargement were impacted by both patient demographic and anatomic dissection characteristics. Growth in zone 3 and zone 9 significantly increased odds for aortic intervention. Odds for 5-year mortality were significantly increased in the presence of large thoracic aneurysms. Results highlight risk of progressive degeneration beyond acute phase in SVS/STS Type B aortic dissections with visceral aortic involvement, with life-long surveillance remaining crucial in management of dissections.

Disparities in reporting and representation by sex, race, and ethnicity in endovascular aortic device trials.

Vulnerable populations, including women and racial and ethnic minorities, have been historically underrepresented in clinical trials. We, therefore, studied the demographics of patients enrolled in pivotal endovascular aortic device trials in the United States. We queried the Food and Drug Administration (FDA) medical devices database for all FDA-approved endografts for the treatment of aortic aneurysms, transections, and dissections from September 1999 to November 2021. These included abdominal endovascular aortic repair (EVAR), thoracic EVAR (TEVAR), fenestrated EVAR (FEVAR) devices, and dissection stents. Multiple cases of approval for expanded indications were included separately. The primary outcomes included the proportion of trials reporting participant sex, race, and ethnicity and the proportion of enrolled participants across sex, racial, and ethnic groups. The FDA provided 29 approvals from 29 trials of 24 devices: 15 EVAR devices (52%), 12 TEVAR devices (41%), 1 FEVAR device (3.4%), and 1 dissection stent (3.4%). These trials had included 4046 patients. Of the 29 trials, all had reported on the sex of the participants, and the median female enrollment was 21% (interquartile range [IQR], 11%-34%). The EVAR trials had the lowest female enrollment (11%; IQR, 8.7%-13%) compared with 41% (IQR, 27%-45%) in the TEVAR trials, 21% in the FEVAR trial, and 34% in the dissection stent trial (P< .01 for the difference). Only 52% of the trials had reported the three most common racial groups (White, Black, Asian), and only 48% had reported Hispanic ethnicity. The TEVAR trials were the most likely to report all three racial groups and Hispanic ethnicity (92% and 75%, respectively), while the EVAR trials had the lowest reporting rates (13% and 20%, respectively). Where reported, the median enrollment of racial and ethnic groups across the trials was as follows: Black patients, 9.8% (FEVAR, 0%; EVAR, 1.9%; TEVAR, 12%; dissection stent, 25%; P= .01); Asian patients, 2.4% (EVAR, 0.6%; FEVAR, 2.4%; TEVAR, 2.5%; dissection stent, 11%; P= .24); and Hispanic patients, 3.8% (EVAR, 1.3%; FEVAR, 2.4%; TEVAR, 3.9%; dissection stent, 4.1%; P= .75). Racial and ethnic minority groups were underrepresented and underreported in pivotal aortic device trials that led to FDA approval. Female patients were also underrepresented in these aortic trials, especially for EVAR. These data suggest the need for standardization of reporting practices and minimum thresholds for minority and female participation in pivotal trials to promote equitable representation.