Type B Aortic Dissection Research Articles

Abstract 12844: Weekend Admission is Associated With Higher Renal Complications in Thoracic Endovascular Aneurysm Repair for Stanford Type B Aortic Dissection

Introduction: A weekend effect characterized by worse perioperative outcomes has been demonstrated in some surgery patients admitted on weekends, as opposed to weekdays. This study aims to examine the weekend effect on outcomes after open surgical repair or thoracic endovascular aneurysm repair (TEVAR) in Stanford Type B Aortic Dissection (TBAD). Methods: Patients who underwent TBAD repair were identified in the National Inpatient Sample (NIS) from 2015-2020 by ICD10-CM/PCS. Open surgery and TEVAR were examined separately. Patients were stratified into two cohorts based on weekday or weekend admission. Significant preoperative differences were present between cohorts, so multivariable logistic regressions were performed comparing in-hospital perioperative outcomes. Adjusted preoperative variables included sex, age, race, socioeconomic status, comorbidity, hospital characteristics, length of stay (LOS), days from admission to operation, and total hospital charge were compared. Results: Among patients who underwent open TBAD repair, 1,321 were admitted on weekdays and 340 on weekends. Among patients who underwent TEVAR after TBAD, there were 2,018 admitted on weekdays and 440 admitted on weekends. There was no difference in open repair outcomes between those admitted on weekdays versus weekends. In the TEVAR cohort, weekend admission has associated with higher acute kidney injury (AKI) (aOR=1.69, 95% CI 1.33-2.15, p<0.01), post-procedural kidney failure (aOR=5.65, 95% CI 1.45-22.06, p=0.01), and transfer to another center (aOR=1.54, 95% CI 1.21-1.96, p<0.01). Also in the TEVAR cohort, weekend admission was associated with longer LOS, longer wait to operation, and higher cost (all p<0.01). Conclusion: Weekend admission is an independent risk factor for higher renal complications patients with TBAD who undergo TEVAR. Eliminating delays in treatment associated with the weekend effect may decrease renal complications, decrease LOS, and decrease cost.

Abstract 16995: Distensibility and Aortic Growth Rate Predict Type B Aortic Dissection in Marfan Syndrome

Introduction: Marfan syndrome (MFS) is associated with high aortic growth rate (GR) and incidence of aortic dissection (AD), including delayed type B AD (TBAD) after prophylactic root repair. Elevated aortic stiffness has been investigated as a biomarker in MFS, but it remains uncertain how stiffness relates to GR and risk of AD. Vascular deformation mapping (VDM) is a technique that uses clinical CT angiography (CTA) to yield accurate, 3D maps of aortic growth over surveillance (VDM-G). This technique can also be used to assess aortic stiffness via quantification of cyclic wall stretch between systole and diastole (VDM-D) using multi-phasic dynamic CTA. Research Question: Is distensibility of the descending thoracic aorta associated with aortic GR or development of TBAD in MFS patients? Goal: The aim of this study was to analyze stiffness of the descending thoracic aorta in MFS and its association with aortic GR and occurrence of TBAD. Methods: We identified 36 adult MFS patients with dynamic CTA studies (>1 year interval) between 2004-2020. Growth was quantified by VDM-G, and linearized descending aortic stiffness by VDM-D - via calculation of distensibility - as the ratio of cyclic aortic surface area change (AR) over pulse pressure [(AR-1)/PP]. Results: Patients were 38.9 ± 12.1 years old, 58% were male and 25 (69%) had prior ascending repair. Mean CT follow-up interval was 5.7 ± 3.4 years and 8 developed TBAD during follow-up with pre-dissection diameter of 31.12 ± 6.01 mm at tear location. Age (β -0.4, 95%CI: -0.07, -0.01, p=0.015) and baseline diameter (β 0.10, 95%CI: 0.02, 0.18, p=0.017 ) independently predicted GR on multivariable analysis, but distensibility did not (p=0.38). Both distensibility (OR 0.02, 95% CI: 0.00, 0.68, p=0.03) and GR (OR 8687.05, 95% CI: 1.43, 5x10^7, p=0.04) were independent predictors of TBAD during follow-up, but diameter was not (p=0.49). Conclusion: Aortic stiffness and growth rate are likely predictors of type B aortic dissection in MFS.

Early and mid-term results of endovascular repair for type B aortic dissections: A single tertiary center experience

Aim: The utility of thoracic endovascular aortic repair (TEVAR) in Type B Aortic dissections (TBAD) continues to advance at a growing rate. The purpose of this research was to investigate our management strategy and early-mid-term outcomes of endovascular procedures for TBAD, in a single tertiary center. Material and Methods: Sixty-six eligible TBAD patients (2 hyperacute complicated, 12 acute complicated and 52 uncomplicated) were enrolled in this single-center, retrospective cohort study between January 2016 and January 2023. The endpoints of the study were technical success, early and late morbidity and mortality, reinterventions throughout the follow-up period, as well as late open conversion. Results: Technical success was achieved in all cases. Early mortality was seen in only 3 patients (4.5%). Only patients with one hyperacute and two acute complicated TBAD (cTBAD) had early death. There was one late mortality in an acute cTBAD patient, who developed retrograde type A dissection two months after TEVAR. The median follow-up period was 26.1±13.7 months. Six reinterventions were performed for extension of dissection or covering the entries distally (9.1%). No endoleak, graft infection or migration were observed. Open surgical repair was performed; however, the patient did not survive. Conclusion: Early results of TEVAR in elective TBAD is trouble-free. Carrying the patients to the subacute phase seems to be the most suitable timing for TEVAR. Anti-stimulus and anti-hypertensive treatment with surveillance programme is mandatory for this patient cohort. Pre-emptive TEVAR has satisfactory results; however, long-term results are mandatory for further recommendations.

Natural history of the distal aorta following elective root replacement in patients with Marfan syndrome

ObjectiveIt is unclear if the addition of a prophylactic arch operation is beneficial at the time of root replacement in patients with Marfan syndrome (MFS). This project aims to understand the fate of the distal aorta following elective root replacement in patients with MFS. MethodsBetween 2000 and 2019, 124 adult patients with MFS were identified as having undergone elective aortic root replacement with a clamped distal aortic anastomosis during their lifetime. Serial axial imaging was analyzed. The primary outcome was a composite of subsequent type B aortic dissection (TBAD), aneurysmal degeneration (>4 cm), and aortic reintervention. Secondary outcomes included subsequent TBAD and mortality. ResultsMean age at root replacement was 33.3 years. Median follow-up was 11.3 years. Thirty-one patients (25%) experienced the primary outcome, with no survival difference (P = .9). The crossclamp and aortic cannulation sites were stable (growth rate, 0.33 mm/year), and 2 patients (1.6%) required reintervention there. Twenty-three patients (19.8%) experienced subsequent TBAD. Patients with TBAD had a higher rate of distal degeneration (P < .001), but no significant change in survival (P = .2). Preoperative hypertension (odds ratio, 3.96; P < .05) and younger age at root replacement (odds ratio, 1.05; P < .05) increased the risk of TBAD, based on regression analysis. ConclusionsThe distal aorta (including the clamp and cannulation site) overall appears stable in patients with MFS following elective root replacement without prophylactic arch operation. Development of TBAD seems to be the primary driver of distal degeneration. Factors associated with TBAD development included hypertension, underscoring the importance of strict blood pressure control in these patients.

Outcomes of Castor Single-Branched Stent Graft for Reconstruction of Multiple Supra-Aortic Branches in Aortic Arch Disease.

To report the outcomes of a combination of Castor single-branched stent grafts with other techniques for the reconstruction of multiple supra-aortic branches in aortic arch disease. Between December 2019 and December 2021, 20 patients with aortic arch disease underwent thoracic endovascular aortic repair (TEVAR) at our institution using a Castor single-branched stent graft combined with the fenestration, chimney, or bypass techniques. Thoracic endovascular aortic repair is indicated for complicated or acute type B aortic dissection (TBAD), nonruptured aneurysms with a maximum aneurysm diameter >5.5 cm or showing rapidly expanded, ruptured, or threatened aneurysms, and penetrating aortic ulcers (PAUs) with a maximal aortic diameter >5.5 cm or with PAUs >10 mm deep or >20 mm in diameter. Preoperative, intraoperative, and postoperative clinical data were recorded. The median age of the patients was 56 (range=52-69 years) years, and 19 patients were men. Seven patients underwent the Castor single-branched stent graft and left common carotid artery (LCCA) chimney technique, 8 patients underwent the Castor single-branched stent graft and fenestration technique, and 5 patients underwent the Castor single-branched stent graft and bypass technique. The technical success rate was 100%. Major adverse events included 2 endoleaks, 1 spinal cord ischemia, and 1 early-stage retrograde type A aortic dissection. No cerebral stroke-related complications were observed. The mortality rate was 10% (2/20 patients). One patient with thoracic aortic aneurysm (TAA) died because of a sudden decrease in oxygen saturation and blood pressure after surgery. Relatives declined autopsy, and the cause of death was not determined. Another patient died of a retrograde type A dissection after surgery. The median follow-up period was 6 months (range=3.5-12 months). During follow-up, 1 patient with type I endoleak underwent thoracotomy again after a year. The remaining patients recovered well. The combination of a Castor single-branched stent graft with fenestration, chimney, or bypass techniques may be an effective treatment for preserving multiple supra-aortic branches in aortic arch disease. This study introduced three methods of reconstruction of multiple supra-aortic branches using a Castor single-branched stent graft (Castor single-branched stent graft combined with fenestration, chimney, or bypass technique) and analysed their advantages and shortcomings to provide experience for the future treatment of aortic arch diseases.

Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection

Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD. A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant. A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n=10) and 29.3% (n=17). Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

Establishing and Validating a Morphological Prediction Model Based on CTA to Evaluate the Incidence of Type-B Dissection.

Background: Many patients with Type B aortic dissection (TBAD) may not show noticeable symptoms until they become intervention and help prevent critically ill, which can result in fatal outcomes. Thus, it is crucial to screen people at high risk of TBAD and initiate the necessary preventive and therapeutic measures before irreversible harm occurs. By developing a prediction model for aortic arch morphology, it is possible to accurately identify those at high risk and take prompt action to prevent the adverse consequences of TBAD. This approach can facilitate timely the development of serious illnesses. Method: The predictive model was established in a primary population consisting of 173 patients diagnosed with acute Stanford TBAD, with data collected from January 2017 and December 2018, as well as 534 patients with healthy aortas, with data collected from April 2018 and December 2018. Explicitly, the data were randomly separated into the derivation set and validation set in a 7:3 ratio. Geometric and anatomical features were extracted from a three-dimensional multiplanar reconstruction of the aortic arch. The LASSO regression model was utilized to minimize the data dimension and choose relevant features. Multivariable logistic regression analysis and backward stepwise selection were employed for predictive model generation, combining demographic and clinical features as well as geometric and anatomical features. The predictive model's performance was evaluated by examining its calibration, discrimination, and clinical benefit. Finally, we also conducted internal verification. Results: After applying LASSO logistic regression and backward stepwise selection, 12 features were entered into the prediction model. Age, aortic arch angle, total thoracic aorta distance, ascending aorta tortuosity, aortic arch tortuosity, distal descending aorta tortuosity, and type III arch were protective factors, while male sex, hypertension, aortic arch height, and aortic arch distance were risk factors. The model exhibited satisfactory discrimination (AUC, 0.917 [95% CI, 0.890-0.945]) and good calibration in the derivation set. Applying the predictive model to the validation set also provided satisfactory discrimination (AUC, 0.909 [95% CI, 0.864-0.953]) and good calibration. The TBAD nomogram for clinical use was established. Conclusions: This study demonstrates that a multivariable logistic regression model can be used to predict TBAD patients.

Aortic Remodeling After Thoracic Endovascular Aortic Repair for Nonacute Uncomplicated Type B Aortic Dissection

Entry closure with thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD) results in aortic remodeling recently. This study aimed to evaluate the relationship between aortic diameter or timing of surgical intervention from onset and remodeling after TEVAR for uncomplicated nonacute TBAD. Between April 2014 and December 2021, 83 consecutive patients underwent TEVAR for TBAD at our center. Forty patients with subacute and chronic uncomplicated TBADs with a patent false lumen, who could be followed up for at least 6months, were included in this study. Indications for TEVAR included aortic diameter enlargement and preemptive treatment to prevent future aneurysmal changes in patients at risk of aortic diameter enlargement. Aortic remodeling was accessed, and data between the remodeling and nonremodeling groups were compared. The technical success rate was 97.5%, with a type Ia endoleak remaining in 1 patient. No operative or in-hospital mortality occurred. Paraparesis occurred in only 1 patient (2.5%). Follow-up was completed at a median of 53.5months. Late death occurred in 3 cases, but there were no aortic-related deaths. Late aortic remodeling was achieved in 22 patients (55%). The preoperative maximum aortic diameter (PMAD) in the thoracic aortic region was 51.5mm in the nonremodeling group, significantly larger than 42.5mm in the remodeling group (P<0.0001). The cutoff value of the PMAD for predicting aortic remodeling was 45mm (area under the curve, 0.917; P=0.028). The remodeling group had an earlier time from onset to intervention than the nonremodeling group, with a cutoff value of 6.3months (area under the curve, 0.743; P=0.021). TEVAR for nonacute uncomplicated TBAD resulted in a late aortic remodeling rate of 55%. This study suggested that a PMAD of >45mm or a period >6.3months between dissection onset and surgery hinders aortic remodeling after TEVAR.

The role of aorta distal to stent in the occurrence of distal stent graft-induced new entry tear: A computational fluid dynamics and morphological study

Distal stent graft-induced new entry tear (dSINE) is an important complication of thoracic endovascular aortic repair (TEVAR) for the treatment of type B aortic dissection (TBAD). This study aims to explore whether the aorta distal to the stent plays an important role in the occurrence of dSINE. Sixty-nine patient-specific geometrical models of twenty-three enrolled patients were reconstructed from preoperative, postoperative, and predSINE computed tomography scans. Computational fluid dynamics (CFD) simulations were performed to calculate the von Mises stress in the CFD group. Meanwhile, morphological measurements were performed in all patients, including measurements of the inverted pyramid index at different follow-up time points and the postoperative true lumen volume change rate. In the CFD study, the time-averaged von Mises stress of the true lumen distal to the stent in dSINE patients was significantly higher than that in the CFD controls (20.42 kPa vs. 15.47 kPa). In the morphological study, a special aortic plane (plane A) with an extremely small area distal to the stent was observed in dSINE patients, which resulted in an inverted pyramid structure in the true lumen distal to the stent. This structure in dSINE patients became increasingly obvious during the follow-up period and finally reached the maximum value before dSINE occurred (mean, 3.91 vs. 1.23). At the same time, enlargement of the true lumen distal to the stent occurs before dSINE, manifesting as a continuous increase in the true lumen volume (mean, 0.70 vs. 013). A new theory of what causes dSINE to occur has been proposed: the inverted pyramid structure of the true lumen distal to the stent caused an increase in the von Mises stress in this region and aortic enlargement, which ultimately led to the occurrence of dSINE.

One-Year Results of a Low-Profile Endograft in Acute, Complicated Type B Aortic Dissection

BackgroundThe safety and effectiveness of the RelayPro endograft (Terumo Aortic) was assessed for the treatment of acute, complicated type B aortic dissection (TBAD). MethodsA prospective pivotal trial analyzed a primary end point of all-cause mortality at 30 days. Secondary end points included technical success, major adverse events (disabling stroke, renal failure, and paraplegia/paralysis), endoleaks, patency, rupture, device integrity, false lumen perfusion, reinterventions, aortic expansion, and migration evaluated to 5 years. ResultsThe study involved 22 United States centers and enrolled 56 patients (mean age, 59.5 ± 11.4 years) from 2017 to 2021; of whom, 73.2% were men and 53.6% were African American. TBAD was complicated by malperfusion of the kidneys (51.8%), lower extremities (35.7%), and viscera (33.9%), and rupture (10.7%). Dissection extended proximally to zones 1/2 (14.3%) and zone 3 (78.6%) and distally to the iliac arteries (67.3%). Most procedures were percutaneous (85.5%). Technical success was 100%. Median hospitalization was 7 days (interquartile range, 5-12 days). All-cause mortality at 30 days was 1.8% (1 of 56; upper 95% CI, 8.2%; P < .0001). Seven major adverse events occurred in 6 patients (10.7%), consisting of paraplegia (n = 3), paraparesis (n = 2), disabling stroke (n = 1), and renal failure (n = 1). All paraplegia/paraparesis resolved with lumbar drainage. Kaplan-Meier analysis estimated a freedom from major adverse events of 89.1% at each interval from 30 days to 3 years. There was 1 endoleak (Type Ia), 2 retrograde dissections, and aortic diameter growth occurred in 2. There has been no rupture, fistula, component separation, patency loss, stenosis, kinking, twisting, bird beak, loss of device integrity, or fracture. ConclusionsRelayPro is safe and effective in acute, complicated TBAD. Follow-up is ongoing to evaluate longer-term outcomes and durability.

The Role of Location, Length, and Thickness of the Intimal Flap in the Propagation of Stanford Type B Aortic Dissection Based on Ex Vivo Porcine Aorta Models.

To explore the role of location, length, and thickness of the intimal flap in the propagation of Stanford type B aortic dissection (TBAD) based on ex vivo porcine aorta models based on ex vivo porcine aorta models. The porcine aortas were harvested and randomly divided into 6 groups to create various TBAD aortic models. We constructed intimal flaps for different locations (group A [entry tear on outer curvature] and group B [entry tear on inner curvature]), lengths (group C [long] and group D [short]), and thicknesses (group E [thick] and group F [thin]). For the ex vivo perfusion experiments conducted on model aortas, an experimental circulation loop (ECL) was employed. The pressure in false lumen (FL) was constantly monitored. A comparison was made between the morphological data collected before and after the experiment to quantify the changes in the FL after the experiment. Compared the results with group B, the mean peak pressures of the FL in group A were lower (106.87±15.55 vs. 124.01±22.75 mm Hg, p=0.028). The mean axial propagation length in group A was shown to be shorter than that of group B (88.14±33.38 vs. 197.43±41.65 mm, p<0.001). The mean peak pressure was higher in group C than in group D (144.04±19.37 vs. 92.51±26.70 mm Hg, p<0.001). The mean peak pressure of group E was higher than that of group F (160.83±32.83 vs. 109.33±15.62 mm Hg, p<0.001), as was the mean axial propagation length of group E (143.11±39.73 vs. 100.45±35.44 mm, p=0.021). According to the results of multivariable linear regression, axial propagation length=45.873-0.703×length of initial FL+0.863× peak pressure (p<0.001). There was a relationship between FL propagation and the location, length, and thickness of the intimal flap. The axial propagation length was related to the length of the intimal flap and the peak pressure of propagation. It may be helpful to evaluate the risk of propagation in patients with TBAD. This study found that the locations, lengths, and thickness of the intimal flap significantly contributed to propagation pressure of FL. Using dissection flap characteristics, a physician can predict FL development in a patient and formulate a treatment plan.The purpose was to investigate the relationship between the dissection flap characteristics (location, length, and thickness) and the propagation of the FL, which is not clear at present. This study employed porcine models to create an experimental circulation loop. The perfusion experiment was conducted using a FL without distal re-entry and a non-pulsating flow.

The Role of Spatial Aortic Arch Architecture in Type B Aortic Dissection.

The incidence of type B aortic dissection (TBAD) is increasing worldwide; however, the underlying pathomechanisms are not conclusively understood. This study explores the geometric architecture of the aortic arch and supra-aortic branches in TBAD patients as opposed to non-TBAD patients. Patient characteristics were retrieved from archived medical records. Computer-assisted tomography (CAT) scans of patients with TBAD and carotid stenosis (CS) from two high-volume centers were analyzed. Various aortic arch parameters and take-off angles of the supra-aortic branches of TBAD patients were measured following centerline normalization in comparison CS patients. A compression index (C-index) was calculated from the para-sagittal, and a torsion index (T-index) was calculated from the para-coronal take-off angles of the supra-aortic branches to analyze aortic arch tortuosity. A total of 199 CAT scans were analyzed, namely, 85 in the TBAD group and 114 in the CS group. The average age was 61.5 ± 13.1 years among the TBAD patients and 71 ± 9.3 years among the CS patients. We found a significantly higher proportion of type III aortic arch configurations in TBAD patients compared with CS patients. Further, the aortic arch angle was steeper in the TBAD group. In the para-sagittal plane, the left subclavian artery (LSA) take-off angle was less steep in TBAD patients. In the para-coronal plane, the left carotid artery (LCA) had a less steep take-off angle, while the LSA had a more obtuse take-off angle in the TBAD group when compared with the CS group. In addition, the inter-vessel distance was increased in TBAD patients. Finally, the T-index was increased, suggesting a significant torsion resulting from the deviating take-off angles of the supra-aortic branches supplying the left half of the body as opposed to the innominate artery (IA) in TBAD patients. Our results suggest several aortic arch-specific geometric configurations in patients suffering from TBAD that significantly differ from those in CS patients. Further functional studies are needed to verify the pathogenetic relevance of our results and their disease-specific causality. Although our data are not mechanistically explorative, they may serve as a basis for identifying future patients with aortic arch morphology at higher risk for TBAD development and who may benefit from more stringent adjustment of risk factors as a primary prevention concept.

Management of acute type B aortic dissection: treatment and follow-up

Aortic dissection is a life-threatening condition caused by a tear in the tunica intima which creates a false lumen into the aortic wall. Acute type B aortic dissection (TBAD) is defined by the presence of the entry tear in the aorta distal to the left subclavian artery, without ascending aorta and arch involvement, and accounts for 25-40% of all aortic dissections. Optimal medical therapy (OMT), focused on blood pressure and heart rate control, remains the gold standard treatment, especially for patients with uncomplicated TBAD, while complicated dissections require surgical therapy. Recent studies have shown that a considerable number of patients treated only with OMT develop late aorta-related complications that increase morbidity and mortality, as well as the need for surgical intervention. During the last decades, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is safe and effective in the treatment of TBAD, both complicated and uncomplicated, with improved long-term survival outcomes and aortic remodeling in combination with OMT compared to OMT alone. However, in cases of acute uncomplicated TBAD the optimal timing for TEVAR is not entirely clarified and there is lack of long-term evidence. Therefore, the role of pre-emptive TEVAR for these patients is still uncertain and the management of acute uncomplicated TBAD remains challenging.

Aneurysmal growth in type-B aortic dissection: assessing the impact of patient-specific inlet conditions on key haemodynamic indices.

Type-B aortic dissection is a cardiovascular disease in which a tear develops in the intimal layer of the descending aorta, allowing pressurized blood to delaminate the layers of the vessel wall. In medically managed patients, long-term aneurysmal dilatation of the false lumen (FL) is considered virtually inevitable and is associated with poorer disease outcomes. While the pathophysiological mechanisms driving FL dilatation are not yet understood, haemodynamic factors are believed to play a key role. Computational fluid dynamics (CFD) and 4D-flow MRI (4DMR) analyses have revealed correlations between flow helicity, oscillatory wall shear stress and aneurysmal dilatation of the FL. In this study, we compare CFD simulations using a patient-specific, three-dimensional, three-component inlet velocity profile (4D IVP) extracted from 4DMR data against simulations with flow rate-matched uniform and axial velocity profiles that remain widely used in the absence of 4DMR. We also evaluate the influence of measurement errors in 4DMR data by scaling the 4D IVP to the degree of imaging error detected in prior studies. We observe that oscillatory shear and helicity are highly sensitive to inlet velocity distribution and flow volume throughout the FL and conclude that the choice of IVP may greatly affect the future clinical value of simulations.

Predictors of Return to Work After Thoracic Endovascular Aortic Repair in Patients With Type B Aortic Dissection.

Type B aortic dissection (TBAD) is a life-threatening condition, and it takes heavy burden to family and society. Return to work (RTW) not only means patients' physical health but also demonstrates their mental well-being. Thoracic endovascular aortic repair (TEVAR) has been successful in treatment of TBAD patients. However, less studies have addressed on the social functional recovery of TBAD after TEVAR, especially for RTW. From January 1, 2017 to January 1, 2021, TBAD patients who underwent TEVAR and completed a 12-month follow-up were retrospectively enrolled. Primary outcome was RTW. Patients' demographic, sociological, and clinical characteristics, and so on were recorded to analyze and demonstrate independent risk factors for RTW. Four hundred thirty-two TBAD patients (388 males) were enrolled with a mean age of 48.3±8.9 years (ranged from 19 to 60 years). The 12-month cumulative RTW rate was 62.7% (95% confidence interval [CI]: 57.2%-67.8%). Age <50 years (odds ratio [OR]=3.675, 95% CI: 1.436-9.405) was identified as independent protective factors for RTW, while preoperative job as manual workers (OR=0.101, 95% CI: 0.029-0.353), average annual income, <30 000 Chinese Yuan (CNY) [<4400 US dollar], (OR=0.186, 95% CI: 0.054-0.637), complicated TBAD (malperfusion) (OR=0.246, 95% CI: 0.092-0.659), and distal stent graft-induced new entry (SINE) (OR=0.218, 95% CI: 0.083-0.575, p=0.002) were identified as independent risk factors. Approximately 64% of our patients were able to RTW in the 12 months post-TEVAR for TBAD. Younger patients, patients with less physically demanding jobs, and patients with less complex surgeries were more likely to RTW. Based on these results, more can be done to facilitate the patient's ability and willingness to RTW after TEVAR. Type B aortic dissection (TBAD) is a life-threatening condition that poses significant burden on both individuals and society. The ability to return to work (RTW) not only reflects the patient's physical health but also indicates their mental well-being. Therefore, identifying risk factors for RTW and promoting the reintegration of TBAD patients into the workforce is crucial in clinical practice.To our knowledge, this study is the first to elucidate and predict the RTW outcomes of TBAD patients who underwent thoracic endovascular aortic repair (TEVAR).

3D Printing-Assisted versus Conventional Extracorporeal Fenestration Tevar for Stanford Type B Arteries Dissection with Undesirable Proximal Anchoring Zone: Efficacy Analysis

Background: To compare the outcomes of two Thoracic Endovascular Aortic Repair (TEVAR) techniques of Left Subclavian Artery (LSA) reconstruction for Stanford Type B Aortic Dissection (TBAD) patients with undesirable proximal anchoring zone. Methods: We retrospectively reviewed 57 patients with TBAD who underwent either three dimensional (3D)-printing-assisted extracorporeal fenestration (n = 32) or conventional extracorporeal fenestration (n = 25) from December 2021 to January 2023. We compared their demographic characteristics, operative time, technical success rate, complication rate, secondary intervention rate, mortality rate, and aortic remodeling. Results: Compared with the conventional group, the 3D-printing-assisted group had a significantly shorter operative time (147.84 ± 33.94 min vs. 223.40 ± 65.93 min, p &lt; 0.001), a significantly lower rate of immediate endoleak (3.1% vs. 24%, p = 0.048) and a significantly higher rate of true lumen diameter expansion in the stent-graft segment (all p &lt; 0.05), but a significantly longer stent graft modification time (37.63 ± 2.99 min vs. 28.4 ± 2.12 min, p &lt; 0.001). There were no significant differences in other outcomes between the two groups (p &gt; 0.05). The degree of false lumen thrombosis was higher in the stent-graft segment than in the non-stent-graft segment in both groups and the difference was statistically significant (X2 = 5.390, 4.878; p = 0.02, 0.027). Conclusions: Both techniques are safe and effective for TBAD with an undesirable proximal landing zone. The 3D-printing-assisted extracorporeal fenestration TEVAR technique has advantages in operative time, endoleak risk, and aortic remodeling, while the traditional extracorporeal fenestration TEVAR technique has advantages in stent modification.

Long-Term Outcomes in Thoracic Endovascular Aortic Repair for Complicated Type B Aortic Dissection or Intramural Hematoma Depending on Proximal Landing Zone.

Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for complicated type B aortic dissection (TBAD) or intramural hematoma (IMH). This study aimed to investigate the association of the proximal landing zone and its morphology with long-term outcomes in patients with TBAD or IMH. A total of 94 patients who underwent TEVAR for TBAD or IMH between 10/2003 and 01/2020 were included. The cohort was divided according to the proximal landing in Ishimaru zone 2 or 3 and the presence of a healthy landing zone (HLZ; non-dissected or aneurysmatic, ≥2 cm length). Primary outcome was freedom from aortic reintervention. Secondary endpoints were freedom from aortic growth, stroke, spinal cord ischemia, retrograde dissection, proximal stent-graft induced new entry (pSINE), debranching failure, and mortality. Outcomes were assessed using Cox proportional hazard models with mortality as a competing risk. A proximal TEVAR landing in zone 2 was associated with higher rates of reinterventions compared to zone 3 (33% vs. 15%, p = 0.031), spinal cord ischemia (8% vs. 0%, p = 0.037), and pSINE (13% vs. 2%, p = 0.032). No difference was found for the other outcomes, including mortality. Landing in dissected segments was not associated with impaired results. Proximal TEVAR landing in zone 3 may be preferable with regard to long-term aortic reintervention in patients with TBAD or IMH.

Analysis of risk factors associated with acute Stanford type B aortic dissection complicated with pleural effusion and observation of the curative effect after intracavitary repair

Objective: To investigate the risk factors of acute Stanford type B aortic dissection (TBAD) complicated with pleural effusion (PE) and the short-term and long-term outcomes of thoracic endovascular aortic repair (TEVAR). Methods: A case-control study. The clinical and imaging data of 1 083 patients with acute TBAD admitted to the General Hospital of Northern Theater Command from April 2002 to December 2020 were retrospectively analyzed, including 211 cases with pleural effusion and 872 cases without pleural effusion. The baseline analysis of the two groups of patients was performed. The risk factors associated with pleural effusion were analyzed by binary logistic regression, and the results were expressed as odds ratio (OR) and 95% confidence interval (CI). According to the quantity of pleural effusion, they were simultaneously divided into small pleural effusion group and medium large pleural effusion group, to compare the short-term and long-term effects of TEVAR patients with different amounts of pleural effusion. Results: The incidence of pericardial effusion (17.5% vs. 3.8%, P<0.001), anemia (21.3% vs. 12.5%, P=0.001), aortic spiral tear (49.8% vs. 37.8%, P=0.002), dissection tear over diaphragm (57.8% vs. 48.1%, P=0.011), serum creatinine [85 (69, 111) vs. 81 (67, 100) μmol/L, P=0.011] and white blood cell levels[(11.3±4.2)×109/L vs. (10.3±4.2)×109/L, P=0.002] in acute TBAD pleural effusion group were significantly higher than those in non-pleural effusion group, and the hemoglobin level was significantly lower than that in non-pleural effusion group [(128±20) vs. (133±17) g/L, P<0.05]. Logistic stepwise regression analysis showed that pericardial effusion (OR=5.038,95%CI 2.962-8.568,P<0.001), anemia (OR=2.047,95%CI 1.361-3.079,P=0.001), spiral tear (OR=1.551,95%CI 1.030-2.336, P=0.002) and elevated white blood cell (OR=1.059,95%CI 1.011-1.102, P=0.005) were independent risk factors for TBAD complicated with pleural effusion. The incidences of all-cause death (4/19 vs. 1.5% vs. 0.9%, P<0.001), aortogenic death (4/19 vs. 0.7% vs. 0.7%, P<0.001) and aortic related adverse events (4/19 vs. 1.5% vs. 1.1%, P<0.001) in patients with large pleural effusion during TEVAR operation were significantly higher than those in patients with small pleural effusion and those without pleural effusion, and the differences were statistically significant. At 1 month follow-up after TEVAR, the incidence of all-cause death (4/16 vs. 3.3% vs. 1.6%, P<0.001), aortogenic death (4/16 vs. 0.8% vs.0.7%, P<0.001), aorta related adverse events (4/16 vs. 4.1% vs. 4.7%, P=0.013) and overall clinical adverse events (4/16 vs.9.8% vs. 6.7%, P=0.014) in the medium and large thoracic group were significantly higher than those in the small pleural effusion group and no pleural effusion group, and the differences were statistically significant. At 1 year follow-up after TEVAR, the incidence of all-cause death (4/15 vs. 4.9% vs. 3.9%, P=0.004), aortogenic death (4/15 vs.2.5% vs. 2.1%, P<0.001), aorta related adverse events (5/15 vs. 11.5% vs. 9.4%, P=0.012) and overall clinical adverse events (5/15 vs. 18.9% vs. 13.1%, P=0.029) in the medium and large thoracic group were significantly higher than those in the small pleural effusion group and no pleural effusion group, and the differences were statistically significant. Conclusions: Single center data showed that pericardial effusion, anemia, spiral tear and elevated white blood cell were independent risk factors for acute TBAD complicated with pleural effusion; the early (1 month) and long-term (1 year) rates of all-cause death, aortic mortality, aortic adverse events and overall clinical adverse events were significantly higher in TBAD patients with moderate pleural effusion after TEVAR, and moderate and large pleural effusion was an independent risk factor for near and long-term aortic related adverse events after TEVAR surgery.

Preoperative Immature Neutrophils Predict Clinical Outcomes in Patients with Uncomplicated Type-B Aortic Dissection After Thoracic Endovascular Aortic Repair.

Inflammation is a hallmark of the initial development and progression of aortic dissection. This study aimed to investigate the predictive value of preoperative neutrophils in aorta-related adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). A total of 80 patients with TBAD undergoing TEVAR were enrolled in our hospital. Preoperative inflammatory markers, including white blood cells (WBCs), neutrophils, neutrophil-to-lymphocyte ratio (NLR) and plasma high-sensitivity C-reactive protein (hs-CRP), were measured. Circulating neutrophil subpopulation was determined by flow cytometry. Kaplan-Meier curve was performed to determine whether neutrophil subsets independently predicted aorta-related adverse events (AAEs) after TEVAR. Compared with control group, the prevalence of hypertension and the levels of inflammatory indicators including WBCs, total neutrophils, NLR, immature neutrophils and hs-CRP were significantly higher in TBAD patients. Receiver operating characteristic (ROC) curve showed that NLR, absolute number of total neutrophils and percent CD10- immature neutrophils had excellent area under curves. During the 18-month follow-up, 16 (20.0%) were reported to occur AAEs, while 4 deaths (5.0%) were documented. Percent immature neutrophil was markedly higher in TBAD patients experiencing AAEs as compared with those without AAEs. Kaplan-Meier curve and Cox regression analysis demonstrated that percent immature neutrophil was the only predictor correlated with the occurrence of AAEs (hazard ratio 7.66, 95% CI: 2.91, 20.17, P = 0.018). Increased CD10- immature neutrophils could act as a potential biomarker related to long-term adverse outcomes in TBAD patients following TEVAR.

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.