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Thoracic endovascular aortic repair (TEVAR) represents optimal therapy for complicated acute type B aortic dissection (aTBAD). Persistent knowledge gaps remain, including the optimal length of aortic coverage, impact on distal aortic remodeling, and fate of the dissected abdominal aorta. Review of the Emory Aortic Database identified 92 patients who underwent TEVAR for complicated aTBAD from 2012 to 2018. Standard TEVAR covered aortic zones 3 and 4 (from the left subclavian to the mid-descending thoracic aorta). Extended TEVAR fully covered aortic zones 3 though 5 (from the left subclavian to the celiac artery). Long-term imaging, clinical follow-up, and overall and aortic-specific mortality were reviewed. Extended TEVAR (n = 52) required a greater length of coverage vs standard TEVAR (n = 40) (240 ± 32 mm vs 183 ± 23 mm; P <.01). In-hospital mortality occurred in 5.4% of patients (7.7% vs 2.5%; P =.27) owing to mesenteric malperfusion (n = 3) or rupture (n = 2). The overall incidences of postoperative stroke, transient paraparesis, paraplegia, and dialysis were 5.4% (3.9% vs 7.5%; P =.38), 3.2% (5.8% vs 0%; P =.18), 0%, and 0% respectively, equivalent between groups. Follow-up was 96.6% complete to a mean of 6.1 years (interquartile range, 3.5-8.6 years). There were significantly higher rates of complete thrombosis or obliteration of the entire thoracic false lumen after Extended TEVAR (82.2% vs 51.5%; P =.04). Distal aortic reinterventions were less frequent after extended TEVAR (5.8% vs 20%; P =.04). Late aorta-specific survival was 98.1% after extended TEVAR vs 92.3% for standard TEVAR (P =.32). Extended TEVAR for complicated aTBAD is safe, results in a high rate of total thoracic false lumen thrombosis/obliteration, and reduces distal reinterventions. Longer-term follow-up will be needed to demonstrate a survival benefit compared to limited aortic coverage. [ABSTRACT FROM AUTHOR]

Hybrid approaches involving staged open surgical and percutaneous endovascular procedures are rapidly emerging in the panorama of major aortic disease. The most recent guidelines support progressive expansion and adoption of this approach especially for patients who might not tolerate major aortic surgery. The multidisciplinary context in which these hybrid procedures arise require more comprehensive and integrated anaesthesiology involvement in the in their planning and execution. This review will summarize the key concepts in aortic disease management, the current status of hybrid aortic procedures and focus on the anaesthetic management of thoracic aortic endovascular and hybrid procedures. As utilization of endovascular arch stents is expected to rise, it is crucial that cardiac anaesthesiologists are familiar with their inherent complexities, anaesthetic considerations, and potential complications. [ABSTRACT FROM AUTHOR]

Late adverse events (LAEs) are common among initially uncomplicated type B aortic dissection (uTBAD); however, identifying those patients at highest risk of LAEs remains a significant challenge. Early false lumen (FL) growth has been suggested to increase risk, but confident determination of growth is often hampered by error in two-dimensional clinical measurements. Semi-automated three-dimensional (3D) mapping of aortic growth, such as by vascular deformation mapping (VDM), can potentially overcome this limitation using computed tomography angiograms (CTA). We hypothesized that FL growth in the early pre-dissection phase by VDM can accurately predict LAEs. We performed a two-center retrospective study of patients with uTBAD, with paired CTAs in the acute (1-14 days) and subacute/early chronic (1-6 months) periods. VDM analysis was used to map 3D growth. Standard clinical CT measures (ie, aortic diameters, tear characteristics) were also collected. Multivariate analysis was conducted using a decision tree and Cox proportional hazards model. LAEs were defined as aneurysmal FL (>55 mm); rapid growth (>5 mm within 6 months); aorta-specific mortality, rupture, or re-dissection. A total of 107 (69% male) patients with uTBAD initially met inclusion criteria with a median follow-up of 7.3 years (interquartile range [IQR], 4.7-9.9 years). LAEs occurred in 72 patients (67%) at 2.5 years (IQR, 0.7-4.8 years) after the initial event. A multivariate decision tree model identified VDM growth (>2.1 mm) and baseline diameter (>42.7 mm) as optimal predictors of LAEs (area under the receiver operating characteristic curve = 0.94), achieving an 87% accuracy (sensitivity of 93%, specificity of 76%) after leave-one-out validation. Guideline reported high-risk features were not significantly different between groups. Early growth of the FL in uTBAD was the best tested indicator for LAEs and improves upon the current gold-standard of baseline diameter in selecting patients for early prophylactic thoracic endovascular aortic repair. [ABSTRACT FROM AUTHOR]

Acute aortic dissection is a rare but catastrophic condition. When the dissection extends through the adventitia, blood can extravasate into the extrapleural or intrapleural spaces, causing an extrapleural hematoma or hemothorax. The early recognition of extrapleural hematoma and distinguishing it from hemothorax is critical because the management of those two entities is different. The authors present a case of a late diagnosis of a large extrapleural hematoma in a patient with Stanford type B acute aortic dissection that required thoracotomy for hematoma evacuation. The patient underwent successful thoracic endovascular aortic repair (TEVAR). Postoperatively, the patient had worsening pulmonary function, with a large fluid collection on imaging that was not drained by the thoracostomy tubes. Surgical exploration revealed a large extrapleural hematoma. Timely recognition of the extrapleural hematoma was key in the patient's clinical management. Without clear radiographic diagnostic features of extrapleural hematoma, unsuccessful drainage of hematoma after insertion of a chest tube may suggest an extrapleural hematoma or a clotted hemothorax. If patients continue to have circulatory or respiratory compromises, prompt surgical exploration should be considered. It is important for clinicians to be aware of extrapleural hematoma in complicated acute aortic dissection, especially when chest tube drainage of an apparent hemothorax is unsuccessful. [ABSTRACT FROM AUTHOR]

Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention. This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates. During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, −1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P <.001), preoperative carotid-subclavian bypass (OR, 8; P =.003), and graft oversizing <20% (OR, 15; P =.046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P =.049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P =.0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of <.001 (P =.032). This was counterbalanced by the fact that patients with graft oversizing >30% had an increased odds of mortality with HR >10 (P =.049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P =.033), diabetes (HR, 4.1; P =.048), age (every 1-year increase in age; HR, 1.2; P =.002), year of surgery (every year subsequent to 2004; HR, 1.3; P =.012), and peripheral artery disease (HR, 5.2; P =.041). The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention. [ABSTRACT FROM AUTHOR]

To evaluate outcomes of patients with acute complicated or chronic Type B or non-A non-B aortic dissection who underwent the frozen elephant trunk (FET) technique. Between April 2013 and July 2019, 41 patients presenting with acute complicated (n = 29) or chronic (n = 12) descending thoracic aortic dissection were treated by the FET technique, which was the treatment of choice when supra-aortic vessel transposition would not suffice to create a satisfactory proximal landing zone for endovascular aortic repair, when a concomitant ascending or arch aneurysm was present, or in patients with connective tissue diseases. One patient (2%) died intra-operatively secondary to an aortic rupture in dwnstream aortic segments. No post-operative deaths occurred. Four patients (10%) suffered a non-disabling posto-operative stroke and were discharged with no clinical symptoms (modified Rankin Scale [mRS] 0, n = 1), no significant disability (mRS 1, n = 2), or with slight disability (mRS 2, n = 1). No spinal cord ischaemia was observed. The primary entry tear was either surgically resected or excluded from circulation in all patients. During follow up, one patient (2%) died after two years (not aorta related) and 16 patients (39%) underwent an aortic re-intervention after 7.7 [interquartile range 0.7, 15.8] months (endovascular aortic repair: n = 14; open thoraco-abdominal aortic replacement: n = 1, hybrid approach: n = 1). The FET technique is an effective treatment option for acute complicated and chronic Type B or non-A non-B aortic dissection in patients in whom primary endovascular aortic repair is non-feasible. While the post-operative outcome is acceptable with a relatively low incidence of non-disabling strokes, this study also underlines the considerable need for aortic re-interventions. Continuous follow up of all patients undergoing the FET procedure is essential. [ABSTRACT FROM AUTHOR]

Using a national data set, we sought to describe the population of patients and the nature and timing of reinterventions after thoracic endovascular aortic repair (TEVAR) by aortic disease as well as their impact on survival. We evaluated the national data set for TEVAR in the Vascular Quality Initiative from 2010 to 2017. Student t -test and χ 2 analysis were used to compare continuous and categorical variables in the reintervention and no reintervention groups, respectively. Freedom from reintervention and survival analysis was performed using Kaplan-Meier methods. A total of 7006 patients were evaluated: 51.2% thoracic aortic aneurysm, 33.5% type B dissection (TBD), 7.0% penetrating aortic ulcer, 6.7% trauma, and 1.6% intramural hematoma. Overall, 553 patients (7.9%) underwent at least one reintervention, with an in-hospital reintervention rate of 3.5%. Reinterventions were most commonly performed for TBD (11.5%), with reinterventions for other diseases occurring at lower rates: thoracic aortic aneurysm, 6.7%; intramural hematoma, 5.4%; penetrating aortic ulcer, 4.8%; and trauma, 1.8%. The most common cause of reintervention across all aortic diseases was type I endoleak. The most common long-term reinterventions were placement of endovascular stent graft (65%), other surgical treatments (15.9%), other endovascular treatment (13%), endovascular branch treatment (12.4%), surgical treatment with no device removal (11.0%), and surgical branch treatment (10.4%). Freedom from reintervention was decreased for TBD compared with other diseases (P <.001). There was no difference in survival comparing patients undergoing reinterventions and those without (P =.87). However, patients undergoing in-hospital reintervention trended toward increased mortality (P =.075). Whereas reinterventions were not rare after TEVAR, there was no difference in mortality between patients undergoing reintervention and those without. Patients undergoing TEVAR for TBD demonstrated the highest reintervention rate. This study highlights the importance of long-term follow-up to address disease-specific patterns of reintervention. [ABSTRACT FROM AUTHOR]

Objective Endovascular stent-grafting provides an alternative treatment option for high-risk patients with ascending aortic disease. The feasibility of this approach has been demonstrated before. We assess the updated experience with ascending thoracic endovascular aortic repair and propose a modification of the landing zone classification based on the outcomes. Methods From 2006 to 2016, 39 patients deemed very high risk for open replacement underwent endovascular repair of ascending aorta for acute type A dissection (12, 31%), intramural hematoma (2, 5%), pseudoaneurysm (22, 56%), and chronic dissection suture line entry tear (3, 8%). Ascending thoracic endovascular aortic repair was performed in 36 patients. In 3 patients with pseudoaneurysm, occluder devices were used. Computed tomography imaging analysis was performed, and the extent of aortic pathology was designated by segmental proximity to the left ventricle. Segmental anatomy of the proximal aorta was designed as zone 0A from the annulus to the distal margin of highest coronary, 0B extends from above the coronary to the distal margin of right pulmonary artery, and 0C extends from the right pulmonary artery border to the innominate artery. Multivariable time to event Cox regression analysis was performed to predict mortality, and long-term survival was estimated using the Kaplan–Meier method. Results Operative mortality was 13%; all 5 deaths occurred after emergency ascending thoracic endovascular aortic repair for type A dissection. Other complications included stroke in 4 patients (10%), myocardial infarction in 2 patients (5%), tracheostomy in 2 patients (5%), and dialysis in 2 patients (5%). In patients with acute type A dissection, the ascending pathology extended into zone 0A in 10 (71%) and 0B in 4 (29%). Among those with pseudoaneurysm, the location of the defect was in 0B in 11 (50%), 0C in 10 (45%), and 0A in 1. Among the patients with chronic dissection, the defect was located in 0C in all 3 (100%). After multivariable adjustment, Cox regression predicted significantly higher hazard of mortality with disease involving zone 0A versus 0C ( P = .020) and older age ( P = .026). Kaplan–Meier estimate of survival was also significantly worse in patients with disease extension into 0A versus 0C ( P = .0018). At 30 days, 1 year, and 5 years, the overall survival was 81%, 74%, and 64% and freedom from reintervention was 85%, 77%, and 68%, respectively. Conclusions The modified zone zero classification is useful for characterizing extent of ascending aortic pathology and assessing prognosis. Location of the defect varies by pathology, and the presence of 0A disease predicts worse outcomes. Design of endovascular devices should be tailored to the aortic pathology and zone characteristics. [ABSTRACT FROM AUTHOR]

Objective This study aimed to evaluate the safety and feasibility of total endovascular repair of the aortic arch using a novel designed stent-graft system (Yanger stent-graft system; Lifetech Scientific, Shenzhen, China) in vitro and in a canine model. Methods The Yanger stent-graft system is composed of a main stent-graft, branched stent-graft, and a delivery system. In an in vitro aortic arch simulation test bench, the system was tested, and the success rate of stent-graft releasing, anchoring, and positioning was recorded and analyzed. Meanwhile, in vivo implantation of the Yanger stent-graft system was carried out in 16 healthy adult crossbreed dogs. The feasibility of using these stent-grafts was evaluated with aortography, multislice computed tomography, and autopsy 6 months after the procedure. Results All stent-graft releasing and positioning were successful for in vitro test. In the canine model, the Yanger stent-graft system was placed successfully in the aortic arch in all 14 dogs with the exception of 2 mortalities. All dogs survived for at least 3 months with normal physiologic signs. Aortography, multislice computed tomography, and animal necropsy revealed good fixation in all cases. The ascending aorta, descending aorta, brachiocephalic trunk, and left subclavian artery were all covered without endoleak. There was no significant obstruction or stenosis in brachiocephalic branches at the 6-month follow-up. Conclusions Total endovascular repair of aortic arch with the novel designed Yanger stent-graft system is safe and feasible in preclinical studies. With a better understanding of preclinical knowledge, patient selection criteria and first-in-human studies will be addressed. [ABSTRACT FROM AUTHOR]

Objective: Patients with Stanford type B acute aortic dissection usually receive medical treatment during the acute phase. The present study aimed to elucidate the factors predicting late aortic events in patients treated conservatively for acute type B dissections. Methods: From March 1991 to March 2011, 117 patients were enrolled in the present study, with a mean follow-up period of 5.1 ± 4.1 years. The patients were divided into 4 groups according to their false lumen status at onset: group F, fully open (n = 26, 22.2%); group P, partially thrombosed (n = 23, 19.6%); group U, ulcer-like projections (n = 22, 18.9%); and group T, completely thrombosed (n = 46, 39.3%). Results: Long-term survival did not significantly differ among the groups. The Kaplan-Meier event-free rate curve showed that aortic events occurred less frequently in group T than in the other 3 groups; the 5-year event-free rate was 65.4%, 58.8%, 36.1%, and 95.7% for groups F, P, U, and T, respectively. Cox regression analysis showed that the presence of ulcer-like projections (P = .016) and a maximum aortic diameter of ≥ 40 mm (P = .003) were predictors of late aortic events. Conclusions: When patients have a maximum aortic diameter of ≥40 mm or ulcer-like projections at onset, early surgical intervention should be considered to prevent positive remodeling of the aorta. [Copyright &y& Elsevier]

Objective: Long-term survival after aortic surgery has remained largely unexplored, despite suggestions of superior durability compared with endovascular techniques. The objective of the present study was to determine the long-term survival after open thoracic aortic surgery and to identify the predictors of mortality. Methods: The provincial database was accessed to identify all adult patients who had undergone primary open thoracic aortic surgery in British Columbia since 1993. Kaplan-Meier survival analyses were performed for the entire group and by year of surgery, urgency of surgery, and aortic segment requiring surgery. Multivariate analyses were performed to identify the predictors of mortality. Results: From January 1993 to June 2010, 1960 patients underwent primary open thoracic aortic surgery at 4 hospitals in British Columbia. Overall, the 30-day mortality was 9.1%, with a perioperative stroke rate of 5.8%. Long-term survival was 77.7%, 59.6%, and 44.7% at 5, 10, and 15 years, respectively. Subanalyses demonstrated improved long-term survival in the modern era; among patients undergoing elective aortic surgery; and among patients undergoing surgery on the ascending aorta or aortic root (P < .0001). The preoperative characteristics associated with decreased long-term survival included age older than 65 years, acute renal failure, dialysis, cerebrovascular accident, chronic obstructive pulmonary disease, peripheral vascular disease, and descending or thoracoabdominal aorta surgery. Conclusions: Long-term survival after elective thoracic aortic surgery is excellent, with improved outcomes in the modern era. Several preoperative risk factors associated with decreased survival were identified, which could assist in risk stratification and patient selection. Finally, the long-term survival rates identified in the present study should serve as a benchmark to which new aortic interventions should be compared. [Copyright &y& Elsevier]

Background: To evaluate trends and outcomes of descending thoracic aortic aneurysm (DTAA) repair in the United States. Methods: Adults undergoing DTAA repair between 1998 and 2008 were identified in the Nationwide Inpatient Sample. To limit confounding, patients with connective tissue disorders, aortic dissection, or thoracoabdominal aneurysms were excluded. Stratification was based on intact versus ruptured DTAA and open versus endovascular approach. Standardized annual rates of repair were calculated based on US Census Bureau population estimates. Logistic regression analysis incorporating multiple patient, operative, and hospital variables was used for risk adjustment. Results: A total of 20,568 DTAA patients (intact, 17,780; ruptured, 2788) underwent repair (open, 15,265; endovascular, 5303). Patients undergoing repair in the more recent era had higher comorbidity burdens than those undergoing repair in the earlier era. Despite this, annual rates of repair for both intact and ruptured DTAAs increased significantly during the study period (intact, 2.2-10.6 per 1 million; ruptured, 0.8-1.3 per 1 million; P < .05), primarily because of increases in rates of endovascular repair in recent years. Operative mortality decreased from 10.3% to 3.1% for repairs of intact DTAAs (P < .001) and from 52.6% to 23.4% for ruptured DTAAs (P = .002). Endovascular repair was associated with reduced risk-adjusted mortality for both intact (odds ratio, 0.31; P < .001) and ruptured (odds ratio, 0.41; P = .001) DTAAs. Conclusions: Although patients undergoing DTAA repair in the modern era have a higher comorbidity burden, rates of repair have increased and operative mortality has decreased, in part because of the increasing adoption of endovascular approaches. [Copyright &y& Elsevier]

Background: Risk factors and outcomes after iliofemoral complications after thoracic aortic endovascular repair remain poorly characterized. This study was performed to characterize factors influencing perioperative iliofemoral complications during thoracic aortic endovascular repair. Methods: All patients undergoing transfemoral thoracic aortic endovascular repair since 2005 with adequate preoperative aortoiliac 3-dimensional imaging (n = 126) were identified. Assessment of imaging was blinded with regard to occurrence of iliofemoral complications, defined as anything other than successful transfemoral device delivery and primary closure of an arteriotomy. Results: The complication rate was 12% (n = 15). Univariate analysis identified that female gender, preoperative ankle-brachial index, average and minimal iliac diameters, diameter difference between iliac artery and sheath size, and iliac morphology score (calculated by combining iliac tortuosity, calcification, and vessel diameter) were associated with iliofemoral complications (all P < .05). Multivariate analysis identified the (1) difference between average iliac diameter and sheath size (P = .014), (2) iliac artery morphology score (P = .033), and (3) ankle-brachial index (P = .012) as independent predictors for iliofemoral complications. Early mortality was higher in those with complications (13.3% vs 1.8%, P = .069). Four-year freedom from limb loss, claudication, or revascularization was 97.9%. Iliofemoral complications reduced late survival primarily as a result of increased mortality within the first year (P = .047). Conclusions: Thoracic aortic endovascular repair can be performed safely via a transfemoral approach. Alternative access in patients with high preoperative iliac artery morphology scores and device delivery size requirements over the native iliofemoral size may reduce iliofemoral complications. If early complications occur, prompt repair results in low rates of ischemic limb complications at late follow-up. [Copyright &y& Elsevier]

Abstract: Purpose: To evaluate the diagnostic performance of dual-energy (DE) computed tomography (CT) after thoracic endovascular aortic repair (TEVAR) of type B dissection, and to investigate the value of late delayed (LD) acquisition in endoleak detection and false lumen patency assessment. Materials and Methods: Twenty-four patients with TEVAR for type B dissection underwent 53 tripe-phase CT examinations. Single-source unenhanced acquisition was followed by single-source arterial-phase and DE LD phase (300-s delay) imaging. Virtual noncontrast images were generated from DE acquisition. Two blinded radiologists retrospectively evaluated the cases in three reading sessions: session A (triphasic protocol), session B (virtual noncontrast and arterial phase), and session C (virtual noncontrast and arterial and LD phases). Endoleak detection accuracy during sessions B and C compared with session A (reference standard) was investigated. False lumen patency was assessed. Effective radiation dose was calculated. Results: Session A revealed 37 endoleaks in 30 of 53 studies (56.6%). Session B revealed 31 of the 37 endoleaks, with one false-positive case, 83.8% sensitivity, 95.8% specificity, 79.3% negative predictive value, and 96.9% positive predictive value. Session C correctly depicted all 37 endoleaks, with one false-positive case, 100% sensitivity, 95.8% specificity, 100% negative predictive value, and 97.4% positive predictive value. Underestimation of false lumen patency was found in session B (P = .013). Virtual noncontrast imaging resulted in 17% radiation exposure reduction. Conclusions: Virtual noncontrast imaging can replace standard unenhanced images in follow-up after TEVAR of type B dissection, thus reducing radiation dose. Delayed-phase imaging is valuable in low-flow endoleaks detection and false lumen patency assessment. [Copyright &y& Elsevier]

Objective: Retrograde dissection is now recognized as an important complication after thoracic endovascular aortic repair (TEVAR), but its treatment is poorly understood. Our objectives were to investigate the risks, describe the repair methods, and assess the outcomes of this complication. Methods: From 2000 to 2012, 766 patients underwent TEVAR. Of these patients, 14 (1.8%), plus 1 who had undergone TEVAR elsewhere (n = 15), developed retrograde dissection after stent grafting. They had undergone TEVAR for distal aortic dissection in 7, intramural hematoma in 5, aneurysm in 2, and transection in 1. Their mean age was 65 ± 9 years. At the initial TEVAR, the left subclavian artery was covered in 9, the mean stent graft diameter was 34 ± 2 mm, and >1 device was used in 8 patients. The site of entry tear was at the greater curvature in 11 and lesser curvature in 4. One patient ruptured and died 12 days after TEVAR and never made it to the operating room. The other 14 underwent proximal aortic repair. The median interval between TEVAR and repair of retrograde dissection was 6 months; 3 patients presented within 1 month. The repair techniques included reverse frozen elephant trunk in 5, total arch repair in 4, ascending or hemiarch repair in 4, and ascending TEVAR in 1. Concomitant procedures included aortic valve repair in 4, replacement in 2, root remodeling in 1, and coronary bypass in 1. Results: No operative mortality occurred. One patient underwent reoperation for bleeding. Two required a tracheostomy for respiratory failure. However, no renal failure, stroke, or spinal injury occurred. At a median follow-up of 26 months, 4 aortic reoperations had occurred: 1 distal stent graft extension for type 1b endoleak, 2 hybrid thoracoabdominal completion repairs for growth of residual distal disease, and 1 emergency TEVAR for aortobronchial fistula. The latter patient died of septic complications, and 3 other late noncardiac deaths occurred. Conclusions: Retrograde ascending dissection can present as an early or a late complication after descending stent grafting because of aortic instability or disease progression and has usually been associated with descending dissection or intramural hematoma. It is a life-threatening complication that can be managed safely with early recognition and rapid delivery of open or hybrid repair. [Copyright &y& Elsevier]

Objective: Blunt traumatic aortic injury is associated with significant mortality, and increased computed tomography use identifies injuries not previously detected. This study sought to define parameters identifying patients who can benefit from medical management. Methods: We reviewed 4.5 years of blunt traumatic aortic injuries. Injury was classified as grade I (intimal flap or intramural hematoma), II (small pseudoaneurysm <50% circumference), III (large pseudoaneurysm >50% circumference), and IV (rupture/transection). Secondary signs of injury included pseudocoarctation, extensive mediastinal hematoma, and large left hemothorax. Follow-up, including computed tomography, was reviewed. Results: We identified 97 patients: 31 grade I, 35 grade II, 24 grade III, and 7 grade IV; 67(69%) male; mean age 47 ± 18.8 years, mean Injury Severity Score 38.8 ± 14.6; overall survival 76 (78.4%). Secondary signs of injury were found in 30 patients. Overall, 52 (53.6%) underwent repair, 45 undergoing thoracic endovascular aortic repair, with 2 (2.22%) procedure-related deaths, and 7 undergoing open repair. Five patients undergoing thoracic endovascular aortic repair required 7 additional procedures. In 45 medically managed patients, there were 14 deaths (31%), all secondary to associated injuries. Injury Severity Scores of survivors and nonsurvivors were 33 ± 10.8 and 48.6 ± 12.8, respectively (P < .001). Follow-up showed resolution or no change in 21 (91%) and a small increase in 2 grade I injuries. Conclusions: All blunt traumatic aortic injury does not necessitate repair. Stratification by injury grade and secondary signs of injury identifies patients appropriate for medical management. Grade IV injury necessitates emergency procedures and carries high mortality. Grade III injury with secondary signs of injury should be urgently repaired; patients without secondary signs of injury may undergo delayed repair. Grade I and II injuries are amenable to medical management. [Copyright &y& Elsevier]

Abstract: Purpose: To investigate the long-term morphologic changes of the aorta after thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection and to analyze whether these changes differed between DeBakey class IIIa and IIIb dissections. Materials and Methods: During the period 1999–2009, 58 patients with acute complicated type B aortic dissection were treated with TEVAR. Seven patients lacked follow-up data, leaving 51 patients—17 patients with DeBakey IIIa aortic dissection and 34 patients with DeBakey IIIa aortic dissection IIIb—for inclusion in the study. Computed tomography scans performed before and after TEVAR were evaluated. Maximum thoracic and abdominal aortic diameters and diameters of the true lumen and false lumen at the level of the maximum aortic diameter in the thorax and abdomen were analyzed as well as degree of thrombosis of the false lumen. Results: There was an overall significant reduction of the thoracic aortic diameter, increased true lumen diameter, and reduced false lumen diameter (P < .05). Total thrombosis of the false lumen, with or without reintervention, was seen in 53% of all patients, in 41% primarily and in 12% after reintervention. The IIIa group had a higher degree of total false lumen thrombosis. All patients in the IIIb group had total thrombosis of the false lumen along the stent graft. Conclusions: Long-term follow-up showed favorable aortic remodeling after TEVAR for acute complicated type B aortic dissection. Total thrombosis of the false lumen occurred more often in patients with DeBakey IIIa aortic dissection compared with patients with DeBakey IIIb aortic dissection. [Copyright &y& Elsevier]

Abstract: The authors have seen four cases of asymptomatic delayed intimal injury adjacent to a stent graft diagnosed 7 to 16 months after thoracic endovascular aortic repair. Endovascular repeat intervention was successfully performed in three of the four cases as described in the present report. A second consecutive “intimal blowout” in one patient remains under close radiologic surveillance. Possible causes for the intimal blowouts, including stent-graft size, landing zone anatomy, and intrinsically weak aortic tissue, are discussed. [Copyright &y& Elsevier]

Abstract: Purpose: To assess the effect of the extent of stent graft coverage and anatomic properties of aortic dissection on the outcomes of thoracic endovascular aortic repair (TEVAR) for complicated chronic type B aortic dissection (CCBAD) in terms of survival, reintervention, and false lumen thrombosis. Materials and Methods: A retrospective analysis was performed of 71 patients who underwent TEVAR for CCBAD. Mean patient age was 54.7 years. Distal extent of stent graft coverage was categorized as short (≤ T7) or long (≥ T8) coverage. Indications of reintervention were categorized into three groups: proximal, alongside, and distal according to the anatomic relationship of the culprit lesion and the stent graft. Overall survival, reintervention-free survival, and extent of false lumen thrombosis were compared. Results: The technical success rate was 97.2%. The 1-year, 3-year, and 5-year overall survival rates were 97.1%, 88.9%, and 88.9%, and 1-year, 3-year, and 5-year reintervention-free survival rates were 80.7%, 73.8%, and 60.6%. There were no differences in overall survival, reintervention-free survival rates, and extent of false lumen thrombosis between the groups. In the short coverage group, distal reintervention was more frequent in patients with an abdominal aortic diameter ≥ 37 mm compared with patients with an abdominal aortic diameter < 37 mm (P = .005). Conclusions: TEVAR was effective for CCBAD with a high technical success rate and low mortality. The extent of stent graft coverage did not make a difference in terms of survival and false lumen thrombosis. Reinterventions were more frequently performed in patients with a large baseline abdominal aortic diameter who were treated with short stent graft coverage, and so longer coverage is recommended in such patients. [Copyright &y& Elsevier]

Objectives: Stent graft-induced new entry (SINE) has been increasingly observed after thoracic endovascular aortic repair of aortic dissection. We illustrate the possible mechanism by exploring predictive factors of late distal SINE after hybrid arch elephant trunk repair for aortic dissection. Methods: From November 2006, to May 2011, 20 of 99 patients underwent hybrid arch repair using the elephant trunk graft as the proximal landing zone. After a mean follow-up period of 27.9 ± 12.0 months, 12 patients had late distal SINE events and the others were free of events. False lumen remodeling level was observed and maximal longitudinal diameter, average of longitudinal and transverse maximal diameter, circumference, and area of true lumen were analyzed for precise size selection of stent graft before and after the procedure. Taper ratio, true lumen:aorta ratio, prestent grafting oversizing ratio, poststent grafting oversizing ratio, and expansion mismatch ratio of distal true lumen were proposed and calculated for further evaluation of the mechanism of late distal SINE. Results: Only the area oversizing ratio between true lumen and the distal selected stent graft at the presumed distal end of stent grafting was found as a significant predictive factor of SINE before procedure (4.00 ± 2.96 vs 1.98 ± 0.66 for SINE vs non-SINE, respectively; P = .031). The significant difference of the expansion mismatch ratio of true lumen between the 2 groups was found not only in the size measurement of mean diameter (1.48 ± 0.29 vs 1.22 ± 0.15; P = .039), but also in the area (2.39 ± 0.85 vs 1.58 ± 0.42; P = .031) and circumference (1.43 ± 0.27 vs 1.18 ± 0.14; P = .016) after stent grafting. Conclusions: We found that taper ratio is not an optimal criteria for stent graft size selection and distal oversizing calculated by true-lumen area is a significant factor causing delayed distal SINE. Use of the prestenting area oversizing ratio should be limited. [Copyright &y& Elsevier]

Objectives: This study sought to evaluate long-term survival in type B aortic dissection patients treated with thoracic endovascular aortic repair (TEVAR) therapy. Background: Historical data have supported medical therapy in type B acute aortic dissection (TBAAD) patients. Recent advances in TEVAR appear to improve in-hospital mortality. Methods: We examined 1,129 consecutive patients with TBAAD enrolled in IRAD (International Registry of Acute Aortic Dissection) between 1995 and 2012 who received medical (n = 853, 75.6%) or TEVAR (n = 276, 24.4%) therapy. Results: Clinical history was similar between groups. TEVAR patients were more likely to present with a pulse deficit (28.3% vs. 13.4%, p < 0.001) and lower extremity ischemia (16.8% vs. 3.6%, p < 0.001), and to characterize their pain as the “worst pain ever” (27.5% vs. 15.7%, p < 0.001). TEVAR patients were also most likely to present with complicated acute aortic dissection, defined as shock, periaortic hematoma, signs of malperfusion, stroke, spinal cord ischemia, mesenteric ischemia, and/or renal failure (61.7% vs. 37.2%). In-hospital mortality was similar in patients managed with endovascular repair (10.9 % vs. 8.7%, p = 0.273) compared with medically managed patients. One-year mortality was also similar in both groups (8.1% endovascular vs. 9.8% medical, p = 0.604). Among adverse events during follow-up, aortic growth/new aneurysm was most common, occurring in 73.3% of patients with medical therapy and in 62.7% of patients after TEVAR, based on 5-year Kaplan-Meier estimates. Kaplan-Meier survival estimates showed that patients undergoing TEVAR had a lower death rate (15.5% vs. 29.0%, p = 0.018) at 5 years. Conclusions: Results from IRAD show that TEVAR is associated with lower mortality over a 5-year period than medical therapy for TBAAD. Further randomized trials with long-term follow-up are needed. [Copyright &y& Elsevier]

Abstract: Thoracic aortic aneurysm (TAA) is a silent disease, often discovered at a time point that dramatic complications, as rupture and dissection, occur. For the detection of asymptomatic TAA and prevention of such complications, it is essential to have an adequate screening tool. Until now, routine laboratory blood tests have played only a minor role in the screening, diagnosis, tracking and prediction of the natural history of TAAs. However, the knowledge about biomarkers is rapidly expanding in the cardiovascular field, and there are several potential biomarkers that might be implemented into TAA clinical practice in the near future. The most important and promising markers for TAA will be discussed in this overview. [Copyright &y& Elsevier]

Abstract: Endovascular treatments for catastrophic aortic conditions have gained increasing popularity over the past 20years. Originally developed for abdominal aortic aneurysms (EVAR), treatment has been modified for use in thoracic aortic repair (TEVAR). As expanding numbers of patients with increasingly intractable conditions and more hostile anatomies are treated, endovascular stent designs are maturing to be suitable for these more demanding situations. This article discusses the engineering considerations that apply to changing stent graft designs for current and evolving thoracic applications. The biological parameters that differentiate thoracic from abdominal aortic environments are outlined. Factors concerning materials, sealing mechanisms, deployment, stent frame architecture, and migration resistance are described, and eagerly awaited potential future developments are summarized. [Copyright &y& Elsevier]

Thoracic endovascular aortic repair is the standard of care for acute complicated type B aortic dissections, but long-term single-device outcomes are limited. Fifty patients were treated with the Valiant Captivia thoracic stent graft (Medtronic Inc, Santa Rosa, Calif) for acute complicated type B aortic dissections in this prospective, nonrandomized Dissection Trial. All-cause mortality, secondary procedures, and serious adverse events were assessed, and a core lab evaluated images for aortic remodeling. Compliance for both clinical and imaging follow-up was 78% (18 out of 23) for the available patients at 5 years. Notable baseline characteristics were 86% of patients (43 out of 50) had malperfusion, 20% (10 out of 50) had ruptures, and 94% (46 out of 49) had DeBakey class IIIB dissections. The 5-year freedom from dissection-related mortality, secondary procedures related to the dissection, and endoleaks was 83%, 86%, and 85%, respectively. After 5 years, 89% of patients (16 out of 18) had a completely thrombosed false lumen in the stented segment of the aorta and the true lumen diameter over the length of stent graft was stable or increased for 94% of patients (16 out of 17) while the false lumen diameter was stable or decreased in 77% (13 out of 17) after 5 years. In the Dissection Trial, patients experienced positive and sustained measures of aortic remodeling. Survival outcomes, need for secondary procedures, and adverse event rates were consistent with previous thoracic endovascular aortic repair studies. Although limitations exist with the follow-up compliance, the Valiant Captivia thoracic stent graft system was effective in the long-term management of acute complicated type B aortic dissections in this patient population with a challenging condition. Through 5 years, the Valiant Captivia stent graft (Medtronic Inc, Santa Rosa, Calif) had positive aortic remodeling of the true lumen (TL) and false lumen (FL) in challenging Dissection Trial patients. TL volume was increased in 94% of patients (16 out of 17) after 5 years. FL thrombosis in the stented region of the aorta was completely thrombosed in 89% of patients (16 out of 18) after 5 years. [Display omitted] [ABSTRACT FROM AUTHOR]

This study evaluated the efficacy of the provisional extension to induce complete attachment (PETTICOAT) technique for type B and postoperative residual type B aortic dissections compared with the conventional thoracic endovascular aortic repair (TEVAR) technique. In this retrospective study, we compared sequential aortic morphologic changes in consecutive patients with type B and postoperative residual type B aortic dissections treated with the PETTICOAT technique between January 2016 and December 2017 with patients treated with the conventional TEVAR between January 2013 and December 2015. Outcomes included aortic remodeling and aorta-related adverse events for 2 years postoperatively. Forty-eight patients were included in this study (24 in the PETTICOAT group, 24 patients in the conventional TEVAR group). Although both groups showed aortic remodeling in the descending thoracic aorta, the PETTICOAT group developed significantly better aortic remodeling in the abdominal aorta compared with the conventional TEVAR group during the observation period. The PETTICOAT group had significantly fewer aorta-related adverse events compared with the conventional TEVAR group (8% vs 54%; P <.001). Aorta-related adverse events more commonly occurred in the poor remodeling group compared with in the good remodeling group (P =.001; hazard ratio, 8.32; 95% confidence interval, 2.26-30.64). This study suggests that the PETTICOAT technique for aortic dissection may promote aortic remodeling and decrease the incidence of aorta-related adverse events. Additional studies are required to confirm these preliminary findings. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To compare the durability of thoracic endovascular aortic repair (TEVAR) in two similar clinical trials that used early- and later-generation stent grafts. Materials and Methods: Secondary procedures from the prospective, nonrandomized, multicenter, clinical trial databases of the test arm of the VALOR and VALOR II trials were analyzed at 3 years. Descriptive and statistical analyses were employed to compare the rate of and potential predictors for secondary procedures. Results: A total of 127 and 96 patients were available for a minimum of 3 years of follow-up in the test arm of VALOR and VALOR II, respectively. By the first year after the index procedure, VALOR II patients were significantly less likely to have undergone a secondary procedure versus patients in the test arm of VALOR (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.01–0.63; P = .02), with most procedures performed for type I endoleak. Multivariate predictors at 3 years for the need for a secondary procedure in the VALOR test arm were maximum aneurysm diameter (P = .002) and aneurysm length (P = .01), both of which remained significant at the end of the study period. The estimated freedoms from secondary procedures in the VALOR test arm and VALOR II at 3 years were 85.1% (95% CI, 78.5%–89.8%) and 94.9% (95% CI, 88.8%–97.7%), respectively (P < .001). Conclusions: The rate of secondary procedures after TEVAR differed between the two cohorts, being substantially lower in the VALOR II trial at 1 year of follow-up. This finding suggests significant benefit from advances in some combination of operator experience, imaging systems, treatment planning, and device design. [Copyright &y& Elsevier]