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We review current knowledge regarding the natural transition of aortic dissection from acute to chronic stages. As this is not well understood, we also bring to bear new data from our institution. Type A dissection rarely transitions naturally into the chronic state; consequently, information is limited. Type B dissections are routinely treated medically and indeed undergo substantial changes during their temporal course. General patterns include: 1) the aorta dilates and, absent surgical intervention, aortic enlargement may cause mortality; 2) continued false lumen patency, particularly with an only partially thrombosed false lumen, increases aortic growth, whereas calcium-channel blockers affect aortic dilation favorably; 3) aortic dilation manifests a temporal dynamic, with early rapid growth and deceleration during transition; 4) the intimal flap dynamically changes over time via thickening, straightening, and loss of mobility; and 5) temporal remodeling, on the cellular level, initially shows a high grade of wall destruction; subsequently, significant fibrosis ensues.

To examine the potential of aortic arch variants, specifically bovine aortic arch, isolated left vertebral artery, and aberrant right subclavian artery, as markers for thoracic aortic disease (TAD).We screened imaging data of 556 patients undergoing surgery due to TAD for presence of aortic arch variations. Demographic data were collected during chart review and compared with a historical control group of 4617 patients.Out of 556 patients with TAD, 33.5% (186 patients) demonstrated anomalies of the aortic arch, compared with 18.2% in the control group (P.001). Three hundred seventy (66.5%) had no anomaly of the aortic arch. Bovine aortic arch emerged as the most common anomalous branch pattern with a prevalence of 24.6% (n = 137). Thirty-five patients (6.3%) had an isolated left vertebral artery, and 10 patients (1.8%) had an aberrant right subclavian artery. When compared with the control group, all 3 arch variations showed significant higher prevalence in patients with TAD (P.001). Patients with aortic aneurysms and anomalous branch patterns had hypertension less frequently (73.5% vs 81.8%; P = .048), but had a higher rate of bicuspid aortic valve (40.8% vs 30.6%; P = .042) when compared with patients with aneurysms but normal aortic arch anatomy. Patients with aortic branch variations were significantly younger (58.6 ± 13.7 years vs 62.4 ± 12.9 years; P = .002) and needed intervention for the aortic arch more frequently than patients with normal arch anatomy (46% vs 34.6%; P = .023).Aortic arch variations are significantly more common in patients with TAD than in the general population. Atypical branching variants may warrant consideration as potential anatomic markers for future development of TAD.

The aim of this study was to evaluate if the presence of a bovine aortic arch (BAA)- the most common aortic arch anomaly-influences the location of the primary entry tear, the surgical procedure, and the outcome of patients undergoing operation for type A acute aortic dissection (AAD).A total of 157 patients underwent emergency operations because of AAD (71% men, mean age 59.5 ± 13 years). Preoperative computed tomographic scans were screened for the presence of BAA. Patients were separated into 2 groups: presenting with BAA (BAA+, n = 22) or not (BAA-, n = 135). Location of the primary tear, surgical treatment, outcome, and risk factors for postoperative neurologic injury and in-hospital mortality were analyzed.Fourteen percent (22 of 157) of all patients operated on for AAD had a concomitant BAA. Location of the primary entry tear was predominantly in the aortic arch in patients with BAA (BAA+, 59.1% versus BAA-, 13.3%; p0.001). Multivariate analysis revealed the presence of a BAA to be an independent risk factor for having the primary tear in the aortic arch (odds ratio [OR], 14.79; 95% confidence interval [CI] 4.54-48.13; p 0.001) but not for in-hospital mortality. Patients with BAA had a higher rate of postoperative neurologic injury (BAA+, 35% versus BAA-, 7.9%; p = 0.004). Multivariate analysis identified the presence of BAA as an independent risk factor for postoperative neurologic injury (OR, 4.9; 95% CI, 1.635-14.734; p = 0.005).In type A AAD, the presence of a BAA predicts the location of the primary entry site in the aortic arch and is an independent risk factor for a poor neurologic outcome.

BACKGROUND: Computed tomography (CT)-based fat and muscle measures are associated with outcome in large populations. We tested if muscle and fat characteristics are associated with long-term outcomes after TAVR. METHODS: We included 403 clinical CTs performed prior to TAVR at our center between 2008 and 2016, measuring area (cm(2)) and density (Hounsfield units, HU) of both psoas muscles (PM), subcutaneous adipose (SAT), and visceral adipose tissue (VAT). Area measures were indexed to height, log-transformed and both area and density were standardized for analysis. We assessed the association of each measure with all-cause mortality (adjusted for age, sex, body mass index (BMI), and the Society of Thoracic Surgeons (STS) risk score. RESULTS: Of the 403 individuals (83 ± 8 years; 52% female), 167 (41.4%) died during a median follow-up of 458 days (interquartile range IQR 297–840). Fat measures were feasible and rapid. Fat area was available in 242 (60%) patients with an adequate field of view. Individuals with the lowest PM area, SAT area or VAT area exhibited the highest hazard of mortality. In addition, greater SAT density was associated with a higher mortality hazard (adjusted HR per standard deviation increase in density= 1.35, 95%CI 1.10–1.67, P = 0.005). CONCLUSION: Rapid CT-based tissue characterization is feasible in patients referred for TAVR. Decreased PM area and increased SAT density are associated with long-term mortality after TAVR, even after accounting for age, sex, BMI, and STS score. Further studies are necessary to interrogate sex-specific relationships between CT tissue metrics and mortality and whether CT measures are incremental to well-established frailty metrics.

Background Results after thoracic endovascular aortic repair in penetrating atherosclerotic ulcers are uncertain. Methods From 1997 to 2010, 72 patients (median age, 67 years) presented with penetrating atherosclerotic ulcers (symptomatic, 58%; rupture, 36%). Median logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 32. Mean follow-up was 42 months (range, 19 to 56 months). In-hospital mortality, occurrence of endoleaks, reinterventions, and survival were recorded. Results In hospital mortality was 4%. The primary success rate was 100%. Actuarial survival rates at 1, 5, and 10 years were 93%, 72%, and 60%. The early type I and III endoleak rate was 2.7%. The late type I and III endoleak rate was 4%. One late surgical conversion was performed. Aortic-related actuarial survival was 100% at 1 year and 98.6% at 5 and 10 years. Age older than 75 years (odds ratio, 8.928; 95% confidence interval, 2.05 to 38.93) was an independent predictor of survival. During follow-up, 21% of patients underwent a cardiovascular intervention. Conclusions Results after thoracic endovascular aortic repair in patients with penetrating atherosclerotic ulcers are excellent for early and late type I and III endoleak formation and aortic-related survival. Patients are mainly limited by age and by the aggressive underlying obliterative atherosclerotic process.

Background Midterm results of TEVAR (thoracic endovascular aortic repair) in patients with aneurysms involving the descending aorta originating from chronic type B dissections are not known. Methods Between 2004 and 2009, 14 patients with a median age of 63 years (79% male) with this pathology were treated. Seven patients underwent supraaortic transpositions in various extents prior to TEVAR in order to gain a sufficient proximal landing zone. Results Median time from dissection to treatment was 19 months (4 to 84 months). All patients had an uneventful in-hospital course. The median covered length of the aortic arch and descending aorta was 190 mm (100 to 250 mm). Primary success rate defined as absence of type Ia endoleakage was 86%. No patient, where visceral or renal vessels originated from the false or from both lumina sustained ischemic injury by TEVAR. The median follow-up period is 34 months to date (6 to 64 months). Aortic-related morbidity and mortality during follow-up was low (14%). Conclusions Midterm results of TEVAR in patients with aneurysms involving the descending aorta originating from chronic type B dissections are good. The self-expanding capability of the stent grafts is sufficient over time. However, extensive coverage of the descending aorta is warranted to achieve success. Further studies are needed to extend our knowledge in this particular subgroup of patients.

Modern developments such as the Differential Global Positioning System (DGPS) and echo-sounding enable fast, accurate and cost-effective surveys of the area distribution of emersed and submersed macrophytes. The basis of the surveys is provided by accurate digital positioning of the shore line in order to obtain a clear delimitation of the areas under water for vegetation surveys and to link the digital model of the lake basin across the shore line to an existing terrestrial digital terrain model. The stands of macrophytes are systematically mapped from the boat by echo-sounding the littoral zone. Scuba diving is used for identifying species, determining vegetation density and delimiting homogeneous zones of plant cover. Based on these surveys, the parameters necessary for evaluating the macrophyte vegetation according to the Austrian standard ONORM M 6231 can be determined and included in the status classification of the lake according to the Water Framework Directive. The digital terrain model also serves water conservation numerous applications in the field of water ecology, helping with issues such as water management, hydrology and nature conservation.

Patients with penetrating cardiac injuries caused by a gunshot have a poor outcome [3,18]. Less than 10% of these patients reach the hospital alive [6]. Survival rates after hospital admission are reported with a percentage of 15–30 [3,18,35]. Acute traumatic aortic lesions are as well life-threatening injuries appearing typically in patients who sustain blunt deceleration trauma in car accidents or falls from a height [31,14,13]. 80–85% of the patients suffering this injury die at the scene of accident itself [29]. Gunshot wounds to the aorta are rarely reported, but penetrating trauma to the aorta is usually rapidly fatal [30,4,12]. To our knowledge there is no reported combined lesion of the left ventricle and the descending aorta due to a single gunshot bullet in the same patient. Which of these two potentially lethal injuries should be addressed first?

Objective The purpose of the study was to assess the anticipated incremental risk of a concomitant aortic resection performed with an aortic valve replacement. Methods Patients who underwent aortic valve replacement with root-sparing ascending replacement were compared with those who underwent isolated aortic valve replacement using propensity score matching (81 pairs; mean age, 63 ± 11 years [root-sparing ascending replacement] vs 64 ± 14 years). To evaluate the impact of the technique at distal site, 71 pairs of those undergoing root-sparing ascending replacement also were matched by propensity score according to distal anastomosis performed clamped and open under deep hypothermic circulatory arrest. Results Operative mortality was equal between the root-sparing ascending replacement and isolated aortic valve replacement groups. No significant difference was found regarding postoperative morbidities, such as bleeding, renal failure, stroke, and length of stay, except prolonged ventilation was found after root-sparing procedures ( P = .028). Survival estimation showed no difference between the groups. Comparing the patients undergoing root-sparing ascending replacement with clamped and opened distal anastomosis revealed a prolonged ventilation requirement (7% vs 3%; P = not significant) in the open group. Operative mortality was 0% in both groups, and midterm survival was comparable. Conclusions The concomitant replacement of the aorta in root-sparing fashion is associated with an excellent operative outcome and adds no additional risk to aortic valve replacement in elective and non–high-risk patients. If the distal anastomosis is performed in an open fashion, while the operative mortality is still very low, morbidities are slightly higher, but midterm survival remains comparable.

Background The purpose of this study is to compare costs of conventional surgical therapy with costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms. Methods Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. A catalog of costs was then created for both procedures and this catalog was applied individually to each patient. Results Total costs of the service provision of endovascular stent-graft placement including anesthesia were 38.220.98€ considering 1.7 stent-grafts per patient and including 5900.00€ (Euros) for days of care. In conventional surgical therapy, adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12€ was calculated. Days of care accounted for 31.230.00€ and total costs of 50.764.12€ were calculated. The difference between total costs of the two procedures was 12.543.14€. Conclusions Costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.