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In diagnosing and following patients with acute aortic syndromes and thoracic aortic aneurysms, high-quality imaging of the thoracic aorta is indispensable. Mainstay modalities for thoracic aortic imaging are echocardiography, computed tomographic angiography, and magnetic resonance angiography. For any given clinical scenario, the imaging modality and protocol chosen will have a significant impact on sensitivity and specificity for the aortic diagnosis of concern. Imaging can also provide important ancillary information regarding myocardial performance, aortic valve morphology and function, and end-organ perfusion. Surveillance of patients following thoracic aortic surgery with serial imaging studies can identify complications that may require reintervention, and imaging has played an integral role in development of new surgical and interventional methods. Emerging techniques in thoracic aortic imaging include positron emission tomography, which addresses vessel wall inflammation, and 4-dimensional magnetic resonance angiography, which illustrates flow dynamics., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To report early experience with a new endovascular graft developed for aortic arch aneurysm repair in patients unfit for open surgery., Case Report: Three consecutive men (62, 74, and 69 years old) at high risk for open repair were treated for postdissection aortic arch aneurysms using a custom-made 3 inner branched endovascular graft. The 2 proximal branches are antegrade and perfuse the innominate artery and the left common carotid artery; the third branch is retrograde and perfuses the left subclavian artery. The latter is preloaded with a catheter and wire to aid cannulation. Technical success was achieved in each case. The mean procedure time, fluoroscopy duration, and contrast volume were 180 minutes, 35 minutes, and 145 mL, respectively. The perioperative period was uneventful. All branches were patent on 6-month computed tomography and duplex ultrasound imaging., Conclusion: This new patient-specific device allows total endovascular revascularization of the supra-aortic trunks during arch repair. These encouraging results support its more widespread use.

The hemodynamic and geometric factors leading to propagation of acute Type B dissections are poorly understood. The objective is to elucidate whether geometric and hemodynamic parameters increase the predilection for aortic dissection propagation. A pulse duplicator set-up was used on porcine aorta with a single entry tear. Mean pressures of 100 and 180 mmHg were used, with pulse pressures ranging from 40 to 200 mmHg. The propagation for varying geometric conditions (%circumference of the entry tear: 15-65%, axial length: 0.5-3.2 cm) were tested for two flap thicknesses (1/3rd and 2/3rd of the thickness of vessel wall, respectively). To assess the effect of pulse and mean pressure on flap dynamics, the %true lumen (TL) cross-sectional area of the entry tear were compared. The % circumference for propagation of thin flap (47 ± 1%) was not significantly different (p = 0.14) from thick flap (44 ± 2%). On the contrary, the axial length of propagation for thin flap (2.57 ± 0.15 cm) was significantly different (p < 0.05) from the thick flap (1.56 ± 0.10 cm). TL compression was observed during systolic phase. For a fixed geometry of entry tear (%circumference = 39 ± 2%; axial length = 1.43 ± 0.13 cm), mean pressure did not have significant (p = 0.84) effect on flap movement. Increase in pulse pressure resulted in a significant change (p = 0.02) in %TL area (52 ± 4%). The energy acting on the false lumen immediately before propagation was calculated as 75 ± 9 J/m 2 and was fairly uniform across different specimens. Pulse pressure had a significant effect on the flap movement in contrast to mean pressure. Hence, mitigation of pulse pressure and restriction of flap movement may be beneficial in patients with type B acute dissections.

Objective: Thoracic endovascular aortic repair (TEVAR) has demonstrated encouraging results and is gaining increasing acceptance as a treatment option for aortic aneurysms and dissections. Yet, its role in managing proximal aortic pathologies is unknown-this is important because in proximal (Stanford type A) aortic dissections, 10% to 30% are not accepted for surgery and 30% to 50% are technically amenable for TEVAR. We describe our case series of type A aortic dissections treated by using TEVAR., Methods: Between year 2009 and 2016, 12 patients with acute, subacute, or chronic type A aortic dissection with the proximal entry tear located between the coronaries and brachiocephalic artery were treated with TEVAR at 3 centers. Various stent-graft configurations were used to seal the proximal entry tear in the ascending aorta under rapid pacing., Results: A total of 12 patients (9 male, 3 female), mean age 81 ± 7 years, EuroSCORE II 9.1 ± 4.5, underwent TEVAR for the treatment of type A aortic dissection. Procedural success was achieved in 11 of 12 patients (91.7%). There was 1 minor stroke and 1 intraprocedural death. No additional deaths were reported at 30 days. At 36 months, there were 4 further deaths (all from nonaortic causes). The mean survival of these 4 deceased was 23 months (range 15-36 months). Follow-up computed tomography demonstrated favorable aortic remodeling., Conclusions: TEVAR is feasible and reveals promising early results in selected patients with type A aortic dissection who are poor candidates for surgical repair. The current iteration of stent-graft technology, however, needs to be adapted to features specific to the ascending aorta., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Obstructive sleep apnea syndrome (OSAS) is a risk factor for resistant arterial hypertension and aortic dilatation. We assessed the value of systematic screening for OSAS in patients soon after the onset of acute aortic syndrome (AAS)., Methods: Between January 2010 and June 2014, patients were prospectively screened for post AAS OSAS. The severity of OSAS was defined by the Apnea-Hypopnea Index (AHI) and the Oxygen Desaturation Index (ODI). Blood pressure control was assessed with 24-h ambulatory monitoring., Results: The study population comprised 71 patients (males: 64.7%; median age [interquartile range]: 57 [49 to 64] years; type A AAS: 49.3%; type B AAS: 50.7%). According to the AHI, 58 patients (81.7%) had OSAS and 31 (43.6%) had severe OSAS. A prognostic analysis revealed that the descending thoracic false lumen dilatation rate rose significantly with the severity of OSAS (p = 0.0008 for the AHI and p = 0.0284 for the ODI). The median rate of increase was 7.5 (5 to 10) mm/year in the AHI greater than 30 events/h group and 5.0 (0 to 8) mm/year in the ODI greater than 30 events/h group. With regard to blood pressure control, the diastolic blood pressure varied as function of the ODI category (p = 0.0074)., Conclusions: Our results suggest that systematic screening for post-ASS OSAS is of value. The false lumen dilatation rate appears to be related to the severity of OSAS. It remains to be seen whether treatment of OSAS would modify the false lumen dilatation rate., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Despite advances in imaging techniques, mediastinoscopy remains an important tool for the staging of the mediastinum in non-small cell lung cancer and diagnosing lymphoma with mediastinal adenopathy. Injury to the arterial system during mediastinoscopy is infrequent but a potentially fatal complication. We report three cases of injury to the aorta and supra-aortic arteries sustained during mediastinoscopy. These were effectively managed by endovascular techniques. Patient recovery was uncomplicated and median length of stay was 3 days. This technique avoids major open surgery in a high-risk group of patients and may offer a mortality benefit and more rapid resumption of oncological treatment., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The term acute aortic syndrome (AAS) encompasses a range of conditions that have a risk of imminent aortic rupture and where delays in treatment result in increased mortality. Endovascular treatment offers an attractive alternative to open surgery but little is known about the durability of the repair and the factors that predict mortality., Methods: Prospective data were collected for a cohort of 110 consecutive patients with endovascular treatment for AAS. Patient and procedural characteristics were related to short- and midterm outcome using multivariate logistic regression analysis., Results: There were 75 men and 35 women with a median age of 68 (range 57-76) years. The pathologies treated were acute dissection (35), symptomatic aneurysm (32), infected aneurysm (18), transection (12), chronic dissection (9), penetrating ulcer (3), and intramural hematoma (1). Thirty-day mortality was 12.7% and this was associated with hypotension (odds ratio [OR], 5.25), use of general anesthetic (OR, 5.23), long procedure duration (OR, 2.03), and increasing age (OR, 1.07). The causes of death were aortic rupture (4), myocardial infarction (4), stroke (3), and multisystem organ failure (3). The stroke and paraplegia rates were 7.3% and 6.4%, respectively. The 1-year survival was 81% and the 5-year survival 63%. Secondary procedures were required in 13 (11.8%) patients. Factors associated with death at 1 year were presence of an aortic fistula (OR, 9.78), perioperative stroke (OR, 5.87), and use of general anesthetic (OR, 3.76); and at 5 years were aortic fistula (OR, 12.31) and increasing age (OR, 1.06)., Conclusions: Acute aortic syndrome carries significant early and late mortality. Emergency endovascular repair offers a minimally invasive treatment option associated with acceptable short and midterm results. Continued surveillance is important as secondary procedures and aortic-related deaths continue to occur throughout the follow-up period., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)