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Background: Increasing aortic diameter is thought to be an important risk factor for acute type B aortic dissection (ABAD). However, some patients develop ABAD in the absence of aortic dilatation. In this report, we sought to characterize ABAD patients who presented with a descending thoracic aortic diameter <3.5 cm., Methods: We categorized 613 ABAD patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2009 according to the aortic diameter <3.5 cm (group 1) and ≥3.5 cm (group 2). Demographics, clinical presentation, management, and outcomes of the two groups were compared., Results: Overall, 21.2% (n = 130) had an aortic diameter <3.5 cm. Patients in group 1 were younger (60.5 vs 64.0 years; P = .015) and more frequently female (50.8% vs 28.6%; P < .001). They presented more often with diabetes (10.9% vs 5.9%; P = .050), history of catheterization (17.0% vs 6.7%; P = .001), and coronary artery bypass grafting (9.7% vs 3.4%; P = .004). Marfan syndrome was equally distributed in the two groups. The overall in-hospital mortality did not differ between groups 1 and 2 (7.6% vs 10.1%; P = .39)., Conclusions: About one-fifth of patients with ABAD do not present with any aortic dilatation. These patients are more frequently females and younger, when compared with patients with aortic dilatation. This report is an initial investigation to clinically characterize this cohort, and further research is needed to identify risk factors for aortic dissection in the absence of aortic dilatation., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The risk of acute type B aortic dissection is thought to increase with descending thoracic aortic diameter. Currently, elective repair of the descending thoracic aorta is indicated for an aortic diameter of 5.5 cm or greater. We sought to investigate the relationship between aortic diameter and acute type B aortic dissection, and the utility of aortic diameter as a predictor of acute type B aortic dissection., Methods: We examined the descending aortic diameter at presentation of 613 patients with acute type B aortic dissection who were enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2009, and analyzed the subset of patients with acute type B aortic dissection with an aortic diameter less than 5.5 cm., Results: The median aortic diameter at the level of acute type B aortic dissection was 4.1 cm (range 2.1-13.0 cm). Only 18.4% of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection had an aortic diameter of 5.5 cm or greater. Patients with Marfan syndrome represented 4.3% and had a slightly larger aortic diameter than patients without Marfan syndrome (4.68 vs 4.32 cm, P = .121). Complicated acute type B aortic dissection was more common among patients with an aortic diameter of 5.5 cm or greater (52.2% vs 35.6%, P < .001), and the in-hospital mortality for patients with an aortic diameter less than 5.5 cm and 5.5 cm or greater was 6.6% and 23.0% (P < .001), respectively., Conclusions: The majority of patients with acute type B aortic dissection present with a descending aortic diameter less than 5.5 cm before dissection and are not within the guidelines for elective descending thoracic aortic repair. Aortic diameter measurements do not seem to be a useful parameter to prevent aortic dissection, and other methods are needed to identify patients at risk for acute type B aortic dissection., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: To investigate the thoracic aortic pulsatility during hypovolemic shock in an experimental porcine model., Methods: The circulating blood volume of 7 healthy Yorkshire pigs was gradually lowered until the subjects had lost 40% of their normal blood volume. Intravascular ultrasound was used to assess the aortic pulsatility in normovolemic and hypovolemic state at the level of the ascending and descending thoracic aorta., Results: The mean aortic pulsatility at the level of the ascending aorta decreased from 15.9% ± 7.2% (range 6.3%-25.7%) in normovolemia to 6.2% ± 2.8% (range 2.9%-10.7%, p = 0.018) in hypovolemia. At the level of the descending thoracic aorta, the mean aortic pulsatility decreased from 8.7% ± 2.8% (range 4.4%-12.2%) at baseline to 5.6% ± 2.5% (range 1.5%-9.5%, p = 0.028) in hypovolemia. The maximum mean aortic diameter, obtained in cardiac systole, was significantly smaller as well at both evaluated levels during hypovolemic shock compared with the mean diameter in normovolemia., Conclusion: The thoracic aortic diameter and pulsatility decreased significantly during hypovolemic shock in this porcine model, most impressively at the level of the ascending aorta. Electrocardiographically-gated imaging may not be necessary for hypovolemic patients with acute aortic disease requiring endovascular repair because of the minimal aortic pulsatility.

Purpose: To provide insight into the causes, timing, and optimal management of endograft collapse after thoracic endovascular aortic repair (TEVAR)., Methods: A comprehensive review was conducted of all published cases of endograft collapse after TEVAR identified using Medline, Cochrane Library Central, and EMBASE. In total, 32 articles describing 60 patients (45 men; mean age 40.6 ± 17.2 years, range 17-78) with endograft collapse were included. All data were extracted from the articles and systematically entered into a database for meta-analysis., Results: In the 60 cases of endograft collapse, TEVAR had most commonly been applied to repair traumatic thoracic aortic injuries (39, 65%), followed by acute and chronic type B aortic dissections (9, 15%). The median time interval between TEVAR and diagnosis of endograft collapse was 15 days (range 1 day to 79 months). On average, the collapsed endografts were oversized by 26.7% ± 12.0% (range 8.3%-60.0%). Excessive oversizing was reported as the primary cause of endograft collapse in 20%, and a small radius of curvature of the aortic arch was responsible for 48% of the cases. The 30-day mortality was 8.3%, and the freedom from procedure-related death at 3 years after diagnosis of stent-graft collapse was 83.1% for asymptomatic patients compared with 72.7% for patients who had symptoms at diagnosis (p=0.029)., Conclusion: Endograft collapse typically occurs shortly after TEVAR, most frequently after endovascular repair of traumatic aortic injury. A high level of suspicion for endograft collapse in the first month after TEVAR, as well as further improvement of current endovascular devices, may be required to improve the long-term outcomes of patients after TEVAR.

Objectives: To investigate the impact of hypovolaemic shock on the aortic diameter in a porcine model, and to determine the implications for the endovascular management of hypovolaemic patients with traumatic thoracic aortic injury (TTAI)., Materials and Methods: The circulating blood volume of seven Yorkshire pigs was gradually lowered in 10% increments. At 40% volume loss, an endograft was deployed in the descending thoracic aorta, followed by gradual fluid resuscitation. Potential changes in aortic diameter during the experiment were recorded using intravascular ultrasound (IVUS)., Results: The aortic diameter decreased significantly at all evaluated levels during blood loss. The ascending aortic diameter decreased on average with 38% after 40% blood loss (range 24-62%, p = 0.018), the descending thoracic aorta with 32% (range 18-52%, p = 0.018) and the abdominal aorta with 28% (range 15-39%, p = 0.018). The aortic diameters regained their initial size during fluid resuscitation., Conclusion: The aortic diameter significantly decreases during blood loss in this porcine model. If these changes take place in hypovolaemic TTAI patients as well, it may have implications for thoracic endovascular aortic repair (TEVAR). Increased oversizing of the endograft, or additional computed tomography (CT) or IVUS imaging after fluid resuscitation for more adequate aortic measurements, may be needed in TTAI patients with considerable blood loss., (Copyright © 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: To investigate changes in aortic diameter in hemodynamically unstable trauma patients and the implications for sizing of thoracic endovascular aortic repair (TEVAR) in patients with traumatic thoracic aortic injury (TTAI)., Methods: We retrospectively evaluated all trauma patients that were admitted with hemodynamic instability (mean arterial pressure <95 mm Hg and a pulse >or=100 beats/min) and underwent computed tomography (CT) of the thorax and abdomen both at admission and at another moment (control CT scan), at the Yale New Haven Hospital between 2002 and 2009. The CT examinations were reviewed in a blinded fashion and the aortic diameter was measured at six different levels by a cardiovascular radiologist. Differences in aortic diameter between the initial CTs obtained in the trauma bay and the control CTs were compared using the paired Student t test., Results: Forty-three patients were identified, including 32 males. Mean age was 37 +/- 16 years, mean injury severity score was 26 +/- 15, the mean pulse and blood pressure were 122 beats/min and 103/63 mm Hg, respectively. Overall, the mean aortic diameter was significantly larger at the control CT examinations compared with the initial CT examinations while hemodynamically unstable, at all evaluated levels. Among patients with a pulse >or=130/min, the mean increase in aortic diameter was most consistent at the level of the mid descending thoracic aorta (DTA, +12.6%, P = .003) and at the level of the infrarenal aorta (+12.6%, P = .004)., Conclusions: The aortic diameter decreases dramatically in trauma patients with hemodynamic instability. This decrease in aortic diameter could theoretically lead to inaccurate aortic measurements and undersizing of the endograft in hemodynamically unstable TTAI patients requiring TEVAR. Further research is needed to better predict the actual aortic diameters in individual hemodynamically unstable patients requiring endovascular aortic repair., (Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Traumatic thoracic aortic injury (TTAI) is associated with high mortality rates. Data supporting thoracic endovascular aortic repair (TEVAR) to reduce mortality and morbidity for TTAI is limited to small series and meta-analyses. In this study, we evaluated the trends and outcomes of open surgery and TEVAR for TTAI in New York State., Methods: All cases of TTAI in New York State between 2000 and 2007 were extracted from the New York Statewide Planning and Research Cooperative System (SPARCS) database. A diagnosis by International Classification of Diseases, 9th Revision coding of TTAI was required for inclusion., Results: We identified 328 patients with TTAI who underwent surgical repair in New York State between 2000 and 2007; mean age of the cohort was 39.3 years +/- 18 years; 80% were male. Open repair of TTAI was performed in 79.6% and 20.4% underwent TEVAR. Open repair was performed for all cases of TTAI until the introduction of TEVAR in 2005; TEVAR exceeded the use of open repair for TTAI in 2006 and 2007. Additional major injuries were present in 71.7% in the open repair group vs 91.0% of the TEVAR group (P = .001). The overall in-hospital mortality rate for the 8-year period was significantly increased after open repair of TTAI compared with TEVAR: 17% vs 6%, (odds ratio [OR] 3.19, 95% confidence interval [CI], 1.11-9.23; P = .024). After controlling for the significant covariates, TEVAR independently reduced the risk of death following surgical intervention for TTAI compared with the open procedure (OR 3.8, 95% CI, 1.28-10.99; P = .010). Respiratory complications were the most common postoperative morbidity, and were significantly increased after open repair: 38% vs 24% (OR 1.95; 95% CI, 1.05-3.60; P = .032). There were no significant differences in cardiac complications, acute renal failure (ARF), paraplegia, or stroke. Endoleak and distal embolization each occurred in 9% of patients after TEVAR., Conclusions: There has been a shift toward endovascular management of patients with TTAI. This change in surgical strategy has been associated with less postoperative mortality and fewer pulmonary complications in patients suffering from TTAI. TEVAR is associated with significant device-related complications.

Purpose: To identify in-hospital and follow-up outcomes of thoracic endovascular aortic repair (TEVAR) for aortobronchial fistula (ABF) and aortoesophageal fistula (AEF)., Methods: The authors reviewed all published cases of ABF and AEF undergoing TEVAR indexed in the MEDLINE, Cochrane Library CENTRAL, and EMBASE databases. After removal of duplicates, 850 articles were scrutinized for relevance and validity. Exclusion criteria included: (1) no clear description of the organs involved with the fistula, (2) no description of outcomes after TEVAR for ABF or AEF, or (3) no original data presented in the article. In this manner, 66 relevant articles were identified that included original data on 114 patients (76 men; mean age 63+/-1.5 years) with ABF (n = 71) or AEF (n = 43). Meta-analyses were performed to investigate outcomes of TEVAR for ABF and AEF., Results: Patients with AEF presented more frequently with hypovolemic shock (33% versus 13%, p = 0.012) and systemic infection (36% versus 9%, p<0.001) compared to patients with ABF. In-hospital mortality was 3% (n = 2) after TEVAR for ABF and 19% (n = 8) after TEVAR for AEF (p = 0.004). Additional thoracic surgery in the first 30 days after TEVAR was performed in 3% (n = 2) of ABF patients and in 37% (n = 16) of AEF patients (p<0.001); 12 AEF patients who had received esophageal surgery in the first month after TEVAR showed lower fistula-related mortality during 6 months of follow-up compared to patients who did not receive additional esophageal surgery (p = 0.018)., Conclusion: TEVAR is associated with superior outcomes in patients with ABF. Endovascular management of AEF is associated with poor results and should not be considered definitive treatment. TEVAR could serve as a bridge to surgery for emergency cases of AEF only, with definitive open surgical correction of the fistula undertaken as soon as possible.