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Aortic dissection is a critical vascular disease that is characterized by a high mortality rate and inflammation significantly influences its onset and progression. Recent studies highlight the integral role of macrophages, key players in the immune system, in the pathological landscape of aortic dissection. These cells are involved in crucial processes, such as the remodeling of the extracellular matrix, immunocyte infiltration, and phenotypic switching of smooth muscle cells, which are essential for the structural integrity and functional dynamics of the aortic wall. Despite these insights, the specific contributions of macrophages to the development and progression of aortic dissection remains unclear. This review explores the pathogenesis of aortic dissection with a focus on macrophages and describes their origins, phenotypic variations, and potential roles based on the most recent research findings. Furthermore, we discuss key molecules related to macrophages during aortic dissection, their interactions with other cellular components within the aorta, and the implications of these interactions for future therapeutic strategies. This comprehensive analysis aimed to improve our understanding of macrophages in aortic dissection and promote the development of targeted interventions., (© 2024. Science China Press.)

Purpose: This study aimed to develop a deep learning model for predicting distal aortic remodeling after proximal thoracic endovascular aortic repair (TEVAR) in patients with Stanford type B aortic dissection (TBAD) using computed tomography angiography (CTA)., Methods: A total of 147 patients with acute or subacute TBAD who underwent proximal TEVAR at a single center were retrospectively reviewed. The boundary of aorta was manually segmented, and the point clouds of each aorta were obtained. Prediction of negative aortic remodeling or reintervention was accomplished by a convolutional neural network (CNN) and a point cloud neural network (PC-NN), respectively. The discriminatory value of the established models was mainly evaluated by the area under the receiver operating characteristic curve (AUC) in the test set., Results: The mean follow-up time was 34.0 months (range: 12-108 months). During follow-up, a total of 25 (17.0%) patients were identified as having negative aortic remodeling, and 16 (10.9%) patients received reintervention. The AUC (0.876) by PC-NN for predicting negative aortic remodeling was superior to that obtained by CNN (0.612, p=0.034) and similar to the AUC by PC-NN combined with clinical features (0.884, p=0.92). As to reintervention, the AUC by PC-NN was significantly higher than that by CNN (0.805 vs 0.579; p=0.042), and AUCs by PC-NN combined with clinical features and PC-NN alone were comparable (0.836 vs 0.805; p=0.81)., Conclusion: The CTA-based deep learning algorithms may assist clinicians in automated prediction of distal aortic remodeling after TEVAR for acute or subacute TBAD., Clinical Impact: Negative aortic remodeling is the leading cause of late reintervention after proximal thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD), and possesses great challenge to endovascular repair. Early recognizing high-risk patients is of supreme importance for optimizing the follow-up interval and therapy strategy. Currently, clinicians predict the prognosis of these patients based on several imaging signs, which is subjective. The computed tomography angiography-based deep learning algorithms may incorporate abundant morphological information of aorta, provide with a definite and objective output value, and finally assist clinicians in automated prediction of distal aortic remodeling after TEVAR for acute or subacute TBAD., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: The aim of this study was to report the long-term outcomes of proximal thoracic endovascular aortic repair (TEVAR) for chronic Stanford type B aortic dissection (cTBAD)., Methods: We retrospectively analyzed the clinical data of 48 cases of patients with cTBAD who underwent proximal TEVAR in Zhongshan Hospital Fudan University from January 2010 to September 2013. The preoperative and postoperative imaging examinations, overall survival rate, aortic-related survival rate, and freedom from reintervention rate data were collected to evaluate aortic remodeling and clinical outcomes. The enrolled patients received follow-up at 1, 3, 6, and 12 months following treatment and annually thereafter., Results: A total of 48 patients (mean age, 58.3 ± 10.6 years; men:women, 40:8) were included, of which 38 cases (79.2%) were uncomplicated dissection and 10 cases (20.8%) were complicated. The mean follow-up time was 48.7 ± 40 months (1-120 months). The mean time interval from the initial procedure to reintervention was 50.6 ± 32.7 months (11-98 months). The following changes were observed at preoperative versus last follow-up timepoints. Descending aortic level: true lumen, 19.2 ± 7.01 mm vs. 36.9 ± 9.53 mm ( p < 0.001); false lumen, 30.47 ± 15.89 mm vs. 19.16 ± 15.33 mm ( p < 0.001); maximum diameter, 49.67 ± 13.96 mm vs. 56.66 ± 14.95 mm ( p = 0.018). Diaphragm level: true lumen, 16.24 ± 5.41 mm vs. 24.41 ± 8.04 mm ( p < 0.001); false lumen, 12.37 ± 11.49 mm vs. 14.92 ± 12.25 mm ( p = 0.196); and maximum diameter, 34 ± 7.81 mm vs. 38.04 ± 7.7 mm ( p < 0.001). The freedom from reintervention rate was 81% in 5 years and 50.6% in 10 years. The overall 10-years survival rate was 83% (6 of 48), and the aortic-related survival rate was 92.3% (3 of 48)., Conclusions: TEVAR is a safe and effective proximal repair intervention for cTBAD that can reliably induce the positive remodeling of the descending aorta., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To evaluate the clinical outcomes of thoracic endovascular aortic repair (TEVAR) in the treatment of Stanford type B aortic dissection (TBAD) in Marfan syndrome patients who had no history of aortic arch replacement. Methods: This is a retrospective case-series study. From January 2009 to December 2019,the clinical data of Marfan syndrome patients who underwent TEVAR for TBAD at the Department of Vascular Surgery were collected. A total of 23 patients were enrolled,including 15 males and 8 females. The age was (38.0±11.0) years (range:24 to 56 years). Among them,12 patients had history of ascending aortic surgery. Details of TEVAR,perioperative complications and reintervention were recorded and survival rate was analyzed by Kaplan-Meier curve. Results: Technical success was 91.3% (21/23). Two patients with technical failure were as follows:one patient had type Ⅰa endoleak at the completion angiography,which healed spontaneously during the follow-up,and the other patient suffered aortic intimal intussusception after the deployment of the first stent-graft, and the second stent-graft was deployed. However, type Ⅲ endoleak was detected,which disappeared during the follow-up. One patient died during hospitalization. The median follow-up time ( M (IQR)) was 60 (48) months (range:12 to 132 months). Reintervention was performed on 7 patients,including 3 distal stent-graft-induced new entry,2 distal aortic dilation,1 Ⅰa endoleak and 1 retrograde type A aortic dissection,respectively. Five-year cumulative survival rate was 86.7% (95% CI :86.6% to 86.8%) and the 5-year freedom from reintervention rate was 81.8% (95% CI :61.8% to 92.8%). Conclusions: TEVAR is feasible in the treatment of TBAD in Marfan syndrome patients who has no history of aortic arch replacement. It has high technical success rate and low perioperative complication.

Background: Thoracic aortic dissection (TAD) is one of the most fatal cardiovascular diseases. One of its important pathological characteristics is the local inflammatory response. Many studies have found that Macrophage polarization plays an extremely critical role in the inflammatory progression and tissue remodeling of TAD. Costunolide (CTD) has an improving effect on oxidative stress and inflammation in the body. However, whether it can promote the integrity of extracellular matrix in Aortic dissection and its mechanism are still unclear., Methods: The male C57BL/6J mice were used to construct an animal model of TAD with β-aminopropionitrile (BAPN) (100 mg/kg/day, lasting for 28 days), and then CTD (10 mg/kg or 100 mg/kg) was injected intraperitoneally for 28 days to check the survival rate, TAD incidence, aortic morphology and other indicators of the mice. Using hematoxylin-eosin (HE), Masson, Elastin van Gieson (EVG) staining, immunofluorescence (IF), and immunohistochemical staining, the study aimed to determine the therapeutic effects of CTD on an animal model with BAPN-induced TAD. To enhance the examination of the regulatory mechanism of CTD, we conducted transcriptome sequencing on arterial tissues of mice in both the BAPN group and the BAPN + CTD100 group. Next, ANG II were used to construct TAD model in vascular smooth muscle cells (VMSCs). The effects of CTD on the proliferation, migration, invasion, and apoptosis of ANG II-induced cells are to be detected. The expression of MMP2, MMP9, P65, and p-P65 in each group will be examined using Western blot. Finally, the overexpression of IκB kinaseβ (IKKβ) will be established in VMSCs cells to further explore the protective function of CTD., Results: The result showed that CTD significantly inhibited BAPN induced mortality and TAD incidence in the animal model, improved aortic vascular morphology, promoted the integrity of extracellular matrix in TAD, reduced tissue inflammation, reduced the accumulation of M1 macrophage, promoted M2 macrophage polarization, and reduced the expression of NF-κB pathway related proteins. Mechanistically, CTD significantly weakened the proliferation, migration, invasion, and apoptosis. p-P65 protein expression of TAD cells were induced by ANG II and IKK-β., Conclusion: CTD has the potential to alleviate inflammation, VSMC apoptosis, MMP2/9 levels, and enhance extracellular matrix integrity in TAD by inhibiting the NF-κB signaling pathway., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: To explore the surgical strategies and clinical efficacy for aortic dissection combined with refractory superior mesenteric artery (SMA) ischemia. Methods: This is a retrospective case series study. Clinical data of 24 patients with aortic dissection and refractory SMA ischemia admitted to the Department of Vascular Surgery, Zhongshan Hospital, Fudan University from August 2010 to August 2020 were retrospectively collected. Of the 24 patients, 21 were males and 3 were females, with an age of (50.3±9.9) years (range: 44 to 72 years).Among them, 9 cases were Stanford type A aortic dissection, and 15 cases were type B. All patients underwent CT angiography upon admission, and based on imaging characteristics, they were classified into three types. Type Ⅰ: severe stenosis/occlusion of the SMA true lumen only; Type Ⅱ: stenosis of the true lumens in the descending aorta and SMA (isolated type); Type Ⅲ: stenosis of the true lumens in the thoracoabdominal aorta and SMA (continuation type). Surgical procedures, complications, mortality, and reintervention rates were recorded. Results: Among the 24 patients, 17 (70.8%) were classified as Type Ⅰ, 4 (16.7%) as Type Ⅱ, and 3 (12.5%) as Type Ⅲ. Fourteen cases of Type Ⅰ underwent thoracic endovascular aortic repair combined with SMA stent implantation. Additionally, 3 Type Ⅰ and 1 Type Ⅱ patients underwent only SMA reconstruction (with one case of chronic TAAD treated with iliac artery-SMA bypass surgery). Moreover, 3 Type Ⅱ and 3 Type Ⅲ patients underwent descending aorta combined with SMA stent implantation. There were 5 patients (20.8%) who underwent small bowel resection, either in the same sitting or in a staged procedure. During hospitalization, 4 patients died, resulting in a mortality rate of 16.7%. Among these cases, two patients succumbed to severe intestinal ischemia resulting in multiple organ dysfunction syndrome. The follow-up duration was (46±9) months (range: 13 to 72 months). During the follow-up, 2 patients died, unrelated to intestinal ischemia. The 5-year freedom from reintervention survival rate was 86.1%, and the 5-year cumulative survival rate was 82.6%. Conclusions: Patients with aortic dissection and refractory SMA ischemia have a high perioperative mortality. However, implementing appropriate surgical strategies according to different clinical scenarios can reduce mortality and alleviate intestinal ischemia.

Abstract: Aortic dissection is a life-threatening condition for which diagnosis mainly relies on imaging examinations, while reliable biomarkers to detect or monitor are still under investigation. Recent advances in technologies provide an unprecedented opportunity to yield the identification of clinically valuable biomarkers, including proteins, ribonucleic acids (RNAs), and deoxyribonucleic acids (DNAs), for early detection of pathological changes in susceptible patients, rapid diagnosis at the bedside after onset, and a superior therapeutic regimen primarily within the concept of personalized and tailored endovascular therapy for aortic dissection., (Copyright © 2024 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.)

Purpose: False lumen (FL) expansion often occurs in type B aortic dissection (TBAD) and has been associated with the presence of re-entry tears. This longitudinal study aims to elucidate the role of re-entry tears in the progression of TBAD using a controlled swine model, by assessing aortic hemodynamics through combined imaging and computational modeling., Materials and Methods: A TBAD swine model with a primary entry tear at 7 cm distal to the left subclavian artery was created in a previous study. In the current study, reintervention was carried out in this swine model to induce 2 additional re-entry tears of approximately 5 mm in diameter. Computed tomography (CT) and 4-dimensional (4D) flow magnetic resonance imaging (MRI) scans were taken at multiple follow-ups before and after reintervention. Changes in aortic volume were measured on CT scans, and hemodynamic parameters were evaluated based on dynamic data acquired with 4D-flow MRI and computational fluid dynamics simulations incorporating all available in vivo data., Results: Morphological analysis showed FL growth of 20% following the initial TBAD-growth stabilized after the creation of additional tears and eventually FL volume reduced by 6%. Increasing the number of re-entry tears from 1 to 2 caused flow redistribution, with the percentage of true lumen (TL) flow increasing from 56% to 78%; altered local velocities; reduced wall shear stress surrounding the tears; and led to a reduction in FL pressure and pressure difference between the 2 lumina., Conclusion: This study combined extensive in vivo imaging data with sophisticated computational methods to show that additional re-entry tears can alter dissection hemodynamics through redistribution of flow between the TL and FL. This helps to reduce FL pressure, which could potentially stabilize aortic growth and lead to reversal of FL expansion. This work provides a starting point for further study into the use of fenestration in controlling undesirable FL expansion., Clinical Impact: Aortic growth and false lumen (FL) patency are associated with the presence of re-entry tears in type B aortic dissection (TBAD) patients. Guidelines on how to treat re-entry tears are lacking, especially with regards to the control and prevention of FL expansion. Through a combined imagining and computational hemodynamics study of a controlled swine model, we found that increasing the number of re-entry tears reduced FL pressure and cross lumen pressure difference, potentially stabilising aortic growth and leading to FL reduction. Our findings provide a starting point for further study into the use of fenestration in controlling undesirable FL expansion., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Type A aortic dissection (TAAD) is characterized by acute onset, high mortality and high surgical risks.Although open surgery has been the first-line treatment for TAAD in current guidelines, 10% to 30% of them will accept conservative treatment due to the high risk of open surgery.In recent years, with the rapid progress of endovascular technology and the innovations of various devices, endovascular repair for TAAD has shown encouraging preliminary results.Thoracic endovascular aortic repair (TEVAR) has become the first-line treatment for complicated type B aortic dissection (TABD).By sealing the primary entry tear and promoting the remodeling of the false lumen, TEVAR is more minimally invasive and efficient compared to open repair.Compared with TBAD, TEVAR for TAAD is not fully elucidated.The primary entry tear is located in the ascending aorta, which has different pathophysiology characteristics from that in TBAD.More suitable and safe stent-graft and delivery system are needed. In terms of technology, the selection of proximal and distal landing zone and intraoperative brain protection are still the key and difficult problems. At the same time, there is a lack of mature programs in the treatment of the aortic root and the reconstruction of the aortic arch branches.

Background: To evaluate the safety and efficacy of the conformable thoracic aortic endograft (Conformable TAG Thoracic Endoprosthesis [CTAG]; W. L. Gore & Associates, Flagstaff, Ariz) and Valiant Captivia thoracic stent graft (Medtronic Inc., Santa Rosa, CA) for acute type B aortic dissection (TBAD)., Methods: The early and mid-term outcomes were analyzed for 413 patients undergoing TEVAR using conformable TAG thoracic endoprosthesis and Valiant Captivia thoracic stent graft for acute TBAD. 100 propensity-matched pairs of patients were generated, including 100 patients in the CTAG group and 200 patients in the Valiant Captivia group., Results: Operative mortality were 2.33% (3 of 129) in the CTAG group and 1.76% (5 of 284) in the Valiant Captivia group. The median follow-up was 41.67 (26.00-60.67) months. No significant difference in mortality (9 [7.00%] vs. 36 [12.68%], P = 0.95) or re-intervention rate (3 [2.33%] vs. 20 [7.04%], P = 0.29) was observed between two groups. CTAG group have a lower incidence rate of distal stent graft-induced new entry tear than Valiant Captivia group (2.33% vs. 9.86%, P = 0.045). Lower incidence of type Ia endoleak was identified in the CTAG group (2.22%) than the Valiant Captivia group (14.41%) in patients with type III arch (P = 0.039)., Conclusions: Both Valiant Captivia thoracic stent graft and CTAG thoracic endoprosthesis can be safely performed for acute TBAD with low operative mortality, favorable mid-term survival and freedom from reintervention. CTAG thoracic endoprosthesis had fewer dSINE even with larger oversizing and potentially suitable for type III arch with fewer type Ia endoleaks., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate the mid-term outcomes of thoracic endovascular aorta repair (TEVAR) for Stanford type B aortic dissection (TBAD) in patients with Marfan syndrome (MFS)., Methods: Between January 2009 and December 2019, patients with MFS who underwent TEVAR for TBAD were enrolled. Demographic data, preoperative and perioperative clinical profiles, and follow-up data were collected and analyzed. The cumulative survival and freedom from reintervention rates were calculated with Kaplan-Meier analysis., Results: A total of 26 patients were enrolled. The mean age was 38.5 ± 10.7 (range, 24-64 years). The in-hospital mortality was 0. The cumulative survival rate was 88.1% (95% confidence interval [CI], 67.5%-98.5%) at 5 years and 82.9% (95% CI, 60.2%-93.3%) at 10 years. Patients with a thrombosed false lumen (FL) along the length of the stent had a significantly higher cumulative survival rate (P < .05) and freedom from reintervention (P = .01) than patients with patent FL. The freedom from reintervention was 83.4% (95% CI, 61.4% to 93.4%) at 5 years and 50.3% (95% CI, 21.4%-97.3%) at 10 years. There was no significant difference freedom from reintervention in freedom from reintervention between patients with and those without a previous aortic root procedure (P = .46)., Conclusions: TEVAR can be performed safely and effectively for TBAD in patients with MFS. Perioperative mortality and morbidity were low; however, lifelong close follow-up in the clinic and imaging are mandatory to prevent aortic rupture. Patients with a patent FL were at high risk of late death., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

The study aimed at investigating the association between postoperative inflammatory scores and aorta-related adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) for patients with type B aortic dissection (TBAD). This single-centre, retrospective cohort included all patients who underwent TEVAR for TBAD between November 2016 and November 2020 at a university hospital. The risk factors for AAEs were analyzed by Cox proportional hazards model regression. Prediction accuracy was assessed using the area under the receiver operating characteristic curves. This study included 186 patients with a mean age of 58.5 years and a median follow-up period of 26 months. A total of 68 patients developed AAEs. Age and postoperative systemic immune inflammation index (SII) (>2893) were associated with post-TEVAR AAEs (hazard ratio (HR) 1.03, p = 0.003; HR 1.88, p = 0.043, respectively). Increased postoperative SII and age are independent risk factors for AAE post-TEVAR in patients with TBAD., Competing Interests: The authors have no relevant financial or nonfinancial interests to disclose., (Copyright © 2023 Yufei Zhao et al.)

Background The treatment of chronic type B aortic dissection by thoracic endovascular aortic repair has some challenges, and its long-term outcomes remain unclear. This study aimed to analyze the 5-year clinical outcomes of thoracic endovascular aortic repair of chronic type B aortic dissection, compare the differences between patients with and without adverse aortic events (AAEs), and identify risk factors for AAEs. Methods and Results Patients who underwent thoracic endovascular aortic repair of chronic type B aortic dissection from January 2009 to June 2017 were retrospectively enrolled. The primary end points were AAEs, including aorta-related death, procedural complications, and disease progression requiring reintervention. Clinical outcomes were described at the 5-year follow-up visit. The secondary end point was the comparison of the results between patients with and without AAEs. Univariable and multivariable logistic analyses were used to identify potential risk factors for AAEs. A total of 214 patients were enrolled. AAEs occurred in 46 (21.5%) patients. Compared with patients without AAEs, those with AAEs had higher rates of residual type A aortic dissection (26.1% versus 4.2%, P <0.001) and aortic diameter ≥5.5 cm (69.6% versus 11.3%, P <0.001), and a lower rate of complete false lumen thrombosis (23.9% versus 89.9%, P <0.001). Meanwhile, the median interval from symptom onset to intervention was longer in patients with AAEs (26 months versus 12 months, P =0.004). Partial or no false lumen thrombosis (adjusted odds ratio [AOR], 14.71 [95% CI, 5.67-38.14; P <0.001]) and aortic diameter ≥5.5 cm (AOR, 10.16 [95% CI, 3.86-26.73; P <0.001]) were identified as independent risk factors for AAEs. Conclusions While thoracic endovascular aortic repair of chronic type B aortic dissection might be challenging in some cases, its long-term outcomes appeared promising as this treatment was effective in preventing catastrophic aortic events. Patients with AAEs showed higher rates of residual type A aortic dissection and aortic diameter ≥5.5 cm, a lower rate of complete false lumen thrombosis, and a longer median interval from symptom onset to intervention. Failure of complete false lumen thrombosis and an aortic diameter ≥5.5 cm were predictors of AAEs.

Purpose: To introduce a new spot stenting, combined with a false lumen endovascular occlusive repair (SS-FLEVOR) technique for treating post-dissection abdominal aortic aneurysms., Technique: This technique is demonstrated in a 74-year-old man who received an initial thoracic endovascular aortic repair 7 years ago and suffered from distal aortic expansion during the follow-up session. All the tears located more than 15 mm away from the orifice of visceral arteries were excluded by spot stenting in the aortic true lumen. Then, a compliant stent-graft was implanted in the false lumen to seal the tears near the visceral arteries orifice from the outside. In addition, coils were deployed to block the potential backflow from the intercostal arteries and to induce false lumen thrombosis. Moreover, visceral arteries originated from false lumen were repaired by covered-stents implanted from the true lumen. The distal iliac arteries were sealed either with iliac extensions or cover-stents. This new technique has been applied in 5 patients, resulting in 100% technical success and encouraging intermediate outcomes., Conclusion: SS-FLEVOR is a feasible and safe technique to promote false lumen thrombosis in selected cases.

Objectives: Inflammation is a hallmark of the initial development and progression of aortic dissection. This study aimed to investigate the value of preoperative inflammatory biomarkers in predicting aorta-related adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection., Methods: We included all patients who underwent TEVAR for type B aortic dissection between November 2016 and November 2020 in this single-center, retrospective cohort study. Patients were divided into two groups: the AAEs group (n = 75) and the non-AAEs group (n = 126). Preoperative inflammatory biomarkers were recorded, including neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic immune inflammation index (SII), and systemic inflammatory response index (SIRI). Patients were followed-up for the development of AAEs. Prediction accuracy of inflammatory biomarkers for AAEs were evaluated using the area under the receiver operating characteristic curves., Results: This study included 201 patients, of whom 80.0% were men, with a mean age of 59.1 ± 12.5 years. A total of 75 patients developed AAEs after TEVAR. The AUCs of NLR, MLR, PLR, SII, and SIRI for AAEs were.746,.782,.534,.625 and.807, respectively. Age and SIRI were independent risk factors for the AAEs after TEVAR (HR 3.264, p <.001; HR 4.281, p <.001, respectively). Survival analysis revealed significantly lower AAE-free status in patients with preoperative SIRI > = 4 (p <.001)., Conclusion: Increased preoperative SIRI and age are independent risk factors for AAEs after TEVAR in type B aortic dissection., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Zhao, Hong, Xie, Guo, Chen, Fu and Wang.)

Objectives: This study aimed to investigate the characteristics of and risk factors for aortic-related readmission after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD)., Methods: Data from TBAD patients who underwent TEVAR from 2009-2018 at a Chinese tertiary center were retrospectively collected and analyzed. Enrolled patients were categorized into 2 groups according to whether aortic-related readmission occurred during follow-up, which was defined as hospitalization at least once after the initial procedure due to events that were related to or caused by aortic dissection or the initial procedure., Results: A total of 1 288 TBAD patients were enrolled, and 99 patients experienced aortic-related readmissions (7.7%), among whom chronic patients had the highest readmission rate (9.8%). The yearly proportion of readmission during the first year after initial procedure revealed a decreasing trend with a -9.7% annual percentage change. Seventy-one patients underwent reintervention (71.7%). Distal aneurysmal degeneration (43.7%) and distal stent graft-induced new entries (32.4%) were 2 major causes for reintervention. Fourteen patients in the reintervention subgroup underwent a second reintervention (19.7%). In-hospital mortality was 1.0% during the readmission and 14.3% during the second readmission. The overall survival was comparable between two groups (P = 0.93)., Conclusions: This study highlighted the importance of surveillance after initial procedure for TBAD patients with potential risk factors for aortic-related readmission, and the predisposition of patients with reintervention to multiple readmissions deserves attention., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To identify the differences between clinical features and outcomes after endovascular therapy for penetrating aortic ulcer (PAU) and intramural hematoma (IMH)., Methods: From January 2009 to March 2020, patients who underwent endovascular therapy for PAU and IMH were enrolled. Information on patient demographics, presentation, PAU and IMH morphology, laboratory examination, and clinical follow-up information was collected and analyzed. Univariate analysis was performed to identify the differences between IMH and PAU, and Kaplan-Meier was used to calculate the cumulative survival rate and freedom from reintervention., Results: A total of 114 patients were enrolled; 80 (70.2%) of them were diagnosed with PAU. Compared with PAU, patients with IMH were younger ( p  = 0.006), more likely to be admitted emergently ( p  = 0.001), had longer hospital stay ( p  = 0.028), and had higher levels of C-reactive protein ( p  = 0.030). Meanwhile, patients with IMH were more likely to be associated with hypertension ( p  = 0.020) and pleural effusion ( p  < 0.001) and less likely to have a history of acute coronary syndrome ( p  = 0.019) and prior cardiovascular intervention ( p  = 0.017). The five-year freedom from reintervention and cumulative survival rate were 94.2% (95% confidential interval, 88.9%-99.9%) and 87.8% (95% confidential interval, 79.5%-96.9%) in PAU patients and 89.6% (95% confidential interval, 75.8%-99.9%) and 85.1% (95% confidential interval, 68.0%-99.9%) in IMH patients, respectively. There was no significant difference in freedom from reintervention ( p  = 0.795) or cumulative survival rate ( p  = 0.817)., Conclusions: IMH appeared to occur in younger patients with hypertension and usually had an acute onset, while PAU was more likely to be found incidentally in older patients with atherosclerosis. Endovascular therapy was effective in both IMH and PAU patients with encouraging outcomes.

Objective: To investigate the risk factors for unrelieved malperfusion after thoracic endovascular aortic repair (TEVAR) alone., Methods: From January 2009 to December 2019, 86 patients with type B aortic dissection-induced malperfusion were enrolled. Demographics and clinical and imaging data, as well as treatment outcomes, were collected and compared between patients with malperfusion relieved by TEVAR alone (TR) or by TEVAR with adjunctive procedures (TA)., Results: Among the 86 enrolled patients, 17 (19.8%) had malperfusion requiring TA. Patients in the TA group were more likely to suffer lower limb ischemia (P = .004), present with severe ischemia (P = .003), and have more than one end-organ ischemia (P = .015). There were more involved vessels classified as the mixed type in the TA group (P = .002). Mixed ischemia was the only independent risk factor for malperfusion requiring TA (odds ratio, 4.7; 95% confidence interval [CI], 1.3-17.2; P = .017). The ischemia-related in-hospital mortality rate of the TA group was significantly higher than that of the TR group (P = .023), and malperfusion requiring TA was the only risk factor in the multivariate logistic regression (odds ratio, 14.6; 95% CI, 1.4-150.5; P = .025). The 5-year overall cumulative survival rates were 82.4% (95% CI, 66.1%-100.0%) in the TA group and 89.5% (95% CI, 81.6%-98.1%) in the TR group (P = .294)., Conclusions: Type B aortic dissection-induced malperfusion requiring TA was associated with a higher ischemia-related in-hospital mortality rate. Mixed obstruction was an independent risk factor for unrelieved malperfusion after TEVAR alone, and early identification of potential patients requiring TA could thereby be achieved. Reasonable treatment strategies could contribute to the successful management of malperfusion requiring TA., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the midterm outcomes of in situ fenestration (ISF) with an adjustable puncture device for aortic arch branch preservation during thoracic endovascular aortic repair (TEVAR)., Methods: From October 2016 to April 2019, patients with complicated type B aortic dissection, thoracic aortic aneurysm > 5.5 cm in diameter, or aortic penetrating ulcer with a base > 20 mm or depth > 15 mm, who received TEVAR requiring a proximal sealing beyond zone 3 and underwent ISF using an adjustable puncture device, were included. After the procedure, patients were monitored at one, three, six, and 12 months, and annually thereafter. Peri-operative and follow up data were collected and analysed., Results: Fifty of 51 patients (98%) received successful ISFs. One, two, or three aortic arch branches were preserved in 44, six, and one patient, respectively. Intra-operatively, eight type Ia endoleaks and one type II endoleak were found on angiography. One patient died of cerebral hernia three days post-procedure from a severe stroke; one patient suffered from transient paraplegia but recovered in two weeks; one patient had a non-disabling stroke. The median follow up was 31 months (22.5 - 36.5 months). At six month follow up, all nine unmanaged endoleaks had disappeared. One new type Ia endoleak was identified in a patient at the one month follow up which resolved spontaneously one year later. All revascularised arteries were patent at the last follow up. No fractures, migrations, or bridging stent kinks were found., Conclusion: In this largest mechanical based ISF study to date, an adjustable puncture device was shown to facilitate the procedure of ISF during endovascular repair of aortic diseases involving the aortic arch, with high success. The midterm outcome demonstrates the efficacy and safety of the device in assisting with preservation of aortic arch branches., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

To review the incidence of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) of patients with type B aortic dissection, and to investigate its time trends and underlying risk factors. The incidence rate of RTAD after TEVAR for type B aortic dissection was gathered as a cumulative pool for each year in meta-analysis. Linear regression was used to establish the temporal trend of RTAD incidence. Annual decrease rate was calculated for the fulltime frame. Sixty-six articles were included in this study, which represented 11,149 patients enrolled since 1994, and the research published between 2000 and 2019. The overall pooled rate of RTAD incidence is 2.20% (95% confidence interval 0.0162-0.0284; P < 0.0001). The incidence numbers fluctuated for many years while continuing to decline, ultimately reaching a valley in 2016-2017. The linear regression analysis identified a 0.4% decrease in incidence rate along with a declining oversize rate of stent-grafts. The overall average incidence of RTAD in the past 21 years was 2.2%. The downward incidence trend may be attributed to the lower oversize rate and the improved design of stent-grafts, as well as sophisticated manipulation and delayed TEVAR intervention., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Despite its association with static mesenteric malperfusion, the morphologic characteristics and optimal management of acute type B aortic dissection (ABAD) with superior mesenteric artery (SMA) involvement are poorly understood. We studied the associated risk factors and reported the outcomes of endovascular treatment., Methods: From May 2016 to May 2018, we examined 212 consecutive patients with ABAD in our center. Those with SMA involvement (SMAI) were included in the present study and divided into those with and without mesenteric malperfusion (MMP) according to the clinical findings. After thoracic endovascular aortic repair (TEVAR) with or without SMA revascularization, we compared the clinical data, imaging results, and outcomes for those with and without MMP., Results: Computed tomography angiography confirmed 44 cases of SMAI: 12 (27.3%) with MMP and 32 (72.7%) without MMP. The patients with MMP had presented more frequently with lower extremity malperfusion (33.3% vs 3.1%; P = .023) than had those without MMP, with an odds ratio of 14.15 (P = .047). Multivariate analysis showed that patients with a low true lumen (TL)/false lumen (FL) diameter ratio of the SMA (TL/FL-SMA <1) had a greater risk of developing MMP than those with a high TL/FL-SMA ratio of >1 (odds ratio, 8.49; 95% confidence interval, 1.24-58.26; P = .029). SMA TL thrombosis was a significant predictor of the requirement for additional SMA revascularization after TEVAR among patients with MMP (P = .045). During a mean 10-month follow-up period, complete FL thrombosis in the SMA was seen in 11 patients (25%; 33.3% with MMP vs 21.9% without MMP; P = .43). The overall mortality rate was 6.82% (16.7% in the MMP group and 3.1% in the non-MMP group; P = .09)., Conclusions: In the present study, limb ischemia and the TL/FL-SMA ratio were two independent predictors for the development of MMP in patients with ABAD and SMAI. We found that TEVAR can be safely performed for these patients, and SMA TL thrombosis predicted for the need for SMA revascularization., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: This study aimed to construct a risk prediction model for distal aortic enlargement in patients with type B aortic dissection (TBAD) treated with proximal thoracic endovascular aortic repair (TEVAR)., Methods: From June 2010 to June 2016, patients with TBAD who underwent proximal TEVAR were retrospectively analyzed. A total of 38 clinical and imaging variables were collected. Univariable logistic regression was conducted to explore potential risk factors associated with distal aortic enlargement. Elastic net regression was employed to select significantly influential variables. Then, machine learning algorithms (logistic regression (LR), artificial neutral network (ANN), random forest and support vector machine) were applied to build risk prediction models. The area under the receiver operating characteristic curve (AUC), sensitivity and specificity were used to evaluate the performance of these models., Results: A total of 503 patients were enrolled in this study. During the follow-up, 105 (20.9%) patients were identified as having distal aortic enlargement, and 69 (13.7%) patients were found to have distal aortic aneurysm formation. Five patients were identified with aortic rupture. True lumen collapse and multi-false lumens were two potential risk factors for distal aortic enlargement after proximal repair of TBAD. The LR model performed the best in predicting distal aortic enlargement, with the highest sensitivity (96.7%) and an AUC of 0.773. The best model for predicting distal aneurysm formation was the ANN model, which yielded the highest AUC (0.876) and a specificity of 79.1%., Conclusions: Machine learning approaches can produce accurate predictions of distal aortic enlargement after proximal repair of TBAD, which potentially benefits subsequent management., (Copyright © 2021. Published by Elsevier Inc.)

Background: Thoracic aortic dissection (TAD) is a severe disease with limited understandings in its pathogenesis. Altered DNA methylation has been revealed to be involved in many diseases etiology. Few studies have examined the role of DNA methylation in the development of TAD. This study explored alterations of the DNA methylation landscape in TAD and examined the potential role of cell-free DNA (cfDNA) methylation as a biomarker in TAD diagnosis., Results: Ascending aortic tissues from TAD patients (Stanford type A; n = 6) and healthy controls (n = 6) were first examined via whole-genome bisulfite sequencing (WGBS). While no obvious global methylation shift was observed, numerous differentially methylated regions (DMRs) were identified, with associated genes enriched in the areas of vasculature and heart development. We further confirmed the methylation and expression changes in homeobox (Hox) clusters with 10 independent samples using bisulfite pyrosequencing and quantitative real-time PCR (qPCR). Among these, HOXA5, HOXB6 and HOXC6 were significantly down-regulated in TAD samples relative to controls. To evaluate cfDNA methylation pattern as a biomarker in TAD diagnosis, cfDNA from TAD patients (Stanford type A; n = 7) and healthy controls (n = 4) were examined by WGBS. A prediction model was built using DMRs identified previously from aortic tissues on methylation data from cfDNA. Both high sensitivity (86%) and specificity (75%) were achieved in patient classification (AUC = 0.96)., Conclusions: These findings showed an altered epigenetic regulation in TAD patients. This altered epigenetic regulation and subsequent altered expression of genes associated with vasculature and heart development, such as Hox family genes, may contribute to the loss of aortic integrity and TAD pathogenesis. Additionally, the cfDNA methylation in TAD was highly disease specific, which can be used as a non-invasive biomarker for disease prediction.

Objective/background: This study examined the 10-year hospitalization characteristics, economic patterns and early clinical outcomes of type B aortic dissection (TBAD) patients that underwent thoracic endovascular aortic repair (TEVAR) in one high-volume hospital in China., Methods: We performed a population-based retrospective analysis based on electronic medical record system data provided by Zhongshan Hospital Fudan University from 2009 to 2018., Results: We identified 1,367 cases of TBAD patients with TEVAR over the past decade. The total incidence of in-hospital complications was 7.6% (104 of 1,367), among which acute kidney injury (AKI) had the highest incidence (3.1%, 42 of 1,367). Aortic-related reintervention was performed in 7 patients (0.5%). The overall aortic-related in-hospital mortality rate was 2.7% (37 of 1,367) and had no significant time-varying trend ( P = 0.2). Among these, 27% of in-hospital deaths were caused by retrograde type A dissection (RTAD). Chronic TBAD had a higher risk of in-hospital death versus acute TBAD, with a risk ratio of 2.69 (95% confidence interval [CI]: 1.19-6.09). Patients with hypertension (risk ratio 4.63, 95% CI: 1.38, 15.54) also had a higher in-hospital death risk. These 2 factors were also the predictive factors for the composite endpoint of in-hospital adverse events (risk ratio 2.17, 95% CI: 1.43, 3.29 and risk ratio 4.83, 95% CI: 1.90, 12.28, respectively), in addition to Marfan syndrome (risk ratio 4.05, 95% CI: 1.61, 10.19). The average length of hospitalization significantly declined during the past decade (annual percentage change -6.3%, 95% CI -8.2 to -4.3), and the stent-grafts (SGs) cost was the main expenditure of the total hospitalization costs., Conclusion: Our study showed a favorable early outcome of TEVAR over the past decade. Greater attention should be paid to certain risk factors in order to reduce the in-hospital adverse events. SG expenditure is still the primary economic burden on Chinese TBAD patients.

Purpose: To report early and midterm outcomes of treating thoracic aortic aneurysm (TAA) and aortic dissection (AD) involving zone 1 and zone 0 with multiple parallel stent grafts (PSGs)., Materials and Methods: From February 2011 to August 2018, 31 of 1,806 patients (1.7%) who underwent thoracic endovascular aortic repair (TEVAR) with double PSGs (DPSGs) (n = 20) or triple PSGs (TPSGs) (n = 11) were retrospectively reviewed. Procedures were performed in high-risk patients who had TAA or AD involving zone 1 or zone 0., Results: Fifteen patients (48.4%) who presented with symptomatic or impending rupture underwent urgent or emergent TEVAR with DPSGs or TPSGs. Nineteen patients (61.3%) were treated for zone 0 disease. Technical and clinical success rates were 70.0% for DPSG cohort and 45.5% for TPSG cohort. Intraoperative type Ia endoleak was observed in 30% of DPSG cohort and 45.5% of TPSG cohort. One patient in the DPSG cohort died of aortic sinus rupture intraoperatively. Minor stroke during the 30-day postoperative period was more frequent in the TPSG cohort (P = .042). Mean duration of follow-up was 28.9 months ± 17.7. The TPSG cohort had a higher incidence of major adverse events (72.7% vs 25.0%, P = .021). The most common adverse events were endoleaks (12.9%), endograft migration (9.7%), PSG stenosis or occlusion (6.5%), retrograde dissection (6.5%), and stroke (3.2%). Endograft migrations were more common in TPSG cohort (27.3%, P = .037). Overall mortality rate was 16.1% (5/31) perioperatively and during follow-up. There were no statistical differences in overall survival and reintervention-free survival., Conclusions: In the context of TEVAR with multiple PSGs for aortic arch repair, TPSGs may have a high risk of major complications., (Copyright © 2020 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: The left subclavian artery (LSA) origin can be intentionally covered by stent grafts, to provide adequate proximal landing zones during thoracic endovascular repair for Stanford type B aortic dissections (TBADs). To preserve the LSA, a novel single branched stent graft, named "Castor" was designed and a clinical trial conducted to investigate its suitability., Methods: From April 2013 to March 2015, 73 patients with TBAD were treated by Castor stent grafts at 11 Chinese tertiary hospitals as part of a single arm prospective clinical trial. There were 50 acute (<2 weeks [68.5%]) and 23 chronic aortic dissections (>2 weeks [31.5%])., Results: The technical success rate was 97% (n = 71/73). The two failures were caused by occlusion of the branch section of the stent graft. There were four intra-operative endoleaks (two type Ia, two type B from the LSA). The endoleak rate was 5% (n = 4/73). There was one in hospital death and no major complications. The median follow up time was 61 months (range 48-72 months). The mortality was 5% (n = 4/73) within one year and 7% within six years (n = 5/73). Two deaths were of unknown cause and three were not related to the aorta. Two new entry tears were found on the proximal or distal edge of the stent graft and were retreated endovascularly. Six occlusions of the branch section of the Castor stent graft were found, and the follow up patency rate of the branch section was 93% (n = 63/68). Two intra-operative endoleaks were left during follow up and eventually disappeared according to the latest computed tomography angiograms., Conclusion: For patients with TBADs needing anchoring proximal to the origin of LSA, the Castor single branched stent graft may provide an easily manipulated, safe, and effective endovascular treatment., (Copyright © 2020. Published by Elsevier B.V.)

Retrograde type A dissection after thoracic endovascular aortic repair has been a major drawback of endovascular treatment. This study investigated the biomechanical mechanism of stent-graft-induced new lesions after implantation and analyzed the relationship between radial force and spring-back force of the stent-graft when it was implanted virtually under different oversizing ratios. Based on the computed tomography angiography images, a three-dimensional geometric model of a patient-specific aortic dissection was established. The stent was designed in CAD software and the stent-graft implantation procedure under different oversizing ratios was simulated in the finite element analysis software. Implantation simulations were performed six times for each stent-graft model under 0%, 3%, 6%, 9%, 12%, and 15% oversizing ratios and the peak stress of the aorta was compared among groups. It was observed that the peak stress of the aorta was located where the proximal bare stent interacted with aortic wall and its value was increased by 62.2% from 0% to 15% oversizing ratio. The conclusions are reached that the long-term higher stress in the aortic wall may lead to the emergence of new lesions in these areas, and the radial force plays a key role in the formation of a new entry in the real aorta model., (© 2020 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

The 2019 coronavirus disease(COVID-19) has cost a great loss to the health and economic property of Chines people. Under such a special circumstance, how to deal with such patients with acute aortic syndrome has become a serious challenge. Rapid diagnosis of concomitant COVID-19, safe and effective transportation, implementation of the interventional procedure, protection of vascular surgical team and postoperative management and follow-up of such patients have become urgent problems for us. Combined with the latest novel government documents, the literature and the experiences from Wuhan, we answered the above questions briefly and plainly. We also hope to inspire the national vascular surgeons to manage critical emergencies in vascular surgery and even routine vascular diseases with COVID-19, as a final point to limit the severe epidemic situation, and minimize the damage of COVID-19.

It remains unknown whether ambient air pollution could induce the onset of acute aortic dissection (AAD). This study aimed to investigate the potential association between fine particulate matter (PM 2.5 ) and AAD onset. We collected new episodes of AAD between January 1, 2014 and December 31, 2018 from the emergency department of a major hospital in Shanghai, China. The overdispersed generalized additive model was used to estimate the association between PM 2.5 and AAD emergency hospitalizations and was adjusted for time trends and weather conditions. During the study period, we identified a total of 1335 cases of AAD hospitalizations and recorded an average PM 2.5 concentration of 45 ± 30 μg/m 3 . The association was statistically significant on the concurrent day of hospital admission, remained on the lag 1 day. For the average of the two lags, a 10 μg/m 3 increase of PM 2.5 was associated with 3.38% (95% confidence interval: 1.02%, 5.79%) increase of AAD hospitalizations. The association between PM 2.5 and AAD remained when adjusting for the concomitant exposures to coarse particulate matter, sulfur dioxide, nitrogen dioxide, carbon monoxide and ozone. The concentration-response curves increased apparently when daily PM 2.5 concentration was beyond the China's National Ambient Air Quality Standard (35 μg/m 3 ). In stratified analyses, the significant association was only present among elders and males, and during cool season. This investigation demonstrated a significant and robust association between short-term PM 2.5 exposure and increased AAD hospitalizations in Shanghai, China. Our findings have important implications for the prevention of AAD., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Computational hemodynamic studies of aortic dissections usually combine patient-specific geometries with idealized or generic boundary conditions. In this study, we present a comprehensive methodology for the simulation of hemodynamics in type B aortic dissection (TBAD), based on fully patient-specific boundary conditions., Methods: Pre-operative four-dimensional (4-D) flow magnetic resonance imaging (MRI) and Doppler-wire pressure measurements (pre- and post-operative) were acquired from a TBAD patient. These data were used to derive boundary conditions for computational modeling of flow before and after thoracic endovascular repair (TEVAR). Validations of the computational results were performed by comparing predicted flow patterns with pre-TEVAR 4-D flow MRI, as well as pressures with in vivo measurements., Results and Conclusion: Comparison of instantaneous velocity streamlines showed a good qualitative agreement with 4-D flow MRI. Quantitative comparison of predicted pressures with pressure measurements revealed a maximum difference of 11 mmHg (-9.7%). Furthermore, our model correctly predicted the reduction of true lumen pressure from 74/115 mmHg pre-TEVAR to 64/107 mmHg post-TEVAR (diastolic/systolic pressures at entry tear level), compared to the corresponding measurements of 72/118 mmHg and 64/114 mmHg. This demonstrates that pre-TEVAR 4D flow MRI can be used to tune boundary conditions for post-TEVAR hemodynamic analyses.

Objective: Haemodynamic and geometric factors play pivotal roles in the propagation of acute type B aortic dissection (TBAD). The aim of this study was to evaluate the association between dissection level within all aortic layers and the propagation of acute TBAD in porcine aorta., Methods: In twelve pigs, two models of TBAD were created. In model A (n = 6), the aortic wall tear was superficial and close to the intima (thin intimal flap), whereas in model B (n = 6) it was deep and close to the adventitia (thick intimal flap). Dissection propagation was evaluated using angiography or computed tomography scans, and the haemodynamic measurements were acquired using Doppler wires. Most pigs were followed up at 1, 3, 6, 12, 18, and up to 24 months; four animals were euthanised at three and six months, respectively (two from each group)., Results: Both models were successfully created. No statistical difference was observed for the median antegrade propagation distance intra-operatively between the two models (p = .092). At 24 months, the longitudinal propagation distance was significantly greater in model B than in model A (p = .016). No statistical difference in retrograde propagation was noted (p = .691). Over time, aortic wall dissection progressed most notably over the first three months in model A, whereas it continued over the first 12 months in model B. Flow velocity was significantly greater in the true lumen than in false lumen at the level of the primary tear (p = .001) and in the middle of the dissection (p = .004). The histopathological images at three and six months demonstrated the fibres were stretched linearly at the outside wall of false lumen in both models, while the depth of intimal tears developed to be superficial and similar at the distal dissection., Conclusion: In this swine model of TBAD, a deeper intimal tear resulted in greater dissection propagation., (Copyright © 2019 European Society for Vascular Surgery. All rights reserved.)

Purpose: This study investigated the outcomes of endovascular treatment for type B aortic dissection (TBAD) complicated by unilateral renal ischemia and determined the associated predictors., Materials and Methods: From January 2010 to December 2016, 44 patients (mean : 54 years of age) with TBAD complicated by a clearly involved unilateral renal artery and a decreased mean density of the unilateral renal parenchyma were enrolled. The volumes and mean densities of each kidney were generated with postprocessing software based on computed tomography angiography. The degree of renal malperfusion (RMD) was defined as the bilateral density difference-to-the mean density ratio of the healthy kidney. The primary outcomes were renal atrophy and renal dysfunction; the secondary outcomes were aorta-related complications., Results: The median follow-up time was 51 months (range: 12-102 months). During follow-up, unilateral renal atrophy and renal dysfunction were observed in 12 patients (27.3%) and 7 patients (15.9%), respectively. RMD showed a moderate predictive value for renal atrophy, with an area under the characteristic curve (AUC) of 0.78. The optimal cutoff value was 27% for RMD in terms of predicting renal atrophy (sensitivity: 91.7%; specificity: 56.2%). Moreover, aorta-related adverse events occurred in 14 patients (31.8%). Preoperative abnormal creatinine level was an independent risk factor for aorta-related complications (odds ratio [OR]: 17.5; P = 0.022) and renal dysfunction (OR: 14.2; P = 0.02)., Conclusions: Preoperative serum creatinine was an effective index used to predict renal and aortic outcomes in this patient cohort. Active imaging follow-up and aggressive endovascular intervention are suggested in patients with RMD >27%., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Objectives: Acute aortic dissection (AAD) is a severe clinical emergency with a high mortality, and is easily misdiagnosed in its early stage. This study aimed at discovering serum metabolomic markers with the potential to diagnose AAD and distinguish between two subtypes of AAD., Methods: Thirty-five patients with AAD, including 20 with Stanford type A and 15 with Stanford type B were enrolled in this study, together with 20 healthy controls. All patients with AAD were admitted within 72 h of onset. Serum metabolomics profiles were determined by ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry and the data were analysed by principal component analysis and partial least squares discriminant analysis., Results: A total of 17 metabolites differing between the control and AAD groups were finally screened and identified as lysophosphatidylcholines (LPC) and sphingolipids including sphinganine, phytosphingosine, sphingomyelin, and ceramide. Compared with those in the healthy control group, LPC levels were significantly lower in both the Stanford type A and type B AAD groups. Interestingly, sphingolipids, including sphinganine, phytosphingosine, and ceramide, were remarkably reduced in the Stanford type A AAD group, but not in the Stanford type B AAD group. Subgroup analysis showed that the changes in LPC and sphingolipid levels were unrelated to hypertension or gender., Conclusions: The present results indicate that LPCs and sphingolipids are significantly altered in patients with AAD, and several sphingolipids, such as sphinganine, phytosphingosine, and ceramide, were dramatically decreased in patients with Stanford type A AAD. A combination of these two families of metabolites could serve as a potential biomarker for the diagnosis of AAD and distinguishing between Stanford type A and Stanford type B., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Acute aortic syndrome(AAS) is a lethal disease with acute onset and a high mortality rate as well as a higher incidence rate especially in an aging population. The diagnostic techniques of AAS have been improving in recent years. Many serum biomarkers have been shown to have the potential of further clinical implication. Advancement of imaging techniques has also improved the accuracy of early diagnosis. Although traditional treatment modality involving open surgery is life-saving, it still has a high mortality rate and a high major morbidity rate. The increasing utilization of endovascular techniques has greatly improved the prognosis of AAS, while it still need further optimization to be applied in different subgroups of patients.

Objectives Obstructive sleep apnea acts as a potential risk factor for the development of cardiovascular disease. We undertook collaborative meta-analyses to clarify the risk of aortic dissection among adults suffering obstructive sleep apnea. Methods A systematic search of the databases (PubMed, Embase, and Cochrane Library) was performed. Studies reporting on the association between obstructive sleep apnea and aortic dissection were included. Information on 424 cases of aortic dissection in 56,291 patients from one cohort, four case-controls, and two cross-sectional studies were included in this study. Results The summary suggested that patients with obstructive sleep apnea are associated with an overall significant 60% increase in the risk of aortic dissection, compared to unexposed patients (odds ratios 1.60; 95% confidence interval 1.01-2.53), with a significantly higher apnea-hypopnea index (mean difference 10.71; 95% confidence interval 7.46-13.96). Moreover, a greater relation was found between moderate-to-severe obstructive sleep apnea and aortic dissection (odds ratios 4.43; 95% confidence interval 2.59-7.59). Adverse outcomes obtained by sleep study such as oxygen desaturation index (mean difference 10.51; 95% confidence interval 7.54-13.48), average SaO 2 (-1.36; 95% confidence interval -2.63 to -0.09), and minimum SaO 2 (-3.63; 95% confidence interval -5.27 to -1.98) were correspondingly related to patients with aortic dissection. Conclusions Obstructive sleep apnea, especially moderate-to-severe obstructive sleep apnea, may impose an additional risk of suffering from aortic dissection with a potential mechanism including intermittent hypoxia.

Stanford type B aortic dissection (TBAD) is an acute and life-threatening disease. The treatment of TBAD used to be depended on whether it is complicated. The therapeutic guidelines recommend thoracic endovascular aortic repair (TEVAR) as first-line treatment for patients with acute complicated TBAD, while recommend best medical therapy for patients with acute uncomplicated TBAD (UTBAD). However, the latest studies suggest that patients with UTBAD also should be treated with pre-emptive TEVAR, which can significantly improve aortic remodeling and clinical outcome. Considering improvement of aortic remodeling and prevention of severe complications, the best timing of pre-emptive TEVAR may be 14-90 days after the onset of TBAD (subacute phase). The other main issue is identifying which patients with UTBAD should undergo pre-emptive TEVAR. Several risk factors including imaging, clinical and laboratory parameters have been shown to be associated with aortic-related events in patients with UTBAD. Among imaging finding, the diameters of aortic or false lumen, the status of true or false lumen, the size or number of entry tears have identified to be as predictors of adverse aortic events in patients with UTBAD.

Purpose: To explore the potential role of morphological factors and wall stress in the formation of stent-graft-induced new entries (SINE) based on computed tomography (CT) images after thoracic endovascular aortic repair (TEVAR)., Case Report: Two female patients aged 59 years (patient 1) and 44 years (patient 2) underwent TEVAR for type B dissection in the chronic (patient 1) or subacute (patient 2) phase. CT scans at 3-month follow-up showed varying degrees of false lumen thrombosis in both patients. At 14-month follow-up, a SINE was observed in patient 1 while the dissected aorta in the other patient remained stable. Morphological and finite element analyses were performed based on the first follow-up CT images. The computational results showed that the SINE patient had higher stent-graft tortuosity than the non-SINE patient and much higher wall stress in the region close to the distal SINE., Conclusion: This case study suggests that high stent-graft tortuosity can lead to high wall stress, which is potentially linked to the formation of SINE. Further large population-based studies are needed to confirm this preliminary finding.

Objectives: This study aims to report mid-term follow-up outcomes of a series of TAAD patients treated with TEVAR in China., Background: Thoracic endovascular aortic repair (TEVAR) has been used to treat type A aortic dissection (TAAD) for years. However, by comparing public reports, their outcomes which were based on different sample sizes show inconsistency., Methods: Between January 2001 and December 2015, there were 56 patients with TAAD received TEVAR identified in 5 medical centers. The morphology changes and early and late outcomes were recorded and analyzed., Results: 56 patients (aged 38 to 80) with TAAD received TEVAR. The average follow-up period was 39.92 ± 34.42 months (ranging from 11 to 140 months). 54 (96.43%) cases were technically successful. 1 patient died on day 2 after TEVAR because of stent graft migration during the procedure. There were 7 early events (within 30 days), including sudden death (1), cerebral infarction (3), stent graft migration (1), new dissection (1) and respiratory failure (1). The 30-day overall survival rate was 92.9%. 27 late events occurred during the follow-up: retrograde dissection (8), endoleak (5), coronary artery stenosis (3), cerebral infarction (3), new dissection (2), multiple organ dysfunction syndrome (1), left ventricular pseudoaneurysm (1), stent graft migration (1), respiratory failure (1), supraventricular tachycardia (1) and pericardial effusion (1). The 5-year overall survival rate of this study was 80.9% and this rate reached 98.2% if aorta-related deaths were excluded., Conclusions: TEVAR could be an effective alternative for high-risk patients. However, issues resulted from postoperative complications still call for attention., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective To discuss the strategies and clinical outcomes of endovascular aortic repair (EVAR) for acute and chronic isolated abdominal aortic dissection (IAAD). Methods From January 2012 to June 2017, 33 patients with IAAD were retrospectively reviewed. Patients were classified into acute and chronic groups based on the time to EVAR from IAAD onset (acute: ≤90 days; chronic: >90 days). Patient demographics, clinical parameters, procedural factors, and clinical outcomes were evaluated and compared between the two groups. Results Among 33 patients, 21 were diagnosed with acute IAAD and 12 were diagnosed with chronic IAAD. All patients underwent EVAR, and no significant difference in EVAR-related procedural factors was observed between the two groups. The primary technical success rate in all patients was 100%. The overall survival rate in the chronic group was lower than that in the acute group, but the difference was not statistically significant ( P = 0.186). However, the reintervention-free survival rate in the chronic group was significantly lower than that in the acute group ( P = 0.039). Significant enlargement of the true lumen (TL) and regression of the false lumen (FL) and maximal aortic diameter were observed in all patients after EVAR ( P < 0.05). The mean diameter of the TL in the acute group increased significantly more than that in the chronic group (14 ± 3 mm vs. 11 ± 3 mm, P = 0.040). A significant difference was not observed in the regression of the FL ( P = 0.628) or maximal aortic diameter ( P = 0.319) between the two groups. Conclusion EVAR continues to be a safe therapeutic approach with a high technical success rate and favorable clinical outcomes. The clinical outcomes and aortic remodeling in the chronic group seem to be poorer than those in the acute group.

Objective: We report the morphologic characteristics and endovascular treatment of primary infrarenal aortic dissections (PIRADs)., Methods: A retrospective study was conducted with 38 consecutive PIRAD patients between January 2010 and May 2016 in our vascular center. Patient demographics, morphologic characteristics, endovascular modalities, and periprocedural and follow-up outcomes were recorded. Patients with symptomatic PIRADs or asymptomatic PIRADs of a maximum diameter >30 mm were indicated for endovascular aneurysm repair (EVAR). We proposed a morphologic categorization of PIRADs into two types (I and II) according to the location of the entry tears and an endovascular strategy for treating type I PIRADs with tubular stent grafts (SGs) and type II PIRADs with bifurcated SGs., Results: According to the categorization, the study recruited 13 patients with type I and 25 patients with type II PIRADs. The patients were predominantly men, with an average age of 60.8 ± 15.2 years. Type I PIRADs usually had larger true lumens (22.6 ± 6.3 vs 13.6 ± 4.0 mm; P = .002) and relatively smaller false lumens (8.4 ± 2.3 vs 19.9 ± 16.1 mm; P = .012). Type II PIRADs had more entry tears (2.2 ± 0.6 vs 1.7 ± 0.6; P = .024) and longer dissections (109.4 ± 38.8 vs 73.9 ± 39.0 mm; P = .011). All patients underwent EVAR, with 19 tubular and 22 bifurcated SGs. One patient died during the hospital stay. The technical success rate was 94.8% (36/38), and the clinical success rate was 97.4% (37/38). During follow-up of 36 patients for 28.8 ± 17.7 months, 2 patients with type II PIRADs developed left iliac extension occlusion at 3 and 6 months after EVAR, and only 1 patient underwent reintervention. All patients survived throughout the follow-up. No endoleak or aortic enlargement was observed. Computed tomography angiography demonstrated a patent infrarenal aorta with completely thrombosed false lumen in all PIRAD patients (36/36 [100.0%]). In both types of PIRAD, EVAR yielded a significant decrease in the maximum diameter of the infrarenal aorta, with a significant increase in the true lumen size and a significant decrease in the false lumen size (P < .05)., Conclusions: The morphologic categorization of PIRADs based on the location of the entry tears appeared to be feasible. The endovascular strategy was safe and effective, with high rates of technical success and clinical success and favorable follow-up outcomes., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To characterize the morphology of type B aortic dissection with aberrant right subclavian artery (ARSA) and present early and midterm outcomes of total endovascular treatment for affected patients., Methods: From January 2010 to December 2015, patients with ARSA and type B aortic dissection treated with total endovascular techniques were enrolled. The angle of the aortic arch was measured on pre-operative CTA. Sixty age and gender matched normal aortic arch patients with type B aortic dissection served as controls. Primary outcomes were technical success, 30 day mortality, and late survival. Secondary outcomes included in hospital morbidity, re-intervention rate, and patency of the subclavian artery., Results: A total of 13 patients (8 men, 5 women; mean age 58 years) were included. The mean angle of the aortic arch in patients with ARSA was significantly smaller than in normal aortic arch patients (117.2° ± 10.8° vs. 124.2° ± 9.4°, respectively; p = .024). Simple thoracic endovascular aortic repair (TEVAR) and TEVAR plus a parallel graft technique were performed in six and seven patients, respectively. Primary technique success was achieved in 11 of the 13 (84.6%) patients. A bird beak configuration occurred significantly more frequently in patients with ARSA than in normal aortic arch patients (91.7% vs. 48.3%, respectively; p = .035). The median follow-up time was 36 months. One patient received a secondary procedure because of a new onset entry tear at the distal end of the stent graft. No posterior circulation stroke, permanent spinal cord ischaemia, or ischaemia of the upper arm was observed., Conclusions: Type B aortic dissection with ARSA was associated with a steep aortic arch. Total endovascular treatment for these patients was feasible and safe. Stent grafts with better flexibility and appropriate extension of the proximal landing zone with a parallel graft technique are suggested based on the observed outcomes., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to evaluate the safety, efficacy, and outcomes of the conformable thoracic endograft (Conformable TAG Thoracic Endoprosthesis [CTAG]; W. L. Gore & Associates, Flagstaff, Ariz) for acute complicated and uncomplicated type B aortic dissection (TBAD)., Methods: Between February and October 2016, 52 consecutive patients with acute complicated or uncomplicated TBAD were treated with a CTAG device. We assessed safety, complications, and device conformability using intraoperative angiography and computed tomography angiography. The mean follow-up period was 8.2 ± 3.5 months (range, 4-12 months)., Results: All patients survived through the follow-up period. No endoleaks, retrograde aortic dissection, distal new entry tear, stroke, or paraplegia was observed postoperatively. Two patients (3.8%) experienced minor wound hematomas without further treatment. Eleven patients (21.2%) underwent a chimney technique to rebuild supra-arch vessels. A bird-beak configuration was observed in seven (13.5%) patients, five of whom underwent a chimney technique. Analysis of aortic remodeling showed that the minimal true lumen area significantly increased in both complicated and uncomplicated acute TBAD (P < .001 and P = .047, respectively). Likewise, the maximal false lumen area significantly decreased in uncomplicated dissection (P = .006), but no change in maximal false lumen area was detected in complicated dissection (P = .32)., Conclusions: Early outcomes indicate that the CTAG device provides reliable clinical effectiveness and excellent conformability in treating acute complicated and uncomplicated TBAD without risk of major complications. Studies with larger sample sizes and longer follow-up periods are required to evaluate longer term outcomes., (Copyright © 2017. Published by Elsevier Inc.)

Objective: Clinical outcomes after thoracic endovascular aortic repair (TEVAR) for patients with multichanneled aortic dissection (MCAD) are poorly understood but seem substantially different from those for patients with double-channeled aortic dissection (AD). This study compared the anatomic and clinical factors for patients with MCAD who underwent TEVAR with or without full true lumen (TL) collapse., Methods: From January 2012 to March 2016, 54 of 644 consecutive type B AD patients (8.4%) who presented with MCAD were reviewed. Patients were classified as MCAD with full TL collapse and without full TL collapse according to computed tomography angiography findings. We analyzed potential variables including clinical characteristics, anatomic morphologic features, and procedural details. Multivariable analysis was performed to determine independent predictors of AD-related deaths., Results: A total of four patients (7.4%) died preoperatively of aortic rupture, all of whom experienced full TL collapse. MCAD patients with full TL collapse showed significantly higher 30-day major adverse events than those without full TL collapse (36.8% vs 9.7%; P = .030). The mean follow-up duration was 25.6 ± 13.2 months (range, 3-53 months). The overall mortality for all MCAD patients was 16.7%, whereas the follow-up major adverse events rate was 40.0% after TEVAR. Significant differences were present between patients with full TL collapse and patients without full TL collapse in survival at 3 years (55.4% vs 94.7%; P = .002). Maximum diameter of affected aorta (hazard ratio, 1.176; 95% confidence interval, 1.015-1.362; P = .031) was identified as the only predictor of AD-related deaths., Conclusions: MCAD was identified in a small but not insignificant number of our patients presenting with type B AD. Urgent or elective TEVAR was indicated in all our patients with MCAD. In patients with MCAD, full TL collapse was associated with worse outcomes, and this finding may indicate the need for more urgent or emergent repair., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To discuss failures and lessons in the endovascular treatment of symptomatic isolated dissection of the superior mesenteric artery (SIDSMA)., Methods: Data from 33 patients with SIDSMA treated between July 2007 and September 2013 were retrospectively collected. The technical failures in and lessons from endovascular management were analyzed in terms of causes and prophylaxis., Results: Eighteen patients were successfully treated medically, 13 underwent stent placement, 1 underwent a hybrid procedure, and 1 had open fenestration. Full follow-ups (37 ± 21 months) were achieved in 28 patients. Failures to cannulate the true lumen occurred in 8 patients. Among these patients, femoral and brachial approaches were taken in 6 and 2 patients, respectively, and a 2-sided Fisher's exact test revealed no significant differences (P = 0.204). Among the 6 femoral failures, the true lumina were cannulated after conversion to the brachial approach in 3 cases. The perfusion of the distal SMA was not improved until the second stent was distally placed to cover the entire expanded false lumen in 1 case. Numerous branches originating from the false lumen were overlooked in 1 patient and were apparently compromised after stenting. Consequently, the patient died of intestinal necrosis. In a patient with a huge dissecting aneurysm, a stent was misplaced across the false lumen. Fortunately, a remarkable aneurysmal thrombosis formed at 3 months. In a patient who received a hybrid procedure, the stent was occluded at 2 weeks, most likely because the thrombus protruded into the stent., Conclusions: Difficulty in cannulating the true lumen is not uncommon in the endovascular treatment of SIDSMA, and the selection of the arterial approach would benefit from being based on the morphology of the SMA arch. The lengths and branches of the involvement of the false lumen should be evaluated beforehand. Covered stents would be a reasonable option for lumina that contain thrombi., (Copyright © 2016 Elsevier Inc. All rights reserved.)