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Mechanical characteristics of both the healthy ascending aorta and acute type A aortic dissection were investigated using in vitro biaxial tensile tests, in vivo measurements via transoesophageal echocardiography and histological characterisations. This combination of analysis at tissular, structural and microstructural levels highlighted the following: (i) a linear mechanical response for the dissected intimomedial flap and, conversely, nonlinear behaviour for both healthy and dissected ascending aorta; all showed anisotropy; (ii) a stiffer mechanical response in the longitudinal than in the circumferential direction for the healthy ascending aorta, consistent with the histological quantification of collagen and elastin fibre density; (iii) a link between dissection and ascending aorta stiffening, as revealed by biaxial tensile tests. This result was corroborated by in vivo measurements with stiffness index, β, and Peterson modulus, E p , higher for patients with dissection than for control patients. It was consistent with histological analysis on dissected samples showing elastin fibre dislocations, reduced elastin density and increased collagen density. To our knowledge, this is the first study to report biaxial tensile tests on the dissected intimomedial flap and in vivo stiffness measurements of acute type A dissection in humans., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The respective place of endovascular repair (ER) versus open surgery (OS) in thoracic dissecting aneurysm treatment remains debatable. This comprehensive review seeks to compare the outcomes of ER versus OS in chronic type B aortic dissection treatment., Methods: Embase and Medline searches (2000 to 2017) were performed following PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines. Outcomes data extracted comprised (1) early mortality and major complications: stroke, spinal cord ischemia (SCI), dialysis, and respiratory complications; and (2) late survival and reinterventions. Reintervention causes were divided into proximal, adjacent, and distal. Comparative studies allowed comparative meta-analysis. Noncomparative studies were analyzed in pooled proportion meta-analyses for each group., Results: A total of 39 studies were identified after exclusions, of which 4 were comparative. Comparative meta-analysis demonstrated lower early mortality for ER (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.10 to 15.4), stroke (OR, 4.33; 95% CI, 1.02 to 18.35), SCI (OR, 3.3; 95% CI, 0.97 to 11.25), and respiratory complications (OR, 6.88; 95% CI,1.52 to 31.02), but higher reintervention rate (OR, 0.34; 95% CI, 0.16 to 0.69). Midterm survival was similar (OR, 1.19; 95% CI, 0.42 to 3.32). Noncomparative studies demonstrated that most reinterventions were related to the aortic segment distal to primary intervention in both groups (OS 73%, ER 59%). Reintervention procedures were mainly surgical for OS (85%), mainly endovascular for ER (75%). Rupture rates were 1.2% (OS) and 3% (ER)., Conclusions: Endovascular repair is associated with significant early benefits, but this is not sustained at midterm. Reintervention is more frequent, but the OS is not exempt from reintervention or late rupture. Both techniques have their place, but patient selection is key., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Technical and clinical success of thoracic aortic endovascular procedures relies mainly on the choice of the proximal sealing zone (PSZ). The latter can be affected by multiple complications, all of them having a potential gravity and a direct link with the quality of the PSZ. The objective of this study was to analyze the risk factors of PSZ complications occurrence., Methods: Between 2007 and 2015, all the patients treated by a thoracic stent graft in zones 2, 3, or 4 were retrospectively reviewed, with analysis of the preoperative and postoperative angio-computed tomography. Proximal sealing zone complications are type Ia endoleaks, bird beak ≥20 mm, malposition ≥11 mm, migration ≥10 mm, and retrograde dissection. Three types of potential risk factors were analyzed: (1) related to the patients (age, gender, pathology, urgency, hybrid surgery); (2) related to the stent graft (bare or covered proximal stent, degree of oversizing, number of stents, generation); (3) related to the morphology (radius of curvature, diameter, degree of conicity, calcifications and thrombus of the neck, depth of the arch, angulation of the proximal sealing zone, and tortuosity index of the arch and the thoracic aorta., Results: Seventy-six patients (mean age: 54 years, 17-93 years) were treated for traumatic aortic rupture (n = 27, 35.5%), aortic dissection (n = 26, 34%), aneurysm (n = 15, 20%), and other diseases (floating thrombus, aortoesophageal fistula) (n = 8, 10.5%). A hybrid surgery was carried out in 18 patients (24%). Primary technical success was 93.5% (n = 71). With a mean follow-up of 29 months, 30 PSZ complications were observed in 21 patients (28%): type Ia endoleaks (n = 3, 4%), bird beak (n = 7, 9%), malposition (n = 3, 4%), migration (n = 1, 1.5%), retrograde dissection (n = 1, 1.5%), or several complications (n = 6, 7.8%). Among the morphological factors, 2 parameters were significantly associated with the occurrence of complications: tortuosity index (group without PSZ complications 1.62 ± 0.2 vs. group with PSZ complications 1.72 ± 0.2, P = 0.042), and the diameter of the proximal neck (group without PSZ complications 25.7 ± 5 vs. group with PSZ complications 31 ± 6.0, P = 0.001). Neither the demographic factors nor those related to the stent graft presented a statistically significant relation with the occurrence of complications., Conclusions: This work clearly highlights the relation between PSZ complications, independently of their type, and the local and global aortic morphology. A wide proximal neck, > 34 mm, and an important aortic tortuosity, > 1.8, are situations at risk., (Copyright © 2017 Elsevier Inc. All rights reserved.)