Inducing false lumen thrombosis for retrograde type A aortic dissection

Background

How to choose the proximal landing zone in endovascular interventions for a patient with a patent retrograde false lumen in dissection of the ascending aorta and aortic arch remains unclear. This study sought to report the safety and efficiency of inducing thrombosis of the retrograde false lumen to enhance a proximal landing zone to treat retrograde type A aortic dissection.

Preoperative thoracic false lumen branches relate to aortic remodeling after thoracic endovascular aortic repair for DeBakey IIIb aortic dissection

Objective

This study evaluated the association between thoracic false lumen branches (TFLBs; dissected thoracic branches fed by a false lumen) and distal thoracic aortic enlargement (DTAE) after thoracic endovascular aortic repair (TEVAR) for DeBakey IIIb aortic dissection.

The characteristics of distal tears affect false lumen thrombosis rate after thoracic endovascular aortic repair for acute type B dissection

 Open in a separate windowOBJECTIVESA low false lumen thrombosis rate (FLTR) is common in patients with type B aortic dissection after they have undergone thoracic endovascular aortic repair, which indicates a poor long-term prognosis. This study aimed to establish a quantitative linear regression model to predict false lumen (FL) thrombosis accurately using morphological parameters.METHODSIn this retrospective study, we included 59 patients diagnosed with acute type B aortic dissection between 2014 and 2017. Morphological parameters were measured. Univariable and multivariable linear regression analyses were performed, and a linear regression model relating FLTR with the number of re-entry tears was proposed. Ten patients were further chosen to validate the linear relationship, and idealized aortic dissection models were adopted for haemodynamic analysis.RESULTSOnly the total area and number of re-entry tears were negatively correlated with FL thrombosis (P < 0.001). Moreover, based on the univariable regression, the number of re-entry tears played a more crucial role in FLTR (R² = 0.509 vs R² = 0.298), and the linear relationship model was created as follows: thrombosis rate (%) = −11.25 × distal tear number + 105.24. This model was perfectly matched in 10 patients (concordance correlation coefficient = 0.880, P = 0.947). Moreover, when the total area of re-entry tears was constant, the net blood flow increased rapidly with an increase in the tear count.CONCLUSIONSThe number of re-entry tears could be a crucial related factor of FL thrombosis; the larger the number of re-entry tears is, the lower the possibility of thrombosis is.     

Castor支架及体外预开窗Ankura支架用于近端锚定区不足Stanford B型主动脉夹层胸主动脉腔内修复术

目的 观察Castor支架及体外预开窗Ankura支架用于近端锚定区不足Stanford B型主动脉夹层（AD）胸主动脉腔内修复术（TEVAR）的价值。方法 对20例（A组）及21例（B组）近端锚定区不足Stanford B型AD患者分别植入Castor支架及体外预开窗Ankura支架行EVAR治疗,观察2组术中支架释放情况。术后1个月复查主动脉血管造影（CTA）,之后每3个月规律复查主动脉CTA,至AD假腔逐渐减少、真腔逐渐恢复至正常;记录术中、术后并发症。结果 对41例均手术成功,A组全部20例（20/20,100%）、B组20例（20/21,95.24%）术中支架成功释放,B组1例（1/21,4.76%）支架轻度向近心端移位,部分遮挡左颈总动脉（LCCA）开口,经植入1枚Wallstent支架后造影LCCA显影良好。术后随访1~24个月,平均（12.5±3.60）个月,A组未见并发症;B组1例发生Ⅰa型内漏,内漏量较小,患者无不适,未予特殊处理。结论 Castor支架或体外预开窗Ankura支架用于TEVAR治疗近端锚定区不足Stanford B型AD均安全、有效。     

Distal landing zone optimization before endovascular repair of aortic dissection

Background

The general goals of endovascular management in chronic distal thoracic aortic dissection are optimizing the true lumen, maintaining branch patency, and promoting false lumen (FL) thrombosis. Distal seal can be challenging in chronic distal thoracic aortic dissection due to the well-established secondary fenestrations and fibrotic septum. We describe our approach of distal landing zone optimization (DLZO) to enable full-diameter contact of the distal endoprosthesis.

Late outcomes of strategic arch resection in acute type A aortic dissection

Objective

To compare perioperative and long-term outcomes in patients undergoing hemiarch and aggressive arch replacement for acute type A aortic dissection (ATAAD).

Stent-assisted balloon-induced intimal disruption and relamination of distal remaining aortic dissection after acute DeBakey type I repair

ObjectivesSurgical repair in patients with acute DeBakey type I aortic dissection (ADIAD) achieves good short-term results, but in several patients the false lumen remains patent in the descending aorta because of distal intimal tears with persisting risk for distal aneurismal evolution. We report the short- and mid-term outcomes of the stent-assisted balloon-induced intimal disruption and relamination of aortic dissection (STABILISE) technique for the 16 first patients treated for a residual dissection of the descending thoracic aorta after repaired ADIAD.MethodsWe reviewed all patients treated with STABILISE for a remaining distal thoracoabdominal aortic dissection after ADIAD repair.ResultsFrom March 2016 to March 2018, 16 patients with previous surgery for ADIAD underwent the STABILISE procedure during the same hospitalization in a second-stage procedure to extend the repair within the descending thoracic aorta. The median age was 56 years (range, 43-65 years). Indication for the STABILISE procedure was persisting false lumen patency within the thoracic descending aorta associated with malperfusion symptoms in 13 patients and associated with dissecting aneurysm of the descending thoracic aorta >40 mm in 3 patients. Technical success was achieved in 100%. Eight (12.5%) renal arteries required stenting during the procedure. In-hospital mortality was 6% (n = 1). There was no stroke, spinal cord ischemia, ischemic colitis, or renal failure requiring dialysis. Median length of follow-up was 8 months (range, 3-24 months). One patient developed a proximal type 1 endoleak in the arch and required reintervention for proximal extension of the stent graft in zone 2. The primary visceral patency rate was 100%. There were no late deaths reported. At last computed tomography scan, all patients had complete aortic remodeling of the treated thoracoabdominal aorta with no aortic enlargement.ConclusionsThe STABILISE technique, in patients with remaining distal thoracoabdominal aortic dissection at the acute stage of a type A repair, allowed an immediate remodeling of the thoracoabdominal aorta, which should improve their long-term outcomes in terms of aortic-related events.     

Initial results of thoracic endovascular repair for uncomplicated type B aortic dissection involving the arch vessels using a semicustom-made thoracic fenestrated stent graft

ObjectiveThoracic endovascular aortic repair (TEVAR) for selected type B aortic dissection (TBAD) is a standard treatment; however, TBAD involving the aortic arch is difficult to treat because of the need for arch vessel reconstruction. We report our initial results of TEVAR for uncomplicated TBAD involving the arch vessels using a semicustom-made fenestrated stent graft.MethodsThis is a retrospective study of 24 patients treated by fenestrated (F group) or debranching (D group) TEVAR from August 2011 to July 2017. The patients in the F group received the Najuta semicustom-made fenestrated stent graft (Kawasumi Laboratories, Tokyo, Japan). The fenestrated graft ensures sufficient sealing at the proximal healthy aorta without the need for arch vessel reconstruction. The primary end point was aorta-related mortality; the secondary end points were technical success and major adverse events (stroke, type IA endoleak, retrograde type A aortic dissection, and secondary intervention).ResultsDuring the study period, we treated 65 TBAD cases by TEVAR, including 17 complicated cases. Of the 48 uncomplicated cases, 24 underwent TEVAR with arch vessel involvement (13 in the F group and 11 in the D group). The technical success rates in the F and D groups were 92.3% and 100.0%, respectively (P > .99, NS). The mean operation time was significantly shorter in the F group (158 minutes) than in the D group (202 minutes; P = .0426), and the mean postoperative hospital stay was also significantly shorter in the F group (7 days) than in the D group (22 days; P = .0168). The primary patency rate of the reconstructed branch vessel was 100%, and there were no aorta-related deaths or retrograde type A aortic dissection in either group. One patient had a type IA endoleak in the F group. In the D group, one patient had a postoperative stroke and two patients required secondary interventions for stent graft-induced new entry at the descending aorta. The median follow-up period was 14.1 months (range, 1-37 months). The rate of freedom from aorta-related death was 100% in both groups (P > .99, NS); the rate of freedom from major adverse events at 24 months was 92.3% in the F group and 72.7% in the D group (P = .749, NS).ConclusionsThe initial results of TEVAR with aortic arch vessel reconstruction for uncomplicated TBAD were acceptable. The fenestrated graft may be a less invasive option for the treatment of TBAD involving the aortic arch.     

Balloon protection of the left subclavian artery in debranching thoracic endovascular aortic repair

Objectives

Since 2012, we have routinely applied balloon protection of the proximal left subclavian artery to prevent embolic events through the left vertebral artery during debranching thoracic endovascular aortic repair. This study aimed to study the effectiveness of balloon protection of the proximal left subclavian artery.

Short- and long-term outcomes of aortic root repair and replacement in patients undergoing acute type A aortic dissection repair: Twenty-year experience

ObjectiveThe study objective was to evaluate the perioperative and long-term outcomes of aortic root repair and aortic root replacement and provide evidence for root management in acute type A aortic dissection.MethodsFrom 1996 to 2017, 491 patients underwent aortic root repair (n = 307) or aortic root replacement (n = 184) (62% bioprosthesis) for acute type A aortic dissection. Indications for aortic root replacement were intimal tear at the aortic root, root measuring 4.5 cm or more, connective tissue disease, or unrepairable aortic valvulopathy. Primary outcomes were in-hospital mortality, long-term survival, and reoperation rate for root pathology.ResultsPatients' median age was 61 years and 56 years in the aortic root repair group and aortic root replacement group, respectively. The aortic root replacement group had more renal failure requiring dialysis, previous cardiac intervention or surgery, heart failure, coronary malperfusion syndrome, acute myocardial infarction, and severe aortic insufficiency, as well as concomitant coronary artery bypass grafting, tricuspid valve repair, and longer cardiopulmonary bypass and aortic crossclamp times but similar arch procedures. Perioperative outcomes were similar in the aortic root repair and aortic root replacement groups, including in-hospital mortality (8.5% and 8.2%), new-onset renal failure requiring permanent dialysis, stroke, myocardial infarction, and sepsis. Kaplan–Meier 10-year survival was 62% and 65%, and the 15-year cumulative incidence of reoperation was 11% and 7% in the aortic root repair and aortic root replacement groups, respectively. The primary indication for root reoperation was aortic root aneurysm in the aortic root repair group and bioprosthetic valve deterioration in the aortic root replacement group.ConclusionsAortic root repair and aortic root replacement are appropriate surgical options for acute type A aortic dissection repair with favorable short- and long-term outcomes. Aortic root replacement should be performed for patients with acute type A aortic dissection presenting with an intimal tear at the aortic root, root aneurysm 4.5 cm or greater, connective tissue disease, or unrepairable aortic valvulopathy.     

Aortic growth and development of partial false lumen thrombosis are associated with late adverse events in type B aortic dissection

BackgroundPatients with medically treated type B aortic dissection (TBAD) remain at significant risk for late adverse events (LAEs). We hypothesize that not only initial morphological features, but also their change over time at follow-up are associated with LAEs.Materials and MethodsBaseline and 188 follow-up computed tomography (CT) scans with a median follow-up time of 4 years (range, 10 days to 12.7 years) of 47 patients with acute uncomplicated TBAD were retrospectively reviewed. Morphological features (n = 8) were quantified at baseline and each follow-up. Medical records were reviewed for LAEs, which were defined according to current guidelines. To assess the effects of changes of morphological features over time, the linear mixed effects models were combined with Cox proportional hazards regression for the time-to-event outcome using a joint modeling approach.ResultsLAEs occurred in 21 of 47 patients at a median of 6.6 years (95% confidence interval [CI], 5.1-11.2 years). Among the 8 investigated morphological features, the following 3 features showed strong association with LAEs: increase in partial false lumen thrombosis area (hazard ratio [HR], 1.39; 95% CI, 1.18-1.66 per cm² increase; P < .001), increase of major aortic diameter (HR, 1.24; 95% CI, 1.13-1.37 per mm increase; P < .001), and increase in the circumferential extent of false lumen (HR, 1.05; 95% CI, 1.01-1.10 per degree increase; P < .001).ConclusionsIn medically treated TBAD, increases in aortic diameter, new or increased partial false lumen thrombosis area, and increases of circumferential extent of the false lumen are strongly associated with LAEs.     

The fate of aortic root and aortic regurgitation after supracoronary ascending aortic replacement for acute type A aortic dissection

BackgroundThe aim of this study was to evaluate the fate of the preserved aortic root after supracoronary aortic replacement for acute type A aortic dissection.MethodsBetween October 1999 and March 2018, 339 patients underwent supracoronary aortic replacement for acute type A aortic dissection at our institution. Late outcomes were evaluated, including overall survival, aortic-related death, and aortic root–related reoperation. The median follow-up was 3.7 years (1.4-8.4 years).ResultsOperative mortality was 46 patients (13.6%). The cumulative incidences at 5 years for aortic root–related reoperation, aortic-related death, and non–aortic related death were 2.5%, 14.5% and 12.4%, respectively. Multivariable Cox hazard regression analysis demonstrated greater sinus of Valsalva diameter and number of commissural detachments to be significant risk factors for a composite outcome consisting of aortic-related death or aortic root–related reoperation. Mixed-effects regression demonstrated that sinus of Valsalva diameter significantly increased with time (P < .001), and aortic regurgitation significantly worsened (P < .001).ConclusionsSinus of Valsalva diameter and commissural detachment were independent predictors of unfavorable outcomes after supracoronary aortic replacement. Close follow-up is particularly necessary for these patients, and aortic root replacement at the time of initial operation may lead to more favorable late outcomes.