Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection

Background

The purpose of this study was to evaluate clinical, anatomic, and procedural characteristics of patients who developed retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection

BackgroundThoracic endovascular aortic repair (TEVAR) has become a mainstay of therapy for acute and chronic type B aortic dissection (TBAD). Dynamic aortic morphologic changes, untreated dissected aorta, and persistent false lumen perfusion have significant consequences for reintervention after TEVAR for TBAD. However, few reports contrast differences in secondary aortic intervention (SAI) after TEVAR for TBAD or describe their influence on mortality. This analysis examined incidence, timing, and types of SAI after TEVAR for acute and chronic TBAD and determined their impact on survival.MethodsAll TEVAR procedures for acute and chronic TBAD (2005-2016) were retrospectively reviewed. Patients with staged (<30 days) or concomitant ascending aortic arch repair or replacement were excluded. Acuity was defined by symptom onset (0-30 days, acute; >30 days, chronic). SAI procedures were grouped into open (intended treatment zone or remote aortic site), major endovascular (TEVAR extension or endograft implanted at noncontiguous site), and minor endovascular (side branch or false lumen embolization) categories. Kaplan-Meier methodology was used to estimate freedom from SAI and survival. Cox proportional hazards were used to identify SAI predictors.ResultsTEVAR for TBAD was performed in 258 patients (acute, 49% [n = 128]; chronic, 51% [n = 130]). Mean follow-up was 17 ± 22 months with an overall SAI rate of 27% (n = 70; acute, 22% [28]; chronic, 32% [42]; odds ratio, 1.7; 95% confidence interval, 0.9-2.9; P = .07]. Median time to SAI was significantly less after acute than after chronic dissection (0.7 [0-12] vs 7 [0-91] months; P < .001); however, freedom from SAI was not different (1-year: acute, 67% ± 4%, vs chronic, 68% ± 5%; 3-year: acute, 65% ± 7%, vs chronic, 52% ± 8%; P = .7). Types of SAI were similar (acute vs chronic: open, 61% vs 55% [P = .6]; major endovascular, 36% vs 38% [P = .8]; minor endovascular, 21% vs 21% [P = 1]). The open conversion rate (either partial or total endograft explantation: acute, 10% [13/128]; chronic, 15% [20/130]; P = .2) and incidence of retrograde dissection (acute, 6% [7/128]; chronic, 4% [5/130]; P = .5) were similar. There was no difference in survival for SAI patients (5-year: acute + SAI, 55% ± 9%, vs acute without SAI, 67% ± 8% [P = .3]; 5-year: chronic + SAI, 72% ± 6%, vs chronic without SAI, 72% ± 7% [P = .7]). Factors associated with SAI included younger age, acute dissection with larger maximal aortic diameter at presentation, Marfan syndrome, and use of arch vessel adjunctive procedures with the index TEVAR. Indication for the index TEVAR (aneurysm, malperfusion, rupture, and pain or hypertension) or remote preoperative history of proximal arch procedure was not predictive of SAI.ConclusionsSAI after TEVAR for TBAD is common. Acute TBAD has a higher proportion of early SAI; however, chronic TBAD appears to have ongoing risk of remediation after the first postoperative year. SAI types are similar between groups, and the occurrence of aorta-related reintervention does not affect survival. Patients' features and anatomy predict need for SAI. These data should be taken into consideration for selection of patients, device design, and surveillance strategies after TEVAR for TBAD.     

Risk factors of acute kidney injury in patients with Stanford type B aortic dissection involving the renal artery who underwent thoracic endovascular aortic repair

BackgroundAcute kidney injury (AKI) is one of the most common and serious complications in patients with type B aortic dissection (TBAD). This study aimed at investigating the incidence and risk factors of in-hospital AKI in TBAD patients involving the renal artery who underwent thoracic endovascular aortic repair (TEVAR) only.MethodsA total of 256 patients who were diagnosed as TBAD combined with renal artery involvement were included in this retrospective study. All patients were divided into the AKI group and the non-AKI group according to the KDIGO criteria. The risk factors for AKI were identified using a multivariate logistic regression model.ResultsA total of 256 patients were included in this study, and the incidence of AKI was 18% (46/256). Patients in the AKI group were more likely to have a higher proportion of the youth, a higher level of body mass index, and a shorter time from onset to admission. Multivariate logistic regression analysis revealed that the youth (age ≤40 years) (OR: 2.853, 95%CI: 1.061–7.668, p = .038) were prone to AKI, and lower estimated glomerular filtration rate (eGFR) (OR: 1.526, per 15-ml/min/1.73 m² decrease, 95%CI: 1.114–2.092; p = .009), higher diastolic blood pressure (DBP) (OR: 1.418, per 10-mmHg increase; 95%CI: 1.070–1.879; p = .015), and fasting blood glucose (FBG) ≥7 mmol/L on admission (OR: 2.592; 95%CI: 1.299–5.174; p = .007) were independent risk factors for AKI.ConclusionsHigher incidence of AKI had been perceived in this study, most of them were young and middle-aged patients. Renopreventive measures should be considered in those high-risk patients with younger age, lower eGFR, higher DBP, and higher FBG on admission.     

Thoracic endovascular repair for acute complicated type B aortic dissections

Objective

This study retrospectively assessed in-hospital mortality and long-term results of emergency thoracic endovascular aortic repair (TEVAR) for patients with life-threatening acute complicated type B aortic dissection (acTBD).

Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project

Objective

The purpose of the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair (TEVAR) for dissection project is to assess the effectiveness of TEVAR for type B dissection by evaluation in a prospective quality improvement registry. Here we describe the project cohort and 30-day outcomes of TEVAR for both acute dissection (AD) and chronic dissection (CD) patients and focus specifically on outcomes of uncomplicated AD patients based on timing of treatment.

Aortic remodelling and late outcomes following thoracic endovascular repair with a bare-metal stent distal extension among patients with complicated type-B aortic dissection

Open in a separate window OBJECTIVESThe goal of this study was to describe the factors affecting mid and late aortic remodelling following thoracic endovascular aortic repair with the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique among patients with complicated acute or subacute type B aortic dissection.METHODSA retrospective single-centre study that evaluates clinical and morphological outcomes among 65 consecutive patients. The area and diameter of the true and false lumen, overall aortic diameter and false lumen perfusion were evaluated.RESULTSConcomitant direct visceral artery stenting was successfully conducted in 32 (49%) patients. There was one (1.5%) postoperative stroke; three (4.6%) patients developed spinal cord ischaemia; two (3%) patients suffered retrograde type A dissection; and two (3%) patients had mesenteric ischaemia, despite successful reperfusion, that required a bowel resection. Median postoperative follow-up was 63.1 (interquartile range, 32.1– 91.8) months. The probability of survival was 96.9% [95% confidence interval (CI) 88.3%–99.2%] at 30 days, 93.9% (95% CI 84.4%–97.6%) at 1 year, 78.0 (95% CI 64.2%–87.0%) at 5 years and 72.8% (95% CI at 57.9%–83.2%) at 10 years postoperatively. There was a statistically significant postoperative increase in true-lumen area, diameter and true-lumen index in all five aortic levels measured. Complete false lumen (FL) thrombosis at the coeliac trunk, renal arteries and aortic bifurcation levels was observed in 47%, 15% and 24% of patients at midterm (6–15 months) and in 29%, 21% and 29% on late (later than 21 months) computed tomography angiograms (CTA). Persistent false lumen (FL) perfusion at the coeliac level on midterm CTA was associated with a larger extent of late aortic growth (P = 0.042) and was, in the majority of cases, caused by iliac re-entries either alone (28.57) or in combination with visceral and lumbar (28.57%) or distal aortic (10.71%) re-entries. A larger abdominal aortic diameter at midterm was associated with an increased probability of distal aortic reinterventions (hazard ratio 7.26, 95% CI 2.41–21.9, P < 0.001).CONCLUSIONSPersistent FL perfusion of the distal aorta at midterm following TEVAR with the PETTICOAT technique among patients with acute and subacute type B dissection is caused mainly by iliac, visceral, lumber and distal aorta re-entries. Patients with persistent FL perfusion have an increased risk of aortic aneurysmal growth at late follow-up.     

Influence of measurement and sizing techniques in thoracic endovascular aortic repair on outcome in acute complicated type B aortic dissections

Open in a separate window OBJECTIVESThoracic endovascular aortic repair (TEVAR) is the first-line therapy in acute complicated type B aortic dissections (cTBAD). Nevertheless, no evidence-based consensus on the optimal measurement technique and sizing for TEVAR in cTBAD exists. The aim was to evaluate how different measurement and sizing techniques for TEVAR affect long-term outcomes.METHODSRetrospective analysis investigating the association between sizing and postoperative results after TEVAR in patients with cTBAD, treated between January 2003 and December 2020. Diameter measurements were performed perpendicular to a centreline in pre-interventional Computed tomography angiographies. Oversizing was determined by measuring aortic diameter in zone 2 of the aortic arch in relation to the implanted stent graft, and categorized into 2 sizing groups (≤10% and >10%). The primary outcome was freedom from aortic-related events. Secondary outcomes included mortality and a comparison of 3 alternative measurement techniques considering the estimated pre-dissection diameter.RESULTSFifty-seven patients (median age 69, interquartile range 59.6–78.2 years) were included. Stent graft oversizing by ≤10% showed a trend towards fewer aortic-related events hazard ratio 0.455 (95% confidence interval 0.128–1.624, P = 0.225).The 3 measurement techniques using the pre-dissection aortic diameter differed by a mean of 1.7–4.0 mm with a variability of up to 8.4 mm. In none of the 57 patients, the same stent graft would have been chosen based on the different measurement techniques using an oversizing ≤10%.CONCLUSIONSTEVAR oversizing of ≤10% in patients with cTBAD might reduce aortic-related events up to 50%. Consensus on measurement techniques of the pre-dissection aortic diameter and stent graft sizing is of paramount importance.     

Thoracic endovascular aortic repair with stent grafts alone or with a composite device design in patients with acute type B aortic dissection in the setting of malperfusion

ObjectiveThe objective of this study was to compare short-term outcomes in patients who underwent thoracic endovascular aortic repair (TEVAR) with stent grafts alone or with a composite device design (stent graft plus bare-metal aortic stent) for acute type B aortic dissection in the setting of malperfusion.MethodsThis retrospective analysis included patients with acute (≤14 days of symptom onset) complicated type B dissection in the setting of malperfusion who were treated with stent grafts alone (TEVAR cohort) at two European institutions vs those who underwent TEVAR with a composite device design (Cook Medical, Bloomington, Ind) in the investigational STABLE I feasibility study and STABLE II pivotal study (STABLE cohort). Preoperative characteristics and 30-day outcomes (including mortality, malperfusion-related mortality, morbidity, and secondary interventions) were compared between the two groups.ResultsThe TEVAR cohort (41 patients; mean age, 58.8 ± 12.7 years; 78.0% male) and the STABLE cohort (84 patients; mean age, 57.8 ± 11.7 years; 71.4% male) were largely similar in preoperative medical characteristics, with more STABLE patients presenting with a history of hypertension (79.8% vs 58.5%; P = .018). The TEVAR and STABLE groups had similar lengths of dissection (451.8 ± 112.7 mm vs 411.8 ± 116.4 mm; P = .10) and similar proximal and distal extent of dissection. At presentation, the two groups exhibited comparable organ system involvement in malperfusion: renal (53.7% TEVAR, 57.1% STABLE), gastrointestinal (41.5% TEVAR, 44.0% STABLE), lower extremities (34.1% TEVAR, 52.4% STABLE), and spinal cord (9.8% TEVAR, 2.4% STABLE). The 30-day rate of all-cause mortality was 17.1% (7/41) in the TEVAR group and 8.3% (7/84) in the STABLE group (P = .22). The 30-day rate of malperfusion-related mortality (deaths from bowel/mesenteric ischemia or multiple organ failure) was 12% (5/41) in the TEVAR group and 2.4% (2/84) in the STABLE group (P = .038). The 30-day morbidity, for the TEVAR and STABLE groups, respectively, included bowel ischemia (9.8% [4/41] vs 2.4% [2/84]; P = .09), renal failure requiring dialysis (7.3% [3/41] vs 9.5% [8/84]; P > .99), paraplegia or paraparesis (4.9% [2/41] vs 3.6% [3/84]; P = .66), and stroke (2.4% [1/41] vs 10.7% [9/84]; P = .16). The occurrence of 30-day secondary intervention was similar in the TEVAR and STABLE groups (7.3% [3/41] vs 7.1% [6/84]; P > .99). True lumen expansion in the abdominal aorta was significantly greater in the STABLE group.ConclusionsIn patients with acute type B aortic dissection in the setting of branch vessel malperfusion, the use of a composite device with proximal stent grafts and distal bare aortic stent appeared to result in lower malperfusion-related mortality than the use of stent grafts alone. The 30-day rates of morbidity and secondary interventions were similar between the groups.     

STABLE II clinical trial on endovascular treatment of acute,complicated type B aortic dissection with a composite device design

ObjectiveTo evaluate the safety and effectiveness of a composite device design (covered stent graft and bare metal stent) for the treatment of patients with acute, complicated type B aortic dissection (TBAD) presenting with aortic rupture and/or branch vessel malperfusion.MethodsIn this prospective, nonrandomized, multicenter study, 73 patients (65.8% male; mean age, 60.7 years) with acute, complicated TBAD were enrolled between August 2012 and January 2015 to receive treatment with the Zenith Dissection Endovascular System (William Cook Europe, Aps, Bjaeverskov, Denmark) at institutions in the United States and Japan. The primary safety end point was the rate of freedom from major adverse events at 30 days, and the primary effectiveness end point was the rate of survival at 30 days. This article reports primary outcomes at 30 days and follow-up results through 1 year, reflecting study data as of March 2018.ResultsOf 73 patients, 20 presented with aortic rupture (27%) and 57 presented with branch vessel obstruction/compromise (78%), including 4 patients presenting with both conditions. The covered stent graft was used in all patients (median, 1; range, 1-3; 1 stent graft used in 64.4%; 47/73), and the bare metal dissection stent was used in 58 of 73 patients (79.5%). Thirty-day mortality occurred in five patients (6.8%): one procedure related, three unrelated to dissection repair, and one indeterminate. Thirty-day major adverse events included myocardial infarction (1.4%), bowel ischemia (1.4%), renal insufficiency/renal failure requiring dialysis (6.8%), stroke (6.8%), paraplegia or paraparesis (5.5%), and prolonged ventilatory support (13.7%). Nine deaths occurred from 31 to 365 days (only one death related to dissection repair); the Kaplan-Meier estimate of freedom from all-cause mortality was 80.3% ± 4.7% at 1 year. Within 365 days, 9 of 73 patients (12.3%) underwent 10 secondary interventions; no patients required conversion to open surgery. At the 12-month follow-up, complete or partial thrombosis of the false lumen was seen in 100% of patients (46/46) within the stent graft region and in 97.4% of patients (38/39) within the dissection stent region. Growth (>5 mm) of the maximum transaortic diameter was observed in 14.9% of patients (7/47) in the stent graft region and in 38.5% of patients (15/39) within the dissection stent region at 12 months.ConclusionsThirty-day and 1-year results from the STABLE II study demonstrated favorable clinical and anatomical outcomes for the treatment of rupture and malperfusion in the setting of acute, complicated TBAD. Five-year follow-up is ongoing.     

Stanford B型主动脉夹层腔内修复术后再干预的危险因素研究

目的 探究Stanford B型主动脉夹层TEVAR术后再干预情况及相关危险因素.方法 回顾性分析2014年1月至2018年1月新疆医科大学第二附属医院初次行TEVAR的Stanford B型主动脉夹层患者93例,对再干预组和无需再干预的对照组进行比较,分析影响患者TEVAR术后再干预的危险因素.结果 22例患者(23...     

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.     

Outcomes of emergency in situ laser fenestration-assisted thoracic endovascular aortic repair in patients with acute Stanford type A aortic dissection unfit for open surgery

ObjectiveThis study investigated the outcomes of emergency in situ laser fenestration (ISLF)-assisted thoracic endovascular aortic repair (TEVAR) for patients with acute Stanford type A aortic dissection unfit for open surgery.MethodsTwenty patients with acute Stanford type A aortic dissection who were found to be unfit for open surgery, underwent emergency ISLF-assisted TEVAR in our center between March 2016 and December 2018. Anatomic criteria for endovascular repair: coronary artery and aortic valve was not involved, proximal landing zone diameter of 45 mm or less, and proximal landing zone length of 20 mm or greater. Their clinical outcomes were reviewed retrospectively.ResultsTwenty patients achieved a procedural success of 100.0%. The 30-day mortality was 10%; two patients died, one of severe pneumonia and the other from cerebral hemorrhage after the operation. Rate of stroke at 30 days was 5%. The average follow-up time was 16 months (range, 3-26 months). One death owing to heart failure occurred at 23 months postoperatively. Kaplan-Meier curve analysis revealed that the 24-month survival rate was 77.1%. Two patients had type Ia endoleaks and one had a type II endoleak. There was no stent graft migration or fenestration-related endoleak and all patients had a thrombosed false lumen in the covered section of the stent grafts. No reintervention, myocardial infarction, transient ischemic attacks, cerebral infarction, or other complications occurred during the follow-up period.ConclusionsEmergency ISLF-assisted TEVAR is a safe and effective alternative method for treating acute Stanford type A aortic dissection unfit for open surgery.     

腔内修复治疗合并慢性肾功能不全的急性B型主动脉夹层

目的 探讨主动脉腔内修复(EVAR)治疗合并慢性肾功能不全的急性B型主动脉夹层患者的早期效果.方法 2009年2月至2011年12月,采用EVAR治疗30例合并慢性肾功能不全的急性B型主动脉夹层患者(CRI组),选取同一时间段连续EVAR治疗的30例非CRI的急性B型主动脉夹层患者作为对照(非CRI组).所有患者均为发病在14天以内的非马方综合征患者,通过主动脉CTA确诊.57例患者局部麻醉下完成EVAR,同期完成左锁骨下动脉“烟囱”支架置入2例、肾动脉支架置入2例.3例在全身麻醉下先行右腋动脉至左腋动脉和左锁骨下动脉的“Y”形人工血管转流术,后行EVAR.术后1个月和1年随访复查肾功能和CTA,评价疗效.结果 CRI组患者年龄显著低于非CRI组[(44.7±13.2)岁对(53.7±16.2)岁,P＜0.05],围手术期并发症发生率显著高于非CRI组(16.7％对3.3％,P＜0.05),均治愈.1例CRI组患者术后6个月因支架远端新发夹层破口,再次入院行EVAR后治愈.术后1个月和1年复查肾功能和CTA,所有患者无肾功能损害加重;CTA显示支架无明显变形、移位和内漏,主动脉真腔及分支动脉血供均有明显改善.结论合并CRI的急性B型主动脉夹层患者,积极行EVAR治疗后,早期效果满意,术后1个月和1年无内漏、夹层破裂出血、神经系统缺血和腹腔脏器缺血等并发症和死亡.     

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。     

裂口位于主动脉弓远端Stanford A型主动脉夹层的腔内修复

目的总结腔内修复术治疗裂口位于主动脉弓远端Stanford A型主动脉夹层的临床经验。方法2001年1月至2006年6月在中山大学附属第一医院血管外科通过股动脉入路行主动脉腔内修复术,对21例内膜撕裂口位于主动脉弓远端和近端降主动脉的Stanford A型主动脉夹层进行血管腔内治疗,根据椎动脉造影确定是否重建左锁骨下动脉。结果全组21例中,急性夹层13例,慢性夹层8例,均接受了血管腔内带膜支架修复术,手术成功率100%。17例同时封闭了左锁骨下动脉,其中4例行左锁骨下动脉重建。4例发生内漏,1例术后发生脑梗死。平均随访22.3个月(6~65个月),所有病例均存活。假腔内完全血栓形成12例,部分血栓形成9例。结论主动脉腔内修复术治疗内膜撕裂口位于主动脉弓远端和近端降主动脉的Stanford A型主动脉夹层是有效和安全的,具有微创、成功率高和并发症少等特点。     

腔内修复术治疗多破口Stanford B型胸主动脉夹层的临床研究

目的 分析多破口Stanford B型胸主动脉夹层的临床特征,探讨胸主动脉腔内修复术处理该病的临床方式.方法 回顾性分析2011年2月-2015年5月因多破口(≥2个破口)Stanford B型胸主动脉夹层在广州军区武汉总医院心胸外科接收TEVAR治疗患者的病例资料,除近心端第一破口外,使用外科方式处理远端夹层破口为处理组,否则为非处理组.比较两组术后6个月内胸背疼痛发病率、远端夹层进展情况、假腔变化情况、远端破口获益情况.结果 检索出符合条件的病例67例,所有腔内修复术均获成功,无严重并发症发生病例,术后6个月内无死亡病例.处理组7例,非处理组60例.TEVAR后两组胸背疼痛发病率、远端夹层进展发病率差异无统计学意义(P＞0.05),处理组夹层假腔较非处理组明显变小(差异有统计学意义,P＜0.05),非处理组19例患者通过夹层远端破口的血流供应腹腔内脏动脉.结论 TEVAR是治疗多破口Stanford B型胸主动脉夹层有效的手术方式,远端破口应根据Stanford B型胸主动脉夹层特点进行个性化处理或尽量不处理.     

Updated outcomes from the TRANSFIX study to evaluate endovascular repair of blunt thoracic aortic injuries with the Zenith Alpha thoracic device

ObjectiveThe purpose of this study was to report the updated results of a prospective, multicenter, nonrandomized, single-arm investigational device exemption study conducted at 17 sites in the United States to assess safety and effectiveness of the Zenith Alpha thoracic endovascular graft (Cook Medical, Bloomington, Ind) for treatment of blunt thoracic aortic injury (BTAI).MethodsThe primary safety end point was 30-day all-cause mortality and aortic injury-related mortality. The primary effectiveness end point was 30-day device success. Additional outcomes evaluated included major adverse events and imaging findings including aortic injury healing, graft patency, and device integrity as analyzed by the core laboratory on follow-up computed tomography imaging through 5 years.ResultsA total of 50 patients with BTAI were enrolled in the TRANSFIX study between January 2013 and May 2014. Mean follow-up was 21 months (range, 0.6-35 months). The 30-day mortality was 2% (n = 1), and it was unrelated to the aortic repair or study device. Five deaths occurred after 30 days, and one was considered procedure related. Freedom from all-cause and BTAI-related mortality was 89.3% and 97.6%, respectively, at 2 years. Aortic injury healing was noted in 96% at 2 years. An incidental finding of thrombus formation within the stent graft, most commonly at the distal aspect of the study device, occurred in 15 patients (30%; 12 by core laboratory, 3 by site) and was confirmed in 13 patients (26%). None of these patients were noted to have clinical sequelae on most recent follow-up.ConclusionsThe updated results from the TRANSFIX study continue to show low rates of aortic injury-related mortality and major adverse events during follow-up. However, findings of in-graft thrombus have resulted in the manufacturer's voluntary removal of the BTAI indication for this device. Caution should be exercised in appropriate and accurate device sizing and planning (eg, limiting graft oversizing) as well as in regular, lifelong follow-up evaluation.     

Toronto PowerWire fenestration technique to access false lumen branches in fenestrated endovascular aneurysm repair for chronic type B dissection

Chronic type B aortic dissection with aneurysmal degeneration requiring intervention presents significant therapeutic challenges. Thoracic endovascular aortic repair with a fenestrated endograft is a feasible option, but false lumen branches without an adjacent re-entry or perforation in the septum can pose a significant challenge. We present two cases of fenestrated endovascular aneurysm repair for chronic type B aortic dissection in which a renal artery from the false lumen was cannulated by creating a “neofenestration” through the dissection flap using a radiofrequency PowerWire (Baylis Medical Inc, Montreal, Quebec, Canada) technique (Toronto PowerWire fenestration technique).     

Endoluminal stent-graft placement in patients with acute aortic dissection type B

Objectives: This study was performed to evaluate the feasibility, safety and effectiveness of endovascular stent-grafting in treating Stanford type B acute aortic dissection. We describe our first clinical experiences and initial results with stent-grafting across the primary entry tear in patients with acute aortic dissection type B. Methods: Between March 2000 and August 2001, nine patients with acute type B dissection were treated endoluminally by stent-graft implantation. There were seven male and two female patients with a mean age of 63 years (between 48 and 85 years). In all nine patients aortic dissection was diagnosed by multislice computed tomography (CT) angiography. All nine patients had a maximal aortic diameter of 5.5 cm or more and recurrent pain, one patient showed hemoptysis. This patient with signs of a contained rupture was treated under emergency condition, the eight remaining patients were in hemodynamic stabile condition at the time of intervention. The GORE^® Excluder stent-graft system was used in eight patients (mean 1.8 stents/patient) and the TALENT^® stent-graft system in one patient, which were introduced transfemorally. Results: The primary entry tear could be sealed successfully in all nine patients. Complete thrombosis of the false thoracic aortic lumen was obtained in two patients, in the remaining seven patients the false lumen was obliterated in the area of the thoracic aorta but perfused via re-entries in the abdominal region. No severe intraoperative complications occurred. One patient developed bilateral incomplete paraplegia with motor and sensory deficits affecting completely the right leg and partially the left leg, 14 h after intervention. A cerebrospinal fluid drainage was initiated by inserting a lumbar catheter. All nine patients, including the patient with the transient paraplegia, could be discharged from the hospital in excellent condition and without remaining neurologic deficits. Control CT scans showed a reduction of the false lumen from 2.34±0.58 to 0.7±0.44 cm and an increase of the true lumen from 1.56±0.5 to 4.10±0.6 cm in the thoracic aortic region. Mean ICU stay was 1.8 days, mean postoperative hospital stay was 7.6 days. Conclusions: Stent-grafting of acute type B dissections may represent a very effective and promising new method by closure of the primary entry tear, thereby minimizing the risk of rupture of the thoracic aorta and optimizing distal perfusion by decompression of the true lumen.