Carotid versus axillary artery cannulation for descending aorta remodeling in type A acute aortic dissection.

BACKGROUND: Arterial cannulation sites for the surgical repair of type A aortic dissection (AAD) have evolved from right axillary artery (AA) cannulation to bilateral carotid artery (CA) based of femoral artery (FA) cannulation. Postoperative descending aorta remodeling is closely linked to the false lumen area ratio (FLAR), defined as false lumen area/aortic area, as well as to the incidence of renal replacement therapy (RRT). AIM: To investigate the effect of the updated arterial cannulation strategy on descending aortic remodeling. METHODS: A total of 443 AAD patients who received FA combined cannulation between March 2015 and March 2023 were included in the study. Of these, 209 received right AA cannulation and 234 received bilateral CA cannulation. The primary outcome was the change in FLAR, as calculated from computed tomography angiography in three segments of the descending aorta: Thoracic (S1), upper abdominal (S2), and lower abdominal (S3). Secondary outcomes were the incidence of RRT and the serum inflammation response, as observed by the levels of high sensitivity C reaction protein (hs-CRP) and Interleukin-6 (IL-6). RESULTS: The postoperative/preoperative ratio of FLAR in S2 and S3 was higher in the AA group compared to the CA group (S2: 0.80 ± 0.08 vs 0.75 ± 0.07, P < 0.001; S3: 0.57 ± 0.12 vs 0.50 ± 0.12, P < 0.001, respectively). The AA group also had a significantly higher incidence of RRT (19.1% vs 8.5%, P = 0.001; odds ratio: 2.533, 95%CI: 1.427-4.493) and higher levels of inflammation cytokines 24 h after the procedure [hr-CRP: 117 ± 17 vs 104 ± 15 mg/L; IL-6: 129 (103, 166) vs 83 (69, 101) pg/mL; both P < 0.001] compared to the CA group. CONCLUSION: The CA cannulation strategy was associated with better abdominal aorta remodeling after AAD repair compared to AA cannulation, as observed by a greater change in FLAR and lower incidence of RRT.

Successful Factors for Improving Aortic Remodeling with Thoracic Endovascular Repair and Bare Stent Extension.

OBJECTIVE: Proximal ExTension to Induce COmplete ATtachment (PETTICOAT), which utilizes downstream bare metal stents for structural support, demonstrates potential, yet its adoption is limited by variable outcomes. This study elucidates the potential of PETTICOAT in aortic dissection, emphasizing the determinants that guide patient selection. METHODS: A retrospective analysis of 60 patients who underwent full PETTICOAT for aortic dissections was conducted. A multivariate logistic regression model identified predictors of favorable aortic remodeling. Patients underwent standardized follow-up with CT scans to assess size, volumetric changes, and anatomical conditions. Selection criteria included full PETTICOAT application and a minimum three-month follow-up. Demographics, preoperative conditions, and procedural details were collected and analyzed. RESULTS: The analysis identified predictors of favorable aortic remodeling, including age over 60, a larger downstream aorta stent graft, a smaller abdominal aorta (<450mm2), and oral angiotensin II receptor blocker (ARB) administration. Over a median 47.5-month follow-up, survival rates in the favorable remodeling (97.3%) and unfavorable groups (100%) were similar. Downstream aortic event-free survival rates did not significantly differ (89.2% vs. 73.9%), although the unfavorable group had a relatively higher incidence of distal stent-induced new entries (26.1% vs. 8.1%). CONCLUSIONS: The PETTICOAT concept effectively enhances aortic remodeling in complex aortic dissections. Predictors for favorable remodeling, including age, stent graft sizing, aortic diameter, and ARB therapy, offer insights for optimizing patient selection. This approach improves survival outcomes, mitigates risks associated with untreated aortic segments, and provides a minimally invasive solution for aortic dissections. Despite some outcome variations, the technique holds promise for addressing the challenges of aortic dissections, with the potential for further refinement in patient selection and technique application.

Long-Term Outcomes of PETTICOAT Technique-Assisted Thoracic Endovascular Aortic Repair for the Treatment of Acute and Subacute Complicated Type B Aortic Dissection.

OBJECTIVE: To evaluate the long-term outcomes of the provisional extension to induce complete attachment technique (PETTICOAT) for the treatment of acute and subacute complicated type B aortic dissection (TBAD). METHODS: We retrospectively collected and analyzed the clinical data of patients with acute and subacute TBAD who were treated using the PETTICOAT technique at our center between March 2014 and March 2023. The primary endpoint was all-cause mortality; secondary endpoints were a composite of complications, such as entry flow, stent-graft-induced new entry (SINE), and re-intervention. RESULTS: The technical success was 92% (46/50). The perioperative mortality was 2% (1/50), and the procedure-related re-intervention was also 2% (1/50). The mean follow-up time was (74.9±33.9) months. The mortality was 4.1% (2/49). The incidence of aortic-related complications was 8.2% (4/49), including new entry flow, 2 retrograde type A aortic dissections, and 1 distal stent graft-induced new entry SINE. The procedure-related re-intervention rate was 4.1% (2/49). After 5 years of follow-up, the total aortic diameter at the renal artery level was reduced from that at the third year of follow-up but was still significantly larger than preoperatively (26.9±6.6 mm vs. 24.1±4.2 mm, p=0.013). While at the covered stent, bare stent, stentless, and celiac artery (CA) levels, the total aortic diameters did not change significantly compared with preoperative values, whereas true lumen (TL) diameters and TL ratios were maintained at obviously higher levels than preoperative. The rate of complete thrombosis of false lumen in the thoracic aortic segment was significantly higher than that in the abdominal aortic segment (79.6% vs 30.6%, p=0.0001). CONCLUSIONS: The results indicated that the PETTICOAT technique is safe and effective and could promote positive remodeling of the aorta from the level of the covered stent to the CA. Remodeling of the distal abdominal aorta may fluctuate and requires close follow-up review. CLINICAL IMPACT: The long-term results from our center suggest that the PETTICOAT technique promotes positive remodeling of the aorta from the level of the covered stent to the CA; whereas this advantage does not seem to be significant in the more distal segment of the abdominal aorta, mainly at the level of RA and distal. Therefore, further procedures may be required for aortic dissection of the abdominal segment. In addition, aortic remodeling may fluctuate to some extent during the follow-up period, especially in the abdominal visceral region, so close follow-up review is quite important, and prompt re-intervention is required if necessary.

Radiomics-Based Risk Assessment Correlates With Outcomes in Patients With Acute Type B Aortic Dissection Undergoing Thoracic Endovascular Repair.

OBJECTIVES: Our study aimed to investigate the correlations between radiomics-based assessment and outcomes, including positive aortic remodeling (PAR), reintervention for dissection at 1 year, and overall survival, in patients with Type B aortic dissection (TBAD) who underwent thoracic endovascular aortic repair (TEVAR). METHODS: This was a single-center, retrospective, cohort study. The cohort comprised 104 patients who had undergone TEVAR of TBAD in our institution between January 2010 and October 2022. We segmented preoperative computed tomography (CT) images of the patients' descending aorta regions, then extracted a comprehensive set of radiomic features, including first-order features, shape features (2D and 3D), gray-level co-occurrence matrix (GLCM), gray-level size zone matrix, gray-level run length matrix, gray-level dependence matrix, neighborhood gray-tone difference matrix, from the regions of interest. Next, we selected radiomics features associated with total descending aorta positive aortic remodeling (TDA-PAR) and reintervention by least absolute shrinkage and selection operator (LASSO) regression and features associated with survival by LASSO-Cox regression. This enabled us to calculate radiomics-based risk scores for each patient. We then allocated the patients to high and low radiomics-based risk groups, the cutoff being the median score. We used 3 different models to validate the radiomics-based risk scores. RESULTS: The patients' baseline characteristics did not differ between those who achieved TDA-PAR and those who did not. The radiomics-based risk scores were significantly and independently associated with all 3 outcomes. As to the impact of specific radiomics features, we found that GLSZM_SmallAreaLowGrayLevelEmphasis and shape_Maximum2DDiameterColumn had positive impacts on both reintervention and survival outcomes, whereas GLCM_Idmn positively affected survival but negatively affected reintervention. We found that radiomics-based risk for TDA-PAR correlated most significantly with zone 6 PAR. CONCLUSIONS: Radiomics-based risk scores were significantly associated with the outcomes of TDA-PAR, reintervention, and overall survival. Radiomics has the potential to make significant contributions to prediction of outcomes in patients with TBAD undergoing TEVAR. CLINICAL IMPACT: In this study of 104 patients with Type B aortic dissection, we demonstrated associations between radiomics-based risk and postoperative outcomes, including total descending aorta positive aortic remodeling, reintervention and survival. These findings highlight radiomics' potential as a tool for risk stratification and prognostication in acute Type B aortic dissection management.

Computed Tomography Imaging Measurements as a Surrogate for Clinical Outcomes After Surgical Management of Acute Type A Aortic Dissection: A Systematic Review.

BACKGROUND: Postoperative computed tomography imaging surveillance is an essential component of care after acute type A aortic dissection (ATAAD) repair. Prognostic imaging factors after ATAAD repair have not been systematically reviewed. METHODS AND RESULTS: We performed a systematic review to summarize postoperative computed tomography measurements including aortic diameter, cross-sectional area, volume, growth rate, and false lumen thrombosis in addition mid- to long-term clinical outcomes after ATAAD repair. Searches were conducted in Medline, Embase, and CENTRAL in October 2022. Studies were included if they reported clinical outcomes such as mortality or aortic reintervention after 1 year and included aforementioned computed tomography findings. Studies of chronic aortic dissection and studies of exclusive patient populations such as those with connective tissue diseases were excluded. Risk of bias was assessed with the Newcastle-Ottawa Scale. Searches retrieved 6999 articles. Sixty-eight studies met inclusion criteria (7885 patients). Extended repairs were associated with improved false lumen thrombosis, decreased aortic growth rate, and decreased rates of reintervention but not improved survival. Growth rates of the aorta post-ATAAD repair were highest in the descending thoracic aorta. The most frequent prognostic imaging factors reported were a patent/partially thrombosed false lumen and postoperative aortic diameter >40 to 45 mm. CONCLUSIONS: Established measurements of positive aortic remodeling, including complete false lumen thrombosis and stabilization of postoperative aortic diameter and growth are the most studied prognostic indicators for improved clinical outcomes after ATAAD repair. Growth rate of the aorta remains significant after ATAAD repair. Future studies should prospectively evaluate and compare prognostic factors for improved surveillance and management.

A novel hybrid prosthesis for open repair of acute DeBakey type I dissection with malperfusion: Early results from the PERSEVERE trial.

BACKGROUND: Outcomes after hemiarch repair for acute DeBakey type I aortic dissection (ADTI) remain unfavorable, with high rates of major adverse events and negative aortic remodeling. The PERSEVERE study evaluates the safety and effectiveness of the AMDS Hybrid prosthesis, a novel bare metal stent, in patients presenting with preoperative malperfusion. METHODS: PERSEVERE is a prospective single-arm investigational study conducted at 26 sites in the United States. Ninety-three patients underwent ADTI aortic dissection repair with AMDS implantation. The 30-day primary endpoints are a composite rate of 4 major adverse events and the rate of distal anastomotic new entry tears. The secondary endpoints include aortic remodeling. RESULTS: Clinical malperfusion was documented in 76 patients (82%); only radiographic malperfusion, in 17 (18%). The median follow-up in the 93 patients was 5.6 months. Within 30 days, 9 patients died (9.7%), 10 patients (10.8%) experienced new disabling stroke, and 18 patients (19.4%) had new-onset renal failure requiring ≥1 dialysis treatment. There were no cases of myocardial infarction. The composite rate of major adverse events (27%) was lower than that reported in the reference cohort (58%). There were no distal anastomotic new entry tears. Technical success was achieved in 99% of patients. Early remodeling indicated total aortic diameter stability, true lumen expansion, and false lumen reduction in the treated aortic segment. CONCLUSIONS: Early results show significant reductions in major adverse events and distal anastomotic new entry tears, successfully meeting both primary endpoints. The technical success rate was high. AMDS can be used safely in patients with ADTI dissection with malperfusion.

Aortic diameter remodeling after frozen elephant trunk as a predictor of early outcomes in thoracoabdominal aortic repair.

OBJECTIVE: Patients who underwent previous frozen elephant trunk implantation for Stanford type A aortic dissection remain at risk for secondary intervention due to unsuccessful distal aortic remodeling. We aimed to investigate the impact of distal aortic remodeling on early outcomes in patients who underwent 2-stage thoracoabdominal aortic repair. METHODS: A total of 106 patients who previously underwent frozen elephant trunk implantation and thoracoabdominal aortic repair between October 2014 and December 2022 were enrolled in this study. The extent of distal aortic remodeling was evaluated, including aortic diameter, area ratio of the false lumen/aortic lumen, and patency of the false lumen at 3 levels of the aorta. Logistic regression analyses were performed to investigate the risk factors for early outcomes. RESULTS: The aortic diameter at the distal frozen elephant trunk was significantly larger in patients who died early than in surviving patients (79.19 ± 22.89 mm vs 46.84 ± 19.17 mm, respectively, adjusted P = .001). The optimal cutoff value for the aortic diameter at the distal frozen elephant trunk was 60 mm. Patients with an aortic diameter 60 mm or more at the distal frozen elephant trunk had worse early outcomes (P < .05), including prolonged intubation, early death, and postoperative complications. The aortic diameter at the distal frozen elephant trunk was identified as a significant risk factor for early death in patients undergoing thoracoabdominal aortic repair. CONCLUSIONS: Patients undergoing thoracoabdominal aortic repair with an aortic diameter 60 mm or more at the distal frozen elephant trunk have worse early outcomes. Moreover, an aortic diameter at the distal frozen elephant trunk is a significant risk factor for early death in patients undergoing thoracoabdominal aortic repair.

Urgent Candy-Plug technique for distal false lumen occlusion in chronic aortic dissection.

OBJECTIVE: This study aimed to assess the impact of urgency on early and midterm outcomes of the Candy-Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection. METHODS: The CP registry was reviewed, and patients were categorized into elective and urgent/emergent groups for analysis. End points included technical success, clinical success, early (30-day) computed tomography angiography findings, early (30-day) mortality, adverse events, and aortic remodeling in patients with available computed tomography angiography follow-up and reintervention. RESULTS: A total of 155 patients received a custom-made CP, of whom 32 patients (44% male, mean age 61 ± 9 years) were treated urgently and 123 patients (63% male, mean age 62 ± 11 years) electively. The primary CP rate was higher in the urgent group (28/32, 88%, in the urgent group vs 96/123, 78%, in the elective group, P = .051). The mean contrast volume was higher in the urgent group (157 ± 56 mL in the urgent group vs 130 ± 71 mL in the elective group, P = .017). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 of 32 (78%) patients in the urgent group vs 113 and 123 (92%) in the elective group (P = .159). The early mortality rate was 13% (4 of 32 patients) in the urgent group vs 1% (1 of 123 patients) in the elective group (P = .120). There was no statistically significant difference regarding the early adverse events between the urgent and elective CP groups. Early aortic-related reinterventions were required in 6 of 32 (19%) patients in the urgent group vs 6 of 123 (5%) in the elective group (P = .094). Thoracic aortic aneurysm sac regression was lower in the urgent group (5/28, 18%, in the urgent group vs 63/114, 55%, in the elective group, P = .001). Stable thoracic aortic aneurysm sac was higher in the urgent group (22/28, 79%, in the urgent group vs 47/114, 41%, in the elective group, P = .000). An increase in thoracic aortic aneurysm sac occurred in 1 of 28 (4%) patients in the urgent group vs 4 of 114 (4%) patients in the elective group (P = .096). CONCLUSIONS: The urgent use of the CP technique for distal FL occlusion in aortic dissection was feasible and effective. The decrease in aortic FL sac diameter may be affected by the urgent use of CP due to limited sizing availability. However, it achieved a high rate of aortic remodeling.

Is TEVAR an Effective Approach to Prevent Complications after Surgery for Aortic Dissection Type A? A Systematic Review.

Introduction: A residual false lumen after treatment for Aortic Dissection type A (AD) has been associated with early complications, such as A malperfusion or rupture and mid-term or delayed complications, such as aneurysm formation or dissection expansion. Thoracic Endovascular Aortic Repair (TEVAR) is considered an effective solution by several surgical teams to prevent future complications. In this systematic review, all published data regarding the implementation of TEVAR after previous treatment for AD were collected in order to investigate indications, methods, clinical outcomes and aortic remodeling in these patients. Methods: The aim of this study was to investigate the indications, the methods and the efficacy of TEVAR usage after surgical treatment of AD. Data for this study were collected from four widely used medical databases (MEDLINE, SCIENCE DIRECT, GOOGLE SCHOLAR, OVID). All the results for each database were recorded and were analyzed with a systematic method. Techniques and clinical outcomes were investigated. Aortic remodeling was evaluated based on the following parameters in these studies: aortic diameter, true lumen diameter, false lumen diameter, false lumen thrombosis and false lumen patency. Results: The results obtained from the search among all databases comprised 1410 articles and of these articles 9 were included in the review. The majority of the studies were retrospective (seven out of nine studies), while no study was randomized. The total number of patients was 157 and 133 of them (84.7% of patients) were treated with TEVAR in zone 3 without extension below the diaphragm intraoperatively. Among 142 patients, the calculated mortality rate was 12.7% (18 of 142 patients), with 2.8% (4 of 142 patients) presenting with stroke. The percentage of patients with total or partial thrombosis combined was 65.9% (62 patients in a population of 92). The reintervention rate was 18.7%. Conclusions: TEVAR after AD surgery is an approach usually chosen in clinical practice, but the criteria of its usage are uncertain. This method is safe and enhances aortic remodeling with an acceptable reintervention rate. Definite guidelines in this field should be created in order to delineate whether TEVAR after AD surgery is beneficial as a preventive measure to aorta-related complications and to decide under which criteria this approach should be chosen.

Clinical outcomes and aortic remodeling after Castor single-branched stent-graft implantation for type B aortic dissections involving left subclavian artery.

Background: The left subclavian artery (LSA) can be intentionally covered by a stent graft to acquire adequate landing zones for a proximal entry tear near the LSA during thoracic endovascular aortic repair (TEVAR). The Castor single-branched stent graft is designed to treat type B aortic dissection (TBAD) to retain the LSA during TEVAR. This study investigates clinical outcomes, aortic remodeling, and abdominal aortic perfusion patterns after TEVAR with the novel Castor device. Methods: From November 2020 to June 2023, 29 patients with TBAD involving the LSA were treated with the Castor single-branched stent graft. In-hospital clinical outcome and aortic computed tomography angiography (CTA) data were analyzed. CTA was performed preoperatively and at follow-up to observe stent morphology; branch patency; endoleak; change in true lumen (TL), false lumen (FL), and transaortic diameters; and abdominal aortic branch perfusion pattern. Results: The technical success rate was 96.6%. One failure was that the branch section did not completely enter the LSA and the main body migrated distally. No in-hospital mortality, paraplegia, or stroke occurred. During follow-up, one type Ib endoleak, four distal new entry tears, and one recurrent type A dissection arose from a new entry tear at the ascending aorta, no stent migration was observed, and the branch patency rate was 100%. At the thoracic aorta, TL diameters significantly increased, FL diameters markedly decreased, and FL was partially or completely thrombosed in most patients at follow-up. At the abdominal aorta, we observed 33.3% of TL growth and 66.7% of TL stabilization or shrinkage. The initial TL ratio at iliac bifurcation negatively predicted abdominal TL growth after TEVAR with a cutoff of 21.0%. Of the 102 abdominal aortic branches, 94.1% of the branches showed no change in perfusion pattern, 3.9% of the branches had an increased TL perfusion, and 2.0% of the branches had an increased FL contribution. Conclusion: The Castor unibody single-branched stent graft offers an efficient endovascular treatment for TBAD involving the LSA. TEVAR with the Castor device effectively induced thoracic FL thrombosis and thoracic TL enlargement and resulted in abdominal TL growth when the initial TL ratio at iliac bifurcation is less than 21.0%. Abdominal aortic branch perfusion patterns remain relatively stable after TEVAR with the Castor stent graft.

Acute Type B Aortic Dissection: Insights From a Single-Center Retrospective Experience Over 12 Years.

INTRODUCTION: The treatment of acute type B aortic dissection (ATBAD) is currently a challenge for vascular surgeons, because of the early morbidity and mortality rates and the high risk of late aortic events up to 50% at 5 years. This study presents the initial outcomes of ATBAD treatment using optimal medical therapy alone or combined with proximal entry tear stent-graft coverage. Additionally, it provides an analysis of the evolution of the aortic diameter and its clinical consequences during the chronic phase in each group. MATERIALS AND METHODS: Conducted as a retrospective, single-center study, we enrolled all consecutive ATBAD patients (n=130) treated between 2008 and 2020. The primary analysis studies the entire patient cohort based on their initial management approach, namely, medical treatment alone for uncomplicated ATBAD (n=67) or combined with stent-graft entry tear coverage (n=63). We also conducted a subgroup analysis to investigate factors associated with disease progression in the medical management group. RESULTS: Median follow-up was 29.5 months. During this time aneurysmal evolution was observed in: 42.4% of cases in the medical group compared with 21.8% in the stent-graft group, primarily affecting the thoracic aorta. The stent-graft group exhibited significant aortic remodeling, with a decrease in false lumen (FL) and thoracic aortic diameters. Initial aortic diameter ≥40 mm and FL ≥22 mm were independent risk factors for aneurysmal degeneration. Five-year survival was consistent at 76.1% in both groups. CONCLUSION: This study confirms the safety and efficacy of stent-graft entry tear coverage for ATBAD. Initial thoracic endovascular aortic repair (TEVAR) appears to reduce late aortic events by promoting aortic remodeling. Considering TEVAR's safety and potential to prevent late aortic complications, it may be considered for uncomplicated ATBAD patients with an initial aortic diameter ≥40 mm or an FL ≥22 mm. CLINICAL IMPACT: This study validates the efficacy and safety of using endovascular stent grafts to seal the proximal entry tear in cases of acute type B aortic dissections, compared to optimal medical therapy. Aortic remodelling significantly benefits from endovascular stent graft coverage of the proximal entry tear. Given the heightened risk of late aortic events observed in the medical therapy cohort, there appears to be a necessity for including endovascular interventions in the management of uncomplicated acute type B aortic dissections, particularly when aortic diameter is ≥40 mm and false lumen diameter is ≥22 mm.

Staging reinterventions for remodeling of residual aortic dissection: a single-center retrospective study.

Objective: Inadequate remodeling of residual aortic dissection (RAD) following repair of Stanford A or B aortic dissections has been identified as a significant predictor of patient mortality. This study evaluates the short- to mid-term outcomes of staged reinterventions for RAD at a single center with prospective follow-up. Methods: Data were retrospectively collected from patients with RAD who underwent staged reinterventions or received none-surgery treatment in the Cardiovascular Surgery Department of our hospital between July 2019 and December 2021. The cohort included 54 patients with residual distal aortic dissection post-primary surgery, comprising 28 who underwent open surgery and 26 who received thoracic endovascular aortic repair (TEVAR). Patients were divided into two groups: those who underwent staged stent interventions for distal dissection [staged reintervention (SR) group] and those who did not undergo surgery (non-surgery group). For the SR group, second or third staged stent interventions were performed. The study assessed distal remodeling of aortic dissection between the groups, focusing on endpoints such as mortality (both general and aortic-specific), occurrences of visceral branch occlusion, necessity for further interventions, and significant adverse events. Morphological changes were analyzed to determine the therapeutic impact. Results: The study encompassed 54 participants, with 33 in the SR group and 21 in the non-surgical control group. Baseline demographics and clinical characteristics were statistically comparable across both groups. During an average follow-up of 31.5 ± 7.0 months, aortic-related mortality was 0% in both groups; all-cause mortality was 3% (one case) and 5% (one case) in the SR and control groups, respectively, with no statistically significant difference noted. In the SR group, a single patient experienced complications, including renal artery thrombosis, leading to diminished blood flow. An increased true lumen (TL) area and a decreased false lumen area at various aortic planes were observed in the SR group compared to the control group. Conclusion: The staged reintervention strategy for treating RAD is safe and provides promising early results.

Efficacy of intentional undersized thoracic endovascular repair for Stanford type B aortic dissection.

OBJECTIVE: Thoracic endovascular aneurysm repair (TEVAR) is widely used for the treatment of aortic dissection. Endograft oversizing is a risk factor for stent graft-induced new entry tears and retrograde type A aortic dissection. However, there is no clear consensus on the optimal graft size selection for Stanford type B acute or subacute aortic dissection (TBAD). Herein, we examined the safety and efficacy of TEVAR using an intentionally undersized endograft to treat TBAD. METHODS: This retrospective chart review study included 82 patients who underwent TEVAR for acute or subacute Stanford TBAD between 2015 and 2022. We measured the true lumen diameter just distal to the subclavian artery and opted for a stent graft of the same diameter. In instances where deformation resulting from false lumen pressure displacement was pronounced, we measured the diameter at the site just proximal to the subclavian artery. Patients' characteristics, procedural, in-hospital, and follow-up data, and aortic remodeling were analyzed. The aortic diameter was analyzed using one-way analysis of variance followed by Dunnett's test. Survival and freedom from reintervention were estimated using Kaplan-Meier curves. RESULTS: The follow-up rate was 98.4%. The mean age was 58.3 ± 12.3 years, and 76 were men (92.7%). The mean diameters of the stent graft and native proximal landing zone were 30.9 ± 3.2 mm and 30.8 ± 3.0 mm, respectively. The oversize rate of the stent graft in relation to the native proximal aortic diameter was 0.3% ± 4.7%. In-hospital mortality was observed in one patient, retrograde type A aortic dissection in one patient, distal stent graft-induced new entry tear in zero patients, and type 1a endoleak in 22 patients (26.8%). Type 1a endoleaks, characterized by antegrade false lumen blood flow originating from the primary entry, in 12 patients spontaneously disappeared within 1 year of follow-up. According to aortic remodeling, 59 patients (86.8%) achieved complete aortic remodeling at the aortic arch level and 51 (75.0%) at the eighth thoracic vertebral level. The diameters of the aortic arch and descending aorta were significantly reduced compared with the postoperative measurements (P <.001). Survival rates were 97.5% and 93.6% at 1 and 3 years, respectively. Freedom from reintervention was 84.7% and 84.7% at 1 and 3 years, respectively. CONCLUSIONS: Intentionally undersized TEVAR was safe and achieved acceptable aortic remodeling despite a high rate of type 1a endoleaks. A type 1a endoleak was acceptable as it primarily diminished during the mid-term follow-up.

Volumetric analysis in primary and residual type B aortic dissection treated with stented-assisted balloon-induced intimal disruption and relamination technique can predict aortic reintervention.

OBJECTIVE: The aim of this study was to investigate the mid-term results of stented-assisted balloon-induced intimal disruption and relamination (STABILISE) in patients with aortic dissection with the implementation of volumetric analysis. METHODS: This was a single-center retrospective analysis of prospectively collected data. From May 2017 to September 2022, 42 patients underwent STABILISE for acute complicated or subacute high-risk aortic dissection. STABILISE was completed with distal extended endovascular aortic repair in 24 patients. A computed tomography scan was performed at baseline, before hospital discharge, and at 1, 3, and 5 years. Perfused total aortic, true lumen, and false lumen volumes were assessed for thoracic, visceral, and aorto-iliac segment. The ratio between false lumen and total volume was named perfusion dissection index (PDI). Complete remodeling was defined as PDI = 0, and positive remodeling as PDI ≤0.1. RESULTS: Technical success was 97.6%. No 30-day deaths, spinal cord injuries, or retrograde dissections were observed. Mean follow-up was 44 ± 19.4 months. Thoracic diameter was lower at last available computed tomography scan (36.7 vs 33.0 mm; P = .01). Aortic growth >5 mm was observed in 9.5% of the patients. Thoracic and visceral aortic complete remodeling were 92.8% and 83.3%, respectively, with no difference between acute and subacute group. Distal extended endovascular aortic repair significantly increased complete remodeling in the aorto-iliac segment, compared with STABILISE alone (69.6% vs 21.4%; P < .001). Freedom from vascular reinterventions at 3 years was 83.1% (95% confidence interval, 71.5%-96.6%). Total PDI ≤0.1 at first postoperative control was a predictor of vascular reinterventions (P < .0001). CONCLUSIONS: STABILISE is a safe and feasible technique associated with high mid-term rates of complete remodeling in the thoracic and visceral aorta. Volumetric analysis allows the quantification of aortic remodeling and represents a predictor of aortic reinterventions.

A Novel Endovascular Double-Disc Implant for Sealing Intimal Tears in Aortic Dissection.

Postdissection thoracoabdominal aortic aneurysm incidence after thoracic endovascular aortic repair for type B aortic dissection is high, with residual distal tears being a major reason for persistent blood flow in the false lumen. The EndoPatch is an endovascular double-disc implant for sealing re-entry tears in aortic dissection, isolating blood flow in the false lumen and promoting thrombosis formation. Compared with conventional endovascular treatment techniques, this endovascular double-disc implant's small size and minimal working space requirements may reduce the risk of spinal ischemia and offer flexible vascular access. Although several barriers still impede this endovascular device's broad application, its innovative design, flexible vascular access, and streamlined surgical process make it a promising alternative for managing intimal tears in aortic dissection, either alone or as a supplementary method combined with conventional endovascular techniques. (Guo's Entry Tear Repair: The First in Man Study of Endopatch System; NCT04745039).

Tomo-seq identifies NINJ1 as a potential target for anti-inflammatory strategy in thoracic aortic dissection.

BACKGROUND: Thoracic aortic dissection (TAD) is a life-threatening disease caused by an intimal tear in the aorta. The histological characteristics differ significantly between the tear area (TA) and the distant area. Previous studies have emphasized that certain specific genes tend to cluster at the TA. Obtaining a thorough understanding of the precise molecular signatures near the TA will assist in discovering therapeutic strategies for TAD. METHODS: We performed a paired comparison of the pathological patterns in the TA with that in the remote area (RA). We used Tomo-seq, genome-wide transcriptional profiling with spatial resolution, to obtain gene expression signatures spanning from the TA to the RA. Samples from multiple sporadic TAD patients and animal models were used to validate our findings. RESULTS: Pathological examination revealed that the TA of TAD exhibited more pronounced intimal hyperplasia, media degeneration, and inflammatory infiltration compared to the RA. The TA also had more apoptotic cells and CD31+α-SMA+ cells. Tomo-seq revealed four distinct gene expression patterns from the TA to the RA, which were inflammation, collagen catabolism, extracellular matrix remodeling, and cell stress, respectively. The spatial distribution of genes allowed us to identify genes that were potentially relevant with TAD. NINJ1 encoded the protein-mediated cytoplasmic membrane rupture, regulated tissue remodeling, showed high expression levels in the tear area, and co-expressed within the inflammatory pattern. The use of short hairpin RNA to reduce NINJ1 expression in the beta-aminopropionitrile-induced TAD model led to a significant decrease in TAD formation. Additionally, it resulted in reduced infiltration of inflammatory cells and a decrease in the number of CD31+α-SMA+ cells. The NINJ1-neutralizing antibody also demonstrated comparable therapeutic effects and can effectively impede the formation of TAD. CONCLUSIONS: Our study showed that Tomo-seq had the advantage of obtaining spatial expression information of TAD across the TA and the RA. We pointed out that NINJ1 may be involved in inflammation and tissue remodeling, which played an important role in the formation of TAD. NINJ1 may serve as a potential therapeutic target for TAD.

Clinical Outcomes and Factors Associated With Aortic Shrinkage After Thoracic Endovascular Aortic Repair for Aneurysmal Chronic Aortic Dissection.

PURPOSE: The effectiveness of thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection (AD) with aneurysmal degeneration remains controversial. We retrospectively investigated clinical outcomes and assessed predictors of aortic shrinkage after TEVAR for chronic aneurysmal AD. MATERIALS AND METHODS: Between January 2010 and December 2021, 70 patients with double-barrel-type chronic AD were enrolled. Major intimal tears in thoracic aorta were covered by stent graft. Early and late clinical outcomes, and diameter change of downstream aorta during follow-up period were reviewed. Subsequently, factors associated with aortic shrinkage were assessed by logistic regression analysis. RESULTS: Mean age was 63 (interquartile range [IQR]: 54-68) years, 54 (80%) men, median duration from AD onset was 4 (IQR: 1-10) years, and maximum aortic diameter was 53 (IQR: 49-58) mm. Supra-aortic debranching procedure was required in 57 (81%) patients. Early aorta-related death occurred in 2 (3%) patients. Both stroke and spinal cord ischemia occurred in 1 (2%) patient. Five-year freedom rates from aorta-related death and reintervention were 96% and 51%, respectively. Sixty-four patients underwent follow-up computed tomography (84%) 1 year after TEVAR, with 33 (52%) achieving aortic shrinkage. In multivariable analysis, duration from AD onset (per year) (odds ratio [OR]: 0.82, 0.70-0.97; p=0.017) and maximum aortic-diameter ratio between aortic arch and descending aorta (per 0.1) (morphologic index; OR: 1.34, 1.04-1.74; p=0.023) were independent aortic shrinkage predictors. CONCLUSIONS: Thoracic endovascular aortic repair for chronic AD with aneurysmal degeneration achieved satisfactory survival outcomes, but with a considerable reintervention rate. Duration from AD onset and preoperative aortic morphology could affect post-TEVAR aortic shrinkage. Earlier intervention could lead to better aortic shrinkage. CLINICAL IMPACT: Thoracic endovascular aortic repair for chronic aortic dissection with aneurysmal degeneration showed low incidence of early and late aorta-related death. By contrast, aortic shrinkage rate was low with high incidence of reintervention to the residual downstream aorta. According to the assessment of preoperative variables, chronicity and aortic morphology could predict postoperative aortic shrinkage.

Preoperative diameters of aorta influence the remodeling after surgery for type A aortic dissection.

Background: Although current research revealed the preoperative diameter of the aorta is related to aortic remodeling, prognosis should consider the true lumen (TL) and false lumen (FL) respectively too. Methods: The cohort of this retrospective analysis included 161 type A aortic dissection (TAAD) patients who underwent surgery at a single institution from September 1, 2017, to September 1, 2018. Computed tomography angiography (CTA) images were reviewed to assess changes of the diameters of the TL, FL and total aorta at the levels of the stented segment, distal end of the stent, celiac trunk, and below the renal artery. Results: During the study period, positive remodeling was observed in 33 (20.5%) patients. The probability of negative remodeling far from the stent segment was greater than the aorta close to the stent. Only the TL diameter was associated with each levels' changes and underwent significant change (P<0.05). Multivariate analysis identified aortic regurgitation as a risk factor for remodeling in the distal end of the stent. The maximum diameter of the FL was the only risk factor related to the remodeling type (odds ratio =0.10; 95% confidence interval: 0.01-0.51), a maximum diameter of the FL of >1.28 cm was associated with a higher probability of negative remodeling after surgery (specificity =0.994; sensitivity =0.571; area under the receiver operating characteristic curve =0.76). Conclusions: The TL and FL diameters on preoperative CTA images can be used to assess the risk of negative remodeling after surgery.

Early endovascular intervention for unfavorable remodeling of the thoracic aorta after open surgery for acute DeBakey type I aortic dissection: study protocol for a multicenter, randomized, controlled trial.

BACKGROUND: Total arch replacement with frozen elephant trunk has been developed with promising results for DeBakey type I aortic dissection. However, several problems, such as continuous perfusion of distal false lumen and unfavorable remodeling of distal aorta postoperatively, can seriously affect the long-term outcome. This trial aims to assess the effects of early minimally invasive endovascular repair on distal aortic remodeling and long-term clinical outcomes in patients with dominant false lumen and residual tears in the descending thoracic aorta after total arch replacement and frozen elephant trunk procedure. METHODS: This is a protocol for a two-arm, parallel, multicenter, randomized controlled trial. A total of 154 eligible patients will be recruited from four hospitals in China and randomized on a 1:1 basis either to the experiment group (endovascular repair in addition to routine antihypertensive therapy) or the control group (routine antihypertensive therapy without early surgical treatment). The primary outcome will be the five-year all-cause mortality. The secondary outcomes will include re-intervention, ischemic symptoms, organ dysfunction, and stent-related adverse events. DISCUSSION: If early minimally invasive endovascular repair could safely and effectively promote distal aortic remodeling and bring favorable long-term outcomes for patients with dominant false lumen and residual tears in the descending thoracic aorta after total arch replacement and frozen elephant trunk technique, it would improve the treatment strategy for DeBakey type I aortic dissection. TRIAL REGISTRATION: Chinese Clinical Trial Registry, CHiCTR2000030050. Registered on 11 March 2020.