Morphologic predictors of aortic expansion in chronic type B aortic dissection.

AIM: To identify morphologic factors affecting aortic expansion in patients with uncomplicated type B aortic dissections. METHODS: Computed tomography data of 24 patients (18 male; median age: 61 years), diagnosed with acute uncomplicated type B aortic dissections between 2002 and 2013, were retrospectively reviewed. All patients had at least two computed tomography angiography scans and six months of uneventful follow-up. Computed tomography scans were assessed by two independent readers with regard to presence and number of entry tears. Thoracic and abdominal aortic diameters were derived using image processing software. RESULTS: Twenty-two of 24 patients showed aortic expansion over a median computed tomography angiographic follow-up of 33.2 months. Annual rates showed an increase of 1.7 mm for total aortic diameter, 2.1 mm for the false and a decrease of -0.4 mm for the true lumen. In three patients (12.5%), aortic diameter exceeded 60 mm during follow-up, and all three patients underwent thoracic endovascular aortic repair. Patients with a maximum aortic diameter <4 cm at baseline showed a significantly higher expansion rate compared to cases with an initial maximum aortic diameter of ≥4 cm (p=0.0471). A median of two entries (range: 1-5) was recognized per patient. Presence of more than two entry tears (n = 13) was associated with faster overall diameter expansion (mean annual rates: 2.18 mm vs. 1.16 mm; p = 0.4556), and decrease of the cross-sectional surface of the true lumen over time (annual rate for > 2 entries vs. ≤2 entries: -7.8 mm2 vs. +37.5 mm2; p = 0.0369). Median size of entry tears was 12 mm (range: 2-53 mm). CONCLUSIONS: The results presented herein suggest that uncomplicated type B aortic dissection patients with more than two entry tears and/or an initial maximum aortic diameter of<4 cm are at risk for aortic dilatation and, therefore, may require stricter follow-up including the possible need for early intervention.

Comparison of morphological and rheological conditions between conventional and eversion carotid endarterectomy using computational fluid dynamics--a pilot study.

PURPOSE: To compare postoperative morphological and rheological conditions after eversion carotid endarterectomy versus conventional carotid endarterectomy using computational fluid dynamics. BASIC METHODS: Hemodynamic metrics (velocity, wall shear stress, time-averaged wall shear stress and temporal gradient wall shear stress) in the carotid arteries were simulated in one patient after conventional carotid endarterectomy and one patient after eversion carotid endarterectomy by computational fluid dynamics analysis based on patient specific data. PRINCIPAL FINDINGS: Systolic peak of the eversion carotid endarterectomy model showed a gradually decreased pressure along the stream path, the conventional carotid endarterectomy model revealed high pressure (about 180 Pa) at the carotid bulb. Regions of low wall shear stress in the conventional carotid endarterectomy model were much larger than that in the eversion carotid endarterectomy model and with lower time-averaged wall shear stress values (conventional carotid endarterectomy: 0.03-5.46 Pa vs. eversion carotid endarterectomy: 0.12-5.22 Pa). CONCLUSIONS: Computational fluid dynamics after conventional carotid endarterectomy and eversion carotid endarterectomy disclosed differences in hemodynamic patterns. Larger studies are necessary to assess whether these differences are consistent and might explain different rates of restenosis in both techniques.

Finite element analysis in asymptomatic, symptomatic, and ruptured abdominal aortic aneurysms: in search of new rupture risk predictors.

OBJECTIVES: To compare biomechanical rupture risk parameters of asymptomatic, symptomatic and ruptured abdominal aortic aneurysms (AAA) using finite element analysis (FEA). STUDY DESIGN: Retrospective biomechanical single center analysis of asymptomatic, symptomatic, and ruptured AAAs. Comparison of biomechanical parameters from FEA. MATERIALS AND METHODS: From 2011 to 2013 computed tomography angiography (CTA) data from 30 asymptomatic, 15 symptomatic, and 15 ruptured AAAs were collected consecutively. FEA was performed according to the successive steps of AAA vessel reconstruction, segmentation and finite element computation. Biomechanical parameters Peak Wall Rupture Risk Index (PWRI), Peak Wall Stress (PWS), and Rupture Risk Equivalent Diameter (RRED) were compared among the three subgroups. RESULTS: PWRI differentiated between asymptomatic and symptomatic AAAs (p < .0004) better than PWS (p < .1453). PWRI-dependent RRED was higher in the symptomatic subgroup compared with the asymptomatic subgroup (p < .0004). Maximum AAA external diameters were comparable between the two groups (p < .1355). Ruptured AAAs showed the highest values for external diameter, total intraluminal thrombus volume, PWS, RRED, and PWRI compared with asymptomatic and symptomatic AAAs. In contrast with symptomatic and ruptured AAAs, none of the asymptomatic patients had a PWRI value >1.0. This threshold value might identify patients at imminent risk of rupture. CONCLUSIONS: From different FEA derived parameters, PWRI distinguishes most precisely between asymptomatic and symptomatic AAAs. If elevated, this value may represent a negative prognostic factor for asymptomatic AAAs.

[Nellix® endovascular aneurysm sealing (EVAS) - a new technology for endovascular management of infrarenal aortic aneurysms]. / Nellix® Endovascular Aneurysm Sealing (EVAS) - eine neue Technologie zur endovaskulären Ausschaltung infrarenaler Aortenaneurysmen.

BACKGROUND: Recently used endografts for envascular aneurysm repair (EVAR) exclude the pathology by fixation at both the proximal and distal landing zone. Due to endoleaks and migration EVAR is associated with a relevant rate of secondary interventions. The Nellix® system (Endologix Inc., CA, USA) was developed to seal the complete aneurysm using a polymer filling, therefore stabilising endograft-position and reducing the rate of endoleaks and reinterventions. The present contribution introduces the method, describes the technique of implantation and presents the first clinical results. Material und Methods: The Nellix system consists of two balloon-expandable stent grafts made of a cobalt-chromium composition, surrounded with ePTFE and the so-called endobags. During the implantation each endobag is filled with a non-biodegradable polymer, sealing the aneurysm lumina including the proximal and distal landing zone. Hence, lumbar arteries will be sealed to reduce the probability of a type II endoleak. RESULTS: Longterm durability as well as the structural integrity of the Nellix system has been proven over 4 years in sheep experiments. The technical success in a multicentre, prospective registry was 94% without the appearance of severe adverse events (migration, occlusion, secondary endoleak). CONCLUSION: EVAS is a new and different concept of endovascular AAA repair. Recent clinical data of the Nellix system are promising showing a high technical success rate while the need for secondary intervention is low. Further studies in larger cohorts are needed.

Decision-making and techniques in hypogastric artery revascularization.

The aim of this article was to describe and discuss the currently available endovascular and open surgical techniques to preserve or occlude the hypogastric artery during aortoiliac aneurysm repair and thus support the process of decision-making in hypogastric artery revascularization.

Accuracy and variability of semiautomatic centerline analysis versus manual aortic measurement techniques for TEVAR.

OBJECTIVES: This study aims to test whether inter-observer variability and time of diameter measurements for thoracic endovascular aortic repair (TEVAR) are improved by semiautomatic centerline analysis compared to manual assessment. METHODS: Preoperative computed tomography (CT) angiographies of 30 patients with thoracic aortic disease (mean age 66.8 ± 11.6 years, 23 males) were retrospectively analysed by two blinded experts in vascular radiology. Maximum aortic diameters at three positions relevant to TEVAR were assessed (P1, distal to left common carotid artery; P2, distal to left subclavian artery; and P3, proximal to coeliac trunk) using three measurement techniques: manual axial slices (axial), manual double-oblique multiplanar reformations (MPRs) and semiautomatic centerline analysis. RESULTS: Diameter measurements by both centerline analysis and the axial technique did not significantly differ from MPR (p = 0.17 and p = 0.37). Total deviation index for 0.9 was for P1 2.7 mm (axial), 3.7 mm (MPR), 1.8 mm (centerline); for P2 2.0 mm (axial), 3.6 mm (MPR), 1.8 mm (centerline); and for P3 3.0 mm (axial), 3.5 mm (MPR), 2.5 mm (centerline). Measurement time using centerline analysis was significantly shorter than for assessment by MPR. CONCLUSIONS: Centerline analysis provides the least variable and fast diameter measurements in TEVAR patients with the same accuracy as the current reference standard MPR.

Reliability of semiautomatic centerline analysis versus manual aortic measurement techniques for TEVAR among non-experts.

OBJECTIVES: The study aimed to test whether reliability and inter-observer variability of preoperative measurements for thoracic endovascular aortic repair (TEVAR) among non-experts are improved by semiautomatic centerline analysis compared with manual assessment. METHODS: Preoperative computed tomography (CT) angiographies of 30 patients with thoracic aortic disease (mean age 66.8 ± 11.6 years, 23 men) were retrospectively analysed in randomised order by one blinded vascular expert (reference standard) and three blinded non-expert readers. Aortic diameters were measured at four positions relevant to TEVAR using three measurement techniques (manual axial slices, manual multiplanar reformations (MPRs) and semiautomatic centerline analysis). Length measurements were performed using centerline analysis. Reliability was calculated as absolute measurement deviation (AMD) from reference standard and inter-observer variability as coefficient of variance (CV) among non-expert readers. RESULTS: For axial, MPR and centerline techniques, mean AMD was 7.3 ± 7.7%, 6.7 ± 4.5% and 4.7 ± 4.8% and mean CV was 5.2 ± 4.2%, 5.8 ± 4.8% and 3.9 ± 5.4%. Both AMD and CV were significantly lower for centerline analysis compared with axial technique (p = 0.001/0.042) and MPR (p = 0.009/0.003). AMD and CV for length measurements by centerline analysis were 3.2 ± 2.8% and 2.6 ± 2.4%, respectively. Centerline analysis was significantly faster than MPR (p < 0.001). CONCLUSIONS: Semiautomatic centerline analysis provides the most reliable and least variable diameter and length measurements among non-experts in candidates for TEVAR.