Management of the False Lumen in Post Type A Aortic Dissection Arch Aneurysms Treated With Branched Endografts.

INTRODUCTION: The treatment of chronic postdissection aneurysms of the aortic arch is a challenge. This study aims to describe false lumen management after aortic arch endovascular repair of post-type A dissection aneurysms treated with a branched endograft. METHODS: In this single-center retrospective observational study, all consecutive patients undergoing endovascular treatment of aneurysmal degeneration of chronic type A aortic dissections following open repair were enrolled. The primary endpoint was maximal aortic diameter evolution measured on computed tomography angiography (CTA) performed during follow-up. Secondary endpoints included procedural success, aortic re intervention, and remodeling during follow-up. RESULTS: Between January 2017 and June 2020, 22 patients underwent endovascular branched arch repair for post type A dissection aneurysms. Technical success was 100%. Thirteen patients (59%) had dissection involvement of at least 1 supra-aortic vessel. Midterm follow-up CTA was performed for 20 patients, 23.1 (±13.3) months after the procedure. Maximal aortic diameter at the level of the repair was decreasing in 13 (65%) patients, increasing in 2 (10%) patients, and no change was observed in 5 (25%) patients. During follow-up, 7 patients (35%) required aortic reintervention. Thoracic candy plugs were implanted for distal false lumen occlusion in 15 patients and associated with a high rate of complete remodeling (6/15 patients, 40%). CONCLUSION: Arch branch endografting of aneurysmal evolution of a post type A dissection aortic arch is a safe and feasible option in experienced hands. Candy plug use in favorable anatomies seems to be associated with accelerated remodeling of the aorta. CLINICAL IMPACT: There are currently no recommendations on dissected supra- aortic vessels management and the use of thoracic aorta false lumen occlusion devices during endovascular repair of chronic post dissection aneurysm of the aortic arch with branched endografts. Based on our clinical experience reported in the current manuscript, we propose a treatment algorithm for the management of the false lumen in this setting.

Gender related Long-term Differences after Open Infrainguinal Surgery for Critical Limb Ischemia.

OBJECTIVE: The role of gender on long-term infrainguinal open surgery outcomes still remains uncertain in critical limb ischemia patients. The aim of this study is to evaluate the gender-specific differences in patient characteristics and long-term clinical outcomes in terms of survival, primary patency and limb salvage among patients undergoing infrainguinal open surgery for CLI. MATERIAL AND METHODS: All consecutive patients undergoing infrainguinal open surgery for critical limb ischemia between 2003 and 2012 were included. Survival, limb salvage and primary patency rates were assessed. Independent outcome determinants were identified by the Cox proportional hazard ratio using age and gender as adjustment factors. RESULTS: 584 patients (269 women and 315 men, mean age 76 and 71 years respectively) underwent 658 infrainguinal open surgery (313 in women and 345 in men). Survival rate at 6 years was lower among women compared to men with 53.5% vs 70.9% (p < 0.001). The same applied to primary patency (35.9% vs 52.4%, p < 0.001) and limb salvage (54.3% vs 81.1%, p < 0.001) at 6 years. Female-gender was an independent factor predicting death (hazard ratio 1.50), thrombosis (hazard ratio 2.37) and limb loss (hazard ratio 7.05) in age and gender-adjusted analysis. CONCLUSION: Gender-related disparity in critical limb ischemia open surgical revascularization outcomes still remains.

[Pre- and postoperative imaging of type B aortic dissection]. / Imagerie de la dissection aortique de type B : ce que veut savoir le chirurgien avant et après l'intervention.

Type B aortic dissections are serious diseases with a 60 to 80 % 5-year survival rate. Although typically managed with a medical treatment, surgery may be necessary in the acute/subacute or the chronic phase if significant complications are encountered. For these patients, CT angiography is the first-line imaging modality, used for indicating and preparing the surgical procedure as well as for follow-up. Physicians in charge of these patients should be familiar with the key reading points. Visceral malperfusion is the most common acute complication, while aneurysmal dilatation of the false lumen is the most common chronic complication, with surgical management generally indicated when the axial diameter of the aorta exceeds 55mm. Endovascular treatment tends to replace open surgery: it requires precise measurements and identification of the entry tear (contribution of 4D-MRA).

[Contribution of mathematical models and biomechanical properties in predicting the risk of abdominal aortic aneurysm rupture]. / Apport des modèles mathématiques et des études biomécaniques dans la prédiction du risque de rupture des anévrysmes de l'aorte abdominale.

INTRODUCTION: Rupture is the worst outcome of abdominal aortic aneurysm (AAA). The decision to operate should include counterbalancing the risk of aneurysm rupture against the risk of aneurysm repair, within the context of a patient's overall life expectancy. Current surgical guidelines are based on population studies, and important variables are missed in predicting individual risk of rupture. METHODS: In this literature review, we focused on the contribution of biomechanical and mathematical models in predicting risk of AAA rupture. RESULTS: Anatomical features as diameter asymmetry and lack of tortuosity are shown to be anatomical risk factors of rupture. Wall stiffness (due to modifications of elastin and collagen composition) and increased inflammatory response are also factors that affect the structural integrity of the AAA wall. Biomechanical studies showed that wall strength is lower in ruptured than non-ruptured AAA. Intra-luminal thrombus also has a big role to play in the occurrence of rupture. Current mathematical models allow more variables to be included in predicting individual risk of rupture. CONCLUSION: Moving away from using maximal transverse diameter of the AAA as a unique predictive factor and instead including biological, structural and biomechanical variables in predicting individual risk of rupture will be essential in the future and will help gain precision and accuracy in surgical indications.

Practical experience with the TAG and conformable TAG devices: lessons learned in about 100 cases.

AIM: We reported our 10-year experience with the Gore TAG thoracic endoprosthesis for treatment of thoracic aorta pathologies. METHODS: We performed a systematic retrospective study of prospectively recorded data of all patients who underwent thoracic endovascular aortic repair (TEVAR) procedure with Gore TAG thoracic endoprosthesis between January 2001 and March 2013, and conducted an analysis of patient demographics, periprocedural records, complications, reinterventions, and survival. RESULTS: During this period, 96 patients underwent TEVAR with Gore TAG device. Indications for operation were degenerative aneurysm in 38 patients (39.6%), type B aortic dissection in 24 (25.0%), penetrating ulcer in 8 (8.3%), intramural hematoma in 10 (10.4%), traumatic transection in 9 (9.4%), and other pathology in 7 (7.3%). Forty-four patients (45.8%) had acute thoracic aortic syndromes requiring immediate or delayed procedures. Forty-two (43.8%) patients underwent supra-aortic trunks debranching. Landing zones were zone 0 in 8 patients (8.3%), zone 1 in 4 (4.2%), zone 2 in 36 (37.5%), zone 3 in 29 (30.2%) and zone 4 in 19 (19.8%). Technical success rate was 96.6%. Thirty-day mortality was 10.4%. Major adverse events included stroke in 8.3%, spinal cord ischemia in 4.2%, and vascular injuries in 7.3%. Overall survival in the cohort was 86% at 1 year and 78% at 2 years with a mean follow-up of 11.1±12.4 months. Major reintervention was required in 10 patients (10.4%). CONCLUSION: This single-center study demonstrates acceptable rates for operative mortality and major adverse events after endovascular repair of various thoracic aortic pathologies with both generations of Gore TAG device. However, a better knowledge in long-term results is necessary to define target populations.