National registry insights on genetic aortopathies and thoracic endovascular aortic interventions.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) in patients with genetic aortopathies (GA) is controversial, given concerns of durability. We describe characteristics and outcomes after TEVAR in patients with GA. METHODS: All patients undergoing TEVAR between 2010 and 2023 in the Vascular Quality Iniatitive were identified and categorized as having a GA or not. Demographics, baseline, and procedural characteristics were compared among groups. Multivariable logistic regression was used to evaluate the independent association of GA with postoperative outcomes. Kaplan-Meier methods and multivariable Cox regression analyses were used to evaluate 5-year survival and 2-year reinterventions. RESULTS: Of 19,340 patients, 304 (1.6%) had GA (87% Marfan syndrome, 9% Loeys-Dietz syndrome, and 4% vascular Ehlers-Danlos syndrome). Compared with patients without GA, patients with GA were younger (50 years [interquartile range, 37-72 years] vs 70 years [interquartile range, 61-77 years]), more often presented with acute dissection (28% vs 18%), postdissection aneurysm (48% vs 17%), had a symptomatic presentation (50% vs 39%), and were less likely to have degenerative aneurysms (18% vs 47%) or penetrating aortic ulcer (and intramural hematoma) (3% vs 13%) (all P < .001). Patients with GA were more likely to have prior repair of the ascending aorta/arch (open, 56% vs 11% [P < .001]; endovascular, 5.6% vs 2.1% [P = .017]) or the descending thoracic aorta (open, 12% vs 2% [P = .007]; endovascular, 8.2% vs 3.6% [P = .011]). No significant differences were found in prior abdominal suprarenal repairs; however, patients with GA had more prior open infrarenal repairs (5.3% vs 3.2%), but fewer prior endovascular infrarenal repairs (3.3% vs 5.5%) (all P < .05). After adjusting for demographics, comorbidities, and disease characteristics, patients with GA had similar odds of perioperative mortality (4.6% vs 7.0%; adjusted odds ratio [aOR], 1.1; 95% confidence interval [CI], 0.57-1.9; P = .75), any in-hospital complication (26% vs 23%; aOR, 1.24; 95% CI, 0.92-1.6; P = .14), or in-hospital reintervention (13% vs 8.3%; aOR, 1.25; 95% CI, 0.84-1.80; P = .25) compared with patients without GA. However, patients with GA had a higher likelihood of postoperative vasopressors (33% vs 27%; aOR, 1.44; 95% CI, 1.1-1.9; P = .006) and transfusion (25% vs 23%; aOR, 1.39; 95% CI, 1.03-1.9; P = .006). The 2-year reintervention rates were higher in patients with GA (25% vs 13%; adjusted hazard ratio, 1.99; 95% CI, 1.4-2.9; P < .001), but 5-year survival was similar (81% vs 74%; adjusted hazard ratio, 1.02; 95% CI, 0.70-1.50; P = .1). CONCLUSIONS: TEVAR for patients with GA seemed to be safe initially, with similar odds for in-hospital complications, in-hospital reinterventions, and perioperative mortality, as well as similar hazards for 5-year mortality compared with patients without GA. However, patients with GA had higher 2-year reintervention rates. Future studies should assess long-term durability after TEVAR compared with the recommended open repair to appropriately weigh the risks and benefits of endovascular treatment in patients with GA.

Early and Midterm Results after Endovascular Repair of Non-infected Saccular Lesions of the Infrarenal Aorta.

OBJECTIVE: The aim was to report short and midterm outcomes of a cohort of consecutive patients treated by endovascular aortic repair (EVAR) for saccular lesion of the abdominal aorta (sl-AA). METHODS: This was a multicentre, retrospective, financially unsupported physician initiated, observational cohort study that involved tertiary referral from Italian hospitals. For this study, between January 2010 and December 2020, only those patients treated by EVAR for non-infected sl-AA, namely blister/ulcer like projection and/or penetrating aortic ulcer, were analysed. Primary outcomes of interest were overall survival and freedom from aorta related mortality (ARM). RESULTS: The final cohort included 120 of 3 982 eligible aortic lesions. There were 103 (85.8%) males and 17 (14.2%) females. The median age was 76 years (interquartile range [IQR] 69, 80). Rupture on admission was observed in 10 (8.3%) cases. Early (≤ 30 days) death occurred in two (1.7%) patients. There were five (4.2%) complications requiring surgical re-intervention (iliac limb occlusion n = 4; groin haematoma, n = 1). The median duration of follow up was 20 months (IQR 4, 59.5): the estimated overall survival was 85.5% (standard error [SE] 0.035; 95% confidence interval [CI] 77.3 - 91.1) at 12 months, 78.7% (SE 0.044; 95% CI 69.0 - 86.0) at 36 months, and 74% (SE 0.050; 95% CI 63.2 - 82.5) at 60 months. Only one (0.8%) patient required aortic re-intervention during follow up because of a late endograft infection. The estimated freedom from ARM was 96% (SE 0.050; 95% CI 90.3 - 98.2) at 36 and 60 months. Cox's regression analysis identified that death was associated with age > 70 years (hazard ratio [HR] 1.10; 95% CI 1.04 - 1.17, p = .001), and coronary artery disease (HR 1.14; 95% CI 1.04 - 1.26, p = .006). CONCLUSION: EVAR for sl-AA proved to be safe and effective. The mortality rate was low for a group of patients known to be at high risk from open repair, and EVAR remained stable with no ARM during midterm follow up, and an acceptably low 0.8% endograft related re-intervention rate.

Midterm outcomes of fenestrated TEVAR using physician-modified endovascular grafts for zone 2.

OBJECTIVES: To summarize the experience and midterm outcomes of physician-modified endovascular grafts for zone 2 thoracic endovascular aortic repair. METHODS: A retrospective analysis was conducted of 51 consecutive patients (mean age 57.6 ± 12.5 years, 39 males) treated with thoracic endovascular aortic repair using physician-modified endovascular grafts for reconstructing the left subclavian artery from November 2015 to December 2019. The primary endpoints during follow-up were the overall mortality, aorta-related mortality, and major complications. The secondary endpoints were reintervention and the patency of the target branches, the demographics and technical details were also described and analyzed. RESULTS: Sixty-three thoracic stent-grafts were deployed in 51 patients and emergency surgery was performed in 10 patients (19.6%). Technical success was 94.1% (48/51). The incidence of perioperative complications was 15.7%, and the 30-day mortality was 0%. At a mean follow-up of 42.0 ± 14.4 months (range, 14-63 months), all the left subclavian arteries remained patent. All-cause mortality was 3.9% (2/51) and not aorta-related deaths. Estimated survival at one and three years was 98.0 ± 1.9% and 96.0 ± 2.8%, respectively. CONCLUSIONS: The physician-modified endovascular grafts is feasible and effective to preserve left subclavian artery in thoracic endovascular aortic repair for aortic arch pathologies with unhealthy proximal landing zone.

Technical Aspects of Fenestrated Arch TEVAR With Preloaded Fenestration.

Fenestrated thoracic endovascular aortic repair (f-TEVAR) has expanded the possibilities of endovascular arch repair, allowing treatment of pathologies involving the aortic arch that require sealing in Ishimaru zones 1 and 2. The growing number of implantations has increased physician experience and helped identify critical procedural points, mainly wire entanglement and device malrotation. Herein we describe a step-by-step approach to a f-TEVAR procedure with the Zenith fenestrated preloaded thoracic endograft, identifying potential pitfalls and suggesting problem-solving solutions.

Loeys-Dietz syndrome pathology and aspects of cardiovascular management: A systematic review.

Loeys-Dietz syndrome is an autosomal dominant genetic disorder which is associated with significant and often crucial vascular manifestations. This review is aimed to examine current evidence on pathophysiology and management of Loeys-Dietz syndrome in current era. A comprehensive electronic search was done to identify the articles that discussed all the aspects of Loeys-Dietz syndrome, combined key words and Medical Subject Headings (MeSH) terms were used. Relevant articles have been summarized in each relevant section. Loeys-Dietz syndrome is an autosomal dominant genetic disorder which has combined and multi-systemic manifestations. The increased breakdown of extracellular matrix predisposes an individual to developing aneurysms in the aortic tree which is undoubtedly the most significant complication of this disorder. Understanding the pathophysiology and natural history of Loeys-Dietz syndrome and regular surveillance is important to plan prophylactic interventions to prevent life-threatening aortic emergencies which can be fatal. Loeys-Dietz syndrome is an aggressive genetic condition that predisposes an individual to the development of life-threatening aortic aneurysms. Our understanding of Loeys-Dietz syndrome remains ever-changing and it is likely that the knowledge regarding its diagnosis and treatment will become more clearly defined in the coming years with deeper genetic studies.

Cross-Entropy Learning for Aortic Pathology Classification of Artificial Multi-Sensor Impedance Cardiography Signals.

An aortic dissection, a particular aortic pathology, occurs when blood pushes through a tear between the layers of the aorta and forms a so-called false lumen. Aortic dissection has a low incidence compared to other diseases, but a relatively high mortality that increases with disease progression. An early identification and treatment increases patients' chances of survival. State-of-the-art medical imaging techniques have several disadvantages; therefore, we propose the detection of aortic dissections through their signatures in impedance cardiography signals. These signatures arise due to pathological blood flow characteristics and a blood conductivity that strongly depends on the flow field, i.e., the proposed method is, in principle, applicable to any aortic pathology that changes the blood flow characteristics. For the signal classification, we trained a convolutional neural network (CNN) with artificial impedance cardiography data based on a simulation model for a healthy virtual patient and a virtual patient with an aortic dissection. The network architecture was tailored to a multi-sensor, multi-channel time-series classification with a categorical cross-entropy loss function as the training objective. The trained network typically yielded a specificity of (93.9±0.1)% and a sensitivity of (97.5±0.1)%. A study of the accuracy as a function of the size of an aortic dissection yielded better results for a small false lumen with larger noise, which emphasizes the question of the feasibility of detecting aortic dissections in an early state.

Association of aberrant subclavian arteries with aortic pathology and proposed classification system.

OBJECTIVE: Aberrant subclavian artery (aSCA) is a rare anatomic variant whose association with other aortic branch variations and aortic pathology has yet to be established. Knowledge of such an association could be relevant to recommendations for screening and awareness as associated variations are important for operative planning. We describe the incidence of aSCA variations, its association with aortic pathology, and a proposed classification system. METHODS: The thoracic cross-sectional imaging database at Keck Hospital of the University of Southern California from 2006 to 2018 was queried for presence of aSCA. Studies were evaluated for aSCA laterality, variant anatomy, and aortic and branch vessel disease. Medical records were reviewed for associated symptoms and diagnoses. The primary outcome was association of aSCA with aortic pathology (aneurysm or dissection). Secondary outcomes were comparison of right and left aSCA, comparison between the sexes, and creation of a proposed classification system. RESULTS: Of 98,580 axial imaging studies, 810 studies (0.82%) were identified with aSCA in 312 unique patients. Right aSCA made up the majority of cases (90.1%). All aSCAs had a retroesophageal course. Kommerell's diverticulum (KD) was present in 184 (59%) with an average diameter of 1.67 cm (range, 1.2-3.3 cm). KD was more frequent (84% vs 56%; P = .0003) and larger (2.05 cm vs 1.61 cm; P < .0001) in left aSCA patients. When present, KD was more often symptomatic in left aSCA compared with right aSCA (77.4% vs 49.1%; P = .005). Dysphagia, chest pain, reflux, and asthma were all more common in left aSCA patients. KD was also more common in men (73.3% vs 50%; P < .0001) and larger in men (1.81 cm vs 1.54 cm; P < .0001) but with no difference in symptoms between sexes. Our proposed classification system based on aortic arch branching is as follows: type 1, left arch with right aSCA (59.9%); type 2, left arch with common carotid trunk and right aSCA (30.1%); type 3, right arch with left aSCA (9.6%); and type 4, right arch with common carotid trunk and left aSCA (0.3%). Subtypes describe the right vertebral artery (RVA) and left vertebral artery (LVA) origin: subclavian (s, RVA 90.1%, LVA 96.8%), carotid (c, RVA 9.6%, LVA 0.3%), or arch (a, RVA 0.3%, LVA 2.9%). Overall, 9.9% (31/312) had associated aortic pathology, although the study was underpowered to detect a difference between right aSCA and left aSCA (9.3% vs 16.1%; P = .213). Type 3 and type 4 arches more often have associated aortic pathology, KD, and symptoms. CONCLUSIONS: aSCAs are frequently symptomatic and commonly associated with aortic dissection and aneurysm. Our proposed classification scheme depicts all four aSCA arch variants and accounts for vertebral artery origin variation. These variants are common, and vertebral anatomy can differ greatly. Knowledge of these anatomic variations is critical to planning for endovascular and open repair of aortic arch pathology.

Results from the Study to Assess Outcomes After Endovascular Repair for Multiple Thoracic Aortic Diseases (SUMMIT).

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is currently the treatment of choice for most diseases of the descending thoracic aorta. Using data from the Study to Assess Outcomes After Endovascular Repair for Multiple Thoracic Aortic Diseases (SUMMIT) study we investigated the outcomes of TEVAR for different aortic diseases and risk factors associated with the outcomes. METHODS: The SUMMIT study included aggregated data of 521 TEVAR patients from five Cook-sponsored multicenter trials evaluating thoracic endografts of the Zenith platform (William Cook Europe, ApS, Bjaeverskov, Denmark). In this post hoc analysis, primary outcomes include 30-day and 1-year mortality and morbidity and cumulative mortality and reinterventions. Cox regression analyses were performed to identify risk factors for mortality and reinterventions. RESULTS: Of the 521 patients (67% male; mean age, 67.2 ± 15 years), 329 were treated for thoracic aortic aneurysms, 56 for thoracic ulcers, 55 for acute and 31 for nonacute type B aortic dissections (TBADs), and 50 for blunt thoracic aortic injuries. The overall 30-day mortality rate was 1.7%, with perioperative stroke occurring in 3.1%, paraplegia in 1.2%, and proximal type I endoleak in 0.4% of patients within 30 days. At 1 year, the cumulative rate was 8.1% for all-cause mortality, 4.0% for stroke, 1.2% for paraplegia, 0.8% for proximal type I endoleak, and 6.0% for secondary interventions. Multivariate analysis showed that significant predictors for all-cause mortality included age (hazard ratio [HR], 1.04 for each additional year), congestive heart failure (HR, 2.87), serum creatinine (HR, 1.19 per 1 mg/dL), iliac tortuosity (HR, 1.32), blood transfusion (HR, 1.59 per 500 mL of packed red blood cells), and occurrence of 30-day stroke (HR, 3.93), paraplegia (HR, 7.79), or paraparesis (HR, 2.46). Patients treated for dissection, but not for thoracic aortic aneurysm or blunt thoracic aortic injury, demonstrated significantly higher risk for reintervention (HR, 5.65 for acute and 6.60 for nonacute TBADs) compared with patients treated for thoracic ulcers (reference group). Intraoperative contrast material (HR, 1.31 per 100 mL) and blood transfusion volumes (HR, 1.42 per 500 mL of packed red blood cells), surrogates of case complexity, were also significant predictors for reintervention. CONCLUSIONS: The results from the SUMMIT study demonstrated exceptionally low mortality and stroke rates at 30 days and low aortic disease-related mortality during follow-up. TBAD is associated with a higher risk for reintervention, possibly attributed to the natural history of the disease, whereas age, reduced cardiac and renal functions, difficult iliac access anatomy, intraoperative transfusion, and early neurologic complications are associated with higher risk for cumulative all-cause mortality.

Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones.

PURPOSE: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. METHODS: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. RESULTS: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. CONCLUSION: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.

The cardiovascular pathologist in the aortic team.

Aortic diseases require a multidisciplinary management for diagnosis, treatment and follow-up with better outcomes in referral centers using a team-based approach. The setting up of a multi-disciplinary aortic team for the discussion of complex cases has been already proposed; it is also supported by the ACC/AHA. Surgeons and radiologists, more or less other physicians such as cardiologists, geneticists, rheumatologists/internal medicine specialists and pathologists are involved into such a team. The role of the cardiovascular pathologist is to examine the aortic specimens, to diagnose and classify the aortic lesions. Herein, the role of the pathologist in the aortic team is discussed and the pathobiology of aortic diseases is reviewed for reference by pathologists. The aortic specimens are mainly obtained from emergency or elective surgical procedures on the thoracic aorta, less frequently from organ/tissue (including cardiac or heart valve) donors, post-mortem procedures or abdominal aortic surgery. In the last decade, together with the progress of medical sciences, the histological definitions and classifications of the aortic pathology are undergoing thorough revisions that are addressed to an etiopathogenetic approach because of possible clinico-pathological correlations, therapeutic and prognostic impact. Pathologists may also have an important role in research and teaching. Therefore, histological analyses of the aortic specimens require adequate sample processing and pathologist expertise because histology contributes to definite diagnosis, correct management of patients and even (in genetic diseases) families, but also to research in the challenging field of aortopathies.

Anterolateral thoracotomy with partial sternotomy: a feasible approach for treating the complex pathology of the aortic arch.

OBJECTIVES: Our goal was to review our surgical experiences in patients with complex pathologies of the aortic arch who have undergone anterolateral thoracotomy with a partial sternotomy (ALPS). METHODS: From October 2019 to November 2023, a total of 23 patients underwent one-stage repairs of complex pathologies of the aortic arch through the ALPS approach. The mean age was 61.9 ± 16.7 years old. The aortic pathologies were as follows: aorta-related infection in 11 (aorto-oesophageal fistula: 4, graft infection: 6, native aortic infection: 1); aortic dissection in 9 including shaggy aorta in 2, non-dissecting aneurysm in 1, and coarctation of the aorta (CoA) in 2. RESULTS: Eighteen patients underwent aortic replacement from either the sinotubular junction or the ascending aorta to the descending aorta; 1 patient underwent it from the aortic root to the descending aorta (redo Bentall procedure and extensive aortic arch replacement); 3 patients underwent it from the aortic arch between the left carotid artery and left subclavian artery to the descending aorta; and 1 patient underwent a descending aortic replacement. Ten patients underwent omentopexy, latissimus dorsi muscle flap installation or both procedures. The hospital mortality rate was 13.0% (3/23). The overall survival and freedom from aortic events were 73.3%±10.2% and 74.1%±10.2%, respectively, at the 3-year follow-up. There was an absence of aorta-related deaths, and no recurrent infections were identified. CONCLUSIONS: The short-term outcomes using the ALPS approach for the treatment of complex pathologies of the aortic arch were acceptable. Further studies will be required to determine the long-term results.

Pathology and pathophysiology of the aortic root.

Pathologies of the aortic root amenable to repair with valve preservation include aneurysm formation, development of aortic insufficiency (AI) and aortic dissection. In the normal aortic root, the walls are constructed of 50-70 layers of concentric lamellar units. These units consist of sheets of elastin sandwiching smooth muscle cells interspersed with collagen and glycosaminoglycans. Medial degeneration results in disruption of the extracellular matrix (ECM), loss of smooth muscle cells and pooling of proteoglycans/glycosaminoglycans. These structural changes are associated with aneurysm formation. Aortic root aneurysms are commonly linked to hereditary thoracic aortic diseases including Marfan syndrome and Loeys-Dietz syndrome. One important pathway for hereditary thoracic aortic diseases is the transforming growth factor-ß (TGF-ß) cell-signalling pathway. Pathogenic gene mutations affecting various levels of this pathway have been implicated in aortic root aneurysm formation. Secondary effects of aneurysm formation include AI. Severe chronic AI leads to a pressure and volume load on the heart. Once symptoms develop or significant left ventricular remodelling and dysfunction occurs, the patient's prognosis is poor without surgery. Another consequence of aneurysm formation and medial degeneration is the risk of aortic dissection. Aortic root surgery is performed in 34-41% of surgeries for type A aortic dissection. Predicting those who will experience aortic dissections remains a challenge. Finite element analysis, study of fluid-structure interactions and aortic wall biomechanics are important areas of ongoing research.

Systematic Review and Meta-Analysis of the Incidence of Rupture, Repair, and Death of Small and Large Abdominal Aortic Aneurysms under Surveillance.

BACKGROUND: The ultimate goal of treating patients with abdominal aortic aneurysms (AAAs) is to repair them when the risk of rupture exceeds the risk of repair. Small AAAs demonstrate a low rupture risk, and recently, large AAAs just above the threshold (5.5-6.0 cm) seem to be at low risk of rupture as well. The present review aims to investigate the outcomes of AAAs under surveillance through a comprehensive systematic review and meta-analysis. METHODS: PubMed, Embase, and the Cochrane Central Register were searched (22 March 2022; PROSPERO; #CRD42022316094). The Cochrane and PRISMA statements were respected. Blinded systematic screening of the literature, data extraction, and quality assessment were performed by two authors. Conflicts were resolved by a third author. The meta-analysis of prevalence provided estimated proportions, 95% confidence intervals, and measures of heterogeneity (I2). Based on I2, the heterogeneity might be negligible (0-40%), moderate (30-60%), substantial (50-90%), and considerable (75-100%). The primary outcome was the incidence of AAA rupture. Secondary outcomes included the rate of small AAAs reaching the threshold for repair, aortic-related mortality, and all-cause mortality. RESULTS: Fourteen publications (25,040 patients) were included in the analysis. The outcome rates of the small AAA group (<55 mm) were 0.3% (95% CI 0.0-1.0; I2 = 76.4%) of rupture, 0.6% (95% CI 0.0-1.9; I2 = 87.2%) of aortic-related mortality, and 9.6% (95% CI 2.2-21.1; I2 = 99.0%) of all-cause mortality. During surveillance, 21.4% (95% CI 9.0-37.2; I2 = 99.0%) of the initially small AAAs reached the threshold for repair. The outcome rates of the large AAA group (>55 mm) were 25.7% (95% CI 18.0-34.3; I2 = 72.0%) of rupture, 22.1% (95% CI 16.5-28.3; I2 = 25.0%) of aortic-related mortality, and 61.8% (95% CI 47.0-75.6; I2 = 89.1%) of all-cause mortality. The sensitivity analysis demonstrated a higher rupture rate in studies including <662 subjects, patients with a mean age > 72 years, >17% of female patients, and >44% of current smokers. CONCLUSION: The rarity of rupture and aortic-related mortality in small AAAs supports the current conservative management of small AAAs. Surveillance seems indicated, as one-fifth reached the threshold for repair. Large aneurysms had a high incidence of rupture and aortic-related mortality. However, these data seem biased by the sparse and heterogeneous literature overrepresented by patients unfit for surgery. Specific rupture risk stratified by age, gender, and fit-for-surgery patients with large AAAs needs to be further investigated.

Yield of Echocardiography in Ischemic Stroke and Patients With Transient Ischemic Attack With Established Indications for Long-Term Direct Oral Anticoagulant Therapy: A Cross-Sectional Diagnostic Cohort Study.

Background We aimed to determine the diagnostic yield of transthoracic (TTE) and transesophageal echocardiography (TEE) in patients with ischemic stroke and transient ischemic attack with established indications for direct oral anticoagulants before the index event. Methods and Results This was a retrospective cohort study of consecutive patients with preceding established indications for long-term therapeutic direct oral anticoagulants presenting to a single comprehensive stroke center with ischemic stroke or transient ischemic attack. Choice of echocardiography modality was based on expert recommendations. The primary outcome was a composite of prespecified management-relevant high-risk findings adjudicated by an expert panel, based on TTE and TEE reports according to evidence-based recommendations. Explorative analyses were performed to identify biomarkers associated with the primary outcome. Of 424 patients included (median [interquartile range] age, 78 [70-84] years; 175 [41%] women; National Institutes of Health Stroke Scale, 4 [1-12]; 67% atrial fibrillation), 292 (69%) underwent echocardiography, while 132 (31%) did not. Modality was TTE in 191 (45%) and TEE in 101 (24%). Median time from index event to echocardiography was 2 (1-3) days. TTE identified 26 of 191 (14%) patients with 35 management-relevant pathologies. TEE identified 16 of 101(16%) patients with 20 management-relevant pathologies. Most management-relevant findings represented indicated coronary artery disease and valvular pathologies. In a further 3 of 191 (2%) patients with TTE and 4 of 101 (4%) patients with TEE, other relevant findings were identified. Variables associated with management-relevant high-risk pathologies included more severe stroke, diabetes, and laboratory biomarkers (NT-proBNP [N-terminal pro-B-type natriuretic peptide], C-reactive protein, d-dimer, and troponin levels). Conclusions In patients with established indications for long-term direct oral anticoagulant therapy and stroke who received echocardiography, both TTE and TEE identified a relevant and similar proportion of management-relevant high-risk pathologies and predictive biomarkers could help to guide diagnostic workup in such patients.

Identifying risk factors for early neurological outcomes following thoracic endovascular aortic repair using the SUMMIT database.

OBJECTIVES: The aim of this study was to assess risk factors for early neurological complications following thoracic endovascular aortic repair (TEVAR) for multiple thoracic aortic diseases using an aggregated dataset. METHODS: The Study to Assess Outcomes After Endovascular Repair for Multiple Throacic Aortic Disease dataset included data from 6 studies evaluating Zenith thoracic endografts. Post hoc analysis identified early (30-day) neurological complications by TEVAR indication and corresponding risk factors. RESULTS: The study included 594 TEVAR patients (67% male; mean age 66 ± 15 years) with thoracic aortic aneurysm (n = 329), ulcer (n = 56), acute (n = 126) or non-acute (n = 33) type B aortic dissection (TBAD) or blunt injury (n = 50). Overall early stroke rate was 3.5% (n = 21). Overall early paraplegia and paraparesis rates were 1.3% (n = 8) and 2.5% (n = 15), respectively. Multivariable analysis identified acute TBAD [versus others, odds ratio (OR) = 3.47, 95% confidence internal (CI): 1.41-8.52) and longer procedural time (OR = 1.33, CI: 1.02-1.73) as early stroke risk factors. Risk factors for paraplegia or paraparesis included more endografts deployed (OR = 2.43, CI: 1.30-4.55), older age (OR = 1.05, CI: 1.01-1.10) and higher preoperative serum creatinine (OR = 1.31, CI: 1.05-1.64). Endografts landing proximal to the left subclavian artery (LSA) increased stroke rate (versus distal to the LSA; 6.8% vs 2.3%, P = 0.014). Intraoperative LSA revascularization was performed in 20.9% of patients with endografts proximal to the LSA; revascularization did not significantly alter stroke rate (8.1% with revascularization vs 6.4% without, P = 0.72). CONCLUSIONS: Acute TBAD and prolonged procedure time increased early stroke risk, while more endografts placed, age and preoperative renal impairment increased early paraplegia or paraparesis risk. For acute TBAD, endograft placement proximal to the LSA, but not LSA patency, increased stroke risk.

Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience.

Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.

The 3-step approach for the treatment of multisegmental thoraco-abdominal aortic pathologies.

OBJECTIVES: The goal of this study was to describe our 3-step approach to treat multisegmental thoraco-abdominal aortic disease due to aortic dissection and to present our initial clinical results. METHODS: Nine patients with multisegmental thoraco-abdominal aortic pathology due to aortic dissection underwent our 3-step approach, which consisted of total aortic arch replacement via the frozen elephant trunk technique, thoracic endovascular aortic repair for distal extension down to the level of the thoraco-abdominal transition and, finally, open thoraco-abdominal aortic replacement for the remaining downstream aortic segments. We assessed their baseline and aortic characteristics, previous aortic procedures, intraoperative details, clinical outcomes and follow-up data. RESULTS: The median age was 58 (42-66) years; 4 patients (44%) presented connective tissue disease. Eight patients (89%) had undergone previous aortic surgery for aortic dissection. In-hospital mortality was 0% (n = 0). None suffered symptomatic spinal cord injury or disabling stroke. During the follow-up period, 1 patient died of acute biliary septic shock 6 months after thoraco-abdominal aortic replacement. CONCLUSIONS: The 3-step approach to treat multisegmental thoraco-abdominal aortic pathology due to aortic dissection, which involves applying both open and endovascular techniques, is associated with an excellent clinical outcome and low perioperative risk. Distal shifting of the disease process through the thoracic endovascular aortic repair extension-and thereby necessitating limited open thoraco-abdominal aortic repair-seems to be the major factor enabling these favourable results. IRB APPROVAL: IRB approval was obtained (No. 425/15) from the institutional review board of the University of Freiburg.