Eversion technique versus traditional carotid endarterectomy with patch angioplasty: a systematic review with meta-analyses and trial sequential analysis.

Introduction: The use of an 'eversion' technique is not unequivocally proven to be superior to carotid endarterectomy with patch angioplasty. An up-to-date systematic review is needed for evaluation of benefits and harms of these two techniques. Methods: RCTs comparing eversion technique versus endarterectomy with patch angioplasty in patients with a symptomatic and significant (≥50 %) stenosis of the internal carotid artery were enrolled. Primary outcomes were all-cause mortality rate, health-related quality of life and serious adverse events. Secondary outcomes included 30-day stroke and mortality rate, (a) symptomatic arterial occlusion or restenosis, and adverse events not critical for decision making. Results: Four RCTs were included with 1272 surgical procedures for carotid stenosis; eversion technique n = 643 and carotid endarterectomy with patch closure n = 629. Meta-analysis comparing both techniques showed, with a very low certainty of evidence, that eversion technique might decrease the number of patients with serious adverse events (RR 0.47; 95% CI 0.34 to 0.64; p ≤ 0.01). However, no difference was found on the other outcomes. TSA demonstrated that the required information sizes were far from being reached for these patient-important outcomes. All patient-relevant outcomes were at low certainty of evidence according to GRADE. Conclusions: This systematic review showed no conclusive evidence of any difference between eversion technique and carotid endarterectomy with patch angioplasty in carotid surgery. These conclusions are based on data obtained in trials with very low certainty according to GRADE and should therefore be interpreted cautiously. Until conclusive evidence is obtained, the standard of care according to ESVS guidelines should not be abandoned.

Stroke Following Thoracic Endovascular Aortic Repair: Determinants, Short and Long Term Impact.

We performed a contemporary assessment of clinical and radiographic factors of stroke after thoracic endovascular aortic repair (TEVAR). Patients undergoing TEVAR from 2006 to 2017 were identified. We assessed clinical and radiographic data, including preoperative head and neck computed tomography, Doppler ultrasonography, and intraoperative angiography. Our primary outcome was stroke after TEVAR. Four hundred seventy-nine patients underwent TEVAR, mean age 68.1 ± 19.5 years, 52.6% male. Indications for TEVAR included aneurysms (n = 238, 49.7%) or dissections (n = 152, 31.7%). Ishimaru landing zones were Zone 2 (n = 225, 47.0%), Zone 3 (n = 151, 31.5%), or Zone 4 (n = 103, 21.5%). Stroke occurred in 3.8% (n = 18) of patients, with 1.9% (8) major events (modified Rankin Scale >3). Pathophysiology was predominantly embolic (n = 14), and occurred in posterior (n = 6), anterior (n = 6), or combined circulation (n = 4), and in the left hemisphere (n = 10) or bilateral (n = 6). Univariate analysis suggested use of lumbar drain (33.3% versus 57.2%, P = 0.04), inability to revascularize the left subclavian artery (16.7% vs 5.2%, P = 0.04) and number of implanted components (2.5 ± 1.2 vs 2.0 ± 0.97, P = 0.03) were associated with stroke. Multivariable analysis identified number of implanted components (OR 1.7, 95%CI 1.17-2.67 P = 0.00) and inability to revascularize the left subclavian artery as independent predictors of stroke. Stroke was associated with a higher perioperative mortality (27.8% vs 3.9%, P < 0.01). Stroke after TEVAR is primarily embolic in nature and related to both anatomic and procedural factors. This may have important implications for device development in the era of endovascular arch repair.

Left ventricular remodeling following aortic root and ascending aneurysm repair.

Objective: Adverse left ventricular remodeling due to a mismatch between stiffness of native aortic tissue and current polyester grafts may be under-recognized. This study was conducted to evaluate the impact of proximal aortic replacement on adverse remodeling of the left ventricle. Materials and methods: All aortic root and ascending aortic aneurysm patients were identified (n = 2,001, 2006-2019). The study cohort consisted of a subset of patients (n = 98) with two or more electrocardiogram (ECG)-gated CT angiograms, but without concomitant aortic valve disease or bicuspid aortic valve, connective tissue disease, acute aortic syndrome or prior history of aortic repair or mitral valve surgery. LV myocardial mass was measured from CT data and indexed to body surface area (LVMI). The study cohort was divided into a surgery group (n = 47) and a control group; optimal medical therapy group (OMT, n = 51). Results: The mean age was 60 ± 11 years (80% male). Beta-blocker use was significantly more frequent in the surgery group (89 vs. 57%, p < 0.001), whereas, all other antihypertensive drugs were more frequent in the OMT group. The average follow-up was 9.1 ± 4.0 months for the surgery group and 13.7 ± 6.3 months for the OMT group. Average LVMI at baseline was similar in both groups (p = 0.934). LVMI increased significantly in the surgery group compared to the OMT group (3.7 ± 4.1 vs. 0.6 ± 4.4 g/m2, p = 0.001). Surgery, baseline LVMI, age, and sex were found to be independent predictors of LVMI increased on multivariable analysis. Conclusion: Proximal aortic repair with stiff polyester grafts was associated with increased LV mass in the first-year post-operative and may promote long-term adverse cardiac remodeling. Further studies should be considered to evaluate the competing effects of aortic aneurysm related mortality against risks of long-term graft induced aortic stiffening and the potential implications on current size thresholds for intervention.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms.

BACKGROUND: Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood. METHODS: We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival. RESULTS: Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72 years; range, 18-94 years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5 years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P = 0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P = 0.034) and preoperative serum albumin level <3 g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P = 0.033) were preoperative parameter that predicted persistent infection. A C-reactive protein level more than 5 mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P < 0.001) was observed in patients with persistent infection. CONCLUSIONS: EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3 g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Mid-Term Outcomes of Chimney Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-analysis.

BACKGROUND: To provide an overview of the literature on the mid-term outcomes of chimney EVAR (ChEVAR) for the treatment of juxtarenal abdominal aortic aneurysms (JAAA). METHODS: Different electronic databases were searched for published articles up to January 2020. The eligibility criteria were studies describing mid- or long-term outcomes of chimney EVAR (mean follow-up at least 1 year) for treatment of JAAA, including more than 10 cases, published in English, and with full text available. The outcomes measure were overall survival rate, target vessel patency, and freedom from reintervention at 3 years. Quality of the included studies was analyzed using the MINORS criteria. Pooled effect estimates were analyzed using random-effect models and heterogeneity was tested using I2 statistics. RESULTS: Thirteen articles met the inclusion criteria. The included studies described 1,019 patients. According to the quality assessment, methodological quality was moderate to poor. The pooled overall survival, freedom from reintervention, and target vessel patency at 3 year was 81.4 % (95%CI 73.8-87.9), 85.7% (95%CI 75.6-93.5), and 95.1% (95%CI 89.3-98.7) respectively. CONCLUSIONS: The results of this review show good to acceptable short and mid-term survival and good mid-term durability, which supports that ChEVAR as a suitable alternative in high-risk JAAA. However, proper patient selection for ChEVAR seems essential to attain good mid-term outcomes, and further large prospective and good quality studies are required to demonstrate its long-term results and enable conclusions on specific determinants for outcome.

Arterio-Ureteral Fistula: Systematic Review of 445 Patients.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but increasingly reported and potentially lethal. This systematic review comprehensively presents risk factors, pathophysiology, location and clinical presentation of AUF aiming to increase clinical awareness of this rare but life-threatening condition, and to put this entity into a contemporary perspective with modern diagnostic tools and treatment strategies. MATERIALS AND METHODS: This review was performed according to the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-Analysis of Individual Participant Data) guidelines. A literature search in PubMed® and EMBASE™ was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and followup, and were collected using a standard template by 2 independent reviewers. RESULTS: A total of 245 articles with 445 patients and 470 AUFs were included. Most patients had chronic indwelling ureteral stents (80%) and history of pelvic oncology (70%). Hematuria was observed in 99% of the patients, of whom 76% presented with massive hematuria with or without previous episodes of (micro)hematuria. For diagnosis, angiography had a sensitivity of 62%. The most predominant location of AUF was at the common iliac artery ureteral crossing. AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stents. CONCLUSIONS: AUF should be considered in patients with a medical history of vascular surgery, pelvic oncologic surgery, irradiation and/or chronic indwelling ureteral stents presenting with intermittent (micro)hematuria. A multidisciplinary consultation is necessary for diagnosis and treatment. The most sensitive test is angiography and the preferred initial treatment is endovascular.

A systematic review of the current status of interventions for type II endoleak after EVAR for abdominal aortic aneurysms.

OBJECTIVE: To study the mid- and long-term outcomes of type II endoleak treatment after EVAR and the technical aspects of different techniques to exclude endoleaks which different embolic agents. METHODS: A systematic review was performed using the approach recommended by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for meta-analyses of interventional studies. The comprehensive search was conducted using the following database: MEDLINE, EMBASE, and the Cochrane Library. Patient characteristic, intervention approaches, embolic agents, and results at mid and long term follow up were studied. RESULTS: A total of 6 studies corresponding to a total of 141 patients fulfilled the inclusion criteria with a mean age of 73-78.6 years and a mean duration of follow up varying from 25 to 42 months. There were different techniques for embolization used (translumbar, transarterial, and transcaval approach) with various types of embolic agents. In all studies, the indication for embolization of the type II endoleaks was sac enlargement of more than 5 mm. A wide range of technical success rate was reported regardless of the intervention strategy being used (17,6%-100%). The overall technical success rate of all studies was 62%. CONCLUSION: This systematic review shows that there is a wide variety of techniques to exclude a persistent type II endoleak. Different kinds of embolic agents have be used. Due to a lack of peer reviewed data on longterm follow-up, it was not possible to come to recommendations what treatment would be the best for a durable exclusion of a persistent type II endoleak after an initially successful EVAR. There remains an urgent need for proper executed studies, either randomized or with close observation in relation to longer follow-up.

False lumen enhancement characteristics on computed tomography angiography predict risk of aneurysm formation in acute type B aortic dissection.

OBJECTIVES: Differential luminal enhancement [between true lumen (TL) and false lumen (FL)] results from differential flow patterns, most likely due to outflow restriction in the FL. We aimed to assess the impact of differential luminal enhancement at baseline computed tomography angiography on the risk of adverse events in patients with acute type B aortic dissection (TBAD). METHODS: Baseline computed tomography angiographies of patients with acute TBAD between 2007 and 2016 (n = 48) were analysed using three-dimensional software at multiple sites along the descending thoraco-abdominal aorta. At each location, we measured contrast density in TL and FL [Houndsfield unit (HU)], maximal diameter (cm) and circumferential FL extent (°). Outcome data were collected via retrospective chart review. Multivariable logistic regression models were employed to determine the independent risk of TL-FL differential luminal enhancement on aneurysm formation (maximal diameter ≥55 mm) and medical treatment failure. RESULTS: Patients were predominately male (75%) and 52.8±12.9 years at diagnosis. The mean follow-up was 5.9±2.6 years, and 42% (n = 20/48) patients were diagnosed with thoraco-abdominal aortic aneurysm. The baseline absolute difference between FL and TL contrast density measured at 2 cm distal to primary entry tear (TL-FLabs-Tear) was significantly higher among patients who developed aneurysm (26 HU, IQR: 15-53 vs 13 HU, IQR: 4-24, P = 0.001). Aneurysm development during follow-up was predicted by TL-FLabs-Tear (odds ratio 1.07, P = 0.012) and baseline maximal aortic diameter (odds ratio 1.90, P < 0.001). High (≥18 HU) differential luminal enhancement was associated with lower rates of aneurysm-free survival and higher rates of medical treatment failure. CONCLUSIONS: Differential luminal enhancement may be a novel predictor of aneurysm formation among patients with acute TBAD.

Radiation Awareness for Endovascular Abdominal Aortic Aneurysm Repair in the Hybrid Operating Room: An Instant Operator Risk Chart for Daily Practice.

INTRODUCTION: While the operator radiation dose rates are correlated to patient radiation dose rates, discrepancies may exist in the effect size of each individual radiation dose predictors. An operator dose rate prediction model was developed, compared with the patient dose rate prediction model, and converted to an instant operator risk chart. MATERIALS AND METHODS: The radiation dose rates (DRoperator for the operator and DRpatient for the patient) from 12,865 abdomen X-ray acquisitions were selected from 50 unique patients undergoing standard or complex endovascular aortic repair (EVAR) in the hybrid operating room with a fixed C-arm. The radiation dose rates were analyzed using a log-linear multivariable mixed model (with the patient as the random effect) and incorporated varying (patient and C-arm) radiation dose predictors combined with the vascular access site. The operator dose rate models were used to predict the expected radiation exposure duration until an operator may be at risk to reach the 20 mSv year dose limit. The dose rate prediction models were translated into an instant operator radiation risk chart. RESULTS: In the multivariate patient and operator fluoroscopy dose rate models, lower DRoperator than DRpatient effect size was found for radiation protocol (2.06 for patient vs 1.4 for operator changing from low to medium protocol) and C-arm angulation. Comparable effect sizes for both DRoperator and DRpatient were found for body mass index (1.25 for patient and 1.27 for the operator) and irradiated field. A higher effect size for the DRoperator than DRpatient was found for C-arm rotation (1.24 for the patient vs 1.69 for the operator) and exchanging from femoral access site to brachial access (1.05 for patient vs 2.5 for the operator). Operators may reach their yearly 20 mSv year dose limit after 941 minutes from the femoral access vs 358 minutes of digital subtraction angiography radiation from the brachial access. CONCLUSION: The operator dose rates were correlated to patient dose rate; however, C-arm angulation and changing from femoral to brachial vascular access site may disproportionally increase the operator radiation risk compared with the patient radiation risk. An instant risk chart may improve operator dose awareness during EVAR.

Imaging surveillance after open aortic repair: a feasibility study of three-dimensional growth mapping.

OBJECTIVES: Confident growth assessment during imaging follow-up is often limited by substantial variability of diameter measurements and the fact that growth does not always occur at standard measurement locations. There is a need for imaging-based techniques to more accurately assess growth. In this study, we investigated the feasibility of a three-dimensional aortic growth assessment technique to quantify aortic growth in patients following open aortic repair. METHODS: Three-dimensional aortic growth was measured using vascular deformation mapping (VDM), a technique which quantifies the localized rate of volumetric growth at the aortic wall, expressed in units of Jacobian (J) per year. We included 16 patients and analysed 6 aortic segments per patient (96 total segments). Growth was assessed by 3 metrics: clinically reported diameters, Jacobian determinant and targeted diameter re-measurements. RESULTS: VDM was able to clearly depict the presence or absence of localized aortic growth and allows for an assessment of the distribution of growth and its relation to anatomic landmarks (e.g. anastomoses, branch arteries). Targeted diameter change showed a stronger and significant correlation with J (r = 0.20, P = 0.047) compared to clinical diameter change (r = 0.15, P = 0.141). Among 20/96 (21%) segments with growth identified by VDM, growth was confirmed by clinical measurements in 7 and targeted re-measurements in 11. Agreement of growth assessments between VDM and diameter measurements was slightly higher for targeted re-measurements (kappa = 0.38) compared to clinical measurements (kappa = 0.25). CONCLUSIONS: Aortic growth is often uncertain and underappreciated when assessed via standard diameter measurements. Three-dimensional growth assessment with VDM offers a more comprehensive assessment of growth, allows for targeted diameter measurements and could be an additional tool to determine which post-surgical patients at high and low risk for future complications.

Endovascular ascending aortic repair in type A dissection: A systematic review.

PURPOSE: Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD. METHODS: A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma). RESULTS: A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%). CONCLUSION: This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.

Important longitudinal and circumferential pulsatile changes in zone 0 of the aorta during the cardiac cycle.

OBJECTIVES: Correct stent-graft sizing is important when planning for thoracic endovascular repair in zone 0. As the movements of the aorta are constantly evolving in longitudinal and circumferential directions during the cardiac cycle, the diameter may not be the only important measurement. The aim of this study is to measure the circumferential and longitudinal pulsatile changes throughout the cardiac cycle. METHODS: Ninety-two patients, who were evaluated for transcatheter aortic valve replacement, were selected for this retrospective study. Their electrocardiogram-gated cardiac computed tomography was analysed. We identified the area, perimeter and diameter of the thoracic aorta in zone 0 and calculated the differences between these parameters at 3 locations in zone 0. The measurements were made in multiplanar views perpendicular to the semi-automatically created centreline in both systolic and diastolic phases. RESULTS: The mean age of our study cohort was 77 ± 11 years. The mean change between systole and diastole of the area (mm2), perimeter (mm) and diameter (mm) were compared at 3 different locations in the ascending aorta: at the sinotubular junction (0.78 mm2 vs 0.89 mm vs 1.41 mm), mid-ascending (0.72 mm2 vs 0.68 vs 0.81 mm) and proximal edge of the brachiocephalic artery (0.76 mm2 vs 0.73 mm vs 0.73 mm). The change in percentage is the smallest in the area at the sinotubular junction compared to the perimeter and diameter (2.6% vs 3.1% vs 4.7%). CONCLUSIONS: Changes in measurement of ascending aortic diameter with cardiac cycle are larger than measurement change in the area. This is especially more pronounced in zone 0A. For more accurate information on the morphometric changes, it may be necessary to measure the area when planning for thoracic endovascular repair to maximize results. A prospective study comparing these different measurements regarding the outcomes is advised by the authors to understand the clinical implications.

Eversion technique versus conventional endarterectomy with patch angioplasty in carotid surgery: protocol for a systematic review with meta-analyses and trial sequential analysis of randomised clinical trials.

INTRODUCTION: Traditional carotid endarterectomy is considered to be the standard technique for prevention of a new stroke in patients with a symptomatic carotid stenosis. Use of patch angioplasty to restore the arterial wall after longitudinal endarterectomy is, to date, not unequivocally proven to be superior to eversion technique. A systematic review is needed for evaluation of benefits and harms of the eversion technique versus the traditional endarterectomy with patch angioplasty in patients with symptomatic carotid stenosis. METHODS AND OUTCOMES: The review will be conducted according to this protocol following the recommendations of the 'Cochrane Handbook for Systematic Reviews' and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomised clinical trials comparing eversion technique versus endarterectomy with patch angioplasty in patients with a symptomatic stenosis of the internal carotid artery will be included. Primary outcomes are all-cause mortality rate, health-related quality of life and serious adverse events. Secondary outcomes are 30-day stroke and mortality rate, symptomatic arterial restenosis or occlusion and non-serious adverse events. The databases Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE will be searched (November 2019). We will primarily base our conclusions on meta-analyses of trials with overall low-risk of bias. We will use trial sequential analysis to assist the evaluation of imprecision in Grading of Recommendations, Assessment, Development and Evaluation. However, if pooled point estimates of all trials are similar to pooled point estimates of trials with overall low risk of bias and there is lack of a statistical significant interaction between estimates from trials with overall high risk of bias and trials with overall low risk of bias we will consider the trial sequential analysis adjusted precision of the estimate achieved in all trials as the result of our meta-analyses. ETHICS AND DISSEMINATION: The proposed systematic review will collect and analyse data from published studies, therefore, ethical approval is not required. The results of the review will be disseminated by publication in a peer-review journal and submitted for presentation at conferences. PROSPERO REGISTRATION NUMBER: CRD42019119361.

Critical appraisal of multidimensional CT measurements following acute open repair of type A aortic dissection.

INTRODUCTION: To identify patients with aneurysmal degeneration of the native aorta following type A aortic dissection (TAAD), reproducible serial measurements of aortic dimensions are critical. We used a systematic workflow for measuring aortic geometry following TAAD, using computed tomography angiography data, and test its reproducibility. METHODS: The workflow for aortic measurements included centerline generation, luminal diameter, and area measurement at six anatomically defined locations along the aorta and luminal volumetric measurements in the descending aorta. Two independent observers measured the aortic geometry in 20 surgically repaired TAAD patients, preoperatively and at 3 months follow-up. To test reproducibility, intraobserver and interobserver agreement scores were analyzed using a concordance correlation coefficient (CCC). RESULTS: The interobserver agreement scores of the diameter, area, and volumetric measurements in the descending aorta were acceptable. The agreement scores of the area measurements were highest, with CCCs ranging from 0.909 to 0.984. Luminal diameter measurements scored lower than luminal area measurements and were least reproducible at the mid aortic arch (CCC < 0.886). Overall, intraobserver agreement scores were better than interobserver agreement scores (SD of mean difference was 1.89 vs 1.94 for intraobserver vs interobserver diameter measurements, and 0.61 vs 0.66 for area measurements). CONCLUSION: Although overall reproducibility was acceptable in descending aortic measurements, our results show that it remains challenging to reliably measure luminal diameters, compared with areas. To aid identification of early adverse remodeling following acute TAAD, novel two- and three-dimensional measurement techniques are needed that capture locoregional changes in the false lumen and true lumen morphology more accurately.

Impact of Aortic Tortuosity on Displacement Forces in Descending Thoracic Aortic Aneurysms.

OBJECTIVE: As elastin fibres in the aorta deteriorate with age, the descending thoracic aorta (DTA) becomes longer and more tortuous. In patients with DTA aneurysms, this increased tortuosity may result in a hostile haemodynamic environment for thoracic endovascular aortic repair (TEVAR). The objective of this study was to analyse how increased tortuosity affects haemodynamic displacement forces (DFs) in different segments of the DTA in patients with DTA aneurysms (DTAAs). METHODS: Thirty patients with DTAAs were selected to form three equal groups based on the maximum tortuosity of their DTA: low < 30°, moderate 30°-60°, and high > 60°. Computational fluid dynamics simulations were performed to calculate DFs in all patients. Image based segmentations were carried out to create patient specific models of the aortic geometry. When physiological simulation results were obtained, the haemodynamic DFs on the aortic wall were calculated in four segments of the DTA (zones 4A - D). To enable comparison of DFs in different segments, the DF was normalised by the aortic wall surface area, the equivalent surface traction (EST). RESULTS: The mean age was 73 years, with 67% male. In zone 4C, where most tortuosity occurs, the EST in patients with high tortuosity was more than three times higher, than those with low tortuosity (low, 743 N/m2; moderate, 956 N/m2; high, 2294 N/m2; p = .004). These differences could be attributed to the higher sideways components of the DF vectors, which were more than two times greater in patients with high tortuosity than in patients with low or moderate tortuosity (low, 5.01 N; moderate, 5.50 N; high, 13.21 N; p = .009). CONCLUSION: High tortuosity results in increased displacement forces in the distal segments of the DTA. These forces should be taken into account when planning for TEVAR, as potentially they increase the risk of stent graft related complications, such as migration and endoleak.

Mapping pre-dissection aortic wall abnormalities: a multiparametric assessment.

OBJECTIVES: Maximal aortic diameter is commonly used to assess aortic risk but poorly predicts the timing and location of dissection events in patients with connective tissue disease who undergo regular imaging surveillance. Hence, we aimed to use available surveillance computed tomography angiography (CTA) scans to investigate the correlation between 3-dimensional (3D) growth and cyclic transmural wall stress with the location of intimal tear formation. METHODS: Three type B aortic dissection patients with 2 available electrocardiogram (ECG)-gated pre-dissection CTA scans and without surgical repair during the pre-dissection interval were retrospectively identified at our institution. Vascular deformation mapping was used to measure 3D aortic growth between 2 pre-dissection clinical CTA studies. In addition, we performed a computational analysis to estimate cyclic transmural wall stress in patient-specific baseline CTA geometries. RESULTS: In all 3 connective tissue disease patients, the site of type B aortic intimal tear co-localized with areas of peak 3D aortic wall growth. Aortic growth was detected by clinical radiological assessment in only 1 case. Co-localization of peak transmural stress and the site of intimal tear formation were found in all cases. CONCLUSIONS: Focal areas of growth and transmural wall stress co-localized with the site of intimal tear formation. These hypothesis-generating results suggest a possible new analytic pathway for a more sophisticated assessment of the factors leading to the initiation of dissection in patients with connective tissue disease. These methods could improve on current risk-stratification techniques.

The early days of vascular and heart valve prostheses: a historical review.

This surgical heritage article provides a historical overview of the most important early advances of vascular- and valvular surgery, that lead to the development of currently used vascular- and valvular prostheses and materials. The first writings describing techniques in vascular surgery mainly focussed on hemorrhage control and date from around 1600 B.C. The strategy of vessel ligation was first mentioned in Western literature around 200 B.C. In the 18th century, techniques of ligation were expanded towards attempts of vessel restoration. The first artificial vascular prosthesis was made in 1894. From this time on, vascular prostheses were used in animal experiments and around 1900 for the first time in humans. More than 60 years later, in 1952, the first mechanical heart valve prosthesis was implanted. Four years later, the first successful biological heart valve implantation followed. In 2000, a transcatheter heart valve was successfully implanted in a human for the first time. Over time, procedures and techniques became more efficient and effective. This led to new developments, such as the manufacturing of a tissue engineered blood vessel in 1986. Nowadays, dozens of different valve prostheses have been devised, both mechanical and biological. Still, no ideal model of vascular and heart valve prosthesis exists.

Tortuosity of the Descending Thoracic Aorta in Patients with Aneurysm and Type B Dissection.

OBJECTIVE: Tortuosity in the descending thoracic aorta (DTA) comes with aging and increases the risk of endoleaks after TEVAR. With this report, we would like to define and classify tortuosity in the DTA of patients with thoracic aortic disease. METHODS: Retrospective case-control study of two hundred seven patients, comparing sixty-nine controls without aortic disease (CG), to sixty-nine patients with descending thoracic aortic aneurysm (AG) and sixty-nine patients with type B aortic dissection (DG). 3Mensio Vascular software was used to analyze CTA scans and collect the following measurements; tortuosity index, curvature ratio and the maximum tortuosity of the DTA. The DTA was divided into four equal zones. The maximum tortuosity was divided into three groups: low (<30°), moderate (30°-60°) and high tortuosity (>60°). RESULTS: Compared to the CG, tortuosity was more pronounced in the DG, and even more in the AG, evidenced by the tortuosity index (1.11 vs. 1.20 vs. 1.31; p < 0.001), curvature ratio (1.00 vs. 1.01 vs. 1.03; p < 0.001), maximum tortuosity in degrees (28.17 vs. 33.29 vs. 43.83; p < 0.001) and group of tortuosity (p < 0.001). The maximum tortuosity was further distal for the DG and AG, evidenced by the zone of maximum tortuosity (4A vs. 4B vs. 4B; p < 0.001). CONCLUSION: This study shows that tortuosity in the DTA is more prominent in diseased aortas, especially in aneurysmal disease. This phenomenon needs to be taken into account during planning of TEVAR to prevent stent graft-related complications and to obtain positive long-term outcome.

Reticulated Platelets as Predictor of Myocardial Injury and 30 Day Mortality After Non-cardiac Surgery.

OBJECTIVE: A pre-operative marker for identification of patients at risk of peri-operative adverse events and 30 day mortality might be the percentage of young, reticulated platelets (pRP). This study aimed to determine the predictive value of pre-operative pRP on post-operative myocardial injury (PMI) and 30 day mortality, in patients aged ≥ 60 years undergoing moderate to high risk non-cardiac surgery. METHODS: The incidence of PMI (troponin I > 0.06 µg/L) and 30 day mortality was compared for patients with normal and high pRP (≥2.82%) obtained from The Utrecht Patient Orientated Database. The predictive pRP value was assessed using logistic regression. A prediction model for PMI or 30 day mortality with known risk factors was compared with a model including increased pRP using the area under the receiving operator characteristics curve (AUROC). RESULTS: In total, 26.5% (607/2289) patients showed pre-operative increased pRP. Increased pRP was associated with more PMI and 30 day mortality compared with normal pRP (36.1% vs. 28.3%, p < .001 and 8.6% vs. 3.6%, p < .001). The median pRP was higher in patients suffering PMI and 30 day mortality compared with not (2.21 [IQR: 1.57-3.11] vs. 2.07 [IQR: 1.52-1.78], p = .002, and 2.63 [IQR: 1.76-4.15] vs. 2.09 [IQR: 1.52-3.98], p < .001). pRP was independently related to PMI (OR: 1.28 [95% CI: 1.04-1.59], p = .02) and 30 day mortality (OR: 2.35 [95% CI: 1.56-3.55], p < .001). Adding increased pRP to the predictive model of PMI or 30 day mortality did not increase the AUROC 0.71 vs. 0.72, and 0.80 vs. 0.81. CONCLUSION: In patients undergoing major non-cardiac surgery, increased pre-operative pRP is related to 30 day mortality and PMI.

Type 1b Endoleaks After Thoracic Endovascular Aortic Repair are Inadequately Reported: A Systematic Review.

BACKGROUND: Complications after thoracic endovascular aortic repair (TEVAR) are common. Even after a successful TEVAR, a late endoleak (>30 days) can occur. The objective of this study is to summarize the current evidence and, if lacking, the need of evidence regarding the incidence and predictive factors for type 1b endoleak in patients with aortic aneurysm treated with TEVAR. METHODS: A systematic review of the literature was performed on endoleak type 1b, in patients with aortic aneurysm, after TEVAR. The PubMed and Embase databases were systematically searched for articles regarding endoleak type 1b up to January 2019. The main subjects discussed are the incidence, risk factors, treatment, and prognosis. RESULTS: About 722 articles were screened, and 16 articles were included in this review. The reported incidence of endoleak is between 1.0% and 15.0%, with a mean follow-up duration of at least 1 year. Type 1b endoleak is associated with an increased aortic tortuosity index (>0.15 cm-1). No significant difference is found in relation to age and gender. Treatment is required in most cases (22/27) and is usually performed with distal extension of the stent graft (21/27). There are no data regarding stent graft oversizing, length of distal landing zone, and differences between devices or the prognosis for patients with type 1b endoleak. CONCLUSIONS: Limited literature is available on the occurrence of type 1b endoleak after TEVAR. A tortuous aorta can be associated as a predictive factor for the occurrence of type 1b endoleak. Data clearly delineating the anatomic variables predicting type 1b endoleak should be examined and listed. Likewise, the impact of more recent conformable devices to prevent complications like type 1b endoleaks from occurring should be elucidated.