Sex Representation Among Principal Investigators in Cardiac Surgery Clinical Trials in the United States: The Glass Ceiling and Room for Improvement.

OBJECTIVE: The aim of this study was to determine the sex representation among principal investigators (PIs) in US cardiac surgery clinical trials. SUMMARY BACKGROUND DATA: Being a principal investigator in a US clinical trial confers national recognition among peers. Sex representation among principal investigators (PIs) in US cardiac surgery clinical trials has not been evaluated. METHODS: We evaluated 124 US cardiac surgery trials registered on Clin-icalTrials.gov from 2014 to 2019. Sixty trials included PIs (n = 266) from 128 institutions that had a combined total of 1040 adult cardiac surgeons. We examined sex representation among junior-level (instructor or assistant professor) and senior-level (associate, full, or Emeritus professor) PIs by calculating the participation-to-prevalence ratio (PPR), whereby a PPR range of 0.8 to 1.2 reflects equitable representation. RESULTS: The pool representation percentage was 6.1% (63/1040) for women and 93.9% (977/1040) for men. A total of 266 PI positions were assigned to adult cardiac surgeons: 6 (9.5%; PPR = 0.37) from the female pool and 260 (26.6%; PPR = 1.04) from the male pool ( P = 0.004). The percentage of PIs with studies funded by industry was 9.5% ofthe female pool (PPR = 0.39) and 25.0% of the male pool (PPR = 1.04) ( P = 0.009). No National Institutes of Health-funded or other funded trials had female PIs. An overall trend was observed toward disproportionally more men than women among PIs, especially at the senior level ( P = 0.027). CONCLUSIONS: Equitable opportunities for PI positions are available for junior-level but not senior-level cardiothoracic surgeons. These results suggest a need for active engagement and promotion of equal opportunities in cardiac surgery.

Surgical and endovascular treatment of late postcoarctation repair aortic aneurysms: Results from an international multicenter study.

OBJECTIVE: The formation of postaortic coarctation aneurysms (pCoAA) is well-described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair, depending on the clinical presentation, risk assessment, and anatomy. The aim of this study was to report the early and midterm results of open surgical and endovascular repair of pCoAA. METHODS: This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The preoperative, intraoperative, and postoperative data were recorded and analyzed. RESULTS: A total of 74 patients (46 male; median age, 44 years; interquartile range [IQR], 35-53 years) underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation at a median age of 11 years for the index procedure (IQR, 7-17 years). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. The median pCoAA diameter was 54 mm (IQR, 44-63 mm). The median time from the aortic coarctation repair to the pCoAA diagnosis was 33 years (IQR, 25-40 years). A total of 33 patients had symptoms at presentation, including thoracic or back pain in 8 patients. Open surgical repair was performed in 28 patients, including four frozen elephant trunk procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one frozen elephant trunk and one endovascular). After a median follow-up of 50 months (IQR, 14-127 months), there were a total of seven reinterventions. CONCLUSIONS: This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Because the median time between the coarctation repair and the aneurysm formation was more than 30 years, life-long surveillance of these patients is warranted.

In-hospital outcomes and long-term survival of women of childbearing age with aortic dissection.

OBJECTIVE: In the present study, we defined the outcomes and effects of pregnancy in a cohort of women of childbearing age with acute aortic dissection (AAD). METHODS: We reviewed our database of AAD to identify all eligible female patients. Women aged <45 years were included. Data on pregnancy timing with respect to the occurrence of dissection, the demographic data, dissection extent, dissection treatment, dissection-related outcomes, overall maternal and fetal mortality, and genetic testing results were analyzed. RESULTS: A total of 62 women aged <45 years had presented to us with AAD from 1999 to 2017. Of the 62 women, 37 (60%) had had a history of pregnancy at AAD. Of these 37 patients, 10 (27%) had had a peripartum aortic dissection, defined as dissection during pregnancy or within 12 months postpartum. Of the 10 AADs, 5 were type A and 5 were type B. Three patients had presented with AAD during pregnancy (one in the second and two in the third trimester). Five patients (50%) had developed AAD in the immediate postpartum period (within 3 months) and two (20%) in the late postpartum period. For the immediate postpartum AADs (<3 months), four of the five patients delivered via cesarean section. Of these 10 peripartum AADs, 3 (30%) had occurred in patients with known Marfan syndrome. In-hospital mortality for those with peripartum AAD was 10% (1 of 10). Fetal mortality was 20% (2 of 10). CONCLUSIONS: The frequency of aortic dissection in women of childbearing age at our institution was low. However, pregnancy might increase the risk of those young women genetically predisposed to dissection events. From these data, this risk appears to be greatest in the immediate postpartum period, even for those who undergo cesarean section. Close clinical and radiographic surveillance is required for all women with suspected aortopathy, especially in the third trimester and early postpartum period.

Validation of scoring system predicting permanent pacemaker implantation after transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is being increasingly performed in patients with severe aortic stenosis. Despite newer generation valves, atrioventricular (AV) conduction disturbance is a common complication, necessitating permanent pacemaker (PPM) implantation in about 10% of patients. Hence, it is imperative to improve periprocedural risk stratification to predict PPM implantation after TAVR. The objective of this study was to externally validate a novel risk-stratification model derived from the National Inpatient Sample (NIS) database that predicts risk of PPM from TAVR. METHODS: Components of the score included pre-TAVR left and right bundle branch block, sinus bradycardia, second-degree AV block, and transfemoral approach. The scoring system was applied to 917 patients undergoing TAVR at our institution from November 2011 to February 2017. We assessed its predictive accuracy by looking at two components: discrimination using the C-statistic and calibration using the Hosmer-Lemeshow goodness of fit test. RESULTS: Ninety patients (9.8%) required PPM. The scoring system showed good discrimination with C-statistic score of 0.6743 (95% CI: 0.618-0.729). Higher scores suggested increased PPM risk, that is, 7.3% with score ⩽3, 19.23% with score 4-6, and 37.50% with score ≥7. Patients requiring PPM were older (81.4 versus 78.7 years, P = .002). Length of stay and in-hospital mortality was significantly higher in PPM group. CONCLUSIONS: The NIS database derived PPM risk prediction model was successfully validated in our database with acceptable discriminative and gradation capacity. It is a simple but valuable tool for patient counseling pre-TAVR and in identifying high-risk patients.

Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD.

BACKGROUND: Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data. METHODS: Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am. RESULTS: Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference. CONCLUSIONS: A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.

Clinically Important Misclassification of Aortic Valve Stenosis Severity Using Non-Invasive Techniques: Simultaneous Echocardiography and Cardiac Catheterization During Transcatheter Aortic Valve Implantation in Awake Patients.

BACKGROUND: Suitability for transcatheter aortic valve (AV) implantation (TAVI) is determined by using transthoracic echocardiography (TTE), although left-sided cardiac catheterization (LCC) provides directly measured pressure data. TAVI in awake patients permits simultaneous comparison of TTE and LCC under physiologically relevant left ventricular loading conditions. We hypothesized that clinically important discrepancies between TTE and LCC would be identified. METHODS AND RESULTS: TAVI was performed in 108 awake patients undergoing intra-procedural TTE and LCC between January 1, 2016 and December 31, 2016, based upon pre-procedure TTE data. Intra-procedural assessments simultaneously were performed before and after prosthesis implantation. Based upon mean trans-AV systolic ejection pressure gradient (MSEPG), AS was graded as: mild (<20 mm Hg; grade 1), moderate (20 - <40 mm Hg; grade 2), or severe (≥40 mm Hg; grade 3). In 79 of the 108 (73.1%) patients, intra-procedural TTE and LCC assessments were concordant. In 2 of the 108 (1.9%) patients, TTE overestimated AS severity by ≥1 grade. In 27 of the 108 (25.0%) patients, TTE underestimated AS severity by ≥1 grade. In total, AS severity reclassification occurred in 29 (26.9%) patients. Overall, TTE underestimated MSEPG by 8.9 ± 1.2 mm Hg (TTE MSEPG versus LCC MSEPG; P < .001). CONCLUSION: Current TTE criteria appear to frequently and importantly underestimate AS severity. Because decision-making regarding TAVI often exclusively is based upon TTE data, these findings suggest either a continued role for LCC in the diagnostic assessment of AS in patients who do not meet standard TTE criteria or lowering TTE cutoffs for TAVI.

Genetic Variants in LRP1 and ULK4 Are Associated with Acute Aortic Dissections.

Acute aortic dissections are a preventable cause of sudden death if individuals at risk are identified and surgically repaired in a non-emergency setting. Although mutations in single genes can be used to identify at-risk individuals, the majority of dissection case subjects do not have evidence of a single gene disorder, but rather have the other major risk factor for dissections, hypertension. Initial genome-wide association studies (GWASs) identified SNPs at the FBN1 locus associated with both thoracic aortic aneurysms and dissections. Here, we used the Illumina HumanExome array to genotype 753 individuals of European descent presenting specifically with non-familial, sporadic thoracic aortic dissection (STAD) and compared them to the genotypes of 2,259 control subjects from the Atherosclerosis Risk in Communities (ARIC) study matched for age, gender, and, for the majority of cases, hypertension. SNPs in FBN1, LRP1, and ULK4 were identified to be significantly associated with STAD, and these results were replicated in two independent cohorts. Combining the data from all cohorts confirmed an inverse association between LRP1 rs11172113 and STAD (p = 2.74 × 10(-8); OR = 0.82, 95% CI = 0.76-0.89) and a direct association between ULK4 rs2272007 and STAD (p = 1.15 × 10(-9); OR = 1.35, 95% CI = 1.23-1.49). Genomic copy-number variation analysis independently confirmed that ULK4 deletions were significantly associated with development of thoracic aortic disease. These results indicate that genetic variations in LRP1 and ULK4 contribute to risk for presenting with an acute aortic dissection.

The role of ascending aortic size in outcomes of patients with uncomplicated acute type B aortic dissection.

OBJECTIVE: Recent studies demonstrate that uncomplicated acute type B aortic dissection (uATBAD) patients with enlarged descending thoracic aortic diameters are at high risk for development of complications. This study aimed to determine the association of maximum ascending aortic diameter and area and outcomes in patients with uATBAD. METHODS: All patients admitted with uATBAD from June 2000 to January 2015 were reviewed, and those with available imaging were included. All measurements were obtained by a specialized cardiovascular radiologist, including the maximum ascending aortic diameter and area. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analyses using SAS 9.4 software (SAS Institute, Cary, NC). RESULTS: During the study period, 298 patients with uATBAD were admitted, with 238 having available computed tomography and 131 having computed tomography angiography imaging and adequate follow-up available for analysis. The cohort had an average age of 60.96 ± 13.4 years (60% male, 53% white). Ascending aortic area >12.1 cm2 and ascending aortic diameter >40.8 mm were associated with subsequent arch and proximal progression necessitating open ascending aortic repair (P < .027 and P < .033, respectively). Ascending diameter >40.8 mm predicted lower intervention-free survival (P = .01). However, it failed to predict overall survival (P = .12). Ascending aortic area >12.1 cm2 predicted lower intervention-free survival (P = .005). However, this was not predictive of mortality (P = .08). Maximum aortic diameter along the length of the aorta >44 mm persisted as a risk factor for mortality (P < .001). Neither maximum ascending aortic diameter >40.8 mm (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.42-2.83; P = .85) nor area >12.1 cm2 (HR, 0.992; 95% CI, 0.38-2.61; P = .99) significantly predicted mortality when controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 7.34; 95% CI, 2.3-23.41; P < .001), diabetes mellitus (HR, 6.4; 95% CI, 2.17-18.93; P < .001), age (HR, 1.06/y; 95% CI, 1.03-1.10; P < .001), history of stroke (HR, 5.03; 95% CI, 1.52-16.63; P = .008), and syncope on admission (HR, 21.11; 95% CI, 2.3-193.84; P = .007). Ascending aortic diameter >40.8 mm (HR, 2.01; 95% CI, 1.03-3.95; P = .04) and maximum ascending aortic area >12.1 cm2 (HR, 1.988; 95% CI, 1.02-3.87; P = .04) on admission persisted as predictors of decreased intervention-free survival after controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 3.142; 95% CI, 1.47-6.83; P < .004), syncope on admission (HR, 26.3; 95% CI, 2.81-246; P < .004), and pleural effusion on admission (HR, 3.02; 95% CI, 1.58-5.77; P < .001). CONCLUSIONS: uATBAD patients with ascending aortic area >12.1 cm2 or maximum ascending aortic diameter >40.8 mm are at high risk for development of subsequent arch and proximal progression and may require closer follow-up or earlier intervention. Ascending aortic size (diameter and area) is predictive of decreased intervention-free survival in patients with uATBAD.

Imaging characteristics of acute type A aortic dissection and candidacy for repair with ascending aortic endografts.

BACKGROUND: Acute type A aortic dissection (ATAD) remains associated with substantial short-term mortality, and despite increasing rates of surgical repair, as many as 10% to 20% of patients do not undergo surgery because of comorbidities and dissection-related complications. For patients unable to undergo open repair, previous attempts at endovascular treatment of ATAD used devices originally designed for deployment in the descending thoracic aorta. Industry has begun to support early investigational devices meant specifically for placement within the ascending aorta. We evaluated relevant aortic parameters to examine which patients may be candidates for repair with an ascending aortic endograft. METHODS: We reviewed 100 consecutive patients in our institutional ATAD database with contrast-enhanced computed tomography imaging on an Aquarius iNtuition workstation (TeraRecon, San Mateo, Calif), using curved planar reformatting (vessel tracking) and orthogonal views for measurements. We compared relevant aortic measurements against proposed criteria for future ascending endografts, including various landing zone diameters and intimal tear distances from the distal coronary ostium. RESULTS: Of the 100 patients examined, 39% had proximal intimal tears located outside the tubular ascending aorta. In all, 30% were excluded on the basis of either the presence of a prosthetic aortic valve or significant aortic insufficiency, and 6% were excluded on the basis of the presence of patent coronary artery bypass grafts from the ascending aorta. Many patients had multiple exclusion criteria, and based on various proposed criteria, overall candidacy ranged from 2% to 23%. If a maximum landing zone diameter of 42 mm and intimal tears as little as 20 mm distal to the distalmost coronary were considered treatable, only 8% of patients would have been candidates compared with 20% candidacy if aortic diameters up to 46 mm and intimal tears as little as 10 mm distal to the distalmost coronary were considered treatable. The most frequent single cause for exclusion was inadequacy of the proximal landing zone. Iliofemoral vascular access was also assessed and deemed adequate in >90% of cases. CONCLUSIONS: A minority of patients suffering ATAD would currently qualify for ascending aortic endografting on the basis of anatomic criteria alone. Future device designs should take into account these common anatomic exclusion criteria so that more versatile devices may be developed and commercially available to treat a larger number of patients.

New type A dissection after acute type B aortic dissection.

OBJECTIVE: Aortic dissection is a dynamic process that can progress both proximal and distal to the initial entry tear. We sought to determine associations for development of proximal progression or new type A aortic dissection (NTAD) after acute type B dissection (ATBD) and its effect on survival of the patient. METHODS: We reviewed all cases of acute aortic dissection that we managed from 1999 to 2014. Univariate and bivariate analyses were performed to identify correlates of NTAD. Multivariable regression and proportional hazards regression analysis was done to determine the effect of dissection progression on long-term survival. RESULTS: Among 477 cases of ATBD managed, 19 (4.0%) patients developed NTAD during a median follow-up of 4.1 (interquartile range, 1.4-7.7) years. Median time from diagnosis of ATBD to NTAD was 124 (interquartile range, 23-1201) days. Baseline predictors for development of NTAD at initial ATBD admission included bicuspid aortic valve (P = .006) and age <60 years (P = .012). Although not statistically significant, point estimates indicate that thoracic endovascular aortic repair was twice as frequent in NTAD cases as in non-NTAD cases. Overall 5-year survival was 70.2%. Patients who had repair of NTAD appear to have longer survival, although this effect is on the margin of statistical significance (P = .051). After risk factor and correlates of NTAD adjustment, this effect was no longer apparent (P = .089). CONCLUSIONS: The natural history of ATBD is such that there is a persistent risk of NTAD, with the highest risk in the first 6 months. Factors associated with NTAD include bicuspid aortic valve and young age. Thoracic endovascular aortic repair did not have a large effect on risk. Timely diagnosis and repair of NTAD are associated with good survival rates. Lifelong surveillance is warranted in all cases of descending thoracic aortic dissection regardless of initial treatment modality.

Outcomes and readmissions after transcatheter and surgical aortic valve replacement in patients with cirrhosis: A propensity matched analysis.

BACKGROUND: The data on the comparative outcomes and readmissions after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with cirrhosis are limited. We compared mortality, complications, discharge disposition, 30-day readmission rates, length of stay, and cost of hospitalization in cirrhotic patients undergoing TAVR and SAVR. METHODS: The National Inpatient Sample (NIS) and the National Readmission Database (NRD) were used for the study. The International Classification of Diseases-9th version was used to define cohorts of patients undergoing TAVR and SAVR. Patients undergoing concomitant other valve or coronary bypass surgery were excluded. Propensity-score matching was used to compare the outcomes between the groups. RESULTS: From 2012 to 2014, a total of 126 and 157 patients with cirrhosis underwent TAVR and SAVR, respectively. Of the 283 patients, 16 (5.7%) died during the same hospitalization. We found 345 patients with cirrhosis who had undergone an aortic valve replacement (156 with TAVR, and 189 with SAVR) in the 2013 and 2014 NRD. On propensity matching, there were no significant differences between the in-hospital mortality, readmissions, hospitalization costs, and discharges to home within the TAVR and SAVR groups. However, post-procedure length of stay (6.3 vs. 10.2 days; P < 0.001) and blood transfusion rates (22% vs. 58%; P < 0.001) were significantly lower in TAVR patients. CONCLUSIONS: Cirrhotic patients undergoing TAVR has high, but similar mortality and 30-day readmission rates when compared to SAVR; however, has shorter length of stay and lower blood transfusion rates.

Management strategies in acute type B aortic intramural hematoma.

PURPOSE OF REVIEW: Intramural hematoma (IMH) is one of the acute aortic syndromes. IMH was originally noted as an 'aortic dissection without intimal tear.' It had been speculated that IMHs were caused by ruptured vasa vasorum in the aortic media and distinguished from classical aortic dissections. However, the majority of IMHs are now detected with an intimal defect using high-resolution computed tomography, which implies that IMHs may be a subset of aortic dissections with very limited flow in the false lumen. Management of IMHs had been controversial, but guidelines published in the early 2010 s recommend treating IMHs as classical aortic dissections: surgical repairs were indicated for type A IMHs; complicated acute type B IMHs were treated with endovascular or open repairs and uncomplicated type B IMHs were to be managed with antiimpulse therapy and close surveillance. To date, based on the favorable long-term outcomes of preemptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissections, early TEVAR for uncomplicated type B IMHs has been attempted. In this review, we describe the pathophysiology and management strategies for acute IMHs. RECENT FINDINGS: IMHs have intimal tears or disruptions in 70-80%. SUMMARY: Type B IMH should be managed with antiimpulse therapy, unless the patient has persistent pain or large ulcer-like projection.

Early readmissions after transcatheter and surgical aortic valve replacement.

OBJECTIVES: We aimed to determine and compare the prevalence, and predictors of readmissions after the transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). BACKGROUND: There are limited data on the readmission rates after TAVR in comparison with SAVR. METHODS: We analyzed the data from 2013 National Readmission Database. Propensity-matched pairs were used to analyze differences in readmission rates between TAVR and SAVR for patients aged ≥65. RESULTS: A total of 24,020 (TAVR-transfemoral 3,469, TAVR-transapical 1,433, SAVR 19,118) patients were included. The readmission rates were not statistically different for all propensity-matched TAVR and SAVR patients (17.2% vs. 20.6%, P = 0.28). However, in subgroup analysis, transapical TAVR had the highest readmission rate (22.8% vs. 16.5% vs. 16.0%, P < 0.001, respectively) and readmission leading to death (7.1% vs. 5.3% vs. 3.9%, P = 0.022, respectively) when compared with transfemoral TAVR and SAVR. In all the groups, two-thirds of readmissions were due to noncardiac causes. Congestive heart failure (CHF) and arrhythmia were the most frequent cardiac etiologies. The independent predictors of readmission were female sex, CHF, and chronic obstructive pulmonary disease. Patients who received care in teaching hospitals had lower probability of readmission. CONCLUSIONS: One of six patients were readmitted within 30 days after the aortic valve replacement. On propensity score analysis, there were no significant differences between the early readmission rates between TAVR and SAVR groups. However, the patients undergoing transapical TAVR were at higher risk for readmission, and subsequent deaths when compared with transfemoral TAVR and SAVR. © 2017 Wiley Periodicals, Inc.

Outcomes of Patients With Acute Type B (DeBakey III) Aortic Dissection: A 13-Year, Single-Center Experience.

BACKGROUND: Aortic dissection remains the most common aortic catastrophe. In the endovascular era, the management of acute type B aortic dissection (ATBAD) is undergoing dramatic changes. The aim of this study is to evaluate the long-term outcomes of patients with ATBAD who were treated at our center over a 13-year period. METHODS AND RESULTS: We reviewed patients with ATBAD between 2001 and 2014, analyzing variables based on status (complicated [c] versus uncomplicated [u]) and treatment modalities. We defined cATBAD as rupture, expansion of diameter on imaging during the admission, persistent pain, or clinical malperfusion leading to a deficit in cerebral, spinal, visceral, renal, or peripheral vascular territories at presentation or during initial hospitalization. Postoperative outcomes were defined as deficits not present before the intervention. Outcomes were compared between the groups by use of Kaplan-Meier and descriptive statistics. We treated 442 patients with ATBAD. Of those 442, 60.6% had uATBAD and were treated medically, and 39.4% had cATBAD, of whom 39.0% were treated medically to 30.0% with open repair, 21.3% with thoracic endovascular aortic repair, and 9.7% with other open peripheral procedures. Intervention-free survival at 1 and 5 years was 84.8% and 62.7% for uATBAD, 61.8% and 44.0% for cATBAD-medical, 69.2% and 47.2% for cATBAD-open, and 68.0% and 42.5% for cATBAD-thoracic endovascular aortic repair, respectively (P=0.001). Overall survival was significantly related primarily to complicated presentation. CONCLUSIONS: In our experience, early and late outcomes of ATBAD were dependent on the presence of complications, with cATBAD faring worse. Although uATBAD was associated with favorable early survival, late complications still occurred, mandating radiographic surveillance and open or endovascular interventions. Prospective trials are required to better determine the optimal therapy for uATBAD.

Utility of a tubularized extracellular matrix as an alternative conduit for arteriovenous fistula aneurysm repair.

OBJECTIVE: The treatment of segmental arteriovenous fistula aneurysms (AVFAs) remains a challenge in dialysis access preservation. We examined our experience with the use of tubularized extracellular matrix (ECM; CorMatrix, Roswell, Ga) for AVFA repair. METHODS: Between October 2013 and January 2015, we conducted a prospective study of CorMatrix ECM for AVFA repair. All patients underwent intraoperative fistulography. Patients with central venous stenosis or occlusion had simultaneous angioplasty and stenting as indicated. The aneurysm and overlying skin were then resected, and an ECM patch was fashioned into a tube for interposition repair. Patients with multiple AVFAs underwent staged repair. Cannulation of the repaired segments was allowed after 6 weeks. RESULTS: During the study period, 15 patients (40% male; mean age, 49.5 years) underwent 18 AVFA repairs using ECM (3 staged repairs). Six patients (40%) underwent simultaneous treatment of central vein lesions, whereas eight patients (53%) had associated skin erosion. Treated sites included radiocephalic (2), brachiobasilic (1), and brachiocephalic (15) AVFAs. All patients had hemodialysis at an alternative location on the same extremity without the need for catheter placement. Five patients underwent a follow-up ultrasound examination at a mean of 6 weeks. All studies demonstrated patency of the ECM segments without stenosis. At a mean follow-up time of 6.9 months, two thrombosis events were observed, both in patients with known refractory central venous stenosis treated with previous angioplasty (2) and stenting (1). Both patients required new access placement. No complications were attributable to ECM sites. CONCLUSIONS: ECM is an alternative conduit for salvage of an autologous AVFA. This technique may help avoid the use of prosthetic grafts and hemodialysis catheters. Patients with associated central venous stenosis are at risk of thrombosis.

Injury grade is a predictor of aortic-related death among patients with blunt thoracic aortic injury.

OBJECTIVE: The current Society for Vascular Surgery Clinical Practice Guidelines suggest urgent (<24 hours) thoracic endovascular aortic repair for grade (G) II to G IV blunt thoracic aortic injuries (BTAIs). The purpose of this study was to determine whether some patients may require more emergency treatment. METHODS: We reviewed imaging variables of prospectively collected BTAI patients between 1999 and 2014. We used computed tomographic angiography to classify BTAIs into four categories: G I, intimal tear; G II, intramural hematoma; G III, aortic pseudoaneurysm; and G IV, free rupture. Specific examination of G III injuries was undertaken in an effort to predict aortic-related mortality (ARM) before repair. For this subset, we examined pseudoaneurysm size, lesion/normal aortic diameter ratio, and mediastinal hematoma location and size. RESULTS: Among 331 patients with BTAIs, 86 died before imaging. Admission computed tomographic angiography was available for 205 patients (71.2% male; mean age, 39.3 years) with BTAIs (24 G I, 49 G II, 124 G III, 8 G IV). The mean Injury Severity Score was 35.6, and 22.4% had hypotension (<90 mm Hg). Overall mortality was 11.2% (G I/G II, 4.1%; G III/G IV, 15.3%; P = .02). ARM was 2.4% (G I/G II, 0%; G III/G IV, 3.8%; P = .09). ARM was significantly greater in G IV (3 of 8 [37.5%]) than G III (2 of 124 [1.6%]) vs G I/II (0 of 73 [0%]) injuries (P < .0001). Medical management alone was used in 53 (20 G I, 18 G II, 13 G III, and 2 G IV). Open repair was performed in 51 (3 G I, 9 G II, 36 G III, and 3 G IV) at a mean time to repair (TTR) of 10.6 hours. Thoracic endovascular aortic repair was conducted for 101 patients (1 G I, 22 G II, 75 G III, and 3 G IV) at a mean TTR of 9.4 hours. Median TTR for the overall population of BTAI patients was 24.0 hours from admission. (G I, 64.5 hours; G II, 24.0 hours; G III, 19.7 hours; and G IV, 3.5 hours). ARM occurred in four of five patients before planned repair (2 G III and 2 G IV), 7.0 ± 3.6 hours from admission. No G I/II ARM occurred. Among eight G IV injuries, there were three ARMs. Focus on G III injuries through regression analysis demonstrated that early clinical/imaging variables (eg, mediastinal hematoma dimensions and lesion/normal aortic diameter ratio) were not significant predictors of ARM. CONCLUSIONS: Injury grade is a predictor of ARM among patients with BTAIs. Aggressive use of the current Society for Vascular Surgery Clinical Practice Guidelines at a busy level I trauma center resulted in low rates of ARM. In this setting, identification of additional physiologic and radiographic criteria indicating the need for emergency (vs urgent) repair of aortic pseudoaneurysms remains elusive.

Predictors of intervention and mortality in patients with uncomplicated acute type B aortic dissection.

OBJECTIVE: Patients with uncomplicated acute type B aortic dissection (uATBAD) have historically been managed with medical therapy. Recent studies suggest that high-risk patients with uATBAD may benefit from thoracic endovascular aortic repair. This study aims to determine the predictors of intervention and mortality in patients with uATBAD. METHODS: All patients admitted with uATBAD from 2000 to 2014 were reviewed, and those with computed tomographic angiography imaging were included. Multiplanar reconstruction was used to obtain double orthogonal oblique measurements. All measurements were obtained by a specialized cardiovascular radiologist (D.O.). The maximum aortic diameter, proximal descending thoracic aorta false lumen (FL) diameter, and area were recorded. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analysis using SAS v 9.4 (SAS Institute, Cary, NC). RESULTS: During the study period, 294 patients with uATBAD were admitted with 156 having admission computed tomographic angiography imaging available for analysis. The cohort had an average age of 60.6 years (±13.6 years); 60% were males. The average follow-up time was 3.7 years (interquartile range, 2.1-6.9). A stratified analysis demonstrated the most sensitive cutoff for mortality was aortic diameter >44 mm (P < .01), and it appeared to be a threshold effect with minimal additional information added by finer size stratification. FL diameter did not predict mortality in our series (P = .36). Intervention-free survival, alternatively, appeared to decrease over the range of diameters from 35 to 44 mm (P < .01). An FL diameter >22 mm was associated with decreased intervention-free survival (P < .04). Age >60 years on admission also demonstrated decreased survival compared with those ≤60 years of age (P < .01). Diameter >44 mm persisted as a risk factor for mortality (hazard ratio, 8.6; P < .01) after adjustment for diabetes (6.7; P < .01), age (1.06/y; P < .01), history of stroke (5.4; P < .01), connective tissue disorder (2.3; P < .01), and syncope on admission (9.5; P < .04). The 1-, 5-, and 10-year intervention rate for patients with admission aortic diameter >44 mm was 18.8%, 29.5%, and 50.3%, respectively, compared with 4.8%, 13.3%, and 13.3% in the ≤44 mm group (P < .01). CONCLUSIONS: Aortic diameter >44 mm is a predictor of mortality after adjustment for other significant risk factors. Age >60 years on admission is a predictor of mortality. An FL diameter >22 mm as well as those with maximum aortic diameter >44 mm on admission were associated with decreased intervention-free survival. Patients with these high-risk criteria may benefit from thoracic endovascular aortic repair. Further studies are needed to further define those patients at highest risk and, thus, most likely to benefit from early intervention.

Observation May Be Safe in Selected Cases of Blunt Traumatic Abdominal Aortic Injury.

BACKGROUND: Blunt traumatic abdominal aortic injury (BTAAI) is a rare lesion, often associated with extensive intraperitoneal injuries. Optimal management remains unclear, including the role of prosthetic aortic graft replacement with concomitant bowel injury and the management of small pseudoaneurysms. METHODS: We reviewed BTAAI cases occurring between 2000 and 2014. Thoracic and isolated iliac artery injuries were excluded. We included patient demographics, mechanism of injury, admission physiology, and reviewed available imaging to characterize aortic injury type and severity. RESULTS: BTAAI was noted in 16 of 8,751 (0.2%) blunt abdominal trauma patients admitted during the study period. Of these, 56% were males and the median age was 47 years (range, 5-80). Aortic repair was attempted in 7 patients, including 3 open prosthetic aortobi-iliac bypass grafts, 1 endovascular repair, and 2 primary repairs. One patient died before repair. The remaining patients were medically managed for their aortic injury, including 3 with pseudoaneurysm and 3 with large intimal flaps. There were 5 in-hospital deaths (31%) but only 1 attributed to aortic injury. Among patients surviving to discharge, there were no readmissions or delayed deaths. All nonoperative and surgically repaired patients seen in follow-up had stable aortic lesions. No patient with graft or endograft repair had evidence of graft infection on follow-up (median, 52 months; range, 21-121). CONCLUSIONS: BTAAI is a rare entity and is associated with high in-hospital mortality, primarily due to associated injuries. Observation of selected small pseudoaneurysms and intimal flaps appear safe. Survival after hospital discharge is excellent, and aortic-related complications are rare. The indications for repair and the role of revascularization with in situ prosthetic graft in the setting of concomitant bowel injuries are not well defined.

Need for Limb Revascularization in Patients with Acute Aortic Dissection is Associated with Mesenteric Ischemia.

BACKGROUND: Acute aortic dissection (AAD) can cause limb ischemia due to branch vessel occlusion. A minority of patients have persistent ischemia after central aortic repair and require peripheral arterial revascularization. We investigated whether the need for limb revascularization is associated with adverse outcomes. METHODS: We reviewed our cases of AAD from 2000 to 2014 and identified patients with malperfusion syndromes (coronary, cerebral, spinal, visceral, renal, or peripheral ischemia). Patients with DeBakey I/II (Stanford type A) dissection had urgent open repair of the ascending aorta. Patients with DeBakey III (Stanford type B) dissection were initiated on anti-impulse medical therapy and had either open aortic repair or thoracic endovascular aortic repair for malperfusion syndromes. Patients with persistent lower limb ischemia after aortic repair usually had either extra-anatomic bypass grafting or iliac stenting. Some DeBakey III patients had peripheral revascularization without central aortic repair. We performed univariate and multivariate analysis to determine the effects of need for limb revascularization and clinical outcomes. RESULTS: We treated 1,015 AAD patients (501 [49.4%] DeBakey I/II and 514 [50.6%] DeBakey III) with a mean age of 59.7 ± 14.5 years (67.5% males). Aortic repair was performed in all DeBakey I/II patients and in 103 (20.0%) DeBakey III patients. Overall 30-day mortality was 11.3%. Lower limb ischemia was present in 104 (10.3%) patients and was more common in DeBakey I/II compared with DeBakey III dissections (65.4% vs. 34.6%; odds ratio [OR] 2.1, confidence interval [CI] 1.4-3.2; P = 0.001). Among the 40 patients who required limb revascularization, there was no difference in need for revascularization between DeBakey I/II and III patients. Patients requiring limb revascularization were more likely to have mesenteric ischemia compared with the rest of the cohort in both DeBakey I/II (P = 0.037) and DeBakey III dissections (P < 0.001) with worse 10-year survival (21.9 % vs. 59.2%, P < 0.001). When adjusted for other malperfusion syndromes, patients with limb revascularization had similar long-term survival compared to uncomplicated dissection patients (P = 0.960). CONCLUSIONS: Patients requiring lower limb revascularization after treatment for AAD are more likely to have mesenteric ischemia and worse survival. The need for limb revascularization is a marker for more extensive dissection and should prompt evaluation for visceral malperfusion.