Impact of thoracic endovascular aortic repair following blunt traumatic thoracic aortic injury on blood pressure.

BACKGROUND: Blunt traumatic thoracic aortic injuries (BTAIs) are associated with a high mortality rate. Thoracic endovascular aortic repair (TEVAR) is the most frequently used surgical strategy in patients with BTAI, as it offers good short- and middle-term results. Previous studies have reported an abnormally high prevalence of hypertension (HT) in these patients. This work aimed to describe the long-term prevalence of HT and provide a comprehensive evaluation of the biomechanical, clinical, and functional factors involved in HT development. METHODS: Twenty-six patients treated with TEVAR following BTAI with no history of HT at the time of trauma were enrolled. They were matched with 37 healthy volunteers based on age, sex, and body surface area and underwent a comprehensive follow-up study, including cardiovascular magnetic resonance, 24-hour ambulatory blood pressure monitoring, and assessment of carotid-femoral pulse wave velocity (cfPWV, a measure of aortic stiffness) and flow-mediated vasodilation. RESULTS: The mean patient age was 43.5 ± 12.9 years, and the majority were male (23 of 26; 88.5%). At a mean of 120.2 ± 69.7 months after intervention, 17 patients (65%) presented with HT, 14 (54%) had abnormal nighttime blood pressure dipping, and 6 (23%) high cfPWV. New-onset HT was related to a more proximal TEVAR landing zone and greater distal oversizing. Abnormal nighttime blood pressure was related to high cfPWV, which in turn was associated with TEVAR length and premature arterial aging. CONCLUSIONS: HT frequently occurs otherwise healthy subjects undergoing TEVAR implantation after BTAI. TEVAR stiffness and length, the proximal landing zone, and distal oversizing are potentially modifiable surgical characteristics related to abnormal blood pressure.

Prevalence of Peripheral Arterial Disease and Associated Vascular Risk Factors in 65-Years-Old People of Northern Barcelona.

OBJECTIVE: To determine the prevalence and risk factors associated with peripheral arterial disease (PAD) in Northern Barcelona at 65 years of age. METHODS: A single-center, cross-sectional study, including males and females 65 years of age, health care cardholders of Barcelona Nord. PAD was defined as an ankle-brachial index (ABI) < 0.9. Attending subjects were evaluated for a history of common cardiovascular risk factors. A REGICOR score was obtained, as well as a physical examination and anthropometric measurements. RESULTS: From November 2017 to December 2018, 1174 subjects were included: 479 (40.8%) female and 695 (59.2%) male. Overall prevalence of PAD was 6.2% (95% CI: 4.8-7.6%), being 7.9% (95% CI: 5.9-9.9%) in males and 3.8% (95% CI: 2.1-5.5%) in females. An independent strong association was seen in male smokers and diabetes, with ORs pf 7.2 (95% CI: 2.8-18.6) and 1.8 (95% CI: 1.0-3.3), respectively, and in female smokers and hypertension, with ORs of 5.2 (95% CI: 1.6-17.3) and 3.3 (95% CI: 1.2-9.0). Male subjects presented with higher REGICOR scores (p < 0.001). CONCLUSION: Higher-risk groups are seen in male subjects with a history of smoking and diabetes and female smokers and arterial hypertension, becoming important subgroups for our primary healthcare centers and should be considered for ABI screening programs.

Geometric, Biomechanic and Haemodynamic Aortic Abnormalities Assessed by 4D Flow Cardiovascular Magnetic Resonance in Patients Treated by TEVAR Following Blunt Traumatic Thoracic Aortic Injury.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is widely used for the treatment of patients with blunt traumatic thoracic aortic injury (BTAI). However, aortic haemodynamic and biomechanical implications of this intervention are poorly investigated. This study aimed to assess whether patients treated by TEVAR following BTAI have thoracic aortic abnormalities in geometry, stiffness, and haemodynamics. METHODS: Patients with BTAI treated by TEVAR at Vall d'Hebron Hospital between 1999 and 2019 were compared with propensity score matched healthy volunteers (HVs). All subjects underwent cardiovascular magnetic resonance (CMR) comprising a 4D flow CMR sequence. Spatially resolved aortic diameter, length, volume, and curvature were assessed. Pulse wave velocity, distensibility, and longitudinal strain (all measurements of aortic stiffness) were determined regionally. Moreover, advanced haemodynamic descriptors were quantified: systolic flow reversal ratio (SFRR), quantifying backward flow during systole, and in plane rotational flow (IRF), measuring in plane strength of helical flow. RESULTS: Twenty-six BTAI patients treated by TEVAR were included and matched with 26 HVs. They did not differ in terms of age, sex, and body surface area. Patients with TEVAR had a larger and longer ascending aorta (AAo) and marked abnormalities in local curvature. Aortic stiffness was greater in the aortic segments proximal and distal to TEVAR compared with controls. Moreover, TEVAR patients presented strongly altered flow dynamics compared with controls: a reduced IRF from the distal AAo to the proximal descending aorta and an increased SFRR in the whole thoracic aorta. These differences persisted adjusting for cardiovascular risk factors and were independent of time elapsed since TEVAR implantation. CONCLUSION: At long term follow up, previously healthy patients who underwent TEVAR implantation following BTAI had increased diameter, length and volume of the ascending aorta, and increased aortic stiffness and abnormal flow patterns in the whole thoracic aorta compared with matched controls. Further studies should address whether these alterations have clinical implications.

Cauda Equina Syndrome Caused by Epidural Venous Plexus Engorgement in a Patient with May-Thurner Syndrome.

The purpose of this article is to present a case of cauda equina syndrome in a patient with incomplete motor and sensory deficits due to epidural venous plexus engorgement, owing to May-Thurner syndrome successfully treated with venous iliac stenting. A 40-year-old woman, with previous history of deep vein thrombosis and miscarriages, gradually developed right leg and back pain, with functional limitation, perineal hypoesthesia, and sphincter incontinence. Magnetic resonance imaging revealed epidural venous plexus engorgement and cauda equina roots involvement. Phlebography showed perimedullary venous enlargement and left common iliac vein stenosis, leading to the diagnosis of May-Thurner syndrome. Stenting of the left common iliac vein was performed resulting in pain improvement and disappearance of neurological symptoms. Thrombophilia study was positive to heterozygous factor V Leiden. Cauda equina syndrome as the first presentation of a May-Thurner syndrome is very rare. In this case, venous iliac stent placement was an effective and safe treatment.

Long-Term Outcomes of Thoracic Endovascular Aortic Repair Focused on Bird Beak and Oversizing in Blunt Traumatic Thoracic Aortic Injury.

BACKGROUND: The acute aortic arch angle and narrow aortic diameter in young patients may lead to bird-beak configuration and excessive oversizing of the stent graft in thoracic endovascular aortic repair (TEVAR) for blunt traumatic thoracic aortic injury (BTTAI). Little is known about the association of these factors and complications in long-term follow-up. We evaluated the long-term outcomes in terms of complications, reinterventions, and survival, focusing on the effects of bird-beak configuration and oversizing. METHODS: This prospective cohort study included patients who underwent TEVAR for BTTAI in our department between October 1999 and January 2015. The main outcomes were migration, collapse, intragraft mural thrombus, reintervention, and survival and their association with oversizing and bird-beak configuration. RESULTS: Thirty-four patients were included. Median age was 36 years, and 21% were women. Mean graft oversizing was 19% (range: 8-27%) at the proximal end and 27% (range:, -20% to 50%) at the distal end. Mean follow-up was 98 months (12-198 months). Seven patients presented intragraft mural thrombus, one of whom developed an occlusive parietal thrombosis 1 year after the procedure. Four patients (9%) required reintervention: postoperative revascularization of the left subclavian artery in 2 cases and aortic reinterventions in 2 others. No migration or mortality was seen during follow-up. Bird-beak configuration was seen in 65%: the mean protrusion extension was 16 mm (standard deviation [SD]: 7.4 mm) and the mean angle was 51° (SD: 16°). The association between the complications and bird beak was not statistically significant. Patients with complications had significantly higher proximal end oversizing (23%) than the group with no complications (17%) (P = 0.0007). CONCLUSIONS: TEVAR for BTTAI shows good results in the long-term follow-up. Complications in our series seemed related to proximal end oversizing. Thoracic stent grafts with a smaller diameter should be available in all trauma centers to avoid excessive oversizing.