Renal Dysfunction at Discharge and Long-Term Survival in Acute Type A Aortic Dissection.

INTRODUCTION: We aimed to investigate the association between renal dysfunction at discharge and long-term survival in acute type A aortic dissection (ATAAD) patients following surgery. METHODS: From 2000 to 2021, 784 patients underwent aortic repair for an ATAAD. Patients were stratified based on creatinine (Cr) level at discharge alive or dead: normal Cr (n = 582) and elevated Cr defined as >1.3 mg/dL for males and >1.0 mg/dL for females or on dialysis at discharge (n = 202). RESULTS: Preoperatively, both groups had similar rates of comorbidities except for the elevated-Cr group which had more diabetes, chronic obstructive pulmonary disease, and chronic and acute renal insufficiency. Both groups had similar open ATAAD repair procedures. Postoperative outcomes in the elevated-Cr group were significantly worse, including six times higher operative mortality (20% versus 3.4%, P < 0.0001). The landmark long-term survival after discharge alive was significantly worse in the elevated-Cr group than the normal-Cr group (10-y survival: 48% versus 69%, P = 0.0009). The elevated Cr on dialysis at discharge group had significantly worse five-year survival (40%) than the elevated Cr not on dialysis at discharge group (80%, P = 0.02) and the normal-Cr group (87%, P < 0.0001). Additionally, the elevated Cr not on dialysis had a worse five-year survival than the normal-Cr group (80% versus 87%, P = 0.02). Elevated Cr at discharge on dialysis was a significant risk factor for late mortality (hazard ratio = 4.22, 95% confidence interval: [2.07, 8.61], P < 0.0001). CONCLUSIONS: Renal dysfunction at discharge was associated with significantly decreased short-term and long-term survival following open ATAAD repair. Surgeons should aggressively prevent renal dysfunction, especially new-onset dialysis, at discharge as it is correlated with significantly worse short-term and long-term outcomes.

Mixed methods approach to understanding COVID-19 vaccine hesitancy among immigrants in the Chicago.

BACKGROUND: COVID-19 vaccine hesitancy has been particularly high among immigrant populations, whose experience is shaped by a history of racism and discriminations, and distrust of the healthcare system. In this study we draw from the Theory of Planned Behavior to examine COVID-19 vaccine hesitancy among immigrants in Chicago. METHODS: A mixed-methods approach comprising of both focus groups and a health survey was conducted from February to August 2022. Five focus groups were held (N = 35) among Black, Asian and Arab/Palestine participants to understand attitudes and beliefs around the COVID-19 vaccine. Focus groups were analyzed using a modified template approach to text analysis. Based on these findings and themes, we developed a survey that was conducted among 413 immigrants from the mentioned communities. We used hierarchical ordinal regression analyses to examine the relationship between COVID-19 vaccine hesitancy and vaccination status. RESULTS: Qualitative analysis suggest that the major factors influencing COVID-19 vaccine hesitancy included fear of adverse reactions, misinformation around COVID-19 and the vaccine, negative social norms around vaccination, and external pressure to get vaccinated. From our quantitative analysis we found that 24% of participants were unvaccinated, 5% were partially vaccinated, 32.3% were vaccinated but not boosted, and 39% were vaccinated and boosted for COVID-19. Hierarchical regression models suggest that immigrants who hold negative attitudes and social norms around the COVID-19 vaccine are less likely to vaccinate. CONCLUSIONS: Understanding vaccine hesitancy among immigrants allows for the creation of culturally and linguistically tailored education that can be utilized to increase vaccine confidence and uptake.

Smoking behavior among Asian Americans during the initial phase of the COVID-19 pandemic: The influence of pandemic stressors and depression.

INTRODUCTION: Heightened levels of distress among Asian Americans during the initial phases of the pandemic may be associated with current smoking behavior. In this study, we examine differences in current smoking among Asian Americans from two different ethnic backgrounds before and during the COVID-19 pandemic. METHODS: We analyzed cross-sectional survey data (n=202) from Chinese and South Asian adults in Chicago, collected between February and May 2020. We conducted logistic regression models to estimate the relationship between exposure to the COVID-19 pandemic and current smoking. We tested whether the association varied by Asian American ethnic group, unemployment, racial discrimination, and depression symptoms. RESULTS: We found that current smoking increased from 28% to 48% among Asian Americans (i.e. Chinese and South Asians) during the pandemic. We found a statistically significant interaction between the COVID-19 period indicator variable and current smoking by Asian American ethnic groups (p=0.014), such that current smoking was lower for Chinese compared to South Asians before COVID-19, but was comparable for both groups during the pandemic. We also found a statistically significant interaction between the period indicator variable and current smoking by racial discrimination (p=0.047) and depression symptoms (p=0.02). Results from these interactions suggest that Asian Americans who experienced racial discrimination and depression during the pandemic may be more likely to be current smokers compared to their pre-pandemic counterparts. CONCLUSIONS: The findings of the study highlight the need for culturally tailored smoking cessation interventions for Asian American communities that address pandemic-related stressors such as discrimination that may trigger cigarette use.

Acute type A intramural hematoma: The less-deadly acute aortic syndrome?

OBJECTIVE: To evaluate the short- and midterm outcomes of surgically managed acute type A intramural hematoma (IMH) versus classic acute type A aortic dissection (ATAAD). METHODS: From 1996 to February 2023, a total of 106 patients with acute type A IMH and 795 patients with classic ATAAD presented for open aortic repair at our institution. Data were obtained from the local Society of Thoracic Surgeons' Data Warehouse and medical chart review. RESULTS: Compared with the classic ATAAD group, the IMH group was older (65 vs 59 years, P < .001) and more likely to be female (45% vs 32%, P = .005), with fewer comorbidities such as severe aortic insufficiency (5.0% vs 25%, P < .001), acute stroke (2.8% vs 8.3%, P = .05), acute renal failure (5.7% vs 13%, P = .04), and malperfusion syndrome (8.5% vs 26%, P < .001) but more cardiac tamponade (18% vs 11%, P = .03). The IMH group had less aortic root replacement (15% vs 33%, P < .001), zone 2 arch replacements (9.4% vs 18%, P = .02), and shorter crossclamp times (120 minutes vs 150 minutes, P < .001). The operative mortality was significantly lower in the IMH group (0.9% vs 8.8%, P = .005) and a multivariable regression model showed IMH to be protective, odds ratio of 0.11, P = .03. The 10-year survival was similar between the 2 groups (65% vs 61%, P = .35). The hazard ratio of IMH for midterm mortality after surgery was 0.73, P = .12. CONCLUSIONS: Acute type A IMH could be treated with emergency open aortic repair with excellent short- and midterm outcomes.

The Role of Health Insurance Type and Clinic Visit on Hypertension Status Among Multiethnic Chicago Residents.

PURPOSE: To investigate the joint relationship of health insurance and clinic visit with hypertension among underserved populations. DESIGN: Population-based cohort study. SUBJECTS: Data from 1092 participants from the Chicago Multiethnic Prevention and Surveillance Study (COMPASS) between 2013 and 2020 were analyzed. MEASURES: Five health insurance types were included: uninsured, Medicaid, Medicare, private, and other. Clinic visit over past 12 months were retrieved from medical records and categorized into 4 groups: no clinic visit, 1-3 visits, 4-7 visits, >7 visits. ANALYSIS: Inverse-probability weighted logistic regression was used to estimate odds ratios (OR) and 95% confidence interval (CI) for hypertension status according to health insurance and clinic visit. Models were adjusted for individual socio-demographic variables and medical history. RESULTS: The study population was predominantly Black (>85%) of low socioeconomic status. Health insurance was not associated with more clinic visit. Measured hypertension was more frequently found in private insurance (OR = 6.48, 95% CI: 1.92-21.85) compared to the uninsured group, while 1-3 clinic visits were associated with less prevalence (OR = .59, 95% CI: .35-1.00) compared to no clinic visit. These associations remained unchanged when health insurance and clinic visit were adjusted for each other. CONCLUSION: In this study population, private insurance was associated with higher measured hypertension prevalence compared to no insurance. The associations of health insurance and clinic visit were independent of each other.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2023 Update on Procedure Data and Research.

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database is one of the largest and most comprehensive contemporary clinical databases in use. It now contains >9 million procedures from 1010 participants and 3651 active surgeons. Using audited data collection, it has provided the foundation for multiple risk models, performance metrics, health policy decisions, and a trove of research studies to improve the care of patients in need of cardiac surgical procedures. This annual report provides an update on the current status of the database and summarizes the development of new risk models and the STS Online Risk Calculator. Further, it provides insights into current practice patterns, such as the change in the demographics among patients undergoing aortic valve replacement, the use of minimally invasive techniques for valve and bypass surgery, or the adoption of surgical ablation and left atrial appendage ligation among patients with atrial fibrillation. Lastly, an overview of the research conducted using the STS Adult Cardiac Surgery Database and future directions for the database are provided.

Air quality and cancer risk in the All of Us Research Program.

INTRODUCTION: The NIH All of Us Research Program has enrolled over 544,000 participants across the US with unprecedented racial/ethnic diversity, offering opportunities to investigate myriad exposures and diseases. This paper aims to investigate the association between PM2.5 exposure and cancer risks. MATERIALS AND METHODS: This work was performed on data from 409,876 All of Us Research Program participants using the All of Us Researcher Workbench. Cancer case ascertainment was performed using data from electronic health records and the self-reported Personal Medical History questionnaire. PM2.5 exposure was retrieved from NASA's Earth Observing System Data and Information Center and assigned using participants' 3-digit zip code prefixes. Multivariate logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI). Generalized additive models (GAMs) were used to investigate non-linear relationships. RESULTS: A total of 33,387 participants and 46,176 prevalent cancer cases were ascertained from participant EHR data, while 20,297 cases were ascertained from self-reported survey data from 18,133 participants; 9,502 cancer cases were captured in both the EHR and survey data. Average PM2.5 level from 2007 to 2016 was 8.90 µg/m3 (min 2.56, max 15.05). In analysis of cancer cases from EHR, an increased odds for breast cancer (OR 1.17, 95% CI 1.09-1.25), endometrial cancer (OR 1.33, 95% CI 1.09-1.62) and ovarian cancer (OR 1.20, 95% CI 1.01-1.42) in the 4th quartile of exposure compared to the 1st. In GAM, higher PM2.5 concentration was associated with increased odds for blood cancer, bone cancer, brain cancer, breast cancer, colon and rectum cancer, endocrine system cancer, lung cancer, pancreatic cancer, prostate cancer, and thyroid cancer. CONCLUSIONS: We found evidence of an association of PM2.5 with breast, ovarian, and endometrial cancers. There is little to no prior evidence in the literature on the impact of PM2.5 on risk of these cancers, warranting further investigation.

Duration-sensitive association between air pollution exposure and changes in cardiometabolic biomarkers: Evidence from a predominantly African American cohort.

BACKGROUND: Ambient fine particulate matter (PM2.5) exposure has been related to cardiometabolic diseases, but the underlying biological pathways remain unclear at the population level. OBJECTIVE: To investigate the effect of PM2.5 exposure on changes in multiple cardiometabolic biomarkers across different exposure durations. METHOD: Data from a prospective cohort study were analyzed. Ten cardiometabolic biomarkers were measured, including ghrelin, resistin, leptin, C-peptide, creatine kinase myocardial band (CK-MB), monocyte chemoattractant protein-1 (MCP-1), tumor necrosis factor alpha (TNF-alpha), N-terminal pro B-type natriuretic peptide (NT-proBNP), troponin, and interleukin-6 (IL-6). PM2.5 levels across exposure durations from 1 to 36 months were assessed. Mixed effect model was used to estimate changes in biomarker levels against 1 µg/m3 increase in PM2.5 level across different exposure durations. RESULTS: Totally, 641 participants were included. The average PM2.5 exposure level was 9 µg/m3. PM2.5 exposure was inversely associated with ghrelin, and positively associated with all other biomarkers. The magnitudes of these associations were duration-sensitive and exhibited a U-shaped or inverted-U-shaped trend. For example, the association of resistin were ß = 0.05 (95% CI: 0.00, 0.09) for 1-month duration, strengthened to ß = 0.27 (95% CI: 0.14, 0.41) for 13-month duration, and weakened to ß = 0.12 (95% CI: -0.03, 0.26) for 24-month duration. Similar patterns were observed for other biomarkers except for CK-MB, of which the association direction switched from negative to positive as the duration increased. Resistin, leptin, MCP-1, TNF-alpha, and troponin had a sensitive exposure duration of nearly 12 months. Ghrelin and C-peptide were more sensitive to longer-term exposure (>18 months), while NT-proBNP and IL-6 were more sensitive to shorter-term exposure (<6 months). CONCLUSION: PM2.5 exposure was associated with elevated levels in cardiometabolic biomarkers related to insulin resistance, inflammation, and heart injury. The magnitudes of these associations depended on the exposure duration. The most sensitive exposure durations of different biomarkers varied.

Mail-Based Self-Sampling to Complete Colorectal Cancer Screening: Accelerating Colorectal Cancer Screening and Follow-up Through Implementation Science.

Introduction: Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated. Methods: We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects. These projects serve diverse rural, urban, and tribal populations in the US. Results: All 8 ACCSIS projects leveraged self-sampling and mail to promote screening. Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2). We found differences in patient identification strategies, outreach delivery approaches, and test return options. We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach. Conclusion: In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening. Mail and self-sampling, including mailed FIT outreach, could be more broadly leveraged to optimize cancer screening.

Lasers for the treatment of eyebrow microblading and cosmetic tattoo pigment: a review of the literature.

We aim to discuss the use of laser for the treatment of eyebrow microblading and cosmetic tattoo complications through a review of the literature. Our research question is whether quality-switched or picosecond laser is superior for the removal of eyebrow tattoos. This structured review was conducted using a PubMed search using the search terms "laser tattoo removal" AND "cosmetic tattoo" AND "eyebrow" with the article type filtered to "case reports," "clinical trial," and "randomized controlled trial" ranging from dates 1994-2023. All case reports or series evaluating the effect of laser on eyebrow cosmetic tattooing pigment were included. We summarize the results of 11 studies evaluating the use of laser for cosmetic tattoo removal, with 129 patients treated specifically for eyebrow pigment. Most studies (8/11) report Fitzpatrick skin type or race. Seven studies utilize quality-switched (QS) neodymium-doped yttrium aluminum garnet (Nd:YAG), alexandrite or ruby, three used picosecond (PS) Nd:YAG or alexandrite, and three used carbon dioxide (CO2) laser. We report laser energy, spot size, and pulse duration, as well as treatment outcomes and adverse events. Historically, methods of pigment removal included dermabrasion, cryosurgery, electrosurgery, radiofrequency, infrared light, intense pulsed light, and surgical excision; however, these methods often led to poor cosmetic outcomes including scarring and further dyspigmentation. QS laser treatments provided superior cosmetic outcomes and thus were considered the gold standard treatment option for pigment removal. However, the advent of PS lasers has challenged this given their increased selectivity, lower fluence requirements, and reduction in surrounding thermal damage. Our review demonstrates that PS Nd:YAG is quicker and more effective that QS Nd:YAG in the treatment of eyebrow tattoos. Additionally, the paradoxical darkening seen with QS lasers is less common with PS lasers. We also demonstrate that CO2 laser may be a helpful adjunct to QS or PS laser. This review focuses on Fitzpatrick skin type and race, providing a unique perspective on the use of laser treatment in skin of color, which often poses an additional treatment challenge.

Progression of distal aorta after endovascular fenestration/stenting in acute type A aortic dissection with malperfusion syndrome.

Objective: The study objective was to evaluate the progression of dissected distal aorta in patients with acute type A aortic dissection with malperfusion syndrome treated with endovascular fenestration/stenting and delayed open aortic repair. Methods: From 1996 to 2021, 927 patients presented with acute type A aortic dissection. Of these, 534 had DeBakey I dissection with no malperfusion syndrome and underwent emergency open aortic repair (no malperfusion syndrome group), whereas 97 patients with malperfusion syndrome underwent fenestration/stenting and delayed open aortic repair (malperfusion syndrome group). Sixty-three patients with malperfusion syndrome treated with fenestration/stenting were excluded due to no open aortic repair, including death from organ failure (n = 31), death from aortic rupture (n = 16), and discharged alive (n = 16). Results: Compared with the no malperfusion syndrome group, the malperfusion syndrome group had more patients with acute renal failure (60% vs 4.3%, P < .001). Both groups had similar aortic root and arch procedures. Postoperatively, the malperfusion syndrome group had similar operative mortality (5.2% vs 7.9%, P = .35) and permanent dialysis (4.7% vs 2.9%, P = .50), but more new-onset dialysis (22% vs 7.7%, P < .001) and prolonged ventilation (72% vs 49%, P < .001). The growth rate of the aortic arch (0.38 vs 0.35 mm/year, P = .81) was similar between the malperfusion syndrome and no malperfusion syndrome groups. The descending thoracic aorta growth rate (1.03 vs 0.68 mm/year, P = .001) and abdominal aorta growth rate (0.76 vs 0.59 mm/year, P = .02) were significantly higher in the malperfusion syndrome group. The cumulative incidence of reoperation over 10 years (18% vs 18%, P = .81) and 15-year survival outcome (50% vs 48%, P = .43) were similar between the malperfusion syndrome and no malperfusion syndrome groups. Conclusions: Endovascular fenestration/stenting followed by delayed open aortic repair was a valid approach for patients with malperfusion syndrome.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Evaluation of COVID-19 vaccine implementation in a large safety net health system.

Objectives: To evaluate rapid COVID-19 vaccine clinic implementation from January-April 2021 in the Los Angeles County Department of Health Services (LACDHS), the second-largest US safety net health system. During initial vaccine clinic implementation, LACDHS vaccinated 59,898 outpatients, 69% of whom were Latinx (exceeding the LA County Latinx population of 46%). LACDHS is a unique safety net setting to evaluate rapid vaccine implementation due to system size, geographic breadth, language/racial/ethnic diversity, limited health staffing resources, and socioeconomic complexity of patients. Methods: Implementation factors were assessed through semi-structured interviews of staff from all twelve LACDHS vaccine clinics from August-November 2021 using the Consolidated Framework for Implementation Research (CFIR) and themes analyzed using rapid qualitative analysis. Results: Of 40 potential participants, 25 health professionals completed an interview (27% clinical providers/medical directors, 23% pharmacist, 15% nursing staff, and 35% other). Qualitative analysis of participant interviews yielded ten narrative themes. Implementation facilitators included bidirectional communication between system leadership and clinics, multidisciplinary leadership and operations teams, expanded use of standing orders, teamwork culture, use of active and passive communication structures, and development of patient-centered engagement strategies. Barriers to implementation included vaccine scarcity, underestimation of resources needed for patient outreach, and numerous process challenges encountered. Conclusion: Previous studies focused on robust advance planning as a facilitator and understaffing and high staff turnover as barriers to implementation in safety net health systems. This study found facilitators that can mitigate lack of advance planning and staffing challenges present during public health emergencies such as the COVID-19 pandemic. The ten identified themes may inform future implementations in safety net health systems.

Reoperation following transcatheter aortic valve replacement: Insights from 10 years' experience.

OBJECTIVE: Use of transcatheter aortic valve replacement (TAVR) has demonstrated dramatic growth in the past decade. This study aims to investigate implications of post-TAVR reoperation from our 10-year experience. METHODS: Between 2011 and 2022, 66 post-TAVR patients underwent a reoperation, consisting of 42 (63.6%) patients with native TAVR and 24 (36.4%) patients with valve-in-valve TAVR (VIV-TAVR) after surgical aortic valve replacement. RESULTS: The aggregate proportion of patients belonging to the low-/intermediate-risk group at the time of TAVR exceeded that of the high-/extreme-risk cohort in 2021. The native TAVR group received a larger TAVR valve, whereas more frequent low-risk status at the time of TAVR than the VIV-TAVR group. Concurrent procedures were highly common during reoperation and isolated surgical aortic valve replacement represented only 18.2% of the entire cohort. The native TAVR group demonstrated significantly higher TAVR explant difficulty index score (2.0 vs 1.0 points; P < .001) and operative mortality (14.2% vs 0%; P = .079) compared with the VIV-TAVR group. The 8-year cumulative incidence of reoperation was 1.9% and 14.1% (subdistribution hazard ratio, 8.0; 95% CI, 4.1-15.9; P < .001) in the native and VIV-TAVR group, respectively. Furthermore, cumulative incidence of valve reintervention, combining reoperations and redo TAVRs, was 3.3% and 19.0% (subdistribution hazard ratio, 6.2; 95% CI, 3.6-10.9; P < .001). CONCLUSIONS: Low-/intermediate-risk patients are emerging as the predominant group necessitating reoperations. Native TAVR was associated with lower postimplant reintervention rates, albeit with higher reoperative technical difficulty and mortality. Conversely, VIV-TAVR was associated with higher reintervention, but demonstrated lower technical difficulty and mortality for reoperation.

The impact of neighborhood disadvantage on colorectal cancer screening among African Americans in Chicago.

Historically, colorectal cancer (CRC) screening rates have been lower among African Americans. Previous studies that have examined the relationship between community characteristics and adherence to CRC screening have generally focused on a single community parameter, making it challenging to evaluate the overall impact of the social and built environment. In this study, we will estimate the overall effect of social and built environment and identify the most important community factors relevant to CRC screening. Data are from the Multiethnic Prevention and Surveillance Study (COMPASS), a longitudinal study among adults in Chicago, collected between May 2013 to March 2020. A total 2,836 African Americans completed the survey. Participants' addresses were geocoded and linked to seven community characteristics (i.e., community safety, community crime, household poverty, community unemployment, housing cost burden, housing vacancies, low food access). A structured questionnaire measured adherence to CRC screening. Weighted quantile sum (WQS) regression was used to evaluate the impact of community disadvantages on CRC screening. When analyzing all community characteristics as a mixture, overall community disadvantage was associated with less adherence to CRC screening even after controlling for individual-level factors. In the adjusted WQS model, unemployment was the most important community characteristic (37.6%), followed by community insecurity (26.1%) and severe housing cost burden (16.3%). Results from this study indicate that successful efforts to improve adherence to CRC screening rates should prioritize individuals living in communities with high rates of insecurity and low socioeconomic status.

ACR Appropriateness Criteria® Thoracoabdominal Aortic Aneurysm or Dissection: Treatment Planning and Follow-Up.

As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Valve-Sparing Aortic Root Replacement Technique: Valsalva Graft versus Two Straight Tubular Grafts.

Background: There are many variations in valve-sparing aortic root replacement techniques. Our aim is to determine the impact of the graft on mid-term outcomes: Valsalva graft vs. two straight tubular grafts. Methods: From 2004 to 2020, 332 patients underwent valve-sparing aortic root replacement with either a Valsalva graft (Valsalva group: n = 270) or two straight tubular grafts (two-graft group: n = 62). Data were obtained through chart review and the National Death Index. Primary outcomes were mid-term survival and freedom from reoperation. Results: The preoperative characteristics of the groups were similar, but the two-graft group had more type A dissections (32% vs. 19%) and emergent operations (26% vs. 15%) and was younger (45 vs. 50 years). Intraoperatively, the groups were similar, but the two-graft group had longer cross-clamp (245 vs. 215 minutes) and cardiopulmonary bypass times (284 vs. 255 minutes). Postoperative complications including reoperation for bleeding, stroke, pacemaker implantation, and renal failure were slightly more frequent in the Valsalva group, but the differences were not significant. Operative mortality was similar between the Valsalva and two-graft groups (0.7% vs. 0%). Five-year survival in the two-graft group was 100% compared to 96% in the Valsalva group (p=0.56). Five-year freedom from reoperation in the two-graft group was 100% compared to 93% in the Valsalva group (p=0.29). Conclusions: The Valsalva and two-graft techniques both have excellent short- and mid-term outcomes. The two-graft technique might have slightly better survival and freedom from reoperation, but a larger sample size and longer follow-up are needed to determine if these advantages are significant.