Single-Center Preliminary Experience with Gutter-Plugging Chimney Stent-Graft for Aortic Dissection.

PURPOSE: To report the early 2-year results and experience of a novel gutter-plugging chimney stent-graft in a single center that participated in the clinical trial of Prospective Study for Aortic Arch Therapy with stENt-graft for Chimney technology. MATERIALS AND METHODS: Patients diagnosed with aortic dissection were treated with the novel chimney stent-grafts named Longuette™ for the left subclavian artery revascularization. Primary study outcomes were the incidence of freedom from major adverse events within 30 days and success rate of the operation over 12 months. RESULTS: A total of 34 patients were enrolled between September 2019 and December 2020. The immediate technical success rate (stent-grafts successfully deployed without fast-flow type Ia or type III endoleak intraoperatively) was 100%, and there were no conversions to open repair. Type Ia and type II endoleaks were noted in three patients (8.8%) and one patient (2.9%) at discharge, respectively. One patient (2.9%) with type Ia endoleak underwent coil embolization at 12 months because of false lumen dilation, and one (2.9%) case of type Ia endoleak resolved spontaneously at 24 months. One chimney stent (2.9%) was revealed with stenosis at discharge and occluded with thrombosis at 6 months postoperatively. During the 2-year follow-up, there was no death, rupture, stroke, paraplegia, left arm ischemia, retrograde dissection, stent-graft induced new entry, or stent migration. CONCLUSION: The initial results of the Longuette™ stent-graft for revascularization of the left subclavian artery are encouraging with a high technical success rate. Further multicenter follow-up outcomes are required to assess the long-term durability. LEVEL OF EVIDENCE: Level 4, Case Series.

Endovascular aortic arch repair with chimney technique for pseudoaneurysm.

BACKGROUND: Aortic pseudoaneurysm is a life-threatening clinical condition, and thoracic endovascular aortic repair (TEVAR) has been reported to have a relatively satisfactory effect in aortic pathologies. We summarized our single-centre experience using chimney TEVAR for aortic arch pseudoaneurysms with inadequate landing zones. METHODS: A retrospective study was conducted from October 2015 to August 2020, 32 patients with aortic arch pseudoaneurysms underwent chimney TEVAR to exclude an aortic lesion and reconstruct the supra-aortic branches, including 3 innominate artery, 12 left common carotid arteries and 29 left subclavian arteries. Follow-up computed tomography was suggested before discharge; at 3, 6, 12 months and yearly thereafter. RESULTS: The median age of 32 patients was 68.0 years (range, 28-81) with the mean max diameter of aneurysm of 47.9 ± 12.0 mm. Forty-four related supra-aortic branches were well preserved, and the technical success rate was 100%. The Type Ia endoleaks occurred in 3 (9%) patients. Two patients were lost to follow-up and 4 patients died during the follow-up period. The mean follow-up times was 46.5 ± 14.3 months. One patient died due to acute myocardial infarction just 10 days after chimney TEVAR and the other 3 patients passed away at 1.5 months, 20 months, and 31 months with non-aortic reasons. The 4.5-year survival estimate was 84.4%. The primary patency rate of the target supra-arch branch vessels was 97.7% (43/44), and no other aorta-related reinterventions and severe complications occurred. CONCLUSION: For aortic arch pseudoaneurysms with inadequate landing zones for TEVAR, the chimney technique seems to be feasible, with acceptable mid-term outcomes, and it could serve as an alternative minimally invasive approach to extend the landing zone. Slow flow type Ia endoleak could be treated conservatively after chimney TEVAR. Additional experience is needed, and the long-term durability of chimney TEVAR requires further follow-up.

Similar Midterm Clinical Outcomes and Aortic Remodeling in Bifurcated and Straight Aortic Stent Grafts Used to Treat Isolated Abdominal Aortic Dissection.

PURPOSE: The optimal treatment for isolated abdominal aortic dissection (IAAD) is currently unknown. We compared the effects of straight and bifurcated aortic stent grafts on postoperative aortic remodeling in patients with IAAD. MATERIALS AND METHODS: From February 2012 to December 2019, 57 patients with IAAD were treated using endovascular methods, including either a bifurcated or a straight aortic stent graft. The clinical features, risk factors, computed tomography angiograms, midterm follow-up results, and aortic remodeling of these patients were reviewed and analyzed. RESULTS: In total, 44 (77%) patients were treated with a bifurcated graft and 13 (23%) patients were treated with a straight graft. Patients treated with straight grafts had fewer common iliac arteries involved (38% vs 73%, p=0.023), the dissection length was shorter (76.3 ± 40.0 vs 116.2 ± 56.7 mm, p=0.011), and the preoperative aortic diameter (26.0 ± 5.6 vs 35.2 ± 12.1 mm) and the false lumen diameter (13.1 ± 5.2 vs 21.2 ± 11.3 mm) were smaller. During the procedure, there were 3 (5.3%) type I endoleaks, 1 (1.8%) surgical conversion and 1 (1.8%) partial renal artery coverage without perioperative mortality. Patients with straight grafts had shorter operative time (96.5 ± 24.4 vs 144.2 ± 49.0 minutes, p<0.0001). The median follow-up duration was 37.6 ± 21.0 (range = 3-89) months with 1 (1.8%) aortic-related death. Type A aortic dissection occurred in 1 (1.8%) patient. New descending aortic dissection occurred in 3 (5.3%) patients, and 1 patient advanced to type A aortic dissection 3 months later. Two (3.5%) patients had limb occlusion. There was no significant difference in aortic remodeling, survival, and freedom from all adverse events between the 2 treatment strategies. CONCLUSIONS: Endovascular treatment provides a safe, minimally invasive treatment for IAAD in midterm follow-up. Compression of the true lumen at the aortic bifurcation is the main concern after treatment with a bifurcated graft. Straight grafts are an excellent alternative for some patients, with the benefit of reduced procedural time, effective aortic remodeling, and excellent clinical prognosis. More experience is needed to offer clear recommendations for making treatment decisions as well as determine long-term effectiveness and durability.

WITHDRAWN: Endovascular Repair with Stent-Graft of Symptomatic Tuberculous Aortic Pseudoaneurysm

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Post-Transcriptional Control of Tropoelastin in Aortic Smooth Muscle Cells Affects Aortic Dissection Onset.

Aortic dissection (AD) is a catastrophic disease with high mortality and morbidity, characterized with fragmentation of elastin and loss of smooth muscle cells. Although AD has been largely attributable to polymorphisms defect in the elastin-coding gene, tropoelastin (TE), other undermined factors also appear to play roles in AD onset. Here, we investigated the effects of post-transcriptional control of TE by microRNAs (miRNAs) on elastin levels in aortic smooth muscle cells (ASMC). We found that miR-144-3p is a miRNA that targets TE mRNA in both human and mouse. Bioinformatics analyses and dual luciferase reporter assay showed that miR-144-3p inhibited protein translation of TE, through binding to the 3'-UTR of the TE mRNA. Interestingly, higher miR-144-3p levels and lower TE were detected in the ASMC obtained from AD patients, compared to those from non-AD controls. In a mouse model for human AD, infusion of adeno-associated viruses (serotype 6) carrying antisense for miR-144-3p (as-miR-144-3p) under CAG promoter significantly reduced the incidence and severity of AD, seemingly through enhancement of TE levels in ASMC. Thus, our data suggest an essential role of miR-144-3p on the pathogenesis of AD.

[Clinical features and management of complete heart block after transaortic extended septal myectomy in patients with hypertrophic obstructive cardiomyopathy].

OBJECTIVE: To analyze the clinical features, precaution and management of complete heart block (CHB) after transaortic extended septal myectomy operation (extended Morrow procedure) in patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS: From October 1996 to December 2011, 10[6 men; mean age (45.4 ± 15.8) years, range 13-60 years] out of 160 consecutive HOCM patients underwent extended Morrow procedure developed CHB postoperatively. Their clinical data were retrospectively analyzed. Baseline transthoracic echocardiography showed that the left ventricular outflow tract (LVOT) gradients was from 68 to 149 (105.1 ± 25.9) mm Hg (1 mm Hg = 0.133 kPa), ECG showed right bundle branch block in 5 patients and atrial fibrillation, atrial premature beats or ST-T segment changes in other 5 patients. Besides extended Morrow procedure, concomitant surgical procedures included mitral valve replacement (MVR) in 2 (2/10) and MVR plus coronary artery bypass grafting in another 2 (2/10) patients. Follow-up data were obtained by subsequent clinic visits in outpatient department and telephone interviews. RESULTS: The in-hospital mortality was 20% (these two patients died of low cardiac output syndrome and multiple organs failure). Four patients underwent MVR simultaneously survived the operation. Postoperative echocardiography demonstrated a reduced LVOT gradient[(13.6 ± 9.7) mm Hg, P < 0.001]. Permanent pacemakers were implanted in all 8 survived patients at 6 days to 7 months after operation. No other severe complications were observed. During follow-up [from 4 to 72 (19.4 ± 22.1) months], there was no death, 1 patient readmitted to our center at 71 months post operation to change the pacemaker because of low voltage of previously implanted pacemaker. Physical capacity and quality of life improved significantly post operation in these 8 patients. The NYHA functional class remained at I-II post operation and during follow up. CONCLUSIONS: CHB is a severe complication after extended Morrow procedure for patients with HOCM and timely permanent pacemaker implantation is mandatory for patients with post procedure CHB.

[Surgical treatment for hypertrophic obstructive cardiomyopathy: a report of 118 cases].

OBJECTIVE: To assess the clinical outcomes of transaortic extended septal myectomy on early and midterm survival of patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS: From October 2009 to April 2012, 118 consecutive patients underwent extended Morrow's procedure for HOCM. There were 69 males and 49 females with an average age of (46 ± 13) years. Their clinical data were analyzed retrospectively. Preoperative transthoracic, intraoperative transoesophageal and postoperative transthoracic echocardiography was performed to assess septal thickness, left ventricular outflow tract (LVOT) gradient, mitral valve function and systolic anterior motion (SAM) of anterior mitral valve leaflet, etc. Concomitant surgical procedures were performed if other cardiac diseases required surgical interventions. Follow-up study was carried out during subsequent clinic visits at outpatient department and through telephone interviews with patients and their relatives. RESULTS: The septal thickness was (25 ± 7) mm. SAM was detected in all. The in-hospital mortality was 0.8% (1/118) since one patient died of multiple organs failure one week later. Postoperative echocardiography demonstrated marked reduction in LVOT gradient (92 ± 22 vs 13 ± 10 mm Hg (1 mm Hg = 0.133 kPa), P = 0.000), New York Heart Association (NYHA) class (2.9 ± 0.6 vs 1.2 ± 0.4, P = 0.000) and significant improvement in mitral regurgitation. Concomitant surgical procedures were performed in 45 cases (38.1%, all for preexisting conditions). Complications included complete atrioventricular block (n = 3), first degree atrioventricular block (n = 6), complete left bundle branch block (n = 51), intraventricular conduction delay or left anterior division block (n = 26), transient renal dysfunction (n = 2) and intra-aortic-balloon-pumping (n = 2). No other severe complication was observed. During a follow-up period of 1 - 27 (7 ± 6) months, there was no readmission or death. All patients reported significant increase in physical ability and obvious decrease in limiting symptoms. At the latest follow-up, the NYHA functional class maintained grade I-II in all. And mitral regurgitation remained absent or mild. CONCLUSION: Surgical procedure for HOCM patients is both safe and efficacious. It provides an excellent relief of LVOT obstruction.

Thoracic endovascular aortic repair for retrograde type A aortic dissection with an entry tear in the descending aorta.

PURPOSE: To report the immediate and follow-up outcome of thoracic endovascular aortic repair (TEVAR) in highly selected patients with retrograde type A aortic dissection (RAAD) and an entry tear in the descending aorta. MATERIALS AND METHODS: TEVAR was performed in 17 patients with RAAD and an entry tear in the descending aorta. None of the patients had severe aortic regurgitation, cardiac tamponade, coronary artery involvement, or brain ischemia. The false lumen in the ascending aorta was patent in nine patients. Two patients had acute malperfusion of the branched artery. Computed tomography (CT) was performed 14 days, 3 months, and 6 months after the intervention and annually thereafter. RESULTS: All procedures were technically successful, with complete coverage of the entry tear and complete thrombosis of the false lumen in the ascending aorta. All patients survived through the follow-up period (25.7 months ± 17.2). TEVAR resulted in thrombosis of the false lumen, reabsorption of the false lumen thrombus, and enlargement of the true lumen. The mean maximal diameter of the ascending aorta and the false lumen in the ascending aorta significantly decreased after TEVAR. At the distal edge of the stent graft, the mean diameter of the descending aorta and the false lumen markedly decreased after TEVAR. Complete thrombosis of the false lumen was observed at the distal edge of the stent graft in 16 (94.1%) patients and at the diaphragmatic level in 9 (52.9%) patients. CONCLUSIONS: TEVAR for RAAD with an entry tear in the descending aorta is a safe and effective technique in highly selected patients.

Early results of left carotid chimney technique in endovascular repair of acute non-a-non-B aortic dissections.

PURPOSE: To report our early experience with endovascular repair of acute non-A-non-B aortic dissections using chimney grafts to preserve blood flow to a left common carotid artery (LCCA) located in the proximal landing zone. METHODS: From June 2009 to May 2010, 8 patients (7 men; mean age 49 years, range 29-75) with acute non-A-non-B aortic dissection and no adequate proximal sealing zones underwent thoracic endovascular aortic repair (TEVAR). Covered stents were placed parallel to the aortic stent-grafts to restore flow to the LCCAs while extending the proximal fixation zones; the left subclavian arteries were intentionally covered after carefully cerebrovascular assessment. Follow-up examinations included computed tomography (CT) at 2 weeks, 3 months, 6 months, 12 months, and yearly thereafter. RESULTS: All the procedures were completed successfully, with one main aortic stent-graft deployed and one chimney graft implanted in the LCCA. Two retrograde type II endoleaks identified intraoperatively were left untreated but followed closely using CT. There were no instances of puncture site complications, stroke, paralysis, or death during the hospital stay. The 30-day mortality was 0%. During the mean 11.4-month follow-up (range 6-15), there was no mortality, and duplex ultrasound and CT showed patency of all stent-grafts, enlargement of the true lumen, and compression of the false lumen. One type II endoleak disappeared in 2 weeks postoperatively, while the other gradually faded until it was nearly gone at 11 months postoperatively. During follow-up, no renal insufficiency, new late endoleaks, endograft migration, fracture, stent-graft related complications, or deaths were observed. CONCLUSION: In short-term follow-up, TEVAR combined with the chimney technique seems promising for aortic dissections that involve the aortic arch with inadequate proximal sealing zones. More cases and long-term results are needed to evaluate the safety and efficiency of this alternative endovascular technique.