Long-term outcomes of TEVAR for thoracic aortic diseases: a retrospective single-center study.

BACKGROUND: The outcomes of Thoracic Endovascular Aortic Repair (TEVAR) vary depending on thoracic aortic pathologies, comorbidities. This study presents our comprehensive endovascular experience, focusing on exploring the outcome in long term follow-up. METHODS: From 2006 to 2018, we conducted TEVAR on 97 patients presenting with various aortic pathologies. This retrospective cohort study was designed primarily to assess graft durability and secondarily to evaluate mortality causes, complications, reinterventions, and the impact of comorbidities on survival using Kaplan-Meier and Cox regression analyses. RESULTS: The most common indication was thoracic aortic aneurysm (n = 52). Ten patients had aortic arch variations and anomalies, and the bovine arch was observed in eight patients. Endoleaks were the main complications encountered, and 10 of 15 endoleaks were type I endoleaks. There were 18 reinterventions; the most of which was TEVAR (n = 5). The overall mortality was 20 patients, with TEVAR-related causes accounting for 12 of these deaths, including intracranial bleeding in three patients. Multivariant Cox regression revealed chronic renal diseases (OR = 11.73; 95% CI: 2.04-67.2; p = 0.006), previous cardiac operation (OR = 14.26; 95% CI: 1.59-127.36; p = 0.01), and chronic obstructive pulmonary diseases (OR = 7.82; 95% CI: 1.43-42.78; p = 0.001) to be independent risk factors for 10-year survival. There was no significant difference in the survival curves of the various aortic pathologies. In the follow-up period, two non-symptomatic intragraft thromboses and one graft infection were found. CONCLUSION: Comorbidities can increase the risk of TEVAR-related mortality without significantly impacting endoleak rates. TEVAR is effective for severe aortic pathologies, though long-term graft durability may be compromised by its thrombosis and infection.

Deciphering Abdominal Aortic Diseases Through T-Cell Clonal Repertoire of Perivascular Adipose Tissue.

BACKGROUND: Recent studies suggest that immune-mediated inflammation of perivascular adipose tissue of abdominal aortic aneurysms (AAAs) contributes to disease development and progression. Whether the perivascular adipose tissue of AAA is characterized by a specific adaptive immune signature remains unknown. METHODS AND RESULTS: To investigate this hypothesis, we sequenced the T-cell receptor ß-chain in the perivascular adipose tissue of patients with AAA and compared it with patients with aortic occlusive disease, who share the former anatomical site of the lesion and risk factors but differ in pathogenic mechanisms. Our results demonstrate that patients with AAA have a lower repertoire diversity than those with aortic occlusive disease and significant differences in variable/joining gene segment usage. Furthermore, we identified a set of 7 public T-cell receptor ß-chain clonotypes that distinguished AAA and aortic occlusive disease with very high accuracy. We also found that the T-cell receptor ß-chain repertoire differentially characterizes small and large AAAs (aortic diameter<55 mm and ≥55 mm, respectively). CONCLUSIONS: This work supports the hypothesis that T cell-mediated immunity is fundamental in AAA pathogenesis and opens up new clinical perspectives.

Role of aortic valve replacement in moderate aortic stenosis: a 10-year outcomes study.

OBJECTIVE: Patients with moderate aortic stenosis (AS) exhibit high morbidity and mortality. Limited evidence exists on the role of aortic valve replacement (AVR) in this patient population. To investigate the benefit of AVR in moderate AS on survival and left ventricular function. METHODS: In a retrospective cohort study, patients with moderate AS between 2008 and 2016 were selected from the Cleveland Clinic echocardiography database and followed until 2018. Patients were classified as receiving AVR or managed medically (clinical surveillance). All-cause and cardiovascular mortality were assessed by survival analyses. Temporal haemodynamic and structural changes were assessed with longitudinal analyses using linear mixed effects models. RESULTS: We included 1421 patients (mean age, 75.3±5.4 years and 39.9% women) followed over a median duration of 6 years. Patients in the AVR group had lower risk of all-cause (adjusted HR (aHR)=0.51, 95% CI: 0.34 to 0.77; p=0.001) and cardiovascular mortality (aHR=0.50, 95% CI: 0.31 to 0.80; p=0.004) compared with those in the clinical surveillance group irrespective of sex, receipt of other open-heart surgeries and underlying malignancy. These findings were seen only in those with preserved left ventricular ejection fraction (LVEF) ≥50%. Further, patients in the AVR group had a significant trend towards an increase in LVEF and a decrease in right ventricular systolic pressure compared with those in the clinical surveillance group. CONCLUSIONS: In patients with moderate AS, AVR was associated with favourable clinical outcomes and left ventricular remodelling.

Comparison of total percutaneous in situ microneedle puncture and chimney technique for left subclavian artery fenestration in thoracic endovascular aortic repair for type B aortic dissection.

OBJECTIVE: To compare the outcomes of totally percutaneous in situ microneedle puncture for left subclavian artery (LSA) fenestration (ISMF) and chimney technique in type B aortic dissection (TBAD) during thoracic endovascular aortic repair (TEVAR). MATERIALS AND METHODS: Data on patients who underwent either chimney-TEVAR (n = 89) or ISMF-TEVAR (n = 113) from October 2018 to April 2022 were analyzed retrospectively. The primary outcomes were mortality and major complications at 30 days and during follow-up. RESULTS: The technical success rate was 84.3% in the chimney group and 93.8% in the ISMF group (p = 0.027). The incidence of immediate endoleakage was significantly higher in the chimney than ISMF group (15.7% vs 6.2%, respectively; p = 0.027). The 1- and 3-year survival rates in the chimney and ISMF groups were 98.9% ± 1.1% vs 98.1% ± 0.9% and 86.5% ± 6.3% vs 92.6% ± 4.1%, respectively (log-rank p = 0.715). The 3-year rate of cumulative freedom from branch occlusion in the chimney and ISMF group was 95.4% ± 2.3% vs 100%, respectively (log-rank p = 0.023). CONCLUSION: Both ISMF-TEVAR and chimney-TEVAR achieved satisfactory short- and mid-term outcomes for the preservation of the LSA in patients with TBAD. ISMF-TEVAR appears to offer better clinical outcomes with higher patency and lower reintervention rates. However, ISMF-TEVAR had longer operation times with higher procedure expenses. CLINICAL RELEVANCE STATEMENT: When LSA revascularization is required during TEVAR, in situ, fenestration, and chimney techniques are all safe and effective methods; in situ, fenestration-TEVAR appears to offer better clinical outcomes, but takes longer and is more complicated. KEY POINTS: LSA revascularization during TEVAR reduces post-operative complication rates. Both in situ ISMF-TEVAR and chimney-TEVAR are safe and effective techniques for the preservation of the LSA during TEVAR. The chimney technique is associated with a higher incidence of endoleakage and branch occlusion, but ISMF-TEVAR is a more complicated and expensive technique.

Computed Tomography Angiography for Aortic Diseases.

Aortic pathologies encompass a heterogeneous group of disorders, including acute aortic syndrome, traumatic aortic injury , aneurysm, aortitis, and atherosclerosis. The clinical manifestations of these disorders can be varied and non-specific, ranging from acute presentations in the emergency department to chronic incidental findings in an outpatient setting. Given the non-specific nature of their clinical presentations, the reliance on non-invasive imaging for screening, definitive diagnosis, therapeutic strategy planning, and post-intervention surveillance has become paramount. Commonly used imaging modalities include ultrasound, computed tomography (CT), and MR imaging. Among these modalities, computed tomography angiography (CTA) has emerged as a first-line imaging modality owing to its excellent anatomic detail, widespread availability, established imaging protocols, evidence-proven indications, and rapid acquisition time.

Validation of 2D flow MRI for helical and vortical flows.

PURPOSE: The main objective of this study was to develop two-dimensional (2D) phase contrast (PC) methods to quantify the helicity and vorticity of blood flow in the aortic root. METHODS: This proof-of-concept study used four-dimensional (4D) flow cardiovascular MR (4D flow CMR) data of five healthy controls, five patients with heart failure with preserved ejection fraction and five patients with aortic stenosis (AS). A PC through-plane generated by 4D flow data was treated as a 2D PC plane and compared with the original 4D flow. Visual assessment of flow vectors was used to assess helicity and vorticity. We quantified flow displacement (FD), systolic flow reversal ratio (sFRR) and rotational angle (RA) using 2D PC. RESULTS: For visual vortex flow presence near the inner curvature of the ascending aortic root on 4D flow CMR, sFRR demonstrated an area under the curve (AUC) of 0.955, p<0.001. A threshold of >8% for sFRR had a sensitivity of 82% and specificity of 100% for visual vortex presence. In addition, the average late systolic FD, a marker of flow eccentricity, also demonstrated an AUC of 0.909, p<0.001 for visual vortex flow. Manual systolic rotational flow angle change (ΔsRA) demonstrated excellent association with semiautomated ΔsRA (r=0.99, 95% CI 0.9907 to 0.999, p<0.001). In reproducibility testing, average systolic FD (FDsavg) showed a minimal bias at 1.28% with a high intraclass correlation coefficient (ICC=0.92). Similarly, sFRR had a minimal bias of 1.14% with an ICC of 0.96. ΔsRA demonstrated an acceptable bias of 5.72°-and an ICC of 0.99. CONCLUSION: 2D PC flow imaging can possibly quantify blood flow helicity (ΔRA) and vorticity (FRR). These imaging biomarkers of flow helicity and vorticity demonstrate high reproducibility for clinical adoption. TRIALS REGISTRATION NUMBER: NCT05114785.

Identifying Predictors for Hypoplastic Aortic Arch (HAA) in Pediatric Patients with Complex Coarctation of the Aorta (CoA).

OBJECTIVE: HAA is a significant risk factor in complex CoA patients. We conducted a retrospective study to explore the relationship between HAA and other cardiovascular factors. METHODS: We analyzed 103 patients diagnosed with complex CoA using CT angiography and echocardiography. Aortic diameter was measured at six levels, and severe coarctation was defined as coarctation site to diaphragmatic level ratio (CDR) < 50%. Correlations between non-HAA and HAA groups were assessed. Univariate and multivariate logistic regression identified HAA risk factors. RESULTS: Among 103 children with complex CoA, 55 were in the non-HAA group and 48 in the HAA group. The incidence of PDA (56.3% vs. 32.7%, p < 0.05), severe coarctation (CDR < 50%, 81.3% vs. 34.5%, p < 0.01), and collateral arteries (39.6% vs. 0, p < 0.01) were higher in the HAA group than one in the non-HAA group. The aortic arch size was positively correlated with age and negatively correlated with severe coarctation, VSD, collateral arteries, and left heart dysfunction. Logistic regression results showed that collateral arteries were risk factors for the whole aortic arch (proximal arch OR = 11.458; p < 0.01, distal arch OR = 4.211; p < 0.05, and isthmus OR = 11.744; p < 0.01), severe coarctation (OR = 6.653; p < 0.01), and left heart dysfunction (OR = 5.149; p < 0.01) associated with isthmus hypoplasia. CONCLUSION: This study highlights the prevalence of HAA in complex CoA patients and its associations with various cardiovascular factors. These insights improve diagnosis and treatment approaches.

Is Deep Hypothermic Cardiac Arrest Mandatory in Aortic Arch Surgeries?

Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Aortic Cellular Heterogeneity in Health and Disease: Novel Insights Into Aortic Diseases From Single-Cell RNA Transcriptomic Data Sets.

Aortic diseases such as atherosclerosis, aortic aneurysms, and aortic stiffening are significant complications that can have significant impact on end-stage cardiovascular disease. With limited pharmacological therapeutic strategies that target the structural changes in the aorta, surgical intervention remains the only option for some patients with these diseases. Although there have been significant contributions to our understanding of the cellular architecture of the diseased aorta, particularly in the context of atherosclerosis, furthering our insight into the cellular drivers of disease is required. The major cell types of the aorta are well defined; however, the advent of single-cell RNA sequencing provides unrivaled insights into the cellular heterogeneity of each aortic cell type and the inferred biological processes associated with each cell in health and disease. This review discusses previous concepts that have now been enhanced with recent advances made by single-cell RNA sequencing with a focus on aortic cellular heterogeneity.

Herramientas para el tamizaje de aneurisma de aorta abdominal / Tools for abdominal aortic aneurysm screening

Introducción. El aneurisma de la aorta abdominal (AAA) es la dilatación de la aorta abdominal mayor de 1,5 veces el diámetro esperado. Su prevalencia es variable, con tasas reportadas de hasta el 12,5 %. Se considera como causa de muerte de más de 10.000 personas al año en los Estados Unidos. El objetivo de esta revisión de la literatura fue describir los factores de riesgo y las herramientas de tamizaje de AAA. Métodos. Se realizó una búsqueda de la literatura utilizando dos ecuaciones en bases de datos electrónicas, empleando términos seleccionados de "Medical Subject Heading" (MeSH) y "Descriptores en Ciencias de la Salud" (DeCS). Se evaluó la calidad de los estudios con la herramienta STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Resultados. Se recolectaron 40 artículos y a partir de ellos se construyó el texto de revisión, identificando en estos, los factores de riesgo asociados al desarrollo de AAA, tales como sexo masculino, tabaquismo, hipertensión arterial, antecedente familiar y obesidad, entre otros. La diabetes mellitus parece actuar como factor protector. Dentro de los instrumentos de tamizaje, el ultrasonido abdominal es uno de los más usados. Conclusión. El AAA es una patología multifactorial. En la actualidad la ultrasonografía de aorta es el método de elección para el tamizaje, permitiendo la detección precoz. El tamizaje de AAA con métodos no invasivos, como el ultrasonido, es útil sobre todo en zonas con prevalencia alta de la patología y en pacientes con determinados factores de riesgo.

Introduction. Abdominal aortic aneurysm (AAA) is a dilation of the abdominal aorta greater than 1.5 times the expected diameter. Its prevalence is variable, with reported rates of up to 12.5%. It is considered the cause of death of more than 10,000 people a year in the United States. The objective of this literature review was to describe risk factors and screening tools for AAA. Methods. A literature search was conducted using two equations in electronic databases, using terms selected from "Medical Subject Heading" (MeSH) and "Descriptors in Health Sciences" (DeCS). The quality of the studies was evaluated with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) tool. Results. Forty articles were collected and from them the review text was constructed, identifying the risk factors associated with the development of AAA, such as male sex, smoking, high blood pressure, family history and obesity, among others. Diabetes mellitus seems to act as a protective factor. Among the screening instruments, abdominal ultrasound is one of the most used. Conclusion. AAA is a multifactorial pathology. Currently, aortic ultrasonography is the method of choice for screening, allowing early detection. Screening for AAA with non-invasive methods, such as ultrasound, is useful especially in areas with a high prevalence of this pathology and in patients with certain risk factors.

Five Year Results of Endovascular versus Medical Therapy in Acute Type B Aortic Intramural Haematoma: Meta-Analysis of Reconstructed Time to Event Data.

OBJECTIVE: To evaluate outcomes in the follow up of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in patients with acute type B aortic intramural haematoma (IMH). DATA SOURCES: The following sources were searched for articles meeting the inclusion criteria and published by July 2023: PubMed/MEDLINE, EMBASE, CENTRAL/CCTR (Cochrane Controlled Trials Register). REVIEW METHODS: This systematic review with pooled meta-analysis of time to event data followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and its protocol was registered on the public platform PROSPERO (CRD42023456222). The following were analysed: overall survival (all cause mortality), aortic related mortality, and restricted mean survival time. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. RESULTS: Eight studies met the eligibility criteria, including 1 015 patients (440 in the TEVAR group and 575 in the medical therapy group). All studies were observational, and the pooled cohort had a median follow up of 5.1 years. Compared with patients who received medical therapy alone, those who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.44, 95% CI 0.30 - 0.65; p < .001; GRADE certainty: low), lower risk of aortic related death (HR 0.04, 95% CI 0.01 - 0.31; p = .002; GRADE certainty: low) and lifetime gain (restricted mean survival time was overall 201 days longer with TEVAR; p < .001). CONCLUSION: Thoracic endovascular aortic repair may be associated with lower risk of all cause and aortic related death compared with medical therapy in patients with acute type B IMH; however, the underlying data are not strong enough to draw robust clinical conclusions. Randomised controlled trials with large sample sizes and longer follow up are warranted to elucidate this question.

Is Deep Hypothermic Cardiac Arrest Mandatory in Aortic Arch Surgeries?

ABSTRACT Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Treatment For Infected Frozen Elephant Trunk Prosthesis Caused by Propionibacterium acnes: A Surgical Challenge

ABSTRACT In this article, we present the case of a 47-year-old man who underwent Bentall-Bono procedure and frozen elephant trunk prosthesis implantation due to severe aortic regurgitation and aortic dilatation with a second-time endovascular stent-graft repair in descending aorta. Over eight years, a subacute graft infection by Propionibacterium acnes was developed, culminating in cardiogenic shock secondary to severe aortic regurgitation due to a complete aortic root dehiscence because of multiple aortic pseudoaneurysms. The patient underwent emergency surgery in which the replacement of the graft by a biological valve tube was performed accompanied by a complete debranching of the three supra-aortic vessels.

[Complex management of intramural hematoma of the descending aorta: about a case]. / Manejo complejo del hematoma intramural de aorta descendente: a propósito de un caso.

Acute aortic syndromes (AAS) include a variety of overlapping anatomical and clinical conditions. Intramural hematoma (IMH), penetrating aortic ulcer, and aortic dissection occur in isolation or may coexist in the same patient. IMH represents 5-30% of all AAS and 60-70% of cases are located in the descending aorta. The diagnosis relies on a high index of clinical suspicion and on the use of complementary images. Management is conservative, but patients with some high-risk characteristics have a higher risk of mortality in the acute phase, so initial endovascular management should be considered. We present the case of a 69-year-old patient, in whom IMH was diagnosed in the course of a hypertensive emergency and who required hybrid management due to high-risk anatomical characteristics for endovascular management only.

Thoracic endovascular aortic repair for hyperacute, acute, subacute and chronic type B aortic dissection: Meta-analysis of reconstructed time-to-event data.

Since the optimal timing for thoracic endovascular aortic repair (TEVAR) in the context of type B aortic dissections (TBAD) remains an open question, we performed a systematic review with meta-analysis to evaluate outcomes of TEVAR according to the phases of TBAD - hyperacute, acute, subacute and chronic. We carried out a pooled meta-analysis of time-to-event data extracted from studies published by June 2023 for the following outcomes: all-cause mortality, aortic-related mortality, and late aortic reinterventions. Thirteen studies met our eligibility criteria, comprising 4,793 patients (10.3 % hyperacute, 51.9 % acute, 25.9 % subacute, 11.9 % chronic). Considering the overall population, we observed a statistically significant difference between the groups (Log-rank test, P < 0.0001) and the main differences were found in the following comparisons: hyperacute versus acute (HR 1.61; 95 %CI 1.21-2.13; P = 0.001); hyperacute versus chronic (HR 1.70; 95 %CI 1.17-2.46; P = 0.005); subacute versus acute (HR 0.78; 95 %CI 0.63-0.98; P = 0.032). Considering the population with uncomplicated TBAD, we also observed a statistically significant difference for all-cause death between the groups (Log-rank test, P < 0.0001) and the main differences were found in the comparisons for subacute versus acute (HR 0.72; 95 %CI 0.58-0.88; P = 0.002). Furthermore, we observed statistically significant differences between the groups for aortic-related death (Log-rank test, P < 0.0001) and late aortic reintervention (Log-rank test, P < 0.0001), all favoring mostly the subacute phase as the optimal timing for TEVAR. In conclusion, there seems to be a timing-specific difference in the outcomes of TEVAR for TBAD pointing to the subacute phase as the optimal timing to achieve better long-term outcomes.

Challenging Diagnosis and Management: A Complex Case Following an Urgent Caeserean Section.

Hemodynamic changes during pregnancy are physiological adaptations to fulfill new demands. Although these adaptations are often well-tolerated, they may unmask or exacerbate underlying cardiovascular conditions, posing unique challenges for medical professionals. We present a case that outlines the evaluation and treatment of a 38-year-old woman who experienced health complications shortly after undergoing a Caesarean section.  A 38-year-old woman who had a previous caeserean section presented for an urgent caeserean section at 39 weeks of gestational age due to non-reassuring cardiotocography. Shortly after spinal anesthesia and misoprostol administration, she developed cyanosis, confusion, mottling skin, tachycardia, tachypnea, and hypotension. The patient's clinical presentation led to a broad differential diagnosis, including cardiovascular complications, infection, medication reactions, and hemorrhage, being the ultimate diagnosis of a case of severe aortic stenosis. Successful management involved a multidisciplinary approach and coordinated effort, particularly involving the anesthesiology team, which was pivotal in timely diagnosis and intervention. The ultimate diagnosis of severe aortic stenosis emphasized the significance of accurate and coordinated healthcare. Successful management involves collaboration between obstetric, intensive care, and cardiac care teams, highlighting the potential for improved outcomes when healthcare professionals work together in complex clinical scenarios.

Cardiac MR modelling of systolic and diastolic blood pressure.

AIMS: Blood pressure (BP) is a crucial factor in cardiovascular health and can affect cardiac imaging assessments. However, standard outpatient cardiovascular MR (CMR) imaging procedures do not typically include BP measurements prior to image acquisition. This study proposes that brachial systolic BP (SBP) and diastolic BP (DBP) can be modelled using patient characteristics and CMR data. METHODS: In this multicentre study, 57 patients from the PREFER-CMR registry and 163 patients from other registries were used as the derivation cohort. All subjects had their brachial SBP and DBP measured using a sphygmomanometer. Multivariate linear regression analysis was applied to predict brachial BP. The model was subsequently validated in a cohort of 169 healthy individuals. RESULTS: Age and left ventricular ejection fraction were associated with SBP. Aortic forward flow, body surface area and left ventricular mass index were associated with DBP. When applied to the validation cohort, the correlation coefficient between CMR-derived SBP and brachial SBP was (r=0.16, 95% CI 0.011 to 0.305, p=0.03), and CMR-derived DBP and brachial DBP was (r=0.27, 95% CI 0.122 to 0.403, p=0.0004). The area under the curve (AUC) for CMR-derived SBP to predict SBP>120 mmHg was 0.59, p=0.038. Moreover, CMR-derived DBP to predict DBP>80 mmHg had an AUC of 0.64, p=0.002. CONCLUSION: CMR-derived SBP and DBP models can estimate brachial SBP and DBP. Such models may allow efficient prospective collection, as well as retrospective estimation of BP, which should be incorporated into assessments due to its critical effect on load-dependent parameters.