Evolución en el diagnóstico, el tratamiento y la mortalidad del síndrome aórtico agudo en los últimos 20 años / Changes in the diagnosis and management of acute aortic syndrome and associated mortality in the last 20 years

Introducción y objetivos El síndrome aórtico agudo (SAA) tiene una alta mortalidad que obliga a un tratamiento precoz. El propósito del presente estudio es analizar los cambios en el abordaje y el tratamiento del SAA a lo largo de 20 años.MétodosSe incluyó prospectivamente a 451 pacientes (336 varones; media de edad, 60,9±12,4 años) diagnosticados de SAA, 270 con el tipo A y 181 con el tipo B, desde 1999 hasta 2018. Se analizaron variables clínicas, diagnósticas y del tratamiento y las complicaciones hospitalarias.ResultadosEl uso de la tomografía computarizada (TC) como primera técnica diagnóstica se incrementó del 62,8 al 94,2% (p <0,001). El tratamiento quirúrgico del SAA tipo A aumentó del 67,4 al 82,5% (p=0,09). La mortalidad del SAA tipo A disminuyó del 53,1 al 26,3% (p <0,001) como consecuencia de la reducción de la mortalidad del tratamiento quirúrgico (del 45,4 al 17,0%; p <0,001). El tratamiento exclusivamente médico del SAA tipo B disminuyó del 91,8 al 61,7% (p <0,001), debido al aumento del tratamiento endovascular. La mortalidad del SAA tipo B no mostró una disminución significativa (del 16,2 al 10,6%; p=0,15).ConclusionesEl diagnóstico y el tratamiento del SAA han presentado importantes cambios en las últimas 2 décadas. La TC se ha consolidado como la técnica diagnóstica de elección. La mortalidad del SAA tipo A ha disminuido de manera muy importante debido a la mejora de los resultados del tratamiento quirúrgico. En el SAA tipo B, el tratamiento médico solo se ha reducido debido a la aparición del tratamiento endovascular, pero la mortalidad hospitalaria no ha disminuido de manera significativa. (AU)

Introduction and objectives Mortality is high in acute aortic syndrome (AAS), which therefore requires early treatment. This study aimed to analyze changes in the diagnosis and treatment of AAS over 20 years at our center.MethodsFrom 1999 to 2018, 451 patients diagnosed with AAS (336 men; mean age, 60.9±12.4 years) were prospectively included (270 type A and 181 type B). Clinical variables, diagnosis, treatment, and in-hospital complications were analyzed.ResultsThe use of computed tomography (CT) as the first-line diagnostic technique increased from 62.8% to 94.2% (P <.001). Surgical treatment of type A AAS rose from 67.4% to 82.5% (P=.09). Mortality from type A AAS decreased significantly from 53.1% to 26.3% (P <.001) as a result of the fall in mortality from surgical treatment (from 45.4% to 17.0%; P <.001). The use of medical treatment alone for type B AAS decreased from 91.8% to 61.7% (P <.001) due to the greater use of endovascular treatment. Mortality from type B AAS showed no significant reduction (16.2% to 10.6%; P=.15).ConclusionsThe diagnosis and treatment of AAS has changed substantially in the last 2 decades. CT has become the first-line diagnostic technique for AAS. In type A AAS, mortality has fallen significantly due to improvements in the results of surgical treatment. In type B AAS, the use of medical treatment alone has decreased due to the expansion of endovascular treatment, although in-hospital mortality has not decreased significantly. (AU)

Changes in the diagnosis and management of acute aortic syndrome and associated mortality in the last 20 years.

INTRODUCTION AND OBJECTIVES: Mortality is high in acute aortic syndrome (AAS), which therefore requires early treatment. This study aimed to analyze changes in the diagnosis and treatment of AAS over 20 years at our center. METHODS: From 1999 to 2018, 451 patients diagnosed with AAS (336 men; mean age, 60.9±12.4 years) were prospectively included (270 type A and 181 type B). Clinical variables, diagnosis, treatment, and in-hospital complications were analyzed. RESULTS: The use of computed tomography (CT) as the first-line diagnostic technique increased from 62.8% to 94.2% (P <.001). Surgical treatment of type A AAS rose from 67.4% to 82.5% (P=.09). Mortality from type A AAS decreased significantly from 53.1% to 26.3% (P <.001) as a result of the fall in mortality from surgical treatment (from 45.4% to 17.0%; P <.001). The use of medical treatment alone for type B AAS decreased from 91.8% to 61.7% (P <.001) due to the greater use of endovascular treatment. Mortality from type B AAS showed no significant reduction (16.2% to 10.6%; P=.15). CONCLUSIONS: The diagnosis and treatment of AAS has changed substantially in the last 2 decades. CT has become the first-line diagnostic technique for AAS. In type A AAS, mortality has fallen significantly due to improvements in the results of surgical treatment. In type B AAS, the use of medical treatment alone has decreased due to the expansion of endovascular treatment, although in-hospital mortality has not decreased significantly.

Prospective Multicenter Study of the Low-Profile Relay Stent-Graft in Patients with Thoracic Aortic Disease: The Regeneration Study.

BACKGROUND: To evaluate the early safety and clinical performance of the new low-profile RelayPro Thoracic Stent-Graft System in patients with thoracic aortic disease. METHODS: This was an international, prospective, single-arm study in patients diagnosed with thoracic aorta disease (aneurysm, pseudoaneurysm, dissection, penetrating atherosclerotic ulcer, or intramural hematoma) and treated with a RelayPro stent-graft (in bare stent and/or nonbare stent configurations). The primary endpoints were freedom from aneurysm or dissection-related mortality and stent-graft performance. RESULTS: A total of 31 patients were treated with the RelayPro thoracic stent-graft between 2014 and 2015 at 8 sites in Italy and Spain. Mean age was 72.1 (±10.2) years and 77% were male, 74% with hypertension, and 42% with a history of smoking. Twenty-four (77%) had aneurysms (fusiform in 46%, saccular in 42%, pseudoaneurysm in 12%); 5 (16%) had penetrating atherosclerotic ulcer; and 2 (6%) had chronic Type B dissection. Mean vascular access diameter was 9.1 mm (6-13 mm); 7 patients (23%) had vascular access of 7 mm or less. Technical success was 100% (primary, 90%; assisted primary, 10%). Freedom from aneurysm/dissection-related mortality through 30 days was 100%. Freedom from device-related major adverse events through 30 days was 94%. At 1 year, there was 1 (3%) type Ib and 1 (3%) type II endoleak, 1 (3%) nonaneurysm-related late death, and 1 (3%) secondary intervention (to correct type Ib endoleak). CONCLUSIONS: The RelayPro has a 3-4 French profile reduction to allow endovascular repair of thoracic aortic disease in patients with smaller anatomies. This study shows good initial stent-graft performance and a favorable early safety profile.

Aortic Arch and Thoracic Aorta Curvature Remodeling after Thoracic Endovascular Aortic Repair.

BACKGROUND: The objective of this study was to analyze the original curvature of the aortic arch and thoracic aorta, and how it is modified after the placement of a thoracic endograft. METHODS: We retrospectively analyzed all patients primarily treated for thoracic aortic aneurysms and blunt traumatic aortic injuries by means of an endograft sealed into the aortic arch (zones, Z1-Z3) in 2 different centers (Vascular Surgery Division, Hospital Clinic, UB; and Vascular and Endovascular Surgery Department, Hospital Vall d'Hebron, UAB; Barcelona, Spain), between 2010 and 2015. The last preoperative and early (1-month) postoperative computed tomography angiography (CTA) was obtained for all cases, and an accurate 3-dimensional (3D) center lumen line was created, from the aortic valve to the renal arteries. Angles in 2-dimensional (2D; XY-plane) and 3D (referred to cranial-caudal Z-axis) were analyzed in: the distal ascending aorta, aortic arch, and thoracic aorta (at 5, 10, 15, and 20 cm from the brachiocephalic trunk [BCT]) and celiac trunk (CT). Changes in preoperative-postoperative CTA were compared independently for both diseases. Thirty-six cases were included (20 aneurysms, 16 blunt traumatic injuries; mean age, 69.5 and 42.5 years). RESULTS: After placement of an aortic endograft (sealed in Z1-Z2 in 30% of aneurysms and 75% of traumatic injuries; mean endograft length: 22.6 cm and 11.3 cm, respectively), a global left anterior displacement of the ascending aorta was observed (2D examination: -13.1° and -7.5°, P = 0.049 and 0.041, respectively). The 3D examination showed an average increase of the aortic angle at 5 and 10 cm from the BCT in the whole sample (+4.0°, +4.9° in reference to the vertical; P = 0.017, 0.001), softening the curvature of the proximal descending thoracic aorta. In addition, in traumatic injuries, a decrease in the aortic arch angle was observed (-3.5°, P = 0.030). CONCLUSIONS: Placement of an endograft into the aortic arch and proximal thoracic aorta engenders a softening of the proximal descending thoracic aorta curvature, increasing its angle from the vertical. In blunt traumatic aortic injuries (with shorter and more proximally sealed endografts), an additional decrease of the aortic arch angle (3.5° more vertical), was observed.

Transcervical carotid stenting with flow reversal is a safe technique for high-risk patients older than 70 years.

BACKGROUND: Recent evidence regarding carotid revascularization advises against carotid angioplasty and stenting (CAS) in patients aged >70 years with conventional risk for carotid endarterectomy (CEA). The poor outcome of transfemoral CAS in this age group may be explained by the anatomic characteristics of the aortic trunk and supra-aortic vessels in elderly patients, as well as by a high prevalence of aortic arch atheromatosis. Transcervical CAS with flow reversal for cerebral protection avoids these unfavorable characteristics. This study analyzed the short-term and middle-term results of transcervical CAS with flow reversal in patients aged >70 years at high risk for CEA. METHODS: Between January 2006 and January 2011, 219 cases of >70% carotid artery stenosis in high-risk patients aged >70 years (55.7% asymptomatic and 44.3% symptomatic) were treated by transcervical CAS. All patients underwent complete neurologic examination by a stroke neurologist before and after the procedure. Primary end points were stroke, death, or myocardial infarction (MI), technical success, and complications at 30 days. During follow-up, we analyzed the rate of restenosis ≥50% and ipsilateral stroke. Data were collected prospectively and outcome was analyzed in all cases, including technical failures. RESULTS: The 30-day combined stroke/death/MI rate was 2.2% (stroke, 1.8%; stroke/death, 2.2%; and MI, 0.45%). In symptomatic patients, stroke/death/MI was 5.1% (stroke, 4.1%; stroke/death, 5.1%). None of the asymptomatic patients suffered stroke, MI, or death postoperatively. Technical success was 96.3% (four inability to cross lesion, two major common carotid dissections, one failed preangioplasty, one stent thrombosis). One cervical hematoma required surgical drainage. At follow-up (18.8 ± 16.9 months), cumulative (standard error) incidence of >70% restenosis was 3% (1%) at 1 year and 8% (3%) at 2 and 3 years. Only one patient experienced ipsilateral stroke during follow-up. Overall survival (standard error) was 94% (2%) at 1 year and 90% (3%) at 2 and 3 years. CONCLUSIONS: In our experience, transcervical CAS with flow reversal is a safe technique for treating carotid stenosis in patients aged >70 years. We believe that avoiding the aortic arch and tortuous supra-aortic vessels is responsible for the favorable results in this study.

Endovascular treatment of traumatic thoracic aortic injuries: short- and medium-term Follow-up.

BACKGROUND: Successful thoracic endovascular aortic repair (TEVAR) with low rates of complications has been referred to in the treatment of traumatic thoracic aortic injuries; however, we still do not know the long-term behavior. In this series, short- and intermediate-term results of TEVAR of traumatic aortic injuries are analyzed. METHODS: The clinical charts and courses of 20 patients (mean age, 31.8 years; age range, 15-65 years; 14 [70%] men) with traumatic thoracic aortic injuries treated with TEVAR were retrospectively reviewed. Mean delay from trauma to intervention was 15 days (range, 0-180 days). RESULTS: The initial success rate was 100%, with no deaths or intraoperative leaks, although in 4 (20%) patients, injuries were repaired in the arterial access site. The mean postoperative follow-up was 43.53 months (range, 5.5-108.0 months). Four (20%) patients required reintervention: 2 postoperative revascularizations of the left subclavian artery (20% of the patients in whom the ostium was intentionally occluded) and 2 aortic reinterventions (endovascular treatment of a collapsed stent graft and open repair after thrombosis of another stent graft). All reinterventions were successfully performed and no additional complications were registered during follow-up. Asymptomatic findings related to the stent graft included lack of proximal device-wall apposition in 8 patients (40%), intragraft mural thrombus formation during the first 6 months in 7 patients (35%), and an asymptomatic fracture of the longitudinal reinforcing bar of the stent graft 4 years later in 1 patient (5%). CONCLUSION: Although not completely exempt of complications, TEVAR provides a reliable method for the treatment of traumatic thoracic aortic injuries with good results in the short- and medium-term follow-up. All complications have been treated successfully. Long-term evolution of lack of proximal device-wall apposition and intragraft mural thrombus formation should be closely monitored to prevent long-term complications.

Incidence and evolution of mural thrombus in abdominal aortic endografts.

BACKGROUND: The aims of this study were to analyze the predictive factors for intragraft mural thrombus formation and evolution during follow-up after endovascular treatment of abdominal aortic aneurysms and to evaluate its relationship with the subsequent appearance of complications. METHODS: A retrospective study was performed by selecting those patients who underwent endovascular repair of an abdominal aortoiliac aneurysm between June 1998 and September 2004, with a minimum follow-up of 24 months. Preoperative clinical data, anatomical characteristics of the aneurysm, and endograft type were analyzed. In addition, clinical evaluation and abdominal computed tomography angiography (CT scans) performed at 1, 6, 12, and 24 months after the surgery were reviewed. RESULTS: Eighty-nine patients were submitted for endovascular aneurysm repair in this period, and 75 completed the 24-month follow-up. Eighteen patients developed intragraft mural thrombus (24% incidence), 13 (72.2%) appearing at 1 month of follow-up, and up to 16 (88.9%) appearing during the first 6 months. Logistic regression analysis showed that the lumen percentage of mural thrombus in the native aorta and the use of aortouniiliac endografts were independent predictors of intragraft mural thrombus formation (odds ratio, 1.065; 95% confidence interval, 1.022-1.110, and odds ratio, 8.014; 95% confidence interval, 1.598-40.181, respectively). No spontaneous regression of the thrombus was observed. The area of intragraft mural thrombus had increased at 12 and 18-24 months after their diagnosis (Wilcoxon signed rank test, p = 0.028 and 0.028, respectively). The presence of intragraft mural thrombus was associated with a greater tendency to endograft body or branch occlusion (5 of 18 cases with intragraft mural thrombus (27.8%) versus 1 of 57 cases without it (1.8%), (p = 0.003). CONCLUSION: Intragraft formation of mural thrombus is a common finding during the follow-up of abdominal aortic endografts, particularly in aneurysms with large mural thrombus of the native aorta, and is associated with the use of aortouniiliac endografts. The area occupied by the mural thrombus was shown to gradually increase during follow-up and was associated with a greater tendency for endograft occlusion.

Late thrombosis of a thoracic aorta stent graft: Therapeutic management.

The case of a 17-year-old adolescent boy with severe polytrauma is reported. Among other injuries, he presented with aortic rupture distal to the origin of the subclavian artery with no bleeding into the mediastinum. The lesion was repaired by placement of a Cook TX2 endovascular graft (Cook Incorporated, Bloomington, Ind). One year later, he was hospitalized with acute heart failure. Computed tomography angiography showed nearly complete stent graft occlusion and no evidence of altered integrity of the device. A right axillofemoral bypass was performed, allowing conversion to successful definitive repair consisting of an extra-anatomic bypass from the ascending aorta to the supraceliac abdominal aorta.

Transcervical carotid stenting with flow reversal is safe in octogenarians: a preliminary safety study.

BACKGROUND: The use of carotid stenting in octogenarian patients is controversial; some authors consider this population at high risk for the procedure. Anatomic vascular complexity may be an important reason for the high reported rates of periprocedural thromboembolic complications. Transcervical carotid angioplasty and stenting (TCS) with flow reversal avoids aortic arch instrumentation. In this study, we analyzed our experience with TCS in octogenarian patients and compared the results with those of carotid endarterectomy (CEA) in the same age group in terms of safety. METHODS: The study included 81 patients, > or =80 years, a retrospective cohort of 45 consecutive patients treated with CEA (January 2002 to January 2005), and a prospective cohort of 36 consecutive patients treated with TCS with protective flow reversal (January 2005 to January 2007). Patients were considered symptomatic according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Stenting indication was established on the SAPPHIRE criteria. General anesthesia was used in patients undergoing CEA, and local anesthesia in those receiving TCS. Primary endpoints were: stroke, death, or acute myocardial infarction within 30 days. Secondary endpoints were peripheral nerve paralysis and cervical hematoma. Statistical significance for between-group differences was assessed by Pearson chi(2) or Fisher exact test, and Student t test. A P value of <.05 was considered statistically significant. Follow-up was limited to 30 days. RESULTS: Baseline epidemiological characteristics and revascularization indications were similar between both groups. Mean age was significantly higher in the TCS group (83.5 +/- 3.35) than the CEA group (81.7 +/- 1.55) (P = .004). Percentage of symptomatic lesions was similar: 30.6% in TCS vs 44.4% in CEA (P = .2). Comorbid conditions (respiratory or cardiac) were more frequent in TCS group (61.6% vs 26.6%; P = .002). There were no significant differences between groups for the primary endpoints: 4.4% (one stroke, one acute myocardial infarction) for CEA vs 0% for TCS (P = .5). Among CEA patients, there were two peripheral nerve palsies (4.4%) and one cervical hematoma (2.2%); there were no such complications with TCS (P = .5 and P = 1, respectively). In one asymptomatic TCS patient, Doppler study at 24 hours following the procedure showed a common carotid artery dissection, which was treated by a common carotid to internal carotid bypass. CONCLUSIONS: In this preliminary experience, transcervical carotid angioplasty and stenting with flow reversal for cerebral protection was as safe at short term as carotid endarterectomy in octogenarian patients, who additionally had considerable comorbidity; thus, it may be possible to extend the indications for carotid revascularization in this population. Studies in larger patient series are required to confirm the trends observed in this study.

Transcervical carotid stenting with flow reversal protection: experience in high-risk patients.

BACKGROUND: Carotid angioplasty and stenting (CAS) with cerebral embolic protection is a safe alternative to carotid endarterectomy in high-risk patients. Among the various systems proposed for cerebral protection, transcervical CAS avoids crossing the lesion without protection and eliminates the complications associated with transfemoral access. This study analyzes our experience and the results obtained with a transcervical stenting technique for carotid revascularization. METHODS: From January 2005 to June 2006, 62 CAS were performed in our center in high-risk patients with >70% stenosis (38.7% had a previous neurologic event and 61.3% were asymptomatic). The indications for CAS were severe heart disease (45.1%), severe pulmonary disease (6.4%), paralysis of the contralateral laryngeal nerve (6.4%), recurrent stenosis (3.2%), and high carotid lesion (1.6%). Twenty-one patients were >80 years old. A complete neurologic examination was performed by a stroke neurologist in all patients before and after stenting. The protection system used was carotid flow reversal by transcervical access. Transcranial Doppler monitoring was done during the procedure in 35 patients. We analyzed technical success, the presence of high-intensity transient signals during the procedure, neurologic morbidity and mortality at 30 days and 6 months, and stent patency at 6 months (range, 1 to 18 months). Technical success was 96.8%. Perioperative high-intensity transient signals were observed in two patients (5.7%). In the immediate postoperative period, one patient had a transient ischemic attack of the anterior cerebral artery and another had a stroke, with contralateral hemiplegia. At 48 hours after discharge, a third patient returned to the hospital with a severe cerebral hemorrhage that required surgical drainage; hence, neurologic morbidity was 4.9%. There were no deaths at 6 months. Among the total, 98.4% of the stents remained patent, two showed restenosis of 50% to 70%, and one restenosis of >70%. No patients presented a neurologic event during the follow-up. CONCLUSIONS: Transcervical carotid artery stenting with flow reversal cerebral protection is a relatively simple, safe technique that avoids instrumentation of the aortic arch and crossing the target lesion without protection. It is less expensive than techniques requiring a filter device and provides excellent outcome with an acceptable incidence of complications.

Symptomatic collapse of a thoracic aorta endoprosthesis.

We present the case of a 40-year-old man who underwent aortic endoprosthesis implantation for a traumatic lesion of the thoracic aorta (Gore TAG, 26 x 100 mm, after the instructions for use for a thoracic aorta of 22-24 mm). At 6 months, he came to the emergency room for a hypertensive crisis and acute pulmonary edema. The chest radiograph and thoracoabdominal computed tomographic angiography study showed collapse of the endoprosthesis and a type I proximal leak. A second TAG graft was inserted within the previously collapsed device, and re-expansion was achieved, with resolution of the initial symptoms. At 3 and 6 months, the patient remained asymptomatic, and there were no new findings on computed tomographic angiography.