Intravascular ultrasound enhances the PETTICOAT technique in endovascular therapy for complicated type B aortic dissection with malperfusion syndrome.

OBJECTIVE: To present the value of intravascular ultrasound (IVUS) in diagnosis and treatment of complicated type B aortic dissection (TBD) with malperfusion (MP). Especially the value of IVUS regarding the treatment strategy, reoperation rate, acute kidney injury (AKI) and false lumen thrombosis (FLT) was investigated. METHODS: Retrospective analysis of 25 TBD cases with MP treated with endovascular therapy from April 2019 to August 2022. In 17 cases angiography & IVUS were applied during the operation (IVUS group) and in 8 cases angiography was used without IVUS (control group) for final intraoperative control. IVUS was used to assess the true lumen collapse and to decide if additional bare stenting was necessary or not. Details from patients' charts and documentation from surgeries were analyzed. The endovascular technique included thoracic endovascular aortic repair (TEVAR) with primary entry sealing and -if needed- bare stenting of the true lumen distal of the entry tears using the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique. RESULTS: All patients presented with pain localized mostly (48%) in thorax and abdomen. In all patients the proximal entry tear of the dissection was covered using TEVAR. The PETTICOAT technique was applied in 13 cases (52%), whereas most combined procedures were applied in the IVUS group (12 compared to 1; p=0,02). A total of 3 patients (1 in the control group; 12,5% and 2 in the IVUS group; 11,8%) underwent a bowel resection. Totally 8 patients (32%) underwent a reoperation in aorta (3 during the hospital stay). There were no statistical differences between IVUS and control group regarding the preoperative findings, the reoperation rates and the postoperative complications. 5 patients died (4 during the hospital stay), 1 in control and 4 in IVUS group; p=0,53. The follow up included a clinical and a computed tomography angiography (CTA) examination. No statistically significant difference regarding occurrence and extension of FLT was observed between the two groups. CONCLUSIONS: The IVUS and control groups showed no difference in survival rates. The use of IVUS extended the indication for PETTICOAT technique with statistically significant difference. A milder form of AKI presented in the IVUS group compared to the control group. In addition, a stronger correlation between IVUS and the avoidance of an aorta reoperation was observed, though it did not reach statistical significance.

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.

The safety and prognostic evaluation of subsequent aortic surgery after thoracic endovascular aortic repair: a retrospective cohort study.

Background: Thoracic endovascular aortic repair (TEVAR) is a widely employed clinical procedure for treating various aortic pathologies. However, some patients require subsequent surgical interventions post-TEVAR, particularly due to life-threatening complications such as aortic dissection. This study aimed to evaluate the safety and prognosis associated with additional aortic surgeries following TEVAR. Methods: A retrospective analysis was conducted on 21 patients who underwent aortic surgery after TEVAR at Guangdong Provincial People's Hospital between September 2016 and August 2020. By compiling and reviewing perioperative data, we assessed surgical-related complications and survival rates. Results: Among the 21 patients, 95.2% were male, with an average age of 53 years. Preoperative comorbidities included hypertension in 15 individuals, abdominal aortic aneurysm in one patient, and coronary heart disease in two patients. The primary complications of TEVAR were stent leakage and retrograde aortic dissection, with the latter being the predominant type in subsequent aortic surgeries. The mean duration of aortic clamping during surgery was 130.0 minutes, with a deep hypothermic circulatory arrest time of 8.5 minutes. Postoperatively, two patients suffered in-hospital mortality, one developed renal dysfunction, four required re-entry into the operating room for further treatment, and the average length of hospital stay was 20 days. Following discharge, 14.3% of patients experienced complications, with central nervous system symptoms being the most prevalent. Kaplan-Meier survival analysis indicated a 5-year survival rate of 85.7%. Conclusions: Aortic surgical intervention following TEVAR is a safe therapeutic approach that can improve patient prognosis. However, meticulous management of the perioperative period is crucial for reducing the risk of complications and improving survival rates. This study provides valuable insights into aortic surgery post-TEVAR, but large-scale research is needed to validate these findings.

Total aortic arch debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR) in acute non-A non-B aortic dissection.

BACKGROUND: The surgical evaluation and management of non-A non-B aortic dissections, in the absence of ascending aortic involvement, remains a grey area. It is in these scenarios when thorough evaluation of patient/family history, clinical presentation, but also overall lifestyle, is of immense importance when determining an optimal intervention. CASE PRESENTATION: We present a 38-year-old patient with a physically demanding lifestyle as a professional wrestler, uncontrolled hypertension due to history of medical non-adherence, and family history of aortic dissection who presented with acute non-A non-B aortic dissection. He was spared a total arch replacement by undergoing a hybrid approach of complete aortic debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR). The patient was able to benefit from reduced cardiopulmonary bypass (CPB) time, avoidance of aortic cross clamp, circulatory arrest, and hypothermic circulation. CONCLUSIONS: This patient's unique composition of a physically demanding lifestyle, personal history of medical non-adherence, family history of aortic dissection, and clinical presentation required a holistic approach to understanding an ideal intervention that would be best suited long-term. Due to this contextualization, the patient was able to be spared a total arch replacement, or suboptimal medical management, by instead undergoing a hybrid-approach with total aortic arch debranching with antegrade TEVAR.

Optimal antiplatelet therapy after revascularization of left subclavian artery during TEVAR.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is required when treating patients with involvement of LSA. The best antiplatelet therapy after LSA reconstruction is presently uncertain. METHODS: This study retrospectively analyzed 245 type B aortic dissection patients who underwent left subclavian artery revascularization during TEVAR. Out of 245 patients, 159 (64.9%) were in the single antiplatelet therapy (SAPT) group, receiving only aspirin, and 86 (35.1%) were in the dual antiplatelet therapy (DAPT) group, receiving aspirin combined with clopidogrel. During the 6-month follow-up, primary endpoints included hemorrhagic events (general bleeding and hemorrhagic strokes), while secondary endpoints comprised ischemic events (left upper limb ischemia, ischemic stroke, and thrombotic events), as well as death and leakage events. Both univariate and multivariate Cox regression analyses were performed on hemorrhagic and ischemic events, with the Kaplan-Meier method used to generate the survival curve. RESULTS: During the six-month follow-up, the incidence of hemorrhagic events in the DAPT group was higher (8.2% vs. 30.2%, P < 0.001). No significant differences were observed in ischemic events, death, or leakage events among the different antiplatelet treatment schemes. Multivariate Cox regression analysis showed that DAPT (HR: 2.22, 95% CI: 1.07-4.60, P = 0.032) and previous chronic conditions (HR:3.88, 95% CI: 1.24-12.14, P = 0.020) significantly affected the occurrence of hemorrhagic events. Chronic conditions in this study encompassed depression, vitiligo, and cholecystolithiasis. Carotid subclavian bypass (CSB) group (HR:0.29, 95% CI: 0.12-0.68, P = 0.004) and single-branched stent graft (SBSG) group (HR:0.26, 95% CI: 0.13-0.50, P < 0.001) had a lower rate of ischemic events than fenestration TEVAR (F-TEVAR). Survival analysis over 6 months revealed a lower risk of bleeding associated with SAPT during hemorrhagic events (P = 0.043). CONCLUSIONS: In type B aortic dissection patients undergoing LSA blood flow reconstruction after synchronous TEVAR, the bleeding risk significantly decreases with the SAPT regimen, and there is no apparent ischemic compensation within 6 months. Patients with previous chronic conditions have a higher risk of bleeding. The CSB group and SBSG group have less ischemic risk compared to F-TEVAR group.

Combined Endovascular and Endoscopic Management of a Secondary Aortoesophageal Fistula after Open Surgical Aortic Repair in a Giant Descending Thoracic Aortic Pseudoaneurysm: Case Report and Review of Literature.

Secondary aortoesophageal fistula (AEF) is defined as a communication between the aorta and the esophagus, occurring after aortic disease treatment or esophageal procedures, associating very high mortality rates with treatment and being fatal without it. Several treatment strategies have been described in the literature, combining open surgery or endovascular aortic repair with surgical or endoscopic management of the esophageal lesion. We present the case of a 53-year-old patient with a history of open aortic surgery for a giant descending thoracic aortic pseudoaneurysm complicated with secondary AEF, successfully managed using emergency transiliac TEVAR (thoracic endovascular aortic repair), extensive antibiotic therapy associated with nutritional replenishment, and rehabilitation therapy. Novel endovascular and endoscopic devices have been developed, offering less invasive treatment strategies with improved outcomes, especially for high risk surgical patients. This case highlights the importance of a multidisciplinary approach to personalized medicine to manage such complex situations.

A Case of Aortic Strain due to Spring Back Force by Stent Graft 3 Years after Thoracic Endovascular Aortic Repair.

A 79-year-old man underwent 1-debranched thoracic endovascular aortic repair (TEVAR) for a saccular aneurysm of the distal arch of the aorta. Computed tomography performed 3 years after surgery revealed a significant displacement of the distal side of the stent graft and severe deformity due to displacement of the aorta. There were no obvious findings after aortic dissection. Endovascular treatment was selected, and surgery was performed semiemergency. Additional TEVAR was performed to restore the aortic shape and displacement to its normal position.

Interventions in Acute or Subacute Phase for Type B Aortic Dissection.

The treatment strategy for acute and subacute Stanford type B aortic dissection has changed significantly since the advent of thoracic endovascular aortic repair (TEVAR). Indication for invasive treatment: In addition to the conventional complicated cases (rupture or malperfusion case), the indication for invasive treatment now includes cases with refractory hypertension, persistent or recurrent pain, large aortic diameter, and other conditions that are considered to have a poor prognosis with conservative treatment. Treatment methods: TEVAR is the first choice for acute, subacute, and early chronic-stage treatment, and when this is not possible, other techniques (fenestration and graft replacement) are chosen. Treatment timing: The timing of invasive treatment should be emergent in life-threatening conditions (for rupture or malperfusion case) and immediate in symptomatic cases, while in other cases, preemptive TEVAR is considered appropriate on a scheduled timing within 6 months of onset. (This is a translation of Jpn J Vasc Surg 2023; 32: 157-163.).

A computational study of artery curvature and endograft oversize influence on seal zone behavior in endovascular aortic repair.

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive procedure involving the placement of an endograft inside the dissection or an aneurysm to direct blood flow and prevent rupture. A significant challenge in endovascular surgery is the geometrical mismatch between the endograft and the artery, which can lead to endoleak formation, a condition where blood leaks between the endograft and the vessel wall. This study uses computational modeling to investigate the effects of artery curvature and endograft oversizing, the selection of an endograft with a larger diameter than the artery, on endoleak creation. Finite element analysis is employed to simulate the deployment of endografts in arteries with varying curvature and diameter. Numerical simulations are conducted to assess the seal zone and to quantify the potential endoleak volume as a function of curvature and oversizing. A theoretical framework is developed to explain the mechanisms of endoleak formation along with proof-of-concept experiments. Two main mechanisms of endoleak creation are identified: local buckling due to diameter mismatch and global buckling due to centerline curvature mismatch. Local buckling, characterized by excess graft material buckling and wrinkle formation, increases with higher levels of oversizing, leading to a larger potential endoleak volume. Global buckling, where the endograft bends or deforms to conform to the centerline curvature of the artery, is observed to require a certain degree of oversizing to bridge the curvature mismatch. This study highlights the importance of considering both curvature and diameter mismatch in the design and clinical use of endografts. Understanding the mechanisms of endoleak formation can provide valuable insights for optimizing endograft design and surgical planning, leading to improved clinical outcomes in endovascular aortic procedures.

Beyond the Slopes and Highways: Endovascular Repair of Blunt Traumatic Aortic Injuries after Skiing versus Motor Vehicle Accidents.

Background: Blunt traumatic aortic injury (BTAI) is a potentially fatal condition, typically resulting from high-velocity trauma. To date, little is known about this type of injury among skiers, who form the largest patient cohort with aortic injuries in the alpine region of Tyrol, Austria. Methods: This retrospective, single-center study at the University Hospital of Innsbruck analyzed patients who underwent endovascular treatment for blunt traumatic aortic injury from 2005 to 2023. Patient data were extracted from electronic and digitalized medical history records. Subsequent analyses compared the baseline characteristics and clinical results of the skiing accident (SA) group to the motor vehicle accident (MVA) group. Results: A total of 48 BTAI patients receiving TEVAR were included, 25 (52%) from SAs versus 23 (48%) from MVAs, who were predominantly male (92% vs. 78.3%). Despite similar preoperative risk profiles and ASA Scores (1.44 vs. 1.74) and no marked differences in BTAI injury grades or the affected aortic zones, significant disparities emerged: the SA group experienced shorter median ICU stays (3 vs. 11 days, p = 0.0007), fewer concomitant injuries (5 vs. 7, p = 0.005), and lower Injury Severity Scores (ISSs) (29 vs. 33, p = 0.003) than their MVA counterparts. The presence of rib fractures alongside other thoracic injuries, such as lung injury, pneumothorax, or hemothorax, was strongly correlated with BTAI in patients following skiing accidents (OR = 128.5). Conclusions: The injury severities and locations of BTAI in SA patients were comparable to those in MVA patients, indicating similar mechanisms of thoracic trauma. However, the SA patients experienced fewer concurrent pelvic and extremity fractures, had less post-procedural morbidity, and required shorter ICU stays. The presence of rib fractures combined with other thoracic injuries strongly suggests BTAI. These indicators should lead to prompt imaging and appropriate therapy.

Simulation of thoracic endovascular aortic repair in a perfused patient-specific model of type B aortic dissection.

PURPOSE: Complicated type B Aortic dissection is a severe aortic pathology that requires treatment through thoracic endovascular aortic repair (TEVAR). During TEVAR a stentgraft is deployed in the aortic lumen in order to restore blood flow. Due to the complicated pathology including an entry, a resulting dissection wall with potentially several re-entries, replicating this structure artificially has proven to be challenging thus far. METHODS: We developed a 3d printed, patient-specific and perfused aortic dissection phantom with a flexible dissection flap and all major branching vessels. The model was segmented from CTA images and fabricated out of a flexible material to mimic aortic wall tissue. It was placed in a pulsatile hemodynamic flow loop. Hemodynamics were investigated through pressure and flow measurements and doppler ultrasound imaging. Surgeons performed a TEVAR intervention including stentgraft deployment under fluoroscopic guidance. RESULTS: The flexible aortic dissection phantom was successfully incorporated in the hemodynamic flow loop, a systolic pressure of 112 mmHg and physiological flow of 4.05 L per minute was reached. Flow velocities were higher in true lumen with a up to 35.7 cm/s compared to the false lumen with a maximum of 13.3 cm/s, chaotic flow patterns were observed on main entry and reentry sights. A TEVAR procedure was successfully performed under fluoroscopy. The position of the stentgraft was confirmed using CTA imaging. CONCLUSIONS: This perfused in-vitro phantom allows for detailed investigation of the complex inner hemodynamics of aortic dissections on a patient-specific level and enables the simulation of TEVAR procedures in a real endovascular operating environment. Therefore, it could provide a dynamic platform for future surgical training and research.

Clinical outcomes of the type II hybrid procedure for the repair of extensive aortic arch pathology.

Background: Type II hybrid arch repair (HAR) has been used for the repair of extensive aortic arch pathology. The aim of this study was to retrospectively analyze single-stage hybrid treatment involving replacement of the ascending aorta, arch debranching, and zone 0 stent graft deployment. Methods: We retrospectively analyzed clinical data from 41 patients with acute and chronic aortic disease who underwent a type II hybrid arch procedure at Beijing Anzhen Hospital and Beijing Chaoyang Hospital from January 2020 to August 2022. The femoral arteries and right axillary arteries were used as cannulation sites to decrease the risk of malperfusion. During surgery, the nasopharyngeal temperature was lowered to 30 ℃. Demographic, perioperative, and late results data were retrieved and analyzed. Results: The mean age of the patients was 54.9±11.1 years, and 31 patients (75.6%) were men. In all cases, zone 0 stent graft deployment was successful, with no in-hospital mortality. The median follow-up time was 10.5 [interquartile range (IQR), 4.8-17.6] months, and the survival rate was 94.9% during follow-up. Complications included cerebral infarction (3 patients, 7.3%) and renal failure requiring dialysis (3 patients, 7.3%). There were no occurrences of paraplegia, and no stent-related complications occurred during the follow-up period. Conclusions: The single-stage hybrid arch procedure achieved satisfactory early results and represents a less invasive approach for treating complex diffuse aortic disease that affects the arch. This strategy is an important technical advance in the treatment of high-risk patients with extensive aortic arch pathology.

Surgical repair of an aortoesophageal fistula after salvage thoracic endovascular aortic repair: a case report.

BACKGROUND: An aortoesophageal fistula can prove to be fatal. Salvage thoracic endovascular aortic repair as a bridging therapy and radical surgery with thoracotomy should be considered while treating aortoesophageal fistula without spontaneous closure. Moreover, it is essential to select a technique that reduces the risk of reinfection. Here we report a rare case of a ruptured thoracic aortic aneurysm related to esophageal perforation by a fish bone that led to massive hematemesis and shock, and the surgical treatment of an aortoesophageal fistula that developed after salvage thoracic endovascular aortic repair. CASE PRESENTATION: A 70-year-old Japanese female patient was admitted with hematemesis, thoracic pain, and shock related to esophageal perforation of a ruptured descending aortic aneurysm caused by fish bone aspiration and esophageal perforation 1 month previously. An emergency thoracic endovascular aortic repair was performed. Postoperatively, an aortoesophageal fistula that remained open and a food intake-related increase in the inflammatory response was noted. Radical blood-vessel prosthesis implantation and fistula closure were performed. The patient's postoperative course was favorable and the patient was discharged 22 days after the blood vessel prosthesis implantation. CONCLUSION: Such a case of rupture of a descending aortic aneurysm related to perforation by a fish bone and an aortoesophageal fistula is considerably rare. Thus, we report the therapeutic strategy of this particular case and review the relevant literature.

Comparison of open and endovascular left subclavian artery revascularization for zone 2 thoracic endovascular aortic repair.

OBJECTIVE: In patients undergoing elective thoracic endovascular aortic repair (TEVAR) and left subclavian artery (LSA) coverage, routine preoperative LSA revascularization is recommended. However, in the current endovascular era, the optimal surgical approach is debated. We compared baseline characteristics, procedural details, and perioperative outcomes of patients undergoing open or endovascular LSA revascularization in the setting of TEVAR. METHODS: Adult patients undergoing TEVAR with zone 2 proximal landing and LSA revascularization between 2013-2023 were identified in the Vascular Quality Initiative. We excluded patients with traumatic aortic injury, aortic thrombus, or ruptured presentations, and stratified based on revascularization type (open vs. any endovascular). Open LSA revascularization included surgical bypass or transposition. Endovascular LSA revascularization included single-branch, fenestration, or parallel stent grafting. Primary outcomes were stroke, spinal cord ischemia, and perioperative mortality (Pearson's χ2-test). Multivariable logistic regression was used to evaluate associations between revascularization type and primary outcomes. Secondarily, we studied other in-hospital complications and 5-year mortality (Kaplan-Meier, multivariable Cox-regression). Sensitivity analysis was performed in patients undergoing concomitant LSA revascularization to TEVAR. RESULTS: Of 2,489 patients, 1,842 (74%) underwent open and 647 (26%) received endovascular LSA revascularization. Demographics and comorbidities were similar between open and endovascular cohorts. Compared with open, endovascular revascularization had shorter procedure times (median 135 vs. 174min, p<.001), longer fluoroscopy time (median 23 vs. 16min, p<.001), lower estimated blood loss (median 100 vs. 123ml, p<.001), and less preoperative spinal drain use (40% vs. 49%, p<.001). Patients undergoing endovascular revascularization were more likely to present urgently (24% vs. 19%) or emergently (7.4% vs. 3.4%) (p<.001). Compared with open, endovascular patients experienced lower stroke rates (2.6% vs. 4.8%, p=.026; aOR 0.50[95%C.I., 0.25-0.90]), but had comparable spinal cord ischemia (2.9% vs. 3.5%, p=.60; 0.64[0.31-1.22]) and perioperative mortality (3.1% vs. 3.3%, p=.94; 0.71[0.34-1.37]). Compared with open, endovascular LSA revascularization had lower rates of overall composite in-hospital complications (20% vs. 27%, p<.001; 0.64[0.49-0.83]) and shorter overall hospital stay (7 vs. 8 days, p<.001). After adjustment, 5-year mortality was similar among groups (aHR 0.85[0.64-1.13]). Sensitivity analysis supported the primary analysis with similar outcomes. CONCLUSIONS: In patients undergoing TEVAR starting in zone 2, endovascular LSA revascularization had lower rates of postoperative stroke and overall composite in-hospital complications, but similar spinal cord ischemia, perioperative and 5-year mortality rates compared with open LSA revascularization. Future comparative studies are needed to evaluate the mid- to long-term safety of endovascular LSA revascularization and assess differences between specific endovascular techniques.

Aggressive Treatment Strategy at Index TEVAR Is Associated With Reduced Need For Short-Term Reintervention In Patients With Aortic Dissection.

INTRODUCTION: Thoracic endovascular aortic surgery (TEVAR) is the modern standard of treatment for patients with Type B aortic dissection, however it is unclear how the initial length of treated aorta affects long-term outcomes. This study aims to elucidate risk factors for secondary intervention after TEVAR for aortic dissection, focusing on length of aortic treatment at index operation. METHODS: A retrospective multihospital chart review was completed for patients treated between 2011 and 2022 who underwent TEVAR for aortic dissection with at least one year of post-TEVAR imaging and follow-up. Patient demographics and characteristics were analyzed. In this study, aortic zones treated only included those managed with a covered stent graft. The primary outcome measure was any need for secondary intervention. RESULTS: A total of 151 patients were identified. Demographics included a mean age of 57 years, with 31.8% of the patients being female. Forty-three patients (28.5%) underwent secondary intervention after TEVAR, with a mean follow-up of 1.6 years. The most common indication for secondary intervention was aneurysmal degeneration of the residual false lumen (76%). There was a significant difference in the number of aortic zones treated in patients who did and did not require secondary intervention (2.3 ± 1 vs. 2.7 ± 1, p = 0.04). Additionally, patients with three or more aortic zones of treatment had a significant difference in the need for reintervention (32% secondary intervention vs 52% no secondary intervention, p = 0.02). CONCLUSIONS: At least three zones of aortic treatment at index TEVAR is associated with a decreased need for overall reintervention. Modern treatment of acute and subacute type B dissection should stress an aggressive initial repair, balanced by the potential increased risk of spinal cord ischemia.

Readmissions Following Endovascular Thoracic and Thoracoabdominal Aortic Repairs in The Vascular Implant Surveillance and Interventional Outcomes Network (VISION).

OBJECTIVES: Investigate readmission rates, diagnoses associated with readmission, and associations with mortality through 90-days post-operatively after elective endovascular thoracic and thoracoabdominal aortic repair overall and by extent of coverage. METHODS: A cohort of index elective non-traumatic endovascular thoracic and thoracoabdominal aortic cases from 2010-2018 was derived from the Vascular Implant Surveillance and Interventional Outcomes Network. Cohort readmissions within 90-days postoperative were examined both overall and by Crawford extent (CE) of aortic coverage. Postoperative mortality was examined by reason for readmission and CE. RESULTS: The cohort consisted of 2,093 patients who underwent endovascular thoracic and thoracoabdominal aortic repair (1,541 CE 0A/0B; 240 CE 1-3; 312 CE 4-5). Cumulative risk for 90-day readmission was 34.3% in CE 0A/0B repairs, 33.4% in CE4-5 repairs and 47.4% in CE 1-3 repairs. Compared to CE 0A/B, patients with CE 1-3 repairs experienced an increased risk of readmission within 90 days postoperatively after adjusting for preoperative factors (aHR 1.27(1.00,1.61) while the readmission risk for CE 4-5 repairs did not differ significantly (aHR 0.83 (0.64,1.06). Significant risk factors for 90-day readmission included COPD, dialysis dependence, limited ambulation, visceral/spinal ischemia, and in-hospital stroke. Discharge to home was protective against readmission (HR 0.65, CI 0.54-0.79). Patients with a readmission within 90-days had a 7.89-fold increase in 90-day mortality (HR 7.84; 5.17, 11.9) compared to those not readmitted. CONCLUSIONS: Increasing extent of endovascular thoracic and thoracoabdominal aortic repair was associated with higher 90-day readmission rates. Readmission for all CE was associated with near 8-fold increased risk of mortality. Risk factors associated with increased risk for readmission included pulmonary insufficiency, renal disease, and poor functional status. These findings can inform stakeholders about investment of resources to improve processes of care that both target prevention and mitigate risk of readmission after elective endovascular thoracic and thoracoabdominal aortic repair.

The Utility of Three-Dimensional Printing in Physician-Modified Stent Grafts for Aortic Lesions Repair.

Background: Three-dimensional (3D) printing is becoming increasingly popular around the world not only in engineering but also in the medical industry. This trend is visible, especially in aortic modeling for both training and treatment purposes. As a result of advancements in 3D technology, patients can be offered personalized treatment of aortic lesions via physician-modified stent grafts (PMSG), which can be tailored to the specific vascular conditions of the patient. The objective of this systematic review was to investigate the utility of 3D printing in PMSG in aortic lesion repair by examining procedure time and complications. Methods: The systematic review has been performed using the PRISMA 2020 Checklist and PRISMA 2020 flow diagram and following the Cochrane Handbook. The systematic review has been registered in the International Prospective Register of Systematic Reviews: CRD42024526950. Results: Five studies with a total number of 172 patients were included in the final review. The mean operation time was 249.95± 70.03 min, and the mean modification time was 65.38 ± 10.59 min. The analysis of the results indicated I2 of 99% and 100% indicating high heterogeneity among studies. The bias assessment indicated the moderate quality of the included research. Conclusions: The noticeable variance in the reviewed studies' results marks the need for larger randomized trials as clinical results of 3D printing in PMSG have great potential for patients with aortic lesions in both elective and urgent procedures.

Hybrid management of iliac injury during thoracic endovascular aortic repair: A case report.

Thoracic endovascular aortic repair is nowadays the preferred option to manage descending thoracic aorta diseases. However, despite feasibility and safety of the procedures, several complications may occur. We report the case of an 83-year-old female patient with inadvertent iliac rupture occurred during thoracic endovascular aortic repair. To limit massive bleeding, considering the patient's comorbidities contraindicating open surgical repair and the morphology of the arterial injury (circumferential rupture of the artery from its origin), we chose to perform a homolateral hypogastric and common iliac artery embolization and an aorto-uniliac balloon expandable stent graft deployment from the distal aorta to the contralateral common iliac artery. A femoro-femoral crossover bypass graft was performed to restore both lower limbs perfusion. Final angiography documented correct positioning and regular patency of the implanted grafts and bypass with no blood loss from the right iliac vessels. Despite careful preoperative assessment, iliac artery injury can represent a challenging complication of thoracic endovascular aortic repair, particularly in the setting of inadequate iliac diameter, calcification and vessel tortuosity, or when large-caliber introducers are required. The hybrid approach we describe is a valid and effective solution to minimize blood loss and avoid major consequences in the management of iatrogenic iliac artery rupture during endovascular procedures.

Multicentre experience of antegrade thoracic endovascular aortic repair for the treatment of thoracic aortic diseases.

OBJECTIVES: The goal of this multicentre retrospective cohort study was to evaluate technical success and early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside down through antegrade access, to treat thoracic aortic diseases. METHODS: Antegrade TEVAR operations performed between January 2010 and December 2021 were collected and analysed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed in previous or concomitant surgical or endovascular repairs. RESULTS: Fourteen patients were enrolled; 13 were males (94%) with a mean age of 71 years (interquartile range 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indications for treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (interquartile range 1; 44). Late deaths occurred in 2 (20%) patients, both operated on in elective settings. The first died at 19 months of aortic-related reintervention; the second died at 34 months of a non-aortic-related cause. Two patients (14%) underwent aortic-related reinterventions for late type I endoleak. The survival rate of those having the elective procedures was 100%, 84% and 67% at 12, 24 and 36 months, respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months, respectively. CONCLUSIONS: Antegrade TEVAR can seldom be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and few access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.

Current expert-based opinions on endovascular treatment of blunt thoracic aortic injury: A state-of-the-art narrative review on indications, techniques, results, and challenges.

INTRODUCTION: Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma which warrants prompt recognition with expedited management. Clinical manifestations of BTAI may not be straightforward to detect and may be misdiagnosed. Therefore, diagnosis of BTAI requires a high index of suspicion based on the mechanism of injury along with urgent transfer to centers with appropriate expertise and facilities. METHODS: We provide an expert-based narrative review on endovascular treatment of BTAI highlighting indications, techniques, results, and challenges. RESULTS: Multiple imaging modalities can be used including computed tomography angiography, transesophageal echocardiography, magnetic resonance imaging, and intravascular ultrasound. Whilst conservative pharmacological management can be a safe option in low-grade BTAI, thoracic endovascular aortic repair has become the gold-standard strategy in most cases, replacing open surgical repair. Nevertheless, it is important to account for patient demographics particularly age, severity of injury, choice of endograft including its type and size, and endovascular technique including landing zone and left subclavian artery revascularization. CONCLUSIONS: Overall, TEVAR in BTAI has been shown to be an efficacious strategy with favorable early outcomes. In contrast, less is known on the long-term clinical outcomes of TEVAR in BTAI. Hence, despite the optimal early technical and clinical success rates, concerns remain about the need for long-term surveillance. The exact timing of follow-up and the integration of different modalities that can also investigate potential downstream cardiovascular effects remain hot topics for future research. Finally, industry should focus on developing more compliant endografts to improve the stiffness mismatch between the endograft and the aorta to optimize results.