Assessment of CardiOvascular Remodelling following Endovascular aortic repair through imaging and computation: the CORE prospective observational cohort study protocol

Thoracic aortic stent grafts are orders of magnitude stiffer than the native aorta. These devices have been associated with acute hypertension, elevated pulse pressure, cardiac remodelling and reduced coronary perfusion. However, a systematic assessment of such cardiovascular effects of thoracic endovascular aortic repair (TEVAR) is missing. The CardiOvascular Remodelling following Endovascular aortic repair (CORE) study aims to (1) quantify cardiovascular remodelling following TEVAR and compare echocardiography against MRI, the reference method; (2) validate computational modelling of cardiovascular haemodynamics following TEVAR using clinical measurements, and virtually assess the impact of more compliant stent grafts on cardiovascular haemodynamics; and (3) investigate diagnostic accuracy of ECG and serum biomarkers for cardiac remodelling compared to MRI

Predictors of aortic growth in uncomplicated type B aortic dissection from the Acute Dissection Stent Grafting or Best Medical Treatment (ADSORB) database

Background: The high-risk patient cohort of uncomplicated type B aortic dissections (uTBADs) needs to be clarified. We compared uTBAD patients treated with best medical treatment (BMT), with and without aortic growth, from the Acute Dissection Stent Grafting or Best Medical Treatment (ADSORB) trial database. Furthermore, we looked for trends in outcome for aortic growth and remodeling after BMT and thoracic endovascular aortic repair (TEVAR) and BMT (TEVAR+BMT). Methods: BMT patients with available baseline and a 1-year follow-up arterial computed tomography scan were identified. True lumen and false lumen diameter was assessed at baseline and at follow-up. Patients with false lumen growth (group I) and without false lumen growth (group II) were compared. Predictors of false lumen and total lumen (aortic) growth were identified. Lastly, BMT outcomes were compared with BMT+TEVAR for false lumen thrombosis and change in false lumen and total aortic diameter in four sections: 0 to 10 cm (A), 10 to 20 cm (B), 20 to 30 cm (C), and 30 to 40 cm (D) from the left subclavian artery. Results: The dissection was significantly longer in group I than in group II (43.2 \ub1 4.9 cm vs 30.4 \ub1 8.8 cm; . P = .002). The number of vessels originating from the false lumen at baseline was identified as an independent predictor of false lumen growth (odds ratio, 22.1; 95% confidence interval, 1.01-481.5; . P = .049). Increasing age was a negative predictor of total aortic diameter growth (odds ratio, 0.902; 95% confidence interval, 0.813-1.00; . P = .0502). The proximal sections A and B showed complete thrombosis in 80.6% in the BMT+TEVAR group compared with 9.5% in the BMT group. In these sections, changes from patent to partial or partial to complete thrombosis were observed in 90.3% of the TEVAR+BMT group vs 31.0% in the BMT group. In sections C and D, the change in thrombosis was 74.1% for the TEVAR+BMT group vs 20.6% for the BMT group. The false lumen diameter increase at section C was larger in the BMT group. Total lumen diameter decreased in sections A and B in the TEVAR+BMT group compared with an increase in the BMT group (-4.8 mm vs +2.9 mm, and -1.5 mm vs +3.8 mm, respectively). Sections C and D showed minimal and comparable expansion in both treatment groups. Conclusions: The new imaging analysis of the ADSORB trial patients identified the number of vessels originating from the false lumen as an independent predictor of false lumen growth in uTBAD patients. Increasing age was a negative predictor of aortic growth. Our analysis may help to identify which uTBAD patients are at higher risk and should receive TEVAR or be monitored closely during follow-up

A review of follow-up outcomes after elective endovascular repair of degenerative thoracic aortic aneurysms

Long-term outcomes of elective thoracic endovascular aortic repair (TEVAR) for degenerative thoracic aortic aneurysms (TAA) are not well defined. A review of the literature on the follow-up outcomes of elective TEVAR for degenerative TAA resulted in 22 relevant articles. Two- and five-year freedom from aneurysm-related death varied between 93.0% and 100.0%, and 82.4% to 92.7%, respectively. Two-year and five-year all-cause survival ranged between 68.0% and 97.2% and 47.0% to 78.0%, respectively. Follow-up ranged between 17.3 and 66.0 months. Most common endograft-related complication was endoleak, with reported rate between 1.4% and 14.8% during six months up to five years of follow-up. Endovascular reinterventions were reported in 0.0-32.3%, secondary open surgery was needed in 0.0% to 4.7% during follow-up. Aneurysm-related survival rates after elective TEVAR for degenerative TAA are acceptable. However, reported incidences of endograft-related complications vary considerably in the literature, but the majority can be managed with conservative treatment or additional endovascular procedures

Standardized Protocol to Analyze Computed Tomography Imaging of Type B Aortic Dissections

Purpose: To propose a standard measuring protocol for type B aortic dissections so as to improve comparability between studies reporting aortic dimensions. Methods: Fifteen computed tomography (CT) scans of type B aortic dissections were measured with a standard protocol by 2 independent observers using postprocessing software. The following parameters were assessed: true, false, and total lumen diameter; true and false lumen volume; and entry tear size, location, and number. Diameters were measured in a perpendicular plane at 2, 10, and 20 cm from the left subclavian artery and 5 cm from the most distal renal artery. True lumen volume was assessed from the left subclavian artery to the aortic bifurcation, while the false lumen volume was from the start to end up to the aortic bifurcation. Entry tear location was assessed in relation to the left subclavian artery. Intra- and interobserver repeatability and agreement were evaluated using the Bland-Altman method, an a priori set of acceptable differences, and Lin's concordance correlation coefficient (LCCC). Results: Intra- and interobserver mean differences for aortic diameter and true and false lumen volumes were generally within the limits of agreement and the a priori differences; the LCCC showed excellent agreement. Entry tear location, size, and number were difficult to measure in a repeatable manner, with inconsistent correlation coefficients, especially between the 2 observers. Conclusion: This protocol showed acceptable repeatability for aortic diameter and aortic volume measurements. Assessment of entry tears proved challenging and associated with less favorable results. Additionally, investigators are urged to be more transparent regarding the measurement methodology used in studies describing aortic dimensions

Impact of Left Subclavian Artery Revascularization before Thoracic Endovascular Aortic Repair on Postoperative Cerebrovascular Hemodynamics

Background The impact of left subclavian artery (LSA) revascularization before thoracic endovascular aortic repair (TEVAR) on cerebrovascular flow is not well described. We studied bilateral vertebral and carotid artery flow characteristics before and after TEVAR to evaluate the hemodynamic effects of LSA revascularization. Methods Seventy-four patients with mixed etiologies (mean age 70.9 \uc2\ub1 10.5 years) underwent LSA revascularization and TEVAR (2006\ue2\u80\u932016) and had available preoperative and postoperative carotid duplex study available. Data from patient demographics, procedures, preoperative, and postoperative carotid duplex studies were gathered. Revascularization was by left common carotid artery (LCCA) to LSA bypass (n = 70, 94.6%) or LSA to LCCA transposition (n = 4, 5.4%). Results Duplex confirmation of antegrade left vertebral artery (LVA) flow decreased significantly after TEVAR with LSA revascularization (100.0% vs. 77.9%, P < 0.001). Incidence of retrograde LVA flow increased from 0.0% to 8.3% (P = 0.063). Postoperatively, LVA bidirectional flow was observed in 3 patients (4.4%). Flow directions in the right vertebral artery (RVA) did not change significantly. Peak systolic velocity (PSV) in the LVA decreased significantly after TEVAR from 55.1 \uc2\ub1 22.0 cm/s to 35.9 \uc2\ub1 26.3 cm/s (P < 0.001). In contrast, PSV increased in the RVA and the right internal carotid artery (ICA; 52.2 \uc2\ub1 21.7 cm/s to 63.2 \uc2\ub1 23.3 cm/s, P = 0.012 and 95.3 \uc2\ub1 46.8 cm/s to 102.8 \uc2\ub1 42.9 cm/s, P = 0.011). PSV did not change significantly in the left ICA. At mean follow-up of 36.6 \uc2\ub1 26.8 months, primary bypass patency was 100.0%. Postoperatively, one case of temporary spinal cord ischemia was seen (1.4%). Stroke rate was 6.9% (n = 5, 100.0% embolic), all without permanent disabilities. Stroke circulation distribution was 60.0% posterior, 20.0% anterior, and 20.0% mixed. Location of stroke was left sided (n = 2) or in both hemispheres (n = 3). There were no deaths at 30 days. Neurological events during follow-up included 3 new strokes. All-cause mortality rate during follow-up was 12.2% (n = 9). Conclusions Adjunctive LSA revascularization in the setting of zone 2 TEVAR coverage is associated with hemodynamic vertebral artery changes. Future studies in larger sample sizes should evaluate whether these novel findings are an important determinant of postoperative neurologic events

Update in the management of type B aortic dissection

Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature

Biomechanical changes after thoracic endovascular aortic repair in type B dissection : a systematic review

Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives

An experimental investigation of the impact of thoracic endovascular aortic repair on longitudinal strain

OBJECTIVES: To investigate the impact of thoracic endovascular aortic repair (TEVAR) on longitudinal strain and assess aortic tensile properties in order to better understand complications associated with TEVAR. METHODS: Twenty fresh thoracic porcine aortas were harvested and connected to a mock circulatory loop driven by a centrifugal flow pump at body temperature. Length measurements were conducted before and after TEVAR through aortic marking, high-definition imaging and custom-developed software under physiological pressure conditions (i.e. between 100 and 180 mmHg with 20 mmHg increments). Longitudinal strain was derived from length amplitude divided by the baseline length at 100 mmHg. Three groups of stent-graft oversizing were created (0\u20139, 10\u201319 and 20\u201329%). Finally, elastic properties of the aortic samples were assessed in both longitudinal and circumferential directions through uniaxial tensile testing. Longitudinal strain was compared before and after TEVAR, and stress-to-rupture was compared among specimens and locations. RESULTS: TEVAR induced a longitudinal strain decrease from 11.9 to 5.6% (P < 0.001) in the stented segments and a longitudinal strain mismatch between stented (5.6%) and non-stented segments (9.1%, P < 0.001). Stent-graft oversizing did not affect the magnitude of strain reduction (P = 0.77). Tensile testing showed that peak stress-to-rupture was lower for longitudinal (1.4 \ub1 0.4 MPa) than for circumferential fragments (2.3 \ub1 0.4 MPa, P < 0.001). In addition, longitudinal fragments were more prone to rupture proximally than distally (P = 0.01). CONCLUSIONS: This experimental study showed that TEVAR acutely stiffens the aorta in the longitudinal direction and thereby induces a strain mismatch, while tensile testing confirmed that longitudinal aortic fragments are most prone to rupture, particularly close to the arch. Such an acute strain mismatch of potentially vulnerable tissue might play a role in TEVAR-related complications, including retrograde dissection and aneurysm formation. The finding that TEVAR stiffens the aorta longitudinally may also shed light on systemic complications following TEVAR, such as hypertension and cardiac remodelling. These observations may imply the need for further improvement of stent-graft design

Changes in operative strategy for patients enrolled in the International Registry of Acute Aortic Dissection interventional cohort program

Objective: Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time. Methods: One thousand seven hundred thirty-two patients undergoing surgery for type A aortic dissection were identified from the International Registry of Acute Aortic Dissection Interventional Cohort Database. Patients were divided into time tertiles (T) (T1: 1996-2003, T2: 2004-2010, and T3: 2011-2016). Results: Frequency of valve sparing procures increased (T1: 3.9%, T2: 18.6%, and T3: 26.7%; trend P < .001). Biologic valves were increasingly utilized (T1: 35.6%, T2; 40.6%, and T3: 52.0%; trend P = .009), whereas mechanical valve use decreased (T1: 57.6%, T2: 58.0%, and T3: 45.4%; trend P = .027) for aortic valve replacement. Adjunctive cerebral perfusion use increased (T1: 67.1%, T2: 89.5%, and T3: 84.8%; trend P < .001), with increase in antegrade cerebral techniques (T1: 55.9%, T2: 58.8%, and T3: 66.1%; trend P = .005) and hypothermic circulatory arrest (T1: 80.1%, T2: 85.9%, and T3: 86.8%; trend P = .030). Arterial perfusion through axillary cannulation increased (T1: 18.0%, T2: 33.2%, and T3: 55.7%), whereas perfusion via a femoral approach diminished (T1: 76.0%, T2: 53.3%, and T3: 30.1%) (both P values < .001). Hemiarch replacement was utilized more frequently (T1: 27.0%, T2: 63.3%, and T3: 51.7%; trend P = .001) and partial arch was utilized less frequently (T1: 20.7%, T2: 12.0%, and T3: 8.4%; trend P < .001), whereas complete arch replacement was used similarly (P = .131). In-hospital mortality significantly decreased (T1: 17.5%, T2: 15.8%, and T3: 12.2%; trend P = .017). Conclusions: There have been significant changes in operative strategy over time in the management of type A aortic dissection, with more frequent use of valve-sparing procedures, bioprosthetic aortic valve substitutes, antegrade cerebral perfusion strategies, and hypothermic circulatory arrest. Most importantly, a significant decrease of in-hospital mortality was observed during the 20-year timespan

Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction

Background: Although self-expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left-sided obstructing colonic cancer has shown promising short-term results, it is used infrequently owing to uncertainty about its oncological safety. This population study compared long-term oncological outcomes between emergency resection and SEMS placement as BTS.Methods: Through a national collaborative research project, long-term outcome data were collected for all patients who underwent resection for left-sided obstructing colonic cancer between 2009 and 2016 in 75 Dutch hospitals. Patients were identified from the Dutch Colorectal Audit database. SEMS as BTS was compared with emergency resection in the curative setting after 1: 2 propensity score matching.Results: Some 222 patients who had a stent placed were matched to 444 who underwent emergency resection. The overall SEMS-related perforation rate was 7.7 per cent (17 of 222). Three-year locoregional recurrence rates after SEMS insertion and emergency resection were 11-4 and 13.6 per cent (P= 0-457), disease-free survival rates were 58-8 and 52.6 per cent (P= 0-175), and overall survival rates were 74-0 and 68-3 per cent (P= 0.231), respectively. SEMS placement resulted in significantly fewer permanent stomas (23.9 versus 45.3 per cent; P < 0-001), especially in elderly patients (29.0 versus 57.9 per cent; P < 0-001). For patients in the SEMS group with or without perforation, 3-year locoregional recurrence rates were 18 and 11.0 per cent (P= 0.432), disease-free survival rates were 49 and 59.6 per cent (P= 0-717), and overall survival rates 61 and 75.1 per cent (P= 0.529), respectively.Conclusion: Overall, SEMS as BTS seems an oncologically safe alternative to emergency resection with fewer permanent stomas. Nevertheless, the risk of SEMS-related perforation, as well as permanent stoma, might influence shared decision-making for individual patients.Research into fetal development and medicin