Acute type A aortic dissection and pregnancy: a population-based study

Objective: Pregnancy has been reported to be an independent risk factor for 50% of acute aortic dissections recorded in women younger than 45 years of age. The present epidemiologic study aimed to identify whether this putative association of pregnancy and acute type A dissection could be an artifact of selective reporting. Methods: This population-based study was conducted in the City of Vienna, Austria, Europe, in an average female population of 341381 women in the age range of 15-45 years who were followed up between 1994 and 2004 (total of 3755.195 person-years of observation). During this study, the incidence, management, and outcome of acute type A dissection were determined. Results: Fifteen patients (mean age: 38.8 years, SD: 4.8) with acute aortic dissection were identified, and an overall incidence of 0.4 case per 100000 person-years was estimated. The prehospital mortality rate was recorded to be 53%. Six patients, including two women in late pregnancy (incidence: 0.05 cases per 100000 person-years), were treated successfully by surgical repair during deep hypothermic circulatory arrest (in-hospital mortality rate: 6.6%). Pregnancy and aortic dissection were identified as events that were not related (RR: 3.27; 95% confidence interval (CI): 0.82-12.95; P=0.14). Observation during long-term follow-up was uneventful. Conclusions: Acute aortic dissection represents a rare pathology in women younger than 45 years of age; however, it is associated with a high rate of sudden death. Pregnancy may not be a risk factor for this life-threatening vascular emergency. Immediate referral to surgery, even during pregnancy, will result in a prognosis of favorable outcom

The influence of gender on mortality in patients after thoracic endovascular aortic repair

Objectives: The aim of this study was to determine if gender affects mortality in patients after thoracic endovascular aortic repair (TEVAR). Methods: We retrospectively analyzed 286 consecutive patients undergoing TEVAR at our institution during a 12-year period (female 29%, median age 69 years). Chronic health conditions, risk factors, as well as early and long-term outcome were assessed. Follow-up data were available in all patients. Results: For female gender, 1-year survival and 5-year survival was 84% and 56% versus 83% and 60% for male gender. No significant gender influence was observed (odds ratio (OR) 0.96, 95% confidence interval (CI) 0.59-1.56). Furthermore, no significant gender influence could be observed according to the individual indication - atherosclerotic aneurysms (OR 0.78 95%CI 0.41-1.47), acute type B dissections (OR 0.78 95%CI 0.21-2.83), penetrating atherosclerotic ulcers/intramural hematoma (OR 1.48 95%CI 0.53-4.19), and traumatic aortic lesions (OR 1.48 95%CI 0.53-4.19). Age (OR 3.6 95%CI 1.24-10.45) and chronic obstructive pulmonary disease (COPD; OR 3.09 95%CI 0.98-9.73) were independent predictors of mortality in females. Conclusions: Gender does not affect mortality in patients after TEVAR irrespective of the underlying indication, atherosclerotic aneurysms, acute type B dissections, penetrating ulcers/intramural hematoma, and traumatic aortic lesions. Classical risk factors such as age and the presence of COPD at the time of TEVAR remain the most important risk factors in female

The location of the primary entry tear in acute type B aortic dissection affects early outcome†

OBJECTIVES The goal of the retrospective study was to relate the site of the primary entry tear in acute type B aortic dissections to the presence or development of complications. METHODS A consecutive series of 52 patients referred with acute type B aortic dissection was analysed with regard to the location of the primary entry tear (convexity or concavity of the distal aortic arch) using the referral CT scans at the time of diagnosis. These findings were related to the clinical outcome as well as to the need for intervention. RESULTS Twenty-five patients (48%) had the primary entry tear located at the convexity of the distal aortic arch, whereas 27 patients (52%) had the primary entry tear located at the concavity of the distal aortic arch. Twenty per cent of patients with the primary entry tear at the convexity presented with or developed complications, whereas 89% had or developed complications with the primary entry tear at the concavity (P<0.001). Furthermore, in patients with complicated type B aortic dissection, the distance of the primary entry tear to the left subclavian artery was significantly shorter as in uncomplicated patients (8 vs. 21mm; P=0.002). In Cox regression analysis, a primary entry tear at the concavity of the distal aortic arch was identified as an independent predictor of the presence or the development of complicated type B aortic dissection. CONCLUSIONS A primary entry tear at the concavity of the aortic arch as well as a short distance between the primary entry tear and the left subclavian artery are frequently associated with the presence or the development of complicated acute type B aortic dissection. These findings shall help us to further differentiate acute type B aortic dissections in addition to the common categorization in complicated and uncomplicated. These findings may therefore also have an impact on primary treatmen

Statistical and data reporting guidelines for the European Journal of Cardio-Thoracic Surgery and the Interactive CardioVascular and Thoracic Surgery

As part of the peer review process for the European Journal of Cardio-Thoracic Surgery (EJCTS) and the Interactive CardioVascular and Thoracic Surgery (ICVTS), a statistician reviews any manuscript that includes a statistical analysis. To facilitate authors considering submitting a manuscript and to make it clearer about the expectations of the statistical reviewers, we present up-to-date guidelines for authors on statistical and data reporting specifically in these journals. The number of statistical methods used in the cardiothoracic literature is vast, as are the ways in which data are presented. Therefore, we narrow the scope of these guidelines to cover the most common applications submitted to the EJCTS and ICVTS, focusing in particular on those that the statistical reviewers most frequently comment o

Antegrade selective cerebral perfusion and moderate hypothermia in aortic arch surgery: clinical outcomes in elderly patients†

OBJECTIVES To evaluate the outcome in elderly patients (≥75 years) undergoing elective aortic arch surgery with the aid of selective antegrade cerebral perfusion (SACP) and moderate hypothermic circulatory arrest (HCA). METHODS A series of 95 patients ≥75 years (median age 77 years, median EuroSCORE 28) undergoing elective aortic arch surgery with SACP and moderate HCA were analysed with regard to clinical outcome. Risk factors for serious adverse events (mortality, neurological injury) were determined. RESULTS Sixty-three patients (66%) underwent ascending aorta and hemiarch replacement, whereas 32 patients (34%) underwent ascending aorta and total arch replacement. Isolated arch replacement was rare. Additionally, 27% of patients underwent aortic valve replacement and 26% underwent root replacement. In-hospital mortality was 7%. Permanent neurological deficits occurred in 5%, transient neurological deficits occurred in 2%. Median SACP time was 24min. Univariate analysis revealed femoral cannulation site (OR: 3.4; CI: 1.25-9.22, P=0.016) as well as HCA ≥40min (OR: 4.21; CI: 1.83-12.58, P=0.001) as predictors of serious adverse events (mortality, neurological injury). CONCLUSIONS Summarizing, elective aortic arch surgery in elderly patients using SACP and moderate HCA provides excellent results regarding mortality and postoperative neurological outcome. Prolonged HCA time and femoral cannulation were the only predictors of serious adverse events (mortality, neurological injury

What makes the difference between the natural course of a remaining type B dissection after type A repair and a primary type B aortic dissection?†

OBJECTIVES To analyse the outcome and need for intervention [surgery or thoracic endovascular aortic repair (TEVAR)] in patients after surgery for remaining type B dissection after type A repair and primary type B aortic dissection. METHODS Within a 10-year period, 247 patients with remaining type B after type A, and 112 patients with primary type B aortic dissection were analysed. We assessed the clinical outcome as well as the need for intervention (surgery or TEVAR) within the aortic arch and the thoracoabdominal aorta as well as risk factors. RESULTS The median follow-up was 23 months (interquartile range 5-52). There was a significant difference with regard to the status of the primary entry tear between patients after surgical repair of an acute type A aortic dissection and primary acute type B aortic dissection (patent vs. non-patent entry 35 vs. 83%, P<0.001). The overall need for any kind of intervention (surgery or TEVAR) was 19%. Multivariate Cox regression analysis revealed a patent primary entry tear in patients after surgery for acute type A aortic dissection as an independent predictor for intervention (surgery or TEVAR) during follow-up [odds ratio (OR) 6.4; confidence interval (CI) 1.39-29.81, P=0.017]. Multivariate Cox regression analysis did not reveal a patent primary entry tear in patients after acute type B aortic dissection as an independent predictor for intervention (surgery or TEVAR) during follow-up (OR 0.67; CI 0.27-1.69, P=0.671). Finally, the thrombosis status of the false lumen was not an independent predictor for intervention (surgery or TEVAR) either in patients after surgery for acute type A aortic dissection (OR 3.46; CI 0.79-15.16, P=0.100) or in patients after acute type B aortic dissection (OR 0.77; CI 0.31-1.93, P=0.580). CONCLUSIONS A remaining type B dissection after type A repair and a primary type B aortic dissection represent two distinct pathophysiological entities with regard to late outcome. The need for any kind of intervention in the thoracoabdominal aorta is significantly higher in primary type B aortic dissections. A remaining patent primary entry tear independently predicts the need for intervention (surgery or TEVAR) in patients after surgery for acute type A aortic dissection and, thereby, remains the main target of initial therapy. The thrombosis status of the false lumen seems to be of secondary importanc

Effect on false-lumen status of a combined vascular and endovascular approach for the treatment of acute type A aortic dissection

OBJECTIVE The aim of the study is to evaluate midterm results with regard to false-lumen status of a combined vascular and endovascular approach for the treatment of acute type A aortic dissection. METHODS We performed ascending/hemiarch replacement during hypothermic circulatory arrest with additional open implantation of the Djumbodis Dissection System (non-self-expanding bare metal stent) to readapt the dissected layers in the arch and the proximal descending aorta in a consecutive series of 15 patients (mean age 61 years, 20% female) suffering from acute type A aortic dissections. The primary end point was the status of the false lumen at the level of the stent. RESULTS We observed three in-hospital deaths (20%). Complete thrombosis of the false lumen was observed in one patient (8%). In 25% of patients, partial thrombosis of the false lumen was observed. The remaining patients had continuing antegrade perfusion. Surgical conversion during a mean follow-up of 37 months was required in two patients (16%) due to continuing enlargement of the distal arch and the proximal descending aorta. No late deaths were observed. CONCLUSION Additional implantation of the Djumbodis Dissection System to readapt the dissected layers in the arch and the proximal descending aorta does not seem to have additive value as an adjunct to standard ascending/hemiarch replacement with regard to closure of the false lumen in the arch and the proximal descending aorta. The most limiting factor seems to be the non-self-expanding capability of the devic

Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). METHODS Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). RESULTS Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). CONCLUSIONS ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strateg

New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR). METHODS International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres). RESULTS Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33). CONCLUSIONS The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patient