Utilisation de la technique cheminée après couverture accidentelle de l’artère carotide commune gauche lors de la pose d’une endoprothèse aortique=use of chimney graft after accidental coverage of the left common carotid artery in TEVAR procedure

Thoracic endovascular aneurysm repair (TEVAR) is currently the therapy of first choice for most thoracic aortic disease. Because aortic stent grafts are placed in the vicinity of aortic side branches, unintentional coverage of these arteries may occur.Pr\ue9requis : Le traitement endovasculaire est actuellement le traitement de choix dans le traitement des pathologies de l\u2019aorte thoracique. Les endoproth\ue8ses aortiques sont plac\ue9es \ue0 proximit\ue9 des art\ue8res des troncs supra\u2010aortiques et une couverture accidentelle de ses art\ue8res peut se produire. Observation : Nous rapportons le cas d\u2019un homme \ue2g\ue9 de 69 ans pr\ue9sentant un ulc\ue8re p\ue9n\ue9trant de la crosse aortique asymptomatique, \ue0 proximit\ue9 de l\u2019origine de l\u2019art\ue8re sous clavi\ue8re gauche. En raison des ant\ue9c\ue9dents m\ue9dicaux, nous d\ue9cidons de r\ue9aliser un traitement endovasculaire avec mise en place d\u2019une endoproth\ue8se au niveau de l\u2019h\ue9mi crosse aortique gauche, apr\ue8s avoir r\ue9alis\ue9 un pontage carotido\u2010sous clavier. Lors du d\ue9ploiement, le segment proximal de l\u2019endoproth\ue8se aortique couvre accidentellement l\u2019origine de la carotide commune gauche. Comme proc\ue9dure de sauvetage, nous avons r\ue9aliser avec succ\ue8s la revascularisation de l\u2019art\ue8re carotide commune gauche en utilisant la technique chemin\ue9e. Conclusion : Le traitement endovasculaire des pathologies aortiques a connu un regain de popularit\ue9 lors de la derni\ue8re d\ue9cennie. Malgr\ue9 les \ue9volutions r\ue9alis\ue9es, cette proc\ue9dure reste un challenge technique. La couverture accidentelle d\u2019une branche principale de la crosse aortique durant les proc\ue9dures endovasculaire est une complication s\ue9rieuse n\ue9cessitant une intervention imm\ue9diate. La technique chemin\ue9e est une solution peu invasive dans ce genre d\u2019accident, avec des r\ue9sultats promettant

Update in the management of aortic dissection

Opinion statement: Recent improvements in diagnosis, peri-operative management, surgical techniques and postoperative care have resulted in decreased mortality and morbidity in acute aortic dissections (AAD). The classic treatment algorithm indicates that type A patients require direct surgical intervention and type B patients should be treated medically, in absence of complications. Initial medical treatment is adopted in all AAD patients, as it reduces propagation of the dissection and aortic rupture. In type A aortic dissection (TAAD) several techniques have contributed to major changes in the surgical approach, such as cerebral protection using moderate circulatory arrest, selective cerebral perfusion, and aortic valve sparing with root replacement. In TAAD with involvement of the descending aorta, thoracic endovascular aortic repair (TEVAR) can be performed as a part of a complex hybrid procedure, in which surgical ascending/arch repair is combined with the placement of a stent graft in the descending aorta. Future developments in stent graft technologies might broaden the usefulness of TEVAR for the total endovascular repair of TAAD. In complicated type B aortic dissection (TBAD), the use of TEVAR has become the therapy of first choice. By covering the proximal entry tear, the stent graft reduces the pressurization of the false lumen, treating malperfusion and inducing favorable aortic remodeling. In uncomplicated TBAD, TEVAR has been used to prevent long term complications, such as aortic aneurysm, but this concept is not yet routinely recommended. Regardless of their initial treatment, all AAD patients should be administered with strict antihypertensive management combined with imaging surveillance and careful periodic clinical follow-up

Patient-specific aortic endografting simulation : from diagnosis to prediction

Traditional surgical repair of ascending aortic pseudoaneurysm is complex, technically challenging, and associated with significant mortality. Although new minimally invasive procedures are rapidly arising thanks to the innovations in catheter-based technologies, the endovascular repair of the ascending aorta is still limited because of the related anatomical challenges. In this context, the integration of the clinical considerations with dedicated bioengineering analysis, combining the vascular features and the prosthesis design, might be helpful to plan the procedure and predict its outcome. Moving from such considerations, in the present study we describe the use of a custom-made stent-graft to perform a fully endovascular repair of an asymptomatic ascending aortic pseudoaneurysm in a patient, who was a poor candidate for open surgery. We also discuss the possible contribution of a dedicated medical images analysis and patient-specific simulation as support to procedure planning. In particular, we have compared the simulation prediction based on pre-operative images with post-operative outcomes. The agreement between the computer-based analysis and reality encourages the use of the proposed approach for a careful planning of the treatment strategy and for an appropriate patient selection, aimed at achieving successful outcomes for endovascular treatment of ascending aortic pseudoaneurysms as well as other aortic diseases

Influence of oversizing on outcome in thoracic endovascular aortic repair

Purpose: To investigate the influence of stent-graft oversizing on device-related complications after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA). Methods: The study cohort was composed of patients enrolled in 4 clinical trials of the TAG thoracic stent-graft. A total of 337 TAA patients (222 men; mean age 72 years) treated in these trials had sufficient data for analysis of oversizing and post-procedure mortality and complications, such as endoleak, migration, rupture, and reinterventions. Mean oversizing at the proximal landing zone was 14.6% (range -3.4% to 39.7%). Patients were stratified based on the percentage of oversizing: 20% (n=64, group 3). Results: Patients in group 1 had significantly larger preoperative proximal aortic diameters (32.6 vs. 31.3 vs. 28.2 mm, respectively; p<0.001) and neck lengths (6.9 vs. 5.8 vs. 5.2 cm (p=0.035). Overall, type I endoleak was the most frequent complication during the first 30 days of follow-up (35, 10.4%), but the incidences did not differ among the 3 groups (10.6% vs. 11.2% vs. 7.8%, respectively; p=0.809). Over a mean follow-up of 41.8\ub120.7 months, there were no significant differences in the occurrence of device-related complications among the groups, though the incidence of type I endoleaks was lower in group 2 (9.4% vs. 3.2% vs. 7.8%, respectively; p=0.073). Cox proportional hazards modeling showed no difference in the time to type I endoleak among oversizing groups [group 1 vs. 2: HR 1.24, 95% CI 0.65 to 2.36 (p=0.509) and group 3 vs. 2: HR 1.24, 95% CI 0.60 to 2.60 (p=0.562)]. Conclusion: The percentage of oversizing did not significantly affect the incidence of devicerelated complications after TEVAR for TAA. Although oversizing may enhance the radial force and help maintain a good proximal seal, additional oversizing seemed not to improve the overall outcome in this analysis. The current guidelines regarding stent-graft oversizing for TAA seem appropriate, though the correct percentage remains to be determined

Predicting aortic enlargement in type B aortic dissection

Patients with uncomplicated acute type B aortic dissection (ABAD) can generally be treated with conservative medical management. However, these patients may develop aortic enlargement during follow-up, with the risk of rupture. Several predictors have been studied in recent years to identify ABAD patients at high risk of aortic enlargement, who may benefit from early surgical or endovascular intervention. This study reviewed and summarized the current available literature on prognostic variables related to aortic enlargement during follow-up in uncomplicated ABAD patients. It revealed multiple factors affecting aortic expansion including demographic, clinical, pharmacologic and radiologic variables. Such predictors may be used to identify those ABAD patients at higher risk for aortic enlargement who may benefit from closer radiologic surveillance or early endovascular intervention. This approach deserves even more consideration because a significant number of patients develop aneurysmal degeneration along the dissected segments during follow-up, and may lose the opportunity for endovascular treatment if not identified at an early stage

Predictors of aortic growth in uncomplicated type B aortic dissection

Background Patients with uncomplicated acute type B aortic dissection (ABAD) generally can be treated with conservative medical management. However, these patients may develop aortic enlargement during follow-up, with the risk for rupture, which necessitates intervention. Several predictors have been studied in recent years to identify ABAD patients at high risk for aortic enlargement who may benefit from early surgical or endovascular intervention. This study systematically reviewed and summarized the current available literature on prognostic variables related to aortic enlargement during follow-up in uncomplicated ABAD patients. Methods Studies were included if they reported predictors of aortic growth in uncomplicated ABAD patients. Studies about type A aortic dissection, aortic aneurysm, intramural hematoma, or ABAD that required acute intervention were excluded. Results A total of 18 full-text articles were selected. The following predictors of aortic growth in ABAD patients were identified: age <60 years, white race, Marfan syndrome, high fibrinogen-fibrin degradation product level ( 6520 \u3bcg/mL) at admission, aortic diameter 6540 mm on initial imaging, proximal descending thoracic aorta false lumen (FL) diameter 6522 mm, elliptic formation of the true lumen, patent FL, partially thrombosed FL, saccular formation of the FL, presence of one entry tear, large entry tear ( 6510 mm) located in the proximal part of the dissection, FL located at the inner aortic curvature, fusiform dilated proximal descending aorta, and areas with ulcer-like projections. Tight heart rate control (<60 beats/min), use of calcium-channel blockers, thrombosed FL, two or more entry tears, FL located at the outer aortic curvature, and circular configuration of the true lumen were associated with negative or limited aortic growth. Conclusions Several predictors might be used to identify those ABAD patients at high risk for aortic growth. Although conservative management remains indicated in uncomplicated ABAD, these patients might benefit from closer follow-up or early endovascular intervention

The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection

Introduction Aortic intramural hematoma type B (IMHB) is a variant of acute aortic syndrome, which presents with symptoms similar to classic type B aortic dissection (ABAD). However, the natural history of IMHB is not well understood. The purpose of this study was to better characterize IMHB, comparing its clinical characteristics, treatment, and in-hospital and long-term outcomes to those with classic ABAD. Methods A total of 107 IMHB and 790 ABAD patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between January 1996 and June 2012 were analyzed. Accordingly, differences in presentation, diagnostics, therapeutic management, and outcomes were assessed. Results As compared with the ABAD, IMHB presented predominantly in males (62% vs 33%; P <.001) at older age (69 \ub1 12 vs 63 \ub1 14; P <.001). IMHB patients more often had chest pain (80% vs 69%; P =.020) and periaortic hematoma (22% vs 13%; P =.020) and were more often treated medically (88% vs 62%; P <.001), with surgical/endovascular interventions being reserved for more complicated patients. Overall in-hospital mortality was 10% (IMHB, 7% vs ABAD, 11%; P = NS). Six out of seven IMHB deaths occurred during medical treatment, two due to aortic rupture. During follow-up in IMHB, patient mortality was 7%, and no adverse events, including progression to an aortic dissection or aortic rupture, were observed. Imaging showed significantly more aortic enlargement at the level of the descending aorta in ABAD patients (39% vs 61%; P =.034). Conclusions Most IMHB patients can be treated medically, and aortic enlargement is less common during follow-up, which may suggest that IMHB may have a slightly more benign course compared with classic ABAD in the acute setting