Analysis of Target Vessel Instability in Fenestrated Endovascular Repair (f-EVAR) in Thoraco-Abdominal Aortic Pathologies.

Objective: The aim of this study was to evaluate the influence of target vessel anatomy and post-stenting geometry on the outcome of fenestrated endovascular aortic repair (f-EVAR). Methods: A retrospective review of data from a single center was conducted, including all consecutive fenestrated endovascular aortic repairs (f-EVARs) performed between September 2018 and December 2023 for thoraco-abdominal aortic aneurysms (TAAAs) and complex abdominal aortic aneurysms (cAAAs). The analysis focused on the correlation of target vessel instability to target vessel anatomy and geometry after stenting. The primary endpoint was the cumulative incidence of target vessel instability. Secondary endpoints were the 30-day and follow-up re-interventions. Results: A total of 136 patients underwent f-EVAR with 481 stented target vessels. A total of ten target vessel instabilities occurred including three in visceral and seven instabilities in renal vessels. The cumulative incidence of target vessel instability with death as the competing risk was 1.4%, 1.8% and 3.4% at 1, 2 and 3 years, respectively. In renal target vessels (260/481), a diameter ≤ 4 mm (OR 1.21, 95% CI 1.035-1.274, p = 0.009) and an aortic protrusion ≥ 5.75 mm (OR 8.21, 95% CI 3.150-12-23, p = 0.027) was associated with an increased target vessel instability. In visceral target vessels (221/481), instability was significantly associated with a preoperative tortuosity index ≥ 1.25 (HR 15.19, CI 95% 2.50-17.47, p = 0.045) and an oversizing ratio of ≥1.25 (HR 7.739, CI % 4.756-12.878, p = 0.049). Conclusions: f-EVAR showed favorable mid-term results concerning target vessel instability in the current cohort. A diameter of ≤4 mm and an aortic protrusion of ≥5.75 mm in the renal target vessels as well as a preoperative tortuosity index and an oversizing of the bridging stent of ≥1.25 in the visceral target vessels should be avoided

Over eight years survival after ascending endovascular repair of type A intramural hematoma.

Acute Type A aortic syndromes are catastrophic events whose management relies primarily on conventional surgery. For several years, various endovascular attempts have been described, however long-term data is inexistent. We describe a case of stenting of the ascending aorta for a Type A intramural haematoma with survival and freedom from reintervention at more than 8 years postoperatively

Impact of the bicuspid aortic valve on aortic root haemodynamics: three-dimensional computed fluid dynamics simulation

Abstract OBJECTIVES The aim was to evaluate the impact of a bicuspid aortic valve (BAV) on local shear stress and on the pressure profile on the elements of the aortic root (AoR). METHODS The experiment setup included a BAV with aortic valve stenosis (n = 5 pigs, 67 ± 3.5 kg) and insufficiency (n = 5 pigs, 66.7 ± 4.4 kg). By implanting 6 high-fidelity microsonometric crystals in each AoR, we determined the 3-dimensional (3D) geometry of the AoR. Experimental and geometric data were used to create a 3D time- and pressure-dependent computed fluid dynamic model of the AoR with the BAV. RESULTS 3D AoR geometry was determined by AoR tilt (α) and rotation angle (β). Both values were maximal at the end of diastole: 24.41 ± 1.70° (α) and 20.90 ± 2.11° (β) for BAV with stenosis and 31.92 ± 11.51° (α) and 20.84 ± 9.80° (β) for BAV with insufficiency and minimal at peak ejection 23.42 ± 1.65° (α), 20.38 ± 1.61° (β) for stenosis and 26.62 ± 7.86° (α), 19.79 ± 8.45° (β) for insufficiency. In insufficiency, low shear stress of 0-0.08 Pa and moderate pressure (60-80 mmHg) were present. In BAV with stenosis, low shear stress of 0-0.5 Pa and moderate pressure (0-20 mmHg) were present at diastole; at peak ejection high shear stress >2 Pa and elevated pressure of >80 mmHg were present. CONCLUSIONS In a BAV with aortic valve stenosis, the haemodynamics are less favourable. The elevated pressure with elevated shear stress may over the long term promote degenerative processes in the leaflets and consequently valve function failure

A systemic review and meta-analysis: long-term results of the Bentall versus the David procedure in patients with Marfan syndrome

This systemic review of the literature and meta-analysis aimed to evaluate the current state of the evidence for and against reimplantation of the aortic valve (RAV) versus the composite valve graft (CVG) intervention in patients with Marfan syndrome. Random effects meta-regression was performed across the study arms with logit-transformed proportions of in-hospital deaths as an outcome measure when possible. Results are presented as odds ratios with 95% confidence intervals (CIs) and P-values. Other outcomes are summarized with medians, interquartile ranges (IQR) and ranges and the numbers of patients at risk. Twenty retrospective studies that included a combined 2156 patients with long-term follow-up were identified for analysis after a literature search. The in-hospital mortality rate favoured the RAV procedure with an odds ratio of 0.23 [95% CI 0.09-0.55, P = 0.001]. The survival rate at mid-term for the RAV cohort was 96.7% (CI 94.2-98.5) vs. 86.4% (CI 82.8-89.6) for the CVG group and 93.1% (CI 66.4-100) for the RAV group vs. 82.6% (CI 74.9-89.2) for the CVG group for the long term. Freedom from valve-related reintervention (median percentages) for the long term was 97.6% (CI 90.3-100%) for the RAV procedure and 88.6% (CI 79.1-95.5) for a CVG. This systematic review of the literature stresses the advantages of the RAV procedure in patients with Marfan syndrome in regard to long- and short-term results as the treatment of choice in aortic root surgery. The RAV procedure reduces in-hospital as well as long-term deaths and protects against aortic valve reintervention

Outcome of Stanford type B dissection in patients with Marfan syndrome.

OBJECTIVE To determine the outcome of Stanford type B aortic dissection in patients with Marfan syndrome and to evaluate aortic diameters at time of dissection as well as the impact of previous aortic root replacement. METHODS Analysis of all patients with Marfan syndrome fulfilling Ghent criteria seen at this institution since 1995 until 2022. RESULTS Thirty-six (19%) out of 188 patients with Marfan syndrome suffered from Stanford type B aortic dissection during the study period. Mean aortic diameter at time of dissection was 39.0 mm (95% CI: 35.6-42.3). Mean pre-dissection diameter (available in 25% of patients) was 32.1 mm (95% CI: 28.0-36.3) and mean expansion was 19% (95% CI: 11.9-26.2). There was no correlation between age and diameter at time of dissection (<20, 21-30, 31-40, 41-50, 51-60, <61 years; p = 0.78). Freedom-from-intervention after dissection was 53%, 44%, 33% at 1, 5 and 10 years. Aortic growth rate in those patients that had to undergo intervention within the 1st year after dissection was 10.2 mm/y (95% CI: 4.4-15.9) compared to 5.8 mm/y (95% CI: 3.3-8.3), p = 0.109 in those thereafter. Mean time between dissection and intervention was 1.8 years (95% CI: 0.6-3.0). While type B dissection seems more frequent after previous elective aortic repair (58% vs 42%), there was no difference between valve-sparing root replacement (VSRR) compared to Bentall procedures (HR for VSRR 0.78, 95% CI: 0.31-2.0, p-value = 0.61). Mean age of the entire population at end of follow-up was 42 years (95% CI: 39.2-44.7). Mean follow-up time was 9 years (95% CI: 7.8-10.4). CONCLUSIONS Stanford type B dissection in patients with Marfan syndrome occurs far below accepted thresholds for intervention. Risk for type B dissection is present throughout lifetime and two third of patients need an intervention after dissection. There is no difference in freedom from type B dissection between a Bentall procedure and a valve-sparing root replacement