Santi Trimarchi

Abdominal Aortic Aneurysm Acute Aortic Syndromes American Association for Surgery of Trauma Aortic Dissection Acute Type B Aortic Dissection Coeliac Artery Coronary Artery Disease Common Carotid Artery Chronic Obstructive Pulmonary Disease Cerebrospinal Fluid Computed Tomography Computed Tomographic Angiography Chronic Type B Aortic Dissection Digital Subtraction Angiography Descending Thoracic Aorta Descending Thoracic Aortic Aneurysm Electrocardiogram Ehlers-Danlos Syndrome European Journal of Vascular and Endovascular Surgery Erythrocyte Sedimentation Rate European Society for Vascular Surgery False Lumen Giant Cells Arteritis Intramural Haematoma International Registry of Aortic Dissection Intravascular Ultrasonography Loeys-Dietz Syndrome Left Heart Bypass Left Subclavian Artery Mean Arterial Pressure Motor Evoked Potentials Marfan Syndrome Magnetic Resonance Angiography Magnetic Resonance Imaging Nephrogenic Systemic Fibrosis Open Repair Penetrating Aortic Ulcer Positron Emission Tomography Polymyalgia Rheumatica Randomized Clinical Trial Spinal Cord Ischaemia Superior Mesenteric Artery Somatosensory Evoked Potentials Takayasu Arteritis Thoraco-Abdominal Aortic Aneurysm Thoracic Aortic Injury Type B Aortic Dissection Thoracic Endovascular Repair True Lumen Transoesophageal Echocardiography Turner Syndrome Transthoracic Echocardiography Writing Committee The European Society for Vascular Surgery (ESVS) appointed the Descending Thoracic Aorta (DTA) Writing Committee (WC) to produce the current clinical practice guidelines document for surgeons and other physicians who are involved in the overall care of patients with DTA disorders. The goal of these guidelines is to summarize and evaluate all current available evidence to assist physicians in selecting the best management strategies for all DTA pathologies. However, each respective physician must make the ultimate decision regarding the particular care of an individual patient. The present guidelines document aims to improve decision making and decrease variability in the vascular surgical care of patients presenting with pathology of the DTA. Unfortunately, robust evidence from prospective and randomized studies is not available for management of most DTA diseases. Consequently, the recommendations in these guidelines are entirely based on level B and C evidence. Nevertheless, when managing DTA pathology, it is clinically helpful to have access to the most recent and best available clinical and experimental knowledge to determine the current standard of care. The DTA WC intentionally agreed to exclude pathology of the ascending aorta and aortic arch from the current document to avoid potential inter-specialty conflict. The cost analysis of different treatments was also excluded because of differences in financial management and differing health systems across Europe. Primarily infectious or mycotic disease processes were also considered outside of the scope of this document because of their low incidence and poor outcomes. All disorders originating in the DTA from the left subclavian artery (LSA) origin to the diaphragm were considered for these guidelines. Pathology involving the thoraco-abdominal segment of the aorta was also included. The DTA WC was formed by members of the ESVS from different European countries, various academic and private hospitals, and by both vascular surgeons and endovascular specialists, to maximize the applicability of the final guidelines document. The DTA Guidelines Committee met in November 2011 for the first time to discuss the purpose, contents, methods, and timeline of the following recommendations. The DTA WC performed a systematic English literature search in the MEDLINE, EMBASE, and COCHRANE Library databases for each of the different topics that are discussed and reviewed. The latest literature search was performed in December 2015. With regard to evidence gathered, the following eligibility criteria were applied:•Only peer reviewed published literature was considered•Published abstracts or congress proceedings were excluded•Randomized clinical trials (RCT) as well as meta-analyses and systematic reviews were assessed with priority•Non-randomized clinical trials and non-controlled studies were included•Well conducted observational studies (cohort and case control studies) were included•Previous guidelines, position papers, and published consensus documents were included as part of the review process when new evidence was absent•We minimized the use of reports from a single medical device or from pharmaceutical companies in order to reduce the risk of bias across studies. A grading system was adopted based on the European Society of Cardiology (ESC) guidelines methodology.1European Society of Cardiology. Recommendations for guidelines production. www.escardio.org/static_file/Escardio/Guidelines/about/ESC_Guidelines_for_Guidelines_Update_2012_for_web.pdf.Google Scholar The level of evidence classification provides information about the study characteristics supporting the recommendation and expert consensus, according to the categories shown in Table 1.Table 1Levels of evidence.1European Society of Cardiology. Recommendations for guidelines production. www.escardio.org/static_file/Escardio/Guidelines/about/ESC_Guidelines_for_Guidelines_Update_2012_for_web.pdf.Google Scholar The recommendation grade indicates the strength of a recommendation. Definitions of the classes of recommendation are shown in Table 2.Table 2Grades of strength of recommendations according to the ESC grading system.1European Society of Cardiology. Recommendations for guidelines production. www.escardio.org/static_file/Escardio/Guidelines/about/ESC_Guidelines_for_Guidelines_Update_2012_for_web.pdf.Google Scholar For each recommendation, two members of the WC assessed the strength of a recommendation and the quality of supporting evidence independently. A full master copy of the manuscript with all recommendations was electronically circulated and approved by all WC members. Recommendations that required consensus were discussed and voted on by email among all members of the WC. This system permits strong recommendations, supported by low or very low quality evidence from downgraded RCTs or observational studies, only when a general consensus is achieved among the WC members and reviewers. Two members of the WC prepared each part of the guidelines document. An internal review process was performed before the manuscript was sent to independent external reviewers. External reviewers made critical suggestions, comments, and corrections on all preliminary versions of this guideline. In addition, each member participated in the consensus process concerning conflicting recommendations. The final document was reviewed and approved by the ESVS Guidelines Committee and submitted to the European Journal of Vascular and Endovascular Surgery (EJVES). Further updated guidelines documents on DTA management will be provided periodically by the ESVS when new evidence and/or new clinical practice arise in this field. To optimize the implementation of the current document, the length of the guideline has been kept as short as possible to facilitate access to guideline information. Following this decision, the “References” list has been limited to the most relevant references related to these guidelines. Nevertheless, an Appendix of recommended additional references, also reviewed by the WC, has been added for further information for readers. This clinical guidelines document was constructed as a guide, not a document of rules, allowing for flexibility with various patient presentations. The resulting clinical practice guidelines provide recommendations for the clinical care of patients with thoracic aortic diseases including pre-, peri-, and post-operative care. Conflicts of interest of each WC member were collected prior to the writing process. These conflicts were assessed and accepted by each member of the WC and are reported on the ESVS website. In addition, the WC agreed that all intellectual work should be expressed without any interference beyond the honesty and professionalism of all members and assistants during the writing process. The DTA originates from the isthmus, the region of the thoracic aorta between the origin of the LSA and the ductus arteriosus. The descending thoracic aorta runs in a left para-spinal location until its distal segment, where it passes anteriorly through the diaphragmatic aortic hiatus and inferiorly into the abdomen. Important aortic side branches originating from the descending thoracic aorta include the intercostal arteries, spinal arteries, and bronchial arteries. The normal diameter of the mid-descending aorta ranges from 24 to 29 mm in men and 24 to 26 mm in women, whereas the normal diameter at the level of the diaphragm is 24 to 27 mm in men and 23 to 24 mm in women. Aortic diameter is influenced by age and body mass index.2Johnston K.W. Rutherford R.B. Tilson M.D. Shah D.M. Hollier L. Stanley J.C. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery.J Vasc Surg. 1991; 13: 452-458Abstract Full Text Full Text PDF PubMed Scopus (684) Google Scholar, 3Kälsch H. Lehmann N. Möhlenkamp S. Becker A. Moebus S. Schmermund A. et al.Body-surface adjusted aortic reference diameters for improved identification of patients with thoracic aortic aneurysms: results from the population-based Heinz Nixdorf Recall study.Int J Cardiol. 2013; 163: 72-78Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar The aortic wall is composed of three layers: the intima, media, and adventitia. The intima, the innermost layer, consists of an endothelial monolayer and an internal elastic lamina. Because it is in direct contact with blood, the function of the intima is to prevent thrombosis and atherosclerosis. Its anti-thrombotic and anti-atheroscle-rotic function can be reduced by risk factors, such as smoking, hypertension, hyperlipidaemia, diabetes, and direct trauma, each making patients more prone to aortic disease. The media consists of concentric layers of elastin, collagen, and smooth muscle cells. These components are responsible for aortic wall elasticity, which accommodates the changes in stroke volume during the cardiac cycle, converts pulsatile inflow into a smoother outflow (Windkessel function), and maintains the integrity of the aortic wall. Congenital or hereditary disorders (e.g. bicuspid aortic valve, Marfan syndrome [MFS], Ehlers-Danlos syndrome [EDS]), risk factors (hypertension, atherosclerosis, and trauma) all influence aortic wall function. These conditions can stiffen the aortic wall, decreasing its ability to accommodate the stroke volume, resulting in systemic hypertension, or weakening of the aortic wall, leading to dilatation or dissection. The adventitia is the outermost layer of the aortic wall and is composed mainly of collagen fibres, external elastic lamina, and small vessels (the vasa vasorum), which provide the blood supply to the aortic wall and surrounding nerves. DTA diseases consist of a broad spectrum of degenerative, structural, acquired, genetic, and traumatic disorders. The true incidence of descending thoracic aortic pathology remains unclear. Epidemiological studies are sparse and it is likely that many DTA related deaths are attributed to other cardiovascular diseases, such as cardiac arrest, myocardial infarction, cerebrovascular accidents, or abdominal aneurysm rupture. Therefore, the overall incidence of DTA disease is likely to be underestimated. The pathophysiology of thoracic aortic diseases is believed to be multifactorial, resulting both from genetic susceptibility and environmental exposure. Therefore, the incidence of the different thoracic aortic diseases can vary significantly among different population groups. Acute aortic syndromes (AAS) consist of three interrelated diseases: aortic dissection, penetrating aortic ulcer (PAU), and intramural haematoma (IMH). Type B aortic dissection (TBAD) most commonly affects male patients and has an incidence between 2.9 and 4.0 per 100,000 person-years.4Clouse W.D. Hallet Jr., J.W. Shaff H.V. Spittell P.C. Rowland C.M. Ilstrup C.M. et al.Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture.Mayo Clin Proc. 2004; 79: 176-180Abstract Full Text Full Text PDF PubMed Google Scholar The incidence of TBAD seems to be increasing. A recent prospective analysis of 30,412 middle aged men and women from Malmö, Sweden with a 20 year follow up reported an incidence of acute aortic dissection of 15 per 100,000 patient years.5Landenhed M. Engstrom G. Gottsater A. Caulfield M.P. Hedblad B. Newton-Cheh C. et al.Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study.J Am Heart Assoc. 2015; 4: e001513Crossref PubMed Google Scholar This increase is probably caused by the increasing age of the population and improving diagnostic modalities. The exact incidence remains unknown, but PAU has been diagnosed with increasing frequency because of the widespread use of advanced cross sectional imaging techniques. In symptomatic patients suspected of AAS, the prevalence of PAU is 2.3–7.6% and the lesion is localised in the DTA in 90% of patients.6Eggebrecht H. Nienaber C.A. Neuhauser M. Baumgart D. Kische S. Schmermund A. et al.Endovascular stent graft placement in aortic dissection: a meta-analysis.Eur Heart J. 2006; 27: 489-498Crossref PubMed Scopus (0) Google Scholar IMH may be related to PAU, accounting for 5–20% of patients with AAS and more commonly involving the DTA (60%) than the ascending aorta.7Evangelista A. Mukherjee D. Mehta R.H. O'Gara P.T. Fattori R. Cooper J.V. et al.Acute intramural hematoma of the aorta: a mystery in evolution.Circulation. 2005; 111: 1063-1070Crossref PubMed Scopus (277) Google Scholar Trauma is the leading cause of death during the first four decades of life, accounting for more than 250,000 deaths every year in the European Union alone.8http://ec.europa.eu/eurostat/statistics-explained/index.php/Transport_accident_statistics#Main_statistical_findings.Google Scholar Blunt aortic injury is the second leading cause of death in these patients, and although it occurs in less than 1% of all motor vehicle accidents, it accounts for 16% of all traumatic deaths.9European Commission. Mobility and transport. Road safety. http://ec.europa.eu/transport/road_safety/specialist/statistics/.Google Scholar Concerning ruptured descending thoracic aortic aneurysm (DTAA), a Swedish population study reported an incidence of 5 per 100,000 person-years. The mean age of patients in this cohort was 70 years for men and 72 years for women.10Johansson G. Markström U. Swedenborg J. Ruptured thoracic aortic aneurysms: a study of incidence and mortality rates.J Vasc Surg. 1995; 21: 985-988Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar Aneurysmal dilatation of the DTA is a degenerative disease with an estimated incidence of 6–10.4 per 100,000 person-years. The incidence seems to be increasing with ageing of the general population and continually improving diagnostic modalities.11Fowkes F.G. Macintyre C.C. Ruckley C.V. Increasing incidence of aortic aneurysms in England and Wales.BMJ. 1989; 298: 33-35Crossref PubMed Google Scholar Aortitis is a relatively uncommon disorder with a broad spectrum of clinical features. The most common autoimmune disorders affecting the DTA are Takayasu's arteritis (TA), giant cell arteritis (GCA), and Behçet's disease. The best estimates of the incidence of TA suggest that two or three cases occur each year per million people.12Karageorgaki Z.T. Bertsias G.K. Mavragani C.P. Kritikos H.D. Spyropoulou-Vlachou M. Drosos A.A. et al.Takayasu arteritis: epidemiological, clinical, and immunogenetic features in Greece.Clin Exp Rheumatol. 2009; 27: S33-S39PubMed Google Scholar There is a 9:1 female to male predominance. Although the disease has a worldwide distribution, it appears to occur more frequently in Asian women. GCA is the most common type of vasculitis observed in patients older than 50 years. Predominantly observed in populations of Scandinavian descent, it has a reported prevalence that varies between 1 and 30 per 100,000 people.13Nordborg E. Nordborg C. Giant cell arteritis: epidemiological clues to its pathogenesis and an update on its treatment.Rheumatology. 2003; 42: 413-421Crossref PubMed Scopus (0) Google Scholar The male to female ratio is around 2.5 to 1 and is highly dependent on geographic and genetic parameters.14Lee J.L. Naguwa S.M. Cheema G.S. Gershwin M.E. The geo-epidemiology of temporal (giant cell) arteritis.Clin Rev Allergy Immunol. 2008; 35: 88-95Crossref PubMed Scopus (38) Google Scholar Behçet's disease has been observed most commonly along the classic Silk Route, with a peak prevalence in Turkey of 80–370 per 100,000 people, compared with 1–3 per million people in the Western world. Presentation is typically in the third to fifth decade of life, and both genders are affected equally.15Idil A. Gurler A. Boyvat A. Caliskan D. Ozdemir O. Isik A. et al.The prevalence of Behcet's disease above the age of 10 years. The results of a pilot study conducted at the Park Primary Health Care Center in Ankara, Turkey.Ophthalmic Epidemiol. 2002; 9: 325-331Crossref PubMed Scopus (0) Google Scholar Coarctation of the aorta is a congenital cardiovascular defect, most commonly occurring at the level of the isthmus and accounts for 5–8% of all congenital heart defects. The overall incidence ranges between 20 and 60 per 100,000 person-years, with a slight male predominance. Patients with Turner syndrome (TS) are more commonly affected.16Teo L.L. Cannell T. Babu-Narayan S.V. Hughes M. Mohiaddin R.H. Prevalence of associated cardiovascular abnormalities in 500 patients with aortic coarctation referred for cardiovascular magnetic resonance imaging to a tertiary center.Pediatr Cardiol. 2011; 32: 1120-1127Crossref PubMed Scopus (24) Google Scholar A comprehensive medical and family history, assessment of symptoms, and careful physical examination including blood pressure measurement and electrocardiography (ECG), are required in all patients suspected of thoracic aortic disease. Patients should be examined for suspicious clinical signs such as aortic regurgitation, cardiac murmur, pericardial rub, signs of tamponade, and an expansile abdominal aorta. The diagnosis of thoracic aortic disease is based on imaging and the choice of imaging modality should be based on the patient's condition and the availability of different imaging modalities.17Goldstein S.A. Evangelista A. Abbara S. Arai A. Asch F.M. Badano L.P. et al.Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2015; 28: 119-182Abstract Full Text Full Text PDF PubMed Google Scholar Postero-anterior and lateral chest radiographs can be used to diagnose calcification within atheromatous lesions, left pleural effusions, aortic enlargement, and anomalous aortic contours in asymptomatic or symptomatic patients. A left pleural effusion can indicate a frank rupture, an exudate from inflammation of the adventitia in AAS, or, less commonly, inflammatory aortic disease. The International Registry of Acute Aortic Dissection (IRAD) showed that 21% of patients with a type B aortic dissection presented with a normal chest X-ray, and a meta-analysis demonstrated a sensitivity for an abnormal chest X-ray of 90% for TBAD.18Klompas M. Does this patient have an acute thoracic aortic dissection?.J Am Med Assoc. 2002; 287: 2262-2272Crossref PubMed Google Scholar Although chest X-rays might be used in very low risk patients to exclude thoracic aortic diseases, these potentially lethal diseases require a conclusive diagnosis with the use of multiplanar imaging techniques such as computed tomographic angiography (CTA). The use of TTE to assess the DTA is limited by structures in the thorax that weaken or distort the ultrasound signal and compromise image quality. Via a suprasternal, subcostal, or parasternal view, small parts of the DTA can be visualized, while in the case of a pleural effusion, the back of the patient can be used for transthoracic imaging.19Evangelista A. Flachskampf F.A. Erbel R. Antonini-Canterin F. Vlachopoulos C. Rocchi G. et al.Echocardiography in aortic diseases: EAE recommendations for clinical practice.Eur J Echocardiogr. 2010; 11: 645-658Crossref PubMed Scopus (159) Google Scholar The major advantage of TTE is that it is non-invasive and can be used to visualize the ascending aorta, aortic arch, and supra-aortic vessels. In addition, the abdominal aorta can be visualized to check for abdominal extension of aortic dissection (AD). During TTE, all planes should be used to assess the extent of aortic disease and to exclude additional aortic or cardiac involvement. Because of its non-invasive nature and wide availability, TTE is increasingly used in the emergency department of community hospitals to screen patients suspected of having one or other acute aortic syndrome, such as type A dissection. However, the value of TTE in the diagnosis of DTA pathology remains limited. In cases of examination limitations or inconclusive diagnosis, the use of additional imaging modalities is recommended.19Evangelista A. Flachskampf F.A. Erbel R. Antonini-Canterin F. Vlachopoulos C. Rocchi G. et al.Echocardiography in aortic diseases: EAE recommendations for clinical practice.Eur J Echocardiogr. 2010; 11: 645-658Crossref PubMed Scopus (159) Google Scholar There are currently no specific studies to validate the usefulness of TTE for diagnosis of DTA pathology. TOE can visualize the DTA from the LSA to the coeliac artery (CA). This diagnostic test is generally used as a second line imaging modality and is useful to differentiate between AD, IMH, and PAU. With a reported sensitivity of 98% and a specificity of 95%, TOE is an accurate diagnostic tool for aortic disease, providing functional information in both the pre- and intra-operative settings.19Evangelista A. Flachskampf F.A. Erbel R. Antonini-Canterin F. Vlachopoulos C. Rocchi G. et al.Echocardiography in aortic diseases: EAE recommendations for clinical practice.Eur J Echocardiogr. 2010; 11: 645-658Crossref PubMed Scopus (159) Google Scholar The semi-invasive nature of TOE has rare procedure related risks, but it can cause patient discomfort, requires sedation, and is contraindicated in the presence of oesophageal pathologies. In the majority of cases, computed tomographic angiography (CTA) scanning is performed as the first imaging modality, providing all required information. TOE may be used in specific circumstances as a second line option. CTA offers a detailed visualisation of the entire aorta and its surrounding structures. It can distinguish different aortic pathologies and is quick and widely available. Over the last two decades, CTA has become more sophisticated and is more readily available, with an increase in the number of scanners, the use of retrospective and prospective ECG-gated techniques, and through advances in post-processing software. These advances have resulted in motion free images with better resolution, reduced scanning times, and better visualisation.20Parodi J. Berguer R. Carrascosa P. Khanafer K. Capunay C. Wizauer E. Sources of error in the measurement of aortic diameter in computed tomography scans.J Vasc Surg. 2014; 59: 74-79Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Current CTA scanners have a sensitivity of up to 100% and a specificity of 98–99%, with slight variations between different DTA pathologies.21Wicky S. Wintermark M. Schnyder P. Capasso P. Denys A. Imaging of blunt chest trauma.Eur Radiol. 2000; 10: 1524-1538Crossref PubMed Scopus (0) Google Scholar Imaging should include a non-contrast study, followed by an early and late phase contrast study and should examine the part of the body between the thoracic inlet and the common femoral arteries. This range provides complete information with three dimensional reconstruction. In addition, dynamic images can further assist in surgical planning or endovascular interventions. Consequently, CTA has replaced digital subtraction aortography as the “gold standard” for aortic imaging. Important disadvantages of CTA include the use of nephrotoxic contrast agents and the exposure of patients to ionizing radiation. In patients at increased risk of contrast induced nephropathy, circulating volume expansion with either isotonic sodium chloride or sodium bicarbonate solutions is recommended.22Ad-hoc Working Group of ERBP Fliser D. Laville M. Covic A. Fouque D. Vanholder R. Juillard L. et al.A European Renal Best Practice (ERBP) position statement on the Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines on acute kidney injury: part 1: definitions, conservative management and contrast-induced nephropathy.Nephrol Dial Transplant. 2012; 27: 4263-4272Crossref PubMed Scopus (188) Google Scholar MRI has an excellent diagnostic capability that is comparable with CTA and TOE and can be used for both pre-operative planning and follow up.23François C.J. Markl M. Schiebler M.L. Niespodzany E. Landgraf B.R. Schlensak C. Four-dimensional, flow-sensitive magnetic resonance imaging of blood flow patterns in thoracic aortic dissections.J Thorac Cardiovasc Surg. 2013; 145: 1359-1366Abstract Full Text Full Text PDF PubMed Google Scholar A major advantage of MRI is that it offers multiplanar evaluation with good differentiation between different soft tissues. Moreover, MRI can provide additional dynamic imaging regarding entry tear flow or arterial vessel involvement.23François C.J. Markl M. Schiebler M.L. Niespodzany E. Landgraf B.R. Schlensak C. Four-dimensional, flow-sensitive magnetic resonance imaging of blood flow patterns in thoracic aortic dissections.J Thorac Cardiovasc Surg. 2013; 145: 1359-1366Abstract Full Text Full Text PDF PubMed Google Scholar Although contrast is not usually required, the use of gadolinium enhances the quality of MRI. MRI can be used to visualize the aortic wall in detail and is, therefore, more commonly used in patients with aortic wall pathologies such as IMH or aortitis. Furthermore, MRI does not require ionizing radiation and offers an alternative for patients with renal insufficiency in some circumstances. Important disadvantages of MRI include its limited availability and longer scanning times, which makes it less suitable for critically ill or unstable patients. In addition, the ability of MRI to detect calcification is decreased (compared with CTA), and artefacts from respiration or metallic implants reduce image quality. Post-gadolinium nephrogenic systemic fibrosis (NSF) is a rare, but devastating, side-effect in patients with impaired renal function. Using alternative imaging modalities or using the lowest possible amount of gadolinium may prevent NSF.24Wang Y. Alkasab T.K. Narin O. Nazarian R.M. Kaewlai R. Kay J. et al.Incidence of nephrogenic systemic fibrosis after adoption of restrictive gadolinium-based contrast agent guidelines.Radiology. 2011; 260: 105-111Crossref PubMed Scopus (87) Google Scholar PET is a nuclear imaging modality that is based on the detection of increased metabolic activity in inflammatory cells, resulting in increased uptake of a gammagraphic tracer, most commonly fluorodeoxyglucose ([18F] FDG). PET can be used for the diagnosis of aortitis and in the assessment of the extent and activity of any inflammatory disease. The diagnostic value of FDG-PET differs among the various inflammatory aortic diseases with a reported sensitivity ranging between 83% and 100% and specificity between 77% and 100%.25Walter M.A. Melzer R.A. Schindler C. Muller-Brand J. Tyndall A. Nitzsche E.U. The value of [18F]FDG-PET in the diagnosis of large-vessel vasculitis and the assessment of activity and extent of disease.Eur J Nucl Med Mol Imaging. 2005; 32: 674-681Crossref PubMed Scopus (229) Google Scholar Development of PET in combination with computed tomography (CT) scanners has made it possible to combine functional and anatomic imaging, thereby making it possible for PET findings to be correlated with adjacent anatomical features. Although the availability of PET and PET/CT is limited, this modality may be used for diagnosis and follow up of aortitis.26Litmanovich D.E. Yıldırım A. Bankier A.A. Insights into imaging of aortitis.Insights Imaging. 2012; 3: 545-560Crossref PubMed Scopus (21) Google Scholar Increased patient radiation exposure is a major disadvantage of PET/CT (when compared with PET or CT examinations alone), as the effective radiation dose is a combination of the dose from both scans.27Huang B. Law M.W. Khong P.L. Whole-body PET/CT scanning: estimation of radiation dose and cancer risk.Radiology. 2009; 251: 166-174Crossref PubMed Scopus (200) Google Scholar IVUS permits 360° visualisation of the aortic wall. It can be very helpful in confirming intimal defects when CTA and digital subtraction angiography (DSA) are inconclusive in the diagnosis of aortic injuries. IVUS is an operator and experience-dependent invasive procedure, and a complete evaluation of the aorta using IVUS can be time consuming. In some centres, IVUS is routinely used as an adjuvant imaging technique during endovascular repair (see also Section 3.1.4.1). Table 3 compares different imaging diagnostic tests for DTA according to their features and performance.Table 3Comparison of different imaging modalities for DTA diagnosis.17Goldstein S.A. Evangelista A. Abba

Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. The International Registry of Acute Aortic Dissection was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment. Since then, >7300 cases have been included from >51 sites in 12 countries. Although presenting symptoms and physical findings have not changed significantly over this period, the use of computed tomography in the diagnosis has increased, and more patients are managed with interventional procedures: surgery in type A AAD and endovascular therapy in type B AAD; with these changes in care, there has been a significant decrease in overall in-hospital mortality in type A AAD but not in type B AAD. Herein, we summarized the key lessons learned from this international registry of patients with AAD over the past 20 years.

Diagnosis, treatment, and outcomes of acute aortic dissection (AAS) are changing.This study examined 17-year trends in the presentation, diagnosis, and hospital outcomes of AAD from the International Registry of Acute Aortic Dissection (IRAD).Data from 4,428 patients enrolled at 28 IRAD centers between December 26, 1995, and February 6, 2013, were analyzed. Patients were divided according to enrollment date into 6 equal groups and by AAD type: A (n = 2,952) or B (n = 1,476).There was no change in the presenting complaints of severe or worst-ever pain for type A and type B AAD (93% and 94%, respectively), nor in the incidence of chest pain (83% and 71%, respectively). Use of computed tomography (CT) for diagnosis of type A increased from 46% to 73% (p < 0.001). Surgical management for type A increased from 79% to 90% (p < 0.001). Endovascular management of type B increased from 7% to 31% (p < 0.001). Type A in-hospital mortality decreased significantly (31% to 22%; p < 0.001), as surgical mortality (25% to 18%; p = 0.003). There was no significant trend in in-hospital mortality in type B (from 12% to 14%).Presenting symptoms and physical findings of AAD have not changed significantly. Use of chest CT increased for type A. More patients in both groups were managed with interventional procedures: surgery in type A and endovascular therapy in type B. A significant decrease in overall in-hospital mortality was seen for type A but not for type B.

Background— Studies of aortic aneurysm patients have shown that the risk of rupture increases with aortic size. However, few studies of acute aortic dissection patients and aortic size exist. We used data from our registry of acute aortic dissection patients to better understand the relationship between aortic diameter and type A dissection. Methods and Results— We examined 591 type A dissection patients enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2005 (mean age, 60.8 years). Maximum aortic diameters averaged 5.3 cm; 349 (59%) patients had aortic diameters &lt;5.5 cm and 229 (40%) patients had aortic diameters &lt;5.0 cm. Independent predictors of dissection at smaller diameters (&lt;5.5 cm) included a history of hypertension (odds ratio, 2.17; 95% confidence interval, 1.03 to 4.57; P =0.04), radiating pain (odds ratio, 2.08; 95% confidence interval, 1.08 to 4.0; P =0.03), and increasing age (odds ratio, 1.03; 95% confidence interval, 1.00 to 1.05; P =0.03). Marfan syndrome patients were more likely to dissect at larger diameters (odds ratio, 14.3; 95% confidence interval, 2.7 to 100; P =0.002). Mortality (27% of patients) was not related to aortic size. Conclusions— The majority of patients with acute type A acute aortic dissection present with aortic diameters &lt;5.5 cm and thus do not fall within current guidelines for elective aneurysm surgery. Methods other than size measurement of the ascending aorta are needed to identify patients at risk for dissection.

Background— Follow-up survival studies in patients with acute type B aortic dissection have been restricted to a small number of patients in single centers. We used data from a contemporary registry of acute type B aortic dissection to better understand factors associated with adverse long-term survival. Methods and Results— We examined 242 consecutive patients discharged alive with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. Kaplan-Meier survival curves were constructed, and Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. Three-year survival for patients treated medically, surgically, or with endovascular therapy was 77.6±6.6%, 82.8±18.9%, and 76.2±25.2%, respectively (median follow-up 2.3 years, log-rank P =0.61). Independent predictors of follow-up mortality included female gender (hazard ratio [HR],1.99; 95% confidence interval [CI], 1.07 to 3.71; P =0.03), a history of prior aortic aneurysm (HR, 2.17; 95% CI, 1.03 to 4.59; P =0.04), a history of atherosclerosis (HR, 2.48; 95% CI, 1.32 to 4.66; P &lt;0.01), in-hospital renal failure (HR, 2.55; 95% CI, 1.15 to 5.63; P =0.02), pleural effusion on chest radiograph (HR, 2.56; 95% CI, 1.18 to 5.58; P =0.02), and in-hospital hypotension/shock (HR, 12.5; 95% CI, 3.24 to 48.21; P &lt;0.01). Conclusions— Contemporary follow-up mortality in patients who survive to hospital discharge with acute type B aortic dissection is high, approaching 1 in every 4 patients at 3 years. Current treatment and follow-up surveillance require further study to better understand and optimize care for patients with this complex disease.

Background: Surgical mortality for acute type A aortic dissection reported in different experiences from single centers or surgeons varies from 7% to 30%.The International Registry of Acute Aortic Dissection, collecting patients from 18 referral centers worldwide, identifies a preoperative risk stratification scheme and a real average surgical mortality for acute type A aortic dissection in the current era.Methods: A comprehensive analysis was completed of 290 clinical variables and their relationship to surgical outcomes in 526 of 1032 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 through 2001.Extracted cases, categorized according to risk profile, were defined as unstable (group I) in the presence of cardiac tamponade; shock; congestive heart failure; cerebrovascular accident; stroke; coma; myocardial ischemia, infarction, or both; electrocardiograms with new Q waves or ST elevation; acute renal failure; or mesenteric ischemia-infarction at the time of the operation.Outside of an unstable condition, patients were categorized as stable (group II). Results:The overall in-hospital mortality was 25.1%.Mortality in group I was 31.4% compared with 16.7% in group II (P Ͻ .001).Independent preoperative predictors of operative mortality were history of aortic valve replacement (odds ratio ϭ 3.12), migrating chest pain (odds ratio ϭ 2.77), hypotension as sign of acute type A aortic dissection (odds ratio ϭ 1.95), shock or tamponade (odds ratio ϭ 2.69), preoperative cardiac tamponade (odds ratio ϭ 2.22), and preoperative limb ischemia (odds ratio ϭ 2.10). Conclusions:The International Registry of Acute Aortic Dissection experience confirms that patient selection plays an important role in determining surgical outcomes in patients with acute type A aortic dissection.Knowledge of significant risk factors for operative mortality can contribute to better management and a more defined risk assessment in patients affected by acute type A aortic dissection.

Clinical profiles and outcomes of patients with acute type B aortic dissection have not been evaluated in the current era.Accordingly, we analyzed 384 patients (65+/-13 years, males 71%) with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD). A majority of patients had hypertension and presented with acute chest/back pain. Only one-half showed abnormal findings on chest radiograph, and almost all patients had computerized tomography (CT), transesophageal echocardiography, magnetic resonance imaging (MRI), and/or aortogram to confirm the diagnosis. In-hospital mortality was 13% with most deaths occurring within the first week. Factors associated with increased in-hospital mortality on univariate analysis were hypotension/shock, widened mediastinum, periaortic hematoma, excessively dilated aorta (>or=6 cm), in-hospital complications of coma/altered consciousness, mesenteric/limb ischemia, acute renal failure, and surgical management (all P<0.05). A risk prediction model with control for age and gender showed hypotension/shock (odds ratio [OR] 23.8, P<0.0001), absence of chest/back pain on presentation (OR 3.5, P=0.01), and branch vessel involvement (OR 2.9, P=0.02), collectively named 'the deadly triad' to be independent predictors of in-hospital death.Our study provides insight into current-day profiles and outcomes of acute type B aortic dissection. Factors associated with increased in-hospital mortality ("the deadly triad") should be identified and taken into consideration for risk stratification and decision-making.

Impact on survival of different treatment strategies was analyzed in 571 patients with acute type B aortic dissection enrolled from 1996 to 2005 in the International Registry of Acute Aortic Dissection.The optimal treatment for acute type B dissection is still a matter of debate.Information on 290 clinical variables were compared, including demographics; medical history; clinical presentation; physical findings; imaging studies; details of medical, surgical, and endovascular management; in-hospital clinical events; and in-hospital mortality.Of the 571 patients with acute type B aortic dissection, 390 (68.3%) were treated medically, 59 (10.3%) with standard open surgery and 66 (11.6%) with an endovascular approach. Patients who underwent emergency endovascular or open surgery were younger (mean age 58.8 years, p < 0.001) than their counterparts treated conservatively, and had male preponderance and hypertension in 76.9%. Patients submitted to surgery presented with a wider aortic diameter than patients treated by interventional techniques or by medical therapy (5.36 +/- 1.7 cm vs. 4.62 +/- 1.4 cm vs. 4.47 +/- 1.4 cm, p = 0.003). In-hospital complications occurred in 20% of patients subjected to endovascular technique and in 40% of patients after open surgical repair. In-hospital mortality was significantly higher after open surgery (33.9%) than after endovascular treatment (10.6%, p = 0.002). After propensity and multivariable adjustment, open surgical repair was associated with an independent increased risk of in-hospital mortality (odds ratio: 3.41, 95% confidence interval: 1.00 to 11.67, p = 0.05).In the International Registry of Acute Aortic Dissection, the less invasive nature of endovascular treatment seems to provide better in-hospital survival in patients with acute type B dissection; larger randomized trials or comprehensive registries are needed to access impact on outcomes.

<h2>Abstract</h2> Acute aortic dissection is a rare but deadly disease first described over 200 years ago by the physician to the late King George II on necropsy. Over the ensuing 2 centuries, the understanding of the pathophysiology, presentation, diagnosis, treatment and follow-up has matured. In an effort to understand the contemporary treatment of this disease, the International Registry of Acute Aortic Dissection (IRAD) has enrolled over 2000 patients over the past 12 years. In this article we summarize the key lessons learned from this multi-national registry of patients presenting with acute aortic dissection.

<h3>Importance</h3> Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100 000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary. <h3>Objective</h3> To systematically review the current evidence on diagnosis and treatment of AAS. <h3>Evidence Review</h3> Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57 311 patients were reviewed. <h3>Findings</h3> Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%,<i>P</i> &lt; .001) for the primary end point of “favorable aortic remodeling” (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias. <h3>Conclusions and Relevance</h3> Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.

Surgical mortality for acute type A aortic dissection is frequently related to preoperative clinical conditions. We report a predictive score to identify risk of death that may be helpful to assist surgeons who are considering whether to proceed with surgical correction in the case of patients in extreme clinical risk.Surgical outcome of 682 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2003 was analyzed. Two different models were used. The initial model included only preoperative variables such as demographics, history, symptoms, signs, and diagnostic methods (model 1). The second model also tested intraoperative hemodynamic and surgical variables (model 2). A bedside risk prediction tool to predict operative mortality in individual patients was developed.The overall in-hospital surgical mortality was 23.9%. Independent preoperative predictors of mortality in model 1 were age greater than 70 years, prior cardiac surgery, hypotension (systolic blood pressure less than 100 mm Hg) or shock at presentation, migrating pain, cardiac tamponade, any pulse deficit, and electrocardiogram with findings of myocardial ischemia or infarction. In model 2, other predictors of surgical death were intraoperative hypotension, a right ventricle dysfunction at surgery, and a necessity to perform coronary revascularization. An independent predictor for favorable surgical outcome was right hemiarch replacement.Surgery in unstable patients with acute type A aortic dissection can be highly unsuccessful. The International Registry of Acute Aortic Dissection risk models predict in-hospital mortality using a multivariable risk prediction tool, useful for surgeons and patients as they consider their surgical risk and the pros and cons of embarking on high-risk surgery.

D-dimer has been reported to be elevated in acute aortic dissection. Potential use as a "rule-out" marker has been suggested, but concerns remain given that it is elevated in other acute chest diseases, including pulmonary embolism and ischemic heart disease. We evaluated the diagnostic performance of D-dimer testing in a study population of patients with suspected aortic dissection.In this prospective multicenter study, 220 patients with initial suspicion of having acute aortic dissection were enrolled, of whom 87 were diagnosed with acute aortic dissection and 133 with other final diagnoses, including myocardial infarction, angina, pulmonary embolism, and other uncertain diagnoses. D-dimer was markedly elevated in patients with acute aortic dissection. Analysis according to control disease, type of dissection, and time course showed that the widely used cutoff level of 500 ng/mL for ruling out pulmonary embolism also can reliably rule out aortic dissection, with a negative likelihood ratio of 0.07 throughout the first 24 hours.D-dimer levels may be useful in risk stratifying patients with suspected aortic dissection to rule out aortic dissection if used within the first 24 hours after symptom onset.

Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year.The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB.Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062).Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

Numbers of anatomical segments used in the 2004 revision 5 of the CEAP classification.y New specific anatomical location(s) to be reported under each Pathophysiological (P) class to identify anatomical location(s) corresponding to P class.

The increasing life expectancy of the population will likely be accompanied by a rise in the incidence of acute type A aortic dissection. However, because of an increased risk of cardiac surgery in an elderly population, it is important to define when, if at all, the risks of aortic repair outweigh the risk of death from unoperated type A aortic dissection.We analyzed 936 patients with type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2004. Patients with type A aortic dissection were categorized according to patient age by decade and by surgical versus medical management, and outcomes of both management types were investigated in the different age groups.The rate of surgical aortic repair decreased progressively with age, whereas surgical mortality significantly increased with age. Age 70 years or more was an independent predictor for mortality (38.2% vs 26.0%; P < .0001, odds ratio 1.73). The in-hospital mortality rate was significantly lower after surgical management compared with medical management until the age of 80 years. For patients aged 80 to 90 years, the in-hospital mortality appeared to be lower after surgical management (37.9% vs 55.2%; P = .188); however, this failed to reach clinical significance owing to the limited patient number in this age group.Although the surgical mortality significantly increased with increased age, surgical management was still associated with significantly lower in-hospital mortality rates compared with medical management until the age of 80 years. Surgery may decrease the in-hospital mortality rate for octogenarians with type A aortic dissection and might be considered in all patients with type A aortic dissection regardless of age.

The classification of aortic dissection into acute (<14 days from symptom onset) versus chronic (≥14 days) is based on survival estimates of patients treated decades before modern diagnostic and treatment modalities were available. A new classification of aortic dissection in the current era may provide clinicians with a more precise method of characterizing the interaction of time, dissection location, and treatment type with survival.We developed separate Kaplan-Meier survival curves for Type A and Type B aortic dissection using data from the International Registry of Aortic Dissection (IRAD). Daily survival was stratified based on type of therapy provided: medical therapy alone (medical), nonsurgical intervention plus medical therapy (endovascular), and open surgery plus medical therapy (surgical). The log-rank statistic was used to compare the survival curves of each management type within Type A and Type B aortic dissection.There were 1815 patients included, 67.3% male with mean age 62.0 ± 14.2 years. When survival curves were constructed, 4 distinct time periods were noted: hyperacute (symptom onset to 24 hours), acute (2-7 days), subacute (8-30 days), and chronic (>30 days). Overall survival was progressively lower through the 4 time periods.This IRAD classification system can provide clinicians with a more robust method of characterizing survival after aortic dissection over time than previous methods. This system will be useful for treating patients, counseling patients and families, and studying new diagnostic and treatment methods.

BackgroundFew data exist on clinical/imaging characteristics, management, and outcomes of patients with type A acute dissection and mesenteric malperfusion.MethodsPatients with type A acute dissection enrolled in the International Registry for Acute Dissection (IRAD) were evaluated to assess differences in clinical features, management, and in-hospital outcomes according to the presence/absence of mesenteric malperfusion. A mortality model was used to identify predictors of in-hospital mortality in patients with mesenteric malperfusion.ResultsMesenteric malperfusion was detected in 68 (3.7%) of 1809 patients with type A acute dissection. Patients with mesenteric malperfusion were more likely to be older and to have coma, cerebrovascular accident, spinal cord ischemia, acute renal failure, limb ischemia, and any pulse deficit. They were less likely to undergo surgical/hybrid treatment (52.9% vs 87.9%) and more likely to receive only medical (30.9% vs 11.6%) or endovascular (16.2% vs 0.5%) management (P < .001). Overall in-hospital mortality was 63.2% and 23.8% in patients with and without mesenteric malperfusion, respectively (P < .001). In-hospital mortality of patients with mesenteric malperfusion receiving medical, endovascular, and surgical/hybrid therapy was 95.2%, 72.7%, and 41.7%, respectively (P < .001). At multivariate analysis, male gender (odds ratio [OR], 1.7; P = .002), age (OR, 1.1/y; P = .002), and renal failure (OR, 5.9; P = .020) were predictors of mortality whereas surgical/hybrid management (OR, 0.1; P = .005) was associated with better outcome.ConclusionsType A acute aortic dissection complicated by mesenteric malperfusion is a rare but ominous complication carrying a high risk of hospital mortality. Surgical/hybrid therapy, although associated with 2-fold hospital mortality, appears to be associated with better long-term outcomes in the management of type A acute aortic dissection in this setting. Few data exist on clinical/imaging characteristics, management, and outcomes of patients with type A acute dissection and mesenteric malperfusion. Patients with type A acute dissection enrolled in the International Registry for Acute Dissection (IRAD) were evaluated to assess differences in clinical features, management, and in-hospital outcomes according to the presence/absence of mesenteric malperfusion. A mortality model was used to identify predictors of in-hospital mortality in patients with mesenteric malperfusion. Mesenteric malperfusion was detected in 68 (3.7%) of 1809 patients with type A acute dissection. Patients with mesenteric malperfusion were more likely to be older and to have coma, cerebrovascular accident, spinal cord ischemia, acute renal failure, limb ischemia, and any pulse deficit. They were less likely to undergo surgical/hybrid treatment (52.9% vs 87.9%) and more likely to receive only medical (30.9% vs 11.6%) or endovascular (16.2% vs 0.5%) management (P < .001). Overall in-hospital mortality was 63.2% and 23.8% in patients with and without mesenteric malperfusion, respectively (P < .001). In-hospital mortality of patients with mesenteric malperfusion receiving medical, endovascular, and surgical/hybrid therapy was 95.2%, 72.7%, and 41.7%, respectively (P < .001). At multivariate analysis, male gender (odds ratio [OR], 1.7; P = .002), age (OR, 1.1/y; P = .002), and renal failure (OR, 5.9; P = .020) were predictors of mortality whereas surgical/hybrid management (OR, 0.1; P = .005) was associated with better outcome. Type A acute aortic dissection complicated by mesenteric malperfusion is a rare but ominous complication carrying a high risk of hospital mortality. Surgical/hybrid therapy, although associated with 2-fold hospital mortality, appears to be associated with better long-term outcomes in the management of type A acute aortic dissection in this setting.

therapy ARR Absolute risk reduction ARWMC Age related white matter change AF Atrial fibrillation BA Basilar artery BES Balloon expandable stent BMS Bare metal stent

Acute aortic intramural hematoma (IMH) is an important subgroup of aortic dissection, and controversy surrounds appropriate management.Patients with acute aortic syndromes in the International Registry of Acute Aortic Dissection (1996-2011) were evaluated to examine differences between patients (based on the initial imaging test) with IMH or classic dissection (AD). Of 2830 patients, 178 had IMH (64 type A [42%], 90 type B [58%], and 24 arch). Patients with IMH were older and presented with similar symptoms, such as severe pain. Patients with type A IMH were less likely to present with aortic regurgitation or pulse deficits and were more likely to have periaortic hematoma and pericardial effusion. Although type A IMH and AD were managed medically infrequently, type B IMH were more frequently treated medically. Overall in-hospital mortality was not statistically different for type A IMH compared to AD (26.6% versus 26.5%; P=0.998); type A IMH managed medically had significant mortality (40.0%), although less than classic AD (61.8%; P=0.195). Patients with type B IMH had a hospital mortality that was less but did not differ significantly (4.4% versus 11.1%; P=0.062) from classic AD. One-year mortality was not significantly different between AD and IMH.Acute IMH has similar presentation to classic AD but is more frequently complicated with pericardial effusions and periaortic hematoma. Patients with IMH have a mortality that does not differ statistically from those with classic AD. A small subgroup of type A IMH patients are managed medically and have a significant in-hospital mortality.

Type A acute aortic dissection (TAAD) is a disease that has a catastrophic impact on a patient's life and emergent surgery represents a key goal of early treatment. Despite continuous improvements in imaging techniques, medical therapy and surgical management, early mortality in patients undergoing TAAD repair still remains high, ranging from 17% to 26%. In this setting, the International Registry of Acute Aortic Dissection (IRAD), the largest worldwide registry for acute aortic dissection, was established to assess clinical characteristics, management and outcomes of TAAD patients. The present review aimed to evaluate and comment on outcomes of TAAD surgery as reported from IRAD series.

Importance Early data revealed a mortality rate of 1% to 2% per hour for type A acute aortic dissection (TAAAD) during the initial 48 hours. Despite advances in diagnostic testing and treatment, this mortality rate continues to be cited because of a lack of contemporary data characterizing early mortality and the effect of timely surgery. Objective To examine early mortality rates for patients with TAAAD in the contemporary era. Design, Setting, and Participants This cohort study examined data for patients with TAAAD in the International Registry of Acute Aortic Dissection between 1996 and 2018. Patients were grouped according to the mode of their intended treatment, surgical or medical. Exposure Surgical treatment. Main Outcomes and Measures Mortality was assessed in the initial 48 hours after hospital arrival using Kaplan-Meier curves. In-hospital complications were also evaluated. Results A total of 5611 patients with TAAAD were identified based on intended treatment: 5131 (91.4%) in the surgical group (3442 [67.1%] male; mean [SD] age, 60.4 [14.1] years) and 480 (8.6%) in the medical group (480 [52.5%] male; mean [SD] age, 70.9 [14.7] years). Reasons for medical management included advanced age (n = 141), comorbidities (n = 281), and patient preference (n = 81). Over the first 48 hours, the mortality for all patients in the study was 5.8%. Among patients who were medically managed, mortality was 0.5% per hour (23.7% at 48 hours). For those whose intended treatment was surgical, 48-hour mortality was 4.4%. In the surgical group, 51 patients (1%) died before the operation. Conclusions and Relevance In this study, the overall mortality rate for TAAAD was 5.8% at 48 hours. For patients in the medical group, TAAAD had a mortality rate of 0.5% per hour (23.7% at 48 hours). However, among those in the surgical group, 48-hour mortality decreased to 4.4%.

Worse outcomes have been reported for women with type A acute aortic dissection (TAAD). We sought to determine sex-specific operative approaches and outcomes for TAAD in the current era.The Interventional Cohort (IVC) of the International Registry of Acute Aortic Dissection (IRAD) database was queried to explore sex differences in presentation, operative approach, and outcomes. Multivariable logistic regression was performed to identify adjusted outcomes in relation to sex.Women constituted approximately one-third (34.3%) of the 2823 patients and were significantly older than men (65.4 vs 58.6 years, P < .001). Women were more likely to present with intramural hematoma, periaortic hematoma, or complete or partial false lumen thrombosis (all P < .05) and more commonly had hypotension or coma (P = .001). Men underwent a greater proportion of Bentall, complete arch, and elephant trunk procedures (all P < .01). In-hospital mortality during the study period was higher in women (16.7% vs 13.8%, P = .039). After adjustment, female sex trended towards higher in-hospital mortality overall (odds ratio, 1.40; P = .053) but not in the last decade of enrollment (odds ratio, 0.93; P = .807). Five-year mortality and reintervention rates were not significantly different between the sexes.In-hospital mortality remains higher among women with TAAD but demonstrates improvement in the last decade. Significant differences in presentation were noted in women, including older age, distinct imaging findings, and greater evidence of malperfusion. Although no distinctions in 5-year mortality or reintervention were observed, a tailored surgical approach should be considered to reduce sex disparities in early mortality rates for TAAD.

2 Dimensional 3 Dimensional Image Fusion Artificial Intelligence Artificial Intelligence Fluoroscopy As Low As Reasonably Achievable Air Kerma Automatic Brightness Control Automatic Exposure Control Anterior Posterior Active Personal Dosimeter Cumulative Air Kerma Cone Beam Computed Tomography Computed Tomography Computed Tomography Angiography Dose Area Product Digital Imaging and Communications in Medicine Deoxyribonucleic Acid Detective Quantum Efficiency Diagnostic Reference Level Digital Subtraction Angiography Effective Dose European Basic Safety Standards Directive European Journal of Vascular and Endovascular Surgery Electromagnetic Endovascular Navigation System European Society of Cardiology Entrance Skin Dose European Society for Vascular Surgery European Union European Vascular Surgeons in Training Electron Volt Endovascular Aortic Repair US Food and Drug Administration Fenestrated Endovascular Aortic Repair Field Of View Flat Panel Detector Fiber Optic RealShape Fluoroscopy Time Guideline Committee Guideline Writing Committee Gray “Personal dose equivalent” in soft tissue below body surface International Atomic Energy Agency International Commission on Radiological Protection Instructions For Use Image Intensifier In room Protective Equipment Ionising Radiation Regulations Air Kerma Area Product Kilo Voltage Peak Kilo Voltage Left Anterior Oblique Lifetime Attributable Risk Lower Extremity Peripheral Arterial Disease Lead Free Apron Linear No Threshold Milliamperage Medical Physics Expert Multiplanar Reconstructions National Council on Radiation Protection and Measurements Operator Controlled Imaging Optical Stimulated Luminescence Optically Stimulated Luminescence Dosimeters Lead Personal Protective Equipment PROficiency based StePwise Endovascular Curricular Training programme Peak Skin Dose Quality Assurance Reference Air Kerma Randomised Controlled Trial Radiation Induced Cataract RiboNucleic Acid Region Of Interest Sievert Thoraco-Abdominal Aortic Aneurysm Thoracic Endovascular Aortic Repair Thermoluminescent Dosimeter United Kingdom United Nations Scientific Committee on the Effects of Atomic Radiation Virtual Reality Absorbed dose: The mean energy imparted to matter of mass by ionising radiation. The SI unit for absorbed dose is joule per kilogram and is usually denoted in Gray (Gy). Organ absorbed doses are often quoted. Air kerma (AK): The quotient of the sum of the kinetic energies of all charged particles liberated by uncharged particles in a mass, dm, of air. The AK is measured or calculated at a reference point 15 cm from the isocentre in the direction of the focal spot cumulated from a whole Xray guided procedure. Air kerma area product (KAP, or dose area product, DAP): The KAP is the integral of the air kerma free in air (i.e., in the absence of backscatter) over the area of the Xray beam in a plane perpendicular to the beam axis (usually measured in Gy.cm2). The ICRP now recommends referring to those values as air-air-kerma area product (PKA). C-arm: A fixed or mobile Xray system used for diagnostic imaging and for fluoroscopic guidance during minimally invasive procedures. The name C-arm is derived from the C shaped arm that connects and maintains fixed in space, the Xray source and Xray detector. Collimation: The process of shaping the Xray beam to minimise the radiation field size to the required area of interest using metallic apertures within the Xray source. Computed tomography angiography (CTA): The combination of computed tomography cross sectional imaging with intravenous contrast in order to visualise arterial anatomy and pathology. Cone beam computed tomography (CBCT): A modality, available in modern endovascular operating rooms, that allows rotational acquisition and provides cross sectional imaging of the patient while still on the operating table. Deterministic effects: Deterministic effects of radiation exposure are related to a threshold dose of radiation exposure above which the severity of injury increases with increasing dose. Deterministic effects include harmful tissue reactions and organ dysfunction that result from radiation induced cell death, for example, skin lesions and lens opacities. Diagnostic reference levels (DRLs): Used for medical imaging with ionising radiation to indicate whether, in routine conditions, the patient radiation dose for a specified procedure is unusually high or low for that procedure. DRL values are usually defined as the third quartile of the distribution of the median values of the appropriate DRL quantity observed at each healthcare facility. Digital subtraction angiography (DSA): The acquisition of multiple images in succession within one field of view, with the subsequent digital subtraction of images taken prior to contrast injection, leaving a contrast enhanced image of the vessels, and removing non-vascular structures such as bone. Effective dose: The tissue weighted sum of the equivalent doses in all specified tissues and organs of the body, calculated in Sieverts (Sv). Endovascular operator: Any person carrying out an Xray guided procedure on the vasculature. Endovascular operating room: Any environment where endovascular procedures are carried out with Xray guidance using a C-arm as part of a mobile or fixed imaging system. Endovascular procedure: Any procedure on the vasculature that uses Xray guidance. Entrance skin dose (ESD): The dose absorbed by the skin at the entrance point of the Xray beam measured in Gy. This includes the back scattered radiation from the patient. Equivalent dose: Equivalent dose is the mean absorbed dose in a tissue or organ multiplied by the radiation weighting factor. This weighting factor is 1 for Xrays. Equivalent dose is measured in Sieverts (Sv). European Basic Safety Standards (EBSS) Directive: Describes the standards for protection against the risks associated with exposure to ionising radiation, including radioactive material and natural radiation sources, and also preparedness for the management of emergency exposure situations in the European Union. This is a European Council directive. Filtration: The materials of the Xray tube window and any permanent or variable or adjustable filters that predominantly attenuate the low energetic Xrays in the beam. Fluoroscopy time: The cumulative time spent using fluoroscopy during an endovascular procedure. Gray (Gy): The unit of absorbed radiation dose used to evaluate the amount of energy transferred to matter. One Gy is equivalent to 1 joule/kg. Image intensifier: This component of an imaging system relies on the fact that when Xrays are absorbed in a phosphor screen they convert into light photons. These photons impinge upon a photocathode that emits electrons in proportion to the number of incident Xrays. These photo-electrons are then accelerated across a vacuum in an image intensifier to produce an amplified light image. International Commission on Radiation Protection (ICRP): An independent, international organisation that advances for the public benefit the science of radiological protection, in particular by providing recommendations and guidance on all aspects of protection against ionising radiation. Medical physics expert (MPE): An individual or, if provided for in national legislation, a group of individuals, having the knowledge, training, and experience to act or give advice on matters relating to radiation physics applied to medical exposure, whose competence in this respect is recognised by the competent authority. Peak skin dose (PSD): The dose delivered, by both the primary beam and scatter radiation, at the most irradiated area of the skin. Pulse rate: The number of radiation pulses per second. Radiation exposed worker: Those over the age of 18 years who may be at risk of receiving radiation doses greater than the stipulated public exposure limit of 1 mSv per year of effective dose. Sievert (Sv): The unit used to measure both “effective dose” and “equivalent dose”. For Xrays, 1 Sievert equals 1 Gray (Gy). Stochastic effects: Stochastic effects of radiation exposure are those that occur by chance and, as such, the probability of them occurring, but not the severity, increases with increasing dose. A Linear No Threshold model has been adopted internationally, acknowledging that there is no threshold dose. The development of malignancy is the most common stochastic effect of radiation exposure. The past two decades have witnessed an exponential rise in the number of Xray guided minimally invasive procedures in vascular surgery.1Schanzer A. Steppacher R. Eslami M. Arous E. Messina L. Belkin M. 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Thomson I.A. et al.Editor's Choice - International variations and sex disparities in the treatment of peripheral arterial occlusive disease: a report from VASCUNET and the International Consortium of Vascular Registries.Eur J Vasc Endovasc Surg. 2020; 60: 873-880Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar With time, many of these endovascular procedures have been validated and have established themselves as the preferred treatment modality based on lower morbidity, mortality, and reduced length of hospital stay, compared with the open surgical alternatives. A large proportion of all vascular interventions are now performed using Xray guided endovascular techniques. Advances in technical expertise, evolving materials technology, and improved imaging capabilities have led to increasingly complex endovascular solutions which are associated with prolonged fluoroscopy times and consequently a rise in radiation exposure to both the patient and the endovascular operating team. There is growing concern regarding the increasing radiation exposure to the patient, and to the whole endovascular team.5Kirkwood M.L. Guild J.B. Arbique G.M. Anderson J.A. Valentine R.J. Timaran C. Surgeon radiation dose during complex endovascular procedures.J Vasc Surg. 2015; 62: 457-463Abstract Full Text Full Text PDF PubMed Google Scholar,6El-Sayed T. Patel A.S. Cho J.S. Kelly J.A. Ludwinski F.E. Saha P. et al.Radiation-induced DNA damage in operators performing endovascular aortic repair.Circulation. 2017; 136: 2406-2416Crossref PubMed Scopus (80) Google Scholar Endovascular operators are key personnel for promoting radiation safety and should work with other key stakeholders in a team approach to protect the patient and all healthcare staff in the endovascular operating room. The risks of radiation exposure are not universally recognised by all, however, because of a poor understanding of key concepts and paucity of educational material directly relevant to vascular surgery.7Mohapatra A. Greenberg R.K. Mastracci T.M. Eagleton M.J. Thornsberry B. Radiation exposure to operating room personnel and patients during endovascular procedures.J Vasc Surg. 2013; 58: 702-709Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar The present guidelines on the subject of radiation safety are the first to be written under the auspices of a vascular surgical society. Their explicit aim is to inform the reader about radiation physics and radiation dosimetry, raising awareness of the risks of ionising radiation and describing the methods available to protect against radiation exposure. Key issues of relevance to radiation protection for endovascular operators and all allied personnel have been outlined, and recommendations provided for best practice. This will no doubt also result in better radiation protection for the patient but a focus on patient radiation protection has been reserved, including during diagnostic procedures that require radiation exposure, for future iterations of the guideline. The guideline was written and approved by 14 members who, as well as vascular surgeons and interventional radiologists, included a radiation protection scientist and a medical physicist. The collated work is based on the best available evidence but also relies on the expert opinion of the aforementioned individuals who, as part of the process of gathering the evidence, identified several areas where future studies would better guide opinion. The reader should note that this document offers guidance and does not aim to dictate standards of care. The grading of each recommendation in these guidelines was agreed by a virtual meeting on 18 February 2022. If there was no unanimous agreement, discussions were held to decide how to reach a consensus. If this failed, then the wording, grade, and level of evidence was secured via a majority vote of the Guidelines Writing Committee (GWC) members. The final version of the guideline was submitted in July 2022. These guidelines will be updated according to future evidence and to the decisions made by the European Society for Vascular Surgery (ESVS) Guidelines Committee (GC). The GWC performed a literature search in Medline (through PubMed), Embase, Clinical Trial databases, and the Cochrane Library up to July 2022. Reference checking and hand search by the GWC added other relevant literature. The GWC selected literature based on the following criteria: (1) Language: English; (2) Level of evidence (Table 1). (3) Sample size: Larger studies were given more weight than smaller studies. (4) Relevant articles published after the search date or in another language were included, but only if they were of paramount importance to this guideline.Table 1Levels of evidence according to European Society of CardiologyLevel of evidence AData derived from multiple randomised clinical trials or meta-analysesLevel of evidence BData derived from a single randomised clinical trial or large non-randomised studiesLevel of evidence CConsensus of opinion of the experts and or small studies, retrospective studies, registries Open table in a new tab The recommendations in the guidelines in this document are based on the European Society of Cardiology (ESC) grading system. For each recommendation, the letter A, B, or C marks the level of current evidence (Table 1). Weighing the level of evidence and expert opinion, every recommendation is subsequently marked as Class I, IIa, IIb, or III (Table 2).Table 2Classes of recommendations according to European Society of CardiologyClasses of recommendationsDefinitionClass IEvidence and or general agreement that a given treatment or procedure is beneficial, useful, effectiveClass IIConflicting evidence and or a divergence of opinion about the usefulness or efficacy of the given treatment or procedure Class IIaWeight of evidence or opinion is in favour of usefulness or efficacy Class IIbUsefulness or efficacy is less well established by evidence or opinionClass IIIEvidence or general agreement that the given treatment or procedure is not useful or effective, and in some cases may be harmful Open table in a new tab It is important to note that for the general aspects of radiation safety, international bodies such as the International Commission on Radiological Protection (ICRP), the American Association of Physicists in Medicine, the European Federation of Organisations for Medicine and the International Atomic Energy Agency (IAEA) regularly carry out a thorough synthesis of available evidence to publish guidance documents and inform legislation pertaining to safety standards. Legislation in this context refers to statutory regulations that form the main legal requirements for the use and control of ionising radiation. These overview documents, rather than individual literature citations, have been used in the present guidelines to inform recommendations where this was thought to be appropriate. The present radiation protection guidelines are unique in that several of the recommendations made are actually based on legislation that derives from physics principles and extensive, irrefutable evidence that is the basis of this legislation. There have been extensive discussions within the GWC and Guidelines Committee as we have not been confronted previously with this issue in other guidelines. The conclusion agreed between all parties involved is that we could not make recommendations for what are legal requirements but that it is important for the guidelines to highlight areas where law “must” be followed. For this reason, we have, by unanimous decision, used the wording that recommendations based on legislation “must” be followed and the level of evidence has been marked as “law”. It must be noted that in some instances these are not “global or universal laws” and that the level of evidence denoted as “law” means law under most jurisdictions. The recommendations that are based on law are automatically Class I or III. This guideline also has several recommendations, where the evidence is based on physics principles and the results of studies are absolute truths even in small series. For example, increasing distance from the source of radiation reduces the amount of exposure. This is a principle of physics. The level of evidence used to make this type of recommendation reflects this concept and each of these recommendations is marked with a footnote as a “physics principle.” The GWC was selected by the ESVS to represent both physicians and scientists with expertise in the management of radiation exposure. The members of the GWC have provided disclosure statements of all relationships that might be perceived as real or potential sources of conflict of interest. The ESVS Guidelines Committee (GC) was responsible for the review and ultimate endorsement of these guidelines. All experts involved in the GWC have approved the final document. The guideline document underwent the formal external expert review process and was reviewed and approved by the ESVS GC. This document has been reviewed in three rounds by 25 reviewers, including vascular surgeons, interventional radiologists, and medical physics experts (MPE). All reviewers approved the final version of this document. Patient and public perceptions of radiation safety pertaining to endovascular surgery were captured. This section was written in partnership with patients and members of the public, to ensure the patient perspective is adequately represented in these guidelines and that medical professionals are aware of these views. The individuals consulted included (1) volunteers from the joint Health Protection Research Unit Public and Community Oversight Committee (https://crth.hpru.nihr.ac.uk/wider-engagement/), from the Scottish Environment Protection Agency, and from the Society and College of Radiographers; and (2) patients who had undergone endovascular procedures at Guy’s and St Thomas’ NHS Foundation Trust. The group was consulted about the guidelines and asked what they understood by the risks of radiation exposure. The patients’ opinions on the information that they would have liked pertaining to radiation exposure prior to their endovascular procedures were sought. We explored whether they would have found this useful despite the many unknowns about the risks associated with low dose radiation exposures. The following was understood by the group. Firstly, endovascular surgery, involving the blood vessels, referred to as minimally invasive procedures (those which use only small incisions, resulting in the need for only a small number of stiches) is used to diagnose and treat problems affecting the blood vessels (vascular disease). Secondly, endovascular surgery requires use of ionising radiation, which is radiation of high enough energy to cause damage to cells, potentially resulting in health effects such as cancer. Diagnosis prior to surgery and surveillance commonly requires computed tomography angiography (CTA) using Xrays. It was explained that the use of ionising radiation is in most countries very tightly controlled through legislation; however, the regulations do not cover all the detailed technical aspects of the use of radiation. As such, it is important that appropriate guidance is provided to ensure that use of radiation for each specific discipline is justified and safe. We explained that these ESVS guidelines have been prepared by physicians and scientists who are members of the GWC, selected by ESVS on the basis of their expertise in relevant areas of vascular surgery and radiation protection. The aims of the Guidelines are to outline for medical professionals the key issues of relevance to protect against exposure to ionising radiation. The Guidelines are written for doctors who perform vascular procedures and all allied personnel to provide recommendations for best practice. The Guidelines cover a range of topics including how to measure radiation exposure, the evidence for radiation effects, the current legislation and how to control exposure of the medical personnel through appropriate use of the equipment in the operating room and personal protection, education, and training, and the requirements for the future. The Guidelines and recommendations are based on the state of the art in terms of scientific evidence (based on the available studies), as reviewed by the committee, and regular updates are anticipated. The group stated that medical practitioners must have a good understanding of patient perceptions and expectations. In recent years information has become easy to find; however, the benefits and risks of health effects associated with ionising radiation are not well understood by the non-specialist, and there is a lot of misinformation. The majority perceived the main risk of radiation exposure to be development of cancer. Further, the real and perceived risk varies greatly depending on the source of radiation and how it is used, as well as on the basis of individual experience. It is generally accepted by the public that imaging involving radiation is an important tool; however, practitioners must ensure that the basic concepts such as what radiation is and why it is being used, as well as the value and risks of the specific procedure are clearly explained to every patient. This can be done both face to face, as part of the consent process, and by providing written literature. Anecdotally, some patients reported that this has not happened. Some patients also do not feel it is appropriate to question their doctor and they may say that they understand information provided when this may not be the case. The group, therefore, stated that generic literature about the procedures should include specific mention of the radiation risks and that the medical practitioner should spend time explaining possible risks to the patient to ensure mutual understanding is reached as far as is practical. This should include a clear explanation to the patient who should be aware that it is acceptable to ask questions. It should also be noted that paediatric exposures are not considered here as endovascular procedures on children are very rare; however, this is something that should perhaps be further considered in future iterations of these Guidelines.Tabled 1Recommendation 1Information regarding the risks of radiation exposure must be provided in plain, easy to understand language to patients before undertaking endovascular procedures.ClassLevelReferencesILawEBSS (2013)8Council Directive 2013/59/EURATOM of 5 December 2013 laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom. Official Journal of the European Union https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2014:013:0001:0073:EN:PDF.Google Scholar Open table in a new tab The group stated that it was important for physicians to be aware that the use of ionising radiation in general is based on three principles. Firstly, the principle of justification, which requires that use of radiation should do more good than harm. Secondly, the principle of optimisation requires that radiation doses should be kept as low as reasonably achievable. Thirdly, the principle of dose limitation requires that the dose to individuals from planned exposure situations, other than medical exposure of patients, should not exceed the appropriate limits. In contrast to non-medical uses of ionising radiation, which are solely process based, medical uses of radiation also depend on the requirements of the individual patient. When ionising radiation is used for medical purposes, exposure of the patient is carried out on the basis of the principles of justification and optimisation. Dose limitation is not considered relevant because a dose of ionising radiation that is too low is undesirable as the images produced may not be of high enough quality to perform a procedure. Justification of radiation exposure for each procedure ensures that the benefit the patient receives from exposure outweighs the radiation detriment and that associated risks are minimised. Justification is the legal responsibility of the registered healthcare professional (who may or may not be the vascular surgeon). The medical practitioner then takes responsibility to ensure that the patient understands the potential risks and that they understand and agree that the risks are worth taking, after weighing against the benefit of the procedure. If the procedure is justified, optimisation ensures that the procedure is carried out in the best possible way to deliver the best medical goal with the least radiation detriment. In medical settings such as during vascular surgery, where the operator of the imaging equipment is not a radiographer or radiologist, the primary responsibility for ensuring the radiation safety of the patient lies with the medical practitioner. In endovascular surgery, ionising radiation is used only for real time imaging purposes, to allow the surgeon to “see” what they are doing inside the body. As such, in practice, the vascular surgeons themselves have direct responsibility for how much radiation the patient receives as it is the vascular surgeon who directly controls when and how often imaging occurs (through use of a pedal or similar). The doses received by patients undergoing endovascular surgery vary depending on a number of factors including the type and complexity of the procedure. There are only a small number of studies which look explicitly at the doses patients receive, and more work is clearly needed here. In general, as discussed in Chapter 2 and Appendix 2, information about the risks associated with ionising radiation exposure come from information gathered through many years of use of ionising radiation in medical and nuclear settings, as well as from experience following atomic bomb testing and radiation accidents. For the doses experienced by patients, direct “tissue reactions” such as skin burns are rare. However, such effects do occur, and the risks and severity vary on a patient by patient basis. Further research is ongoing to better understand and guard against such effects. The patients and members of the public who have contributed to this chapter suggest that future research focuses more clearly on the patient specific dose levels involved in different procedures and how these vary on a case by case basis, which will facilitate clearer discussions on risk between patients and medical professionals prior to procedures being carried out; how cumulative doses might be recorded and used within the medical profession as a whole (something which is not generally done yet); and on the doses received by the practitioners themselves to underpin appropriate protection. Radiation exposure of the patient who receives specific limited exposure as part of treatment or diagnosis does slightly increase the average risk of late effects such as radiation induced cancer, which depends on cumulative lifetime dose, perhaps up to about 5% for a vascular surgery patient, depending on the type of procedure. However, the combined data from all studies suggest that the risk of developing cancer associated with ionising radiation is very small compared with the overall lifetime risk of all cancers, which is now about 50%. Such a risk is acceptable because it is substantially outweighed by the high risk of early death associated with not having the vascular procedure. Hence the procedure is justified. Patients thought they had very little information about radiation exposure and risks prior to their intervention and universally said they would want more despite some of the exact risks being unknown. Several felt that being empowered with information, either in the form of written information or a dedicated website, would raise their curiosity and make them want to find out more. They thought it essential that they be counselled about the risks of radiation exposure prior to their procedure but that it was unlikely the risks would impact their decision to undergo the procedure. It was

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Jersemann K. et al.Prevention of thromboembolic complications in patients with superficial-vein thrombosis given rivaroxaban or fondaparinux: the open-label, randomised, non-inferiority SURPRISE phase 3b trial.Lancet Haematol. 2017; 4: e105-e113Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Acute STroke or Transient IscHaemic Attack Treated With TicAgreLor and ASA for PrEvention of Stroke and Death27Johnston S.C. Amarenco P. Denison H. Evans S.R. Himmelmann A. James S. et al.Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA.N Engl J Med. 2020; 383: 207-217Crossref PubMed Scopus (227) Google Scholar Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischaemic Events trial28Morrow D.A. Braunwald E. Bonaca M.P. Ameriso S.F. Dalby A.J. Fish M.P. et al.Vorapaxar in the secondary prevention of atherothrombotic events.N Engl J Med. 2012; 366: 1404-1413Crossref PubMed Scopus (770) Google Scholar Vascular Outcomes Study of ASA (acetylsalicylic acid) Along with Rivaroxaban in Endovascular or surgical limb Revascularisation for Peripheral Arterial Disease29Bonaca M.P. Bauersachs R.M. Anand S.S. Debus E.S. Nehler M.R. Patel M.R. et al.Rivaroxaban in Peripheral Artery Disease after Revascularization.N Engl J Med. 2020; 382: 1994-2004Crossref PubMed Scopus (393) Google Scholar Warfarin and Antiplatelet Vascular Evaluation30Anand S. Yusuf S. Xie C. Pogue J. Eikelboom J. Budaj A. et al.Oral anticoagulant and antiplatelet therapy and peripheral arterial disease.N Engl J Med. 2007; 357: 217-227Crossref PubMed Scopus (330) Google Scholar The European Society for Vascular Surgery (ESVS) has developed a series of clinical practice guidelines for clinicians caring for patients with vascular diseases. This is the first guideline specifically examining antithrombotic therapy. The aim of the guideline is to assist clinicians and patients in selecting an optimal antithrombotic strategy. The antithrombotic field has evolved rapidly over the last few years with the introduction of new classes of agents and a better understanding of the use of established agents. This guideline is all encompassing to cover as many arterial and venous conditions as possible for patients cared for by vascular departments across Europe and the rest of the world. Some arterial territories are beyond the scope of this guidance such as intracerebral and coronary, although occasionally data have been extrapolated from trials in these areas. The term “patient” as used in the guideline is all encompassing. Where age is important for a specific recommendation, it will be considered in the relevant section. Otherwise, these guidelines apply to adults over the age of 18. The clinician responsible for that person’s care will differ by condition and country. They will include angiologists, cardiologists, interventional radiologists, haematologists, neurologists, phlebologists, vascular physicians, and vascular surgeons. The guidelines were therefore developed by a multidisciplinary group of specialists in the field to promote a high standard of care based on the highest quality evidence available. As always, guidelines should not be viewed as a legal standard of care. The document provides guidance and support, and the choice of therapy will depend on the individual patient and treatment setting. This guidance and support is especially important in the context of antithrombotic therapy as some drugs will not be available in certain countries, or the cost of use may be prohibitive. There may also be more than one antithrombotic option available for a patient. This is where shared decision making is particularly important and will need to balance the risk of bleeding (section 1.3.1) with the reduction in risk of cardiovascular events. Cost is likely to be the greatest barrier to implementation of these guidelines, especially for newer drugs. These guidelines do not have the scope to go into detail on the health economics of antithrombotic drugs, as both cost and cost thresholds vary by country. Health economic analysis will need to be performed locally, when relevant, using standardised methodology.31Guillemin F. de Wit M. Fautrel B. Grimm S. Joore M. Boonen A. Steps in implementing a health economic evaluation.RMD Open. 2020; 6Crossref Scopus (0) Google Scholar Bleeding concerns are also likely to be a barrier to implementation. This has been considered in detail in the relevant chapters, as well as section 1.3. Vascular centres are encouraged to audit any implementations made as a result of this guideline. Audit cycles should be repeated regularly and changes implemented based on results. As well as use of appropriate antithrombotic assessments, major bleeding using a standard definition should also be monitored (see section 1.3). There are many ways to perform clinical audit, and most centres now require that any audit is registered with a local audit committee. Paid and not-for-profit tools are readily available online if necessary. To enhance the global reach and applicability of this guideline, external international reviewers have reviewed the document. All ESVS guidelines and the app can be downloaded free of charge from the ESVS website (https://www.esvs.org/journal/guidelines/). The abbreviation “peripheral artery disease” (PAD) is used in the guideline to encompass atherosclerotic lower extremity arterial disease (LEAD) from the aorta to the toes, atherosclerotic upper limb arterial disease, atherosclerotic visceral artery disease, and atherosclerotic cerebrovascular disease. There are many terms and definitions for “chronic” or “stable” atherosclerotic arterial disease. In the guideline the term “chronic” is used to cover all non-acute presentations. The AGREE reporting standards for clinical practice guidelines were used throughout the guideline process and the checklist is included as Appendix B.32Brouwers M.C. Kerkvliet K. Spithoff K. The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.BMJ. 2016; 352: i1152Crossref PubMed Scopus (378) Google Scholar Members of the Guideline Writing Committee (GWC) were selected by the guideline chairs and ESVS Guideline Steering Committee to represent clinician groups involved in antithrombotic therapy decision making for patients with vascular disease. This included representation from the disciplines of angiology, phlebology, cardiology, clinical pharmacology, interventional radiology, vascular medicine, and vascular surgery (Appendix A). Members of the GWC have provided disclosure statements regarding relationships that might be perceived as conflicts of interest. These are available from ESVS headquarters ([email protected]). Members of the GWC received no financial support from any pharmaceutical, device, or industry body to develop these guidelines. Videoconference software support was funded by the ESVS. The ESVS Guideline Steering Committee was responsible for undertaking the review process and reviewed the document at each round. The final version was checked and approved by the GWC and ESVS Guideline Steering Committee. The GWC held an introductory meeting on 3 and 4 July 2020 by videoconference where the list of topics and author tasks were determined. The GWC met monthly by videoconference to discuss the writing process and ongoing issues. After the first draft was completed and internally reviewed, the GWC held a further videoconference on 15 and 16 April 2021 to review and approve the wording of each recommendation. Consensus recommendations were discussed and agreed during these meetings and had to have majority consensus from all members of the GWC to be included. A further videoconference was held on 10 January 2022 to review and approve the wording of each recommendation following changes made after peer review. Detailed search strategies for sections of the guideline are available in Appendix C. Members of the GWC performed literature searches in Medline (through PubMed), Embase, Clinical Trials databases, and the Cochrane Library from inception up to the date specified in the search for peer reviewed publications. Hand searching of included references was also performed. Literature searches were updated for guideline publication in October 2022. Selection of studies for inclusion was based on the titles and abstracts of retrieved studies. The selection process followed the pyramid of evidence with systematic review and meta-analysis of randomised controlled trials (RCT) at the top, followed by RCTs, meta-analysis of observational studies, and finally observational studies. Case reports, abstracts, and in vitro studies were excluded leaving expert opinion at the base of the pyramid. Expanded information from the studies used for each recommendation is shown in the tables of evidence (ToE, Appendix D). A fundamental part of this guideline is to guide clinicians in assessing the risk of bleeding when recommending antithrombotic therapy (see section 1.3). There was no well validated scoring system to assess the risk of bleeding for a patient with PAD, so a study was performed to create and internally validate a score by the GermanVasc group and members of the GWC.33Behrendt C.A. Kreutzburg T. Nordanstig J. Twine C.P. Marschall U. Kakkos S. et al.The OAC3-PAD risk score predicts major bleeding events at one year after hospitalisation for peripheral artery disease.Eur J Vasc Endovasc Surg. 2022; 63: 503-510Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar This score (the OAC3 PAD score) used data from over 80 000 patients hospitalised with PAD in Germany to predict the risk of major bleeding at one year. There is more detail in section 1.3.1. Section 3.2.2 on antiplatelet function testing following arterial endovascular intervention had a large amount of low quality literature with no RCT to form recommendations. A systematic review and meta-analysis specifically on the impact of antiplatelet function testing to detect high on treatment platelet reactivity following endovascular intervention was therefore performed by members of the GWC.34Zlatanovic P. Wong K.H.F. Kakkos S.K. Twine C.P. A Systematic Review and Meta-Analysis on the Impact of High On-Treatment Platelet Reactivity on Clinical Outcomes for Patients Taking ADP Receptor Inhibitors Following Lower Limb Arterial Endovascular Intervention.Eur J Vasc Endovasc Surg. 2022; 63: 91-101Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar This meta-analysis included eight prospective and two retrospective studies examining platelet resistance (high on treatment platelet reactivity) in 1 444 patients following endovascular intervention for LEAD. The meta-analysis findings were of such low certainty that evidence based recommendations based on them could not be made (see section 3.2.2). Section 4.8, antithrombotics for aneurysmal disease had no systematic review and meta-analysis available to combine the small number of heterogeneous RCTs and cohort studies available. This was therefore performed by members of the GWC to guide recommendations (sections 4.8.1 – 4.8.2, recommendations 46 – 48).35Wong K.H.F. Zlatanovic P. Bosanquet D.C. Saratzis A. Kakkos S. Aboyans V. et al.Antithrombotic therapy for aortic and peripheral artery aneurysms: a systematic review and meta-analysis.Eur J Vasc Endovasc Surg. 2022; 64: 544-556Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Finally, an update of the Cochrane review, Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts,36Mohamed I. Kamarizan M.F.A. Da Silva A. Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts.Cochrane Database Syst Rev. 2021; 7Cd002786PubMed Google Scholar was triggered by the process of writing this guideline to guide recommendations in section 4.10 Vascular access for haemodialysis (section 4.10). A modification of the European Society of Cardiology (ESC) system was used for grading the level of evidence and class of recommendations. For each recommendation made in the guideline, the level of evidence was graded from A to C (Table 1) with A being the highest. The strength (class) of each recommendation was graded from I to III, with I being the strongest (Table 2).Table 1Levels of evidence from the adapted European Society of Cardiology evidence grading systemLevel of Evidence AData derived from multiple randomised trials or meta-analyses of randomised trialsLevel of Evidence BData derived from a single randomised trial, large non-randomised studies or a meta-analysis of non-randomised studiesLevel of Evidence CConsensus opinion of experts and or small studies, retrospective studies, registries Open table in a new tab Table 2Class of recommendations from the European Society of Cardiology evidence grading systemClassDefinitionSuggested wordingIEvidence and or general agreement that a given treatment or procedure is beneficial, useful, effectiveis recommendedIIConflicting evidence and or divergence of opinion about the usefulness or efficacy about the given treatment or procedure.IIaWeight of evidence or opinion is in favour of usefulness or efficacyshould be consideredIIbUsefulness or efficacy is less well established by evidence or opinionmay be consideredIIIEvidence or general agreement that a given treatment or procedure is not useful or effective and in some cases may be harmfulis not recommended Open table in a new tab Almost every ESVS guideline has a section on antithrombotic therapy. The purpose of this guideline was to update and add significant detail over the basic recommendations made in pre-existing guidelines. This led to differences in recommendations which are explained in Tables 3 and 4. There are multiple other guidelines from other major bodies with antithrombotic recommendations. Major differences in recommendations are also explored in Table 3 and 4. This guideline often goes into more detail and has more recommendations on various antithrombotic therapies than other guidelines. Unless there is a clear clash these are not highlighted. This includes recommendations on aspirin and rivaroxaban which were not considered by other guidelines (other than the 2023 update to the ESVS carotid guideline37Naylor R. Rantner B. Ancetti S. de Borst G.J. De Carlo M. Halliday A. et al.European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease.Eur J Vasc Endovasc Surg. 2023; 65: 7-111Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar and the European Society for Cardiology focused update38Aboyans V. Bauersachs R. Mazzolai L. Brodmann M. Palomares J.F.R. Debus S. et al.Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy.Eur Heart J. 2021; 42: 4013-4024PubMed Google Scholar) as the seminal studies were not published.Table 3Differences between recommendations from other major guidelines and this guideline for Section 4. Antithrombotics for patients with arterial diseaseGuideline, publication yearRecommendationESVS antithrombotic guideline recommendationReasons for differencesAntithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy38Aboyans V. Bauersachs R. Mazzolai L. Brodmann M. Palomares J.F.R. Debus S. et al.Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy.Eur Heart J. 2021; 42: 4013-4024PubMed Google Scholar 2021Long term low dose rivaroxaban plus aspirin may be proposed for inpatients with asymptomatic carotid stenosis or in those with a history of carotid revascularisation, who are considered at very high risk because of associated comorbidities (especially polyvascular patients), provided bleeding risk is not highNo recommendation for aspirin and rivaroxaban for carotid diseaseThis GWC along with the ESVS carotid guideline GWC notes the major problem with forming recommendations for patients with carotid stenoses from COMPASS was that patients with pre-existing indications for DAPT and a non-aspirin antiplatelet were excluded, which would exclude many patients with asymptomatic carotid disease2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery39Aboyans V. Ricco J.B. Bartelink M.E.L. Björck M. Brodmann M. Cohnert T. et al.Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 305-368Abstract Full Text Full Text PDF PubMed Scopus (548) Google Scholar 2017For patients requiring antiplatelet therapy, clopidogrel may be preferred over aspirin (Class IIb, level B)Patients with chronic symptomatic lower extremity arterial disease should be considered for clopidogrel (75 mg) as the first choice antiplatelet agent when single antiplatelet therapy is indicated for secondary cardiovascular prevention (Class IIa, level B)The recommendation for stable or chronic symptomatic patients with LEAD was re-considered in the light of the COMPASS trial. The decision for this to be IIa or IIb was debated extensively over the course of developing this guideline, but on balance it was changed to IIa in line with the new recommendation on aspirin plus low dose rivaroxabanDAPT with aspirin and clopidogrel for at least one month should be considered after infrainguinal stent implantation (Class I, level B)Patients undergoing endovascular intervention for lower extremity arterial disease who are not at high risk of bleeding may be considered for a short course (a minimum of one month to a maximum of six) dual antiplatelet therapy (aspirin 75 mg plus clopidogrel 75 mg) to reduce the risk of secondary cardiovascular and major adverse limb events (Class IIb, level C)As there is no powered RCT evidence to support DAPT, this was downgraded. The only RCT (leading to a level B in the ESC guidelines) is MIRROR, which is too underpowered to be considered level BCombination treatment with ASA and cilostazol may be considered to improve patency and reduce amputation rates following infra-inguinal endovascular treatmentNo recommendations on cilostazolThis GWC recognised that cilostazol was contentious. The randomised evidence is weak (underpowered) and confusion over the antiplatelet properties of cilostazol with subsequent reports of major bleeding has led to a notification from the European Medicines Agency. This led the GWC to not form any recommendations2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease40Gerhard-Herman M.D. Gornik H.L. Barrett C. Barshes N.R. Corriere M.A. Drachman D.E. et al.2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Ankle Brachial Index Bare Metal Stent Coronary Artery Disease Confidence Interval Chronic Limb Threatening Ischaemia Cardiac Rehabilitation Computed Tomography Angiography Cardiovascular Dual Antiplatelet Therapy Drug Coated Balloon Drug Eluting Stent Digital Subtraction Angiography expanded PolyTetraFluoroEthylene European Society of Cardiology European Society for Vascular Surgery Guidelines Steering Committee Guideline Writing Committee Home Based Exercise Therapy Hazard Ratio Health Related Quality of Life Intermittent Claudication International Normalised Ratio Major Adverse Cardiovascular Events Major Adverse Limb Events Magnetic Resonance Angiography Odds Ratio Peripheral Arterial Disease Proprotein Convertase Subtilisin/Kexin type 9 Percutaneous Transluminal Angioplasty Patient Reported Outcome Measure Quality Adjusted Life Years Randomised Controlled Trial Risk Ratio Supervised Exercise Therapy Toe Brachial Index Toe Pressure The Active detection and Management of the Extension of atherothrombosis in high Risk coronary patients In comparison with standard of Care for coronary Atherosclerosis Bare Metal Stent Versus Paclitaxel Eluting Stent in the Setting of Primary Stenting of Intermediate Length Femoropopliteal Lesions BIOTRONIK’s First in Man study of the Passeo-18 LUX drug releasing PTA Balloon Catheter vs. the uncoated Passeo-18 PTA balloon catheter in subjects requiring revascularisation of infrapopliteal arteries CANagliflozin cardioVascular Assessment Study Clopidogrel versus vs.Aspirin in Patients at Risk of Ischaemic Events Clopidogrel and AcetylSalicylic acid in bypass surgery for Peripheral ARterial disease Cilostazol:A STudy in Long-term Effects Comparison and Evaluation of Cardiac Biomarkers in Patients with Intermittent Claudication Claudication:Exercise Vs. Endoluminal Revascularisation Covered Versus vs. Balloon Expandable Stent Trial the Danish Cardiovascular Screening trial Dapagliflozin and Prevention of Adverse outcomes in Chronic Kidney Disease trial Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes Dutch Iliac Stent trial:COVERed balloon-expandable versus vs.uncovered balloon-expandable stents in the common iliac artery Bypass Oral anticoagulants or Aspirin Trial Comparing ELUVIA Versus vs.Bare Metal Stent in Treatment of Superficial Femoral and/or Proximal Popliteal Artery Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes Empagliflozin in Heart Failure with a Preserved Ejection Fraction Ticagrelor versus vs. Clopidogrel in Symptomatic Peripheral Artery Disease Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk German Epidemiological Trial on Ankle Brachial Index Heart Outcomes Prevention Evaluation Heart Protection Study The Nord-Trøndelag Health Survey Self-Expanding Versus vs.Balloon-Expandable Stents for Iliac Artery Occlusive Disease Invasive revascularisation or not in intermittent claudication Management of peripheral arterial interventions with mono or dual antiplatelet therapy Self-Assessment Method for Statin side-effects Or Nocebo Prevalence of peripheral Arterial disease in patients with a non-high cardiovascular disease risk, with No overt vascular Diseases nOR diAbetes mellitus Prevention Of Progression of Arterial Disease And Diabetes PAD Awareness, Risk, and Treatment: NEw Resources for Survival Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome Stents versus vs.angioplasty for the treatment of iliac artery occlusions Supervised Exercise Therapy vs. Endovascular Revascularisation for Intermittent Claudication Caused by Iliac Artery Obstruction Viborg Vascular Trial VIABAHN endoprosthesis versus vs.bare nitinol stent implantation for complex superficial femoral artery occlusive disease Viabahn endoprosthesis with PROPATEN bioactive surface versus vs.bare nitinol stent in the treatment of long lesions in superficial femoral artery occlusive disease Rivaroxaban in Peripheral Artery Disease after Revascularisation YUKON-drug-eluting Stent Below The Knee ZILVER PTX Stent versus vs.Bypass Surgery in Femoropopliteal Lesions Zilver PTX randomised trial of paclitaxel-eluting stents for femoropopliteal artery disease The European Society for Vascular Surgery (ESVS) continuously develops clinical practice guidelines for patients with vascular diseases. This is the first guideline that specifically covers the diagnosis and treatment of patients with atherosclerotic lower extremity peripheral arterial disease (PAD, see also section 2.1) falling within the following clinical stages: (1) asymptomatic lower limb PAD (Rutherford grade 0/Fontaine stage I); and (2) intermittent claudication (IC, Rutherford grade I–III/Fontaine stage IIa and IIb). Thus, the management of patients with chronic limb threatening ischaemia (CLTI) falls outside the primary purpose of this guideline, as the management of such patients is already covered by other recent guidelines from the Society.1Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.Eur J Vasc Endovasc Surg. 2019; 58: S1-S109Abstract Full Text Full Text PDF PubMed Scopus (648) Google Scholar Throughout the guideline, the term lower limb PAD refers to both aforementioned patient categories, whereas the terms asymptomatic PAD and IC are used where a certain section or recommendation only applies to that particular subcategory. Within the context of this guideline, the term PAD includes atherosclerotic disease from the infrarenal aorta to the toes. The primary aim of the guideline is to assist clinicians and patients in their selection of an optimal diagnostic and therapeutic pathway for PAD during patient centred shared decision making. A secondary aim is to contribute to an aligned management and research process of the disease across European countries and globally. Both the diagnostic and the therapeutic landscapes have evolved markedly within the PAD space during recent years with the introduction of new diagnostic modalities, imaging protocols, and therapeutic options. These include increased understanding and utilisation of non-interventional treatment options such as exercise therapy and secondary preventive pharmacotherapy and continuous advancements in endovascular therapeutic options that are becoming available to an increasing number of PAD patients. The scope of this guideline is to provide comprehensive, evidence based and clear recommendations on as many as possible of the different steps and decisions that fall within the clinical PAD patient management process. The term patient as used in the guideline is all encompassing, including people of all sex identities, and in general, these guidelines apply to adults over the age of 18 years. The clinician responsible for a PAD patient’s care will also differ by country, and will among others include vascular surgeons, angiologists, cardiologists, interventional radiologists, vascular physicians, primary care physicians, and exercise rehabilitation specialists. The guidelines were therefore developed by a multidisciplinary group of specialists in the field (see Appendix B) to promote a high standard of care based on the highest quality evidence available. This guideline should not be considered as a legal standard of care. The document provides guidance and support, and the choice of therapy will ultimately depend on the individual patient and treatment setting and fall within the responsibility of the treating physician. All ESVS guidelines, including app based smartphone and tablet versions, can be downloaded free of charge from the ESVS website (https://www.esvs.org/journal/guidelines/). The AGREE reporting standards for clinical practice guidelines were used throughout the guideline process and the AGREE II checklist is included as supplementary material (Appendix A).2Brouwers M.C. Kerkvliet K. Spithoff K. AGREE Next Steps ConsortiumThe AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.BMJ. 2016; 352: i1152Crossref PubMed Scopus (436) Google Scholar The development of these guidelines also followed the principal steps suggested for the ESVS guidelines development cycle, and was further informed by the ESVS Clinical Practice Guideline Development Scheme.3Antoniou G.A. Bastos Goncalves F. Bjorck M. Chakfe N. Coscas R. Dias N.V. et al.Editor's Choice - European Society for Vascular Surgery Clinical Practice Guideline Development Scheme: An Overview of Evidence Quality Assessment Methods, Evidence to Decision Frameworks, and Reporting Standards in Guideline Development.Eur J Vasc Endovasc Surg. 2022; 63: 791-799Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Members of the Guideline Writing Committee (GWC) were selected by the guideline chairs in collaboration with the ESVS Guideline Steering Committee (GSC) to represent an expert clinician group deeply involved in the management of PAD. This included representation from the disciplines of vascular surgery, angiology, physiotherapy, and vascular medicine (Appendix A). Members of the GWC have provided annual disclosure statements regarding relationships which might be perceived as conflicts of interest. These are available from ESVS headquarters upon request ([email protected]). Members of the GWC received no financial support from any pharmaceutical, medical device, or industry body to develop these guidelines. Videoconference software support along with travel and accommodation costs for mandatory meetings to develop the guideline were funded by the ESVS. The ESVS GSC was responsible for undertaking the review process which also included several independent external experts outside of the ESVS organisation. The final version was checked and approved by all members of both the GWC and the GSC. Following the completion of the second draft of the guideline on 15 January 2022, the GWC sent out the Guideline draft for review by the Swedish Heart and Lung Association (https://www.hjart-lung.se/om-oss/about-us/); a non-profit Swedish national patient organisation formed in 1939 that strives to improve the quality of life for persons with cardiovascular and lung diseases and works to ensure that patients with heart, vascular, and lung disease receive the care they need. This organisation was invited to review and provide comments from the patient and public perspectives on the full guideline content. After reading through the guideline document the response received stated that, as the organisation does not have medically trained personnel, neither among elected representatives nor civil servants, they could not comment on the specific medical content of the guidelines. They, however, welcomed the work done by the ESVS to design a compilation of knowledge, and in the guidelines propose the best possible care and treatment, based on science and clinical experience. Overall, the guideline content received a positive opinion from the patient organisation. The GWC held an introductory meeting on 23 and 24 June 2021 by video conference, where the list of topics and author assignments was determined by consensual agreement. The GWC met monthly by videoconference to discuss the writing process and any ongoing issues. After the first draft was completed and internally reviewed, the GWC met again on 21 and 22 April 2022 to review and approve the wording and content of each recommendation. If any of the GWC members disagreed with the content of a particular recommendation during this meeting, an open vote was held (where all GWC members participated and had the same voting rights) where a simple majority decision was decisive for acceptance of the recommendation. Detailed search strategies for the different topic specific sections of the guideline are available in Supplementary material. Members of the GWC performed literature searches in Medline/PubMed, Embase, and the Cochrane Library from inception up to the date specified in the search for peer reviewed publications. Hand searching of included references was also performed. As per the ESVS guideline development process cycle, all systematic literature searches were last updated in November 2022 when the GWC worked with the first revision of the guideline draft. The last literature search was done in July 2023. Selection of studies for inclusion was based on the titles and abstracts of retrieved studies. The selection process followed the pyramid of evidence with systematic review and meta-analysis of randomised trials at the top, followed by individual randomised trials, meta-analysis of observational studies, and finally observational studies. Case reports, abstracts, and in vitro studies were excluded leaving expert opinion at the base of the pyramid. Other guideline documents were considered only if they applied a systematic approach for literature searches and or produced their own meta-analyses of existing literature. For section 3.3 where no suitable systematic review or consensus document was available, an extensive DELPHI expert consensus process on the use of patient reported outcome measures was arranged and published separately to support this part of the guideline.4Arndt H. Nordanstig J. Bertges D.J. Budtz-Lilly J. Venermo M. Espada C.L. et al.A Delphi Consensus on patient reported outcomes for registries and trials including patients with intermittent claudication: recommendations and reporting standard.Eur J Vasc Endovasc Surg. 2022; 64: 526-533Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar For section 6.4 of the guidelines where there was no appropriate systematic review and meta-analysis available, such a study was performed by members of the GWC.5Koeckerling D. Raguindin P.F. Kastrati L. Bernhard S. Barker J. Quiroga Centeno A.C. et al.Endovascular revascularization strategies for aortoiliac and femoropopliteal artery disease: a meta-analysis.Eur Heart J. 2023; 44: 935-950Google Scholar The studies that underpin each recommendation are shown directly in the individual recommendation table, and further details are given for each in more comprehensive tables of evidence Supplementary material. The European Society of Cardiology (ESC) system was used for grading the level of evidence and the accompanying class of each recommendation. For each guideline recommendation, the level of evidence was graded from A to C (Table 1) with A being the highest. The strength (class) of each recommendation was graded from I to III with I as the strongest (Table 2). The class II subcategory was also further subcategorised into IIa and IIb based on an overall assessment of the strength and robustness of available evidence alongside concurrent clinical experience and expert consensus opinion within the GWC.Table 1Levels of evidence adapted from the European Society of Cardiology evidence grading system.Level of Evidence AData derived from multiple randomised trials or meta-analyses of randomised trialsLevel of Evidence BData derived from a single randomised trial or large non-randomised studiesLevel of Evidence CConsensus opinion of experts and or small studies, retrospective studies, registries Open table in a new tab Table 2Class of recommendations from the European Society of Cardiology evidence grading system.ClassDefinitionWordingIEvidence and or general agreement that a given treatment or procedure is beneficial, useful, effectiveis recommendedIIaConflicting evidence and or divergence of opinion about the usefulness or efficacy of the given treatment or procedure: weight of evidence or opinion is in favour of usefulness or efficacyshould be consideredIIbConflicting evidence and or divergence of opinion about the usefulness or efficacy of the given treatment or procedure: usefulness or efficacy is less well established by evidence or opinionmay be consideredIIIEvidence or general agreement that a given treatment or procedure is not useful or effective and in some cases may be harmfulis not recommended, should not be done Open table in a new tab This is the first ESVS guideline focusing on asymptomatic PAD and IC. However, the ESC/ESVS 2017 Guidelines on the Diagnosis and Treatment of PAD included several relevant sections and recommendations that potentially overlap with this guideline.6Aboyans V. Ricco J.B. Bartelink M.E.L. Bjorck M. Brodmann M. Cohnert T. et al.Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 305-368Abstract Full Text Full Text PDF PubMed Scopus (608) Google Scholar Furthermore, this guideline does not cover acute lower limb PAD presentations, as these are already covered by the ESVS 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia.7Bjorck M. Earnshaw J.J. Acosta S. Bastos Goncalves F. Cochennec F. Debus E.S. et al.Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia.Eur J Vasc Endovasc Surg. 2020; 59: 173-218Abstract Full Text Full Text PDF PubMed Scopus (214) Google Scholar The ESVS 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases contains comprehensive recommendations on antithrombotic therapies for both asymptomatic PAD and IC patients, and the recommendations from that guideline are aligned with this as far as possible; however, an updated literature search was done on this topic to account for potential new evidence that may have emerged following the publication of the antithrombotic guideline. When this guideline changes or updates a previous recommendation from any of these previous guidelines, it is discussed in the relevant section, and all changed or updated recommendations are also briefly summarised below (Table 3).Table 3Brief overview of differences between previous cardiovascular guideline recommendations and this guideline.GuidelineYear of printed publicationRecommendation in previous guidelinesESVS lower limb PAD and intermittent claudication guideline recommendationReasons for differencesCanadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease2022We suggest against routine PAD testing for inferring global cardiovascular risk, in patients without symptoms of PAD, who have clinically symptomatic atherosclerosis in another vascular territory (Weak Recommendation;Moderate quality evidence).Recommendation 4:For clinically asymptomatic individuals at increased risk of lower limb peripheral arterial disease, focused screening for peripheral arterial disease with ankle brachial index measurements based on the lowest recorded ankle pressure may be considered, to support secondary prevention strategies. (IIb, B)They suggest against screening in patients who already manifested atherosclerotic symptoms from other vascular territories than the legs (and thus are already considered having a high cardiovascular risk).European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019It is recommended that patients with diabetes should be screened for PAD (Class I Level B)Recommendation 4:For clinically asymptomatic individuals at increased risk of lower limb peripheral arterial disease, focused screening for peripheral arterial disease with ankle brachial index measurements based on the lowest recorded ankle pressure may be considered, to support secondary prevention strategies. (IIb, B)They recommend PAD screening only for patients with diabetes whereas the ESVS guideline suggest focused screening in a broader high risk population (see section 3.1.1.2).2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)2018In patients with coronary artery disease, screening for lower extremity atherosclerotic disease (LEAD) by ABI measurement may be considered for risk stratification. (IIb, B)Screening for LEAD may be considered in patients with heart failure. (IIb, C)Recommendation 4:For clinically asymptomatic individuals at increased risk of lower limb peripheral arterial disease, focused screening for peripheral arterial disease with ankle brachial index measurements based on the lowest recorded ankle pressure may be considered, to support secondary prevention strategies. (IIb, B)They recommend PAD screening only for patients with manifest coronary artery disease or heart failure whereas this guideline suggests focused screening in a broader high risk population (see section 3.1.1.2).2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)2018Measurement of the ABI is indicated as a first line non-invasive test for screening and diagnosis of lower extremity atherosclerotic disease (LEAD). (Class 1 Level C)Recommendation 5:The ankle brachial index is recommended as the appropriate test to establish the diagnosis of lower limb peripheral arterial disease.(I, B)Current evidence level supports upgrading from level C to B, based on two review studies, one systematic Cochrane review, one meta-analysis, and one clinical trial (see section 3.1.3.1)Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication2015Recommendation 2.1We recommend using the ABI as the first line non-invasive test to establish a diagnosis of PAD in individuals with symptoms or signs suggestive of disease. When the ABI is borderline or normal (> 0.9) and symptoms of claudication are suggestive, we recommend an exercise ABI. (Grade 1 Level A)Recommendation 5:The ankle brachial index is recommended as the appropriate test to establish the diagnosis of lower limb peripheral arterial disease.(I, B)Current evidence level supports a downgrading from level A to B. (see section 3.1.3.1)European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019Measurement of the ABI by non-invasive measurements using Doppler occlusion pressure is indicated as an appropriate test to verify PAD. (Class 1 Level C)Recommendation 5:The ankle brachial index is recommended as the appropriate test to establish the diagnosis of lower limb peripheral arterial disease.(I, B)Current evidence level supports upgrading from level C to B, based on two review studies, one systematic Cochrane review, one meta-analysis and one clinical trial (see section 3.1.3.1)European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019It is recommended that ABI values ≤ 0.9 are evidence of significant PAD. (Class I Level B)Recommendation 6:It is recommended that an ankle brachial index cutoff value at ≤ 0.9 is used for lower limb peripheral arterial disease diagnosis, and that a value ≥ 1.4 be considered inconclusive.(I, C)A cutoff value has been added for incompressible ankle arteries (ABI ≥ 1.4) which led to an overall downgrading of evidence to level C. No references are provided in support of the level B evidence level in the ESVM guideline.European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019It is recommended that the ABI score with the highest ankle artery pressure value is to be used for the calculation of ABI. (Class I Level C)Recommendation 7:When the ankle brachial index is used to estimate the severity of lower limb peripheral arterial disease in symptomatic patients or is being used during follow up after revascularisation, it is recommended to be calculated by dividing the highest systolic pressure at the ankle level by the highest systolic arm pressure. (I, B)The recommendation has been upgraded to level B based on two observational studies and one review. The level C evidence statement suggested by ESVM refers to the scientific statement from the American Heart Association. (Aboyans et al. Circulation 2012) that in turn suggested a Grade I Level A recommendation.Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease2022We recommend smoking cessation interventions ranging from intensive counselling, nicotine replacement therapy, bupropion, varenicline, and sometimes nicotine e-cigarettes (Strong Recommendation; High quality Evidence).Recommendation 22:For patients with lower limb peripheral arterial disease who smoke, councelling as part of intensive smoking cessation intervention is recommended. (I, B)Recommendation 23:For patients with lower limb periperal arterial disease who smoke, varenicline, either alone or in combination with nicotine replacement therapy, is recommended as the first line pharmacological smoking cessation treatment due to its higher effectiveness as compared to other pharmacological alternatives. (I, B)We considered the current evidence base differently, especially for bupropion. We also considered the potential harm of e-cigarettes (see chapter 4.1.1.1)Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease2022Statin add on therapies (ezetimibe and or PCSK-9 inhibitors) if receiving maximally tolerated dose of statin therapy and the low density lipoprotein cholesterol is ≥ 1.8 mmol/L, non-high density lipoprotein cholesterol ≥ 2.4 mmol/L or apolipoprotein B 100 ≥ 0.7 mg/dL.Recommendation 32:For patients with lower limb peripheral arterial disease, it is recommended to reduce the low density lipoprotein cholesterol concentrations to < 1.4 mmol/L (< 55 mg/dL) and decrease it by ≥ 50% if baseline values are within 55–110 mg/dL. (I, B)We recommended a slightly lower low density lipoprotein cholesterol threshold, although we recognise that the current evidence for a lower threshold is mainly based on heterogeneous cohorts and was mainly driven by positive data from recent trials on PCSK-9 inhibitors.2021 ESC Guidelines on cardiovascular disease prevention in clinical practice2021Considered to be at high risk:Documented atherosclerotic cardiovascular disease (ASCVD), clinical or unequivocal on imaging. Documented clinical ASCVD includes previous AMI, ACS, coronary revascularisation and other arterial revascularisation procedures, stroke and TIA, aortic aneurysm and PAD.Symptomatic or asymptomatic lower extremity atherosclerotic disease (LEAD) (ABI < 0.90) is associated with a doubling of the 10 year rate of coronary events, CV mortality, and total mortality.Recommendation 44For patients with lower limb peripheral arterial disease, even if asymptomatic, it is recommended to consider an ankle brachial index ≤ 0.9 or ≥ 1.4 a risk enhancing factor for a cardiovascular event and for an increased all cause mortality. (I, A)The ESC document classifies PAD as a documented ASCVD, and further emphasises the high cardiovascular risk associated with PAD.In our document we have suggested a diagnostic method for PAD which is not given in the ESC guideline.European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019It is recommended that recognition be given that patients with PAD have a high risk of vascular events in other vascular beds, and as such these patients should always be considered very high risk for further events. (Class I Level A)andIt is recommended that ABI values ≤ 0.9 are evidence of significant PAD (Class I Level B)Recommendation 44:For patients with lower limb peripheral arterial disease, even if asymptomatic, it is recommended to consider an ankle brachial index ≤ 0.9 or ≥ 1.4 a risk enhancing factor for a cardiovascular event and for an increased all cause mortality. (I, A)The two quoted recommendations from ESVM together provide a similar message to recommendation 43 in this guideline.Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication2015Recommendation 5.5We recommend the selective use of BMS or covered stents for aorto-iliac angioplasty for common iliac artery or external iliac artery occlusive disease, or both, due to improved technical success and patency. (Grade 1 Level B)Recommendation 55:For patients with disabling intermittent claudication undergoing revascularisation, primary bare metal stenting is recommended over primary balloon angioplasty for iliac artery occlusions due to the lower risk of distal embolisation. (I, B)We have also considered the risk of distal embolisation when performing balloon angioplasty on iliac artery occlusions why we did not recommend selective use of stents for iliac artery occlusions. We also considered the results from the recently published DISCOVER trial that did not show any benefit of covered vs. uncovered stents in the common iliac artery (see chapter 6.4).Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication2015Recommendation 5.6We recommend the use of covered stents for treatment of AIOD in the presence of severe calcification or aneurysmal changes where the risk of rupture may be increased after unprotected dilation. (Grade 1 Level C)Recommendation 57:For patients with disabling intermittent claudication undergoing revascularisation who have Trans-Atlantic Inter-Society Consensus Document II C/D iliac lesions, covered stent placement may be considered over bare metal stents due to higher patency rates. (IIb, B)Our recommendation more precisely targets complex (i.e., TASC II C and D) aorto-iliac lesions, where the risk of vessel rupture is substantially higher. We also considered the results of the recently published

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological complications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair.Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair were included (69.4% male, mean age 62.7 ± 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neurological events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points.Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6, 1.0%). The group with neurological events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P < .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indication for thoracic endovascular aortic repair (38.8% vs 16.5%, P < .001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events.In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women.

Background— The clinical profiles and outcomes of patients treated surgically for acute type B aortic dissection (ABAD) are often reported for those in small series or for those cared for at a single institution over a long time period, during which a continuous evolution in techniques has occurred. Accordingly, we sought to evaluate the clinical features and surgical results of patients enrolled in the International Registry of Acute Aortic Dissection by identifying primary factors that influenced surgical outcome and estimating average surgical mortality for ABAD in the current era. Methods and Results— A comprehensive analysis of 290 clinical variables and their relation to surgical outcomes for 82 patients who required surgery for ABAD (from a population of 1256 patients; mean±SD age, 60.6±15.0 years; 82.9% male) and who were enrolled in the International Registry of Acute Aortic Dissection was performed. The overall in-hospital mortality was 29.3%. Factors associated with increased surgical mortality based on univariate analysis were preoperative coma or altered consciousness, partial thrombosis of the false lumen, evidence of periaortic hematoma on diagnostic imaging, descending aortic diameter &gt;6 cm, right ventricle dysfunction at surgery, and shorter time from the onset of symptoms to surgery. Factors associated with favorable outcomes included radiating pain, normotension at surgery (systolic blood pressure 100 to 149 mm Hg), and reduced hypothermic circulatory arrest time. The 2 independent predictors of surgical mortality were age &gt;70 years (odds ratio, 4.32; 95% confidence interval, 1.30 to 14.34) and preoperative shock/hypotension (odds ratio, 6.05; 95% confidence interval, 1.12 to 32.49). Conclusions— The present study provides insights into current-day clinical profiles and surgical outcomes of ABAD. Knowledge about different preoperative clinical conditions may help surgeons in making treatment decisions among these high-risk patients.

Background— In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection. Methods and Results— Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. “High-risk” patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P =0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P =0.0003). Mortality rates after surgical (20% versus 28%; P =0.74) or endovascular management (3.7% versus 9.1%; P =0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P =0.041). Conclusions— Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group.

<h3>Introduction</h3> Ruptured descending thoracic aortic aneurysm (rDTAA) is associated with high mortality rates. Data supporting endovascular thoracic aortic aneurysm repair (TEVAR) to reduce mortality compared with open repair are limited to small series. We investigated published reports for contemporary outcomes of open and endovascular repair of rDTAA. <h3>Methods</h3> We systematically reviewed all studies describing the outcomes of rDTAA treated with open repair or TEVAR since 1995 using MEDLINE, Cochrane Library CENTRAL, and Excerpta Medica Database (EMBASE) databases. Case reports or studies published before 1995 were excluded. All articles were critically appraised for relevance, validity, and availability of data regarding treatment outcomes. All data were systematically pooled, and meta-analyses were performed to investigate 30-day mortality, myocardial infarction, stroke, and paraplegia rates after both types of repair. <h3>Results</h3> Original data of 224 patients (70% male) with rDTAA were identified: 143 (64%) were treated with TEVAR and 81 (36%) with open repair. Mean age was 70 ± 5.6 years. The 30-day mortality was 19% for patients treated with TEVAR for rDTAA compared 33% for patients treated with open repair, which was significant (odds ratio [OR], 2.15, <i>P</i> = .016). The 30-day occurrence rates of myocardial infarction (11.1% vs 3.5%; OR, 3.70, <i>P</i> < .05), stroke (10.2% vs 4.1%; OR, 2.67; <i>P</i> = .117), and paraplegia (5.5% vs 3.1%; OR, 1.83; <i>P</i> = .405) were increased after open repair vs TEVAR, but this failed to reach statistical significance for stroke and paraplegia. Five additional patients in the TEVAR group died of aneurysm-related causes after 30 days, during a median follow-up of 17 ± 10 months. Follow-up data after open repair were insufficient. The estimated aneurysm-related survival at 3 years after TEVAR was 70.6%. <h3>Conclusion</h3> Endovascular repair of rDTAA is associated with a significantly lower 30-day mortality rate compared with open surgical repair. TEVAR was associated with a considerable number of aneurysm-related deaths during follow-up.

BackgroundPartial thrombosis of the false lumen has been reported as a significant predictor of mortality during follow-up in patients with acute type B aortic dissection. The purpose of this study was to investigate the correlation of false lumen thrombosis and aortic expansion during follow-up in patients with acute type B aortic dissection.MethodsAll medically treated patients with acute type B aortic dissection observed in 4 cardiovascular referral centers between 1998 and 2011, with admission and follow-up computed tomography or magnetic resonance imaging scans, were included. Aortic diameters of the dissected aortas were measured at 4 levels on the baseline and follow-up scans, and annual growth rates were calculated. Univariate and multivariate regression analyses were used to investigate the effect of false lumen thrombosis on aortic growth rate.ResultsA total of 84 patients were included, of whom 40 (47.6%) had a partially thrombosed false lumen, 7 (8.3%) had a completely thrombosed false lumen, and 37 (44.0%) had a patent false lumen. A total of 273 of the 336 (81.3%) evaluated aortic levels were dissected segments. Overall, the mean aortic diameter increased significantly at all evaluated levels (P < .001). Univariate analysis showed that annual aortic growth rates were significantly higher in those segments having a false lumen with partial thrombosis (mean, 4.25 ± 10.2) when compared with the patent group (mean, 2.10 ± 5.56; P = .035). In multivariate analysis, partial lumen thrombosis was an independent predictor of higher aortic growth (adjusted mean difference, 2.05 mm/year; 95% confidence interval, 0.10-4.01; P = .040).ConclusionsIn patients with acute type B aortic dissection, aortic segments with a partially thrombosed false lumen have a significantly higher annual aortic growth rate when compared with those presenting with patent or complete thrombosis of the false lumen. Therefore, patients with partial thrombosis require more intensive follow-up and may benefit from prophylactic intervention. Partial thrombosis of the false lumen has been reported as a significant predictor of mortality during follow-up in patients with acute type B aortic dissection. The purpose of this study was to investigate the correlation of false lumen thrombosis and aortic expansion during follow-up in patients with acute type B aortic dissection. All medically treated patients with acute type B aortic dissection observed in 4 cardiovascular referral centers between 1998 and 2011, with admission and follow-up computed tomography or magnetic resonance imaging scans, were included. Aortic diameters of the dissected aortas were measured at 4 levels on the baseline and follow-up scans, and annual growth rates were calculated. Univariate and multivariate regression analyses were used to investigate the effect of false lumen thrombosis on aortic growth rate. A total of 84 patients were included, of whom 40 (47.6%) had a partially thrombosed false lumen, 7 (8.3%) had a completely thrombosed false lumen, and 37 (44.0%) had a patent false lumen. A total of 273 of the 336 (81.3%) evaluated aortic levels were dissected segments. Overall, the mean aortic diameter increased significantly at all evaluated levels (P < .001). Univariate analysis showed that annual aortic growth rates were significantly higher in those segments having a false lumen with partial thrombosis (mean, 4.25 ± 10.2) when compared with the patent group (mean, 2.10 ± 5.56; P = .035). In multivariate analysis, partial lumen thrombosis was an independent predictor of higher aortic growth (adjusted mean difference, 2.05 mm/year; 95% confidence interval, 0.10-4.01; P = .040). In patients with acute type B aortic dissection, aortic segments with a partially thrombosed false lumen have a significantly higher annual aortic growth rate when compared with those presenting with patent or complete thrombosis of the false lumen. Therefore, patients with partial thrombosis require more intensive follow-up and may benefit from prophylactic intervention.

To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR).A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database.In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90).Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

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.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.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 (≥20 μg/mL) at admission, aortic diameter ≥40 mm on initial imaging, proximal descending thoracic aorta false lumen (FL) diameter ≥22 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 (≥10 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.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.

Conservative management of acute type B aortic dissection (ABAD) is often associated with aortic dilatation during follow-up increasing the risk of aortic rupture. The goal of this study was to investigate whether morphologic characteristics of the dissection can predict aortic growth.All conservatively managed ABAD patients from four referral centers were included (2000 to 2010). Aortic diameters were measured at five levels at baseline and at the last follow-up computed tomography angiography, and annual aortic growth rates were calculated for all segments. Linear regression was used to study the influence of aortic morphologic characteristics for aortic dilatation.Included were 62 patients (41 men) with a mean age of 60.3 ± 10.7 years. Among the 310 analyzed aortic segments, 248 (80.0%) were dissected, of which 211 (85.1%) showed aortic growth. Overall, the mean diameter increased from 36.1 ± 9.4 to 40.2 ± 11.1 mm (P < .01), which corresponds with a mean aortic growth rate of 3.1 ± 6.3 mm/y. Multivariate linear regression analysis showed that male sex (95% confidence interval [CI], 0.60-4.04; P = .005) and a saccular false lumen (95% CI, 2.07-7.81: P = .001) were associated with a significantly increased aortic growth rate. Increasing age (95% CI, -0.23 to -0.04; P = .005), increased number of entry tears (95% CI, -2.40 to -0.43; P = .005), false lumen located on the aortic outer curvature (95% CI, -4.30 to -0.38; P = .019), and a circular configuration of the true lumen (95% CI, -5.35 to -0.32; P = .027) were associated with a decreased aortic growth rate.Multiple morphologic characteristics appear to predict aortic dilatation in ABAD patients treated medically. Early assessment of these morphologic signs may be useful in the selection of ABAD patients who might benefit from closer radiologic surveillance or prophylactic intervention.

Background— The outcome of patients with acute type B aortic dissection (ABAD) is strongly related to their clinical presentation. The purpose of this study was to investigate predictors for mortality among patients presenting with ABAD and to create a predictive model to estimate individual risk of in-hospital mortality using the International Registry of Acute Aortic Dissection (IRAD). Methods and Results— All patients with ABAD enrolled in IRAD between 1996 and 2013 were included for analysis. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality. Significant risk factors for in-hospital death were used to develop a prediction model. A total of 1034 patients with ABAD were included for analysis (673 men; mean age, 63.5±14.0 years), with an overall in-hospital mortality of 10.6%. In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: increasing age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00–1.06; P =0.044), hypotension/shock (OR, 6.43; 95% CI, 2.88–18.98; P =0.001), periaortic hematoma (OR, 3.06; 95% CI, 1.38–6.78; P =0.006), descending diameter ≥5.5 cm (OR, 6.04; 95% CI, 2.87–12.73; P &lt;0.001), mesenteric ischemia (OR, 9.03; 95% CI, 3.49–23.38; P &lt;0.001), acute renal failure (OR, 3.61; 95% CI, 1.68–7.75; P =0.001), and limb ischemia (OR, 3.02; 95% CI, 1.05–8.68; P =0.040). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed. Conclusions— We present a simple prediction model using variables that are independently associated with in-hospital mortality in patients with ABAD. Although it needs to be validated in an independent population, this model could be used to assist physicians in their choice of management and for informing patients and their families.

<h3>Objectives</h3> The management strategy remains controversial for patients presenting with type A acute aortic dissection with cerebrovascular accident or coma. The present study aimed to help guide surgeons treating these high-risk patients. <h3>Methods</h3> Of 1873 patients with type A acute aortic dissection enrolled in the International Registry for Acute Dissection, 87 (4.7%) presented with cerebrovascular accident and 54 (2.9%) with coma. The hospital and 5-year results were stratified by the presence and type of brain injury (no injury vs stroke vs coma) and management type (medical vs surgical). Independent predictors of short- and mid-term survival were identified. <h3>Results</h3> Presentation with shock, hypotension, or tamponade (46.8% vs 25.2%; <i>P</i> < .001) and arch vessel involvement (55.0% vs 36.1%; <i>P</i> < .001) was more likely in patients with brain injury. Surgical management was avoided more often in patients with coma (33.3%) or cerebrovascular accident (24.1%) than in those without brain injury (11.1%; <i>P</i> < .001). The overall hospital mortality was 22.7% without brain injury, 40.2% with cerebrovascular accident, and 63.0% with coma (<i>P</i> < .001). Mortality varied among the management types for both cerebrovascular accident (76.2% medical vs 27.0% surgical; <i>P</i> < .001) and coma (100% medical vs 44.4% surgical; <i>P</i> < .001). Postoperatively, cerebrovascular accident and coma resolved in 84.3% and 78.8% of cases, respectively. On logistic regression analysis, surgery was protective against mortality in patients presenting with brain injury (odds ratio 0.058; <i>P</i> < .001). The 5-year survival of patients presenting with cerebrovascular accident and coma was 23.8% and 0% after medical management versus 67.1% and 57.1% after surgery (log rank, <i>P</i> < .001), respectively. <h3>Conclusions</h3> Brain injury at presentation adversely affects hospital survival of patients with type A acute aortic dissection. In the present observational study, the patients selected to undergo surgery demonstrated improved late survival and frequent reversal of neurologic deficits.

A considerable number of patients with acute type B aortic dissection (ABAD) treated with medical management alone will exhibit aortic enlargement during follow-up, which could lead to aortic aneurysm and rupture. The purpose of this study was to investigate predictors of aortic expansion among ABAD patients enrolled in the International Registry of Acute Aortic Dissection.We analyzed 191 ABAD patients treated with medical therapy alone enrolled in the registry between 1996 and 2010, with available descending aortic diameter measurements at admission and during follow-up. The annual aortic expansion rate was calculated for all patients, and multivariate regression analysis was used to investigate factors affecting the expansion rate.Aortic expansion was observed in 59% of ABAD patients; mean expansion rate was 1.7±7 mm/y. In multivariate analysis, white race (regression coefficient [RC], 4.6; 95% confidence interval [CI], 1.4 to 7.7) and an initial aortic diameter less than 4.0 cm (RC, 6.3; 95% CI, 4.0 to 8.6) were associated with increased aortic expansion. Female sex (RC, -3.8; 95% CI, -6.1 to -1.4), intramural hematoma (RC, -3.8; 95% CI, -6.5 to -1.1), and use of calcium-channel blockers (RC, -3.8; 95% CI, -6.2 to -1.3) were associated with decreased aortic expansion.White race and a small initial aortic diameter were associated with increased aortic expansion during follow-up, and decreased aortic expansion was observed among women, patients with intramural hematoma, and those on calcium-channel blockers. These data raise the possibility that the use of calcium-channel blockers after ABAD may reduce the rate of aortic expansion, and therefore further investigation is warranted.

Aortic root management in type A acute aortic dissection is controversial. This study compared outcomes of root replacement (RR) interventions versus more conservative root (CR) management.Of 1,995 type A acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection, 699 (35%) underwent RR interventions and 1,296 (65%) underwent CR management. Independent predictors of hospital and 3-year survival were identified using multivariable logistic and Cox regression models.Compared with CR patients, RR patients were younger (56.9 versus 62.3 years; p = 0.023) and more likely to present with larger root diameter (4.7 cm versus 4.0 cm; p < 0.001), Marfan syndrome (8.7% versus 2.5%; p < 0.001), aortic insufficiency (64.0% versus 50.3%; p < 0.001), and hypotension, shock, or tamponade (33.0% versus 26.5%; p = 0.003). Root replacement management did not increase hospital mortality (propensity score-adjusted odds ratio, 1.14; p = 0.674). On Kaplan-Meier analysis, 3-year survival (RR, 92.5% ± 1.7% versus CR, 91.6% ± 1.3%; log-rank p = 0.623) and freedom from aortic root reintervention (RR, 99.2% ± 0.1% versus CR, 99.3% ± 0.1%; log-rank p = 0.770) were similar. Only 2 patients (1 per group) underwent follow-up root reintervention. Propensity score-adjusted Cox regression excluded a relationship between root treatment and follow-up survival (hazard ratio, 1.5; 95% confidence interval, 0.502 to 5.010; p = 0.432).In type A acute aortic dissection patients more-extensive RR interventions are not associated with increased hospital mortality. This supports such an approach in young patients and patients with connective tissue diseases and bicuspid aortic valves. Excellent midterm survival and freedom from root reintervention in both groups suggest stable behavior of the nonreplaced aortic sinuses at 3 years. Thus, pending studies with longer follow-up, the use of aggressive RR techniques can be determined by patient-specific and dissection-related factors.

<h2>Abstract</h2><h3>Background</h3> 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). <h3>Methods</h3> 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. <h3>Results</h3> The dissection was significantly longer in group I than in group II (43.2 ± 4.9 cm vs 30.4 ± 8.8 cm; <i>P</i> = .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; <i>P</i> = .049). Increasing age was a negative predictor of total aortic diameter growth (odds ratio, 0.902; 95% confidence interval, 0.813-1.00; <i>P</i> = .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. <h3>Conclusions</h3> 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.

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.

Between January 1996 and May 2017, the International Registry on Acute Aortic Dissections has collected information on a total of 6,424 consecutive patients with acute aortic dissection, including 258 individuals with a diagnosis of Marfan syndrome. Patients with Marfan syndrome presented at a significantly younger age compared to patients without Marfan syndrome (38.2±13.2 vs. 63.0±14.0 years; P<0.001) and in general had fewer comorbidities, although they more frequently had a known aortic aneurysm and history of prior cardiac surgery. We noted significantly larger diameters of the aortic annulus and root in the Marfan syndrome cohort, but no larger diameters more distally. The in-hospital mortality in type A dissection was not significantly different in patients with or without Marfan syndrome, despite the differences in age and comorbidities and the lower incidence of aortic rupture in the Marfan syndrome cohort. In contrast, the in-hospital mortality of Marfan syndrome patients with type B dissection appears to be lower than that of patients without Marfan syndrome. The Marfan syndrome cohort that was treated with open surgery for type B dissection seemed to do especially well, with a 0% mortality rate (n=27). Follow-up data for type A and B dissections combined show an estimated five-year survival rate of 80.1% and an estimated reintervention rate of 55.3% in patients with Marfan syndrome. Such a high rate of reinterventions highlights the need for careful surveillance and treatment for patients with Marfan syndrome surviving the acute phase of aortic dissection.

ObjectivesAcute type B aortic dissection can have a stable course or evolve into aneurysm and subsequent adverse events. The aim of this systematic review was to analyze the morphologic predictors of an adverse course to establish their validity based on consistency of results.MethodsFifty-one studies were included in this review, reporting on aortic size, false lumen (FL) size, primary entry tear (ET) size and location, status of FL thrombosis, number of ETs, branch vessels involvement, and FL longitudinal extent.ResultsSome predictors showed good consistency, whereas others did not. Aortic size was the most investigated predictor. A larger diameter at presentation predicted worse outcomes, with few exceptions. Both FL size and size relative to true lumen size also predicted an adverse course, although a standardized measurement method was not used. Regarding primary ET size and location, evidence was sparse and somewhat conflicting. Although FL complete thrombosis was consistently associated with a more benign course, the role of partial thrombosis remained unclear and the concept of FL saccular formation might account for the inconsistency, but further evidence is needed. A higher number of re-entry tears was considered to be protective against false channel expansion, but results need to be confirmed. The predictive role of branch vessels involvement and FL longitudinal extent remain controversial.ConclusionsAmong several predictors of aortic growth and events in acute type B aortic dissection, controversial and even conflicting results have been described. Consistent evidence has been demonstrated only for two predictors: aortic size at presentation is associated with adverse events and total FL thrombosis has a protective role.

BackgroundThe strategy for intervention remains controversial for patients presenting with type A aortic dissection (TAAAD) and cerebral malperfusion with neurologic deficit.MethodsSurgically managed patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection were evaluated to determine the incidence and prognosis of patients with cerebral malperfusion.ResultsA total of 2402 patients underwent surgical repair of TAAAD. Of these, 362 (15.1%) presented with cerebral malperfusion (CM) and neurologic deficits, and 2040 (84.9%) patients had no neurologic deficits at presentation. Patients with CM were more less likely to present with chest pain (66% vs 86.5%; P < .001) and back pain (35.9% vs 44.4%; P = .008). Patients with CM were more likely to present with syncope (48.4% vs 10.1%; P < .001), peripheral malperfusion (52.7% vs 38.0%; P < .001), and shock (16.2% vs 4.1%; P < .001). There was no difference in the incidence of Marfan syndrome (2.8% vs 3.0%; P = .870) or history of known aortic aneurysm (11.7% vs 13.9%; P = .296). Patients with CM were more likely to have a DeBakey I (63.8% vs 47.1%; P < .001) and a pericardial effusion (53.8% vs 40.6; P < .001) on presentation. There was no difference in total arch replacement (21.3% for CM vs 19.5% for no CM; P = .473). Patients with CM had an increased incidence of postoperative cerebrovascular accident (17.5% vs 7.2%; P < .001) and acute kidney injury (28.3% vs 18.1%; P < .001). In-hospital mortality was greater in patients with CM (25.7% vs 12.0%; P < .001).ConclusionsFifteen percent of patients with TAAAD presented with CM and neurologic deficits. Despite the fact that this subset of the population was older and more likely to present with peripheral malperfusion, cardiac tamponade, and in shock, in-hospital survival was noted in nearly 75% of the patients. Surgeons may continue to offer lifesaving surgery for TAAAD to this critically ill cohort of patients with acceptable morbidity and mortality.

The study objective was to analyze the outcomes of thoracic endovascular aortic repair performed for complicated and uncomplicated acute type B aortic dissections.Patients from WL Gore's Global Registry for Endovascular Aortic Treatment who underwent thoracic endovascular aortic repair for acute type B aortic dissections were included, and data were retrospectively analyzed.Of 5014 patients enrolled in the Global Registry for Endovascular Aortic Treatment, 172 underwent thoracic endovascular aortic repair for acute type B aortic dissections. Of these repairs, 102 were for complicated acute type B aortic dissections and 70 were for uncomplicated acute type B aortic dissections. There were 46 (45.1%) procedures related to aortic branch vessels versus 15 (21.4%) in complicated type B aortic dissections and uncomplicated type B aortic dissections (P = .002). The mean length of stay was 14.3 ± 10.6 days (median, 11; range, 2-75) versus 9.8 ± 7.9 days (median, 8; range, 0-42) in those with complicated type B aortic dissections versus those with uncomplicated acute type B aortic dissections (P < .001). Thirty-day mortality was not different between groups (complicated type B aortic dissections 2.9% vs uncomplicated acute type B aortic dissections 1.4%, P = .647), as well as aortic complications (8.8% vs 5.7%, P = .449). Aortic event-free survival was 62.9% ± 37.1% versus 70.6% ± 29.3% at 3 years (P = .696).In the Global Registry for Endovascular Aortic Treatment, thoracic endovascular aortic repair results for complicated type B aortic dissections versus uncomplicated acute type B aortic dissections showed that 30-day mortality and perioperative complications were equally low for both. The midterm outcome was positive. These data confirm that thoracic endovascular aortic repair as the first-line strategy for treating complicated type B dissections is associated with a low risk of complications. Further studies with longer follow-up are necessary to define the role of thoracic endovascular aortic repair in uncomplicated acute type B dissections compared with medical therapy. However, in the absence of level A evidence from randomized trials, results of the uncomplicated acute type B aortic dissection patient cohort treated with thoracic endovascular aortic repair from registries are important to understand the related risk and benefit.

Vascular compromise seen with pulse deficits is common in patients with type A dissection. However, patient characteristics and in-hospital outcomes associated with pulse deficits have not been evaluated. Accordingly, we studied 513 patients (mean age 62 +/- 14 years, 65% men) with acute type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection. Pulse deficits, defined as decreased or absent carotid or peripheral pulses as noted by clinicians and later confirmed by diagnostic imaging, at surgery or at autopsy were noted in 154 patients (30%). Age <70 years, male gender, neurologic deficit(s), altered mental status, and hypotension, shock, or tamponade on admission were all significantly higher in patients with than without pulse deficits. The etiology of aortic dissection, clinical symptoms, and imaging findings were similar in the 2 groups. In-hospital complications (hypotension, coma, renal failure, and limb ischemia) and mortality (41% vs 25%, p = 0.0002) were significantly higher in patients with pulse deficit. Cox proportional-hazards regression analysis identified pulse deficit as an independent predictor of 5-day in-hospital mortality (risk ratio 2.73, 95% confidence interval 1.7 to 4.4; p <0.0001). Further, overall mortality rates increased with an increasing number of pulse deficits (p for trend <0.0001). Pulse deficits are common findings in patients with type A aortic dissection and identify those at high risk of in-hospital adverse events. This simple clinical sign should direct physicians to consider a diagnosis of aortic dissection in patients with acute chest pain, and should help identify a subgroup of patients who would benefit from more aggressive strategies.

Structural alterations of aortic wall resulting from degradation of matrix proteins by matrix metalloproteinases (MMPs) characterize abdominal aortic aneurysms (AAAs). No studies have compared circulating levels of MMPs after endovascular graft (EVG) exclusion in comparison with open surgical repair (OSR) in patients affected by AAA.An abdominal angiography and CT scan were performed in all patients at the time of enrollment. A spiral CT scan was performed at 6 months to detect presence of endoleaks. MMP-3 and MMP-9 levels were measured before EVG (n=30) and OSR (n=15) treatments and at 1, 3, and 6 months of follow-up by a sandwich ELISA technique. Healthy volunteers (n=10) were used as control subjects. Immunohistochemical staining for MMP-9 and MMP-3 was performed on tissue samples from surgical cases. Both MMP-9 and MMP-3 mean basal levels were significantly higher in patients affected by AAA than in control subjects (32.3+/-20.7 ng/mL for EVG and 28+/-9.9 ng/mL for OSR versus 8.9+/-2.5 ng/mL, 2P<0.05; 18.3+/-9.7 ng/mL and 26.7+/-10.8 ng/mL versus 8.2+/-5.3 ng/mL, 2P<0.001). In the OSR group, both MMP-9 and MMP-3 mean levels decreased after surgery (28+/-9.9 ng/mL at basal versus 14.7+/-6.6 ng/mL at 6 months, 2P<0.001; 26.7+/-10.8 versus 12+/-5.3 ng/mL; 2P<0.001). In the EVG group, a statistically significant difference at 6-month follow-up in MMP-9 and MMP-3 mean plasma values was detected in patients who had endoleakage in comparison with patients without endoleakage (44.3+/-20.7 versus 14.6+/-7.0 ng/mL, 2P<0.005; 25+/-11.5 versus 10.3+/-5.4 ng/mL, 2P<0.005).After EVG exclusion, MMP-9 and MMP-3 levels decreased to a level similar to that of patients undergoing OSR. In addition, a lack of decrease in MMP levels after EVG exclusion may help in identifying patients who will have endoleakage and consequent aneurysm expansion caused by continuous sac pressurization during follow-up.

Ruptured descending thoracic aortic aneurysm (rDTAA) is a cardiovascular catastrophe, associated with high morbidity and mortality, which can be managed either by open surgery or thoracic endovascular aortic repair (TEVAR). The purpose of this study is to retrospectively compare the mortality, stroke, and paraplegia rates after open surgery and TEVAR for the management of rDTAA.Patients with rDTAA treated with TEVAR or open surgery between 1995 and 2010 at seven institutions were identified and included for analysis. The outcomes between both treatment groups were compared; the primary end point of the study was a composite end point of death, permanent paraplegia, and/or stroke within 30 days after the intervention. Multivariate logistic regression analysis was used to identify risk factors for the primary end point.A total of 161 patients with rDTAA were included, of which 92 were treated with TEVAR and 69 with open surgery. The composite outcome of death, stroke, or permanent paraplegia occurred in 36.2% of the open repair group, compared with 21.7% of the TEVAR group (odds ratio [OR], 0.49; 95% confidence interval [CI], .24-.97; P = .044). The 30-day mortality was 24.6% after open surgery compared with 17.4% after TEVAR (OR, 0.64; 95% CI, .30-1.39; P = .260). Risk factors for the composite end point of death, permanent paraplegia, and/or stroke in multivariate analysis were increasing age (OR, 1.04; 95% CI, 1.01-1.08; P = .036) and hypovolemic shock (OR, 2.47; 95% CI, 1.09-5.60; P = .030), while TEVAR was associated with a significantly lower risk of the composite end point (OR, 0.44; 95% CI, .20-.95; P = .039). The aneurysm-related survival of patients treated with open repair was 64.3% at 4 years, compared with 75.2% for patients treated with TEVAR (P = .191).Endovascular repair of rDTAA is associated with a lower risk of a composite of death, stroke, and paraplegia, compared with traditional open surgery. In rDTAA patients, endovascular management appears the preferred treatment when this method is feasible.

Isolated acute dissection of the abdominal aorta is an unusual event that may present with several different clinical scenarios. Because its incidence is low, the natural history is unknown. We report data from the International Registry of Acute Aortic Dissection (IRAD), the largest group of patients treated for acute aortic dissections. The aim of this study was to identify clinical characteristics, therapeutic approaches, risk factors for mortality, in-hospital outcome, and long-term results of this cohort, thus clarifying its natural history.A comprehensive analysis of 290 clinical variables on 18 patients affected by isolated acute abdominal aortic dissection (IAAAD) was performed. Among 1417 patients enrolled in the IRAD from 1996 to 2003, 532 (37.5%) had an acute type B dissection, of which 18 (1.3%) had an IAAAD. Theor mean age was 67.7 +/- 13.3 years, with a male predominance (n = 12, 67%). Aortic aneurysms pre-existed in 5 patients (28%). IAAAD was iatrogenic in 2 cases (11%).Compared with patients with type B aortic dissections, abdominal pain, mesenteric ischemia or infarction, limb ischemia, and hypotension as initial clinical signs were significantly more frequent in patients with IAAAD, whereas chest pain was more typical in patients with type B dissections. No neurologic symptoms, such as ischemic spinal cord damage or ischemic peripheral neuropathy, occurred in the IAAAD cohort. The 18 IAAAD patients were medically, surgically, or percutaneously managed in 12 (66.6%), five (27.8%), and one (5.6%) cases, respectively. The overall in-hospital mortality rate was 5.6% (n = 1). The patient who died was medically managed. No deaths were reported among patients who underwent surgery or had an endovascular procedure, irrespective of their preoperative status. A mean follow-up of 5 years (range, 1 month to 9 years) was completed for 71% (12 of 17) of the patients. Four patients (33.3%) died during the 9-year follow-up period. Overall survival was 93.3% +/- 12.6% at 1 year and 73.3% +/- 27.2% at 5 years. All patients who died during the follow-up period had in-hospital medical management (P = .04).IAAAD is a condition that may present differently compared with classic type B aortic dissections. IAAAD patients treated with surgical or endovascular procedures had a lower unadjusted in-hospital and long-term mortality rate compared with medically managed patients. On the basis of the present natural history report, continued surveillance appears mandatory. To improve the life expectancy of patients with IAAAD, aggressive surgical or endovascular management seems justified.

AimsThe early diagnosis of acute aortic dissection (AD) remains challenging. We sought to determine the utility of the troponin-like protein of smooth muscle, calponin, as a diagnostic biomarker of acute AD.

BackgroundAortobronchial fistula (ABF) and aortoesophageal fistula (AEF) are rare but lethal if untreated; open thoracic surgery is associated with high operative mortality and morbidity. In this case series, we sought to investigate outcomes of thoracic endovascular aortic repair (TEVAR) for emergency cases of ABF and AEF.MethodsWe retrospectively reviewed all patients with AEF and ABF undergoing TEVAR in three European teaching hospitals between 2000 and January 2009. Eleven patients were identified including 6 patients with ABF, 4 patients with AEF, and 1 patient with a combined ABF and AEF. In-hospital outcomes and follow-up after TEVAR were evaluated.ResultsMedian age was 63 years (interquartile range, 31); 8 were male. Ten patients presented with hemoptysis or hematemesis; 4 developed hemorrhagic shock. All patients underwent immediate TEVAR, and 3 AEF patients required additional esophageal surgery. Five patients died (45%), including 3 patients with AEF, 1 patient with ABF, and 1 patient with a combined ABF and AEF, after a median duration of 22 days (interquartile range, 51 days). The patient with AEF that survived had received early esophageal reconstruction. Causes of death were: sepsis (n = 2), acute respiratory distress syndrome (ARDS) (n = 1), thoracic infections (n = 1), and aortic rupture (n = 1). Median follow-up of surviving patients was 45 months (interquartile range, 45 months). Six additional vascular interventions were performed in 3 survivors.ConclusionTEVAR does prevent immediate exsanguination in patients admitted with AEF and ABF, but after initial deployment of the endograft and control of the hemodynamic status, most patients, in particular those with AEF, are at risk for infectious complications. Early esophageal repair after TEVAR appears to improve the survival in case of AEF. Therefore, TEVAR may serve as a bridge to surgery in emergency cases of AEF with subsequent definitive open operative repair of the esophageal defect as soon as possible. In patients with ABF, additional open surgery may not be necessary after the endovascular procedure. Aortobronchial fistula (ABF) and aortoesophageal fistula (AEF) are rare but lethal if untreated; open thoracic surgery is associated with high operative mortality and morbidity. In this case series, we sought to investigate outcomes of thoracic endovascular aortic repair (TEVAR) for emergency cases of ABF and AEF. We retrospectively reviewed all patients with AEF and ABF undergoing TEVAR in three European teaching hospitals between 2000 and January 2009. Eleven patients were identified including 6 patients with ABF, 4 patients with AEF, and 1 patient with a combined ABF and AEF. In-hospital outcomes and follow-up after TEVAR were evaluated. Median age was 63 years (interquartile range, 31); 8 were male. Ten patients presented with hemoptysis or hematemesis; 4 developed hemorrhagic shock. All patients underwent immediate TEVAR, and 3 AEF patients required additional esophageal surgery. Five patients died (45%), including 3 patients with AEF, 1 patient with ABF, and 1 patient with a combined ABF and AEF, after a median duration of 22 days (interquartile range, 51 days). The patient with AEF that survived had received early esophageal reconstruction. Causes of death were: sepsis (n = 2), acute respiratory distress syndrome (ARDS) (n = 1), thoracic infections (n = 1), and aortic rupture (n = 1). Median follow-up of surviving patients was 45 months (interquartile range, 45 months). Six additional vascular interventions were performed in 3 survivors. TEVAR does prevent immediate exsanguination in patients admitted with AEF and ABF, but after initial deployment of the endograft and control of the hemodynamic status, most patients, in particular those with AEF, are at risk for infectious complications. Early esophageal repair after TEVAR appears to improve the survival in case of AEF. Therefore, TEVAR may serve as a bridge to surgery in emergency cases of AEF with subsequent definitive open operative repair of the esophageal defect as soon as possible. In patients with ABF, additional open surgery may not be necessary after the endovascular procedure.

This study sought to evaluate the prevalence, risk factors, outcomes, and predictors of mortality of retroperitoneal hematoma (RPH) following percutaneous coronary intervention.Retroperitoneal hematoma is a serious complication of invasive cardiovascular procedures.The study sample included 112,340 consecutive patients undergoing percutaneous coronary intervention in a large, multicenter registry between October 2002 and December 2007. End points evaluated included the development of RPH and mortality.Retroperitoneal hematoma occurred in 482 (0.4%) patients. Of these, 92.3% were treated medically and 7.7% underwent surgical repair. Female sex, body surface area <1.8 m(2), emergency procedure, history of chronic obstructive pulmonary disease, cardiogenic shock, pre-procedural IV heparin, pre-procedural glycoprotein IIb/IIIa inhibitors, adoption of sheath size >or=8-F, and use of vascular closure devices were independent predictors of RPH, whereas the use of bivalirudin was associated with a lower risk. The development of RPH was associated with a higher frequency of post-procedure myocardial infarction (5.81% vs. 1.67%, p < 0.0001), infection and/or sepsis (17.43% vs. 3.00%, p < 0.0001), and heart failure (8.00% vs. 1.63%, p < 0.0001). In-hospital mortality was significantly higher in patients who developed RPH than in patients who did not (6.64% vs. 1.07%, p < 0.0001). Among patients with RPH, independent predictors of death were history of myocardial infarction, cardiogenic shock, pre-procedural creatinine >or=1.5 mg/dl, and left ventricular ejection fraction <50%.Retroperitoneal hematoma is an uncommon complication of contemporary percutaneous coronary intervention associated with high morbidity and mortality. The identification of risk factors for the development of RPH could lead to modification of procedure strategies aimed toward reducing its incidence.

Open repair is the gold standard for type A aortic dissection (TAAD). Endovascular option has been proposed in very limited and selected TAAD patients. We report our experience with endovascular TAAD repair.Inclusion criteria were: (1) entry tear in the ascending aorta; (2) proximal landing zone of at least 2 cm; (3) distance between entry tear and brachio-cephalic trunk of at least 0.5 cm; (4) no signs of cardiac tamponade or severe aortic regurgitation and (5) no signs of aortic branches ischaemia. Patients with cardiac revascularisation from ascending aorta were excluded.From April 2009 to June 2012, 37 patients with TAAD were admitted to our hospital. As many as 28 underwent surgical repair and 9 were considered at high surgical risk in a multidisciplinary meeting. Four met our inclusion criteria for an endovascular approach. Two of them had previous ascending aortic repair for TAAD and one had aortic valve replacement. Technical success was achieved in 100% of the patients. No mortality was registered during a median follow-up of 15 months (range 4-39 months), no migration of the graft and complete false lumen thrombosis of the ascending aorta in three patients.Endovascular treatment of TAAD is challenging but feasible in a selected subset of patients. Further research remains mandatory.

ObjectiveThe risk of acute type B aortic dissection is thought to increase with descending thoracic aortic diameter. Currently, elective repair of the descending thoracic aorta is indicated for an aortic diameter of 5.5 cm or greater. We sought to investigate the relationship between aortic diameter and acute type B aortic dissection, and the utility of aortic diameter as a predictor of acute type B aortic dissection.MethodsWe examined the descending aortic diameter at presentation of 613 patients with acute type B aortic dissection who were enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2009, and analyzed the subset of patients with acute type B aortic dissection with an aortic diameter less than 5.5 cm.ResultsThe median aortic diameter at the level of acute type B aortic dissection was 4.1 cm (range 2.1–13.0 cm). Only 18.4% of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection had an aortic diameter of 5.5 cm or greater. Patients with Marfan syndrome represented 4.3% and had a slightly larger aortic diameter than patients without Marfan syndrome (4.68 vs 4.32 cm, P = .121). Complicated acute type B aortic dissection was more common among patients with an aortic diameter of 5.5 cm or greater (52.2% vs 35.6%, P < .001), and the in-hospital mortality for patients with an aortic diameter less than 5.5 cm and 5.5 cm or greater was 6.6% and 23.0% (P < .001), respectively.ConclusionsThe majority of patients with acute type B aortic dissection present with a descending aortic diameter less than 5.5 cm before dissection and are not within the guidelines for elective descending thoracic aortic repair. Aortic diameter measurements do not seem to be a useful parameter to prevent aortic dissection, and other methods are needed to identify patients at risk for acute type B aortic dissection. The risk of acute type B aortic dissection is thought to increase with descending thoracic aortic diameter. Currently, elective repair of the descending thoracic aorta is indicated for an aortic diameter of 5.5 cm or greater. We sought to investigate the relationship between aortic diameter and acute type B aortic dissection, and the utility of aortic diameter as a predictor of acute type B aortic dissection. We examined the descending aortic diameter at presentation of 613 patients with acute type B aortic dissection who were enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2009, and analyzed the subset of patients with acute type B aortic dissection with an aortic diameter less than 5.5 cm. The median aortic diameter at the level of acute type B aortic dissection was 4.1 cm (range 2.1–13.0 cm). Only 18.4% of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection had an aortic diameter of 5.5 cm or greater. Patients with Marfan syndrome represented 4.3% and had a slightly larger aortic diameter than patients without Marfan syndrome (4.68 vs 4.32 cm, P = .121). Complicated acute type B aortic dissection was more common among patients with an aortic diameter of 5.5 cm or greater (52.2% vs 35.6%, P < .001), and the in-hospital mortality for patients with an aortic diameter less than 5.5 cm and 5.5 cm or greater was 6.6% and 23.0% (P < .001), respectively. The majority of patients with acute type B aortic dissection present with a descending aortic diameter less than 5.5 cm before dissection and are not within the guidelines for elective descending thoracic aortic repair. Aortic diameter measurements do not seem to be a useful parameter to prevent aortic dissection, and other methods are needed to identify patients at risk for acute type B aortic dissection.

<h3>Objective</h3> Acute type B aortic dissection (ABAD) can lead to visceral malperfusion, a potentially life-threatening complication. The purpose of this study was to investigate the presentation, management, and outcomes of ABAD patients with visceral ischemia who are enrolled in the International Registry of Acute Aortic Dissection. <h3>Methods</h3> Patients with ABAD enrolled in the registry between 1996 and 2013 were identified and stratified based on presence of visceral ischemia at admission. Demographics, medical history, imaging results, management, and outcomes were compared for patients with versus without visceral ischemia. <h3>Results</h3> A total of 1456 ABAD patients were identified, of which 104 (7.1%) presented with visceral ischemia. Preoperative limb ischemia (28% vs 7%, <i>P</i> < .001) and acute renal failure (41% vs 14%, <i>P</i> < .001) were more common among patients with visceral ischemia. Endovascular treatment and surgery were offered to 49% and 30% of the visceral ischemia cohort, respectively; remaining patients were managed conservatively. The in-hospital mortality was 30.8% for patients with visceral ischemia and 9.1% for those without visceral ischemia (odds ratio [OR] 4.44; 95% confidence interval [CI], 2.8-7.0, <i>P</i> < .0001). Mortality rates were similar after surgical and endovascular management of visceral ischemia (25.8% and 25.5%, respectively, <i>P</i> = not significant). Among the visceral ischemia group, medical management was a predictor of mortality in multivariate analysis (OR, 5.91; 95% CI, 1.2-31.0; <i>P</i> = .036). <h3>Conclusions</h3> Patients with ABAD complicated by visceral ischemia have a high risk of mortality. We observed similar outcomes for patients treated by endovascular management versus surgery, whereas medical management was an independent predictor of mortality. Early diagnosis and intervention for visceral ischemia seems to be crucial.

BackgroundAortic growth rate in acute type B aortic dissection (ABAD) is a significant predictor for aortic complications and death. To improve the overall outcome, radiologic predictors might stratify patients who benefit from successful medical management vs those who require intervention. This study investigated whether the number of identifiable entry tears in ABAD patients is associated with aortic growth.MethodsABAD patients with uncomplicated clinical conditions and therefore treated with medical therapy were evaluated. Those with a computed tomography angiography (CTA) obtained at clinical presentation and a subsequent CTA obtained at least 90 days after medical treatment were included (2005 to 2010). The CTAs were investigated for the number of entry tears between the true and false lumen. Diameters of the dissected aortas were measured at five levels on the baseline and on the last available follow-up CTA, and annual aortic growth rates were calculated. The number of entry tears in these patients and the location in the aorta were compared with the aortic growth rate.ResultsIncluded were 60 patients who presented with 243 dissected segments. Mean growth rates during follow-up (median, 23.2; range, 3 to 132 months) were significantly higher in patients with 1 entry tear (5.6 ± 8.9 mm) than in those with 2 (2.1 ± 1.7 mm; p = 0.001) and 3 entry tears (mean 2.2 ± 4.1; p = 0.010). The distance of the primary entry tear from the left subclavian artery did not have an effect on the aortic growth rate (median, 38; interquartile range, 24 to 137 mm; p = 0.434).ConclusionsThe number of entry tears in ABAD patients detected on the first CTA after clinical presentation is a significant predictor for aortic growth. Patients with 1 entry tear at presentation show a higher growth rate than other patients and might benefit from more strict surveillance or early prophylactic intervention. Aortic growth rate in acute type B aortic dissection (ABAD) is a significant predictor for aortic complications and death. To improve the overall outcome, radiologic predictors might stratify patients who benefit from successful medical management vs those who require intervention. This study investigated whether the number of identifiable entry tears in ABAD patients is associated with aortic growth. ABAD patients with uncomplicated clinical conditions and therefore treated with medical therapy were evaluated. Those with a computed tomography angiography (CTA) obtained at clinical presentation and a subsequent CTA obtained at least 90 days after medical treatment were included (2005 to 2010). The CTAs were investigated for the number of entry tears between the true and false lumen. Diameters of the dissected aortas were measured at five levels on the baseline and on the last available follow-up CTA, and annual aortic growth rates were calculated. The number of entry tears in these patients and the location in the aorta were compared with the aortic growth rate. Included were 60 patients who presented with 243 dissected segments. Mean growth rates during follow-up (median, 23.2; range, 3 to 132 months) were significantly higher in patients with 1 entry tear (5.6 ± 8.9 mm) than in those with 2 (2.1 ± 1.7 mm; p = 0.001) and 3 entry tears (mean 2.2 ± 4.1; p = 0.010). The distance of the primary entry tear from the left subclavian artery did not have an effect on the aortic growth rate (median, 38; interquartile range, 24 to 137 mm; p = 0.434). The number of entry tears in ABAD patients detected on the first CTA after clinical presentation is a significant predictor for aortic growth. Patients with 1 entry tear at presentation show a higher growth rate than other patients and might benefit from more strict surveillance or early prophylactic intervention.

Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time.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).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).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.

IntroductionAortic 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.MethodsA 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.ResultsAs compared with the ABAD, IMHB presented predominantly in males (62% vs 33%; P < .001) at older age (69 ± 12 vs 63 ± 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).ConclusionsMost 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.

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.

Abstract OBJECTIVES Current endografts for thoracic endovascular aortic repair (TEVAR) are much stiffer than the aorta and have been shown to induce acute stiffening. In this study, we aimed to estimate the impact of TEVAR on left ventricular (LV) stroke work (SW) and mass using a non-invasive image-based workflow. METHODS The University of Michigan database was searched for patients treated with TEVAR for descending aortic pathologies (2013–2016). Patients with available pre-TEVAR and post-TEVAR computed tomography angiography and echocardiography data were selected. LV SW was estimated via patient-specific fluid–structure interaction analyses. LV remodelling was quantified through morphological measurements using echocardiography and electrocardiographic-gated computed tomography angiography data. RESULTS Eight subjects were included in this study, the mean age of the patients was 68 (73, 25) years, and 6 patients were women. All patients were prescribed antihypertensive drugs following TEVAR. The fluid–structure interaction simulations computed a 26% increase in LV SW post-TEVAR [0.94 (0.89, 0.34) J to 1.18 (1.11, 0.65) J, P = 0.012]. Morphological measurements revealed an increase in the LV mass index post-TEVAR of +26% in echocardiography [72 (73, 17) g/m2 to 91 (87, 26) g/m2, P = 0.017] and +15% in computed tomography angiography [52 (46, 29) g/m2 to 60 (57, 22) g/m2, P = 0.043]. The post- to pre-TEVAR LV mass index ratio was positively correlated with the post- to pre-TEVAR ratios of SW and the mean blood pressure (ρ = 0.690, P = 0.058 and ρ = 0.786, P = 0.021, respectively). CONCLUSIONS TEVAR was associated with increased LV SW and mass during follow-up. Medical device manufacturers should develop more compliant devices to reduce the stiffness mismatch with the aorta. Additionally, intensive antihypertensive management is needed to control blood pressure post-TEVAR.

Patients presenting with type A acute aortic dissection (TAAD) complicated by malperfusion syndromes represent one of the highest surgical risk cohorts for cardiovascular surgeons. In the setting of aortic dissection, end-organ ischemia may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral and/or limb ischemia. In TAAD patients with malperfusion, notwithstanding continuous improvement in diagnostic and management strategies, surgical and clinical outcomes remain poor and the optimal therapy is controversial. The present review aimed to assess current evidence on TAAD patients with the complication of malperfusion, as enunciated by the International Registry of Acute Aortic Dissection (IRAD) investigators.

Background Acute aortic dissection associated with cocaine use is rare and has been reported predominantly as single cases or in small patient cohorts. Methods Our study analyzed 3584 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2012. We divided the population on the basis of documented cocaine use (C+) versus noncocaine use (C-) and further stratified the cohorts into type A (33 C+/2332, 1.4%) and type B (30 C+/1252, 2.4%) dissection. Results C+ patients presented at a younger age and were more likely to be male and black. Type B dissections were more common among C+ patients than in C- patients. Cocaine-related acute aortic dissection was reported more often at US sites than at European sites (86.4%, 51/63 vs 13.6%, 8/63; P < .001). Tobacco use was more prevalent in the C+ cohort. No differences were seen in history of hypertension, known atherosclerosis, or time from symptom onset to presentation. Type B C+ patients were more likely to be hypertensive at presentation. C+ patients had significantly smaller ascending aortic diameters at presentation. Acute renal failure was more common in type A C+ patients; however, mortality was significantly lower in type A C+ patients. Conclusions Cocaine use is implicated in 1.8% of patients with acute aortic dissection. The typical patient is relatively young and has the additional risk factors of hypertension and tobacco use. In-hospital mortality for those with cocaine-related type A dissection is lower than for those with noncocaine-related dissection, likely due to the younger age at presentation.

ObjectiveThis study assessed whether the additional use of the aortic arch classification in type I, II, and III may complement Ishimaru's aortic arch map and provide valuable information on the geometry and suitability of proximal landing zones for thoracic endovascular aortic repair.MethodsAnonymized thoracic computed tomography scans of healthy aortas were reviewed and stratified according to the aortic arch classification, and 20 of each type of arch were selected. Further processing allowed calculation of angulation and tortuosity of each proximal landing zone. Data were described indicating both proximal landing zone and type of arch (eg, 0/I).ResultsAngulation was severe (>60°) in 2/III and in 3/III. Comparisons among the types of arch showed an increase in proximal landing zones angulation (P < .001) and tortuosity (P = .009) depending on the type of arch. Comparisons within type of arch showed no change in angulation and tortuosity across proximal landing zones within type I arch (P = .349 and P = .409), and increases in angulation and tortuosity toward more distal proximal landing zones within type II (P = .003 and P = .043) and type III (P < .001 in both).ConclusionsThe aortic arch classification is associated with a consistent geometric pattern of the aortic arch map, which identifies specific proximal landing zones with suboptimal angulation for stent graft deployment. Arches II and III also appear to have progressively less favorable anatomy for thoracic endovascular aortic repair compared with arch I.

The recommended extent of surgical resection and reconstruction of the arch in acute DeBakey Type I aortic dissection is an ongoing controversy. However, several recent reports indicate a trend towards a more extensive arch operation in several institutions. We have analysed the recent data from the International Registry of Acute Aortic Dissection to assess the choice of procedure over time and to evaluate the surgical outcome in a ‘real-world’ database. Our aim was to compare short- and mid-term outcomes of limited repairs versus complete arch surgery. Of the 1241 patients included in the ‘Interventional Cohort’ of the International Registry of Acute Aortic Dissection from March 1996 to March 2015, 907 underwent ascending aortic or hemiarch replacement (Group A) and 334 had extended arch replacement (Group B). An extended resection was a surgeon’s ‘judgement call’. Logistic regression analysis, propensity-adjusted multivariable comparisons and Kaplan–Meier curves were used for analyses. Overall in-hospital mortality was 14.2% with no difference between groups (Group A 13.1%, Group B 17.1%). Coma/altered consciousness (odds ratio 3.16, 95% confidence interval 1.60–6.25, P = 0.001), hypotension, tamponade or shock (2.03, 1.11–3.73, P = 0.022) and any pulse deficit (1.92, 1.04–3.54, P = 0.038) were predictors of in-hospital mortality in a propensity score-adjusted multivariable analysis. Overall 5-year survival was 69.4% in the ascending group and 73.1% in the total arch group (P = 0.83 by Kaplan–Meier analysis). For survivors of the index hospitalization, the 5-year freedom from death, aortic rupture and reintervention were 71.1% in Group A and 76.4% in Group B (P = 0.54 by Kaplan–Meier analysis). Selective, or ‘surgeon’s choice’, extended arch replacement had no discernible acute downside compared with less extensive surgery. Whether extended arch replacement improves the prognosis beyond 5 years remains to be settled.

HomeCirculationVol. 129, No. 15Standardizing Clinical End Points in Aortic Arch Surgery Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBStandardizing Clinical End Points in Aortic Arch SurgeryA Consensus Statement From the International Aortic Arch Surgery Study Group Tristan D. Yan, MBBS, MS, MD, PhD, David H. Tian, BMed, Scott A. LeMaire, MD, PhD, G. Chad Hughes, MD, Edward P. Chen, MD, Martin Misfeld, MD, PhD, Randall B. Griepp, MD, Teruhisa Kazui, MD, PhD, Paul G. Bannon, MBBS, PhD, Joseph S. Coselli, MD, John A. Elefteriades, MD, Nicholas T. Kouchoukos, MD, Malcolm J. Underwood, MD, Joseph P. Mathew, MD, MHSc, Friedrich-Wilhelm Mohr, MD, PhD, Aung Oo, MD, Thoralf M. Sundt, MD, Joseph E. Bavaria, MD, Roberto Di Bartolomeo, MD, Marco Di Eusanio, MD, PhD and Santi Trimarchi, MD, PhDon behalf of the International Aortic Arch Surgery Study Group Tristan D. YanTristan D. Yan From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , David H. TianDavid H. Tian From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Scott A. LeMaireScott A. LeMaire From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , G. Chad HughesG. Chad Hughes From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Edward P. ChenEdward P. Chen From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Martin MisfeldMartin Misfeld From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Randall B. GrieppRandall B. Griepp From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Teruhisa KazuiTeruhisa Kazui From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Paul G. BannonPaul G. Bannon From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Joseph S. CoselliJoseph S. Coselli From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , John A. ElefteriadesJohn A. Elefteriades From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Nicholas T. KouchoukosNicholas T. Kouchoukos From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Malcolm J. UnderwoodMalcolm J. Underwood From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Joseph P. MathewJoseph P. Mathew From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Friedrich-Wilhelm MohrFriedrich-Wilhelm Mohr From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Aung OoAung Oo From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC (G.C.H., J.P.M.); Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (E.P.C.); Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany (M.M., F.-W.M.); Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY (R.B.G.); Cardiovascular Center, Hokkaido Ohno Hospital, Sapporo, Japan (T.K.); Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT (J.A.E.); Missouri Baptist Medical Center, St. Louis (N.T.K.); Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Hong Kong, China (M.J.U.); Liverpool Heart and Chest Hospital, Liverpool, UK (A.O.); Thoracic Aortic Center, Massachusetts General Hospital, Boston (T.M.S.); Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (J.E.B.); Cardiovascular Surgery Department, Sant’Orsola-Malpighi Hospital, Bologna University, Bologna, Italy (R.D.B., M.D.E.); and Thoracic Aortic Research Center, I.R.C.C.S. Policlinico San Donato, Milan, Italy (S.T.). , Thoralf M. SundtThoralf M. Sundt From the Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia (T.D.Y., D.H.T., P.G.B.); Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia (T.D.Y., P.G.B.); Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston (S.A.L., J.S.C.); Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (S.A.L., J.S.C.); Department of Surgery, Division of Cardiovascular and Thoracic Surgery and Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, N

OBJECTIVESTo 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).

Multiple medical device manufacturers are developing branched endografts for thoracic endovascular aortic repair (TEVAR), to provide a minimally invasive alternative for the treatment of aortic arch pathologies in patients who are deemed unfit for open or hybrid arch repair. Different branched endografts have been introduced, with varying number, size and orientation of the branches that redirect flow to the supra-aortic arteries. We present an overview of the currently investigated devices and review their outcomes. The results of branched TEVAR are promising, yet stroke remains the predominant periprocedural concern. For now, these procedures should be limited to select expert centers where the design and deployment procedure of branched endografts can be further developed to reduce the risk of stroke.

<h3>Background</h3> The study sought to learn about incidence and reasons for distal stent graft–induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms. <h3>Methods</h3> In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison. <h3>Results</h3> The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE. <h3>Conclusions</h3> dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.

Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI).Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included.One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated.Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics.Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.

To evaluate early and midterm outcomes of the Candy Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection (AD) in a more real world cohort of patients from an international multicentre registry.A multicentre retrospective study was conducted of all consecutive patients from the contributing centres with subacute and chronic AD treated with the CP technique from October 2013 to April 2020 at 18 centres.A custom made CP was used in 155 patients (92 males, mean age 62 ± 11 years). Fourteen (9%) presented with ruptured false lumen aneurysms. Technical success was achieved in all patients (100%). Clinical success was achieved in 138 patients (89%). The median hospital stay was 7 days (1 - 77). The 30 day mortality rate was 3% (n = 5). Stroke occurred in four patients (3%). Spinal cord ischaemia occurred in three patients (2%). The 30 day computed tomography angiogram (CTA) confirmed successful CP placement at the intended level in all patients. Early complete FL occlusion was achieved in 120 patients (77%). Early (30 day) CP related re-intervention was required in four patients (3%). The early (30 day) stent graft related re-intervention rate was 8% (n = 12). Follow up CTA was available in 142 patients (92%), with a median follow up of 23 months (6 - 87). Aneurysmal regression was achieved in 68 of 142 patients (47%); the aneurysm diameter remained stable in 69 of 142 patients (49%) and increased in five of 142 patients (4%). A higher rate of early FL occlusion was detected in the largest volume centre patients (50 [88%] vs. 70 [71%] from other centres; p = .019). No other differences in outcome were identified regarding volume of cases or learning curve.This international CP technique experience confirmed its feasibility and low mortality and morbidity rates. Aortic remodelling and false lumen thrombosis rates were high and support the concept of distal FL occlusion in AD using the CP technique.

Importance Endovascular treatment is not recommended for aortic pathologies in patients with connective tissue diseases (CTDs) other than in redo operations and as bridging procedures in emergencies. However, recent developments in endovascular technology may challenge this dogma. Objective To assess the midterm outcomes of endovascular aortic repair in patients with CTD. Design, Setting, and Participants For this descriptive retrospective study, data on demographics, interventions, and short-term and midterm outcomes were collected from 18 aortic centers in Europe, Asia, North America, and New Zealand. Patients with CTD who had undergone endovascular aortic repair from 2005 to 2020 were included. Data were analyzed from December 2021 to November 2022. Exposure All principal endovascular aortic repairs, including redo surgery and complex repairs of the aortic arch and visceral aorta. Main Outcomes and Measures Short-term and midterm survival, rates of secondary procedures, and conversion to open repair. Results In total, 171 patients were included: 142 with Marfan syndrome, 17 with Loeys-Dietz syndrome, and 12 with vascular Ehlers-Danlos syndrome (vEDS). Median (IQR) age was 49.9 years (37.9-59.0), and 107 patients (62.6%) were male. One hundred fifty-two (88.9%) were treated for aortic dissections and 19 (11.1%) for degenerative aneurysms. One hundred thirty-six patients (79.5%) had undergone open aortic surgery before the index endovascular repair. In 74 patients (43.3%), arch and/or visceral branches were included in the repair. Primary technical success was achieved in 168 patients (98.2%), and 30-day mortality was 2.9% (5 patients). Survival at 1 and 5 years was 96.2% and 80.6% for Marfan syndrome, 93.8% and 85.2% for Loeys-Dietz syndrome, and 75.0% and 43.8% for vEDS, respectively. After a median (IQR) follow-up of 4.7 years (1.9-9.2), 91 patients (53.2%) had undergone secondary procedures, of which 14 (8.2%) were open conversions. Conclusions and Relevance This study found that endovascular aortic interventions, including redo procedures and complex repairs of the aortic arch and visceral aorta, in patients with CTD had a high rate of early technical success, low perioperative mortality, and a midterm survival rate comparable with reports of open aortic surgery in patients with CTD. The rate of secondary procedures was high, but few patients required conversion to open repair. Improvements in devices and techniques, as well as ongoing follow-up, may result in endovascular treatment for patients with CTD being included in guideline recommendations.

Background Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details. Methods Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI. Results A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001). Conclusions AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.

Aberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset.Patients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak.Overall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms.Treatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate.

The primary objectives of this scoping review were to assess the rate of and risk factors for type Ib endoleak and to evaluate the extent of the evidence base that links type Ib endoleak to short and long term outcomes in patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA).Potentially eligible studies were searched in the Cochrane Central Register of Controlled Trials, MEDLINE, Web of Science Core Collection, SciELO Citation Index, Russian Science Citation Index, and KCI-Korean Journal Database. A scoping review was performed according to PRISMA extension for Scoping Reviews.A total of 27 articles (four prospective registries and 23 retrospective cohort studies) dealing with type Ib endoleak were included in the final analysis. The number of patients reported on was 7 197, with follow up ranging between 12 months and 93 months. The reported frequency of type Ib endoleak in patients treated with EVAR ranged from 0% to 8%, Patient and or procedure related factors associated with risk of type Ib endoleak were (1) common iliac artery (CIA) diameter ˃ 18 mm requiring use of flared stent graft limbs (FLs) ˃ 20 mm, (2) length of CIA landing zone ˂ 20 mm, (3) marked iliac tortuosity, and (4) large initial AAA diameter. Depending on the study, 50 - 100% of type Ib endoleaks were corrected by endovascular means, with a reported immediate technical success of 100% in the studies providing this information.Type Ib endoleak after EVAR has been reported to occur in 0 - 8% of cases. Several anatomical features, including CIA diameter ˃ 18 mm or requiring the use of FLs ˃ 20 mm, length of CIA landing zone ˂ 20 mm, marked iliac tortuosity, and large initial AAA diameter, could increase the risk of type Ib endoleak and may require alternative therapeutic options and or more stringent follow up. Therefore, this updated scoping review provides a comprehensive summary of the frequency, risk factors, prognosis, and treatment of type Ib endoleaks, and has identified knowledge gaps in the literature to guide further studies.

<h2>Abstract</h2><h3>Objective</h3> To investigate associations between patient characteristics, intraprocedural complexity factors, and radiation exposure to patients during endovascular abdominal aortic aneurysm repair (EVAR). <h3>Methods</h3> Elective standard EVAR procedures between January 2015 and December 2020 were retrospectively analyzed. Patient characteristics and intraprocedural data (i.e., type of device, endograft configuration, additional procedures, and contralateral gate cannulation time [CGCT]), were collected. Dose area product (DAP) and fluoroscopy time (FT) were considered as measurements of radiation exposure. Furthermore, effective dose (ED) and doses to internal organs were calculated using PCXMC 2.0 software. Descriptive statistics, univariable and multivariable linear regression were applied to investigate predictors of increased radiation exposure. <h3>Results</h3> The 99 patients were mostly male (90.9%) with a mean age of 74 ± 7 years. EVAR indications were most frequently abdominal aortic aneurysm (AAA, 93.9%), penetrating aortic ulceration (2.0%), focal dissection (2.0%), or subacute rupture of infrarenal AAA (2.0%). Median FT was 19.6 minutes (interquartile range [IQR], 14.1 – 29.4) and median DAP was 86 311 mGy·cm² (IQR, 60 160 – 130 385). Median ED was 23.2 mSv (IQR, 17.0 – 34.8) for 93 patients (93.9%). DAP and ED were positively correlated with body mass index (BMI) and CGCT. Kidneys, small intestine, active bone marrow, colon, and stomach were the organs that received the highest equivalent doses during EVAR. Higher DAP and ED values were observed using the Excluder endograft, other bi- and tri-modular endografts, and EVAR with ≥2 additional procedures. Multivariable linear regression analysis revealed that BMI, ≥2 additional procedures during EVAR, and CGCT were independent positive predictors of DAP and ED levels, after accounting for endograft type. <h3>Conclusions</h3> Patient-related and procedure-related factors such as BMI, ≥2 additional procedures during EVAR, and CGCT resulted predictors of radiation exposure for patients undergoing EVAR, as quantified by higher DAP and ED levels. The main intraprocedural factor that increased radiation exposure was CGCT. These data can be of importance for better managing radiation exposure during EVAR.

Background— Earlier studies evaluating long-term survival in type A acute aortic dissection (TA-AAD) have been restricted to a small number of patients in single center experiences. We used data from a contemporary, multi-center international registry of TA-AAD patients to better understand factors associated with long-term survival. Methods and Results— We examined 303 consecutive patients with TA-AAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. We included patients who were discharged alive and had documented clinical follow-up data. Kaplan-Meier survival curves were constructed to depict cumulative survival in patients from date of hospital discharge. Stepwise Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. We found that 273 (90.1%) patients had been managed surgically and 30 (9.9%) were managed medically. Patients who were dead at follow-up were more likely to be older (63.9 versus 58.4 years, P =0.007) and to have had previous cardiac surgery (23.9% versus 10.6%, P =0.01). Survival for patients treated with surgery was 96.1%±2.4% and 90.5%±3.9% at 1 and 3 years versus 88.6%±12.2% and 68.7%±19.8% without surgery (mean follow-up overall, 2.8 years, log rank P =0.009). Multivariate analysis identified a history of atherosclerosis (relative risk (RR), 2.17; 95% confidence interval [CI], 1.08 to 4.37; P =0.03) and previous cardiac surgery (RR, 2.54; 95% CI, 1.16 to 5.57; P =0.02) as significant, independent predictors of follow-up mortality. Conclusions— Contemporary 1- and 3-year survival in patients with TA-AAD treated surgically are excellent. Independent predictors of survival during the follow-up period do not appear to be influenced by in-hospital risks but rather preexisting comorbidities.

The study aim was to evaluate serologic expression of pregnancy-associated protein-A (PAPP-A) in patients affected by cerebrovascular accidents and to correlate it with histopathologic carotid plaque complexity. Little is known about PAPP-A expression in carotid atherosclerotic disease and whether this protein represents a marker of plaque vulnerability also in carotid district. Seventy-two carotid plaques from patients submitted to surgical endarterectomy (19 who suffered a major stroke, 24 transient ischemic attack, and 29 asymptomatic) were evaluated. Serologic PAPP-A levels were determined by enzyme-linked immunoadsorbent assay. Plaques were divided in three groups based on histology: 1) stable (n = 38); 2) vulnerable (n = 13); 3) ruptured with thrombus (n = 14). Immunohistochemical staining for PAPP-A, smooth muscle cells, macrophages, and T-lymphocytes was performed in all cases. Real-time polymerase chain reaction assessed local PAPP-A production, and double immunofluorescence confocal microscopy (ICM) characterized cell type expressing PAPP-A. Pregnancy-associated protein-A (serologic values were 4.02 ± 0.18 mIU/l in Group 1, 7.43 ± 0.97 mIU/l in Group 2, and 6.97 ± 0.75 mIU/l in Group 3 [1 vs. 3, p = 0.01; 1 vs. 2, p = 0.004; 2 vs. 3, p = 0.71, respectively]). Pregnancy-associated protein-A (expression showed a mean score value of 0.62 ± 0.06 for stable plaques, 2.54 ± 0.14 for vulnerable plaques, and 2.71 ± 0.12 for ruptured plaques [1 vs. 2, p = 0.001; 1 vs. 3, p = 0.001; 2 vs. 3, p = 0.37, respectively]). Real-time polymerase chain reaction demonstrated local messenger ribonucleic acid PAPP-A production, and double ICM confirmed monocyte/macrophage expression of PAPP-A in Groups 2 and 3 but not Group 1. This study suggests that PAPP-A is a marker of carotid plaque destabilization and rupture. Further studies are necessary to determine if PAPP-A can represents a new target for stratifying the risk of cerebrovascular events.

<h2>Abstract</h2><h3>Objective</h3> Although cardiovascular risk factors have been strongly linked to carotid intimal-media thickness, their association with plaque progression towards instability is poorly understood. We evaluated a large database of endarterectomy specimens removed from symptomatic and asymptomatic patients to determine the correlation between major cardiovascular risk factors and carotid plaque morphology. <h3>Methods</h3> Incidence of thrombotic, vulnerable and stable plaques together with the degree of plaque inflammatory infiltration was evaluated in 457 carotid atherosclerotic lesions. Clinical records were reviewed in all cases for risk factors profile. <h3>Results</h3> Thrombotic plaques were more frequently observed in patients affected by stroke (66.9%) as compared to TIA (36.1%) and asymptomatic patients (26.8%, <i>p</i><0.001). Out of 457 carotid plaques removed during carotid endarterectomy, 181 (39.6%) were represented by thrombotic plaques, 72 (15.8%) by vulnerable plaques (thin cap fibroateroma) and 204 (44.6%) by stable plaques. At the multivariate analysis, a strong association was observed between hypertension, low HDL-cholesterol (HDL-C) and ratio of total to HDL-C >5 with vulnerable and thrombotic carotid plaques. Hypertension (<i>p</i>=0.001), hypercholesterolemia (<i>p</i>=0.05) and low HDL-C (<i>p</i>=0.001) significantly also correlated with the presence of high inflammatory infiltrate of the plaque. When multivariate analysis was restricted to asymptomatic patients, hypertension (<i>p</i>=0.009, OR 2.29), low HDL-cholesterol (<i>p</i>=0.01 OR 2.21) and the ratio of total to HDL-C >5 (<i>p</i>=0.03, OR 2.07) were confirmed to be the risk factors most significantly associated to unstable plaques. The relative risk to carry an unstable plaque for asymptomatic patients with high Framingham Risk Score as compared with those with low risk score was 2.06 (95% C.I., 1.26–3.36). <h3>Conclusions</h3> The present histopathological study identifies risk factors predictive of increased risk of carotid plaque rupture and thrombosis. Asymptomatic patients with high risk factors profile may constitute a specific target to reduce the likelihood of cerebrovascular accidents even in the presence of non-flow-limiting plaque.

Thoracic endovascular aortic repair offers a less invasive approach for the treatment of ruptured descending thoracic aortic aneurysms (rDTAA). Due to the low incidence of this life-threatening condition, little is known about the outcomes of endovascular repair of rDTAA and the factors that affect these outcomes.We retrospectively investigated the outcomes of 87 patients who underwent thoracic endovascular aortic repair for rDTAA at 7 referral centers between 2002 and 2009. The mean age was 69.8+/-12 years and 69.0% of the patients were men. Hypovolemic shock was present in 21.8% of patients, and 40.2% were hemodynamically unstable. The 30-day mortality rate was 18.4%, and hypovolemic shock (odds ratio 4.75; 95% confidence interval, 1.37 to 16.5; P=0.014) and hemothorax at admission (odds ratio 6.65; 95% confidence interval, 1.64 to 27.1; P=0.008) were associated with increased 30-day mortality after adjusting for age. Stroke and paraplegia occurred each in 8.0%, and endoleak was diagnosed in 18.4% of patients within the first 30 days after thoracic endovascular aortic repair. Four additional patients died as a result of procedure-related complications during a median follow-up of 13 months; the estimated aneurysm-related mortality at 4 years was 25.4%.Endovascular repair of rDTAA is associated with encouraging results. The endovascular approach was associated with considerable rates of neurological complications and procedure-related complications such as endoleak.

ObjectiveThis study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR).MethodsEight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR.ResultsA total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P < .0001) and urgent/emergency EVAR (P = .01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32 months (interquartile range, 11-75 months) for the ATS group and 14 months (interquartile range, 10.5-21.5 months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15 months, and the remaining three were alive at a median follow-up of 12 months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28 months.ConclusionsLate AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up. This study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR). Eight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR. A total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P < .0001) and urgent/emergency EVAR (P = .01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32 months (interquartile range, 11-75 months) for the ATS group and 14 months (interquartile range, 10.5-21.5 months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15 months, and the remaining three were alive at a median follow-up of 12 months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28 months. Late AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up.

Aortic arch repair remains a major surgical challenge. Multiple manufacturers are developing branched endografts for Zone 0 endovascular repair, extending the armamentarium for minimally invasive treatment of aortic arch pathologies. We hypothesize that the design of the Zone 0 endograft has a significant impact on the postoperative haemodynamic performance, particularly in the cervical arteries. The goal of our study was to compare the postoperative haemodynamic performance of different Zone 0 endograft designs.Patient-specific, clinically validated, computational fluid dynamics simulations were performed in a 71-year-old woman with a 6.5-cm saccular aortic arch aneurysm. Additionally, 4 endovascular repair scenarios using different endograft designs were created. Haemodynamic performance was evaluated by calculation of postoperative changes in blood flow and platelet activation potential (PLAP) in the cervical arteries.Preoperative cervical blood flow and mean PLAP were 1080 ml/min and 151.75, respectively. Cervical blood flow decreased and PLAP increased following endovascular repair in all scenarios. Endografts with 2 antegrade inner branches performed better compared to single-branch endografts. Scenario 3 performed the worst with a decrease in the total cervical blood flow of 4.8%, a decrease in the left hemisphere flow of 6.7% and an increase in the mean PLAP of 74.3%.Endograft design has a significant impact on haemodynamic performance following Zone 0 endovascular repair, potentially affecting cerebral blood flow during follow-up. Our results demonstrate the use of computational modelling for virtual testing of therapeutic interventions and underline the need to monitor the long-term outcomes in this cohort of patients.

Optimal management of acute type B aortic dissection with retrograde arch extension is controversial. The effect of retrograde arch extension on operative and long-term mortality has not been studied and is not incorporated into clinical treatment pathways.The International Registry of Acute Aortic Dissection was queried for all patients presenting with acute type B dissection and an identifiable primary intimal tear. Outcomes were stratified according to management for patients with and without retrograde arch extension. Kaplan-Meier survival curves were constructed.Between 1996 and 2014, 404 patients (mean age, 63.3 ± 13.9 years) were identified. Retrograde arch extension existed in 67 patients (16.5%). No difference in complicated presentation was noted (36.8% vs 31.7%, p = 0.46), as defined by limb or organ malperfusion, coma, rupture, and shock. Patients with or without retrograde arch extension received similar treatment, with medical management in 53.7% vs 56.5% (p = 0.68), endovascular treatment in 32.8% vs 31.1% (p = 0.78), open operation in 11.9% vs 9.5% (p = 0.54), or hybrid approach in 1.5% vs 3.0% (p = 0.70), respectively. The in-hospital mortality rate was similar for patients with (10.7%) and without (10.4%) retrograde arch extension (p = 0.96), and 5-year survival was also similar at 78.3% and 77.8%, respectively (p = 0.27).The incidence of retrograde arch dissection involves approximately 16% of patients with acute type B dissection. In the International Registry of Acute Aortic Dissection, this entity seems not to affect management strategy or early and late death.

To assess whether the Modified Arch Landing Areas Nomenclature (MALAN), which merges Ishimaru's map with the Aortic Arch Classification, predicts the magnitude of displacement forces and their orientation in proximal landing zones for TEVAR.Computational fluid dynamic (CFD) modelling was employed to prove the hypothesis. Healthy aorta CT angiography scans were selected based on aortic arch geometry to reflect Types I to III arches equally (each n = 5). CFDs were used to compute pulsatile displacement forces along the Ishimaru's landing zones in each aorta including their three dimensional orientation along the upward component and sideways component. Values were normalised to the corresponding aortic wall area to calculate equivalent surface traction (EST).In Types I and II arches, EST did not change across proximal landing zones (p = .297 and p = .054, respectively), whereas in Type III, EST increased towards more distal landing zones (p = .019). Comparison of EST between adjacent zones, however, showed that EST was greater in 3/II than in 2/II (p = .016), and in 3/III than in 2/III (p = .016). Notably, these differences were related to the upward component, that was four times greater in 3/II compared with 2/II (p < .001), and five times greater in 3/III compared with 2/III (p < .001).CFD modelling suggests that MALAN improves discrimination of expected displacement forces in proximal landing zones for TEVAR, which might influence clinical outcomes. The clinical relevance of the finding, however, remains to be validated in a dedicated post-operative outcome analysis of patients treated by TEVAR of the arch.

Thoracic Endovascular Aortic Repair (TEVAR) is the preferred treatment option for thoracic aortic pathologies and consists of inserting a self-expandable stent-graft into the pathological region to restore the lumen. Computational models play a significant role in procedural planning and must be reliable. For this reason, in this work, high-fidelity Finite Element (FE) simulations are developed to model thoracic stent-grafts. Experimental crimp/release tests are performed to calibrate stent-grafts material parameters. Stent pre-stress is included in the stent-graft model. A new methodology for replicating device insertion and deployment with explicit FE simulations is proposed. To validate this simulation, the stent-graft is experimentally released into a 3D rigid aortic phantom with physiological anatomy and inspected in a computed tomography (CT) scan at different time points during deployment with an ad-hoc set-up. A verification analysis of the adopted modeling features compared to the literature is performed. With the proposed methodology the error with respect to the CT is on average 0.92 ± 0.64%, while it is higher when literature models are adopted (on average 4.77 ± 1.83%). The presented FE tool is versatile and customizable for different commercial devices and applicable to patient-specific analyses.

Thoracic Endovascular Aortic Repair (TEVAR) is a minimally invasive technique to treat thoracic aorta pathologies and consists of placing a self-expandable stent-graft into the pathological region to restore the vessel lumen and recreate a more physiological condition. Exhaustive computational models, namely the finite element analysis, can be implemented to reproduce the clinical procedure. In this context, numerical models, if used for clinical applications, must be reliable and the simulation credibility should be proved to predict clinical procedure outcomes or to build in-silico clinical trials. This work aims first at applying a previously validated TEVAR methodology to a patient-specific case. Then, defining the TEVAR procedure performed on a patient population as the context of use, the overall applicability of the TEVAR modeling is assessed to demonstrate the reliability of the model itself following a step-by-step method based on the ASME V&V40 protocol. Validation evidence sources are identified for the specific context of use and adopted to demonstrate the applicability of the numerical procedure, thereby answering a question of interest that evaluates the deployed stent-graft configuration in the vessel.

Clinical practice guidelines summarize and assess all relevant evidence on a specific topic at the time of their creation, with the goal of assisting physicians in selecting the best management strategies for individual patients with a given condition. These guidelines take into consideration the impact on patient outcomes as well as the risk–benefit ratio of different diagnostic or therapeutic methods. Although these guidelines do not replace textbooks, they complement them and cover topics pertinent to contemporary clinical practice.

Background— Stanford Type B acute aortic dissection (TB-AAD) spares the ascending aorta and is optimally managed with medical therapy in the absence of complications. However, the treatment of TB-AAD with aortic arch involvement (AAI) remains an unresolved issue. Methods and Results— We examined 498 patients with TB-AAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. Kaplan-Meier mortality curves were constructed and multivariate regression models were performed to identify independent predictors of AAI and to evaluate whether AAI was an independent predictor of follow-up mortality. We found that 371 (74.5%) patients with TB-AAD did not have AAI versus 127 (25.5%) with AAI. Independent predictors of AAI were a history of previous aortic surgery (OR 3.4; 95% CI, 1.6 to 7.6; P =0.002), absence of back pain (OR 1.6; 95% CI, 1.1 to 2.5; P =0.05), and any pulse deficit (1.9; 95% CI, 1.1 to 3.3, P =0.03). Mortality for patients without AAI was 9.4%±4.3% and 21.0%±6.9% at 1 and 3 years versus 9.2%±7.7% and 19.9%±11.1% with AAI, respectively (mean follow-up overall, 2.3 years, log rank P =0.82). AAI was not an independent predictor of long-term mortality. Conclusions— Patients with TB-AAD and aortic arch involvement do not differ with regards to mortality at 3 years. Whether or not AAI involvement impacts other measures of morbidity such as freedom from operation or endovascular intervention deserves further study.

This study analyzed morbidity, mortality, and quality of life after aortic valve replacement with mechanical and biologic prostheses in octogenarian patients.A retrospective analysis was performed in 345 consecutive patients, mean age of 82 +/- 2 years (range, 80 to 92), who had aortic valve replacement from May 1991 to April 2005. A bioprosthesis (group I) was used in 200 patients (58%), and 145 (42%) received a mechanical prosthesis (group II). Associated cardiac procedures were done in 211 patients (61%), of which 71% were coronary artery bypass grafting. Patients had symptomatic aortic stenosis (84.3%) or associated aortic insufficiency; 88% were in New York Heart Association (NYHA) class III or IV. The mean preoperative aortic valve gradient was 62 +/- 16 mm Hg (range, 25 to 122 mm Hg). The mean left ventricular ejection fraction was good (0.52 +/- 0.12); 30 patients (8.7%) had an ejection fraction of less than 0.30.The in-hospital mortality rate was 7.5% (26 patients); 17 (8.5%) in group I and 9 (6.2%) in group II (p = 0.536) Significant predictors of operative mortality were preoperative renal insufficiency (blood creatinine > 2.00 mg/mL) and need for urgent operation. Mean follow-up, complete at 100%, was 40 +/- 33 months (range, 1 to 176 months). Long-term follow-up, using Kaplan-Meier analysis, showed an overall survival of 61% at 5 years and 21% at 10 years; survival by type of prosthesis was significantly higher with mechanical prostheses (log-rank p = 0.03). Freedom from cerebrovascular events (thromboembolic/hemorrhagic) at 5 and 10 years was 89% and 62% in the mechanical group and 92% and 77% in the biologic group (p = 0.76). Postoperative NYHA functional class was I or II in 96% of patients. Quality-of-life scores were excellent considering the age of the patients. No differences were found between the two groups.Surgical treatment for symptomatic aortic stenosis in octogenarians has an acceptable operative risk with excellent long-term results and good quality of life. In this cohort, survival rate is slightly but significantly higher with mechanical prostheses.

Aortic dissection is characterized by an acute phase of medial dissection and a subacute-chronic phase of vessel wall repair. Matrix metalloproteinases (MMPs), through degradation of extracellular matrix, may play an important role in these processes. Elevation of MMPs might represent an opportunity to diagnostically characterize acute or chronic aortic processes. We examined the potential diagnostic role of MMP-9 and MMP-2 in different phases of aortic dissection.Plasma levels of MMPs were evaluated by enzyme-linked immunosorbent assay technique in 13 patients affected by acute aortic dissection (nine type A, four type B). Ten healthy subjects were used as controls. In patients with type B aortic dissection treated medically, plasma curves (1, 3, 6, 12, 24, 48 and 96 h; 1 and 2 weeks; and 2 months from symptom onset) were also assessed. Aortic tissue samples obtained during surgery were evaluated by immunohistochemistry and western blot for MM-9 and tissue inhibitor of metalloproteinase-1 expression.MMP-9 plasma levels were increased in patients affected by type A and type B aortic dissection presenting within 1 h from onset of symptoms compared to controls (29.3 +/- 16.1 and 16.7 +/- 2.1 ng/ml versus 7.74 +/- 1.6 ng/ml, P < 0.03, respectively). No differences were detected in MMP-2 plasma levels compared to controls (4.84 +/- 1.2 ng/ml for type A and 6.16 +/- 0.6 ng/ml versus 3.17 +/- 1.0 ng/ml for controls, P = NS, respectively). In type B aortic dissection, mean MMP-9 plasma levels increased significantly from hospital admission to 2-month follow-up (16.7 +/- 2.1 ng/ml versus 58.0 +/- 8.2 ng/ml, P < 0.0001). Conversely, no difference in MMP-2 plasma levels was evident during follow-up (6.16 +/- 0.6 ng/ml versus 4.28 +/- 0.4 ng/ml, P = NS, respectively). Low-moderate (+/++) expression of MMP-9 was evident at immunohistochemistry in the acute phase whereas a marked expression (++++) was detected in the subacute phase.This pilot study suggests that the acute and subacute phase of both type A and type B aortic dissection is characterized by an increase of MMP-9 plasma levels. A marked increase is also evident in the subacute phase of medically treated type B aortic dissection as an expression of aortic wall remodelling. An increase of proteolytic activity could accompany attempts of the dissected aorta to heal itself but such a phenomena might further weaken the aortic wall, predisposing it to dilation and/or rupture.

Acute type A aortic dissection (AAD) remains a highly lethal entity for which emergent surgical correction is standard care. Prior studies have identified specific clinical findings as being predictive of outcome. The prognostic significance of specific findings on imaging studies is less well described. We sought to identify the prognostic value of transesophageal echocardiography (TEE) in medically and surgically treated patients with AAD. We studied 522 AAD patients enrolled over 6 years in the International Registry of Acute Aortic Dissection who underwent TEE. Multivariate analysis identified independent associations of inhospital mortality, first using clinical variables (model 1), after which TEE data were added to build a final model (model 2). Inhospital mortality was 28.7%. Transesophageal echocardiographic evidences of pericardial effusion (P = .04), tamponade (P < .01), periaortic hematoma (P = .02), and patent false lumen (P = .08) were more frequent in nonsurvivors. Dilated ascending aorta (P = .03), dissection localized to the ascending aorta (P = .02), and thrombosed false lumen (P = .08) were less common in nonsurvivors. Model 1 identified age ≥70 years, any pulse deficit, renal failure, and hypotension/shock as independent predictors of death. Model 2 identified dissection flap confined to ascending aorta (odds ratio 0.2, 95% CI 0.1-0.6) and complete thrombosis of false lumen (odds ratio 0.15, 95% CI 0.03-0.86) as protective. In the medically treated group, mortality was 31% for subjects with a partially or completely thrombosed false lumen versus 66% in the presence of a patent false lumen. Transesophageal echocardiography provides prognostic information in AAD beyond that provided by clinical risk variables.

Although several studies have provided robust evidence about global differences for several cardiovascular emergencies, such as myocardial infarction and stroke, data were limited for aortic disease. The aim was to explore geographic variation in type A acute aortic dissection (TA-AAD) in a large group of consecutive patients. Patients (n = 615) from the IRAD with TA-AAD were studied with respect to presenting symptoms and signs, diagnosis, management, and outcomes in Europe versus North America. Compared with Europeans, North Americans were more likely to be older and present with atypical features and without many of the classic chest X-ray findings of AAD. In the North American cohort, electrocardiographic findings showed higher rates of nonspecific ST changes and a trend toward ST-elevation or new myocardial infarction (North Americans vs Europeans 7.9% vs 4.4%; p = 0.09). Use of imaging studies to confirm the diagnosis of AAD varied between North American and European centers. North American centers performed an average of 1.6 imaging studies compared with 1.8 in the European group (p = 0.002). Furthermore, they were significantly less likely to use computed tomography and significantly more likely to use transesophageal examination as part of the overall diagnostic algorithm. Compared with Europeans, TA-AAD occurred at smaller aortic diameters and there was a substantial delay to presentation and diagnosis in North Americans. No significant differences for early mortality rates were observed between the 2 groups. In conclusion, geographic differences in presentation and initial management were highlighted, but this did not translate into a difference in early mortality. Although several studies have provided robust evidence about global differences for several cardiovascular emergencies, such as myocardial infarction and stroke, data were limited for aortic disease. The aim was to explore geographic variation in type A acute aortic dissection (TA-AAD) in a large group of consecutive patients. Patients (n = 615) from the IRAD with TA-AAD were studied with respect to presenting symptoms and signs, diagnosis, management, and outcomes in Europe versus North America. Compared with Europeans, North Americans were more likely to be older and present with atypical features and without many of the classic chest X-ray findings of AAD. In the North American cohort, electrocardiographic findings showed higher rates of nonspecific ST changes and a trend toward ST-elevation or new myocardial infarction (North Americans vs Europeans 7.9% vs 4.4%; p = 0.09). Use of imaging studies to confirm the diagnosis of AAD varied between North American and European centers. North American centers performed an average of 1.6 imaging studies compared with 1.8 in the European group (p = 0.002). Furthermore, they were significantly less likely to use computed tomography and significantly more likely to use transesophageal examination as part of the overall diagnostic algorithm. Compared with Europeans, TA-AAD occurred at smaller aortic diameters and there was a substantial delay to presentation and diagnosis in North Americans. No significant differences for early mortality rates were observed between the 2 groups. In conclusion, geographic differences in presentation and initial management were highlighted, but this did not translate into a difference in early mortality.

In-hospital outcome of acute type B dissection (ABAD) is strongly related to preoperative aortic conditions. In order to clarify the influence of the clinical presentation on the outcome, we analyzed the patients of the International Registry of Acute Aortic Dissection (IRAD). All patients affected by complicated ABAD, enrolled in the IRAD from 1996-2004, were included. Complications were defined as the presence of shock, periaortic hematoma, spinal cord ischemia, preoperative mesenteric ischemia/infarction, acute renal failure, limb ischemia, recurrent pain, refractory pain or refractory hypertension (group I). All other patients were categorized as uncomplicated (group II). A comprehensive analysis was performed of all clinical variables in relation to in-hospital outcome.The overall in-hospital mortality among 550 patients was 12.4%. Mortality in group I (250 patients) was 20.0 %, compared to 6.1% in group II (300 patients) (P<0.001). Univariate predictors of ABAD complications were Marfan syndrome, abrupt onset of pain, migrating pain, any focal neurological deficits, need for higher number of diagnostic examinations and use of magnetic resonance and/or aortogram, abdominal vessels involvement at aortogram, larger descending aortic diameter, especially >6 cm, pleural effusion, and widened mediastinum on chest X-ray. Univariate predictors of a non complicated status were normal chest X-ray and medical management. In group I, in-hospital mortality following surgical and endovascular intervention were 28.6% and 10.1% (P=0.006), respectively. Independent predictors of overall in-hospital mortality included age >70 years, female gender, ECG showing ischemia, preoperative acute renal failure, preoperative limb ischemia, periaortic hematoma, and surgical management. The only independent variable protective for mortality was magnetic resonance as diagnostic test.ABAD is a heterogeneous disease that produces dissimilar clinical subsets, each of which can have specific clinical signs, management and in-hospital results. In IRAD ABAD uncomplicated patients, medical therapy was associated with best hospital outcome, while endovascular interventions were associated with better results than surgery when invasive treatments were required. Although selection bias may be possible, and irrespective of treatments, knowledge of significant risk factors for mortality may contribute to a better management and a more defined risk-assessment in patients affected by ABAD.

Increasing aortic diameter is thought to be an important risk factor for acute type B aortic dissection (ABAD). However, some patients develop ABAD in the absence of aortic dilatation. In this report, we sought to characterize ABAD patients who presented with a descending thoracic aortic diameter <3.5 cm.We categorized 613 ABAD patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2009 according to the aortic diameter <3.5 cm (group 1) and ≥3.5 cm (group 2). Demographics, clinical presentation, management, and outcomes of the two groups were compared.Overall, 21.2% (n = 130) had an aortic diameter <3.5 cm. Patients in group 1 were younger (60.5 vs 64.0 years; P = .015) and more frequently female (50.8% vs 28.6%; P < .001). They presented more often with diabetes (10.9% vs 5.9%; P = .050), history of catheterization (17.0% vs 6.7%; P = .001), and coronary artery bypass grafting (9.7% vs 3.4%; P = .004). Marfan syndrome was equally distributed in the two groups. The overall in-hospital mortality did not differ between groups 1 and 2 (7.6% vs 10.1%; P = .39).About one-fifth of patients with ABAD do not present with any aortic dilatation. These patients are more frequently females and younger, when compared with patients with aortic dilatation. This report is an initial investigation to clinically characterize this cohort, and further research is needed to identify risk factors for aortic dissection in the absence of aortic dilatation.

ObjectiveThe aim of this paper is to report midterm results of thoracic endovascular aortic repair (TEVAR) for ascending aortic pseudoaneurysms (AAPs) and penetrating aortic ulcers (PAUs) of the ascending aorta.MethodsThis study was retrospective and performed at tertiary centers. Eight patients with AAPs (n = 5) and PAUs (n = 3) received total endovascular repair of the ascending aorta. Patients with a history of type A aortic dissection or fusiform aneurysm were excluded. All patients analyzed were considered to be at high risk for open repair at the time of presentation.ResultsUrgent intervention was performed in 6 (75%) cases. Primary clinical success was achieved in 7 (87.5%) cases. A low-flow type 3 endoleak remained asymptomatic and was managed conservatively. No TEVAR-related in-hospital mortality, primary conversion, cerebrovascular accidents, valve impairment, or myocardial infarction occurred. All patients were discharged home, alive and independent, after a median length of stay of 6 (range: 5-24) days. No patient was lost at a mean follow-up of 40 ± 33 (range: 4-93) months. Ongoing primary clinical success was maintained in all but 1 patient (type 3 endoleak): aortically related reintervention was never required. No endograft breakage or migration was observed. At 1-year follow-up, 7 (87.5%) aortic lesions had significant reduction in diameter (≥5 mm).ConclusionsAscending TEVAR was feasible, safe, and effective for AAPs and PAUs. In a very select subset of lesions, midterm results were favorable, with both standard and custom-designed endografts.

Currently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.EMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.Thirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7-2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%-9.4%), cardiac complications (0.0%-5.9%) and rupture (0.5%-5.0%). Most common long-term complications after TEVAR were rupture (0.5%-7.1%), endoleaks (0.0%-15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.We found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.

ObjectiveThe Global Registry for Endovascular Aortic Treatment (GREAT) is a prospective multicenter registry collecting real-world data on the performance of W. L. Gore (Flagstaff, Ariz) aortic endografts. The purpose of the present study was to analyze the implementation and outcomes of thoracic endovascular aortic repair (TEVAR) in GREAT patients with type B aortic dissection (TBAD).MethodsFrom 2010 to 2016, >5000 patients were enrolled in the GREAT from 113 centers in 14 countries across 4 continents. The study population comprised those treated for TBAD. The primary outcomes of interest were mortality and freedom from aortic events (AEs).ResultsA total of 264 patients (80% male; mean age, 62 years) underwent TEVAR for the treatment of 170 (64%) acute and 94 (36%) chronic cases of TBAD. Chronic TBAD patients required significantly longer endograft coverage than did acute TBAD patients (P = .05). Early postoperative complications occurred in 9% of patients, with no difference in chronic vs acute dissection (P = .11). The 30-day aortic mortality and all-cause mortality were 1.5% and 2.3%, respectively, with no differences based on chronicity. During a mean follow-up of 26 months, the total aortic mortality was 2.7% and the total all-cause mortality was 12.5%. The all-cause mortality was significantly greater for chronic vs acute TBAD (19.2% vs 8.8%, respectively; P = .02). On multivariate analysis, patients with acute uncomplicated dissections had significantly improved overall survival compared with all other categories of dissections (93% vs 83% at 2 years; P < .05). A proximal landing zone diameter >40 mm was associated with an increased risk of retrograde type A dissection (18% vs 2%; P = .02). Patients undergoing left subclavian artery (LSA) coverage experienced a twofold greater rate of AEs compared with noncoverage patients (P < .01). Patients who underwent LSA revascularization experienced a 1.5-fold greater rate of AEs compared with patients covered without revascularization (P = .04).ConclusionsTEVAR for TBAD using the conformable GORE TAG thoracic endoprosthesis device can be performed with a low incidence of aortic mortality and complications. Acute uncomplicated TBAD patients had a significantly lower mortality rate than that of other patients. Larger proximal landing zones were associated with more frequent retrograde type A dissection. LSA involvement (coverage and/or revascularization) was associated with an increased risk of AEs during follow-up.

BackgroundWe present the possible utility of computational fluid dynamics in the assessment of thrombus formation and virtual surgical planning illustrated in a patient with aortic thrombus in a kinked ascending aortic graft following thoracic endovascular aortic repair.MethodsA patient-specific three-dimensional model was built from computed tomography. Additionally, we modeled 3 virtual aortic interventions to assess their effect on thrombosis potential: (1) open surgical repair, (2) conformable endografting, and (3) single-branched endografting. Flow waveforms were extracted from echocardiography and used for the simulations. We used the computational index termed platelet activation potential (PLAP) representing accumulated shear rates of fluid particles within a fluid domain to assess thrombosis potential.ResultsThe baseline model revealed high PLAP in the entire arch (119.8 ± 42.5), with significantly larger PLAP at the thrombus location (125.4 ± 41.2, p < 0.001). Surgical repair showed a 37% PLAP reduction at the thrombus location (78.6 ± 25.3, p < 0.001) and a 24% reduction in the arch (91.6 ± 28.9, p < 0.001). Single-branched endografting reduced PLAP in the thrombus region by 20% (99.7 ± 24.6, p < 0.001) and by 14% in the arch (103.8 ± 26.1, p < 0.001), whereas a more conformable endograft did not have a profound effect, resulting in a modest 4% PLAP increase (130.6 ± 43.7, p < 0.001) in the thrombus region relative to the baseline case.ConclusionsRegions of high PLAP were associated with aortic thrombus. Aortic repair resolved pathologic flow patterns, reducing PLAP. Branched endografting also relieved complex flow patterns reducing PLAP. Computational fluid dynamics may assist in the prediction of aortic thrombus formation in hemodynamically complex cases and help guide repair strategies. We present the possible utility of computational fluid dynamics in the assessment of thrombus formation and virtual surgical planning illustrated in a patient with aortic thrombus in a kinked ascending aortic graft following thoracic endovascular aortic repair. A patient-specific three-dimensional model was built from computed tomography. Additionally, we modeled 3 virtual aortic interventions to assess their effect on thrombosis potential: (1) open surgical repair, (2) conformable endografting, and (3) single-branched endografting. Flow waveforms were extracted from echocardiography and used for the simulations. We used the computational index termed platelet activation potential (PLAP) representing accumulated shear rates of fluid particles within a fluid domain to assess thrombosis potential. The baseline model revealed high PLAP in the entire arch (119.8 ± 42.5), with significantly larger PLAP at the thrombus location (125.4 ± 41.2, p < 0.001). Surgical repair showed a 37% PLAP reduction at the thrombus location (78.6 ± 25.3, p < 0.001) and a 24% reduction in the arch (91.6 ± 28.9, p < 0.001). Single-branched endografting reduced PLAP in the thrombus region by 20% (99.7 ± 24.6, p < 0.001) and by 14% in the arch (103.8 ± 26.1, p < 0.001), whereas a more conformable endograft did not have a profound effect, resulting in a modest 4% PLAP increase (130.6 ± 43.7, p < 0.001) in the thrombus region relative to the baseline case. Regions of high PLAP were associated with aortic thrombus. Aortic repair resolved pathologic flow patterns, reducing PLAP. Branched endografting also relieved complex flow patterns reducing PLAP. Computational fluid dynamics may assist in the prediction of aortic thrombus formation in hemodynamically complex cases and help guide repair strategies.

<h2>Abstract</h2><h3>Objective</h3> To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch. <h3>Methods</h3> Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared. <h3>Results</h3> The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; <i>P</i> = .115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; <i>P</i> < .001), endovascular treatment (3.5% vs 25.0%; <i>P</i> < .001), and medical management (16.2% vs 51.4%; <i>P</i> < .001). Overall in-hospital mortality was similar (16.7% vs 19.3%; <i>P</i> = .574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; <i>P</i> = .090), and higher after endovascular (25.0% vs 14.3%; <i>P</i> = .597) or medical treatment (24.3% vs 13.9%; <i>P</i> = .191), although the differences were not significant. <h3>Conclusions</h3> Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.