Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection

Aortic dissection is the deadliest disease of the cardiovascular system.Type B aortic dissection accounts for 30%-60%of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair(TEVAR).However,patients are prone to various complications after surgery,with central nervous system injury being the most common,which seriously affects their prognosis and increases the risk of disability and death.Therefore,exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.AIM To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.METHODS We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022.The patients were categorized into injury(n=159)and non-injury(n=147)groups based on central nervous system injury following surgery.The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups.Multivariate logistic regression analysis was performed.RESULTS The Association between age,history of hypertension,blood pH value,surgery,mechanical ventilation,intensive care unit stay,postoperative recovery times on the first day after surgery,and arterial partial pressure of oxygen on the first day after surgery differed substantially(P<0.05).Multivariate logistic regression analysis indicated that age,surgery time,history of hypertension,duration of mechanical ventilation,and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection(P<0.05).CONCLUSION For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection,early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.

Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

Objective Acute kidney injury （AKI） frequently occurs after catheter-based interventional procedures and increases mortality. However, the implications of AKI before thoracic endovascular aneurysm repair （TEVAR） of type B acute aortic dissection （AAD） remain unclear. This study evaluated the incidence, predictors, and in-hospital outcomes of AKI before TEVAR in patients with type B AAD. Methods Between 2009 and 2013, 76 patients were retrospectively evaluated who received TEVAR for type B AAD within 36 h from symptom onset. The patients were classified into no-AKI vs. AKI groups, and the severity of AKI was further staged according to kidney disease： im- proving global outcomes criteria before TEVAR. Results The incidence of preoperative AKI was 36.8%. In-hospital complications was significantly higher in patients with preoperative AKI compared with no-AKI （50.0% vs. 4.2%, respectively; P 〈 0.001）, including acute renal failure （21.4% vs. O, respectively; P 〈 0.001）, and they increased with severity of AKI （P 〈 0.001）. The maximum levels of body tem- perature and white blood cell count were significantly related to maximum serum creatinine level before TEVAR. Multivariate analysis showed that systolic blood pressure on admission （OR： 1.023; 95% CI： 1.003-1.044; P ： 0.0238） and bilateral renal artery involvement （OR： 19.076; 95% CI： 1.914 190.164; P = 0.0120） were strong predictors of preoperative AKI. Conclusions Preoperative AKI frequently occurred in patients with type B AAD, and correlated with higher in-hospital complications and enhanced inflammatory reaction. Systolic blood pressure on admission and bilateral renal artery involvement were major risk factors for AKI before TEVAR.

Study on hemodynamics in patient-specific thoracic aortic aneurysm

The objective of this study is to investigate the hemodynamics in patient-specific thoracic aortic aneurysm and discuss the reason for formation of aortic plaque.A 3-Dimensional pulsatile blood flow in thoracic aorta with a fusiform aneurysm and 3 main branched vessels was studied numerically with the average Reynolds number of 1399 and the Womersley number of 19.2.Based on the clinical 2-Dimensional CT slice data,the patient-specific geometry model was constructed using medical image process software.Unsteady,incompressible,3-Dimensional Navier-Stokes equations were employed to solve the flow field.The temporal distributions of hemodynamic variables during the cardiac cycle such as streamlines,wall shear stresses in the arteries and aneurysm were analyzed. Growth and rupture mechanisms of thoracic aortic aneurysm in the patient can be analyzed based on patient-specific model and hemodynamics simulation.

A Case of Thoracic Aortic Aneurysm with Hemoptysis as the First Symptom

This article reports a case of thoracic aortic aneurysm with hemoptysis as the first clinical manifestation, hemoptysis as the first clinical manifestation is very uncommon and to the best of our knowledge, only twenty of such cases have been previously reported. The case report presented here constitutes the longest course of the disease reported in medical literature, and good recovery after thoracic endovascular aortic repair, may help us to increase the understanding and diagnosis of the disease.

Innovation in pathogenesis and management of aortic aneurysm

Aortic aneurysm(AA)refers to the persistent dilatation of the aorta,exceeding three centimeters.Investigating the pathophysiology of this condition is important for its prevention and management,given its responsibility for more than 25000 deaths in the United States.AAs are classified based on their location or morphology.various pathophysiologic pathways including inflammation,the immune system and atherosclerosis have been implicated in its development.Inflammatory markers such as transforming growth factorβ,interleukin-1β,tumor necrosis factor-α,matrix metalloproteinase-2 and many more may contribute to this phenomenon.Several genetic disorders such as Marfan syndrome,Ehler-Danlos syndrome and Loeys-Dietz syndrome have also been associated with this disease.Recent years has seen the investigation of novel management of AA,exploring the implication of different immune suppressors,the role of radiation in shrinkage and prevention,as well as minimally invasive and newly hypothesized surgical methods.In this narrative review,we aim to present the new contributing factors involved in pathophysiology of AA.We also highlighted the novel management methods that have demonstrated promising benefits in clinical outcomes of the AA.

Surgical Treatment of Aortic Aneurysm and Aortic Dissection:A Retrospective Analysis of 122 Cases

The study summarizes the clinical experience of surgical treatments of various types of thoracic aneurysm and aortic dissection. Clinical data of 122 patients with thoracic aneurysm and aortic dissection during July 2005 to July 2008 were retrospectively analyzed. The elective operations were performed in 107 patients while emergency surgery was done in 15 cases. Different surgical strategies were employed on the basis of diseased region, including simple ascending aortic replacement （n=3）, aortic root replacement （n=43）, hemi-arch replacement/total arch replacement ＋ elephant trunk technique （n=32）, thoracic/thoracoabdominal aortic replacement （n=8） and endovascular repair （n=36）. In this series, there is 4 cases of perioperative death due to massive cerebral hemorrhage （n=1）, respiratory failure （n=1） and multiple organ dysfunction syndrome （MODS） （n=2）. Three cases developed post-operative massive cerebral infarction and the relatives of the patients abandoned treatment. Instant success rate of endovascular repair was 100%. The intimal rupture was sealed. Blood flow was unobstructed in true lumen and no false lumen was visualized. It was concluded that aggressive surgery should be considered in the patients with thoracic aneurysm and aortic dissection. Surgical procedures should vary with the location and the nature of the lesions.

Effects of COL1A1 and SYTL2 on inflammatory cell infiltration and poor extracellular matrix remodeling of the vascular wall in thoracic aortic aneurysm

Background:Thoracic aortic aneurysm(TAA)is a fatal cardiovascular disease,the pathogenesis of which has not yet been clarified.This study aimed to identify and validate the diagnostic markers of TAA to provide a strong theoretical basis for developing new methods to prevent and treat this disease.Methods:Gene expression profiles of the GSE9106,GSE26155,and GSE155468 datasets were acquired from the Gene Expression Omnibus(GEO)database.Differentially expressed genes(DEGs)were identified using the"limma"package in R.Least absolute shrinkage and selection operator(LASSO),support vector machine-recursive feature elimination(SVM-RFE),random forest,and binary logistic regression analyses were used to screen the diagnostic marker genes.Single-sample gene set enrichment analysis(ssGSEA)was used to estimate immune cell infiltration in TAA.Results:A total of 16 DEGs were identified.The enrichment and functional correlation analyses showed that DEGs were mainly associated with inflammatory response pathways and collagen-related diseases.Collagen type I alpha 1 chain(COL1A1)and synaptotagmin like 2(SYTL2)were identified as diagnostic marker genes with a high diagnostic value for TAA.The expression of COL1A1 and SYTL2 was considerably higher in TAA vascular wall tissues than in the corresponding normal tissues,and there were significant differences in the infiltration of immune cells between TAA and normal vascular wall tissues.Additionally,COL1A1 and SYTL2 expression were associated with the infiltration of immune cells in the vascular wall tissue.Single-cell analysis showed that COL1A1 in TAA was mainly derived from fibroblasts and SYTL2 mainly from cluster of differentiation(CD)8+T cells.In addition,single-cell analysis indicated that fibroblasts and CD8+T cells in TAA were significantly higher than those in normal arterial wall tissue.Conclusions:COL1A1 and SYTL2 may serve as diagnostic marker genes for TAA.The upregulation of SYTL2 and COL1A1 may be involved in the inflammatory infiltration of the vessel wall and poor extracellular matrix remodeling,promoting the progression of TAA.

Endovascular repair of a tuberculous aneurysm of descending thoracic aorta

Tuberculous aortic aneurysm （TBAA） is an extremely rare clinical event with life-threatening implication. Management for this condition is challenging and its therapeutic option has not been yet established. A few recent reports described endovascular repair rather than open surgery as the method for treatment. Although this remains controversial,endovascular exclusion has been gaining acceptance for some surgeons. We present a case of TBAA who was treated by endovascular stent grafting for a descending thoracic aortic aneurysm with simultaneous anti-tuberculous medication.The outcome was favorable.

Circumferential variation in mechanical characteristics of porcine descending aorta

Arterial characterization of healthy descending thoracic aorta(DTA)is indispensable in determining stress distributions across wall thickness and different regions that may be responsible for aorta inhomogeneous dilation,rupture,and dissection when aneurysm occurs.Few studies have shown the inhomogeneity of DTA along the aorta tree considering changes in circumferential direction.The present study aims to clarify the circumferential regional characterization of DTA.Porcine DTA tissues were tested according to region and orientation using uniaxial tension.For axial test,results show that the difference in circumferential direction was mainly in collagen fiber modulus,where the anterior collagen fiber modulus was significantly lower than the posterior quadrant.For circumferential test,the difference in circumferential direction was mainly in the recruitment parameter,where the circumferential stiffness is significantly higher in the posterior region at physiological maximum stress.The proximal posterior quadrant and left quadrant showed significantly lower axial collagen fiber stiffness than the right and anterior quadrants,which may be a factor in aneurysm development.Furthermore,the constitutive parameters for similar detailed regions can be used by biomedical engineers to investigate improved therapies and thoroughly understand the initial stage of aneurysm development.The regional collagen fiber modulus can help improve our understanding of the mechanisms of arterial dilation and aortic dissection.

Outcome of stented elephant trunk technique for extensive thoracic aortic aneurysms

Extensive aneurysms involving the ascending aorta, aortic arch, and the descending aorta stand as a therapeutic dilemma in simultaneous management of multiple sites of pathology of the aortic arch and the descending thoracic aorta. We systematically reviewed about literatures of stented elephant trunk operation （SET） identified through searches of the electronic databasesEMBASE and Medline, and aimed to summarize studies of patients undergoing SET for extensive aneurysms. Since 1996, Kato Mintroduced a hybrid technique by using stented graft implantation to the descending aorta for treatment of thoracic aortic aneurysm or dissection. It has been describe a good option for extensive thoracic aortic aneurysms and in a fashion similar to the elephant trunk technique.

Fractionated-clamping for thoracoabdominal aortic aneurysm repair: a modified Crawford technique

OBJECTIVE: To apply fractionated-clamping for repair of thoracoabdominal aortic aneurysm (TAA), and evaluate its effects in decreasing surgical mortality and severe complications, such as renal failure and paraplegia, a modified crawford procedure were prospectively evaluated. METHODS: Using modified shunting and cross-clamping techniques, modified Crawford repair in 13 thoracoabdominal aorta patients were performed in the Vascular Division at Peking Union Medical College Hospital. TAA Crawford classification: 1 type I, 2 type II, 2 type III and 3 type IV TAA. Debakey classification: 1 type I, 4 type III (including 2 ruptured aneurysms), and 1 aortic coarctation. RESULTS: Thirteen procedures were performed successfully. One died of ventricular fibrillation just before completing the operation. Surgical mortality rate was 7.7% (1/13). Postoperative complications included 1 acute necrotic pancreatitis, 1 ARDS, 1 paraplegia, 1 acute renal failure, and 2 thoracic cavity bleeding. Total complication rate was 53.8% (7/13). CONCLUSIONS: Fractionated-clamping in thoracoabdominal aortic aneurysm repair is our modified Crawford procedure and aortic bypass. Clinical results demonstrate that our procedure decreased surgical mortality and major complication rate, and also alleviated viscera ischemic injury. Fractionated-clamping in aorta replacement is a practical procedure for TAA repair under general anesthesia at normal temperature.