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.

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients

Introduction:Blunt thoracic aortic injury(BTAI)is rare in elderly patients.As the population ages and life expectancy increases,the frequency of this injury will increase,while the treatment and outcomes remain unclear.Methods:We retrospectively analyzed the collected data of patients>60 years old with BTAI to investigate the mechanism of trauma;time interval from injury to diagnosis;type and timing of surgical intervention;aortic arch pattern;choice of left subclavian artery reconstruction;endograft to treat BTAI;length of the endovascular procedure;endoleaks;complications including stroke,paraplegia,and renal failure;length of hospital stay(LOS)and intensive care unit stay(L.ICUS);and 30-day mortality.Results:Five elderly trauma patients were found to have BTAI.Four(80%)were males,the cohort mean age was68 years,the major mechanism of trauma was fall injury,and the associated injury was thoracic trauma.All patients were transferred to our hospital,and emergency computed tomography angiography showed BTAI in each patient.The average time interval from injury to diagnosis was 2.7 days.Two patients suddenly showed signs of instability in their vital signs and underwent immediate endovascular repair,while 3 patients underwent delayed endovascular repair.The injury site was located in the aortic isthmus just distal to the origin of the left subclavian artery;the aortic arch pattern was II(80.0%)in 4 cases and III in 1 case(20.0%).The choice of left subclavian artery reconstruction included chimney,double chimney,prefenestration,and chimney combined with in situ fenestration.Endografts to treat BTAI included the Ankura(Lifetech Scientific,Shenzhen,China)and the C-TAG(W.L.Gore&Associates,Flagstaff,AZ USA).The length of the endovascular procedure was 75.4 min;there were no endoleaks and no complications including stroke,paraplegia,or renal failure.The average LOS was25 days,and the average L.ICUS of 2 patients was 15 days,with no 30-day mortality.Conclusion:Elderly patients with fall injury should promptly exclude BTAI.Thoracic endovascular aortic repair(TEVAR)with a left subclavian artery reconstruction technique provided good results without procedure-related or neurological complications.Because of the low incidence of this type of injury,we are unable to provide any evidence to guide the treatment option for this life-threatening condition.

Endovascular repair of thoracic aortic dissection associated with right-sided aortic arch：report of four cases

Aortic dissection involving a right-sided aortic arch（RAA）is extremely rare with an incidence in adults of 0.04%to 0.1%^（[1]）.Thoracic aortic dissection associated with RAA is even a more uncommon and life-threatening condition.For complicated aortic dissection,conventional open surgical repair is considered a standard therapy^（[2]）.However,

Review of Thoracic Endovascular Aneurysm Repair (TEVAR), Spinal Cord Ischemia (SCI), Cerebrospinal Fluid (CSF) Drainage and Blood Pressure (BP) Augmentation

The object of this review is to examine the role of TEVAR in causing SCI. The anatomy and physiology of blood flow to the spinal cord is examined. The role of auto regulation of blood flow within the spinal cord is also examined. This review examines the reported results from the scientific literature of the effect of thoracic aortic aneurysm repair on spinal cord blood flow. In the light of the-se findings several conclusions can reasonably be reached. These conclusions are that the development of SCI can reasonably be predicted based on complexity and extent of the TEVAR procedure performed and BP augmentation and CSF drainage can significantly reduce the impact of SCI.

Thoracic Endovascular Aortic Repair for Cardiopulmonary Arrest Due to Aortic Dissection

Background and Aim: Reports on recovery from Stanford type A aortic dissection (TAAD) leading to cardiopulmonary arrest (CPA) are few. In retrograde TAAD (r-TAAD) cases, some authors reported the efficacy of thoracic endovascular aortic repair (TEVAR). However, only a few reports chose TEVAR for the treatment of r-TAAD resulting in cardiac arrest before hospital arrival. We report a case of r-TAAD presenting with cardiac arrest before hospital arrival not indicated for surgery but TEVAR as treatment. Case: A 65-year-old woman with a history of Marfan syndrome presented to the emergency department after a CPA. Sequential return of spontaneous circulation was achieved 27 min after CPA. Contrast-enhanced computed tomography showed retrograde r-TAAD with an entry tear to the false lumen in the thoracic descending aorta. Therefore, thoracic endovascular aortic repair (TEVAR) was performed with r-TAAD. Afterward, the clinical course was stabilized. This patient suggests that TEVAR is an effective option for the treatment of patients with hemodynamically unstable r-TAAD, even after CPA. Conclusion: TEVAR can lead to a successful recovery from cardiac arrest due to r-TAAD.

Custom Made Fenestrated Stent Graft Collapse after Thoracic Endovascular Aortic Repair: A Case Report

We present a case of stent graft collapse after performing thoracic endovascular aortic repair with a custom-made fenestrated stent graft. The patient was a 70-year-old woman with an asymptomatic aneurysm of the distal aortic arch, and thoracic endovascular aortic repair was performed. The patient showed a blood pressure difference between the left arm and the right arm on postoperative day (POD) 17 prompting the performance of a chest computed tomography scan which revealed stent graft collapse. She then underwent staged debranching of thoracic endovascular aortic repair. Stent graft collapse is a rare but well-described complication of thoracic endovascular repair. Therefore, patients who undergo such a procedure should be carefully monitored for signs and symptoms, which suggest the possibility of stent collapse.

Thoracic endovascular aortic repair of chronic type B aortic dissection in 84 patients

Objective The optimal treatment for chronic type B dissection remains controversial. The purpose of this study was to report early and mid-term results of thoracic endovascular aortic repair (TEVAR) of chronic type B aortic dissection. Methods From June 2001 to September 2007, 84 patients with chronic type B aortic

Early and mid-term outcome of endovascular repair in retrograde type A aortic dissection with an entry tear located in descending aorta

Objective Acute Stanford type A aortic dissection is typically presented as antegrade dissection from a primary intimal tear in the proximal ascending aorta extending to the arch and the downstream distal aorta.However,it may also develop in a retrograde fashion with an intimal tear located in descending aorta causing retrograde extension of aortic dissection into ascending aorta,namely,retrograde type A aortic dissection(RTAAD).Though open surgery remains the golden standard to treat type A dissection,as to RTAAD,the distal location of its primary entry tear in descending aorta warrants more extensive aortic repair with higher surgical risks of mortality or morbidity through a median sternotomy.Conversely,confining the surgical extent to the proximal aorta leaves the risks of complications related to the residual tear in the distal aorta untreated.More recently,thoracic endovascular aortic repair(TEVAR)is attempted for the treatment of RTAAD with favorable shortterm and long-term prognosis.To the best of our knowledge,this was the largest serial study to apply TEVAR in the treatment of RTAAD.

Antegrade in situ laser fenestration of aortic stent graft during endovascular aortic repair:A case report

BACKGROUND The endovascular repair of juxtarenal abdominal aortic aneurysms(JAAA)usually requires combination treatment with various stent graft modifications to preserve side branch patency.As a feasible technique,according to the situation,antegrade in situ laser fenestration still needs to be improved.CASE SUMMARY This report describes a case that was successfully treated with endovascular repair facilitated by antegrade in situ laser fenestration while maintaining renal arterial flow.Laser fenestration was performed using a steerable sheath positioned in the stent graft lumen in front of the renal artery ostium.With the bare stent region unreleased,renal artery perfusion could be maintained and accurate positioning could be achieved by angiography in real time.CONCLUSION This study suggests the feasibility and short-term safety of this novel antegrade in situ laser fenestration technique for select JAAA patients.

急性A型主动脉夹层术后主动脉远端TEVAR的效果分析

目的:探讨Stanford A型主动脉夹层(type A aortic dissection,TAAD)术后主动脉远端扩张及支架所致的新发破口(stent induced new entry,SINE)的患者采取胸主动脉腔内血管修复术(thoracic endovascular aortic repair,TEVAR)治疗的安全性及有效性。方法:回顾性分析南京医科大学第一附属医院2018年1月—2023年3月连续收治的27例TAAD术后支架象鼻远端再次TEVAR治疗的患者,统计分析27例患者孙氏手术(主动脉全弓替换+降主动脉术中支架置入术)术中资料,孙氏手术后早期随访结果、TEVAR术中资料以及术后随访结果。结果:TEVAR术后随访率92.3%,随访时间为(35±21)个月。远期死亡2例,病死率7.4%,无主动脉相关死亡病例。TEVAR术后均未出现支架内漏、移位、下肢截瘫、新发透析(TEVAR术后新发肾功能不全)、肠缺血或坏死等后遗症。在随访的病例中,成功收集术前及术后复查胸腹部大血管计算机断层扫描血管造影(com⁃puted tomographic angiography,CTA)25例(92.3%),术后6个月复查CTA提示支架象鼻远端破口均覆盖完全,胸主动脉覆膜支架远端真腔打开程度均满意,内脏区及下肢血管通畅程度为100%,术后1年随访患者19例,其中胸主动脉覆膜支架周围段完全血栓化13例(68.4%),部分血栓化6例(31.6%),真腔有效打开,支架覆盖区域真腔明显增大,假腔缩小。结论:急性A型主动脉夹层术后主动脉远端TEVAR治疗效果显著,无明显不良事件发生,是值得推广的手术方案。

Total endovascular repair of aberrant right subclavian artery using caster branched stent-graft

A 57-year-old man has 20-year history of hypertension presented with intermittent chronic pain in the chest area and shoulder blades over the last three months.Computed tomographic angiography(CTA)on admission revealed a chronic type B aortic dissection(TBAD)with an aberrant right subclavian artery(ARSA)crossed behind the trachea and bovine aortic arch(Figure IB).

Stanford B型主动脉夹层行TEVAR干预时机分析

目的探索胸主动脉腔内修复术(thoracic endovascular aortic repair,TEVAR)不同干预时机治疗Stanford B型主动脉夹层后的疗效。方法回顾性分析2018年1月至2023年4月于我院就诊的126例Stanford B型主动脉夹层患者,根据发病时间至手术时间分为A组(<24 h)、B组(2~7 d)和C组(8~14 d)。比较三组围手术期不良事件(内漏、脑梗死、死亡、主动脉破裂及总并发症等)发生情况,并根据随访情况进行生存分析。结果本研究共计纳入126例Stanford B型主动脉夹层患者,其中A组50例,B组43例,C组33例。三组在一般情况方面无统计学差异(P>0.05);三组在围手术期急性脑梗死、内漏、感染及死亡发生率方面无统计学差异(P>0.05),在总并发症发生率方面存在统计学差异(P<0.05);应用Log-rank检验比较三组生存曲线,A组5年累计无主动脉夹层复发及生存率低于B组、C组,差异有统计学意义(P<0.05)。结论本研究认为在症状出现后24 h内行TEVAR治疗B型主动脉夹层不良事件发生率及近中期疗效不佳,而在症状出现2~14 d行TEVAR可获得较好的围手术期及近中期结果。

SII和MHR对Stanford B型主动脉夹层患者TEVAR术后发生院内MACE的预测价值

目的:探讨全身免疫炎症指数(SII)和单核细胞/高密度脂蛋白胆固醇比值(MHR)对Stanford B型主动脉夹层(TBAD)胸主动脉血管修复术(TEVAR术)后发生院内主要不良心血管事件(MACE)的预测价值。方法:回顾性分析2019-06-2023-06于孝感市中心医院接受TEVAR术治疗的145例TBAD患者的临床资料。根据患者院内MACE发生情况,将患者分成MACE组(n=30)和非MACE组(n=115)。比较两组患者的临床资料,采用Logistic回归分析TBAD患者TEVAR术后发生院内MACE的危险因素,采用ROC曲线评估SII和MHR对TBAD患者TEVAR术后发生院内MACE的预测价值。结果:与非MACE组相比,MACE组入院白细胞计数、MHR、SII、TC/HDL升高,高密度脂蛋白胆固醇(HDL-C)降低,年龄较小(P<0.05);多因素Logistic回归分析结果显示,较高水平的SII和MHR是TBAD患者TEVAR术后发生院内MACE的危险因素(P<0.05)。ROC曲线分析结果显示,SII和MHR均对TBAD患者TEVAR术后发生院内MACE具有预测价值(P<0.05),SII灵敏度为43.3%,特异度为84.3%,AUC为0.669(95%CI 0.558-0.780,P<0.05);MHR灵敏度为76.7%,特异度为57.4%,AUC为0.703(95%CI 0.640-0.797,P<0.05);两者联合预测时灵敏度、特异度分别为83.3%、61.7%,AUC为0.766(95%CI 0.682-0.849,P<0.01),联合检测预测价值更高。结论:SII、MHR对TBAD患者TEVAR术后院内MACE的发生具有预测价值,且两者联合预测价值更高。

A pilot study of aortic hemodynamics before and after thoracic endovascular repair with a double-branched endograft

Branched endografts have been developed to treat complex pathology in the aortic arch and ascending aorta.This study aims to evaluate the haemodynamic performance of a double-branched thoracic endograft by detailed comparison of flow patterns and wall shear stress in the aorta and supra-aortic branches before and after stentgraft implantation.Pre-and post-intervention CT images were acquired from two patients who underwent thoracic endovascular aortic repair(TEVAR)with a double-branched endograft for thoracic aortic aneurysms.These images were used to reconstruct patient-specific models,which were analysed using computational fluid dynamics employing physiologically realistic boundary conditions.Our results showed that there was sufficient blood perfusion through the arch branches.The presence of inner tunnels caused flow derangement and asymmetric wall shear stress in the ascending aorta,where shear range index was up to 6 times higher than in the preintervention model.Wall shear stress in the aortic arch increased considerably after intervention as a result of accelerated flow.The maximum flow-induced displacement forces on the branched endografts were around 22 N for both patients,which was below the threshold for device migration.Results from this pilot study demonstrated that aortic flow patterns were significantly altered by the branched endograft which caused increased spatial variation of wall shear stress in the ascending aorta and the arch.Although no obvious adverse hemodynamic features were found immediately after intervention for the cases we analysed,follow-up studies will be needed to assess durability of the device.

Modified Double-Fenestrated Stent Graft for Branched Thoracic Endovascular Aortic Repair of an Irregular Aortic Arch Aneurysm:A Case Report

A 43-year-old male was admitted to General Hospital of Northern Theater Command with exacerbation of chest pain for 10 d.Computed tomographic angiography(CTA)showed an irregular aortic arch aneurysm involving the left subclavian artery(LSA),with penetrating aortic ulcer and intramural hematoma.A modified fenestrated thoracic endovascular aortic repair(TEVAR)technique was performed successfully.Follow-up CTA showed that stent grafts were well-apposed,without endoleaks,migration,or branch artery occlusion,and the hematoma was almost completely absorbed.In this case,precise fenestrations were created by measurements based on three-dimensional CT reconstruction and angiography.Furthermore,the physician chose an LSA approach to catch the guide wire and deployed branched stent grafts,considering the oblique direction of this branch and the small size of the fenestration.This case shows that pre-fenestrated and inner bare stent enhancing TEVAR is a safe and feasible technique for repair of complicated aortic arch aneurysm.

体外开窗TEVAR技术治疗不良近端锚定区Stanford B型主动脉夹层的近期疗效分析

目的探讨体外开窗腔内修复术(thoracic endovascular repair,TEVAR)治疗不良(短或不健康)近端锚定区Stanford B型主动脉夹层的近期疗效。方法选择2015年11月至2016年4月天津医科大学总医院血管外科收治的7例不良近端锚定区Stanford B型主动脉夹层患者。所有患者均采取体外开窗TEVAR技术进行治疗,观察术后即时血管造影结果。术后随访4~9月,于7~30 d、90 d行主动脉CT血管造影检查。以手术成功率、存活率和分支支架通畅率为有效性观察指标,并统计相应的不良事件。结果 7例患者术中支架全部释放成功。平均手术时间为(55±12)min,围手术期Ⅰa型内漏1例,与开窗直径过大有关,经封堵器封堵后消失。随访期7例患者无死亡,无支架近端内漏,夹层假腔均血栓化,无LSA支架闭塞。结论体外开窗TEVAR技术治疗不良近端锚定区Stanford B型主动脉夹层近期效果良好。

A computational fluid study on hemodynamics in visceral arteries in a complicated type B aortic dissection after thoracic endovascular repair

Objective:To report a numerical research on the effect of a renal artery arising from false lumen(FL)on the treatment outcome of thoracic endovascular repair(TEVAR)for complicated type B aortic dissection(TBAD).Methods:The original patient-specific model with the right renal artery(RRA)partially supplied by the FL(TFM)was reconstructed from its postoperative computed tomography images.Two additional models were reconstructed by artificially modifying the RRA either fully arising from the FL(CFM)or true lumen(CTM).Computational fluid dynamics(CFD)simulations were performed.Results:First,for all the models,the flow splits to all the visceral arteries were much less than those of a healthy aorta.Second,the flow split to RRA in the CFM and in CTM was the least and largest respectively.Third,in TFM,the pressure gradient between the true lumen(TL)and FL was negative at the proximal FL and the entire FL was full of active blood flow.In the contrast,in CTM and CFM,the pressure differences between the two lumens remained positive and little flow was present in FL.Finally,both TL and proximal FL of this particular patient expanded and the diameters of all visceral arteries decreased at one-year follow-up.Conclusions:Compared to a healthy aorta,a renal artery arising from FL following TEVAR would result in severe visceral ischemia including RA and superior mesenteric artery(SMA).In addition,our numerical simulation of the postoperative hemodynamics of this particular patient perfectly matched with its TL remodeling,FL expansion and contraction of the visceral arteries at one-year follow-up,and a patient-specific CFD simulation may be adopted to obtain information on visceral perfusion after endovascular repair for TBAD patients.

预开窗技术保留弓上分支血管在TEVAR治疗术中的临床应用经验

目的:回顾性分析预开窗技术保留弓上分支血管在胸主动脉腔内修复(throacic endovascular aortic repair,TEVAR)治疗术中的初步临床经验。方法 :对2015年12月至2017年4月25例累及主动脉弓部病变病人实施TEVAR治疗。采用预开窗技术保留弓上分支动脉。应用3种方法处理:(1)窗口预留导丝法4例;(2)窗口4点标记法6例;(3)主动脉翻转效应结合2点标记法15例。其中单开窗22例,双开窗3例。分析技术成功率、血管通畅率、内漏发生率、并发症发生率和近期临床结果。结果:本研究技术成功率为92.0%(23/25),失败2例改行烟囱支架。术后血管造影示各开窗血管血流通畅,支架形态良好,少量近端内漏2例(8.0%)。手术时间0.5~3 h。无卒中和心肌梗死发生。随访20例(80.0%),随访时间(180.2±6.0)(15~390)d。血管通畅率为100%,无内漏。结论:应用预开窗技术保留弓上分支血管在TEVAR治疗中具有创伤小、成功率较高、并发症发生率及病死率较低等优点。需进一步随访远期疗效。

TEVAR术在Stanford B型主动脉夹层的临床疗效及相关分析

目的探讨胸主动脉腔内修复术（thoracic endovascular aortic repair，TEVAR）术后治疗StanfordB型主动脉夹层的临床治疗疗效。方法回顾性分析无锡市人民医院2012年1月--2014年1月95例StanfordB型主动脉夹层患者的相关临床资料，依照是否行TEVAR，分为支架组80例及保守组15例。采集患者的基本临床资料，通过门诊随访评价患者的生存情况及术后康复情况。结果80例支架组患者手术全部成功，围手术期死亡2例（2．5％），随访期间无死亡患者，患者定期复查CTA显示，术后3—6个月、术后1年主动脉最大直径较术前明显减小，具有统计学意义，支架组术后主动脉呈减小趋势且假腔血栓化。15例保守治疗患者院内死亡1例（6．67％），随访期间死亡3例（20％）。K—M生存曲线分析显示支架组1年生存率明显高于保守组。结论对于StanfordB型主动脉夹层的患者，TEVAR治疗成功率较高，中期效果较好，可显著提高患者的生存率。