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.

Endovascular graft exclusion for descending thoracic aortic dissections

Objective: To assess the operation indications, preoperative evaluation, technique essential and clinical prospective of Endovascular Graft Exclusion for thoracic aortic dissection. Methods: Since September 1998, Endovascular Graft Exclusion for thoracic aortic dissection has been performed on 10 patients. Graft was constructed from self-expanding Z-stents covered with a woven Dacron polyester fabric graft. Ged dimensions were determined ftom spiral computed tomographic scans. All operations were performed under DSA guidance. Results: There was one early death resulting from endoleaks. Proedures in the other 9 patients succeeded. No complications such as myocardial infarction, lung failure, kidney failureand paralysis that commonly occurred ther conventional operations were obsered. Immediate thrombosis in false lumen was achieved in 6 patients, and late thrombosis occurred in 3 patients. Mean follow-up duration was 3 months, the aneurysmal diameter was decreased obviously. Conclusion: These early results support the hypothesis that Endovascular Graft Exclusion may be a safe and durable treatment for selected patients with theracic aortic dissection. Endoleak may allow continued aneurysmal expansion and rupture. Further follow-up is necessary to evaluate the true long-term effectiveness of this procedure.

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,

Acute Type A Aortic Dissection—Replacement of Ascending Aorta, Aortic Arch and Antegrade Stenting of the Descending Thoracic Aorta Using the Thoraflex™Hybrid Plexus Device (Terumo Aortic)—“Frozen Elephant Trunk”: The Plymouth Way!

Objectives: To describe our technique for the implantation of the Thoraflex Hybrid prosthesis for replacement of the aortic arch in a safe and reproducible way. Materials: Thoraflex™ Hybrid Plexus Device (Terumo Aortic). Design: Drawing on our own experience over the past 4 years in the management of acute type A aortic dissection, we have distilled the essentials of our “Frozen Elephant Trunk” technique which have led us through our own learning curve to the improved management of this taxing condition. Method/ Results: Small extension of the median sternotomy incision along the medial border of sternocleidomastoid muscle. End to side graft anastomosis near the origin of the left subclavian artery during cooling on bypass towards 20 degrees. Attention to cardiac protection and maintenance of cerebral perfusion during the shortened corporeal arrest period. Excellent results in 24 consecutive AAAD patients with just one hospital mortality. Conclusions: We believe we are entering a new phase in the treatment of AAAD, facilitated by the availability of a hybrid prosthesis which combines expanding stent technology with familiar surgical graft material. Our particular management of the left subclavian artery and of the cerebral circulation during implantation has contributed to an expeditious and reproducible method of treating dissection within the arch of the aorta and beyond.

Diagnosis and management of thoracic aortic dissection:An update

Acute thoracic aortic dissection is part of the acute aortic syndrome triad.Caused by an intimal tear in the lumen of the aorta,it leads to the creation and propagation of a false lumen.In the acute setting this can lead to malignant hypertension,pain and end organ malperfusion.In the chronic setting it can lead to aneurysm formation and rupture.It remains the most common aortic emergency,affecting up to 4 per 100000 people per year in the United Kingdom and United States.Despite advances in treatment and centralisation of vascular services,it continues to be associated with a high pre-admission and in-hospital mortality.Dissection is classified in several ways according to anatomical extent,timing and underlying pathology,all of which guides clinical management.Traditionally,medical management has been the mainstay of treatment in patients with uncomplicated disease.Surgery has been used in symptomatic patients.With published information now available from several prospective international registries,we are beginning to see the advantages of newer surgical treatment options such as endovascular repair,in the acute setting.This review provides an update on diagnosis and management of aortic dissection,including new information that has become available in recent years.

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.

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

The clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment for patients with DeBakey Ⅰ thoracic aortic dissection

Objective To summarize the clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment to patients with DeBakey Ⅰ thoracic aortic dissection. Methods From January 2006 to October 2010,101 cases of DeBakeyⅠaortic dissection were treated by modified total arch replacement and stent elephant trunk technique,in which emergencey surgery were performed on 73 cases. There were 76 male and 25

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.

Current knowledge and contemporary management of non-A non-B aortic dissections

Non-A non-B aortic dissection(AAD)is an infrequently documented condition,comprising of only a small proportion of all AADs.The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD,have led to an ongoing controversy around the topic.It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections,frequently leading to serious complications and thus mandating early intervention.Currently,the available treatment methods in the surgical armamentarium are conventional open,endovascular techniques and combined hybrid methods.The optimum approach is tailored in every individual case and may be determined by the dissection’s location,extent,the aortic diameter,the associated complications and the patient’s status.The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached.In an attempt to provide further insight into this perplexing entity,we performed a minireview of the literature,aiming to elucidate the epidemiology,clinical course and the optimal treatment modality.

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.

Blunt aortic injury-traumatic aortic isthmus pseudoaneurysm with right iliac artery dissection aneurysm:A case report

BACKGROUND Blunt aortic injury is a special type of aortic disease.Due to its low incidence,high prehospital mortality and high probability of leakage diagnosis,the timely identification of patients with blunt aortic injury who survive the initial injury has always been a clinical challenge.CASE SUMMARY We report a case of traumatic aortic pseudoaneurysm with right iliac artery dissection aneurysm that was diagnosed 3 mo after a traffic accident.The patient is a 76-year-old male who was knocked down by a fast-moving four-wheel motor vehicle while crossing the road(the damage mechanism was side impact).He received chest,cranial computed tomography(CT)and whole abdomen enhanced CT in the local hospital.The images suggested subarachnoid hemorrhage,right frontoparietal scalp hematoma,fracture of the right clavicle and second rib,lumpshaped mediastinal shadow outside the anterior descending thoracic aorta(mediastinal hematoma),mesenteric vascular injury with hematoma formation,pelvic fracture,and subluxation of the left sacroiliac joint.After the pelvic fracture was fixed with an external stent,he was sent to our hospital for further treatment.In our hospital,he successfully underwent partial resection of the small intestine and CT-guided screw internal fixation of the left sacroiliac joint and returned to the local hospital for rehabilitation treatment.However,since the accident,the patient has been suffering from mild chest pain,which has not aroused the attention of clinicians.During rehabilitation,his chest pain gradually worsened,and the thoracic aorta computed tomography angiography performed in the local hospital showed a pseudoaneurysm in the initial descending segment of the aortic arch.After transfer to our hospital,a dissecting aneurysm of the right external iliac artery was incidentally found in the preoperative evaluation.Finally,endovascular stent graft repair was performed,and he was discharged on the 10th day after the operation.No obvious endo-leak was found after 4 years of follow-up.CONCLUSION We highlight that emergency trauma centers should consider the possibility of aortic injury in patients with severe motor vehicle crashes and repeat the examination when necessary to avoid missed diagnoses.

Perioperative factors analysis in patients with aortic aneurysm and aortic dissection aneurysm

This study was undertaken to analyze the perioperative factors and complications that influence the final outcome after deep hypothermic circulatory arrest and superficial hypothermia during operations on aortic aneurysms from Jan 2000 to Jun 2004. The results show that deep hypthermic circulatory arrest group provided a high risk of pulmonary insufficiency-hypoxemia and temporary neurological dysfunction in complication but not increased the risk of hospital mortality.

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.

Surgical repair of an emergent giant hepatic aneurysm with an abdominal aortic dissection:A case report

BACKGROUND Hepatic artery aneurysm(HAA)is the second most common visceral aneurysm.A significant number of hepatic aneurysms are found accidentally on examination.However,their natural history is characterized by their propensity to rupture,which is very serious and requires urgent treatment.An emergent giant hepatic aneurysm with an abdominal aortic dissection is less commonly reported.CASE SUMMARY We report the complicated case of a giant hepatic aneurysm with an abdominal aortic dissection.A 66-year-old female presented with the complaint of sudden upper abdominal pain accompanied by vomiting.Physical examination showed that her blood pressure was 214/113 mmHg.Her other vital signs were stable.Computed tomography found a giant hepatic proper aneurysm and dissection of the lower segment of the abdominal aorta.Furthermore,angiography showed a HAA with the maximum diameter of approximately 56 mm originating from the proper hepatic artery and located approximately 15 mm from the involved bifurcation of the left and right hepatic arteries with no collateral circulation.Therefore,we decided to use a stent to isolate the abdominal aortic dissection first,and then performed open repair.After the operation,the patient recovered well without complications,and her 3-month follow-up checkup did not reveal any late complications.CONCLUSION Open surgery is a proven method for treating giant hepatic aneurysms.If the patient's condition is complex,staged surgery is an option.

Marfan Syndrome Complicated by Aortic Arch Aneurysm and Aortic Dissection: A Case Report from Congo

Context and Aim: Marfan syndrome is a transmissible genetic disease of the connective tissue that is rarely encountered in Congo and in sub-Saharan African countries. Its cardiovascular complications can be life frightening. The management of that disease is still limited in our country because of a lack of technical capacity in cardiovascular surgery. The aim of this clinical report is to show the interest of echocardiography and especially angioscanner as the main technique in the diagnosis of the severity of this disease, elaborate a literature review, but also to highlight the difficulties encountered in the management of that affection in our countries. Observation: The authors report the medical observation of a 48-year-old adult with a history of cataract of the left eye and a subluxation of the lens for which he underwent surgery in 2016, without any etiology being found. He is a smoker at a rate of 6 packs yearly. He consulted for progressively worsening dyspnea and constrictive mediosternal pain. The clinical examination revealed a moderate alteration of the general state, apyrexia, a blood pressure of 140/90 mmHg, a SPO2 of 97% in ambient air, a respiratory frequency of 32 cycles/min, signs of left ventricular insufficiency, a diastolic murmur of aortic insufficiency of intensity 4/6th, a long-limbed morphotype with a wingspan superior to the height and a kyphoscoliosis. Chest X-ray showed cardiomegaly with a cardiothoracic ratio of 58%, a highly dilated and uncoiled aorta, convexity of the left inferior arch, and venocapillary hypertension and a quiet alveolar-interstitial pulmonary oedema. The ECG was in sinus rhythm and showed a poor R-wave progression in anteroseptal leads. Echocardiography showed significant aortic root dilatation up to 72.6 mm and aortic regurgitation grade IV. Angioscanner showed a dissected aortic aneurysm and areas of emphysema located in the lungs. The medical treatment was palliative with beta blocker and angiotensin II receptor antagonists, diuretics and analgesics. The patient is awaiting surgery. Conclusion: Marfan syndrome is a genetic disease of the connective tissue that can manifest itself by cardiovascular, pulmonary, orthopedic, ophthalmological and cutaneous signs. Echocardiography and especially angioscanner are the tools of choice for the diagnosis and follow-up of this condition. Surgery is reserved for serious complications of this condition.

With autosomal dominant polycystic kidney disease,aortic dissection follows an abdominal aneurysm ten years later:a case report

A case of aortic dissection with a repaired abdominal aneurysm with prosthetic graft ten years ago in a 45-year-old woman is presented.Stanford type B dissection and multiple renal cysts diagnosed by contrast enhanced CT and an iliac false aneurysm by intraoperational angiography.Four stents were deployed to repair these arterial lesions with one fenestrated.With her only son revealed also with renal cysts by ultrasonogram,the diagnosis of autosomal dominant polycystic kidney disease (ADPKD) was confirmed.

A new way to produce descending thoracic aorta dissection in the dogs

To oonstruct a canine thoracic aortic dissection （TAD） model for later studying. Methods： we opened the thorax of the dog and exposed the aorta. The descending aorta right below the left innominated artery was damped. The median was cut 1/3 in depth and 1/3 in circumference. Then the head of the ballcon was put into the interspace of the median, the balloon was dilated after putting forward the tube, the normal saline was instilled into the interspace and a suit pressure was kept. The balloon proceeded alongside the separation of the median. After that the elasticity Protease was instilled into the separation maintained for 2 hours. The balloon was put out, the other 2/3 of the median in depth and the intima were cut. The external 1/3 part of the median and the adventitia were sutured. At last the chest wall was dosed. Results： TAD model was established instantly, proved by angiography, MRI and autopsy. Conclusion： it is applicable to construction of a canine TAD model by this procedure.

Risk factors of distal segment aortic enlargement after complicated type B aortic dissection

Objectives:Distal segment aortic enlargement(DSAE)is a common complication that influences the long-term prognosis of type B aortic dissection(TBAD)after thoracic endovascular aortic repair(TEVAR).In this study,a multivariate analysis was performed to find potential factors predictive of DSAE.Methods:A single-center retrospective study was performed from 1999 to 2016.Included in the study were complicated TBAD patients who underwent TEVAR with uncovered residual tears.Based on the diameter of the distal segment of the uncovered aorta,we assigned patients to an enlargement group and a non-enlargement group.Data extracted from the medical records included demographic and clinical characteristics and followup computed tomography angiography data.The primary endpoints were the all-cause mortality and the presumably aortic-related events that required reintervention during the follow-up period.Results:For the 333 patients,all-cause mortality was 38(11.41%),and 76(22.82%)patients underwent reintervention.A total of 70(21.02%)patients experienced DSAE,among them were 2 patients who died of aortic rupture and 58 patients who accepted reintervention.Multivariate analysis reviewed independent risk factors of postoperative DSAE,including current smoking,the residual length of the patent false lumen,the postoperative number of dissection tears in the thoracic aorta and type III aortic arch;as well as protective factors,including the application of a restrictive bare stent(RBS),the length of covered stent in the descending thoracic aorta,and the distance from the residual first tear to the left subclavian artery(LSA).Conclusion:DSAE after TEVAR for patients with a complicated TBAD can be influenced by their current smoking habit,the residual length of patent false lumen,the postoperative number of dissection tears in the thoracic aorta and the aortic arch type.Meanwhile,RBS usage,the length of the covered stent in the descending thoracic aorta and the distance from the residual first tear to the LSA could have positive effect on the prognosis.