Anatomical features of aortic transection: analysis of the heart line to facilitate graft selection (2023)

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The anchorage of the aorta between the origin of the left subclavian artery and the ligamentum arteriosum explains the high frequency of aortic injuries in this region.94,95 Other locations include the transverse arch, the proximal ascending aorta, and the descending aorta just proximal to the diaphragm . 96-98 Initially, rupture of the intimal and medial aortic layers occurs.

Luminal narrowing, presumably secondary to thrombus, occurs in stent grafts with an unclear incidence following thoracic endovascular aortic repair (TEVAR). The significance of this phenomenon has not been established, nor have the risk factors for the development of intragraft luminal narrowing. Small graft diameter is believed to be a risk factor for the development of graft stenosis.

A retrospective analysis was performed of a multicenter healthcare system including all patients who underwent TEVAR between July 2011 and July 2019 with at least 1 year of available contrast-enhanced computed tomography monitoring thereafter. Standard demographic, preoperative, intraoperative, and postoperative variables were collected. Measurements were obtained via direct offline images from computed tomography scans. Patent intragraft diameters were compared to baseline and interval change values ​​were normalized to time to follow-up. The primary outcome measure was the annual rate of intragraft luminal narrowing.

There were 208 patients who met the inclusion criteria (94 women, 114 men) with a median follow-up of 822 days. The mean annual percentage intragraft diameter reduction was 10.5 ± 7.7% for females and 7.6 ± 5.6% for males (P= .0026). Multivariate analysis showed female gender (P= .0283), preoperative diagnosis of hypertension (P= .0449), and need for left subclavian artery coverage (P= .0328) were all significant predictors of intragraft luminal narrowing. Small aortic diameters were not found to be independently associated with graft luminal narrowing, nor the concomitant use of antiplatelet or anticoagulant medications. Significant amounts of graft luminal narrowing, defined as a greater than 20% decrease in graft diameter, were associated with a greater need for reintervention, including for malperfusion, endoleak, and symptomatic aneurysm (P= .0249). Kaplan-Meier estimates showed a significant sex-associated difference in high rates of intragraft luminal narrowing (P=.00189).

In this analysis, female gender is shown to be a significant non-modifiable risk factor for intragraft luminal narrowing after TEVAR. The development of this phenomenon is not benign; as such, these findings were associated with a greater need for reintervention. This finding can be attributed to differences in aortic compliance or sex-related differences in coagulation pathways and merits further investigation. Surveillance after thoracic stent grafting should take into account patient-specific variations in the risk of complications.

Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic blunt aortic injury (TBAI). A 20 mm proximal seal zone is recommended based on literature on aneurysmal disease, which often results in coverage of the left subclavian artery (LSA). The aim of this study was to analyze our experience with TEVAR for TBAI and evaluate whether 20 mm is necessary for successful remodeling.

This is a single-center, retrospective study of all consecutive patients who received TEVAR for the treatment of moderate and severe TBAI between April 2014 and November 2018. Three-dimensional software reconstruction was used for computed tomography (CT) midline measurements. Outcomes included technical success, need for reinterventions, and immediate and long-term aortic-related complications.

Sixty-one patients underwent TEVAR for TBAI during the study period. Twenty-eight (46%) patients underwent LSA coverage with a mean distance from the LSA to the injury of 6.4 mm (0–15.1 mm). Of the 33 (54%) patients who did not undergo LSA coverage, 22 patients (66%) had less than 20 mm proximal seal zone. The mean distance from LSA to injury in this group was 16.6 mm (7.9-29.5 mm). None of the patients with LSA coverage developed ischemic symptoms and a mean reduction in left arm systolic blood pressure of 24.8 mm Hg (0-62 mm Hg) was observed compared to the right arm. There was no aortic-related mortality in either group. Follow-up CT scans revealed excellent remodeling.

TEVAR immediate results for TBAI with LSA coverage are well tolerated; however, the long-term consequences of LSA coverage are unknown. Exclusion of the injury and excellent remodeling appear to occur with less than 20 mm of proximal occlusion, and more attention may need to be paid to preserving the LSA.

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For example, in this study, a 15-year-old patient with a Grade III injury had an 18 mm native aorta and a 26 mm endograft (smallest available) placed resulting in a 44.4% excess. It should be noted that the mean excess in this study exceeds current guidelines for the treatment of BTAI.15 However, this is influenced and biased by several factors, including conservative calculation of excess over the entire length of a stented aorta, sizing of the graft performed on CTA in a peritrauma, hypovolemic state, and as previously noted, lack of appropriate device diameters in a younger population.

Thoracic endovascular aneurysm repair (TEVAR) has become the current standard of care for the emerging treatment of traumatic blunt thoracic aortic injury (BTAI). Although aortic dilatation (AD) of the infrarenal neck after EVAR for aortic aneurysms has been studied, the change in aortic diameter after TEVAR for BTAI is not well understood. This study aims to characterize changes in thoracic aortic diameter following stent-graft placement in the setting of non-aneurysmal traumatic aortic injury.

A single-center retrospective review was conducted with patients who exhibited BTAI and were treated with TEVAR. Only patients with a follow-up of at least 12 months were included. Aortic diameter, defined as the outer-to-outer diameter on 3D centerline imaging, was measured at six locations along the proximal and mid-thoracic aorta. The first postoperative CT (≤1 month) served as a baseline from which interval measurements were compared.

Twenty patients with BTAI treated from 2011 to 2017 had adequate imaging available for assessment and were included in this study cohort. The median follow-up time was 46.8 (12-80, range) months. At last follow-up, AD occurred at all measured locations within the endograft, starting from the proximal graft edge (0.62 ± 0.69 mm,P=0.027) to the distal graft edge (1.21 ± 1.28 mm,P=0.003). AD was most pronounced in the distal graft segment 2 cm proximal to the distal edge of the graft, with a mean AD of 1.32 ± 1.59 mm (+5.3%,P<0.001). At this location, AD was found to increase linearly at an estimated rate of 0.67 ± 0.20 mm/year (P=0.006). The native aorta proximal and distal to the endograft did not appear to expand significantly during follow-up (P=0.280–0.897). Seventy percent of patients were found to have AD >5%. The amount of AD was not found to be associated with graft excess (P=0.151) or age (P=0.340). There were no cases of graft migration, erosion or endoleak.

AD is a common benign finding after TEVAR for BTAI. AD is most pronounced near the distal end of the stent graft. At late-term follow-up, there are no known associated complications related to AD.

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In this study, the mean length from the left subclavian artery to the proximal site of injury was 16.2 mm (range: 2-31 mm). The mean length of the injured aortic segment was 27 mm.21 Borsa et al22 also presented an angiographic description of blunt traumatic injuries to the thoracic aorta in 50 patients and showed comparable measurements.

The usual location of thoracic blunt traumatic aortic injury (BTAI) is just distal to the left subclavian artery; however, injuries can also be found in other locations in the thoracic aorta (DTA).

This is a single institution retrospective study, using 74 consecutive BTAIs in the DTA. The patients were divided into two groups based on the location of the lesion. The proximal group included injuries within 5 cm of the left subclavian artery, while the distal group included injuries throughout the rest of the DTA. A total of 27 factors were compared.

Between 2010 and July 2017, we identified 14 of 74 patients (19%) with BTAI in the distal zone. Women were 9 of 14 (64%) in the distal zone group, while women were 16 of 60 (27%) in the proximal zone group (P< .012). Thoracic vertebral fractures occurred in 7 of 14 patients (50%) with distal zone injuries, while they occurred in 12 of 60 patients (20%) in the proximal zone group (P< .038). Eleven of 14 injuries in the distal zone (79%) were Grade 1 or 2 compared to 15 of 60 injuries (25%) in the proximal zone (P= .016). Only 2 of 14 injuries (14%) in the distal zone required endovascular repair versus 39 of 60 (65%) in the proximal zone (P< .001). The mean hospital stay in patients with BTAI in the distal zone was 8.5 days compared to 20.3 days for patients in the proximal zone group (P< .004). Mortality occurred in 5 of 14 patients (36%) in the distal zone group compared to 5 of 60 patients (8%) in the proximal zone group (P= .017). The probability of death from a distal zone injury was nearly 6 times greater than the probability of death from a proximal zone injury (odds ratio, 5.9; 95% confidence interval, 1.2-31.8). There were no deaths related to the BTAI itself. The association of location with mortality remained significant even after adjusting for other significant factors such as Injury Severity Score and patient age. Patients who died from injuries in the distal zone had a shorter length of stay (5 days versus 20 days;P= .0002).

BTAI in the distal zone of DTA are associated with unique features. They are (1) more commonly associated with thoracic vertebral fractures, (2) are more common in females, (3) tend to be of lower grade, (4) require intervention less often, and (5) appear to have a higher mortality due to other related traumatic injuries.

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Such knowledge may assist the interventionist in planning a second intervention with extension graft, as this change in aortic length should be kept in mind when selecting the appropriate extension graft length. The methods used for assessment and measurement are similar to previously reported methods (13, 17-19). For the stent graft itself, we observed a change in graft length (increase or decrease) in 19 patients, taking into account that seven of them had multiple stent grafts implanted; however, the change in stent-graft length was not statistically significant at follow-up.

To study long-term changes in the thoracic aorta after thoracic endovascular aortic repair (TEVAR) for the treatment of various pathological conditions of the aorta.

This retrospective study included 53 consecutive patients (mean age 58.8 years ± 14; 13 females and 40 males) who underwent TEVAR between October 2002 and May 2010. The mean duration of follow-up was 21.1 months (range 0.5-96 months). mon). Statistical analysis was performed with the Friedman test and the Conover-Iman test.

Nineteen patients with aortic aneurysm (group 1), 25 patients with type B dissection (group 2), and 9 patients with other pathological conditions (group 3) were treated with TEVAR. The mean total length of the aorta (from the origin of the left subclavian artery to the origin of the celiac trunk) before TEVAR was 271.4 mm, 268.6 mm, and 233.6 mm in groups 1, 2, and 2, respectively. 3. At 12-month follow-up, lengths were 282.8 mm, 294.4 mm, and 237.5 mm in Groups 1, 2, and 3, respectively. The changes in aortic lengths after TEVAR were statistically significant (P< .001). A second intervention was required in 14 patients and 6 patients died during follow-up.

A significant change in total aortic length was observed after TEVAR. The changes in aortic length reached statistical significance at 12 months.

The location of the carotid artery bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing the technical difficulty and potentially increasing the incidence of cranial nerve damage or paralysis. The aim of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare the results of CEA in 2 groups of patients treated with standard CEA or with MS-CEA according to the number of serious neurological complications , death, and the occurrence of postoperative peripheral nerve palsy.

Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic lesions of the internal carotid artery (ICA) in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were eligible for comparative analysis.

MS-CEA patients were more often male (P=0.03), more often presented with symptomatic lesions (P=0.007), longer lesions (P=0.01), and had regular ICA bypass implantation (P=0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurological mortality and no long-term discomfort associated with MS were recorded. The overall neurological morbidity rate (major stroke/minor stroke/transient ischemic attachment) was similar in the 2 groups (P=0.78). The overall rate of direct peripheral nerve injury was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P=0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P=0,24).

MS-CEA can be a very useful technical tool for high carotid artery bifurcations or challenging carotid artery lesions, with an overall risk similar to that of standard CEA.

Objective performance goals (OPGs) are a set of standardized endpoints generated from well-documented historical controls against which new therapeutic procedures can be compared in single-arm studies. Recently, the Society for Vascular Surgery has proposed a series of OPGs designed based on vein bypass controls that can be used to evaluate the safety and efficacy of endovascular devices applied to critical limb ischemia through a non-inferiority analysis. Our aim is to analyze the results of infrapopliteal endovascular procedures performed in patients with critical limb ischemia according to these OPG endpoints.

This is a retrospective study of 121 infrapopliteal endovascular procedures. The tibial intervention was combined with femoropopliteal angioplasty in 70 procedures. Major adverse cardiovascular events (MACEs), major adverse limb events (MALEs), and major amputations at 30 days were recorded as safety outcomes. Freedom from any MALE or perioperative death (Freedom from MALE+POD) and amputation-free survival were calculated as primary efficacy endpoints at both 12 months and 8 years. The 95% confidence intervals (CIs) of all endpoints were calculated to perform a non-inferiority comparison using OPGs as a reference.

The incidence of MACEs, MALEs and amputations after 30 days was 5% (95% CI: 2-10% [OPG-MACE <10%]), 2.5% (95% CI: 0.5-7% [OPG -MALE <9 %]) and 1.7% (95% CI: 0.2–6% [OPG major amputation <4%]), respectively. We recorded a freedom from MALE+POD of 76% (95% CI: 67–83% [OPG-MALE+POD >67%]) and an amputation-free survival of 78% (95% CI: 69–85% [OPG- amputation-free survival >68%]) at 12 months. Freedom from MALE+POD and amputation-free survival at 8 years decreased to 60% (95% CI: 49-69%) and 26% (95% CI: 11-44%), respectively.

Infrapopliteal endovascular procedures performed in the routine practice of vascular surgery could meet the key OPG endpoints proposed for catheter-based management of critical limb ischemia.

We sought to evaluate the best therapeutic management of postbiopsy arteriovenous fistulas (AVFs) in transplanted kidneys.

Between January 2005 and December 2011, we observed 17 cases of AVF after biopsy in transplanted kidneys (9 asymptomatic; 8 symptomatic). Asymptomatic cases were treated conservatively, while patients with symptomatic AVF underwent endovascular treatment. We used a technique consisting of a superselective transcatheter embolization of the afferent branch. We evaluated technical success (postoperative closure of AVF), immediate clinical efficacy (cessation of symptoms), and clinical efficacy at follow-up (measurement of serum creatinine at 7 days and 6 and 12 months compared to preoperative levels usingT-samples).

Asymptomatic AVFs resolved spontaneously, while endovascular treatment of symptomatic AVFs showed complete technical and clinical success with rapid remission of the presented symptoms. We observed a statistically significant decrease in serum creatinine at 7 days and 6 and 12 months postoperatively (mean creatinine preoperative: 3.23 ± 1.4 mg/dL; 7 days: 2.25 ± 0.8 mg/dL; 6 months: 1.65 ± 0.28 mg/dL, 12 months: 1.4 ± 0.26 mg/dL, in all casesP<0,05).

In our experience, asymptomatic AVFs can be treated conservatively with close follow-up, while endovascular treatment of symptomatic AVFs is both safe and effective in the short and long term.

We compared initial and long-term outcomes between men and women after endovascular and open repair of popliteal artery aneurysms (PAAs).

Between January 1993 and July 2011, 202 patients (185 men [92%]) underwent open (N= 186) of endovasculair (N= 16) repair of a PAA. Data were analyzed retrospectively.

Significant differences in baseline characteristics were noted between men and women with respect to aneurysm diameter (men: 30 mm [range: 14–90]; women: 26 mm [range: 13–70];P= 0.02) and age (men: 66 ± 10 years; women: 71 ± 9 years;P= 0.05). The mortality rate after 30 days was 0% in both groups. No significant differences were observed with regard to complications after 30 days. The median follow-up was 55 months (range: 1-121 months) in men, compared with 35 months (range: 1-183 months) in women (P= 0.74). The primary patency rates at 1, 3, and 5 years were 88%, 82%, and 76% in males compared to 64%, 64%, and 48% in females, respectively (P= 0.007). The limb survival rates in males at 1, 3, and 5 years were 97%, 97%, and 96%, respectively, and in females, 87%, 87%, and 87%, respectively (P= 0.07). When adjusted for potential confounders with multivariable regression analysis, gender was independently associated with primary patency (hazard ratio: 2.98 [95% confidence interval: 1.39-6.42];P= 0,005).

No significant differences between men and women were observed in 30-day mortality and morbidity after PAA repair. In the long term, women are associated with lower primary patency rates and a trend toward lower extremity recovery rates compared to men.