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Objective The perioperative outcomes of open surgical and endovascular repair of intact thoracic aortic aneurysms (TAAs) during the last 3 months of 2005 were compared using a national administrative database. Methods The Nationwide Inpatient Sample was used to identify patients undergoing open aneurysm repair (OAR) or endovascular TAA repair (TEVAR) from October 1 to December 31, 2005. Patient demographic data, length of stay, hospital charges, patient disposition, and mortality were examined. Where appropriate, univariate tests of association used the χ 2 test, and multiple logistic regression analysis was used to determine predictors of in-hospital mortality, complications, and discharge status. Results A total of 1030 patients underwent open TAA repair and 267 underwent TEVAR. There was no significant difference in mortality between OAR and TEVAR (adjusted odds ratio [OR], 1.2; 95% confidence interval [CI], 0.73-2.12), although OAR patients were more likely to have cardiac, respiratory, and hemorrhagic complications. Patients undergoing TEVAR were more likely to be discharged to home (adjusted OR, 6.37; 95% CI, 2.93-13.70) and had a decreased length of stay (5.7 days vs 9.9 days; P = .0015). The differences in hospital charges and costs were not significant. Conclusion Although further study is warranted, this study of a national sample suggests that endovascular TAA repair is safe in the short-term, associated with fewer cardiac, respiratory, and hemorrhagic complications, and requires a shorter hospital stay.

Aortic aneurysms are the 13th-leading cause of mortality in the United States.1 The incidence of thoracic aortic aneurysms (TAA) is increasing with improvements in screening, as well as advances in imaging.2 Replacement of the ascending aorta accounts for the majority of thoracic aortic procedures. TAAs are more frequently present in men and typically occur in the 50- to 70-year age range.3 Disease processes affecting the ascending and arch aorta include degenerative aneurysms and aneurysms associated with connective tissue disease, as well as acute aortic dissection and its variants of intramural hematoma and penetrating ulcer. Syphilitic aneurysms, once the predominant cause of ascending aneurysms, are exceedingly rare today. In the present review, we will discuss these pathological conditions as well as operative techniques and outcomes after medical and operative therapy. ### Degenerative Aneurysms Degenerative aneurysms comprise the majority of those seen in the ascending aorta and have a specific pathological profile.3 Whereas the elastin content in the ascending aorta is high, that seen in ascending aortic aneurysms is significantly reduced. In addition, the media of the aneurysm displays a loss of smooth muscle cells and fragmentation of the elastic fibers from a process known as cystic medial degeneration. Although this process is seen normally as a consequence of aging, it is accelerated in some and results in the phenotypic expression of an ascending aortic aneurysm. Recent studies have focused on differences in ascending aneurysm pathogenesis for patients with bicuspid and tricuspid aortic valves, with the former suggested as a more-aggressive variant.4 ### Marfan Syndrome Marfan syndrome is the most common inherited connective tissue disease, with an incidence of 1 in 10 000.5 The basic genetic defect is a mutation of the gene for fibrillin-1, an essential protein of microfibrils. The phenotypic manifestation is that of disorganized elastic fibers, premature cystic medial …

Objective: Patients with aortic dissection were studied to define (1) anatomic and physiologic derangements in renal artery blood flow, (2) differences in clinically suspected renal malperfusion and true functional malperfusion, and (3) variations in endovascular interventions for the treatment of renal malperfusion. Methods: The cohort comprised 165 patients (mean age, 58 years) with dissections who were thought to have malperfusion sufficient to require arteriography. They were treated from 1996 to 2004 for acute (n = 115) or chronic (n = 50) aortic dissections (75 had type A, 90 had type B lesions). All patients had suspected peripheral vascular malperfusion (ie, cerebral, spinal, mesenteric, renal, or lower extremity vascular beds). Renal malperfusion was suspected in 88 patients secondary to worsening hypertension (n = 34), evolving renal insufficiency (n = 37), computed tomography evidence of impaired renal blood flow (n = 13), or a combination of factors (n = 4). Patients underwent angiographic and intravascular ultrasound studies. Renal malperfusion was confirmed with a systolic gradient between the aortic root and renal hilum (average, 44 mm Hg). Results: Right renal arteries arose exclusively from the true lumen in 115 patients (70%), the false lumen in 11 (7%), and both lumens in 37 (23%). Left renal arteries arose exclusively from the true lumen in 69 patients (42%), the false lumen in 32 (20%), and both lumens in 62 (38%). Angiographic confirmation of malperfusion existed in 59 patients (67%) of the 88 suspected of such, and in 31 patients (39%) of the 79 with suspected malperfusion of nonrenal tissues. Of the 90 patients with confirmed renal malperfusion, 71 underwent endovascular therapy, including isolated renal artery stenting (n = 31), as well as proximal aortic fenestration with or without aortic stenting (n = 24), or both renal and aortic intervention (n = 16). Residual pressure gradients averaged 8.1 mm Hg after these interventions. Five procedure-related complications (7%) occurred. The periprocedural postintervention mortality rate was 21% (n = 15), including multisystem organ failure (n = 7), false lumen rupture (n = 3), reperfusion injury (n = 2), cerebral ischemia (n = 1), cardiac arrest (n = 1), and unknown (n = 1). Conclusions: Percutaneous aortic fenestration and renal artery stenting are both technically feasible and associated with an acceptable complication rate. Most patients respond well symptomatically, obviating the need for immediate surgical relief of renal artery obstruction and allowing for renal malperfusion recovery.

OBJECTIVE. The purpose of this study was to document the spectrum of CT findings and the clinical outcome of thoracic aortic graft complications.CONCLUSION. Aortic graft complications detected with CT may or may not be clinically apparent and/or relevant. CT characterization in combination with clinical findings helps to determine patient treatment.

Acute aortic dissection is a lethal disease. Based on classic studies from the 1950s, ascending aortic dissection has a mortality rate that increases on an hourly basis, and is fatal in over 90% of patients at one month if untreated1. However, recent reports on mortality with maximal antihypertensive therapy reveal improvements with medical therapy. Survival in patients who survive the initial event and present to the hospital has been reported as high as 70% at two years2.

Despite recent advances, reported mortality rates after repair for acute type A aortic dissection vary from 5% to 30%. This study was conducted to assess cross-sectional mortality after operative repair of type A dissection in the United States, and to determine whether a volume-outcome relationship exists for this operative procedure.Data were obtained from the Nationwide Inpatient Sample, which is a cross-sectional administrative database incorporating 20% of all annual US hospital discharges. From 1995 to 2003, a cohort of 3013 patients with thoracic or thoracoabdominal dissection who underwent aortic resection was identified. Patient demographics, hospital volumes, and teaching status were included as independent variables.The mean age was 62 +/- 14 years (65% male). In-hospital mortality for the study period was 26%, but it decreased from 27% in 1995 to 23% in 2003 (P = .03). A significant correlation was found between procedural volume and mortality (P.001). By multivariate analysis, independent predictors of mortality included increasing age (P.0001) and operation at a non-teaching hospital (P = .002).Operative mortality for repair of ascending aortic dissection in the United States has shown modest temporal improvements. More importantly, operative mortality seems to be dependent on the arena of care.

Objective This study evaluated the safety and effectiveness of the Zenith Alpha Thoracic Endovascular Graft (Cook Medical, Bloomington, Ind) for the treatment of descending thoracic aortic aneurysms and large ulcers. Methods The Zenith Alpha Thoracic Endovascular Graft, with a 16F to 20F delivery system, was developed to address vascular access issues associated with larger-profile devices and to increase conformability in tortuous anatomy. This prospective, nonrandomized, multicenter study was conducted in Europe, Japan, and the United States. The main anatomical inclusion criteria included proximal neck seal zone of ≥20 mm, aortic arch radius of ≥20 mm, and a neck diameter of 15 to 42 mm. Patients were evaluated preprocedure, predischarge, and postdischarge 1, 6, and 12 months and yearly thereafter through 5 years. Results Between March 2010 and January 2013, 110 patients (64 men and 46 women; mean age, 72 ± 10 years) were enrolled in the study for the treatment of descending thoracic aortic aneurysms (n = 90) or ulcers (n = 20). Access was percutaneous in 36% (40 of 110) of patients. The study device was successfully implanted in all but two patients (both due to inability to gain access or advance to the target treatment site). There was no 30-day mortality. Five deaths occurred ≤1 year (only one was aneurysm-related by independent adjudication), resulting in a 95% freedom from all-cause mortality and a 99% freedom from thoracic aortic aneurysm-related mortality. At one or more time points ≤1 year, type I endoleak (all distal) was observed in 4 patients, type III endoleak in 2, and aneurysm growth in 4. Five patients experienced stroke ≤1 year (2 procedure-related). No aortic rupture, paraplegia, paralysis, or permanent spinal cord injury was observed ≤1 year. Conclusions Early outcomes after Zenith Alpha implantation appear promising and suggest expanded thoracic endovascular aortic repair applicability in patients with smaller access vessels. Longer-term follow-up is ongoing.

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.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.A total of 1456 ABAD patients were identified, of which 104 (7.1%) presented with visceral ischemia. Preoperative limb ischemia (28% vs 7%, P .001) and acute renal failure (41% vs 14%, P .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, P .0001). Mortality rates were similar after surgical and endovascular management of visceral ischemia (25.8% and 25.5%, respectively, P = 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; P = .036).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.

Background Despite acceptable results reported with endovascular thoracic aortic repair (TEVAR), recent studies have questioned the merit of repair in asymptomatic patients considered high risk for open surgery. In this group, advanced age or comorbid conditions may reduce life expectancy, thus limiting the benefit of elective aneurysmectomy. This study was conducted to determine whether elective TEVAR improves survival for this cohort. Methods Forty-six asymptomatic patients with descending thoracic aortic disease were considered high risk for open surgery for reasons of age of 80 years or older (47.8%) or comorbid conditions (84.8%), and were subsequently evaluated for elective TEVAR. Of these, 21 underwent TEVAR, while another 25 patients were excluded from TEVAR on the basis of unfavorable anatomy or refused intervention. Results The mean age of the cohort was 77.0 ± 7.0 years ( p = 0.9 between groups). Prevalent comorbid conditions were similar between groups, and included coronary artery disease ( p = 1.0), chronic obstructive pulmonary disease ( p = 1.0), and peripheral vascular disease ( p = 0.23). Mean maximum aortic diameter was 6.0 ± 1.4 cm ( p = 0.54 between groups). Indications for intervention included fusiform aneurysm (65.2%) and pseudoaneurysm or penetrating ulcer (32.6%). No 30-day mortality was observed after TEVAR. All-cause mortality in the entire cohort was 50%. Median actual time to mortality was different between groups (control, 9.2 months versus TEVAR, 24.9 months; p = 0.01). Life-table analysis demonstrated improved survival for TEVAR at 24 months ( p = 0.05). Conclusions Although the overall prognosis for the asymptomatic patient with descending thoracic aortic disease at high risk for open surgery is poor, elective endovascular repair improves survival and should be considered a therapeutic option in this setting.

PURPOSE Small areas of blood flow are sometimes seen within an otherwise thrombosed false lumen on computed tomography (CT) scans of intramural hematomas of the aorta. These are blood-filled spaces that, although they have no apparent communication with the true lumen, appear isodense with the aorta on contrast-enhanced CT scans. The purpose of this report is to describe angiographic and autopsy studies that establish the nature of this entity and describe the principal CT features distinguishing it from a penetrating ulcer. MATERIALS AND METHODS Conventional angiographic and CT aorta findings in two cases with small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection are discussed. Also examined is another case with pathologic and histologic findings in addition to those of small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection, which illustrate the pathoanatomy of these lesions. RESULTS Angiographic and necropsy evidence shows that some of these lesions represent branch artery pseudoaneurysms and, as such, are secondary to an intramural hematoma, not the primary cause of it. CONCLUSIONS Difficulty in demonstrating communication between these collections of contrast material and the adjacent true lumen of the aorta on helical CT examinations and the characteristic location of these lesions along the nonpleural portion of the aortic circumference distinguish them from penetrating ulcers and should suggest the diagnosis of branch artery pseudoaneurysm. Demonstration of a branch artery originating from the contrast collection confirms the diagnosis. These branch artery pseudoaneurysms should be distinguished from penetrating atherosclerotic ulcers.

Background Use of hypothermic circulatory arrest (HCA) for operations on the descending thoracic aorta is controversial. While deep hypothermia may provide better end-organ and spinal cord function, prolonged cardiopulmonary bypass and circulatory arrest may increase morbidity. This study assessed outcomes after use of HCA for descending thoracic aortic resection in a large cohort of consecutive patients. Methods Hypothermic circulatory arrest was utilized if arch or extensive descending thoracic aortic resection was required, or if aortic pathology precluded cross-clamping. One hundred thirty-two patients (mean age, 61.3 years) were identified. Diagnosis included fusiform (41.2%) or saccular aneurysm (10.7%) and acute (4.6%) or chronic (38.9%) dissection. Twenty-one patients presented with rupture. Arch resection (distal arch 100, total arch 11) was required in 111 patients (84.1%). The extent of descending thoracic aortic resection (required in 94%) included proximal third in 41 patients, proximal two-thirds in 6, and complete thoracic aorta in 77. The proximal anastomosis was performed with total body HCA while the distal anastomosis was constructed with lower body HCA only (duration upper body HCA 33.7 ± 8.0 minutes; total duration lower body HCA 71.3 ± 24.2 minutes). Results Thirty-day mortality was 6.0%. Neurologic events included stroke (6.8%) and permanent lower extremity paralysis-paresis (4.5%). Temporary dialysis was needed in 7 (5.3%), though only 2 patients required permanent dialysis (1.9%). Independent predictors of a composite endpoint of death, stroke, permanent paralysis, or dialysis included duration of lower body HCA ( p = 0.03) and major postoperative infection ( p = 0.003). Conclusions Adjunctive use of deep hypothermic circulatory arrest for descending thoracic aortic resection affords excellent preservation of end-organ and spinal cord function with acceptable rates of mortality and significant morbidity.

ObjectiveThis study was undertaken to define matrix metalloproteinase (MMP) expression in the anterior and posterior wall of descending thoracic aortic aneurysms (TAAs) and correlate it with specific computed tomography (CT) image sites within the descending thoracic aorta.MethodsSerial CT images of patients with TAAs were compared with age- and gender-matched normal descending thoracic aortas at levels T4-T12. The mean circumference of the TAAs was 153 mm (n = 12) and 148 mm (n = 11) at T8 and T10, respectively, compared with 75 mm (n = 12) and 75 mm (n = 10) in controls (P < .001). Aortic tissue was collected from a separate set of eight patients undergoing descending TAA resection (processed ≤12 hours of excision) and six cadavers (processed ≤24 hours of death). Tissue collected between the intercostals arteries was defined as posterior wall, and directly opposite was the anterior wall. MMP-9 and MMP-2 messenger RNA (mRNA) extracted from aortic tissue was analyzed by quantitative real time polymerase chain reaction (PCR) and normalized to β-actin. Immunohistochemistry was performed for MMP-9 and MMP-2. CT aortic measurements and MMP expression were compared by t tests and analysis of variance, respectively.ResultsThe ratio of arc distance between the intercostals on the posterior wall to total aortic circumference was 0.14 in healthy controls compared with 0.08 in TAAs at vertebral level T8 (P = .001). At T10, the ratio was 0.15 in healthy controls compared with 0.11 in TAAs (P = .001). MMP-9 expression in TAAs was 4.3-fold higher in the anterior wall compared with the posterior wall (P = .03). Conversely, MMP-2 expression in TAAs was 3.2-fold higher in the posterior wall compared with the anterior wall (P = .008). MMP expression was not detected in control cadaver aortas.ConclusionAnterior walls of expanding TAAs grow at a greater rate than the posterior wall, as determined from the lower ratio of intercostal arc distance to total circumference in TAAs. Differential MMP expression appears to be a biologic marker for asymmetric growth in the TAA wall.Clinical RelevanceThe pathogenesis of thoracic aortic aneurysms (TAAs) is poorly understood. Multiple lines of evidence suggest that matrix metalloproteinases (MMPs), a family of enzymes, are important in aneurysm development. Earlier experiments documented a regional variation of MMP-9 in stimulated rodent aortas, with production greater in the abdominal aorta compared with the thoracic aorta. The present study extends that observation and documents asymmetric aneurysm development in the TAA wall, with increased anterior wall growth in correlation to increased MMP-9 production. An improved understanding of the mechanisms by which MMP production is regulated is critical.

Background Anterior leaflet repair continues to pose significant operative challenges, particularly in patients with retracted or "short" anterior leaflets, due to rheumatic or radiation induced mitral valve disease. This often results in abandonment of repair in favor of mitral valve replacement, requiring anticoagulation and altering left ventricular (LV) function and geometry. This study examines our experience of anterior leaflet repair with patch augmentation. Methods Forty-two patients underwent mitral valve repair for a shortened anterior leaflet from 1994 to 2003. Twenty-two patients with a mean age of 53 ± 6 years had radiation valvulitis (XR) whereas 20 patients, age 28 ± 7 years had rheumatic heart disease (RHD). Those patients with XR had a mean New York Heart Association (NYHA) class of 3.2 ± 0.4 and an angina score of 2.1 ± 0.6 compared with a NYHA class 3.8 ± 0.2 and no angina in RHD patients. All patients presented with severe MR. Anterior leaflet augmentation with a gluteraldehyde-treated, autologous pericardial patch and complete annuloplasty ring was used in all patients. Additionally, extensive subvalvar debridement was performed in RHD patients. Twelve XR patients underwent concomitant CABG with a mean of 2.4 ± 0.8 grafts/patient. Additional surgical procedures included tricuspid valve repair, anterior septal defect, and aortic valve replacement. Mean follow-up was 39 ± 10 months for XR patients and 12 ± 25 months for RHD patients. Results There were two late deaths in XR patients from underlying malignancies and no deaths in RHD patients. Two RHD patients required reoperation for recurrent mitral regurgitation at 3 and 20 months. All patients demonstrated clinical improvements (NYHA I-II) following repair. No mitral stenosis was induced. Conclusions Despite anterior leaflet shortening from XR or rheumatic alterations, opportunity still exists for gratifying mitral valve repair. By utilizing anterior leaflet patch augmentation, concomitantly with ring annuloplasty, anticoagulation is avoided, LV geometry is preserved, and follow-up reveals excellent functional improvement.

Objective The optimal surgical treatment of paraesophageal hiatal hernia is in debate. Our experience with a traditional transthoracic approach was reviewed to provide "benchmark" data against which newer surgical techniques can be measured. Methods Between 1977 and 2001, 240 patients had primary transthoracic repair of paraesophageal hiatal hernia. Presenting complaints included reflux (69%), pain (67%), dysphagia (36%), and bleeding or anemia (33%). Preoperative esophageal function testing showed abnormal reflux in 86%. Hernia types were combined (type III) in 92% and type IV in 8%. All patients had reduction of the hernia and a concomitant antireflux procedure. An esophageal lengthening Collis gastroplasty was performed in 96%. Results There were 3 perioperative deaths (1.7%). The median length of hospital stay was 7 days. Early complications requiring reoperation occurred in 12 patients (5%) and included recurrent hernia in 4, leak in 3, and a tight hiatal closure in 3. Mean follow-up in 226 patients was 42 months (median 27.8 months). Satisfactory results were obtained in 86% of patients. Follow-up complaints (moderate or persistent symptoms) included dysphagia (4), reflux (1), dumping (3), and post-thoracotomy pain (1). Routine postoperative barium radiographs showed intact repair in 71% (108/153). Of 19 patients with an anatomic recurrence, 4 (2%) had more than a partial asymptomatic migration of the fundoplication and required reoperation. Postoperative esophageal function testing, obtained in 28% of the patients, showed abnormal gastroesophageal reflux in 2. Conclusion Open transthoracic repair of paraesophageal hiatal hernia provides good to excellent long-term control of both the hernia and gastroesophageal reflux with relatively low early morbidity.

There are currently several safe and effective options to provide temporary MCS for patients presenting with cardiogenic shock or refractory heart failure. Newer device designs are currently being developed that will increase the options available to patients. Due to the technological advancements, it will be difficult to predict what devices will ultimately prove to be the most efficacious. It is likely that a variety of devices will be necessary, depending on clinical circumstances and patient characteristics.

Background Dynamic cardiomyoplasty is a promising new therapy for dilated cardiomyopathy. The girdling effects of a conditioned muscle wrap alone have recently been postulated to partly explain its mechanism. We investigated this effect in a canine model of chronic dilated cardiomyopathy. Methods and Results Twenty dogs underwent rapid ventricular pacing (RVP) for 4 weeks to create a model of dilated cardiomyopathy. Seven dogs were then randomly selected to undergo subsequent cardiomyoplasty, and all dogs had 6 weeks of additional RVP. The cardiomyoplasty group also received 6 weeks of concurrent skeletal muscle stimulation consisting of single twitches delivered asynchronously at 2 Hz to transform the wrap without active assistance. All dogs were studied by pressure-volume analysis and echocardiography at baseline and after 4 and 10 weeks of pacing. Systolic indices, including ejection fraction (EF), end-systolic elastance (Ees), and preload-recruitable stroke work (PRSW) were all increased at 10 weeks in the wrap versus controls (EF, 34.0 versus 27.1, P =.008; Ees, 1.65 versus 1.26, P =.09; PRSW, 35.9 versus 25.5, P =.001). Ventricular volumes, diastolic relaxation, and left ventricular end-diastolic pressures stabilized in the cardiomyoplasty group but continued to deteriorate in controls. Both the end-systolic and end-diastolic pressure-volume relationships shifted farther rightward in controls but remained stable in the cardiomyoplasty group. Conclusions In addition to potential benefits from active systolic assistance, benefits from dynamic cardiomyoplasty appear to be partially accounted for by the presence of a conditioned muscle wrap alone. This conditioned wrap stabilizes the remodeling process of heart failure, arresting progressive deterioration of systolic and diastolic function.

BACKGROUND: Few data exist on clinical/imaging characteristics, management, and outcomes of patients with type A acute dissection and mesenteric malperfusion. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

To document the natural history of branch artery pseudoaneurysms (BAPs), which are sequelae of aortic dissection with false lumen thrombosis that have been distinguished anatomically from penetrating ulcers.Serial computed tomography (CT) scans in 50 patients with at least two CT scans greater than 1 month apart were retrospectively studied. Mean follow-up was 29 months, with longitudinal analyses of 119 BAPs. Changes in BAPs, false lumen thrombosis, and aortic diameter were assessed.No patient had an aortic rupture or other poor outcome. All BAPs eventually disappeared (ie, thrombosed), with 50% thrombosed within 18 months. Aortas were ectatic, with a mean diameter of 36 mm. There was no statistically significant change in total aortic diameters; however, there was a significant increase in true lumen diameters (P.0001) and a significant decrease in false lumen thickness (P.0001) at the level of the BAP over time (mean 50% reduction in maximum thickness of thrombosed false lumen). There were no significant associations between BAP thrombosis and vertebral level, presence of more than one BAP, presence of branch artery in communication with the BAP, history of smoking, diabetes mellitus or hypertension, or treatment with β-blockers, other antihypertensive medication, statins, or anticoagulation therapy. After controlling for other variables, BAPs were less likely to thrombose if an ulcerlike projection was present (P = .003), in men (P = .02), in subjects with hypertension (P = .04), and in older patients (P = .05).Most BAPs spontaneously thrombose, and associated intramural hematoma regresses/disappears. Isolated BAPs were not associated with poor clinical outcomes.

average time to discharge was 13.3 days. Postoperative courses following LVAD replacement were shorter than those following initial LVAD implantation. ICU stays were decreased by 3.7 days (43%) and total hospital stays were decreased by 14.6 days (52%). Outcomes tended to be better in those who underwent abdominal only approaches (mortality 0 of 8, 0%) versus those who also underwent sternotomy (mortality 3 of 8, 47%). Conclusions: In this experience, the largest reported to date, LVAD replacement was undertaken with acceptable outcomes, including shortened postoperative courses. Further improvements in outcomes will be important as LVAD replacement is made commonplace by durations of support exceeding the life expectancies of current technology.

BackgroundRisk factors and outcomes after iliofemoral complications after thoracic aortic endovascular repair remain poorly characterized. This study was performed to characterize factors influencing perioperative iliofemoral complications during thoracic aortic endovascular repair.MethodsAll patients undergoing transfemoral thoracic aortic endovascular repair since 2005 with adequate preoperative aortoiliac 3-dimensional imaging (n = 126) were identified. Assessment of imaging was blinded with regard to occurrence of iliofemoral complications, defined as anything other than successful transfemoral device delivery and primary closure of an arteriotomy.ResultsThe complication rate was 12% (n = 15). Univariate analysis identified that female gender, preoperative ankle-brachial index, average and minimal iliac diameters, diameter difference between iliac artery and sheath size, and iliac morphology score (calculated by combining iliac tortuosity, calcification, and vessel diameter) were associated with iliofemoral complications (all P

Background The presence of penetrating aortic ulcers (PAUs) of the descending thoracic aorta has been associated with a poor long-term prognosis. Although early results have suggested acceptable outcomes for thoracic endovascular aortic repair (TEVAR) for PAU, few studies have described the late outcomes of this approach. Methods From 1993 to 2009, 37 patients (43.2% male; mean age, 72 years) underwent TEVAR for PAU. Associated intramural hematoma was present in 19. Comorbidities included hypertension in 31, chronic obstructive pulmonary disease in 16, coronary artery disease in 22, and renal failure (mean preoperative creatinine, 1.4 mg/dL). Urgent or emergent indications were identified in 22 patients (59.5%), including presentation with rupture in 15 (40.5%). Results TEVAR was successfully performed in all patients. Arch repair was performed in 14 and total descending repair in 13. Concomitant procedures included coronary artery bypass grafting (CABG) and total arch debranching in one patient electively presenting with an asymptomatic PAU. Early morbidity included stroke (5.4%), temporary paraplegia (5.4%), and need for dialysis (2.7%). In-hospital or 30-day mortality was seen in two patients (5.4%). By Kaplan-Meier analysis, median survival was 89.8 months. Independent predictors of late mortality included urgent or emergent presentation (odds ratio, 14.7; P = .007). Actuarial freedom from TEVAR treatment failure (ie, need for open or endovascular aortic reintervention, aortic rupture, or aortic-related death) was 81.6% ± 7.8% at 5 years. Analysis stratified by type of pathology (PAU vs PAU and intramural hematoma) showed no significant baseline differences in age, comorbidities, or extent of repair. By Kaplan-Meier analysis, however, presentation with PAU and intramural hematoma was associated with an increased risk for TEVAR treatment failure ( P = .033). Conclusions TEVAR can be safely accomplished for patients presenting with PAU. The presence of associated intramural hematoma may adversely affect the late outcomes of therapy, highlighting the need for careful planning, prudent balancing of the benefits of immediate vs delayed treatment of the fragile aortic wall, and the imperative nature of attentive follow-up in patients with PAU.

BackgroundWe previously reported an improvement in early mortality for patients presenting with acute type A dissection with malperfusion using a strategy of initial percutaneous intervention to restore end-organ perfusion and delayed operative repair after resolution of the malperfusion syndrome. This study evaluates the late outcomes with this approach.MethodsA total of 196 patients were admitted with acute type A dissection (1997–2007). Seventy patients with ischemic end-organ dysfunction underwent percutaneous fenestration or branch vessel stenting. Operative therapy was planned after resolution of the reperfusion injury. Outcomes were compared for patients with (MP) and without (UC) dissection with ischemic end-organ dysfunction.ResultsThe mean age of the patients was 57.1 years, and 173 patients underwent operative repair (n = 126 UC group; n = 47 MP group). The remaining 23 patients in the MP group died before repair from complications of malperfusion (11) or aortic rupture (12) while awaiting resolution of the malperfusion syndrome. Operative mortality was seen in 9.2% of all patients (9.5% in UC group vs 8.5% in MP group; P = 1.0). On analysis of the entire cohort (n = 196), the mean survival was higher for the uncomplicated group (95.9 months for UC group vs 53.7 months for MP group; P < .001). A subgroup analysis of patients who underwent operation (n = 173) revealed similar mean survival (95.9 months for UC group vs 80.5 months for MP group; P = .45).ConclusionA strategy of immediate reperfusion, stabilization, and planned operative repair for acute type A dissection with malperfusion still carries a significant risk for early and late mortality. However, those patients who survive the initial malperfusion and undergo repair have a similar operative and late survival when compared with those patients presenting with uncomplicated dissection.

Background Iliac artery endoconduits (ECs) have emerged as important alternatives to retroperitoneal open iliac conduits (ROICs) to aid in transfemoral delivery for thoracic endovascular aortic repair (TEVAR). We present, to our knowledge, the first comparative analysis between these alternative approaches. Methods All patients undergoing TEVAR with either ROIC (n = 23) or internal EC (n = 16) were identified. The mean age of the cohort was 72.4 ± 11.5 years (82.1% female). Device delivery was accomplished in 100% of cases. The primary outcome was the presence of iliofemoral complications, which was defined as: (1) the inability to successfully deliver the device into the aorta via the ROIC or EC approach; (2) rupture, dissection, or thrombosis of the ipsilateral iliac or femoral artery; and/or (3) retroperitoneal hematoma requiring exploration and evacuation. Secondary outcomes were 30-day mortality and rates of limb loss, claudication, or revascularization. Results At a median follow-up of 10.1 months, the incidence of iliofemoral complications was less for the EC approach compared with the ROIC technique (12.5% vs 26.1%; P = .301). No patients sustained limb loss. Revascularization was performed in two patients after ROIC. Lower extremity claudication occurred in one patient after EC. Early mortality was seen in one patient who underwent EC. Two-year Kaplan-Meier survival for the entire cohort was 74.4%, and did not differ between groups (ROIC, 78.3% vs EC, 68.8%; P = .350). Two-year Kaplan-Meier freedom from limb loss, claudication, or revascularization did not differ between the two approaches (ROIC, 91.3% vs EC, 93.8%; P = .961). Conclusions Results of this early comparative evaluation of alternative access routes for TEVAR suggest that an EC approach is safe, effective, and associated with low rates of early mortality and late iliofemoral complications. In selected patients, the EC may be considered an appropriate delivery route for transfemoral TEVAR.

ObjectiveOpen repair for acute type B dissection with malperfusion is associated with significant morbidity. Thoracic aortic endovascular repair has been proposed as a less-invasive therapy for acute type B dissection with malperfusion. Benefits of thoracic aortic endovascular repair include the potential for false lumen thrombosis. Its risks include both early morbidity and mortality, and uncertain late results with potentially unstable landing zones. We present the first long-term analysis of an alternative endovascular approach consisting of percutaneous flap fenestration with true lumen and branch vessel stenting to restore end-organ perfusion.MethodsOutcomes were analyzed for 69 patients presenting with acute type B dissection with malperfusion from 1997 to 2008. All patients were evaluated with angiography and treated with a combination of flap fenestration, true lumen, or branch vessel stenting where appropriate.ResultsMean age was 57.3 years. Identified malperfused vascular beds included spinal cord (5), mesenteric (40), renal (51), and lower extremity (47). Major morbidity included dialysis need (11), stroke (3), paralysis (2), and 30-day mortality (n = 12, 17.4%). Mean Kaplan–Meier survival was 84.3 months. Although late mortality was associated with age (P < .0001), neither the type nor the number of malperfused vascular beds correlated with vital status at last follow-up (P > .4). Freedom from aortic rupture or open repair at 1, 5, and 8 years was 80.2%, 67.7%, and 54.2%, respectively.ConclusionPresentation with acute type B dissection with malperfusion carries a significant risk for both early and late mortality. Percutaneous approaches allow for rapid restoration of end-organ perfusion with acceptable results. These long-term results can serve as comparative data by which to evaluate newer therapies for acute type B dissection with malperfusion, such as thoracic aortic endovascular repair.

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

Presentation with acute type B aortic dissection (B-AD) in the setting of malperfusion is associated with a high risk for major morbidity due to end-organ ischemia. This presentation has traditionally been considered an indication for operation where the entry tear is resected, and branch vessel perfusion is subsequently restored either as a result of the aortic repair or by direct revascularization of the peripheral arterial bed. There are two predominant mechanisms by which malperfusion can occur, and these have previously been defined by our group. 1,2 In static obstruction, the dissection flap entersthebranchvessellumenwithoutanadequatereentrytear (or a diminutive reentry tear) within the course of that artery. The compromised true lumen of that artery then becomes the sole source of inflow into that end organ. In contrast, in dynamic obstruction, the mobile aortic dissection flap intermittently covers the orifice of the branch vessel during the cardiac cycle, thus impeding arterial inflow into the end organ. Treatment is directed at restoring the integrity of the arterial true lumen in static obstruction and of the aortic true lumen in dynamic obstruction. Finally, end-organ perfusion may be compromised by a combination of both mechanisms, as well as by miscellaneous causes including thrombosis or embolism of branches supplied by either lumen. Whereasmalperfusionhastraditionallybeenanindication to proceed with early operative repair of the aorta, endovascular approaches have emerged as an alternative to allow restoration of end-organ perfusion. Two types are discussed in this report, and each has a different focus. The traditional endovascular approach has relied on a percutaneous method of creating a fenestration in the dissection flap to equalize

Objective Hybrid thoracic endovascular aneurysm repair (H-TEVAR) to include visceral and renal debranching has emerged as a potential therapeutic option for thoracoabdominal aneurysms (TAAA). This study was performed to characterize the frequently noted development of postoperative fluid collections surrounding the bypass grafts. Methods All patients undergoing H-TEVAR from 2000-2010 (n = 39, 43.6% male) were identified. One hundred thirty-two bypasses were constructed (median 4 per patient) using either polyester (30), thin-walled polytetrafluoroethylene (ePTFE, 100) or saphenous vein (2). Follow-up computed tomography (CT) imaging was routinely performed at 1 and 6 months, and annually thereafter. Results Of the 37 patients with one follow-up CT, 20 (54.1%) were found to have fluid collections. The natural history of the 17 patients with collections and further follow-up imaging was variable, with 2 resolving, 6 stable, and 9 enlarging. Two patients with collections developed evidence of graft infection requiring reoperation. Two patients with enlarging sterile collections required evacuation for symptoms. By multivariate analysis, both preoperative creatinine (P = .005) and number of bypasses constructed (P = .04) independently correlated with the development of a fluid collection. Conclusions Postoperative fluid collections following hybrid debranching procedures identified in this series represent a unique complication not previously described. The subsequent clinical course of these fluid collections is variable and ranges from benign to frank graft infection and relate both to patient factors, as well as specific operative strategies. Longer-term studies with more robust numbers of patient numbers are warranted to determine whether this complication may limit the long-term durability of this procedure.

Background. Optimal treatment of chronic type B aortic dissection (CBAD), whether open (open descending aortic repair, OAR) or endovascular (thoracic endovascular aortic repair, TEVAR), is controversial, suggesting a comparative analysis is warranted. Methods. One hundred twenty-two of 1,049 patients (1993 to 2013) undergoing descending aortic repair required intervention for CBAD 29.2 ± 34.9 months after the initial acute event and formed the study cohort (mean age 59.7 years). Those with degenerated residual type A dissection were excluded (n[ 65). Eighty-eight had extent IIIB CBAD; 11 had intramural hematoma. Indications for surgery included aneurysmal degeneration (n [ 105), rupture (n [ 8), acute or chronic dissection (n [ 8), and extension of dissection (n [ 1). Open strategy included descending (n [ 71) and thoracoabdominal repair (n [ 19), with hypothermic circulatory arrest used in 70 patients. The TEVAR was performed with (n [ 2) or without (n [ 30) visceral debranching. A treatment strategy propensity score incorporating time since initial acute event, CBAD extent, year of intervention, age, and selected comorbidities was constructed for multivariable analysis. Results. Early outcome included the following: 30-day mortality 4% (n [ 5); stroke 2% (n [ 2); permanent

Studies have shown acute aortic dissection (AAD) pts ≥70 years of age have higher in-hospital mortality and less Type A (TA) surgical management (mgmt). These differences may also hold true within the elderly cohort. We studied 1139 elderly pts from the International Registry of Acute Aortic

Renal insufficiency is common in patients evaluated for transcatheter aortic valve replacement (TAVR). While computed tomography (CT) can assess arterial access, it can cause contrast-induced nephropathy. We examined the feasibility of non-contrast magnetic resonance angiography (MRA) to assess