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Scientific Reports Jun 2021Type A aortic dissection (TAAD) involves the ascending aorta or the arch. Acute TAAD usually requires urgent replacement of the ascending aorta. However, a subset of...
Type A aortic dissection (TAAD) involves the ascending aorta or the arch. Acute TAAD usually requires urgent replacement of the ascending aorta. However, a subset of these patients develops aortic rupture due to further dilatation of the residual dissected aorta. There is currently no reliable means to predict the risk of dilatation following TAAD repair. In this study, we performed a comprehensive morphological and hemodynamic analysis for patients with and without progressive aortic dilatation following surgical replacement of the ascending aorta. Patient-specific models of repaired TAAD were reconstructed from post-surgery computed tomography images for detailed computational fluid dynamic analysis. Geometric and hemodynamic parameters were evaluated and compared between patients with stable aortic diameters (N = 9) and those with aortic dilatation (N = 8). Our results showed that the number of re-entry tears and true/false lumen pressure difference were significantly different between the two groups. Patients with progressive aortic dilatation had higher luminal pressure difference (6.7 [4.6, 10.9] vs. 0.9 [0.5, 2.3] mmHg; P = 0.001) and fewer re-entry tears (1.5 [1, 2.8] vs. 5 [3.3, 7.5]; P = 0.02) compared to patients with stable aortic diameters, suggesting that these factors may serve as potential predictors of aneurysmal dilatation following surgical repair of TAAD.
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Dilatation, Pathologic; Female; Hemodynamics; Humans; Male; Models, Cardiovascular
PubMed: 34075164
DOI: 10.1038/s41598-021-91079-5 -
The Journal of Thoracic and... Oct 2019
Topics: Aged; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Elective Surgical Procedures; Humans
PubMed: 30665759
DOI: 10.1016/j.jtcvs.2018.11.114 -
The Journal of Cardiovascular Surgery Aug 2020This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition... (Review)
Review
This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Chronic Disease; Endovascular Procedures; Humans
PubMed: 32337939
DOI: 10.23736/S0021-9509.20.11395-8 -
Circulation Research May 2024The resiliency of embryonic development to genetic and environmental perturbations has been long appreciated; however, little is known about the mechanisms underlying...
BACKGROUND
The resiliency of embryonic development to genetic and environmental perturbations has been long appreciated; however, little is known about the mechanisms underlying the robustness of developmental processes. Aberrations resulting in neonatal lethality are exemplified by congenital heart disease arising from defective morphogenesis of pharyngeal arch arteries (PAAs) and their derivatives.
METHODS
Mouse genetics, lineage tracing, confocal microscopy, and quantitative image analyses were used to investigate mechanisms of PAA formation and repair.
RESULTS
The second heart field (SHF) gives rise to the PAA endothelium. Here, we show that the number of SHF-derived endothelial cells (ECs) is regulated by (vascular endothelial growth factor receptor 2) and . Remarkably, when the SHF-derived EC number is decreased, PAA development can be rescued by the compensatory endothelium. Blocking such compensatory response leads to embryonic demise. To determine the source of compensating ECs and mechanisms regulating their recruitment, we investigated 3-dimensional EC connectivity, EC fate, and gene expression. Our studies demonstrate that the expression of VEGFR2 by the SHF is required for the differentiation of SHF-derived cells into PAA ECs. The deletion of 1 VEGFR2 allele () reduces SHF contribution to the PAA endothelium, while the deletion of both alleles () abolishes it. The decrease in SHF-derived ECs in and embryos is complemented by the recruitment of ECs from the nearby veins. Compensatory ECs contribute to PAA derivatives, giving rise to the endothelium of the aortic arch and the ductus in mutants. Blocking the compensatory response in mutants results in embryonic lethality shortly after mid-gestation. The compensatory ECs are absent in embryos, a model for 22q11 deletion syndrome, leading to unpredictable arch artery morphogenesis and congenital heart disease. regulates the recruitment of the compensatory endothelium in an SHF-non-cell-autonomous manner.
CONCLUSIONS
Our studies uncover a novel buffering mechanism underlying the resiliency of PAA development and remodeling.
Topics: Animals; Vascular Endothelial Growth Factor Receptor-2; Mice; Aorta, Thoracic; Heart Defects, Congenital; T-Box Domain Proteins; Endothelial Cells; Gene Expression Regulation, Developmental; Cell Differentiation; Mice, Inbred C57BL
PubMed: 38618720
DOI: 10.1161/CIRCRESAHA.123.322767 -
European Journal of Cardio-thoracic... Jun 2023(i) To monitor cerebral blood flow velocity (CBFv) throughout aortic arch repair surgery and during the recovery period. (ii) To examine the relationship between...
OBJECTIVES
(i) To monitor cerebral blood flow velocity (CBFv) throughout aortic arch repair surgery and during the recovery period. (ii) To examine the relationship between transcranial doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) during cardiac surgery. (iii) To examine CBFv in patients cooled to 20°C and 25°C.
METHODS
During aortic arch repair and after surgery, measurements of TCD, NIRS, blood pH, pO2, pCO2, HCO3, lactate, Hb, haematocrit (%) and temperature (core and rectal) were recorded in 24 neonates. General linear mixed models were used to examine differences over time and between two cooling temperatures. Repeated measures correlations were used to determine the relationship between TCD and NIRS.
RESULTS
CBFv changed during arch repair (main effect of time: P = 0.001). During cooling, CBFv increased by 10.0 cm/s (5.97, 17.7) compared to normothermia (P = 0.019). Once recovering in paediatric intensive care unit (PICU), CBFv had increased from the preoperative measurement by 6.2 cm/s (0.21, 13.4; P = 0.045). CBFv changes were similar between patients cooled to 20°C and 25°C (main effect of temperature: P = 0.22). Repeated measures correlations (rmcorr) identified a statistically significant but weak positive correlation between CBFv and NIRS (r = 0.25, P≤0.001).
CONCLUSIONS
Our data suggested that CBFv changed throughout aortic arch repair and was higher during the cooling period. A weak relationship was found between NIRS and TCD. Overall, these findings could provide clinicians with information on how to optimise long-term cerebrovascular health.
Topics: Infant, Newborn; Child; Humans; Temperature; Aorta, Thoracic; Perfusion; Ultrasonography, Doppler, Transcranial; Cerebrovascular Circulation; Blood Flow Velocity
PubMed: 37280071
DOI: 10.1093/ejcts/ezad220 -
Journal of Vascular Surgery Apr 2022An aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. A paucity of reported studies is available regarding the treatment...
OBJECTIVE
An aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. A paucity of reported studies is available regarding the treatment of these patients. The purpose of the present study was to evaluate the contemporary management strategies and natural history of ARSA in these patients.
METHODS
A single-center retrospective review of patients with a diagnosis of ARSA from 2009 to 2019 was performed. Computed tomography scans were analyzed, and the aortic and ARSA diameters were measured at 10 different segments. The demographic data, comorbidities, and operative interventions were collected. The patients were categorized into those who had undergone intervention and those who had undergone expectant management. Linear mixed effect models were used to estimate the annual ARSA diameter changes.
RESULTS
A total of 30 patients with ARSA were identified, 17 (57%) of whom were women. The average age for the cohort was 54.5 ± 14.6 years. Of the 30 patients, 20 (67%) had undergone operative repair at presentation and 10 (33%) were initially observed. The most common presenting symptom was dysphagia (30%). Of the 10 patients who had been initially treated expectantly, 4 had subsequently required intervention. Of the 24 operative interventions, 13 (54%) were hybrid procedures involving right carotid-subclavian bypass or transposition and thoracic endovascular aortic repair. The mean diameter of ARSA at its origin was 20.4 ± 5.7 mm, and the mean cross-sectional aortic diameter at the level of the ARSA was 31.8 ± 8.5 mm for the entire cohort. For the patients who had initially been observed and had subsequently required intervention, the largest change in the ARSA cross-sectional diameter was observed 1 cm distally to the vessel ostium at a rate of 3.05 mm annually (95% confidence interval, 1.54-4.56; P < .001). No statistically significant changes in the annual growth rate of the aortic segments were observed in the entire cohort or for those patients who had undergone intervention (P > .05).
CONCLUSIONS
The decision to intervene on an ARSA should be individualized by the presence of symptoms (eg, dysphagia lusoria) or complications (eg, dissection, concomitant aortic aneurysmal disease, enlarging Kommerell diverticulum). Asymptomatic patients with nonaneurysmal ARSA might not require any intervention and can be safely observed. Measurement of the cross-sectional ARSA diameter 1 cm distally to the ostium of the vessel might aid in the surveillance of vessel diameter changes. Additional studies are required to determine the specific size criteria as an indication for operative repair of asymptomatic Kommerell diverticulum.
Topics: Adult; Aged; Aorta, Thoracic; Blood Vessel Prosthesis Implantation; Cardiovascular Abnormalities; Deglutition Disorders; Diverticulum; Endovascular Procedures; Female; Humans; Male; Middle Aged; Subclavian Artery; Treatment Outcome
PubMed: 34838611
DOI: 10.1016/j.jvs.2021.11.051 -
Medicina (Kaunas, Lithuania) Jun 2023: Vascular abnormalities within the anatomical coverage are frequently encountered in imaging studies. The aortic arch is often overlooked as an anatomical blind spot,...
: Vascular abnormalities within the anatomical coverage are frequently encountered in imaging studies. The aortic arch is often overlooked as an anatomical blind spot, especially in neck magnetic resonance (MR) angiography. This study investigated the prevalence of incidental aortic arch abnormalities. We also estimated the potential clinical significance of aortic arch abnormalities as blind spots detected on contrast-enhanced neck MR angiography. : Between February 2016 and March 2023, 348 patients were identified based on contrast-enhanced neck MR angiography reports. The clinical and radiological characteristics of the patients and the presence of additional imaging studies were assessed. The aortic arch abnormalities and coexisting non-aortic arterial abnormalities were classified into two categories according to their clinical significance. We performed the χ test and Fisher's exact test for group comparisons. : Of the 348 study patients, only 29 (8.3%) had clinically significant incidental aortic arch abnormalities. Among these 348 patients, 250 (71.8%) and 136 (39%) had intracranial and extracranial abnormalities, respectively; the clinically significant intracranial abnormalities in the two groups were 130 lesions (52.0%) and 38 lesions (27.9%), respectively. In addition, there was a significantly higher tendency of clinically significant aortic arch abnormalities (13/29, 44.8%) in the patients who had clinically significant coexisting non-aortic arterial abnormalities than in the other group (87/319, 27.3%) ( = 0.044). The patient groups with clinically significant intracranial or extracranial arterial abnormalities had higher rates of clinically significant aortic abnormalities (31.0% and 17.2%), but there was no statistical significance ( = 0.136). : The incidence of clinically significant aortic arch abnormalities was 8.3% on neck MR angiography, with a significant association between aortic and coexisting non-aortic arterial abnormalities. The findings of this study could improve the understanding of incidental aortic arch lesions on neck MR angiography, which is of crucial clinical importance for radiologists to achieve accurate diagnoses and management.
Topics: Humans; Aorta, Thoracic; Prevalence; Magnetic Resonance Angiography; Neck; Heart Defects, Congenital; Vascular Diseases
PubMed: 37374376
DOI: 10.3390/medicina59061172 -
Interactive Cardiovascular and Thoracic... May 2022Acute aortic dissection leads to the destabilization of the aortic wall, followed by an immediate increase in aortic diameter. It remains unclear how the aortic diameter...
OBJECTIVES
Acute aortic dissection leads to the destabilization of the aortic wall, followed by an immediate increase in aortic diameter. It remains unclear how the aortic diameter changes during the dissection's acute and subacute phases. The aim of this study was to evaluate the change in aortic geometry within 30 days after the onset of a descending aortic dissection.
METHODS
Patients with acute type B and non-A non-B dissection who had at least 2 computed tomography angiography scans obtained within 30 days after the onset of dissection were evaluated. Exclusion criteria were a thrombosed false lumen, connective tissue disorders and endovascular or open aortic repair performed prior to the second computed tomography angiography.
RESULTS
Among 190 patients with acute aortic dissection, 42 patients met our inclusion criteria. Their aortic geometry was analysed according to the computed tomography angiography scans obtained between 0-3 (N = 35), 4-7 (N = 9) and 8-30 (N = 12) days after the dissection onset. The highest aortic diameter growth rate was observed in the first quartile of the thoracic aorta and measured 0.66 (0.06; 1.03), 0.29 (-0.01; 0.41) and 0.06 (-0.13; 0.26) mm/day at 0-3, 4-7 and 8-30 days after the dissection, respectively. Proximal entry location (P = 0.037) and entry located at the arch concavity (P = 0.008) were associated with a higher aortic diameter increase.
CONCLUSIONS
Early rapid growth occurs during the first week after the descending aortic dissection-most intensely over the first 3 days, and this is associated with the location of the dissection's entry.
Topics: Aortic Dissection; Aorta; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Aortography; Blood Vessel Prosthesis Implantation; Computed Tomography Angiography; Endovascular Procedures; Humans; Retrospective Studies; Treatment Outcome
PubMed: 35043199
DOI: 10.1093/icvts/ivab351 -
Interactive Cardiovascular and Thoracic... May 2021With development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To...
OBJECTIVES
With development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To minimize the adverse effects of hypothermia, surgeons now perform these procedures closer to normothermia. This study examined postoperative outcomes of hemiarch replacement patients using unilateral selective antegrade cerebral perfusion and mild hypothermic CA.
METHODS
Single-centre retrospective review of 66 patients undergoing hemiarch replacement with mild hypothermic CA (32°C) and unilateral selective antegrade cerebral perfusion between 2011 and 2018. Antegrade cerebral perfusion was delivered using right axillary artery cannulation. Postoperative data included death, neurological dysfunction, acute kidney injury and renal failure requiring new dialysis. Additional intraoperative metabolic data and blood transfusions were obtained.
RESULTS
Eighty-six percent of patients underwent elective surgery. Mean age was 67 ± 3 years. Lowest mean core body temperature was 32 ± 2°C. Average CA was 17 ± 5 min. No intraoperative or 30-day mortality occurred. Survival was 97% at 1 year, 91% at 3 years and 88% at 5 years. Permanent and temporary neurological dysfunction occurred in 1 (2%) and 2 (3%) patients, respectively. Only 3 (5%) patients suffered postoperative stage 3 acute kidney injury requiring new dialysis. Intraoperative transfusions occurred in 44% of patients and no major metabolic derangements were observed.
CONCLUSIONS
In patients undergoing hemiarch surgery, mild hypothermia (32°C) with unilateral selective antegrade cerebral perfusion via right axillary cannulation is associated with low mortality and morbidity, offering adequate neurological and renal protection. These findings require validation in larger, prospective clinical trials.
Topics: Aorta, Thoracic; Cerebrovascular Circulation; Circulatory Arrest, Deep Hypothermia Induced; Humans; Hypothermia, Induced; Perfusion; Retrospective Studies; Treatment Outcome
PubMed: 33432355
DOI: 10.1093/icvts/ivaa321 -
Innovations (Philadelphia, Pa.) 2023Thoracic endovascular aortic repair (TEVAR) explantation remains a challenge due to endovascular graft ingrowth into the aortic wall with time. Surgical access into the...
Thoracic endovascular aortic repair (TEVAR) explantation remains a challenge due to endovascular graft ingrowth into the aortic wall with time. Surgical access into the aortic arch can be difficult either via sternotomy or thoracotomy, and proximal barbs become engaged firmly into the aortic wall. Explantation often requires extensive thoracic aortic resection, sometimes from the distal aortic arch to the abdominal aorta, followed by reconstruction, risking injury to surrounding neurovascular structures and even death. In cases of blunt thoracic aortic injury, the original injury is often healed, and failed TEVAR could theoretically be removed when thrombotic complications occur. We present a novel technique to facilitate TEVAR recapture with limited distal thoracic aorta replacement.
Topics: Humans; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Stents; Aortic Aneurysm, Thoracic; Aorta, Thoracic; Endovascular Procedures; Treatment Outcome; Retrospective Studies
PubMed: 36872584
DOI: 10.1177/15569845231158659