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Journal of Cardiothoracic Surgery Jun 2024Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is...
BACKGROUND
Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is required when treating patients with involvement of LSA. The best antiplatelet therapy after LSA reconstruction is presently uncertain.
METHODS
This study retrospectively analyzed 245 type B aortic dissection patients who underwent left subclavian artery revascularization during TEVAR. Out of 245 patients, 159 (64.9%) were in the single antiplatelet therapy (SAPT) group, receiving only aspirin, and 86 (35.1%) were in the dual antiplatelet therapy (DAPT) group, receiving aspirin combined with clopidogrel. During the 6-month follow-up, primary endpoints included hemorrhagic events (general bleeding and hemorrhagic strokes), while secondary endpoints comprised ischemic events (left upper limb ischemia, ischemic stroke, and thrombotic events), as well as death and leakage events. Both univariate and multivariate Cox regression analyses were performed on hemorrhagic and ischemic events, with the Kaplan-Meier method used to generate the survival curve.
RESULTS
During the six-month follow-up, the incidence of hemorrhagic events in the DAPT group was higher (8.2% vs. 30.2%, P < 0.001). No significant differences were observed in ischemic events, death, or leakage events among the different antiplatelet treatment schemes. Multivariate Cox regression analysis showed that DAPT (HR: 2.22, 95% CI: 1.07-4.60, P = 0.032) and previous chronic conditions (HR:3.88, 95% CI: 1.24-12.14, P = 0.020) significantly affected the occurrence of hemorrhagic events. Chronic conditions in this study encompassed depression, vitiligo, and cholecystolithiasis. Carotid subclavian bypass (CSB) group (HR:0.29, 95% CI: 0.12-0.68, P = 0.004) and single-branched stent graft (SBSG) group (HR:0.26, 95% CI: 0.13-0.50, P < 0.001) had a lower rate of ischemic events than fenestration TEVAR (F-TEVAR). Survival analysis over 6 months revealed a lower risk of bleeding associated with SAPT during hemorrhagic events (P = 0.043).
CONCLUSIONS
In type B aortic dissection patients undergoing LSA blood flow reconstruction after synchronous TEVAR, the bleeding risk significantly decreases with the SAPT regimen, and there is no apparent ischemic compensation within 6 months. Patients with previous chronic conditions have a higher risk of bleeding. The CSB group and SBSG group have less ischemic risk compared to F-TEVAR group.
Topics: Humans; Male; Female; Retrospective Studies; Platelet Aggregation Inhibitors; Subclavian Artery; Middle Aged; Aortic Dissection; Endovascular Procedures; Aortic Aneurysm, Thoracic; Aged; Clopidogrel; Aspirin; Aorta, Thoracic; Treatment Outcome; Blood Vessel Prosthesis Implantation; Postoperative Complications; Endovascular Aneurysm Repair
PubMed: 38937841
DOI: 10.1186/s13019-024-02932-3 -
Journal of Cardiothoracic Surgery Jun 2024The surgical evaluation and management of non-A non-B aortic dissections, in the absence of ascending aortic involvement, remains a grey area. It is in these scenarios...
BACKGROUND
The surgical evaluation and management of non-A non-B aortic dissections, in the absence of ascending aortic involvement, remains a grey area. It is in these scenarios when thorough evaluation of patient/family history, clinical presentation, but also overall lifestyle, is of immense importance when determining an optimal intervention.
CASE PRESENTATION
We present a 38-year-old patient with a physically demanding lifestyle as a professional wrestler, uncontrolled hypertension due to history of medical non-adherence, and family history of aortic dissection who presented with acute non-A non-B aortic dissection. He was spared a total arch replacement by undergoing a hybrid approach of complete aortic debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR). The patient was able to benefit from reduced cardiopulmonary bypass (CPB) time, avoidance of aortic cross clamp, circulatory arrest, and hypothermic circulation.
CONCLUSIONS
This patient's unique composition of a physically demanding lifestyle, personal history of medical non-adherence, family history of aortic dissection, and clinical presentation required a holistic approach to understanding an ideal intervention that would be best suited long-term. Due to this contextualization, the patient was able to be spared a total arch replacement, or suboptimal medical management, by instead undergoing a hybrid-approach with total aortic arch debranching with antegrade TEVAR.
Topics: Humans; Adult; Male; Aortic Dissection; Endovascular Procedures; Aortic Aneurysm, Thoracic; Aorta, Thoracic; Blood Vessel Prosthesis Implantation; Acute Disease; Endovascular Aneurysm Repair
PubMed: 38937775
DOI: 10.1186/s13019-024-02917-2 -
European Journal of Vascular and... Jun 2024
PubMed: 38936691
DOI: 10.1016/j.ejvs.2024.06.039 -
European Journal of Vascular and... Jun 2024
PubMed: 38936690
DOI: 10.1016/j.ejvs.2024.05.046 -
European Journal of Vascular and... Jun 2024Numerous articles have reported an increased incidence of limb graft occlusion (LGO) with the Cook Zenith Alpha endograft compared with other endografts in endovascular...
OBJECTIVE
Numerous articles have reported an increased incidence of limb graft occlusion (LGO) with the Cook Zenith Alpha endograft compared with other endografts in endovascular aortic aneurysm repair (EVAR). The present study aimed to assess the rate of LGO after EVAR in particular with the Cook Zenith Alpha device when adhering to a standardised protocol designed to prevent limb related complications.
METHODS
This was a non-sponsored retrospective study performed in two university vascular surgery centres employing the same protocol for limb complication prevention during EVAR from 2016 to 2019. The protocol encompassed: (1) angioplasty of any common/external iliac artery with > 50% stenosis before endograft navigation; (2) proximal sealing zone of limbs at the same level of the flow divider with minimum overlap, which is more restrictive than the Cook Zenith Alpha instructions for use; (3) semicompliant kissing ballooning of limbs; (4) limb stenting in case of any residual tortuosity/kinking/stenosis; and (5) adjunctive common and external iliac stenting for residual stenosis/dissection after EVAR. Patients enrolled in this study were treated with standard aorto-bis-iliac EVAR. Follow up was performed by clinical visit and duplex ultrasonography at discharge, six months, and yearly thereafter. The primary endpoint was to evaluate the LGO rate with different EVAR devices (Cook Zenith Alpha, Gore C3, and Medtronic Endurant) and to determine potential risk factors for LGO associated with the Zenith Alpha.
RESULTS
In the study period, 547 EVARs were considered: 233 (42.6%) Cook Zenith Alpha, 196 (35.8%) Gore Excluder, and 118 (21.6%) Medtronic Endurant. The mean follow up was 44 ± 23 months, and the five year freedom from LGO was 97 ± 3%, without differences between groups (97 ± 2%, 95 ± 3%, and 100% with Cook Zenith Alpha, Medtronic Endurant, and Gore Excluder, respectively; p = .080). In the Zenith Alpha group, intra-operative adjunctive iliac artery angioplasty, iliac artery stenting, or iliac limb stenting was performed in 8%, 3.4%, and 9.7%, respectively. Analysis of potential risk factors for LGO identified external iliac artery distal landing and large main bodies (ZIMB 32 - 36) independently associated with LGO during follow up (hazard ratio [HR] 18, 95% confidence interval [CI] 3 - 130, p = .004; and HR 12, 95% CI 1.2 - 130, p = .030, respectively).
CONCLUSION
The present experience with a protocol for limb complication prevention allows one to obtain a low rate of LGO at five years with Zenith Alpha endografts similar to other endografts. Specific risk factors for the Cook Zenith Alpha endograft are the external iliac artery distal landing and the use of a large main body (ZIMB 32 - 36).
PubMed: 38936689
DOI: 10.1016/j.ejvs.2024.06.036 -
European Journal of Vascular and... Jun 2024
PubMed: 38936687
DOI: 10.1016/j.ejvs.2024.06.041 -
Arteriosclerosis, Thrombosis, and... Jun 2024Vascular smooth muscle cells (VSMCs) are highly plastic. Vessel injury induces a phenotypic transformation from differentiated to dedifferentiated VSMCs, which involves...
BACKGROUND
Vascular smooth muscle cells (VSMCs) are highly plastic. Vessel injury induces a phenotypic transformation from differentiated to dedifferentiated VSMCs, which involves reduced expression of contractile proteins and increased production of extracellular matrix and inflammatory cytokines. This transition plays an important role in several cardiovascular diseases such as atherosclerosis, hypertension, and aortic aneurysm. TGF-β (transforming growth factor-β) is critical for VSMC differentiation and to counterbalance the effect of dedifferentiating factors. However, the mechanisms controlling TGF-β activity and VSMC phenotypic regulation under in vivo conditions are poorly understood. The extracellular matrix protein TN-X (tenascin-X) has recently been shown to bind TGF-β and to prevent it from activating its receptor.
METHODS
We studied the role of TN-X in VSMCs in various murine disease models using tamoxifen-inducible SMC-specific knockout and adeno-associated virus-mediated knockdown.
RESULTS
In hypertensive and high-fat diet-fed mice, after carotid artery ligation as well as in human aneurysmal aortae, expression of , the gene encoding TN-X, was increased in VSMCs. Mice with smooth muscle cell-specific loss of TN-X (SMC-Tnxb-KO) showed increased TGF-β signaling in VSMCs, as well as upregulated expression of VSMC differentiation marker genes during vascular remodeling compared with controls. SMC-specific TN-X deficiency decreased neointima formation after carotid artery ligation and reduced vessel wall thickening during Ang II (angiotensin II)-induced hypertension. SMC-Tnxb-KO mice lacking ApoE showed reduced atherosclerosis and Ang II-induced aneurysm formation under high-fat diet. Adeno-associated virus-mediated SMC-specific expression of short hairpin RNA against showed similar beneficial effects. Treatment with an anti-TGF-β antibody or additional SMC-specific loss of the TGF-β receptor reverted the effects of SMC-specific TN-X deficiency.
CONCLUSIONS
In summary, TN-X critically regulates VSMC plasticity during vascular injury by inhibiting TGF-β signaling. Our data indicate that inhibition of vascular smooth muscle TN-X may represent a strategy to prevent and treat pathological vascular remodeling.
PubMed: 38934115
DOI: 10.1161/ATVBAHA.123.321067 -
Annals of Pediatric Cardiology 2024Noonan syndrome (NS) is a pleomorphic genetic disorder. Up to 50-80% of individuals have associated congenital heart disease. The scope of cardiac disease in NS is quite...
Noonan syndrome (NS) is a pleomorphic genetic disorder. Up to 50-80% of individuals have associated congenital heart disease. The scope of cardiac disease in NS is quite variable depending on the gene mutation. The most common forms of cardiac defects include pulmonary stenosis, hypertrophic cardiomyopathy (HCM), atrial septal defect and left-sided lesions. Amongst the rare vascular abnormalities few case reports have been mentioned about coronary artery lesions apart from sinus of Valsalva aneurysm, aortic dissection, intracranial aneurysm. This is a case report a rare case of asymptomatic coronary artery aneurysm in a young male with NS. There is lack of unified protocol for the screening, diagnosis, treatment, and follow-up of coronary artery disease in patients with NS. We conclude, echocardiography is sufficient in most cases in children. But a CT scan is appropriate in adults or when other lesions are suspected.
PubMed: 38933057
DOI: 10.4103/apc.apc_145_23 -
Journal of the Belgian Society of... 2024Aneurysmal dilatations can affect any aortic segment and represent the result of various causes, atherosclerotic disease being the most common and frequently involved....
Aneurysmal dilatations can affect any aortic segment and represent the result of various causes, atherosclerotic disease being the most common and frequently involved. We hereby illustrate a case of a patient with thoracic aortic aneurysm rupture due to extensive atherosclerotic disease, with multiple complex penetrating ulcerated atherosclerotic plaques located in the descending aorta. CT angiography evaluation included a comprehensive description of imaging features and extent of the thoracic aortic aneurysm, the presence of thrombus, relationship to adjacent structures and branches, associated complications. Thoracic aortic aneurysm rupture due to extensive atherosclerotic disease with multiple penetrating ulcers.
PubMed: 38932986
DOI: 10.5334/jbsr.3314 -
Journal of Clinical Medicine Jun 2024: Among the endovascular approaches for the management of endoleak type 2 (EL 2), transcaval embolization (TCE) has shown encouraging outcomes. However, the literature...
: Among the endovascular approaches for the management of endoleak type 2 (EL 2), transcaval embolization (TCE) has shown encouraging outcomes. However, the literature is still limited. This study aimed to present the early and mid-term outcomes of TCE for EL 2 after endovascular aortic repair. : A retrospective, single-center analysis of consecutive patients managed with TCE for EL 2 after standard or complex endovascular aortic repair, from August 2015 to March 2024, was conducted. The indication for TCE was the presence of an EL 2 related to ≥5 mm sac increase, compared to the first imaging after aneurysm exclusion or the smallest diameter during follow-up. Patients managed with TCE for other types of endoleaks were excluded. The primary outcomes were technical and clinical successes during follow-up. Forty-three patients were included (mean age: 75.1 ± 6.0 years, 90.7% males). Technical success was 97.7%. Selective embolization was performed in 48.8% and non-selective in 51.2%. No death was recorded at 30 days. The estimated clinical success was 90.0% (standard error; SE: 6.7%) and the freedom from EL 2 was 89.0% (SE 6.4%) at 36 months. Cox regression analysis showed that the type of embolization (selective vs. non-selective), type of previous repair (f/bEVAR vs. EVAR), and use of anticoagulants did not affect follow-up outcomes. Reinterventions related to EL 2 were performed in 12.5%; three underwent an open conversion. : TCE was related to high technical success and limited peri-operative morbidity, regardless of the type of initial endovascular aortic repair. Clinical success was encouraging with reinterventions for EL 2 affecting 12.5% of patients.
PubMed: 38930107
DOI: 10.3390/jcm13123578