Background Partial thrombosis of the false lumen has been reported as a significant predictor of mortality during follow-up in patients with acute type B aortic dissection. The purpose of this study ...was to investigate the correlation of false lumen thrombosis and aortic expansion during follow-up in patients with acute type B aortic dissection. Methods All medically treated patients with acute type B aortic dissection observed in 4 cardiovascular referral centers between 1998 and 2011, with admission and follow-up computed tomography or magnetic resonance imaging scans, were included. Aortic diameters of the dissected aortas were measured at 4 levels on the baseline and follow-up scans, and annual growth rates were calculated. Univariate and multivariate regression analyses were used to investigate the effect of false lumen thrombosis on aortic growth rate. Results A total of 84 patients were included, of whom 40 (47.6%) had a partially thrombosed false lumen, 7 (8.3%) had a completely thrombosed false lumen, and 37 (44.0%) had a patent false lumen. A total of 273 of the 336 (81.3%) evaluated aortic levels were dissected segments. Overall, the mean aortic diameter increased significantly at all evaluated levels ( P < .001). Univariate analysis showed that annual aortic growth rates were significantly higher in those segments having a false lumen with partial thrombosis (mean, 4.25 ± 10.2) when compared with the patent group (mean, 2.10 ± 5.56; P = .035). In multivariate analysis, partial lumen thrombosis was an independent predictor of higher aortic growth (adjusted mean difference, 2.05 mm/year; 95% confidence interval, 0.10-4.01; P = .040). Conclusions In patients with acute type B aortic dissection, aortic segments with a partially thrombosed false lumen have a significantly higher annual aortic growth rate when compared with those presenting with patent or complete thrombosis of the false lumen. Therefore, patients with partial thrombosis require more intensive follow-up and may benefit from prophylactic intervention.
Background Conservative management of acute type B aortic dissection (ABAD) is often associated with aortic dilatation during follow-up increasing the risk of aortic rupture. The goal of this study ...was to investigate whether morphologic characteristics of the dissection can predict aortic growth. Methods All conservatively managed ABAD patients from four referral centers were included (2000 to 2010). Aortic diameters were measured at five levels at baseline and at the last follow-up computed tomography angiography, and annual aortic growth rates were calculated for all segments. Linear regression was used to study the influence of aortic morphologic characteristics for aortic dilatation. Results Included were 62 patients (41 men) with a mean age of 60.3 ± 10.7 years. Among the 310 analyzed aortic segments, 248 (80.0%) were dissected, of which 211 (85.1%) showed aortic growth. Overall, the mean diameter increased from 36.1 ± 9.4 to 40.2 ± 11.1 mm ( P < .01), which corresponds with a mean aortic growth rate of 3.1 ± 6.3 mm/y. Multivariate linear regression analysis showed that male sex (95% confidence interval CI, 0.60-4.04; P = .005) and a saccular false lumen (95% CI, 2.07-7.81: P = .001) were associated with a significantly increased aortic growth rate. Increasing age (95% CI, −0.23 to −0.04; P = .005), increased number of entry tears (95% CI, −2.40 to −0.43; P = .005), false lumen located on the aortic outer curvature (95% CI, −4.30 to −0.38; P = .019), and a circular configuration of the true lumen (95% CI, −5.35 to −0.32; P = .027) were associated with a decreased aortic growth rate. Conclusions Multiple morphologic characteristics appear to predict aortic dilatation in ABAD patients treated medically. Early assessment of these morphologic signs may be useful in the selection of ABAD patients who might benefit from closer radiologic surveillance or prophylactic intervention.
Objective This study was conducted to provide insight into the safety, applicability, and outcomes of thoracic endovascular aortic repair (TEVAR) with the chimney graft technique. Methods Original ...data regarding the chimney technique in TEVAR in the emergent and elective setting were collected from MEDLINE, Embase, and Scopus databases. All variables were systematically extracted and included in a database. Patient and procedural characteristics, details, and outcomes were analyzed. Results In total, 94 patients with 101 chimney-stented aortic arch branches were analyzed, consisting of the brachiocephalic artery in 20, the left common carotid artery in 48, and the left subclavian artery in 33. Balloon-expandable stents were used in 36% and self-expandable stents in 64% for the aortic side branch. The interventions were elective in 72% and emergent in 28%. Technical success was achieved in 98% in elective and emergent settings combined. Endoleaks were described in 18%; with type Ia being most frequently reported in 6.4% overall and in 6.5% in the elective setting. Stroke was reported in 5.3% of the patients, of which 40% were fatal. The overall perioperative mortality was 3.2%. Median follow-up time was 11 months, and chimney stents remained patent in all patients. Conclusions TEVAR with the chimney technique is a viable treatment option and may expand treatment strategies for patients with challenging thoracic aortic pathology and anatomy in the emergent and elective setting. Patency of the thoracic chimney stents appears to be good during short-term follow-up. Other complications, such as endoleak and stroke, deserve attention by future research to further improve treatment strategies and the prognosis of these patients.
Background Aortic growth rate in acute type B aortic dissection (ABAD) is a significant predictor for aortic complications and death. To improve the overall outcome, radiologic predictors might ...stratify patients who benefit from successful medical management vs those who require intervention. This study investigated whether the number of identifiable entry tears in ABAD patients is associated with aortic growth. Methods ABAD patients with uncomplicated clinical conditions and therefore treated with medical therapy were evaluated. Those with a computed tomography angiography (CTA) obtained at clinical presentation and a subsequent CTA obtained at least 90 days after medical treatment were included (2005 to 2010). The CTAs were investigated for the number of entry tears between the true and false lumen. Diameters of the dissected aortas were measured at five levels on the baseline and on the last available follow-up CTA, and annual aortic growth rates were calculated. The number of entry tears in these patients and the location in the aorta were compared with the aortic growth rate. Results Included were 60 patients who presented with 243 dissected segments. Mean growth rates during follow-up (median, 23.2; range, 3 to 132 months) were significantly higher in patients with 1 entry tear (5.6 ± 8.9 mm) than in those with 2 (2.1 ± 1.7 mm; p = 0.001) and 3 entry tears (mean 2.2 ± 4.1; p = 0.010). The distance of the primary entry tear from the left subclavian artery did not have an effect on the aortic growth rate (median, 38; interquartile range, 24 to 137 mm; p = 0.434). Conclusions The number of entry tears in ABAD patients detected on the first CTA after clinical presentation is a significant predictor for aortic growth. Patients with 1 entry tear at presentation show a higher growth rate than other patients and might benefit from more strict surveillance or early prophylactic intervention.
Introduction Ruptured descending thoracic aortic aneurysm (rDTAA) is associated with high mortality rates. Data supporting endovascular thoracic aortic aneurysm repair (TEVAR) to reduce mortality ...compared with open repair are limited to small series. We investigated published reports for contemporary outcomes of open and endovascular repair of rDTAA. Methods We systematically reviewed all studies describing the outcomes of rDTAA treated with open repair or TEVAR since 1995 using MEDLINE, Cochrane Library CENTRAL, and Excerpta Medica Database (EMBASE) databases. Case reports or studies published before 1995 were excluded. All articles were critically appraised for relevance, validity, and availability of data regarding treatment outcomes. All data were systematically pooled, and meta-analyses were performed to investigate 30-day mortality, myocardial infarction, stroke, and paraplegia rates after both types of repair. Results Original data of 224 patients (70% male) with rDTAA were identified: 143 (64%) were treated with TEVAR and 81 (36%) with open repair. Mean age was 70 ± 5.6 years. The 30-day mortality was 19% for patients treated with TEVAR for rDTAA compared 33% for patients treated with open repair, which was significant (odds ratio OR, 2.15, P = .016). The 30-day occurrence rates of myocardial infarction (11.1% vs 3.5%; OR, 3.70, P < .05), stroke (10.2% vs 4.1%; OR, 2.67; P = .117), and paraplegia (5.5% vs 3.1%; OR, 1.83; P = .405) were increased after open repair vs TEVAR, but this failed to reach statistical significance for stroke and paraplegia. Five additional patients in the TEVAR group died of aneurysm-related causes after 30 days, during a median follow-up of 17 ± 10 months. Follow-up data after open repair were insufficient. The estimated aneurysm-related survival at 3 years after TEVAR was 70.6%. Conclusion Endovascular repair of rDTAA is associated with a significantly lower 30-day mortality rate compared with open surgical repair. TEVAR was associated with a considerable number of aneurysm-related deaths during follow-up.
Objective True splenic artery aneurysms (SAAs) are a rare but potentially fatal pathology. For many years, open repair (OPEN) and conservative management (CONS) were the treatments of choice, but ...throughout the last decade endovascular repair (EV) has become increasingly used. The purpose of the present study was to perform a systematic review and meta-analysis evaluating the outcomes of the three major treatment modalities (OPEN, EV, and CONS) for the management of SAAs. Methods A systematic review of all studies describing the outcomes of SAAs treated with OPEN, EV, or CONS was performed using seven large medical databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure a high-quality review. All articles were subject to critical appraisal for relevance, validity, and availability of data regarding characteristics and outcomes. All data were systematically pooled, and meta-analyses were performed on several outcomes, including early and late mortality, complications, and number of reinterventions. Results Original data of 1321 patients with true SAAs were identified in 47 articles. OPEN contained 511 patients (38.7%) in 31 articles, followed by 425 patients (32.2%) in CONS in 16 articles and 385 patients (29.1%) in EV in 33 articles. The CONS group had fewer symptomatic patients (9.5% vs 28.7% in OPEN and 28.8% in EV; P < .001) and fewer ruptured aneurysms (0.2% vs 18.4% in OPEN and 8.8% in EV; P < .001), but no significant differences were found in existing comorbidities. CONS patients were usually older and had smaller-sized aneurysms than patients in the OPEN and EV groups. The only identified difference in baseline characteristics between OPEN and EV was the number of ruptured aneurysms (18.4% vs 8.8%; P < .001). OPEN had a higher 30-day mortality than EV (5.1% vs 0.6%; P < .001), whereas minor complications occurred in a larger number of the EV patients. EV required more reinterventions per year (3.2%) compared with OPEN (0.5%) and CONS (1.2%; P < .001). The late mortality rate was higher in patients treated with CONS (4.9% vs 2.1% in OPEN and 1.4% in EV; P = .04). Conclusions EV of SAA has better short-term results compared with OPEN, including significantly lower perioperative mortality. OPEN is associated with fewer late complications and fewer reinterventions during follow-up. Patients treated with CONS showed a higher late mortality rate. Ruptured SAAs are predictors of a significantly higher perioperative mortality compared with nonruptured SAAs in the OPEN and EV groups.
Objective Open repair (OPEN) and conservative management (CONS) have been the treatments of choice for splenic artery aneurysms (SAAs) for many years. Endovascular repair (EV) has been increasingly ...used with good short-term results. In this study, we evaluated the cost-effectiveness of OPEN, EV, and CONS for the treatment of SAAs. Methods A decision analysis model was developed using TreeAge Pro 2013 software (TreeAge Inc, Williamstown, Mass) to evaluate the cost-effectiveness of the different treatments for SAAs. A hypothetical cohort of 10,000 55-year-old female patients with SAAs was assessed in the reference-case analysis. Perioperative mortality, disease-specific mortality rates, complications, rupture risks, and reinterventions were retrieved from a recent and extensive meta-analysis. Costs were analyzed with the 2014 Medicare database. The willingness to pay was set to $60,000/quality-adjusted life years (QALYs). Outcomes evaluated were QALYs, costs from the health care perspective, and the incremental cost-effectiveness ratio (ICER). Extensive sensitivity analyses were performed and different clinical scenarios evaluated. Probabilistic sensitivity analysis was performed to include the uncertainty around the variables. A flowchart for clinical decision-making was developed. Results For a 55-year-old female patient with a SAA, EV has the highest QALYs (11.32; 95% credibility interval CI, 9.52-13.17), followed by OPEN (10.48; 95% CI, 8.75-12.25) and CONS (10.39; 95% CI, 8.96-11.87). The difference in effect for 55-year-old female patients between EV and OPEN is 0.84 QALY (95% CI, 0.42-1.34), comparable with 10 months in perfect health. EV is more effective and less costly than OPEN and more effective and more expensive compared with CONS, with an ICER of $17,154/QALY. Moreover, OPEN, with an ICER of $223,166/QALY, is not cost-effective compared with CONS. In elderly individuals (age >78 years), the ICER of EV vs CONS is $60,503/QALY and increases further with age, making EV no longer cost-effective. Very elderly patients (age >93 years) have higher QALYs and lower costs when treated with CONS. The EV group has the highest number of expected reinterventions, followed by CONS and OPEN, and the number of expected reinterventions decreases with age. Conclusions EV is the most cost-effective treatment for most patient groups with SAAs, independent of the sex and risk profile of the patient. EV is superior to OPEN, being both cost-saving and more effective in all age groups. Elderly patients should be considered for CONS, based on the high costs in relation to the very small gain in health when treated with EV. The very elderly should be treated with CONS.
Objective Evidence regarding the influence of cardiovascular risk factors, comorbidities, and patient characteristics on the growth of small abdominal aortic aneurysms (AAA) is limited. We assessed, ...in an observational cohort study, rupture rates, risks of mortality, and the effects of cardiovascular risk factors and patient demographics on growth rates of small AAAs. Methods Between September 1996 and January 2005, 5057 patients with manifest arterial vascular disease or cardiovascular risk factors were included in the Second Manifestation of ARTerial disease (SMART) study. Measurements of the abdominal aortic diameter were performed in all patients. All patients with an initial AAA diameter between 30 and 55 mm were selected for this study. All AAA measurements during follow-up until August 2007 were collected. Multivariate regression analysis was performed to calculate the effects of demographic patient characteristics, initial AAA diameter, and cardiovascular risk factors on AAA growth. Results Included were 230 patients, with a mean age of 66 years and 90% were male. Seven AAA ruptures (six fatal) occurred in 755 patient years of follow-up (rupture rate 0.9% per patient-year). In 147 patients, AAA measurements were performed for a period of more than 6 months. The median follow-up time was 3.3 years (mean 4.0, range 0.5 to 11.1 years, standard deviation (SD) 2.5). Mean AAA diameter was 38.8 mm (SD 6.8) and mean expansion rate 2.5 mm/y. Patients using lipid-lowering drugs had a 1.2 mm/y (95% confidence interval CI −2.34 to −0.060 mm/y) lower AAA growth rate compared to nonusers of these drugs. Initial AAA diameter was associated with a 0.09 mm/y (95% CI 0.01 to 0.18 mm/y) higher growth rate per millimetre increase of the diameter. No other factors, including blood lipid values, were independently associated with AAA growth. Conclusions Lipid-lowering drug treatment and initial AAA diameter appear to be independently associated with lower AAA growth rates. The risk of rupture of these small abdominal aortic aneurysms was low, which pleads for watchful waiting.
Background Ruptured descending thoracic aortic aneurysm (rDTAA) is a cardiovascular catastrophe, associated with high morbidity and mortality, which can be managed either by open surgery or thoracic ...endovascular aortic repair (TEVAR). The purpose of this study is to retrospectively compare the mortality, stroke, and paraplegia rates after open surgery and TEVAR for the management of rDTAA. Methods Patients with rDTAA treated with TEVAR or open surgery between 1995 and 2010 at seven institutions were identified and included for analysis. The outcomes between both treatment groups were compared; the primary end point of the study was a composite end point of death, permanent paraplegia, and/or stroke within 30 days after the intervention. Multivariate logistic regression analysis was used to identify risk factors for the primary end point. Results A total of 161 patients with rDTAA were included, of which 92 were treated with TEVAR and 69 with open surgery. The composite outcome of death, stroke, or permanent paraplegia occurred in 36.2% of the open repair group, compared with 21.7% of the TEVAR group (odds ratio OR, 0.49; 95% confidence interval CI, .24-.97; P = .044). The 30-day mortality was 24.6% after open surgery compared with 17.4% after TEVAR (OR, 0.64; 95% CI, .30-1.39; P = .260). Risk factors for the composite end point of death, permanent paraplegia, and/or stroke in multivariate analysis were increasing age (OR, 1.04; 95% CI, 1.01-1.08; P = .036) and hypovolemic shock (OR, 2.47; 95% CI, 1.09-5.60; P = .030), while TEVAR was associated with a significantly lower risk of the composite end point (OR, 0.44; 95% CI, .20-.95; P = .039). The aneurysm-related survival of patients treated with open repair was 64.3% at 4 years, compared with 75.2% for patients treated with TEVAR ( P = .191). Conclusions Endovascular repair of rDTAA is associated with a lower risk of a composite of death, stroke, and paraplegia, compared with traditional open surgery. In rDTAA patients, endovascular management appears the preferred treatment when this method is feasible.
Objective Open revascularization (OR) has been the treatment of choice for chronic mesenteric ischemia (CMI) for many years, but endovascular revascularization (EV) has been increasingly used with ...good short-term results. In this study, we evaluated the comparative effectiveness and cost-effectiveness of EV and OR in patients with CMI refractory to conservative management. Methods A Markov-state transition model was developed using TreeAge Pro 2012 (TreeAge Inc, Williamstown, Mass) to simulate a hypothetical cohort of 10,000 65-year-old female patients with CMI requiring treatment with either OR or EV. Data for the model, including perioperative and long-term overall mortality risks, disease-specific mortality risks, complications, and reintervention and patency rates, were retrieved from original studies and systematic reviews about CMI. Costs were analyzed with the 2013 Medicare database. Outcomes evaluated were quality-adjusted life-years (QALYs), costs from the health care perspective, and the incremental cost-effectiveness ratio. Extensive sensitivity analyses were performed and different clinical scenarios evaluated. Probabilistic sensitivity analysis was performed to assess robustness of the model. Results For a reference-case 65-year-old female patient with CMI and an average risk for operation, EV is preferred with 10.03 QALYs (95% credibility interval CI, 9.76-10.29) vs 9.59 after OR (95% CI, 9.29-9.87). The difference is comparable to 5 months in perfect health: 0.44 QALY (95% CI, 0.13-0.76). For 65-year-old men, this was 8.71 QALYs (95% CI, 8.48-8.94) for EV vs 8.42 (95% CI, 8.14-8.63) for OR. Sensitivity analysis showed that for younger patients, EV results in a higher increase in QALYs compared with older patients. Total expected reinterventions per patient are 1.70 for EV vs 0.30 for OR. Total expected health care costs for the reference-case patient were $39,942 (95% CI, $28,509-$53,380) for OR and $38.217 (95% CI, $29,329-$48,309) for EV. For men, this was $39,375 (95% CI, $28,092-$52,853) for OR and $35,903 (95% CI, $27,685-$45,597) for EV. For patients younger than 60 years, EV is a more expensive treatment strategy compared with OR, but with an incremental cost-effectiveness ratio for EV of less than $60,000/QALY. For patients 60 years and older, EV dominated OR as preferential treatment because effectiveness was higher than for OR and costs were lower. Conclusions The results of this decision analysis model suggest that EV is favored over OR for patients with CMI in all age groups. Although EV is associated with more expected reinterventions, EV appears to be cost-effective for all age groups.
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