Early three-dimensional growth in uncomplicated type B aortic dissection is associated with long-term outcomes.

Late adverse events (LAEs) are common among initially uncomplicated type B aortic dissection (uTBAD); however, identifying those patients at highest risk of LAEs remains a significant challenge. Early false lumen (FL) growth has been suggested to increase risk, but confident determination of growth is often hampered by error in two-dimensional clinical measurements. Semi-automated three-dimensional (3D) mapping of aortic growth, such as by vascular deformation mapping (VDM), can potentially overcome this limitation using computed tomography angiograms (CTA). We hypothesized that FL growth in the early pre-dissection phase by VDM can accurately predict LAEs. We performed a two-center retrospective study of patients with uTBAD, with paired CTAs in the acute (1-14 days) and subacute/early chronic (1-6 months) periods. VDM analysis was used to map 3D growth. Standard clinical CT measures (ie, aortic diameters, tear characteristics) were also collected. Multivariate analysis was conducted using a decision tree and Cox proportional hazards model. LAEs were defined as aneurysmal FL (>55 mm); rapid growth (>5 mm within 6 months); aorta-specific mortality, rupture, or re-dissection. A total of 107 (69% male) patients with uTBAD initially met inclusion criteria with a median follow-up of 7.3 years (interquartile range [IQR], 4.7-9.9 years). LAEs occurred in 72 patients (67%) at 2.5 years (IQR, 0.7-4.8 years) after the initial event. A multivariate decision tree model identified VDM growth (>2.1 mm) and baseline diameter (>42.7 mm) as optimal predictors of LAEs (area under the receiver operating characteristic curve = 0.94), achieving an 87% accuracy (sensitivity of 93%, specificity of 76%) after leave-one-out validation. Guideline reported high-risk features were not significantly different between groups. Early growth of the FL in uTBAD was the best tested indicator for LAEs and improves upon the current gold-standard of baseline diameter in selecting patients for early prophylactic thoracic endovascular aortic repair.

Marway PS ，Campello Jorge CA ，Tjahjadi N ，Baker TJ ，Mistelbauer G ，Baeumler K ，Hinostroza V ，Higashigaito K ，Mastrodicasa D ，Masotti M ，Nordsletten D ，Patel HJ ，Fleischmann D ，Burris NS ... -  《-》

Predicting Late Adverse Events in Uncomplicated Stanford Type B Aortic Dissection: Results From the ROADMAP Validation Study.

Fleischmann D ，Mastrodicasa D ，Willemink MJ ，Turner VL ，Hinostroza V ，Burris NS ，Yang B ，Hanneman K ，Ouzounian M ，Ocazionez Trujillo D ，Afifi RO ，Estrera AL ，Lacomis JM ，Sultan I ，Gleason TG ，Pacini D ，Folesani G ，Lovato L ，Stillman AE ，De Cecco CN ，Chen EP ，Hinzpeter R ，Alkadhi H ，Hedgire S ，Sundt TM 3rd ，van Kuijk SMJ ，Schurink GWH ，Chin AS ，Codari M ，Sailer AM ，Mistelbauer G ，Madani MH ，Bäumler K ，Shen J ，Lai KM ，Fischbein MP ，Miller DC ... -  《-》

Interval changes in four-dimensional flow-derived in vivo hemodynamics stratify aortic growth in type B aortic dissection patients.

Aortic diameter growth in type B aortic dissection (TBAD) is associated with progressive aortic dilation, resulting in increased mortality in patients with both de novo TBAD (dnTBAD) and residual dissection after type A dissection repair (rTAAD). Preemptive thoracic endovascular aortic repair may improve mortality in patients with TBAD, although it is unclear which patients may benefit most from early intervention. In vivo hemodynamic assessment using four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) has been used to characterize TBAD patients with growing aortas. In this longitudinal study, we investigated whether changes over time in 4D flow-derived true and false lumen (TL and FL) hemodynamic parameters correlate with aortic growth rate, which is a marker of increased risk. We retrospectively identified TBAD patients with baseline and follow-up 4D flow CMR at least 120 days apart. Patients with TBAD intervention before baseline or between scans were excluded. 4D flow CMR data analysis included segmentation of the TL and FL, followed by voxel-wise calculation of TL and FL total kinetic energy (KE), maximum velocity (MV), mean forward flow (FF), and mean reverse flow (RF). Changes over time (Δ) were calculated for all hemodynamic parameters. Maximal diameter in the descending aorta was measured from magnetic resonance angiogram images acquired at the time of 4D flow. Aortic growth rate was defined as the change in diameter divided by baseline diameter and standardized to scan interval. Thirty-two patients met inclusion criteria (age: 56.9 ± 14.1 years, female: 13, n = 19 rTAAD, n = 13 dnTBAD). Mean follow-up time was 538 days (range: 135-1689). Baseline aortic diameter did not correlate with growth rate. In the entire cohort, Δ FL MV (Spearman's rho [rho] = 0.37, p = 0.04) and Δ FL RF (rho = 0.45, p = 0.01) correlated with growth rate. In rTAAD only, Δ FL MV (rho = 0.48, p = 0.04) and Δ FL RF (rho = 0.51, p = 0.03) correlated with growth rate, while in dnTBAD only, Δ TL KE (rho = 0.63, p = 0.02) and Δ TL MV (rho = 0.69, p = 0.01) correlated with growth rate. 4D flow-derived longitudinal hemodynamic changes correlate with aortic growth rate in TBAD and may provide additional prognostic value for risk stratification. 4D flow MRI could be integrated into existing imaging protocols to allow for the identification of TBAD patients who would benefit from preemptive surgical or endovascular intervention.

Engel J ，Kilinc O ，Weiss E ，Baraboo J ，Mehta C ，Hoel A ，Malaisrie SC ，Markl M ，Allen BD ... -  《-》

Effectiveness of Proximal Landing Zone 1 and 2 Thoracic Endovascular Aortic Repair for Type B Aortic Dissection by Comparing Outcomes With Thoracic Arch Aneurysm.

Kudo T ，Kuratani T ，Sawa Y ，Miyagawa S ... -  《-》

Thoracic endovascular aortic repair in connective tissue disease patients is not a definitive option.

Open surgery is the gold standard for patients a connective tissue disorder (CTD). Thoracic endovascular aortic repair (TEVAR) is used in emergencies and patient-specific situations. Limited data on durability of TEVAR in patients with CTD exist. The purpose of this study was to investigate the durability, complications, and outcomes of TEVAR in patients with CTD. This single-center retrospective study included 40 patients with CTD who underwent TEVAR for thoracoabdominal aortic aneurysm or aortic dissection from February 2014 to April 2021. CTDs included Marfan syndrome, Loey-Dietz syndrome, and nonspecific CTD-related diagnoses. Primary outcomes included aortic-related morbidities, time to and type of postoperative reinterventions, and time to open/hybrid conversion. Time to conversion and reintervention was calculated using Kaplan-Meier estimation. Predictors of reintervention and open/hybrid conversion were evaluated using Cox proportional hazards models. The median age was 53 years with 52.5% of the patients being female. Marfan syndrome was diagnosed in 57.5%, Loey-Dietz syndrome in 2.5%, and 40% had a diagnosed nonspecific or other CTD. Thirty-two (80%) had prior aortic interventions. Thoracic aneurysm existed in 52.5% and dissection in 82.5%. The average maximum thoracic aortic diameter was 55.2 mm. There were two mortalities within the first month. Of the remaining 38 patients, 71.1% had aneurysm-related morbidities, including 81.5% with aneurysmal degeneration and 33.3% with endoleak. Overall, 62.5% required reintervention. Of those, median time to reintervention was 9.1 months, including redo-TEVAR/extension in 32%, ascending/arch repair in 24%, open thoracoabdominal aortic repair in 56%, and false lumen embolization in 16%. Open conversions and reintervention were most likely to occur within the first year, with freedom of open conversion of 67.2% at 1 year, and 59.7% at 2 and 3 years, and freedom of reintervention of 49.8%, 36.0%, and 30.0% at 1, 2, and 3 years, respectively. This study suggests that TEVAR for patients with CTD can be performed safely; however, patients are at high risk for aortic-related morbidities and reintervention. Reinterventions and open conversion are common and more likely to occur within 1 year. TEVAR should remain limited in this population until more durable outcomes are possible.

Cass BD ，Hanak CR ，Ellis RC ，Sorour AA ，Quatromoni JG ，Khalifeh A ，Ambani RN ，Kirksey L ，Vargo PR ，Roselli EE ，Lyden SP ，Caputo FJ ... -  《-》