The replacement of thoracic aorta and elimination of proximal intimal tear are the classic methods for the treatment of Stanford type A aortic dissection. However, some patients still have residual tears in the distal aorta after operation and lead to dilation of the false lumen due to continuous perfusion. As negative remodeling of distal aorta is closely related to the long-term prognosis of patients, the exploration of related influencing factors has attracted the attention of scholars recently. We aim to review the definition, pathological mechanism and risk factors of unfavorable remodeling after open surgery.
ObjectiveTo investigate the impact of anatomical variations of the isolated left vertebral artery (ILVA) on clinical outcomes and imaging outcomes in patients with Stanford type B aortic dissection (TBAD) who underwent thoracic endovascular aortic repair. MethodsThe clinical data of patients with TBAD in West China Hospital, Sichuan University from January 2016 to December 2023 were collected, and the differences of clinical outcomes and imaging outcomes between patients with and without ILVA were compared. ResultsBased on the inclusion criteria and the result of propensity score-based matching, 82 patients with TBAD were included, including 17 patients with ILVA (ILVA group) and 65 patients without ILVA (control group). There was no significant difference between the two groups in terms of the radiological and surgical information (P>0.05). The median time of the follow-up for these 82 patients were 37 months, during which there were no significant differences in aortic-related death, aortic event, stroke, adverse aortic remodeling, type Ⅰ A endoleak, and retrograde progression between the two groups (P>0.05). Compared with the control group, the re-intervention rate [HR=2.56, 95%CI (1.55, 8.11), P=0.03] and the incidence of type Ⅱ internal leakage [OR=1.36, 95%CI (1.08, 2.11), P=0.04] in the ILVA group were higher. ConclusionsNo significant differences were observed for ILVA patients in terms of serious adverse events such as aortic-related death and retrograde progression, comparing with the patients with normal aortic arch. However, the patients with ILVA were more susceptible to complications such as reintervention and type Ⅱ endoleak, which warranted the necessity of intensive postoperative follow-up for these patients.
Chronic post-dissection aortic aneurysms (PDAAs) are severe long-term complications following surgical or medical conservative management of aortic dissection, primarily caused by persistent perfusion of the residual false lumen. The persistent patency of the residual false lumen is the key pathological mechanism leading to adverse distal aortic remodeling, which can result in progressive aortic dilation, increased risk of rupture, and elevated reintervention requirements, significantly affecting patients' long-term prognosis. This article reviews the latest research progress on assessment methods, influencing factors, and intervention strategies for distal aortic remodeling in PDAAs, aiming to provide reference for clinical decision-making.
ObjectiveTo evaluate the clinical efficacy of second-stage endovascular therapy for patients with aortic intramural hematoma (IMH) who developed progression of the distal hematoma into dissection-like changes after an initial procedure. Methods A retrospective analysis was conducted on patients at the University of Hong Kong-Shenzhen Hospital from July 2020 to December 2022. These patients had previously undergone a first-stage procedure to treat the proximal lesion of an IMH. However, follow-up examinations revealed a persistent distal hematoma, the presence of a distal entry tear, and progression of the hematoma into localized or extensive dissection-like changes, which could be accompanied by localized contrast enhancement. These patients then underwent a second-stage stent-graft intervention. The initial procedures included open surgery with total aortic arch replacement or endovascular stent-graft placement to seal the proximal entry tear. In the second-stage procedure, the aorta was divided into three zones based on its anatomy, and zonal stent-graft placement was performed to seal the entry tear and promote thrombosis of the false lumen. Results A total of 18 patients (15 males, 3 females) were included, with a mean age of (53.5±10.6) years (range, 39 to 76 years). The median operation time was 38.0 (29.5, 58.5) min, and the median intraoperative blood loss was 20.0 (20.0, 30.0) mL. The technical success rate was 100.0%. Intraoperative and postoperative imaging confirmed successful exclusion of the distal entry tear of the IMH, with no endoleak, stenosis or occlusion of visceral branches. There were no major perioperative complications, such as death, paraplegia, or visceral ischemia. During follow-up, complete thrombosis or resolution of the false lumen was observed in all patients. Conclusion For patients with residual entry tears and new-onset dissection-like changes in the distal aorta after the first-stage procedure for IMH, second-stage stent-graft placement can effectively seal the entry tear, promote false lumen thrombosis and hematoma resolution, and improve distal aortic remodeling, demonstrating favorable short- to mid-term outcomes.