Amy Rothman Schonfeld

NEW YORK  – A novel technique for aortic arch repair, which avoids both circulatory arrest and profound hypothermia, was associated with low mortality and low cerebral morbidity in a group of 62 patients who underwent aortic arch replacement using this procedure.

Advantages of the "branch-first" procedure include visceral organ and cardiac protection and less need for blood/product transfusions, according to Dr. George Matalanis, who presented the findings at the meeting sponsored by the American Association for Thoracic Surgery.

The branch-first technique avoids many of the pitfalls associated with the widely used combination of antegrade perfusion and deep hypothermic circulatory arrest (DHTA). Such pitfalls include a higher incidence of cerebral injury than with proximal aortic surgery, as well as renal failure, ischemic hepatitis, and paraplegia, said Dr. Matalanis, a cardiothoracic surgeon at Austin Hospital, Kew, Australia. He noted that perfusion cannulas used for antegrade perfusion increase the risk of particulate and air emboli and branch injury or dissection, and their insertion extends cumulative cerebral circulatory arrest time.

DHTA also has a number of clinically significant disadvantages, such as prolongation of cardiopulmonary bypass times during cooling and rewarming, increased potential for cerebral ischemic reperfusion injury, and imposition of time constraints.

A feature of the branch-first technique is that it allows a complete and unhurried repair, allowing the surgeon to systematically interrogate each branch anastomosis, resulting in a low incidence of blood product use. By maintaining cardiac and distal body perfusion, even the most complex reconstructions can be carefully accomplished without concern about incomplete organ protection, allowing complete correction of pathology, according to Dr. Matalanis. The technique avoids the need for deep hypothermia, circulatory arrest, extended periods of cardiopulmonary bypass, and cerebral, cardiac and other organ circulatory exclusion.

Dr. Matalanis presented the results of a study involving 62 patients who underwent arch replacement using the branch-first procedure. The mean age was 65 years, and 60% were men. Almost 40% were urgent/emergent, and 32% had acute type A aortic dissection. One quarter had previous cardiac surgery. This work is an extension of an earlier study, which reported outcomes in 42 patients (Ann. Cardiothorac. Surg. 2013;2:194-201).

There were two deaths (3%), both in patients with acute type A aortic dissection with malperfusion. Neurological events occurred in 5%, with one permanent deficit. Six percent required renal support and 2% intra-aortic balloon support. One-quarter did not need red blood cell transfusion, and 15% did not require red blood cells or platelets/factors. Patients awakened as if they had undergone coronary artery bypass grafting (80% within 48 hours and 25% within 11 hours).

"This technique relies on two basic principles," explained Dr. Matalanis "The first is the extensive collateral network that exists between the three major arch branches, in addition to and far more expansive than the circle of Willis, allowing the brief interruption of one branch to be compensated by collateral flow from the other two. The second is the use of a modified trifurcation graft with a perfusion side arm to reconstruct the arch branches, allowing antegrade perfusion to resume as soon as each branch is reconstructed."

The procedure consists of establishing bypass using femoral inflow and moderate hypothermia (28° C), followed by serial disconnection and reconstruction of each arch branch, proceeding from the innominate to left subclavian, using a trifurcation arch graft with a perfusion side arm port. The proximal descending aorta is clamped, the distal arch anastomosis is constructed, and the aortic root reconstruction is completed. Finally, a connection is made between the common stem of the trifurcation graft and the ascending aorta graft.

There are no periods of global circulatory arrest, no interruption to cerebral perfusion during the anastomosis of the two grafts, and cardiac perfusion is maintained during the whole phase of arch branch reconstruction. Distal organ perfusion is also maintained throughout the procedure, says Dr. Matalanis.

Disadvantages of the branch-first technique include loss of the deep hypothermia "security blanket," the possibility of clamp injuries or air/thrombo-embolism, and difficulties with femoral cannulation. Issues may also arise with kinking or stenosis of the trifurcation graft and adhesions.

Dr. Matalanis reported having no relevant financial disclosures.

NEW YORK  – A novel technique for aortic arch repair, which avoids both circulatory arrest and profound hypothermia, was associated with low mortality and low cerebral morbidity in a group of 62 patients who underwent aortic arch replacement using this procedure.

Advantages of the "branch-first" procedure include visceral organ and cardiac protection and less need for blood/product transfusions, according to Dr. George Matalanis, who presented the findings at the meeting sponsored by the American Association for Thoracic Surgery.

The branch-first technique avoids many of the pitfalls associated with the widely used combination of antegrade perfusion and deep hypothermic circulatory arrest (DHTA). Such pitfalls include a higher incidence of cerebral injury than with proximal aortic surgery, as well as renal failure, ischemic hepatitis, and paraplegia, said Dr. Matalanis, a cardiothoracic surgeon at Austin Hospital, Kew, Australia. He noted that perfusion cannulas used for antegrade perfusion increase the risk of particulate and air emboli and branch injury or dissection, and their insertion extends cumulative cerebral circulatory arrest time.

DHTA also has a number of clinically significant disadvantages, such as prolongation of cardiopulmonary bypass times during cooling and rewarming, increased potential for cerebral ischemic reperfusion injury, and imposition of time constraints.

A feature of the branch-first technique is that it allows a complete and unhurried repair, allowing the surgeon to systematically interrogate each branch anastomosis, resulting in a low incidence of blood product use. By maintaining cardiac and distal body perfusion, even the most complex reconstructions can be carefully accomplished without concern about incomplete organ protection, allowing complete correction of pathology, according to Dr. Matalanis. The technique avoids the need for deep hypothermia, circulatory arrest, extended periods of cardiopulmonary bypass, and cerebral, cardiac and other organ circulatory exclusion.

Dr. Matalanis presented the results of a study involving 62 patients who underwent arch replacement using the branch-first procedure. The mean age was 65 years, and 60% were men. Almost 40% were urgent/emergent, and 32% had acute type A aortic dissection. One quarter had previous cardiac surgery. This work is an extension of an earlier study, which reported outcomes in 42 patients (Ann. Cardiothorac. Surg. 2013;2:194-201).

There were two deaths (3%), both in patients with acute type A aortic dissection with malperfusion. Neurological events occurred in 5%, with one permanent deficit. Six percent required renal support and 2% intra-aortic balloon support. One-quarter did not need red blood cell transfusion, and 15% did not require red blood cells or platelets/factors. Patients awakened as if they had undergone coronary artery bypass grafting (80% within 48 hours and 25% within 11 hours).

"This technique relies on two basic principles," explained Dr. Matalanis "The first is the extensive collateral network that exists between the three major arch branches, in addition to and far more expansive than the circle of Willis, allowing the brief interruption of one branch to be compensated by collateral flow from the other two. The second is the use of a modified trifurcation graft with a perfusion side arm to reconstruct the arch branches, allowing antegrade perfusion to resume as soon as each branch is reconstructed."

The procedure consists of establishing bypass using femoral inflow and moderate hypothermia (28° C), followed by serial disconnection and reconstruction of each arch branch, proceeding from the innominate to left subclavian, using a trifurcation arch graft with a perfusion side arm port. The proximal descending aorta is clamped, the distal arch anastomosis is constructed, and the aortic root reconstruction is completed. Finally, a connection is made between the common stem of the trifurcation graft and the ascending aorta graft.

There are no periods of global circulatory arrest, no interruption to cerebral perfusion during the anastomosis of the two grafts, and cardiac perfusion is maintained during the whole phase of arch branch reconstruction. Distal organ perfusion is also maintained throughout the procedure, says Dr. Matalanis.

Disadvantages of the branch-first technique include loss of the deep hypothermia "security blanket," the possibility of clamp injuries or air/thrombo-embolism, and difficulties with femoral cannulation. Issues may also arise with kinking or stenosis of the trifurcation graft and adhesions.

Dr. Matalanis reported having no relevant financial disclosures.

NEW YORK  – A novel technique for aortic arch repair, which avoids both circulatory arrest and profound hypothermia, was associated with low mortality and low cerebral morbidity in a group of 62 patients who underwent aortic arch replacement using this procedure.

Advantages of the "branch-first" procedure include visceral organ and cardiac protection and less need for blood/product transfusions, according to Dr. George Matalanis, who presented the findings at the meeting sponsored by the American Association for Thoracic Surgery.

The branch-first technique avoids many of the pitfalls associated with the widely used combination of antegrade perfusion and deep hypothermic circulatory arrest (DHTA). Such pitfalls include a higher incidence of cerebral injury than with proximal aortic surgery, as well as renal failure, ischemic hepatitis, and paraplegia, said Dr. Matalanis, a cardiothoracic surgeon at Austin Hospital, Kew, Australia. He noted that perfusion cannulas used for antegrade perfusion increase the risk of particulate and air emboli and branch injury or dissection, and their insertion extends cumulative cerebral circulatory arrest time.

DHTA also has a number of clinically significant disadvantages, such as prolongation of cardiopulmonary bypass times during cooling and rewarming, increased potential for cerebral ischemic reperfusion injury, and imposition of time constraints.

A feature of the branch-first technique is that it allows a complete and unhurried repair, allowing the surgeon to systematically interrogate each branch anastomosis, resulting in a low incidence of blood product use. By maintaining cardiac and distal body perfusion, even the most complex reconstructions can be carefully accomplished without concern about incomplete organ protection, allowing complete correction of pathology, according to Dr. Matalanis. The technique avoids the need for deep hypothermia, circulatory arrest, extended periods of cardiopulmonary bypass, and cerebral, cardiac and other organ circulatory exclusion.

Dr. Matalanis presented the results of a study involving 62 patients who underwent arch replacement using the branch-first procedure. The mean age was 65 years, and 60% were men. Almost 40% were urgent/emergent, and 32% had acute type A aortic dissection. One quarter had previous cardiac surgery. This work is an extension of an earlier study, which reported outcomes in 42 patients (Ann. Cardiothorac. Surg. 2013;2:194-201).

There were two deaths (3%), both in patients with acute type A aortic dissection with malperfusion. Neurological events occurred in 5%, with one permanent deficit. Six percent required renal support and 2% intra-aortic balloon support. One-quarter did not need red blood cell transfusion, and 15% did not require red blood cells or platelets/factors. Patients awakened as if they had undergone coronary artery bypass grafting (80% within 48 hours and 25% within 11 hours).

"This technique relies on two basic principles," explained Dr. Matalanis "The first is the extensive collateral network that exists between the three major arch branches, in addition to and far more expansive than the circle of Willis, allowing the brief interruption of one branch to be compensated by collateral flow from the other two. The second is the use of a modified trifurcation graft with a perfusion side arm to reconstruct the arch branches, allowing antegrade perfusion to resume as soon as each branch is reconstructed."

The procedure consists of establishing bypass using femoral inflow and moderate hypothermia (28° C), followed by serial disconnection and reconstruction of each arch branch, proceeding from the innominate to left subclavian, using a trifurcation arch graft with a perfusion side arm port. The proximal descending aorta is clamped, the distal arch anastomosis is constructed, and the aortic root reconstruction is completed. Finally, a connection is made between the common stem of the trifurcation graft and the ascending aorta graft.

There are no periods of global circulatory arrest, no interruption to cerebral perfusion during the anastomosis of the two grafts, and cardiac perfusion is maintained during the whole phase of arch branch reconstruction. Distal organ perfusion is also maintained throughout the procedure, says Dr. Matalanis.

Disadvantages of the branch-first technique include loss of the deep hypothermia "security blanket," the possibility of clamp injuries or air/thrombo-embolism, and difficulties with femoral cannulation. Issues may also arise with kinking or stenosis of the trifurcation graft and adhesions.

Dr. Matalanis reported having no relevant financial disclosures.

NEW YORK – Bicuspid aortic valve repair with reimplantation is feasible with very good midterm outcomes, and the results are getting better as techniques are refined, according to a study presented by Dr. Joseph E. Bavaria at a meeting sponsored by the American Association for Thoracic Surgery.

He and his colleagues performed a retrospective analysis of a prospectively maintained database of patients with bicuspid aortic valve (BAV) disease who had minimal sinus segment dilation or aneurysm, and presented with eccentric, BAV aortic insufficiency (AI) alone, with only a dilated annulus. In these patients, the study showed that simple repair with subcommissural annuloplasty (SCA) was not an appropriate treatment choice, since it was associated with heightened risk of AI recurrence, compared with cusp repair combined with root implantation. The worst outcomes were seen for those who underwent SCA when the preoperative annular diameter was 28 mm or more.

"A fundamental dilemma for surgeons today worldwide is the decision to either repair an insufficient BAV or perform an aortic valve replacement (or a Bentall)," said Dr. Bavaria, director of the thoracic aortic surgery program at the University of Pennsylvania Medical Center, Philadelphia. "The key overall conceptual question in front of the cardioaortic surgical community is: Can we repair virtually every pure BAV AI presentation as we presently perform in the mitral valve repair arena?"

This study analyzed data from 88 patients with type I BAV disease who had AI (with or without aortic root aneurysm), who underwent primary valve repair between 2002 and 2013. The reimplantation group (n = 36) underwent primary leaflet repair and annular stabilization by root reimplantation, and the repair group (n = 52) underwent primary leaflet repair with subannular stabilization by SCA.

At 5 years, freedom from AI recurrence was significantly better in the reimplantation group than in the repair group (92% vs. 62%; P = .03). Overall survival was 100% for both groups. Results from a smaller cohort were published recently (Ann. Thorac. Surg. 2014;97:1227-34).

"In patients who have minimal sinus segment dilation or aneurysm and present with eccentric, BAV AI alone, with only a dilated annulus, it is becoming increasingly obvious and understood that this reparative technique [simple repair with SCA] is inadequate," said Dr. Bavaria.

Subgroup analysis showed that SCA in patients with enlarged annular diameters had poor outcomes. In those who underwent SCA, 88% of those with small preoperative annular diameters (27 mm or less) had no AI recurrence, compared with only 53% of those with larger diameters (28 mm or more) (P = .02). Root implantation was associated with excellent outcomes, regardless of preoperative annular size (100% vs. 88%; P = .30). "We have abandoned this particular procedure [SCA for these patients]," said Dr. Bavaria, noting that in his practice, he reserves SCA only for those who have normal annular size (27 mm or less) and a nonaneurysmal root.

Dr. Bavaria outlined some risk factors he associates with poor outcomes in BAV repair. These include excessive calcification of the leaflets, including the commissures or raphe; severely enlarged annular diameters without robust subannular stabilization; leaflet surface areas that are not adequate to provide excellent cusp coaptation (and therefore would require leaflet augmentation); and reimplantation with very extensive cusp repair.

Dr. Bavaria reported no relevant financial disclosures.

NEW YORK – Bicuspid aortic valve repair with reimplantation is feasible with very good midterm outcomes, and the results are getting better as techniques are refined, according to a study presented by Dr. Joseph E. Bavaria at a meeting sponsored by the American Association for Thoracic Surgery.

He and his colleagues performed a retrospective analysis of a prospectively maintained database of patients with bicuspid aortic valve (BAV) disease who had minimal sinus segment dilation or aneurysm, and presented with eccentric, BAV aortic insufficiency (AI) alone, with only a dilated annulus. In these patients, the study showed that simple repair with subcommissural annuloplasty (SCA) was not an appropriate treatment choice, since it was associated with heightened risk of AI recurrence, compared with cusp repair combined with root implantation. The worst outcomes were seen for those who underwent SCA when the preoperative annular diameter was 28 mm or more.

"A fundamental dilemma for surgeons today worldwide is the decision to either repair an insufficient BAV or perform an aortic valve replacement (or a Bentall)," said Dr. Bavaria, director of the thoracic aortic surgery program at the University of Pennsylvania Medical Center, Philadelphia. "The key overall conceptual question in front of the cardioaortic surgical community is: Can we repair virtually every pure BAV AI presentation as we presently perform in the mitral valve repair arena?"

This study analyzed data from 88 patients with type I BAV disease who had AI (with or without aortic root aneurysm), who underwent primary valve repair between 2002 and 2013. The reimplantation group (n = 36) underwent primary leaflet repair and annular stabilization by root reimplantation, and the repair group (n = 52) underwent primary leaflet repair with subannular stabilization by SCA.

At 5 years, freedom from AI recurrence was significantly better in the reimplantation group than in the repair group (92% vs. 62%; P = .03). Overall survival was 100% for both groups. Results from a smaller cohort were published recently (Ann. Thorac. Surg. 2014;97:1227-34).

"In patients who have minimal sinus segment dilation or aneurysm and present with eccentric, BAV AI alone, with only a dilated annulus, it is becoming increasingly obvious and understood that this reparative technique [simple repair with SCA] is inadequate," said Dr. Bavaria.

Subgroup analysis showed that SCA in patients with enlarged annular diameters had poor outcomes. In those who underwent SCA, 88% of those with small preoperative annular diameters (27 mm or less) had no AI recurrence, compared with only 53% of those with larger diameters (28 mm or more) (P = .02). Root implantation was associated with excellent outcomes, regardless of preoperative annular size (100% vs. 88%; P = .30). "We have abandoned this particular procedure [SCA for these patients]," said Dr. Bavaria, noting that in his practice, he reserves SCA only for those who have normal annular size (27 mm or less) and a nonaneurysmal root.

Dr. Bavaria outlined some risk factors he associates with poor outcomes in BAV repair. These include excessive calcification of the leaflets, including the commissures or raphe; severely enlarged annular diameters without robust subannular stabilization; leaflet surface areas that are not adequate to provide excellent cusp coaptation (and therefore would require leaflet augmentation); and reimplantation with very extensive cusp repair.

Dr. Bavaria reported no relevant financial disclosures.

NEW YORK – Bicuspid aortic valve repair with reimplantation is feasible with very good midterm outcomes, and the results are getting better as techniques are refined, according to a study presented by Dr. Joseph E. Bavaria at a meeting sponsored by the American Association for Thoracic Surgery.

He and his colleagues performed a retrospective analysis of a prospectively maintained database of patients with bicuspid aortic valve (BAV) disease who had minimal sinus segment dilation or aneurysm, and presented with eccentric, BAV aortic insufficiency (AI) alone, with only a dilated annulus. In these patients, the study showed that simple repair with subcommissural annuloplasty (SCA) was not an appropriate treatment choice, since it was associated with heightened risk of AI recurrence, compared with cusp repair combined with root implantation. The worst outcomes were seen for those who underwent SCA when the preoperative annular diameter was 28 mm or more.

"A fundamental dilemma for surgeons today worldwide is the decision to either repair an insufficient BAV or perform an aortic valve replacement (or a Bentall)," said Dr. Bavaria, director of the thoracic aortic surgery program at the University of Pennsylvania Medical Center, Philadelphia. "The key overall conceptual question in front of the cardioaortic surgical community is: Can we repair virtually every pure BAV AI presentation as we presently perform in the mitral valve repair arena?"

This study analyzed data from 88 patients with type I BAV disease who had AI (with or without aortic root aneurysm), who underwent primary valve repair between 2002 and 2013. The reimplantation group (n = 36) underwent primary leaflet repair and annular stabilization by root reimplantation, and the repair group (n = 52) underwent primary leaflet repair with subannular stabilization by SCA.

At 5 years, freedom from AI recurrence was significantly better in the reimplantation group than in the repair group (92% vs. 62%; P = .03). Overall survival was 100% for both groups. Results from a smaller cohort were published recently (Ann. Thorac. Surg. 2014;97:1227-34).

"In patients who have minimal sinus segment dilation or aneurysm and present with eccentric, BAV AI alone, with only a dilated annulus, it is becoming increasingly obvious and understood that this reparative technique [simple repair with SCA] is inadequate," said Dr. Bavaria.

Subgroup analysis showed that SCA in patients with enlarged annular diameters had poor outcomes. In those who underwent SCA, 88% of those with small preoperative annular diameters (27 mm or less) had no AI recurrence, compared with only 53% of those with larger diameters (28 mm or more) (P = .02). Root implantation was associated with excellent outcomes, regardless of preoperative annular size (100% vs. 88%; P = .30). "We have abandoned this particular procedure [SCA for these patients]," said Dr. Bavaria, noting that in his practice, he reserves SCA only for those who have normal annular size (27 mm or less) and a nonaneurysmal root.

Dr. Bavaria outlined some risk factors he associates with poor outcomes in BAV repair. These include excessive calcification of the leaflets, including the commissures or raphe; severely enlarged annular diameters without robust subannular stabilization; leaflet surface areas that are not adequate to provide excellent cusp coaptation (and therefore would require leaflet augmentation); and reimplantation with very extensive cusp repair.

Dr. Bavaria reported no relevant financial disclosures.

NEW YORK – A significantly higher percentage of patients achieved false lumen thrombosis in the best medical therapy plus stent group, compared with those who received only BMT, based on 1-year results of the ADSORB trial.

The maximum true lumen diameter at 1 year was also greater in those who received the combination treatment, Dr. G. Chad Hughes of Duke University Medical Center, Durham, N.C., said at the meeting sponsored by the American Association for Thoracic Surgery.

The ADSORB trial is a European study sponsored by W.L. Gore and Associates and is the first-ever randomized trial comparing BMT with BMT plus stent grafting of the proximal tear in patients having an uncomplicated type B acute dissection of the descending aorta. The stent used was the Gore TAG Endoprosthesis (TAG). BMT consisted of a regimen of antihypertensive medications used to maintain blood pressure below 125/80 mm/Hg throughout the entire follow-up period. The regimen was individualized to each patient, but typically consisted of one to four concomitant antihypertensive medications.

The final study cohort was comprised of 30 patients with acute uncomplicated type B dissection of the descending aorta who received TAG + BMT and 31 who received BMT alone. All were randomized within 5 days of symptom onset. For inclusion in the study, patients could not have a descending thoracic aortic aneurysm or a transverse diameter of the descending thoracic aorta of 55 mm or greater.

The primary endpoint consisted of three components. For the first component, the percentage of patients achieving false lumen thrombosis in the TAG + BMT group was statistically higher than in the group who received BMT alone (P less than .001). Complete thrombosis was seen in 63.3% of those receiving combination treatment vs. 6.5% of the BMT-alone group, while a much higher rate of no or incomplete thrombosis was found in the BMT group (67.7% vs. 13.3%). About one-quarter of each group were considered failures because of incomplete imaging.

The second component, which evaluated aortic dilatation, showed no significant differences. For instance, 70% of the TAG + BMT group showed no dilatation, compared with 61.3% of the BMT-alone group; the rates of dilatation were 22.6% in the BMT group vs. 6.7% in the combination treatment group (P = .474).

One-year aortic rupture was the third component of the primary endpoint, and no differences were apparent between groups. There were no aortic ruptures within 365 days of randomization in either of the treatment groups, with excellent survival seen in both groups at 1 year.

When all three components were taken into consideration, 56.7% of those treated with TAG + BMT were free from all of the endpoint events, compared with 3.2% of the BMT group, and this difference was significant (P less than .001).

The secondary endpoint related to evidence of aortic remodeling at 1 year. The study found that the maximum true lumen diameter was significantly larger in the BMT + TAG group (P less than .001). A nonsignificant trend was seen toward smaller overall aortic diameter in the TAG + BMT group (P = .06)

Dr. Hughes addressed some of the criticisms of the ADSORB trial. For instance, it has been suggested that the surrogate composite endpoint does not yield clinically useful information that can be applied to make treatment decisions. Dr. Hughes explained that the study was conceived as a feasibility study rather than one designed to give definitive advice about treatment. He also acknowledged that the small sample size was underpowered to detect differences in aortic-related or all-cause mortality. Objections have also been raised that the definitions of false lumen thrombosis differed for the two groups, and might have favored the TAG + BMT group.

Dr. Hughes did not participate in the ADSORB trial but said he does have a financial relationship with W.G. Gore and Associates, the study sponsor. He presented the results on behalf of the principal investigator, Dr. Jan Brunkwall of the University of Cologne (Germany).

NEW YORK – A significantly higher percentage of patients achieved false lumen thrombosis in the best medical therapy plus stent group, compared with those who received only BMT, based on 1-year results of the ADSORB trial.

The maximum true lumen diameter at 1 year was also greater in those who received the combination treatment, Dr. G. Chad Hughes of Duke University Medical Center, Durham, N.C., said at the meeting sponsored by the American Association for Thoracic Surgery.

The ADSORB trial is a European study sponsored by W.L. Gore and Associates and is the first-ever randomized trial comparing BMT with BMT plus stent grafting of the proximal tear in patients having an uncomplicated type B acute dissection of the descending aorta. The stent used was the Gore TAG Endoprosthesis (TAG). BMT consisted of a regimen of antihypertensive medications used to maintain blood pressure below 125/80 mm/Hg throughout the entire follow-up period. The regimen was individualized to each patient, but typically consisted of one to four concomitant antihypertensive medications.

The final study cohort was comprised of 30 patients with acute uncomplicated type B dissection of the descending aorta who received TAG + BMT and 31 who received BMT alone. All were randomized within 5 days of symptom onset. For inclusion in the study, patients could not have a descending thoracic aortic aneurysm or a transverse diameter of the descending thoracic aorta of 55 mm or greater.

The primary endpoint consisted of three components. For the first component, the percentage of patients achieving false lumen thrombosis in the TAG + BMT group was statistically higher than in the group who received BMT alone (P less than .001). Complete thrombosis was seen in 63.3% of those receiving combination treatment vs. 6.5% of the BMT-alone group, while a much higher rate of no or incomplete thrombosis was found in the BMT group (67.7% vs. 13.3%). About one-quarter of each group were considered failures because of incomplete imaging.

The second component, which evaluated aortic dilatation, showed no significant differences. For instance, 70% of the TAG + BMT group showed no dilatation, compared with 61.3% of the BMT-alone group; the rates of dilatation were 22.6% in the BMT group vs. 6.7% in the combination treatment group (P = .474).

One-year aortic rupture was the third component of the primary endpoint, and no differences were apparent between groups. There were no aortic ruptures within 365 days of randomization in either of the treatment groups, with excellent survival seen in both groups at 1 year.

When all three components were taken into consideration, 56.7% of those treated with TAG + BMT were free from all of the endpoint events, compared with 3.2% of the BMT group, and this difference was significant (P less than .001).

The secondary endpoint related to evidence of aortic remodeling at 1 year. The study found that the maximum true lumen diameter was significantly larger in the BMT + TAG group (P less than .001). A nonsignificant trend was seen toward smaller overall aortic diameter in the TAG + BMT group (P = .06)

Dr. Hughes addressed some of the criticisms of the ADSORB trial. For instance, it has been suggested that the surrogate composite endpoint does not yield clinically useful information that can be applied to make treatment decisions. Dr. Hughes explained that the study was conceived as a feasibility study rather than one designed to give definitive advice about treatment. He also acknowledged that the small sample size was underpowered to detect differences in aortic-related or all-cause mortality. Objections have also been raised that the definitions of false lumen thrombosis differed for the two groups, and might have favored the TAG + BMT group.

Dr. Hughes did not participate in the ADSORB trial but said he does have a financial relationship with W.G. Gore and Associates, the study sponsor. He presented the results on behalf of the principal investigator, Dr. Jan Brunkwall of the University of Cologne (Germany).

NEW YORK – A significantly higher percentage of patients achieved false lumen thrombosis in the best medical therapy plus stent group, compared with those who received only BMT, based on 1-year results of the ADSORB trial.

The maximum true lumen diameter at 1 year was also greater in those who received the combination treatment, Dr. G. Chad Hughes of Duke University Medical Center, Durham, N.C., said at the meeting sponsored by the American Association for Thoracic Surgery.

The ADSORB trial is a European study sponsored by W.L. Gore and Associates and is the first-ever randomized trial comparing BMT with BMT plus stent grafting of the proximal tear in patients having an uncomplicated type B acute dissection of the descending aorta. The stent used was the Gore TAG Endoprosthesis (TAG). BMT consisted of a regimen of antihypertensive medications used to maintain blood pressure below 125/80 mm/Hg throughout the entire follow-up period. The regimen was individualized to each patient, but typically consisted of one to four concomitant antihypertensive medications.

The final study cohort was comprised of 30 patients with acute uncomplicated type B dissection of the descending aorta who received TAG + BMT and 31 who received BMT alone. All were randomized within 5 days of symptom onset. For inclusion in the study, patients could not have a descending thoracic aortic aneurysm or a transverse diameter of the descending thoracic aorta of 55 mm or greater.

The primary endpoint consisted of three components. For the first component, the percentage of patients achieving false lumen thrombosis in the TAG + BMT group was statistically higher than in the group who received BMT alone (P less than .001). Complete thrombosis was seen in 63.3% of those receiving combination treatment vs. 6.5% of the BMT-alone group, while a much higher rate of no or incomplete thrombosis was found in the BMT group (67.7% vs. 13.3%). About one-quarter of each group were considered failures because of incomplete imaging.

The second component, which evaluated aortic dilatation, showed no significant differences. For instance, 70% of the TAG + BMT group showed no dilatation, compared with 61.3% of the BMT-alone group; the rates of dilatation were 22.6% in the BMT group vs. 6.7% in the combination treatment group (P = .474).

One-year aortic rupture was the third component of the primary endpoint, and no differences were apparent between groups. There were no aortic ruptures within 365 days of randomization in either of the treatment groups, with excellent survival seen in both groups at 1 year.

When all three components were taken into consideration, 56.7% of those treated with TAG + BMT were free from all of the endpoint events, compared with 3.2% of the BMT group, and this difference was significant (P less than .001).

The secondary endpoint related to evidence of aortic remodeling at 1 year. The study found that the maximum true lumen diameter was significantly larger in the BMT + TAG group (P less than .001). A nonsignificant trend was seen toward smaller overall aortic diameter in the TAG + BMT group (P = .06)

Dr. Hughes addressed some of the criticisms of the ADSORB trial. For instance, it has been suggested that the surrogate composite endpoint does not yield clinically useful information that can be applied to make treatment decisions. Dr. Hughes explained that the study was conceived as a feasibility study rather than one designed to give definitive advice about treatment. He also acknowledged that the small sample size was underpowered to detect differences in aortic-related or all-cause mortality. Objections have also been raised that the definitions of false lumen thrombosis differed for the two groups, and might have favored the TAG + BMT group.

Dr. Hughes did not participate in the ADSORB trial but said he does have a financial relationship with W.G. Gore and Associates, the study sponsor. He presented the results on behalf of the principal investigator, Dr. Jan Brunkwall of the University of Cologne (Germany).

NEW YORK – Five-year results from the INSTEAD trial showed that patients with stable type B aortic dissections who were randomized to receive thoracic endovascular aneurysm repair plus optimal medical treatment showed significantly less aorta-specific mortality and delayed disease progression than did those who received OMT alone, according to Rachel Clough, Ph.D., MRCS, who presented the findings at the AATS 2014 Aortic Symposium.

The results indicate that delayed adverse events, such as sudden fatalities, expansion of the false lumen, rupture, and other late complications that occur in patients treated medically in the years subsequent to dissection, are prevented or attenuated with stent grafts.

"Uncomplicated patients with type B aortic dissection have traditionally been treated with antihypertensive medication but what we see is, even in patients with very good blood pressure control, there is a continued attrition rate looking out toward 5 years. In some series, more than 50% of patients are dead [at that time point]," said Dr. Clough of King’s College London.

INSTEAD (Investigation of Stent Grafts in Aortic Dissection) is the first randomized trial comparing thoracic endovascular aneurysm repair (TEVAR) with a stent graft. When 2-year results were published in 2009 (Circulation 2009;120:2519-28), there was criticism that the study was underpowered as no differences were seen in all-cause deaths, aorta-related deaths due to aortic rupture, or dissection progression plus rupture. There was even a trend toward better cumulative survival in the OMT group.

Sixty-eight patients were randomized to receive OMT and 72 patients received TEVAR plus OMT. Eighty-three percent had one stent placed, 11% had two stents, and 6% had three stents. The proximal thoracic aorta was covered in all cases, and the range of coverage was 15-35 cm.

No significant differences between groups were found in the comorbidity profile, presence of risk factors, or dissection morphology. With patients followed for 5 years, differences in outcomes between patients who had undergone TEVAR plus OMT and those who received only OMT began to emerge.

Analysis of these long-term data shows that patients with stable type B aortic dissections who were randomized to receive TEVAR plus OMT showed less aorta-specific mortality (7 vs. 19%, P = .04) and delayed disease progression (27% vs. 46%, P = .04) than did those who received OMT alone. Landmark analysis suggested a benefit of TEVAR for all endpoints between 2 and 5 years, including all-cause mortality (0 vs. 17%, P = .0003).

Both improved survival and less progression over 5 years after TEVAR were associated with stent graft–induced false lumen thrombosis in 91% of cases (P less than .0001). Use of the stent graft resulted in a significant reduction in false lumen diameter (P less than .0001) and significant increase in true lumen diameter (P less than .001). In contrast, a significant increase in aortic diameter was noted in those who received only OMT (P less than .0001).

"In conclusion, endovascular therapy in addition to medical therapy is associated with improved 5-year aortic-specific survival and delayed disease progression. In uncomplicated type B dissection with suitable anatomy, preemptive TEVAR should be considered to improve late outcomes," said Dr. Clough.

Dr. Clough had no disclosures. INSTEAD was sponsored by the Medtronic Bakken Research Center.

NEW YORK – Five-year results from the INSTEAD trial showed that patients with stable type B aortic dissections who were randomized to receive thoracic endovascular aneurysm repair plus optimal medical treatment showed significantly less aorta-specific mortality and delayed disease progression than did those who received OMT alone, according to Rachel Clough, Ph.D., MRCS, who presented the findings at the AATS 2014 Aortic Symposium.

The results indicate that delayed adverse events, such as sudden fatalities, expansion of the false lumen, rupture, and other late complications that occur in patients treated medically in the years subsequent to dissection, are prevented or attenuated with stent grafts.

"Uncomplicated patients with type B aortic dissection have traditionally been treated with antihypertensive medication but what we see is, even in patients with very good blood pressure control, there is a continued attrition rate looking out toward 5 years. In some series, more than 50% of patients are dead [at that time point]," said Dr. Clough of King’s College London.

INSTEAD (Investigation of Stent Grafts in Aortic Dissection) is the first randomized trial comparing thoracic endovascular aneurysm repair (TEVAR) with a stent graft. When 2-year results were published in 2009 (Circulation 2009;120:2519-28), there was criticism that the study was underpowered as no differences were seen in all-cause deaths, aorta-related deaths due to aortic rupture, or dissection progression plus rupture. There was even a trend toward better cumulative survival in the OMT group.

Sixty-eight patients were randomized to receive OMT and 72 patients received TEVAR plus OMT. Eighty-three percent had one stent placed, 11% had two stents, and 6% had three stents. The proximal thoracic aorta was covered in all cases, and the range of coverage was 15-35 cm.

No significant differences between groups were found in the comorbidity profile, presence of risk factors, or dissection morphology. With patients followed for 5 years, differences in outcomes between patients who had undergone TEVAR plus OMT and those who received only OMT began to emerge.

Analysis of these long-term data shows that patients with stable type B aortic dissections who were randomized to receive TEVAR plus OMT showed less aorta-specific mortality (7 vs. 19%, P = .04) and delayed disease progression (27% vs. 46%, P = .04) than did those who received OMT alone. Landmark analysis suggested a benefit of TEVAR for all endpoints between 2 and 5 years, including all-cause mortality (0 vs. 17%, P = .0003).

Both improved survival and less progression over 5 years after TEVAR were associated with stent graft–induced false lumen thrombosis in 91% of cases (P less than .0001). Use of the stent graft resulted in a significant reduction in false lumen diameter (P less than .0001) and significant increase in true lumen diameter (P less than .001). In contrast, a significant increase in aortic diameter was noted in those who received only OMT (P less than .0001).

"In conclusion, endovascular therapy in addition to medical therapy is associated with improved 5-year aortic-specific survival and delayed disease progression. In uncomplicated type B dissection with suitable anatomy, preemptive TEVAR should be considered to improve late outcomes," said Dr. Clough.

Dr. Clough had no disclosures. INSTEAD was sponsored by the Medtronic Bakken Research Center.

NEW YORK – Five-year results from the INSTEAD trial showed that patients with stable type B aortic dissections who were randomized to receive thoracic endovascular aneurysm repair plus optimal medical treatment showed significantly less aorta-specific mortality and delayed disease progression than did those who received OMT alone, according to Rachel Clough, Ph.D., MRCS, who presented the findings at the AATS 2014 Aortic Symposium.

The results indicate that delayed adverse events, such as sudden fatalities, expansion of the false lumen, rupture, and other late complications that occur in patients treated medically in the years subsequent to dissection, are prevented or attenuated with stent grafts.

"Uncomplicated patients with type B aortic dissection have traditionally been treated with antihypertensive medication but what we see is, even in patients with very good blood pressure control, there is a continued attrition rate looking out toward 5 years. In some series, more than 50% of patients are dead [at that time point]," said Dr. Clough of King’s College London.

INSTEAD (Investigation of Stent Grafts in Aortic Dissection) is the first randomized trial comparing thoracic endovascular aneurysm repair (TEVAR) with a stent graft. When 2-year results were published in 2009 (Circulation 2009;120:2519-28), there was criticism that the study was underpowered as no differences were seen in all-cause deaths, aorta-related deaths due to aortic rupture, or dissection progression plus rupture. There was even a trend toward better cumulative survival in the OMT group.

Sixty-eight patients were randomized to receive OMT and 72 patients received TEVAR plus OMT. Eighty-three percent had one stent placed, 11% had two stents, and 6% had three stents. The proximal thoracic aorta was covered in all cases, and the range of coverage was 15-35 cm.

No significant differences between groups were found in the comorbidity profile, presence of risk factors, or dissection morphology. With patients followed for 5 years, differences in outcomes between patients who had undergone TEVAR plus OMT and those who received only OMT began to emerge.

Analysis of these long-term data shows that patients with stable type B aortic dissections who were randomized to receive TEVAR plus OMT showed less aorta-specific mortality (7 vs. 19%, P = .04) and delayed disease progression (27% vs. 46%, P = .04) than did those who received OMT alone. Landmark analysis suggested a benefit of TEVAR for all endpoints between 2 and 5 years, including all-cause mortality (0 vs. 17%, P = .0003).

Both improved survival and less progression over 5 years after TEVAR were associated with stent graft–induced false lumen thrombosis in 91% of cases (P less than .0001). Use of the stent graft resulted in a significant reduction in false lumen diameter (P less than .0001) and significant increase in true lumen diameter (P less than .001). In contrast, a significant increase in aortic diameter was noted in those who received only OMT (P less than .0001).

"In conclusion, endovascular therapy in addition to medical therapy is associated with improved 5-year aortic-specific survival and delayed disease progression. In uncomplicated type B dissection with suitable anatomy, preemptive TEVAR should be considered to improve late outcomes," said Dr. Clough.

Dr. Clough had no disclosures. INSTEAD was sponsored by the Medtronic Bakken Research Center.

NEW YORK – Five-year results from the INSTEAD trial showed that patients with stable type B aortic dissections who were randomized to receive thoracic endovascular aneurysm repair plus optimal medical treatment showed significantly less aorta-specific mortality and delayed disease progression than did those who received OMT alone, according to Rachel Clough Ph.D., MRCS, who presented the findings at Aortic Symposium 2014, a meeting sponsored by the American Association for Thoracic Surgery.

The results indicate that delayed adverse events, such as sudden fatalities, expansion of the false lumen, rupture, and other late complications that occur in patients treated medically in the years subsequent to dissection are prevented or attenuated in those who receive stent grafts.

"Uncomplicated patients with type B aortic dissection have traditionally been treated with antihypertensive medication but what we see is, even in patients with very good blood pressure control, there is a continued attrition rate looking out toward 5 years. In some series, more than 50% of patients are dead [at that time point]," said Dr. Clough of Guy’s and St. Thomas NHS Foundation Trust and King’s College London (England).

INSTEAD (Investigation of Stent Grafts in Aortic Dissection) is the first randomized trial comparing thoracic endovascular aneurysm repair (TEVAR) with a stent graft. When 2-year results were published in 2009 (Circulation 2009;120:2519-28), there was criticism that the study was underpowered as no differences were seen in all-cause deaths, aorta-related deaths due to aortic rupture, or dissection progression plus rupture. There was even a trend toward better cumulative survival in the OMT group.

Sixty-eight patients were randomized to receive OMT and 72 patients received TEVAR + OMT. Eighty-three percent had one stent placed, 11% had two stents, and 6% had three stents. The proximal thoracic aorta was covered in all cases, and the range of coverage was 15-35 cm. No significant differences between groups were found in the comorbidity profile, presence of risk factors, or dissection morphology. There were two periprocedural deaths (one retrograde type A dissection and one rupture of the iliac vessels) and a "reasonably low" incidence of neurologic events, according to Dr. Clough.

By following the patients for 5 years, differences in outcomes between patients who had undergone TEVAR plus OMT and those who only received OMT began to emerge. Analysis of this long-term data shows that patients with stable type B aortic dissections who were randomized to receive TEVAR plus OMT showed less aorta-specific mortality (7 vs 19%, P = .04) and delayed disease progression (27% vs 46%, P = .04) than did those who received OMT alone. Landmark analysis suggested a benefit of TEVAR for all endpoints between 2 and 5 years, including all-cause mortality (0 vs 17%, P = .0003).

Both improved survival and less progression of disease over 5 years after elective TEVAR were associated with stent graft–induced false lumen thrombosis in 91% of cases (P less than .0001). Placement of the stent graft resulted in a significant reduction in false lumen diameter (P less than .0001) and significant increase in true lumen diameter (P less than .001). In contrast, a significant increase in aortic diameter was noted in those who received only OMT (P less than .0001).

"In conclusion, endovascular therapy in addition to medical therapy is associated with improved 5-year aortic specific survival and delayed disease progression. In uncomplicated type B dissection with suitable anatomy, preemptive TEVAR should be considered to improve late outcomes," said Dr. Clough.

Dr. Clough had nothing to disclose. INSTEAD was sponsored by the Medtronic Bakken Research Center. Medtronic manufactures the Medtronic Talent Stent-Graft-System used as the endograft.

NEW YORK – Five-year results from the INSTEAD trial showed that patients with stable type B aortic dissections who were randomized to receive thoracic endovascular aneurysm repair plus optimal medical treatment showed significantly less aorta-specific mortality and delayed disease progression than did those who received OMT alone, according to Rachel Clough Ph.D., MRCS, who presented the findings at Aortic Symposium 2014, a meeting sponsored by the American Association for Thoracic Surgery.

The results indicate that delayed adverse events, such as sudden fatalities, expansion of the false lumen, rupture, and other late complications that occur in patients treated medically in the years subsequent to dissection are prevented or attenuated in those who receive stent grafts.

"Uncomplicated patients with type B aortic dissection have traditionally been treated with antihypertensive medication but what we see is, even in patients with very good blood pressure control, there is a continued attrition rate looking out toward 5 years. In some series, more than 50% of patients are dead [at that time point]," said Dr. Clough of Guy’s and St. Thomas NHS Foundation Trust and King’s College London (England).

INSTEAD (Investigation of Stent Grafts in Aortic Dissection) is the first randomized trial comparing thoracic endovascular aneurysm repair (TEVAR) with a stent graft. When 2-year results were published in 2009 (Circulation 2009;120:2519-28), there was criticism that the study was underpowered as no differences were seen in all-cause deaths, aorta-related deaths due to aortic rupture, or dissection progression plus rupture. There was even a trend toward better cumulative survival in the OMT group.

Sixty-eight patients were randomized to receive OMT and 72 patients received TEVAR + OMT. Eighty-three percent had one stent placed, 11% had two stents, and 6% had three stents. The proximal thoracic aorta was covered in all cases, and the range of coverage was 15-35 cm. No significant differences between groups were found in the comorbidity profile, presence of risk factors, or dissection morphology. There were two periprocedural deaths (one retrograde type A dissection and one rupture of the iliac vessels) and a "reasonably low" incidence of neurologic events, according to Dr. Clough.

By following the patients for 5 years, differences in outcomes between patients who had undergone TEVAR plus OMT and those who only received OMT began to emerge. Analysis of this long-term data shows that patients with stable type B aortic dissections who were randomized to receive TEVAR plus OMT showed less aorta-specific mortality (7 vs 19%, P = .04) and delayed disease progression (27% vs 46%, P = .04) than did those who received OMT alone. Landmark analysis suggested a benefit of TEVAR for all endpoints between 2 and 5 years, including all-cause mortality (0 vs 17%, P = .0003).

Both improved survival and less progression of disease over 5 years after elective TEVAR were associated with stent graft–induced false lumen thrombosis in 91% of cases (P less than .0001). Placement of the stent graft resulted in a significant reduction in false lumen diameter (P less than .0001) and significant increase in true lumen diameter (P less than .001). In contrast, a significant increase in aortic diameter was noted in those who received only OMT (P less than .0001).

"In conclusion, endovascular therapy in addition to medical therapy is associated with improved 5-year aortic specific survival and delayed disease progression. In uncomplicated type B dissection with suitable anatomy, preemptive TEVAR should be considered to improve late outcomes," said Dr. Clough.

Dr. Clough had nothing to disclose. INSTEAD was sponsored by the Medtronic Bakken Research Center. Medtronic manufactures the Medtronic Talent Stent-Graft-System used as the endograft.

NEW YORK – Five-year results from the INSTEAD trial showed that patients with stable type B aortic dissections who were randomized to receive thoracic endovascular aneurysm repair plus optimal medical treatment showed significantly less aorta-specific mortality and delayed disease progression than did those who received OMT alone, according to Rachel Clough Ph.D., MRCS, who presented the findings at Aortic Symposium 2014, a meeting sponsored by the American Association for Thoracic Surgery.

The results indicate that delayed adverse events, such as sudden fatalities, expansion of the false lumen, rupture, and other late complications that occur in patients treated medically in the years subsequent to dissection are prevented or attenuated in those who receive stent grafts.

"Uncomplicated patients with type B aortic dissection have traditionally been treated with antihypertensive medication but what we see is, even in patients with very good blood pressure control, there is a continued attrition rate looking out toward 5 years. In some series, more than 50% of patients are dead [at that time point]," said Dr. Clough of Guy’s and St. Thomas NHS Foundation Trust and King’s College London (England).

INSTEAD (Investigation of Stent Grafts in Aortic Dissection) is the first randomized trial comparing thoracic endovascular aneurysm repair (TEVAR) with a stent graft. When 2-year results were published in 2009 (Circulation 2009;120:2519-28), there was criticism that the study was underpowered as no differences were seen in all-cause deaths, aorta-related deaths due to aortic rupture, or dissection progression plus rupture. There was even a trend toward better cumulative survival in the OMT group.

Sixty-eight patients were randomized to receive OMT and 72 patients received TEVAR + OMT. Eighty-three percent had one stent placed, 11% had two stents, and 6% had three stents. The proximal thoracic aorta was covered in all cases, and the range of coverage was 15-35 cm. No significant differences between groups were found in the comorbidity profile, presence of risk factors, or dissection morphology. There were two periprocedural deaths (one retrograde type A dissection and one rupture of the iliac vessels) and a "reasonably low" incidence of neurologic events, according to Dr. Clough.

By following the patients for 5 years, differences in outcomes between patients who had undergone TEVAR plus OMT and those who only received OMT began to emerge. Analysis of this long-term data shows that patients with stable type B aortic dissections who were randomized to receive TEVAR plus OMT showed less aorta-specific mortality (7 vs 19%, P = .04) and delayed disease progression (27% vs 46%, P = .04) than did those who received OMT alone. Landmark analysis suggested a benefit of TEVAR for all endpoints between 2 and 5 years, including all-cause mortality (0 vs 17%, P = .0003).

Both improved survival and less progression of disease over 5 years after elective TEVAR were associated with stent graft–induced false lumen thrombosis in 91% of cases (P less than .0001). Placement of the stent graft resulted in a significant reduction in false lumen diameter (P less than .0001) and significant increase in true lumen diameter (P less than .001). In contrast, a significant increase in aortic diameter was noted in those who received only OMT (P less than .0001).

"In conclusion, endovascular therapy in addition to medical therapy is associated with improved 5-year aortic specific survival and delayed disease progression. In uncomplicated type B dissection with suitable anatomy, preemptive TEVAR should be considered to improve late outcomes," said Dr. Clough.

Dr. Clough had nothing to disclose. INSTEAD was sponsored by the Medtronic Bakken Research Center. Medtronic manufactures the Medtronic Talent Stent-Graft-System used as the endograft.

NEW YORK – Outcomes of thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians vary considerably with the extent of repair. Those who undergo Extent II TAAA repair have significantly higher risks of morbidity and mortality, while Extent I, III, and IV repairs can be performed with relatively good outcomes, according to Dr. Muhammad Aftab, who presented the findings at the 2014 AATSAortic Symposium

"Extensive TAAA repair should be performed with caution in octogenarians," says Dr. Aftab, a Fellow in CT surgery at the Baylor College of Medicine–Texas Heart Institute, Houston. He recommends that a thorough preoperative discussion to assess the risks and benefits with the patient and his family is necessary before proceeding with surgery.

In this retrospective review of patients seen between January 2005 and September 2013, octogenarians with TAAAs (n = 88) were compared with a younger cohort (n = 1,179 patients, aged 70 years). Dr. Aftab found that octogenarians were threefold more likely to present with aneurysm rupture (13.6% vs. 4.6%; P less than .001) but less likely to present with aortic dissections (12.5% vs. 43.9%; P less than .001) than did the younger patients.

The use of adjunctive interventions, such as left heart bypass, cerebrospinal fluid drainage, cold renal perfusion, and visceral perfusion differed significantly among the octogenarians based on the extent of repair and clinical condition (all P less than .001). Because the octogenarians had a greater atherosclerotic burden and higher incidence of renal and mesenteric occlusive disease, they were also more likely to require renal/visceral endarterectomy, stenting, or both (57.9% vs. 33.6%; P less than.001).

Octogenarians had higher rates of operative mortality (26.1% vs. 6.9%), in-hospital deaths (25% vs. 6.4%), 30-day deaths (13.6% vs. 4.8%), and adverse outcomes (36.4% vs. 15.7%; P less than .001) than did the younger group, all significant differences.

The outcomes included significantly higher rates of permanent renal failure, cardiac complications, and pulmonary complications. The octogenarians had longer recovery times, as suggested by longer postoperative ICU and hospital stays. Poor outcomes differed according to the extent of surgery, and seemed to be exacerbated for those who underwent repair of Extent II aneurysms (according to the Crawford Classification, these involve the subclavian artery and extend to the bifurcation of the aorta in the pelvis). For instance, the Extent II group had the highest risk of operative mortality (61.5%) vs. Extent I (31.6%), III (21.4%), and IV (10.7%), a significant difference. The Extent II group also had much higher rates of in-hospital and 30-day death rates. The most common causes of deaths for the Extent II octogenarians were multisystem organ failure and cardiac problems.

Adverse outcomes were also significantly much higher for the Extent II group (76.9%) than for the other groups (42.1%, 28.6%, and 21.4%). Similar patterns were found for permanent paraplegia, renal failure requiring permanent dialysis, stroke, and days spent in the ICU. Almost 85% of those who required Extent II repair needed renal/visceral endarterectomy, stenting, or both as a part of the surgical procedure.

Extent II TAAA repair was an independent predictor of perioperative mortality by multivariate analysis, conferring an 11-fold increased risk of death. Aneurysm rupture and dissection were also identified as predictors of perioperative mortality while only Extent II TAAA and dissection were independent predictors of adverse outcomes.

While these problems were exacerbated in those with Extent II repairs, Extent I, III, and IV TAAA repairs may be performed with relatively low risk, according to Dr. Aftab.

Dr. Aftab had no disclosures.

NEW YORK – Outcomes of thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians vary considerably with the extent of repair. Those who undergo Extent II TAAA repair have significantly higher risks of morbidity and mortality, while Extent I, III, and IV repairs can be performed with relatively good outcomes, according to Dr. Muhammad Aftab, who presented the findings at the 2014 AATSAortic Symposium

"Extensive TAAA repair should be performed with caution in octogenarians," says Dr. Aftab, a Fellow in CT surgery at the Baylor College of Medicine–Texas Heart Institute, Houston. He recommends that a thorough preoperative discussion to assess the risks and benefits with the patient and his family is necessary before proceeding with surgery.

In this retrospective review of patients seen between January 2005 and September 2013, octogenarians with TAAAs (n = 88) were compared with a younger cohort (n = 1,179 patients, aged 70 years). Dr. Aftab found that octogenarians were threefold more likely to present with aneurysm rupture (13.6% vs. 4.6%; P less than .001) but less likely to present with aortic dissections (12.5% vs. 43.9%; P less than .001) than did the younger patients.

The use of adjunctive interventions, such as left heart bypass, cerebrospinal fluid drainage, cold renal perfusion, and visceral perfusion differed significantly among the octogenarians based on the extent of repair and clinical condition (all P less than .001). Because the octogenarians had a greater atherosclerotic burden and higher incidence of renal and mesenteric occlusive disease, they were also more likely to require renal/visceral endarterectomy, stenting, or both (57.9% vs. 33.6%; P less than.001).

Octogenarians had higher rates of operative mortality (26.1% vs. 6.9%), in-hospital deaths (25% vs. 6.4%), 30-day deaths (13.6% vs. 4.8%), and adverse outcomes (36.4% vs. 15.7%; P less than .001) than did the younger group, all significant differences.

The outcomes included significantly higher rates of permanent renal failure, cardiac complications, and pulmonary complications. The octogenarians had longer recovery times, as suggested by longer postoperative ICU and hospital stays. Poor outcomes differed according to the extent of surgery, and seemed to be exacerbated for those who underwent repair of Extent II aneurysms (according to the Crawford Classification, these involve the subclavian artery and extend to the bifurcation of the aorta in the pelvis). For instance, the Extent II group had the highest risk of operative mortality (61.5%) vs. Extent I (31.6%), III (21.4%), and IV (10.7%), a significant difference. The Extent II group also had much higher rates of in-hospital and 30-day death rates. The most common causes of deaths for the Extent II octogenarians were multisystem organ failure and cardiac problems.

Adverse outcomes were also significantly much higher for the Extent II group (76.9%) than for the other groups (42.1%, 28.6%, and 21.4%). Similar patterns were found for permanent paraplegia, renal failure requiring permanent dialysis, stroke, and days spent in the ICU. Almost 85% of those who required Extent II repair needed renal/visceral endarterectomy, stenting, or both as a part of the surgical procedure.

Extent II TAAA repair was an independent predictor of perioperative mortality by multivariate analysis, conferring an 11-fold increased risk of death. Aneurysm rupture and dissection were also identified as predictors of perioperative mortality while only Extent II TAAA and dissection were independent predictors of adverse outcomes.

While these problems were exacerbated in those with Extent II repairs, Extent I, III, and IV TAAA repairs may be performed with relatively low risk, according to Dr. Aftab.

Dr. Aftab had no disclosures.

NEW YORK – Outcomes of thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians vary considerably with the extent of repair. Those who undergo Extent II TAAA repair have significantly higher risks of morbidity and mortality, while Extent I, III, and IV repairs can be performed with relatively good outcomes, according to Dr. Muhammad Aftab, who presented the findings at the 2014 AATSAortic Symposium

"Extensive TAAA repair should be performed with caution in octogenarians," says Dr. Aftab, a Fellow in CT surgery at the Baylor College of Medicine–Texas Heart Institute, Houston. He recommends that a thorough preoperative discussion to assess the risks and benefits with the patient and his family is necessary before proceeding with surgery.

In this retrospective review of patients seen between January 2005 and September 2013, octogenarians with TAAAs (n = 88) were compared with a younger cohort (n = 1,179 patients, aged 70 years). Dr. Aftab found that octogenarians were threefold more likely to present with aneurysm rupture (13.6% vs. 4.6%; P less than .001) but less likely to present with aortic dissections (12.5% vs. 43.9%; P less than .001) than did the younger patients.

The use of adjunctive interventions, such as left heart bypass, cerebrospinal fluid drainage, cold renal perfusion, and visceral perfusion differed significantly among the octogenarians based on the extent of repair and clinical condition (all P less than .001). Because the octogenarians had a greater atherosclerotic burden and higher incidence of renal and mesenteric occlusive disease, they were also more likely to require renal/visceral endarterectomy, stenting, or both (57.9% vs. 33.6%; P less than.001).

Octogenarians had higher rates of operative mortality (26.1% vs. 6.9%), in-hospital deaths (25% vs. 6.4%), 30-day deaths (13.6% vs. 4.8%), and adverse outcomes (36.4% vs. 15.7%; P less than .001) than did the younger group, all significant differences.

The outcomes included significantly higher rates of permanent renal failure, cardiac complications, and pulmonary complications. The octogenarians had longer recovery times, as suggested by longer postoperative ICU and hospital stays. Poor outcomes differed according to the extent of surgery, and seemed to be exacerbated for those who underwent repair of Extent II aneurysms (according to the Crawford Classification, these involve the subclavian artery and extend to the bifurcation of the aorta in the pelvis). For instance, the Extent II group had the highest risk of operative mortality (61.5%) vs. Extent I (31.6%), III (21.4%), and IV (10.7%), a significant difference. The Extent II group also had much higher rates of in-hospital and 30-day death rates. The most common causes of deaths for the Extent II octogenarians were multisystem organ failure and cardiac problems.

Adverse outcomes were also significantly much higher for the Extent II group (76.9%) than for the other groups (42.1%, 28.6%, and 21.4%). Similar patterns were found for permanent paraplegia, renal failure requiring permanent dialysis, stroke, and days spent in the ICU. Almost 85% of those who required Extent II repair needed renal/visceral endarterectomy, stenting, or both as a part of the surgical procedure.

Extent II TAAA repair was an independent predictor of perioperative mortality by multivariate analysis, conferring an 11-fold increased risk of death. Aneurysm rupture and dissection were also identified as predictors of perioperative mortality while only Extent II TAAA and dissection were independent predictors of adverse outcomes.

While these problems were exacerbated in those with Extent II repairs, Extent I, III, and IV TAAA repairs may be performed with relatively low risk, according to Dr. Aftab.

Dr. Aftab had no disclosures.

NEW YORK – Patients with acute type B aortic dissections who are treated with thoracic endovascular aortic repair within 48 hours of symptom onset are more than three times as likely to have a severe complication as are those who are treated between 2 and 6 weeks after initial presentation, according to Dr. Nimesh D. Desai.

"There has been a dramatic increase in survival of patients managed with TEVAR for life-threatening complications of type B dissection versus any other therapy. Recently, [FDA] approval of two devices in the U.S. (Gore cTAG and Medtronic Valiant Captiva TEVAR grafts) has really opened up the field of inquiry into the optimal timing of TEVAR in the nonemergent, non–life-threatening complicated type B dissection patient. In the current study, we analyzed the impact of timing of intervention," Dr. Desai said at the meeting sponsored by the American Association for Thoracic Surgery.

Between 2005 and 2012, 317 people were admitted to the Hospital of the University of Pennsylvania, Philadelphia, for acute (less than 6 weeks) type B dissections, said Dr. Desai. He reviewed the outcomes for 132 patients who had undergone TEVAR, dividing them into three groups according to the timing of the procedure: acute/early (TEVAR within 48 hours of symptom onset), n = 70; acute/delayed (TEVAR 48 hours to 14 days following symptom onset), n = 44; and subacute (TEVAR 2-6 weeks following symptom onset), n = 18. Patients in all three groups were generally between 63 and 65 years old. Most were men who had histories of severe hypertension and smoking. About 10% had a previous stroke.

Those in the acute/early group were more likely to have undergone TEVAR for life-threatening conditions. For instance, 43.28% of the acute/early group had a contained rupture vs. 25% of the acute/delayed and 11.11% of the subacute patients, a significant difference. The acute/early group also had higher rates of frank rupture and clinical malperfusion than did the other groups.

In contrast, 56% of the subacute group underwent TEVAR because they manifested "softer indications" of impending rupture or radiographic malperfusion, which were not considered to be as emergent. Three-quarters of the subacute group had already been discharged home and were readmitted for the procedure, reported Dr. Desai, who is at the University of Pennsylvania.

The overall rate of severe postoperative complications was 39% in the acute/early group, 27% in the acute/delayed group, and 11.1% in the subacute group, a significant difference.

In-house mortality was 8.5% in the acute/early group (nine patients), 4.5% in the acute/delayed group (three), and 0 in the subacute group, a nonsignificant difference. Similar, but nonsignificant trends were found in 30-day mortality (11.7%, 6.8%, and 0%) and stroke (5.6%, 4.6%, and 0%).

An opposite trend toward higher rates of paralysis was observed in the subacute group (7.04%, 4.5%, and 9.5%, respectively, in the three groups).

The incidence of retrograde type A aortic dissection was 8.5% in the acute/early, 6.8% in the acute/delayed, and 4.7% in the subacute groups. "Retrograde type A dissections are an iatrogenic disease caused by stenting type B dissections," said Dr. Desai. "They almost never happen with any other type of stent graft category."

He said that in his experience, the risk increases with excessive oversizing of stents and the dissections tend to occur at the interface between the native aorta and stent graft. In addition, he noted, many of the dissections occur a year or more after the original dissection.

"Delayed intervention appears to lower the risk of complications of TEVAR for aortic dissection in patients who are stable enough to wait. Our practice is to wait 10-14 days for remodeling indications," said Dr. Desai. Type B patients who are initially managed medically should be followed closely, he said, because they are at risk for the onset of new indications that might require TEVAR.

Operator experience and adequate case planning are critical when treating patients in the setting of acute or subacute type A dissections, Dr. Desai said, adding that the development of devices specific for dissections, rather than those designed for aneurysm pathologies, may lead to fewer complications.

Dr. Desai is a primary investigator for Food and Drug Administration TEVAR trials for W.L. Gore and Associates, Medtronic, and Cook Medical.

NEW YORK – Patients with acute type B aortic dissections who are treated with thoracic endovascular aortic repair within 48 hours of symptom onset are more than three times as likely to have a severe complication as are those who are treated between 2 and 6 weeks after initial presentation, according to Dr. Nimesh D. Desai.

"There has been a dramatic increase in survival of patients managed with TEVAR for life-threatening complications of type B dissection versus any other therapy. Recently, [FDA] approval of two devices in the U.S. (Gore cTAG and Medtronic Valiant Captiva TEVAR grafts) has really opened up the field of inquiry into the optimal timing of TEVAR in the nonemergent, non–life-threatening complicated type B dissection patient. In the current study, we analyzed the impact of timing of intervention," Dr. Desai said at the meeting sponsored by the American Association for Thoracic Surgery.

Between 2005 and 2012, 317 people were admitted to the Hospital of the University of Pennsylvania, Philadelphia, for acute (less than 6 weeks) type B dissections, said Dr. Desai. He reviewed the outcomes for 132 patients who had undergone TEVAR, dividing them into three groups according to the timing of the procedure: acute/early (TEVAR within 48 hours of symptom onset), n = 70; acute/delayed (TEVAR 48 hours to 14 days following symptom onset), n = 44; and subacute (TEVAR 2-6 weeks following symptom onset), n = 18. Patients in all three groups were generally between 63 and 65 years old. Most were men who had histories of severe hypertension and smoking. About 10% had a previous stroke.

Those in the acute/early group were more likely to have undergone TEVAR for life-threatening conditions. For instance, 43.28% of the acute/early group had a contained rupture vs. 25% of the acute/delayed and 11.11% of the subacute patients, a significant difference. The acute/early group also had higher rates of frank rupture and clinical malperfusion than did the other groups.

In contrast, 56% of the subacute group underwent TEVAR because they manifested "softer indications" of impending rupture or radiographic malperfusion, which were not considered to be as emergent. Three-quarters of the subacute group had already been discharged home and were readmitted for the procedure, reported Dr. Desai, who is at the University of Pennsylvania.

The overall rate of severe postoperative complications was 39% in the acute/early group, 27% in the acute/delayed group, and 11.1% in the subacute group, a significant difference.

In-house mortality was 8.5% in the acute/early group (nine patients), 4.5% in the acute/delayed group (three), and 0 in the subacute group, a nonsignificant difference. Similar, but nonsignificant trends were found in 30-day mortality (11.7%, 6.8%, and 0%) and stroke (5.6%, 4.6%, and 0%).

An opposite trend toward higher rates of paralysis was observed in the subacute group (7.04%, 4.5%, and 9.5%, respectively, in the three groups).

The incidence of retrograde type A aortic dissection was 8.5% in the acute/early, 6.8% in the acute/delayed, and 4.7% in the subacute groups. "Retrograde type A dissections are an iatrogenic disease caused by stenting type B dissections," said Dr. Desai. "They almost never happen with any other type of stent graft category."

He said that in his experience, the risk increases with excessive oversizing of stents and the dissections tend to occur at the interface between the native aorta and stent graft. In addition, he noted, many of the dissections occur a year or more after the original dissection.

"Delayed intervention appears to lower the risk of complications of TEVAR for aortic dissection in patients who are stable enough to wait. Our practice is to wait 10-14 days for remodeling indications," said Dr. Desai. Type B patients who are initially managed medically should be followed closely, he said, because they are at risk for the onset of new indications that might require TEVAR.

Operator experience and adequate case planning are critical when treating patients in the setting of acute or subacute type A dissections, Dr. Desai said, adding that the development of devices specific for dissections, rather than those designed for aneurysm pathologies, may lead to fewer complications.

Dr. Desai is a primary investigator for Food and Drug Administration TEVAR trials for W.L. Gore and Associates, Medtronic, and Cook Medical.

NEW YORK – Patients with acute type B aortic dissections who are treated with thoracic endovascular aortic repair within 48 hours of symptom onset are more than three times as likely to have a severe complication as are those who are treated between 2 and 6 weeks after initial presentation, according to Dr. Nimesh D. Desai.

"There has been a dramatic increase in survival of patients managed with TEVAR for life-threatening complications of type B dissection versus any other therapy. Recently, [FDA] approval of two devices in the U.S. (Gore cTAG and Medtronic Valiant Captiva TEVAR grafts) has really opened up the field of inquiry into the optimal timing of TEVAR in the nonemergent, non–life-threatening complicated type B dissection patient. In the current study, we analyzed the impact of timing of intervention," Dr. Desai said at the meeting sponsored by the American Association for Thoracic Surgery.

Between 2005 and 2012, 317 people were admitted to the Hospital of the University of Pennsylvania, Philadelphia, for acute (less than 6 weeks) type B dissections, said Dr. Desai. He reviewed the outcomes for 132 patients who had undergone TEVAR, dividing them into three groups according to the timing of the procedure: acute/early (TEVAR within 48 hours of symptom onset), n = 70; acute/delayed (TEVAR 48 hours to 14 days following symptom onset), n = 44; and subacute (TEVAR 2-6 weeks following symptom onset), n = 18. Patients in all three groups were generally between 63 and 65 years old. Most were men who had histories of severe hypertension and smoking. About 10% had a previous stroke.

Those in the acute/early group were more likely to have undergone TEVAR for life-threatening conditions. For instance, 43.28% of the acute/early group had a contained rupture vs. 25% of the acute/delayed and 11.11% of the subacute patients, a significant difference. The acute/early group also had higher rates of frank rupture and clinical malperfusion than did the other groups.

In contrast, 56% of the subacute group underwent TEVAR because they manifested "softer indications" of impending rupture or radiographic malperfusion, which were not considered to be as emergent. Three-quarters of the subacute group had already been discharged home and were readmitted for the procedure, reported Dr. Desai, who is at the University of Pennsylvania.

The overall rate of severe postoperative complications was 39% in the acute/early group, 27% in the acute/delayed group, and 11.1% in the subacute group, a significant difference.

In-house mortality was 8.5% in the acute/early group (nine patients), 4.5% in the acute/delayed group (three), and 0 in the subacute group, a nonsignificant difference. Similar, but nonsignificant trends were found in 30-day mortality (11.7%, 6.8%, and 0%) and stroke (5.6%, 4.6%, and 0%).

An opposite trend toward higher rates of paralysis was observed in the subacute group (7.04%, 4.5%, and 9.5%, respectively, in the three groups).

The incidence of retrograde type A aortic dissection was 8.5% in the acute/early, 6.8% in the acute/delayed, and 4.7% in the subacute groups. "Retrograde type A dissections are an iatrogenic disease caused by stenting type B dissections," said Dr. Desai. "They almost never happen with any other type of stent graft category."

He said that in his experience, the risk increases with excessive oversizing of stents and the dissections tend to occur at the interface between the native aorta and stent graft. In addition, he noted, many of the dissections occur a year or more after the original dissection.

"Delayed intervention appears to lower the risk of complications of TEVAR for aortic dissection in patients who are stable enough to wait. Our practice is to wait 10-14 days for remodeling indications," said Dr. Desai. Type B patients who are initially managed medically should be followed closely, he said, because they are at risk for the onset of new indications that might require TEVAR.

Operator experience and adequate case planning are critical when treating patients in the setting of acute or subacute type A dissections, Dr. Desai said, adding that the development of devices specific for dissections, rather than those designed for aneurysm pathologies, may lead to fewer complications.

Dr. Desai is a primary investigator for Food and Drug Administration TEVAR trials for W.L. Gore and Associates, Medtronic, and Cook Medical.

NEW YORK – Patients with acute type B aortic dissections who are treated with thoracic endovascular aortic repair within 48 hours of symptom onset are more than three times as likely to have a severe complication as are those who are treated between 2 and 6 weeks after initial presentation, according to Dr. Nimesh D. Desai.

"We know that there has been a dramatic increase in survival of patients managed with TEVAR for life-threatening complications of type B dissection versus any other therapy. Recently, [Food and Drug Administration] approval of two devices in the U.S. (Gore cTAG and Medtronic Valiant Captiva TEVAR grafts) has really opened up the field of inquiry into the optimal timing of TEVAR in the nonemergent, non–life-threatening complicated type B dissection patient. In the current study, we analyzed the impact of timing of intervention," Dr. Desai said at the meeting sponsored by the American Association for Thoracic Surgery. Dr. Desai was the first recipient of the Randall B. Griepp Honorary Paper Presentation.

Between 2005 and 2012, 317 people were admitted to the Hospital of the University of Pennsylvania for acute (less than 6 weeks) type B dissections, said Dr. Desai. He reviewed the outcomes for 132 patients who had undergone TEVAR, dividing them into three groups according to the timing of the procedure: acute early (TEVAR within 48 hours of symptom onset), n = 70; acute delayed (TEVAR 48 hours to 14 days following symptom onset), n = 44; and subacute (TEVAR 2-6 weeks following symptom onset), n=18.

Patients in all three groups were generally between 63 and 65 years old. Most were men who had histories of severe hypertension and smoking. About 10% had a previous stroke.

Those in the acute/early group were more likely to have undergone TEVAR for life-threatening conditions. For instance, 43.28% of the acute/early group had a contained rupture vs. 25% of the acute/delayed and 11.11% of the subacute patients, a significant difference. The acute/early group also had higher rates of frank rupture and clinical malperfusion than did the other groups.

In contrast, 56% of the subacute group underwent TEVAR because they manifested "softer indications" of impending rupture or radiographic malperfusion, which were not considered to be as emergent. Three-quarters of the subacute group had already been discharged home and were readmitted for the procedure, reported Dr. Desai, a cardiothoracic surgeon at the Hospital of the University of Pennsylvania, Philadelphia.

The overall rate of severe postoperative complications was 39% in the acute/early group, 27% in the acute/delayed group, and 11.1% in the subacute group, a significant difference.

In-house mortality was 8.5% in the acute/early group (nine patients), 4.5% in the acute/delayed group (three), and 0 in the subacute group, a nonsignificant difference. Similar, but nonsignificant trends were found in 30-day mortality (11.7%, 6.8%, and 0%, respectively) and stroke (5.6%, 4.6%, and 0%). Causes of early death included rupture of the descending aorta, retrograde type A rupture, or the consequences of severe malperfusion.

An opposite trend toward higher rates of paralysis was observed in the subacute group (7.04%, 4.5%, and 9.5%, respectively, in the three groups).

The incidence of retrograde type A aortic dissection was 8.5% in the acute/early, 6.8% in the acute/delayed, and 4.7% in the subacute groups. "Retrograde type A dissections are an iatrogenic disease caused by stenting type B dissections," said Dr. Desai. "They almost never happen with any other type of stent graft category." He said that in his experience, the risk increases with excessive oversizing of stents and the dissections tend to occur at the interface between the native aorta and stent graft. In addition, he noted, many of the dissections occur a year or more after the original dissection.

"Delayed intervention appears to lower the risk of complications of TEVAR for aortic dissection in patients who are stable enough to wait. Our practice is to wait 10-14 days for remodeling indications," said Dr. Desai. Type B patients who are initially managed medically should be followed closely, he said, because they are at risk for the onset of new indications that might require TEVAR.

Operator experience and adequate case planning are critical when treating patients in the setting of acute or subacute type A dissections, Dr. Desai said, adding that the development of devices specific for dissections, rather than those designed for aneurysm pathologies, may lead to fewer complications.

*Dr. Desai is a primary investigator for FDA clinical trials using TEVAR for W.L. Gore and Associates, Inc., Medtronic, and Cook Medical.

*Correction 5/22/14: An earlier version of this article did not state Dr. Desai's disclosure information.

NEW YORK – Patients with acute type B aortic dissections who are treated with thoracic endovascular aortic repair within 48 hours of symptom onset are more than three times as likely to have a severe complication as are those who are treated between 2 and 6 weeks after initial presentation, according to Dr. Nimesh D. Desai.

"We know that there has been a dramatic increase in survival of patients managed with TEVAR for life-threatening complications of type B dissection versus any other therapy. Recently, [Food and Drug Administration] approval of two devices in the U.S. (Gore cTAG and Medtronic Valiant Captiva TEVAR grafts) has really opened up the field of inquiry into the optimal timing of TEVAR in the nonemergent, non–life-threatening complicated type B dissection patient. In the current study, we analyzed the impact of timing of intervention," Dr. Desai said at the meeting sponsored by the American Association for Thoracic Surgery. Dr. Desai was the first recipient of the Randall B. Griepp Honorary Paper Presentation.

Between 2005 and 2012, 317 people were admitted to the Hospital of the University of Pennsylvania for acute (less than 6 weeks) type B dissections, said Dr. Desai. He reviewed the outcomes for 132 patients who had undergone TEVAR, dividing them into three groups according to the timing of the procedure: acute early (TEVAR within 48 hours of symptom onset), n = 70; acute delayed (TEVAR 48 hours to 14 days following symptom onset), n = 44; and subacute (TEVAR 2-6 weeks following symptom onset), n=18.

Patients in all three groups were generally between 63 and 65 years old. Most were men who had histories of severe hypertension and smoking. About 10% had a previous stroke.

Those in the acute/early group were more likely to have undergone TEVAR for life-threatening conditions. For instance, 43.28% of the acute/early group had a contained rupture vs. 25% of the acute/delayed and 11.11% of the subacute patients, a significant difference. The acute/early group also had higher rates of frank rupture and clinical malperfusion than did the other groups.

In contrast, 56% of the subacute group underwent TEVAR because they manifested "softer indications" of impending rupture or radiographic malperfusion, which were not considered to be as emergent. Three-quarters of the subacute group had already been discharged home and were readmitted for the procedure, reported Dr. Desai, a cardiothoracic surgeon at the Hospital of the University of Pennsylvania, Philadelphia.

The overall rate of severe postoperative complications was 39% in the acute/early group, 27% in the acute/delayed group, and 11.1% in the subacute group, a significant difference.

In-house mortality was 8.5% in the acute/early group (nine patients), 4.5% in the acute/delayed group (three), and 0 in the subacute group, a nonsignificant difference. Similar, but nonsignificant trends were found in 30-day mortality (11.7%, 6.8%, and 0%, respectively) and stroke (5.6%, 4.6%, and 0%). Causes of early death included rupture of the descending aorta, retrograde type A rupture, or the consequences of severe malperfusion.

An opposite trend toward higher rates of paralysis was observed in the subacute group (7.04%, 4.5%, and 9.5%, respectively, in the three groups).

The incidence of retrograde type A aortic dissection was 8.5% in the acute/early, 6.8% in the acute/delayed, and 4.7% in the subacute groups. "Retrograde type A dissections are an iatrogenic disease caused by stenting type B dissections," said Dr. Desai. "They almost never happen with any other type of stent graft category." He said that in his experience, the risk increases with excessive oversizing of stents and the dissections tend to occur at the interface between the native aorta and stent graft. In addition, he noted, many of the dissections occur a year or more after the original dissection.

"Delayed intervention appears to lower the risk of complications of TEVAR for aortic dissection in patients who are stable enough to wait. Our practice is to wait 10-14 days for remodeling indications," said Dr. Desai. Type B patients who are initially managed medically should be followed closely, he said, because they are at risk for the onset of new indications that might require TEVAR.

Operator experience and adequate case planning are critical when treating patients in the setting of acute or subacute type A dissections, Dr. Desai said, adding that the development of devices specific for dissections, rather than those designed for aneurysm pathologies, may lead to fewer complications.

*Dr. Desai is a primary investigator for FDA clinical trials using TEVAR for W.L. Gore and Associates, Inc., Medtronic, and Cook Medical.

*Correction 5/22/14: An earlier version of this article did not state Dr. Desai's disclosure information.

NEW YORK – Patients with acute type B aortic dissections who are treated with thoracic endovascular aortic repair within 48 hours of symptom onset are more than three times as likely to have a severe complication as are those who are treated between 2 and 6 weeks after initial presentation, according to Dr. Nimesh D. Desai.

"We know that there has been a dramatic increase in survival of patients managed with TEVAR for life-threatening complications of type B dissection versus any other therapy. Recently, [Food and Drug Administration] approval of two devices in the U.S. (Gore cTAG and Medtronic Valiant Captiva TEVAR grafts) has really opened up the field of inquiry into the optimal timing of TEVAR in the nonemergent, non–life-threatening complicated type B dissection patient. In the current study, we analyzed the impact of timing of intervention," Dr. Desai said at the meeting sponsored by the American Association for Thoracic Surgery. Dr. Desai was the first recipient of the Randall B. Griepp Honorary Paper Presentation.

Between 2005 and 2012, 317 people were admitted to the Hospital of the University of Pennsylvania for acute (less than 6 weeks) type B dissections, said Dr. Desai. He reviewed the outcomes for 132 patients who had undergone TEVAR, dividing them into three groups according to the timing of the procedure: acute early (TEVAR within 48 hours of symptom onset), n = 70; acute delayed (TEVAR 48 hours to 14 days following symptom onset), n = 44; and subacute (TEVAR 2-6 weeks following symptom onset), n=18.

Patients in all three groups were generally between 63 and 65 years old. Most were men who had histories of severe hypertension and smoking. About 10% had a previous stroke.

Those in the acute/early group were more likely to have undergone TEVAR for life-threatening conditions. For instance, 43.28% of the acute/early group had a contained rupture vs. 25% of the acute/delayed and 11.11% of the subacute patients, a significant difference. The acute/early group also had higher rates of frank rupture and clinical malperfusion than did the other groups.

In contrast, 56% of the subacute group underwent TEVAR because they manifested "softer indications" of impending rupture or radiographic malperfusion, which were not considered to be as emergent. Three-quarters of the subacute group had already been discharged home and were readmitted for the procedure, reported Dr. Desai, a cardiothoracic surgeon at the Hospital of the University of Pennsylvania, Philadelphia.

The overall rate of severe postoperative complications was 39% in the acute/early group, 27% in the acute/delayed group, and 11.1% in the subacute group, a significant difference.

In-house mortality was 8.5% in the acute/early group (nine patients), 4.5% in the acute/delayed group (three), and 0 in the subacute group, a nonsignificant difference. Similar, but nonsignificant trends were found in 30-day mortality (11.7%, 6.8%, and 0%, respectively) and stroke (5.6%, 4.6%, and 0%). Causes of early death included rupture of the descending aorta, retrograde type A rupture, or the consequences of severe malperfusion.

An opposite trend toward higher rates of paralysis was observed in the subacute group (7.04%, 4.5%, and 9.5%, respectively, in the three groups).

The incidence of retrograde type A aortic dissection was 8.5% in the acute/early, 6.8% in the acute/delayed, and 4.7% in the subacute groups. "Retrograde type A dissections are an iatrogenic disease caused by stenting type B dissections," said Dr. Desai. "They almost never happen with any other type of stent graft category." He said that in his experience, the risk increases with excessive oversizing of stents and the dissections tend to occur at the interface between the native aorta and stent graft. In addition, he noted, many of the dissections occur a year or more after the original dissection.

"Delayed intervention appears to lower the risk of complications of TEVAR for aortic dissection in patients who are stable enough to wait. Our practice is to wait 10-14 days for remodeling indications," said Dr. Desai. Type B patients who are initially managed medically should be followed closely, he said, because they are at risk for the onset of new indications that might require TEVAR.

Operator experience and adequate case planning are critical when treating patients in the setting of acute or subacute type A dissections, Dr. Desai said, adding that the development of devices specific for dissections, rather than those designed for aneurysm pathologies, may lead to fewer complications.

*Dr. Desai is a primary investigator for FDA clinical trials using TEVAR for W.L. Gore and Associates, Inc., Medtronic, and Cook Medical.

*Correction 5/22/14: An earlier version of this article did not state Dr. Desai's disclosure information.

SAN DIEGO – Analyses of a single-center cohort of nearly 3,400 patients with unruptured aneurysms who underwent either treatment or observation suggest that aneurysms larger than 5 mm should be treated.

"Treatment, of course, has complications, and some patients deteriorate clinically. However, we find that unruptured aneurysm treatment-related complications leave no effect on function, as measured by modified Rankin Scale scores. On the other hand, once an aneurysm ruptures, there is a high incidence of death and disability. Based on that, we conclude unruptured aneurysms larger than 5 mm should be treated," Dr. Yuichi Murayama said at the annual meeting of the American Society of Neuroradiology.

In the cohort of 3,395 patients with unruptured intracranial aneurysms (UIAs), 28% were treated while the remaining 72% were managed conservatively and underwent biannual 3D computed tomography angiography (CTA). They were referred to Jikei University in Tokyo between January 2003 and December 2012.

Most UIAs were measured using 3D CTA because magnetic resonance angiography (MRA) was thought to be less accurate and more invasive. Patients were recommended for treatment (with either endovascular coiling or microsurgical clipping) if the aneurysm was larger than 5 mm and considered safely treatable, multiple aneurysms were present and one had previously ruptured, or there was a family history of subarachnoid hemorrhage. Endovascularly treated patients underwent MRA follow-up at 3, 6, and 12 months after treatment and then subsequently underwent annual MRA and magnetic resonance imaging (MRI) studies. Surgically treated patients had angiography at 12 months after treatment and then 3D CTA.

Almost 1,700 patients with UIAs who were not treated were followed over the 10-year period with CTA. Overall, 49 (2.9%) aneurysms ruptured, yielding an annual rupture rate of 0.8%/year. The average size of aneurysms in the treatment group was 7.8 mm, compared with 4.4 mm in the observation group. The frequency of treatment increased with size: 10% of small aneurysms (up to 4.9 mm in diameter), 50% of medium aneurysms (5.0-9.9 mm), and almost 100% of large (10.0-24.9 mm) and giant aneurysms (greater than 25 mm), reported Dr. Murayama, director of the center of endovascular surgery at Jikei University.

Rupture rates were 0.35%/year for small aneurysms, 2.2%/year for medium, 10.75%/year for large, and 50%/year for giant. Although the risk of rupture of small aneurysms is low, 17 small aneurysms ruptured within the observation period. Furthermore, Dr. Murayama said that while most ruptures occurred within the first 2 years of discovery, even apparently stable aneurysms might rupture after 2 years. The most common sites for aneurysm rupture were the anterior cerebral, middle cerebral, vertebral, and posterior communicating arteries.

About 200 additional patients were followed with MRA rather than CTA, Dr. Murayama said after the meeting. Ongoing analyses of the rupture rates in these patients may change the rupture rates for various aneurysm sizes, he said.

Dr. Murayama compared the results from his institution to the findings of another Japanese cohort in the UCAS study, which included 5,700 patients with almost 6,700 aneurysms enrolled from 283 medical centers (N. Engl. J. Med. 2012;366:2474-82). The annual risk of rupture for small aneurysms was 0.36%, very similar to that found by the Jikei group (0.35%). Similarly, the annual risk for 7- to 10-mm aneurysms was 1.7%, which was very similar to that found by the Jikei group (1.5%).

There was a more substantial difference between the two studies in the annual risk of rupture for aneurysms measuring 5-7 mm (0.5% in the UCAS cohort vs. 2.3% in the Jikei cohort). "For this size, the decision to treat is difficult because the risk of rupture is relatively low but treatment risk also exists. That is why, in our database, 50% of patients with 5- to 7-mm-sized aneurysms went to observation," Dr. Murayama said.

Using 3D CTA, Dr. Murayama addressed the question whether UIAs grow. In the Jikei cohort, 10% of aneurysms grew in size (defined as a change of 1 mm or more between the baseline measurement and follow-up). "If you see a change in morphology, treat without delay," he said.

Dr. Murayama reported no relevant financial relationships.

SAN DIEGO – Analyses of a single-center cohort of nearly 3,400 patients with unruptured aneurysms who underwent either treatment or observation suggest that aneurysms larger than 5 mm should be treated.

"Treatment, of course, has complications, and some patients deteriorate clinically. However, we find that unruptured aneurysm treatment-related complications leave no effect on function, as measured by modified Rankin Scale scores. On the other hand, once an aneurysm ruptures, there is a high incidence of death and disability. Based on that, we conclude unruptured aneurysms larger than 5 mm should be treated," Dr. Yuichi Murayama said at the annual meeting of the American Society of Neuroradiology.

In the cohort of 3,395 patients with unruptured intracranial aneurysms (UIAs), 28% were treated while the remaining 72% were managed conservatively and underwent biannual 3D computed tomography angiography (CTA). They were referred to Jikei University in Tokyo between January 2003 and December 2012.

Most UIAs were measured using 3D CTA because magnetic resonance angiography (MRA) was thought to be less accurate and more invasive. Patients were recommended for treatment (with either endovascular coiling or microsurgical clipping) if the aneurysm was larger than 5 mm and considered safely treatable, multiple aneurysms were present and one had previously ruptured, or there was a family history of subarachnoid hemorrhage. Endovascularly treated patients underwent MRA follow-up at 3, 6, and 12 months after treatment and then subsequently underwent annual MRA and magnetic resonance imaging (MRI) studies. Surgically treated patients had angiography at 12 months after treatment and then 3D CTA.

Almost 1,700 patients with UIAs who were not treated were followed over the 10-year period with CTA. Overall, 49 (2.9%) aneurysms ruptured, yielding an annual rupture rate of 0.8%/year. The average size of aneurysms in the treatment group was 7.8 mm, compared with 4.4 mm in the observation group. The frequency of treatment increased with size: 10% of small aneurysms (up to 4.9 mm in diameter), 50% of medium aneurysms (5.0-9.9 mm), and almost 100% of large (10.0-24.9 mm) and giant aneurysms (greater than 25 mm), reported Dr. Murayama, director of the center of endovascular surgery at Jikei University.

Rupture rates were 0.35%/year for small aneurysms, 2.2%/year for medium, 10.75%/year for large, and 50%/year for giant. Although the risk of rupture of small aneurysms is low, 17 small aneurysms ruptured within the observation period. Furthermore, Dr. Murayama said that while most ruptures occurred within the first 2 years of discovery, even apparently stable aneurysms might rupture after 2 years. The most common sites for aneurysm rupture were the anterior cerebral, middle cerebral, vertebral, and posterior communicating arteries.

About 200 additional patients were followed with MRA rather than CTA, Dr. Murayama said after the meeting. Ongoing analyses of the rupture rates in these patients may change the rupture rates for various aneurysm sizes, he said.

Dr. Murayama compared the results from his institution to the findings of another Japanese cohort in the UCAS study, which included 5,700 patients with almost 6,700 aneurysms enrolled from 283 medical centers (N. Engl. J. Med. 2012;366:2474-82). The annual risk of rupture for small aneurysms was 0.36%, very similar to that found by the Jikei group (0.35%). Similarly, the annual risk for 7- to 10-mm aneurysms was 1.7%, which was very similar to that found by the Jikei group (1.5%).

There was a more substantial difference between the two studies in the annual risk of rupture for aneurysms measuring 5-7 mm (0.5% in the UCAS cohort vs. 2.3% in the Jikei cohort). "For this size, the decision to treat is difficult because the risk of rupture is relatively low but treatment risk also exists. That is why, in our database, 50% of patients with 5- to 7-mm-sized aneurysms went to observation," Dr. Murayama said.

Using 3D CTA, Dr. Murayama addressed the question whether UIAs grow. In the Jikei cohort, 10% of aneurysms grew in size (defined as a change of 1 mm or more between the baseline measurement and follow-up). "If you see a change in morphology, treat without delay," he said.

Dr. Murayama reported no relevant financial relationships.

SAN DIEGO – Analyses of a single-center cohort of nearly 3,400 patients with unruptured aneurysms who underwent either treatment or observation suggest that aneurysms larger than 5 mm should be treated.

"Treatment, of course, has complications, and some patients deteriorate clinically. However, we find that unruptured aneurysm treatment-related complications leave no effect on function, as measured by modified Rankin Scale scores. On the other hand, once an aneurysm ruptures, there is a high incidence of death and disability. Based on that, we conclude unruptured aneurysms larger than 5 mm should be treated," Dr. Yuichi Murayama said at the annual meeting of the American Society of Neuroradiology.

In the cohort of 3,395 patients with unruptured intracranial aneurysms (UIAs), 28% were treated while the remaining 72% were managed conservatively and underwent biannual 3D computed tomography angiography (CTA). They were referred to Jikei University in Tokyo between January 2003 and December 2012.

Most UIAs were measured using 3D CTA because magnetic resonance angiography (MRA) was thought to be less accurate and more invasive. Patients were recommended for treatment (with either endovascular coiling or microsurgical clipping) if the aneurysm was larger than 5 mm and considered safely treatable, multiple aneurysms were present and one had previously ruptured, or there was a family history of subarachnoid hemorrhage. Endovascularly treated patients underwent MRA follow-up at 3, 6, and 12 months after treatment and then subsequently underwent annual MRA and magnetic resonance imaging (MRI) studies. Surgically treated patients had angiography at 12 months after treatment and then 3D CTA.

Almost 1,700 patients with UIAs who were not treated were followed over the 10-year period with CTA. Overall, 49 (2.9%) aneurysms ruptured, yielding an annual rupture rate of 0.8%/year. The average size of aneurysms in the treatment group was 7.8 mm, compared with 4.4 mm in the observation group. The frequency of treatment increased with size: 10% of small aneurysms (up to 4.9 mm in diameter), 50% of medium aneurysms (5.0-9.9 mm), and almost 100% of large (10.0-24.9 mm) and giant aneurysms (greater than 25 mm), reported Dr. Murayama, director of the center of endovascular surgery at Jikei University.

Rupture rates were 0.35%/year for small aneurysms, 2.2%/year for medium, 10.75%/year for large, and 50%/year for giant. Although the risk of rupture of small aneurysms is low, 17 small aneurysms ruptured within the observation period. Furthermore, Dr. Murayama said that while most ruptures occurred within the first 2 years of discovery, even apparently stable aneurysms might rupture after 2 years. The most common sites for aneurysm rupture were the anterior cerebral, middle cerebral, vertebral, and posterior communicating arteries.

About 200 additional patients were followed with MRA rather than CTA, Dr. Murayama said after the meeting. Ongoing analyses of the rupture rates in these patients may change the rupture rates for various aneurysm sizes, he said.

Dr. Murayama compared the results from his institution to the findings of another Japanese cohort in the UCAS study, which included 5,700 patients with almost 6,700 aneurysms enrolled from 283 medical centers (N. Engl. J. Med. 2012;366:2474-82). The annual risk of rupture for small aneurysms was 0.36%, very similar to that found by the Jikei group (0.35%). Similarly, the annual risk for 7- to 10-mm aneurysms was 1.7%, which was very similar to that found by the Jikei group (1.5%).

There was a more substantial difference between the two studies in the annual risk of rupture for aneurysms measuring 5-7 mm (0.5% in the UCAS cohort vs. 2.3% in the Jikei cohort). "For this size, the decision to treat is difficult because the risk of rupture is relatively low but treatment risk also exists. That is why, in our database, 50% of patients with 5- to 7-mm-sized aneurysms went to observation," Dr. Murayama said.

Using 3D CTA, Dr. Murayama addressed the question whether UIAs grow. In the Jikei cohort, 10% of aneurysms grew in size (defined as a change of 1 mm or more between the baseline measurement and follow-up). "If you see a change in morphology, treat without delay," he said.

Dr. Murayama reported no relevant financial relationships.