Abdominal Aortic Remodeling After Thoracic Endovascular Aortic Repair for Type B (DeBakey IIIb) Aortic Dissection
Hunter M Ray1, Daniel Ocazionez1, Charles C Miller, III1, Harleen K Sandhu1, Naveed U Saqib1, Kristofer M Charlton-Ouw1, Hazim J Safi1, Ali Azizzadeh2
1The University of Texas Health Science Center at Houston, Houston, TX;2Cedars-Sinai, Los Angeles, CA
INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) is increasingly used in the treatment of Type B aortic dissection; however, the fate of the uncovered abdominal aortic segment of the dissection remains unclear. Here we examine the impact of TEVAR on abdominal aortic remodeling.
Patients presenting to our center with Type B aortic dissection involving the thoracic and abdominal aorta (DeBakey IIIb) from December 2010-April 2018 were reviewed and those with adequate pre and postoperative computed tomography angiography (CTA) imaging were included. All CTAs were loaded into advanced imaging software (TeraRecon, Foster City, CA) to allow for double orthogonal oblique measurements. Pre and postoperative measurements were taken at serial locations and included total vessel diameter and area, true lumen (TL) diameter and area, and false lumen (FL) diameter and area. Aortic measurements were taken at the location of left main pulmonary artery (proximal descending thoracic aorta), mid left atrial appendage (mid descending thoracic aorta), diaphragmatic hiatus (distal thoracic aorta), maximum abdominal aortic diameter, celiac, superior mesenteric artery (SMA), renal, and above the bifurcation. Branch vessel lumen measurements were taken at the celiac, SMA, bilateral renal, inferior mesenteric artery (IMA) and bilateral common iliac arteries.
RESULTS: During the study period 222 patients presented with type B dissection, 74 underwent TEVAR, and 27 (36.5%) were DeBakey IIIb with adequate pre and postoperative CTA imaging for analysis. The cohort had an average age of 59.4 years: 81.5% male. At TEVAR 14/27 (51.9%) patients were in the acute phase (≤14 days) of aortic dissection. The distal SVS landing zone of attachment was zone 4 in 14.8% and zone 5 in 85.2%. The TLarea/Total Aorticarea ratio (True Lumen Area %) was examined and demonstrated increasing TLarea (p<0.0001) with concomitant decrease in FLarea (p<0.0001) after TEVAR with largest change noted over thoracic aortic segment with diminishing, but present effect noted further from the distal extent of the device down to the aortic bifurcation.(Figure 1)
CONCLUSIONS: Positive aortic remodeling, as measured by True Lumen Area %, occurs primarily along the segments of the aorta treated by TEVAR. The remodeling benefits diminish distal to the treated segment. The results support longer segment coverage with TEVAR in Type B dissection.
Figure 1: The TLarea/Total Aorticarea ratio (True Lumen Area %) demonstrates increasing TLarea%(p<0.0001) with concomitant decrease in the FLarea/Total Aorticarea ratio (False Lumen Area %) (p<0.0001) after TEVAR for DeBakey IIIb aortic dissection with largest change noted over thoracic aortic segment with diminishing, but present effect noted further from the distal extent of the device down to the aortic bifurcation. 1= Main pulmonary artery, 2=Mid left atrium, 3=Diaphragmatic hiatus, 4=Celiac, 5=SMA, 6=Renal, 7=Bifurcation
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