Background: Much of the literature describing treatment for thoracoabdominal aortic aneurysm (TAAA) consists of operative series reported by centers of excellence. These studies are limited by referral and selection bias and exclude patients who are not candidates for the reported modality of repair. Little is known about the patients who are not referred or selected for repair. For those undergoing intervention, outcomes such as functional status after surgery are rarely reported. In this study, we address these gaps by reporting two primary end points: 1-year survival and a "good" outcome (defined as successful aneurysm exclusion, freedom from permanent loss of organ system function, and return to preoperative functional status after surgery) in a cohort of TAAA patients, including all nonoperative and operative patients, irrespective of treatment modality. Methods: A single-institution database was screened by diagnosis codes for TAAA from 2009 to 2017 using the International Classification of Diseases versions 9 and 10. Diagnosis was confirmed by retrospective chart review and computed tomography findings of aneurysmal degeneration >= 3.2 cm of the paravisceral aorta in continuity with aneurysmal aorta meeting standard criteria for repair. Patients <18 years of age and those with mycotic aneurysm were excluded. Patients were either managed nonoperatively or by one of four operative strategies: (i) open; (ii) endovascular with branched endografts; (iii) hybrid, defined as iliovisceral debranching followed by endograft placement; or (iv) partial repair in which the paravisceral segment was intentionally left unaddressed. Results: Among the entire cohort of 432 patients with TAAA, significant comorbidities were seen in 143 (33%). Forty-seven percent of the patients were managed nonoperatively. Of these, 65% survived to 1 year. A survival benefit was seen in the open, endovascular, and partial, but not hybrid, operative groups compared with the nonoperative group during a 3-year period. Overall 1-year survival was 81%, but only 65% had a good outcome (P=.0016). Conclusions: Nearly half of the patients in this inclusive cohort study did not undergo repair despite access to a variety of operative techniques. Many of these patients die in the short term due to high burden of comorbid disease rather than aneurysm rupture. Among those undergoing operation, a notable difference between survival and good outcome was observed. Operation appears to confer a survival advantage among appropriately selected patients with TAAA, but a large proportion are high risk and may not benefit from operative repair due to limited baseline survival and lower probability of good outcome.

OBJECTIVE:This study characterized duplex ultrasound (DUS) findings and clinical outcomes associated with covered stent placement in renal arteries during fenestrated endovascular aortic repair (FEVAR) to determine if velocity criteria for native renal artery stenosis can be applied. METHODS:Data from a prospectively maintained database of patients who underwent FEVAR between January 2010 and August 2014 were obtained before FEVAR (preoperative or baseline) and at follow-up assessments at 30 days, 6 months, and 1, 2, and 3 years. The established DUS threshold criteria for ≥60% stenosis in native renal arteries were applied at baseline and all follow-up intervals: renal artery peak systolic velocity (PSV) ≥200 cm/s or renal-aortic velocity ratio (RAR) ≥3.5. RESULTS:Forty-nine patients underwent placement of 88 covered renal artery stents during FEVAR. At least 30-day follow-up was available for 43 patients with 80 stents. A ≥60% stenosis was identified in seven renal arteries of six patients on baseline DUS, and these patients were analyzed separately. The remaining 73 renal arteries were classified as normal or <60% stenosis at baseline, with a median PSV of 121 cm/s (interquartile range, 96-143) and median RAR of 1.4 (interquartile range, 1.1-1.7). No significant differences were found between the baseline and follow-up PSV measurements at any time point. The RAR differed significantly at some time points, although median values remained below the ≥60% stenosis threshold. Some increased RAR values were attributed to low aortic velocities after repair. In the 13 patients with 17 covered renal artery stents found to have PSV or RAR exceeding a DUS threshold for ≥60% native renal artery stenosis, there was no evidence of stenosis by computed tomography angiography, of renal dysfunction by estimated glomerular filtration rate, or of renal volume decrease by three-dimensional analysis. None of the seven renal arteries with ≥60% stenosis at baseline showed evidence of restenosis at 1, 2, or 3 years. CONCLUSIONS:Covered stent placement in nonstenotic renal arteries during FEVAR is safe and durable, with PSV and RAR remaining in the normal or <60% stenosis range in most patients. Increases in PSV or RAR that occur are not associated with clinically significant sequelae or in-stent stenosis on computed tomography angiography. DUS velocity criteria for stenosis in native renal arteries appear to overestimate the severity of stenosis in covered stents after FEVAR.

Peak wall stress (PWS) derived from finite element analysis (FEA) of abdominal aortic aneurysms (AAAs) predicts clinical outcomes better than maximum diameter. Unfortunately, FEA is computationally intensive and therefore is currently unsuited for broad clinical application. Meanwhile, purely geometric indices can be derived more easily from computed tomographic imaging. We compared FEA’s ability to predict aneurysm growth with that of various geometric indices.

Low-grade endometrial stromal sarcoma with intracaval and intracardiac extension represents a complex and often lethal condition. A case of a 40-year-old woman, who underwent hysterectomy for endometrial stromal sarcoma 4 years previously and developed recurrence with intracaval and intracardiac metastases, is presented. Operative management of resection of the intracaval and intracardiac tumor is described. The literature is reviewed in order to highlight the data on diagnosis and management of recurrent endometrial stromal sarcoma with vascular involvement, including the multimodality approach required in treating this disease.

Renal insufficiency is associated with an increased incidence of poor outcomes, including cardiovascular events and death, in the general population. Renal dysfunction appears to have a particularly negative impact in patients undergoing vascular surgery and endovascular therapy. Although the exact mechanism is unknown, increased levels of inflammatory and biochemical modulators associated with adverse cardiovascular outcomes, as well as endothelial dysfunction, appear to play a role in the association between renal insufficiency and adverse outcomes. Outcomes after the surgical and endovascular treatment of abdominal aortic aneurysms, carotid disease, and peripheral arterial disease are all negatively affected by renal insufficiency. Patients with renal dysfunction may warrant intervention for the treatment of critical limb ischemia and symptomatic carotid stenosis, given the comparatively worse outcomes associated with medical management. Open repair of aortic aneurysms and carotid intervention for asymptomatic disease in patients with severe renal dysfunction should be performed with significant caution, as the risks of repair may outweigh the benefits in this population. Further study is needed to better delineate the risks of medical management for these conditions in patients with coexisting severe renal dysfunction. Lastly, current guidelines for the management of vascular diseases, including objective performance goals for critical limb ischemia, are likely not applicable in patients with severe renal insufficiency.

Objective: Stent graft therapy has emerged as an alternative to open surgery in the management of chronic dissection-related aneurysmal degeneration (DRAD) in the descending thoracic aorta (DTA). The incidence of perioperative complications, need for secondary aortic intervention (SAI), and rate of aneurysmal false-lumen thrombosis have not been thoroughly described.Methods: Perioperative and midterm outcomes in patients who underwent stent graft therapy for chronic DRAD DTA at a single institution between January 2006 and September 2013 were retrospectively analyzed. Preoperative anatomic factors, including the number of visceral and renal side branches off the false lumen, and false lumen volume, were analyzed for their ability to predict treatment failure. Treatment failure was defined as death, need for a SAI, and failure to achieve thrombosis of the DRAD DTA. Treatment success was defined as thrombosis of the false lumen in the area of the DRAD DTA with stability or a decrease in the maximum diameter of the DRAD DTA.Results: During the study period, 47 patients underwent stent graft therapy for chronic DRAD DTA. Patients were a mean age of 58.3 +/- 11.7 years, 74.5% (n = 35) were male, and 14.9% (n = 7) had a history of connective tissue disease. The left subclavian artery was covered in 48.9% (n = 23), and revascularization was performed in 87.0% (n = 20). Spinal drains were used in 74.5% (n = 35). Spinal cord ischemia developed in 6.4% (n = 3), which resolved in two and improved in one. No retrograde aortic dissections occurred. The 30-day mortality was 4.3% (n = 2); one death was in a patient with rupture. Mean clinical follow-up was 35.1 +/- 20.9 months. The 5-year Kaplan-Meier survival was 89% +/- 5%. Treatment failure occurred in 18 patients (38.3%): 9 required SAIs, 6 did not have thrombosis of the false lumen in the area of the DRAD DTA, and 4 died, with 1 patient dying during a SAI. No preoperative anatomic factor predicted treatment failure. The 5-year freedom from treatment failure was 54% +/- 9%. Including the nine patients who underwent SAI, treatment success was achieved in 85.2% of patients.Conclusions: In this single-center experience of stent graft therapy for chronic DRAD DTA, treatment success was achieved in 85% of patients after a SAI rate of 20%. No preoperative anatomic factor predicted treatment failure, which occurred in almost 40% of the patients. Identifying predictors of treatment failure may improve future outcomes.

Objectives: While uncomplicated acute type B aortic dissections are often medically managed with good outcomes, a subset develop subacute or chronic aneurysmal dilatation. We hypothesize that computational fluid dynamics (CFD) simulations may be useful in identifying patients at risk for this complication. Methods: Patients with acute type B dissection complicated by rapidly expanding aortic aneurysms (N=7) were compared to patients with stable aortic diameters (N=7). Three dimensional patient-specific dissection geometries were generated from CTA and used in CFD simulations of pulsatile blood flow. Hemodynamic parameters including false lumen flow and wall shear stress were compared. Results: Patients with rapid aneurysmal degeneration had a growth rate of 5.3 ± 2.7 mm/month compared to those with stable aortic diameters who had rates of 0.2 ± 0.02 mm/month. Groups did not differ in initial aortic diameter (36.1±2.9 vs 34.4±3.6 mm, P=0.122) or false lumen size (22.6±2.9 vs 20.2±4.5 mm, P=0.224). In patients with rapidly expanding aneurysms, a greater percentage of total flow passed through the false lumen (78.3±9.3 vs 56.3±11.8%, P=0.016). The time averaged wall shear stress on the aortic wall was also significantly higher (12.6±3.7 vs 7.4±2.8 Pa, P=0.028, see Figure). Conclusions: Hemodynamic parameters derived from CFD simulations of acute type B aortic dissections were significantly different in dissections complicated by aneurysm formation. Thus, CFD may assist in predicting which patients may benefit from early stent grafting.

Objective Growing evidence suggests that peak wall stress (PWS) derived from finite element analysis (FEA) of abdominal aortic aneurysms (AAAs) predicts clinical outcomes better than diameter alone. Prior models assume uniform wall thickness (UWT). We hypothesize that inclusion of locally variable wall thickness (VWT) into FEA of AAAs will improve the ability to predict clinical outcomes. Methods Patients with AAAs (n=26) undergoing radiologic surveillance were identified. Custom MATLAB algorithms generated UWT and VWT aortic geometries from CTA images, which were subsequently loaded with systolic blood pressure using FEA. PWS and aneurysm growth (as a proxy for rupture risk and the need for repair) were examined. Results The average radiologic follow-up time was 22.0±13.6 months and the average aneurysm growth rate was 2.8±1.7 mm/year. PWS in VWT models significantly differed from PWS in UWT models (238±68 vs 212±73 kPa, P=0.025). In our sample, initial aortic diameter was not found to be correlated with aneurysm growth (r=0.26, P=0.19). A stronger correlation was found between aneurysm growth and PWS derived from VWT models as compared to PWS from UWT models (r=0.86 vs r=0.58, P=0.032 by Fisher’s r to Z transformation). The three panels in the figure demonstrate the correlation between aneurysm growth rate and (1) initial diameter, (2) PWS using UWT model, and (3) PWS using VWT model, respectively. Conclusion The inclusion of locally variable wall thickness significantly improved the correlation between PWS and aneurysm growth. Aortic wall thickness should be incorporated into future FEA models to accurately predict clinical outcomes.

Background— Wall stress calculated using finite element analysis has been used to predict rupture risk of aortic aneurysms. Prior models often assume uniform aortic wall thickness and fusiform geometry. We examined the effects of including local wall thickness, intraluminal thrombus, calcifications, and saccular geometry on peak wall stress (PWS) in finite element analysis of descending thoracic aortic aneurysms. Methods and Results— Computed tomographic angiography of descending thoracic aortic aneurysms (n=10 total, 5 fusiform and 5 saccular) underwent 3-dimensional reconstruction with custom algorithms. For each aneurysm, an initial model was constructed with uniform wall thickness. Experimental models explored the addition of variable wall thickness, calcifications, and intraluminal thrombus. Each model was loaded with 120 mm Hg pressure, and von Mises PWS was computed. The mean PWS of uniform wall thickness models was 410±111 kPa. The imposition of variable wall thickness increased PWS (481±126 kPa, P <0.001). Although the addition of calcifications was not statistically significant (506±126 kPa, P =0.07), the addition of intraluminal thrombus to variable wall thickness (359±86 kPa, P ≤0.001) reduced PWS. A final model incorporating all features also reduced PWS (368±88 kPa, P <0.001). Saccular geometry did not increase diameter-normalized stress in the final model (77±7 versus 67±12 kPa/cm, P =0.22). Conclusions— Incorporation of local wall thickness can significantly increase PWS in finite element analysis models of thoracic aortic aneurysms. Incorporating variable wall thickness, intraluminal thrombus, and calcifications significantly impacts computed PWS of thoracic aneurysms; sophisticated models may, therefore, be more accurate in assessing rupture risk. Saccular aneurysms did not demonstrate a significantly higher normalized PWS than fusiform aneurysms.

Objective: Repair of saccular aortic aneurysms (SAAs) is frequently recommended based on a perceived predisposition to rupture, despite little evidence that these aneurysms have a more malignant natural history than fusiform aortic aneurysms.Methods: The radiology database at a single university hospital was searched for the computed tomographic (CT) diagnosis of SAA between 2003 and 2011. Patient characteristics and clinical course, including the need for surgical intervention, were recorded. SAA evolution was assessed by follow-up CT, where available. Multivariate analysis was used to examine potential predictors of aneurysm growth rate.Results: Three hundred twenty-two saccular aortic aneurysms were identified in 284 patients. There were 153 (53.7%) men and 131 women with a mean age of 73.5 +/- 10.0 years. SAAs were located in the ascending aorta in two (0.6%) cases, the aortic arch in 23 (7.1%), the descending thoracic aorta in 219 (68.1%), and the abdominal aorta in 78 (24.2%). One hundred thirteen (39.8%) patients underwent surgical repair of SAA. Sixty-two patients (54.9%) underwent thoracic endovascular aortic repair, 22 underwent endovascular aneurysm repair (19.5%), and 29 (25.6%) required open surgery. The average maximum diameter of SAA was 5.0 +/- 1.6 cm. In repaired aneurysms, the mean diameter was 5.4 +/- 1.4 cm; in unrepaired aneurysms, it was 4.4 +/- 1.1 cm (P < .001). Eleven patients (3.9%) had ruptured SAAs on initial scan. Of the initial 284 patients, 50 patients (with 54 SAA) had CT follow-up after at least 3 months (23.2 +/- 19.0 months). Fifteen patients (30.0%) ultimately underwent surgical intervention. Aneurysm growth rate was 2.8 +/- 2.9 mm/yr, and was only weakly related to initial aortic diameter (R-2 = .19 by linear regression, P = .09 by multivariate regression). Decreased calcium burden (P = .03) and increased patient age (P = .05) predicted increased aneurysm growth by multivariate analysis.Conclusions: While SAA were not found to have a higher growth rate than their fusiform counterparts, both clinical and radiologic follow-up is necessary, as a significant number ultimately require surgical intervention. Further clinical research is necessary to determine the optimal management of SAA. (J Vasc Surg 2013;57:84-8.)

Background. Using human mitral valve (MV) models derived from three-dimensional echocardiography, finite element analysis was used to predict mechanical leaflet and chordal stress. Subsequently, valve geometries were altered to examine the effects on stresses of the following: (1) varying coaptation area; (2) varying noncoapted leaflet tissue area; and (3) varying interleaflet coefficient of friction (11).Methods. Three human MV models were loaded with a transvalvular pressure of 80 mm Hg using finite element analysis. Initially leaflet coaptation was set to 10%, 50%, or 100% of actual coaptation length to test the influence of coaptation length on stress distribution. Next, leaflet surface areas were augmented by 1% overall and by 2% in the noncoapted "belly" region to test the influence of increased leaflet billowing without changing the gross geometry of the MV. Finally, the coefficient of friction between the coapted leaflets was set to mu = 0, 0.05, or 0.3, to assess the influence of friction on MV function.Results. Leaflet coaptation length did not affect stress distribution in either the coapted or noncoapted leaflet regions; peak leaflet stress was 0.36 +/- 0.17 MPa at 100%, 0.35 +/- 0.14 MPa at 50%, and 0.35 +/- 0.15 MPa at 10% coaptation lengths (p = 0.85). Similarly, coaptation length did not affect peak chordal tension (p = 0.74). Increasing the noncoapted leaflet area decreased the peak valvular stresses by 5 +/- 2% (p = 0.02). Varying the coefficient of friction between leaflets did not alter leaflet or chordal stress distribution (p = 0.18).Conclusions. Redundant MV leaflet tissue reduces mechanical stress on the noncoapted leaflets; the extent of coaptation or frictional interleaflet interaction does not independently influence leaflet stresses. Repair techniques that increase or preserve noncoapted leaflet area may decrease mechanical stresses and thereby enhance repair durability. (Ann Thorac Surg 2012;93:1141-5) (C) 2012 by The Society of Thoracic Surgeons

Objective: Biomechanical analysis can predict mechanical stresses in cardiovascular structures. Prior models often assume uniform arterial wall thickness (WT). We hypothesize that including local WT in finite element analysis (FEA) of the carotid artery will effect wall stress (WS) distribution and maxima. Methods: CTAs in patients with carotid occlusive disease (n=5) were analyzed with custom algorithms to segment luminal and adventitial surfaces, providing local WT. A control model was defined with variable wall thickness (VWT) and hyperelastic material properties (MP). Experimental models tested the effects of: (1) uniform wall thickness (UWT), (2) soft and calcified plaque, and (3) linear MP. Commercial FEA software was used to load each model with 80 mmHg pulse pressure and compute Von Mises WS. Results: The mean (across n=5 patients) peak WS of the VWT model was 162±29 kPa. Peak WS decreased with the imposition of UWT (112±19 kPa, P=0.01) and with linear MP (105±24 kPa, P=0.01). UWT decreased both the average WS over the entire carotid bifurcation (31±4 kPa, P=0.04) compared to VWT control (42±9 kPa) and the mean normalized nodal variance (a measure of inhomogeneity) of the WS over the bifurcation (0.34±0.03 vs 0.30±0.04, P=0.03). Conclusion: Incorporation of local WT can significantly increase peak WS and cause less uniform WS distribution. Aortic wall thickness should be incorporated in FEA of aneurysms to accurately predict rupture risk and in other bioengineering analyses.

OBJECTIVE:The purpose of this study was to describe the results of an alternative technique for inferior vena cava filter (IVCF) retrieval that can be used when the retrieval hook cannot be snared. METHODS:Retrospective review of all patients undergoing attempted IVCF retrieval by a single surgeon between March 2009 and March 2011 was undertaken. After December 2009, in cases where the retrieval hook could not be snared, an 18F/85 cm sheath was inserted into the internal jugular vein and a Bentson wire (Cook Medical, Bloomington, Ind) and snare were advanced across separate interstices of the filter. The resulting "lasso" was pulled up below the collar at the top of the filter, and the filter collapsed into the sheath. RESULTS:Over 28 months, 34 patients underwent attempted retrieval of Günther Tulip filters (Cook Medical). Patients were 44±15 years old; 59% were women (n=20). Filters were placed for venous thromboembolism with contraindication to anticoagulation in seven cases and prophylactically in 27 cases. Of the prophylactic cases, 18 (67%) were placed before planned bariatric surgery. Before December 2009, the success rate was 86% (6 of 7): the retrieval hook of one filter could not be snared and seemed to be embedded in the wall of the cava. After adoption of the described technique, the success rate was 96% (26 of 27): one patient refused further attempts at central venous catheterization after multiple unsuccessful attempts. Filters retrieved conventionally by snaring the hook (n=18) were implanted on average for 4.8±3.7 months and 12.1±10.1 months for those retrieved using the new technique (n=14; P=.02). All patients were discharged on the day of the procedure without complication. The one patient in whom the retrieval hook could not be snared before December 2009 has refused another attempt at retrieval. CONCLUSIONS:The method of IVCF retrieval described here was successful in every instance in which it was attempted. It was associated with no morbidity despite the customary use of an 18F sheath in the internal jugular vein. The approach constitutes an appropriate "fall-back" technique when the retrieval hook of a removable IVCF cannot be snared.

Objective: The objective of this study was to examine the results of thoracic endovascular aneurysm repair (TEVAR) for chronic descending thoracic aortic (DTA) dissections with aneurysmal degeneration.Methods: Over 70 months at a single institution, 27 patients underwent TEVAR for aneurysms related to chronic (>6 weeks) DTA dissections.Results: Mean patient age was 67.5 +/- 9.6 years; 18 were men. Primary indications for repair were aneurysm size (n = 20), rapid aneurysmal growth (n = 5), saccular aneurysm (n = 1), and rupture (n = 1). Preoperative false lumen status was patent in 18 patients, partially thrombosed in 8 patients, and unknown in the patient whose aneurysm ruptured. The proximal entry tear was covered in all 27 patients. Fourteen patients required coverage of the left subclavian artery, of which 9 patients underwent prophylactic revascularization. On completion angiogram, no patient had antegrade perfusion of the aneurysmal false lumen. There were three procedural complications: 2 patients sustained paraparesis (one resolved and one improved), and 1 patient had an access injury requiring stent graft placement. Thirty-day mortality was 3.7% (1 of 27); the one death was in the patient whose aneurysm ruptured. Of the 26 surviving patients, 23 (88.5%) had thrombosis of the aneurysmal false lumen. Twenty-two patients (84.6%) had stability or decrease in maximal aneurysm diameter on last radiographic follow-up at 18 +/- 20 months. Three-year Kaplan-Meier survival was 90.3% +/- 6.5% in the 26 patients who survived to hospital discharge, with a mean follow-up of 27.3 +/- 22.1 months. In patients with preoperatively partially thrombosed false lumens (n = 8), 3-year survival was 100%.Conclusions: TEVAR for aneurysms due to chronic dissections of the DTA can be performed safely and effectively at midterm follow-up according to this single-institution study. Stent graft therapy may be of particular benefit in patients presenting with partially thrombosed false lumens. (J Vasc Surg 2012;55:963-7.)

Objective: To evaluate the qualitative impact of training in the endovascular era (post-2000) on vascular surgeons’ comfort level and enjoyment with abdominal aortic aneurysm (AAA) repairs. Methods: A sample of vascular surgeons (n = 1754) were sent a survey pertaining to their fellowship training and practice of AAA repair. The influence of training- and practice-related variables on qualitative outcomes was assessed. Results: A total of 382 (22%) surgeons completed the survey. Surgeons who performed more endovascular aneurysm repairs (EVARs) than open AAA repairs were more likely to enjoy EVAR ( P < .001). Those completing fellowship after 2000 reported a higher level of procedure-related comfort with EVAR ( P = .001) compared to those completing fellowship before 2000. Conversely, surgeons completing fellowship before 2000 reported a higher level of procedure-related comfort with open AAA repair ( P = .001). Conclusion: The advent of EVAR has changed fellowship training of AAA repair and has translated into changes in both practice patterns and comfort level.

Objective: To explore the incidence, predictors, and outcomes of hemodynamic instability (HI) following carotid angioplasty and stenting (CAS).Methods: We retrospectively evaluated data on 257 CAS procedures performed in 245 patients from 2002 to 2011 at a single institution. The presence of periprocedural HI, as defined by hypertension (systolic blood pressure >160 mm Hg), hypotension (systolic blood pressure <90 mm Hg), and/or bradycardia (heart rate <60 beats per minute), was recorded. Clinically significant HI (CS-HI) was defined as periprocedural HI lasting greater than 1 hour in total duration. Logistic regression was used to analyze the role of multiple demographic, clinical, and procedural variables.Results: Mean age was 70.9 +/- 9.9 years (67% male). HI occurred following 84% (n = 216) of procedures. The incidence of hypertension, hypotension, and bradycardia was 54%, 31%, and 60%, respectively. Sixty-three percent of cases involved CS-HI. Recent stroke was an independent risk factor for the development of CS-HI (odds ratio, 5.24; confidence interval, 1.28-21.51; P = .02), whereas baseline chronic obstructive pulmonary disease was protective against CS-HI (odds ratio, 0.34; confidence interval, 0.15-0.80; P = .01). Patients with CS-HI were more likely to experience periprocedural stroke compared to other patients (8% vs 1%; P = .03). There were no significant differences in the incidence of mortality or other major complications between those with and without CS-HI.Conclusions: HI represents a common occurrence following CAS. While the presence of periprocedural HI alone did not portend a worse clinical outcome, CS-HI was associated with increased risk of stroke. Expeditious intervention to prevent and manage CS-HI is of critical importance in order to minimize adverse clinical events following CAS.

Repair of saccular aortic aneurysms (SAA) is frequently recommended based on a perceived predisposition to rupture, despite little evidence that these aneurysms have a more malignant natural history than fusiform aortic aneurysms. The radiology database at a single university hospital was searched for the computed tomographic (CT) diagnosis of SAA between 2003 and 2011. Patient characteristics and clinical course, including the need for surgical intervention, were recorded. SAA evolution was assessed by follow-up CT, where available. Multivariate analysis was used to examine potential predictors of aneurysm growth rate. A total of 322 saccular aortic aneurysms were identified in 284 patients. There were 153 (59.0%) men and 131 women with a mean age of 73.5 ± 10.0 years. SAA were located in the ascending aorta in 2 (0.6%), the aortic arch in 24 (7.4%), the descending thoracic aorta in 227 (70.5%), and the abdominal aorta in 79 (24.5%). Surgical SAA repair was done in 113 patients (40.0%). Sixty-three patients (54.3%) underwent TEVAR, 24 underwent EVAR (20.7%) and 29 (25.0%) required open surgery. The average maximum SAA diameter, measured perpendicular to the aortic lumen centerline and including the aortic lumen diameter, was 5.0 ± 1.7 cm. The mean diameter was 5.4 ± 1.4 cm in repaired aneurysms and was 4.4 ± 1.1 cm in unrepaired aneurysms (P < .001). Eleven patients (3.9%) had ruptured SAA on initial scan. Of the initial 284 patients, 50 patients (with 54 SAA) had CT follow-up after at least 3 months (mean, 23.2 ± 19.0 months). Aneurysms grew an average of 2.8 ± 2.9 mm/year. Aneurysm growth was only weakly related to initial aortic diameter (R2 = 0.19 by linear regression, P = .09 by multivariate regression). Decreased calcium burden (P = .03) and increased patient age (P = .05) predicted increased aneurysm growth. SAA were not found to have a markedly malignant natural history. Close clinical follow-up in the individual patient and further clinical research are necessary to determine the optimal management of SAA.

BACKGROUND:The efficacy of endovascular treatment of aneurysms secondary to chronic DeBakey type III aortic dissection (CD3) remains controversial. The objective of this study was to compare outcomes from open and endovascular treatment of CD3 aneurysms, and to determine the efficacy of thoracic endovascular aortic repair (TEVAR) in remodeling the chronically dissected thoracoabdominal aorta. METHODS:From 2005 to 2012, 58 patients underwent open aortic replacement (open) and 31 patients underwent endovascular therapy (TEVAR) for the treatment of CD3 aneurysms. The TEVAR patients were divided into CD3a (n = 12) or CD3b (n = 19) subgroups based upon the DeBakey classification of aortic dissection. Total aortic, true and false lumen diameters were measured at different anatomic locations. True lumen and false lumen indices were calculated to evaluate the impact of TEVAR on remodeling. RESULTS:In the open group, operative mortality was 10.3% and the incidence of pulmonary failure, renal failure, and paraplegia was 13.8%, 10.3%, and 12.1%, respectively. There were no operative mortalities in TEVAR patients, and no cases of pulmonary failure, renal failure, or paraplegia. Endovascular therapy stabilized aneurysm size and remodeled the thoracic aorta in 87% of patients. The TEVAR significantly expanded the true lumen and reduced the false lumen within the stent graft in CD3a and CD3b patients (p < 0.001). Thoracic false lumen thrombosis was achieved in 100% of CD3a and in 68% of CD3b patients. CONCLUSIONS:In these early results, TEVAR reduces operative morbidity and mortality compared with open aortic replacement in the treatment of CD3 aneurysms. The TEVAR is effective in remodeling the chronically dissected thoracic aorta. Abdominal false lumen patency is maintained in patients with thoracoabdominal dissection-related aneurysms.