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To evaluate short-term outcomes of redo surgical aortic valve replacement (SAVR) versus valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) with bioprosthetic valve fracture (ViVBVF) in patients with bioprosthetic structural valve deterioration undergoing reintervention. This retrospective single-center study was conducted between 2015 and 2025. Data were obtained from institutional registries. A total of 128 consecutive patients met the inclusion criteria (75 with redo-SAVR and 53 with ViVBVF). Patients requiring concomitant cardiac procedures, mechanical valves, or unsuitable anatomy for ViV were excluded. The primary endpoints were 30-day mortality, stroke, and readmission; secondary endpoints included echocardiographic changes and postoperative complications. Overlap propensity score weighting to adjust baseline differences was performed. Compared to the redo-SAVR patients, the ViVBVF patients were older and had a higher predicted risk of mortality. The rates of 30-day mortality, stroke, and readmission were similar in the 2 groups. ViVBVF achieved significantly greater reductions in mean gradient (-26.0 mm Hg vs -17.4 mm Hg; P =.003), peak gradient (-39.2 mm Hg vs -23.3 mm Hg; P =.004), and peak velocity. After matching, 30-day mortality was higher after redo-SAVR (8.9% vs 0%; P < .001). The ViVBVF group showed a greater reduction in peak velocity but more frequent pacemaker implantation. In patients with bioprosthetic valves requiring reintervention, ViVBVF offers greater gradient reduction, with a perioperative safety advantage suggested in the adjusted analysis.
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The sentinel cerebral embolic protection device has been used as prophylaxis of stroke and transient ischemic attack during transcatheter aortic valve replacement. However, there are no absolute criteria guiding cerebral embolic protection device placement. This study aimed to evaluate the impact of cerebral embolic protection on postoperative cerebrovascular events in patients at high risk for stroke. Between April 2021 and August 2023, 695 patients underwent transcatheter aortic valve replacement through a transfemoral approach. The cerebral embolic protection device was placed at the beginning of transcatheter aortic valve replacement procedure when 1 of the following criteria was met preoperatively: bicuspid aortic valve, valve-in-valve procedure, or calcium score in computed tomography greater than 1000. Of 695 patients with transcatheter aortic valve replacement, 636 met the criteria. The cerebral embolic protection device was placed in 55% of patients (350/636, cerebral embolic protection group) and not placed in 45% of patients (286/636, non-cerebral embolic protection group) because cerebral embolic protection was not feasible anatomically. A 1:1 propensity score matching was performed using the nearest neighbor method between cerebral embolic protection and non-cerebral embolic protection groups. A total of 245 pairs were matched in propensity score matching. After matching, postoperative stroke/transient ischemic attack occurred in 0.4% (1/245) in the cerebral embolic protection group and 2.9% (7/245) in the non-cerebral embolic protection group. A significant difference was noted in postoperative stroke/transient ischemic attack between the 2 groups (P = .03). Early mortality and other complications did not differ between the 2 groups. In postoperative follow-up, incidence of stroke/transient ischemic attack was similar in 30 days (2.0% vs 1.2%, P = .72) and 1 year (0.4% vs 1.2%, P = .62). There was no vascular complication at the cerebral embolic protection access site. Cerebral embolic protection during transcatheter aortic valve replacement might reduce postoperative cerebrovascular events in patients who are high risk for stroke in this patient cohort.
Moderate levels of frailty or a previous sternotomy make open repair of aortic arch pathology high risk or even preclude any treatment. This study examined 30-day outcomes from the NEXUS Aortic Arch Clinical Study to Evaluate Safety and Effectiveness investigational device exemption (TRIOMPHE IDE) study of an off-the-shelf stent-graft system for Zone 0 endovascular aortic arch repair in patients with high-risk chronic dissection. TRIOMPHE IDE is a prospective, multicenter study evaluating the NEXUS system (Endospan) in chronic aortic dissection (n = 54). Following cervical debranching, NEXUS was delivered into the arch first, followed by an ascending aortic stent-graft. All subjects were deemed high-risk for open repair (American Society of Anesthesiologists class IV 51.9% or class III 48.1%; mean European System for Cardiac Operative Risk Evaluation II score 10.3%). Comorbidities included chronic obstructive pulmonary disease (18.5%), coronary disease (42.6%), previous stroke (25.9%), and 70% with previous sternotomy. Successful deployment occurred in 100% of cases, with device technical success in 98.2% (53 out of 54) as 1 retrograde type A dissection required open repair. Thirty-day mortality was 9.3% (5 out of 54). One disabling stroke occurred after bypass (1.9%). There was 1 disabling thromboembolic stroke and 1 intracranial hemorrhage (3.7%) after the index procedure. There were no aortic ruptures, spinal cord ischemia, or permanent dialysis. On core-lab adjudicated 30-day computed tomography angiography, there were no Type 1a/1b or III endoleaks and 100% device patency. Median intensive care unit and hospital stays were 3.0 days (range, 1.0-13.0 days) and 7.0 days (range, 1.0-40.0 days). The 30-day results from the TRIOMPHE IDE study primary statistical cohort support the hypothesis that high-risk aortic arch dissection patients can be successfully treated using an off-the-shelf branched stent graft system, obviating the need for sternotomy or hypothermic arrest with open repair.
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This report provides a concise overview of the published literature and clinical outcomes on ascending thoracic endovascular aortic repair (aTEVAR) for diseases originating in, but not restricted to, the ascending aorta. PubMed, Scopus, and Web of Science were systematically searched for aTEVAR procedures for diseases originating in the ascending aorta. Nonadult patients or studies with fewer than 5 patients were excluded. This review was registered in the International Prospective Register of Systematic Reviews and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements. The Risk of Bias in Non-randomized Studies - of Interventions tool was used to assess quality. A Grading of Recommendations, Assessment, Development, and Evaluation evidence certainty analysis was performed. One prospective and 22 retrospective studies included a total of 356 patients (weighted mean age 68.6 ± 10.9 years; 59.3% male). The weighted mean follow-up was 21.2 ± 20.3 months, and prevalent comorbidities were hypertension (72.8%) and coronary artery disease (24.2%). Indications included type A dissections (acute 36.0%; chronic 19.9%), penetrating aortic ulcer (11.5%), and pseudoaneurysm (16.9%). Rapid ventricular pacing (33.4%) was most frequently adopted strategy to reduce cardiac output, and femoral/iliac artery access was used in 84.3%. Tubular stent grafts were used in 229 cases (64.3%), whereas physician-modified stent grafts were necessary in 110 cases (30.9%). In-hospital and follow-up mortality rates were 10.7% (95% CI, 6.3-13.1) and 20.5% (95% CI, 16.4-25.1). Subgroup analyses showed in-hospital and follow-up mortality rates for (acute and chronic) type A dissections of 9.8% (95% CI, 5.9-15.0) and 18.0% (95% CI, 12.7-24.3) subsequently; for penetrating aortic ulcer 9.0% (95% CI, 1.9-24.3) and 15.2% (95% CI, 5.1-31.9); and for pseudoaneurysm 2.8% (95% CI, 1.0-13.9) and 13.3% (95% CI, 5.9-24.6). Intra- and postoperative complications were reported in 43 and 192 cases, with endoleaks occurring in 14 (3.9%) and 37 (10.4%) cases, respectively. This systematic review assessed current strategies and outcomes for aTEVAR. The findings suggest that aTEVAR holds promise as a treatment option and highlight the potential for further integration of aTEVAR into clinical practice.
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Pregnancy induces hemodynamic stress that may predispose the thoracic aorta to accelerated growth or acute events. Here, we present a single-center experience with vascular outcomes in an obstetric population with thoracic aortic disease. Electronic health records of pregnant patients with thoracic aortic aneurysm at our health care system were reviewed. Information was collected regarding demographics, aortic size, arterial complications, and clinical management of pregnancy. Twenty-six patients with a total of 92 pregnancies (median per patient, 3; interquartile range, 2-4) were identified. Data were available for 39 pregnancies between 2011 and 2023. At the time of the first pregnancy, 23% (6 out of 26) of patients had no known diagnosis of thoracic aortic aneurysm, despite 2 patients known to have connective tissue disease. Among 26 patients, 57.7% (15 out of 26) had a heritable cause of thoracic aortic disease, whereas 42.3% (11 out of 26) had no identifiable etiology and were classified as sporadic dilations. Pregnancy-associated vascular complications occurred in 11.5% (3 out of 26) of patients. All vascular complications occurred in patients with heritable thoracic aortic disease. No type A aortic dissection was noted. Aortic surveillance and imaging schedules varied among patients. Proximal aortic growth pattern is variable across pregnancy. No acute aortic events were observed during pregnancy. However, the risk of pregnancy-related vascular complications is higher during the postpartum period.
We aimed to examine early outcomes of surgical aortic valve replacement (SAVR) with Y-incision aortic annular enlargement (Y-AAE) versus transcatheter AVR (TAVR) in native aortic valve stenosis. From August 2020 to March 2024, 362 patients with severe native aortic valve stenosis underwent SAVR + Y-AAE with bioprosthetic valves (n = 70) or TAVR (n = 292) with ejection fraction ≥50%, Society of Thoracic Surgeons predicted risk of mortality score ≤8, and minimal aortic annular diameter ≤25 mm by computed tomography. Nearest-neighbor 1:3 propensity score matching was conducted across all preoperative variables. The minimal aortic annular diameter by CT was 22 mm (IQR, 20, 23 mm) in the TAVR group and 21 mm (IQR, 19, 23 mm) in the SAVR + Y-AAE group. The TAVR group had median implanted valve sizes of Edwards LifeSciences Sapien 26 mm (IQR, 25, 29 mm) and Medtronic Evolut 29 mm (29, 34 mm), whereas the SAVR + Y-AAE group had a median implant size of 29 mm (27, 29 mm). Compared with the TAVR group, the SAVR + Y-AAE group had similar operative mortality (0% vs 2%; P > .99) and lower postoperative pacemaker implantation rate (1.4% vs 10.3%; P = .03). At 24 to 36 months postoperative, the SAVR + Y-AAE group had significantly larger effective orifice area (2.7 vs 1.9 cm2), lower aortic valve mean gradients (5 vs 9.5 mm Hg), greater dimensionless index (0.67 vs 0.54), lower rates of aortic insufficiency (3.0% vs 26%), and less moderate/severe prosthesis-patient mismatch (0% vs 20.1%). The left ventricular mass index regression was greater in SAVR + Y-AAE patients (42% vs 22%; P = .05). The SAVR + Y-AAE 3-year survival was 96% versus 79% for TAVR in the propensity-score matched cohort (P = .12). The hazard ratio of SAVR + Y-AAE for early mortality was 0.15 (95% CI, 0.02-1.13; P = .066). Low- and intermediate-risk patients with aortic valve stenosis should be considered for SAVR + Y-AAE for excellent hemodynamics and early outcomes.
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The optimal treatment for acute uncomplicated type B aortic dissection (AUTBAD) remains unknown. The aim of this study was to characterize the efficacy of optimal medical therapy (OMT) in the treatment of AUTBAD and identify anatomic risk factors for OMT failure. A retrospective review of an aortic database from 2 aortic centers identified 293 patients with AUTBAD treated initially with OMT from 1995 to 2025. Inclusion criteria consisted of patients with initial imaging and death status available for analysis. An aortic event was defined as the need for an aortic intervention or an aortic-related death. In total, 153 (52.2%) patients required an aortic intervention or experienced an aortic-related death during the study period. Aortic event-free survival at 1, 5, and 10 years was 62.9%, 43.8%, and 37.6%. For the 140 (47.8%) patients successfully maintained on OMT alone, aortic-related survival was 89.4%, 82.2%, and 76.9% at 1, 5, and 10 years. Patients with type B aortic dissection extending into the iliac arteries had a superior aortic event-free survival at 1 (iliac 70.8% vs no iliac 55.5%), 5 (iliac 49.5% vs no iliac 37.2%), and 10 years (iliac 44.6% vs no iliac 28.8%, P = .008) compared with patients without iliac involvement. Iliac involvement was independently associated with freedom from aortic intervention or aortic-related death (hazard ratio, 0.69, P = .049). Aortic intervention resulted in improved survival (P < .001) compared with OMT in patients without iliac involvement but had no impact in patients with iliac involvement. Patients with AUTBAD and dissections ending proximal to the aortoiliac bifurcation benefit from TEVAR compared with OMT. Conversely, patients with dissections extending into the iliac arteries should be treated with OMT alone.
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Thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms remains technically challenging because of supra-aortic vessel involvement and complex arch anatomy. This study evaluated the feasibility and outcomes of branched TEVAR using fenestrated stent grafts in conjunction with small-caliber stent grafts for selective cervical branch reconstruction. From December 2017 to November 2024, 53 patients with degenerative aortic arch aneurysms underwent branched TEVAR at a single center. A Najuta endograft was used as a fenestrated stent graft, with selective branch reconstruction using VIABAHN or VIABAHN VBX stent grafts. The outcomes included technical success, perioperative complications, endoleak occurrence, aneurysm growth, secondary intervention, and survival. The predictors of aneurysm expansion were also analyzed. Technical success was achieved in all patients. Cervical branch reconstruction was performed in 53 patients (1 branch, n = 23; 2 branches, n = 22; 3 branches, n = 8). There was no 30-day mortality. Ischemic stroke occurred in 2 patients (3.8%). Endoleaks were identified in 7 patients (13.2%) before discharge, and most resolved spontaneously. During an average follow-up period of 884.8 ± 699.1 days (median, 736 days), aneurysm enlargement occurred in 6 patients and 2 required secondary interventions. No aortic-related death was observed. Lower preoperative fibrinogen levels were independently associated with aneurysm expansion (P = .025). Branched TEVAR using a fenestrated stent graft combined with small-caliber stent grafts is a feasible and minimally invasive option for selected high-risk patients with aortic arch aneurysms. This approach enables total endovascular arch repair with complete cervical branch reconstruction and demonstrates satisfactory midterm outcomes.
[This corrects the article DOI: 10.1016/j.xjse.2025.100085.].
Thoracic endovascular aortic repair is the preferred approach for treating pathology of the descending thoracic aorta. Infection after thoracic endovascular aortic repair is reported to occur in less than 1% of patients and is associated with significant mortality. The purpose of the present study is to describe the surgical management and outcomes of patients who underwent explant of infected thoracic endovascular aortic repairs at our institution. Patients with an infected thoracic endovascular aortic repair who underwent surgical management at our institution between January 2017 and June 2024 were included. Chart review was performed to identify comorbidities and operative variables including method of reconstruction, postoperative complications, and mortality. Nine patients were identified in the study period. There were 7 men and 2 women with an age range of 29 to 67 years. Indications for thoracic endovascular aortic repair included type B aortic dissection, pseudoaneurysm, and rupture of the descending thoracic aorta. The median time from endograft implant to diagnosis of infection was 182 days (range, 31-1826 days). The causative infectious organism was identified in 77% of cases (7/9). Five patients underwent extra-anatomic bypass and aortic ligation followed by interval thoracic endovascular aortic repair explant. Four patients underwent thoracic endovascular aortic repair explant and in situ aortic reconstruction. There were no instances of graft thrombosis. In-hospital mortality was 22% (2 patients) with 1-year mortality of 50% (4 patients). One patient was lost to follow-up. As thoracic endovascular aortic repair volume continues to increase, the prevalence of thoracic endograft infection will continue to increase. Our experience demonstrates thoracic aortic endograft explantation with extra-anatomic or in-line aortic reconstruction is viable; however, mortality from this pathology and its management remain high.
Zone 2 thoracic endovascular aortic repair with a single-branched endograft (GORE TAG Thoracic Branch Endoprosthesis [TBE], W.L. Gore & Associates, Inc) was approved by the Food and Drug Administration in May 2022 on the basis of 1-year results from a pivotal trial. This report presents 3-year trial outcomes in patients with nondissection descending thoracic aortic lesions requiring zone 2 proximal landing zone. In this prospective, nonrandomized cohort study across 40 US sites, 106 adults underwent thoracic endovascular aortic repair using the TBE device, which includes a side-branch for left subclavian artery perfusion. Three cohorts were evaluated: aneurysm (AN; n = 84), traumatic aortic injury (TAI; n = 9), and other isolated lesions (OL; n = 13). Mean ages were AN 70 ± 11, TAI 42 ± 19, and OL 65 ± 13 years; male patients comprised 63%, 89%, and 46%, respectively. At 36 months, all-cause mortality was 14% overall (AN 13%, TAI 0%, OL 31%) with 1 lesion-related death (1%). Late (>30 days) stroke occurred in 5%. Core laboratory-adjudicated imaging follow-up revealed 8% type I/III endoleaks and 99% left subclavian artery branch patency. Aortic enlargement (>5 mm) was observed in 5% (all in AN cohort; none requiring reintervention), with no instances of aortic rupture, device migration, or wire fracture reported. Late reinterventions were required in 7% of patients, all in the AN group. At 3 years, the TBE device demonstrated durable outcomes for nondissection descending thoracic aortic disease, with high branch patency, low lesion-related mortality, and minimal complications across diverse pathology cohorts. These results support its role as a safe, effective alternative to surgical revascularization in anatomically suitable zone 2 cases.