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Background Chronic type B aortic dissection (TBAD) is associated with poor long-term outcome, and accurate risk stratification tools remain lacking. Pressurization of the false lumen (FL) has been recognized as central in promoting aortic growth. Several surrogate imaging-based metrics have been proposed to assess FL hemodynamics; however, their relationship to enlarging aortic dimensions remains unclear. We investigated the association between aortic growth and three cardiovascular magnetic resonance (CMR)-derived metrics of FL pressurization: false lumen ejection fraction (FLEF), maximum systolic deceleration rate (MSDR), and FL relative pressure (FL ΔP max ). Methods C MR/CMR angiography was performed in 12 patients with chronic dissection of the descending thoracoabdominal aorta, including contrast-enhanced CMR angiography and time-resolved three-dimensional phase-contrast CMR (4D Flow CMR). Aortic growth rate was calculated as the change in maximal aortic diameter between baseline and follow-up imaging studies over the time interval, with patients categorized as having either ‘stable’ (< 3 mm/year) or ‘enlarging’ (≥ 3 mm/year) growth. Three metrics relating to FL pressurization were defined as: (1) FLEF: the ratio between retrograde and antegrade flow at the TBAD entry tear, (2) MSDR: the absolute difference between maximum and minimum systolic acceleration in the proximal FL, and (3) FL ΔP max : the difference in absolute pressure between aortic root and distal FL. Results FLEF was higher in enlarging TBAD (49.0 ± 17.9% vs. 10.0 ± 11.9%, p = 0.002), whereas FL ΔP max was lower (32.2 ± 10.8 vs. 57.2 ± 12.5 mmHg/m, p = 0.017). MSDR and conventional anatomic variables did not differ significantly between groups. FLEF showed positive (r = 0.78, p = 0.003) correlation with aortic growth rate whereas FL ΔP max showed negative correlation (r = − 0.64, p = 0.026). FLEF and FL ΔP max remained as independent predictors of aortic growth rate after adjusting for baseline aortic diameter. Conclusion Comparative analysis of three 4D flow CMR metrics of TBAD FL pressurization demonstrated that those that focusing on retrograde flow (FLEF) and relative pressure (FL ΔP max ) independently correlated with growth and differentiated patients with enlarging and stable descending aortic dissections. These results emphasize the highly variable nature of aortic hemodynamics in TBAD patients, and suggest that 4D Flow CMR derived metrics of FL pressurization may be useful to separate patients at highest and lowest risk for progressive aortic growth and complications.

To evaluate the efficacy of endovascular circulating false lumen occlusion (CFLO) in inducing positive aortic remodeling in chronic aneurysmal descending aortic dissection (AD). This retrospective monocentric study included patients treated by CFLO between 2003 and 2022 in the context of chronic AD with progressive descending aneurysmal evolution and persistent circulating false lumen (FL). The procedure was achieved with coils, plugs, and/or glue at the entry tear or in the FL and/or with covered stenting in the supra-aortic trunk. The primary endpoint evaluated the positive aortic remodeling, defined as stabilization or a decrease in the aortic diameter on a computed tomography scan at the 1-year follow-up after the procedure. The FL circulating status, safety, and occurrence of aneurysm events during follow-up were also evaluated. Twenty patients [median age: 65.4 years, interquartile range (IQR): 58.4–69.9; 13 men] were included, with a median duration from an acute AD of 32.5 months (IQR: 8.8–76.5). Twelve patients (60%) achieved complete FL thrombosis after CFLO, whereas 8/20 patients (40.0%) experienced partial thrombosis. Additionally, positive aortic remodeling was observed in 13 patients (65%). Following the procedure, the aneurysmal aortic diameter decreased in 8/20 patients (40.0%) and remained stable in 5/20 patients (25.0%). Two patients (10%) had complications related to the procedure. Two patients (10%) had secondary aneurysm events during follow-up. CFLO is a feasible and efficient method to induce FL thrombosis and reduce aneurysmal progression in chronic AD. The positive outcomes observed highlight the potential of this technique to improve patient management in complex aortic pathologies. This approach offers a valuable option in the management of chronic AD and emphasizes the importance of endovascular interventions in enhancing patient outcomes.

Purpose: To assess the significance of aortic remodeling in the prevention of the late aortic events after thoracic endovascular aortic repair (TEVAR) for aortic dissection. Methods: The study involved 52 patients (41 men; mean age was 59.7±13.3 years) with type B aortic dissections and patent false lumens treated with TEVAR between 2004 and 2011. Of the 52 patients, 18 were treated in the acute phase for rupture (n=1), malperfusion (n=10), aortic diameter over 40 mm at onset (n=3), and rapid enlargement of the false lumen (n=4). In the chronic setting, the indications for TEVAR were rupture (n=1), malperfusion (n=2), aortic diameter >50 mm (n=18), and rapid enlargement of the false lumen (n=13). Aortic remodeling was evaluated at 6 months postoperatively, and risk factors for late aortic events were evaluated in multivariate analysis using aortic remodeling and other pre-, peri-, and postoperative factors. Results: Over a mean 36.0±18.9 months, 19 aortic events were documented: enlargement of the false lumen (n=4), type I endoleak (n=2), and erosion at the stent-graft edges (n=13). Multivariate analysis revealed that failure to achieve aortic remodeling at 6 months postoperatively was the only significant risk factor for late aortic events (hazard ratio 0.20, p=0.037). Patients with aortic remodeling had a higher rate of freedom from aortic events compared with those without aortic remodeling (100% vs. 81.5% at 1 year and 79.3% vs. 48.4% at 3 years, respectively). Conclusion: Aortic remodeling after TEVAR is a significant prognostic factor for better long-term results for type B aortic dissection.

Purpose Aim of this technical note article is to introduce a modified, novel way to custom create a candy-plug (CP) device to endovascularly occlude false lumen. The technique is illustrated by a patient case with significant backflow to false lumen (FL). The patient had already undergone surgical repair of the ascending aorta, aortic arch and subsequent TEVAR procedure down to the ostium of the celiac trunk because of type A aortic dissection, but the descending thoracic aorta continued to dilate due to backflow to the FL from an uncovered tear at the level of the renal arteries. Materials and methods We modified a Gore Excluder 36–45 mm aortic extender (W. L. Gore & Associates, Inc. Flagstaff, USA) endoprosthesis into a CP device that was subsequently positioned under local anesthesia into the FL of the distal descending thoracic aorta. Results In 1 month control the backflow to false lumen had ceased and the aorta had decreased in diameter from 69 to 66 mm, FL from 37 to 34 mm, true lumen (TL) remained the same 32 mm. Conclusion We describe a modified, effective candy-plug technique to occlude retrograde false lumen filling in aortic dissection.

Purpose To investigate the predictors of failed false lumen (FL) volume reduction at 12 months after stent-graft implantation in patients with type B aortic dissection. Methods The retrospective analysis comprised 38 patients (25 men; mean age 60±12 years) with double-barrel type B aortic dissection (9 acute) treated with thoracic endovascular aortic repair (TEVAR) and evaluated with serial computed tomography (CT) scans up to 12 months. Aortic volume changes were determined. Based on FL volume change at 1 year after stent-graft implantation, patients were dichotomized according to the presence or absence of FL volume reduction. Clinical and CT variables were compared between groups to determine risk factors of failed FL volume reduction. A major adverse event (MAE) was defined as death or reintervention. Results Patients were followed for 4.2±2.8 years. FL volume reduction (+FLVR) occurred in 27 (71%) patients, whereas 11 (29%) patients had no FL volume reduction (-FLVR). The MAE-free survival rate was significantly higher in the +FLVR patients than in the -FLVR group (88.9% vs. 27.3%, respectively; p=0.001). Chronicity of dissection, location of tear site, or the maximum total aortic lumen area was not associated with failure to achieve FL volume reduction. However, the maximum preprocedure FL area was significantly lower in the +FLVR group than in the -FLVR group (12.6±6.6 vs. 21.0±11.4 cm2, respectively; p=0.041) and was an independent predictor for failed FL volume reduction (odds ratio 1.3, 95% confidence interval 1.02 to 1.70, p=0.031). Conclusion Failed FL volume reduction after TEVAR was associated with a significantly increased rate of mortality or reintervention during follow-up. A larger preprocedure maximum FL area was a predictor of failed FL volume reduction after TEVAR in type B dissection.

This study evaluated whether degradation products of plasma fibrin and fibrinogen (FDP) level can be used to differentiate acute aortic dissection (AAD) from acute myocardial infarction (AMI), angina pectoris, acute cerebral infarction, or transient cerebral ischemic attack (TIA). Ninety-six consecutive patients with definitive diagnosis of AAD by contrast-enhanced computed tomography scan underwent measurement of FDP on admission. Of these patients, 45 had a patent false lumen (patent-type), and 51 had complete thrombosis of the false lumen (thrombosed-type). Control groups were patients admitted during the same period for whom a diagnosis of either AMI ( n  = 187), angina pectoris ( n  = 142), cerebral infarction ( n  = 353), or TIA ( n  = 94) was confirmed. FDP was significantly higher in patients with patent-type AAD (median, 210 μg/mL; interquartile range, 70–358 μg/mL) than in those with thrombosed-type AAD (16.5, 7.2–50.1). Patients with patent-type AAD or thrombosed-type AAD had a significantly higher FDP than patients in any of the control groups. Receiver operating characteristic curve analysis indicated that FDP ≥ 12.6 μg/mL was the cutoff value that best differentiated patients with patent-type AAD from patients in any of the control groups (sensitivity, 100 %; negative predictive value [NPV], 100 %). And, this FDP cutoff level was associated with a high positive predictive value (PPV) (80–92 %). The cutoff value to differentiate patients with thrombosed-type AAD from patients in any of the control groups was FDP ≥ 5.6 μg/mL (sensitivity, 100 %; NPV, 100 %). However, this FDP cutoff level was associated with a low PPV (36–81 %). FDP and D-dimer were measured at the same time on admission in 30 patients with AAD and 41 patients in control groups. A simple liner regression, calculated using FDP and D-dimer values from a total of 71 patients, yielded a correlation coefficient ( R 2 ) of 0.95, indicating a strong correlation. In symptomatic patients with suspected AAD, a diagnosis of patent-type AAD should be considered if FDP ≥ 12.6 μg/mL. Patients with FDP ≥ 5.6 μg/mL have the possibility of thrombosed-type AAD.

Side-branches (SBs) emanating from the false lumen (FL) in Type-B aortic dissection (TBAD) has been shown to influence patency and FL growth, making FL hemodynamics crucial to understand. This study employs a strongly coupled Fluid-Solid interaction simulation to compare FL hemodynamics in four scenarios: (1) without SB (NSB), (2) single SB in FL (SB_FL), (3) single SB in FL with no re-entry tear (SB_FL_1T), and (4) single SB in true lumen (SB_TL). A pulsatile mass flow is imposed at the inlet, while 3-element windkessel models are applied at the outlets, ensuring equal total vascular resistance for all scenarios. While idealized in terms of geometry, the model incorporates residually stressed, externally supported and anisotropic tissue. Results demonstrate that SB presence leads to higher pressures in both TL and FL during systole, with the highest increase in systolic pressure when the SB emanates from the FL (∼6 mmHg vs ∼3 mmHg for SB_TL). A side branch in the FL reduces FL ejection fraction (FLEF) and leads to higher cycle-averaged transmembrane pressure (TMP¯), which however remains below 1 mmHg for all scenarios. NSB exhibits the highest dissected membrane displacement (∼8 mm), while SB_FL shows the lowest displacement across all planes (∼5.5 mm). These findings suggest that SBs in TBAD affect hemodynamics beyond an altered flow velocity field within the false lumen and, in a setting with maintained mass flow and total vascular resistance, leads to increased TL and FL pressures. The idealized nature of the geometry, however, is to be kept in mind when interpreting our data and extrapolating towards clinical reality.

We investigated the influence of false lumen (FL) status on the systemic inflammatory response triggered by acute aortic dissection (AAD) using cytokine profiling. The study included 44 patients with AAD. Patients were divided between those with a thrombosed FL (Group T, n  = 21) and those with a non-thrombosed FL (Group P, n  = 23). On-admission serum concentrations of 29 cytokines were compared between unmatched and propensity-score matched ( n  = 10 pairs) FL groups and a control group (non-ruptured thoracic aortic aneurysm, Group C, n  = 20). Unmatched analysis showed 12 cytokines differed between groups and fell into three categories: Category A (increased expression in both FL groups: IL-6, IL-10, IL-15, G-CSF); Category B (increased expression only in Group P: IL-1Ra, IL-1β, IL-8, IL-12p70, GM-CSF); and Category C (others: IP-10, VEGF-A, eotaxin). The increases in Category A and Category B cytokines in Group T were attenuated, but not significantly, compared to their increases in Group P. Propensity-score matching analysis revealed a similar expression pattern with respect to all four Category A cytokines, four Category B cytokines (IL-1β, IL-1Ra, IL-12p70, and GM-CSF), and two Category C cytokines (IP-10 and VEGF-A). A robust inflammatory response occurs in patients with AAD, but the response is attenuated when the FL is thrombosed.

Thoracic endovascular repair (TEVAR) has recently been established as the preferred treatment option for complicated type B dissection. This procedure involves covering the primary entry tear to stimulate aortic remodelling and promote false lumen thrombosis thereby restoring true lumen flow. However, complications associated with incomplete false lumen thrombosis, such as aortic dilatation and stent graft induced new entry tears, can arise after TEVAR. This study presents the application and validation of a recently developed mathematical model for patient-specific prediction of thrombus formation and growth under physiologically realistic flow conditions. The model predicts thrombosis through the evaluation of shear rates, fluid residence time and platelet distribution, based on convection-diffusion-reaction transport equations. The model was applied to 3 type B aortic dissection patients: two TEVAR cases showing complete and incomplete false lumen thrombosis respectively, and one medically treated dissection with no signs of thrombosis. Predicted thrombus growth over time was validated against follow-up CT scans, showing good agreement with in vivo data in all cases with a maximum difference between predicted and measured false lumen reduction below 8%. Our results demonstrate that TEVAR-induced thrombus formation in type B aortic dissection can be predicted based on patient-specific anatomy and physiologically realistic boundary conditions. Our model can be used to identify anatomical or stent graft related factors that are associated with incomplete false lumen thrombosis following TEVAR, which may help clinicians develop personalised treatment plans for dissection patients in the future.

The impact of inconsistent enhancement within the patent false lumen on the occurrence of late aortic events remains uncertain. We enrolled 55patients who exhibited a patent false lumen after hemiarch replacement. The Hounsfield unit (HU) measurements in the patent false lumen were obtained at 2 specific locations: the aortic arch (a) and the descending aorta (b). The false lumen HU score was calculated as the absolute value of 1 − a/b, representing the discrepancy in HUs within the patent false lumen. We investigated the cut-off value of the false lumen HU score with the receiver operating characteristics curve to predict the incidence of late aortic events. We divided the patients based on the cut-off value and compared the cumulative incidence of the late aortic events. The analysis of the receiver operating characteristics curve showed that the cut-off value of the false lumen HU score was 0.345. Based on this cut-off value, we divided them into 2 groups: Group A (score <0.345, n = 26) and Group B (score ≥0.345, n = 29). The baseline characteristics were similar between the 2 groups. The cumulative incidence of the late aortic events was significantly lower in Group A (7.8% at 5 years) than in Group B (39.9% at 5 years) (p = 0.02). The false lumen HU score might be useful to predict the incidence of late aortic events after hemiarch replacement.