Katrin Meisenbacher

Introduction: To improve the outcomes of thoracic endovascular aortic repair (TEVAR), we investigated the dynamic morphology of dilated and nondilated ascending aortas (AAs) to determine whether an appropriate proximal landing zone for TEVAR exists if the middle AA is dilated. Materials and Methods: Patients with dilated (diameter 40–50 mm) and nondilated (<40 mm) AAs underwent electrocardiogram-gated computed tomography angiography of the entire AA in the systolic and diastolic phases. For each plane of each AA segment, the maximal and minimal diameters in systole and diastole were recorded. Results: A total of 105 patients were enrolled (54% male; median age: 80 years [IQR 78–85]). A total of 35 patients were included in the dilated AA group (DG), and 70 patients were included in the nondilated AA group (n-DG). The aortic planes of the AA segment at the sinotubular junction (STJ) showed a more oval-shaped morphology compared with the distal planes of the same segment (the differences between the maximum and minimum diameters were 8.9% to 9.4% and 4.8% to 5.6%, respectively). If the mid-ascending aorta was dilated, the aortic segment at the STJ showed a more pronounced reversed-funnel 3D morphology, with a 14% (IQR 11%–19%) difference in diameters between the proximal and distal segmental planes shown in the n-DG and 18% (IQR 16%–22%, p<0.001) in the DG. Conclusion: If the middle AA is dilated, it is considered unsuitable to perform TEVAR using conventional endografts without additional proximal fixation in the aortic segment at the STJ due to its pronounced reversed-funnel segmental morphology. By contrast, the aortic segment at the brachiocephalic trunk seems to be promising for performing TEVAR using an endograft of the appropriate size and conformability. Moreover, endograft sizing using the average aortic diameter instead of the maximal AA diameter in an oval-shaped aortic plane morphology should be considered. Clinical Impact: If the middle ascending aorta is dilated, it is considered unsuitable to perform TEVAR with a proximal landing in the aortic segment at the sinotubular junction due to its pronounced reversed-funnel segmental morphology and high risk of type Ia endoleak and endograft migration. By contrast, the aortic segment at the brachiocephalic trunk seems to be promising for performing TEVAR due to its moderate funnel morphology using an endograft of appropriate size and conformability.

Purpose: Anatomical understanding is an important basis for medical teaching, especially in a surgical context. The interpretation of complex vascular structures via two-dimensional visualization can yet be difficult, particularly for students. The objective of this study was to investigate the feasibility of an MxR-assisted educational approach in vascular surgery undergraduate education, comparing an MxR-based teaching-intervention with CT-based material for learning and understanding the vascular morphology of the thoracic aorta. Methods: In a prospective randomized controlled trial learning success and diagnostic skills following an MxR- vs. a CT-based intervention was investigated in 120 thoracic aortic visualizations. Secondary outcomes were motivation, system-usability as well as workload/satisfaction. Motivational factors and training-experience were also assessed. Twelve students (7 females; mean age: 23 years) were randomized into two groups undergoing educational intervention with MxR or CT. Results: Evaluation of learning success showed a mean improvement of 1.17 points (max.score: 10; 95%CI: 0.36–1.97). The MxR-group has improved by a mean of 1.33 [95% CI: 0.16–2.51], against 1.0 points [95% CI: -0.71- 2.71] in the CT-group. Regarding diagnostic skills, both groups performed equally (CT-group: 58.25 ± 7.86 vs. MxR-group:58.5 ± 6.60; max. score 92.0). 11/12 participants were convinced that MxR facilitated learning of vascular morphologies. The usability of the MxR-system was rated positively, and the perceived workload was low. Conclusion: MxR-systems can be a valuable addition to vascular surgery education. Further evaluation of the technology in larger teaching situations are required. Especially regarding the acquisition of practical skills, the use of MxR-systems offers interesting application possibilities in surgical education.

Objectives: A growing body of evidence highlights the effects of air pollution on chronic and acute cardiovascular diseases, such as associations between PM₁₀ and several cardiovascular events. However, evidence of the impact of fine air pollutants on the development and progression of peripheral arterial aneurysms is not available. Methods: Data were obtained from the multicenter PAA outcome registry POPART and the German Environment Agency. Means of the mean daily concentration of PM₁₀, PM_2.5, NO_2, and O₃ concentrations were calculated for 2, 10, and 3650 days prior to surgery for each patient. Additionally, weighted ten-year averages were analyzed. Correlation was assessed by calculating Pearson correlation coefficients, and regression analyses were conducted as multiple linear or multiple logistic regression, depending on the dependent variable. Results: For 1193 patients from the POPART registry, paired air pollution data were available. Most patients were male (95.6%) and received open surgical repair (89.9%). On a regional level, the arithmetic means of the daily means of PM₁₀ between 2000 and 2022 were neither associated with average diameters nor runoff vessels. Negative correlations for mean PAA diameter and mean NO₂, as well as a positive correlation with mean O₃, were found; however, they were not statistically significant. On patient level, no evidence for an association of mean PM₁₀ exposure over ten years prior to inclusion in the registry and PAA diameter or the number of runoff vessels was found. Weighted PM_10, NO_2, and O₃ exposure over ten years also did not result in significant associations with aneurysm diameter or runoff vessels. Short-term air pollutant concentrations were not associated with symptomatic PAAs or with perioperative complications. Conclusions: We found no indication that long-term air pollutant concentrations are associated with PAA size or severity, neither on a regional nor individual level. Additionally, short-term air pollution showed no association with clinical presentation or treatment outcomes.

Mixed reality (MxR) enables the projection of virtual three-dimensional objects into the user’s field of view via a head-mounted display (HMD). This phantom model study investigated three different workflows for navigated common femoral arterial (CFA) access and compared it to a conventional sonography-guided technique as a control. A total of 160 punctures were performed by 10 operators (5 experts and 5 non-experts). A successful CFA puncture was defined as puncture at the mid-level of the femoral head with the needle tip at the central lumen line in a 0° coronary insertion angle and a 45° sagittal insertion angle. Positional errors were quantified using cone-beam computed tomography following each attempt. Mixed effect modeling revealed that the distance from the needle entry site to the mid-level of the femoral head is significantly shorter for navigated techniques than for the control group. This highlights that three-dimensional visualization could increase the safety of CFA access. However, the navigated workflows are infrastructurally complex with limited usability and are associated with relevant cost. While navigated techniques appear as a potentially beneficial adjunct for safe CFA access, future developments should aim to reduce workflow complexity, avoid optical tracking systems, and offer more pragmatic methods of registration and instrument tracking.

Long-term outcome after thoracic endovascular aortic repair (TEVAR) of acute type B aortic dissection (aTBAD) is still underreported in current literature. This case report shows persistence of aortic remodeling without secondary complication or need of reintervention 13 years after TEVAR. A 45-year-old woman was referred to the emergency room with aTBAD. Due to early diameter progression in combination with therapy-refractory pain and uncontrolled hypertension, TEVAR was performed. Hereafter, the patient showed complete remodeling of the descending thoracic aorta without persistent false lumen perfusion in this segment and with stable true and false lumen diameter in the untreated abdominal segment for a 13-year period. No aortic-related reintervention was needed. With contemporary devices and adapted therapy, TEVAR seems able to treat complex thoracic disease. Long-term follow-up (FU) is mandatory to monitor the efficacy and durability of endovascular treatment in aortic disease.

In this study, we assessed the dynamic segmental anatomy of the entire ascending aorta (AA), enabling the determination of a favorable proximal landing zone and appropriate aortic sizing for the most proximal thoracic endovascular aortic repair (TEVAR). Methods: Patients with a non-operated AA (diameter < 40 mm) underwent electrocardiogram-gated computed tomography angiography (ECG-CTA) of the entire AA in the systolic and diastolic phases. For each plane of each segment, the maximum and minimum diameters in the systole and diastole phases were recorded. The Wilcoxon signed-rank test was used to compare aortic size values. Results: A total of 100 patients were enrolled (53% male; median age 82.1 years; age range 76.8–85.1). Analysis of the dynamic plane dimensions of the AA during the cardiac cycle showed significantly higher systolic values than diastolic values (p < 0.001). Analysis of the proximal AA segment showed greater distal plane values than proximal plane values (p < 0.001), showing a reversed funnel form. At the mid-ascending segment, the dynamic values did not notably differ between the distal plane and the proximal segmental plane, demonstrating a cylindrical form. At the distal segment of the AA, the proximal plane values were larger than the distal segmental plane values (p < 0.001), thus generating a funnel form. Conclusions: The entire AA showed greater systolic than diastolic aortic dimensions throughout the cardiac cycle. The mid-ascending and distal-ascending segments showed favorable forms for TEVAR using a regular cylindrical endograft design. The most proximal segment of the AA showed a pronounced conical form; therefore, a specific endograft design should be considered.

Acute Type B aortic dissection (TBAD) can cause organ malperfusion, e.g., lower limb ischemia (LLI). Thoracic endovascular aortic repair (TEVAR) represents the standard treatment for complicated TBAD; however, with respect to LLI, data is scant. The aim of this study was to investigate clinical and morphological outcomes in patients with complicated TBAD and LLI managed with a “TEVAR-first” policy. Between March 1997 and December 2021, 731 TEVAR-procedures were performed, including 106 TBAD-cases. Cases with TBAD + LLI were included in this retrospective analysis. Study endpoints were morphological/clinical success of TEVAR, regarding aortic and extremity-related outcome, including extremity-related adjunct procedures (erAP) during a median FU of 28.68 months. A total of 20/106 TBAD-cases (18.8%, 32–82 years, 7 women) presented with acute LLI (12/20 Rutherford class IIb/III). In 15/20 cases, true lumen-collapse (TLC) was present below the aortic bifurcation. In 16/20 cases, TEVAR alone resolved LLI. In the remaining four cases, erAP was necessary. A morphological analysis showed a relation between lower starting point and lesser extent of TLC and TEVAR success. No extremity-related reinterventions and only one major amputation was needed. The data strongly suggest that aTEVAR-first-strategy for treating TBAD with LLI is reasonable. Morphological parameters might be of importance to anticipate the failure of TEVAR alone.

Purpose: The objective of this systematic review was to report the cumulative incidence of endograft migration (EM), as well as the morbidity, reintervention rates, and mortality related to EM. This study aimed to provide evidence-based data on patient-relevant sequelae of EM after thoracic endovascular aortic repair (TEVAR) performed using contemporary aortic endografts. Materials and Methods: A systematic electronic search of literature in MEDLINE (via PubMed), Web of Science, and Cochrane Central Register of Controlled Trials was performed. The pooled synthesis of outcomes was performed using the inverse variance method. Results: Seven prospective non-randomized and 4 retrospective studies, including a total of 1783 patients presenting 70 EMs, were considered for the quantitative analysis. The pooled rate of EM was 4% (95% CI, 2%–7%; range, 0.2%–11%; I2=82%); pooled morbidity rate was 31% (95% CI, 12%–59%; range, 0%–100%; I2=64%) and pooled reintervention rate was 32% (95% CI, 15%–56%; range, 0%–100%; I2=55%). The pooled mortality rate due to EM was 5% (95% CI, 1%–21%; range, 0%–40%; I2=24%). Conclusion: For the first time, this meta-analysis provides pooled reference estimates of EM after TEVAR. Thus, the results hold the potential to further characterize EM after TEVAR. The clinical relevance of EM is underlined by its association with high rates of endoleak-related morbidity, reintervention, and mortality. Close standardized surveillance after TEVAR for early detection of EM and prophylaxis of its sequelae is essential.