Ernst Weigang

Time-resolved 3D MR velocity mapping at 3T: Improved navigator-gated assessment of vascular anatomy and blood flow

To evaluate an improved image acquisition and data‐processing strategy for assessing aortic vascular geometry and 3D blood flow at 3T.

Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Thoracic endovascular aortic repair (TEVAR) is an emerging treatment modality, which has been rapidly embraced by clinicians treating thoracic aortic disease.1–4 Fundamentally, it is a far less invasive approach than open surgery and its availability and relative ease of application has changed and extended management options in thoracic aortic disease, including in those patients deemed unfit or unsuitable for open surgery. In the operating room, this requires considerable perceptual, cognitive and psychomotor demands on the operators. The dramatic expansion of TEVAR activity has necessarily prompted a requirement to systematically consider the indications, appropriateness, limitations and delivery of this treatment, which has been adopted by many specialties including cardiologists, cardiovascular surgeons, radiologists and vascular surgeons.5 Our task has been to generate a multidisciplinary position statement that supports and advises all clinicians utilizing this technological advance. This document focuses on the main diagnoses—thoracic aortic aneurysm (TAA), thoracic aortic dissection (TAD) of the descending aorta (type B according to the Stanford classification) and thoracic aortic injury (TAI)—indications and applicability of TEVAR and includes information regarding its limitations and complications. It acts as a position statement for both societies that reflects current understanding of thoracic aortic endovascular therapy. ### Evaluation of symptoms and patient status Symptoms in patients with TAA and chronic dissection are rare and non-specific.6,7 New onset of hoarseness or dysphagia may suggest a developing aneurysm in the distal aortic arch and proximal descending aorta. Most asymptomatic cases are discovered incidentally, while symptomatic patients have usually developed complications. Even in patients with acute aortic syndromes, chest pain, back pain and signs of malperfusion are often misinterpreted due to lack of awareness. In cases of clinical suspicion, a computed tomography (CT)-angiography is the diagnostic modality of first choice. ### Multidisciplinary consultation Patient selection should be performed on an individual basis according to anatomy, pathology, comorbidity and …

Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.

Time-resolved, 3-dimensional magnetic resonance flow analysis at 3 T: visualization of normal and pathological aortic vascular hemodynamics.

Flow-sensitive 3-dimensional magnetic resonance imaging at 3 T and advanced 3-dimensional visualization were used to visualize local and global vascular hemodynamics in the thoracic aorta. In patients with pathological geometric alterations of the thoracic aorta, this technique revealed considerable changes in local blood flow characteristics, compared with normal volunteers. Specifically, relatively small geometric changes, such as a partially thrombosed aortic arch or a mild aneurysm of the ascending aorta, resulted in major disturbances of local blood flow patterns within and even further downstream to the pathology.

Supra-aortic Transposition for Combined Vascular and Endovascular Repair of Aortic Arch Pathology

BACKGROUND Supra-aortic transpositions in various extents followed by endovascular stent graft placement are now an established tool in the treatment of various pathologies affecting the aortic arch. Results remain to be determined. METHODS From 1996 through 2007, 73 patients (median age, 71 years) presented with aortic arch pathology (atherosclerotic aneurysms, n = 42; type B dissections, n = 9; penetrating ulcers, n = 17; traumatic lesions, n = 2; aneurysms based on prior surgery for aortic coarctation, n = 3). Strategy for distal arch disease was subclavian-to-carotid transposition (n = 24) or autologous double-vessel transposition through upper hemisternotomy (n = 36). For entire arch disease, total supra-aortic rerouting with a reversed bifurcated prosthesis was applied (n = 13). Endovascular stent graft placement was performed metachronously. RESULTS In-hospital mortality was 6.8% (n = 5). Persistent early type I and III endoleak rate was 9.6%. Persistent late type I and III endoleak rate was 5.5%. Overall actuarial survival was 90%, 86%, and 72% at 1, 3, and 5 years. Mean follow-up is 37 months (range, 1 to 120). Early and late endoleak formation was independently predicted by the number of prostheses (early odds ratio [OR] 0.210, p = 0.0003; late OR 0.216, p = 0.012), whereas logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) reached borderline significance regarding late endoleaks (OR 2.1, p = 0.095). An earlier year of implantation reached borderline significance predicting survival (OR 1.9, p = 0.062). Furthermore, survival was independently predicted by higher logistic EuroSCORE levels (OR 1.8, p = 0.020). Interestingly, type of arch rerouting did not influence endoleak formation and survival (OR 0.9, p = 0.812). CONCLUSIONS Results after supra-aortic transpositions in various extents followed by endovascular stent graft placement for the treatment of various pathology affecting the aortic arch are promising. Endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. Each type of arch rerouting, irrespective of extent, has turned out to be effective. Therefore, extended applications of these combined treatment strategies substantially augment the therapeutic options.

Targeting Landing Zone 0 by Total Arch Rerouting and TEVAR: Midterm Results of a Transcontinental Registry

BACKGROUND Landing zone 0, defined as a proximal landing zone in the ascending aorta, remains the last frontier to be taken. Midterm results of total arch rerouting and thoracic endovascular aortic repair (TEVAR) extending into landing zone 0 remain to be determined. METHODS From 2003 to 2011, 66 patients (mean age, 70 years; 68% men) presenting with pathologic conditions affecting the aortic arch (atherosclerotic aneurysms [n = 48], penetrating ulcers [n = 6], type B dissections [n = 6], type B after type A dissections [n = 5], and anastomotic aneurysm [n = 1]) were treated in 5 participating centers. Of these 66 patients, only 12% would have been deemed suitable for any kind of conventional surgical repair because of multisegmental aortic disease or comorbidities. RESULTS In-hospital mortality was 9%. Retrograde type A dissection was observed in 3% of patients. The assisted type I and type III endoleak rate was 0%. Stroke was seen in 5% of patients. Permanent paraplegia was observed in 3% of those studied. Median follow-up was 25 months (8-41 months). There was 1 late type Ib endoleak, which was followed by watchful waiting. Five-year survival was 72%. Five-year aorta-related survival was 96%. No aorta-related reintervention had to be performed in the segments treated. CONCLUSIONS Midterm results of total arch rerouting and TEVAR extending into landing zone 0 are excellent in regard to aorta-related survival and freedom from aorta-related reintervention. Retrograde type A dissection, potentially related to compliance mismatch between the ascending aorta and the stent-graft, warrants further attention. Extended application of this strategy augments therapeutic options in a group of patients who are not suitable candidates for conventional therapy.

Cerebral Protection During Surgery for Acute Aortic Dissection Type A Results of the German Registry for Acute Aortic Dissection Type A (GERAADA)

Background— Cerebral protection during surgery for acute aortic dissection type A relies on hypothermic circulatory arrest, either alone or in conjunction with cerebral perfusion. Methods and Results— The perioperative and intraoperative conditions of 1558 patients submitted from 44 cardiac surgery centers in German-speaking countries were analyzed. Among patients with acute aortic dissection type A, 355 (22.8%) underwent surgery with hypothermic circulatory arrest alone. In 1115 patients (71.6%), cerebral perfusion was used: Unilateral antegrade cerebral perfusion (ACP) in 628 (40.3%), bilateral ACP in 453 (29.1%), and retrograde perfusion in 34 patients (2.2%). For 88 patients with acute aortic dissection type A (5.6%), no circulatory arrest and arch intervention were reported (cardiopulmonary bypass–only group). End points of the study were 30-day mortality (15.9% overall) and mortality-corrected permanent neurological dysfunction (10.5% overall). The respective values for the cardiopulmonary bypass–only group were 11.4% and 9.1%. Hypothermic circulatory arrest alone resulted in a 30-day mortality rate of 19.4% and a mortality-corrected permanent neurological dysfunction rate of 11.5%, whereas the rates were 13.9% and 10.0%, respectively, for unilateral ACP and 15.9% and 11.0%, respectively, for bilateral ACP. In contrast with the ACP groups, there was a profound increase in mortality when systemic circulatory arrest times exceeded 30 minutes in the hypothermic circulatory arrest group (P<0.001). Mortality-corrected permanent neurological dysfunction correlated significantly with perfusion pressure in the ACP groups. Conclusions— This study reflects current surgical practice for acute aortic dissection type A in Central Europe. For arrest times less than 30 minutes, hypothermic circulatory arrest and ACP lead to similar results. For longer arrest periods, ACP with sufficient pressure is advisable. Outcomes with unilateral and bilateral ACP were equivalent.

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC).

Purpose To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection: analysis of the German Registry for Acute Aortic Dissection Type A.

OBJECTIVE Patients treated with an extensive approach including total aortic arch replacement for acute aortic dissection type A may have a favorable long-term prognosis by treating the residual false lumen. Our goal was to analyze the operative strategy for treatment of type I DeBakey aortic dissection from the German Registry for Acute Aortic Dissection Type A (GERAADA) data. METHODS A total of 658 patients with type I DeBakey aortic dissection and entry only in the ascending aorta were identified in the GERAADA. Patients in group A underwent replacement of the ascending aorta with hemiarch replacement. Patients in group B received extensive treatment with total arch replacement or conventional or frozen elephant trunk. RESULTS A total of 518 patients in group A and 140 patients in group B were treated. There was an overall 30-day mortality of 20.2% (n = 133). Group A had a slightly lower rate of mortality with 18.7% (n = 97) compared with 25.7% for group B (n = 36), but with no statistical significant difference (P = .067). The onset of new neurologic deficit (13.6% in group vs 12.5% in group B, P = .78) and new malperfusion deficit (8.4% in group A vs 10.7% in group B, P = .53) showed no statistical difference. CONCLUSIONS On analysis of the GERAADA data, it seems that a more aggressive approach of aortic arch treatment can be applied without higher perioperative risk even in the onset of acute aortic dissection type A. Long-term follow-up data analysis will be necessary to offer the optimal surgical strategy for different patient groups.

Acute aortic dissection type A: age-related management and outcomes reported in the German Registry for Acute Aortic Dissection Type A (GERAADA) of over 2000 patients.

Objective:To determine the association between age and clinical presentation, management and surgical outcomes in a large contemporary, prospective cohort of patients with acute aortic dissection type A (AADA). Background:AADA is one of the most life-threatening cardiovascular diseases, and delayed surgery or overly conservative management can result in sudden death. Methods:The perioperative and intraoperative conditions of 2137 patients prospectively reported to the multicenter German Registry for Acute Aortic Dissection Type A were analyzed. Results:Of all patients with AADA, 640 (30%) were 70 years or older and 160 patients (7%) were younger than 40 years. The probability of aortic dissection extension to the supra-aortic vessels and abdominal aorta decreased with age (P < 0.0001 and P = 0.0017, respectively). In 1447 patients (69%), the aortic root was preserved and supracoronary replacement of the ascending aorta was done. The probability of this procedure increased with age (P < 0.0001). The incidence of new postoperative neurological disorders was not influenced by age. The lowest probability of 30-day mortality was noted in the youngest patients (11%–14% for patients aged between 20 and 40 years) and rose progressively with age, peaking at 25% in octogenarians. Conclusions:This study reflects current results after surgical treatment of AADA in relation to patient age. Current survival rates are acceptable, even in very elderly patients. The contemporary surgical mortality rate among young patients is lower than that previously reported in the literature. The postoperative stroke incidence does not increase with age.