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Aortic Remodeling after Endovascular Repair of the Descending Thoracic Aorta

Aortic Remodeling after Endovascular Repair of the Descending Thoracic Aorta. G. William Moser CRNP, Patrick Moeller BS, Thomas Bavaria Jr. BS, Ahmad Zeeshan MD, Joseph Bavaria MD Hospital of the University of Pennsylvania Division of Cardiovascular Surgery. Background.

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Aortic Remodeling after Endovascular Repair of the Descending Thoracic Aorta

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  1. Aortic Remodeling after Endovascular Repair of the Descending Thoracic Aorta G. William Moser CRNP, Patrick Moeller BS, Thomas Bavaria Jr. BS, Ahmad Zeeshan MD, Joseph Bavaria MD Hospital of the University of Pennsylvania Division of Cardiovascular Surgery

  2. Background • Thoracic endovascular repair of the aorta (TEVAR) has created new therapeutic issues and challenges • Decreased operative mortality, decreased hospital length of stay, decreased mechanical ventilation time, and decreased blood transfusion requirements relative to open repair have led to much increased volume of implantation since the technology was approved • TEVAR produces its own challenges, in particular the possibility of endoleaks • Occur in up to 29% of patients. • Late term development of endoleaks raises the inherent risks of anesthesia, vascular access and hospitalization again face the patient.

  3. Changes in Aortic Length • The appearance of latent type III endoleaks in patients showing no sign of device migration raises the possibility of changes in aortic length • Few studies have specifically targeted analysis of aortic length. • Previous work has found: • Landing zone lengthening in the abdomen1 • A case study noting aortic lengthening in a patient with aortic lengthening-induced aortic valve stenosis2 • We set out to review our descending thoracic aorta (DTA) experience from the perspective of aortic length. • Litwinski et al, Journal of Vascular Surgery, 2006; 44: 1176-81. • Shah et al, Annals of Thoracic Surgery, 2007; 84: 1010-2

  4. Methods •  A retrospective review of all evaluable CT angiograms (CTA) submitted to M2S (Medical Metrix Solutions, West Lebanon, NH) between January 2000 and August 2009 for 3D modeling of the DTA was conducted. • Aortic centerline is computed along 1 mm slices • Initial data: 1004 patients with 1844 scans • Patients and scans were excluded if: • Scans preceded TEVAR, or Patient did not receive TEVAR • Length of follow-up from first to last scan was less than 300 days • Patients with prior open repair of the DTA were excluded, as some portion of their descending aorta was synthetic graft material • In cases of reintervention, the longer period of follow-up (between intervention 1 and 2, or after intervention 2) was used

  5. Final Cohort • 82 patients • 211 scans • Mean length of time from first to last CTA: 897±556 days • Measurements were taken from centerline slices from celiac artery to subclavian artery • If the subclavian artery was covered, the left common carotid or next proximal vessel was used

  6. Annualized Changes in Length: Total Cohort • Mean overall change per year: 4.5±7.8mm • Proportion of patients experiencing changes in aortic centerline • Increase of >10mm per year in 16% (13 patients) • Increase of 5-10mm per year in 18% (15 patients) • Change of between +5 and -5 mm per year in 60% (49 patients) • Decrease in length of >5mm per year in 6% (5 patients)

  7. Annualized change in Centerline Length by Surgical Indication P value between groups is .014

  8. Annualized Change in centerline length by number of implanted stents P value between groups is .008

  9. Annualized Change in centerline length by Age P value between groups is .013

  10. Conclusions • Aortic lengthening occurs in up to 34% of patients who underwent TEVAR • Annual length changes of >1cm in 16% of patients • Lengthening may be more common in older patients, patients with redo TEVAR or fusiform aneurysm, and patients with more than 2 stents implanted

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