Journal of Vascular Surgery
Volume 48, Issue 6, Supplement , Pages 17S-23S, December 2008

Complex aortic disease: Changes in perception, evaluation and management

  • Tara M. Mastracci, MD
    • ,
  • Roy K. Greenberg, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Roy K. Greenberg, MD, The Cleveland Clinic Foundation, Vascular Surgery, S40, 9500 Euclid Ave, Cleveland, OH 44108

Endovascular and Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio

Received 6 August 2008; accepted 4 September 2008.

Article Outline

Complex aortic disease continues to have a high mortality and morbidity despite advances in medical and surgical treatment. Repair of thoracoabdominal aneurysms, treatment of patients with connective tissue disorders, and the approach to dissections of the ascending and descending aorta have evolved over time; however, the results of intervention in all but highly specialized centers remain poor. As vascular surgeons, our role must extend beyond that of the pure technician; we have been vested with the life-long care of these patients and, therefore, have a responsibility to the patient in addition the scientific community and society at large to create a strategy for management that serves all three interests justly. We will outline some of the changes in the conceptual approach that we consider important to the treatment of complex aortic disease.

 

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Thoracoabdominal aneurysm 

Open thoracoabdominal aortic aneurysm (TAAA) repair was first reported by Etheredge in 1955.1 He described the use of a polyethylene shunt to assist with the placement of an aortic homograft, anastomosed systematically using 4-0 cardiovascular silk to the celiac and superior mesenteric arteries, as well as proximal and distal aorta, with resection of the left kidney and intervening aneurysmal aorta. DeBakey subsequently presented the first series of cases in 1956,2 where he emphasized the use of a shunt to prevent prolonged end-organ ischemia. By 1965 DeBakey's group had amassed 42 cases and reported an operative mortality of 26%.3 Modifications on the original technique, specifically the use of a Carrell patch4 to expedite revascularization of the mesenteric vessels and minimize ischemia time, were proposed by Crawford and heralded the onset of a series of incremental improvements in the operative management of complex aortic repair.5

Now, modern series of elective TAAA repair from single-center, high-volume institutions report comparatively low mortality rates (Table),6, 7, 8, 9, 10, 11, 12, 13, 14, 15 but these results are not likely to reflect the true efficacy of the operation. Aggregate data that include outcomes from institutions with lower volume or limited expertise, such as reported by Rigberg et al,16 do not reflect the same perioperative success. In the Rigberg report, the elective operative mortality was 19% at 30 days and 31% at 1 year.16

Table. Mortality and rates of spinal cord injury in patients undergoing thoracoabdominal aortic aneurysm repair at specialized institutions
Trial, yearNo.Mortality, No. (%)Spinal cord injury, No.
Coselli,6 20072286150(6.56)87(3.81)
Schepens,7 200750062(12.40)N/A
Etz,8 200785883(9.67)10(1.17)
Achneck,9 2007130N/A(11.9)5(14.29)
Conrad,10 200745539(8.57)43(9.66)
Fehrenbacher,11 20071105(4.55)5(4.55)
Jacobs,12 200427924(8.60)4(1.43)
Safi,13 20051106162(14.65)36(3.25)
Grabitz,14 199626037(14.23)6(2.31)
Svensson,15 19931509123(8.15)234(15.51)

A disappointing finding was that the highest volume centers in this series performed only seven to 14 TAAA cases per year, suggesting that volume is likely associated with outcomes. Unfortunately, there are no multicenter trials or even prospective studies that have evaluated open TAAA surgery outcomes that may be used to help with the decision making regarding the risks and benefits of treatment.

Mortality alone is not a sufficient metric on which to base conclusions about TAAA repair. Serious morbidities have also been associated with the open approach, including spinal cord injury, stroke, and renal dysfunction. When combined with mortality, complications of open surgery have been frequent even in high-volume institutions. At institutions with reported perioperative mortality rates (6% to 9%), spinal cord ischemia has been reported in up to 15.5% of patients (range, 1.4%-15.5%), and renal complications occur in as many as 21% (range, 5.6-21). The reported outcomes challenge the role for open surgical treatment of extensive TAAA in institutions other than highly specialized open vascular surgery centers and call for an innovative new approach.

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Acute aortic dissection 

Acute aortic dissection was found in 3.5 per 100,000 population (95% confidence interval [CI], 2.4-4.6) in a population-based study from Olmsted County, Minnesota.17 In that review, 85% of dissections occurred in the ascending aorta and 15% in the descending. The survival rate was dismal in the mid-20th century, with a 5-year survival of 5% between 1951 and 1980, and demonstrated a moderate improvement to 32% between 1980 and 1994 as a result of improved early diagnosis, surgical techniques, and nonoperative medical management.18

The treatment for acute dissection is tailored to the anatomic regions involved. When the ascending aorta is affected, the risk of deterioration as a result of dissection progression to involve the aortic valves, coronary vasculature, or rupture into the pericardium is significant. The treatment for this condition is ascending aortic replacement.

The Stanford experience of acute proximal dissections from 1963 to 1982 was associated with a perioperative mortality of 42% ± 10%, which dropped to 27% ± 7% between 1988 and 1992.19 This is consistent with other publications reporting a 19.6% perioperative mortality for type A dissection20 and the International Registry of Acute Aortic Dissection (IRAD), which reported an in-hospital mortality of 26% for type A.21 A review of the national database in Taiwan (1996 to 2001) stratified outcomes for acute type A dissection by age >70 or <70 years. They found that contemporary perioperative mortality rates averaged 25% at 30 days for both groups.22 Likewise, review of the Nationwide Inpatient Sample in the United States revealed an in hospital mortality rate of 26% for the study period of 1995 to 2003.23 However in keeping with the trend in TAAA, other authors, notably at high-volume centers, have estimated more significant improvements in contemporary series.24, 25

Detailed study of aortic dissection has evolved an appreciation of the continuum of disease that can be found when a patient presents with what is now termed “acute aortic syndrome.”26, 27 The treatment for penetrating ulcer and the management of intramural hematoma has evolved during the last decade, and an understanding of the common pathologies has had an effect on management.27 Several factors have been noted to drive patient management decisions. The location of the primary fenestration may have an effect on outcome.28 Other disease variants such as intramural hematoma and nonperfused false lumen have been observed to have better outcome,29 whereas periaortic hematoma,30 concurrent acute coronary symptoms,31 and cocaine use32 are predictive of poor outcome.

Late outcomes after intervention for type A dissection do not provide any further encouragement. The data from the national database in Taiwan revealed a freedom from mortality of 56% at 6 years.20 Results from a single-center experience showed that the risk of reoperation at 10 years was 16% in the type A group, and late risk of death is approximately twice that of the healthy population.33 The late cause of death in patients who are treated operatively for acute proximal dissections has historically been aortic rupture (29%15 and 12%33), cardiac death (16%20 and 26%33), and neurologic causes (16%20 and 9%20).

In contrast to acute type A dissection, the role of the open operative approach for acute type B dissection has evolved during the last 4 decades, from primary operative management to a nonoperative strategy involving an aggressive medical therapy in the absence of complications such as rupture or malperfusion. The reasoning for this approach relates to the dismal surgical outcomes when early operative treatment is attempted in conjunction with the reasonable results associated with pure medical management.21, 34

The Stanford group reported acute type B dissection perioperative outcomes and found that they decreased from 43% ± 13% to 20% ± 19% from the time intervals of 1963 to 1976 and 1988 to 1992, respectively. Similarly, the IRAD database reports a contemporary mortality of 31% for acute type B dissections treated surgically.21 It is important to take note of this history in the era of endovascular repair, where some authors advocate early intervention in type B dissection even in the absence of conventional surgical indications.35 Further evidence lies in the medical arm of the single randomized trail for acute type B dissection, had notably few complications through two years of follow-up (personal communication from C. Nienaber).

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Role of the endovascular approach 

In the context of the sustained poor outcomes outside of centers of excellence reported in the literature for both TAAA and acute aortic dissection, it follows that a minimally invasive approach would be welcome and may be beneficial. However, much like the trend demonstrated above, the same may be echoed in the endovascular treatment of the above diseases: Except for a small sample of reported good outcomes from high-volume, expertise-dense centers, the outcomes for endovascular intervention of complex aortic disease have been guarded. As reporting standards become more stringent, challenges will arise in the ability to interpret the applicability of outcomes reported heterogeneous populations that may be used to imply efficacy and safety of the interventions themselves.

Few series have studied the role of endovascular repair for TAAA. Early-generation techniques such as mesenteric bypass procedures coupled with endovascular aortic relining confer high-risk solutions where the perioperative results are still associated with a mortality as high as 23% (range, 12%-23%).36, 37, 38, 39, 40 A few groups have reported series of branched endografts (Fig 1) in patients considered to be high operative risk, with mortality ranging from 0% to 9%.41, 42, 43 Because of the technical challenges associated with the technique, widespread utilization has not been reported, thus its adoption as a replacement for open repair remains untested.

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  • Fig 1. 

    This three-dimensional reconstruction of a computed tomography scan of a fenestrated endograft in situs shows the incorporation of renal and superior mesenteric arteries. The uncovered stent is apposing the celiac orifice. Postprocessing software provides the ability to interrogate the repair to assess stent integrity and aneurysm sac changes.

The endovascular approach to type B dissection is the subject of much debate, with variable agreement on the timing and indications for repair and a great deal of heterogeneity in the patients included in reports of acute or chronic outcomes. Endovascular intervention for patients with acute, symptomatic, or complicated type B dissection is accepted as an option by most; however, the procedure performed varies, with some groups suggesting septal fenestration, simple branch stenting, or thoracic endografting, depending on the clinical scenario.44, 45, 46

A recent review of penetrating aortic ulcer described the risk of death, endoleak, and spinal ischemia in the available published series and found that perioperative mortality ranges from 0% to 12%.47 One high-volume center that uses central aortic fenestration and renal artery stenting as a treatment for malperfusion complicating acute dissection reports a perioperative mortality of 21%.44 Other groups, reporting on their experience in both the acute and chronic thoracic aortic population, found a perioperative mortalities of 5% to 16%, but these results are difficult to interpret because of the heterogeneity of the patients undergoing intervention.45, 48, 49, 50, 51

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The surgeon's responsibility 

Balancing accountability to patients, the scientific community, and the society in which we live provides the parameters within which further progress in the treatment of complex aortic disease will be made.

From a patient-care perspective, finding a treatment approach that confers the maximum benefit with minimal invasiveness and expedites rapid and complete recovery is the aim. This mandates an outcomes-driven approach, where clinicians with greatest expertise are vested with the dual responsibilities of providing both excellent patient care and detailed outcome-driven training to emerging professionals. An environment that best serves the needs of clinicians dedicated to innovative and effective treatment should be developed.

Our accountability to society lies in creating an approach to complex aortic disease that emphasizes distributive justice. Our understanding of mortality can be expressed as a sum of two factors: one age-dependent and one age-independent (the Gompertz-Makeham Law).52, 53 Basic improvements in health care through the early 19th century, such as effective treatments for infection and traumatic injury, have decreased the age-independent factors and contributed to the rectangularization of the survival curve.54 Pursuit of more effective treatments for conditions known to shorten survival will mean that a greater fraction of society will continue to thrive and contribute at older ages, using fewer health care resources for chronic or debilitating conditions.

Applying this theory to aortic disease requires two fundamentals: first, a treatment that eliminates the risk of aortic mortality but returns the patient back to a normal level of functioning; and second, the ability to identify, among a group of patients with multiple life-threatening comorbidities, those who are most likely to die from aortic causes. Investing in an approach that fulfills these criteria is the most just method of distributing limited health care resources.

Surgeons' accountability to the scientific community implies that effective and innovative treatments, distributed justly, should be developed and tested using rigorous scientific methods in a timely fashion. Providing care that meets the highest standards of clinical excellence requires that the rate of investigation and testing of new treatments keeps pace with the rate of emerging technology. Thus, it follows that innovation in basic science, methodologic, and statistical techniques will have to be as rich and creative as that which is applied to aortic disease itself. Authors who question the role of evidence-based surgery and, specifically, randomized controlled trials, cite an intrinsic lack of individual equipoise, challenges with blinding or inherent bias.55 However, alternate methods have been proposed, such as expertise-based randomized controlled trials56 that address these concerns and provide a framework for the testing of new devices. The recent upsurge in the use of propensity score analysis for observational data is another example of how creative statistical innovation can increase the strength of evidence for emerging treatments.57, 58

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Changing the approach: Perception and management 

Changes in the conventional approach to aortic disease are necessary because the diseases themselves have taken on a Hausdorff dimension. The new paradigm for care of the aorta involves clinicians from multiple disciplines with diverse skills sets and training programs that cross traditional boundaries. Evaluating the patient with aortic disease has, in many circumstances, evolved into a multidisciplinary pursuit. Acute aortic syndrome is one example of how improved ability to differentiate among aortic dissection, intramural hematoma, and penetrating ulcers has affected management strategies.

Another important paradigm shift has come with a deepening appreciation of the hereditary nature of many forms of aortic disease. Connective tissue disorders such as Marfan syndrome59 have been described for years, and the quest for other uncharacterized genetic links has intensified60 and resulted in newer recognition for familial patterns, such as Loeys-Dietz syndrome.61 It is estimated that 21% of non-Marfan patients presenting with aneurysm have some family member with aneurysmal disease, and TAAs have a predominant autosomal dominant mode of inheritance with variable penetrance and expressivity.62 Monitoring this group reveals that familial TAAAs grow at a higher rate relative to aneurysms that occur sporadically and even aneurysms associated with Marfan syndrome.62

Furthermore, the differentiation of ascending, descending, and abdominal aortic disease is also likely genetically linked.62 Pathologic comparison of specimens taken from Marfan and non-Marfan aneurysmal aortas have very similar features, with the Marfan tissue merely demonstrating a greater quantity of tissue degeneration.63

Certainly, in our practice, the role of transforming growth factor β (TGF-β) in the diagnosis and investigation of such disorders is becoming more important as we routinely involve the medical geneticist in the plan of care to coordinate genetic testing and provide genetic counseling to younger patients (<60 years old) presenting with aortic disease.

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Changing the approach: Evaluation 

Imaging for the aorta is also rapidly evolving. The endovascular era has ushered in an expansion in the noninvasive imaging technology necessary for planning and evaluation, so that diagnostic angiography is becoming extinct. Isotropic voxel resolution from 64 slice computed tomography (CT) scans has enhanced postprocessing algorithms and enabled more accurate multiplanar reconstructions. Thus in the absence of a contraindication, CT scanning has become the standard of care for cardiovascular imaging,64, 65 given that a broad range of conditions can be assessed, making it both versatile and more economically feasible.66 Center lumen of flow analysis is essential to the planning of the repair of most complex endovascular approached to aortic disease, such as branched and fenestrated endografts,67 (Fig 2) and now vascular surgeons are often trained in postprocessing software and image interrogation.

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  • Fig 2. 

    The strategy of approach for complex cases, such as endograft failures, are facilitated using postprocessing imaging, which provides the needed detail and relational anatomy to size and plan a repair in the presence of a previous device. A, A failed aortic endograft is depicted, and the short-bodied graft design and crossed limbs will have ramifications for repair. B, A different patient who has had an endo-to-endo conversion of an original aortic repair is shown.

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The future: Automation, engineering and etiology 

The future of treatment for complex aortic disease lies in use of minimally invasive technology and growing an expertise base. The challenge will be at the convergence of innovation that simplifies and standardizes procedures with the development of training programs and implementation of techniques to maintain benchmark outcomes. The Cleveland Clinic is changing its approach to aortic disease by creating an Aortic Institute that will combine expertise in multiple disciplines to strengthen treatment options.

The current process to design and plan an endovascular TAAA repair requires knowledge of graft engineering, and the experience that has been accrued by a few individuals in the field is very difficult to replicate and limits its widespread use. However, because most errors arise during the planning stages of the procedure, creation of a semiautomated process to measure and design the grafts may expand the feasibility of the technique and decrease the time-intensive process of measurement and graft design. The goal of automation of this process is to find the balance that will increase precision of assessing the geometric relationships while allowing the physician user to determine the critical aspects of treatment that require clinical judgment.

To that end, our group has developed a patient-specific mathematic model based on Digital Imaging and Communications in Medicine (DICOM; NEMA, Rosslyn, Va) CT data to create geometric analysis of aortic dimensions in an efficient and reproducible way and has evaluated this against traditional measurement techniques (Fig 3).68 This work demonstrates that a mathematic algorithm can be developed to measure critical aortic dimensions of TAAA for the purpose of automated graft design with an acceptable degree of error compared with individual expert measurements, although more work needs to be done. Models that are created for planning and sizing of endografts can then be used in concert with the procedures using registration processes, allowing physicians to visualize the procedure in three, rather than two, dimensions.

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  • Fig 3. 

    A computed tomography scan during a patient's workup for aortic repair is shown with analytic surfaces generated using our geometric analyses. Left, The intensity-cropped arterial scan. Middle, The analytic surface is superimposed in a wire frame. Right, The same surface is shown rendered with a shading model to show the complexity of the geometry. (Permission to reproduce granted by IEEE Computer Graphics and Applications. Goel VR, Greenberg DP, Greenberg RK. Automated Vascular Geometric Analysis of Aortic Aneurysms, Figure 10c).

Devices and delivery systems have undergone iterative improvements for conventional applications in infrarenal aneurysms and descending thoracic aneurysms. Systems have been developed and used clinically that readily navigate the entire aorta, allowing endovascular treatment of the ascending aorta. The curvature of the arch, variability of the rotational alignment of the supra-aortic trunks, and the anatomic limitations of the proximal ascending aorta have posed a hurdle for graft design at present, but the experience being gained with visceral devices will certainly inform the evolution of devices that are steerable, even within the inherent tortuosity of the aortic arch. Implants also have undergone improvements. It is unusual to find tears within the fabric of endografts, and stent fractures have become increasingly less common.

Yet late failures are reported at an alarming rate, many likely because of an under-appreciation of the extent of the aneurysmal disease, resulting in device fixation or sealing in unhealthy aorta. Although this may be due to an inability to assess the true extent of the disease, often it relates to the limits imposed by adding complexity to the repair (open or endovascular) such as the visceral or internal iliac arterial branches. Early devices capable of maintaining flow to critical aortic branches have been used clinically in thousands of patients already. New devices that require less customization have more simplified implantation paradigms and may combat some of the recognized late complications are under investigation.

The implementation of individualized methods of predicting the long-term survival of patients juxtaposed with their risk of an aortic-related death is underway. Improved methods for determining rupture risk, coupled with validated scoring systems capable of assessing perioperative and long-term risk, must be used to appropriately recommend intervention. Current treatment paradigms result in the lumping of patients into surgically fit or unfit groups, yet the means and validation of the discrimination process is subject to skepticism.

Finally, even more research and understanding will need to be gained with respect to the etiology and natural history of the diseases of the aorta. Understanding the role of intervention in complex aortic diseases, such as aortic dissection or TAAA, will only be achieved if the mechanisms of disease are understood. That knowledge will afford us the ability to determine who requires treatment, the ability to properly treat patients, provide counseling to relatives, and limit the debilitating and often fatal aspects of this complex disease.

In conclusion, the next generation of discovery in aortic disease will focus less on the characterization of new disease entities and more on the exploration of the complexities that lurk below the surface of the conditions we already know. Creating an environment to house innovation in all aspects of training, treatment, and investigation will be the challenge for the future.

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Author contributions 


Conception and design: TM, RG

Analysis and interpretation: TM, RG

Data collection: TM, RG

Writing the article: TM

Critical revision of the article: RG

Final approval of the article: RG

Statistical analysis: TM, RG

Obtained funding: Not applicable

Overall responsibility: RG

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References 

  1. Etheredge SN, Yee J, Smith JV, Schonberger S, Goldman MJ. Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft. Surgery. 1955;38:1071–1081
  2. Creech O, DeBakey ME, Morris GC. Aneurysm of thoracoabdominal aorta involving the celiac, superior mesenteric, and renal arteries; report of four cases treated by resection and homograft replacement. Ann Surg. 1956;144:549–573
  3. DeBakey ME, Crawford ES, Garrett HE, Beall AC, Howell JF. Surgical considerations in the treatment of aneurysms of the thoraco-abdominal aorta. Ann Surg. 1965;162:650–662
  4. Carrel A, Guthrie C. Resultats du Patching des Arteres. Comptes Rendus Hebdomadaires des Seances et Memoires de la Societe de Biologie. 1906;1009
  5. Crawford ES, De Bakey ME, Blaisdell FW. Simplified treatment of large, sacciform aortic aneurysms with patch grafts (Experiences with 5 cases). J Thorac Cardiovasc Surg. 1961;41:479–491
  6. Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007;83:S862–S864
  7. Schepens MA, Kelder JC, Morshuis WJ, Heijmen RH, van Dongen EP, ter Beek HT. Long-term follow-up after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 2007;83:S851–S855
  8. Etz CD, Homann TM, Plestis KA, Zhang N, Luehr M, Weisz DJ, et al. Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented?. Eur J Cardiothorac Surg. 2007;31:643–648
  9. Achneck HE, Rizzo JA, Tranquilli M, Elefteriades JA. Safety of thoracic aortic surgery in the present era. Ann Thorac Surg. 2007;84:1180–1185
  10. Conrad MF, Crawford RS, Davison JK, Cambria RP. Thoracoabdominal aneurysm repair: a 20-year perspective. Ann Thorac Surg. 2007;83:S856–S861
  11. Fehrenbacher J, Siderys H, Shahriari A. Preservation of renal function utilizing hypothermic circulatory arrest in the treatment of distal thoracoabdominal aneurysms (types III and IV). Ann Vasc Surg. 2007;21:204–207
  12. Jacobs MJ, van Eps RG, de Jong DS, Schurink GW, Mochtar B. Prevention of renal failure in patients undergoing thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2004;40:1067–1073
  13. Safi HJ, Estrera AL, Miller CC, Huynh TT, Porat EE, Azizzadeh A, et al. Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair. Ann Thorac Surg. 2005;80:2173–2179
  14. Grabitz K, Sandmann W, Stuhmeier K, Mainzer B, Godehardt E, Ohle B, et al. The risk of ischemic spinal cord injury in patients undergoing graft replacement for thoracoabdominal aortic aneurysms. J Vasc Surg. 1996;23:230–240
  15. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17:357–368
  16. Rigberg DA, McGory ML, Zingmond DS, Maggard MA, Agustin M, Lawrence PF, et al. Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: a statewide experience. J Vasc Surg. 2006;43:217–222
  17. Clouse WD, Hallett JW, Schaff HV, Spittell PC, Rowland CM, Ilstrup DM, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc. 2004;79:176–180
  18. Bickerstaff LK, Pairolero PC, Hollier LH, Melton LJ, Van Peenen HJ, Cherry KJ, et al. Thoracic aortic aneurysms: a population-based study. Surgery. 1982;92:1103–1108
  19. Fann JI, Smith JA, Miller DC, Mitchell RS, Moore KA, Grunkemeier G, et al. Surgical management of aortic dissection during a 30-year period. Circulation. 1995;92:II113–II121
  20. Yu HY, Chen YS, Huang SC, Wang SS, Lin FY. Late outcome of patients with aortic dissection: study of a national database. Eur J Cardiothorac Surg. 2004;25:683–690
  21. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283:897–903
  22. Wu IH, Yu HY, Liu CH, Chen YS, Wang SS, Lin FY. Is old age a contraindication for surgical treatment in acute aortic dissection? (A demographic study of national database registry in Taiwan). J Card Surg. 2008;23:133–139
  23. Knipp BS, Deeb GM, Prager RL, Williams CY, Upchurch GR, Patel HJ. A contemporary analysis of outcomes for operative repair of type A aortic dissection in the United States. Surgery. 2007;142:524–528
  24. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of the aorta and dissecting aortic aneurysms (Improving early and long-term surgical results). Circulation. 1990;82:IV24–IV38
  25. Lytle BW, Mahfood SS, Cosgrove DM, Loop FD. Replacement of the ascending aorta (Early and late results). J Thorac Cardiovasc Surg. 1990;99:651–657
  26. Vilacosta I, San Roman JA, Aragoncillo P, Ferreiros J, Mendez R, Graupner C, et al. Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography. J Am Coll Cardiol. 1998;32:83–89
  27. Vilacosta I, Roman JA. Acute aortic syndrome. Heart. 2001;85:365–368
  28. Lansman SL, McCullough JN, Nguyen KH, Spielvogel D, Klein JJ, Galla JD, et al. Subtypes of acute aortic dissection. Ann Thorac Surg. 1999;67:1975–1978
  29. Srichai MB, Lieber ML, Lytle BW, Kasper JM, White RD. Acute dissection of the descending aorta: noncommunicating versus communicating forms. Ann Thorac Surg. 2004;77:2012–2020
  30. Mukherjee D, Evangelista A, Nienaber CA, Sechtem U, Suzuki T, Trimarchi S, et al. Implications of periaortic hematoma in patients with acute aortic dissection (from the International Registry of Acute Aortic Dissection). Am J Cardiol. 2005;96:1734–1738
  31. Biagini E, Lofiego C, Ferlito M, Fattori R, Rocchi G, Graziosi M, et al. Frequency, determinants, and clinical relevance of acute coronary syndrome-like electrocardiographic findings in patients with acute aortic syndrome. Am J Cardiol. 2007;100:1013–1019
  32. Singh S, Trivedi A, Adhikari T, Molnar J, Arora R, Khosla S. Cocaine-related acute aortic dissection: patient demographics and clinical outcomes. Can J Cardiol. 2007;23:1131–1134
  33. Halstead JC, Meier M, Etz C, Spielvogel D, Bodian C, Wurm M, et al. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg. 2007;133:127–135
  34. Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Bossone E, et al. Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2006;114:I357–I364
  35. Kahn SL, Dake MD. Stent graft management of stable, uncomplicated type B aortic dissection. Perspect Vasc Surg Endovasc Ther. 2007;19:162–169
  36. Black SA, Wolfe JH, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg. 2006;43:1081–1089
  37. Resch TA, Greenberg RK, Lyden SP, Clair DG, Krajewski L, Kashyap VS, et al. Combined staged procedures for the treatment of thoracoabdominal aneurysms. J Endovasc Ther. 2006;13:481–489
  38. Donas KP, Schulte S, Krause E, Horsch S. Combined endovascular stent-graft repair and adjunctive visceral vessel reconstruction for complex thoracoabdominal aortic aneurysms. Int Angiol. 2007;26:213–218
  39. Saccani S, Nicolini F, Beghi C, Marcato C, Uccelli M, Larini P, et al. Thoracic aortic stents: a combined solution for complex cases. Eur J Vasc Endovasc Surg. 2002;24:423–427
  40. Bockler D, Kotelis D, Geisbusch P, Hyhlik-Durr A, Klemm K, von Tengg-Kobligk H, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients. J Vasc Surg. 2008;47:724–732
  41. Greenberg RK, West K, Pfaff K, Foster J, Skender D, Haulon S, et al. Beyond the aortic bifurcation: branched endovascular grafts for thoracoabdominal and aortoiliac aneurysms. J Vasc Surg. 2006;43:879–886
  42. Chuter TA, Rapp JH, Hiramoto JS, Schneider DB, Howell B, Reilly LM. Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg. 2008;47:6–16
  43. Verhoeven EL, Muhs BE, Zeebregts CJ, Tielliu IF, Prins TR, Bos WT, et al. Fenestrated and branched stent-grafting after previous surgery provides a good alternative to open redo surgery. Eur J Vasc Endovasc Surg. 2007;33:84–90
  44. Barnes DM, Williams DM, Dasika NL, Patel HJ, Weder AB, Stanley JC, et al. A single-center experience treating renal malperfusion after aortic dissection with central aortic fenestration and renal artery stenting. J Vasc Surg. 2008;47:903–910
  45. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med. 1999;340:1546–1552
  46. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von KY, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med. 1999;340:1539–1545
  47. Ford PF, Farber MA. Role of endovascular therapies in the management of diverse thoracic aortic pathology. Perspect Vasc Surg Endovasc Ther. 2007;19:134–143
  48. Brown KE, Eskandari MK, Matsumura JS, Rodriguez H, Morasch MD. Short and midterm results with minimally invasive endovascular repair of acute and chronic thoracic aortic pathology. J Vasc Surg. 2008;47:714–722
  49. Dick F, Hinder D, Immer FF, Hirzel C, Do DD, Carrel TP, et al. Outcome and quality of life after surgical and endovascular treatment of descending aortic lesions. Ann Thorac Surg. 2008;85:1605–1612
  50. Verhoye JP, de LB, Heautot JF, Vola M, Langanay T, Corbineau H, et al. Mid-term results of endovascular treatment for descending thoracic aorta diseases in high-surgical risk patients. Ann Vasc Surg. 2006;20:714–722
  51. Baumgart D, Eggebrecht H, Herold U, Kuehl H, Piotrowski J, Niebel W, et al. Underlying aortic pathology and clinical health status determine success of endovascular stent-grafting for descending thoracic aortic disease. Cathet Cardiovasc Interv. 2006;67:527–534
  52. Gompertz B. On the nature of the function expressive of the law of human mortality, and on a new mode of determining the value of life contingencies. Philosophical Transactions of the Royal Society of London. 1825;115:513–585
  53. Makeham WM. On the law of mortality and the construction of annuity tables. J Inst Actuaries Assur. 1860;301–310
  54. Gavrilov LA, Gavrilova NS. The reliability theory of aging and longevity. J Theor Biol. 2001;213:527–545
  55. Cook RC, Alscher KT, Hsiang YN. A debate on the value and necessity of clinical trials in surgery. Am J Surg. 2003;185:305–310
  56. Devereaux PJ, Bhandari M, Clarke M, Montori VM, Cook DJ, Yusuf S, et al. Need for expertise based randomised controlled trials. BMJ. 2005;330:88
  57. Mansson R, Joffe MM, Sun W, Hennessy S. On the estimation and use of propensity scores in case-control and case-cohort studies. Am J Epidemiol. 2007;166:332–339
  58. Glynn RJ, Schneeweiss S, Sturmer T. Indications for propensity scores and review of their use in pharmacoepidemiology. Basic Clin Pharmacol Toxicol. 2006;98:253–259
  59. Marfan AB. Un cas de deformation congenitale des quarte membres plus prononcee aux extremities caracterisee par l'allongement des os avec un certain degre d'amincissement. Bull Mem Soc Med Hop Paris. 1896;220–226
  60. Callewaert BL, Willaert A, Kerstjens-Frederikse WS, De BJ, Devriendt K, Albrecht B, et al. Arterial tortuosity syndrome: clinical and molecular findings in 12 newly identified families. Hum Mutat. 2008;29:150–158
  61. Loeys BL, Chen J, Neptune ER, Judge DP, Podowski M, Holm T, et al. A syndrome of altered cardiovascular, craniofacial, neurocognitive and skeletal development caused by mutations in TGFBR1 or TGFBR2. Nat Genet. 2005;37:275–281
  62. Albornoz G, Coady MA, Roberts M, Davies RR, Tranquilli M, Rizzo JA, et al. Familial thoracic aortic aneurysms and dissections–incidence, modes of inheritance, and phenotypic patterns. Ann Thorac Surg. 2006;82:1400–1405
  63. Dingemans KP, Teeling P, van der Wal AC, Becker AE. Ultrastructural pathology of aortic dissections in patients with Marfan syndrome: comparison with dissections in patients without Marfan syndrome. Cardiovasc Pathol. 2006;15:203–212
  64. Flamm SD. Cross-sectional imaging studies: what can we learn and what do we need to know?. Semin Vasc Surg. 2007;20:108–114
  65. Budoff MJ, Cohen MC, Garcia MJ, Hodgson JM, Hundley WG, Lima JA, et al. ACCF/AHA clinical competence statement on cardiac imaging with computed tomography and magnetic resonance: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. J Am Coll Cardiol. 2005;46:383–402
  66. Otero HJ, Rybicki FJ. Reimbursement for chest-pain CT: estimates based on current imaging strategies. Emerg Radiol. 2007;13:237–242
  67. O'Neill S, Greenberg RK, Resch T, Bathurst S, Fleming D, Kashyap V, et al. An evaluation of centerline of flow measurement techniques to assess migration after thoracic endovascular aneurysm repair. J Vasc Surg. 2006;43:1103–1110
  68. Goel VR, Greenberg RK, Greenberg DP. Mathematical analysis of DICOM CT datasets: can endograft sizing be automated for complex anatomy?. J Vasc Surg. 2008;47:1306–1312discussion 1312

 STATEMENT OF CONFLICT OF INTEREST: Dr. Greenberg has intellectual property rights with Cook, Inc.

PII: S0741-5214(08)01590-5

doi:10.1016/j.jvs.2008.09.010

Journal of Vascular Surgery
Volume 48, Issue 6, Supplement , Pages 17S-23S, December 2008

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