Background Thoracic endovascular aortic repair (TEVAR) is widely used for the treatment of blunt traumatic thoracic aortic injuries. Aortic flow dynamics and mechanical implications of this intervention are poorly investigated and may be of particular interest in the long-term follow-up of these mostly young patients. Purpose To assess whether the presence of TEVAR in a cohort of otherwise healthy subjects was related to dilation of the proximal aorta or increase in aortic stiffness and flow alterations. Methods Nineteen patients who underwent TEVAR implantation after a traumatic injury of the thoracic descending aorta (DAo) (10.0±6.1 years from intervention) and 44 healthy volunteers (HV) underwent 4D flow CMR to compute ascending aorta (AAo) pulse wave velocity (PWV), a marker of aortic stiffness, systolic flow reversal ratio (SFRR), quantifying backward flow during systole and in-plane rotational flow (IRF), measuring in-plane strength of helical flow. IRF and SFRR were assessed at 20 planes between the sinotubular junction and the mid thoracic DAo. Aortic diameters were measured using double-oblique cine CMR. Results Patients with TEVAR and HV did not differ in age, sex, body surface area, blood pressure and DAo diameter distal to TEVAR (Table). However, TEVAR patients presented larger diameters at the sinus of Valsalva and AAo, increased AAo PWV and strong flow alterations: IRF was reduced from the distal AAo to the proximal DAo, while SFRR was increased in the whole thoracic aorta (Figure). Conclusions In patients with blunt traumatic thoracic aortic injury treated with TEVAR the aorta proximal to TEVAR is dilated, stiffer and present potentially pathogenic flow conditions. Longitudinal studies are needed to assess whether these alterations have prognostic value and may improve clinical prevention and management of these patients. Figure 1. IRF and SFRR in healthy vs TEVAR Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been funded by Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation (PI19/01480). Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

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Background Thoracic endovascular aortic repair (TEVAR) is becoming the preferred treatment option to repair the proximal descending aorta after rupture following blunt traumatic injury. However, hemodynamic and mechanic implications of this intervention are poorly understood. Exploiting the possibilities of 4D flow magnetic resonance imaging, hemodynamics, stiffness and local dilation in the ascending aorta in patients following aortic repair by TEVAR are studied. Methods Fifteen apparently healthy individuals who underwent TEVAR implantation after traumatic descending aortic injury and 44 healthy volunteers (HV) underwent 4D flow-MRI. Ascending aorta pulse wave velocity was computed [1]. Moreover, at eight planes equally distributed in the ascending aorta systolic flow reversal ratio, i.e. relative amount of backward flow during systole, and in-plane rotational flow, measuring the strength of helical flow, were computed [2,3]. Results TEVAR patients and HV did not differ in terms of age, sex, BSA and blood pressure (Table). However, compared to HV, TEVAR patients showed reduced in-plane rotational flow in the distal ascending aorta in patients with TEVAR and increased backward systolic flow in the whole ascending aorta (Figure). Patients with TEVAR had a stiffer ascending aorta, with pulse wave velocity higher compared control (7.8 ± 4.2 vs 5.3 ± 1.9, p = 0.004). Finally, aortic root and ascending aorta diameters were larger in TEVAR patients compared to HV (Table). Conclusions The implantation of TEVAR in apparently healthy individuals after traumatic rupture of the proximal descending aorta is associated with altered hemodynamics, higher stiffness and larger aortic diameter in the region proximal to the TEVAR. Table Healthy volunteers TEVAR patients p N 44 15 Age [years] 40 ± 12 43 ± 10 0.392 Sex [% male] 66 80 0.075 Years from intervention [years] N/A 10.3 ± 6.4 N/A Body surface area [m2] 1.87 ± 0.15 1.96 ± 0.23 0.088 Systolic blood pressure [mmHg] 127 ± 19 131 ± 15 0.389 Diastolic blood pressure [mmHg] 70 ± 11 74 ± 9 0.198 Aortic root diameter [mm] 31 ± 4 34 ± 4 0.026 Ascending aorta diameter [mm] 28 ± 4 32 ± 3 0.003 Ascending aorta PWV [m/s] 5.3 ± 1.9 7.8 ± 4.2 0.004

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Background. Acute esophageal necrosis is a rare and potentially lethal entity. The pathogenesis is multifactorial, generally presenting with symptoms of upper gastrointestinal bleeding. We present a case that presents atypically with initial esophageal perforation. Case presentation. A 46-year-old man with a history of alcoholism and cocaine use, an active smoker, and a ruptured celiac trunk aneurysm treated by embolization, who, after acute chest and epigastric pain, is diagnosed with a Stanford B thoracoabdominal aortic dissection, being repaired endovascularly by placing an aortic endoprosthesis. Due to clinical suspicion of mesenteric ischemia complicated with esophageal/gastric perforation, a postoperative tomography was performed, revealing perforation of the esophagus distal to the left pleura and ischemic cholecystitis. Transhiatal esophagectomy, cervical esophagostomy, Witzel-type decompressive gastrostomy, Witzel-type feeding jejunostomy, classic cholecystectomy, and mediastinum drainage were performed. During the postoperative period, the patient remained in critical condition, dying as a result of hypoxic encephalopathy. The histopathological study reported acute transmural esophageal ischemia. Discussion. Tissue hypoperfusion plays a dominant role in the pathogenesis of acute esophageal necrosis. Esophageal perforation is a serious complication and can occur in the early stages, with esophagectomy and deferred digestive reconstruction being the appropriate treatment. Conclusion. Ischemia is a fundamental mechanism of acute esophageal necrosis; its diagnosis must always be established in the various complications that may occur in patients with hemodynamic compromise, in order to obtain a timely treatment.