Endovascular Repair of Blunt Thoracic Aortic Trauma is Associated With Increased Left Ventricular Mass, Hypertension, and Off-target Aortic Remodeling

Abstract

Background: Aortic elasticity creates a cushion that protects the heart from pressure injury, and a recoil that helps perfuse the coronary arteries. TEVAR has become first-line therapy for many aortic pathologies including trauma, but stent-grafts stiffen the aorta and likely increase LV afterload. Objective: Test the hypothesis that trauma TEVAR is associated with LV mass increase and adverse off-target aortic remodeling. Methods: Computed Tomography Angiography (CTA) scans of 20 trauma TEVAR patients (17 M/3 F) at baseline ) years] and 5.1 AE 3.1 (1.1-12.3) years after repair were used to measure changes in LV mass, LV mass index, and diameters and lengths of the ascending thoracic aorta (ATA). Measurements were compared with similarly-aged control patients without aortic repair (21 M/21 F) evaluated at similar follow-ups. Results: LV mass and LV mass index of TEVAR patients increased from 138.5 AE 39.6 g and 72.35 AE 15.17 g/m 2 to 173.5 AE 50.1 g and 85.48 AE 18.34 g/ m 2 at the rate of 10.03 AE 12.79 g/yr and 6.25 AE 10.28 g/m 2 /yr, whereas in control patients LV characteristics did not change. ATA diameters of TEVAR patients increased at a rate of 0.60 AE 0.80 mm/yr, which was 2.4-fold faster than in controls. ATA length in both TEVAR and control patients increased at 0.58 mm/yr. Half of TEVAR patients had hypertension at follow-up compared to only 5% at baseline. Conclusions: TEVAR is associated with LV mass increase, development of hypertension, and accelerated expansile remodeling of the ascending aorta. Although younger trauma patients may adapt to these effects, these changes may be even more important in older patients with other aortic pathologies and diminished baseline cardiac function.

Aortic Biomechanics and Clinical Applications

“…56 After endovascular stent implantation, increases in pulse wave velocity have been measured, along with concurrent increases in left ventricular hydraulic load (which is similar characteristic impedance), left ventricular hypertrophy, diastolic dysfunction, and potentially detrimental effects on coronary perfusion, although the clinical ramifications have not been fully delineated. [57][58][59] The surrounding aortic tissue may also be impacted. After ascending aortic replacement with an interposition graft, greater aortic strain has been measured in the native descending aorta, suggesting that a larger pulse wave (and possibly greater loading or shearing forces) is being transmitted.…”

Short Term Prognosis of Renal Artery Stenosis Secondary to Acute Type B Aortic Dissection With TEVAR

“…We found that few of these studies clearly distinguished RAS from RAI. Postoperative acute kidney injury (AKI) and refractory hypertension are common complications and severely impact the prognosis after TEVAR (9,10). Renal artery stenosis but not RAI could be one of the reasons for these complications.…”

Corrigendum

“…The same process, but faster and worse, happens after open or endovascular aortic grafting operations, leading to an increased cardiac afterload and onset of arterial hypertension. 2,3 Consequently, the left ventricle remodels with an augmented mass, and the coronary system, especially if already reduced in its reserve and then decreased in its blood supply, dissection, but are possible consequences to be evaluated at the moment of surgical decision. Furthermore, the basal principle also remains valid that the length of the aortic prosthesis must respect the safety limits in its proximal and distal anchoring levels, in order to incorporate the most diseased aortic tract and reduce risks of secondary endoleaks, mainly of type 1b.…”