[Aortic aneurysms and aortic dissection: epidemiology, pathophysiology and diagnostics]

Evaluation of the Value of Histological Examination for the Prediction of Genetic Thoracic Proximal Aortopathies

Background: Heritable connective tissue disorders are often accompanied by an increased risk for thoracic aortic aneurysm and dissection (TAAD). Profound knowledge of the underlying pathology may have an impact on individual treatment, systematic follow-up, and early detection by the screening of offspring. The aim of this study, based in a single high-volume tertiary center, was an analysis of the diagnostic validity of histopathologic findings in patients with TAAD due to these findings' accuracy in diagnosing heritable connective tissue disorders. Methods: Therefore, genetic testing by next-generation sequencing (NGS) was performed to evaluate the correlations. In total, 65 patients with TAAD undergoing surgical treatment before the age of 60 years or with age up to 80 years if they had offspring at the time of the procedure were included in the analysis. Results: In our cohort, no certain correlation of histological findings to the results of genetic diagnostics in patients with clinically relevant aortic pathology could be shown. Patients with histopathologic findings for heritable connective tissue disorder and a positive gene variant were 11.6 years younger than patients without mutation and without histological evidence for connective tissue disorder. Conclusions: Genetic clarification is useful to define the specific genotype of the disease of the aortic wall in the case of non-specific histological characteristics.

The evolution of arch surgery: Frozen elephant trunk or conventional elephant trunk?

Treatment of aortic arch aneurysms and dissections require highly complex surgical procedures with devastating complications and mortality rates. Currently, repair of the complete arch until the proximal descending thoracic aorta consists of a two-stage procedure, called elephant trunk (ET) technique, or a single stage a single-stage technique referred to as frozen elephant trunk (FET). There is conflicting evidence about the perioperative results of ET in comparison with FET. We carried out a meta-analysis to investigate possible differences in perioperative and early (up to 30 days) outcomes of ET vs. FET, particularly for mortality, spinal cord injury (SCI), stroke, and renal failure. We also performed a meta-regression to explore the effects of age and sex as possible cofactors. Twenty-one studies containing data from interventions conducted between 1997 and 2019 and published between 2008 and 2021 with 3153 patients (68.5% male) were included. ET was applied to 1,693 patients (53.7%) and FET to 1460 (46.3%). Overall mortality after ET was 250/1693 (14.8%) and after FET 116/1460 (7.9%). Relative risk (RR) and 95% confidence interval (CI) were 1.37 [1.04 to 1.81], p = 0.027. There was no significant effect of age and sex. SCI occurrence after the second stage of ET was 45/1693 (2.7%) and after FET 70/1,460 patients (4.8%) RR 0.53 [0.35 to 0.81], p = 0.004. Age and sex were not associated with the risk of SCI. No significant differences were observed between ET and FET in the incidence of stroke and renal failure. Our results indicate that ET is associated with higher early mortality but lower incidence of SCI compared to FET. When studies published in the last 5 years were analyzed, no significant differences in mortality or SCI were found between ET and FET. This difference is attributed to a decrease in mortality after ET, as the mortality after FET did not change significantly over time.

Long non-coding RNA RP11-465L10.10 promotes vascular smooth muscle cells phenotype switching and MMP9 expression via the NF-κB pathway

Background

Thoracic aortic aneurysm/dissection (TAA/D) are complicated vascular disorders with rapid development and high mortality. Vascular smooth muscle cells (VSMCs) phenotype switching plays an important role in the pathological process of TAA/D. Previous studies have indicated a potential correlation between long non-coding RNA (lncRNA) RP11-465L10.10 and matrix metallopeptidase 9 (MMP9) involved in the development of TAA/D. This study aims to investigate the role of lncRNA RP11-465L10.10 in VSMCs phenotype switching and the molecular mechanism in regulating MMP9 expression.

Methods

The expression of RP11-465L10.10 in vascular tissues and in VMSCs was detected by RT-qPCR. To investigate the role of RP11-465L10.10 on VSMCs phenotype switching, an RP11-465L10.10-overexpressed lentiviral vector was constructed and transfected into VSMCs. Through EdU staining, migration assay, flow cytometry analysis, the roles of RP11-465L10.10 were estimated. Bioinformatics indicated that RP11-465L10.10 upregulating MMP9 expression via NF-κB signaling, and SN50 (a specific inhibitor of NF-κB pathway) was used to inhibit the NF-κB pathway activation, then the expression of MMP9 was detected in RP11-465L10.10 overexpressed VMSCs.

Results

In this study, we found RP11-465L10.10 and MMP9 were highly increased in TAD patient tissues, which was consistent in angiotensin II-induced VSMCs phenotype switching. RP11-465L10.10 overexpression facilitated VSMCs phenotype switching and MMP9 expression. Mechanismly, NF-κB signal pathway was involved in RP11-465L10.10 induced VSMCs phenotype switching and MMP9 expression by transcriptome data analysis and experimental confirm.

Conclusion

This study demonstrated that RP11-465L10.10 induces VSMCs phenotype switching and MMP9 expression via the NF-κB signal pathway, suggesting that RP11-465L10.10 might be a potential therapeutic target for TAA/D treatment.

Factors predictive for early and late mortality after surgical repair for Stanford A acute aortic dissection

OBJECTIVES

The aim of this study was to evaluate independent risk factors predictive for mortality of patients with Stanford A acute aortic dissection.

METHODS

From January 2006 to March 2015, a total of 240 consecutive patients diagnosed with acute Stanford A acute aortic dissection underwent surgical aortic repair in our center. After analysis of pre- and perioperative variables, univariate logistic and multivariate logistic regression analyses were performed for mortality of patients. Subsequently, Kaplan-Meier estimation analysis of short- and long-term survival of these variables was carried out.

RESULTS

Primary entry tear in descending aorta (odds ratio = 4.71, p = 0.021), preoperative international normalized ratio higher than 1.2 (odds ratio = 7.36, p = 0.001), additional coronary artery bypass grafting (odds ratio = 3.39, p = 0.003), cannulation in ascending aorta (odds ratio = 3.22, p = 0.005), preoperative neurological coma (odds ratio = 3.30, p = 0.003), and reduced perfusion (odds ratio = 2.91, p = 0.006) as well as prolonged reperfusion time (odds ratio = 3.36, p = 0.002) showed to be independent predictors for early mortality as well as for late mortality (hazard ratio of all variables p < 0.05). Kaplan-Meier survival estimation analysis with up to 9-year-follow-up in terms of these risk factors showed significantly poorer short- and long-term survival (log-rank and Breslow test all p < 0.05).

CONCLUSION

Our study revealed that early and late mortality of patients with Stanford A acute aortic dissection surgery was significantly influenced by preoperative and perioperative variables as independent predictors especially of variables displaying coronary, cerebral, and visceral malperfusion. Also, short- and long-term survival of patients was significantly poorer in terms of these risk factors.

Serum matrix metalloproteinase-9 is a valuable biomarker for identification of abdominal and thoracic aortic aneurysm: a case-control study

Background

Matrix metalloproteinase-9 (MMP9) has been reported to play a key role in the pathogenesis of aortic aneurysm. However, few studies have assessed serum MMP9 levels in both abdominal aortic aneurysm (AAA) and thoracic aortic aneurysm (TAA). In this study, we investigated the serum levels of MMP9 in aortic aneurysm to evaluate its predictive and diagnostic efficacy for AAA and TAA, and explored the association of MMP9 with circulating laboratory markers.

Methods

A total of 296 subjects were enrolled, including 105 AAA patients, 79 TAA patients and 112 healthy controls. The levels of serum MMP9 were detected by enzyme-linked immunosorbent assay (ELISA).

Results

Compared to control group, both AAA and TAA patients had higher serum MMP9 levels in the overall comparison and subgroup analysis based on subjects aged<65 years, either male or female, hypertension, non-diabetes and non-hyperlipidemia (all P<0.05). Moreover, MMP9 levels were significantly higher in TAA group than those in AAA group in the total comparison, and this discrepancy was also found in the non-diabetes, non-hyperlipidemia and aortic diameter ≥ 5.5 cm subgroup analysis. Serum MMP9 levels were influenced by age and hypertension. There was a positive association of serum MMP9 with CRP (r = 0.33, P < 0.001) and Hcy (r = 0.199, P = 0.033). Multiple logistic analyses showed that serum MMP9 was an independent risk factor for AAA and TAA. Based on receiver operating characteristic (ROC) analysis, the area under the curve (AUC) of MMP9 for predicting TAA was 0.83 with 70% sensitivity and 91% specificity, while the AUC of MMP9 to detect AAA was 0.69 and the sensitivity and specificity were 50% and 88%.

Conclusions

Serum MMP9 was closely related to the existence of aortic aneurysms and could be a valuable marker for the discrimination of aortic aneurysm, especially for TAA.

Impact of hypertension on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection

INTRODUCTION

Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in hypertensive patients, requiring immediate surgical repair. The aim of this study was to evaluate early outcomes and long-term survival of hypertensive patients in comparison to normotensive patients suffering from Stanford A AAD.

METHODS

In our center, 240 patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015. After statistical and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up.

RESULTS

The proportion of hypertensive patients suffering from Stanford A AAD was 75.4% (n=181). There were only few statistically significant differences in terms of basic demographics, comorbidities, preoperative baseline and clinical characteristics of hypertensive patients in comparison to normotensive patients. Hypertensive patients were significantly older (p=0.008), more frequently received hemi-arch repair (p=0.028) and selective brain perfusion (p=0.001). Our study showed similar statistical results in terms of 30-day mortality (p=0.196), long-term overall cumulative survival of patients (Log-Rank p=0.506) and survival of patients free from cerebrovascular events (Log-Rank p=0.186). Furthermore, subgroup analysis for long-term survival in terms of men (Log-Rank p=0.853), women (Log-Rank p=0.227), patients under and above 65 years of age (Log-Rank p=0.188 and Log-Rank p=0.602, respectively) and patients undergoing one of the three types of aortic repair surgery showed similar results for normotensive and hypertensive patient groups. Subgroup analysis for long-term survival of patients free from cerebrovascular events for women, patients under 65 years of age and patients undergoing aortic arch repair showed significant differences between the two groups in favor of hypertensive patients.

CONCLUSIONS

Hypertensive patients suffering from Stanford A AAD were older, more frequently received hemi-arch replacement and were not associated with increased risk of 30-day mortality and poorer long-term survival compared to normotensive patients.

Microarray expression profile analysis of long non-coding RNAs in thoracic aortic aneurysm

Thoracic aortic aneurysm (TAA) is a highly lethal vascular disease. Long non-coding RNAs (lncRNAs) are newly discovered as a regulator of protein genes and play critical roles in cardiovascular physio-pathological processes. However, there were a few studies looking at lncRNAs in TAA. In this study, we profiled differential expression of lncRNAs between TAA (TAA group, N = 6) and normal thoracic aorta (control group, n = 6) by third-generation lncRNA microarray. We identified 1352 up-regulated and 1624 down-regulated lncRNAs with differential expression (log fold-change > 2.0, p < 0.01). Through nearby protein-coding gene associated with extracellular matrix (ECM) metabolism and vascular smooth muscle cell (VSMC) apoptosis, 12 up-regulated and 9 down-regulated lncRNAs were selected for further analysis. By calculating phastCons score of base, we identified 8 candidate lncRNAs (4 up-regulated and 4 down-regulated) with high conservation across species. By tissue specificity analysis, we found that 5 lncRNAs (HIF1A-AS1, RP11-465L10.10, LOC100506472, CTD-2184D3.5 and RP-399O19.5) were highly expressed in aortic tissues, suggested that they may be closely associated with TAA. Among them, 2 lncRNAs (RP11-465L10.10 and CTD-2184D3.5) with higher specificity in aorta (p < 0.01) were analyzed by bioinformatics. Further catRAPID analysis revealed a strong RNA-protein interaction between RP11-465L10.10 and myeloid zinc finger gene 1 (MZF1), a transcription factor of MMP9. However, no intense RNA-protein interactions were observed between CTD-2184D3.5 and transcript factors of MAPK6. In conclusions, our study showed differential expression profiles of lncRNAs in TAA and revealed the interaction between certain lncRNAs and coding genes. These data provides insights into new biomarker and therapeutic targets for TAA.

Association of Inter-Arm Systolic Blood Pressure Difference with Coronary Atherosclerotic Disease Burden Using Calcium Scoring

PURPOSE

There are no sufficient data on the correlation between inter-arm blood pressure (BP) difference and coronary atherosclerosis found using coronary artery calcium score (CACS). We aimed to investigate if the increased difference in inter-arm BP is independently associated with severity of CACS.

MATERIALS AND METHODS

Patients who had ≥3 cardiovascular risk factors or an intermediate Framingham Risk Score (FRS; ≥10) were enrolled. Inter-arm BP difference was defined as the absolute difference in BP in both arms. Quantitative CACS was measured by using coronary computed tomography angiography with the scoring system.

RESULTS

A total of 261 patients were included in this study. Age (r=0.256, p<0.001), serum creatinine (r=0.139, p=0.030), mean of right arm systolic BP (SBP; r=0.172, p=0.005), mean of left arm SBP (r=0.190, p=0.002), inter-arm SBP difference (r=0.152, p=0.014), and the FRS (r=0.278, p<0.001) showed significant correlation with CACS. The increased inter-arm SBP difference (≥6 mm Hg) was significantly associated with CACS ≥300 [odds ratio (OR) 2.17, 95% confidence interval (CI) 1.12-4.22; p=0.022]. In multivariable analysis, the inter-arm SBP difference ≥6 mm Hg was also significantly associated with CACS ≥300 after adjusting for clinical risk factors (OR 2.34, 95 % CI 1.06-5.19; p=0.036).

CONCLUSION

An increased inter-arm SBP difference (≥6 mm Hg) is associated with coronary atherosclerotic disease burden using CACS, and provides additional information for predicting severe coronary calcification, compared to models based on traditional risk factors.

Matrix metalloproteinase family polymorphisms and the risk of aortic aneurysmal diseases: A systematic review and meta-analysis

It has been suggested that matrix metalloproteinase (MMP) polymorphisms are associated with the pathogenesis of aortic aneurysmal diseases. In this study, we conducted a systematic review with an update meta-analysis to investigate the relationship between MMP family polymorphisms and aortic aneurysmal diseases. We systematically reviewed 24 polymorphisms in 8 MMP genes related to the risk of abdominal aortic aneurysm (AAA), thoracic AA or thoracic aortic dissection (TAD). A total of 19 case-control studies with 15 highly studied MMP polymorphisms were included in our meta-analysis. Our results suggested that MMP2rs243865, MMP3rs3025058, MMP13rs2252070 polymorphisms were significantly associated with AAA risk, MMP2rs11643630, MMP8rs11225395 polymorphisms were correlated with TAD risk, and MMP9rs3918242 under the dominant model could increase AAA risk in hospital-based subgroup. No associations with aortic aneurysmal diseases were identified for other polymorphisms assessed in our meta-analysis. In summary, some studied MMP polymorphisms associated with the risk of aortic aneurysmal diseases are potential predictive biomarkers for the clinical application. Moreover, other MMP polymorphisms with limited studies but relevant to aortic aneurysmal formation and progression need further prospective and large investigations to confirm results.

[Management of anesthesia in endovascular interventions]

Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use a wide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate a differentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.

Association of an inter-arm systolic blood pressure difference with all-cause and cardiovascular mortality: An updated meta-analysis of cohort studies

OBJECTIVE

To evaluate whether an association exists between an inter-arm systolic blood pressure difference (sIAD) and all-cause and cardiovascular mortality.

METHODS

We searched for cohort studies that evaluated the association of a sIAD and all-cause or cardiovascular mortality in the electronic databases Medline/PubMed and Embase (August 2014). Random effects models were used to calculate pooled hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Nine cohort studies (4 prospective and 5 retrospective) enrolling 15,617 participants were included. The pooled HR of all-cause mortality for a sIAD of ≥ 10 mm Hg was 1.53 (95% CI 1.14-2.06), and that for a sIAD of ≥ 15 mm Hg was 1.46 (1.13-1.88). Pooled HRs of cardiovascular mortality were 2.21 (95% CI 1.52-3.21) for a sIAD of ≥ 10mm Hg, and 1.89 (1.32-2.69) for a sIAD of ≥ 15 mm Hg. In the patient-based cohorts including hospital- and diabetes-based cohorts, both sIADs of ≥ 10 and ≥ 15 mm Hg were associated with increased all-cause (pooled HR 1.95, 95% CI 1.01-3.78 and 1.59, 1.06-2.38, respectively) and cardiovascular mortality (pooled HR 2.98, 95% CI 1.88-4.72 and 2.10, 1.07-4.13, respectively). In the community-based cohorts, however, only a sIAD of ≥ 15 mm Hg was associated with increased cardiovascular mortality (pooled HR 1.94, 95 % CI 1.12-3.35).

CONCLUSIONS

In the patient populations, a sIAD of ≥ 10 or of ≥ 15 mm Hg could be a useful indictor for increased all-cause and cardiovascular mortality, and a sIAD of ≥ 15 mm Hg might help to predict increased cardiovascular mortality in the community populations.

The Predictive Value of Admission Fragmented QRS Complex for In-Hospital Cardiovascular Mortality of Patients with Type 1 Acute Aortic Dissection

BACKGROUND

Fragmented QRS (fQRS) arises from impaired ventricular depolarization due to heterogeneous electrical activation of ischemic and/or infarcted ventricular myocardium. The short- and long-term prognostic values of fQRS have been reported for myocardial infarction, heart failure, fatal cardiac arrhythmias, and sudden cardiac death. The aim of this study was to investigate the predictive value of admission fQRS complex for in-hospital cardiovascular mortality of patients with type 1 acute aortic dissection (AAD).

METHODS

In this retrospective study, 203 consecutive patients with type 1 AAD who had been admitted to either of two large-volume tertiary hospitals between December 2008 and October 2013 were included. The patients were divided into two groups according to the presence or absence of the fQRS complex on admission.

RESULTS

In-hospital cardiovascular mortality (P < 0.001), major adverse cardiovascular events (P < 0.001), acute renal failure (P = 0.022), multiorgan dysfunction (P < 0.001), and acute decompensated heart failure (P < 0.001) were observed to be significantly more frequent in the fQRS-positive group than in the fQRS-negative group. fQRS (odds ratio [95% confidence interval]: 4.184 [1.927-9.082], P < 0.001), operation duration (4.184 [1.927-9.082], P = 0.001), and Killip class IV (3.900 [1.699-8.955], P = 0.001) were found to be significant independent predictors of in-hospital cardiovascular mortality after adjustment of other risk factors in the multivariate analysis.

CONCLUSIONS

fQRS is a simple, inexpensive, and readily available electrocardiographic entity that provides an additional risk stratification level beyond that provided by conventional risk parameters in predicting in-hospital cardiovascular mortality in type 1 AAD.

[Acute rupture of an abdominal aortic aneurysm revealing Takayasu arteritis]

Arterial aneurysms are most commonly (60% of cases) located in the infrarenal abdominal aorta. An inflammatory mechanism is involved in only 10% of cases. Infrarenal abdominal aortic aneurysms revealing Takayasu's disease is unusual. Takayasu's disease is a rare vasculitis affecting large arteries in young people. It is 10 times more common in women. We report the case of an acute rupture of an abdominal aortic aneurysm revealing Takayasu arteritis in a 39-year-old man with an uneventful medical history.

Abdominal vascular emergencies: US and CT assessment

Acute vascular emergencies can arise from direct traumatic injury to the vessel or be spontaneous (non-traumatic).The vascular injuries can also be divided into two categories: arteial injury and venous injury.Most of them are life-treatening emergencies, sice they may cause an important ipovolemic shock or severe ischemia in their end organ and require prompt diagnosis and treatment.In the different clinical scenarios, the correct diagnostic approach to vascular injuries isn't firmly established and advantages of one imaging technique over the other are not obvious.Ultrasound (US) is an easy accessible, safe and non-invasive diagnostic modality but Computed Tomography (CT) with multiphasic imaging study is an accurate modality to evaluate the abdominal vascular injuries therefore can be considered the primary imaging modality in vascular emergencies.The aim of this review article is to illustrate the different imaging options for the diagnosis of abdominal vascular emergencies, including traumatic and non traumatic vessel injuries, focusing of US and CT modalities.