Re-elevation of D-dimer as a predictor of re-dissection and venous thromboembolism after Stanford type B acute aortic dissection

Influence of abdominal aortic calcification on the distal extent and branch blood supply of acute aortic dissection

OBJECTIVE

This study aimed to investigate the influence of abdominal aortic calcification on the distal extent, blood supply, and mid-term outcomes of acute aortic dissection (AAD).

METHODS

This single-centre retrospective study was conducted from August 2014 to May 2021. The aortic calcification index (ACI) was used to evaluate abdominal aortic calcification. The standardized method provided by the Society for Vascular Surgery (SVS) was used to evaluate the distal extent of AAD. Patients were divided into three groups according to the degree of calcification: no calcification (NC), low calcification (LC), and high calcification (HC).

RESULTS

In a cohort of 723 patients, abdominal aortic calcification was present in 424 (58.6%) patients. The prevalence of coronary heart disease increased with the degree of calcification (NC vs. LC vs. HC: 8.4% vs. 9.5% vs. 19.3%, P<0.001). The ACI of the distal extent at zone 9 was higher than that of the distal extent exceeding zone 9 (P=0.001). The proportions of the NC, LC and HC groups with distal extents exceeding zone 9 were 65.9% vs. 56.2% vs. 37.7%, P<0.001. In multivariate logistics analysis, the calcification grades was a protective factor of distal extents exceeding zone 9 (P<0.001, OR=0.592). Hypertension (P=0.019, OR=1.559) and D-dimer (P<.001, OR=1.045) were risk factors. There was a higher proportion of branch-vessels on the abdominal aorta supplied by the true lumen in the calcification group (NC vs. LC vs. HC: 27.8% vs. 43.8% vs. 51.1%, P<0.001). There were no significant differences in the mid-term outcomes among the groups.

CONCLUSIONS

Abdominal aortic calcification could limit the distal extent in patients with AAD and increase the proportion of branch-vessels on the abdominal aorta supplied by the true lumen.

The diagnostic value of D-dimer in acute aortic dissection: a meta-analysis

Objective

This study aims to evaluate the diagnostic value of D-dimer for acute aortic dissection (AAD) by the method of meta-analysis.

Methods

PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang databases from the establishment of the databases to December 2020 were systematically searched, and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) system was used to evaluate the quality of the literature. STATA 15.0 software was applied to calculate the pooled sensitivity, specificity, diagnostic odds ratio (DOR), positive likelihood ratio (+LR), negative likelihood ratio (−LR) to draw summary receiver operating characteristics (SROC) curve and calculate the area under the curve (AUC). Meta-regression and subgroup analyses were used to explore the source of heterogeneity.

Results

A total of 16 clinical studies were enrolled in this study, including 1135 patients. The results of the meta-analysis showed that the pooled sensitivity was 0.96 (95% CI 0.91–0.98), the pooled specificity was 0.70 (95% CI 0.57–0.81), and the pooled DOR was 56.57 (95% CI 25.11–127.44), the pooled +LR was 3.25 (95% CI 2.18–4.85), the pooled −LR was 0.06 (95% CI 0.03–0.12), and the AUC was 0.94 (95% CI 0.91–0.95). Meta-regression and subgroup analysis results showed that publication year, sample size and cutoff value might be sources of heterogeneity. When the concentration of D-dimer was less than or equal to 500 ng/ml, the sensitivity significantly increased.

Conclusion

D-dimer has an excellent diagnostic value for AAD. It is a useful tool for detecting suspected AAD because of the excellent pooled sensitivity. D-dimer ≤ 500 ng/ml increases the potential to identify the suspected patients with AAD.

Diagnosing Aortic Intramural Hematoma: Current Perspectives

Aortic intramural hematoma (AIH) is an entity within the acute aortic syndrome. Combination of a priori probability, clinical history, laboratory blood test and imaging techniques are the basis for diagnosis of AIH. This review is focused on all aspects related to diagnosis of patients with AIH, from clinical to imaging and analytical.

Characteristics of emergency patients with markedly elevated D-dimer levels

BACKGROUND

Markedly elevated D-dimer levels can occur in emergency patients with various clinical situations, and is likely to indicate the presence of coagulopathy, rapid differential diagnosis was crucial for them.

METHODS

D-dimer was detected in consecutive 813 patients entering the emergency department of our hospital, for the patients with D-dimer levels above 5.0 µg/mL, the final diagnoses and 28-day mortality were confirmed, and the levels of thrombomodulin (TM), thrombin-antithrombin complex (TAT) and plasmin-antiplasmin complex (PAP) on admission were detected.

RESULTS

There were 148 emergency patients with D-dimer levels higher than 5.0 µg/mL mainly due to sepsis, malignancy, trauma, venous thromboembolism (VTE), cerebrovascular accident, and so on. Both of the TM and TAT levels among these diagnoses were significantly different (p < 0.001). The elevated TM (>13.3 TU/mL) had a predictive value of 96.0% for excluding VTE, and the normal TM had a predictive value of 90.4% for excluding sepsis. The overall 28-day mortality of these patients with D-dimer >5.0 ug/mL was 14.2%, the TAT level on admission was independently associated with 28-day mortality (odds ratio 1.014, 95% CI 1.001-1.027, P = 0.030).

CONCLUSIONS

The medical emergencies associated with markedly elevated D-dimer levels were revealed, specific markers of endothelial dysfunction and thrombin generation measured by automatic analyzer have the potential to distinguish diagnoses and predict outcomes in these patients.

Cardiovascular Disease in Ageing: An Overview on Thoracic Aortic Aneurysm as an Emerging Inflammatory Disease

Medial degeneration associated with thoracic aortic aneurysm and acute aortic dissection was originally described by Erdheim as a noninflammatory lesion related to the loss of smooth muscle cells and elastic fibre fragmentation in the media. Recent evidences propose the strong role of a chronic immune/inflammatory process in aneurysm evocation and progression. The coexistence of inflammatory cells with markers of apoptotic vascular cell death in the media of ascending aorta with aneurysms and type A dissections raises the possibility that activated T cells and macrophages may contribute to the elimination of smooth muscle cells and degradation of the matrix. On the other hand, several inflammatory pathways (including TGF-β, TLR-4 interferon-γ, chemokines, and interferon-γ) seem to be involved in the medial degeneration related to aged and dilated aorta. This is an overview on thoracic aortic aneurysm as an emerging inflammatory disease.

Acute Aortic Dissection Biomarkers Identified Using Isobaric Tags for Relative and Absolute Quantitation

The purpose of this study was to evaluate the utility of potential serum biomarkers for acute aortic dissection (AAD) that were identified by isobaric Tags for Relative and Absolute Quantitation (iTRAQ) approaches. Serum samples from 20 AAD patients and 20 healthy volunteers were analyzed using iTRAQ technology. Protein validation was performed using samples from 120 patients with chest pain. A total of 355 proteins were identified with the iTRAQ approach; 164 proteins reached the strict quantitative standard, and 125 proteins were increased or decreased more than 1.2-fold (64 and 61 proteins were up- and downregulated, resp.). Lumican, C-reactive protein (CRP), thrombospondin-1 (TSP-1), and D-dimer were selected as candidate biomarkers for the validation tests. Receiver operating characteristic (ROC) curves show that Lumican and D-dimer have diagnostic value (area under the curves [AUCs] 0.895 and 0.891, P < 0.05). For Lumican, the diagnostic sensitivity and specificity were 73.33% and 98.33%, while the corresponding values for D-dimer were 93.33% and 68.33%. For Lumican and D-dimer AAD combined diagnosis, the sensitivity and specificity were 88.33% and 95%, respectively. In conclusion, Lumican has good specificity and D-dimer has good sensitivity for the diagnosis of AAD, while the combined detection of D-dimer and Lumican has better diagnostic value.

Impact of d-Dimer Levels on Admission on Inhospital and Long-Term Outcome in Patients With Type A Acute Aortic Dissection

Limited studies with relatively small sample sizes have reported that elevated d-dimer levels on admission were associated with increased risk of short-term mortality in patients with type A acute aortic dissection (AAD). However, there were unavailable data regarding the impact of admission d-dimer levels on long-term outcomes. Our present study aimed to evaluate the association of admission d-dimer levels with both inhospital and long-term all-cause mortality in patients with type A AAD. A total of 212 consecutive patients with type A AAD were enrolled. d-Dimer levels were measured on admission, and patients were followed up prospectively. The primary end points were inhospital and long-term all-cause mortality. The median length of follow-up was 18.8 months (interquartile range 6.7 to 24.4 months). The inhospital and long-term all-cause mortality rates were 12.7% and 12.4%, respectively. Compared with the survivors, the nonsurvivors had significantly higher d-dimer levels (p <0.001). When divided into 4 groups according to admission d-dimer quartiles, patients in Q4 (>6.10 μg/ml) had the highest inhospital and long-term mortality among groups. After multivariate adjustment, the d-dimer level in Q4 (>6.10 μg/ml) was an independent risk factor for inhospital mortality (hazard ratio [HR] 6.12, 95% confidence interval 1.35 to 27.89, p = 0.019) in addition to surgical treatment; however, this was not an independent predictor for long-term mortality. In conclusion, our study with a relatively large sample size suggested that elevated admission d-dimer levels (>6.10 μg/ml) might be a predictor for increased risk of inhospital mortality, and urgent-emergent surgery might be needed in patients with elevated d-dimer levels on admission. However, d-dimer levels at admission failed to predict long-term mortality.

Current evidence for thoracic aorta type B dissection management

Aortic dissection is a devastating cardiovascular condition and represents the most common aortic emergency. Outcome is determined by the type and extent of dissection and the presence of associated complications requiring early diagnosis and treatment. Aortic dissection is defined as acute within 14 days from onset and chronic after that time period. The natural course of type B dissection is determined by 2 elements, early and chronic complications. An uncomplicated acute type B dissection is less frequently lethal but it is not totally benign. Some peculiar issues must be taken into account, such as the high probability of complications development in a dissected aorta and the poor long-term prognosis on medical treatment alone. Then, it would be helpful to identify which patients with uncomplicated type B dissection will have a poorest aortic prognosis over time in order to apply an early intervention.

Biological features of thoracic aortic diseases. Where are we now, where are we heading to: established and emerging biomarkers and molecular pathways

Thoracic aortic aneurysms (TAAs) and aortic dissections (ADs) are among the main causes of mortality and morbidity in Western countries. For this reason, the diagnosis, prevention and prediction of TAAs and ADs have become a very active area of research; in fact, it is important to monitor and predict the evolution of these diseases over time. It is also critical, in cases of doubtful diagnosis, to receive some guidance from biochemical assays, particularly in the case of ADs. Although biological testing for disease prediction has already been discussed several times, the role of biomarkers in TAAs and ADs is still under discussion for routine patient screening, periodical follow-up or for prompt diagnosis in emergency conditions. In this review, we update the current knowledge and new trends regarding the role of biomarkers in thoracic aortic diseases, focusing on established and emerging biomarkers in the fields of genetics, inflammation, haemostasis and matrix remodelling as well as on substances released upon cell damage. Other than D-dimer, a sensitive but not a specific marker for the diagnosis of AD that has been widely tested by several authors and currently seems a viable option in ambiguous cases, the remaining markers have been most frequently assessed in limited or mixed patient populations. This currently precludes their widespread adoption as diagnostic or prognostic tools, even if many of these markers are conceptually promising. In years to come, we expect that future studies will further clarify the diagnostic and prognostic features of several established and emerging biomarkers that, to date, are still in the translational limbo separating biological discovery from a practical clinical role.

Utility of measuring C-reactive protein for prediction of in-hospital events in patients with acute aortic dissection

Controlling blood pressure is essential for prevention of events after acute aortic dissection (AAD). However, in some instances a cardiac event occurs despite controlled blood pressure, and its prediction is difficult. We continuously monitored C-reactive protein (CRP) in patients receiving medical treatment for AAD and retrospectively examined the utility of CRP measurement for prediction of in-hospital events. Five hundred and eight patients were diagnosed as having AAD between 1993 and 2009, 240 of whom underwent antihypertensive medical therapy. These subjects were 156 males and 84 females, average age 67.4 years, with 68 cases of Stanford type A and 172 cases of Stanford type B. C-reactive protein was measured in all patients daily until a peak; subsequently, CRP was measured 2-3 times per week following the peak until discharge. In the event-free group CRP demonstrated a peak on the 4th day after the onset (average 13.7 mg/dl), then gradually decreased to an average of 4.6 mg/dl 4 weeks later, displaying a "gradual decay" pattern. Despite controlled systolic arterial pressure of approximately 120 mmHg, 7 of 68 Stanford A cases (10.3 %) and 8 of 172 Stanford B cases (4.7 %) developed cardiovascular events. The group characterized by events exhibited a CRP pattern distinct from that of the event-free group, i.e., prolonged elevation and/or re-elevation. We demonstrated that the CRP pattern could provide information regarding prediction of cardiovascular events. Prolonged elevation or re-elevation of CRP may indicate the necessity of (1) application of computed tomography or magnetic resonance imaging, (2) more rigorous blood pressure management, or (3) early surgical intervention.