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Borghese O, Pisani A, Lopez-Marco A, Adams B, Oo AY, Kapil V, Mastracci T. Aortic Outcome After Implementation of a Treatment Strategy for Type B Aortic Dissection Involving the Aortic Arch. Ann Vasc Surg 2024:S0890-5096(24)00499-0. [PMID: 39127369 DOI: 10.1016/j.avsg.2024.07.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/25/2024] [Accepted: 07/07/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE To evaluate outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD). METHODS This retrospective observational study adhered to the STROBE checklist. All cases of NANB AAD (B 1-2 D) treated at our Institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodelling were analysed. RESULTS Among 519 cases of acute aortic syndrome, n=22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n=16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly two days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7(31.8%) needed emergent operation for risks of impending aortic rupture/retrograde AD extension and 4(26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of FL thrombosis (100% vs 55.5%, p=.033) and a significant positive aortic remodelling in zone 3 (p<.001) and 4 (p=0.038) were reported in operated versus medically managed patients. CONCLUSION The best treatment for NANB is not established. We advocate for medical stabilisation with an operative approach that favours open surgery in the acute post dissection period, promotes aortic remodelling and carries acceptable risk in centres where FET is performed routinely.
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Affiliation(s)
- Ottavia Borghese
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; PhD school angio-cardio-thoracic pathophysiology and imaging, Sapienza University, Rome, Italy.
| | - Angelo Pisani
- PhD school angio-cardio-thoracic pathophysiology and imaging, Sapienza University, Rome, Italy
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, London, UK
| | - Benjamin Adams
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, London, UK
| | - Viskas Kapil
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, London, UK
| | - Tara Mastracci
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK; Department of Surgery and Interventional Sciences, University College London, London, UK
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Valente T, Sica G, Romano F, Rea G, Lieto R, De Feo M, Della Corte A, Guarino S, Massimo C, Scaglione M, Muto E, Bocchini G. Non-A Non-B Acute Aortic Dissection: Is There Some Confusion in the Radiologist's Mind? Tomography 2023; 9:2247-2260. [PMID: 38133078 PMCID: PMC10746994 DOI: 10.3390/tomography9060174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/08/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND The aim of this study is to define and determine the rate of acute non-A-non-B aortic dissections, and to evaluate CT angiography findings and possible complications, as well as to discuss management strategies and currently available therapy. Non-A non-B type of aortic dissection is still a grey area in the radiologist's mind, such that it is not entirely clear what should be reported and completed in terms of this disease. METHODS A retrospective single-center study including 36 pre-treatment CT angiograms of consecutive patients (mean age: 61 years) between January 2012 and December 2022 with aortic dissection involving the aortic arch with/without the thoracic descending/abdominal aorta (type non-A non-B). RESULTS According to the dissection anatomy, we identified three modalities of spontaneous acute non-A-non-B anatomical configurations. Configuration 1 (n = 25) with descending-entry tear and retrograde arch extension (DTA entry). Configuration 2 (n = 4) with Arch entry tear and isolated arch involvement (Arch alone). Configuration 3 (n = 7) with Arch entry and anterograde descending (±abdominal) aorta involvement (Arch entry). CT angiogram findings, management, and treatment options are described. CONCLUSIONS Acute non-A non-B dissection represents an infrequent occurrence of aortic arch dissection (with or without involvement of the descending aorta) that does not extend to the ascending aorta. The complete understanding of its natural progression, distinct CT angiography subtypes, optimal management, and treatment strategies remains incomplete. Within our series, patients frequently exhibit a complex clinical course, often necessitating a more assertive approach to treatment compared to type B dissections.
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Affiliation(s)
- Tullio Valente
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
| | - Giacomo Sica
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
| | - Federica Romano
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
| | - Gaetano Rea
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
| | - Roberta Lieto
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
| | - Marisa De Feo
- Department of Translational Medical Sciences, Vanvitelli University, Monaldi Hospital, 80131 Naples, Italy
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, Vanvitelli University, Monaldi Hospital, 80131 Naples, Italy
| | - Salvatore Guarino
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
| | - Candida Massimo
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
| | - Mariano Scaglione
- Department of Medicine, Surgery and Pharmacy, University of Sassary, 07100 Sassari, Italy;
| | - Emanuele Muto
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
| | - Giorgio Bocchini
- General Radiology Unit, AORN Ospedali dei Colli, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (S.G.); (G.B.)
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Trimarchi S, Mandigers TJ, Bissacco D, Nienaber C, Isselbacher EM, Evangelista A, Suzuki T, Bossone E, Pape LA, Januzzi JL, Harris KM, O'Gara PT, Gilon D, Hutchison S, Patel HJ, Woznicki EM, Montgomery D, Kline-Rogers E, Eagle KA. Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00608-6. [PMID: 37453718 DOI: 10.1016/j.jtcvs.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/21/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years. METHODS IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents. RESULTS Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index. CONCLUSIONS IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.
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Affiliation(s)
- Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
| | - Tim J Mandigers
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniele Bissacco
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Christoph Nienaber
- Department of Cardiology, Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, Imperial College, London, United Kingdom
| | - Eric M Isselbacher
- Cardiology Department, Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
| | - Arturo Evangelista
- Cardiology Department, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Toru Suzuki
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | | | - Linda A Pape
- Department of Medicine, University of Massachusetts Hospital, Worcester, Mass
| | - James L Januzzi
- Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Mass; Cardiology Division, Massachusetts General Hospital, Boston, Mass
| | - Kevin M Harris
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Patrick T O'Gara
- Department of Cardiology, Brigham & Women's Hospital, Boston, Mass
| | - Dan Gilon
- Department of Non-invasive Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Stuart Hutchison
- Department of Cardiac Sciences, University of Calgary Medical Centre, Calgary, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | | | | | | | - Kim A Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor, Mich
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Tian C, Chen D, Zhao J, Zhang Y, Luo M, Fang K, Tian C, Sun X, Guo H, Qian X, Shu C. Surgical treatment patterns and clinical outcomes of type B aortic dissection involving the aortic arch. J Vasc Surg 2023; 77:1016-1027.e9. [PMID: 36410607 DOI: 10.1016/j.jvs.2022.11.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In the present report, we have described the outcomes of endovascular repair, hybrid arch repair, and open surgical repair for type B dissection involving the aortic arch (B1-2, D). METHODS Cases of endovascular repair, hybrid arch repair, and open surgical repair performed between January 2015 and December 2019 for aortic dissection designated as B1-2, D by the Society for Vascular Surgery/Society of Thoracic Surgeons classification were retrospectively analyzed. The primary end point was all-cause mortality at follow-up. The secondary end points included early mortality, early morbidities, and aortic-related late events. Kaplan-Meier curves were created to analyze survival from all-cause mortality and freedom from aortic-related late events in the endovascular, hybrid, and open groups. Propensity score matching and stratification (stratified by proximal dissection extension: B1, D and B2, D) were performed as sensitivity analyses to compare the outcomes among the three treatment patterns after controlling for major confounders. RESULTS The present study included 151 patients (men, 79.5%; mean age, 47.3 ± 10.5 years), with 72 (47.7%) in the endovascular group, 46 (30.5%) in the hybrid group, and 33 (21.8%) in the open group. No significant difference was noted in early mortality between the endovascular, hybrid, and open groups (1.4% vs 2.2% vs 3.0%; P = .791). The incidence of early endoleak was significantly greater (33.3% vs 13.0% vs 6.1%; P = .002) and the incidence of renal function deterioration was less (4.2% vs 26.1% vs 24.2%; P = .001) after endovascular repair vs hybrid arch repair and open surgery. After a median follow-up of 40.0 months (range, 0-84.0 months), no significant differences were found in all-cause mortality (5.6% vs 4.3% vs 3.0%; P = 1.0), aortic-related late events (16.7% vs 15.2% vs 12.1%; P = .834), or late endoleak (9.7% vs 4.3% vs 6.1%; P = .630) after endovascular, hybrid, and open surgery. The propensity score matching and stratification analyses displayed consistent outcomes for early mortality, all-cause mortality, and aortic-related late events among the three groups. CONCLUSIONS The mid- to long-term outcomes after endovascular repair, hybrid arch repair, and open surgical repair for type B dissection involving the aortic arch (B1-2, D) were favorable and comparable in selected patients. Extensive experience and multidisciplinary teamwork are prerequisites for individualized strategies for repair of B1-2, D.
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Affiliation(s)
- Chen Tian
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Chen
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawei Zhao
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yidan Zhang
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingyao Luo
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun Fang
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chuan Tian
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwei Guo
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chang Shu
- Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.
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5
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Li Q, Wu Q, Wu W, Dai X, Fang G, Xie X, Chen L. Triple-Branched Stent Graft Implantation for Acute Non-A-non-B Aortic Dissection. Ann Thorac Surg 2023; 115:583-589. [PMID: 34971594 DOI: 10.1016/j.athoracsur.2021.11.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/26/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal treatment for acute non-A-non-B aortic dissection remains controversial. Triple-branched stent graft (TBSG) implantation has been used to treat acute type A aortic dissection. This study aimed to evaluate the safety and efficacy of TBSG as a treatment for acute non-A-non-B aortic dissection. METHODS Fifty patients with non-A-non-B dissection received TBSG implantation in our center between January 2014 and December 2019. Early mortality, morbidity, and dissected aorta remodeling during follow-up were calculated. RESULTS There were no deaths in-hospital or within 30 days. Postoperative complications included pneumonia (n = 12), acute kidney injury (n = 6; preoperative renal malperfusion, n = 4), transient cerebral injury (n = 6; preoperative cerebral malperfusion, n = 4), pleural effusion (n = 4), and pericardial effusion (n = 2). During follow-up, 1 patient experienced a stroke, and 2 patients required secondary interventional therapy for residual dissection below the level of the TBSG. All implanted TBSGs had good positioning, and all sidearm stent graft grafts were fully patent. No retrograde aortic dissection or type I endoleak was detected. CONCLUSIONS TBSG implantation for acute non-A-non-B aortic dissection had a low incidence of mortality and morbidity, featuring good remodeling of the dissected aortic wall during follow-up. The early outcomes of this technique were satisfactory.
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Affiliation(s)
- Qianzhen Li
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Vascular Aging, Fujian Medical University, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Qingsong Wu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Weixiong Wu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Xaofu Dai
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Guanhua Fang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Xianbiao Xie
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Vascular Aging, Fujian Medical University, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China.
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Brown JA, Sultan I. Commentary: Delaying the inevitable? Interventions for medically managed, uncomplicated type B aortic dissection. J Thorac Cardiovasc Surg 2023; 165:966-969. [PMID: 33972114 DOI: 10.1016/j.jtcvs.2021.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 11/26/2022]
Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Preemptive fenestrated endovascular repair aimed at perfusion of cervical branches in acute type B aortic dissection. Gen Thorac Cardiovasc Surg 2022; 71:339-346. [PMID: 36414798 DOI: 10.1007/s11748-022-01886-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Most of the entry tears of uncomplicated type B aortic dissection are located in the distal arch and extends in a retrograde manner to the level of the left subclavian artery. Our objective was to evaluate feasibility and effectiveness using fenestrated sent graft with complete neck vessel preservation to treat uncomplicated type B aortic dissection. SUBJECTS AND METHODS We retrospectively reviewed the record of patients with uncomplicated type B aortic dissection who underwent fenestrated thoracic endovascular aortic repair in subacute phase (15-90 days) between August 2016 and April 2020. The Najuta fenestrated stent graft was placed proximally beyond he left subclavian artery (zone 0-2) in an attempt to seal the entry while preserving the neck vessels. RESULTS We evaluated 9 cases (male: 7, female: 2; median age 70 years). The median distance from the LSA to the proximal entry was 37 mm. The landing zones of the proximal end of the Najuta were zone 0: 3, zone 1: 2, and zone 2: 4 cases. Technical success was 100% with no 30-day death. None of the patients had a stroke, paraplegia or retrograde dissection, and no endoleak was observed. Complete aortic remodeling with false lumen resolution was obtained in all cases while each fenestrated vessels remained patent during the follow-up period. CONCLUSION Preemptive thoracic endovascular aortic repair aimed at perfusion of cervical branches using the Najuta fenestrated stent is safe and effective and may be considered as a reasonable treatment option for the treatment is a safe and an effective treatment.
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Liu J, Yang F, Chen L, Xie E, Su S, Liu Y, Geng Q, Fan R, Li J, Luo J. Management and Outcomes of Non-A Non-B Aortic Dissection. Eur J Vasc Endovasc Surg 2022; 64:497-506. [PMID: 35667594 DOI: 10.1016/j.ejvs.2022.05.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The results of best medical treatment (BMT), endovascular based treatment (EBT), and total arch replacement (TAR) with frozen elephant trunk (FET) treatment in a single centre experience were reported in non-A non-B aortic dissection patients. METHODS From January 2016 to May 2020, 215 consecutive patients with acute or subacute non-A non-B aortic dissection were enrolled. The primary endpoints were all cause death. Secondary endpoints included follow up adverse aortic event (AE), a composite of the outcomes of dissection related death, rupture, retrograde type A aortic dissection, stent graft induced new entry tear, secondary endoleak, and follow up re-intervention. Kaplan-Meier curves were used to evaluate associations between different treatments and outcomes. RESULTS Among the 215 dissection patients, 127 (59.1%) received EBT, 42 (19.5%) received TAR + FET, and the remaining 46 (21.4%) received BMT. Thirty day mortality was higher in patients receiving TAR + FET (7.1%) than in those treated with EBT (1.6%) or BMT (2.2%) (p = .12). However, after a median follow up of 39.1 (27.0 - 50.7) months, no additional death was recorded in the TAR + FET group, while nine (7.3%) patients died in the EBT group and 14 (31.8%) died in the BMT group (p < .001). Specifically, EBT and TAR + FET showed no significant difference in midterm mortality rate, follow up AE, and re-intervention for complicated or uncomplicated dissection patients involving zone 2. For patients with uncomplicated non-A non-B aortic dissection involving zone 2, EBT could profoundly decrease the mortality rate, follow up AE and re-intervention when compared with BMT (p < .010 for all), although this difference was not statistically significant between TAR + FET and BMT. No statistical comparison was performed in patients with zone 1 involvement because of the limited number of patients. CONCLUSION It was demonstrated that EBT or TAR + FET might be a viable strategy for non-A non-B aortic dissection patients.
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Affiliation(s)
- Jitao Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Fan Yang
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Lyufan Chen
- The School of Medicine, South China University of Technology, Guangzhou, China
| | - Enmin Xie
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Sheng Su
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yuan Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qingshan Geng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruixin Fan
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jie Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Jianfang Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
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Kimura N, Nakamura M, Takagi R, Mieno MN, Yamaguchi A, Czerny M, Beyersdorf F, Kari FA, Rylski B. False lumen/true lumen wall pressure ratio is increased in acute non-A non-B aortic dissection. Interact Cardiovasc Thorac Surg 2022; 35:6585342. [PMID: 35552699 PMCID: PMC9486891 DOI: 10.1093/icvts/ivac138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
We aimed to determine whether non-A non-B aortic dissection (AD) differs in morphologic and haemodynamic properties from type B AD.
METHODS
We simulated and compared haemodynamics of patients with acute type B or acute non-A non-B AD by means of computational fluid dynamics. Wall pressure and wall shear stress (WSS) in both the true lumen (TL) and false lumen (FL) at early, mid- and late systole were evaluated. Morphology, WSS and the FL/TL wall pressure ratio were compared between groups.
RESULTS
Nineteen patients (type B, n = 7; non-A non-B, n = 12) were included. The median age (51 [46, 67] vs 53 [50, 63] years; P = 0.71) and a complicated course (14% vs 33%; P = 0.6) did not differ between the type B group and the non-A non-B group. However, the median entry tear width was increased in the non-A non-B group (9.7 [7.3, 12.7] vs 16.3 [11.9, 24.9] mm; P = 0.010). Streamlines showed, in patients with non-A non-B AD, blood from the TL flowed into the FL via the entry tear. Prevalence of a FL/TL wall pressure ratio >1.0 (type B versus non-A non-B) at early, mid- and late systole was 57% vs 83% (P = 0.31), 43% vs 83% (P = 0.13) and 57% vs 75% (P = 0.62), respectively. WSS did not differ between the groups.
CONCLUSIONS
The increased FL/TL wall pressure ratio observed during systole in non-A non-B AD may beget a complicated presentation.
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Affiliation(s)
- Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University , Saitama, Japan
| | - Masanori Nakamura
- Department of Electrical and Mechanical Engineering, Nagoya Institute of Technology , Nagoya, Japan
| | - Reiya Takagi
- Department of Electrical and Mechanical Engineering, Nagoya Institute of Technology , Nagoya, Japan
| | - Makiko Naka Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University , Shimotsuke, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University , Saitama, Japan
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University of Freiburg , Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University of Freiburg , Freiburg, Germany
| | - Fabian Alexander Kari
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University of Freiburg , Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University of Freiburg , Freiburg, Germany
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10
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Tijmes FS, Karur GR. Imaging of Heritable Thoracic Aortic Disease. Semin Roentgenol 2022; 57:364-379. [DOI: 10.1053/j.ro.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 11/11/2022]
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11
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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12
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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13
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Jubouri M, Al-Tawil M, Yip HCA, Bashir A, Tan SZCP, Bashir M, Anderson R, Bailey D, Nienaber CA, Coselli JS, Williams I. Mid- and long-term outcomes of thoracic endovascular aortic repair in acute and subacute uncomplicated type B aortic dissection. J Card Surg 2022; 37:1328-1339. [PMID: 35191082 DOI: 10.1111/jocs.16349] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 01/28/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Uncomplicated type B aortic dissection (un-TBAD) has been managed conservatively with medical therapy to control the heart rate and blood pressure to limit disease progression, in addition to radiological follow-up. However, several trials and observational studies have investigated the use of thoracic endovascular aortic repair (TEVAR) in un-TBAD and suggested that TEVAR provides a survival benefit over medical therapy. Outcomes of TEVAR have also been linked with the timing of intervention. AIMS The scope of this review is to collate and summarize all the evidence in the literature on the mid- and long-term outcomes of TEVAR in un-TBAD, confirming its superiority. We also aimed to investigate the relationship between the timing of TEVAR intervention and results. METHODS We carried out a comprehensive literature search on multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on the mid- and long-term outcomes of TEVAR in un-TBAD, as well as its relationship with intervention timing. RESULTS TEVAR has proven to be a safe and effective tool in un-TBAD, offering superior mid- and long-term outcomes including all-cause and aorta-related mortality, aortic-specific adverse events, aortic remodeling, and need for reintervention. Additionally, performing TEVAR during the subacute phase of dissection seems to yield optimal results. CONCLUSION The evidence demonstrating a survival advantage in favor TEVAR over medical therapy in un-TBAD means that with further research, particular trials and observational studies, TEVAR could become the gold-standard treatment option for un-TBAD patients.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | | | - Ali Bashir
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, Wales, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, Wales, UK
| | - Damian Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, Wales, UK
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St Luke's-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, Wales, UK
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14
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MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal. Tomography 2022; 8:200-228. [PMID: 35076599 PMCID: PMC8788571 DOI: 10.3390/tomography8010017] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 01/16/2023] Open
Abstract
Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient’s management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replicable, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.
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15
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Singh S, Nassiri N, Vallabhajosyula P. All type B aortic dissections should undergo thoracic endovascular aneurysm repair. JTCVS Tech 2021; 9:17-24. [PMID: 34647046 PMCID: PMC8501243 DOI: 10.1016/j.xjtc.2021.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/25/2021] [Indexed: 12/26/2022] Open
Affiliation(s)
- Saket Singh
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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16
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Schenning RC, Al-Hakim R. Aortic Dissection: Branched, Fenestrated, and Parallel Aortic Stent Grafts in the Ascending Aorta and Arch. Tech Vasc Interv Radiol 2021; 24:100754. [PMID: 34602271 DOI: 10.1016/j.tvir.2021.100754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Open surgical repair of dissections and post-dissection degenerative aneurysms involving the ascending thoracic aorta and aortic arch, whether in the acute or post-repair state, is associated with high rates of morbidity and mortality. Recent advancements in minimally invasive endovascular techniques have expanded the role of thoracic endovascular aortic repair (TEVAR) for dissections and dissection-related arch pathologies. Image-guided endovascular techniques, such as in situ fenestrated grafts, chimney and/or periscope grafts, along with newly developed commercially available branched aortic devices, have allowed for an increasing number of high-risk operative candidates to undergo definitive repair of aortic arch pathology who otherwise would have been destined for non-operative management. This paper reviews the data, pre-procedural planning, and technical considerations for complex TEVAR techniques for ascending and aortic arch dissections and dissection-related aneurysms.
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Affiliation(s)
- Ryan C Schenning
- Charles T. Dotter Department of Interventional Radiology, Oregon Health & Science University, Portland, OR.
| | - Ramsey Al-Hakim
- Charles T. Dotter Department of Interventional Radiology, Oregon Health & Science University, Portland, OR
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17
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Koechlin L, Schuerpf J, Bremerich J, Sommer G, Gahl B, Reuthebuch O, Gurke L, Mujagic E, Eckstein F, Berdajs DA. Acute aortic dissection with entry tear at the aortic arch: long-term outcome. Interact Cardiovasc Thorac Surg 2021; 32:89-96. [PMID: 33221851 DOI: 10.1093/icvts/ivaa228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/16/2020] [Accepted: 08/31/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES The goal was to evaluate outcomes after conservative or surgical treatment of acute aortic arch dissections. METHODS Between January 2009 and December 2018, patients with a diagnosis of acute aortic dissection were analysed. Aortic arch aortic dissection was defined as a dissection with an isolated entry tear at the aortic arch with no involvement of the ascending aorta. RESULTS Aortic arch dissection was diagnosed in 31 patients (age 59 ± 11 years). Surgical intervention was performed in 13 (41.9%) cases. Overall in-hospital mortality was 3% (n = 1), and all deaths occurred in the conservative group (n = 1; 6%), whereas the overall stroke rate was 3% (n = 1), and all strokes occurred in the group treated surgically (n = 1; 8%). Surgical repair was necessary for the following conditions: end-organ malperfusion (n = 9; 69%), impending rupture (n = 3; 23%) and dilatation of the aorta with ongoing pain refractory to medical treatment (n = 1; 8%). Overall survival at the end of the follow-up period was 71%, with 77% in the surgical group and 63% in the conservative group (P = 0.91). Freedom from surgical intervention was 71%, with 82% in the surgical and 63% in the conservative group (P = 0.21), and freedom from a neurological event was 88%, with 89% versus 89% (P = 0.68) in the surgical and conservative groups, respectively. CONCLUSIONS Aortic arch dissection is a rare pathological condition that is one of the most challenging decision-making entities. Patients manifesting an uneventful course not requiring a surgical intervention during a hospital stay were at a higher risk for aorta-related intervention during the follow-up period. The treatment modality had no impact on survival or on the incidence of a neurological event.
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Affiliation(s)
- Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Julia Schuerpf
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Jens Bremerich
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Gregor Sommer
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Lorenz Gurke
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, Basel, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Denis A Berdajs
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
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18
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Ko JP, Goldstein JM, Latson LA, Azour L, Gozansky EK, Moore W, Patel S, Hutchinson B. Chest CT Angiography for Acute Aortic Pathologic Conditions: Pearls and Pitfalls. Radiographics 2021; 41:399-424. [PMID: 33646903 DOI: 10.1148/rg.2021200055] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chest CT angiography (CTA) is essential in the diagnosis of acute aortic syndromes. Chest CTA quality can be optimized with attention to technical parameters pertaining to noncontrast imaging, timing of contrast-enhanced imaging, contrast material volume, kilovolt potential, tube-current modulation, and decisions regarding electrocardiographic-gating and ultra-fast imaging, which may affect the accurate diagnosis of acute aortic syndromes. An understanding of methods to apply to address suboptimal image quality is useful, as the accurate identification of acute aortic syndromes is essential for appropriate patient management. Acute aortic syndromes have high morbidity and mortality, particularly when involving the ascending aorta, and include classic aortic dissection, penetrating atherosclerotic ulcer, and acute intramural hematoma. An understanding of the pathogenesis and distinguishing imaging features of acute aortic syndromes and aortic rupture and some less common manifestations is helpful when interpreting imaging examinations. Related entities, such as ulcerated plaque, ulcerlike projections, and intramural blood pools, and mimics, such as vasculitis and aortic thrombus, are important to recognize; knowledge of these is important to avoid interpretive pitfalls. In addition, an awareness of postsurgical aortic changes can be useful when interpreting CTA examinations when patient history is incomplete. The authors review technical considerations when performing CTA, discuss acute aortic syndromes, and highlight diagnostic challenges encountered when interpreting aortic CTA examinations. ©RSNA, 2021.
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Affiliation(s)
- Jane P Ko
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Jonathan M Goldstein
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Larry A Latson
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Lea Azour
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Elliott K Gozansky
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - William Moore
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Smita Patel
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
| | - Barry Hutchinson
- From the Department of Radiology, NYU Langone Health, 660 First Ave, Room 747, New York, NY 10016 (J.P.K., J.M.G., L.A.L., L.A., E.K.G., W.M.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (S.P.); and Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland (B.H.)
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19
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Howard C, Ponnapalli A, Shaikh S, Idhrees M, Bashir M. Non-A non-B aortic dissection: A literature review. J Card Surg 2021; 36:1806-1813. [PMID: 33547714 DOI: 10.1111/jocs.15349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/09/2021] [Indexed: 01/16/2023]
Abstract
Non-A non-B aortic dissections are an infrequent occurrence and represent a small proportion of aortic dissections. Treating this life-threatening medical emergency often requires surgeons to undertake some one of the most challenging surgical or endovascular cases in medicine. This literature review aims to define and classify non-A non-B dissections, describe their epidemiology as well as their pathology. This review also aims to discuss the range of surgical techniques employed in their treatment and management and to investigate the patient outcomes associated with each technique.
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Affiliation(s)
- Callum Howard
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - Anuradha Ponnapalli
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - Safwan Shaikh
- Dentistry and Biomedical Sciences, Queen's University Belfast School of Medicine, Queen's University Belfast, Belfast, UK
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohammad Bashir
- Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
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20
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Management of type-A intramural hematoma: Does classification matter? Int J Cardiol 2020; 313:121-122. [DOI: 10.1016/j.ijcard.2020.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 11/20/2022]
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21
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Qanadli SD, Malekzadeh S, Villard N, Jouannic AM, Bodenmann D, Tozzi P, Rotzinger DC. A New Clinically Driven Classification for Acute Aortic Dissection. Front Surg 2020; 7:37. [PMID: 32656225 PMCID: PMC7324626 DOI: 10.3389/fsurg.2020.00037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/20/2020] [Indexed: 12/20/2022] Open
Abstract
Objectives: To report a new classification scheme for acute aortic dissection (AAD) that considers the aortic arch as a separate entity and integrates patterns of malperfusion syndrome (MPS). The proposed classification was evaluated retrospectively in a large population. Materials and Methods: We retrospectively reviewed pre-therapy CT angiograms of 226 consecutive patients (mean ± SD age: 64 ± 12 years) with AAD. AADs were reclassified with a new classification scheme that included three aortic dissection types (A, involving at least the ascending aorta; B, involving exclusively the descending aorta; and C, involving the aortic arch with/without the descending aorta) and four malperfusion grades (0: no MPS; 1: dynamic MPS; 2: static MPS; 3: static and dynamic MPS). AAD features were assessed and correlated to patient outcomes. Results: According to the new classification, we identified 152 type A dissections (92 A0, 11 A1, 38 A2, 11 A3); 50 type B (38 B0, 5 B1, 6 B2, 1 B3); and 24 type C (17 C0, 6 C2, 1 C3). Type C represented 11% of all AADs. MPS occurred in 39, 24, and 29% in type A, B, and C, respectively. Type C was treated with significantly more endovascular or hybrid interventions (37%) than in types A (3%) and B (20%) (p < 0.001). Conclusion: The new AAD classification was feasible, and type C was easily identified (“non-A, non-B”). Preliminary findings supported the usefulness of this classification for the decision-making process and subsequent treatments.
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Affiliation(s)
- Salah D Qanadli
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Sonaz Malekzadeh
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Nicolas Villard
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Anne-Marie Jouannic
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Daniel Bodenmann
- Department of Radiology, Kantonsspital Frauenfeld, Frauenfeld, Switzerland
| | - Piergiorgio Tozzi
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland.,Department of Heart and Vessels, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - David C Rotzinger
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
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22
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Murana G, Di Marco L, Amodio C, Costantino A, Di Bartolomeo R, Leone A, Pacini D. Use of the frozen elephant trunk technique for type B aortic dissection and aberrant right subclavian artery: an anatomic repair of the "arteria lusoria". Ann Cardiothorac Surg 2020; 9:254-256. [PMID: 32551265 DOI: 10.21037/acs.2020.03.15] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Ciro Amodio
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Antonino Costantino
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Leone
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
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23
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Mougin J, Charbonneau P, Guihaire J, Schwein A, Tyrrell MR, Maurel B, Fabre D, Haulon S. Endovascular management of chronic post-dissection aneurysms of the aortic arch. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:402-415. [PMID: 32337939 DOI: 10.23736/s0021-9509.20.11395-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.
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Affiliation(s)
- Justine Mougin
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Philippe Charbonneau
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Julien Guihaire
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Adeline Schwein
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | | | - Blandine Maurel
- Service of Vascular Surgery, Thorax Institute, Nantes University Hospital, Nantes, France
| | - Dominique Fabre
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France
| | - Stéphan Haulon
- Aortic Center, INSERM UMR_S 999, Marie Lannelongue Hospital, Hospitalier Paris Saint Joseph, Paris Saclay University, Le Plessis Robinson, Paris, France -
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24
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Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections. J Vasc Surg 2020; 71:723-747. [DOI: 10.1016/j.jvs.2019.11.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/03/2019] [Indexed: 12/11/2022]
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25
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Lombardi JV, Hughes GC, Appoo JJ, Bavaria JE, Beck AW, Cambria RP, Charlton-Ouw K, Eslami MH, Kim KM, Leshnower BG, Maldonado T, Reece TB, Wang GJ. Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) Reporting Standards for Type B Aortic Dissections. Ann Thorac Surg 2020; 109:959-981. [PMID: 32000979 DOI: 10.1016/j.athoracsur.2019.10.005] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/15/2019] [Indexed: 01/09/2023]
Abstract
This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.
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Affiliation(s)
- Joseph V Lombardi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Cooper University Hospital, Camden, New Jersey.
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, Massachusetts
| | - Kristofer Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Karen M Kim
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Thomas Maldonado
- Division of Vascular Surgery, New York University Medical Center, New York, New York
| | - T Brett Reece
- Department of Surgery, Division of Cardiothoracic, University of Colorado, Denver, Colorado
| | - Grace J Wang
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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26
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Nauta F, de Beaufort H, Mussa FF, De Vincentiis C, Omura A, Matsuda H, Trimarchi S. Management of retrograde type A IMH with acute arch tear/type B dissection. Ann Cardiothorac Surg 2019; 8:531-539. [PMID: 31667150 PMCID: PMC6785497 DOI: 10.21037/acs.2019.08.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/04/2019] [Indexed: 01/16/2023]
Abstract
The incidence of intramural hematomas (IMH) in acute dissection (AD) patients varies between 6% and 30% in the literature, most frequently involving only the descending aorta (58%) than the arch or ascending aorta (42%). In this setting, IMH that initiate in the descending aorta, but extend into the arch or ascending aorta have been described, and referred to as a retrograde type A IMH. In these patients the risk of neurological or cardiac complications are high, and therefore an open surgical or hybrid approach has been proposed as the most appropriate. Nevertheless, the endovascular management of such lesions in surgically unfit patients for open surgery have been offered with acceptable outcomes, although the risk of landing in an unsuitable proximal landing zone is evident. In conclusion, retro-TAIMH is an acute aortic syndrome and should be managed as such. The recommended treatment strategy is open surgery for treating ascending or arch involvement, and TEVAR/medical, based on a complication-specific approach, for those with only descending localization. In those patients in whom retro-TAIMH is associated with an acute B dissection presenting with a proximal entry tear located into the descending aorta, a TEVAR represents an option treatment.
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Affiliation(s)
- Foeke Nauta
- Department of Cardiothoracic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Hector de Beaufort
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Firas F Mussa
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Carlo De Vincentiis
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Atsushi Omura
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Santi Trimarchi
- Department of Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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27
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Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, Ehrlich MP, Trimarchi S, Braverman AC, Myrmel T, Harris KM, Hutchinson S, O'Gara P, Suzuki T, Nienaber CA, Eagle KA. Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research. Circulation 2019; 137:1846-1860. [PMID: 29685932 DOI: 10.1161/circulationaha.117.031264] [Citation(s) in RCA: 720] [Impact Index Per Article: 144.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. The International Registry of Acute Aortic Dissection was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment. Since then, >7300 cases have been included from >51 sites in 12 countries. Although presenting symptoms and physical findings have not changed significantly over this period, the use of computed tomography in the diagnosis has increased, and more patients are managed with interventional procedures: surgery in type A AAD and endovascular therapy in type B AAD; with these changes in care, there has been a significant decrease in overall in-hospital mortality in type A AAD but not in type B AAD. Herein, we summarized the key lessons learned from this international registry of patients with AAD over the past 20 years.
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Affiliation(s)
- Arturo Evangelista
- Hospital General Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain (A.E.)
| | | | | | | | | | - Udo Sechtem
- Robert-Bosch Krankenhaus, Stuttgart, Germany (U.S.)
| | | | | | - Alan C Braverman
- Washington University School of Medicine, St. Louis, MO (A.C.B.)
| | | | | | | | | | - Toru Suzuki
- University of Leicester, United Kingdom (T.S.)
| | - Christoph A Nienaber
- The Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom (C.A.N.)
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28
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Lou X, Jordan WD, Leshnower BG. Chimney endovascular technique for acute retrograde type A dissection in a Jehovah's Witness. J Thorac Cardiovasc Surg 2019; 157:e305-e307. [PMID: 30803773 DOI: 10.1016/j.jtcvs.2018.12.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 12/20/2018] [Accepted: 12/30/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Xiaoying Lou
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - William D Jordan
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
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29
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DeAnda A, Balsam LB. Commentary: Extending into zone 0 with a little help. J Thorac Cardiovasc Surg 2019; 157:e309-e310. [PMID: 30770114 DOI: 10.1016/j.jtcvs.2019.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Abe DeAnda
- Division of Cardiovascular and Thoracic Surgery, UTMB-Galveston, Galveston, Tex.
| | - Leora B Balsam
- Division of Cardiac Surgery, UMass Memorial Medical Center, Worcester, Mass
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30
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Trimarchi S, de Beaufort HWL, Tolenaar JL, Bavaria JE, Desai ND, Di Eusanio M, Di Bartolomeo R, Peterson MD, Ehrlich M, Evangelista A, Montgomery DG, Myrmel T, Hughes GC, Appoo JJ, De Vincentiis C, Yan TD, Nienaber CA, Isselbacher EM, Deeb GM, Gleason TG, Patel HJ, Sundt TM, Eagle KA. Acute aortic dissections with entry tear in the arch: A report from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg 2019; 157:66-73. [PMID: 30396735 DOI: 10.1016/j.jtcvs.2018.07.101] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/03/2018] [Accepted: 07/19/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch. METHODS Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared. RESULTS The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; P = .115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; P < .001), endovascular treatment (3.5% vs 25.0%; P < .001), and medical management (16.2% vs 51.4%; P < .001). Overall in-hospital mortality was similar (16.7% vs 19.3%; P = .574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; P = .090), and higher after endovascular (25.0% vs 14.3%; P = .597) or medical treatment (24.3% vs 13.9%; P = .191), although the differences were not significant. CONCLUSIONS Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.
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Affiliation(s)
- Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy; Department of Scienze Biomediche per la Salute, University of Milan, Milan, Italy.
| | - Hector W L de Beaufort
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Jip L Tolenaar
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marco Di Eusanio
- Department of Cardiac Surgery, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Mark D Peterson
- Division of Cardiac Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | - Arturo Evangelista
- Department of Cardiology, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Daniel G Montgomery
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Truls Myrmel
- Department of Thoracic and Cardiovascular Surgery, University of Tromsø, Tromsø, Norway
| | - G Chad Hughes
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carlo De Vincentiis
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Tristan D Yan
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton & Harefield NHS Trust, Imperial College London, London, United Kingdom
| | - Eric M Isselbacher
- Thoracic Aortic Center and Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - G Michael Deeb
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Kim A Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
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31
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Abstract
Thoracic endovascular aortic repair (TEVAR) for thoracic aortic disease constitutes a paradigm shift in the treatment strategy of aortic dissection, as well as thoracic aortic aneurysms. Conventionally, most patients with Stanford type B acute aortic dissection are treated using conservative medical treatment during the acute phase. However, in patients with complicated type B aortic dissection who present with life-threatening complications, TEVAR has been introduced as a novel and less-invasive alternative and has shown better early results than those observed with conventional therapy. Recently, TEVAR was reported to be effective in not only promoting thrombosis of the false lumen but also in preventing aortic enlargement observed at long-term follow-up. TEVAR has been established as first-line therapy for complicated type B aortic dissection. In contrast, a considerable number of patients who received acute phase medical treatment required surgical intervention for chronic dissecting aortic aneurysms. With the increasing popularity of TEVAR for the treatment of complicated type B aortic dissection, prophylactic and pre-emptive TEVAR has been considered in patients with uncomplicated type B aortic dissection. However, supportive evidence for this strategy is limited, and reassessment is mandatory because it is continuously evolving. Although acute type A aortic dissection is a life-threatening condition, the results of open surgery continue to improve in the modern surgical era. Open surgical treatment is well established and recognized as a gold standard even in the endovascular era. Presently, the application of TEVAR for ascending aortic dissection has undergone a change, and TEVAR is considered a viable rescue option for patients with type A aortic dissection who are not eligible for open surgical repair. However, TEVAR for the descending aorta is well-established treatment for retrograde type A dissection. Several conceptual and technical issues remain unresolved, and technological advances would lead to the development of innovative disease-specific devices and solutions in the future for endovascular treatment of acute aortic dissection. (This is a translation of Jpn J Vasc Surg 2018; 27: 337–345.)
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Affiliation(s)
- Tetsuro Uchida
- Second Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
| | - Mitsuaki Sadahiro
- Second Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
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32
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Qi RD, Zhu JM, Liu YM, Chen L, Li CN, Xing XY, Zhang N, Sun LZ. Frozen Elephant Trunk for Acute Type B Dissection Involving the Distal Arch in the Hybrid Repair Era. Ann Thorac Surg 2018; 106:1182-1188. [DOI: 10.1016/j.athoracsur.2018.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/27/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022]
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33
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Baliyan V, Parakh A, Prabhakar AM, Hedgire S. Acute aortic syndromes and aortic emergencies. Cardiovasc Diagn Ther 2018; 8:S82-S96. [PMID: 29850421 DOI: 10.21037/cdt.2018.03.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute aortic syndrome (AAS) and emergencies are relatively uncommon but are considered as life threatening, potentially fatal conditions. Different forms of aortic emergencies/AAS are often clinically indiscernible. Prompt and accurate diagnosis of these entities significantly influences prognosis and guides therapy. We aim to elucidate the pertinent role that radiology plays in the management of acute aortic diseases, with contrast-enhanced computed tomography angiography (CTA) being the most rapid and robust imaging technique.
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Affiliation(s)
- Vinit Baliyan
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Anushri Parakh
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Anand M Prabhakar
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sandeep Hedgire
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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34
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Urbanski PP, Sodah A, Matveeva A, Irimie V, Wagner M, Agaev A, Schmitt R. Importance of accurately locating the entry site for endovascular treatment of retrograde Type A acute aortic dissection. Interact Cardiovasc Thorac Surg 2018; 26:731-737. [DOI: 10.1093/icvts/ivx399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/01/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Paul P Urbanski
- Department of Cardiovascular Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
| | - Ayman Sodah
- Department of Cardiovascular Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
| | - Anna Matveeva
- Department of Radiology, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
| | - Vadim Irimie
- Department of Cardiovascular Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
| | - Matthias Wagner
- Department of Radiology, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
| | - Arzou Agaev
- Department of Vascular Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
| | - Rainer Schmitt
- Department of Radiology, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
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35
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Rylski B, Pérez M, Beyersdorf F, Reser D, Kari FA, Siepe M, Czerny M. Acute non-A non-B aortic dissection: incidence, treatment and outcome. Eur J Cardiothorac Surg 2017; 52:1111-1117. [DOI: 10.1093/ejcts/ezx142] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/07/2017] [Indexed: 01/16/2023] Open
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36
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DiMusto PD, Rademacher BL, Philip JL, Akhter SA, Goodavish CB, De Oliveira NC, Tang PC. Acute retrograde type A aortic dissection: morphologic analysis and clinical implications. J Surg Res 2017; 213:39-45. [PMID: 28601330 PMCID: PMC6942928 DOI: 10.1016/j.jss.2017.02.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/17/2017] [Accepted: 02/20/2017] [Indexed: 11/28/2022]
Abstract
Background: This study compares the morphology and outcomes of acute retrograde type A dissections (RTADs) with acute antegrade type A dissections (ATADs), and acute type B dissections. Materials and methods: From 2000 to 2016, there were 12 acute RTADs, 96 ATADs, and 92 type B dissections with available imaging. Dissections were characterized using computerized tomography angiography images. We examined clinical features, tear characteristics, and various morphologic measurements. Results: Compared with acute type B dissections, RTAD primary tears were more common in the distal arch (75% versus 43%, P = 0.04), and the false-to-true lumen contrast intensity ratio at the mid-descending thoracic aorta was lower (0.46 versus 0.71, P = 0.020). RTAD had less false lumen decompression because there were fewer aortic branch vessels distal to the subclavian that were perfused through the false lumen (0.40 versus 2.19, P < 0.001). Compared with ATAD, RTAD had less root involvement where root true-to-total lumen area ratio was higher (0.88 versus 0.76, P = 0.081). Furthermore, RTAD had a lower false-to-true lumen contrast intensity ratio at the root (0.25 versus 0.57, P < 0.05), ascending aorta (0.25 versus 0.72, P < 0.001), and proximal arch (0.39 versus 0.67, P < 0.05). RTAD were more likely to undergo aortic valve resuspension (100% versus 74%, P = 0.044). Conclusions: RTAD tends to occur when primary tears occur in close proximity to the aortic arch and when false lumen decompression through the distal aortic branches are less effective. Compared with ATAD, RTAD has less root involvement, and successful aortic valve resuspension is more likely.
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Affiliation(s)
- Paul D DiMusto
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brooks L Rademacher
- Division of General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jennifer L Philip
- Division of General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Shahab A Akhter
- Division of Cardiothoracic Surgery, Section of Cardiac Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Christopher B Goodavish
- Division of Cardiothoracic Surgery, Section of Cardiac Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Nilto C De Oliveira
- Division of Cardiothoracic Surgery, Section of Cardiac Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Paul C Tang
- Division of Cardiothoracic Surgery, Section of Cardiac Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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37
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Roughneen PT, Fankhauser GT, DeAnda A. Acute retrograde aortic dissection: "To be [treated] or not to be, that is the question". J Thorac Cardiovasc Surg 2016; 153:66-67. [PMID: 27986259 DOI: 10.1016/j.jtcvs.2016.09.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 09/30/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Patrick T Roughneen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Texas Medical Branch-Galveston, Galveston, Tex
| | - Grant T Fankhauser
- Division of Vascular Surgery, Department of Surgery, University of Texas Medical Branch-Galveston, Galveston, Tex
| | - Abe DeAnda
- Division of Cardiothoracic Surgery, Department of Surgery, University of Texas Medical Branch-Galveston, Galveston, Tex.
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