Non-operative Management of Type A Acute Aortic Syndromes: A Systematic Review and Meta-Analysis

Watch-and-wait strategy for selected patients with type A intramural hematoma

OBJECTIVE

This single-center retrospective study evaluated early and midterm outcomes of 100 consecutive patients with type A intramural hematoma.

METHODS

Initial watch-and-wait strategy was indicated if the maximum aortic diameter was < 50 mm, pain score was < 3/10 on the numerical rating scale, and no ulcer-like projection was observed in the ascending aorta. The primary endpoints of this study were all-cause and aorta-related deaths, and the secondary endpoint was aortic events.

RESULTS

Initial watch-and-wait strategy was indicated in 52 patients. Emergency aortic repair was indicated in the remaining 48 patients; 2, 31, and 15 patients died before surgery, underwent emergency surgery, and declined emergency surgery, respectively. Among the watch-and-wait group, 11 (21%) patients underwent aortic repair during hospitalization. In-hospital mortality rates, 5-year survival rates, and 5-year freedom from aorta-related death were not significantly different between the initial watch-and-wait strategy and emergency surgery (2% vs. 6%, 92% vs. 82%, and 100% vs. 94%, respectively). In the initial watch-and-wait strategy group, 5-year freedom from aortic events and freedom from aortic events involving the ascending aorta were 60% and 66%, respectively.

CONCLUSIONS

The early and midterm outcomes with the initial watch-and-wait strategy in patients with type A intramural hematoma with a maximum aortic diameter of ≤ 50 mm, pain score of ≤ 3/10, and no ulcer-like projection in the ascending aorta were favorable with no aorta-related death.

Temporal trends in mortality of aortic dissection and rupture in the UK, Japan, the USA and Canada

OBJECTIVE

Aortic dissection and aortic aneurysm rupture are aortic emergencies and their clinical outcomes have improved over the past two decades; however, whether this has translated into lower mortality across countries remains an open question. The purpose of this study was to compare mortality trends from aortic dissection and rupture between the UK, Japan, the USA and Canada.

METHODS

We analysed the WHO mortality database to determine trends in mortality from aortic dissection and rupture in four countries from 2000 to 2019. Age-standardised mortality rates per 100 000 persons were calculated, and annual percentage change was estimated using joinpoint regression.

RESULTS

Age-standardised mortality rates per 100 000 persons from aortic dissection and rupture in 2019 were 1.04 and 1.80 in the UK, 2.66 and 1.16 in Japan, 0.76 and 0.52 in the USA, and 0.67 and 0.81 in Canada, respectively. There was significantly decreasing trends in age-standardised mortality from aortic rupture in all four countries and decreasing trends in age-standardised mortality from aortic dissection in the UK over the study period. There was significantly increasing trends in mortality from aortic dissection in Japan over the study period. Joinpoint regression identified significant changes in the aortic dissection trends from decreasing to increasing in the USA from 2010 and Canada from 2012. In sensitivity analyses stratified by sex, similar trends were observed.

CONCLUSIONS

Trends in mortality from aortic rupture are decreasing; however, mortality from aortic dissection is increasing in Japan, the USA and Canada. Further study to explain these trends is warranted.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Feasibility of Total Endovascular Repair of the Aorta in Patients with Acute Type A Aortic Dissection: Morphological Analysis of 119 Patients

(1) Background: This study aimed to morphologically analyze acute type A aortic dissection (aTAAD) patients for potential endovascular treatment candidates. The objective was to specify requirements for aTAAD endovascular devices. (2) Methods: A single-center retrospective analysis included aTAAD patients who underwent open surgical repair between November 2005 and December 2020. Preoperative CTA scans were used for morphological analysis, assessing endovascular repair eligibility. Statistical tests were performed. (3) Results: A total of 129 patients with aTAAD were studied, with 119 included. Entry tear (ET) locations were identified, mainly in the aortic root, 20 mm above the sinotubular junction (STJ) and within the ascending aorta (20 mm above STJ to -20 mm before the brachiocephalic trunk). Endovascular treatment was deemed feasible for 36 patients, with suggested solutions for the aortic arch and descending aorta. Significant differences were observed between eligible and noneligible groups for aortic diameter, false lumen diameter, distance between STJ and entry tear, and more. Dissection extension showed no significant difference. (4) Conclusions: Morphological analysis identified potential aTAAD candidates for endovascular treatment, highlighting differences between eligible and noneligible morphologies. This study offers insights for implementing endovascular approaches in aTAAD treatment and emphasizes the need for research and standardized protocols.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Impact of unintentional coronary angiography on outcomes of emergency surgery in acute type A aortic dissection: a retrospective study

Background

This study investigated the impact of coronary angiography on outcomes of emergency operation in acute type A aortic dissection (ATAAD) patients who were initially misdiagnosed as an acute coronary syndrome.

Methods

From October 2016 to April 2019, 129 patients underwent emergency operation for ATAAD in our institution, including 21 patients (16.3%, coronary angiography group) who received preoperative coronary angiography without knowledge of the ATAAD, and the rest 108 did not (Non-coronary angiography group). Preoperative clinical characteristics, 30-day mortality and postoperative complications were compared. Multivariable logistic regression was performed to confirm the independent prognostic factors for short-term and long-term outcomes.

Results

Patients undergoing coronary angiography had higher prevalence of preoperative hypotension or shock (61.9% vs 35.2%, P = 0.022), ischemic changes on electrocardiogram (66.7% vs 37.0%, P = 0.012), platelet inhibition (ADP-induced inhibition 92.0% vs 46.0%, P = 0.001), and coronary involvement (66.7% vs 30.6%, P = 0.002). 30-day mortality was 4.8% versus 9.3% (P = 0.84). Coronary angiography group had more intraoperative bleeding (1900 ml vs 1500 ml, P = 0.013) and chest-tube drainage on the first postoperative day (1040 ml vs 595 ml, P = 0.028). However, preoperative coronary angiography was not independent risk factors for 30-day mortality (OR 0.171, 95%CI 0.013–2.174, P = 0.173) and overall survival (HR 0.407; 95%CI 0.080–2.057; P = 0.277).

Conclusion

Patients undergoing coronary angiography carried a higher risk of preoperative hemodynamic instability, myocardial ischemia, and perioperative bleeding. However, unintentional coronary angiography did not have a significant impact on short-term and long-term outcomes of emergency surgery in ATAAD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02821-4.

Elevated cardiac troponin I and short-term mortality in patients with acute type A aortic dissection

AIMS

To explore the association between elevated cardiac troponin I (cTnI) on 30-day mortality in patients with acute type A aortic dissection (ATAAD).

METHODS AND RESULTS

A total of 1321 consecutive patients who were admitted to the emergency department of Fuwai Hospital from January 2016 to December 2020 were enrolled. Patients had computed tomography-confirmed ATAAD and were measured serum cTnI on admission. Patients were divided into the troponin-positive (cTnI > 0.02 ng/mL) or the troponin-negative group (cTnI ≤ 0.02 ng/mL). Troponin was detected by PATHFAST instrument produced by Medins Co., Ltd., and the reference range of normal value is 0-0.02 ng/mL. A total of 522 out of 1321 patients (39.5%) in our study had elevated cTnI, who had higher 30-day mortality rate compared with the troponin-negative group (44.4% vs. 19.4% P < 0.0001). Multivariate logistic regression results showed that elevated cTnI was an independent risk indicator for 30-day mortality (odds ratio: 2.582; 95% confidence interval: 1.357-4.914; P = 0.0039). The addition of elevated cTnI level to a clinical-based risk prediction model resulted in significant incremental prognostic value (AUC difference: 0.0261).

CONCLUSION

Elevated cTnI is common in patients with ATAAD, and is associated with increased 30-day mortality risk.

Outcome Comparison Between Open and Endovascular Aortic Repair for Retrograde Type A Intramural Hematoma With Intimal Tear in the Descending Thoracic Aorta: A Retrospective Observational Study

Objective: The optimal treatment modality for retrograde type A intramural hematoma (IMH) remains debatable. This study evaluated and compared surgical outcomes and aortic remodeling after open aortic repair and thoracic endovascular aortic repair (TEVAR) in patients with retrograde type A IMH with a primary intimal tear or ulcer like projection in the descending aorta.

Methods: A single center, retrospective observational study was performed on patients with retrograde type A IMH undergoing either open aortic repair and TEVAR. From June 2009 and November 2019, 46 patients with retrograde type A IMH who received either open aortic repair or TEVAR at our institution were reviewed for clinical outcomes, including post-operative mortality/morbidity, re-intervention rate and aortic remodeling.

Results: 33 patients underwent open aortic repair and 13 underwent TEVAR. Median age was 68 years (interquartile range [IQR] 15.2 years) and 63 years (IQR 22.5 years) for the open repair group and TEVAR group, respectively. The median duration of follow-up for TEVAR patients was 37.6 months and 40.3 months for open aortic repair. No difference in the 5-year estimated freedom from all-cause mortality (82.1 vs. 87.8%, p = 0.34), re-intervention (82.5 vs. 93.8%, p = 0.08), and aortic-related mortality (88.9 vs. 90.9%, p = 0.88) were observed between the TEVAR and open repair group, respectively; however, the open repair group had a significantly higher 30-day composite morbidity (39.4 vs. 7.7%, p = 0.037). All patients from both treatment groups had complete resolution of the IMH in the ascending aorta. With regard to the descending thoracic aorta, TEVAR group had a significantly greater regression in the diameter of the false lumen or IMH thickness when compared to the open repair group [median 14mm (IQR 10.1) vs. 5mm (IQR 9.5), p < 0.001].

Conclusion: TEVAR and open aortic repair were both effective treatments for retrograde type A IMH, in which no residual ascending aortic IMH was observed during follow-up. TEVAR was also associated with lower post-operative composite morbidities and better descending aortic remodeling. In selected patients with retrograde type A IMH, TEVAR might be a safe, effective alternative treatment modality.

A framework for designing medical devices resilient to low-resource settings

Background

To date (April 2021), medical device (MD) design approaches have failed to consider the contexts where MDs can be operationalised. Although most of the global population lives and is treated in Low- and Middle-Income Countries (LMCIs), over 80% of the MD market share is in high-resource settings, which set de facto standards that cannot be taken for granted in lower resource settings. Using a MD designed for high-resource settings in LMICs may hinder its safe and efficient operationalisation. In the literature, many criteria for frameworks to support resilient MD design were presented. However, since the available criteria (as of 2021) are far from being consensual and comprehensive, the aim of this study is to raise awareness about such challenges and to scope experts’ consensus regarding the essentiality of MD design criteria.

Results

This paper presents a novel application of Delphi study and Multiple Criteria Decision Analysis (MCDA) to develop a framework comprising 26 essential criteria, which were evaluated and chosen by international experts coming from different parts of the world. This framework was validated by analysing some MDs presented in the WHO Compendium of innovative health technologies for low-resource settings.

Conclusions

This novel holistic framework takes into account some domains that are usually underestimated by MDs designers. For this reason, it can be used by experts designing MDs resilient to low-resource settings and it can also assist policymakers and non-governmental organisations in shaping the future of global healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00718-z.

Type A Acute Aortic Dissection Presenting With Cerebrovascular Accident at Advanced Age

Our aim was to analyze outcomes of patients aged 70 years or above presenting with type A acute aortic dissection (TAAAD) and cerebrovascular accident (CVA). A retrospective analysis of the International Registry of Acute Aortic Dissection (IRAD) was conducted. Patients aged 70 years or above (n = 1449) were stratified according to presence or absence of CVA before surgery (CVA: n = 110, 7.6%). In-hospital outcomes and mortality up to 5 years were analyzed. Additionally, in-hospital outcomes of patients who received medical management were described. No patient presenting with CVA over the age of 87 years underwent surgery. The rates of in-hospital mortality and post-operative CVA were significantly higher in patients presenting with CVA (in-hospital mortality: 32.7% vs 21.7%, P = 0.008; post-operative CVA: 23.4% vs 8.3%, P < 0.001). Presence of CVA was independently associated with significantly increased in-hospital mortality (odds ratio 2.99, 95% confidence interval 1.35 - 6.60, P = 0.007). In survivors of the hospital stay, presenting CVA had no independent influence on mortality up to 5 years (hazard ratio 1.52, 95% confidence interval 0.99 - 2.31, P = 0.54). In medically managed patients, exceedingly high rates of in-hospital mortality (71.4%) and CVA (90.9%) were noted. Patients presenting with TAAAD and CVA at ≥ 70 years of age are at significantly increased risk of in-hospital mortality, although long-term mortality is not affected in hospital survivors. Medical management is associated with poor outcomes. We believe that surgical management should be offered after critical assessment of comorbidities.

Efficiency of atorvastatin on in-hospital mortality of patients with acute aortic dissection (AAD): study protocol for a randomized, open-label, superiority clinical trial

BACKGROUND

Dyslipidemia and local inflammation at sites of lipid deposition on blood vessel walls have been demonstrated to be risk factors for patients with acute aortic dissection (AAD). Statins have anti-inflammatory and lipid-lowering effects, which suggest that statins may play an important role in the prevention and treatment of AAD. Some retrospective studies show that statins can protect patients with aortic dissection. However, the effect of statins on the survival of AAD patients has been scarcely investigated, especially in randomized trials. In this study, we will perform a randomized clinical trial to understand whether statins can reduce in-hospital mortality of AAD patients.

METHODS

A total of 384 subjects diagnosed with AAD in the First Affiliated Hospital of Shantou University Medical College will be recruited. Participants will be randomly divided into an atorvastatin-treated or control group. The primary outcome will be the in-hospital mortality at 30 days.

DISCUSSION

This study is designed to verify the efficacy of atorvastatin on reducing in-hospital mortality of patients with AAD. The aim is to provide a new means of improving survival as a complement to conventional drug therapy.

TRIAL REGISTRATION

Chinese Clinical Trials Registry ChiCTR1900023515 . Registered on 1 June 2019.

Ultrasound diagnosis of dissecting thoracic aortic aneurysms: procedure with a handheld device and a video-illustrated case

Acute thoracic aortic dissection is an uncommon, although not rare, life-threatening condition. With protean signs and symptoms that often suggest more common cardiac or pulmonary conditions, it can be difficult to diagnose. Ultrasound has proven useful in making the correct diagnosis. This case demonstrates that training gained using standard ultrasound machines can be easily and successfully adapted to newer handheld ultrasound devices. The examination technique using the handheld device is illustrated with photos and a video.

Chest CT Angiography for Acute Aortic Pathologic Conditions: Pearls and Pitfalls

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.

Endovascular ascending aortic repair in type A dissection: A systematic review

PURPOSE

Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD.

METHODS

A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma).

RESULTS

A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%).

CONCLUSION

This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.

Turn down of acute aortic syndrome cases during COVID-19: Results from UK multicentre studies

Objective

The coronavirus disease 2019 (COVID‐19) pandemic has restructured the healthcare systems, prioritizing resources to treat COVID‐19 patients. The aim of this study was to establish if patients affected by acute aortic syndrome (AAS) had unrestricted access to emergency treatment and evaluate outcome of these patients during the peak of the pandemic.

Methods

This is a retrospective analysis of prospectively collected data between March and June 2020 from 19 participating cardiac surgery centers in the United Kingdom.

Results

Among 95 patients who presented with an AAS in the participating centers; 85 (89%) underwent surgery, 7 (7%) were turned down for surgery because of their profile of comorbidities, and 3 (3%) died on transfer. Among the patients treated conservatively, three of them (43%) were alive at 30 days. We observed no significant restriction in access to treatment for AAS during the early months of the pandemic.

Conclusion

Services for life‐threatening aortic surgery patients were maintained during the COVID‐19 period through patient selection and timing of surgery. The rate of surgical turn‐down was comparable to published figures despite the challenges faced during the COVID‐19 pandemic.

Top 10 candidate aortic disease trials

Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced unprecedented technical and medical developments in the field. Despite this, there is a great need, and great opportunities, to further explore the area. In this review, we have identified important areas that need to be further studied and selected priority aortic disease trials. There is a pressing need to update the AAA natural history and the role for endovascular AAA repair as well as to define biomarkers and genetic risk factors as well as influence of gender for development and progression of aortic disease. A key limitation of contemporary treatment strategies of AAA is the lack of therapy directed at small AAA, to prevent AAA expansion and need for surgical repair, as well as to reduce the risk for aortic rupture. Currently, the most promising potential drug candidate to slow AAA growth is metformin, and RCTs to verify or reject this hypothesis are warranted. In addition, the role of endovascular treatment for ascending pathologies and for uncomplicated type B aortic dissection needs to be clarified.