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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [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] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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Jung JC, Chang HW, Lee JH, Park KH. Features and outcomes of focal intimal disruption in acute type B intramural haematoma. Eur J Cardiothorac Surg 2024; 65:ezae193. [PMID: 38733570 DOI: 10.1093/ejcts/ezae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/16/2024] [Accepted: 05/10/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVES A focal intimal disruption (FID) is a risk factor for adverse aorta-related events in patients with acute type B intramural haematoma. This study evaluated the impact of FIDs on overall survival with a selective intervention strategy for large or growing FIDs. Additionally, this study evaluated the risk factors associated with the growth of FIDs. METHODS This retrospective study included all consecutive patients admitted for acute type B intramural haematomas between November 2004 and April 2021. The primary outcome was overall survival. The secondary outcome was the cumulative incidence of composite aortic events and the growth of FIDs. The latter was calculated on centreline-reconstructed computed tomography images. RESULTS A total of 105 patients were included. A total of 106 FIDs were identified in 73 patients (73/105, 69.5%). The 1- and 5-year cumulative incidence rates of composite aortic events were 36.2% and 39.2%, respectively. The 1- and 5-year overall survival was 93.3% and 81.5%, respectively. Initial maximal aortic diameter and large FIDs during acute phase were significant risk factors for composite aortic events, but not risk factors for overall survival. The early appearance interval of an FID was a significant risk factor for growth of an FID. CONCLUSIONS With a selective intervention strategy for large or growing FIDs, the presence of large FIDs during the acute phase does not affect overall survival. The early appearance interval was associated with the growth of FIDs.
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Affiliation(s)
- Joon Chul Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Hyoung Woo Chang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Jae Hang Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
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3
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Chen D, Fang K, Luo M, Shu C. Timing of Intervention and Long-Term Outcomes of Type B Aortic Intramural Hematoma with Intimal Disruption at Admission. Ann Vasc Surg 2024; 101:29-40. [PMID: 38128692 DOI: 10.1016/j.avsg.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/30/2023] [Accepted: 10/03/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND To compare the 30-day and long-term outcomes between patients with concomitant type B intramural hematoma and intimal disruption upon admission who underwent endovascular repair in the acute or subacute phases. METHODS Data were extracted from January 1, 2010, to December 31, 2019. Logistic regression and Cox regression were performed to evaluate the impact of timing of intervention on 30-day and long-term outcomes, respectively. RESULTS The study included 241 patients, among which 159 were in the acute group. No significant difference was observed in 30-day mortality (0.6% vs. 0%, P = 1), 30-day complication rate (2.5% vs. 1.2%, P = 0.664), long-term all-cause mortality (10.7% vs. 7.3%, P = 0.540), and aortic reintervention rate (2.5% vs. 2.4%, P = 1) between the acute and subacute group. In multivariable analysis, the timing of intervention was not associated with 30-day mortality (odds ratio (OR) = 0, 95% confidence interval CI: 0-Inf, P = 0.999), 30-day complication (OR = 0.30, 95% CI: 0.02-3.77, P = 0.348), long-term mortality (hazard ratio = 0.56, 95% CI: 0.20-1.61, P = 0.283), and aortic reintervention (OR = 0.97, 95% CI: 0.15-6.08, P = 0.970). CONCLUSIONS For patients with concomitant type B intramural hematoma and intimal disruption upon admission, there is no significant difference in 30-day and long-term outcomes between those who undergo endovascular treatment in the acute or subacute phase.
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Affiliation(s)
- Dong Chen
- Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun Fang
- Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingyao Luo
- Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chang Shu
- Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [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: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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5
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Wang B, Miao M, Shi Q, Xian H, Wang J, Cao Y. The Role of Endovascular Repair Timing in Uncomplicated Acute Type B Intramural Hematoma Management. Ann Vasc Surg 2024; 99:233-241. [PMID: 37802137 DOI: 10.1016/j.avsg.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/28/2023] [Accepted: 08/04/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND With favorable results of thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated acute type B intramural hematoma (uTBIMH), TEVAR is increasingly utilized in the management of patients with uTBIMH. However, optimal timing for intervention has not been decided. This study aimed to compare the efficacy of acute and delayed TEVAR in patients with uTBIMH. METHODS We included patients with uTBIMH who underwent TEVAR between October 2014 and December 2021. The participants were divided into the acute TEVAR (aTEVAR) and delayed TEVAR (dTEVAR) groups. We analyzed the total aortic diameter (TAD)/true lumen diameter (TLD) ratio on computed tomography angiography (CTA) and aortic-related adverse events and all-cause mortality (AREM). RESULTS We included 34 individuals with uTBIMH, among which 20 underwent aTEVAR and 14 underwent dTEVAR. We observed no significant differences in baseline characteristics between both groups. However, compared with the aTEVAR group, better aortic remodeling was achieved in the dTEVAR group before discharge (1.32 ± 0.11 vs. 1.21 ± 0.09, P = 0.005) and at the 1-year follow-up (1.18 ± 0.09 vs. 1.10 ± 0.04, P = 0.034). Although the 30-day and 1-year follow-up outcomes of AREM were not significantly different, the Kaplan-Meier analysis showed that AREM incidence in the dTEVAR group was significantly lower than that in the aTEVAR group (85.7% for dTEVAR vs. 65.0% for aTEVAR, log-rank P = 0.20). Moreover, subgroup analysis revealed a significant difference in the TAD/TLD ratio between the aTEVAR and dTEVAR groups in individuals without a focal intimal disruption (1.33 ± 0.11 vs. 1.17 ± 0.09, P = 0.008). CONCLUSIONS For individuals with uTBIMH, delaying TEVAR by >7 days improved aortic remodeling and lowered the incidence of early AREM. Additionally, the absence of focal intimal disruption on preoperative CTA supports delayed intervention.
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Affiliation(s)
- Bin Wang
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China.
| | - Miao Miao
- Department of Endocrinology, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Qiulin Shi
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Haiying Xian
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Jinxing Wang
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Yuecheng Cao
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
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6
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Spanos K, Kölbel T. Role of Initial Focal Contrast Enhancement in Type B Intramural Hematoma. J Am Coll Cardiol 2024; 83:514-515. [PMID: 38267113 DOI: 10.1016/j.jacc.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, School of Health Sciences, Faculty of Medicine, University Hospital of Larissa, University of Thessaly, Larissa, Greece; German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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7
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Jiang X, Pan T, Liu Y, Chen B, Jiang J, Guo D, Xu X, Hou K, Lin J, Ju S, Fu W, Dong Z. Prognostic Implications of Initial Focal Contrast Enhancement in Acute Type B Intramural Hematoma. J Am Coll Cardiol 2024; 83:503-513. [PMID: 38267112 DOI: 10.1016/j.jacc.2023.10.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/30/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND The prognostic implication of initial focal contrast enhancement (FCE), including focal intimal disruption (FID) and intramural blood pool (IBP), in acute type B intramural hematoma (IMH) remain unclear. OBJECTIVES The purpose of this study was to compare the prognostic implications in IMH with or without FCE. METHODS A total of 574 patients were enrolled. FID was defined as an intimal disruption with contrast-filled out-pouching from the aorta lumen with a communicating orifice of >3 mm, and IBP was defined as a localized contrast medium-filled pool inside the IMH. RESULTS A total of 207 (36.1%) patients with initial FCE, including 132 (63.8%) FIDs and 75 (36.2%) IBPs, were identified. Patients with FCE accompanying IMH were more likely to have hypertension (P = 0.001), pleural effusion (P = 0.006), fewer aortic segments involved (P < 0.001), more adverse aortic events (AAEs) (P < 0.001), and fewer freedom from intervention (P = 0.002). Pleural effusion (HR: 1.79; 95% CI: 1.25-2.55; P = 0.001) and FCE (HR: 1.51; 95% CI: 1.12-2.02; P = 0.006) were identified to be the independent risk factors of AAEs. In the subgroup analysis, IMH with initial FID were more likely to progress than those with initial IBP (P < 0.001). FIDs located at the proximal descending aorta (HR: 2.95; 95% CI: 1.65-5.29; P < 0.001) were associated with AAEs. CONCLUSIONS Patients with FCE accompanying IMH were more likely to progress, especially in those initial FID localized at the proximal descending aorta. (Nature course and predictors of progression of intramural hematoma: A retrospective, multicenter study; ChiCTR2300073829).
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Affiliation(s)
- Xiaolang Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Tianyue Pan
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yifan Liu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Bin Chen
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Junhao Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Daqiao Guo
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xin Xu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Kai Hou
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiang Lin
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuai Ju
- Center for Vascular Surgery and Wound Care, Jinshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Zhihui Dong
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Center for Vascular Surgery and Wound Care, Jinshan Hospital, Fudan University, Shanghai, China.
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8
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 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. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
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.
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9
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Garg I, Grist TM, Nagpal P. MR Angiography for Aortic Diseases. Magn Reson Imaging Clin N Am 2023; 31:373-394. [PMID: 37414467 DOI: 10.1016/j.mric.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Aortic pathologic conditions represent diverse disorders, including aortic aneurysm, acute aortic syndrome, traumatic aortic injury, and atherosclerosis. Given the nonspecific clinical features, noninvasive imaging is critical in screening, diagnosis, management, and posttherapeutic surveillance. Of the commonly used imaging modalities, including ultrasound, computed tomography, and MR imaging, the final choice often depends on a combination of factors: acuity of clinical presentation, suspected underlying diagnosis, and institutional practice. Further research is needed to identify the potential clinical role and define appropriate use criteria for advanced MR applications such as four-dimenional flow to manage patients with aortic pathologic conditions.
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Affiliation(s)
- Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1 University Of New Mexico, Albuquerque, NM 87131, USA
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin-Madison, E3/366 Clinical Science Center 600 Highland Avenue Madison, WI 53792, USA
| | - Prashant Nagpal
- Cardiovascular and Thoracic Radiology, University of Wisconsin School of Medicine and Public Health, E3/366 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA.
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10
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Meng D, Gu R, Wang Y, Zhang Z, Xu T, Wang X. Analysis of Short-Term Clinical Outcomes and Influencing Factors in Patients with Acute Type B Aortic Intramural Hematoma Treated with Optimal Medical Therapy. Int Heart J 2023; 64:708-716. [PMID: 37460317 DOI: 10.1536/ihj.23-023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
This study aimed to investigate the short-term predictors of aortic-related adverse events in patients with acute type B aortic intramural hematoma (IMH) initially treated with optimized medical therapy.A total of 157 patients with acute type B IMH were included in this study. These patients were divided into worsening group (n = 45) and stable group (n = 112) based on the incidence of aortic-related adverse events. The clinical data and imaging features of the two groups were compared. Multivariate logistic regression analysis of predictors of aortic-related adverse events in type B IMH was performed. Receiver operating characteristic (ROC) curve was applied to determine the optimal cutoff value for maximum descending aorta diameter (MDAD). Kaplan-Meier survival curve was used to analyze the incidence of aortic-related adverse events.Worsening and stable groups were statistically significant in diuretics, abnormal D-dimer level, observation endpoint systolic blood pressure (SBP), MDAD, aortic atherosclerosis, ulcer-like projection (ULP), and thickness of hematoma (P < 0.05). Multivariate logistic regression showed that abnormal D-dimer level (OR = 12.464, P = 0.025), MDAD (OR = 1.113, P = 0.030), and ULP (OR = 5.849, P = 0.022) were powerful independent risk factors for predicting aortic-related adverse events in type B IMH, and observation endpoint SBP within 100-120 mmHg (OR = 0.225, P = 0.014) was a protective factor for predicting aortic-related adverse events in type B IMH. The cutoff value of MDAD was 35.2 mm.Short-term imaging is recommended for type B IMH patients with abnormal D-dimer level, MDAD > 35.2 mm, and ULP. Blood pressure should also be strictly monitored and controlled during the acute phase of IMH.
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Affiliation(s)
- Dujuan Meng
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
- The General Hospital of Northern Theater Command Training Base for Graduate, Dalian Medical University
| | - Ruoxi Gu
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
| | - Yasong Wang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
| | - Zhiqiang Zhang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
| | - Tianshu Xu
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
| | - Xiaozeng Wang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
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11
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 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. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 349] [Impact Index Per Article: 174.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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12
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 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. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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13
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Xu X, Lu F, Li L. Thoracic endovascular aortic repair and optimal medical treatment for acute type B penetrating aortic ulcer associated with intramural hematoma. Medicine (Baltimore) 2022; 101:e31301. [PMID: 36397387 PMCID: PMC9666100 DOI: 10.1097/md.0000000000031301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
To compare the safety and efficacy of thoracic endovascular aortic repair (TEVAR) and optimal medical treatment (OMT) for type B penetrating aortic ulcer (PAU) associated with intramural hematoma (IMH). From January 2015 to December 2018, 68 consecutive patients with acute type B PAU associated with IMH were enrolled in the study. TEVAR was performed following initially OMT in 30 patients (group A), and OMT was performed in 38 patients (group B). Primary outcome was aortic-related mortality. Secondary outcomes included all-cause mortality, aortic-related adverse events, and complete aortic remodeling. There was no significant difference in the baseline characteristics of patients among the 2 groups except for the depth of PAU and the thickness of IMH. Patients in group B had a significant higher risk of aortic-related mortality (13.3% vs 0%, P = .045), as the same to aortic-related adverse events during follow-up. Compared to OMT, TEVAR contributed to the favorable aortic remodeling more significantly during the mid-term follow-up (85.7% vs 18.2%, P < .001). Comparing with optimal medical repair, TEVAR for patients with PAU associated with IMH could promote the favorable aortic remolding more significantly and result in lower aortic-related mortality during mid-term follow-up. It should be considered as the first-line therapeutic option when intervention is required.
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Affiliation(s)
- Xiuchun Xu
- Department of General Surgery, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
| | - Feng Lu
- Department of General Surgery, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
| | - Li Li
- Department of Clinical Laboratory, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
- * Correspondence: Li Li, Department of Clinical Laboratory, Binhai People’s Hospital, Yancheng, Jiangsu Province 224500, People’s Republic of China (e-mail: )
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14
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Colacchio EC, Squizzato F, Piazza M, Menegolo M, Grego F, Antonello M. Clinical and Imaging Predictors of Disease Progression in Type B Aortic Intramural Hematomas and Penetrating Aortic Ulcers: A Systematic Review. Diagnostics (Basel) 2022; 12:2727. [PMID: 36359569 PMCID: PMC9689060 DOI: 10.3390/diagnostics12112727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/29/2022] [Accepted: 11/06/2022] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND This work aims to review recent literature on penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs), in order to identify clinical and imaging factors connected to aortic-related adverse events (AAE). METHODS We performed a systematic review according to the Preferred Reporting Items for Systematic review and Metanalyses (PRISMA) guidelines. An electronic search was conducted on Medline and Embase databases. We included articles reporting on PAUs and/or IMHs localized in the descending thoracic and/or abdominal aorta and analyzing clinical and/or radiological markers of AAE. RESULTS Of 964 records identified through database searching, 17 were incorporated in the present review, including 193 and 1298 patients with type B PAUs and IMHs, respectively. The 30-days aortic-related mortality (ARM) was 4.3% and 3.9% for PAUs and IMHs. A total of 21% of patients with IMHs underwent intervention during the follow-up period, and 32% experienced an AAE. PAU markers of AAE were minimum depth (ranging from 9.5 to 15 mm) and diameter (≥12.5 mm). Maximum aortic diameter (MAD) cut-off values ranging from 38 to 44.75 mm were related to AAE for IMHs, together with ulcer-like projection (ULP) of the aortic wall. CONCLUSIONS Despite data heterogeneity in the literature, this PAU- and IMH-focused review has highlighted the imaging and clinical markers of disease progression, thus identifying patients that could benefit from an early intervention in order to reduce the AAE rate.
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Affiliation(s)
- Elda Chiara Colacchio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Section, University of Padova, Azienda Ospedale-Università di Padova, 35128 Padova, Italy
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15
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Chen Q, Jiang D, Shan Z. The influence of dipeptidyl peptidase-4 inhibitor on the progression of type B intramural hematoma. Front Cardiovasc Med 2022; 9:969357. [PMID: 36330007 PMCID: PMC9623157 DOI: 10.3389/fcvm.2022.969357] [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: 06/14/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Investigating whether dipeptidyl peptidase-4 inhibitors (DPP4i) could influence the progression of type B intramural hematoma (IMHB) in patients with diabetes mellitus (DM). Materials and methods Uncomplicated IMHB patients were matched by age, sex, and body mass index. Cox proportional hazard models were constructed to identify risk factors. A Kaplan–Meier survival analysis was used to estimate all-cause and aorta-related mortality. Results Ninety-six matched IMHB patients were divided into Group A (n = 32, IMHB patients without DM), Group B (n = 32, IMHB patients with DMreceiving oral antidiabetic drugs [without DPP4i]) and Group C (n = 32, IMHB patients with DM receiving oral antidiabetic drugs [with DPP4i]). Group C had the lowest rate of aorta-related adverse events (3.1%), aorta-related mortality (0.0%) and reintervention (3.1%). Cox proportional hazard models revealed that a lower eosinophil count (per 0.1, HR, 0.48; 95% CI, 0.29–0.79, P = 0.004) and a higher neutrophil to lymphocyte ratio (NLR) (HR, 1.13; 95% CI, 1.05–1.21, P = 0.001) were associated with higher occurrences of aorta-related adverse events. A lower eosinophil count (per 0.1, HR, 0.40; 95% CI, 0.18–0.89, P = 0.025) and a higher NLR (HR, 1.19; 95% CI, 1.08–1.32, P = 0.001) were also associated with increased aorta-related mortality. Conclusion DPP4i administration in DM patients with IMHB was associated with lower aorta-related mortality and more benign progression than in those who did not receive DPP4i or those without DM. Furthermore, a higher eosinophil count and a lower NLR ratio are potential protective factors that may explain the potential therapeutic benefit of DPP4i.
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Affiliation(s)
- Qu Chen
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Dandan Jiang
- Department of Respiratory Medicine, Xinglin Branch of the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Zhonggui Shan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
- *Correspondence: Zhonggui Shan,
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Ludwig DR, Raptis CA, Bhalla S. Emergent Magnetic Resonance Angiography for Evaluation of the Thoracoabdominal and Peripheral Vasculature. Magn Reson Imaging Clin N Am 2022; 30:465-477. [PMID: 35995474 DOI: 10.1016/j.mric.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Thoracoabdominal and peripheral vasculature pathologies include a variety of severe and life threatening conditions that may be encountered in the emergent setting. Computed tomography angiography (CTA) is the first-line modality for imaging of the vasculature in this context, but magnetic resonance angiography (MRA) also plays an important and emerging role in the evaluation of carefully selected patients. Intravenous (IV) iodinated contrast is necessary for CTA, although MRA is most useful in patients who cannot receive IV iodinated contrast for reasons including prior severe allergic-like reaction to iodinated contrast, poor IV access, or severe renal insufficiency. Gadolinium-based contrast agents are administered for MRA when possible, as they generally improve the diagnostic quality and shorten the duration of the exam. In most clinical situations, however, noncontrast MRA is sufficient to obtain a diagnostic evaluation. In this review, we discuss the key strengths and limitations of MRA performed in the emergent setting, highlighting the role of MRA in the diagnosis of acute aortic syndromes, aortitis, aortic aneurysm, pulmonary embolism, and peripheral vascular disease.
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Affiliation(s)
- Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA.
| | - Constantine A Raptis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA.
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17
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Chen Q, Jiang D, Shan Z. Progression of Type B Intramural Hematoma Patients with Obstructive Sleep Apnea. J Vasc Surg 2022; 76:378-388.e3. [PMID: 35351604 DOI: 10.1016/j.jvs.2022.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/11/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE This study aimed to estimate the influence of obstructive sleep apnea (OSA) on type B intramural hematoma (IMHB) progression. METHODS All 127 patients received sleep evaluations and esophageal pressure measurements. Variables associated with aorta-related adverse events and mortality were summarized by logistic regression analysis and Cox proportional hazard models. Competing risk analysis of death was used to estimate aorta-related and non-aorta-related mortality. RESULTS The OSA group had a higher aorta-related adverse events rate (46% vs. 4%, P<0.001). The mean nighttime systolic pressure (OR, 1.24; 95% CI, 1.11-1.38, P<0.001) was associated with aorta-related adverse events during the acute phase. Thoracic endovascular aortic repair (TEVAR) (HR, 16.2; 95% CI, 7.68-34.22, P<0.001) and mean morning systolic pressure (HR, 1.43; 95% CI, 1.22-1.68, P<0.001) were associated with a higher rate of occurrence of aorta-related adverse events. The occurrence of OSA (HR, 3.19; 95% CI, 2.57-12.15, P<0.001) and mean morning systolic pressure (HR, 1.59; 95% CI, 1.27-2.01, P=0.002) were significantly associated with aorta-related mortality. Competing risk analysis revealed significantly higher aorta-related mortality in the OSA group (11.8% vs. 2.0%, P=0.0412). A neutrophil-to-lymphocyte ratio (NLR) of > 3.52 (specificity: 90.2%, sensitivity: 89.5%) and a mean platelet volume-to-platelet ratio (MPV/PLT) of > 0.049 (specificity: 98.0%, sensitivity: 98.7%) have diagnostic value for detecting OSA in IMHB. CONCLUSIONS OSA leads to a higher aorta-related adverse event rate and mortality in patients with IMHB. Variables associated with outcomes include TEVAR, mean morning/nighttime systolic pressure and OSA. The NLR and MPV/PLT ratios are valuable for detecting OSA in IMHB patients.
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Affiliation(s)
- Qu Chen
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian Province, People's Republic of China
| | - Dandan Jiang
- Department of Respiratory Medicine, Xinglin Branch of The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian Province, People's Republic of China
| | - Zhonggui Shan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian Province, People's Republic of China.
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Fleischmann D, Afifi RO, Casanegra AI, Elefteriades JA, Gleason TG, Hanneman K, Roselli EE, Willemink MJ, Fischbein MP. Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2022; 15:e000075. [PMID: 35172599 DOI: 10.1161/hci.0000000000000075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.
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19
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Survival and Aortic Remodeling Outcomes in Patients with Type B Aortic Intramural Hematoma in Endovascular Era: An Observational Cohort Study. J Vasc Surg 2022; 76:70-78. [DOI: 10.1016/j.jvs.2022.01.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/31/2022] [Indexed: 11/24/2022]
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20
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Castro-Verdes M, Yuan X, Mitsis A, Li W, Nienaber CA. Transesophageal Ultrasound Guidance for Endovascular Interventions on the Aorta. AORTA 2022; 10:3-12. [PMID: 35640581 PMCID: PMC9179212 DOI: 10.1055/s-0042-1743107] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AbstractAortic pathologies in general require a multidisciplinary approach and decision-making to integrate elements of clinical acuity, vascular pathology, individual comorbidity, and risk assessment; thus, ideally it is a center with access to multiple imaging modalities and expertise in all treatment options. Besides classic open surgical options, endovascular procedures have been accepted for a variety of aortic pathologies. More recently, novel transcatheter interventions even to the proximal aorta have been introduced, particularly for patients unfit for open surgery. Nevertheless, the role of transesophageal echocardiography to guide percutaneous aortic interventions is not well established, notwithstanding the growing potential as an ancillary tool to guide the procedure and document success.
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Affiliation(s)
- Mireya Castro-Verdes
- Department of Echocardiography and Paediatric Cardiology, Royal Brompton and Harefield, National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Xun Yuan
- Department of Cardiology and Aortic Centre, Royal Brompton & Harefield National Health Service Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Andreas Mitsis
- Department of Cardiology, Nicosia General Hospital, Strovolos, Cyprus
| | - Wei Li
- Department of Echocardiography and Congenital Heart Disease, Royal Brompton & Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Christoph A. Nienaber
- Department of Cardiology and Aortic Centre, Royal Brompton & Harefield National Health Service Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
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21
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Eto R, Kawano H, Hata S, Kumamoto T, Yoshimuta T, Maemura K. Intramural hematoma with intramural blood pool associated with vertebral compression fracture. J Cardiol Cases 2022; 25:19-22. [PMID: 35024062 DOI: 10.1016/j.jccase.2021.05.013] [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: 10/26/2020] [Revised: 05/15/2021] [Accepted: 05/29/2021] [Indexed: 11/18/2022] Open
Abstract
Although intramural blood pools due to intercostal arteries in intramural hematoma have been reported as a traumatic aortic injury, the precise mechanism is unclear. We present the case of an elderly patient who presented with an intramural blood pool due to an intercostal artery prolapse in an intramural hematoma associated with a compression fracture of the thoracic vertebra after a fall. <Learning objective: It is possible to treat intramural blood pool due to intercostal artery prolapse in an intramural hematoma associated with thoracic vertebral compression and intramural blood pool in an intramural hematoma as a traumatic aortic injury with medications.>.
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Affiliation(s)
- Ryo Eto
- Department of Cardiology, Sasebo City General Hospital, Nagasaki, Japan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shiro Hata
- Department of Cardiology, Sasebo City General Hospital, Nagasaki, Japan
| | - Taku Kumamoto
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tsuyoshi Yoshimuta
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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22
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Wang Y, Li T, Chen Y, Liu J, Shi Q, Yang C, Huang S, Zhou C, Xiong B. Management of spontaneous isolated intramural hematoma of the superior mesenteric artery: a single-center experience. Langenbecks Arch Surg 2022; 407:1217-1224. [PMID: 34994827 DOI: 10.1007/s00423-022-02429-4] [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: 10/20/2021] [Accepted: 01/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the clinical course and optimal management for spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA). METHODS From January 2015 to October 2020, a total of 31 consecutive patients with SIHSMA were included in this study. The demographics, clinical features, treatment details, imaging information, and outcomes were reviewed. RESULTS There were 24 males and 7 females, with a mean age of 54.9 years (SD 6.9 years). Seven patients (7/31, 23%) were associated with ulcer-like projection (ULP), one patient (1/31, 3%) with intramural blood pool (IBP), and the remaining twenty-three patients (23/31, 74%) had no ULP or IBP. All patients were initially managed conservatively and underwent a median follow-up of 25.5 months (IQR 14.5, 39.9), which showed 3 patients (3/31, 10%) subsequently underwent stenting (2 within 7 days and 1 after 1.5 months), 1 patient (1/31, 3%) progressed to a localized dissection 7 months later but remained stable and asymptomatic until the time of writing, and the remaining patients (27/31, 87%) had no progression. In the present cohort, the overall survival was 100% (31/31). The free-from progression and stenting rate under conservative treatment was 87% (27/31). The invasive intervention rate was 10% (3/31). The natural complete regression rate of IMH in patients without ULP was higher than those with ULP (91% [21/23] vs. 29% [2/7], p = .003). CONCLUSION The majority of patients with SIHSMA can be managed conservatively. Patients with ULP seemed to have a lower IMH regression rate than those without ULP.
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Affiliation(s)
- Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
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Chen D, Luo M, Fang K, Shu C. Endovascular repair of acute zone 0 intramural hematoma with most proximal tear or ulcer-like projection in the descending aorta. J Vasc Surg 2021; 75:1561-1569. [PMID: 34973400 DOI: 10.1016/j.jvs.2021.12.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/01/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE In the present study, we have reported the midterm results of endovascular repair of acute zone 0 intramural hematomas (IMHs) with the most proximal tear or ulcer-like projection (ULP) in the descending aorta. METHODS Data from patients with acute zone 0 IMH with the most proximal tear or ULP in the descending aorta from January 1, 2010, to December 31, 2019, were retrospectively reviewed. We performed Kaplan-Meier curves to calculate the intervention-free survival and survival after endovascular or open surgical repair. We used propensity score matching to compare the outcomes of endovascular and open surgical repair. RESULTS The present study included 99 patients. Of the 99 patients, 34 had initially received medical treatment. The 0.5-, 1-, and 3-year intervention-free survival rates for the 34 patients were 23.5%, 17.6%, and 14.7%, respectively. Of the 99 patients, 51 had undergone endovascular therapy, 27 after initial medical treatment. Most of these 51 patients had had a maximal diameter of the ascending aorta of <50 mm and a maximal diameter of IMH in the ascending aorta of <10 mm. The 1-, 3-, and 5-year survival rate for the endovascular group was 98.0%. Finally, 42 patients had undergone open surgery (3 after medical treatment), and the 1-, 3-, 5-year survival rates were all 92.9%. After propensity score matching, no statistically significant difference was found in the 30-day and follow-up mortality. However, endovascular repair was associated with a shorter operation time (69 vs 314 minutes; P < .001), shorter length of intensive care unit stay (24 vs 70 hours; P = .001), and shorter length of hospital stay (7 vs 12 days; P = .011). CONCLUSIONS For patients with acute zone 0 IMH and the most proximal tear or ULP in the descending aorta, in addition to open surgery, endovascular repair is an option if the maximal diameter of the ascending aorta is <50 mm and the maximal diameter of the IMH in the ascending aorta is <10 mm.
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Affiliation(s)
- Dong Chen
- Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingyao Luo
- Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun Fang
- Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chang Shu
- Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, 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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Steinbrecher KL, Marquis KM, Bhalla S, Mellnick VM, Ohman JW, Raptis CA. CT of the Difficult Acute Aortic Syndrome. Radiographics 2021; 42:69-86. [PMID: 34951836 DOI: 10.1148/rg.210098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute aortic syndrome (AAS) is classically attributed to three underlying pathologic conditions-aortic dissection (AD), intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU). In the majority of cases, the basics of image interpretation are not difficult and have been extensively reviewed in the literature. In this article, the authors extend existing imaging overviews of AAS by highlighting additional factors related to the diagnosis, classification, and characterization of difficult AAS cases. It has been well documented that AAS is caused not only by an AD but by a spectrum of lesions that often have overlap in imaging features and are not clearly distinguishable. Specifically, phase of contrast enhancement, flow artifacts, and flapless AD equivalents can complicate diagnosis and are discussed. While the A/B dichotomy of the Stanford system is still used, the authors subsequently emphasize the Society for Vascular Surgery's new guidelines for the description of acute aortic pathologic conditions given the expanded use of endovascular techniques used in aortic repair. In the final section, atypical aortic rupture and pitfalls are described. As examples of pericardial and shared sheath rupture become more prevalent in the literature, it is important to recognize contrast material third-spacing and mediastinal blood as potential mimics. By understanding these factors related to difficult cases of AAS, the diagnostic radiologist will be able to accurately refine CT interpretation and thus provide information that is best suited to directing management. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Kacie L Steinbrecher
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Kaitlin M Marquis
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Vincent M Mellnick
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - J Westley Ohman
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Constantine A Raptis
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
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Vilacosta I, San Román JA, di Bartolomeo R, Eagle K, Estrera AL, Ferrera C, Kaji S, Nienaber CA, Riambau V, Schäfers HJ, Serrano FJ, Song JK, Maroto L. Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:2106-2125. [PMID: 34794692 DOI: 10.1016/j.jacc.2021.09.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023]
Abstract
The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.
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Affiliation(s)
- Isidre Vilacosta
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain.
| | - J Alberto San Román
- Instituto de Ciencias del Corazón, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - Kim Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, UTHealth, Houston, Texas, USA; Memorial Hermann Heart and Vascular Institute. University of Texas, Houston, Texas, USA
| | - Carlos Ferrera
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital, Osaka, Japan
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, The Royal Brompton and Harefield MHS Trust, London, United Kingdom
| | - Vicenç Riambau
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Hans-Joachim Schäfers
- Klinik für Thorax- und Herz-Gefäßchirurgie Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | | | - Jae-Kwan Song
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Luis Maroto
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
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26
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Kicska GA, Hurwitz Koweek LM, Ghoshhajra BB, Beache GM, Brown RKJ, Davis AM, Hsu JY, Khosa F, Kligerman SJ, Litmanovich D, Lo BM, Maroules CD, Meyersohn NM, Rajpal S, Villines TC, Wann S, Abbara S. ACR Appropriateness Criteria® Suspected Acute Aortic Syndrome. J Am Coll Radiol 2021; 18:S474-S481. [PMID: 34794601 DOI: 10.1016/j.jacr.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 01/17/2023]
Abstract
Acute aortic syndrome (AAS) includes the entities of acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. AAS typically presents with sudden onset of severe, tearing, anterior, or interscapular back pain. Symptoms may be dominated by malperfusion syndrome, due to obstruction of the lumen of the aorta and/or a side branch when the intimal and medial layers are separated. Timely diagnosis of AAS is crucial to permit prompt management; for example, early mortality rates are reported to be 1% to 2% per hour after the onset of symptoms for untreated ascending aortic dissection. The appropriateness assigned to each imaging procedure was based on the ability to obtain key information that is used to plan open surgical, endovascular, or medical therapy. This includes, but is not limited to, confirming the presence of AAS; classification; characterization of entry and reentry sites; false lumen patency; and branch vessel compromise. Using this approach, CT, CTA, and MRA are all considered usually appropriate in the initial evaluation of AAS if those procedures include intravenous contrast administration. Ultrasound is also considered usually appropriate if the acquisition is via a transesophageal approach. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Brian B Ghoshhajra
- Panel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts; Executive Committee, Society of Cardiovascular Computed Tomography
| | - Garth M Beache
- University of Louisville School of Medicine, Louisville, Kentucky
| | | | - Andrew M Davis
- Associate Vice-Chair, Quality, Department of Medicine, The University of Chicago Medical Center, Chicago, Illinois; and American College of Physicians
| | - Joe Y Hsu
- Kaiser Permanente, Los Angeles, California
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada; and Co-Chair of Equity, Diversity and Inclusion Committee, UBC
| | | | - Diana Litmanovich
- Harvard Medical School, Boston, Massachusetts; and Past-President, NASCI
| | - Bruce M Lo
- Sentara Norfolk General/Eastern Virginia Medical School, Norfolk, Virginia; Board Member, American Academy of Emergency Medicine; and American College of Emergency Physicians
| | | | - Nandini M Meyersohn
- Massachusetts General Hospital, Boston, Massachusetts; and AMA Delegate, RSNA
| | - Saurabh Rajpal
- Ohio State University, Nationwide Children's Hospital, Columbus, Ohio; Society for Cardiovascular Magnetic Resonance
| | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear cardiology expert
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas; and BOD SCCT
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27
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Li J, Xia L, Ma M, Feng X, Wei X. Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta. J Vasc Surg 2021; 75:56-64.e2. [PMID: 34481899 DOI: 10.1016/j.jvs.2021.07.231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 07/19/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The optimal treatment of intramural hematoma (IMH) involving the ascending aorta remains controversial. This study aimed to analyze the results of the management of patients with acute IMH involving the ascending aorta and extending into the descending thoracic aorta, to compare outcomes of descending thoracic endovascular aortic repair (TEVAR) with that of medical therapy (MT), and to assess the risk factors associated with adverse aortic events. METHODS We retrospectively analyzed all patients diagnosed with acute IMH involving the ascending aorta and extending into the descending thoracic aorta from January 2012 to December 2019. The primary end points during follow-up were aortic disease-related death and adverse aorta-related events that required surgical or endovascular treatment, such as aortic rupture, the progression of aortic disease, or endoleak. RESULTS We identified a total of 135 patients with acute IMH involving the ascending aorta and extending into the descending thoracic aorta, of whom 104 underwent descending TEVAR (group 1) and 31 were managed with MT (group 2). Freedom from adverse aorta-related events at 1, 3, and 5 years was significantly higher for patients who underwent descending TEVAR compared with those managed with MT (89.2%, 88.2%, and 84.0% vs 74.2%, 74.2%, and 74.2%, respectively; P = .026). The 1-, 3-, and 5-year survival rates for patients in the descending TEVAR group was 100%, 100%, and 100%, respectively, which was significantly higher than the survival of the MT group: 93.5%, 93.5%, and 81.9%, respectively (P = .002). On a univariate analysis among patients receiving MT, those who suffered adverse aorta-related events showed a higher prevalence of renal insufficiency (55.6% vs 9.1%; P = .003). In MT patients, multivariate analysis showed that renal insufficiency was the only independent risk factor associated with adverse aorta-related events (hazard ratio, 8.691; 95% confidence interval, 2.056-36.737; P = .003). CONCLUSIONS Based on our study, compared with MT, descending TEVAR might be the more favorable treatment for patients with IMH involving the ascending aorta and extending into the descending thoracic aorta. Patients with renal insufficiency are more likely to experience adverse aorta-related events, which implies the need for subsequent intervention or an increased risk of mortality. The risk factor would be helpful for clinical decision-making.
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Affiliation(s)
- Jiangtao Li
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liangtao Xia
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingjia Ma
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Feng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China; NHC Key Laboratory of Organ Transplantation, Wuhan, China; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China.
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28
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Li J, Zhang X, Peng Y, Wang L, Wang T, Li X, He H, Li Q, Shu C. Endovascular repair for retrograde type A intramural hematoma with focal intimal disruption in descending aorta. J Thorac Dis 2021; 13:4250-4259. [PMID: 34422353 PMCID: PMC8339735 DOI: 10.21037/jtd-21-574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/04/2021] [Indexed: 12/22/2022]
Abstract
Background This study aims to report the experience of a single center using thoracic endovascular aortic repair (TEVAR) to treat retrograde type A intramural hematoma (IMH) with focal intimal disruption (FID) in descending aorta. Methods A total of 24 consecutive patients with retrograde type A IMH and complicated with FID in descending aorta underwent TEVAR in our center from 2015 to 2020. Their clinical data, imaging manifestation and follow-up results were retrospectively reviewed and analyzed. Results The median age of patients was 57.9 years (range, 42–80 years) and 18 were men (75%). As the preoperative CT angiography showed, the 24 patients developed IMH complicated with different kinds of FIDs in descending aorta [5 had intramural blood pool (IBP), 15 had ulcer-like projection (ULP), 2 had penetrating atherosclerotic ulcer (PAU), and 5 had localized dissection]. Successful deployment of aortic stent graft was achieved in all patients. There was no endoleak, stent graft migration, spinal cord ischemia, stroke, or 30-day mortality observed after TEVAR. The median duration of follow-up was 30.0 months (range, 3–60 months). As the last follow-up CT angiography showed, most of the patients (23 in 24, 96%) had favorable aortic remodeling. The maximum hematoma thicknesses and maximum diameters of both ascending and descending aorta were significantly decreased. During follow-up, 1 patient developed retrograde type A aortic dissection (RAAD) and underwent open surgery 3 months after TEVAR. 1 patient died of lung cancer 2 years later. There was no aorta-related death observed. Conclusions TEVAR provides a safe and effective treatment strategy for selected patients with retrograde type A IMH, and FID developed in descending aorta could be the possible treatment target. However, RAAD remains one of the most serious postoperative complications of concern.
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Affiliation(s)
- Jiehua Li
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Xiaolong Zhang
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Yuan Peng
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Lunchang Wang
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Tun Wang
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Xin Li
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Hao He
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Quanming Li
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Chang Shu
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China.,Center of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Ishizu K, Kaji S, Nakashima M, Kitai T, Kim K, Ehara N, Kinoshita M, Furukawa Y. Focal Intimal Disruption Size at Multidetector CT and Disease Progression in Type B Aortic Intramural Hematoma. Radiology 2021; 301:311-319. [PMID: 34374587 DOI: 10.1148/radiol.2021204385] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Recent imaging techniques show that patients with aortic intramural hematoma (IMH) have various sizes of focal intimal disruptions (FIDs) that may affect clinical outcomes. Purpose To evaluate the relationship between size of FIDs detected at multidetector CT and disease progression in patients with type B IMH. Materials and Methods This retrospective study analyzed consecutive patients with type B IMH who underwent multidetector CT at admission within 24 hours after symptom onset from January 2011 to March 2017. FID was defined as a focal contrast material-filled pouch projecting outside of the aorta lumen with a communicating orifice greater than 3 mm. Large FID was defined as an FID of at least 10 mm in length and width and at least 5 mm in depth. Aorta-related events were defined as a composite of aortic rupture, surgical or endovascular aortic repair, progressive aortic enlargement, and development of aortic dissection. Results Seventy-six patients (mean age, 72 years ± 11 [standard deviation]; 54 men) were evaluated. Fifty patients (66%; 50 of 76) had 91 FIDs. Twenty-eight patients had large FIDs and 22 patients had small FIDs. Aorta-related events occurred in 15 of 28 patients with large FIDs, two of 22 patients with small FIDs, and four of 26 patients with no FID. Patients with large FIDs showed lower aorta-related event-free survival rates than did patients with small FIDs or no FID (small FIDS, 63% ± 10 vs 90% ± 7 at 3 years, respectively [P = .001]; and no FIDS, 63% ± 10 vs 84% ± 7 at 3 years, respectively [P = .005]). Multivariable analysis showed that a maximum aortic diameter of at least 40 mm (hazard ratio, 4.8; 95% CI: 1.8, 12.6; P = .001) and large FID (hazard ratio, 3.2; 95% CI: 1.1, 8.9; P = .03) were the independent predictors of aorta-related events. Conclusion A large portion of patients with B-intramural hematoma (IMH) had focal intimal disruption (FID) detected at CT at admission. Large FIDs were associated with disease progression of IMH. © RSNA, 2021 See also the editorial by Raptis and Braverman in this issue. Online supplemental material is available for this article.
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Affiliation(s)
- Kenichi Ishizu
- From the Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, 650-0047 Kobe, Japan
| | - Shuichiro Kaji
- From the Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, 650-0047 Kobe, Japan
| | - Masaki Nakashima
- From the Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, 650-0047 Kobe, Japan
| | - Takeshi Kitai
- From the Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, 650-0047 Kobe, Japan
| | - Kitae Kim
- From the Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, 650-0047 Kobe, Japan
| | - Natsuhiko Ehara
- From the Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, 650-0047 Kobe, Japan
| | - Makoto Kinoshita
- From the Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, 650-0047 Kobe, Japan
| | - Yutaka Furukawa
- From the Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, 650-0047 Kobe, Japan
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Raptis CA, Braverman AC. Intramural Hematoma and Focal Intimal Disruption: The Importance of Communication. Radiology 2021; 301:320-321. [PMID: 34374599 DOI: 10.1148/radiol.2021211564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Constantine A Raptis
- From the Mallinckrodt Institute of Radiology (C.A.R.) and Cardiovascular Division, Department of Medicine (A.C.B.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Alan C Braverman
- From the Mallinckrodt Institute of Radiology (C.A.R.) and Cardiovascular Division, Department of Medicine (A.C.B.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
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31
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Chen L, Yang F, Liu J, Luo S, Yuan H, Fan R, Zeng H, Geng Q, Luo J. Risk stratification of ulcer-like projection in uncomplicated acute type B aortic intramural haematoma. Eur J Cardiothorac Surg 2021; 60:1032-1040. [PMID: 34265045 DOI: 10.1093/ejcts/ezab249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/01/2021] [Accepted: 04/16/2021] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES This study aimed to investigate the morphological evolution and risk stratification of ulcer-like projection (ULP) in patients with uncomplicated acute type B aortic intramural haematoma. METHODS A retrospective study was conducted on patients with uncomplicated acute type B intramural haematoma admitted in our institution from January 2015 to June 2020. The primary end points were adverse aortic events (AAE), including aortic rupture, aortic dissection, aortic aneurysm and ULP enlargement. RESULTS The study cohort comprised 140 patients, including 62 (44%) and 78 (56%) patients with and without initial ULP, respectively. AAE occurred in 13 patients (9%) in the early term and 42 patients (33%) in the mid-term. Compared with patients without ULP, patients with initial ULP had no significant difference in early outcomes but a higher mid-term AAE rate [8% vs 11%, odds ratio (OR) 1.5, P = 0.47; 17% vs 55%, OR 6.0, P < 0.001]. Significantly higher AAE rate was observed in patients with high-risk ULP (depth ≥5.0 mm and located in the proximal aortic segments) than those with only low-risk ULP (depth <5.0 mm and/or located in the distal aortic segments) (87% vs 51%, OR 6.2, P = 0.014). In the multivariable analysis, high-risk ULP was an independent predictor of AAE (hazard ratio 2.8, P = 0.009). CONCLUSIONS High-risk ULP is a rapidly evolving entity and a marker of AAE despite optimal medical therapy. Therefore, close follow-up and prompt intervention are recommended for patients with high-risk ULP.
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Affiliation(s)
- Lyufan Chen
- School of Medicine, South China University of Technology, Guangzhou, China.,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
| | - Jitao Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Songyuan Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hui Yuan
- Department of Nuclear Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruixin Fan
- School of Medicine, South China University of Technology, Guangzhou, China.,Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hongke Zeng
- School of Medicine, South China University of Technology, Guangzhou, China.,Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qingshan Geng
- School of Medicine, South China University of Technology, Guangzhou, China.,Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jianfang Luo
- School of Medicine, South China University of Technology, Guangzhou, China.,Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Mokhtari S, Anane O, Banana Y, El Aissaouy W, Rezziki A, Skiker I, Benzirar A, El Mahi O. [Acute localized dissection of the descending thoracic aorta: A diagnostic trap]. Ann Cardiol Angeiol (Paris) 2021; 70:171-176. [PMID: 33962784 DOI: 10.1016/j.ancard.2021.04.005] [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: 10/15/2020] [Accepted: 04/03/2021] [Indexed: 06/12/2023]
Abstract
Localized dissection of the descending thoracic aorta; class 3 of the classification proposed by the European Society of Cardiology; is a short and limited length dissection involving the descending thoracic aorta. It is a rare and unrecognized variant that poses a clinical and radiological diagnostic challenge. Indeed, it is manifested by an aspecific clinical profile represented by the acute aortic syndrome and characterized by a confused radiological aspect that entangled with the other differential diagnoses. We would like to emphasize the rarity of this uncommon pathology and the difficulty encountered in defining it based on a case treated in our department and a review of the literature.
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Affiliation(s)
- S Mokhtari
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Maroc; University Mohammed 1st. Faculty of medicine and pharmacy, Oujda, Maroc.
| | - O Anane
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Maroc; University Mohammed 1st. Faculty of medicine and pharmacy, Oujda, Maroc.
| | - Y Banana
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Maroc; University Mohammed 1st. Faculty of medicine and pharmacy, Oujda, Maroc.
| | - W El Aissaouy
- University Mohammed 1st. Faculty of medicine and pharmacy, Oujda, Maroc; Radiology Department, Mohammed VI University Hospital Center, Oujda, Maroc.
| | - A Rezziki
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Maroc; University Mohammed 1st. Faculty of medicine and pharmacy, Oujda, Maroc.
| | - I Skiker
- University Mohammed 1st. Faculty of medicine and pharmacy, Oujda, Maroc; Radiology Department, Mohammed VI University Hospital Center, Oujda, Maroc.
| | - A Benzirar
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Maroc; University Mohammed 1st. Faculty of medicine and pharmacy, Oujda, Maroc.
| | - O El Mahi
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Maroc; University Mohammed 1st. Faculty of medicine and pharmacy, Oujda, Maroc.
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Role of MRI in the Evaluation of Thoracoabdominal Emergencies. Top Magn Reson Imaging 2021; 29:355-370. [PMID: 33264275 DOI: 10.1097/rmr.0000000000000252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thoracic and abdominal pathology are common in the emergency setting. Although computed tomography is preferred in many clinical situations, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have emerged as powerful techniques that often play a complementary role to computed tomography or may have a primary role in selected patient populations in which radiation is of specific concern or intravenous iodinated contrast is contraindicated. This review will highlight the role of MRI and MRA in the emergent imaging of thoracoabdominal pathology, specifically covering acute aortic pathology (acute aortic syndrome, aortic aneurysm, and aortitis), pulmonary embolism, gastrointestinal conditions such as appendicitis and Crohn disease, pancreatic and hepatobiliary disease (pancreatitis, choledocholithiasis, cholecystitis, and liver abscess), and genitourinary pathology (urolithiasis and pyelonephritis). In each section, we will highlight the specific role for MRI, discuss basic imaging protocols, and illustrate the MRI features of commonly encountered thoracoabdominal pathology.
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Chen Q, Jiang D, Kuang F, Yang F, Shan Z. Outcomes of uncomplicated Type B intramural hematoma patients with Type 2 diabetes mellitus. J Card Surg 2021; 36:1209-1218. [PMID: 33462880 DOI: 10.1111/jocs.15336] [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: 11/18/2020] [Revised: 12/15/2020] [Accepted: 01/04/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVES We aimed to summarize the clinical presentations, therapeutic approaches, and outcomes of Type B intramural hematoma (IMHB) patients with and without Type 2 diabetes mellitus (DM). METHODS Patients with uncomplicated IMHBs were included between January 2016 and January 2018 and divided into two groups according to whether or not they had DM. We also assessed the potential diagnostic value of serum matrix metalloproteinase-9 (MMP-9) level and the association of it with the disease progression of uncomplicated IMHB patients with and without DM. RESULTS A total of 149 patients were included (DM group [n = 60] and non-DM group [n = 89]). Patients in the non-DM group underwent thoracic endovascular aortic repair treatment more frequently (12% vs 2%, p = .028) and had a higher reintervention rate during the follow-up (9 in 81 patients, 11% vs. 2%, p = .043). There were significant differences between the two groups regarding the aorta-related mortality rate during the acute phase (9% vs. 0%, p = .042) and the all-cause mortality rate (22% vs. 7%, p = .011). Ulcer-like projection (ULP) development (during the acute phase; hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.15-1.79, p = .005), C-reactive protein (CRP) levels (HR, 2.08; 95% CI, 1.91-3.91, p = .003), and MMP-9 levels (HR, 15.77; 95% CI, 6.48-21.62, p < .001) were associated with an elevated risk for aorta-related mortality. CONCLUSIONS IMHBs with DM have a considerably better prognosis and serum MMP-9 level appear to be a potential biomarker to predict the disease progression. ULP development (during the acute phase) and CRP levels are also associated with an elevated risk for aorta-related mortality.
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Affiliation(s)
- Qu Chen
- School of Clinical Medicine, Fujian Medical University, Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Dandan Jiang
- School of Clinical Medicine, Fujian Medical University, Department of Internal Medicine, Xinglin Branch of The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Feng Kuang
- School of Clinical Medicine, Fujian Medical University, Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Fan Yang
- School of Clinical Medicine, Fujian Medical University, Department of Radiology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhonggui Shan
- School of Clinical Medicine, Fujian Medical University, Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
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Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, Murad MH, Perry RJ, Singh MJ, Veeraswamy RK, Wang GJ. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73:55S-83S. [DOI: 10.1016/j.jvs.2020.05.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
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Czerny M, Pacini D, Aboyans V, Al-Attar N, Eggebrecht H, Evangelista A, Grabenwöger M, Stabile E, Kolowca M, Lescan M, Micari A, Muneretto C, Nienaber C, de Paulis R, Tsagakis K, Rylski B, Braverman AC, Di Marco L, Eagle K, Falk V, Gottardi R. Current options and recommendations for the use of thoracic endovascular aortic repair in acute and chronic thoracic aortic disease: an expert consensus document of the European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2020; 59:65-73. [DOI: 10.1093/ejcts/ezaa268] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022] Open
Abstract
Abstract
Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of—in analogy to the heart team—aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta—the aortic root, in particular in acute type A aortic dissection—which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments.
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Affiliation(s)
- Martin Czerny
- University Heart Center Freiburg—Bad Krozingen, Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | | | | | - Nawwar Al-Attar
- Golden Jubilee National Hospital, University of Glasgow, Glasgow, UK
| | | | | | | | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, University of Napoli “Federico II”, Naples, Italy
| | | | - Mario Lescan
- Department of Cardiac, Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Antonio Micari
- Department of Cardiology, Humanitas Gavazzeni, Bergamo, Italy
| | | | | | | | | | - Bartosz Rylski
- University Heart Center Freiburg—Bad Krozingen, Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
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Abstract
PURPOSE OF REVIEW Penetrating aortic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media. With the advances in imaging techniques, the differential diagnosis between PAU and other aortic ulcers remains a challenge. This review aims to summarize the latest insight into PAU, based on clinical context and the newest imaging characteristics, to aid treatment decision-making. RECENT FINDINGS Most PAUs are asymptomatic and do not require urgent invasive treatment. Nevertheless, when PAU leads to an acute aortic syndrome, emergency invasive therapy is recommended. A differential diagnosis with other lesions, such as ulcerated plaques or intimal disruptions within the context of an aortic intramural hematoma, is required as the risk of complications and management differ. Imaging technique plays a pivotal role in the correct diagnosis of aortic ulcers. SUMMARY The differential diagnosis of PAU with other aortic ulcers based on clinical and imaging technique information is mandatory as it may imply different prognosis and management. This diagnosis is particularly important when PAU is the cause of acute aortic syndromes as urgent invasive treatment should be recommended.
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Qin H, Wei L, Zhang B, Wang Y, Liu Y. Clinical medical decision-making of acute aortic intramural hematoma: A non-randomized retrospective case study. J Interv Med 2020; 3:132-135. [PMID: 34805923 PMCID: PMC8562252 DOI: 10.1016/j.jimed.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective This study explored the timing of interventional treatment for acute intramural aortic hematoma (IMH) and the corresponding high-risk factors for its development into local aortic dissection (AD). Method This retrospective case study method examined clinical follow-up data of 42 patients with acute IMH between April 2013 and October 2016 from the First Affiliated Hospital of Xiʹan Jiaotong University. SPSS 17.0 and PPMS1.5 were used to analyze follow-up data spanning 3–12 months (mean, 7.5 ± 3.7 months). Results Patients were divided into the conversion group and the hematoma group according to whether they developed AD. Among them, 16 patients (38.1%) developed AD and were treated with thoracic endovascular aortic repair (TEVAR). The remaining patients (61.89%) were treated conservatively. After 1 week, the mean aortic diameter of the conversion versus hematoma group was significantly widened. Hemodynamically unstable patients and those with hematoma to the abdominal aorta extension were more likely to develop AD. Patient outcomes after TEVAR were similar between groups. Conclusion Our findings suggest that aortic isthmus diameter ≥3.0 cm, hematoma extending to the abdominal aorta, and hemodynamic instability are associated with AD development in acute IMH patents. TEVAR should be considered if hematoma thickening, calcification ingression, ulcer progression, or contrast enhancement within the intramural hematoma is noted beyond 2 weeks after IMH onset.
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Affiliation(s)
- Hao Qin
- Department of Peripheral Vascular Disease of the First Affiliated Hospital of Xi′an Jiaotong University, China
- Corresponding author.
| | - Li Wei
- Surgery and Anesthesia Department of the First Affiliated Hospital of Xi′an Jiaotong University, China
| | - Bo Zhang
- Department of Peripheral Vascular Disease of the First Affiliated Hospital of Xi′an Jiaotong University, China
| | - Yujing Wang
- Department of Peripheral Vascular Disease of the First Affiliated Hospital of Xi′an Jiaotong University, China
| | - Yamin Liu
- Department of Peripheral Vascular Disease of the First Affiliated Hospital of Xi′an Jiaotong University, China
- Corresponding author.
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Prediction of adverse events in patients with initially medically treated type A intramural hematoma. Int J Cardiol 2020; 313:114-120. [PMID: 32223964 DOI: 10.1016/j.ijcard.2020.03.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/11/2020] [Accepted: 03/16/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Prior studies provided limited data regarding natural history of initially medically treated type A intramural hematoma (IMH). OBJECTIVES To develop predictive models for adverse aorta-related events in patients with type A IMH. METHODS We performed a retrospective pooled analysis of individual patient data, including baseline clinical and CT characteristics. All patients enrolled were followed up for adverse aorta-related events, defined as a composite of aortic disease-related death and the presence of aortic complications that required aortic invasive treatment. RESULTS A total of 172 patients (52.9% men) were included, with a mean age of 61.1 ± 11.2 years. During a median follow-up time of 770.5 (45.3-1695.8) days, 60 patients (34.9%) experienced adverse aorta-related events. In Cox regression model for predicting adverse aorta-related events, hypertension (HR = 3.78, p = .067), MAD (HR = 1.05, p = .018), presence of ULP (HR = 2.43, p = .002) and pericardial effusion (HR = 1.65, p = .061) were independently associated with adverse aorta-related events. A majority of the adverse aorta-related events (n = 46, 76.7%) occurred within acute and subacute phase (90 days) of IMH. In predictive model for 90 days aortic events, MAD≥50.7 mm (OR = 2.79, p = .006) and presence of ULP (OR = 3.20, p = .002) were independent predictors. C statistic of the predictive model were 0.71 (p < .001). CONCLUSIONS Predictive models including baseline clinical and CT characteristics as predictors allow for accurate estimation of risk of adverse aorta-related events in patients with type A IMH. The proposed predictive models are helpful for risk estimates and decision making.
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Imaging and Biomarkers in Acute Aortic Syndromes: Diagnostic and Prognostic Implications. Curr Probl Cardiol 2020; 46:100654. [PMID: 32958324 DOI: 10.1016/j.cpcardiol.2020.100654] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/03/2020] [Indexed: 01/16/2023]
Abstract
Acute aortic syndrome (AAS) is an emergency and life-threatening condition including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer and iatrogenic-traumatic aortic injury. An integrated multiparametric approach (clinical history and examination, electrocardiogram, biomarkers and imaging techniques) is recommended in order to make timely and accurate diagnosis, delineate the prognosis, choose the most appropriate therapeutic interventions tailored for the individual patient. Nowadays the best imaging strategy for diagnosing AAS and its complications is a combination of transthoracic echocardiography and computed tomography angiography (CTA). Transesophageal echocardiography tends to be carried out in complicated cases prior to surgical or endovascular therapy, often in the operating room and under general anesthesia. In this regard, intravascular ultrasound and intraluminal phase array imaging may be implemented during the endovascular procedures depending on operator expertise and cost issues. On the other hand, owing to its intrinsic characteristics, magnetic resonance imaging is an ideal imaging technique for serial measurements in patients at risk of AAS or with chronic dissection. Among biomarkers, D-dimer is the closest to "golden status" (high sensitivity and low negative likelihood ratio). Interestingly, 18fluorodeoxyglucose positron emission tomography/CT is increasingly being used along with specific serologic biomarkers (white blood cells, C-reactive protein, fibrinogen and D-dimer) to detect and monitor vascular inflammation affecting the aorta and systemic arteries. It is expected, in the near future, the development of serologic and imaging biomarkers able to early detect clinically-silent pathologic changes in the aorta wall before (primary prevention) and after (secondary prevention) the acute index event.
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Brown JA, Arnaoutakis GJ, Kilic A, Gleason TG, Aranda‐Michel E, Sultan I. Medical and surgical management of acute type B aortic intramural hematoma. J Card Surg 2020; 35:2324-2330. [DOI: 10.1111/jocs.14823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James A. Brown
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
| | - George J. Arnaoutakis
- Division of Thoracic and Cardiovascular SurgeryUniversity of Florida Gainesville Florida
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Thomas G. Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Edgar Aranda‐Michel
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
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Ferrera C, Vilacosta I, Cabeza B, Cobiella J, Martínez I, Saiz-Pardo Sanz M, Bustos A, Serrano FJ, Maroto L. Diagnosing Aortic Intramural Hematoma: Current Perspectives. Vasc Health Risk Manag 2020; 16:203-213. [PMID: 32606717 PMCID: PMC7292252 DOI: 10.2147/vhrm.s193967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/07/2020] [Indexed: 01/16/2023] Open
Abstract
Aortic intramural hematoma (AIH) is an entity within the acute aortic syndrome. Combination of a priori probability, clinical history, laboratory blood test and imaging techniques are the basis for diagnosis of AIH. This review is focused on all aspects related to diagnosis of patients with AIH, from clinical to imaging and analytical.
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Affiliation(s)
- Carlos Ferrera
- Department of Cardiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Isidre Vilacosta
- Department of Cardiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Beatriz Cabeza
- Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Javier Cobiella
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - Isaac Martínez
- Department of Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Ana Bustos
- Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Luis Maroto
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Madrid, Spain
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Evangelista A, Moral S, Ballesteros E, Castillo-Gandía A. Beyond the term penetrating aortic ulcer: A morphologic descriptor covering a constellation of entities with different prognoses. Prog Cardiovasc Dis 2020; 63:488-495. [PMID: 32497587 DOI: 10.1016/j.pcad.2020.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Penetrating aortic ulcer (AU) is defined as localized disruption of the intimal layer of the aortic wall, resulting in a crater-like lesion outpouching from the vessel contour. AU is a generic term which encompasses a constellation of entities with different etiologies and prognoses and may be a complication of infective, inflammatory, traumatic, iatrogenic, atherosclerotic processes or intramural hematoma. One of the most challenging scenarios of AU for a differential diagnosis, but also for treatment implications, is when they are associated with acute aortic syndrome. Despite advances in the field of aortic disease, lack of consensus defining these lesions and the significant semantic confusion in the medical literature of the acronym PAU (for penetrating aortic ulcer but also for penetrating atherosclerotic ulcer) have given rise to controversy in guidelines and expert consensus, leading to the same treatment being recommended for entities with different etiology and prognosis. Moreover, in the medical literature, most diagnoses were mainly based on imaging techniques which identified AU regardless of clinical symptoms, surrounding imaging findings or dynamic morphologic changes. In this Review, we provide the latest insight into the differential diagnosis between AU, also called penetrating aortic ulcers, based on clinical context and the newest imaging characteristics to aid treatment decision-making.
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Affiliation(s)
- Arturo Evangelista
- Cardiology Department, Hospital General Universitari Vall d'Hebron, VHIR, CIBER-CV, Barcelona, Spain; Heart Institute, Quirónsalud-Teknon, Barcelona, Spain.
| | - Sergio Moral
- Cardiology Department, Hospital Universitari Doctor Josep Trueta, CIBER-CV, Girona, Spain
| | - Esther Ballesteros
- Radiology Department, Centro de atención primaria Pare Claret, Institut Català de la Salut, Barcelona, Spain
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Chen Q, Jiang D, Kuang F, Shan Z. The evolution of treatments for uncomplicated type B intramural hematoma patients. J Card Surg 2020; 35:580-590. [PMID: 31945227 DOI: 10.1111/jocs.14431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES We aimed to investigate whether uncomplicated type B intramural hematoma (IMHB) patients with known evolution predictors could benefit from more aggressive therapy. METHODS Retrospective analysis was performed in uncomplicated IMHB patients with evolution predictors between January 2001 and August 2018. Cox proportional hazard models were constructed to identify the specific factors associated with aorta-related mortality. RESULTS A total of 226 uncomplicated acute IMHB patients with evolution predictors were included. The conventional therapy group included 187 patients, and the other 39 patients received the more aggressive therapy. Aorta-related mortality in the first year was higher in the conventional therapy group than in the more aggressive therapy group (15% vs 2.5%, P = .035), and more patients died after thoracic endovascular aortic repair (TEVAR) (13 of 27 patients, 48.1% vs 2.5%, P < .001). The more aggressive therapy group had a higher rate of hematoma resolution than the conventional therapy group (81.6% vs 62.2%, P = .024), a lower possibility of hematoma worsening (2.6% vs 17.0%, P = .021), and a lower reintervention rate (0% vs 11.9%, P = .028). Cox regression analysis revealed that a higher rate of focal intimal disruption (FID) development (hazard ratio [HR], 3.99; 95% confidence interval [CI], 1.16-11.46, P = .010), and a higher C-reactive protein (CRP) level (HR, 1.27; 95% CI, 1.16-1.40, P < .001) were associated with increased aorta-related mortality. CONCLUSIONS More aggressive therapy for uncomplicated IMHB patients with evolution predictors during the acute phase may result in better clinical outcomes. A higher rate of FID development and a higher CRP level are associated with increased aorta-related mortality.
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Affiliation(s)
- Qu Chen
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen, China
| | - Dandan Jiang
- Department of Internal Medicine, Xinglin Branch of The First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen, China
| | - Feng Kuang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen, China
| | - Zhonggui Shan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen, China
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Bolomey S, Blanchard A, Barral PA, Mancini J, Lagier D, Bal L, De Masi M, Jacquier A, Piquet P, Gaudry M. Is the Natural Anatomical Evolution of Type B Intramural Hematomas Reliable to Identify the Patients at Risk of Aneurysmal Progression? Ann Vasc Surg 2020; 64:62-70. [PMID: 31904521 DOI: 10.1016/j.avsg.2019.11.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/29/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The natural history of type B intramural hematomas is little-known. Aneurysmal progression or an aortic dissection occurs in 15 to 20% of the cases. The study of the natural anatomical evolution could help identify the patients at risk of unfavorable evolution. METHODS All the patients monitored for a type B intramural hematoma between 2009 and 2018 were included in this monocentric retrospective study. Computed tomography angiography centerline measurement of diameters was obtained in various points of aortic segmentation on day (D) 0 and at one month (M1). Aortic volumes (lumen, intramural hematoma, and total volume) were calculated. The circulating volume was calculated using the volume rendering method. The volume of the intramural hematoma was measured using a manual section-by-section segmentation tool, and the total volume was obtained by summing up the two preceding volumes. Two groups of patients were compared: group 1 (favorable anatomical evolution) and group 2 (unfavorable anatomical evolution). RESULTS Between January 2008 and August 2018, 25 patients were managed for a type B intramural hematoma in our center. After an average follow-up of 15.5 months (1-52), 13 patients (52%) presented a favorable evolution and 12 (48%) an unfavorable evolution. At M1, a significant increase of the luminal diameters (37 mm vs. 32 mm; P < 0.01) and a significant reduction in the longitudinal extension (19 mm vs. 26 mm; P < 0.01) were observed. The maximum aortic diameter evolved significantly between D0 and M1 in the unfavorable evolution group (49 mm vs. 44 mm, respectively; P = 0.038). Such a difference was not found in the favorable evolution group (37.4 vs. 37.1, respectively; P = 0.552). An overall significant reduction in the total aortic volume (166 cm3 vs. 219 cm3; P < 0.01), the circulating volume (124 cm3 vs. 145 cm3; P = 0,026), and the volume of the hematoma (42 cm3 vs. 39 cm3; P < 0.01) was observed. The circulating volume decreased significantly between D0 and M1 in the favorable evolution group (110 cm3 vs. 135 cm3; P = 0.05), whereas no difference was noted in the unfavorable group (142 cm3 vs, 157 cm3; P = 0.24). CONCLUSIONS The progression of the maximum aortic diameter and of the circulating volume after one month of follow-up could be predictive factors of the poor long-term evolution of type B intramural hematomas.
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Affiliation(s)
- Sonia Bolomey
- APHM, Hôpital de La Timone, Department of Vascular Surgery, Marseille, France
| | - Arnaud Blanchard
- APHM, Hôpital de La Timone, Department of Vascular Surgery, Marseille, France
| | | | - Julien Mancini
- Aix-Marseille University, APHM, INSERM, IRD Biostatistics Department, SESSTIM, BIOSTIC, Marseille, France
| | - David Lagier
- APHM, Hôpital de La Timone, Department of Anesthesiology, Marseille, France
| | - Laurence Bal
- APHM, Hôpital de La Timone, Department of Vascular Surgery, Marseille, France
| | - Mariangela De Masi
- APHM, Hôpital de La Timone, Department of Vascular Surgery, Marseille, France
| | - Alexis Jacquier
- APHM, Hôpital de La Timone, Department of Radiology, Marseille, France
| | - Philippe Piquet
- APHM, Hôpital de La Timone, Department of Vascular Surgery, Marseille, France
| | - Marine Gaudry
- APHM, Hôpital de La Timone, Department of Vascular Surgery, Marseille, France.
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Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J 2019; 39:739-749d. [PMID: 29106452 DOI: 10.1093/eurheartj/ehx319] [Citation(s) in RCA: 198] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/13/2017] [Indexed: 01/16/2023] Open
Abstract
Acute aortic syndromes (AAS) encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural haematoma, and penetrating atherosclerotic aortic ulcer. Given the non-specific symptoms and physical signs, a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur. In order to reduce the diagnostic time delay, a comprehensive flowchart for decision-making based on pre-test sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases and should be thus applied in the emergency scenario. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken if indicated by a highly specialized aortic team. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) is generally indicated. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts. Finally, it should be highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
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Affiliation(s)
| | - Troy M LaBounty
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, USA
| | - Kim A Eagle
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, USA
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Haensig M. Type B intramural hematoma: focus on reasons for development and overlapping clinical disease. Ann Cardiothorac Surg 2019; 8:494-496. [PMID: 31463214 DOI: 10.21037/acs.2019.06.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Martin Haensig
- Department of Vascular Surgery, University of Leipzig, Leipzig, Germany
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Houben IB, van Bakel TMJ, Patel HJ. Type B intramural hematoma: thoracic endovascular aortic repair (TEVAR) or conservative approach? Ann Cardiothorac Surg 2019; 8:483-487. [PMID: 31463210 DOI: 10.21037/acs.2019.05.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ignas B Houben
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Theodorus M J van Bakel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Health Center, Ann Arbor, MI, USA
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Filippone G, La Barbera G, Valentino F, Ocello S, Guardì D, Ferro G, Talarico F. Conservative Management of Uncomplicated Acute Type B Intramural Hematoma of the Aorta Not Always Is the Right Solution. Ann Vasc Surg 2019; 61:469.e5-469.e11. [PMID: 31394219 DOI: 10.1016/j.avsg.2019.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 11/19/2022]
Abstract
The natural course of intramural hematoma (IMH) of the aorta remains unpredictable and despite an increasing amount of literature reports its treatment is still debatable. IMH typically is diagnosed by computed tomography that has permitted to identify specific images whose onset, in uncomplicated cases, appears to be associated to a dismal prognosis. We report on a case series of acute uncomplicated type B IMH in which early detection of such findings, given the expected poor prognosis associated to the aorta-related mortality, suggests the need to shift toward an aggressive endovascular aortic repair in this subset of patients.
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Affiliation(s)
| | | | | | | | - Diego Guardì
- Vascular and Endovascular Unit, ARNAS Civico, Palermo, Italy
| | - Gabriele Ferro
- Vascular and Endovascular Unit, ARNAS Civico, Palermo, Italy
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Evangelista A, Maldonado G, Moral S, Teixido-Tura G, Lopez A, Cuellar H, Rodriguez-Palomares J. Intramural hematoma and penetrating ulcer in the descending aorta: differences and similarities. Ann Cardiothorac Surg 2019; 8:456-470. [PMID: 31463208 DOI: 10.21037/acs.2019.07.05] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute aortic syndromes include a variety of overlapping clinical and anatomic diseases. Intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and aortic dissection can occur as isolated processes or can be found in association. All these entities are potentially life threatening, so prompt diagnosis and treatment is of paramount importance. IMH and PAU affect patients with atherosclerotic risk factors and are located in the descending aorta in 60-70% of cases. IMH diagnosis can be correctly made in most cases. Aortic ulcer is a morphologic entity which comprises several entities-the differential diagnosis includes PAU, focal intimal disruptions (FID) in the context of IMH evolution and ulcerated atherosclerotic plaque. The pathophysiologic mechanism, evolution and prognosis differ somewhat between these entities. However, most PAU are diagnosed incidentally outside the acute phase. Persistent pain despite medical treatment, hemodynamic instability, maximum aortic diameter (MAD) >55 mm, significant periaortic hemorrhage and FID in acute phase of IMH are predictors of acute-phase mortality. In these cases, TEVAR or open surgery should be considered. In non-complicated IMH or PAU, without significant aortic enlargement, strict control of cardiovascular risk factors and frequent follow-up imaging appears to be a safe management strategy.
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Affiliation(s)
- Arturo Evangelista
- Servei de Cardiología, Hospital Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain.,Instituto del Corazón, Quironsalud Teknon, Barcelona, Spain
| | | | - Sergio Moral
- Cardiology Department, Hospital Universitari Doctor Josep Trueta, CIBER-CV, Girona, Spain
| | - Gisela Teixido-Tura
- Servei de Cardiología, Hospital Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Angela Lopez
- Servei de Cardiología, Hospital Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Hug Cuellar
- Institut Diagnostic per la Imatge, Hospital Vall d'Hebron, Barcelona, Spain
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