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Oh N, Roselli EE, Vargo PR. A 25-Year-Old With an Incidentally Detected Ascending Thoracic Aortic Aneurysm and Bicuspid Aortic Valve. JAMA 2024:2821253. [PMID: 39023879 DOI: 10.1001/jama.2024.12435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
A woman with shortness of breath underwent imaging that showed an isolated dilatation in the mid ascending aorta and a bicuspid aortic valve but no pulmonary infiltrates, effusion, or embolism and no aortic stenosis or regurgitation; her family history is notable for aortic dissection. What would you do next?
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Affiliation(s)
- Nicholas Oh
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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2
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Garrido JM, Ferreiro-Marzal A, Esteban-Molina M, Rodríguez-Morata A, Rodríguez-Serrano F. Endovascular Technique for Ascending Aorta Repair Based on TEVAR and TAVI Procedures. J Endovasc Ther 2024; 31:360-365. [PMID: 36680500 DOI: 10.1177/15266028221148383] [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] [Indexed: 01/22/2023]
Abstract
PURPOSE Ascending aorta (AAo) acute pathology still has an open-surgery indication with a high mortality rate associated to cardiopulmonary bypass and circulatory arrest. In these cases, the endovascular aortic approach could be an excellent option. The aim of the present study is to detail an optimized technique for the endovascular treatment of AAo diseases, based on thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve implantation (TAVI) procedures. TECHNIQUE The procedure implies the usual preparation for TEVAR and TAVI implants. A transient pacemaker lead is necessary to deliver the prosthesis under "rapid pacing." As in the TAVI technique, a final high-support guidewire is placed at the left ventricle. The proximal landing zone is the sinotubular junction (zone 0B). Transesophageal echocardiography is essential to ensure aortic valve function and patency in coronary arteries during the delivery. To assess a potential occlusion of the brachiocephalic artery, a guidewire is positioned in the descending aorta from the axillary artery. Finally, a noncovered stent is implanted to stabilize the AAo prosthesis. CONCLUSION The technique presented here can standardize a safe and reproducible procedure to endovascular repair of AAo diseases. However, new devices specifically designed for the AAo could facilitate the transcatheter approach. CLINICAL IMPACT Ascending aorta acute pathology still has an open-surgery indication with high mortality rate associated to cardiopulmonary bypass and circulatory arrest. Moreover, near 30% of patients are not considered suitable for surgery because of age, critical situation or the presence of severe comorbidities. The present study provides a detailed and optimized technique for the endovascular treatment of ascending aorta disease, based on TEVAR and TAVI procedures.
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Affiliation(s)
- José M Garrido
- Biosanitary Research Institute of Granada (ibs.GRANADA), Granada, Spain
- Department of Cardiovascular Surgery, Virgen de las Nieves University Hospital, Granada, Spain
- Department of Surgery and Surgical Specialties, School of Medicine, University of Granada, Granada, Spain
| | - Andrea Ferreiro-Marzal
- Biosanitary Research Institute of Granada (ibs.GRANADA), Granada, Spain
- Department of Cardiovascular Surgery, Virgen de las Nieves University Hospital, Granada, Spain
| | - María Esteban-Molina
- Biosanitary Research Institute of Granada (ibs.GRANADA), Granada, Spain
- Department of Cardiovascular Surgery, Virgen de las Nieves University Hospital, Granada, Spain
| | | | - Fernando Rodríguez-Serrano
- Biosanitary Research Institute of Granada (ibs.GRANADA), Granada, Spain
- Biopathology and Regenerative Medicine Institute (IBIMER), University of Granada, Granada, Spain
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3
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Xiao X, Liu H, Wan J, Yang P, Xu Z, Wang S, Guo Q, Chen S, Ye P, Wang S, Xia J. Single-cell sequencing reveals the impact of endothelial cell PIEZO1 expression on thoracic aortic aneurysm. J Mol Cell Cardiol 2024; 191:63-75. [PMID: 38718563 DOI: 10.1016/j.yjmcc.2024.04.015] [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: 09/28/2023] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Thoracic aortic aneurysm (TAA) is a severe vascular disease that threatens human life, characterized by focal dilatation of the entire aortic wall, with a diameter 1.5 times larger than normal. PIEZO1, a mechanosensitive cationic channel, monitors mechanical stimulations in the environment, transduces mechanical signals into electrical signals, and converts them into biological signals to activate intracellular signaling pathways. However, the role of PIEZO1 in TAA is still unclear. METHODS We analyzed a single-cell database to investigate the expression level of PIEZO1 in TAA. We constructed a conditional knockout mouse model of Piezo1 and used the PIEZO1 agonist Yoda1 to intervene in the TAA model mice established by co-administration of BAPN and ANG-II. Finally, we explored the effect of Yoda1 on TAA in vitro. RESULTS AND DISCUSSION We observed decreased PIEZO1 expression in TAA at both RNA and protein levels. Single-cell sequencing identified a specific reduction in Piezo1 expression in endothelial cells. Administration of PIEZO1 agonist Yoda1 prevented the formation of TAA. In PIEZO1 endothelial cell conditional knockout mice, Yoda1 inhibited TAA formation by interfering with PIEZO1. In vivo and in vitro experiments demonstrated that the effect of Yoda1 on endothelial cells involved macrophage infiltration, extracellular matrix degradation, and neovascularization. This study highlights the role of PIEZO1 in TAA and its potential as a therapeutic target, providing opportunities for clinical translation.
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Affiliation(s)
- Xiaoyue Xiao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hao Liu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junhao Wan
- Department of Thoracic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peiwen Yang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiyue Xu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shilin Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiang Guo
- Department of Thoracic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanshan Chen
- Key Laboratory for Molecular Diagnosis of Hubei Province, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Ping Ye
- Department of Cardiovascular Medicine, Central Hospital of Wuhan, Wuhan, China.
| | - Sihua Wang
- Department of Thoracic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Jiahong Xia
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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4
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Benites-Yshpilco L, Barriales-Revilla L, Baltodano-Arellano R, Falcón-Quispe L, Cupe-Chacalcaje K, Cachicatari-Beltrán Á, Lévano-Pachas G. Multimodal imaging in Ig G4- related aortitis: case report. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2024; 5:50-53. [PMID: 38596609 PMCID: PMC10999319 DOI: 10.47487/apcyccv.v5i1.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/26/2023] [Indexed: 04/11/2024]
Abstract
We present the case of a 56-year-old patient with fever of unknown origin associated with chest and lumbar pain. Multimodality imaging revealed diffuse peri-aortitis in the thoracic aorta without involvement of the aortic valve, contributing substantially to the diagnosis of Ig G4-associated aortitis. Immunosuppressive therapy was started. Follow-up at five months with cardiac magnetic resonance imaging showed a reduction in the inflammatory process in the thoracic aorta.
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Affiliation(s)
- Lindsay Benites-Yshpilco
- Hospital Guillermo Almenara Irigoyen - EsSalud, Lima, Perú.Hospital Guillermo Almenara Irigoyen - EsSaludLimaPerú
| | - Lucia Barriales-Revilla
- Hospital Guillermo Almenara Irigoyen - EsSalud, Lima, Perú.Hospital Guillermo Almenara Irigoyen - EsSaludLimaPerú
| | - Roberto Baltodano-Arellano
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, PerúUniversidad Nacional Mayor de San MarcosFacultad de MedicinaUniversidad Nacional Mayor de San MarcosLimaPeru
- Cardiac imaging area of Cardiology Service, Hospital Guillermo Almenara Irigoyen - EsSalud, Lima, Perú.Cardiac imaging area of Cardiology ServiceHospital Guillermo Almenara Irigoyen - EsSaludLimaPerú
| | - Luis Falcón-Quispe
- Cardiac imaging area of Cardiology Service, Hospital Guillermo Almenara Irigoyen - EsSalud, Lima, Perú.Cardiac imaging area of Cardiology ServiceHospital Guillermo Almenara Irigoyen - EsSaludLimaPerú
| | - Kelly Cupe-Chacalcaje
- Cardiac imaging area of Cardiology Service, Hospital Guillermo Almenara Irigoyen - EsSalud, Lima, Perú.Cardiac imaging area of Cardiology ServiceHospital Guillermo Almenara Irigoyen - EsSaludLimaPerú
| | - Ángela Cachicatari-Beltrán
- Cardiac imaging area of Cardiology Service, Hospital Guillermo Almenara Irigoyen - EsSalud, Lima, Perú.Cardiac imaging area of Cardiology ServiceHospital Guillermo Almenara Irigoyen - EsSaludLimaPerú
| | - Gerald Lévano-Pachas
- Hospital Guillermo Almenara Irigoyen - EsSalud, Lima, Perú.Hospital Guillermo Almenara Irigoyen - EsSaludLimaPerú
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5
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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: 12] [Impact Index Per Article: 12.0] [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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6
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Gedney R, Wooster M. Thoracic Aortic Aneurysms and Arch Disease. Surg Clin North Am 2023; 103:615-627. [PMID: 37455028 DOI: 10.1016/j.suc.2023.04.013] [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] [Indexed: 07/18/2023]
Abstract
Aortic arch and descending thoracic pathology have historically remained in the realm of open surgical repair. Technology is quickly pushing to bring these under the endovascular umbrella, with lower morbidity repairs proving safe in their early experience. Much work remains particularly for acute aortic syndromes, however, to understand who is best treated medically, surgically, endovascularly, or with hybrid approaches.
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Affiliation(s)
- Ryan Gedney
- Medical University of South Carolina, 30 Courtenay Drive, MSC 25, STE 654, Charleston, SC 29924, USA
| | - Mathew Wooster
- Division of Vascular Surgery, Medical University of South Carolina, 30 Courtenay Drive, MSC 25, Suite 654, Charleston, SC 29924, USA.
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7
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Owen CE, Yates M, Liew DFL, Poon AMT, Keen HI, Hill CL, Mackie SL. Imaging of giant cell arteritis - recent advances. Best Pract Res Clin Rheumatol 2023; 37:101827. [PMID: 37277245 DOI: 10.1016/j.berh.2023.101827] [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: 04/12/2023] [Accepted: 04/23/2023] [Indexed: 06/07/2023]
Abstract
Imaging is increasingly being used to guide clinical decision-making in patients with giant cell arteritis (GCA). While ultrasound has been rapidly adopted in fast-track clinics worldwide as an alternative to temporal artery biopsy for the diagnosis of cranial disease, whole-body PET/CT is emerging as a potential gold standard test for establishing large vessel involvement. However, many unanswered questions remain about the optimal approach to imaging in GCA. For example, it is uncertain how best to monitor disease activity, given there is frequent discordance between imaging findings and conventional disease activity measures, and imaging changes typically fail to resolve completely with treatment. This chapter addresses the current body of evidence for the use of imaging modalities in GCA across the spectrum of diagnosis, monitoring disease activity, and long-term surveillance for structural changes of aortic dilatation and aneurysm formation and provides suggestions for future research directions.
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Affiliation(s)
- Claire E Owen
- Department of Rheumatology, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.
| | - Max Yates
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, United Kingdom; Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - David F L Liew
- Department of Rheumatology, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Aurora M T Poon
- Department of Molecular Imaging and Therapy, Austin Health, Heidelberg, Victoria, Australia
| | - Helen I Keen
- Department of Rheumatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Catherine L Hill
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom; NIHR-Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, United Kingdom
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8
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Perone F, Guglielmo M, Coceani M, La Mura L, Dentamaro I, Sabatino J, Gimelli A. The Role of Multimodality Imaging Approach in Acute Aortic Syndromes: Diagnosis, Complications, and Clinical Management. Diagnostics (Basel) 2023; 13:diagnostics13040650. [PMID: 36832136 PMCID: PMC9954850 DOI: 10.3390/diagnostics13040650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
Acute aortic syndromes are life-threatening conditions with high morbidity and mortality. The principal pathological feature is acute wall damage with possible evolution towards aortic rupture. Accurate and timely diagnosis is mandatory to avoid catastrophic consequences. Indeed, misdiagnosis with other conditions mimicking acute aortic syndromes is associated with premature death. In this view, cardiovascular imaging is necessary for the correct diagnosis and management. Echocardiography, computed tomography, magnetic resonance imaging, and aortography allow for diagnosis, guarantee immediate treatment, and detect associated complications. Multimodality imaging is essential in the diagnostic work-up to confirm or rule out acute aortic syndromes. The aim of this review is to highlight the contemporary evidence on the role of single cardiovascular imaging techniques and multimodality imaging in the diagnosis and management of acute aortic syndromes.
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Affiliation(s)
- Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic “Villa delle Magnolie”, Castel Morrone, 81020 Caserta, Italy
| | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Michele Coceani
- Diagnostic and Interventional Cardiology Unit, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | - Lucia La Mura
- Department of Advanced Biomedical Sciences, University Federico II of Naples, 80133 Naples, Italy
| | - Ilaria Dentamaro
- Cardiology Department and Cardiovascular Imaging Laboratory, Hospital Miulli, 70124 Bari, Italy
| | - Jolanda Sabatino
- Pediatric and Congenital Cardiology Unit, Department for Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy
| | - Alessia Gimelli
- Imaging Department, Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
- Correspondence:
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9
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Leach JR, Zhu C, Burris N, Hope MD. Editorial: Advances in aortic imaging. Front Cardiovasc Med 2023; 10:1137949. [PMID: 36818356 PMCID: PMC9929938 DOI: 10.3389/fcvm.2023.1137949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Affiliation(s)
- Joseph R. Leach
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States,*Correspondence: Joseph R. Leach ✉
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Nicolas Burris
- Department of Radiology, University of Michigan, Ann Arbor, MI, United States
| | - Michael D. Hope
- California Advanced Imaging Medical Associates, San Francisco, CA, United States
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10
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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: 397] [Impact Index Per Article: 198.5] [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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11
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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: 138] [Impact Index Per Article: 69.0] [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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12
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The Echocardiographic Evaluation of Aortic Aneurysm. Curr Cardiol Rep 2022; 24:1893-1900. [PMID: 36242729 DOI: 10.1007/s11886-022-01791-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Aortic aneurysm is the second most common aortic disease associated with significant morbidity and mortality. We summarize the role of echocardiography in the evaluation of aortic aneurysms in assessing the different etiologies, associated complications, and the role in serial follow-up. In addition, we discuss the limitations of echocardiographic evaluation and the role of multimodality imaging. RECENT FINDINGS Echocardiographic tools such as 2D/3D and Doppler imaging have helped improve the quality of aortic evaluation in acute and long-term follow-up. Moreover, multimodality imaging (CT and MR angiography) has advanced the field of aortic imaging. Echocardiography is an essential and critical tool for the evaluation of normal aorta and various aortic pathologies. It provides valuable information with its diverse modalities such as TTE and TEE. Echocardiography along with complimentary multimodality imaging is critical to identify the acute aortic syndromes and other associated complications of aortic aneurysms, and in long-term follow-up.
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13
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Maas A, van Bakel PAJ, Ahmed Y, Patel HJ, Burris NS. Natural history and clinical significance of aortic focal intimal flaps. Front Cardiovasc Med 2022; 9:959517. [PMID: 36267637 PMCID: PMC9576867 DOI: 10.3389/fcvm.2022.959517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/14/2022] [Indexed: 12/04/2022] Open
Abstract
Objective Focal intimal flaps (FIF) are a variety of defects of the aorta that result in a short, flap-like projection into the lumen, and are often encountered in asymptomatic patients undergoing computed tomography angiography (CTA) surveillance for aortic aneurysm, but the natural history and clinical significance of such lesions has not yet been studied. Methods We retrospectively identified patients with an asymptomatic FIF and available imaging follow-up (>1 year). FIF was defined as flap-like intimal irregularity < 4 cm in length involving the thoracic aorta (TA), abdominal aorta (AA) or common iliac arteries (CIA). FIF characteristics included length and circumferential extent as well as the presence and size (width and depth) of associated penetrating aortic ulcers (PAUs). Patient characteristics, adverse events and history of surgical repair was determined by chart review. FIFs and associated PAUs were assessed for progression by comparing baseline and follow-up CTA studies. Results A total of 84 FIFs were identified in 77 patients. Average age was 69.2 ± 10.1 years, and 81% were male (81%). Common co-morbidities included: hypertension (78%), hyperlipidemia (68%), smoking (60%), coronary artery disease (41%), aortic aneurysm (34%), type II diabetes mellitus (27%) and prior cardiovascular surgery (25%). FIFs were most commonly located in the abdominal aorta (n = 50, 60%). Nearly all FIFs were associated with local atherosclerotic plaque (93%). Mean follow-up interval was 3.5 ± 2.6 years (259 cumulative follow-up years). Change in FIF length and local aortic diameter over follow-up were 0.7 ± 2.3 mm and 0.8 ± 1.1 mm, respectively. Nearly half (47%) of FIFs were associated with penetrating aortic ulcers (PAU) with baseline depth of 7.3 mm (IQR: 6.1–10.2) and change in depth of 0.5 ± 1.4 mm. Only 12% of FIFs and 0% of associated PAUs demonstrated growth (≥3 mm) at follow-up. No acute pathology developed in the location of FIFs and no aortic interventions were performed specifically to treat FIFs. Conclusion Focal intimal flaps identified in asymptomatic patients with aortic disease were co-localized with atherosclerotic plaque and PAUs, and demonstrated indolent behavior, not leading to significant growth or acute aortic events, supporting a conservative management approach.
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Affiliation(s)
- Austin Maas
- Department of Radiology, University of Michigan, Ann Arbor, MI, United States
| | - Pieter A. J. van Bakel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States,Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Yunus Ahmed
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States,Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Himanshu J. Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Nicholas S. Burris
- Department of Radiology, University of Michigan, Ann Arbor, MI, United States,*Correspondence: Nicholas S. Burris,
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14
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Muhammad R, Lefi A, Ghassani DN, Mulia EPB. An atypical presentation of aortic dissection: echocardiography for accurate detection. J Ultrasound 2022; 25:737-743. [PMID: 34981448 PMCID: PMC9402858 DOI: 10.1007/s40477-021-00617-4] [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: 03/31/2021] [Accepted: 08/05/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Aortic dissection (AD) is a relatively rare but dreadful illness, often accompanied by severe, sharp (or 'tearing') back pain or anterior chest pain, as well as acute hemodynamic compromise. Painless dissection has also been reported in rare cases. Echocardiography has become the most commonly used imaging test for evaluating cardiovascular disease and, thus, plays an important role in aortic disease diagnosis and follow-up. CASE PRESENTATION This paper presents the case of a 63-year-old female presenting a chronic cough for more than 30 days, accompanied by chest pain radiating to the left scapula, a history of chronic hypertension, and recent chest x-ray findings of mediastinal mass on the upper left of the aortic knob. Transthoracic echocardiography (TTE) shows a clear image of a dissection flap on the ascending aorta and abdominal aorta, with a false lumen that is larger than the true lumen and filled with intramural thrombus. A transesophageal echocardiography (TOE) examination performed later shows a clear entry tear near the sinuses of Valsalva directly above the ostium of the right coronary artery (RCA). The patient was diagnosed with AD Stanford A de Bakey Type 1. Computed tomography (CT) focusing on the thoracoabdominal aorta and coronary artery was ordered upon suspicion of RCA ostium obstruction by the dissection flap and to further direct the surgical management. However, later on, the patient refused to undergo surgery, opting instead for conservative medical therapy. CONCLUSION The diagnosis of AD is challenging. Our case emphasizes the vital role of TTE in diagnosing AD, particularly in patients with atypical symptoms in which the diagnosis of AD might not be considered. Such missed AD diagnoses can lead to precarious outcomes.
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Affiliation(s)
- Rizal Muhammad
- Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Jalan Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, 60286, Indonesia
| | - Achmad Lefi
- Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Jalan Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, 60286, Indonesia.
| | - Dara Ninggar Ghassani
- Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Jalan Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, 60286, Indonesia
| | - Eka Prasetya Budi Mulia
- Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Jalan Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, 60286, Indonesia
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15
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Abstract
The aorta contributes to cardiovascular physiology and function. Understanding biomechanics in health, disease, and after aortic interventions will facilitate optimization of perioperative patient care.
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16
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Pikija S, Kunz AB, Nardone R, Enzinger C, Pfaff JA, Trinka E, Seifert-Held T, Sellner J. Spontaneous spinal cord infarction in Austria: a two-center comparative study. Ther Adv Neurol Disord 2022; 15:17562864221076321. [PMID: 35299778 PMCID: PMC8921761 DOI: 10.1177/17562864221076321] [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: 11/11/2021] [Accepted: 01/07/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Spinal cord infarction (SCI) is a neurological emergency associated with high rates of persistent neurological deficits. Knowledge about this rare but potentially treatable condition needs to be expanded. Objective: To describe the characteristics of spontaneous SCI in a large retrospective series of patients treated at two tertiary care centers in Austria. Methods: We performed a descriptive and comparative analysis of spontaneous SCI treated at the University Hospitals of Salzburg and Graz between the years 2000 and 2020. The analysis included pre- and in-hospital procedures, clinical presentation, etiology, diagnostic certainty, reperfusion therapy, and functional outcome at discharge. Results: We identified 88 cases, 61% were ascertained in the second half of the study period. The median age was 65.5 years [interquartile range (IQR) = 56–74], 51.1% were women. Anterior spinal artery infarction was the predominant syndrome (82.9%). Demographics, vascular comorbidities, and clinical presentation did not differ between the centers. The most frequent etiology and level of diagnostic certainty were distinct, with atherosclerosis (50%) and definite SCI (42%), and unknown (52.5%) and probable SCI (60%) as front runners in Salzburg and Graz, respectively. Patients arrived after a median of 258.5 min (IQR = 110–528) at the emergency room. The first magnetic resonance imaging (MRI) of the spinal cord was performed after a median of 148 min (IQR = 90–312) from admission and was diagnostic for SCI in 45%. Two patients received intravenous thrombolysis (2.2%). The outcome was poor in 37/77 (48%). Conclusion: Demographics, clinical syndromes, and quality benchmarks for spontaneous SCI were consistent at two Austrian tertiary care centers. Our findings provide the foundation for establishing standards for pre- and in-hospital care to improve outcomes.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Alexander B. Kunz
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Raffaele Nardone
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy; Spinal Cord Injury and Tissue Regeneration Center, Salzburg, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Johannes A.R. Pfaff
- University Institute for Neuroradiology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria Neuroscience Institute, Christian Doppler Medical Center and Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | | | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstr. 67, 2130 Mistelbach, Austria
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany
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17
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Diagnosis and Management of Acute Aortic Syndromes: Dissection, Penetrating Aortic Ulcer, and Intramural Hematoma. Curr Cardiol Rep 2022; 24:209-216. [PMID: 35029783 PMCID: PMC9834910 DOI: 10.1007/s11886-022-01642-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Acute aortic syndromes, including aortic dissection, intramural hematoma, and penetrating aortic ulcer, are a group of highly morbid, related pathologies that are defined by compromised aortic wall integrity. The purpose of this review is to summarize current management strategies for acute aortic syndromes. RECENT FINDINGS All acute aortic syndromes have potential for high morbidity and mortality and must be quickly identified and managed with the appropriate algorithm to prevent suboptimal outcomes. Recent trials suggest that TEVAR is increasingly useful in stabilizing pathology of the descending thoracic aorta but when possible should be applied in a delayed fashion and with limited coverage to minimize neurologic complications. Treatment for acute aortic syndrome is frequently dictated by the anatomic location and extent of the wall compromise as well as patient comorbidities. Therapy is often individualized and often includes some combination of medical, procedural, and surgical intervention.
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18
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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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19
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King RW, Bonaca MP. Acute aortic syndromes: a review of what we know and future considerations. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:1197-1203. [PMID: 34849689 DOI: 10.1093/ehjacc/zuab106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 12/27/2022]
Abstract
Acute aortic syndromes represent a spectrum of life-threatening aortic pathologies. Prompt diagnosis and proper management of these syndromes are important in reducing overall mortality and morbidity, which remains high. Acute aortic dissections represent most of these aortic wall pathologies, but intramural haematomas and penetrating atherosclerotic ulcers have been increasingly diagnosed. Type A dissections require prompt surgical treatment, with endovascular options on the horizon. Type B dissections can be complicated or uncomplicated, and treatment is determined based on this designation. Complicated Type B dissections require prompt repair with thoracic endovascular aortic repair (TEVAR) becoming the preferred method. Uncomplicated Type B dissections require medical management, but early TEVAR in the subacute setting is becoming more prominent. Proper surveillance for an uncomplicated Type B dissection is crucial in detecting aortic degeneration and need for intervention. Intramural haematomas and penetrating atherosclerotic ulcers are managed similarly to aortic dissections, but more research is needed to determine the proper management algorithms. Multi-disciplinary aortic programmes have been shown to improve patient outcomes and are necessary in optimizing long-term follow-up.
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Affiliation(s)
- R Wilson King
- CPC Clinical Research, 2115 N. Scranton St., Suite 2040 Aurora, CO, USA.,Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Marc P Bonaca
- CPC Clinical Research, 2115 N. Scranton St., Suite 2040 Aurora, CO, USA.,Department of Medicine, University of Colorado, Aurora, CO, USA
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20
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Vargo PR, Reich H, Roselli EE. Computed Tomography Imaging of Aortic Dissections with Endovascular Treatment Considerations. Curr Cardiol Rep 2021; 23:113. [PMID: 34269860 DOI: 10.1007/s11886-021-01541-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW In the present review, we discuss the role of CT imaging in the management of aortic dissection, with a particular emphasis on endovascular treatment considerations. RECENT FINDINGS Computed tomography imaging is a fundamental tool in the diagnosis and management of acute and chronic aortic dissection. Its diagnostic accuracy and high resolution contribute to and guide operative strategy. Persistent high mortality for patients who develop aortic dissections suggests a need for innovative diagnostic and treatment strategies. In the recent era, considerable advances have been made in computed tomography (CT) image acquisition, processing, and analysis as well as endovascular technologies with expanded roles in the treatment of aortic diseases.
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Affiliation(s)
- Patrick R Vargo
- Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Heidi Reich
- Central California Heart and Lung Surgery, Clovis, CA, USA
| | - Eric E Roselli
- Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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21
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Gunn AJ, Kalva SP, Majdalany BS, Craft J, Eldrup-Jorgensen J, Ferencik M, Ganguli S, Kendi AT, Khaja MS, Obara P, Russell RR, Sutphin PD, Vijay K, Wang DS, Dill KE. ACR Appropriateness Criteria® Nontraumatic Aortic Disease. J Am Coll Radiol 2021; 18:S106-S118. [PMID: 33958105 DOI: 10.1016/j.jacr.2021.02.004] [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: 01/27/2021] [Accepted: 02/08/2021] [Indexed: 01/16/2023]
Abstract
Nontraumatic aortic disease can be caused by a wide variety of disorders including congenital, inflammatory, infectious, metabolic, neoplastic, and degenerative processes. Imaging examinations such as radiography, ultrasound, echocardiography, catheter-based angiography, CT, MRI, and nuclear medicine examinations are essential for diagnosis, treatment planning, and assessment of therapeutic response. Depending upon the clinical scenario, each of these modalities has strengths and weaknesses. Whenever possible, the selection of a diagnostic imaging examination should be based upon the best available evidence. 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. The purpose of this document is to assist physicians select the most appropriate diagnostic imaging examination for nontraumatic aortic diseases.
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Affiliation(s)
- Andrew J Gunn
- University of Alabama at Birmingham, Birmingham, Alabama, Director, Interventional Oncology, Director, Ambulatory Clinic, Assistant Program Director, Diagnostic Radiology Residency, Assistant Program Director, Interventional Radiology Residency, University of Alabama at Birmingham, Member, American College of Radiology-Radiologic Society of North America Patient Information Committee.
| | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts, Chief, Division of Interventional Radiology, Massachusetts General Hospital
| | | | - Jason Craft
- St. Francis Hospital, Catholic Health Services of Long Island, Roslyn, New York, Society for Cardiovascular Magnetic Resonance
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts, Society for Vascular Surgery
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, Society of Cardiovascular Computed Tomography
| | | | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapies at Mayo Clinic Rochester
| | - Minhajuddin S Khaja
- University of Virginia, Charlottesville, Virginia, Vice-Chair ACR Vascular Imaging Panel 2, Program Director, Independent IR Residency, UVA Health
| | - Piotr Obara
- Loyola University Medical Center, Maywood, Illinois
| | - Raymond R Russell
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, Nuclear cardiology expert, Program Director, Cardiology Fellowship, Director, Nuclear Cardiology, Director, Cardio-Oncology Program, Rhode Island Hospital
| | | | | | - David S Wang
- Stanford University Medical Center, Stanford, California
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
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22
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Cheng C, Nguyen MN, Nayernama A, Jones SC, Brave M, Agrawal S, Amiri-Kordestani L, Woronow D. Arterial aneurysm and dissection with systemic vascular endothelial growth factor inhibitors: A review of cases reported to the FDA Adverse Event Reporting System and published in the literature. Vasc Med 2021; 26:526-534. [PMID: 33840328 DOI: 10.1177/1358863x211006470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The US Food and Drug Administration (FDA) has approved multiple systemic vascular endothelial growth factor (VEGF) inhibitors since 2004 to treat various malignancies. Inhibition of the VEGF signaling pathway can result in impairment of vascular wall integrity through medial degeneration and endothelial dysfunction, potentially resulting in arterial (including aortic) aneurysm/dissection. We performed a postmarketing review to evaluate arterial aneurysm/dissection as a potential safety risk for patients with cancer treated with VEGF inhibitors. We searched the FDA Adverse Event Reporting System (FAERS) database and literature for reports of arterial (including aortic) aneurysm/dissection with VEGF inhibitors currently approved by the FDA for a cancer indication. We identified 240 cases of arterial aneurysm/dissection associated with VEGF inhibitors. The median time to onset of an arterial aneurysm/dissection event from the initiation of a VEGF inhibitor was 94 days (range 1-1955 days). Notably, 22% (53/240) of cases reported fatal outcomes related to arterial aneurysm/dissection. We determined the drug-event association as probable in 15 cases that lacked relevant confounding factors for arterial aneurysm/dissection, which is supported by unremarkable computed tomography (CT) findings prior to starting VEGF inhibitor therapy, despite nondrug-associated background arterial aneurysm/dissection generally demonstrating preexisting arterial abnormalities. FAERS and literature case-level evidence suggests that VEGF inhibitors may have contributed to arterial aneurysm/dissection, as a class effect, based on short onset relative to natural history of disease and biologic plausibility. Cardiovascular and oncology healthcare professionals should be aware of this rare, but life-threatening safety risk associated with VEGF inhibitors.
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Affiliation(s)
- Connie Cheng
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Michelle Nadeau Nguyen
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Afrouz Nayernama
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - S Christopher Jones
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Michael Brave
- Division of Oncology, Office of Oncologic Diseases, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Sundeep Agrawal
- Division of Oncology, Office of Oncologic Diseases, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Laleh Amiri-Kordestani
- Division of Oncology, Office of Oncologic Diseases, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Daniel Woronow
- Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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23
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Yacoub B, Stroud RE, Piccini D, Schoepf UJ, Heerfordt J, Yerly J, Di Sopra L, Rollins JD, Turner DA, Emrich T, Xiong F, Suranyi P, Varga-Szemes A. Measurement accuracy of prototype non-contrast, compressed sensing-based, respiratory motion-resolved whole heart cardiovascular magnetic resonance angiography for the assessment of thoracic aortic dilatation: comparison with computed tomography angiography. J Cardiovasc Magn Reson 2021; 23:7. [PMID: 33557887 PMCID: PMC7871614 DOI: 10.1186/s12968-020-00697-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 12/09/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Patients with thoracic aortic dilatation who undergo annual computed tomography angiography (CTA) are subject to repeated radiation and contrast exposure. The purpose of this study was to evaluate the feasibility of a non-contrast, respiratory motion-resolved whole-heart cardiovascular magnetic resonance angiography (CMRA) technique against reference standard CTA, for the quantitative assessment of cardiovascular anatomy and monitoring of disease progression in patients with thoracic aortic dilatation. METHODS: Twenty-four patients (68.6 ± 9.8 years) with thoracic aortic dilatation prospectively underwent clinical CTA and research 1.5T CMRA between July 2017 and November 2018. Scans were repeated in 15 patients 1 year later. A prototype free-breathing 3D radial balanced steady-state free-precession whole-heart CMRA sequence was used in combination with compressed sensing-based reconstruction. Area, circumference, and diameter measurements were obtained at seven aortic levels by two experienced and two inexperienced readers. In addition, area and diameter measurements of the cardiac chambers, pulmonary arteries and pulmonary veins were also obtained. Agreement between the two modalities was assessed with intraclass correlation coefficient (ICC) analysis, Bland-Altman plots and scatter plots. RESULTS Area, circumference and diameter measurements on a per-level analysis showed good or excellent agreement between CTA and CMRA (ICCs > 0.84). Means of differences on Bland-Altman plots were: area 0.0 cm2 [- 1.7; 1.6]; circumference 1.0 mm [- 10.0; 12.0], and diameter 0.6 mm [- 2.6; 3.6]. Area and diameter measurements of the left cardiac chambers showed good agreement (ICCs > 0.80), while moderate to good agreement was observed for the right chambers (all ICCs > 0.56). Similar good to excellent inter-modality agreement was shown for the pulmonary arteries and veins (ICC range 0.79-0.93), with the exception of the left lower pulmonary vein (ICC < 0.51). Inter-reader assessment demonstrated mostly good or excellent agreement for both CTA and CMRA measurements on a per-level analysis (ICCs > 0.64). Difference in maximum aortic diameter measurements at baseline vs follow up showed excellent agreement between CMRA and CTA (ICC = 0.91). CONCLUSIONS The radial whole-heart CMRA technique combined with respiratory motion-resolved reconstruction provides comparable anatomical measurements of the thoracic aorta and cardiac structures as the reference standard CTA. It could potentially be used to diagnose and monitor patients with thoracic aortic dilatation without exposing them to radiation or contrast media.
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Affiliation(s)
- Basel Yacoub
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
| | - Robert E Stroud
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
| | - Davide Piccini
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
| | - John Heerfordt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland
| | - Jérôme Yerly
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Center for Biomedical Imaging (CIBM), Lausanne, Switzerland
| | - Lorenzo Di Sopra
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jonathan D Rollins
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
| | - D Alan Turner
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Tilman Emrich
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
- Department of Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Fei Xiong
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
- Cardiovascular MR R&D, Siemens Medical Solutions USA Inc, Charleston, SC, USA
| | - Pal Suranyi
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA.
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24
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Odofin X, Houbby N, Hagana A, Nasser I, Ahmed A, Harky A. Thoracic aortic aneurysms in patients with heritable connective tissue disease. J Card Surg 2021; 36:1083-1090. [PMID: 33476431 DOI: 10.1111/jocs.15340] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/26/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with connective tissue diseases are at high lifetime risk of developing thoracic aortic aneurysms (TAAs) due to defects in extracellular matrix composition which compromise the structural integrity of the aortic wall. It is vital to identify and manage aneurysms early to prevent fatal complications such as dissection or rupture. METHOD This review synthesises information obtained from a thorough literature search regarding the pathophysiology of TAAs in those with heritable connective tissue diseases (HCTDs), the investigations for timely diagnosis and current operative strategies. RESULTS Major complications of open repair (OR) include pneumonia (32%), haemorrhage (31%) and tracheostomy (18%), with a minor risk of vocal cord paresis (9%). For thoracic endovascular aortic repair (TEVAR), high rates of endoleak were documented (38-66.6%). Reintervention rates for TEVAR are also high at 38-44%. Mortality rates were documented as 25% for open repair and vary from 14% to 44% for TEVAR. CONCLUSION OR remains the mainstay of surgical management. While TEVAR use is expanding, it remains the alternative choice due to concerns over endograft durability, limited long-term outcome data and the lack of high-quality evidence regarding its use in HCTD patients.
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Affiliation(s)
- Xuan Odofin
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK
| | - Nour Houbby
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK
| | - Arwa Hagana
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK
| | - Ibrahim Nasser
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK.,Leicester Medical School, College of Life Sciences, University of Leicester, Leicester, UK
| | | | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
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Spanos K, Nana P, Behrendt CA, Kouvelos G, Panuccio G, Heidemann F, Matsagkas M, Debus ES, Giannoukas A, Kölbel T. Management of Descending Thoracic Aortic Diseases: Similarities and Differences Among Cardiovascular Guidelines. J Endovasc Ther 2021; 28:323-331. [PMID: 33435805 DOI: 10.1177/1526602820987808] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cardiovascular societies have developed recommendations regarding the management of thoracic aortic diseases. While improvements in treatment have been observed during the past decade in regard to patient selection, thoracic endovascular aortic repair (TEVAR) and associated techniques, and high-volume centralization, the broad expansion of TEVAR has raised considerations about its indications, appropriateness, limitations, and application. The aim of this systematic review was to assess the similarities and differences among current cardiovascular societies' guidelines for the management of thoracic aortic diseases. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from January 2009 to May 2020. The initial search identified 990 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from cardiovascular societies published between 2010 and 2020. Selected controversial topics were analyzed, including diagnosis, imaging, spinal cord ischemia prevention, and management of the most important thoracic aortic pathologies. The analysis included data concerning the therapeutic approach in acute and chronic type B aortic dissection, penetrating aortic ulcer, intramural hematoma, thoracic aortic aneurysm, and traumatic aortic injury, as well a discussion of inflammatory aneurysms, aortitis, and genetic syndromes. The review presents consistent and controversial recommendations, as well as "gray zone" issues that need further investigation. There was significant overlap and agreement among the 5 societies regarding the management of thoracic aortic diseases. Especially in dissection and aneurysm management, TEVAR has established its role as the treatment of choice. However, robust evidence is still needed in many aspects of the management of thoracic aortic pathologies.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.,German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Petroula Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christian-Alexander Behrendt
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - George Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - E Sebastian Debus
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Athanasios Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
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Morello F, Santoro M, Fargion AT, Grifoni S, Nazerian P. Diagnosis and management of acute aortic syndromes in the emergency department. Intern Emerg Med 2021; 16:171-181. [PMID: 32358680 DOI: 10.1007/s11739-020-02354-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 12/12/2022]
Abstract
Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.
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Affiliation(s)
- Fulvio Morello
- S.C.U. Medicina d'Urgenza, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, Torino, Italy
| | - Marco Santoro
- S.C.U. Medicina d'Urgenza, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
| | | | - Stefano Grifoni
- Department of Emergency Medicine, Careggi University Hospital, Largo Brambilla, 3, 50134, Firenze, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Largo Brambilla, 3, 50134, Firenze, Italy.
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Self-navigated 3D whole-heart MRA for non-enhanced surveillance of thoracic aortic dilation: A comparison to CTA. Magn Reson Imaging 2020; 76:123-130. [PMID: 33309920 DOI: 10.1016/j.mri.2020.12.003] [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] [Received: 10/20/2020] [Revised: 12/02/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To prospectively compare image quality and reliability of a non-contrast, self-navigated 3D whole-heart magnetic resonance angiography (MRA) sequence with contrast-enhanced computed tomography angiography (CTA) for sizing of thoracic aortic aneurysm (TAA). METHODS Self-navigated 3D whole-heart 1.5 T MRA was performed in 20 patients (aged 67 ± 9 years, 75% male) for sizing of TAA; a subgroup of 18 (90%) patients underwent additional contrast-enhanced CTA on the same day. Subjective image quality was scored according to a 4-point Likert scale and ratings between observers were compared by Cohen's Kappa statistics. For MRA, subjective motion blurring and signal inhomogeneity was rated according to a 3-point scale, respectively. Objective signal inhomogeneity of MRA was quantified as standard deviation of the voxel intensities in a circular region of interest (ROI) placed in the ascending aorta divided by their mean value. Continuous MRA and CTA measurements were analyzed with regression and Bland-Altman analysis. RESULTS Overall subjective image quality as rated by two observers was 1 [interquartile range (IQR) 1-2] for self-navigated MRA and 1.5 [IQR 1-2] for CTA (p = 0.717). For MRA, perfect inter-observer agreement was found regarding presence of artefacts and subjective image sharpness (κ = 1). Subjective signal inhomogeneity agreed moderately between the observers (κ = 0.58, p = 0.007), however, it correlated strongly with objectively quantified inhomogeneity of the blood pool signal (r = 0.78, p < 0.0001). Maximum diameters of TAA as measured by self-navigated MRA and CTA showed very strong correlation (r = 0.99, p < 0.0001) without significant inter-method bias (bias -0.03 mm, lower and upper limit of agreement -0.74 and 0.68 mm, p = 0.749). Inter-observer correlation of aortic aneurysm as measured by MRA was very strong (r = 0.96) without significant bias (p = 0.695). CONCLUSION Self-navigated 3D whole-heart MRA enables reliable contrast- and radiation free aortic dilation surveillance without significant difference to standardized CTA while providing predictable acquisition time and offering excellent image quality.
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Chen PA, Huang E, Chen KT, Chen YC, Huang YL, Chuo CC, Wu FZ, Wu MT. Comparison of four contrast medium delivery protocols in low-iodine and low-radiation dose CT angiography of the aorta. Clin Radiol 2020; 75:797.e9-797.e19. [DOI: 10.1016/j.crad.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
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Paulraj S, Ashok Kumar P, Uprety A, Chaudhuri D. Aortic dissection and multimodality imaging. Echocardiography 2020; 37:1485-1487. [DOI: 10.1111/echo.14820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/16/2023] Open
Affiliation(s)
- Shweta Paulraj
- Department of Medicine SUNY Upstate Medical University Syracuse New YorkUSA
| | | | - Ajay Uprety
- Division of Cardiology SUNY Upstate Medical University Syracuse New YorkUSA
| | - Debanik Chaudhuri
- Division of Cardiology SUNY Upstate Medical University Syracuse New YorkUSA
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30
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Direct measurement of ascending aortic diameter by intraoperative caliper assessment. J Thorac Cardiovasc Surg 2020; 161:e143-e146. [PMID: 32891453 DOI: 10.1016/j.jtcvs.2020.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 12/29/2022]
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Commentary: Magnetic resonance imaging for diagnosing vascular pathology. JTCVS Tech 2020; 3:59-60. [PMID: 34317813 PMCID: PMC8302987 DOI: 10.1016/j.xjtc.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022] Open
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Snel GJH, Hernandez LM, Slart RHJA, Nguyen CT, Sosnovik DE, van Deursen VM, Dierckx RAJO, Velthuis BK, Borra RJH, Prakken NHJ. Validation of thoracic aortic dimensions on ECG-triggered SSFP as alternative to contrast-enhanced MRA. Eur Radiol 2020; 30:5794-5804. [PMID: 32506262 PMCID: PMC7554008 DOI: 10.1007/s00330-020-06963-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/07/2020] [Accepted: 05/15/2020] [Indexed: 01/16/2023]
Abstract
Objectives Assessment of thoracic aortic dimensions with non-ECG-triggered contrast-enhanced magnetic resonance angiography (CE-MRA) is accompanied with motion artefacts and requires gadolinium. To avoid both motion artefacts and gadolinium administration, we evaluated the similarity and reproducibility of dimensions measured on ECG-triggered, balanced steady-state free precession (SSFP) MRA as alternative to CE-MRA. Methods All patients, with varying medical conditions, referred for thoracic aortic examination between September 2016 and March 2018, who underwent non-ECG-triggered CE-MRA and SSFP-MRA (1.5 T) were retrospectively included (n = 30). Aortic dimensions were measured after double-oblique multiplanar reconstruction by two observers at nine landmarks predefined by literature guidelines. Image quality was scored at the sinus of Valsalva, mid-ascending aorta and mid-descending aorta by semi-automatically assessing the vessel sharpness. Results Aortic dimensions showed high agreement between non-ECG-triggered CE-MRA and SSFP-MRA (r = 0.99, p < 0.05) without overestimation or underestimation of aortic dimensions in SSFP-MRA (mean difference, 0.1 mm; limits of agreement, − 1.9 mm and 1.9 mm). Intra- and inter-observer variabilities were significantly smaller with SSFP-MRA for the sinus of Valsalva and sinotubular junction. Image quality of the sinus of Valsalva was significantly better with SSFP-MRA, as fewer images were of impaired quality (3/30) than in CE-MRA (21/30). Reproducibility of dimensions was significantly better in images scored as good quality compared to impaired quality in both sequences. Conclusions Thoracic aortic dimensions measured on SSFP-MRA and non-ECG-triggered CE-MRA were similar. As expected, SSFP-MRA showed better reproducibility close to the aortic root because of lesser motion artefacts, making it a feasible non-contrast imaging alternative. Key Points • SSFP-MRA provides similar dimensions as non-ECG-triggered CE-MRA. • Intra- and inter-observer reproducibilities improve for the sinus of Valsalva and sinotubular junction with SSFP-MRA. • ECG-triggered SSFP-MRA shows better image quality for landmarks close to the aortic root in the absence of cardiac motion. Electronic supplementary material The online version of this article (10.1007/s00330-020-06963-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G J H Snel
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - L M Hernandez
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - R H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, University of Twente, Dienstweg 1, 7522 ND, Enschede, The Netherlands
| | - C T Nguyen
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
| | - D E Sosnovik
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
- Division of Health Sciences and Technology, Harvard-MIT, 7 Massachusetts Avenue, Cambridge, MA, 02139, USA
| | - V M van Deursen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - R A J O Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - B K Velthuis
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - R J H Borra
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - N H J Prakken
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Evangelista A, Maldonado G, Gruosso D, Gutiérrez L, Granato C, Villalva N, Galian L, González-Alujas T, Teixido G, Rodríguez-Palomares J. The current role of echocardiography in acute aortic syndrome. Echo Res Pract 2019; 6:R53-R63. [PMID: 30921764 PMCID: PMC6454227 DOI: 10.1530/erp-18-0058] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/06/2019] [Indexed: 01/16/2023] Open
Abstract
Acute aortic syndrome (AAS) comprises a range of interrelated conditions caused by disruption of the medial layer of the aortic wall, including aortic dissection, intramural haematoma and penetrating aortic ulcer. Since mortality from AAS is high, a prompt and accurate diagnosis using imaging techniques is paramount. Both transthoracic (TTE) and transoesophageal echocardiography (TEE) are useful in the diagnosis of AAS. TTE should be the first imaging technique to evaluate patients with thoracic pain in the emergency room. Should AAS be suspected, contrast administration is recommended when images are not definitive. TEE allows high-quality images in thoracic aorta. The main drawback of this technique is that it is semi-invasive and the presence of a blind area that limits visualisation of the distal ascending aorta near. TEE identifies the location and size of the entry tear, secondary communications, true lumen compression and the dynamic flow pattern of false lumen. Although computed tomography (CT) is the most used imaging technique in the diagnosis of AAS, echocardiography offers complementary information relevant for its management. The best imaging strategy for appropriately diagnosing and assessing AAS is to combine CT, mainly ECG-gated contrast-enhanced CT, and TTE. Currently, TEE tends to be carried out in the operating theatre immediately before surgical or endovascular therapy and in monitoring their results. The aims of this review are to establish the current role of echocardiography in the diagnosis and management of AAS based on its advantages and limitations.
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Affiliation(s)
- Arturo Evangelista
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Giuliana Maldonado
- Cardiovascular Imaging Department, Instituto del Corazon, Quironsalud Teknon, Barcelona, Spain
| | - Domenico Gruosso
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Laura Gutiérrez
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Chiara Granato
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Nicolas Villalva
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Laura Galian
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Teresa González-Alujas
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Gisela Teixido
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Jose Rodríguez-Palomares
- Cardiovascular Imaging Department, University Hospital Vall d'Hebron, CIBER-CV, Barcelona, Spain
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IgG4-aortitis among thoracic aortic aneurysms. Heart 2019; 105:1583-1589. [DOI: 10.1136/heartjnl-2018-314499] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 12/13/2022] Open
Abstract
ObjectiveThe incidence of aortitis in patients with thoracic aortic diseases is not well established. The aim of this study was to analyse the frequency and clinical course of patients with aortitis in a surgical series.Methods320 consecutive patients with ascending aorta/aortic arch aneurysm or acute aortic syndrome who underwent surgery from 2012 to 2017 in a single tertiary referral hospital were retrospectively reviewed. Epidemiological data, clinical course and variables related to diagnosis, treatment and follow-up were collected from patients with histologically proven aortitis.ResultsFrom 320 examined aortic samples, 279 (87.2%) thoracic aneurysms and 41 acute aortic syndromes (12.8%), 9 (2.8%) were aortitis: 3 cases of Takayasu’s arteritis, 3 of IgG4-related aortitis, 2 of giant cell, and 1 classified as idiopathic. Median age at surgery was 53.4 (51–69.2) years and six cases were female. Seven patients presented with non-specific symptoms and the diagnosis was made at pathology. Surgery was elective in eight patients and emergent in one case of IgG4-related aortitis. 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) was performed for disease extension study and as a monitoring technique during the follow-up of five patients, with just one case performed presurgically. All the patients with IgG4-related disease showed extrathoracic aortic involvement. There were no deaths, neither in-hospital nor during the 1.7 years of median follow-up.ConclusionsIn surgically treated thoracic aorta pathology, the frequency of aortitis is low; IgG4-related disease is among the most common aetiologies with a frequency similar to other types of aortitis, such as Takayasu’s and giant cell arteritis, and clinical manifestations are non-specific making presurgical diagnosis difficult. 18F-FDG PET/CT allows a better assessment of disease extension and therapeutic response. Surgery can be successfully performed and corticosteroid therapy ensures a good mid-term follow-up.
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