1
|
Lin Q, Fu Y. Editorial for "Thoracic Aortic Volume as a Predictor of Cardiovascular Events: The Multi-Ethnic Study of Atherosclerosis". J Magn Reson Imaging 2024; 60:114-115. [PMID: 37916959 DOI: 10.1002/jmri.29112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 11/03/2023] Open
Affiliation(s)
- Qianqian Lin
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, Fujian Province, China
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Ying Fu
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, Fujian Province, China
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| |
Collapse
|
2
|
Lee H, Zhou Q, Zhang H, Jin M, Tang X, Li K, Tuoerxun T. Computed Tomography Scan of the Aorta to Predict Type B Aortic Dissection. Thorac Cardiovasc Surg 2024; 72:126-133. [PMID: 37137329 PMCID: PMC10914493 DOI: 10.1055/s-0043-57026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND The purpose of this study is to find the high-risk morphological features in type B aortic dissection (TBAD) population and to establish an early detection model. METHODS From June 2018 to February 2022, 234 patients came to our hospital because of chest pain. After examination and definite diagnosis, we excluded people with previous cardiovascular surgery history, connective tissue disease, aortic arch variation, valve malformation, and traumatic dissection. Finally, we included 49 patients in the TBAD group and 57 in the control group. The imaging data were retrospectively analyzed by Endosize (Therevna 3.1.40) software. The aortic morphological parameters mainly include diameter, length, direct distance, and tortuosity index. Multivariable logistic regression models were performed and systolic blood pressure (SBP), aortic diameter at the left common carotid artery (D3), and length of ascending aorta (L1) were chosen to build a model. The predictive capacity of the models was evaluated through the receiver operating characteristic (ROC) curve analysis. RESULTS The diameters in the ascending aorta and aortic arch are larger in the TBAD group (33.9 ± 5.9 vs. 37.8 ± 4.9 mm, p < 0.001; 28.2 ± 3.9 vs. 31.7 ± 3.0 mm, p < 0.001). The ascending aorta was significantly longer in the TBAD group (80.3 ± 11.7 vs. 92.3 ± 10.6 mm, p < 0.001). Besides, the direct distance and tortuosity index of the ascending aorta in the TBAD group increased significantly (69.8 ± 9.0 vs. 78.7 ± 8.8 mm, p < 0.001; 1.15 ± 0.05 vs. 1.17 ± 0.06, p < 0.05). Multivariable models demonstrated that SBP, aortic diameter at the left common carotid artery (D3), and length of ascending aorta (L1) were independent predictors of TBAD occurrence. Based on the ROC analysis, area under the ROC curve of the risk prediction models was 0.831. CONCLUSION Morphological characteristic including diameter of total aorta, length of ascending aorta, direct distance of ascending aorta, and tortuosity index of ascending aorta are valuable geometric risk factors. Our model shows a good performance in predicting the incidence of TBAD.
Collapse
Affiliation(s)
- Han Lee
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, Jiangsu, China
| | - Haitao Zhang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Min Jin
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - XinLong Tang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Kai Li
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Tayierjiang Tuoerxun
- Department of Cardiothoracic Surgery, Nanjing University, Nanjing, Jiangsu, China
| |
Collapse
|
3
|
Zhang X, Peng Y, Li G, Li J, Luo M, Che Y, Zheng L, Anzai H, Ohta M, Shu C. Elongation of the proximal descending thoracic aorta and associated hemodynamics increase the risk of acute type B aortic dissection. Technol Health Care 2024; 32:765-777. [PMID: 37545271 DOI: 10.3233/thc-230194] [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: 08/08/2023]
Abstract
BACKGROUND Acute type B aortic dissection (ATBAD) is a life-threatening aortic disease. However, little information is available on predicting and understanding of ATBAD. OBJECTIVE The study sought to explore the underlying mechanism of ATBAD by analyzing the morphological and hemodynamic characteristics related to aortic length. METHODS The length and tortuosity of the segment and the whole aorta in the ATBAD group (n= 163) and control group (n= 120) were measured. A fixed anatomic landmark from the distal of left subclavian artery (LSA) to the superior border of sixth thoracic vertebra was proposed as the proximal descending thoracic aorta (PDTA), and the dimensionless parameter, length ratio, was introduced to eliminate the individual differences. The significant morphological parameters were filtrated and the associations between parameters were investigated using statistical approaches. Furthermore, how aortic morphology influenced ATBAD was explored based on idealized aortic models and hemodynamic-related metrics. RESULTS The PDTA length was significantly increased in the ATBAD group compared with the control group and had a strong positive correlation with the whole aortic length (r= 0.89). The length ratio (LR2) and tortuosity (T2) of PDTA in the ATBAD group were significantly increased (0.15 ± 0.02 vs 0.12 ± 0.02 and 1.73 ± 0.48 vs 1.50 ± 0.36; P< 0.001), and LR2 was positive correlation with T2 (r= 0.73). In receiver-operating curve analysis, the area under the curve was 0.835 for LR2 and 0.641 for T2. Low and oscillatory shear (LOS) was positive correlation with LR2, and the elevated LOS occurred in the distal of LSA. CONCLUSION Elongation of PDTA is associated with ATBAD, and the length ratio is a novel predictor. Elongated PDTA induced more aggressive hemodynamic forces, and high LOS regions may correspond to the entry tear location. The synergy of the morphological variation and aggressive hemodynamics creates contributory conditions for ATBAD.
Collapse
Affiliation(s)
- Xuelan Zhang
- School of Mathematics and Physics, University of Science and Technology Beijing, Beijing, China
- School of Energy and Environmental Engineering, University of Science and Technology Beijing, Beijing, China
| | - Yuan Peng
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Gaoyang Li
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Jiehua Li
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mingyao Luo
- Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yue Che
- School of Mathematics and Physics, University of Science and Technology Beijing, Beijing, China
| | - Liancun Zheng
- School of Mathematics and Physics, University of Science and Technology Beijing, Beijing, China
| | - Hitomi Anzai
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Makoto Ohta
- Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Chang Shu
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| |
Collapse
|
4
|
Hui DS, Chen EP, DeAnda A, Girardi LN, Kim KM, Woo YJ, Tseng EE, Preventza O. Perspectives on the 2022 joint guidelines on the diagnosis and management of aortic disease. J Thorac Cardiovasc Surg 2023; 166:1413-1417. [PMID: 37543165 DOI: 10.1016/j.jtcvs.2023.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Dawn S Hui
- Department of Cardiothoracic Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Tex.
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Abe DeAnda
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, The University of Texas Medical Branch-Galveston, Galveston, Tex
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Tex
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Elaine E Tseng
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, Calif
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| |
Collapse
|
5
|
Ostberg NP, Zafar MA, Mukherjee SK, Ziganshin BA, Elefteriades JA. A machine learning approach for predicting complications in descending and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2023; 166:1011-1020.e3. [PMID: 35120761 DOI: 10.1016/j.jtcvs.2021.12.045] [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: 07/31/2020] [Revised: 11/30/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To use machine learning to predict rupture, dissection, and all-cause mortality for patients with descending and thoracoabdominal aortic aneurysms in an effort to improve on diameter-based surgical intervention criteria. METHODS Retrospective data from 1083 patients with descending aortic diameters 3.0 cm or greater were collected, with a mean follow-up time of 3.52 years and an average descending diameter of 4.13 cm. Six machine learning classifiers were trained using 44 variables to predict the occurrence of dissection, rupture, or all-cause mortality within 1, 2, or 5 years of initial patient encounter for a total of 54 (6 × 3 × 3) separate classifiers. Classifier performance was measured using area under the receiver operator curve. RESULTS Machine learning models achieved area under the receiver operator curves of 0.842 to 0.872 when predicting type B dissection, 0.847 to 0.856 when predicting type B dissection or rupture, and 0.820 to 0.845 when predicting type B dissection, rupture, or all-cause mortality. All models consistently outperformed descending aortic diameter across all end points (area under the receiver operator curve = 0.713-0.733). Feature importance inspection showed that other features beyond aortic diameter, such as a history of myocardial infarction, hypertension, and patient sex, play an important role in improving risk prediction. CONCLUSIONS This study provides surgeons with a more accurate, machine learning-based, risk-stratification metric to predict complications for patients with descending aortic aneurysms.
Collapse
Affiliation(s)
- Nicolai P Ostberg
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, Calif
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Sandip K Mukherjee
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
| |
Collapse
|
6
|
Trimarchi S, Mandigers TJ, Bissacco D, Nienaber C, Isselbacher EM, Evangelista A, Suzuki T, Bossone E, Pape LA, Januzzi JL, Harris KM, O'Gara PT, Gilon D, Hutchison S, Patel HJ, Woznicki EM, Montgomery D, Kline-Rogers E, Eagle KA. Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00608-6. [PMID: 37453718 DOI: 10.1016/j.jtcvs.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/21/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years. METHODS IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents. RESULTS Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index. CONCLUSIONS IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.
Collapse
Affiliation(s)
- Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
| | - Tim J Mandigers
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniele Bissacco
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Christoph Nienaber
- Department of Cardiology, Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, Imperial College, London, United Kingdom
| | - Eric M Isselbacher
- Cardiology Department, Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass
| | - Arturo Evangelista
- Cardiology Department, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Toru Suzuki
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | | | - Linda A Pape
- Department of Medicine, University of Massachusetts Hospital, Worcester, Mass
| | - James L Januzzi
- Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Mass; Cardiology Division, Massachusetts General Hospital, Boston, Mass
| | - Kevin M Harris
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minn
| | - Patrick T O'Gara
- Department of Cardiology, Brigham & Women's Hospital, Boston, Mass
| | - Dan Gilon
- Department of Non-invasive Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Stuart Hutchison
- Department of Cardiac Sciences, University of Calgary Medical Centre, Calgary, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | | | | | | | - Kim A Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| |
Collapse
|
7
|
Chou E, Pirruccello JP, Ellinor PT, Lindsay ME. Genetics and mechanisms of thoracic aortic disease. Nat Rev Cardiol 2023; 20:168-180. [PMID: 36131050 DOI: 10.1038/s41569-022-00763-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 11/09/2022]
Abstract
Aortic disease has many forms including aortic aneurysm and dissection, aortic coarctation or abnormalities in aortic function, such as loss of aortic distensibility. Genetic analysis in humans is one of the most important experimental approaches in uncovering disease mechanisms, but the relative infrequency of thoracic aortic disease compared with other cardiovascular conditions such as coronary artery disease has hindered large-scale identification of genetic associations. In the past decade, advances in machine learning technology coupled with large imaging datasets from biobank repositories have facilitated a rapid expansion in our capacity to measure and genotype aortic traits, resulting in the identification of dozens of genetic associations. In this Review, we describe the history of technological advances in genetic discovery and explain how newer technologies such as deep learning can rapidly define aortic traits at scale. Furthermore, we integrate novel genetic observations provided by these advances into our current biological understanding of thoracic aortic disease and describe how these new findings can contribute to strategies to prevent and treat aortic disease.
Collapse
Affiliation(s)
- Elizabeth Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
| | - James P Pirruccello
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Patrick T Ellinor
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA
| | - Mark E Lindsay
- Harvard Medical School, Boston, MA, USA.
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA.
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA.
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
8
|
Yu R, Jin M, Wang Y, Cai X, Zhang K, Shi J, Zhou Z, Fan F, Pan J, Zhou Q, Tang X, Wang D. A machine learning approach for predicting descending thoracic aortic diameter. Front Cardiovasc Med 2023; 10:1097116. [PMID: 36860275 PMCID: PMC9969122 DOI: 10.3389/fcvm.2023.1097116] [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: 11/13/2022] [Accepted: 01/27/2023] [Indexed: 02/15/2023] Open
Abstract
Background To establish models for predicting descending thoracic aortic diameters and provide evidence for selecting the size of the stent graft for TBAD patients. Methods A total of 200 candidates without severe deformation of aorta were included. CTA information was collected and 3D reconstructed. In the reconstructed CTA, a total of 12 cross-sections of peripheral vessels were made perpendicular to the axis of flow of the aorta. Parameters of the cross sections and basic clinical characteristics were used for prediction. The data was randomly split into the training set and the test set in an 8:2 ratio. To fully describe diameters of descending thoracic aorta, three predicted points were set based quadrisection, and a total of 12 models at three predicted points were established using four algorithms included linear regression (LR), support vector machine (SVM), Extra-Tree regression (ETR) and random forest regression (RFR). The performance of models was evaluated by mean square error (MSE) of the prediction value, and the ranking of feature importance was given by Shapley value. After modeling, prognosis of five TEVAR cases and stent oversizing were compared. Results We identified a series of parameters which affect the diameter of descending thoracic aorta, including age, hypertension, the area of proximal edge of superior mesenteric artery, etc. Among four predictive models, all the MSEs of SVM models at three different predicted position were less than 2 mm2, with approximately 90% predicted diameters error less than 2 mm in the test sets. In patients with dSINE, stent oversizing was about 3 mm, while only 1 mm in patients without complications. Conclusion The predictive models established by machine learning revealed the relationship between basic characteristics and diameters of different segment of descending aorta, which help to provide evidence for selecting the matching distal size of the stent for TBAD patients, thereby reducing the incidence of TEVAR complications.
Collapse
Affiliation(s)
- Ronghuang Yu
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Min Jin
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China,Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Yaohui Wang
- Shanghai Artificial Intelligence Laboratory, Shanghai, China
| | - Xiujuan Cai
- Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Keyin Zhang
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Jian Shi
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Zeyi Zhou
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Fudong Fan
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Jun Pan
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Qing Zhou
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Xinlong Tang
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China,Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China,*Correspondence: Xinlong Tang,
| | - Dongjin Wang
- Medical School, Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Nanjing University, Nanjing, China,Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China,Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing, China,Dongjin Wang,
| |
Collapse
|
9
|
Li Y, Li Z, Feng J, Feng R, Zhou J, Jing Z. A Novel Solution for Distal Dilation of Chronic Dissection After Repair Involving Visceral Branches: The Road Block Strategy. Front Cardiovasc Med 2022; 9:821260. [PMID: 35355962 PMCID: PMC8959700 DOI: 10.3389/fcvm.2022.821260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/31/2022] [Indexed: 12/02/2022] Open
Abstract
Aim Notwithstanding that unprecedented endovascular progress has been achieved in recent years, it remains unclear what is the best strategy to preserve the blood perfusion of abdominal visceral arteries and promote positive aortic remodeling in patients with distal dilatation of chronic aortic dissection in abdominal visceral part (CADAV) after aortic repair. The present study developed a Road Block Strategy (RBS) to solve this conundrum. Methods and Results This prospective single-center clinical study included patients suffering from symptomatic distal dilatation of CADAV after aortic repair treated with RBS from January 2015 to December 2019 and followed up regularly for at least 2 years. Stent grafts were implanted first to cover distal tears and expand the true lumen. Device embolization was performed to induce proximal and distal segmental false lumen thrombosis (FLT) apart from the level of the ostia of vital branches. Successful RBS was performed in 13 patients. Significant differences were found in maximum true lumen diameter (p < 0.05), blood flow area in false lumen (FL) (p < 0.001), and the ratio of blood lumen to FL area (p < 0.05) between the pre-procedure and the latest follow-up results. No aortic rupture, vital branches occlusion, thoracic and abdominal pain, or death occurred during hospitalization and follow-up. Conclusions Our findings suggest that RBS is feasible in treating distal dilatation of chronic aortic dissection after prior proximal repair, inducing false lumen thrombosis, preventing deterioration of aortic dissection, and maintaining the patency of abdominal visceral arteries.
Collapse
Affiliation(s)
- Yiming Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Zhenjiang Li
- Department of Vascular Surgery, The First Affiliated Hospital of the Medical School of Zhejiang University, Hangzhou, China
| | - Jiaxuan Feng
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Shanghai General Hospital, Affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Jian Zhou
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
- *Correspondence: Zaiping Jing
| | - Zaiping Jing
- Endovascular Diagnosis and Treatment Center for Aortic Diseases, Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
- Jian Zhou
| |
Collapse
|
10
|
Diletta L, Enrico R, Germano M. Thoracoabdominal aortic aneurysm in connective tissue disorder patients. Indian J Thorac Cardiovasc Surg 2022; 38:146-156. [PMID: 35463710 PMCID: PMC8980973 DOI: 10.1007/s12055-021-01324-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022] Open
Abstract
Connective tissue disorders (CTDs) are a group of genetically triggered diseases in which the primary defect involves collagen and elastin protein assembly with potential vascular degenerations such as thoracoabdominal aortic aneurysm (TAAA) and dissection. These most commonly include Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, and familial thoracic aortic aneurysm and dissection. Open surgical repair represents the standard approach in this specific group of patients. Extensive aortic replacements are generally performed in order to reduce long-term complications caused by the progressive dilatation of the remnant aortic segments. In the last decades, endovascular interventions have emerged as a valid alternative in patients affected by degenerative TAAA. However, in patients with CTD, this approach presents higher rates of reinterventions and postoperative complications with a disputable long-term durability, and it is nowadays performed for very selective indications such as severe comorbidities and urgent/emergent settings. Despite a deeper knowledge of the pathophysiological mechanisms involved in CTD, improvements in medical therapy, and a multidisciplinary approach fully involved in the management of these usually frailer patients, this specific group still represents a challenge. Further dedicated studies addressing mid-term and long-term outcomes in this selected population are needed.
Collapse
Affiliation(s)
- Loschi Diletta
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy
| | - Rinaldi Enrico
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy
| | - Melissano Germano
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy
| |
Collapse
|
11
|
Saddic L, Orosco A, Guo D, Milewicz DM, Troxlair D, Heide RV, Herrington D, Wang Y, Azizzadeh A, Parker SJ. Proteomic analysis of descending thoracic aorta identifies unique and universal signatures of aneurysm and dissection. JVS Vasc Sci 2022; 3:85-181. [PMID: 35280433 PMCID: PMC8914561 DOI: 10.1016/j.jvssci.2022.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/05/2022] [Indexed: 01/05/2023] Open
Abstract
Objective Methods Results Conclusions Diseases of the descending thoracic aorta such as aneurysms and dissections carry a high degree of morbidity and mortality. At present, a complete understanding is still lacking of the genetics that drive these diseases and why some aortic segments dissect in the presence or absence of an aneurysm. We compared and contrasted the whole proteome expression of descending aortas from patients with normal, dissected, aneurysmal, and aneurysmal with dissected pathology aortic tissue. We uncovered potential tissue markers that might serve as future targets for therapy or predictors of disease progression.
Collapse
Affiliation(s)
- Louis Saddic
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif
| | - Amanda Orosco
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Dongchuan Guo
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, Tex
| | - Dianna M. Milewicz
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, Tex
| | - Dana Troxlair
- Department of Pathology, Louisiana State University, New Orleans, La
| | | | - David Herrington
- Department of Cardiovascular Medicine, Wake Forest University, Winston-Salem, NC
| | - Yue Wang
- Department of Electrical and Computer Engineering, Virginia Polytechnic Institute and State University, Arlington, Va
| | - Ali Azizzadeh
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Sarah J. Parker
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
- Correspondence: Sarah J. Parker, PhD, Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, AHSP A9228, 8700 Beverly Blvd, Los Angeles, CA 90048
| |
Collapse
|
12
|
Sharples L, Sastry P, Freeman C, Gray J, McCarthy A, Chiu YD, Bicknell C, McMeekin P, Vallabhaneni SR, Cook A, Vale L, Large S. Endovascular stent grafting and open surgical replacement for chronic thoracic aortic aneurysms: a systematic review and prospective cohort study. Health Technol Assess 2022; 26:1-166. [DOI: 10.3310/abut7744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The management of chronic thoracic aortic aneurysms includes conservative management, watchful waiting, endovascular stent grafting and open surgical replacement. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) study investigates timing and intervention choice.
Objective
To describe pre- and post-intervention management of and outcomes for chronic thoracic aortic aneurysms.
Design
A systematic review of intervention effects; a Delphi study of 360 case scenarios based on aneurysm size, location, age, operative risk and connective tissue disorders; and a prospective cohort study of growth, clinical outcomes, costs and quality of life.
Setting
Thirty NHS vascular/cardiothoracic units.
Participants
Patients aged > 17 years who had existing or new aneurysms of ≥ 4 cm in diameter in the arch, descending or thoracoabdominal aorta.
Interventions
Endovascular stent grafting and open surgical replacement.
Main outcomes
Pre-intervention aneurysm growth, pre-/post-intervention survival, clinical events, readmissions and quality of life; and descriptive statistics for costs and quality-adjusted life-years over 12 months and value of information using a propensity score-matched subsample.
Results
The review identified five comparative cohort studies (endovascular stent grafting patients, n = 3955; open surgical replacement patients, n = 21,197). Pooled short-term all-cause mortality favoured endovascular stent grafting (odds ratio 0.71, 95% confidence interval 0.51 to 0.98; no heterogeneity). Data on survival beyond 30 days were mixed. Fewer short-term complications were reported with endovascular stent grafting. The Delphi study included 20 experts (13 centres). For patients with aneurysms of ≤ 6.0 cm in diameter, watchful waiting was preferred. For patients with aneurysms of > 6.0 cm, open surgical replacement was preferred in the arch, except for elderly or high-risk patients, and in the descending aorta if patients had connective tissue disorders. Otherwise endovascular stent grafting was preferred. Between 2014 and 2018, 886 patients were recruited (watchful waiting, n = 489; conservative management, n = 112; endovascular stent grafting, n = 150; open surgical replacement, n = 135). Pre-intervention death rate was 8.6% per patient-year; 49.6% of deaths were aneurysm related. Death rates were higher for women (hazard ratio 1.79, 95% confidence interval 1.25 to 2.57; p = 0.001) and older patients (age 61–70 years: hazard ratio 2.50, 95% confidence interval 0.76 to 5.43; age 71–80 years: hazard ratio 3.49, 95% confidence interval 1.26 to 9.66; age > 80 years: hazard ratio 7.01, 95% confidence interval 2.50 to 19.62; all compared with age < 60 years, p < 0.001) and per 1-cm increase in diameter (hazard ratio 1.90, 95% confidence interval 1.65 to 2.18; p = 0.001). The results were similar for aneurysm-related deaths. Decline per year in quality of life was greater for older patients (additional change –0.013 per decade increase in age, 95% confidence interval –0.019 to –0.007; p < 0.001) and smokers (additional change for ex-smokers compared with non-smokers 0.003, 95% confidence interval –0.026 to 0.032; additional change for current smokers compared with non-smokers –0.034, 95% confidence interval –0.057 to –0.01; p = 0.004). At the time of intervention, endovascular stent grafting patients were older (age difference 7.1 years; 95% confidence interval 4.7 to 9.5 years; p < 0.001) and more likely to be smokers (75.8% vs. 66.4%; p = 0.080), have valve disease (89.9% vs. 71.6%; p < 0.0001), have chronic obstructive pulmonary disease (21.3% vs. 13.3%; p = 0.087), be at New York Heart Association stage III/IV (22.3% vs. 16.0%; p = 0.217), have lower levels of haemoglobin (difference –6.8 g/l, 95% confidence interval –11.2 to –2.4 g/l; p = 0.003) and take statins (69.3% vs. 42.2%; p < 0.0001). Ten (6.7%) endovascular stent grafting and 15 (11.1%) open surgical replacement patients died within 30 days of the procedure (p = 0.2107). One-year overall survival was 82.5% (95% confidence interval 75.2% to 87.8%) after endovascular stent grafting and 79.3% (95% confidence interval 71.1% to 85.4%) after open surgical replacement. Variables affecting survival were aneurysm site, age, New York Heart Association stage and time waiting for procedure. For endovascular stent grafting, utility decreased slightly, by –0.017 (95% confidence interval –0.062 to 0.027), in the first 6 weeks. For open surgical replacement, there was a substantial decrease of –0.160 (95% confidence interval –0.199 to –0.121; p < 0.001) up to 6 weeks after the procedure. Over 12 months endovascular stent grafting was less costly, with higher quality-adjusted life-years. Formal economic analysis was unfeasible.
Limitations
The study was limited by small numbers of patients receiving interventions and because only 53% of patients were suitable for both interventions.
Conclusions
Small (4–6 cm) aneurysms require close observation. Larger (> 6 cm) aneurysms require intervention without delay. Endovascular stent grafting and open surgical replacement were successful for carefully selected patients, but cost comparisons were unfeasible. The choice of intervention is well established, but the timing of intervention remains challenging.
Future work
Further research should include an analysis of the risk factors for growth/rupture and long-term outcomes.
Trial registration
Current Controlled Trials ISRCTN04044627 and NCT02010892.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 6. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Linda Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Priya Sastry
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Carol Freeman
- Papworth Trials Unit Collaboration, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Joanne Gray
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Andrew McCarthy
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Yi-Da Chiu
- Papworth Trials Unit Collaboration, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Medical Research Council (MRC) Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - S Rao Vallabhaneni
- Liverpool Vascular & Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
| | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Large
- Department of Cardiac Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
13
|
Peng Y, Zhang X, Li J, Zhang X, He H, Li X, Fang K, Zheng L, Shu C. Enlarged Lumen Volume of Proximal Aortic Segment and Acute Type B Aortic Dissection: A Computer Fluid Dynamics Study of Ideal Aortic Models. Int J Gen Med 2022; 15:535-543. [PMID: 35046712 PMCID: PMC8763263 DOI: 10.2147/ijgm.s343403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background Recent study has revealed that enlarged diameters of the ascending aorta and proximal aortic arch enhance the probability of ATBAD. However, little is understood about the relation to ATBAD. Objective This study explored the differences in proximal aortic segment (PAS) morphology in patients with acute type B aortic dissection (ATBAD), and performed hemodynamic simulations to provide proof of principle. Materials and Methods The morphological characteristics of PAS in the ATBAD group (n = 163) and corresponding segment in the control group (n = 120) were retrospectively measured. The morphological parameters were analyzed using comprehensive statistical approaches. Ridge regression analysis was also performed to determine the association between independent variable and dependent variable. P < 0.01 was considered significant. Idealized aortic models were established based on variables of statistical significance, and hemodynamic simulations were performed to evaluate blood flow changes caused by morphology. Results Diameters at landmarks of PAS were significantly larger in the ATBAD group. The lumen volume (VPAS) of PAS in the ATBAD group was significantly enlarged than that of the control group (124,659.07 ± 34,089.27 mm3 vs 89,796.65 ± 30,334.40 mm3; P < 0.001). Furthermore, the VPAS was positively correlated to diameters. As the VPAS increased, the fluid kinetic energy in PAS enhanced linearly, and time-averaged wall shear stress and oscillatory shear index at the distal area of the left subclavian artery increased significantly. Conclusion In the ATBAD group, the enlarged VPAS and increased diameters of PAS are positively correlated. Meanwhile, the enlarged VPAS leads to more aggressive hemodynamic parameters at the distal area of the left subclavian artery, which may create a contributory condition for ATBAD.
Collapse
Affiliation(s)
- Yuan Peng
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
| | - Xuelan Zhang
- School of Mathematics and Physics, University of Science and Technology Beijing, Beijing, 100083, People’s Republic of China
| | - Jiehua Li
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
| | - Xiaolong Zhang
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
| | - Hao He
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
| | - Xin Li
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
| | - Kun Fang
- Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100037, People’s Republic of China
| | - Liancun Zheng
- School of Mathematics and Physics, University of Science and Technology Beijing, Beijing, 100083, People’s Republic of China
| | - Chang Shu
- Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
- Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100037, People’s Republic of China
- Correspondence: Chang Shu Tel +86-731-85295832 Email
| |
Collapse
|
14
|
Jubouri M, Bashir M, Tan SZCP, Bailey D, Anderson R, Nienaber CA, Coselli JS, Williams I. What is the optimal timing for thoracic endovascular aortic repair in uncomplicated Type B aortic dissection? J Card Surg 2021; 37:993-1001. [PMID: 34967980 DOI: 10.1111/jocs.16190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Uncomplicated Stanford Type B aortic dissection (un-TBAD) is characterized by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimized cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is both safe and effective in the treatment of un-TBAD with improved long-term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified. AIMS This review critically addresses current state-of-the-art comparing TEVAR with OMT and corresponding clinical outcomes for un-TBAD based on timing of intervention. METHODS We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection. RESULTS TEVAR has proven to be a safe and effective treatment for un-TBAD in combination with OMT through comparable survival outcomes, improved aortic remodeling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un-TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention. CONCLUSIONS Further research is required into both short- and long-term outcomes of TEVAR in addition to its optimal therapeutic window for un-TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold-standard intervention for un-TBAD with definitive timeframe guidelines.
Collapse
Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales, Cardiff, Wales, UK
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Division of Cardiothoracic Surgery, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St Luke's-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| |
Collapse
|
15
|
Sun L, Li J, Liu Z, Li Q, He H, Li X, Li M, Wang T, Wang L, Peng Y, Wang H, Shu C. Aortic arch type, a novel morphological indicator and the risk for acute type B aortic dissection. Interact Cardiovasc Thorac Surg 2021; 34:446-452. [PMID: 34935037 PMCID: PMC8860428 DOI: 10.1093/icvts/ivab359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/05/2021] [Accepted: 11/20/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Aortic arch type is a readily recognizable and obtainable morphological feature of the aorta that does not require complex measurements. The goal of this study was to evaluate whether aortic arch type is a comparable and alternative morphological parameter for predicting acute type B aortic dissection (aTBAD) by comparing the prognostic value of the aortic arch type with that of other morphological parameters such as aortic length, angulation and tortuosity index.
METHODS The patients with aTBAD (n = 216) were matched 1:1 with a control group (n = 263) by propensity score matching. The morphological data of the ascending aorta and the aortic arch, which included diameter, length, angulation and tortuosity index, were collected on a three-dimensional aortic model using 3mensio Vascular software. The aortic arch type was identified by the vertical distance from the origin of the brachiocephalic trunk to the top of the arch. The binary logistic regression models were analysed to determine the independent geometric variables related to the aTBAD. The nonparametric approach was performed to assess whether there were statistical differences between the area under the receiver operating characteristic curves (AUC) of the models. RESULTS After propensity score matching, 151 matched pairs of patients were selected. The diameters at the sinotubular junction and the mid-ascending aorta, the ascending aorta length and the ascending aorta angulation in the aTBAD group were significantly greater than those of the controls. Compared with the control group, the diameters at the proximal aortic arch, mid-aortic arch and distal aortic arch, the angulation and the tortuosity index of the aortic arch were significantly greater in the aTBAD group. The proportion of the type III arch in the patients with aTBAD is higher than that of the type I arch and the type II arch (χ2 = 70.187; P < 0.001). Binary logistic regression analysis showed that the diameter at the mid-aortic arch, the ascending aorta length, the aortic arch angulation and the tortuosity index were independently related to the aTBAD with an AUC value of 0.887. Another binary logistic regression analysis indicated that the diameter at the mid-aortic arch and the aortic arch type were independent correlative variables associated with the aTBAD with an AUC of 0.874. No significant difference was observed in the prognostic value of receiver operating characteristic curves between the 2 models (P = 0.716). CONCLUSIONS The type III arch, which has the characteristics of aortic elongation, incremental angulation and tortuosity index, is a comparable and alternative identifier for patients at high risk for aTBAD.
Collapse
Affiliation(s)
- Likun Sun
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Jiehua Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Zhenyu Liu
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Quanming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Hao He
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Xin Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Ming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Tun Wang
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Lunchang Wang
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Yuan Peng
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Hui Wang
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, China.,Vascular Disease Institute of Central South University, Changsha, China.,Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| |
Collapse
|
16
|
Sun L, Li J, Wang L, Li Q, He H, Li X, Li M, Wang T, Zhao C, Zhang X, Shu C. Aortic Geometric Alteration Associated With Acute Type B Aortic Dissection: Angulation, Tortuosity, and Arch Type. Front Physiol 2021; 12:708651. [PMID: 34489729 PMCID: PMC8417830 DOI: 10.3389/fphys.2021.708651] [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: 05/13/2021] [Accepted: 07/13/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Acute type B aortic dissection is a highly serious aortic pathology. Aortic geometric parameters may be useful variables related to the occurrence of acute type B aortic dissection (aTBAD). The aim of the study is to delineate the alteration in aortic geometric parameters and analyze the specific geometric factors associated with aTBAD. Methods: The propensity score matching method was applied to control confounding factors. The aortic diameter, length, angulation, tortuosity, and type of aortic arch of the aTBAD and control group were retrospectively analyzed via three-dimensional computed tomography imaging created by the 3mensio software (version 10.0, Maastricht, The Netherlands). The geometric variables of true lumen and false lumen in the descending aorta were measured to estimate the severity of aortic dissection. Multivariable logistic regression models were used to investigate the significant and specific factors associated with aTBAD occurrence. The area under the receiver operating characteristic curve (AUC) was used to estimate the performance of the model. Results: After propensity score matching, 168 matched pairs of patients were selected. The ascending aorta and aortic arch diameters were dilated, and the ascending aorta and total aorta lengths were elongated in aTBAD group significantly (P < 0.001). The ascending aorta and aortic arch angulations in the aTBAD group were sharper than those of the controls (P = 0.01, P < 0.001, respectively). The aortic arch and total aorta tortuosities were significantly higher in the aTBAD group (P = 0.001, P < 0.001, respectively). There were more type III arch patients in the aTBAD group than the controls (67.9 vs. 22.6%). The true lumen angulation was sharper than that in the false lumen (P < 0.01). The true lumen tortuosity was significantly lower than that in the false lumen (P < 0.001). The multivariable models identified that aortic arch angulation, tortuosity, and type III arch were independent and specific geometric factors associated with aTBAD occurrence. The AUC of the multivariable models 1, 2, 3 were 0.945, 0.953, and 0.96, respectively. Conclusions: The sharper angulation and higher tortuosity of aortic arch and type III arch were the geometric factors associated with aTBAD in addition to the ascending aorta elongation and aortic arch dilation. The angulation and tortuosity of the true and false lumens may carry significant clinical implications for the treatment and prognosis of aTBAD.
Collapse
Affiliation(s)
- Likun Sun
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Jiehua Li
- 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
| | - Quanming 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
| | - Xin Li
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China
| | - Ming Li
- 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
| | - Chenglei Zhao
- 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
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,Vascular Disease Institute, Central South University, Changsha, China.,Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| |
Collapse
|
17
|
Lescan M. Type B dissection risk assessment-can aortic flow visualization solve the morphological puzzle? Eur J Cardiothorac Surg 2021; 61:140-141. [PMID: 34387662 DOI: 10.1093/ejcts/ezab346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| |
Collapse
|
18
|
Sun L, Li X, Li Q, Li M, He H, Wang T, Li J, Shu C. Morphological Features of Aortic Arch Predicting the Risk for Acute Type B Aortic Dissection. World J Surg 2021; 45:3458-3466. [PMID: 34302195 DOI: 10.1007/s00268-021-06247-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of the study is to elucidate the changes in aortic morphological parameters and identify the specific geometric risk factors associated with aTBAD. METHODS A total of 167 patients in aTBAD group and 196 subjects in control group were enrolled in the study. The aortic morphological data were retrospectively analyzed by 3mensio Vascular software. The aortic morphological parameters include diameter, length, angulation, tortuosity and the type of aortic arch. Multivariable logistic regression models were developed to identify the significant predictors associated with the angulation, tortuosity and aortic arch type. The predictive capacity of the models was evaluated through the receiver operating characteristic (ROC) curve analysis. RESULTS The diameters in the ascending aorta and aortic arch and the lengths in the ascending aorta and total aorta were significantly greater in aTBAD group. Besides, the angulation of the ascending aorta and aortic arch in aTBAD group increased significantly. The tortuosity of aortic arch and total aorta was significantly higher in aTBAD group. The prevalence of type III arch in aTBAD group was significantly higher than that in the controls. Multivariable models demonstrated that aortic arch angulation, tortuosity and type III arch were independent geometric predictors of aTBAD occurrence. Based on the ROC analysis, AUC of the risk prediction models was 0.977, 0.958 and 0.945, respectively. CONCLUSIONS Besides the enlargement of the ascending aorta and aortic arch, incremental aortic arch angulation, tortuosity and type III arch configuration are valuable geometric risk factors that could enhance aTBAD incidence.
Collapse
Affiliation(s)
- Likun Sun
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Vascular Disease Institute of Central South University, Changsha, 410011, China
| | - Xin Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Vascular Disease Institute of Central South University, Changsha, 410011, China
| | - Quanming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Vascular Disease Institute of Central South University, Changsha, 410011, China
| | - Ming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Vascular Disease Institute of Central South University, Changsha, 410011, China
| | - Hao He
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Vascular Disease Institute of Central South University, Changsha, 410011, China
| | - Tun Wang
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Vascular Disease Institute of Central South University, Changsha, 410011, China
| | - Jiehua Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Vascular Disease Institute of Central South University, Changsha, 410011, China
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China. .,Vascular Disease Institute of Central South University, Changsha, 410011, China. .,Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, China.
| |
Collapse
|
19
|
Raman microspectroscopy and Raman imaging reveal biomarkers specific for thoracic aortic aneurysms. CELL REPORTS MEDICINE 2021; 2:100261. [PMID: 34095874 PMCID: PMC8149374 DOI: 10.1016/j.xcrm.2021.100261] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 01/29/2021] [Accepted: 04/06/2021] [Indexed: 01/30/2023]
Abstract
Aortic rupture and dissection are life-threatening complications of ascending thoracic aortic aneurysms (aTAAs), and risk assessment has been largely based on the monitoring of lumen size enlargement. Temporal changes in the extracellular matrix (ECM), which has a critical impact on aortic remodeling, are not routinely evaluated, and cardiovascular biomarkers do not exist to predict aTAA formation. Here, Raman microspectroscopy and Raman imaging are used to identify spectral biomarkers specific for aTAAs in mice and humans by multivariate data analysis (MVA). Multivariate curve resolution-alternating least-squares (MCR-ALS) combined with Lasso regression reveals elastic fiber-derived (Ce1) and collagen fiber-derived (Cc6) components that are significantly increased in aTAA lesions of murine and human aortic tissues. In particular, Cc6 detects changes in amino acid residues, including phenylalanine, tyrosine, tryptophan, cysteine, aspartate, and glutamate. Ce1 and Cc6 may serve as diagnostic Raman biomarkers that detect alterations of amino acids derived from aneurysm lesions. Label-free Raman imaging of human/murine ascending thoracic aortic aneurysm (aTAA) Multivariate analysis of Raman spectra allows detection of aTAA molecular features Identification of spectral biomarkers for aTAA in elastic and collagen fibers Alterations in amino acid spectra correlate with aTAA formation
Collapse
|
20
|
Qi X, Wang F, Chun C, Saldarriaga L, Jiang Z, Pruitt EY, Arnaoutakis GJ, Upchurch GR, Jiang Z. A validated mouse model capable of recapitulating the protective effects of female sex hormones on ascending aortic aneurysms and dissections (AADs). Physiol Rep 2020; 8:e14631. [PMID: 33242364 PMCID: PMC7690909 DOI: 10.14814/phy2.14631] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 09/28/2020] [Accepted: 10/07/2020] [Indexed: 12/19/2022] Open
Abstract
Fewer females develop AADs (ascending aortic aneurysms and dissections) and the reasons for this protection remain poorly understood. The present study seeks to develop a mouse model that may be utilized to address this sexual dimorphism. Adult normolipidemic mice were challenged with BAPN (β-aminopropionitrile), AngII (angiotensin II), or BAPN + AngII. An initial protocol optimization found that 0.2% BAPN in drinking water plus AngII-infusion at 1,000 ng kg-1 min-1 produced favorable rates of AAD rupture (~50%) and dilation (~40%) in 28 days. Using these dosages, further experiments revealed that BAPN is toxic to naïve mature aortas and it acted synergistically with AngII to promote aortic tears and dissections. BAPN + AngII provoked early infiltration of myeloid cells and subsequent recruitment of lymphoid cells to the aortic wall. AADs established with BAPN + AngII, but not AngII alone, continued to expand after the cessation of AngII-infusion. This indefinite growth precipitated a 61% increase in the AAD diameter in 56 days. More importantly, with the optimized protocol, significant differences in AAD dilation (p = .012) and medial degeneration (p = .036) were detected between male and female mice. Treatment of ovariectomized mice with estradiol protected AAD formation (p = .014). In summary, this study developed a powerful mouse AAD model that can be used to study the sexual dimorphism in AAD formation.
Collapse
Affiliation(s)
- Xiaoyan Qi
- Division of Vascular Surgery and Endovascular TherapyUniversity of Florida College of MedicineGainesvilleFLUSA
- Institute of Cardiovascular DiseaseUniversity of South ChinaHengyangChina
| | - Fen Wang
- Division of Vascular Surgery and Endovascular TherapyUniversity of Florida College of MedicineGainesvilleFLUSA
| | - Changzoon Chun
- Division of Vascular Surgery and Endovascular TherapyUniversity of Florida College of MedicineGainesvilleFLUSA
| | - Lennon Saldarriaga
- Division of Vascular Surgery and Endovascular TherapyUniversity of Florida College of MedicineGainesvilleFLUSA
| | - Zhisheng Jiang
- Institute of Cardiovascular DiseaseUniversity of South ChinaHengyangChina
| | - Eric Y. Pruitt
- Division of Vascular Surgery and Endovascular TherapyUniversity of Florida College of MedicineGainesvilleFLUSA
| | - George J. Arnaoutakis
- Division of Vascular Surgery and Endovascular TherapyUniversity of Florida College of MedicineGainesvilleFLUSA
- Division of Thoracic and Cardiovascular SurgeryUniversity of Florida College of MedicineGainesvilleFLUSA
| | - Gilbert R. Upchurch
- Division of Vascular Surgery and Endovascular TherapyUniversity of Florida College of MedicineGainesvilleFLUSA
| | - Zhihua Jiang
- Division of Vascular Surgery and Endovascular TherapyUniversity of Florida College of MedicineGainesvilleFLUSA
| |
Collapse
|
21
|
Shah A, Gupta N, Gewertz BL, Azizzadeh A. TEVAR for high risk patients with uncomplicated type B aortic dissection: a paradigm shift. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01450-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
22
|
Lomazzi C, Trimarchi S, Pyeritz RE, Bekeredjian R, Erlich MP, Braverman AC, Pacini D, Shermerhorn M, Myrmel T, Eagle KA. Lesson learned from the International Registry of Acute Aortic Dissection (IRAD). ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01452-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
23
|
Cao L, Lu W, Ge Y, Wang X, He Y, Sun G, Liu J, Liu X, Jia X, Xiong J, Ma X, Zhang H, Wang L, Guo W. Altered aortic arch geometry in patients with type B aortic dissection. Eur J Cardiothorac Surg 2020; 58:714-721. [PMID: 32303067 DOI: 10.1093/ejcts/ezaa102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 01/22/2023] Open
Abstract
Abstract
OBJECTIVES
This study aims to evaluate differences in proximal aorta geometry and identify specific anatomical predictors of type B aortic dissection (TBAD).
METHODS
We evaluated computed tomographic angiograms of controls (n = 185) and patients with acute TBAD (n = 173). Using propensity score matching, we created 2 groups of 127 patients. 3mensio Vascular software was used to analyse the computed tomographic angiograms and measure the diameter, length, tortuosity index and angulation of the proximal aorta (divided into ascending aorta and aortic arch). Tortuosity index was calculated by dividing the centre lumen line length of the aortic segment by its shortest length. Angulation was measured by the centre lumen line ‘tangent line angle’. Two independent multivariable models identified significant anatomical associations regarding the tortuosity and angulation geometry.
RESULTS
Aortic diameter and ascending aorta and aortic arch lengths in TBAD increased significantly. The aortic arch tortuosity was significantly higher in the TBAD group (P < 0.001), with no difference regarding the ascending aorta (P = 0.11). Ascending aorta and aortic arch angulation were significantly higher in the TBAD group (P = 0.01, P < 0.001, respectively). Multivariable analyses showed that increased aortic arch tortuosity and angulation were significant predictors of the development of TBAD [odds ratio (OR) 1.91, 95% confidence interval (CI) 1.40–2.59; P < 0.001 and OR 1.08, 95% CI 1.04–1.12; P < 0.001], respectively.
CONCLUSIONS
In addition to proximal aorta dilation and elongation, we identified increased aortic arch tortuosity and angulation as possible specific predictors of TBAD.
Collapse
Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
- Department of General Surgery, Chinese PLA No. 983 Hospital, Tianjin, China
| | - Weihang Lu
- Department of General Surgery, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xinhao Wang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yuan He
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Guoyi Sun
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jie Liu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xiaoping Liu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xin Jia
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jiang Xiong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xiaohui Ma
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Lijun Wang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
24
|
Heuts S, Adriaans BP, Rylski B, Mihl C, Bekkers SCAM, Olsthoorn JR, Natour E, Bouman H, Berezowski M, Kosiorowska K, Crijns HJGM, Maessen JG, Wildberger J, Schalla S, Sardari Nia P. Evaluating the diagnostic accuracy of maximal aortic diameter, length and volume for prediction of aortic dissection. Heart 2020; 106:892-897. [PMID: 32152004 DOI: 10.1136/heartjnl-2019-316251] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Management of thoracic aortic aneurysms (TAAs) comprises regular diameter follow-up until the indication criterion for prophylactic surgery is reached. However, this approach is unable to predict the majority of acute type A aortic dissections (ATAADs). The current study aims to evaluate the diagnostic accuracy of ascending aortic diameter, length and volume for occurrence of ATAAD. METHODS This two-centre observational cohort study retrospectively screened 477 consecutive patients who presented with ATAAD between 2009 and 2018. Of those, 25 (5.2%) underwent CT angiography (CTA) within 2 years before dissection onset. Aortic diameter, length and volume of these patients ('pre-ATAAD') were compared with those of TAA controls (n=75). Receiver operating curve analysis was performed to evaluate the predictive accuracy of the three different measurements. RESULTS 96% of patients with pre-ATAAD did not meet the surgical diameter threshold of 55 mm before dissection onset. Maximal aortic diameters (45 (40-49) mm vs 46 (44-49) mm, p=0.075) and volume (126 (95-157) cm3 vs 124 (102-136) cm3, p=0.909) were comparable between patients with pre-ATAAD and TAA controls. Conversely, ascending aortic length (84±9 mm vs 90±16 mm, p=0.031) was significantly larger in patients with pre-ATAAD. All three parameters had an area under the curve of >0.800. At the 55 mm cut-off point, the maximal diameter yielded a positive predictive value (PPV) of 20%. While maintaining same specificity levels, measurements of aortic volume and length showed superior diagnostic accuracy (PPV 55% and 70%, respectively). CONCLUSION Measurements of aortic volume and length have superior diagnostic accuracy compared with the maximal diameter and could improve the timely identification of patients at risk for ATAAD.
Collapse
Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands .,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Bouke P Adriaans
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Casper Mihl
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sebastiaan C A M Bekkers
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.,Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ehsan Natour
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.,Department of Thoracic and Cardiovascular Surgery, Uniklinik RWTH Aachen, Aachen, Germany
| | - Heleen Bouman
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Mikolaj Berezowski
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Kinga Kosiorowska
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Harry J G M Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Joachim Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Simon Schalla
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Limburg, The Netherlands
| |
Collapse
|
25
|
Chou EL, Lindsay ME. The genetics of aortopathies: Hereditary thoracic aortic aneurysms and dissections. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2020; 184:136-148. [PMID: 32034893 DOI: 10.1002/ajmg.c.31771] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/28/2020] [Indexed: 12/15/2022]
Abstract
Aortopathies encompass a variety of inherited and acquired pathologies that increase risk of life-threatening dissection or rupture. Identifying individuals with hereditary thoracic aortic aneurysm and dissection (HTAAD) for longitudinal monitoring, medical therapy, or elective and preventative repair is paramount to reduce risk of cardiovascular-related mortality and complications from dissection and rupture. Over the past couple of decades, pathogenic variants in numerous genes have been identified in relation to HTAAD. The genetic diagnosis can help stratify patient risk and provide guidance on medical treatment, timing of prophylactic surgical repair, as well as longitudinal surveillance and imaging. Implicated genes and their associated proteins have been found to act on a diverse variety of pathways, cells and structural components linked to transforming growth factor beta (TGF-β) signaling pathways, disruption of the vascular smooth muscle cell contractile apparatus, and primary disruption of extracellular matrix homeostasis. This review describes relevant genetic variants that may help identify and guide the management of hereditary thoracic aortic aneurysms and dissections.
Collapse
Affiliation(s)
- Elizabeth L Chou
- Division of Vascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Thoracic Aortic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark E Lindsay
- Thoracic Aortic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiovascular Genetics Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Pediatric Cardiology Division, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
26
|
Zafar MA, Chen JF, Wu J, Li Y, Papanikolaou D, Abdelbaky M, Faggion Vinholo T, Rizzo JA, Ziganshin BA, Mukherjee SK, Elefteriades JA. Natural history of descending thoracic and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2019; 161:498-511.e1. [PMID: 31982126 DOI: 10.1016/j.jtcvs.2019.10.125] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Elucidating critical aortic diameters at which natural complications (rupture, dissection, and death) occur is of paramount importance to guide timely surgical intervention. Natural history knowledge for descending thoracic and thoracoabdominal aortic aneurysms is sparse. Our small early studies recommended repairing descending thoracic and thoracoabdominal aortic aneurysms before a critical diameter of 7.0 cm. We focus exclusively on a large number of descending thoracic and thoracoabdominal aortic aneurysms followed over time, enabling a more detailed analysis with greater granularity across aortic sizes. METHODS Aortic diameters and long-term complications of 907 patients with descending thoracic and thoracoabdominal aortic aneurysms were reviewed. Growth rates (instrumental variables approach), yearly complication rates, 5-year event-free survival (Kaplan-Meier), and risk of complications as a function of aortic height index (aortic diameter [centimeters]/height [meters]) (competing-risks regression) were calculated. RESULTS Estimated mean growth rate of descending thoracic and thoracoabdominal aortic aneurysms was 0.19 cm/year, increasing with increasing aortic size. Median size at acute type B dissection was 4.1 cm. Some 80% of dissections occurred below 5 cm, whereas 93% of ruptures occurred above 5 cm. Descending thoracic and thoracoabdominal aortic aneurysm diameter 6 cm or greater was associated with a 19% yearly rate of rupture, dissection, or death. Five-year complication-free survival progressively decreased with increasing aortic height index. Hazard of complications showed a 6-fold increase at an aortic height index of 4.2 or greater compared with an aortic height index of 3.0 to 3.5 (P < .05). The probability of fatal complications (aortic rupture or death) increased sharply at 2 hinge points: 6.0 and 6.5 cm. CONCLUSIONS Acute type B dissections occur frequently at small aortic sizes; thus, prophylactic size-based surgery may not afford a means for dissection protection. However, fatal complications increase dramatically at 6.0 cm, suggesting that preemptive intervention before that criterion can save lives.
Collapse
Affiliation(s)
- Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Julia Fayanne Chen
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Jinlin Wu
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College, Beijing, China
| | - Yupeng Li
- Department of Political Sciences and Economics, Rowan University, Glassboro, NJ
| | - Dimitra Papanikolaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Mohamed Abdelbaky
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Thais Faggion Vinholo
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - John A Rizzo
- Department of Economics and Department of Preventive Medicine, Stony Brook University, Stony Brook, NY
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - Sandip K Mukherjee
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
| | | |
Collapse
|
27
|
Progressive Pulmonary Artery Dilatation is Associated with Type B Aortic Dissection in Patients with Marfan Syndrome. J Clin Med 2019; 8:jcm8111848. [PMID: 31684091 PMCID: PMC6912475 DOI: 10.3390/jcm8111848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 01/16/2023] Open
Abstract
Objective: Marfan syndrome (MFS) is a connective tissue disorder associated with severe cardiovascular morbidity and mortality. It is unknown if aorta complications in MFS are associated with progressive pulmonary artery (PA) dilatation. Methods: We measured the PA diameter on routine magnetic resonance imaging in a population of MFS patients seen in our specialised centre with follow up of diameters as well as the outcome. Results: PA dilatation was defined as an increase in diameter of 2 mm or more, and 71 patients (44%) of our total cohort (n = 162) met this criterion; mean follow up between two scans was 8.6 years (standard deviation (SD) ± 2.7 years). Furthermore, 28 patients suffered from dissections, of which 14 had a type A dissection, 10 had a type B dissection, and 4 patients suffered from both. Of those who suffered from dissection, 64% (18 out of 28) had a dilatation of the PA, versus 39% (53 out of 134) in the patient group without a dissection (p < 0.05). There was a significant association between type B dissection and descending aorta diameter (OR 1.14; 95% CI 1.05–1.24 p < 0.01) and PA dilatation (OR 1.69; 95% CI 1.03–2.77 p = 0.04). In the multivariable analysis the final model for type B dissection, only systolic blood pressure (OR 1.06; 95% CI 1.01–1.11 p = 0.02) and PA dilatation were statistically significant (OR 1.85; 95% CI 1.10–3.12 p = 0.02) while descending aorta diameter was not. Conclusions: We report an association between progressive PA dilatation and type B dissection. Our findings encourage a renewed interest in PA dimensions in MFS.
Collapse
|
28
|
Adriaans BP, Wildberger JE, Westenberg JJM, Lamb HJ, Schalla S. Predictive imaging for thoracic aortic dissection and rupture: moving beyond diameters. Eur Radiol 2019; 29:6396-6404. [PMID: 31278573 PMCID: PMC6828629 DOI: 10.1007/s00330-019-06320-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/07/2019] [Accepted: 06/11/2019] [Indexed: 01/09/2023]
Abstract
Abstract Acute aortic syndromes comprise a group of potentially fatal conditions that result from weakening of the aortic vessel wall. Pre-emptive surgical intervention is currently reserved for patients with severe aortic dilatation, although abundant evidence describes the occurrence of dissection and rupture in aortas with diameters below surgical thresholds. Modern imaging techniques (such as hybrid PET-CT and 4D flow MRI) afford the non-invasive assessment of anatomic, hemodynamic, and molecular features of the aorta, and may provide for a more accurate selection of patients who will benefit from preventative surgical intervention. In the current review, we summarize evidence and considerations regarding predictive aortic imaging and highlight evolving imaging modalities that have shown promise to improve risk assessment for the occurrence of dissection and rupture. Key Points • Guidelines for the preventative management of aortic disease depend on maximal vessel diameters, while these have shown to be poor predictors for the occurrence of catastrophic acute aortic events. • Evolving imaging modalities (such as 4D flow MRI and hybrid PET-CT) afford a more comprehensive insight into anatomic, hemodynamic, and molecular features of the aorta and have shown promise to detect vessel wall instability at an early stage.
Collapse
Affiliation(s)
- Bouke P Adriaans
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands. .,Department of Cardiology, Maastricht University Medical Center+, Maastricht, the Netherlands. .,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Simon Schalla
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands.,Department of Cardiology, Maastricht University Medical Center+, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
29
|
Abstract
Objective: Neovascularization of the aortic wall may be associated with aortic dissection (AD). Aortic wall endothelial CD31 deposition together with chronic inflammation indicates angiogenesis that may lead to tissue disruption. We studied the presence of neovascularization of the ascending aortic wall by characterizing CD31 positive endothelial cells. Methods: Aortic wall routine histology and immunohistochemistry for CD31, T- and B-lymphocytes, plasma cells, macrophages, endothelial cells, smooth muscle cells, and cell proliferation were performed on 35 selected patients who underwent surgery for the ascending aorta, and the samples were grouped according to the presence of AD. Results: Three subjects with Marfan syndrome were excluded from the study. A total of 14 out of 32 patients had AD. A total of 18 patients were operated on due to dilatation only. Chronic inflammation of the adventitia (p=0.003), media (p=0.001), and intima (p=0.005) was increased in AD. Neovascularization was predominant in the outer third medial layer in AD (p=0.037), corresponding to the site of aortic wall disruption. A receiver operating characteristic curve analysis showed that neovascularization was associated with AD (AUC 0.750; SE 0.092; p=0.022; 95% CI 0.570–0.930). Conclusion: Endothelial immunohistochemistry confirms neovascularization of the outer third medial layer during AD. Aortic wall remodeling including neovascularization characterizes AD. Chronic inflammation and neovascularization of the dilated ascending aorta suggest susceptibility for AD.
Collapse
|
30
|
Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, Ehrlich MP, Trimarchi S, Braverman AC, Myrmel T, Harris KM, Hutchinson S, O'Gara P, Suzuki T, Nienaber CA, Eagle KA. Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research. Circulation 2019; 137:1846-1860. [PMID: 29685932 DOI: 10.1161/circulationaha.117.031264] [Citation(s) in RCA: 691] [Impact Index Per Article: 138.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. The International Registry of Acute Aortic Dissection was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment. Since then, >7300 cases have been included from >51 sites in 12 countries. Although presenting symptoms and physical findings have not changed significantly over this period, the use of computed tomography in the diagnosis has increased, and more patients are managed with interventional procedures: surgery in type A AAD and endovascular therapy in type B AAD; with these changes in care, there has been a significant decrease in overall in-hospital mortality in type A AAD but not in type B AAD. Herein, we summarized the key lessons learned from this international registry of patients with AAD over the past 20 years.
Collapse
Affiliation(s)
- Arturo Evangelista
- Hospital General Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain (A.E.)
| | | | | | | | | | - Udo Sechtem
- Robert-Bosch Krankenhaus, Stuttgart, Germany (U.S.)
| | | | | | - Alan C Braverman
- Washington University School of Medicine, St. Louis, MO (A.C.B.)
| | | | | | | | | | - Toru Suzuki
- University of Leicester, United Kingdom (T.S.)
| | - Christoph A Nienaber
- The Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom (C.A.N.)
| | | | | |
Collapse
|
31
|
Berezowski M, Kosiorowska K, Beyersdorf F, Riesterer T, Jasinski M, Plonek T, Siepe M, Czerny M, Rylski B. Modelling of predissection aortic size in acute descending aortic dissection. Interact Cardiovasc Thorac Surg 2019; 29:124-129. [DOI: 10.1093/icvts/ivz028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/17/2019] [Accepted: 01/19/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mikolaj Berezowski
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Kinga Kosiorowska
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| | - Tatjana Riesterer
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| | - Marek Jasinski
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Plonek
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardio-Thoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| |
Collapse
|
32
|
Affiliation(s)
- Nicholas J. Swerdlow
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Winona W. Wu
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L. Schermerhorn
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| |
Collapse
|
33
|
Yamashiro Y, Thang BQ, Shin SJ, Lino CA, Nakamura T, Kim J, Sugiyama K, Tokunaga C, Sakamoto H, Osaka M, Davis EC, Wagenseil JE, Hiramatsu Y, Yanagisawa H. Role of Thrombospondin-1 in Mechanotransduction and Development of Thoracic Aortic Aneurysm in Mouse and Humans. Circ Res 2018; 123:660-672. [PMID: 30355232 PMCID: PMC6211815 DOI: 10.1161/circresaha.118.313105] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 08/06/2018] [Indexed: 02/07/2023]
Abstract
RATIONALE Abnormal mechanosensing of smooth muscle cells (SMCs) resulting from the defective elastin-contractile units has been suggested to drive the formation of thoracic aortic aneurysms; however, the precise molecular mechanism has not been elucidated. OBJECTIVE The aim of this study was to identify the crucial mediator(s) involved in abnormal mechanosensing and propagation of biochemical signals during the aneurysm formation and to establish a basis for a novel therapeutic strategy. METHODS AND RESULTS We used a mouse model of postnatal ascending aortic aneurysms ( Fbln4SMKO; termed SMKO [SMC-specific knockout]), in which deletion of Fbln4 (fibulin-4) leads to disruption of the elastin-contractile units caused by a loss of elastic lamina-SMC connections. In this mouse, upregulation of Egr1 (early growth response 1) and angiotensin-converting enzyme leads to activation of Ang II (angiotensin II) signaling. Here, we showed that the matricellular protein, Thbs1 (thrombospondin-1), was highly upregulated in SMKO ascending aortas and in human thoracic aortic aneurysms. Thbs1 was induced by mechanical stretch and Ang II in SMCs, for which Egr1 was required, and reduction of Fbln4 sensitized the cells to these stimuli and led to higher expression of Egr1 and Thbs1. Deletion of Thbs1 in SMKO mice prevented the aneurysm formation in ≈80% of DKO (SMKO;Thbs1 knockout) animals and suppressed Ssh1 (slingshot-1) and cofilin dephosphorylation, leading to the formation of normal actin filaments. Furthermore, elastic lamina-SMC connections were restored in DKO aortas, and mechanical testing showed that structural and material properties of DKO aortas were markedly improved. CONCLUSIONS Thbs1 is a critical component of mechanotransduction, as well as a modulator of elastic fiber organization. Maladaptive upregulation of Thbs1 results in disruption of elastin-contractile units and dysregulation of actin cytoskeletal remodeling, contributing to the development of ascending aortic aneurysms in vivo. Thbs1 may serve as a potential therapeutic target for treating thoracic aortic aneurysms.
Collapse
MESH Headings
- Actin Cytoskeleton/metabolism
- Actin Cytoskeleton/pathology
- Aged
- Aged, 80 and over
- Animals
- Aorta, Thoracic/metabolism
- Aorta, Thoracic/pathology
- Aortic Aneurysm, Thoracic/genetics
- Aortic Aneurysm, Thoracic/metabolism
- Aortic Aneurysm, Thoracic/pathology
- Aortic Aneurysm, Thoracic/prevention & control
- Cells, Cultured
- Cofilin 2/metabolism
- Dilatation, Pathologic
- Disease Models, Animal
- Early Growth Response Protein 1/metabolism
- Elastic Tissue/metabolism
- Elastic Tissue/pathology
- Elastin/metabolism
- Extracellular Matrix Proteins/deficiency
- Extracellular Matrix Proteins/genetics
- Female
- Humans
- Male
- Mechanotransduction, Cellular
- Mice, Knockout
- Middle Aged
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Phosphoprotein Phosphatases/metabolism
- Phosphorylation
- Pressoreceptors/metabolism
- Rats
- Stress, Mechanical
- Thrombospondin 1/deficiency
- Thrombospondin 1/genetics
- Thrombospondin 1/metabolism
- Vascular Remodeling
Collapse
Affiliation(s)
- Yoshito Yamashiro
- Life Science Center for Survival Dynamics, Tsukuba Advanced Research Alliance, University of Tsukuba, Ibaraki 305-8577, Japan
| | - Bui Quoc Thang
- Cardiovascular Surgery, University of Tsukuba, Ibaraki 305-8577, Japan
| | - Seung Jae Shin
- Life Science Center for Survival Dynamics, Tsukuba Advanced Research Alliance, University of Tsukuba, Ibaraki 305-8577, Japan
- Graduate School of Life and Environmental Sciences, University of Tsukuba, Ibaraki, 305-8577, Japan
| | - Caroline Antunes Lino
- Anatomy, University of Sao Paulo, Institute of Biomedical Sciences, Sao Paulo, SP 05508-900, Brazil
| | | | - Jungsil Kim
- Mechanical Engineering and Materials Science, Washington University, St. Louis, MO 63130, USA
| | - Kaori Sugiyama
- Life Science Center for Survival Dynamics, Tsukuba Advanced Research Alliance, University of Tsukuba, Ibaraki 305-8577, Japan
- Ph.D. Program in Human Biology, School of Integrative and Global Majors, University of Tsukuba, Ibaraki, 305-8577, Japan
| | - Chiho Tokunaga
- Cardiovascular Surgery, University of Tsukuba, Ibaraki 305-8577, Japan
| | - Hiroaki Sakamoto
- Cardiovascular Surgery, University of Tsukuba, Ibaraki 305-8577, Japan
| | - Motoo Osaka
- Cardiovascular Surgery, University of Tsukuba, Ibaraki 305-8577, Japan
| | - Elaine C. Davis
- Anatomy and Cell Biology, McGill University, Montreal, Quebec H3A0C7, Canada
| | - Jessica E. Wagenseil
- Mechanical Engineering and Materials Science, Washington University, St. Louis, MO 63130, USA
| | - Yuji Hiramatsu
- Cardiovascular Surgery, University of Tsukuba, Ibaraki 305-8577, Japan
| | - Hiromi Yanagisawa
- Life Science Center for Survival Dynamics, Tsukuba Advanced Research Alliance, University of Tsukuba, Ibaraki 305-8577, Japan
- Faculty of Medicine, University of Tsukuba, Ibaraki 305-8577, Japan
| |
Collapse
|
34
|
Ouzounian M, LeMaire SA. How can genetic diagnosis inform the decision of when to operate? J Vis Surg 2018; 4:68. [PMID: 29780714 DOI: 10.21037/jovs.2018.03.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/07/2018] [Indexed: 12/16/2022]
Abstract
Genetic discovery for heritable thoracic aortic disease (HTAD) has been progressing at a brisk pace. Surgical management of thoracic aortic aneurysms and dissections has become more personalized, with genetic factors increasingly informing the decision of when to operate on patients. An improved understanding of genotype-phenotype correlations in patients with HTAD will ultimately lead to gene- and mutation-specific recommendations for surgical repair. Until more robust data from larger cohorts can inform our decisions, patients with HTAD should be seen by an aortic specialist for a tailored approach to elective surgical repair.
Collapse
Affiliation(s)
- Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, and the Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.,Cardiovascular Surgery Service, The Texas Heart Institute, Houston, Texas, USA
| |
Collapse
|
35
|
Adriaans BP, Heuts S, Gerretsen S, Cheriex EC, Vos R, Natour E, Maessen JG, Sardari Nia P, Crijns HJGM, Wildberger JE, Schalla S. Aortic elongation part I: the normal aortic ageing process. Heart 2018; 104:1772-1777. [PMID: 29593078 DOI: 10.1136/heartjnl-2017-312866] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/04/2018] [Accepted: 03/08/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Differentiation between normal and abnormal features of vascular ageing is crucial, as the latter is associated with adverse outcomes. The normal aortic ageing process is accompanied by gradual luminal dilatation and reduction of vessel compliance. However, the influence of age on longitudinal aortic dimensions and geometry has not been well studied. This study aims to describe the normal evolution of aortic length and shape throughout life. METHODS A total of 210 consecutive patients were prospectively enrolled in this cross-sectional single-centre study. All subjects underwent CT on a third-generation dual-source CT scanner. Morphometric measurements, including measurements of segmental length and tortuosity, were performed on three-dimensional models of the thoracic aorta. RESULTS The length of the thoracic aorta was significantly related to age (r=0.54) and increased by 59 mm (males) or 66 mm (females) between the ages of 20 and 80 years. Elongation was most pronounced in the proximal descending aorta, which showed an almost 2.5-fold length increase during life. The lengthening of the thoracic aorta was accompanied by a marked change of its geometry: whereas the aortic apex was located between the branch vessels in younger patients, it shifted to a more distalward position in the elderly. CONCLUSIONS The normal ageing process is accompanied by gradual aortic elongation and a notable change of aortic geometry. Part II of this two-part article investigates the hypothesis that excessive elongation could play a role in the occurrence of acute aortic dissection.
Collapse
Affiliation(s)
- Bouke P Adriaans
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Samuel Heuts
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Suzanne Gerretsen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Emile C Cheriex
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | - Ehsan Natour
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Thoracic and Cardiovascular Surgery, Uniklinik RWTH Aachen, Aachen, Germany
| | - Jos G Maessen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peyman Sardari Nia
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Simon Schalla
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
36
|
Mansour AM, Peterss S, Zafar MA, Rizzo JA, Fang H, Charilaou P, Ziganshin BA, Darr UM, Elefteriades JA. Prevention of Aortic Dissection Suggests a Diameter Shift to a Lower Aortic Size Threshold for Intervention. Cardiology 2018; 139:139-146. [DOI: 10.1159/000481930] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/02/2017] [Indexed: 12/14/2022]
Abstract
Background: Multiple studies have quantified the relationship between aortic size and risk of dissection. However, these studies estimated the risk of dissection without accounting for any increase in aortic size from the dissection process itself. Objectives: This study aims to compare aortic size before and after dissection and to evaluate the change in size consequent to the dissection itself. Methods: Fifty-five consecutive patients (29 type A; 26 type B) with aortic dissection and incidental imaging studies prior to dissection were identified and compared to a control group of aneurysm patients (n = 205). The average time between measurement at and prior to dissection was 1.7 ± 1.9 years (1.9 ± 2.0 years mean inter-image time in the control group). A multivariate regression model controlling for growth rate, age, and gender was created to estimate the effect of dissection itself on aortic size. Results: The mean aortic sizes at and prior to dissection were 54.2 ± 7.0 and 45.1 ± 5.7 mm for the ascending aorta, and 47.1 ± 13.8 and 39.5 ± 13.1 mm for the descending aorta, respectively. The multivariable analysis revealed a significant impact of the dissection itself (p < 0.001) and estimated an increase in size of 7.65 mm (ascending aorta) and 6.38 mm (descending aorta). Thus, a proportional estimate of 82.8% (ascending aorta) and 80.8% (descending aorta) of dissections are made at a size lower than the guideline-recommended threshold (55 mm). Conclusions: The aortic diameter increases substantially due to aortic dissection itself and, thus, aortas are being dissected at clinically meaningfully smaller sizes than natural history analyses have previously suggested. These findings have important implications regarding the size at which the risk of dissection is increased.
Collapse
|
37
|
Boudoulas KD, Triposkiadis F, Stefanadis C, Boudoulas H. Aortic Size and Aortic Dissection: Does One Size Fit All? Cardiology 2018; 139:147-150. [PMID: 29346797 DOI: 10.1159/000484040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/09/2017] [Indexed: 01/16/2023]
|
38
|
Yuan X, Mitsis A, Tang Y, Nienaber CA. The IRAD and beyond: what have we unravelled so far? Gen Thorac Cardiovasc Surg 2017; 67:146-153. [PMID: 28879585 DOI: 10.1007/s11748-017-0817-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/08/2017] [Indexed: 12/13/2022]
Abstract
Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality rates and a long history of challenges to both diagnose and manage this condition successfully. The International Registry of Acute Aortic Dissection (IRAD) was established in 1996 as a global database to understand this old disease better and improve care for dissection. IRAD initially targeted various areas including etiological factors of dissection, modes of presentation, clinical features, physical findings, imaging, management, and outcomes, and is currently branching out in more specific fields such as endovascular intervention, genetic profiling, and functional imaging. Although presenting symptoms and physical findings have not changed significantly over two decades, the widespread use of computed tomography is standard and has improved the diagnostic pathway. Moreover, more patients are managed with appropriate procedures, such as surgery in type A, and endovascular therapy in subsets of type B aortic dissection. With these ongoing improvements in swift diagnostic work-up and therapeutic care, fewer patients are not getting appropriate treatment and more patients survive once they reach hospital.
Collapse
Affiliation(s)
- Xun Yuan
- Cardiology and Aortic Centre, Royal Brompton and Harefield NHS Trust and Imperial College, Sydney Street, London, SW3 6NP, UK
| | - Andreas Mitsis
- Cardiology and Aortic Centre, Royal Brompton and Harefield NHS Trust and Imperial College, Sydney Street, London, SW3 6NP, UK
| | - Yida Tang
- Department of Internal Medicine, Coronary Heart Disease Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield NHS Trust and Imperial College, Sydney Street, London, SW3 6NP, UK.
| |
Collapse
|
39
|
Zhang MH, Du X, Guo W, Liu XP, Jia X, Ge YY. Early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) for acute and chronic complicated type B aortic dissection. Medicine (Baltimore) 2017; 96:e7183. [PMID: 28700467 PMCID: PMC5515739 DOI: 10.1097/md.0000000000007183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) in the current era has been chosen as a dominant and minimally invasive treatment for complicated aorta dissection. This study aimed to assess safety and feasibility of TEVAR in acute and chronic type B aortic dissection.Between January 2011 and December 2013, 85 patients with complicated type B aortic dissection undergoing TEVAR were divided into acute aortic dissection (AAD) (n = 60) group and chronic aortic dissection (CAD) group (n = 25). Computed tomography was used to evaluate postoperative changes in maximal aortic diameter and true and false lumen diameters at 3 levels during a mean follow-up period of 26.4 ± 15.6 months.The technical success rate was 100%. In-hospital and 30-day rates of death were 3.3% in acute group and 0 in chronic group. Postdischarge rates of type I leak, type II leak, and retrograde type A dissection were 6.7%, 5.2%, and 3.4% (acute) and 0%, 4.0%, and 4.0% (chronic), respectively. The maximal aorta diameter remained stable in all the 3 levels in both acute and chronic group. The cumulative freedom from all-cause mortality at 3 years was similar in acute and chronic groups (89.5% vs 95.5%, P = .308). The cumulative freedom from aortic-related mortality was also not significantly different in the acute and chronic groups (92.8% vs 95.2%, P = .531). In the thoracic aorta, TEVAR treatment resulted in a significant increase in true lumen (TL) diameter and decrease in false lumen (FL). However, in the abdominal aorta, TEVAR did not lead to significant change in TL and FL diameters. The rates of complete thrombosis thoracic false lumens were better than that in the abdominal false lumen.TEVAR was a safe and effect therapy for complicated acute and chronic type B dissection with low early and mid-term mortality and morbidity.
Collapse
|
40
|
Abstract
Stanford type B aortic dissections (TBADs) involve the descending aorta and can present with complications, including malperfusion syndrome or aortic rupture, which are associated with significant morbidity and mortality if left untreated. Clinical diagnosis is straightforward, typically confirmed using CT angiography. Treatment begins with immediate anti-impulse medical therapy. Acute TBAD with complications should be repaired with emergent thoracic endovascular aortic repair (TEVAR). Uncomplicated TBAD with high-risk features should undergo TEVAR in the subacute phase. Open surgical repair is seldom required and reserved only for select cases. It is critical to follow these patients clinically and radiographically in the outpatient setting.
Collapse
Affiliation(s)
- Daniel B Alfson
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033-5330, USA
| | - Sung W Ham
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033-5330, USA.
| |
Collapse
|
41
|
Singh P, Almarzooq Z, Salata B, Devereux RB. Role of molecular imaging with positron emission tomographic in aortic aneurysms. J Thorac Dis 2017; 9:S333-S342. [PMID: 28540077 PMCID: PMC5422660 DOI: 10.21037/jtd.2017.04.18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/11/2017] [Indexed: 01/23/2023]
Abstract
Aortic aneurysms (AA) are often asymptomatic before the occurrence of acute, potentially fatal complications including dissection and/or rupture. Beyond aortic size, the ability to assess aortic wall characteristics and processes contributing to aneurysm development may allow improved selection of patients who may benefit from prophylactic surgical intervention. Current risk stratification for aneurysms relies upon routine noninvasive imaging of aortic size without assessing the underlying pathophysiologic processes, including features such as inflammation, which may be associated with aneurysm development and progression. The use of molecular imaging modalities with positron emission tomographic (PET) scan allows characterization of aortic wall inflammatory activity. Elevated uptake of Fuorine-2-deoxy-D-glucose (FDG), a radiotracer with elevated avidity in highly-metabolic cells, has been correlated with the development and progression of both abdominal and thoracic AA in a number of animal models and clinical studies. Other novel PET radiotracers targeting matrix metalloproteinases (MMPs), mitochondrial translocator proteins (TSPO) and endothelial cell adhesion molecules are being investigated for clinical utility in identifying progression of disease in AA. By further defining the activation of molecular pathways in assessing aortic regions at risk for dilatation, this imaging modality can be integrated into future clinical decision-making models.
Collapse
Affiliation(s)
| | | | - Brian Salata
- Department of Cardiology, Weill Cornell Medicine, New York, USA
| | | |
Collapse
|
42
|
Singh P, Almarzooq Z, Codell NCF, Wang Y, Roman MJ, Devereux RB, Weinsaft JW. Cine-CMR partial voxel segmentation demonstrates increased aortic stiffness among patients with Marfan syndrome. J Thorac Dis 2017; 9:S239-S245. [PMID: 28540066 DOI: 10.21037/jtd.2017.04.02] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Standard cine-cardiac magnetic resonance (CMR) imaging is commonly used to evaluate cardiac structure, geometry and function. Prior studies have shown that automated segmentation via partial voxel interpolation (PVI) accurately quantifies phantom-based cardiac chamber volumes and necropsy left ventricular myocardial mass. Despite this, the applicability and usefulness of PVI in the determination of physiologic parameters of the aorta such as aortic stiffness has yet to be investigated. METHODS Routine CMR was conducted with a 1.5T (GE) scanner with pulse sequences similar to that of standard CMR (parameters: TR 3.4 msec, TE 1.14 msec, flip angle 60°, temporal resolution ~30-40 msec). Views were obtained in standard cardiac-oriented longitudinal or axial views (2, 3 and 4 chambers). Within non-dilated regions of the descending thoracic aorta, aortic area was quantified via a novel PVI automated process (LV-METRIC), which discerns relative amounts of blood pool in each voxel. Aortic stiffness, as calculated from brachial artery pulse pressure and aortic area at maximal and minimal dimensions, was evaluated in 60 total segments (one segment per patient). All segments were in the descending aorta and were not aneurysmal. RESULTS Sixty patients in total were studied, including 50 that had genetically-related aortic disorder [35 bicuspid aortic valve (BAV), 15 Marfan syndrome (MFS)]. Ten normal controls without aortic disease were included for comparison purposes. All patients (n=60) had evaluable CMR images for assessment of the descending aorta with use of automated segmentation. Patients with BAV and MFS were similar to controls in age, systolic blood pressure, brachial artery pulse pressure, smoking status or hypercholesterolemia (all P=NS). There were more women (P<0.001), lower body mass index (P=0.008), and greater height (P<0.001) in the MFS cohort compared to BAV and controls. Descending aortic area in either systole (maximal) or diastole (minimal) was similar among all three cohorts. However, change in aortic area (ΔArea) throughout the cardiac cycle was substantially lower in MFS than control subjects (P<0.001). In contrast, change in aortic area throughout the cardiac cycle was not significantly different between BAV vs. controls (P=0.62). Aortic stiffness was increased among MFS patients versus control subjects (P=0.014). When comparing MFS to BAV subjects, a comparable trend was observed (P=0.09). No statistical difference was evident in aortic stiffness in patients with BAV versus control subjects (P=0.29). CONCLUSIONS The application of PVI to standard CMR imaging can assess abnormal descending aorta functional indices in normal caliber segments in MFS subjects. Future prospective studies with larger subject populations are warranted to further determine the overall utility of automated aortic segmentation as a possible early biomarker of aortic dysfunction before overt dilatation.
Collapse
Affiliation(s)
- Parmanand Singh
- Department of Cardiology, Weill Cornell Medical College, NYC, NY, USA
| | - Zaid Almarzooq
- Department of Cardiology, Weill Cornell Medical College, NYC, NY, USA
| | | | - Yi Wang
- Department of Cardiology, Weill Cornell Medical College, NYC, NY, USA
| | - Mary J Roman
- Department of Cardiology, Weill Cornell Medical College, NYC, NY, USA
| | | | | |
Collapse
|
43
|
Craiem D, El Batti S, Casciaro ME, Mousseaux E, Sirieix ME, Simon A, Alsac JM. Age-related changes of thoracic aorta geometry used to predict the risk for acute type B dissection. Int J Cardiol 2017; 228:654-660. [DOI: 10.1016/j.ijcard.2016.11.125] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/04/2016] [Accepted: 11/06/2016] [Indexed: 01/16/2023]
|
44
|
Abstract
Thoracic aortic aneurysm is a potentially life-threatening condition in that it places patients at risk for aortic dissection or rupture. However, our modern understanding of the pathogenesis of thoracic aortic aneurysm is quite limited. A genetic predisposition to thoracic aortic aneurysm has been established, and gene discovery in affected families has identified several major categories of gene alterations. The first involves mutations in genes encoding various components of the transforming growth factor beta (TGF-β) signaling cascade (FBN1, TGFBR1, TGFBR2, TGFB2, TGFB3, SMAD2, SMAD3 and SKI), and these conditions are known collectively as the TGF-β vasculopathies. The second set of genes encode components of the smooth muscle contractile apparatus (ACTA2, MYH11, MYLK, and PRKG1), a group called the smooth muscle contraction vasculopathies. Mechanistic hypotheses based on these discoveries have shaped rational therapies, some of which are under clinical evaluation. This review discusses published data on genes involved in thoracic aortic aneurysm and attempts to explain divergent hypotheses of aneurysm origin.
Collapse
Affiliation(s)
- Eric M Isselbacher
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christian Lacks Lino Cardenas
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mark E Lindsay
- From Thoracic Aortic Center (E.M.I., C.L.L.C., M.E.L.), Cardiovascular Genetics Program (M.E.L.), Cardiovascular Research Center (C.L.L.C., M.E.L.), and Cardiology Division (E.M.I., C.L.L.C., M.E.L.), Department of Medicine, and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital, Harvard Medical School, Boston.
| |
Collapse
|
45
|
Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, Czerny M, Fraedrich G, Haulon S, Jacobs M, Lachat M, Moll F, Setacci C, Taylor P, Thompson M, Trimarchi S, Verhagen H, Verhoeven E, ESVS Guidelines Committee, Kolh P, de Borst G, Chakfé N, Debus E, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Document Reviewers, Kolh P, Black J, Busund R, Björck M, Dake M, Dick F, Eggebrecht H, Evangelista A, Grabenwöger M, Milner R, Naylor A, Ricco JB, Rousseau H, Schmidli J. Editor's Choice – Management of Descending Thoracic Aorta Diseases. Eur J Vasc Endovasc Surg 2017; 53:4-52. [DOI: 10.1016/j.ejvs.2016.06.005] [Citation(s) in RCA: 598] [Impact Index Per Article: 85.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
46
|
Abstract
Aortic dissection is a life-threatening condition caused by a tear in the intimal layer of the aorta or bleeding within the aortic wall, resulting in the separation (dissection) of the layers of the aortic wall. Aortic dissection is most common in those 65-75 years of age, with an incidence of 35 cases per 100,000 people per year in this population. Other risk factors include hypertension, dyslipidaemia and genetic disorders that involve the connective tissue, such as Marfan syndrome. Swift diagnostic confirmation and adequate treatment are crucial in managing affected patients. Contemporary management is multidisciplinary and includes serial non-invasive imaging, biomarker testing and genetic risk profiling for aortopathy. The choice of approach for repairing or replacing the damaged region of the aorta depends on the severity and the location of the dissection and the risks of complication from surgery. Open surgical repair is most commonly used for dissections involving the ascending aorta and the aortic arch, whereas minimally invasive endovascular intervention is appropriate for descending aorta dissections that are complicated by rupture, malperfusion, ongoing pain, hypotension or imaging features of high risk. Recent advances in the understanding of the underlying pathophysiology of aortic dissection have led to more patients being considered at substantial risk of complications and, therefore, in need of endovascular intervention rather than only medical or surgical intervention.
Collapse
|
47
|
Isselbacher EM. The Natural History of Thoracic Aortic Disease: So Much Left to Learn. J Am Coll Cardiol 2016; 67:2755-2757. [PMID: 27282896 DOI: 10.1016/j.jacc.2016.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 04/12/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Eric M Isselbacher
- Thoracic Aortic Center and Cardiology Division, Massachusetts General Hospital, and the Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
48
|
Vapnik JS, Kim JB, Isselbacher EM, Ghoshhajra BB, Cheng Y, Sundt TM, MacGillivray TE, Cambria RP, Lindsay ME. Characteristics and Outcomes of Ascending Versus Descending Thoracic Aortic Aneurysms. Am J Cardiol 2016; 117:1683-1690. [PMID: 27015890 DOI: 10.1016/j.amjcard.2016.02.048] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 11/15/2022]
Abstract
Thoracic aortic aneurysms (TAs) occur in reproducible patterns, but etiologic factors determining the anatomic distribution of these aneurysms are not well understood. This study sought to gain insight into etiologic differences and clinical outcomes associated with repetitive anatomic distributions of TAs. From 3,247 patients registered in an institutional Thoracic Aortic Center database from July 1992 to August 2013, we identified 844 patients with full aortic dimensional imaging by computerized axial tomography or magnetic resonance imaging scan (mean age 62.8 ± 14 years, 37% women, median follow-up 40 months) with TA diameter >4.0 cm and without evidence of previous aortic dissection. Patient demographic and imaging data were analyzed in 3 groups: isolated ascending thoracic aortic aneurysms (AAs; n = 628), isolated descending TAs (DTAs; n = 130), and combined AA and DTA (mixed thoracic aortic aneurysm, MTA; n = 86). Patients with DTA had more hypertension (82% vs 59%, p <0.001) and a higher burden of atherosclerosis (88% vs 9%, p <0.001) than AA. Conversely, patients with isolated AA were younger (59.5 ± 13.5 vs 71.0 ± 11.8 years, p <0.001) and contained almost every case of overt, genetically triggered TA. Patients with isolated DTA were demographically indistinguishable from patients with MTA. In follow-up, patients with DTA/MTA experienced more aortic events (aortic dissection/rupture) and had higher mortality than patients with isolated AA. In multivariate analysis, aneurysm size (odds ratio 1.1, 95% CI 1.07 to 1.16, p <0.001) and the presence of atherosclerosis (odds ratio 5.7, 95% CI 2.02 to 16.15, p <0.001) independently predicted adverse aortic events. We find that DTA with or without associated AA appears to be a disease more highly associated with atherosclerosis, hypertension, and advanced age. In contrast, isolated AA appears to be a clinically distinct entity with a greater burden of genetically triggered disease.
Collapse
Affiliation(s)
- Joshua S Vapnik
- Massachusetts General Hospital Thoracic Aortic Center, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Joon Bum Kim
- Massachusetts General Hospital Thoracic Aortic Center, Harvard Medical School, Boston, Massachusetts; Division of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts; Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eric M Isselbacher
- Massachusetts General Hospital Thoracic Aortic Center, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | | | - Yisha Cheng
- Massachusetts General Hospital Thoracic Aortic Center, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Thoralf M Sundt
- Massachusetts General Hospital Thoracic Aortic Center, Harvard Medical School, Boston, Massachusetts; Division of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts
| | - Thomas E MacGillivray
- Massachusetts General Hospital Thoracic Aortic Center, Harvard Medical School, Boston, Massachusetts; Division of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts
| | - Richard P Cambria
- Massachusetts General Hospital Thoracic Aortic Center, Harvard Medical School, Boston, Massachusetts; Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, Massachusetts
| | - Mark E Lindsay
- Massachusetts General Hospital Thoracic Aortic Center, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
49
|
Trimarchi S, Kamman A, Lomazzi C, Segreti S, Cova M, De Vincentiis C, Frigiola A, Menicanti L, Marrocco-Trischitta MM, Grassi V, Morganti S, Conti M, Auricchio F, Rampoldi V. Activities at Thoracic Aortic Research Center, IRCCS Policlinico San Donato. Eur Heart J Suppl 2016; 18:E57-E63. [PMID: 28533718 DOI: 10.1093/eurheartj/suw015] [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: 11/13/2022]
Abstract
The Thoracic Aortic Research Center (TARC) of the IRCCS Policlinico San Donato (PSD) aims to promote research on thoracic aortic diseases, to disclose the scientific knowledge and clinical experience and to develop new scientific paths within the Hospital and the aortic community, in collaboration with other national and international centres. Thoracic Aortic Research Center collaborates with many centres in both Europe (e.g. University of Utrecht, the Netherlands) and the USA (e.g. University of Michigan). This has led to multiple highly regarded publications in respected cardiovascular journals and has led to several PhD programmes resulting in doctorate degrees. Within Italy, in association with the Bioengineering School of the University of Pavia, TARC has founded the "BETA-lab" (Biomechanics for Endovascular Treatment of the Aorta laboratory), where MDs, Bioengineers, and PhD fellows conduct experimental studies using in vitro/ex vivo models of the physiologic aorta and aortic diseases. Furthermore, a database (iCardiocloud) where the medical imaging of cardiovascular patients from the PSD is structured, for in silico analysis utilizing computational fluid dynamics, and in vitro studies using also 3D printed aortic models. With the role of principal investigator or co-investigator, TARC at PSD has been participating in other several projects, including the International Registry of Acute Aortic Dissection, the International Aortic Arch Surgery Study Group, the European Registry of Endovascular Aortic Repair Complications, the ADSORB and ASSIST trials, and the GREAT registry. International collaborations have included also studies on predictors of aortic growth after dissection with the Yale University and University of Virginia, and on aortic biomarkers with the University of Tokyo.
Collapse
Affiliation(s)
- Santi Trimarchi
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Arnoud Kamman
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Chiara Lomazzi
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Sara Segreti
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Marta Cova
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Carlo De Vincentiis
- Section of Cardiac Surgery, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Milan, Italy
| | - Alessandro Frigiola
- Section of Cardiac Surgery, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Milan, Italy
| | - Lorenzo Menicanti
- Section of Cardiac Surgery, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Milan, Italy
| | - Massimiliano M Marrocco-Trischitta
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Viviana Grassi
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Simone Morganti
- Department of Civil Engineering and Architecture, University of Pavia, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Italy
| | | | - Vincenzo Rampoldi
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| |
Collapse
|
50
|
Nauta FJH, Trimarchi S, Kamman AV, Moll FL, van Herwaarden JA, Patel HJ, Figueroa CA, Eagle KA, Froehlich JB. Update in the management of type B aortic dissection. Vasc Med 2016; 21:251-63. [DOI: 10.1177/1358863x16642318] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.
Collapse
Affiliation(s)
- Foeke JH Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Arnoud V Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Frans L Moll
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost A van Herwaarden
- Vascular Surgery Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - C Alberto Figueroa
- Departments of Biomedical Engineering and Surgery, University of Michigan, USA
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - James B Froehlich
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| |
Collapse
|