1
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Wolk S, Prange LS, Kapalla M, Schaab F, Weiss N, Hoffmann RT, Reeps C. Midterm survival after aortic repair versus conservative treatment in patients with penetrating aortic ulcer. VASA 2024; 53:255-262. [PMID: 38874211 DOI: 10.1024/0301-1526/a001128] [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: 06/15/2024]
Abstract
Background: The clinical outcomes and survival of patients with penetrating aortic ulcers (PAU) were evaluated in a tertiary care hospital, comparing those who underwent aortic repair to those treated conservatively. Patients and methods: A retrospective single-centre analysis included all patients that underwent a computed tomography angiography (CT-A) scan with the diagnosis of a PAU between January 2009 and May 2019. "PAU" was identified in 1,493 of 112,506 CT-A scan reports in 576 patients. Clinical and angiomorphological data were collected. The primary outcome was overall survival (OS), with secondary outcomes focusing on identifying risk factors for poor OS. Survival probabilities were analysed by the Kaplan-Meier method using the log-rank test. A Cox hazard model using survival as dependent variable with stepwise backward eliminations based on the likelihood ratios was employed. Results: 315 PAUs were identified in 278 patients. The prevalence in the cohort was 0.8%. The mean age of the patients was 74.4 years, and they were predominantly male (n = 208, 74.8%). The mean ulcer depth was 11.8 mm (range 2-50 mm). Out of the patients, 232 were asymptomatic (83.5%). Among 178 PAUs (56.5%), high-risk factors, such as ulcer depth >10 mm, aortic diameter >40 mm, and ulcer length >20 mm, were observed. Aortic repair was associated with a better mean OS compared to conservatively managed patients (72.6 versus 32.2 months, p = 0.001). The Cox hazard model showed that ulcer depth >1 mm was associated with poor OS (HR 0.67, p = 0.048), while aortic repair was related to a better OS (HR 4.365, p<0.013). Conclusions: Aortic repair is associated with better OS, but this finding should be interpreted with caution because of differences in age and comorbidities between the groups. Further evaluation is warranted through prospective studies with randomized groups. Further assessment for angiomorphological parameters is recommended to identify patients at increased risk for poor OS.
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Affiliation(s)
- Steffen Wolk
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Lena-Sophie Prange
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Marvin Kapalla
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Felix Schaab
- Medizinische Fakultät Carl Gustav Carus, Institute for Diagnostic and Interventional Radiology, Technische Universität Dresden, Germany
| | - Norbert Weiss
- Division of Angiology, Department of Internal Medicine III, University Center for Vascular Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Medizinische Fakultät Carl Gustav Carus, Institute for Diagnostic and Interventional Radiology, Technische Universität Dresden, Germany
| | - Christian Reeps
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Germany
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2
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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3
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Garg I, Siembida JM, Hedgire S, Priya S, Nagpal P. Computed Tomography Angiography for Aortic Diseases. Radiol Clin North Am 2024; 62:509-525. [PMID: 38553183 DOI: 10.1016/j.rcl.2024.01.001] [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: 04/02/2024]
Abstract
Aortic pathologies encompass a heterogeneous group of disorders, including acute aortic syndrome, traumatic aortic injury , aneurysm, aortitis, and atherosclerosis. The clinical manifestations of these disorders can be varied and non-specific, ranging from acute presentations in the emergency department to chronic incidental findings in an outpatient setting. Given the non-specific nature of their clinical presentations, the reliance on non-invasive imaging for screening, definitive diagnosis, therapeutic strategy planning, and post-intervention surveillance has become paramount. Commonly used imaging modalities include ultrasound, computed tomography (CT), and MR imaging. Among these modalities, computed tomography angiography (CTA) has emerged as a first-line imaging modality owing to its excellent anatomic detail, widespread availability, established imaging protocols, evidence-proven indications, and rapid acquisition time.
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Affiliation(s)
- Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jakub M Siembida
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sarv Priya
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Prashant Nagpal
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.
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4
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Crepy D'Orleans C, Duwayri YM, Zellner AB, Binongo J, Farrington WJ, Keeling WB, Jordan WD, Leshnower BG. Acute Type B Intramural Hematoma: Novel Insights in the Endovascular Era. Ann Vasc Surg 2024; 101:195-203. [PMID: 38301850 DOI: 10.1016/j.avsg.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/13/2023] [Accepted: 11/04/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND The pathophysiology and behavior of acute type B intramural hematoma (TBIMH) is poorly understood. The purpose of this study is to characterize the pathophysiology, fate, and outcomes of TBIMH in the endovascular era. METHODS A retrospective analysis of a US Aortic Database identified 70 patients with TBIMH from 2008 to 2022. Patients were divided into groups and analyzed based upon subsequent management: early thoracic endovascular aortic repair (TEVAR; Group 1) or hospital discharge on optimal medical therapy (OMT) (Group 2). RESULTS Of 70 total patients, 43% (30/70) underwent TEVAR (Group 1) and 57% (40/70) were discharged on OMT (Group 2). There were no significant differences in age, demographics, or comorbidities between groups. Indications for TEVAR in Group 1 were as follows: 1) Penetrating atheroscletoic ulcer (PAU) or ulcer-like projection (n = 26); 2) Descending thoracic aortic aneurysm (n = 3); or 3) Progression to type B aortic dissection (TBAD) (n = 2). Operative mortality was zero. No patient suffered a stroke or spinal cord ischemia. During the follow-up period, 50% (20/40) of Group 2 patients required delayed surgical intervention, including TEVAR in 14 patients and open repair in 6 patients. Indications for surgical intervention were as follows: 1) Development of a PAU / ulcer-like projection (n = 13); 2) Progression to TBAD (n = 3), or 3) Concomitant aneurysmal disease (n = 4). Twenty patients did not require surgical intervention. Of the initial cohort, 71% of patients required surgery, 9% progressed to TBAD, and 19% had regression or stability of TBIMH with OMT alone. CONCLUSIONS The most common etiology of TBIMH is an intimal defect. Progression to TBAD and intramural hematoma regression without an intimal defect occurs in a small percentage of patients. An aggressive strategy with endovascular therapy and close surveillance for TBIMH results in excellent short-term and long-term outcomes.
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Affiliation(s)
| | - Yazan M Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Alysa B Zellner
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Jose Binongo
- Emory University Rollins School of Public Health, Atlanta, GA
| | - Woodrow J Farrington
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - W Brent Keeling
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - William D Jordan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA.
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5
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Rizza A, Castiglione V, Capellini K, Palmieri C, Gasparotti E, Berti S, Celi S. Case Report: Role of numerical simulations in the management of acute aortic syndromes. Front Cardiovasc Med 2024; 11:1309840. [PMID: 38510196 PMCID: PMC10951390 DOI: 10.3389/fcvm.2024.1309840] [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: 10/08/2023] [Accepted: 02/27/2024] [Indexed: 03/22/2024] Open
Abstract
Penetrating aortic ulcer (PAU) represents a subset of acute aortic syndromes characterized by high rupture risk and management challenges, particularly in elderly patients with significant comorbidities. This case report showcases a 75-year-old patient with a history of coronary artery bypass graft (CABG) and with multiple PAUs involving the aortic arch, deemed unfit for conventional open surgery. A branched aortic endograft with a pre-cannulated side component for the left subclavian artery (LSA) was employed to preserve the patency of the previous CABG. Two computational fluid dynamics (CFD) simulations and a morphological analysis were performed on the pre- and post-intervention aortic configurations to evaluate changes in flow rate and pressure drop at LSA level and differences in the lumen size. The results revealed a decrease in the flow rate equal to 2.38% after the intervention and an increase in pressure drop of 4.48 mmHg, while the maximum differences in LSA cross-sectional areas and diameters were 1.49 cm2 and 0.64 cm, respectively. Minimal alteration in LSA blood flow due to the chosen intervention approach confirmed the effectiveness of the selected unibody design endograft with LSA preservation, ensuring myocardial perfusion. Therefore, CFD simulations demonstrate to be a powerful tool to evaluate the hemodynamic consequences of interventions by accurately estimating the main fluid dynamic parameters.
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Affiliation(s)
- Antonio Rizza
- U.O.C. Cardiologia Diagnostica e Interventistica, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Vincenzo Castiglione
- U.O.C. Cardiologia e Medicina Cardiovascolare, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Katia Capellini
- BioCardioLab, UOC Bioingegneria, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Cataldo Palmieri
- U.O.C. Cardiologia Diagnostica e Interventistica, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Emanuele Gasparotti
- BioCardioLab, UOC Bioingegneria, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Sergio Berti
- U.O.C. Cardiologia Diagnostica e Interventistica, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Simona Celi
- BioCardioLab, UOC Bioingegneria, Fondazione Toscana Gabriele Monasterio, Massa, Italy
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6
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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7
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Shao T, Bornak A, Kang N. Penetrating aortic ulcer and aortic intramural hematoma: Treatment strategy. Vascular 2023; 31:1086-1093. [PMID: 35578772 DOI: 10.1177/17085381221102785] [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: 11/17/2022]
Abstract
OBJECTIVES The indication, timing, and choice of the treatment modality for penetrating aortic ulcers (PAUs) and intramural hematoma (IMH) are frequently challenging. This article reviews these pathologies and their relation to aortic dissection and proposes a diagnostic and treatment algorithm. METHODS A review of literature on diagnosis and treatment of PAU and IMH was conducted. The PubMed database was searched using the terms "penetrating aortic ulcer" and "aortic intramural hematoma". Articles were reviewed and the studies involving diagnosis and management of PAU and IMH were included. We subsequently proposed a management algorithm for PAU and IMH based on available evidence. RESULTS PAU and IMH are distinct entities from aortic dissection, although they carry a significant risk of progression into dissection, aneurysm, and rupture. PAU and IMH originating in zone 0 of the aorta generally require surgical treatment. When the origin is beyond zone 0, a trial of medical therapy is recommended. Progression of disease on imaging studies, persistent uncontrolled pain, and certain high-risk features warrant surgery. High-risk features signaling risk of disease progression include PAU with IMH, PAU depth more than 10 mm, PAU diameter more than 20 mm, IMH thickness more than 10 mm, and maximum initial aortic diameter more than 40 mm. CONCLUSIONS High-quality evidence regarding the treatment of PAU and IMH is lacking. These entities can have a malignant course when they are present with associated symptoms and/or when they have associated high-risk features on imaging. An aggressive surgical approach is necessary in that group of patients.
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Affiliation(s)
- Tony Shao
- Division of Vascular and Endovascular Surgery, University of Miami, Miami, FL, USA
| | - Arash Bornak
- Division of Vascular and Endovascular Surgery, University of Miami, Miami, FL, USA
| | - Naixin Kang
- Division of Vascular and Endovascular Surgery, University of Miami, Miami, FL, USA
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8
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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9
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Garg I, Grist TM, Nagpal P. MR Angiography for Aortic Diseases. Magn Reson Imaging Clin N Am 2023; 31:373-394. [PMID: 37414467 DOI: 10.1016/j.mric.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Aortic pathologic conditions represent diverse disorders, including aortic aneurysm, acute aortic syndrome, traumatic aortic injury, and atherosclerosis. Given the nonspecific clinical features, noninvasive imaging is critical in screening, diagnosis, management, and posttherapeutic surveillance. Of the commonly used imaging modalities, including ultrasound, computed tomography, and MR imaging, the final choice often depends on a combination of factors: acuity of clinical presentation, suspected underlying diagnosis, and institutional practice. Further research is needed to identify the potential clinical role and define appropriate use criteria for advanced MR applications such as four-dimenional flow to manage patients with aortic pathologic conditions.
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Affiliation(s)
- Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1 University Of New Mexico, Albuquerque, NM 87131, USA
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin-Madison, E3/366 Clinical Science Center 600 Highland Avenue Madison, WI 53792, USA
| | - Prashant Nagpal
- Cardiovascular and Thoracic Radiology, University of Wisconsin School of Medicine and Public Health, E3/366 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA.
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10
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Sultan S, Acharya Y, Chua Vi Long K, Hatem M, Hezima M, Veerasingham D, Soliman O, Hynes N. Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review. Front Surg 2023; 10:1157457. [PMID: 37065997 PMCID: PMC10097442 DOI: 10.3389/fsurg.2023.1157457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundThoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.MethodsThis is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.ResultsThere were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.ConclusionAcute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- Correspondence: Sherif Sultan
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Keegan Chua Vi Long
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohamed Hatem
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohieldin Hezima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - David Veerasingham
- Department of Cardiothoracic Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
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11
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Feng J, Hu Y, Peng P, Li J, Ge S. Potential biomarkers of aortic dissection based on expression network analysis. BMC Cardiovasc Disord 2023; 23:147. [PMID: 36959563 PMCID: PMC10035273 DOI: 10.1186/s12872-023-03173-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/07/2023] [Indexed: 03/25/2023] Open
Abstract
Background Aortic dissection (AD) is a rare disease with severe morbidity and high mortality. Presently, the pathogenesis of aortic dissection is still not completely clear, and studying its pathogenesis will have important clinical significance. Methods We downloaded 28 samples from the Gene Expression Omnibus (GEO) database (Accession numbers: GSE147026 and GSE190635), including 14 aortic dissection samples and 14 healthy controls (HC) samples. The Limma package was used to screen differentially expressed genes. The StarBasev2.0 tool was used to predict the upstream molecular circRNA of the selected miRNAs, and Cytoscape software was used to process the obtained data. STRING database was used to analyze the interacting protein pairs of differentially expressed genes under medium filtration conditions. The R package "org.hs.eg.db" was used for functional enrichment analysis. Results Two hundred genes associated with aortic dissection were screened. Functional enrichment analysis was performed based on these 200 genes. At the same time, 2720 paired miRNAs were predicted based on these 200 genes, among which hsa-miR-650, hsa-miR-625-5p, hsa-miR-491-5p and hsa-miR-760 paired mRNAs were the most. Based on these four miRNAs, 7106 pairs of circRNAs were predicted to be paired with them. The genes most related to these four miRNAs were screened from 200 differentially expressed genes (CDH2, AKT1, WNT5A, ADRB2, GNAI1, GNAI2, HGF, MCAM, DKK2, ISL1). Conclusions The study demonstrates that miRNA-associated circRNA-mRNA networks are altered in AD, implying that miRNA may play a crucial role in regulating the onset and progression of AD. It may become a potential biomarker for the diagnosis and treatment of AD.
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Affiliation(s)
- Junbo Feng
- grid.412679.f0000 0004 1771 3402Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230000 People’s Republic of China
| | - Yuntao Hu
- grid.412679.f0000 0004 1771 3402Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230000 People’s Republic of China
| | - Peng Peng
- grid.412679.f0000 0004 1771 3402Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230000 People’s Republic of China
| | - Juntao Li
- grid.412679.f0000 0004 1771 3402Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230000 People’s Republic of China
| | - Shenglin Ge
- grid.412679.f0000 0004 1771 3402Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230000 People’s Republic of China
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12
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 424] [Impact Index Per Article: 212.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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13
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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14
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Xu X, Lu F, Li L. Thoracic endovascular aortic repair and optimal medical treatment for acute type B penetrating aortic ulcer associated with intramural hematoma. Medicine (Baltimore) 2022; 101:e31301. [PMID: 36397387 PMCID: PMC9666100 DOI: 10.1097/md.0000000000031301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
To compare the safety and efficacy of thoracic endovascular aortic repair (TEVAR) and optimal medical treatment (OMT) for type B penetrating aortic ulcer (PAU) associated with intramural hematoma (IMH). From January 2015 to December 2018, 68 consecutive patients with acute type B PAU associated with IMH were enrolled in the study. TEVAR was performed following initially OMT in 30 patients (group A), and OMT was performed in 38 patients (group B). Primary outcome was aortic-related mortality. Secondary outcomes included all-cause mortality, aortic-related adverse events, and complete aortic remodeling. There was no significant difference in the baseline characteristics of patients among the 2 groups except for the depth of PAU and the thickness of IMH. Patients in group B had a significant higher risk of aortic-related mortality (13.3% vs 0%, P = .045), as the same to aortic-related adverse events during follow-up. Compared to OMT, TEVAR contributed to the favorable aortic remodeling more significantly during the mid-term follow-up (85.7% vs 18.2%, P < .001). Comparing with optimal medical repair, TEVAR for patients with PAU associated with IMH could promote the favorable aortic remolding more significantly and result in lower aortic-related mortality during mid-term follow-up. It should be considered as the first-line therapeutic option when intervention is required.
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Affiliation(s)
- Xiuchun Xu
- Department of General Surgery, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
| | - Feng Lu
- Department of General Surgery, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
| | - Li Li
- Department of Clinical Laboratory, Binhai People’s Hospital, Yancheng, Jiangsu Province, People’s Republic of China
- * Correspondence: Li Li, Department of Clinical Laboratory, Binhai People’s Hospital, Yancheng, Jiangsu Province 224500, People’s Republic of China (e-mail: )
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15
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Cooper MA, Shahid Z, Upchurch GR. Endovascular Repair of Descending Thoracic Aortic Aneurysms. Adv Surg 2022; 56:129-150. [PMID: 36096564 DOI: 10.1016/j.yasu.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Descending thoracic aortic aneurysms (DTAAs) are an important cause of morbidity and mortality in the elderly. Once diagnosed, they should be surveilled and then repaired at a diameter of 5.5 to 6 cm, depending on the individual patient's physiologic and anatomic risk of repair. Thoracic endovascular aortic repair (TEVAR) is the preferred approach for repair and there are multiple procedural adjuncts that can expand indications for and use of TEVAR. Spinal cord injuries are an important and highly morbid complication after TEVAR and it is imperative to mitigate this risk.
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Affiliation(s)
- Michol A Cooper
- University of Florida College of Medicine, Division of Vascular Surgery and Endovascular Therapy, 1600 SW Archer Road, Room NG-45, Gainesville, FL 32610-0128 USA.
| | - Zain Shahid
- University of Florida College of Medicine, Division of Vascular Surgery and Endovascular Therapy, 1600 SW Archer Road, Room NG-45, Gainesville, FL 32610-0128 USA
| | - Gilbert R Upchurch
- University of Florida College of Medicine, Department of Surgery, 1600 SW Archer Road, Room 6174, Gainesville, FL 32610-0286 USA
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16
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Piazza M, Squizzato F, Porcellato L, Casali E, Grego F, Antonello M. Predictors of Intervention in Acute Type B Aortic Penetrating Ulcer and Intramural Hematoma. Semin Thorac Cardiovasc Surg 2022; 36:1-10. [PMID: 35931348 DOI: 10.1053/j.semtcvs.2022.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 11/11/2022]
Abstract
We aimed to investigate predictors of intervention of acute type B aortic penetrating ulcer (PAU) and intramural hematoma (IMH). We conducted a retrospective chart review of all patients admitted for acute type B PAU or IMH in a tertiary referral hospital. Indications to intervention were "complicated" (rupture, impending rupture, malperfusion) or "high risk for unfavorable outcome" (refractory hypertension and/or pain despite best medical treatment, morphologic aortic evolution, transition to a new aortic syndrome, or increase in IMH/PAU depth >5 mm) during the acute/subacute phase. The primary outcomes were overall mortality, aortic-related mortality, and freedom from intervention. Time-dependent outcomes were estimated with Kaplan-Meier curves. Cox proportional hazards models were used to identify predictors of intervention and mortality. There were 54 acute aortic syndromes, 37 PAUs and 17 IMHs. Mean age was 69 ± 14 years and 33 patients (62.2%) were male. Six (11.5%) patients had complicated aortic syndromes and underwent urgent repair. Two (3.7%) additional patients developed an impending rupture during the acute phase. Eleven (21.1%) patients were classified as at "high risk" during the initial hospitalization. Overall, 22 (40.7%) patients required an aortic intervention during the initial admission (n = 16, 72.7% during the acute phase; n = 6, 27.3% during the subacute phase). In-hospital mortality was 5.5% (1 PAU and 2 IMH), and was aorta-related in all cases. For IMH, disease extension in >3 aortic zones (HR 1.94, 95%CI 1.17-32.6; p = 0.038) and presence of ulcer-like projections (ULPs) (HR 1.23, 95%CI 1.02-9.41; p = 0.042) were associated with the need for intervention. There were no aortic-related deaths or intervention during the chronic phase. PAU width >20 mm (HR 1.68, 95%CI 1.07-16.08; p = 0.014), PAU depth >15 mm (HR 6.74, 95%CI 1.31-34.18; p = 021), PAU depth/total aortic diameter >0.3 (HR 4.31, 95%CI 1.17-20.32; p = 0.043), and location at the level of the paravisceral aorta (HR 2.24, 95%CI 1.23-4.70; p = 0.035) were significantly associated with need for intervention. Six additional (16.2%) PAUs required intervention during the chronic phase owing to PAU growth. Maximum aortic diameter >35 mm was significantly associated with intervention (HR 1.45, 95%CI 1.00-2.32; p = 0.037). Acute symptomatic type B IMHs and PAUs are characterized by a high risk of complications during the first month from presentation. Morphologic features associated with intervention were IMH with ULPs or extension in more than 3 aortic zones, as well as PAUs with depth>15 mm, width >20 mm, or depth/aortic diameter ratio>0.3. A strict follow-up protocol or consideration for early intervention within 30 days from presentation should be taken into account for these high-risk patients. During the chronic phase imaging follow-up is particularly important for PAUs in order to identify progression to saccular aneurysms.
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Affiliation(s)
- Michele Piazza
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Squizzato
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy..
| | - Luca Porcellato
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Eugenia Casali
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Rizza A, Negro F, Palmieri C, Clemente A, Berti S. Coronary Artery Bypass Salvage With Branched Aortic Endograft in a Patient With Aortic Arch Ulcer. JACC Case Rep 2022; 4:851-853. [PMID: 35912332 PMCID: PMC9334133 DOI: 10.1016/j.jaccas.2022.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 11/17/2022]
Abstract
Treatment of multiple penetrating aortic ulcers becomes troublesome if they involve the aortic arch. We report a percutaneous aortic repair using a unibody design endoprosthesis with a precannulated side component for the left subclavian artery to manage a large aortic arch ulcer and preserve the patency of previous coronary artery bypass graft. (Level of Difficulty: Advanced.)
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18
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Murana G, Di Marco L, Fiorentino M, Buia F, Brillanti G, Lovato L, Pacini D. Endovascular treatment of penetrating atherosclerotic ulcers of the arch and thoracic aorta: In-hospital and 5-year outcomes. JTCVS OPEN 2022; 10:12-21. [PMID: 36004263 PMCID: PMC9390477 DOI: 10.1016/j.xjon.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 03/01/2022] [Indexed: 11/24/2022]
Abstract
Objective Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic aorta diseases including penetrating aortic ulcer (PAU). The objective of this study was to analyze the results of TEVAR for the treatment of PAU in our population. Methods From January 1999 to January 2019, 830 patients with type B aortic syndromes were treated with TEVAR in our institution. Of these we selected 73 patients treated for a PAU. Clinical and radiologic follow-up was performed in all patients. Results Mean age of our population was 72 ± 8 years. Fifteen patients (20.5%) were treated in an emergency setting. The proximal landing zone was in arch zone 2 in 22 patients (30.1%). In-hospital mortality was 6.8% and was associated with acute presentation (P = .005). Distal arch delivery of the endograft was unrelated to mortality (Fisher exact test, P = .157). Survival at 1 and 5 years was 81.7% and 67.3%, respectively. Sixteen patients underwent reintervention of the thoracic aorta. Patients who underwent emergency surgery and older patients had a shorter survival (log rank test, P < .001). No difference in survival was shown according to the proximal landing zone (log rank P = .292) or the dimension of the thoracic aorta (log rank P = .067). In multivariable Cox regression analysis, only age older than 75 years was associated with 5-year mortality (hazard ratio, 6.60; 95% CI, 2.12-20.56); P < .001). Conclusions The use of TEVAR for treatment of aortic PAU is a safe procedure in an elective setting despite necessity of arch stent grafting. An early intervention performed at smaller aortic diameters of <55 mm might be beneficial in selected patients to improve late survival.
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Significance of systolic-phase imaging on full-phase ECG-gated CT angiography to detect intimal tears in aortic dissection. Heart Vessels 2022; 37:1947-1956. [PMID: 35569067 PMCID: PMC9515039 DOI: 10.1007/s00380-022-02093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/27/2022] [Indexed: 12/03/2022]
Abstract
Purpose For patients with aortic dissection (AD) and intramural hematoma (IMH), the optimal cardiac phase to detect intimal tears (IT) and ulcer-like projections (ULP) on retrospective electrocardiogram (ECG)-gated computed tomography angiography (CTA) remains unclear. The purpose of this study was to compare the accuracy of retrospective ECG-gated CTA for detecting IT in AD and ULP in IMH between each cardiac phase. Materials and methods A total of 75 consecutive patients with AD and IMH of the thoracic aorta were enrolled in this single-center retrospective study. The diagnostic performance to detect IT and ULP in the thoracic aortic regions (including the ascending aorta, aortic arch, and proximal and distal descending aorta) was compared in each cardiac phase on retrospective ECG-gated CTA. Results In the systolic phase (20%), the accuracy, sensitivity, and specificity to detect IT in AD was 64% (95% confidence interval [CI] 56–72%), 69% (95%CI 60–78%), and 25% (95%CI 3.3–45%), respectively. In the diastolic phase (70%), the accuracy, sensitivity, and specificity to detect IT in AD was 52% (95%CI 43–60%), 52% (95%CI 42–61%), and 50% (95%CI 25–75%), respectively. The accuracy to detect IT in AD on ECG-gated CTA was significantly higher in the systolic phase than that in the diastolic phase (P = 0.025). However, there were no differences in the accuracy (83%; 95%CI 78–89%), sensitivity (71%; 95%CI 62–80%), or specificity (100%; 95%CI 100%) to detect ULP in IMH between the cardiac cycle phases. Conclusion Although it is currently recommended for routine diagnosis of AD and IMH, single-diastolic-phase ECG-gated CTA has risk to miss some IT in AD that are detectable in the systolic phase on full-phase ECG-gated CTA. This information is critical for determining the optimal treatment strategy for AD.
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Penetrating Aortic Ulceration Treated with Castor Branched Aortic Stent Graft—A Case Series. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084809. [PMID: 35457675 PMCID: PMC9033075 DOI: 10.3390/ijerph19084809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/28/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
Penetrating aortic ulceration (PAU) is an acute aortic syndrome similar to aortic dissection and intramural hematoma. It is the result of a tunica intima ulceration due to atherosclerotic disease. This clinical condition can lead to serious complications and a poor short-term prognosis, especially in high-surgical-risk patients. We report three cases of patients referred to “Ospedale del Cuore” of Massa (Italy) with PAU at the aortic arch-proximal descending aorta level who could not undergo surgical intervention. For the first time in Italy, we successfully treated these patients with a full percutaneous implantation of a Castor branched aortic stent graft. Our case series shows that this type of endovascular graft is an effective, safe, and feasible treatment for PAU involving a distal aortic arch and avoiding surgery and related complications.
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Diagnosis and Management of Acute Aortic Syndromes: Dissection, Penetrating Aortic Ulcer, and Intramural Hematoma. Curr Cardiol Rep 2022; 24:209-216. [PMID: 35029783 PMCID: PMC9834910 DOI: 10.1007/s11886-022-01642-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Acute aortic syndromes, including aortic dissection, intramural hematoma, and penetrating aortic ulcer, are a group of highly morbid, related pathologies that are defined by compromised aortic wall integrity. The purpose of this review is to summarize current management strategies for acute aortic syndromes. RECENT FINDINGS All acute aortic syndromes have potential for high morbidity and mortality and must be quickly identified and managed with the appropriate algorithm to prevent suboptimal outcomes. Recent trials suggest that TEVAR is increasingly useful in stabilizing pathology of the descending thoracic aorta but when possible should be applied in a delayed fashion and with limited coverage to minimize neurologic complications. Treatment for acute aortic syndrome is frequently dictated by the anatomic location and extent of the wall compromise as well as patient comorbidities. Therapy is often individualized and often includes some combination of medical, procedural, and surgical intervention.
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Squizzato F, Hyun MC, Sen I, D'Oria M, Bower T, Oderich G, Colglazier J, DeMartino RR. Predictors of Long-Term Aortic Growth and Disease Progression in Patients with Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer. Ann Vasc Surg 2021; 81:22-35. [PMID: 34785342 DOI: 10.1016/j.avsg.2021.10.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/10/2021] [Accepted: 10/18/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND We aimed to identify predictors of long-term aortic diameter change and disease progression in a population cohort of patients with newly diagnosed aortic dissection (AD), intramural hematoma (IMH), or penetrating aortic ulcer (PAU). METHODS We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN-USA, residents diagnosed with AD, IMH, and PAU (1995-2015). The endpoints were aortic diameter change, freedom from clinical disease progression (any related intervention, aortic aneurysm, new aortic syndrome, rupture or death) and disease resolution (complete spontaneous radiological disappear). Linear regression was used to assess aortic growth rate; predictors of disease progression were identified with Cox proportional hazards. RESULTS Of 133 incident cases, 46 ADs, 12 IMHs, and 28 PAUs with sufficient imaging data were included. Overall median follow-up was 8.1 years. Aortic diameter increase occurred in 40 ADs (87%, median 1.0 mm/year), 5 IMHs (42%, median 0.2 mm/year) and 14 PAUs (50%, median 0.4 mm/year). Symptomatic presentation (P = 0.045), connective tissue disorders (P = 0.005), and initial aortic diameter >42 mm (P = 0.013) were associated with AD growth rate. PAU depth >9 mm (P = 0.047) and female sex (P = 0.013) were associated with aortic growth rate in PAUs and IMHs. At 10 years, freedom from disease progression was 22% (95% CI 12-41) for ADs, 44% (95% CI 22-92) for IMHs, and 46% (95% CI 27-78) for PAUs. DeBakey I/IIIB AD (HR 3.09; P = 0.038), initial IMH aortic diameter (HR 1.4; P = 0.037) and PAU depth >10 mm (HR 3.92; P = 0.018) were associated with disease progression. No AD spontaneously resolved; resolution rate at 10 years was 22% (95% CI 0-45) for IMHs and 11% (95% CI 0-23) for PAUs. CONCLUSIONS Aortic growth and clinical disease progression are observed in most patients with aortic syndromes, while spontaneous resolution is uncommon. Predictors of aortic growth and disease progression may be used to tailor appropriate follow-up and eventual early intervention.
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Affiliation(s)
| | - Meredith C Hyun
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN; Division of Vascular and Endovascular Surgery, University of Trieste, Trieste, Italy
| | - Thomas Bower
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Gustavo Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Zhang R, Sun L, Sun W, Yang S, Hao Y. Endovascular repair of penetrating aortic ulcers: Indications and single-center mid-term results. Ann Vasc Surg 2021; 81:129-137. [PMID: 34775025 DOI: 10.1016/j.avsg.2021.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although endovascular repair is used to treat penetrating aortic ulcers (PAUs), the indications for endovascular repair in PAUs remain controversial. The current study evaluated the mid-term results of endovascular repair for PAUs and further explored the endovascular indications for PAUs. METHODS We retrospectively reviewed the clinical data of patients who were diagnosed with PAUs and underwent endovascular repair in our department from October 2018 to August 2020. Endovascular indication included persistent or recurring symptoms, a maximum diameter of the PAU of greater than 20 mm, a maximum depth of the PAU of greater than 10 mm, an increase in the diameter of the aorta at the ulcer of greater than 10 mm annually, and multiple ulcers at the same or adjacent level of the aorta. Patient characteristics, anatomical parameters of the PAU, characteristics of endovascular repair and follow-up data were analyzed. RESULTS Fifteen patients were included in the study. Three patients had PAUs in the aortic arch, 6 PAUs were in the descending thoracic aorta, 4 PAUs were in the abdominal aorta, and 2 PAUS were in the descending thoracic and abdominal aortas. The average age was 70.60±8.27 years. Eight patients were symptomatic. The average depth of the PAUs was 7.32±2.74 mm, and the average diameter was 15.03±6.10 mm. The average operation time was 95.60±33.11 min. Postoperative hospital stay was 3.33±0.61 days. A left subclavian artery chimney stent was implanted in 3 aortic arch cases and 1 occluded case without adverse symptoms during the follow-up period. A bifurcated stent graft was placed in 3 abdominal aorta cases and exhibited good patency during the follow-up period. The duration of follow-up ranged from 3 to 24 months. The follow-up results showed that all PAUs were treated satisfactorily by endovascular repair, and no endoleaks or stent graft-related complications occurred. CONCLUSIONS Endovascular repair is a safe and effective treatment for PAUs, and it may be safely performed in elderly patients and patients with comorbidities. The endovascular indications for PAUs must be further studied and optimized.
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Affiliation(s)
- Rongjie Zhang
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China
| | - Long Sun
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China
| | - Wei Sun
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China
| | - Shiwei Yang
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China.
| | - Yingxue Hao
- Department of Vascular Surgery, Southwest Hospital, Army Medical University (Third Military Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing 400038, China.
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Frankel WC, Weldon SA, Green SY, Amarasekara HS, LeMaire SA, Coselli JS. Open Repair of Acute Type A Intramural Hematoma in 3 Patients. Tex Heart Inst J 2021; 47:290-297. [PMID: 33472224 DOI: 10.14503/thij-20-7242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Acute aortic syndrome encompasses classic aortic dissection and less common aortic phenomena, including intramural hematoma (IMH), a hemorrhage within the aortic media that occurs without a discrete intimal tear. We reviewed our experience with treating acute type A IMH to better understand this acute aortic syndrome. A review of our clinical database identified 1,902 proximal aortic repairs that were performed from January 2006 through December 2018; of these, 266 were for acute aortic syndrome, including 3 (1.1%) for acute type A IMH. Operative technique varied considerably. All IMH repairs involved hemiarch or total arch replacement. In all 3 patients, the IMH extended distally into the descending thoracic aorta. There were no operative deaths or major adverse events (stroke, paraplegia, paraparesis, or renal failure necessitating dialysis) that persisted to hospital discharge. Length of hospitalization ranged from 5 to 20 days. All 3 patients were alive at follow-up (range, 2-6 yr) and needed no aortic reintervention after their index or staged repairs. In our experience, repair of acute type A IMH was infrequent and could be either simple or complex. Despite our limited experience with this disease, we found that it can be repaired successfully in urgent and emergency cases. Following treatment guidelines for aortic dissection appears to be a reasonable strategy for treating IMH.
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Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Baylor College of Medicine; Houston, Texas 77030
| | - Scott A Weldon
- Division of Cardiothoracic Surgery, Baylor College of Medicine; Houston, Texas 77030
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Baylor College of Medicine; Houston, Texas 77030
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Baylor College of Medicine; Houston, Texas 77030
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Baylor College of Medicine; Houston, Texas 77030.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Baylor College of Medicine; Houston, Texas 77030.,Department of Cardiovascular Surgery, Texas Heart Institute and CHI St. Luke's Health-Baylor St. Luke's Medical Center; and Cardiovascular Research Institute, Baylor College of Medicine; Houston, Texas 77030
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine; Houston, Texas 77030.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Baylor College of Medicine; Houston, Texas 77030.,Department of Cardiovascular Surgery, Texas Heart Institute and CHI St. Luke's Health-Baylor St. Luke's Medical Center; and Cardiovascular Research Institute, Baylor College of Medicine; Houston, Texas 77030
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Meharban N, Munir W, Idhrees M, Bashir A, Bashir M. Management of the penetrating atherosclerotic ulcer in the descending thoracic aorta. Asian Cardiovasc Thorac Ann 2021; 29:661-668. [PMID: 34397303 DOI: 10.1177/02184923211033166] [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: 11/16/2022]
Abstract
Penetrating atherosclerotic ulcers present with an insidious onset with a reported mortality of 9%, varying across populations. With vast arrays of risk factors and potentially ominous complications, it is vital to efficiently provide optimum strategies for management. There exists controversy in the literature regarding management, especially for Type B penetrating atherosclerotic ulcers; the decision-making framework encompasses numerous factors in considerations for medical management versus invasive intervention and choice of endovascular versus open repair in the latter. The concomitant presence of intramural haematoma adds further complexity to the already intricate decision-making for management. We performed searches through PubMed and SCOPUS analysing studies reporting outcomes for management strategies for penetrating atherosclerotic ulcers treatment, focusing on Type B, further seeking to analyse studies reporting their experiences of PAU patients with concomitant intramural haematoma. Our review highlights the ambiguity and controversy existing in the literature, comprising studies burdened by their inherent hindering limitations of their single-centre retrospective experiences. Endovascular therapy has come to the forefront of penetrating atherosclerotic ulcers management, often considered first line therapy. In the case of penetrating atherosclerotic ulcers alongside intramural haematoma, there have been reports of potential hybrid surgical approaches to management. Studies further show misdiagnosis of penetrating atherosclerotic ulcers in earlier data sets further complicates management. However, it is clear we must progress on the journey towards precision medicine, allowing delivery of optimum care to our patients.
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Affiliation(s)
- Nehman Meharban
- Barts and the London School of Medicine and Dentistry, 4952Queen Mary University of London, UK
| | - Wahaj Munir
- Barts and the London School of Medicine and Dentistry, 4952Queen Mary University of London, UK
| | | | - Ali Bashir
- Institute of Cardiac and Aortic Disorders, 363954SRM Institutes for Medical Science (SIMS Hospitals), India
| | - Mohamad Bashir
- Vascular Surgery Department, 155510Royal Blackburn Teaching Hospital, UK
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DeCarlo C, Latz CA, Boitano LT, Kim Y, Tanious A, Schwartz SI, Patell R, Mohebali J, Dua A. Prognostication of Asymptomatic Penetrating Aortic Ulcers: A Modern Approach. Circulation 2021; 144:1091-1101. [PMID: 34376058 DOI: 10.1161/circulationaha.121.054710] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Literature detailing the natural history of asymptomatic penetrating aortic ulcers (PAU) is sparse and lacks long-term follow-up. This study sought to determine the rate of asymptomatic PAU growth over time and adverse events from asymptomatic PAU. Methods: A cohort of patients with asymptomatic PAU from 2005-2020 was followed. One ulcer was followed per patient. Primary endpoints were change in size over time and the composite of symptoms, radiographic progression, rupture, and intervention; cumulative incidence function estimated the incidence of the composite outcome. Ulcer size and rate of change were modeled using a linear mixed effects model. Patient and anatomic factors were evaluated as potential predictors of the outcomes. Results: There were 273 patients identified. Mean age was 75.5±9.6 years; 66.4% were male. The majority of ulcers were in the descending thoracic aorta (53.9%), followed by abdominal aorta (41.4%), and aortic arch (4.8%). Fusiform aneurysmal disease was present in 21.6% of patients at a separate location; 2.6% had an associated intramural hematoma; 23.6% had at least one other PAU. Symptoms developed in one patient who ruptured; 8 patients (2.9%) underwent an intervention for PAU (one for rupture, 2 for radiographic progression, 5 for size/growth) at a median of 3.1 years (IQR:1.0-6.5) after diagnosis. Five and 10-year cumulative incidence of the primary outcome, adjusted for competing risk of death, was 3.6% (95% CI: 1.6-6.9%) and 6.5% (95% CI: 3.1-11.4%), respectively. For 191 patients with multiple CT scans (760 total CT's) with median radiographic follow-up of 3.50 years (IQR:1.20-6.63 years), mean initial ulcer width, ulcer depth, and total diameter in millimeters (mm) was 13.6, 8.5, and 31.4, respectively. Small, but statistically significant change over time was observed for ulcer width (0.23 mm/year) and total diameter (0.24 mm/year); ulcer depth did not significantly change over time. Hypertension, hyperlipidemia, diabetes, initial ulcer width>20 mm, thrombosed PAU, and associated saccular aneurysm were associated with larger changes in ulcer size over time, however the magnitude of difference was small, ranging from 0.4-1.9 mm/year. Conclusions: Asymptomatic PAU displayed minimal growth and infrequent complications including rupture. Asymptomatic PAU may be conservatively managed with serial imaging and risk-factor modification.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam Tanious
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Samuel I Schwartz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Rushad Patell
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Nakamura Y, Doi K, Yamaguchi S, Umeda E, Sakai O, Shimabukuro K. A life-threatening spontaneous ascending aortic rupture due to a small penetrating aortic ulcer. SAGE Open Med Case Rep 2021; 9:2050313X211037784. [PMID: 34394939 PMCID: PMC8358570 DOI: 10.1177/2050313x211037784] [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: 03/03/2021] [Accepted: 07/20/2021] [Indexed: 12/02/2022] Open
Abstract
We reported a rare case of spontaneous frank rupture of a small (4 mm) penetrating aortic ulcer in the ascending aorta resulted in catastrophic bleeding. The ulcer only created a pinhole wound in the adventitia without saccular aneurysms, intramural hematomas, or aortic dissections. Notably, the wound could be directly closed because the aortic wall was intact only 5 mm away from the bleeding site. The postoperative course was uneventful, and the patient was discharged on the 11th postoperative day. After 8 months, follow-up computed tomography showed no abnormality of the aortic wall at the repair site.
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Affiliation(s)
- Yasuhito Nakamura
- Department of Cardiovascular Surgery, School of Medicine, Gifu University, Gifu, Japan
| | - Kiyoshi Doi
- Department of Cardiovascular Surgery, School of Medicine, Gifu University, Gifu, Japan
| | - Syojiro Yamaguchi
- Department of Cardiovascular Surgery, School of Medicine, Gifu University, Gifu, Japan
| | - Etsuji Umeda
- Department of Cardiovascular Surgery, School of Medicine, Gifu University, Gifu, Japan
| | - Osamu Sakai
- Department of Cardiovascular Surgery, School of Medicine, Gifu University, Gifu, Japan
| | - Katsuya Shimabukuro
- Department of Cardiovascular Surgery, School of Medicine, Gifu University, Gifu, Japan
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Martín-Gutiérrez E, Gualis-Cardona J, Maiorano P, Castillo-Pardo L, Laguna-Núñez G, Castaño-Ruiz M. Tratamiento conservador vs. quirúrgico en el hematoma intramural agudo tipo A: revisión bibliográfica, metaanálisis y análisis de diferencias temporales y geográficas. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Pandey G, Sharma P. The Management of Patients With Penetrating Aortic Ulcers: A Systematic Review. Vasc Endovascular Surg 2021; 55:730-740. [PMID: 34044670 DOI: 10.1177/15385744211017110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Penetrating aortic ulcers (PAUs) are an entity within acute aortic syndrome. They often remain undiagnosed and are found incidentally or when they become symptomatic. Management is currently guided by clinical judgment. This review aims to identify indications for treatment and inform management. METHODS We searched PubMed for studies on the management of PAUs. The outcome measures were mortality, progression and resolution of symptoms. RESULTS This review incorporates 27 studies involving 1356 patients with PAU. Data was available regarding symptoms for 1213 patients (494 symptomatic, 719 asymptomatic). Overall late mortality for PAUs was found to be higher than 30-day mortality. Early mortality was higher for symptomatic patients as compared to those with asymptomatic PAUs. Early mortality was lowest for PAUs treated with endovascular interventions (5%), followed by PAUs managed medically and highest following open surgical management. Indications for treatment included symptoms, progression/instability, aortic diameter >5 cm, concomitant aortic pathology or pleural effusion. 13% of patients managed conservatively at initial presentation demonstrated progression and were considered for intervention subsequently. 9% of patients required reintervention after initial endovascular surgery. CONCLUSION Endovascular treatment, if anatomically suitable, should be considered as first line treatment for symptomatic PAUs. Patients with asymptomatic PAUs, if associated with high-risk features such as PAU diameter >20 mm, PAU depth >10 mm, aortic diameter >42 mm, concomitant pathology, morphological change or an infective etiology, should also be considered for intervention. Small asymptomatic PAUs with no high-risk features may be managed conservatively but must undergo regular surveillance.
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Affiliation(s)
- Gargi Pandey
- Department of Vascular Surgery, 112001Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Paritosh Sharma
- Department of Vascular Surgery, 112001Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
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Jiang X, Liu Y, Chen B, Jiang J, Shi Y, Ma T, Lin C, Guo D, Xu X, Fu W, Dong Z. Clinical features and outcomes after endovascular therapy for penetrating aortic ulcer and intramural hematoma. Vascular 2021; 30:191-198. [PMID: 33906559 DOI: 10.1177/17085381211012573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To identify the differences between clinical features and outcomes after endovascular therapy for penetrating aortic ulcer (PAU) and intramural hematoma (IMH). METHODS From January 2009 to March 2020, patients who underwent endovascular therapy for PAU and IMH were enrolled. Information on patient demographics, presentation, PAU and IMH morphology, laboratory examination, and clinical follow-up information was collected and analyzed. Univariate analysis was performed to identify the differences between IMH and PAU, and Kaplan-Meier was used to calculate the cumulative survival rate and freedom from reintervention. RESULTS A total of 114 patients were enrolled; 80 (70.2%) of them were diagnosed with PAU. Compared with PAU, patients with IMH were younger (p = 0.006), more likely to be admitted emergently (p = 0.001), had longer hospital stay (p = 0.028), and had higher levels of C-reactive protein (p = 0.030). Meanwhile, patients with IMH were more likely to be associated with hypertension (p = 0.020) and pleural effusion (p < 0.001) and less likely to have a history of acute coronary syndrome (p = 0.019) and prior cardiovascular intervention (p = 0.017). The five-year freedom from reintervention and cumulative survival rate were 94.2% (95% confidential interval, 88.9%-99.9%) and 87.8% (95% confidential interval, 79.5%-96.9%) in PAU patients and 89.6% (95% confidential interval, 75.8%-99.9%) and 85.1% (95% confidential interval, 68.0%-99.9%) in IMH patients, respectively. There was no significant difference in freedom from reintervention (p = 0.795) or cumulative survival rate (p = 0.817). CONCLUSIONS IMH appeared to occur in younger patients with hypertension and usually had an acute onset, while PAU was more likely to be found incidentally in older patients with atherosclerosis. Endovascular therapy was effective in both IMH and PAU patients with encouraging outcomes.
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Affiliation(s)
- Xiaolang Jiang
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yifan Liu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bin Chen
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junhao Jiang
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shi
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changpo Lin
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Xu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Department of Vascular Surgery, Institute of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Huang XZ, Xu P. Pseudoaneurysm after Common Carotid Artery Atherosclerotic Rupture. Radiology 2021; 299:540. [PMID: 33877919 DOI: 10.1148/radiol.2021203807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Online supplemental material is available for this article.
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Affiliation(s)
- Xing-Zhi Huang
- From the Department of Ultrasonography, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Road, Nanchang 330006, China
| | - Pan Xu
- From the Department of Ultrasonography, First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Road, Nanchang 330006, China
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Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, Murad MH, Perry RJ, Singh MJ, Veeraswamy RK, Wang GJ. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73:55S-83S. [DOI: 10.1016/j.jvs.2020.05.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
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Thoracic endovascular aortic repair for symptomatic penetrating aortic ulcers and intramural hematomas is associated with poor outcomes. J Vasc Surg 2020; 74:63-70.e1. [PMID: 33340703 DOI: 10.1016/j.jvs.2020.11.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/19/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The natural history of penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs) of the aorta has not been well described. Although repair is warranted for rupture, unremitting chest pain, or growth, no threshold has been established for treating those found incidentally. Thoracic endovascular aortic repair (TEVAR) offers an attractive approach for treating these pathologic entities. However, the periprocedural and postoperative outcomes have not been well defined. METHODS Patients aged ≥18 years identified in the Vascular Quality Initiative database who had undergone TEVAR for PAUs and/or IMHs from January 2011 to February 2020 were included. We identified 1042 patients, of whom 809 had follow-up data available. The patient demographics and comorbidities were analyzed to identify the risk factors for major adverse events (MAEs) and postoperative and late mortality. RESULTS The cohort was 54.8% female, and 69.9% were former smokers, with a mean age of 71.1 years. Comorbidities were prevalent, with 57.8% classified as having American Society of Anesthesiologists class 4. Of the 1042 patients, 89.8% had hypertension, 28.3% chronic obstructive pulmonary disease, 17.9% coronary artery disease, and 12.2% congestive heart failure. Patients were predominately symptomatic (74%), and 44.5% had undergone nonelective repair. The MAE incidence was 17%. The independent predictors of MAEs were a history of coronary artery disease, nonwhite race, emergent procedural indication, ruptured presentation, and deployment of two or more endografts. In-hospital mortality was 4.3%. Of the index hospitalization mortalities, 73% were treatment related. For the 809 patients with follow-up (mean, 25.1 ± 19 months), the all-cause mortality was 10.6%. The predictors of late mortality during follow-up included age >70 years, ruptured presentation, and a history of chronic obstructive pulmonary disease and end-stage renal disease. A subset analysis comparing symptomatic (74%) vs asymptomatic (26%) patients demonstrated that the former were frequently women (58.2% vs 45.3%; P < .001), with a greater incidence of MAEs (20.6% vs 6.9%; P < .001), including higher in-hospital reintervention rates (5.9% vs 1.5%; P = .002) and mortality (5.6% vs 0.7%; log-rank P = .015), and a prolonged length of stay (6.9 vs 3.7 days; P < .0001), despite similar procedural risks. During follow-up, late mortality was greater in the symptomatic cohort (12.2% vs 6.5%; log-rank P = .025), with all treatment-related mortalities limited to the symptomatic group. CONCLUSIONS We found significantly greater morbidity and mortality in symptomatic patients undergoing repair compared with asymptomatic patients, despite similar baseline characteristics. Asymptomatic patients treated with TEVAR had no treatment-related mortality during follow-up, with the overall prognosis largely dependent on preexisting comorbidities. These findings, in conjunction with increasing evidence highlighting the risk of disease progression and attendant morbidity associated with these aortic entities, suggest a need for natural history studies and definitive guidelines on the elective repair of IMHs and PAUs.
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Population-Based Assessment of Aortic-Related Outcomes in Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer. Ann Vasc Surg 2020; 69:62-73. [DOI: 10.1016/j.avsg.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 11/20/2022]
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Jiang X, Pan T, Zou L, Chen B, Jiang J, Shi Y, Ma T, Lin C, Guo D, Xu X, Yang J, Shi Z, Zhu T, Dong Z, Fu W. Outcomes of endovascular stent graft repair for penetrating aortic ulcers with or without intramural hematoma. J Vasc Surg 2020; 73:1541-1548. [PMID: 33091512 DOI: 10.1016/j.jvs.2020.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 10/04/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We investigated the outcomes of endovascular repair for penetrating aortic ulcers (PAUs) with and without intramural hematoma (IMH). METHODS Patients with PAUs who had undergone thoracic endovascular aortic repair (TEVAR) or endovascular abdominal aortic repair (EVAR) at our center were enrolled. Patient demographics, presenting symptoms, and anatomic characteristics were collected and analyzed to investigate the TEVAR/EVAR indications, perioperative complications, and mortality. RESULTS We identified 138 patients with PAU. Of the 138 patients, 58 (42.0%) had also had IMH. Compared with the patients without IMH, the patients with IMH had had significantly greater emergency admission rates (P < .01), a larger aortic diameter (P = .03), and a greater incidence of stent-induced new entry development (P = .02). No significant differences were found in mortality or freedom from reintervention between patients with PAUs with and without IMH during follow-up. However, the cumulative survival rates calculated using Kaplan-Meier analysis for patients who had undergone TEVAR/EVAR during their first hospitalization were significantly greater than those who had undergone delayed TEVAR/EVAR during follow-up. CONCLUSIONS TEVAR/EVAR was safe and effective, with encouraging outcomes for patients with PAUs with or without IMH, and can be used more aggressively for symptomatic patients. The presence of PAUs with IMH did not seem to adversely affect long-term mortality. However, but stent-induced new entry was more likely to develop.
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Affiliation(s)
- Xiaolang Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianyue Pan
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lingwei Zou
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bin Chen
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junhao Jiang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shi
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changpo Lin
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daqiao Guo
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Xu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jue Yang
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenyu Shi
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ting Zhu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Weiguo Fu
- Institute of Vascular Surgery, Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Yang L, Zhang QY, Wang XZ, Zhao X, Liu XZ, Wang P, Jing QM, Han YL. Long-Term Imaging Evolution and Clinical Prognosis Among Patients With Acute Penetrating Aortic Ulcers: A Retrospective Observational Study. J Am Heart Assoc 2020; 9:e014505. [PMID: 32893719 PMCID: PMC7726995 DOI: 10.1161/jaha.119.014505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Acute penetrating aortic ulcers (PAUs) are reported to dynamically evolve into different clinical outcomes ranging from regression to aortic rupture, but no practice guidelines are available in China. Methods and Results All 109 patients with acute PAUs were monitored clinically. At 30 days follow-up, 31 patients (28.44%) suffered from aortic-related adverse events, a composite of aortic-related mortality, aortic dissection, or an enlarged ulcer. In addition, 7 (6.42%) patients had clinically related adverse events, including all-cause mortality, cerebral stroke, nonfatal myocardial infarction, acute heart failure alone or acute exacerbation of chronic heart failure, acute renal failure, arrhythmia, and bleeding events. In the present study, the intervention criteria for the Chinese PAU population included a PAU diameter of 12.5 mm and depth of 9.5 mm. The multivariate analysis showed that an ulcer diameter >12.5 mm (hazard ratio [HR], 3.846; 95% CI, 1.561-9.476; P=0.003) and an ulcer depth >9.5 mm (HR, 3.359; 95% CI, 1.505-7.494; P=0.003) were each independent predictors of aortic-related events. Conclusions Patients with acute PAUs were at high risk for aortic-related adverse events and clinically related adverse events within 30 days after onset. Patients with an ulcer diameter >12.5 mm or an ulcer depth >9.5 mm have a higher risk for disease progression, and early intervention may be recommended.
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Affiliation(s)
- Lin Yang
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China.,College of Medicine and Biological Information Engineering Northeastern University Shenyang China
| | - Quan-Yu Zhang
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Xiao-Zeng Wang
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Xin Zhao
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Xuan-Ze Liu
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Ping Wang
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Quan-Min Jing
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
| | - Ya-Ling Han
- Department of Cardiology General Hospital of Northern Theater Command Shenyang China
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Kho J, Petrou M. A Review on the Surgical Management of Intramural Haematoma of the Aorta. HEARTS 2020; 1:75-85. [DOI: 10.3390/hearts1020009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
Intramural haematoma (IMH) of the aorta is one of the causes of acute aortic syndrome which often requires emergency or urgent life-saving surgery. In this review, we discuss the pathophysiology, epidemiology, clinical presentation, diagnostic imaging, surgery and clinical outcomes associated with IMH.
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Yanagaki S, Ueda T, Masuda A, Ota H, Onaka Y, Kojima M, Hattori T, Mihara W, Takase K. Detection of the intimal tear in aortic dissection and ulcer-like projection in intramural hematoma: usefulness of full-phase retrospective ECG-gated CT angiography. Jpn J Radiol 2020; 38:1036-1045. [PMID: 32710132 PMCID: PMC7591413 DOI: 10.1007/s11604-020-01008-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/15/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE To compare the accuracy of non-electrocardiogram (ECG)-gated CT angiography (CTA), single-diastolic-phase ECG-gated CTA, and full-phase ECG-gated CTA in detecting the intimal tear (IT) in aortic dissection (AD) and ulcer-like projection (ULP) in intramural hematoma (IMH). MATERIALS AND METHODS A total of 81 consecutive patients with AD and IMH of the thoracic aorta were included in this single-center retrospective study. Non-ECG-gated CTA, single-diastolic-phase ECG-gated CTA, and full-phase ECG-gated CTA were used to detect the presence of the IT and ULP in thoracic aortic regions including the ascending aorta, aortic arch, and proximal and distal descending aorta. RESULTS The accuracy of detecting the IT and ULP was significantly greater using full-phase ECG-gated CTA (88% [95% CI: 100%, 75%]) than non-ECG-gated CTA (72% [95% CI: 90%, 54%], P = 0.001) and single-diastolic-phase ECG-gated CTA (76% [95% CI: 93%, 60%], P = 0.008). CONCLUSION Full-phase ECG-gated CTA is more accurate in detecting the IT in AD and ULP in IMH, than non-ECG-gated CTA and single-diastolic-phase ECG-gated CTA.
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Affiliation(s)
- Satoru Yanagaki
- Departments of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Seiryo 1-1, Sendai, 980-8574, Japan.
| | - Takuya Ueda
- Departments of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Seiryo 1-1, Sendai, 980-8574, Japan
| | - Atsuro Masuda
- Departments of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Seiryo 1-1, Sendai, 980-8574, Japan
| | - Hideki Ota
- Departments of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Seiryo 1-1, Sendai, 980-8574, Japan
| | - Yuta Onaka
- Departments of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Seiryo 1-1, Sendai, 980-8574, Japan
| | - Masatoshi Kojima
- Department of Radiology, Seikeikai Chiba Medical Center, 1-7-1, Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Takashi Hattori
- Departments of Cardiovascular Surgery, Seikeikai Chiba Medical Center, 1-7-1, Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Wahei Mihara
- Departments of Cardiovascular Surgery, Seikeikai Chiba Medical Center, 1-7-1, Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Kei Takase
- Departments of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Seiryo 1-1, Sendai, 980-8574, Japan
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Brown JA, Arnaoutakis GJ, Kilic A, Gleason TG, Aranda‐Michel E, Sultan I. Medical and surgical management of acute type B aortic intramural hematoma. J Card Surg 2020; 35:2324-2330. [DOI: 10.1111/jocs.14823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James A. Brown
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
| | - George J. Arnaoutakis
- Division of Thoracic and Cardiovascular SurgeryUniversity of Florida Gainesville Florida
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Thomas G. Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Edgar Aranda‐Michel
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
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Short- and long-term outcomes in isolated penetrating aortic ulcer disease. J Vasc Surg 2020; 72:84-91. [DOI: 10.1016/j.jvs.2019.09.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/12/2019] [Indexed: 01/16/2023]
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Abstract
Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management.
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Li YL, Ye JC, Yancu H, Liu B, Wang YZ, Wang WJ, Wang W, Li D, Chang HY. Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Associated with Retrograde Type A Intramural Hematoma. J Vasc Interv Radiol 2020; 31:1334-1341. [PMID: 32127315 DOI: 10.1016/j.jvir.2020.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/03/2020] [Accepted: 01/20/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate feasibility and efficacy of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) associated with retrograde type A intramural hematoma (IMH). MATERIALS AND METHODS From April 2013 to January 2017, 15 consecutive patients with TBAD associated with retrograde type A IMH who underwent TEVAR were reviewed retrospectively. There was no cardiac tamponade, aortic regurgitation, involvement of coronary artery, or sign of cerebral ischemia in these patients. Enhanced CT was used in 4 patients to diagnose malperfusion of abdominal visceral arteries or lower extremity artery and underwent emergent TEVAR. For the remaining 11 patients, repeated enhanced CT after initial medical treatment within 24 hours from onset of pain showed expansion of IMH in 8 patients or presence of periaortic hematoma in 3 patients. Delayed TEVAR was scheduled for these cases. RESULTS Successful deployment of the stent graft was achieved in all patients. There were no severe postoperative complications, such as retrograde type A aortic dissection or aortic rupture. Sudden death occurred in 1 patient 3 months after the procedure. Thrombosis of the false lumen, shrinkage of the diameter of the aorta, and complete absorption of the IMH were observed in the remaining patients at a mean follow-up of 19.8 months ± 6.57. CONCLUSIONS TEVAR for treatment of TBAD with retrograde type A IMH is feasible and effective. It represents a treatment option for patients with TBAD associated with type A IMH with a proximal entry tear located in the descending aorta.
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Affiliation(s)
- Yu-Liang Li
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Jia-Cheng Ye
- Department of Intervention Medicine, the First Hospital of Nanping Affiliated to Fujian Medical University, Nanping, Fujian, China
| | - Hertzanu Yancu
- Department of Radiology, Ben Gurion University of the Negev, Beersheba, Israel
| | - Bin Liu
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Yong-Zheng Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Wu-Jie Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Wei Wang
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Dong Li
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China
| | - Hai-Yang Chang
- Department of Intervention Medicine, the Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, Shandong, People's Republic of China; Interventional Oncology Institute of Shandong University, Jinan, Shandong, People's Republic of China.
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Chen YY, Yen HT, Lo CM, Wu CC, Huang DKR, Sheu JJ. Natural courses and long-term results of type A acute aortic intramural haematoma and retrograde thrombosed type A acute aortic dissection: a single-centre experience. Interact Cardiovasc Thorac Surg 2020; 30:113-120. [PMID: 31518390 DOI: 10.1093/icvts/ivz222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/09/2019] [Accepted: 08/16/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Few reports on the outcomes of patients treated for Stanford type A acute aortic intramural haematoma (TAAIMH) and retrograde thrombosed type A acute aortic dissection exist. This study aimed to evaluate their long-term results and predictors of adverse outcomes. METHODS We retrospectively analysed 40 patients with TAAIMH and retrograde thrombosed type A acute aortic dissection. All patients underwent urgent surgery on presentation of life-threatening complications. Before discharge, 18 patients underwent open aortic surgery, and 22 were treated with medical therapy alone. Clinical features of these patients and image appearances were reviewed, and the relationship with overall survival, aortic events, and aortic death was investigated. RESULTS The in-hospital mortality rate was 4.5% (1 patient) with medical therapy alone and 11.1% (2 patients) with surgical intervention. No patient with initial medical therapy required urgent surgery for life-threatening complications beyond 3 days of admission. The overall survival and aortic death-free survival rates at 1, 5 and 10 years were 85.0%, 72.5% and 59.8% and 90.0%, 81.6% and 77.1%, respectively. TAAIMH associated with penetrating aortic ulcer (PAU) was a risk factor of aortic events (P = 0.020) and significantly influenced aortic death-free survival (P = 0.003). CONCLUSIONS Urgent surgery for complicated TAAIMH and retrograde thrombosed type A acute aortic dissection patients and initial medical therapy for uncomplicated patients show favourable long-term survival rates. TAAIMH is frequently associated with PAU; PAU enlargement is common. Although PAU can remain stable for years, it is a strong predictor of poor prognosis. For optimal long-term results, surgical repair is recommended for TAAIMH associated with PAU.
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Affiliation(s)
- Yen-Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsu-Ting Yen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ming Lo
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Chen Wu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - David Kwan-Ru Huang
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jiunn-Jye Sheu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Li JD, Ma WG, Sun LZ. Conservative arch management versus aggressive arch reconstruction for type A intramural hematoma. Ann Cardiothorac Surg 2019; 8:551-555. [PMID: 31667152 DOI: 10.21037/acs.2019.07.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jin-Dong Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
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Norton EL, Williams DM, Kim KM, Wu X, Khaja MS, Patel HJ, Deeb GM, Yang B. Management of malperfusion syndrome in acute type A aortic intramural hematoma. Ann Cardiothorac Surg 2019; 8:540-550. [PMID: 31667151 DOI: 10.21037/acs.2019.07.03] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background We report the outcomes of acute type A aortic intramural hematoma (ATAAIMH) with malperfusion treated with endovascular intervention and delayed open aortic repair. Methods Between April 1998 and April 2018, 644 patients were treated at our institution with an acute type A aortic dissection (ATAAD) or ATAAIMH, 82 (13%) had intramural hematomas (IMHs) including 12 (15%) with malperfusion syndrome (MPS) and 70 (85%) without MPS (no MPS). Data was obtained through medical record review, the Society of Thoracic Surgeons data elements, and the National Death Index database. Results Both MPS and No MPS groups had similar comorbidities including coronary artery disease, hypertension, diabetes, and peripheral vascular disease; however, those with MPS were sicker on admission with higher rates of acute renal failure (50% vs. 1%, P<0.0001) and acute paralysis (17% vs. 0%, P=0.02). Patients with MPS amenable to endovascular reperfusion (n=10) underwent endovascular fenestration/stenting and delayed aortic repair. Those with cerebral or coronary MPS (n=2) and those without MPS (n=70) underwent emergent open aortic repair. Of the ten patients undergoing fenestration/stenting, seven went on to aortic repair, one survived to discharge without aortic repair, one died from aortic rupture on hospital day 34, and one died from organ failure prior to aortic repair. Following endovascular fenestration/stenting or aortic repair, all patients with MPS had higher in-hospital mortality (17% vs. 0%), P=0.02. Following aortic repair, patients with MPS had more postoperative sepsis and longer postoperative length of stay (all P<0.05). However, both groups had a 0% operative mortality (including in-hospital and 30-day mortality following aortic repair). The 5-year survival of all ATAAIMH patients was 79%. The 2-year survival was significantly better in the No MPS group (94% vs. 62%, P=0.006). Conclusions ATAAIMH with MPS can be effectively managed with upfront endovascular fenestration/stenting followed by delayed aortic repair.
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Affiliation(s)
| | | | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Minhaj S Khaja
- Department of Radiologyy, Michigan Medicine, Ann Arbor, MI, USA
| | - Himanshu J Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - G Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA
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Nauta F, de Beaufort H, Mussa FF, De Vincentiis C, Omura A, Matsuda H, Trimarchi S. Management of retrograde type A IMH with acute arch tear/type B dissection. Ann Cardiothorac Surg 2019; 8:531-539. [PMID: 31667150 PMCID: PMC6785497 DOI: 10.21037/acs.2019.08.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/04/2019] [Indexed: 01/16/2023]
Abstract
The incidence of intramural hematomas (IMH) in acute dissection (AD) patients varies between 6% and 30% in the literature, most frequently involving only the descending aorta (58%) than the arch or ascending aorta (42%). In this setting, IMH that initiate in the descending aorta, but extend into the arch or ascending aorta have been described, and referred to as a retrograde type A IMH. In these patients the risk of neurological or cardiac complications are high, and therefore an open surgical or hybrid approach has been proposed as the most appropriate. Nevertheless, the endovascular management of such lesions in surgically unfit patients for open surgery have been offered with acceptable outcomes, although the risk of landing in an unsuitable proximal landing zone is evident. In conclusion, retro-TAIMH is an acute aortic syndrome and should be managed as such. The recommended treatment strategy is open surgery for treating ascending or arch involvement, and TEVAR/medical, based on a complication-specific approach, for those with only descending localization. In those patients in whom retro-TAIMH is associated with an acute B dissection presenting with a proximal entry tear located into the descending aorta, a TEVAR represents an option treatment.
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Affiliation(s)
- Foeke Nauta
- Department of Cardiothoracic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Hector de Beaufort
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Firas F Mussa
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Carlo De Vincentiis
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Atsushi Omura
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Santi Trimarchi
- Department of Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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Filippone G, La Barbera G, Valentino F, Ocello S, Guardì D, Ferro G, Talarico F. Conservative Management of Uncomplicated Acute Type B Intramural Hematoma of the Aorta Not Always Is the Right Solution. Ann Vasc Surg 2019; 61:469.e5-469.e11. [PMID: 31394219 DOI: 10.1016/j.avsg.2019.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 11/19/2022]
Abstract
The natural course of intramural hematoma (IMH) of the aorta remains unpredictable and despite an increasing amount of literature reports its treatment is still debatable. IMH typically is diagnosed by computed tomography that has permitted to identify specific images whose onset, in uncomplicated cases, appears to be associated to a dismal prognosis. We report on a case series of acute uncomplicated type B IMH in which early detection of such findings, given the expected poor prognosis associated to the aorta-related mortality, suggests the need to shift toward an aggressive endovascular aortic repair in this subset of patients.
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Affiliation(s)
| | | | | | | | - Diego Guardì
- Vascular and Endovascular Unit, ARNAS Civico, Palermo, Italy
| | - Gabriele Ferro
- Vascular and Endovascular Unit, ARNAS Civico, Palermo, Italy
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Piffaretti G, Fontana F, Tadiello M, Guttadauro C, Piacentino F, Bush RL, Socrate AM, Tozzi M. Arch and access vessel complications in penetrating aortic ulcer managed with thoracic endovascular aortic repair. Ann Cardiothorac Surg 2019; 8:471-482. [PMID: 31463209 DOI: 10.21037/acs.2019.06.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background To analyze our experience and to describe access and arch-related challenges when performing thoracic endovascular aortic repair (TEVAR) for penetrating aortic ulcers (PAUs). Methods This is a single-center, observational, cohort study. Between October 2003 and February 2019, 48 patients with PAU were identified; 37 (77.1%) treated with TEVAR were retrospectively analyzed. Primary major outcomes were early (<30 days) and late survival, freedom from aortic-related mortality (ARM), and a composite endpoint of arch/vascular access-related complications. Results On admission, 17 (45.9%) patients were symptomatic with 4 (10.8%) presenting with rupture. In-hospital mortality was 8.1% (n=3). We observed 10 (27.0%) arch/access-related complications. There were 4 (10.8%) arch issues: 2 transient ischemic attacks and 2 retrograde acute type A dissections which required emergent open conversion for definitive repair. Access issues occurred in 6 (16.2%) patients: 3 (8.1%) required common iliac artery conduit, and 1 (2.7%) patient required iliac artery angioplasty to deliver the stent-graft. In addition, 2 (5.4%) patients developed access complications which required operative repair [femoral patch angioplasty (n=2), and femoral pseudoaneurysmectomy (n=1)]. Arch/access-related mortality rate was 5.4% (n=2) and median follow-up was 24 (range, 1-156; IQR, 3-52) months. Estimated survival was 87.1% (standard error: 0.6; 95% CI: 71.2-84.9%) at 1 year, and 63.3% (SE: 0.9; 95% CI: 44.1-79%) at 4 years. Estimated freedom from reintervention was 88.9% (SE: 0.5; 95% CI: 74.8-95.6%) at 1 year, and 84.2% (SE: 0.7; 95% CI: 67.3-93.2%) at 4 years. No arch/access-related issues developed during the follow-up period. Conclusions Our experience confirms that vascular access and aortic arch issues are still a challenging aspect of performing TEVAR for PAUs. Our cumulative 27% rate of access/arch issues is lower than previously reported due to both technological advancements and meticulous management of both access routes and arch anatomy.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Federico Fontana
- Interventional Radiology, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Marco Tadiello
- Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Chiara Guttadauro
- Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Filippo Piacentino
- Interventional Radiology, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Ruth L Bush
- University of Houston College of Medicine, Houston, TX, USA
| | | | - Matteo Tozzi
- Vascular Surgery, Department of Medicine and Surgery, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
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Weiss S, Sen I, Huang Y, Killian JM, Harmsen WS, Mandrekar J, Chamberlain AM, Goodney PP, Roger VL, DeMartino RR. Cardiovascular morbidity and mortality after aortic dissection, intramural hematoma, and penetrating aortic ulcer. J Vasc Surg 2019; 70:724-731.e1. [PMID: 30871888 DOI: 10.1016/j.jvs.2018.12.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/11/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The nonaortic cardiovascular morbidity and mortality of patients with aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) is unknown. We aimed to define the rates of cardiovascular (CV) events in a cohort of patients with newly diagnosed AD, IMH, and PAU. METHODS We performed a retrospective review of all Olmsted County, Minnesota, residents diagnosed with AD, IMH, and PAU from 1995 to 2015. The primary outcome was nonaortic CV death. The secondary outcome was a first-time nonfatal CV event (myocardial infarction, heart failure [HF], or stroke). The outcomes were compared with age- and sex-matched population referents using Cox proportional hazards regression, with adjustment for comorbidities. RESULTS A total of 133 patients (77 with AD, 21 with IMH, 35 with PAU; 57% male) with a mean age of 71.8 ± 14.1 years were identified. The median follow-up was 10 years. Compared with the population referents, the patients with AD/IMH/PAU had an increased risk of CV death (adjusted hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.4-4.2; P = .003) and an increased risk of any first-time nonfatal CV event (adjusted HR, 3.0; 95% CI, 1.9-4.8; P < .001), mainly resulting from an increased risk of first-time HF (adjusted HR, 2.7; 95% CI, 1.7-4.3; P < .001). When excluding events within 14 days of the diagnosis, the patients with AD/IMH/PAU remained at increased risk of CV death (adjusted HR, 2.6; 95% CI, 1.4-4.7; P = .002), any first-time nonfatal CV event (adjusted HR, 2.6; 95% CI, 1.5-4.4, P <.001), and first-time HF (adjusted HR 2.5, 95% CI 1.5-4.3; P < .001). CONCLUSIONS Compared with the population referents, the patients with AD/IMH/PAU had a two- to threefold risk of nonaortic CV death, any first-time nonfatal CV event, and first-time HF. These data implicate the need for long-term cardiovascular management for patients with AD/IMH/PAU.
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Affiliation(s)
- Salome Weiss
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn; Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Ying Huang
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jill M Killian
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - W Scott Harmsen
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Jay Mandrekar
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | | | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Liu YJ, Zhang QY, Du ZK, Yang L, Zhang L, He RX, Wang Y, Han YL, Wang XZ. Long-term follow-up and clinical implications in Chinese patients with aortic intramural hematomas. Int J Cardiol 2018; 270:268-272. [PMID: 29945807 DOI: 10.1016/j.ijcard.2018.06.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/06/2018] [Accepted: 06/18/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intramural hematomas (IMHs) are reported to dynamically evolve into different clinical outcomes ranging from regression to aortic rupture, but no practice guidelines are available in China. OBJECTIVE To determine the evolution of IMHs after long-term follow-up and to identify the predictive factors of IMH outcomes in the Chinese population. METHODS A total of 123 IMH patients with clinical and imaging follow-up data were retrospectively studied. The primary endpoints were aortic disease-related death, aortic dissection, penetrating aortic ulcer (PAU), thickening of the aortic hematoma and aortic complications requiring surgical or endovascular treatment. RESULTS All 123 IMH patients were monitored clinically. The follow-up duration ranged from 1.4 to 107 months (median, 20 months). Thirty-nine patients had type A IMH, and 84 had type B. The multivariate analysis showed that a baseline MAD ≥ 44.75 mm (2.9% vs 61.4%, P < 0.001) and acute PAUs (2.9% vs 34.1%, P = 0.008) were independent predictors of aorta-related events. CONCLUSIONS Medication and short-term imaging are recommended for Chinese IMH patients with a hematoma thickness < 10.45 mm and a baseline MAD < 44.75 mm. Rigorous medical observation should also be performed during the acute phase of IMH.
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Affiliation(s)
- Yan-Jie Liu
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Quan-Yu Zhang
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Zhan-Kui Du
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Lin Yang
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Lei Zhang
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Rui-Xia He
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Ya Wang
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China
| | - Ya-Ling Han
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China.
| | - Xiao-Zeng Wang
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Shenyang Military Region, Shenyang, 110016, China.
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