Acute aortic dissection: an update

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Coronary artery involvement in type A aortic dissection: Fate of the coronaries

BACKGROUND

Type A aortic dissection (TAAD) involves a tear in the intimal layer of the thoracic aorta proximal to the left subclavian artery, and hence, carries a high risk of mortality and morbidity and requires urgent intervention. This dissection can extend into the main coronary arteries. Coronary artery involvement in TAAD can either be due to retrograde extension of the dissection flap into the coronaries or compression and/or blockage of these vessels by the dissection flap, possibly causing myocardial ischemia. Due to the emergent nature of TAAD, coronary involvement is often missed during diagnosis, thereby delaying the required intervention.

AIMS

The main scope of this review is to summarize the literature on the incidence, mechanism, diagnosis, and treatment of coronary artery involvement in TAAD.

METHODS

A comprehensive literature search was performed using multiple electronic databases, including PubMed, Ovid, Scopus and Embase, to identify and extract relevant studies.

RESULTS

Incidence of coronary artery involvement in TAAD was seldom reported in the literature, however, some studies have described patients diagnosed either preoperatively, intraoperatively following aortic clamping, or even during autopsy. Among the few studies that reported on this matter, the treatment choice for coronary involvement in TAAD was varied, with the majority revascularizing the coronary arteries using coronary artery bypass grafting or direct local repair of the vessels. It is well-established that coronary artery involvement in TAAD adds to the already high mortality and morbidity associated with this disease. Lastly, the right main coronary artery was often more implicated than the left.

CONCLUSION

This review reiterates the significance of an accurate diagnosis and timely and effective interventions to improve prognosis. Finally, further large cohort studies and longer trials are needed to reach a definitive consensus on the best approach for coronary involvement in TAAD.

Potential metabolomic biomarkers for the identification and diagnosis of type A acute aortic dissection in patients with hypertension

Objectives

Most patients with acute aortic dissection (AAD) have a history of hypertension. Diagnosis of AAD in patients with hypertension at an early stage is complicated and challenging. This study aimed to explore the distinctive metabolic changes in plasma samples of AAD patients with hypertension and patients with hypertension only and provide early identification and diagnosis of AAD in patients with hypertension.

Materials and methods

We collected blood samples from 20 patients with type A AAD and hypertension admitted to the emergency department and physically examined other 20 patients with hypertension as controls. The plasma metabolomic profiles of these patients were determined using untargeted metabolomics with ultra-high-performance liquid chromatography-quadrupole time-of-flight mass spectrometry.

Results

A total of 38 metabolites that differed between the AAD and hypertension groups were screened. In the positive ion mode, 12 metabolites were different between the two groups, and in the negative ion mode, 26 metabolites were different. Among the 26 different metabolites detected by the negative ion mode, 21 were significantly upregulated and five were downregulated in patients with AAD compared to patients with hypertension. Moreover, five metabolites were upregulated and seven were significantly downregulated in patients with AAD compared to those with hypertension, as detected by the positive ion mode. The metabolites differentially expressed in AAD were mainly involved in lipid metabolism (fatty acid biosynthesis, biosynthesis of unsaturated fatty acids, and linoleic acid metabolism), carbohydrate metabolism (galactose, fructose, and mannose metabolisms), and membrane transport (ATP-binding cassette transporters). Interestingly, plasma hydrocortisone and dimethylglycine concentrations were significantly increased in patients with type A AAD, with the highest area under the curve value (AUC = 0.9325 or 0.9200, respectively) tested by the receiver operating characteristic curve analysis.

Conclusion

This study provides possible metabolic markers for the early clinical diagnosis of AAD in patients with hypertension.

The metabolic analysis in human aortic tissues of aortic dissection

Background

The metabolic profile of human aortic tissues is of great importance. Among the analytical platforms utilized in metabolomics, LC‐MS provides broad metabolome coverage. The non‐targeted metabolomics can comprehensively detect the entire metabolome of an organism and find the metabolic characteristics that have significant changes in the experimental group and the control group and elucidate the metabolic pathway concerning the recognized metabolites. Employing non‐targeted metabolomics is helpful to develop biomarkers for disease diagnosis and disease pathology research; for instance, Aortic aneurysm (AA) and Aortic dissection (AD).

Aim

This study sought to describe the non‐targeted analysis of 18 aortic tissue samples, comparing between AA and AD.

Material & Methods

Our experimental flow included dividing the samples into (AA, nine samples) and (AD, nine samples), SCIEX quadrupole timeofflight tandem mass spectrometer (TripleTOF) 6600+ mass spectrometer data refinement, MetDNA database analysis, and pathway analysis. We performed an initial validation by setting quality control parameters to evaluate the stability of the analysis system during the computer operation. We then used the repeatability of the control samples to examine the stability of the instrument during the entire analysis process to ensure the reliability of the results.

Results

Our study found 138 novel metabolites involved in galactose metabolism.

Discussion

138 novel metabolites found in this study will be further studied in the future.

Conclusion

Our study found 138 novel metabolites between AA and AD, which will provide viable clinical data for future studies aimed to implement galactose markers in aortic tissue analysis.

Cerebral infarction and risk factors in acute type A aortic dissection with arch branch extension

OBJECTIVE

Stanford type A aortic dissection (AAD) may affect the supra-aortic arteries, which are associated with acute ischemic stroke (AIS) or transient ischemic attack (TIA). This study aimed to investigate cerebral perfusion, the infarction incidence and risk factors in AAD patients.

METHODS

A total of 156 consecutive AAD patients were enrolled and divided into two groups according to whether the aortic arch branches were involved: the affected group (n = 90) and the unaffected group (n = 66). Clinical, echocardiographic/carotid Doppler data and cerebral infarction morbidity were compared between the groups. Independent predictors of 30-day AAD mortality were identified through multivariable Cox regression, and perioperative risk factors were analyzed.

RESULTS

In total, 57.7% of AAD patients had aortic arch branch involvement. Abnormal Doppler waveforms were more common in the affected group (p < 0.05). Regarding intracranial perfusion, the blood flow volumes (BFVs) of the bilateral internal carotid arteries (ICAs) and right vertebral artery (RVA) in the affected group were significantly reduced (p < 0.05). The incidence of cerebral infarction in the affected group was significantly higher than that in the unaffected group (35.6% vs. 19.7%, p = 0.031). Multivariable analysis revealed that age >45 years old, right internal carotid artery (RICA) involvement and reduced left ventricular ejection fraction (LVEF) were significant predictors of perioperative death.

CONCLUSIONS

Aortic arch branch involvement is common in patients with AAD and is associated with reduced cerebral blood flow (especially on the right side) and a higher incidence of cerebral infarction. Age, extension of the RICA dissection and LVEF impairment are independent risk factors for AAD-related death.

Cluster-Based Ensemble Learning Model for Aortic Dissection Screening

Aortic dissection (AD) is a rare and high-risk cardiovascular disease with high mortality. Due to its complex and changeable clinical manifestations, it is easily missed or misdiagnosed. In this paper, we proposed an ensemble learning model based on clustering: Cluster Random under-sampling Smote–Tomek Bagging (CRST-Bagging) to help clinicians screen for AD patients in the early phase to save their lives. In this model, we propose the CRST method, which combines the advantages of Kmeans++ and the Smote–Tomek sampling method, to overcome an extremely imbalanced AD dataset. Then we used the Bagging algorithm to predict the AD patients. We collected AD patients’ and other cardiovascular patients’ routine examination data from Xiangya Hospital to build the AD dataset. The effectiveness of the CRST method in resampling was verified by experiments on the original AD dataset. Our model was compared with RUSBoost and SMOTEBagging on the original dataset and a test dataset. The results show that our model performed better. On the test dataset, our model’s precision and recall rates were 83.6% and 80.7%, respectively. Our model’s F1-score was 82.1%, which is 4.8% and 1.6% higher than that of RUSBoost and SMOTEBagging, which demonstrates our model’s effectiveness in AD screening.

Preoperative acute lung injury and oxygenation impairment occurred in the patients with acute aortic dissection

Acute lung injury (ALI) and oxygenation impairment (OI) frequently occur in the patients with acute aortic dissection (AAD), which may necessitate mechanical ventilation and result in adverse outcomes. This paper aims to increase clinicians’ awareness of the severe respiratory complications in the patients with AAD, and provide the overview of the epidemiology, adverse outcomes, pathogenesis, predictive markers and therapeutic modalities of the concurrent conditions. Currently, it is considered that inflammatory response plays a great role in the pathogenesis of ALI and OI in the patients with AAD, but the definite pathogenesis remains unclear. Given the great importance of the prediction of the occurrence of the severe respiratory complication at a very early stage, some inflammatory biomarkers have been investigated to predict the occurrence of ALI and OI in several studies. C-reactive protein was found to have a significant predictive effect for the development of ALI and OI. Early use of beta-blockers and the use of bindarit could prevent the occurrence of OI and ALI. Ulinastatin could also improve oxygenation in the patients with type-A AAD. Prevention and management of ALI and OI in AAD remain a great challenge. The definite pathogenesis should be clearly clarified and further studies should be performed to look for potential effective way to predict and manage the severe respiratory conditions.

Nitric Oxide Inhalation Therapy Attenuates Postoperative Hypoxemia in Obese Patients with Acute Type A Aortic Dissection

Objective

To investigate the differences between inhaled nitric oxide (iNO) treatment and conventional therapy in the treatment of postoperative hypoxemia in obese patients with acute type A aortic dissection (ATAAD).

Methods

ATAAD patients diagnosed and treated with emergency surgery in our hospital from June 2017 to December 2019 were retrospectively analyzed. Patients with postoperative hypoxemia were divided into the iNO group and control group. Propensity score matching was used to analyze clinical characteristics and results of the two groups.

Results

A total of 218 ATAAD patients with BMI ≥ 25 were treated with surgery. Among them, 115 patients developed refractory hypoxemia (64 in the control group and 51 in the iNO group). Patients in the iNO group had significantly shorter invasive mechanical ventilation time, intensive care unit (ICU) stay, and hospital stay. After 6 h of iNO treatment, the PaO2/FiO2 ratio in the iNO group increased significantly, and this ratio was higher than that in the control group at 6, 12, 24, 48, and 72 h after treatment.

Conclusion

Low-dose iNO could improve oxygenation and shorten mechanical ventilation and ICU stay in patients with hypoxemia after ATAAD surgery, but without significant side effects or increase in postoperative mortality or morbidity. These findings provide a basis for a randomized multicenter controlled trial to assess the efficacy of iNO in the treatment of hypoxemia after ATAAD surgery.

Comparative analysis of postoperative sexual dysfunction and quality of life in type a aortic dissection patients of different ages

Background

To compare postoperative sexual dysfunction (SD) and quality of life (QOL) in Type A Aortic Dissection (AAD) Patients of Different Ages.

Methods

From January 2018 to December 2019, 204 AAD postoperative survivors in Union Hospital of Fujian Medical University were selected and were divided into young group (less than 50 years old) and elderly group (more than 50 years old). We evaluated SD according to the male International Erectile Dysfunction Index (IIEF-5) and female sexual function index (FSFI). The Short Form 12 Health Survey Questionnaire (SF-12) and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) were used to investigate the QOL, Quick Inventory Depressive Symptomatology-Self Report (QIDS-SR) and the Beck Depression Inventory-II (BDI-II) to investigate depressive symptoms.

Results

One hundred seventy-five patients completed all the questionnaire (85.8%). The total SD prevalence rate was 38.9% (68 cases), with 27.4% of the young (20 cases) and 47.1% of the elderly (48 cases). The age of non-SD and SD patients was 49.0 ± 11.5 and 56.9 ± 10.8 years, respectively (P = 0.03). Compared with non-SD patients, the total physical health of SD patients was significantly worse (P = 0.04), however, the mental health was not significantly worse (P = 0.77); the depressive symptoms did not expressed a significant difference between the SD and non-SD groups (QIDS-SR P = 0.15, BDI-II P = 0.06). Total physical health scores in the young SD group did not show significant better than elderly SD group (P = 0.24), however, total mental health scores showed significantly worse (P = 0.04), depressive symptoms scores were significantly higher (QIDS-SR P = 0.03, BDI-II P = 0.04).

Conclusion

The postoperative AAD SD prevalence of elderly is higher than that of young, and the total physical health of SD patients is poorer than those without SD patients. The young SD patients did not show a significant higher physical health scores than the elderly SD patients, instead, the young SD patients were more psychologically affected than the elderly SD patients, whose mental health was worse, and depression symptoms were more obvious, suggesting that the factors affecting the QOL of postoperative SD patients are related to physical factors, but the young postoperative SD patients mainly affected by psychological factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01468-0.

Early Outcomes of Three Total Arch Replacement Strategies for DeBakey Type I Aortic Dissection

Background: This study employed three surgical techniques: total arch replacement (TAR) with frozen elephant trunk (FET), aortic balloon occlusion technique (ABO) and hybrid aortic arch repair (HAR) on patients with type I aortic dissection in Fuwai Hospital, aiming to compare the early outcomes of these surgical armamentariums.

Methods: From January 2016 to December 2018, an overall 633 patients (431 of TAR+FET, 122 of HAR, and 80 of ABO) with type I aortic dissection were included in the study. Thirty-day mortality, stroke, paraplegia, re-exploration for bleeding, and renal replacement therapy were compared using the matching weight method (MWM).

Results: After MWM process, the baseline characteristics were comparable among three TAR groups. It showed that ABO group had the longest cardiopulmonary bypass (p < 0.001) and aortic cross-clamp time (p < 0.001), while the operation time was longest in the HAR group (p = 0.039). There was no significant difference in 30-day mortality among groups (p = 0.783). Furthermore, the incidence of stroke (p = 0.679), paraplegia (p = 0.104), re-exploration for bleeding (p = 0.313), and CRRT (p = 0.834) demonstrated no significant difference. Of note, no significant differences were found regarding these outcomes even before using MWM.

Conclusions: Based on the early outcomes, the three TAR approaches were equally applicable to type I aortic dissection. We may choose the specific procedure relatively flexibly according to patient status and surgeon's expertise. Importantly, long-term investigations are warranted to determine whether above approaches remain to be of equivalent efficacy and safety.

Epidemiology of thoracoabdominal aortic aneurysms

Thoracoabdominal aortic aneurysms, although rare, continue to be associated with high morbidity and mortality in the modern era of vascular surgery, and knowledge of this disease is essential for those in clinical practice. Given the clinically silent nature of the disease, it is difficult to determine disease incidence, with most epidemiologic recommendations not made based on evidence regarding those diagnosed with the disease, but extrapolated from data on surgical outcomes. It appears that although men are more likely to develop thoracoabdominal aortic aneurysms, the distribution is not as skewed as in abdominal aortic aneurysms. Current evidence suggests that Black and Hispanic patients continue to have disproportionately poor disease outcomes, mostly attributed to later presentation and undergoing interventions at lower-volume centers. Although select patients meet criteria for disease screening based on personal or family history of aneurysmal disease, general population screening has not been recommended by any professional organization to date. Vascular surgeons need to continue to be at the forefront of thoracoabdominal aortic aneurysm management, especially as care becomes centered around comprehensive "aortic care centers" and as more endovascular therapies become available.

An early aortic dissection screening model and applied research based on ensemble learning

Background

As a particularly dangerous and rare cardiovascular disease, aortic dissection (AD) is characterized by complex and diverse symptoms and signs. In the early stage, the rate of misdiagnosis and missed diagnosis is relatively high. This study aimed to use machine learning technology to establish a fast and accurate screening model that requires only patients' routine examination data as input to obtain predictive results.

Methods

A retrospective analysis of the examination data and diagnosis results of 53,213 patients with cardiovascular disease was conducted. Among these samples, 802 samples had AD. Forty-two features were extracted from the patients' routine examination data to establish a prediction model. There were five ensemble learning models applied to explore the possibility of using machine learning methods to build screening models for AD, including AdaBoost, XGBoost, SmoteBagging, EasyEnsemble and XGBF. Among these, XGBF is an ensemble learning model that we propose to deal with the imbalance of the positive and negative samples. The seven-fold cross validation method was used to analyze and verify the performance of each model. Due to the imbalance of the samples, the evaluation indicators were sensitivity and specificity.

Results

Comparative experiments showed that the sensitivity of XGBF was 80.5%, which was better than the 16.1% of AdaBoost, 15.7% of XGBoost, 78.0% of SmoteBagging and 77.8% of EasyEnsemble. Additionally, XGBF had relatively high specificity, and the training time consumption was short. Based on these three indicators, XGBF performed best, and met the application requirements, which means through careful design, we can use machine learning technology to achieve early AD screening.

Conclusions

Through reasonable design, the ensemble learning method can be used to build an effective screening model. The XGBF has high practical application value for screening for AD.

Predictors for the development of preoperative oxygenation impairment in acute aortic dissection in hypertensive patients

BACKGROUND

Acute aortic dissection (AAD) is an acute life-threatening cardiovascular disease, which is frequently complicated with oxygenation impairment (OI). We aim to investigate predictors of the development of OI in the patients with AAD.

METHODS

We retrospectively collected clinical data of AAD in hypertensive patients from July 2012 to March 2020. The patients included in this study were divided into OI (+) group (oxygenation index≤200) and OI (-) group (oxygenation index> 200). Both groups were compared according to demographic and clinical characteristics, and laboratory findings. Characteristics of hypertension in the patients with AAD were described. Predictors for the development of OI were assessed. And cutoff values were determined by receiver operating characteristics (ROC) curve.

RESULTS

A total of 208 patients were included in this study and the incidence of OI was 32.2%. In OI (+) group, patients had significantly higher peak body temperature (37.85 ± 0.60 vs 37.64 ± 0.44 °C, P = .005), higher levels of CRP (42.70 ± 28.27 vs 13.90 ± 18.70 mg/L, P = .000) and procalcitonin (1.07 ± 3.92 vs 0.31 ± 0.77μg/L, P = .027), and lower levels of albumin (34.21 ± 5.65 vs 37.73 ± 4.70 g/L, P = .000). Spearman's rank correlation test showed that the minimum oxygenation index was positively correlated with albumin, and was negatively correlated with the peak body temperature, serum CRP, procalcitonin, BNP and troponin. The stepwise multiple linear regression analysis showed that the peak body temperature, serum CRP and albumin were independently associated with development of OI. An optimal cutoff value for CRP for predicting OI was ≥9.20 mg/L, with a sensitivity of 91.0% and a specificity of 61.0%.

CONCLUSIONS

The peak body temperature, serum CRP and albumin were independent predictors of OI development in the patients with AAD. The serum CRP on admission≥9.20 mg/L might be a valuable and reliable indicator in predicting the development of OI.

Classification of Aortic Dissection and Rupture on Post-contrast CT Images Using a Convolutional Neural Network

Aortic dissections and ruptures are life-threatening injuries that must be immediately treated. Our national radiology practice receives dozens of these cases each month, but no automated process is currently available to check for critical pathologies before the images are opened by a radiologist. In this project, we developed a convolutional neural network model trained on aortic dissection and rupture data to assess the likelihood of these pathologies being present in prospective patients. This aortic injury model was used for study prioritization over the course of 4 weeks and model results were compared with clinicians' reports to determine accuracy metrics. The model obtained a sensitivity and specificity of 87.8% and 96.0% for aortic dissection and 100% and 96.0% for aortic rupture. We observed a median reduction of 395 s in the time between study intake and radiologist review for studies that were prioritized by this model. False-positive and false-negative data were also collected for retraining to provide further improvements in subsequent versions of the model. The methodology described here can be applied to a number of modalities and pathologies moving forward.

Oxygenation impairment in patients with acute aortic dissection is associated with disorders of coagulation and fibrinolysis: a prospective observational study

Background

Stanford type-A acute aortic dissection (AAD) is typically accompanied by oxygenation impairment before surgery. In addition, inflammation, coagulation and fibrinolysis also impair blood oxygenation. However, our understanding of the concentration of these factors in bronchoalveolar lavage fluid (BALF) has not been reported. The objective of the study was to investigate the impact of preoperative acute lung injury (ALI) on postoperative oxygenation impairment and to explore the effect of coagulation and fibrinolysis in blood and BALF.

Methods

This investigation utilized a prospective observational study design, which was registered at www.clinicaltrials.gov (identifier NCT01894334). The study included 53 patients undergoing surgery for Stanford type-A AAD at an academic hospital in China between October 2013 and July 2014. Preoperative ALI was identified according to the oxygenation index calculated by the PaO₂/FiO₂ ratio. The subjects were divided into the ALI group (oxygenation index ≤300 mmHg) or the control group (oxygenation index >300 mmHg). The primary outcome was patient oxygenation index, while secondary outcomes were concentrations of tissue factor (TF), tissue factor pathway inhibitor (TFPI), and plasminogen activator inhibitor-1 (PAI-1) in serum and BALF.

Results

The incidence of preoperative ALI for Stanford type-A AAD patients was 41.5%. Stanford type-A AAD patients with preoperative ALI had a lower postoperative oxygenation index (104.6±31.7 vs. 248.7±48.0 mmHg, P<0.001), higher concentrations of TF in serum and BALF (F=133.67, P<0.001; F=68.14, P<0.001), higher concentrations of TFPI in serum and BALF (F=31.98, P<0.001; F=45.58, P<0.001), and higher concentrations of PAI-1 in serum and BALF (F=213.88, P<0.001; F=107.95, P<0.001) when compared with those without preoperative ALI. Type-A AAD patients also showed a greater loss of blood (1,524±458 vs. 1,175±327 mL, P=0.040), longer mechanical ventilation time in the ICU (27.24±8.37 vs. 17.33±7.36 h, P<0.001), longer total stay in the ICU (42.27±10.85 vs. 33.45±9.05 h, P=0.002), and longer total hospital stay (17.77±5.00 vs. 13.48±3.97 days, P=0.001). Multivariate linear regression analysis indicated that preoperative PAI-1 in BALF, and TF in both serum and BALF were significantly associated with preoperative oxygenation impairment in patients with Stanford type-A AAD.

Conclusions

Preoperative ALI caused more serious postoperative oxygenation impairment for Stanford type-A AAD, and coagulation and fibrinolysis appear to play critical roles in this process. Preoperative PAI-1 in BALF and TF in both serum and BALF were significant factors related to the occurrence of preoperative oxygenation impairment for Stanford type-A AAD.

Inflammation is related to preoperative hypoxemia in patients with acute Stanford type A aortic dissection

Background

Preoperative hypoxemia is a frequent complication of acute Stanford type A aortic dissection (ATAAD). The aim of the present study was to determine which factors were associated with hypoxemia.

Methods

A series of data were collected in a statistical analysis to evaluate preoperative hypoxemia in patients with ATAAD. After retrospectively analyzing data for 172 patients, we identified the risk factors for preoperative hypoxemia. Hypoxemia was defined by an arterial partial pressure of oxygen to fraction of inspired oxygen (PaO₂/FiO₂) ratio of 200 or lower. Subsequent to identifying the patient population, a prospective study was conducted using ulinastatin as a preoperative intervention. The ulinastatin group received ulinastatin at a total dose of 300,000 units prior to surgery. All the pertinent factors were investigated through univariate and multiple logistic regression analysis.

Results

The factors associated with preoperative hypoxemia in ATAAD comprised the following: body mass index (BMI) ≥25; white blood cell count (WBC) and neutrophil counts; levels of C-reactive protein (CRP), D-dimer, and interleukin-6 (IL-6); ATAAD involving the celiac trunk, renal artery, or mesenteric artery. Logistic regression analysis showed that CRP and IL-6 levels were independent predictive factors. We found that ulinastatin effectively could improve oxygenation, since compared to the control group the oxygenation in the ulinastatin group was significantly improved.

Conclusions

Systemic inflammatory reactions played a vital role in preoperative hypoxemia after the onset of ATAAD. The oxygenation of the patient could be improved significantly by inhibiting the inflammatory response prior to surgery.

Acute Myocardial Infarction and Concomitant Stroke as the Manifestations in a Patient with Type A Aortic Dissection: A Case Report with Three Years of Follow-Up

A 55-year-old male patient presented with repeated acute retrosternal chest pain. Twelve-lead electrocardiogram and cardiac enzymes revealed non-ST elevation myocardial infarction. He was treated as non-ST elevation myocardial infarction at first. The symptoms of left-sided hemiparesis and aphasia occurred later on after admission. The results of emergent brain computed tomography and magnetic resonance imagining demonstrated acute stroke. The unusual presentation warned us of the possibility of aortic dissection. Besides the reports of heart and vessels computed tomography indicated aortic dissection as the underlying cause. Emergent surgical repair with preservation of the aortic valve led to a good recovery of heart and cerebral function. To the best of our knowledge, there were only three cases in the review of literature presenting with acute myocardial infarction and concurrent stroke resulting from acute aortic dissection.

Vitamin D Deficiency Is Associated with Increased Osteocalcin Levels in Acute Aortic Dissection: A Pilot Study on Elderly Patients

An imbalance between degradation and reconstruction of the aortic wall is one of the leading causes of acute aortic dissection (AAD). Vitamin D seems an intriguing molecule to explore in the field of AAD since it improves endothelial function and protects smooth muscle cells from inflammation-induced remodeling, calcification, and loss of function, all events which are strongly related to the aging process. We quantified 25-hydroxy vitamin D, calcium, parathormone, bone alkaline phosphatase, and osteocalcin levels in 24 elderly AAD patients to identify a potential pathological implication of these molecules in AAD. Median 25-hydroxy vitamin D (10.75 ng/mL, 25th–75th percentiles: 6.86–19.23 ng/mL) and calcium levels (8.70 mg/dL, 25th–75th percentiles: 7.30–8.80 mg/dL) suggested hypovitaminosis D and a moderate hypocalcemia. Thirty-eight percent of AAD patients had severe (<10 ng/mL), 38% moderate (10–20 ng/mL), and 24% mild 25-hydroxy vitamin D deficiency (20–30 ng/mL). A significant inverse correlation was observed between 25OHD and osteocalcin levels. All the other molecules were unchanged. A condition of hypovitaminosis D associated to an increase in osteocalcin levels is present in AAD patients. The identification of these molecules as new factors involved in AAD may be helpful to identify individuals at high risk as well to study preventing strategies.

Aortic Remodeling Following Sun's Procedure for Acute Type A Aortic Dissection

Background

Sun’s procedure is a surgical technique widely used in type A aortic dissection. The purpose of this study was to analyze clinical outcomes and morphologic changes in true and false lumen by computed tomography (CT) angiography after Sun’s procedure.

Material/Methods

We retrospectively reviewed 51 patients who underwent Sun’s procedure for acute Stanford type A aortic dissection extending down to iliac bifurcation between January 2013 and December 2014. The images of preoperative, one-month, three-month, and six-month follow-up were analyzed by CT angiography to measure the area and diameter of true and false lumen.

Results

Four patients died before surgical intervention and postoperative deaths occurred in five patients (in-hospital mortality rate 10.6%). Only 42 patients (36 male, 6 female; mean age, 45.9±9.8 years; range, 24–65 years) with acute type A aortic dissection were involved in our study. Thirty-five patients (83.3%) suffered from chest or abdominal pain and only one patient (2.4%) was asymptomatic. Thirty-seven patients (88.1%) had hypertension as the most common comorbidity. In the ascending aorta, false lumen was eliminated and the change of true lumen was not significant (p>0.05). In the descending aorta, complete and partial thrombosis of false lumen were observed in eight patients (19.0%) and 33 patients (78.6%) by one-month follow-up CT scan, respectively. After the six-month follow-up, the rate of complete thrombosis increased to 36.1% and partial thrombosis decreased to 61.9%. The area and maximal diameter of true lumen were increased significantly (p<0.05), whereas significant decreases were found in the area and maximal diameter of false lumen (p<0.05). In the abdominal aorta, thrombosis was found in 52.4% patients at one-month follow-up CT. Furthermore, there were no significant changes in both true and false lumen within three months (p>0.05). Nevertheless, the false luminal area and maximal diameter decreased significantly (p<0.05) after six months, while these changes of true lumen were not significant (p>0.05).

Conclusions

After Sun’s procedure, aortic remodeling was a continuous process and occurred in a predictable model, and the extent of aortic remodeling varied at different levels. Remodeling in descending thoracic aorta was earlier than it was in abdominal aorta.

Mortality from thoracic aortic diseases and associations with cardiovascular risk factors

BACKGROUND

Temporal trends in mortality from thoracic aortic disease are unclear. This study examined trends in mortality from thoracic aortic aneurysm (TAA) and aortic dissection (AD) with the aim of identifying associations with trends in established cardiovascular risk factors.

METHODS AND RESULTS

TAA and AD mortality (1994-2010) using International Classification of Diseases codes was extracted from the World Health Organization mortality database and age standardized. World Health Organization InfoBase and International Mortality and Smoking Statistics provided risk factor data. Eighteen World Health Organization member states were included (Europe=13, Australasia=2, North America=2, Asia=1). Ecological regression was performed of temporal trends in cardiovascular risk factors (1946-2010) and independent correlations to mortality trends. TAA and AD mortality trends show substantial heterogeneity but are generally declining. TAA mortality has increased in Hungary, Romania, Japan, and Denmark, and AD mortality has increased in Romania and Japan; therefore, the mortality decline is not universal. A linear relationship exists between trends in systolic blood pressure, cholesterol, and body mass index and mortality from TAA. Body mass index demonstrated a negative linear association with female AD mortality, whereas trends in systolic blood pressure demonstrated a positive linear relationship with male AD mortality. Trends in smoking prevalence were not associated with TAA or AD mortality trends.

CONCLUSIONS

This population-level ecological regression provides evidence that mortality secondary to TAA and mortality secondary to AD are both in decline. Differences between countries could be explained by population-level changes in common cardiovascular risk factors. Public health measures could further reduce mortality from TAA and AD.

Central versus peripheral arterial cannulation and neurological outcomes after thoracic aortic surgery: meta-analysis and meta-regression of 4459 patients

BACKGROUND

Thoracic aortic surgeries remain with high mortality rates, often associated with postoperative neurological complications. The choice of the right cannulation site is extremely important for suitable blood supply and maintenance of vital functions, especially of the central nervous system.

OBJECTIVES

To compare the influence of central versus peripheral arterial cannulation on neurological outcomes in patients undergoing thoracic aortic surgery through systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS and reference lists of relevant articles were searched for clinical studies that reported in-hospital neurological outcomes after central or peripheral arterial cannulation during thoracic aortic surgery procedures until December 2013. The principal summary measures were Odds Ratio (OR) for central compared to peripheral arterial cannulation with 95% confidence interval (CI) and p-values considered statistically significant when <0.05. The ORs were combined across studies, using the DerSimonian-Laird random effects model and fixed effects model using the Mantel-Haenszel model--both models were weighted. The meta-analysis was completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, NJ).

RESULTS

Six studies were identified and included a total of 4459 patients (1180 for central and 3279 for peripheral cannulation). There was no significant difference between the central and peripheral groups regarding neurological outcomes. The meta-regression evidenced no relationship between neurological outcomes and the variables age, sex, previous coronary event, previous neurological event, urgency surgery, cardiopulmonary bypass time, activated clotting time and esophageal temperature with p > 0,05.

CONCLUSION

When it comes to neurological outcomes in patients undergoing thoracic aortic surgery, there was no evidence that argues in favor of any choice of arterial cannulation site, which makes us reject any superiority of one approach over the other in this regard.

Clinical features of acute aortic dissection from the Registry of Aortic Dissection in China

OBJECTIVE

To establish a systematic registry of aortic dissection in China, assess the clinical features of Chinese patients with acute aortic dissection (AAD), and compare our results with the data published by the International Registry of Acute Aortic Dissection (IRAD).

METHODS

We established the first Registry of Aortic Dissection in China (Sino-RAD) in 2011. Then we evaluated 1003 patients with AAD in Sino-RAD and compared our results with those reported by IRAD.

RESULTS

Compared with IRAD, the patients with AAD in Sino-RAD were significantly younger. Also, the ratio of male patients in Sino-RAD was significantly greater for the total cohort and the type A and B cohorts. The overall in-hospital mortality was 10.3% in Sino-RAD. For type A dissection, more patients in Sino-RAD received medical treatment and fewer received surgical treatment. The overall mortality, mortality of medical treatment, and mortality of surgical treatment was lower in Sino-RAD. In type B dissection, fewer patients in Sino-RAD received medical and surgical treatment and more received endovascular treatment.

CONCLUSIONS

The first Sino-RAD, including 15 large cardiovascular centers throughout China, was established. Our data were compared with those reported by IRAD. We found that, compared with Western populations, Chinese patients with AAD showed 6 differences, including earlier onset, more male patients, a low incidence of hypertension, a low incidence of chest pain, a high incidence of back pain, great differences in the choice of therapeutic strategies, and relatively low in-hospital mortality.