Long-Term Survival in Patients Presenting With Type A Acute Aortic Dissection

Progress and perspectives of metabolic biomarkers in human aortic dissection

BACKGROUND

Aortic dissection (AD) significantly threated human cardiovascular health, extensive clinical-scientific research programs have been executed to uncover the pathogenesis and prevention. Unfortunately, no specific biomarker was identified for the causality or development of human AD.

AIM OF REVIEW

Metabolomics, a high-throughput technique capable of quantitatively detecting metabolites, holds considerable promise in discovering specific biomarkers and unraveling the underlying pathways involved. Aiming to provide a metabolite prediction in human AD, we collected the metabolomics data from 2003 to 2023, and diligently scrutinized with the online system MetaboAnalyst 6.0.

KEY SCIENTIFIC CONCEPTS OF REVIEW

Based on the data obtained, we have concluded the metabolic dynamics were highly correlated with human AD. Such metabolites (choline, serine and uridine) were frequently involved in the AD. Besides, the pathways, including amino acids metabolism and lipids metabolism, were also dysregulated in the disease. Due to the current limitation of metabolism analysis, the integrative omics data including genomics, transcriptomics, and proteomics were required for developing the specific biomarker for AD.

A rare case of a simultaneous post-dissection saccular aneurysm of the ascending aorta and large pulmonary artery aneurysm with secondary embolism: a case report

BACKGROUND

Aneurysms of the pulmonary arteries and the ascending aorta are rare, and both bear a high mortality risk if left untreated. In general, these entities are primarily caused by etiologies such as hypertension, pulmonary arterial hypertension, infection or congenital disorders. Treatment requires a rapid diagnostic work-up or even immediate surgical intervention in acute cases. Nevertheless, surgery entails serious perioperative risks, in particular in patients with multiple comorbidities.

CASE PRESENTATION

We discuss a 70-year-old woman presented with decompensated heart failure based on severe pulmonary artery hypertension, coincided by a massive pulmonary artery aneurysm with secondary embolism. Additional diagnostic imaging also showed a chronic post-dissection, saccular aneurysm of the ascending aorta. To our knowledge, this simultaneous diagnosis of a saccular aneurysm of the ascending aorta and a large aneurysm of the pulmonary artery with secondary embolism has not yet been described. Nonetheless, conservative treatment was chosen due to extensive pulmonal and cardiovascular comorbidities and the high-risk profile of surgery.

CONCLUSIONS

Extensive aneurysmatic disease of the pulmonary arteries and ascending aorta come with a serious burden of disease, especially if coincided by severe pulmonal and cardiovascular comorbidities. Both conditions can be curatively treated by surgical intervention. However, in every case the risk of surgery and the patient's vitality, comorbidities and wishes should be taken into account to formulate an adequate treatment plan. Therefore, shared decision making is of utter importance.

The prognostic value of preoperative systemic inflammatory response index in predicting outcomes of acute type A aortic dissection patients underwent surgical treatment

Background

The systemic inflammatory response index (SIRI) is a novel inflammatory-immune biological marker that has prognostic value in various cardiovascular diseases. This study aims to investigate the relationship between SIRI and short-term and long-term prognosis in patients with acute type A aortic dissection (AAAD) underwent surgical treatment.

Methods

We conducted a retrospective analysis of patients with AAAD who underwent emergency surgical treatment at our center. Through multifactorial logistics regression analysis and cox proportional hazards regression analysis, we identified SIRI as an independent risk factor for major adverse events (MAEs) and long-term aorta-related adverse events (ARAEs) post-surgery. The optimal cutoff value of preoperative SIRI was determined using receiver operating characteristic (ROC) curve analysis, and patients were divided into low SIRI group and high SIRI group. The prognostic outcomes at different time points post-surgery for the two groups of patients were analyzed using Kaplan-Meier survival analysis, and the significance was determined by log-rank test.

Results

A total of 691 AAAD patients were included in this study. Among them, 50 patients (7.2%) died within 30 days post-surgery, and 175 patients (25.3%) experienced MAEs. A total of 641 patients were followed up, with an average follow-up time of 33.5 ± 17.5 months, during which 113 patients (17.6%) experienced ARAEs. The results of multifactorial logistics regression analysis and cox proportional hazards regression analysis showed that SIRI was an independent risk factor for postoperative MAEs (OR=3.148, 95%CI[1.650-6.006], p<0.001) and ARAEs (HR=2.248, 95%CI[1.050-4.809], p<0.037). Kaplan-Meier analysis demonstrated that the MAEs-free survival in the high SIRI group was significantly lower than that in the low SIRI group, and a similar trend was observed in the ARAEs-free survival during follow-up (log-rank test, p<0.001).

Conclusion

Preoperative SIRI is significantly associated with the short-term and long-term prognosis of AAAD patients underwent emergency open surgery, demonstrating its valuable prognostic value. Therefore, preoperative SIRI is a reliable biological marker that can serve as a valuable tool for preoperative risk stratification and decision management.

Intimomedial tears of the aorta heal by smooth muscle cell-mediated fibrosis without atherosclerosis

BACKGROUNDDisease of the aorta varies from atherosclerosis to aneurysms, with complications including rupture, dissection, and poorly characterized limited tears. We studied limited tears without any mural hematoma, termed intimomedial tears, to gain insight into aortic vulnerability to excessive wall stresses. Our premise is that minimal injuries in aortas with sufficient medial resilience to prevent tear progression correspond to initial mechanisms leading to complete structural failure in aortas with significantly compromised medial resilience.METHODSIntimomedial tears were macroscopically identified in 9 of 108 ascending aortas after surgery and analyzed by histology and immunofluorescence confocal microscopy.RESULTSNonhemorrhagic, nonatheromatous tears correlated with advanced aneurysmal disease and most lacked distinctive symptoms or radiological signs. Tears traversed the intima and part of the subjacent media, while the resultant defects were partially or completely filled with neointima characterized by differentiated smooth muscle cells, scattered leukocytes, dense fibrosis, and absent elastic laminae despite tropoelastin synthesis. Healed lesions contained organized fibrin at tear edges without evidence of plasma and erythrocyte extravasation or lipid accumulation.CONCLUSIONThese findings suggest a multiphasic model of aortic wall failure in which primary lesions of intimomedial tears either heal if the media is sufficiently resilient or progress as dissection or rupture by medial delamination and tear completion, respectively. Moreover, mural incorporation of thrombus and cellular responses to injury, two historically important concepts in atheroma pathogenesis, contribute to vessel wall repair with adequate conduit function, but even together are not sufficient to induce atherosclerosis.FUNDINGNIH (R01-HL146723, R01-HL168473) and Yale Department of Surgery.

The Learning Curve of Total Arch Replacement via Single Upper Hemisternotomy Approach in Aortic Dissection

Purpose

Upper hemisternotomy (UHS) has benefits over conventional full sternotomy because it ameliorates trauma during cardiac surgery. Owing to its challenging and technically demanding nature, this incision in acute type A aortic dissection (ATAAD) has rarely been reported. This study aimed to analyze the learning curve of total arch replacement (TAR) with moderate hypothermic circulatory arrest via a single UHS approach, which is necessary to guide the training of surgeons in adopting minimally invasive procedures.

Patients and Methods

A total of 202 consecutive patients who were definitively diagnosed with ATAAD between July 2016 and June 2021 were enrolled in this retrospective analysis. Patients were divided into three groups based on cumulative sum plots for circulatory arrest time in chronological order. Perioperative characteristics were compared between the groups.

Results

There was significant difference in the circulatory arrest time and cross-clamp time respectively among three groups (39.0 min vs 28.0 min vs 15.0 min, P < 0.001; 104.5 min vs 106.2 min vs 84.1 min, P < 0.001). The ventilation time and first 24-h chest tube drainage were statistically different among groups (35.5 h vs 24.0 h vs 19.0 h, P = 0.031; 220.0 mL vs 192.5 mL vs 125.5 mL, P = 0.043). No other clinical outcome was observed as significant difference.

Conclusion

A cardiac surgeon can convert a conventional full sternotomy to a single UHS for TAR after experiencing a learning curve, to ensure patient safety. The mastery of this minimally invasive surgical technique may be beneficial for the prognosis of patients with ATAAD.

Hemodynamic Response in Ascending Aorta Surgery Patients during Moderate Intensity Resistance Training

Background

In patients undergoing ascending aortic surgery (AAS), postsurgical physical exercise with a safe and effective exercise prescription is recommended. Resistance training is associated with blood pressure (BP) elevations that may increase the risk of new aortic dissection or rupture. However, the acute hemodynamic response to resistance training for this patient group is unknown.

Aim

The aim of this study was to investigate peak systolic BP (SBP) increases in AAS patients during moderate intensity resistance training.

Methods

SBP was measured continuously beat-to-beat with a noninvasive method during three sets of leg presses at moderate intensity. A 15-repetition maximum strength test was performed to estimate the maximal amount of resistance a participant could manage 15 times consecutively (equivalent to approximately 60-65% of their maximum strength).

Results

The study had 48 participants in total, i.e., 24 cases and 24 controls. Both groups consisted of 10 females (42%) and 14 males (58%). The case group had a mean age of 60.0 (SD ± 11.9) years and a mean of 16.3 months since surgery (minimum 4.4 and maximum 39.6 months). 22 of the 24 cases received antihypertensive medication. The median baseline BP was 119/74 mmHg among cases and 120/73 mmHg among controls. During the first set of leg presses, the median peak SBP was 152 mmHg, in the second set 154 mmHg, and in the third set 165 mmHg. Corresponding values in controls were 170 mmHg, 181 mmHg, and 179 mmHg. The highest peak SBP registered in an AAS patient was 190 mmHg and in any healthy control was 287 mmHg.

Conclusion

The findings indicate that AAS patients in control of their BP have the endurance to perform 3 sets of resistance training at moderate intensity as their SBP increases with a maximum of 39% from the baseline compared to the 51% increase in the control group.

Prognostic significance of neutrophil count on in-hospital mortality in patients with acute type A aortic dissection

Backgrounds

The goal of this study was to assess the impact of neutrophil count, in patients with acute type A aortic dissection (ATAAD).

Methods

This study retrospectively collected data from patients between September 2017 and June 2021. Youden's index was used to determine the optimal cut-off value for the neutrophil count and patients were divided into two subgroups. A restricted cubic spline (RCS) was used to model the relationship between variables and in-hospital mortality. The least absolute shrinkage and selection operator (LASSO) method and multivariate logistic regression analyses were used to investigate the independent prognostic factors for in-hospital mortality in patients with ATAAD.

Results

A total of 467 patients were enrolled in this study. In-hospital mortality was 7.28%. The group with elevated neutrophil counts had significantly higher mortality than the group with decreased neutrophil counts (10.8% vs. 3.2%, P = 0.02). This data shows that elevated neutrophil count was significantly associated with in-hospital mortality (OR 3.07, 95% CI 1.22-7.62, P = 0.02).

Conclusions

Neutrophil count is an independent risk factor for in-hospital mortality in patients with ATAAD. It is an effective inflammatory index, which can be individualized for patients.

Epidemiology, mortality and miss rate of acute aortic syndrome in Ontario, Canada: a population-based study

INTRODUCTION

Acute aortic syndrome (AAS) is a life-threatening emergency. It describes three distinct diagnoses: acute aortic dissection, acute intramural hematoma and penetrating atherosclerotic ulcer. There are currently no accurate estimates for incidence, mortality or misdiagnosis. Our objectives were to determine the incidence, mortality and miss rate of acute aortic syndrome in the emergency department (ED).

METHODS

A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of acute aortic syndrome were identified between 2003 and 2018 using a validated algorithm based on ICD-10 codes and death. Incidence (number of cases/population of Ontario), mortality, and miss rate were calculated. Miss rate was defined as when a patient was seen in the ED within 14 days prior to an acute aortic syndrome diagnosis with a presenting complaint consistent with acute aortic syndrome.

RESULTS

There were 1299 cases of acute aortic syndrome over the study period [age mean (SD) 68.03 ± 14.70; female (n = 500, 38.5%); rural areas (n = 111, 8.6%)]. The overall annual incidence for acute aortic syndrome was 0.61 per 100,000. One year mortality decreased from 47.4 to 29.1%. ED mortality was 14.9%. In the 14 days prior to diagnosis 12.5% of patients were seen in the ED with a presentation consistent with acute aortic syndrome.

CONCLUSIONS

Annual incidence of acute aortic syndrome was found to be lower than other population-based studies. Also, the burden of mortality is seen in the ED. Education initiatives should focus on the identification of acute aortic syndrome in the ED to address mortality and miss rate.

Short- and Mid-Term Survival Prediction in Patients with Acute Type A Aortic Dissection Undergoing Surgical Repair: Based on the Systemic Immune-Inflammation Index

Purpose

The postoperative survival of patients with acute type A aortic dissection (aTAAD) remains unsatisfactory. The current study developed an easy-to-use survival prediction model and calculator.

Methods

A total of 496 patients with aTAAD undergoing surgical repair were included in this study. The systemic immune-inflammation index (SII) and other clinical features were collected and subjected to logistic and Cox regression analyses. The survival prediction model was based on Cox regression analyses and exhibited as a nomogram. For convenience of use, the nomogram was further developed into calculator software.

Results

We demonstrated that a higher preoperative SII was associated with in-hospital death (OR: 4.116, p < 0.001) and a higher postoperative overall survival rate (HR: 2.467, p < 0.001) in aTAAD patients undergoing surgical repair. A survival prediction model and calculator based on SII and four other clinical features were developed. The overall C-index of the model was 0.743. The areas under the curves (AUCs) of the 1- and 3-month and 1- and 3-year survival probabilities were 0.73, 0.71, 0.71 and 0.72, respectively. The model also showed good calibration and clinical utility.

Conclusion

Preoperative SII is significantly associated with postoperative survival. Based on SII and other clinical features, we created the first easy-to-use prediction model and calculator for predicting the postoperative survival rate in aTAAD patients, which showed good prediction performance.

Significant Prediction of In-hospital Major Adverse Events by D-Dimer Level in Patients With Acute Type A Aortic Dissection

Background

Acute type A aortic dissection (ATAAD) is a rare, life-threatening condition affecting the aorta. This study explores the relationship between the level of admission D-dimer, which was assessed during the first 2 h from admission, and in-hospital major adverse events (MAE) with ATAAD.

Methods

A total of 470 patients with enhanced computed tomography (CT) confirmed diagnosis of ATAAD who underwent operation treatment in Guangdong Provincial People's hospital between September 2017 and June 2021 were enrolled in the present study. The X-tile program was used to determine the optimal D-dimer thresholds for risk. Restricted cubic spline (RSC) was performed to assess the association between D-dimer and endpoint. The perioperative data were compared between the two groups, univariate and multivariate analyses were used to investigate the risk factors of major adverse events (in-hospital mortality, gastrointestinal bleeding, paraplegia, acute kidney failure, reopen the chest, low cardiac output syndrome, cerebrovascular accident, respiratory insufficiency, MODS, gastrointestinal bleeding, and severe infection).

Results

Among 470 patients, 151 (32.1%) had MAE. In-hospital mortality was 7.44%. The patients with D-dimer >14,500 ng/ml were more likely to present with acute kidney failure, low cardiac output, cerebrovascular accident, multiple organ dysfunction syndromes (MODS), gastrointestinal bleeding, and severe infection. D-dimer level was an independent risk factor for acute kidney failure (OR 2.09, 95% CI: 1.25–3.51, p = 0.005), MODS (OR 6.40, 95% CI: 1.23–33.39, p = 0.028), gastrointestinal bleeding (OR 17.76, 95% CI: 1.99–158.78, p = 0.010) and mortality (OR 3.17, 95% CI: 1.32–7.63, p = 0.010). Multivariate regression analysis of adverse events also suggested that D-dimer >14,500 ng/ml (OR 1.68, 95% CI: 1.09–2.61, p = 0.020) was the independent risk factor of major adverse events.

Conclusions

Increasing D-dimer levels were independently associated with the in-hospital MAE and thus can be used as a useful prognostic biomarker before the surgery.

High-TSH Subclinical Hypothyroidism Is Associated With Postoperative Mortality in Acute Type A Aortic Dissection

BACKGROUND

Subclinical hypothyroidism can negatively affect the cardiovascular system and increase the risk of mortality, especially for individuals with thyroid-stimulating hormone (TSH) levels above 10 mU/L. We investigated the relationship between high-TSH subclinical hypothyroidism and postoperative mortality in acute type A aortic dissection (ATAAD) patients.

METHOD

We enrolled 146 patients with ATAAD who underwent aortic surgery in Beijing Anzhen Hospital from July 2016 to November 2018. Thyroid hormone levels were obtained before surgery, and participants were divided into a ≥10mU/L TSH level group and a <10mU/L level group. Cox proportional hazard regression and subgroup analysis were conducted to examine the association of preoperative high-TSH subclinical hypothyroidism with postoperative mortality.

RESULT

Participants with preoperative high-TSH (≥10mU/L) subclinical hypothyroidism tended to have longer hospitalization stays after surgery [16.0 (IQR 11.0-21.0) days vs 12.5 (IQR 8.0-16.0) days, P=0.001]. During the first 30 days after operation, 15 of 146 patients died (10.3%); during a median of 3.16 (IQR 1.76-4.56) years of follow-up, 24 patients died (16.4%). Cox proportional hazard regression showed that preoperative high-TSH subclinical hypothyroidism was independently associated with 30-day mortality (HR=6.2, 95% CI, 1.7-22.0, P=0.005) and postoperative mortality after adjusting for age, sex, BMI, hypertension, ejection fraction, diabetes and history of PCI (HR=3.4, 95% CI, 1.4-8.0, P=0.005).

CONCLUSION

This study showed that preoperative high-TSH subclinical hypothyroidism was an independent predictor of postoperative mortality in ATAAD patients who underwent aortic surgery.

Relationship Between Heart Rate at Discharge and Long-Term Outcomes of Surgically Treated Patients With Type A Acute Aortic Dissections

BACKGROUND

Resting heart rate (HR) at discharge is an important predictor of mortality after acute myocardial infarction. However, in patients with Stanford type A acute aortic dissections (TA-AADs), the relationship between HR and long-term outcomes is unclear. Therefore, this relationship was investigated in the present study.

METHODS AND RESULTS

Surgically treated consecutive patients with TA-AAD (n=721) were retrospectively categorized according to HR quartiles, recorded within 24 h before discharge (<70, 70-77, 78-83, and ≥84 beats/min). The study endpoints included aortic aneurysm-related deaths, sudden deaths, aortic surgeries, and hospitalizations for recurrence of acute aortic dissections. The mean (±SD) patient age was 65.8±13.0 years. During a median observation period of 5.8 years (interquartile range 3.9-8.5 years), 17.2% of patients (n=124) experienced late aortic events. Late aortic surgery was performed in 14.0% of patients. After adjusting for potential confounders, including β-blocker use, HR at discharge remained an independent predictor of long-term aortic outcomes. Patients with discharge HR ≥84 beats/min had a higher risk (hazard ratio 1.86; 95% confidence interval 1.06-3.25; P=0.029) of long-term aortic events than those with HR <70 beats/min; the cumulative survival rates were similar among the groups (log-rank, P=0.905).

CONCLUSIONS

In surgically treated patients with TA-AAD, HR at discharge independently predicted long-term aortic outcomes. Consequently, HR in patients with TA-AAD should be optimized before discharge, particularly if the HR is ≥84 beats/min.

The risk factors and outcomes of preoperative hepatic dysfunction in patients who receive surgical repair for acute type A aortic dissection

Background

Hepatic dysfunction (HD) is a common complication that can occur after surgical repair of acute type A aortic dissection (ATAAD) and is associated with poor prognosis. However, the incidence of early preoperative HD and the associated risk factors in patients with ATAAD have not been fully elucidated.

Methods

A total of 984 ATAAD patients who received surgical repair within 48 hours of symptom onset at our department from January 2014 to December 2019 were retrospectively analyzed. Patients were divided into the non-HD group and the HD groups according to the Model of End-Stage Liver Disease (MELD) score before surgery. The clinical parameters and clinical outcomes of the 2 groups were collected and compared.

Results

Preoperative HD was detected in 268 patients (27.2%). The incidence of in-hospital complications, including the need for dialysis (34.0% vs. 9.2%; P<0.001), was significantly higher in patients with HD compared to patients without HD (69.8% vs. 51.0%; P<0.001). Patients with HD had a higher 30-day mortality rate compared to patients without HD (20.1% vs. 8.4%; P<0.001). Multivariate analysis demonstrated that preoperative cardiac tamponade, preoperative serum creatinine levels, and serum troponin T levels upon admission were independent predictors for preoperative HD in patients with ATAAD. Interestingly, even though preoperative HD was associated with an increased 30-day mortality rate, it did not significantly affect the long-term mortality rate (log-rank P=0.259).

Conclusions

Early HD before surgery was commonly observed in patients with ATAAD and was associated with increased in-hospital complications after surgery, but did not significantly affect long-term survival.

Preoperative Predictors of Adverse Clinical Outcome in Emergent Repair of Acute Type A Aortic Dissection in 15 Year Follow Up

Background: Acute type A aortic dissection (AAAD) has high mortality. Improvements in surgical technique have lowered mortality but postoperative functional status and decreased quality of life due to debilitating deficits remain of concern. Our study aims to identify preoperative conditions predictive of undesirable outcome to help guide perioperative management. Methods: We performed retrospective analysis of 394 cases of AAAD who underwent repair in our institution between 2001 and 2018. A combined endpoint of parameters was defined as (1) 30-day versus hospital mortality, (2) new neurological deficit, (3) new acute renal insufficiency requiring postoperative renal replacement, and (4) prolonged mechanical ventilation with need for tracheostomy. Results: Total survival/ follow-up time averaged 3.2 years with follow-up completeness of 94%. Endpoint was reached by 52.8%. Those had higher EuroSCORE II (7.5 versus 5.5), higher incidence of coronary artery disease (CAD) (9.2% versus 3.2%), neurological deficit (ND) upon presentation (26.4% versus 11.8%), cardiopulmonary resuscitation (CPR) (14.4% versus 1.6%) and intubation (RF) before surgery (16.9% versus 4.8%). 7-day mortality was 21.6% versus 0%. Hospital mortality 30.8% versus 0%. Conclusions: This 15-year follow up shows, that unfavorable postoperative clinical outcome is related to ND, CAD, CPR and RF on arrival.

Incidence and Survival of Aortic Dissection in Urban China: Results from the National Insurance Claims for Epidemiological Research (NICER) Study

Background

Aortic dissection (AD) represents a significant mortality; however, there is rare epidemiologic information about the demography of AD in Chinese, especially its incidence rate.

Methods

A retrospective cohort study was established using the Urban Employee Basic Medical Insurance claims data covering 346.7 million residents from 23 provinces in China, 2015-2016. AD cases were then linked to database of the Urban Employee Basic Endowment Insurance for death information. Incidence rate was age- and sex-standardized to the 2010 China census population. The associations between AD and related factors were evaluated with Poisson regression models. Moreover, mortality and sex- and age-adjusted survival rate was estimated by Cox models.

Findings

6084 adult AD cases were included in incidence analysis. Totally 4692(77.1%) were men and 5641(92.7%) were Han Chinese. The overall age- and sex-adjusted incidence rate of AD was 2.78(95%CI:2.59-2.98) per 100,000 person-years. In terms of geographic disparities, the crude incidence rate was significantly higher in Northwest China than South China (4.96[95%CI:4.17-5.75] vs. 2.04[95%CI:0.38-3.71] per 100,000 person-years; risk ratio: 2.67[95%CI: 2.34-3.04]). Moreover, survival analysis of 4518 AD patients with 683 recorded deaths during follow-up (median 2.2 years) showed that overall 3-year survival was 83.7%(95%CI:82.4-84.8).

Interpretation

This contemporary population-based cohort study provides a first comprehensive assessment of incidence of AD in urban Chinese adults. The distinct signatures of different incidence with respect to geographic variations may have important implications for clinical management of AD.

Funding

Chinese Ministry of Science and Technology (2020YFC2003503, 2016YFC0903000), and National Natural Science Foundation of China (91846112, 81973132, 81961128006).

The effect of beta-blockers on hemodynamic parameters in patient-specific blood flow simulations of type-B aortic dissection: a virtual study

Aortic dissection (AD) is one of the fatal and complex conditions. Since there is a lack of a specific treatment guideline for type-B AD, a better understanding of patient-specific hemodynamics and therapy outcomes can potentially control the progression of the disease and aid in the clinical decision-making process. In this work, a patient-specific geometry of type-B AD is reconstructed from computed tomography images, and a numerical simulation using personalised computational fluid dynamics (CFD) with three-element Windkessel model boundary condition at each outlet is implemented. According to the physiological response of beta-blockers to the reduction of left ventricular contractions, three case studies with different heart rates are created. Several hemodynamic features, including time-averaged wall shear stress (TAWSS), highly oscillatory, low magnitude shear (HOLMES), and flow pattern are investigated and compared between each case. Results show that decreasing TAWSS, which is caused by the reduction of the velocity gradient, prevents vessel wall at entry tear from rupture. Additionally, with the increase in HOLMES value at distal false lumen, calcification and plaque formation in the moderate and regular-heart rate cases are successfully controlled. This work demonstrates how CFD methods with non-invasive hemodynamic metrics can be developed to predict the hemodynamic changes before medication or other invasive operations. These consequences can be a powerful framework for clinicians and surgical communities to improve their diagnostic and pre-procedural planning.

Differences in the clinical presentation, management, and in-hospital outcomes of acute aortic dissection in patients with and without end-stage renal disease

Background

Few studies have evaluated the clinical presentation, management, and outcomes of patients with end-stage renal disease (ESRD) presenting with acute aortic dissection (AAD) in real-world clinical practice. Thus, this study investigated the clinical characteristics, management, and outcomes of AAD patients with ESRD.

Methods

A total of 217 patients were included. We evaluated the differences in the clinical features, management, and in-hospital outcomes of patients with and without a history of ESRD presenting with AAD.

Results

A history of ESRD was present in 71 of 217 patients. Patients with ESRD had atypical clinical manifestations (p < 0.001) and were more likely to be managed medically compared with patients without ESRD (p = 0.002). Hypertension and type B aortic dissection were significantly more common among patients with ESRD. Moreover, patients with ESRD had lower leucocyte and platelet counts than patients without ESRD in laboratory findings (p < 0.001). However, hospitalization days and in-hospital mortality were similar between the two groups (p > 0.05). Multivariate analysis identified Type A aortic dissection as an independent predictor of in-hospital mortality among patients without ESRD (OR, 13.68; 95% CI, 1.92 to 98.90; P = 0.006).

Conclusions

This study highlights differences in the clinical characteristics, management, and outcomes of AAD patients with ESRD. These patients usually have atypical symptoms and more comorbid conditions and are managed more conservatively. However, these patients have no in-hospital survival disadvantage over those without ESRD. Further studies are needed to better understand and optimize care for patients with ESRD presenting with AAD.

The association between fluoroquinolones and aortic dissection and aortic aneurysms: a systematic review and meta-analysis

Previous studies have drawn causal associations between fluoroquinolone use and collagen pathologies including tendon rupture and retinopathy. This meta-analysisattempted to assess the association between fluoroquinolone use and the risk of aortic dissection or aortic aneurysm. A systematic search was performed on Medline, EMBASE, and the Cochrane library. 9 studies were included in final analysis. Primary random-effects meta-analysis of 7 studies, excluding 2 pharmacovigilance studies demonstrated statistically increased odds of aortic dissection (OR, 2.38; 95% CI, 1.71-3.32) aortic aneurysm (OR, 1.98; 95% CI, 1.59-2.48), and aortic aneurysm or dissection (OR, 1.47; 95% CI, 1.13-1.89; I² = 72%) with current use of fluoroquinolones compared to their nonuser counterparts. Based on the "number needed-to-harm" analysis, 7246 (95% CI: 4329 to 14,085) patients would need to be treated with fluoroquinolones for a duration of at least three days in order for one additional patient to be harmed, assuming a population baseline incidence of aortic dissection and aneurysm rupture to be 10 per 100,000 patient-years. With strong statistical association, these findings suggest a causal relationship, warranting future research to elucidate the pathophysiological and mechanistic plausibility of this association. These findings however, should not cease prescription of fluoroquinolones, especially when clinically indicated.

False lumen pressure estimation in type B aortic dissection using 4D flow cardiovascular magnetic resonance: comparisons with aortic growth

BACKGROUND

Chronic type B aortic dissection (TBAD) is associated with poor long-term outcome, and accurate risk stratification tools remain lacking. Pressurization of the false lumen (FL) has been recognized as central in promoting aortic growth. Several surrogate imaging-based metrics have been proposed to assess FL hemodynamics; however, their relationship to enlarging aortic dimensions remains unclear. We investigated the association between aortic growth and three cardiovascular magnetic resonance (CMR)-derived metrics of FL pressurization: false lumen ejection fraction (FLEF), maximum systolic deceleration rate (MSDR), and FL relative pressure (FL ΔPmax).

METHODS

CMR/CMR angiography was performed in 12 patients with chronic dissection of the descending thoracoabdominal aorta, including contrast-enhanced CMR angiography and time-resolved three-dimensional phase-contrast CMR (4D Flow CMR). Aortic growth rate was calculated as the change in maximal aortic diameter between baseline and follow-up imaging studies over the time interval, with patients categorized as having either 'stable' (< 3 mm/year) or 'enlarging' (≥ 3 mm/year) growth. Three metrics relating to FL pressurization were defined as: (1) FLEF: the ratio between retrograde and antegrade flow at the TBAD entry tear, (2) MSDR: the absolute difference between maximum and minimum systolic acceleration in the proximal FL, and (3) FL ΔPmax: the difference in absolute pressure between aortic root and distal FL.

RESULTS

FLEF was higher in enlarging TBAD (49.0 ± 17.9% vs. 10.0 ± 11.9%, p = 0.002), whereas FL ΔPmax was lower (32.2 ± 10.8 vs. 57.2 ± 12.5 mmHg/m, p = 0.017). MSDR and conventional anatomic variables did not differ significantly between groups. FLEF showed positive (r = 0.78, p = 0.003) correlation with aortic growth rate whereas FL ΔPmax showed negative correlation (r = - 0.64, p = 0.026). FLEF and FL ΔPmax remained as independent predictors of aortic growth rate after adjusting for baseline aortic diameter.

CONCLUSION

Comparative analysis of three 4D flow CMR metrics of TBAD FL pressurization demonstrated that those that focusing on retrograde flow (FLEF) and relative pressure (FL ΔPmax) independently correlated with growth and differentiated patients with enlarging and stable descending aortic dissections. These results emphasize the highly variable nature of aortic hemodynamics in TBAD patients, and suggest that 4D Flow CMR derived metrics of FL pressurization may be useful to separate patients at highest and lowest risk for progressive aortic growth and complications.

Impact of time between diagnosis to treatment in Acute Type A Aortic Dissection

There is a paucity of data describing the effect of time interval between diagnosis and surgery for Acute Type A Aortic Dissection. We describe our 8-year experience and investigate the impact of time interval between symptom onset, diagnosis and surgery on outcomes. Retrospective single-center study utilizing our Society of Thoracic Surgeons registry and patient records. Subjects were grouped by time interval between radiographic diagnosis and surgical treatment: Group A (0-4 h), Group B (4.1-8 h), Group C (8.1-12 h), and Group D (12.1 + h). Data were analyzed to identify factors associated with mortality and outcomes. 164 patients were included. Overall mortality was 21.3%. Group C had the greatest intervals between symptom onset to diagnosis to surgery, and also the highest mortality (66.7%). Preoperative tamponade, cardiac arrest, malperfusion, elevated creatinine, cardiopulmonary bypass time, and blood transfusions were associated with increased mortality, while distance of referring hospital was not. Time intervals between symptom onset, diagnosis and surgery have a significant effect on mortality. Surgery performed 8-12 h after diagnosis carries the highest mortality, which may be exacerbated by longer interval since symptom onset. Time-dependent effects should be considered when determining optimal strategy especially if inter-facility transfer is necessary.

Femoral arterial cannulation remains a safe and reliable option for aortic dissection repair

Background

The optimal cannulation site for repair of type A aortic dissection remains controversial. The concern for Malperfusion syndrome has initiated a national trend away from femoral cannulation to axillary artery and direct ascending aortic cannulation. The purpose of this study was to report a single center experience with femoral artery cannulation for the repair of a type A dissection.

Methods

A retrospective study was performed on 52 patients who underwent surgical repair for a type A dissection between January 1^st, 2012 and June 30^th, 2019 at a single institution. Of the 52 patients analyzed, 35 (67.3%) underwent femoral artery, 11 (21.2%) direct ascending aortic, and 6 (11%) axillary artery cannulation for arterial access. Deep hypothermic circulatory arrest was used in all the patients. Rates of postoperative complication and mortality were reported.

Results

The mortality and bleeding rates for all the patients undergoing repair of the type A dissection repairs were 27% (14/52) and 19% (10/52), respectively. Cardiopulmonary bypass was established in 100% of the patients that had femoral arterial cannulation. There were no complications specifically related to femoral arterial cannulation nor the axillary or direct aortic approach. Specifically, there was no episodes of malperfusion syndrome, bleeding, or injury with femoral artery cannulation. Bleeding rates were higher in cases that proceeded with a femoral (13%) versus alternate (6%) approach however; neither of the bleeding was related to the cannulation site. None of the mortalities identified were directly attributable to the cannulation approach in each case.

Conclusions

Despite the recent shift away from femoral cannulation, the results of the study show that femoral artery cannulation is safe and produces excellent results for establishing cardiopulmonary bypass. The concerns for malperfusion syndrome related to femoral cannulation were not seen.

High Wall Shear Stress can Predict Wall Degradation in Ascending Aortic Aneurysms: An Integrated Biomechanics Study

Background: Blood flow patterns can alter material properties of ascending thoracic aortic aneurysms (ATAA) via vascular wall remodeling. This study examines the relationship between wall shear stress (WSS) obtained from image-based computational modelling with tissue-derived mechanical and microstructural properties of the ATAA wall using segmental analysis. Methods: Ten patients undergoing surgery for ATAA were recruited. Exclusions: bicuspid aortopathy, connective tissue disease. All patients had pre-operative 4-dimensional flow magnetic resonance imaging (4D-MRI), allowing for patient-specific computational fluid dynamics (CFD) analysis and anatomically precise WSS mapping of ATAA regions (6-12 segments per patient). ATAA samples were obtained from surgery and subjected to region-specific tensile and peel testing (matched to WSS segments). Computational pathology was used to characterize elastin/collagen abundance and smooth muscle cell (SMC) count. Results: Elevated values of WSS were predictive of: reduced wall thickness [coef -0.0489, 95% CI (-0.0905, -0.00727), p = 0.022] and dissection energy function (longitudinal) [-15,0, 95% CI (-33.00, -2.98), p = 0.048]. High WSS values also predicted higher ultimate tensile strength [coef 0.136, 95% CI (0 0.001, 0.270), p = 0.048]. Additionally, elevated WSS also predicted a reduction in elastin levels [coef -0.276, 95% (CI -0.531, -0.020), p = 0.035] and lower SMC count ([oef -6.19, 95% CI (-11.41, -0.98), p = 0.021]. WSS was found to have no effect on collagen abundance or circumferential mechanical properties. Conclusions: Our study suggests an association between elevated WSS values and aortic wall degradation in ATAA disease. Further studies might help identify threshold values to predict acute aortic events.

Covered or Not, Here I Come: Stanford Type B Aortic Dissection Repair With a Covered and Uncovered Stent Hybrid Technique

The complications resulting from aortic dissections are often devastating. Historically, when a Stanford B aortic dissection extended into the visceral abdominal aorta, only surgical management was considered to limit visceral organ malperfusion. Complications of surgical management for Stanford B aortic dissections are as high as 50%. The inherently high complication and mortality rate for any acute aortic dissection, in addition to the complication rates resulting from surgical management, have demonstrated poor outcomes. This is especially true when aortic dissections involve the visceral segment, where thoracic endovascular aortic repair (TEVAR) becomes limited or contraindicated. In the last two decades, various approaches for TEVAR have improved in both endograft design and interventional technique. The current literature demonstrates improved outcomes for patients that receive TEVAR for Stanford B aortic dissections, including those that involve the visceral segment. Despite favorable prognostic advancement in TEVAR, the proven management complexity of Stanford B aortic dissections continue to reflect the pitfalls of the endovascular devices that are currently available. We describe a covered and uncovered stent hybrid technique in patients with complicated Stanford B aortic dissections involving the visceral segment, considering these deficiencies. Hundred percent technical success was demonstrated in the short and mid-term surveillance periods.

Impact of hypertension on short- and long-term survival of patients who underwent emergency surgery for type A acute aortic dissection

Background

To explore the clinical characteristics and prognosis of patients with hypertension underwent emergency surgery for type A acute aortic dissection (TA-AAD).

Methods

The present study enrolled 712 consecutive patients diagnosed with TA-AAD and received aortic repair surgery at our hospital between January 2014 to December 2018. Clinical characteristics of enrolled patients were retrospectively reviewed. Patients were grouped by preexisting hypertension history and matched with propensity scores matching method. Patients’ clinical characteristics were compared and analyzed before and after propensity scoring. To identify predictors for long-term mortality rate, Kaplan-Meier survival estimation and Cox proportional hazard analysis were performed.

Results

A total of 492 patients (69.1% of all patients in the cohort) were included in the hypertensive group and they had increased age and weight compared to patients in the non-hypertensive group. Between two groups, preoperative leukocyte count and serum creatinine level were found significant different (P<0.05). After propensity scoring, 128 pairs (256 patients) were successfully matched. Our analysis showed that there was no significant difference of ventilation duration, 30-day mortality rate, intensive care unit stay and hospitalization time between two groups. However, our data suggested that hypertensive patients presented with less intra-operative aortic valve involvement. There was a significant difference in long-term survival rate (P=0.037) between two groups. Cox regression analysis demonstrated that hypertension was an independent risk factor [hazard ratio (HR), 3.040; 95% confidence interval (CI), 1.124–8.227; P=0.029].

Conclusions

Our data suggested that TA-AAD patients complicated with hypertension had increased age and weight compared to non-hypertensive patients. Concomitant hypertension identified upon hospital administration was an independent risk factor for long-term survival in TA-AAD patients while did not influence the 30-day mortality rate.

Is total arch replacement associated with an increased risk after acute type A dissection?

Background

The surgical strategy for acute type A aortic dissection (AADA) usually consists of reconstruction of the tear-lesion in the affected part of the ascending aorta. The optimal strategy either to replace the ascending aorta (AAR) or to replace the ascending aorta and the total aortic arch (TAAR) is still under debate. Our study compares the 30-day mortality between AAR and TAAR in AADA surgery.

Methods

In this retrospective observational study, we analysed a total patient cohort of 339 patients who underwent surgery for AADA from January 2001 until December 2016. A propensity score-matched analysis between the AAR- and the TAAR-group with 43 patients for each subgroup was subsequently carried out. A multivariable analysis was performed to identify risk-factors for the 30-d-mortality. The 30-day mortality was defined as the primary end-point and long-term survival was the secondary endpoint.

Results

In 292 (86.1%) patients AAR and in 47 (13.9%) patients TAAR was performed for emergent AADA. Patients were older (P=0.049) in the AAR group. The median log Euro-SCORE was 25.5% (12.7; 41.7) for AAR and 19.7% (11.7; 32.2) for the TAAR patient cohort (P=0.12). Operative time, cardiopulmonary bypass- (CPB), cross-clamp- and ischemic time were significantly longer in the TAAR group (P<0.001). The overall 30-day mortality-rate was 17.7% (n=60) but was not significantly different between the two groups (P=0.27). Forty-nine (16.8%) patients died in the AAR and 11 patients (23.4%) in the TAAR group. After propensity-score matching, no difference in mortality was seen between the subgroups as well (P=0.44). Multivariable analysis identified the Euro-SCORE, long operation-time, postoperative dialysis and arrhythmia and administration of red blood cell concentrates as risk factors for 30-day mortality, but not for TAAR versus AAR.

Conclusions

The therapeutic goal in AADA surgery should be the complete restoration of the aorta to avoid further long-term complications and re-operations. Though 30-day mortality and postoperative co-morbidity for AAR are comparable to those in TAAR after treatment of AADA in our analysis, decision-making for the surgical strategy should weigh the operative risk of TAAR against the long-term outcome.

Repair of residual aortic dissections with frozen elephant trunk technique

Background

In this study, we present our mid-term results of reoperation with the frozen elephant trunk procedure due to patent false lumen-related complications in patients previously undergoing supracoronary aortic repair for acute type A aortic dissection.

Methods

Between January 2013 and September 2018, a total of 23 patients (17 males, 6 females; mean age 51.5±9.7 years; range, 30 to 67 years) who underwent ascending aortic replacement due to type A aortic dissection and, later, frozen elephant trunk procedure for residual distal dissection were included. For diagnostic purposes and follow-up, computed tomography angiography was performed in all patients, and both re-entry and aortic diameters were evaluated. Echocardiography was used to evaluate cardiac function and valve pathologies.

Results

The Ishimaru zone 0 (n=11, 47.8%), Ishimaru zone 1 (n=1, 4.3%), Ishimaru zone 2 (n=4, 17.4%), and Ishimaru zone 3 (n=7, 30.4%) were used for frozen elephant trunk stent graft fixation. The mean duration of cardiopulmonary bypass and antegrade selective cerebral perfusion was 223.9±71.2 min and 88.9±60.3 min, respectively. In-hospital mortality was 13%, while there was one (4.3%) aortic-related death and four (17.4%) re-interventions during follow-up.

Conclusion

Early repair should be considered in the presence of persistent dissections due to alarmingly high mortality rates of reoperations. Reoperation with the frozen elephant trunk procedure has acceptable results and the decision of the procedure to be performed should be based on preoperative risk factors of the patient.

Is fibrinogen plasma level a risk factor for the first 24-hour death of medically treated acute type A aortic dissection patients?

Background

The present study aims to assess the risk factors which affect the first 24-hour death of medical treatment in acute type A aortic dissection (ATAAD) patients.

Methods

This is a retrospective cohort study in a single center. From January 2009 to January 2018, 2,379 patients with type A aortic dissection were admitted to Beijing Anzhen Hospital, of which 243 patients who received medical intervention in ATAAD were involved in the final analysis. Fibrinogen plasma was obtained within 6 hours of admission and was assessed by using thrombin to convert fibrinogen to fibrin. Multivariable regressions were used to analyze the association of fibrinogen on in-hospital mortality and the first 24-hour mortality.

Results

The total in-hospital mortality rate was 92 (37.9%) in patients with ATAAD, and 33 (13.6%) of patients died within 24 hours of onset. We found no significant association between fibrinogen plasma level and in-hospital death (HR, 0.91; 95% CI, 0.78, 1.06; P=0.23), but a fibrinogen plasma level of ≤4.0 g/L was an independent risk factor for the first 24-hour mortality (HR, 5.92; 95% CI, 1.40, 25.08, P=0.02).

Conclusions

ATAAD patients with a fibrinogen plasma level of >4.0 g/L have lower first 24-hour mortality when treated medically, while patients with a fibrinogen plasma level of ≤4.0 g/L are more likely to die without surgery in the first 24 hours.

Therapeutic Effect of Rapamycin on Aortic Dissection in Mice

Aortic dissection (AD) is a serious clinical condition that is unpredictable and frequently results in fatal outcome. Although rapamycin, an inhibitor of mechanistic target of rapamycin (mTOR), has been reported to be effective in preventing aortopathies in mouse models, its mode of action has yet to be clarified. A mouse AD model that was created by the simultaneous administration of β-aminopropionitrile (BAPN) and angiotensin II (AngII) for 14 days. Rapamycin treatment was started either at day 1 or at day 7 of BAPN+AngII challenge, and continued throughout the observational period. Rapamycin was effective both in preventing AD development and in suppressing AD progression. On the other hand, gefitinib, an inhibitor of growth factor signaling, did not show such a beneficial effect, even though both rapamycin and gefitinib suppressed cell cycle activation in AD. Rapamycin suppressed cell cycle-related genes and induced muscle development-related genes in an AD-related gene expression network without a major impact on inflammation-related genes. Rapamycin augmented the activation of Akt1, Akt2, and Stat3, and maintained the contractile phenotype of aortic smooth muscle cells. These findings indicate that rapamycin was effective both in preventing the development and in suppressing the progression of AD, indicating the importance of the mTOR pathway in AD pathogenesis.

Genetic Deletion of Socs3 in Smooth Muscle Cells Ameliorates Aortic Dissection in Mice

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Stat3, a major signaling molecule for proinflammatory cytokines including IL-6, was activated both in inflammatory cells and in SMC in the aortic walls of human AD and mouse AD model.

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SMC-specific deletion of Socs3 enhanced Stat3 activation in SMC, induced moderate proinflammatory response in the aortic walls, and ameliorated AD in mice.

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SmSocs3-KO aortas showed increases in fibroblasts, adventitial collagen fibers, and tensile strength of the aortic walls.

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IL-6-stimulated SMC in culture secreted humoral factor(s) that promoted proliferative response of fibroblasts.

Aortic dissection (AD) is the acute destruction of aortic wall and is reportedly induced by inflammatory response. Here we investigated the role of smooth muscle Socs3 (a negative regulator of Janus kinases/signal transducer and activator of transcription signaling) in AD pathogenesis using a mouse model generated via β-aminopropionitrile and angiotensin II infusion. Socs3 deletion specifically in smooth muscle cells yielded a chronic inflammatory response of the aortic wall, which was associated with increased fibroblasts, reinforced aortic tensile strength, and less-severe tissue destruction. Although an acute inflammatory response is detrimental in AD, smooth muscle-regulated inflammatory response seemed protective against AD.

Clinical impact of visceral-to-subcutaneous fat ratio in patients with acute aortic dissection

Background

Obesity has increased worldwide. Although the visceral-to-subcutaneous fat ratio (VS ratio) is an established risk factor for cardiovascular disease, its clinical impact on the long-term prognosis of patients with acute aortic dissection (AAD) remains unclear.

Materials and methods

This retrospective study included 111 patients with AAD admitted to our hospital from 2013 to 2016. Patients who died during hospitalization, and those diagnosed with Marfan’s syndrome were excluded. Visceral and subcutaneous fat accumulation (VFA, SFA) at umbilical level were calculated on a dedicated workstation. Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) and worsening renal function (WRF) at 3 years were evaluated.

Results

Patient characteristics were as below: age, 73 ± 13; male, 55%; Stanford type A, 53%. Average VFA, SFA, and VS ratio on admission were 98 (52–145) cm², 141 (90–185) cm², and 0.75 (0.47–0.97), respectively. VFA was higher in male than in female (male, 134 [84–179] cm²; female, 71 [46–99] cm²; p < 0.001), whereas SFA was similar (male, 141 [91–174] cm²: female, 134 [90–205] cm²; p = 0.687). VS ratio was also higher in male (male, 0.88 [0.75–1.17]; female, 0.49 [0.39–0.65]; p < 0.001). Both MACCE and WRF at 3 years were observed in 17 (15%) and 32 (29%) patients, respectively. Multivariate Cox regression analysis demonstrated that VS ratio tended to be associated with the 3-year MACCE (HR for an increase of 0.5 unit, 1.49; 95% CI, 0.99–2.24; p = 0.056). This result persisted in male (HR for an increase of 0.5 unit, 1.54; 95% CI, 0.96–2.48; p = 0.073) but not female. The VS ratio was not related to the 3-year WRF.

Conclusion

The VS ratio tends to be associated with the 3-year MACCE in patients with AAD. This finding is inconclusive owing to a small sample and low incidence of adverse events. Further studies with larger samples are needed to confirm the clinical significance of VS ratio.

The Clinical Impact of Imaging Surveillance and Clinic Visit Frequency after Acute Aortic Dissection

Background  Guidelines recommend frequent follow-up after acute aortic dissection (AAD), but optimal rates of follow-up are not clear.

Methods  We examined rates of imaging and clinic visits in 267 individuals surviving AAD during recommended intervals (≤1, > 1–3, > 3–6, > 6–12 months, then annually), frequency of adverse imaging findings, and the relationship between follow-up and mortality.

Results  Type A and B AAD were noted in 46 and 54% of patients, respectively. Mean follow-up was 54.7 ± 13.3 months, with 52 deaths. Adverse imaging findings peaked at 6 to 12 months (5.6%), but rarely resulted in an intervention (3.4% peak at 6–12 months). Compared with those with less frequent imaging, patients with imaging for 33 to 66% of intervals ( p  = 0.22) or ≥66% of intervals ( p  = 0.77) had similar adjusted survival. In comparison to patients with fewer clinic visits, those with visits in 33 to 66% of intervals experienced lower adjusted mortality (hazards ratio: 0.47, 95% confidence interval: 0.23–0.97, p  = 0.04), with no difference seen in those with ≥66% (vs. < 33%) interval visits ( p  = 0.47). Imaging at 6 to 12 months (vs. none) was associated with decreased adjusted mortality (hazards ratio: 0.50, 95% confidence interval: 0.27–0.91, p  = 0.02), while imaging during other intervals, or clinic visits during any specific intervals, was not associated with a difference in mortality ( p  > 0.05 for each).

Conclusions  Adverse imaging findings following AAD are common, but rarely require prompt intervention. Patients with the lowest and highest rates of clinic visits experienced increased mortality. While the overall rate of surveillance imaging did not correlate with mortality, adverse imaging findings and related interventions peaked at 6 to 12 months after AAD, and imaging during this time was associated with improved survival.

Rare case of aortic aneurysm with type A dissection (extending to right coronary artery) and severe AR in a nonhypertensive and non pregnant female

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Aortic dissection has a high mortality rate. It is common in elderly males. Aortic dilatation definitely increases risk but is not a must in every case. Clinical manifestation of Aortic dissection can be variable, therefore its diagnosis is challenging.

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Primary suspicion of Aortic dissection is usually based on a patient’s history which varies from typical complaints like a sharp, severe tearing kind of backache with chest pain to asymptomatic until associated with valvular regurgitation.

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Consequent treatment with antiplatelet, antithrombin and thrombolytic agents can cause life-threatening to bleed. Apart from good blood pressure control, prevention of aortic dissection can be done by elective aortic surgery in patients with dilated ascending aorta.

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The most important and common risk factor is the systemic hypertension which has been reported in the 70% of the patients with aortic dissection. Most of the aortic dissection observed in young women has been reported to be related to pregnancy.

Introduction

Typically a patient with acute aortic dissection presents with severe chest pain radiating to the back, tearing in nature. Rarely it can present as painless acute aortic dissection this is seen in iatrogenic cases or when associated with atherosclerosis, diabetes, or aortic aneurysm.

Case presentation

We hereby present a case of a 32-year aged female who presented with dyspnoea & palpitations (NYHA III) from last 6 months, diagnosed to have Aortic Aneurysm with Type A dissection & Severe AR. She eventually underwent BENTALL’S procedure with CABG and had an uneventful recovery.

Discussion

Clinical manifestation of Aortic dissection can be variable, therefore its diagnosis is challenging. 25% of cases, may have associated ECG changes suggestive of acute coronary syndrome leading to a possible misdiagnosis especially if associated ST elevation in ECG. Aorto arteritis is a non-atherosclerotic chronic inflammatory vascular disease of unknown etiology that affects the aorta, proximal parts of its major branches. In this case, there is a possibility that there was underlying spontaneous coronary artery dissection which in turn could be cause for silent ischemia in young women.

Conclusion

Acute aortic dissection is a life-threatening disease with a high rate of cardiovascular morbidity and mortality. The most important and common risk factor is systemic hypertension which has been reported in the 70% of the patients with aortic dissection. Most of the aortic dissection observed in young women has been reported to be related to pregnancy. Dissection should be suspected during any acute coronary syndrome, particularly Inferior wall MI.

Expression profiles of circRNAs and the potential diagnostic value of serum circMARK3 in human acute Stanford type A aortic dissection

CircRNAs are involved in a variety of human diseases, however, the expression profiles and the potential diagnostic value of circRNAs in human acute Stanford type A aortic dissection (AAAD) remains largely unknown. In this study, high-throughput RNA sequencing (RNA-Seq) was used to investigate the differentially expressed circRNAs, microRNAs (miRs) and mRNAs in human AAAD tissues (n = 10) compared with normal aortic tissues (n = 10). The results of RNA-Seq revealed that 506 circRNAs were significantly dysregulated (P<0.05, false discovery rate, FDR<0.05, fold change>2). The subsequent weighted gene correlation network analysis and the following co-expression network analysis revealed that tyrosine-protein kinase Fgr might play important roles in the occurrence and development of AAAD. According to the circRNA-miRNA-mRNA network, we found that the upstream regulatory molecule of Fgr is circMARK3. Finally, a receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of the serum circMARK3 as biomarkers for AAAD (cutoff value = 1.497, area under the curve = 0.9344, P < 0.0001, sensitivity = 90.0%, specificity = 86.7%). These results provided a preliminary landscape of circRNAs expression profiles and indicated that circMARK3 was a potential biomarker for AAAD diagnosis.

[Hybrid procedures for aortic arch disease]

Different surgical approaches for aortic arch disease were reviewed in the article. We have also compared various vascular prostheses for aortic replacement.

Acute Type B Dissection

Aortic dissections are catastrophic vascular emergencies, and early recognition and appropriate interventions can be crucial to survival. Research has changed the way aortic dissections are managed over the past two decades and will continue to contribute to the evolution of treatment modalities. Early treatment for uncomplicated type B dissections still remains controversial but certain characteristics may benefit from early intervention.

Role of Moderate Hypothermia and Antegrade Cerebral Perfusion during Repair of Type A Aortic Dissection

The goal of this study was to compare early postoperative outcomes and actuarial survival between patients who underwent repair of acute type A aortic dissection with deep or moderate hypothermia. A total of 132 consecutive patients from a single academic medical center underwent repair of acute type A aortic dissection between January 2000 and June 2014. Of those, 105 patients were repaired under deep hypothermia (< 24 C°), while 27 patients were repaired under moderate hypothermia (≥24 C°). Median ages were 62 years (range: 27-86) and 59 years (range: 35-83) for patients repaired under deep hypothermia compared with patients repaired under moderate hypothermia, respectively ( p  = 0.451). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. Operative mortality was 17.1 and 7.4% in the deep and moderate hypothermia groups, respectively ( p  = 0.208). Incidence of permanent stroke was 12.4% in the deep hypothermic circulatory arrest group and 0% in the moderate hypothermia group ( p  = 0.054). Actuarial 5- and 10-year survival demonstrated a trend for lower long-term mortality with moderate hypothermia compared with deep hypothermia (69% 5-year and 54% 10-year for deep hypothermia vs. 79% 5-year and 10-year for moderate hypothermia, log-rank p  = 0.161). Moderate hypothermia is a safe and efficient alternative to deep hypothermia and may have protective benefits. Stroke rate was lower with moderate hypothermia.

Medication adherence patterns in aortic dissection survivors

Background & objectives:

Beta-blockers have been shown to improve survival in both type A and type B acute aortic dissection (AAD) patients. Calcium channel blockers have been shown to selectively improve survival only in type B AAD patients. There is a lack of data on medication adherence in AAD survivors. The purpose of this study was to assess medication adherence in patients who survived an AAD.

Methods:

This was a cross-sectional survey-based study of individuals from a single medical centre which was part of the larger International Registry of Acute Aortic Dissection (IRAD). Patients with type A or B AAD who survived to discharge were included in this study. Individuals who were deceased based on the results of an online Social Security Death Index were excluded from the study. Data were obtained from both a survey and also from abstraction from the local academic institution's IRAD registry. A survey packet was sent to patients. One section of this survey was dedicated to assessing medication adherence using the 4-item Morisky scale.

Results:

Eighty two completed surveys were returned; 74 patients completed the section of the survey pertaining to medication adherence (response rate 38%). Morisky score was ≥1.0 for 27 (36%) patients and 0 for 47 (64%) patients. Thirty three patients reported yes to ‘forget to take medications’ and eight reported yes to ‘careless with medications.’ Medication non-adherence (defined as a score of ≥1.0 on Morisky) was associated with increased follow up recurrence of chest pain at one year of follow up. Only two patients stopped their antihypertensive on their own and did not cite a reason for doing this.

Interpretation & conclusions:

The medication adherence rate for patients who survived an AAD was 64 per cent at a median (Q1, Q3) of 7.1 yr (5.6, 11.5) after discharge, as per the Morisky scale. The clinicians should educate their patients on the importance of antihypertensive therapy and assess for forgetfulness and carelessness at each clinic visit, as well as understand patients’ beliefs about drug therapy, all of which have been shown to increase medication adherence.

[Aortic aneurism dissection in an adult patient with tuberculosis infected with HIV-1 during immune reconstitution inflammatory syndrome]

We here report the case of a 35-year old man with HIV-1 but with no previous medical-surgical history hospitalized in Abidjan, Côte d'Ivoire, due to fever, cough, dyspnea, chest pain and unfolding of the aortic arch observed on chest x-ray a week after having started antiretroviral therapy (ART). CT angiography of the thoracic aorta showed overall, extended aortic ectasia with mural thrombus. Transesophageal echocardiography objectified type A ascending aortic dissection (Stanford classification). The diagnosis of tuberculosis was confirmed based on Mycobacterium tuberculosis culture isolation. Eight years after, the patient was still alive without surgical treatment and complained of intermittent chest pain. Blood pressure was stable with moderate renal failure. We here report a rare case of aortic aneurism dissection in an adult patient with tuberculosis infected with HIV-1 during immune reconstitution inflammatory syndrome.

Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection

Background

Type B aortic dissection is a life-threatening acute aortic condition often with acute ischemic signs or symptoms. With initial management focusing on alleviating malperfusion and pain, and avoiding propagation of dissection or rupture both systolic blood and pulse pressure should be reduced initially by an aggressive medical approach. In the setting of persistent signs of complications endovascular strategies have replaced open surgery and led to a fourfold increase in early survival and better long-term outcomes.

Methods

An electronic health database search was performed on articles published between January 2006 and July 2017. Publications were included in this review if (I) the index aortic pathology was type B aortic (distal) dissection; (II) when medical management, open surgical replacement or thoracic endovascular aortic repair were among those options; (III) when at least one of all basic outcome criteria such as survival, spinal cord ischemia and cerebrovascular accident was reported; (IV) when ≥15 serial patients were included. A total of 62 studies were eligible and analysed.

Results

Our manuscript has summarized data collected over 12 years on management specific outcomes in the setting of distal aortic dissection and provides an up-to-date interpretation of the published evidence. For complicated cases, treated acutely, the 30-day or in-hospital mortality was 7.3% when managed by endovascular means, whereas the pooled rate for 30-day or in-hospital mortality was 19.0% when subjected to open repair. For acute uncomplicated type B dissection usually treated with blood pressure lowering medications, the pooled 30-day or in-hospital mortality rate was 2.4%. Survival rates at 5 years averaged at 60% (40% mortality). Freedom from any aortic event ranged from 34.0% to 83.9%, underlining an inherent risk of progression and late complications. For chronic complicated type B dissection, the rates of stroke, paraplegia and operative mortality following endovascular repair ranged from 5% to 13%, 2% to 13% and 2 to 13%, respectively, while 5-year survival rates after open repair ranged from 60% to 90%. In chronic uncomplicated type B dissection almost 90% of patients survive initial hospitalization and were subjected to medical management with a 5-year survival of 50-80%. However, up to 20-55% of medically treated patients develop aneurysmal degeneration after 5 years with an unknown risk of rupture.

Conclusions

Currently, the less invasive strategy of endovascular repair (as compared to open surgery) provides improved 30-day or in-hospital survival in the setting of complicated acute type B aortic dissection and may seek broad application. Open surgical aortic reconstruction should be left to experienced aortic centres if endovascular management is not an option.

Do all type 2 aortic dissection require emergency surgery?

We represent a case of asymptomatic isolated chronic ascending aortic dissection that lasted for 15 years in which a patient was only followed up with medical therapy that saved him from early surgical intervention.

Role of Macrophage Socs3 in the Pathogenesis of Aortic Dissection

BACKGROUND

Aortic dissection (AD) is a life-threatening medical emergency caused by the abrupt destruction of the intimomedial layer of the aortic walls. Given that previous studies have reported the involvement of proinflammatory cytokine interleukin-6 in AD pathogenesis, we investigated the role of signal transduction and activator of transcription 3 signaling, a downstream pathway of interleukin-6 in macrophages in pathogenesis of AD.

METHODS AND RESULTS

We characterized the pathological and molecular events triggered by aortic stress, which can lead to AD. Aortic stress on the suprarenal aorta because of infrarenal aorta stiffening and angiotensin II infusion for 1 week caused focal medial rupture at the branching point of the celiac trunk and superior mesenteric artery. This focal medial rupture healed in 6 weeks in wild-type (WT) mice, but progressed to AD in mice with macrophage-specific deletion of Socs3 gene (mSocs3-KO). mSocs3-KO mice showed premature activation of cell proliferation, an inflammatory response, and skewed differentiation of macrophages toward the tissue-destructive phenotype. Concomitantly, they showed aberrant phenotypic modulation of smooth muscle cells and transforming growth factor beta signaling, which are likely to participate in tissue repair. Human AD samples revealed signal transduction and activator of transcription 3 activation in adventitial macrophages adjacent to the site of tissue destruction.

CONCLUSIONS

These findings suggest that AD development is preceded by focal medial rupture, in which macrophage Socs3 maintains proper inflammatory response and differentiation of SMCs, thus promoting fibrotic healing to prevent tissue destruction and AD development. Understanding the sequence of the pathological and molecular events preceding AD development will help predict and prevent AD development and progression.

The frequency of initial misdiagnosis of acute aortic dissection in the emergency department and its impact on outcome

We determine the frequency of initial misdiagnosis and inappropriate treatment with antiplatelets/anticoagulants in the emergency department (ED) and the resultant clinical outcomes in patients with acute type A aortic dissection (AAOD). Medical records of patients with a final diagnosis of AAOD admitted from March 2004 through October 2015 to our tertiary-level heart hospital were evaluated. Patients with suspected dissection in ED were compared to those with initial misdiagnosis regarding demographics and clinical presentation, laboratory and echocardiographic findings. Our primary outcome was hospital mortality in two groups. Long-term mortality after discharge was our secondary outcome. Among 189 patients, 47 (24.8 %) were initially misdiagnosed and received antiplatelets/anticoagulants in ED (Group F), and 142 (75.1 %) were appropriately diagnosed in ED (Group T). The mean age in group F was 60.4 ± 15.0 vs. 57.4 ± 16.0 years in group T (p = 0.260). In group F, 70.2 % were male vs. 60.6 % in group T (p = 0.311). Hospital mortality was 48.9 % in group F vs. 43.7 % in group T (p = 0.645). Long-term mortality was significantly higher in group F (55.6 vs. 21.2 %, p = 0.007). Univariate hazard ratio (HR) of initial misdiagnosis for long-term mortality was 2.56 (95 % CI 1.08-6.06, p = 0.031). In multivariate Cox regression analysis with adjustment for age and type of management (surgical/medical), initial misdiagnosis lost its significance for predicting long-term mortality (HR 2.14, 95 % CI 0.89-5.13, p = 0.086). Initial misdiagnosis of AAOD is a common problem. Hospital mortality is not significantly affected by receiving antiplatelets/anticoagulants. Although long-term mortality is higher in patients with initial misdiagnosis, it is not an independent predictor for long-term mortality.

Early and late outcomes after open ascending aortic surgery: 47-year experience in a single centre

The aims of the study are to describe the long-term survival of patients undergoing primary open ascending aortic surgery and to portray the evolution of aortic surgery during six decades in a single centre. Included were all 614 patients who underwent primary ascending aortic surgery in 1968–2014 at one Nordic university hospital. Patients were identified and data were collected from patient records and surgical logs. Mortality data were acquired from the national registry. Median follow-up was 11.2 years using reverse Kaplan–Meier method. Overall 30-day survival was 91.2% and for 30-day survivor rates were 86.9, 77.6, 52.1, 38.3 and 26.7% at 5, 10, 20, 30 and 40 years. There was no significant difference in long-term survival for 30-day survivors (p = 0.105) between patients treated emergently for dissection/rupture and electively (mainly ascending aortic aneurysms). On Cox regression era of surgery (p = 0.006), increasing age (p < 0.001) and indication (p < 0.001) were predictors of 30-day mortality. Arch involvement indicated twofold risk (HR 2.09, p = 0.05) compared to non-arch involved. Only increasing age (p < 0.001) predicted long-term mortality. There was a sixfold risk of 30-day mortality in the earliest era compared to the latest (p = 0.03). After the early postoperative phase following ascending aortic surgery, the surgical indication and urgency of the index operation have no significant impact on long-term survival. The very long term survival after ascending aortic surgery is excellent for 30-day survivors and improved through the era. Surgical treatment has improved and perioperative mortality has decreased significantly in 47 years.

The IRAD and beyond: what have we unravelled so far?

Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality rates and a long history of challenges to both diagnose and manage this condition successfully. The International Registry of Acute Aortic Dissection (IRAD) was established in 1996 as a global database to understand this old disease better and improve care for dissection. IRAD initially targeted various areas including etiological factors of dissection, modes of presentation, clinical features, physical findings, imaging, management, and outcomes, and is currently branching out in more specific fields such as endovascular intervention, genetic profiling, and functional imaging. Although presenting symptoms and physical findings have not changed significantly over two decades, the widespread use of computed tomography is standard and has improved the diagnostic pathway. Moreover, more patients are managed with appropriate procedures, such as surgery in type A, and endovascular therapy in subsets of type B aortic dissection. With these ongoing improvements in swift diagnostic work-up and therapeutic care, fewer patients are not getting appropriate treatment and more patients survive once they reach hospital.

Regional Practice Patterns and Outcomes of Surgery for Acute Type A Aortic Dissection

BACKGROUND

The surgical management of acute type A aortic dissection is evolving, and many aortic centers of excellence are reporting superior outcomes. We hypothesize that similar trends exist in a multiinstitutional regional consortium.

METHODS

Records for 884 consecutive patients who underwent aortic operations (2003 to 2015) for acute type A aortic dissection were extracted from a regional The Society of Thoracic Surgeons database. Patients were stratified into three equal operative eras. Differences in outcomes and risk factors for morbidity and mortality were determined.

RESULTS

Surgical procedures for type A aortic dissection are increasing in extent and complexity. Aortic root repair was performed in 16% of early era cases compared with 67% currently (p < 0.0001). Similarly, aortic arch repair increased from 27% to 37% cases (p < 0.0001). Cerebral perfusion is currently used in 85% of circulatory arrest cases, most frequently antegrade (57%). Total circulatory arrest times increased (29 minutes vs 31 minutes vs 36 minutes; p = 0.005), but times without cerebral perfusion were stable (12 minutes vs 6 minutes; p = 0.68). Although the operative mortality rate remained stable at 18.9% during the 3 operative eras, there were significant decreases in pneumonia and reoperations (p < 0.05). Predictors of operative mortality and major morbidity are age (odds ratio [OR], 1.04; p < 0.0001), previous stroke (OR, 2.09; p = 0.03), and elevated creatinine (OR, 1.31; p = 0.01). Importantly, the extent of aortic operation did not increase risk for morbidity or mortality.

CONCLUSIONS

Operative morbidity and mortality remain significant for type A aortic dissection, but lower than historical outcomes. The extent of aortic surgery has increased, resulting in adaptive cerebral protection changes in contemporary "real-world" practice.

Diagnostic implication of fibrin degradation products and D-dimer in aortic dissection

Fibrin degradation products (FDP) and D-dimer have been considered to be involved in many vascular diseases. In this study we aimed to explore the diagnostic implication of FDP and D-dimer in aortic dissection patients. 202 aortic dissection patients were collected as the case group, 150 patients with other cardiovascular diseases, including myocardial infarction (MI, n = 45), pulmonary infarction (n = 51) and abdominal aortic aneurysm (n = 54) were collected as non-dissection group, and 27 healthy people were in the blank control group. The FDP and D-dimer levels were detected with immune nephelometry. Logist regression analysis was performed to evaluate the influence of FDP and D-dimer for the aortic dissection patients. ROC curve was used to determine the diagnostic value of FDP and D-dimer. The FDP and D-dimer levels were significantly higher in aortic dissection patients than in non-dissection patients and the healthy controls. FDP and D-dimer were both the risk factors for patients with aortic dissection. From the ROC analysis, diagnostic value of FDP and D-dimer were not high to distinguish aortic dissection patients from the non-dissection patients. However FDP and D-dimer could be valuable diagnostic marker to differentiate aortic dissection patients and healthy controls with both AUC 0.863.

Exercise and Physical Activity for the Post-Aortic Dissection Patient: The Clinician's Conundrum

Despite the paucity of evidence, it is often presumed, and is physiologically plausible, that sudden, acute elevations in blood pressure may transiently increase the risk of recurrent aortic dissection (AD) or rupture in patients with a prior AD, because a post-dissection aorta is almost invariably dilated and may thus experience greater associated wall stress as compared with a nondilated aorta. Few data are available regarding the specific types and intensities of exercise that may be both safe and beneficial for this escalating patient population. The purpose of this editorial/commentary is to further explore this conundrum for clinicians caring for and counseling AD survivors. Moderate-intensity cardiovascular activity may be cardioprotective in this patient cohort. It is likely that severe physical activity restrictions may reduce functional capacity and quality of life in post-AD patients and thus be harmful, underscoring the importance of further exploring the role of physical activity and/or structured exercise in this at-risk patient population.

Aortic Dissection in a Healthy Male Athlete: A Unique Case with Comprehensive Literature Review

A young otherwise healthy 27-year-old male who has been using anabolic steroids for a long time developed Type I aortic dissection associated with heavy weightlifting. The patient did not have a recent history of trauma to the chest, no history of hypertension, and no illicit drug use. He presented with severe chest pain radiating to back and syncopal event with exertion. Initial vitals were significant for blood pressure of 80/50 mmHg, pulse of 80 beats per minute, respirations of 24 per minute, and oxygen saturation of 92% on room air. Physical exam was significant for elevated jugular venous pressure, muffled heart sounds, and cold extremities with diminished pulses in upper and absent pulses in lower extremities. Bedside echocardiogram showed aortic root dilatation and cardiac tamponade. STAT computed tomography (CT) scan of chest revealed dissection of ascending aorta. Cardiothoracic surgery was consulted and patient underwent successful repair of ascending aorta. Hemodynamic stress of weightlifting can predispose to aortic dissection. Aortic dissection is a rare but often catastrophic condition if not diagnosed and managed acutely. Although rare, aortic dissection needs to be in the differential when a young weightlifter presents with chest pain as a delay in diagnosis may be fatal.

Comparison between antegrade and retrograde cerebral perfusion or profound hypothermia as brain protection strategies during repair of type A aortic dissection

BACKGROUND

The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection by the method of cerebral perfusion used.

METHODS

A total of 324 patients from five academic medical centers underwent repair of acute type A aortic dissection between January 2000 and December 2010. Of those, antegrade cerebral perfusion (ACP) was used for 84 patients, retrograde cerebral perfusion (RCP) was used for 55 patients, and deep hypothermic circulatory arrest (DHCA) was used for 184 patients during repair. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality and Cox Regression hazard ratios were calculated to determine the predictors of long term mortality.

RESULTS

Operative mortality was not influenced by the type of cerebral protection (19% for ACP, 14.5% for RCP and 19.1% for DHCA, P=0.729). In multivariable logistic regression analysis, hemodynamic instability [odds ratio (OR) =19.6, 95% confidence intervals (CI), 0.102-0.414, P<0.001] and CPB time >200 min(OR =4.7, 95% CI, 1.962-1.072, P=0.029) emerged as independent predictors of operative mortality. Actuarial 5-year survival was unchanged by cerebral protection modality (48.8% for ACP, 61.8% for RCP and 66.8% for no cerebral protection, log-rank P=0.844).

CONCLUSIONS

During surgical repair of type A aortic dissection, ACP, RCP or DHCA are safe strategies for cerebral protection in selected patients with type A aortic dissection.

The imaging assessment and specific endograft design for the endovascular repair of ascending aortic dissection

Background

Endovascular option has been proposed for a very limited and selected number of Stanford type A aortic dissection (TAAD) patients. We have performed a computed tomography (CT)-based TAAD study to explore appropriate endograft configurations for the ascending aortic pathology.

Methods

TAAD patients treated with optimal CT scans were retrospectively reviewed, and their entry tears (ETs) were identified using three-dimensional and multiplanar reconstructions in an EndoSize workstation. After generating a centerline of flow, measurements, including numerous morphologic characteristics of anatomy, were evaluated and a selected subset of patients were determined to be suitable for endovascular treatments. Proximal diameter and distal diameter of endograft were selected based on diameters measured at the ET level and at the innominate artery (IA) level, with 10% oversizing with respect to the true lumen, but not exceeding the original aortic diameter. The length of the endograft was determined by the distance from the sinotubular junction to IA.

Results

This study covered 126 TAAD patients with primary ET in ascending aorta, among which, according to the assumed criteria, 48 (38.1%) patients were deemed to be suitable for endovascular treatment. The diameters of ascending aorta from the sinotubular junction to the IA level presented a downward trend, and the proximal diameters differed significantly from distal diameters of the endograft for TAAD (39.9 versus 36.2 mm, P<0.01), implying that the conical endograft might be compatible with the ascending pathology. In the ascending aorta, lengths of the endograft should be 50, 60, 70, 80, and 90 mm in five (10.4%), 22 (45.9%), 13 (27.1%), six (12.5%), and two (4.2%) patients, respectively.

Conclusion

In this selected number of Chinese patients, the suitability of endovascular repair has been demonstrated based on the CT imaging. Shorter, larger, and bare spring-free conical endografts were preferred in the ascending aortic pathology.