Importance of Refractory Pain and Hypertension in Acute Type B Aortic Dissection

Interventions in Acute or Subacute Phase for Type B Aortic Dissection

The treatment strategy for acute and subacute Stanford type B aortic dissection has changed significantly since the advent of thoracic endovascular aortic repair (TEVAR). Indication for invasive treatment: In addition to the conventional complicated cases (rupture or malperfusion case), the indication for invasive treatment now includes cases with refractory hypertension, persistent or recurrent pain, large aortic diameter, and other conditions that are considered to have a poor prognosis with conservative treatment. Treatment methods: TEVAR is the first choice for acute, subacute, and early chronic-stage treatment, and when this is not possible, other techniques (fenestration and graft replacement) are chosen. Treatment timing: The timing of invasive treatment should be emergent in life-threatening conditions (for rupture or malperfusion case) and immediate in symptomatic cases, while in other cases, preemptive TEVAR is considered appropriate on a scheduled timing within 6 months of onset. (This is a translation of Jpn J Vasc Surg 2023; 32: 157-163.).

Initial Triage and Management of Patients with Acute Aortic Syndromes

The acute aortic syndromes (AAS) are life-threatening vascular compromises within the aortic wall. These include aortic dissection (AD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), and blunt traumatic thoracic aortic injury (BTTAI). While patients classically present with chest pain, the presentation may be highly variable. Timely diagnosis is critical to initiate definitive treatment and maximize chances of survival. In high-risk patients, treatment should begin immediately, even while diagnostic evaluation proceeds. The mainstay of medical therapy is acute reduction of heart rate and blood pressure. Surgical intervention is often required but is informed by patient anatomy and extent of vascular compromise.

Outcomes of Patients with Acute Type B Aortic Dissection and High-Risk Features

BACKGROUND

Recently the Society for Vascular Surgery (SVS) and Society for Thoracic Surgeons (STS) published contemporary guidelines clearly defining complicated versus uncomplicated acute type B aortic dissections (TBADs) with an additional high-risk grouping. Few studies have evaluated outcomes associated with "high-risk" TBADs. The objective of this study was to assess differences in demographics, clinical presentation, symptom onset, and outcomes in high-risk patients that underwent either thoracic endovascular aortic repair (TEVAR) or best medical management for acute TBAD compared to those with complicated and uncomplicated acute TBAD.

METHODS

Patients admitted with acute TBADs from a single academic medical center from October 2011 to March 2020 were analyzed. Per the STS/SVS 2020 guidelines, high risk was defined as refractory pain/hypertension, bloody pleural effusion, aortic diameter >4 cm, false lumen diameter >22 mm, radiographic malperfusion, and early readmission, and complicated was defined as ruptured/malperfusion presentation. Uncomplicated patients were those without malperfusion/rupture and without high-risk features. The primary end-point was inpatient mortality. Secondary end-points included complications, reintervention, and survival.

RESULTS

Of the 159 patients identified with acute TBAD, 63 (40%) met the high-risk criteria. In the high-risk cohort, 38 (60%) underwent TEVAR (HR-TEVAR), with refractory pain as the most common indication, while 25 (40%) were managed medically (HR-medical). Malperfusion or rupture was present in 63 (40%) patients (complicated TBAD (C-TBAD)), all of whom underwent TEVAR. An additional 33 patients had no high-risk features and were all managed medically (uncomplicated TBAD). There were no differences in age, body mass index, and race between groups. Among the 4 groups, there were variable distributions in sex, insurance status, and incidence of several baseline comorbidities including congestive heart failure, chronic obstructive pulmonary disease, and renal dysfunction (P < 0.05 for all). C-TBAD had increased length of stay (12, interquartile range [IQR] 9-22) compared to HR-TEVAR (11.5, IQR 7-15), HR-medical (6, IQR 5-8), and uncomplicated TBAD (7, IQR 5-10) (P < 0.01). C-TBAD had decreased days from admission to repair (0, IQR 0-2) compared to HR-TEVAR (3.5, IQR 1-8) (P < 0.01). C-TBAD patients had worse 3-year survival compared to other groups (log-rank P < 0.01), although when in-hospital mortality was excluded, survival was similar among groups (P = 0.37). Of patients initially managed medically, outpatient TEVAR was performed in 6 (24%) HR-medical and 4 (12%) uncomplicated patients, with no difference between rate of intervention between groups (P = 0.22).

CONCLUSIONS

High-risk features, as defined in updated SVS/STS guidelines, are common in patients presenting with acute TBAD. High-risk patients had acceptable outcomes when managed either surgically or medically. High-risk patients that underwent TEVAR had improved perioperative outcomes and mortality compared to those undergoing TEVAR for C-TBAD, a finding which may help guide preoperative risk stratification and patient counseling.

The activator protein-1 complex governs a vascular degenerative transcriptional programme in smooth muscle cells to trigger aortic dissection and rupture

BACKGROUND AND AIMS

Stanford type A aortic dissection (AD) is a degenerative aortic remodelling disease marked by an exceedingly high mortality without effective pharmacologic therapies. Smooth muscle cells (SMCs) lining tunica media adopt a range of states, and their transformation from contractile to synthetic phenotypes fundamentally triggers AD. However, the underlying pathomechanisms governing this population shift and subsequent AD, particularly at distinct disease temporal stages, remain elusive.

METHODS

Ascending aortas from nine patients undergoing ascending aorta replacement and five individuals undergoing heart transplantation were subjected to single-cell RNA sequencing. The pathogenic targets governing the phenotypic switch of SMCs were identified by trajectory inference, functional scoring, single-cell regulatory network inference and clustering, regulon, and interactome analyses and confirmed using human ascending aortas, primary SMCs, and a β-aminopropionitrile monofumarate-induced AD model.

RESULTS

The transcriptional profiles of 93 397 cells revealed a dynamic temporal-specific phenotypic transition and marked elevation of the activator protein-1 (AP-1) complex, actively enabling synthetic SMC expansion. Mechanistically, tumour necrosis factor signalling enhanced AP-1 transcriptional activity by dampening mitochondrial oxidative phosphorylation (OXPHOS). Targeting this axis with the OXPHOS enhancer coenzyme Q10 or AP-1-specific inhibitor T-5224 impedes phenotypic transition and aortic degeneration while improving survival by 42.88% (58.3%-83.3% for coenzyme Q10 treatment), 150.15% (33.3%-83.3% for 2-week T-5224), and 175.38% (33.3%-91.7% for 3-week T-5224) in the β-aminopropionitrile monofumarate-induced AD model.

CONCLUSIONS

This cross-sectional compendium of cellular atlas of human ascending aortas during AD progression provides previously unappreciated insights into a transcriptional programme permitting aortic degeneration, highlighting a translational proof of concept for an anti-remodelling intervention as an attractive strategy to manage temporal-specific AD by modulating the tumour necrosis factor-OXPHOS-AP-1 axis.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community

OBJECTIVE

The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years.

METHODS

IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents.

RESULTS

Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index.

CONCLUSIONS

IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.

Descending thoracic aortic emergencies: Past, present, and future

The most important descending thoracic aortic (DTA) pathologies are aneurysms, dissections, and traumatic injuries. In acute settings, these conditions can constitute a significant risk of bleeding or ischemia of vital organs, resulting in a fatal outcome. Morbidity and mortality associated with aortic pathologies remain significant, despite improvements in medical therapy and endovascular techniques. In this narrative review, we present an overview of the transitions in the management of these pathologies and discuss current challenges and future perspectives. Diagnostic challenges include differentiating between thoracic aortic pathologies and cardiac diseases. Efforts have been made to identify a blood test that can rapidly differentiate these pathologies. Computed tomography is the cornerstone of diagnosing thoracic aortic emergencies. Our understanding of DTA pathologies has improved substantially due to the significant advancement in imaging modalities in the last 2 decades. On the basis of this understanding, the treatment of these pathologies has been revolutionized. Unfortunately, robust evidence from prospective and randomized studies is still lacking for the management of most DTA diseases. Medical management plays a crucial role in achieving early stability during these life-threatening emergencies. This includes intensive care monitoring, heart rate and blood pressure control, and considering permissive hypotension for patients presenting with ruptured aneurysms. Over the years, surgical management of DTA pathologies changed from open repair to endovascular repair with dedicated stent-grafts. Techniques in both spectrums have improved substantially.

Gore TAG thoracic branch endograft for treatment of a subacute type B aortic dissection complicated by rupture

An 80-year-old man presented with a subacute zone 3-5 type B aortic dissection complicated by rupture and visceral and lower extremity malperfusion. He underwent emergent zone 2 repair with a Gore TAG thoracic branch endograft with inclusion of the left subclavian artery for a dominant left vertebral artery. The patient's postoperative course was uncomplicated. Type B aortic dissections can be anatomically complex, and rupture is a rare complication in the subacute phase. We report the novel use of a Gore TAG thoracic branch endograft for the management of type B aortic dissection complicated by rupture and demonstrate its feasibility for patients with type B aortic dissection complicated by rupture.

Risk Factors Associated with Poor Prognosis in Patients with Stanford Type B Aortic Dissection after Thoracic Endovascular Aortic Repair

BACKGROUND

The aim of the study was to analyze the clinical characteristics of patients with Stanford type B aortic dissection (TBAD) and risk factors for poor prognosis after thoracic endovascular aortic repair (TEVAR).

METHODS

Clinical records for patients with TBAD presenting to a medical center between March 1, 2012 and July 31, 2020 were reviewed. Clinical data including demographics, comorbidities, and postoperative complications were obtained from electronic medical records. Comparative analysis and subgroup analysis were performed. A logistic regression model was used to analyze prognostic factors in patients with TBAD after TEVAR.

RESULTS

TEVAR was performed on all 170 patients with TBAD, and poor prognosis was identified in 28.2% (48/170) of cases. Patients with a poor prognosis were younger (38.5 [32.0, 53.8] years vs. 55.0 [48.0, 62.0] years, P < 0.001), had higher systolic blood pressure (SBP) (138.5 [127.8, 152.8] mm Hg vs. 132.0 [120.8, 145.3] mm Hg, P = 0.013) and more complicated aortic dissection patients (19 [60.4] vs. 71 [41.8], P = 0.029) than those without a poor prognosis. According to the results of binary logic regression analysis, the possibility of a poor prognosis after TEVAR decreased with each 10 years increase in age (odds ratio: 0.464, 95% confidence interval: 0.327-0.658, P < 0.001).

CONCLUSIONS

There is an association between younger age and a poor prognosis after TEVAR in patients with TBAD, with the condition that those with poor prognoses have higher SBP and more complicated cases. In younger patients, postoperative follow-up should be more frequent, and complications should be managed in time.

Reintervention after Thoracic Endovascular Aortic Repair of Uncomplicated Type B Aortic Dissection

BACKGROUND

Data are scarce regarding the incidence, reasons, potential risk factors, and long-term outcomes of reintervention after thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated type B aortic dissection (TBAD).

METHODS

Between January 2010 and December 2020, 238 patients with uncomplicated TBAD who received TEVAR were analyzed retrospectively. The clinical baseline data, aorta anatomy, dissection characteristics, and details of the TEVAR procedure were evaluated and compared. A competing-risk regression model was used to estimate the cumulative incidences of reintervention. The multivariate Cox model was used to identify the independent risk factors.

RESULTS

The mean follow-up time was 68.6 months. A total of 27 (11.3%) cases of reintervention were observed. The competing-risk analyses showed that the 1-, 3-, and 5-year cumulative incidences of reintervention were 5.07%, 7.08%, and 14.0%, respectively. Reasons for reintervention included endoleak (25.9%), aneurysmal dilation (22.2%), retrograde type A aortic dissection (18.5%), distal stent-graft-induced new entry and false lumen expansion (18.5%), and dissection progression and/or malperfusion (14.8%). Multivariable Cox analysis demonstrated that a larger initial maximal aortic diameter (Hazard ratio [HR], 1.75; 95% Confidence interval [CI], 1.13-2.69, p = 0.011) and increased proximal landing zone oversizing (HR, 1.07; 95% CI, 1.01-1.47, p = 0.033) were the significant risk factors for reintervention. Long-term survival rates were comparable between patients with or without reintervention (p = 0.915).

CONCLUSIONS

Reintervention after TEVAR in patients with uncomplicated TBAD is not uncommon. A larger initial maximal aortic diameter and excessive proximal landing zone oversizing are associated with the second intervention. Reintervention does not significantly affect long-term survival.

Aortic arch surgery for type B aortic dissection: How far should we go? The value of a hybrid approach

Traditionally, the management of type B aortic dissection has been the domain of the vascular surgeons. Timing and type of intervention still generate debate. We sought to review our early experience with the treatment of this condition based on a hybrid approach following an aortic multi-disciplinary team meeting involving close cooperation between cardiac surgeons, vascular surgeons, interventional radiologists, vascular anesthetists, and cardiac anesthetists. Four patients (age 41-56 years; 3 males; 1 female) with type B aortic dissection underwent aortic arch surgery through a hybrid approach: one elective procedure consisting of ascending aorta and hemi-arch replacement with debranching followed by thoracic endovascular aortic repair (TEVAR); one redo procedure requiring aortic arch replacement with hybrid frozen elephant trunk; two acute presentations (aortic arch replacement and debranching followed by TEVAR; AVR with ascending aorta, arch, and proximal descending thoracic aorta replacement with conventional elephant trunk and debranching). Deep hypothermic circulatory arrest was required in three patients. Despite respiratory complications and slightly prolonged postoperative course, all patients survived without onset of stroke, paraplegia, malperfusion, endoleak, or need for re-exploration. Follow-up remains satisfactory. Different factors may affect outcome following complex aortic procedures. Nevertheless, close cooperation between cardiac surgeons, vascular surgeons, and interventional radiologists may reduce potential for complications and address aspects that may not be completely within the domain of individual specialists.

Emergency Endovascular Interventions on Descending Thoracic Aorta: A Single-Center Experience

Background

Implementation of emergency endovascular aortic repair provides an attractive opportunity in the treatment of complicated acute aortic syndromes involving descending aorta.

Aim

The aim of this study was to analyze the effectiveness of thoracic endovascular aortic repair (TEVAR) for the treatment of acute surgical emergencies involving the descending thoracic aorta.

Methods

A retrospective review of the medical records of all patients undergoing TEVAR in a single center since 2007 was undertaken. Patients with the aortic disease treated on emergency inclusion criteria were complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other indications requiring emergent intervention. Technical and clinical success with patient mortality, survival, and reoperation rate was evaluated according to Society for Vascular Surgery reporting standards for thoracic endovascular aortic repair (TEVAR).

Results

The emergency interventions were necessary in 74 cases (51.0%), including patients with the complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48) and traumatic aortic acute injuries (TAIs) (31.1%). In addition, in one case aortic iatrogenic dissection (AID) and in 2 other fistulas after the previous stent graft, implantations were diagnosed. All procedures were done through surgically exposed femoral arteries while 2 hybrid procedures required additional approaches. The primary technical success rate was 95.9%, in 3 cases endoleak was reported. The primary clinical success occurred in 94.5%. All patients survived the endovascular interventions, whereas during in-hospital stay one of them died due to multiorgan failure (early mortality 1.3%). During the follow-up period, lasting 6 through 164 months (median 67), 11 patients died. Annual, five- and ten-year probability of survival was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, the rate of 5-year survivors was significantly higher after TAI (95.2%) than scAAS (63.4%) (p=0.008). Early after the procedure, one individual developed transient paraparesis (1.3%). No other serious stent-graft-related adverse events were noted within the postdischarge follow-up period.

Conclusions

Descending aortic pathologies requiring emergent interventions can be treated by endovascular techniques with optimal results and low morbidity and mortality in an experienced and dedicated team.

Current management of acute type B dissection in 2021

The rationale for thoracic endovascular aortic repair (TEVAR) for type B aortic dissection depends on the phase of disease: acute phase, which is 'complicated', subacute to early chronic phase, which requires 'preemptive TEVAR' and chronic phase, which entails 'prevention of further dilatation and rupture'. Low operative mortality and morbidity after TEVAR for complicated acute type B aortic dissection have been reported with significant improvement during midterm survival. 'Retrograde' type A dissection, which can be described as type B_0,X (X>3) according to a new reporting standard, has reportedly been treated with TEVAR with less invasiveness. TEVAR is the first and possibly the only effective strategy for acute type B dissection, so that expansion of indications for type B_0,X, as described in the new reporting standard has been validated.

Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection

OBJECTIVE

The study objective was to analyze the outcomes of thoracic endovascular aortic repair performed for complicated and uncomplicated acute type B aortic dissections.

METHODS

Patients from WL Gore's Global Registry for Endovascular Aortic Treatment who underwent thoracic endovascular aortic repair for acute type B aortic dissections were included, and data were retrospectively analyzed.

RESULTS

Of 5014 patients enrolled in the Global Registry for Endovascular Aortic Treatment, 172 underwent thoracic endovascular aortic repair for acute type B aortic dissections. Of these repairs, 102 were for complicated acute type B aortic dissections and 70 were for uncomplicated acute type B aortic dissections. There were 46 (45.1%) procedures related to aortic branch vessels versus 15 (21.4%) in complicated type B aortic dissections and uncomplicated type B aortic dissections (P = .002). The mean length of stay was 14.3 ± 10.6 days (median, 11; range, 2-75) versus 9.8 ± 7.9 days (median, 8; range, 0-42) in those with complicated type B aortic dissections versus those with uncomplicated acute type B aortic dissections (P < .001). Thirty-day mortality was not different between groups (complicated type B aortic dissections 2.9% vs uncomplicated acute type B aortic dissections 1.4%, P = .647), as well as aortic complications (8.8% vs 5.7%, P = .449). Aortic event-free survival was 62.9% ± 37.1% versus 70.6% ± 29.3% at 3 years (P = .696).

CONCLUSIONS

In the Global Registry for Endovascular Aortic Treatment, thoracic endovascular aortic repair results for complicated type B aortic dissections versus uncomplicated acute type B aortic dissections showed that 30-day mortality and perioperative complications were equally low for both. The midterm outcome was positive. These data confirm that thoracic endovascular aortic repair as the first-line strategy for treating complicated type B dissections is associated with a low risk of complications. Further studies with longer follow-up are necessary to define the role of thoracic endovascular aortic repair in uncomplicated acute type B dissections compared with medical therapy. However, in the absence of level A evidence from randomized trials, results of the uncomplicated acute type B aortic dissection patient cohort treated with thoracic endovascular aortic repair from registries are important to understand the related risk and benefit.

Risk factors for distal stent graft-induced new entry after endovascular repair in uncomplicated type B aortic dissection

OBJECTIVE

We investigated the risk factors for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair for patients with uncomplicated type B aortic dissection (TBAD) and reported the outcomes of using a tapered stent graft and dSINE reintervention.

METHODS

A total of 226 patients with uncomplicated TBAD who had undergone thoracic endovascular aortic repair between January 2010 and December 2018 were analyzed retrospectively. The global features of the thoracic aorta and the local features of the proximal and distal landing zones were evaluated and compared between the dSINE and non-dSINE groups. A multivariate Cox model was used to identify the independent risk factors for dSINE. The cumulative incidence of reintervention was estimated using competing risk models.

RESULTS

After a median follow-up of 4.6 years, 16 patients (7.1%) had developed dSINE. Multivariable Cox regression analysis demonstrated that a type III aortic arch, decreased angle, increased distal oversizing, and increased distal mismatch ratio were significant risk factors for dSINE. Of the patients with tapered stent grafts, five with a ≤4-mm taper had developed dSINE. However, no dSINE was seen in the >4-mm taper group (P = .024). Reintervention was performed for 7 of the 16 patients with dSINE (43.8%). The mean time from the initial detection of dSINE to reintervention was 6.43 ± 4.62 months. The competing risk analyses showed that the cumulative incidence of reintervention in the dSINE group at 1, 3, and 5 years was 25.0%, 37.5%, and 43.5%, respectively.

CONCLUSIONS

A type III aortic arch, excessive distal oversizing and mismatch ratio, and severe angulation were associated with dSINE in patients with uncomplicated TBAD. The use of a tapered stent graft with a >4-mm taper could help prevent dSINE in patients with a high taper ratio. Aggressive reintervention was associated with favorable long-term outcomes for patients with progressive dSINE.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

The misnomer of uncomplicated type B aortic dissection

BACKGROUND

Acute type B aortic dissection (TBAD) is a rare condition that can be divided into complicated (CoTBAD) and uncomplicated (UnCoTBAD) based on certain presenting clinical and radiological features, with UnCoTBAD constituting the majority of TBAD cases. The classification of TBAD directly affects the treatment pathway taken, however, there remains confusion as to exactly what differentiates complicated from uncomplicated TBAD.

AIMS

The scope of this review is to delineate the literature defining the intervention parameters for UnCoTBAD.

METHODS

A comprehensive literature search was conducted using multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on intervention parameters and protocols for UnCoTBAD.

RESULTS

A TBAD without evidence of malperfusion or rupture might be classified as uncomplicated but there remains a subgroup who might exhibit high-risk features. Two clinical features representative of "high risk" are refractory pain and persistent hypertension. First-line treatment for CoTBAD is TEVAR, and whilst this has also proven its safety and effectiveness in UnCoTBAD, it is still being managed conservatively. However, TBAD is a dynamic pathology and a significant proportion of UnCoTBADs can progress to become complicated, thus necessitating more complex intervention. While the "high-risk" UnCoTBAD do benefit the most from TEVAR, yet, the defining parameters are still debatable as this benefit can be extended to a wider UnCoTBAD population.

CONCLUSION

Uncomplicated TBAD remains a misnomer as it is frequently representative of a complex ongoing disease process requiring very close monitoring in a critical care setting. A clear diagnostic pathway may improve decision making following a diagnosis of UnCoTBAD. Choice of treatment still predominantly depends on when an equilibrium might be reached where the risks of TEVAR outweigh the natural history of the dissection in both the short- and long-term.

Prognostic Impact of Blood Pressure Change Patterns on Patients With Aortic Dissection After Admission

Objectives

Hypertension is a predominant risk factor for aortic dissection (AD), and blood pressure (BP) control plays a vital role in the management of AD. However, the correlation between BP change and the prognosis for AD remains unclear. This study aims to demonstrate the impact of BP change patterns on AD prognosis.

Methods

This retrospective study included AD patients at two institutions (Shanghai Ninth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine and the Vascular Department of the First Affiliated Hospital of Anhui Medical University) between 2004 and 2018. The systolic BP (SBP) change patterns of these patients were analyzed by functional data analysis (FDA). The relationship between BP change patterns and the risk of adverse events (AEs) was assessed using survival analysis.

Results

A total of 458 patients with AD were eligible for analysis. The logistic regression analysis indicated that compared with that in patients with low SBP variation (SBPV), the incidence of AEs in patients with high SBPV was significantly higher (35.84 vs. 20.35%, OR 2.19, P &lt; 0.001). The patients were divided into four categories (accelerating rise, accelerating drop, decelerating rise, and decelerating drop) based on their SBP patterns after FDA fitting. The results of Kaplan–Meier analysis showed that at the 15- and 20-min time points, the incidence of AEs in the decelerating-drop group was significantly lower than that in the accelerating-rise group (OR 0.19, P = 0.031 and OR 0.23, P = 0.050). However, at the 25- and 30-min time points, the difference between these four groups was not significant (OR 0.26, P = 0.08 and OR 0.29, P = 0.10).

Conclusions

This study classified AD patients into four groups according to the SBP change patterns the first 30 min following admission, of which those with accelerating rises in SBP are at the highest risk of AEs, while those with decelerating drops have the best prognosis in the first 24 h after admission. Clinical practitioners may benefit from analyzing patterns of in-hospital SBP.

Risk profile analysis of uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair: Laboratory and radiographic predictors

BACKGROUND

There is emerging evidence to support pre-emptive thoracic endovascular aortic repair (TEVAR) intervention for uncomplicated type B aortic dissection (unTBAD). Pre-emptive intervention would be particularly beneficial in patients that have a higher baseline risk of progressing to complicated TBAD (coTBAD). There remain debate on the optimal clinical, laboratory, morphological, and radiological parameters, which would identify the highest-risk patients that would benefit most from pre-emptive TEVAR.

AIM

This review summarizes evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients.

METHODS

A comprehensive literature search was carried out on multiple electronic databases including PubMed, EMBASE, Ovid, and Scopus to collate all research evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients RESULTS: At present, there are no clear clinical guidelines using risk-stratification to inform the selection of unTBAD patients for TEVAR. However, there are noticeable literature trends that can assist with the identification of the most at-risk unTBAD patients. Patients are at particular risk when they have refractory pain and/or hypertension, elevated C-reactive protein (CRP), larger aortic diameter, and larger entry tears. These risks should be considered alongside factors that increase the procedural risk of TEVAR to create a well-balanced approach. Advances in biomarkers and imaging are likely to identify more pertinent parameters in the future to optimize the development of balanced, risk-stratified treatment protocols.

CONCLUSION

There are a variety of risk profiling parameters that can be used to identify the high-risk unTBAD patient, with novel biomarkers and imaging parameters emerging. Longer-term evidence verifying these parameters would be ideal. Further randomized controlled trials and multicentre registry analyses are also warranted to guide risk-stratified selection protocols.

Thoracic endovascular aortic repair or best medical therapy for uncomplicated type B aortic dissection? A meta-analysis

INTRODUCTION

The aim of this meta-analysis was to investigate all studies comparing thoracic endovascular aortic repair (TEVAR) and best medical therapy (BMT) for the treatment of uncomplicated type B aortic dissection (TBAD).

EVIDENCE ACQUISITION

PubMed/Medline and Web of Knowledge were searched until September 2014 for relevant studies published in English. Pooled odds ratio (OR) and its corresponding 95% CI were analyzed with Cochrane Review Manager (RevMan v.5.3).

EVIDENCE SYNTHESIS

Our analysis showed that compared with BMT, TEVAR did not significantly affect 30-day (hospital) mortality. A significantly lower 1-year and 2- or 3-year survival rates was observed with TEVAR vs. BMT. Interestingly, a trend just short of statistical significance towards higher 4- or 5-year survival was found with TEVAR treatment (P=0.08). No significant differences were found in false lumen (FL) thrombosis formation with TEVAR vs. BMT treatment. However, a trend toward less incomplete or no FL thrombosis was noted with TEVAR. No significantly impact on the risk of later re-intervention was found with TEVAR vs. BMT.

CONCLUSIONS

TEVAR did not provide obvious early survival advantage for uncomplicated TBAD over BMT, especially in the patients using TEVAR alone. It may remain a treatment option in uncomplicated TBAD patients with high risks for later complications. More randomized, prospective, long-term studies are needed to further clarify whether TEVAR could be a better first-line treatment strategy vs. BMT for uncomplicated TBAD.

Systematic review and meta-analysis of current evidences in endograft therapy versus medical treatment for uncomplicated type B aortic dissection

OBJECTIVE

Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair (TEVAR) has been controversial for uSTBAD.

METHODS

In this paper, a meta-analysis was conducted on all available randomized controlled trials and observational studies that evaluated the relative benefits and harms of TEVAR and BMT for the management of patients suffering from uSTBAD. Primary endpoints consisted of early adverse events, long-term adverse events and aortic remodeling. In addition, Risk difference (RD) or Odds ratios (OR) with 95% confidence intervals (CI) were estimated. The random effects model or the fixed-effects model was used in accordance with the 50% heterogeneity threshold.

RESULTS

Seven observational studies and two RCT studies from 11 articles that contained 15066 patients suffering from uSTBAD (1518 TEVARs) met the inclusion criteria. For early outcomes, no significant differences were found between the TEVAR group and the BMT group in aortic rupture, retrograde dissection, paraplegia/paraparesis, reintervention, aorta-related death and all caused death. In the long run, the TEVAR group was found to have a significantly lower incidence of adverse events, which included aortic rupture (OR:0.26, CI:0.16∼0.42, P<0.05; heterogeneity: P=0.90, I²=0%), reintervention (OR:0.45, CI:0.26∼0.75, P<0.05; heterogeneity: P=0.17, I²=41%), aorta-related death (OR:0.27, CI:0.18∼0.42, P<0.05; heterogeneity: P=0.61, I²=0%) and all caused death (OR:0.52, CI:0.42∼0.66, P<0.05; heterogeneity: P=0.05, I²=53%) as compared with the BMT group. Moreover, in compared with BMT, TEVAR was found to significantly contribute to the complete thrombosis of thoracic false lumen (OR:55.34, CI:34.32∼89.21, P<0.05; heterogeneity: P=0.97, I²=0%) and aortic regression (true lumen expansion and false lumen shrinkage).

CONCLUSIONS

Although early endovascular repair of uSTBAD does not outperform BMT, its implementation is found to be necessary to facilitate the long-term prognosis. Accordingly, if early TEVAR is to be deferred, close follow-up is critical to allow for timely reintervention.

The Necessity to Seal the Re-Entry Tears of Aortic Dissection After TEVAR: A Hemodynamic Indicator

Thoracic endovascular aortic repair (TEVAR) is a common treatment for Stanford type B aortic dissection (TBAD). However, re-entry tears might be found distal to the stented region which transports blood between the true and false lumens. Sealing the re-entry tears, especially for the thoracic tears, could further reduce blood perfusion to the false lumen; however, it might also bring risks by re-intervention or surgery. Wise determination of the necessity to seal the re-entry tears is needed. In this study, patient-specific models of TBAD were reconstructed, and the modified models were established by virtually excluding the thoracic re-entries. Computational hemodynamics was investigated, and the variation of the functional index and first balance position (FBP) of the luminal pressure difference, due to the sealing of the re-entries, was reported. The results showed that the direction of the net flow through the unstented thoracic re-entries varied among cases. Excluding the re-entries with the net flow toward the false lumen may induce the FBP moving distally and the relative particle residence time increasing in the false lumen. This study preliminarily demonstrated that the hemodynamic status of the re-entry tears might serve as an indicator to the necessity of sealing. By quantifying the through-tear flow exchange and shift of FBP, one can predict the hemodynamic benefit by sealing the thoracic re-entries and thus wisely determine the necessity of further interventional management.

Impact of high-risk features and timing of repair for acute type B aortic dissections

OBJECTIVE

The new Society for Vascular Surgery/Society for Thoracic Surgery reporting standards for type B aortic dissection (TBAD) categorize clinical presentations of aortic dissection into uncomplicated, high-risk features (HRF), and complicated groups. Although it is accepted that complicated dissections require immediate repair, the optimal timing of repair for HRF has yet to be established. This study aims to identify the ideal timing of thoracic endovascular aortic repair (TEVAR) for HRF, as well as outcomes associated with specific HRF.

METHODS

The Vascular Quality Initiative was queried for TEVARs performed for acute and subacute TBAD with HRF from 2014 to 2020. Rupture, malperfusion, and uncomplicated patients were excluded. HRF were defined per the guidelines as refractory hypertension, pain, or rapid expansion/aneurysm of more than 40 mm. The primary outcomes were in-hospital/30-day mortality and 1-year survival with primary exposure variables being days from symptoms to repair and number of HRFs. Secondary outcomes were spinal cord ischemia, stroke, and retrograde type A dissection (RTAD).

RESULTS

Of the 1100 patients who met inclusion criteria, 811 had one HRF, 249 had two, and 40 had three. There were no significant differences in primary or secondary outcomes based on number of HRFs. There were 309 patients who underwent repair at 0 to 2 days, 262 at 3 to 6 days, 270 at 7 to 14 days, and 259 at 15 days or more. TEVAR performed at 15 days or more was independently associated with lower in-hospital/30-day mortality (odds ratio, 0.38; P = .0388) and improved 1-year survival. Postoperative stroke was associated with earlier repair (0-2 days). There was no association of timing of repair with spinal cord ischemia, retrograde type A dissection or reintervention.

CONCLUSIONS

TEVAR for TBAD with HRF delayed at least 15 days from symptom onset is associated with improved survival, supporting the theory that it is best to delay TEVAR until the subacute phase. Additionally, TEVAR delayed at least 3 days is associated with a decrease in stroke. Having more than one HRF was not associated statistically with worse outcomes. Because the classification of HRF is relatively new and without guidelines for repair, this study highlights the risks of early intervention for HRF and suggests that these patients seem to benefit from at least a short stabilization period before TEVAR.

Pleural effusion: a potential surrogate marker for higher-risk patients with acute type B aortic dissections

OBJECTIVES

Pleural effusions (PEffs) are known to occur in type B acute aortic dissection (TBAAD). We investigated the relationship between pleural effusion and the development of early or late complications following TBAAD.

METHODS

The incidence of PEff (defined as at least an obliteration of the costophrenic angle in a frontal projection) diagnosed on their initial chest X-ray in patients with TBAAD enrolled in the International Registry of Acute Aortic Dissection was examined. We analysed in-hospital outcomes and long-term survival separately for patients with and without PEffs (PEff+ versus PEff-, respectively).

RESULTS

Included were 1252 patients with TBAAD, of whom 224 (17.9%) had PEff. Compared with patients without PEff in the initial chest X-ray, these were significantly older [mean age 67 (SD: 14.7) vs 63.4 (SD: 14.2) years, P = 0.001] and more often female (42.4% vs 34.2%, P = 0.021) and had more comorbidities (known aortic aneurysm, chronic obstructive pulmonary disease, chronic renal failure, diabetes, congestive heart failure or mitral valve disease). PEff was associated with higher in-hospital mortality (16.1% vs 9.1%, P = 0.002) and increased rates of neurological complications (16.6% vs 11.1%, P = 0.029), acute renal failure (27.2% vs 19.7%, P = 0.017) and hypotension (17.4% vs 9.6%, P = 0.001). In addition, patients with PEff underwent aortic repair more frequently (44.6% vs 32.5%, P < 0.001). In the long-term patients with PEff showed lower 5-year post-discharge survival (67.6% vs 77.6%, P = 0.004). Multivariable analysis with propensity-matched data showed that PEff was not an independent risk factor for in-hospital mortality (odds ratio 1.9, 95% CI 0.8-4.4, P = 0.141).

CONCLUSIONS

Patients with TBAAD and evidence of PEff showed a higher in-hospital mortality, are more likely to develop additional in-hospital complications and have a decreased likelihood of survival during follow-up. However, according to propensity-matched analysis, PEff remained not as an independent predictor of worse outcome but might serve as an early surrogate marker to identify higher-risk patients.

Management of Acute, Complicated Type B Aortic Dissection

Management of acute complicated Type B aortic dissection (TBAD) requires a multidisciplinary approach with careful evaluation and understanding of the complicating features. Patients who present with or progress to a complicated TBAD must be triaged and managed rapidly due to the high morbidity and mortality even in the presence of optimal medical, endovascular, and open therapies. When required, invasive therapies can be broken down most simply into four treatments: thoracic endograft placement, aortic fenestration, branch vessel stenting, and open repair. However, which therapy to offer and in which order is often unclear. In this review, focus is placed on clinical presentation, diagnosis, and explanation for one or a combination of these therapies. In addition, contraindications as well as expected outcomes, complications, and adjunct therapies will be reviewed. The advent of advanced endovascular techniques has certainly improved the immediate morbidity and mortality of acute complicated TBAD; however, much remains to learn about patient selection and therapeutic intervention performed.

The impact of pre-existing blood pressure control in patients with acute aortic dissections

OBJECTIVES

Arterial hypertension (HTN) is considered a seminal risk factor for aortic dissection (AD). The purpose of this study is to evaluate whether pre-existing blood pressure (BP) control lessens the extent of dissection and has a favorable impact on outcome of patients with acute AD.

METHODS

Consecutive acute AD patients who had at least two BPs recorded within the 12 months preceding the AD were retrospectively analyzed. The two most recent BPs were averaged and defined per published guidelines as normal (BP≤ 130/80), Stage I HTN (BP >130/80 and <139/89), or Stage 2 or greater HTN (BP > 140/90). The number of hypertensive medications (MEDs) was also used as a surrogate marker of HTN severity. Patients with known genetic causes of AD were excluded.

RESULTS

89 subjects (55% men, 45% women; mean age, 64±14 years) with acute AD (58% Stanford type A and 42% Stanford type B) were included. Two most recent BPs were recorded a mean of 5±3 and 3±2.7 months before the AD, respectively. Twenty-nine (33%) subjects had normal BP, including nine subjects with no history of HTN and on no MEDs. Sixty (67%) subjects had elevated BP, including 21 (35%) with Stage I HTN and 39 (65%) with Stage 2 HTN. Compared to subjects with normal BP, subjects with Stage 1 and Stage 2 HTN were younger (70±13 years vs 62±1 year, p = 0.01), but there were no differences in other demographics, risk factors, comorbidities, or history of drug use. There were no group differences in the distal extent of the dissections, complications requiring thoracic endograft repair, mean length of hospital stay, final discharge status, or 30-day mortality. Compared to the number of MEDs before AD, all three groups had a higher mean number of MEDs to achieve normal BP at discharge that persisted at a mean follow-up of 18±15 months.

CONCLUSIONS

These data show that approximately one-third of patients with acute AD had well controlled or no antecedent history of HTN. The degree of pre-existing HTN control had no bearing on the type or extent of AD, length of stay, or early outcome. Regardless of the state of HTN control before AD, the consistent and sustained increase in the severity of HTN after AD suggests that the dissection process has a profound and lasting effect on BP regulation. Further studies are indicated to elucidate the pathologic mechanisms involved in AD.

Impact of a multidisciplinary acute aortic dissection program: Improved outcomes with a comprehensive initial surgical repair strategy

OBJECTIVE

As part of a multidisciplinary aortic dissection (AD) program, a more comprehensive repair strategy for patients with acute type A aortic dissection (ATAAD) and frequent endografting for suitable patients with type B aortic dissection (ATBAD) was adopted in 2015. The aim of this study was to evaluate the impact of these changes.

METHODS

This study is a retrospective review of a prospective database containing all patients treated for acute AD between 2003 and 2020. Patients were grouped based on differing repair strategies (pre 2015 vs post 2015). Clinical characteristics, procedural details, and survival data were analyzed.

RESULTS

During this time, 323 patients (210 pre, 113 post) were treated for acute AD at our institution. There were 221 patients with ATAAD (149 pre, 72 post) and 102 patients with ATBAD (61 pre, 41 post). The majority (60%) were males, with a mean age of 65.9 ± 15.2 years. There were no differences in cardiovascular risk factors or demographics between the groups. After 2015, fewer patients with ATAAD underwent medical management alone (15% pre vs 4% post; P = .014), and most that underwent surgical intervention had a total arch or aggressive hemiarch repair (27% pre vs 78% post; P < .001). Seventy-four patients (73%) with ATBAD were treated medically, whereas 28 underwent medical management and endografting (23% pre, 34% post; P = .214). For all patients with AD, 30-day mortality was significantly improved (26% pre vs 10% post; P < .001) especially among patients who underwent ATAAD surgery (23% pre vs 9% post; P = .018). Three-year Kaplan-Meier survival estimates showed survival improvement among patients with ATAAD (Log rank P-value = .019); however, this improvement does not extend to type B dissections or the overall cohort. A survival analysis landmarked to 30 days after initial presentation showed no statistical difference in survival from 30 days to 3 years post-presentation.

CONCLUSIONS

A more comprehensive repair strategy in the management of patients with acute AD resulted in improved overall patient outcomes and significantly decreased 30-day mortality, even though more complex repairs were performed. The long-term impact of the changes made to our program remains to be evaluated.

Long-term results of type B aortic dissection patients with tumor after endovascular repair or optimal medical therapy: a single-center and retrospective cohort study

BACKGROUND

The effect of thoracic endovascular aortic repair (TEVAR) for acute Type B aortic has been confirmed, However, when patients with malignant disease suffer from acute type B aortic dissection (ATBAD), the effect of TEVAR intervention is still unclear.

METHODS

ATBAD patients were identified from electronic medical records between 2009 and 2019. The 5 year overall and aortic-disease free survival rates were analyzed and compared between the two groups.

RESULTS

Of the 40 enrolled patients, 27 (67.5%) received TEVAR and 13 (32.5%) received OMT. The baseline characteristics of the two groups were not significantly different. Kaplan‒Meier survival curve showed that the 5 year overall survival and 5 year aortic-disease free survival of the TEVAR group were better than those of the OMT group. The Cox proportional hazard model with unadjusted risk showed an 83.0% decrease in 5 year overall mortality (HR, 0.17; 95% CI, 0.05-0.56) and a lower aortic-disease related risk (HR, 0.08; 95% CI, 0.02-0.39) in TEVAR group compared to OMT group. After adjusted for age, gender, smoking, drinking and comorbidities (diabetes mellitus, hypertension and coronary artery diseases), the hazard ratio of 5 year overall mortality was 78.0% lower (HR, 0.22; 95% CI, 0.06.0.81) and the risk of aortic-disease related mortality was 93.0% lower (HR, 0.07; 95% CI, 0.01-0.61) in TEVAR group compared to OMT group. In the cohort stratified by age, sex, the risk of the 5 year overall or aortic-disease related mortality in TEVAR group was relatively reduced compared to OMT group.

CONCLUSIONS

Compared to OMT, TEVAR improves the 5 year overall and aortic-disease free survival rates in the cohort of ATBAD patients with a single type of malignant tumors.

Elevated preoperative neutrophil-to-lymphocyte ratio predicts early adverse outcomes in uncomplicated type B aortic dissection undergoing TEVAR

BACKGROUND

Thoracic aortic endovascular repair (TEVAR) of uncomplicated type B aortic dissection (uTBAD) has favorable long-term outcomes but higher early adverse events compared with the optimal medical treatment. Recently, clinical evidence concerning vascular surgery indicates that elevated preoperative systemic inflammatory response predicts adverse clinical events. The aim of our study was to evaluate the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR) and early outcomes of uTBAD patients undergoing TEVAR.

RESULTS

216 patients diagnosed with uTBAD were included in this retrospective study between January 2015 and December 2018. The median (IQR) follow-up period was 21 (15-33) months. An early adverse event was defined as occurring within 2 years after the procedure. Median patient age was 60 (IQR, 48-68) years and 78.7 % were male. Early adverse events occurred in 24 patients (11.1 %). In the multivariable analysis, preoperative NLR (HR per SD, 1.98; 95 % CI, 1.14-3.44; P = 0.015) was associated with 2-year adverse events.

CONCLUSIONS

NLR is an independent predictive factor of early adverse events in uTBAD patients undergoing TEVAR.

Endograft exclusion of the false lumen restores local hemodynamics in a model of type B aortic dissection

OBJECTIVE

Endovascular intervention in uncomplicated type B dissection has not been shown conclusively to confer benefit on patients. The hemodynamic effect of primary entry tear coverage is not known. Endovascular stent grafts were deployed in a model of aortic dissection with multiple fenestrations to study these effects. It is hypothesized that endograft deployment will lead to restoration of parabolic true lumen flow as well as elimination of false lumen flow and transluminal jets and vortices locally while maintaining distal false lumen canalization.

METHODS

Thoracic stent grafts were placed in silicone models of aortic dissection with a compliant and mobile intimal flap and installed in a flow loop. Pulsatile fluid flow was established with a custom positive displacement pump, and the models were imaged by four-dimensional flow magnetic resonance imaging. Full flow fields were acquired in the models, and velocities were extracted to calculate flow rates, reverse flow indices, and oscillatory shear index, the last two of which are measures of stagnant and disturbed flows.

RESULTS

Complete obliteration of the false lumen was achieved in grafted aorta, with normal parabolic flow profiles in the true lumen (maximal velocity, 30.4 ± 8.4 cm/s). A blind false lumen pouch was created distal to this with low-velocity (5.8 ± 2.7 cm/s) and highly reversed (27.9% ± 13.9% reverse flow index) flows. In distal free false lumen segments, flows were comparable to ungrafted conditions with maximal velocities on the order of 7.0 ± 2.1 cm/s. Visualization studies revealed forward flow in these regions with left-handed vortices from true to false lumen. Shear calculations in free false lumen regions demonstrated reduced oscillatory shear index.

CONCLUSIONS

Per the initial hypothesis, endovascular grafting improved true lumen hemodynamics in the grafted region. Just distally, a prothrombotic flow regimen was noted in the false lumen, yet free false lumen distal to this remained canalized. Clinically, this suggests a need for advancing endovascular intervention beyond sole entry tear coverage to prevent further false lumen canalization through uncovered fenestrations.

Current status of the management and outcomes of acute aortic dissection in Japan: Analyses of nationwide Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination data

Background:

Despite recent advances in the diagnosis and management, the mortality of acute aortic dissection remains high. This study aims to clarify the current status of the management and outcome of acute aortic dissection in Japan.

Methods:

A total of 18,348 patients with acute aortic dissection (type A: 10,131, type B: 8217) in the Japanese Registry of All Cardiac and Vascular Diseases database between April 2012–March 2015 were studied. Characteristics, clinical presentation, management, and in-hospital outcomes were analyzed.

Results:

Seasonal onset variation (autumn- and winter-dominant) was found in both types. More than 90% of patients underwent computed tomography for primary diagnosis. The overall in-hospital mortality of types A and B was 24.3% and 4.5%, respectively. The mortality in type A patients managed surgically was significantly lower than in those not receiving surgery (11.8% (799/6788) vs 49.7% (1663/3343); p&lt;0.001). The number of cases managed endovascularly in type B increased 2.2-fold during the period, and although not statistically significant, the mortality gradually decreased (5.2% to 4.1%, p=0.49). Type A showed significantly longer length of hospitalization (median 28 days) and more than five times higher medical costs (6.26 million Japanese yen) than those in type B. The mean Barthel index at discharge was favorable in both type A (89.0±22.6) and type B (92.6±19.0). More than two-thirds of type A patients and nearly 90% of type B patients were directly discharged home.

Conclusions:

This nationwide study elucidated the clinical features and outcomes in contemporary patients with acute aortic dissections in real-world clinical practice in Japan.

STABILISE Technique for a Non-A Non-B Acute Aortic Dissection in Marfan Syndrome

A 35-year-old man, with a deep pectus excavatum due to a Marfan syndrome treated 9 years before for an acute type A dissection involving only the aortic arch, by a Bentall surgery, was admitted for acute chest pain. Computed tomography (CT) scan showed an acute type non-A non-B dissection extending to the iliac. After 5 days with strict arterial blood pressure management, the patient had recurrent refractory chest pain and a hybrid technique associating full supra-aortic vessels debranching and STABILISE technique during the same procedure was performed. The patient had an uneventful recovery with CT scan showing complete aortic arch aneurysm exclusion.

Management of acute type B aortic dissection

BACKGROUND

The best management of acute uncomplicated type B aortic dissection is currently a controversial area. Recent advances in endovascular intervention have begun to establish pre-emptive thoracic endovascular aortic repair as a potential strategy. A review about the management for type B aortic dissection has been conducted.

METHODS

A narrative review consisting of 157 original articles, meta-analyses and guidelines was conducted. The findings were synthesized and summarized using 70 articles.

RESULTS

There are clear guidelines directing surgical management of acute complicated type B aortic dissection. However, the best management of acute uncomplicated disease is more ambiguous, which is especially concerning in a condition which is associated with significant morbidity and mortality. Medical management alone is generally favoured. Endovascular intervention is now being considered by some surgeons, but it can be technically difficult, while exposing the patient to potential surgical risks.

CONCLUSIONS

Clinical and anatomical risk factors have been identified to help vascular surgeons make decisions about treatment in acute uncomplicated type B aortic dissection. New endovascular strategies are being developed to reduce surgical risk and address technical challenges. Registry data should be used to support future best management.

N-terminal pro-brain natriuretic peptide and short-term mortality in acute aortic dissection: A meta-analysis

BACKGROUND

Acute aortic dissection (AAD) is a life-threatening medical emergency that requires immediate diagnosis and rapid treatment. There is a paucity of data on the role of biomarkers in risk stratification of patients with AAD.

HYPOTHESIS

N-terminal pro-brain natriuretic peptide (NT-proBNP) is associated with short-term mortality in AAD patients.

METHODS

We systematically searched Medline and Scopus to identify all observational cohort studies published before January 2020 that compared outcome (short-term mortality) in patients with AAD with high vs low levels of baseline NT-proBNP combining terms "brain natriuretic peptide" and "aortic dissection." A meta-analysis was conducted using the generic inverse variance method. Heterogeneity between studies was investigated using the Cochrane's Q test and I² statistic.

RESULTS

Four studies were included in final analysis including a total of 950 patients, and 105 (11%) patients died. Baseline NT-proBNP concentrations were significantly higher in nonsurvivors (median 2240 pg/mL, range 1678-16 347 pg/mL) when compared to survivors (665 pg/mL, 328-1252 pg/mL). Elevated NT-proBNP values were significantly associated with an increased risk of short-term mortality (odds ratio 4.13, 95% CI [confidence interval] 2.33-7.33), with low heterogeneity (I² = 8.77%, Cochran Q = 2.19, P = .33), and no publication bias. The pooled standardized mean difference between groups was 1.28 (95% CI 0.99-1.56), with low heterogeneity (I² = 38.73%, Cochran Q = 3.26, P = .19).

CONCLUSION

Elevated NT-proBNP levels on admission are associated with an increased risk of short-term mortality in AAD.

Management of Acute Aortic Dissection During Critical Care Air Medical Transport

Acute aortic dissection is a time-critical emergency that air medical teams must be capable of transporting. Aortic dissections can manifest a myriad of complications in which prompt recognition and tailored treatments may mitigate additional physiological burden and limit dissection flap propagation. The purpose of this review is to discuss specific critical scenarios that air medical providers may be faced with and to equip them with a pathophysiological understanding of the disease and best practices for the management of acute aortic dissections.