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Meng D, Wang Y, Zhou T, Gu R, Zhang Z, Zhao T, He H, Min Y, Wang X. A nomogram prediction model for short-term aortic-related adverse events in patients with acute Stanford type B aortic intramural hematoma: development and validation. Front Cardiovasc Med 2024; 11:1364361. [PMID: 39049955 PMCID: PMC11266148 DOI: 10.3389/fcvm.2024.1364361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/20/2024] [Indexed: 07/27/2024] Open
Abstract
Background This study is to examine the factors associated with short-term aortic-related adverse events in patients with acute type B aortic intramural hematoma (IMH). Additionally, we develop a risk prediction nomogram model and evaluate its accuracy. Methods This study included 197 patients diagnosed with acute type B IMH. The patients were divided into stable group (n = 125) and exacerbation group (n = 72) based on the occurrence of aortic-related adverse events. Logistic regression and the Least Absolute Shrinkage and Selection Operator (LASSO) method for variables based on baseline assessments with significant differences in clinical and image characteristics were employed to identify independent predictors. A nomogram risk model was constructed based on these independent predictors. The nomogram model was evaluated using various methods such as the receiver operating characteristic curve, calibration curve, decision analysis curve, and clinical impact curve. Internal validation was performed using the Bootstrap method. Results A nomogram risk prediction model was established based on four variables: absence of diabetes, anemia, maximum descending aortic diameter (MDAD), and ulcer-like projection (ULP). The model demonstrated a discriminative ability with an area under the curve (AUC) of 0.813. The calibration curve indicated a good agreement between the predicted probabilities and the actual probabilities. The Hosmer-Lemeshow goodness of fit test showed no significant difference (χ 2 = 7.040, P = 0.532). The decision curve analysis (DCA) was employed to further confirm the clinical effectiveness of the nomogram. Conclusion This study introduces a nomogram prediction model that integrates four important risk factors: ULP, MDAD, anemia, and absence of diabetes. The model allows for personalized prediction of patients with type B IMH.
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Affiliation(s)
- Dujuan Meng
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- The General Hospital of Northern Theater Command Training Base for Graduate, Dalian Medical University, Shenyang, China
| | - Yasong Wang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Tienan Zhou
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Ruoxi Gu
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zhiqiang Zhang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Tinghao Zhao
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Houlin He
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Ying Min
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaozeng Wang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Wu H, Wang J, Bu Y, Li J, Li Y, Jing Q, Wang X, Yan C, Liu D, Han Y. Pentamethylquercetin attenuates angiotensin II-induced abdominal aortic aneurysm formation by blocking nuclear translocation of C/EBPβ at Lys253. Biochim Biophys Acta Mol Basis Dis 2024; 1870:167224. [PMID: 38723872 DOI: 10.1016/j.bbadis.2024.167224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Pentamethylquercetin (PMQ) is a natural polymethyl flavonoid that possesses anti-apoptotic and other biological properties. Abdominal aortic aneurysm (AAA), a fatal vascular disease with a high risk of rupture, is associated with phenotypic switching and apoptosis of medial vascular smooth muscle cells (VSMCs). This study aimed to investigate the protective effects of PMQ on the development of AAA and the underlying mechanism. METHODS ApoE-/- mice were continuously infused with angiotensin II (Ang II) for 4 weeks to develop the AAA model. Intragastric administration of PMQ was initiated 5 days before Ang II infusion and continued for 4 weeks. In vitro, VSMCs were cultured and pretreated with PMQ, stimulated with Ang II. Real-time PCR, western blotting, and immunofluorescence staining were used to examine the roles and mechanisms of PMQ on the phenotypic switching and apoptosis of VSMCs. RESULTS PMQ dose-dependently reduced the incidence of Ang II-induced AAA, aneurysm diameter enlargement, elastin degradation, VSMCs phenotypic switching and apoptosis. Furthermore, PMQ also inhibited phenotypic switching and apoptosis in Ang II-stimulated VSMCs. PMQ exerted protective effects by regulating the C/EBPβ/PTEN/AKT/GSK-3β axis. AAV-mediated overexpression of PTEN reduced the therapeutic effects of PMQ in the AAA model mice, suggesting that the effects of PMQ on Ang II-mediated AAA formation were related to the PTEN/AKT/GSK-3β axis. PMQ inhibited VSMCs phenotypic switching and apoptosis by bounding to C/EBPβ at Lys253 with hydrogen bond to regulate C/EBPβ nuclear translocation and PTEN/AKT/GSK-3β axis, thereby inhibiting Ang II-induced AAA formation. CONCLUSIONS Pentamethylquercetin inhibits angiotensin II-induced abdominal aortic aneurysm formation by bounding to C/EBPβ at Lys253. Therefore, PMQ prevents the formation of AAA and reduces the incidence of AAA.
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MESH Headings
- Animals
- Aortic Aneurysm, Abdominal/metabolism
- Aortic Aneurysm, Abdominal/pathology
- Aortic Aneurysm, Abdominal/prevention & control
- Aortic Aneurysm, Abdominal/chemically induced
- Aortic Aneurysm, Abdominal/drug therapy
- Angiotensin II/pharmacology
- Mice
- Quercetin/analogs & derivatives
- Quercetin/pharmacology
- Apoptosis/drug effects
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/pathology
- Male
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/drug effects
- Myocytes, Smooth Muscle/pathology
- Disease Models, Animal
- PTEN Phosphohydrolase/metabolism
- PTEN Phosphohydrolase/genetics
- Proto-Oncogene Proteins c-akt/metabolism
- Mice, Inbred C57BL
- Glycogen Synthase Kinase 3 beta/metabolism
- Signal Transduction/drug effects
- Cells, Cultured
- Cell Nucleus/metabolism
- Cell Nucleus/drug effects
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Affiliation(s)
- Hanlin Wu
- Dalian Medical University, Dalian, Liaoning Province 116044, China; State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China
| | - Jing Wang
- Dalian Medical University, Dalian, Liaoning Province 116044, China; State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China
| | - Yuxin Bu
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China
| | - Jia Li
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China
| | - Yiming Li
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China
| | - Quanmin Jing
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China
| | - Xiaozeng Wang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China
| | - Chenghui Yan
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China
| | - Dan Liu
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China.
| | - Yaling Han
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, Liaoning Province 110016, China.
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Ishizue N, Fukaya H, Oikawa J, Sato N, Ogiso S, Murayama Y, Nakamura H, Kishihara J, Niwano S, Ako J. Prognostic impact of oral anticoagulation therapy and atrial fibrillation in patients with type B acute aortic dissection. J Arrhythm 2024; 40:297-305. [PMID: 38586850 PMCID: PMC10995604 DOI: 10.1002/joa3.13020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/09/2024] Open
Abstract
Background The prognostic impact of atrial fibrillation (AF) and oral anticoagulation (OAC) therapy in patients with type B acute aortic dissection (AAD) remains unclear. Therefore, we investigated the prognostic impact of AF and OAC therapy in patients with type B AAD. Methods Consecutive patients diagnosed with AAD were included in this single-center, retrospective study. Patients with type B AAD were selected from the study population and divided into three groups: AF(+)/OAC(+), AF(+)/OAC(-), and AF(-)/OAC(-). The primary end point was major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, progressive aortic events, cerebral infarction, and organ malperfusion. Results In total, 139 patients diagnosed with type B AAD were analyzed. AF was observed in 27 patients (19%). Among them, 13 patients (9%) received OAC therapy for AF. MACCE occurred in 32 patients (23%) during the observation period: all-cause death in four patients, progressive aortic events in 24 patients, cerebral infarction events in two patients, and malperfusion events in two patients. The incidence of MACCE was higher in the AF(+)/OAC(+) group than in the AF(+)/OAC(-) group (hazard ratio[HR]: 3.875; 95% confidence interval [CI]: 1.153-17.496). In contrast, there was no significant difference in the incidence of MACCE between the AF(+)/OAC(-) and AF(-)/OAC(-) groups (HR: 1.001, 95% CI: 0.509-1.802). Conclusion Among patients with type B AAD, the use of OAC for AF was associated with a higher risk of MACCE.
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Affiliation(s)
- Naruya Ishizue
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Hidehira Fukaya
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Jun Oikawa
- Department of Kitasato Clinical Research CenterKitasato University School of MedicineSagamiharaJapan
| | - Nobuhiro Sato
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Sho Ogiso
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Yusuke Murayama
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Hironori Nakamura
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Jun Kishihara
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Shinichi Niwano
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Junya Ako
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
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Lin CY, Kao MC, Lee HF, Wu MY, Tseng CN. Acute type a aortic intramural hematoma complicated with preoperative hemopericardium: early and late surgical outcome analyses. J Cardiothorac Surg 2024; 19:123. [PMID: 38481322 PMCID: PMC10936043 DOI: 10.1186/s13019-024-02616-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/05/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Acute type A aortic intramural hematoma (ATAIMH) is a variant of acute type A aortic dissection (ATAAD), exhibiting an increased risk of hemopericardium and cardiac tamponade. It can be life-threatening without emergency treatment. However, comprehensive studies of the clinical features and surgical outcomes of preoperative hemopericardium in patients with ATAIMH remain scarce. This retrospective study aims to investigate the clinical features and early and late outcomes of patients who underwent aortic repair surgery for ATAIMH complicated with preoperative hemopericardium. METHODS We investigated 132 consecutive patients who underwent emergency ATAIMH repair at this institution between February 2007 and August 2020. These patients were dichotomized into the hemopericardium (n = 58; 43.9%) and non-hemopericardium groups (n = 74; 56.1%). We compared the clinical demographics, surgical information, postoperative complications, 5-year cumulative survival rates, and freedom from reoperation rates. Furthermore, multivariable logistic regression analysis was utilized to identify independent risk factors for patients who underwent re-exploration for bleeding. RESULTS In the hemopericardium group, 36.2% of patients presented with cardiac tamponade before surgery. Moreover, the hemopericardium group showed higher rates of preoperative shock and endotracheal intubation and was associated with an elevated incidence of intractable perioperative bleeding, necessitating delayed sternal closure for hemostasis. The hemopericardium group exhibited higher blood transfusion volumes and rates of re-exploration for bleeding following surgery. However, the 5-year survival (59.5% vs. 75.0%; P = 0.077) and freedom from reoperation rates (93.3% vs. 85.5%; P = 0.416) were comparable between both groups. Multivariable analysis revealed that hemopericardium, cardiopulmonary bypass time, and delayed sternal closure were the risk factors for bleeding re-exploration. CONCLUSIONS The presence of hemopericardium in patients with ATAIMH is associated with an elevated incidence of cardiac tamponade and unstable preoperative hemodynamics, which could lead to perioperative bleeding tendencies and high complication rates. However, patients of ATAIMH complicated with hemopericardium undergoing aggressive surgical intervention exhibited long-term surgical outcomes comparable to those without hemopericardium.
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Affiliation(s)
- Chun-Yu Lin
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.
- Department of Cardiothoracic and Vascular Surgery, New Taipei Municipal TuCheng Hospital, No.6, Sec.2, JinCheng Rd, TuCheng, New Taipei City, 236, Taiwan.
| | - Ming-Chang Kao
- Department of Anesthesiology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Hsin-Fu Lee
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Department of Cardiology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Meng-Yu Wu
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Department of Cardiothoracic and Vascular Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chi-Nan Tseng
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Department of Cardiothoracic and Vascular Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
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Hu X, Yang F, Liu J, Liu Y, Fan R, Luo J. A single-center experience of type B aortic intramural hematoma. J Vasc Surg 2024; 79:514-525. [PMID: 38941265 DOI: 10.1016/j.jvs.2023.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 06/30/2024]
Abstract
OBJECTIVE The outcomes of the best medical treatment (BMT) and intervention treatment (INT) in a single-center experience were reported in type B intramural hematoma (IMH). METHODS From February 2015 to February 2021, a total of 195 consecutive patients with type B IMH were enrolled in the study. The primary end point was mortality, and the secondary end points included clinical and imaging outcomes. The clinical outcomes were aortic-related death, retrograde type A aortic dissection, stent graft-induced new entry tear, endoleak, and reintervention. The imaging outcome was evaluated through the latest follow-up computed tomography angiography, which included aortic rupture, aortic dissection, aortic aneurysm, rapid growth of aortic diameter, newly developed or enlarged penetrating aortic ulcer or ulcer-like projection (ULP) and increased aortic wall thickness. Kaplan-Meier curves were used to assess the association between different treatments. RESULTS Among the enrolled patients, 115 received BMT, and 80 received INT. There was no significant difference in early (1.7% vs 2.5%; P = 1.00) and midterm all-cause death (8.3% vs 5.2%; P = .42) between the BMT and INT groups. However, patients who underwent INT were at risk of procedure-related complications such as stent graft-induced new entry tear and endoleaks. The INT group was associated with a profound decrease in the risk of ULP, including newly developed ULP (4.3% vs 26.9%; P < .05), ULP enlargement (6.4% vs 31.3%; P < .05), and a lower proportion of high-risk ULP (10.9% vs 45.6%; P < .05). Although there was no significant difference in the incidence of IMH regression between the two groups, the maximum diameter of the descending aorta in patients receiving INT was larger compared with those treated with BMT. CONCLUSIONS Based on our limited experience, patients with type B IMH treated with BMT or INT shared similar midterm clinical outcome. Patients who underwent INT may have a decreased risk of ULPs, but a higher risk of procedure-related events and patients on BMT should be closely monitored for ULP progression.
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Affiliation(s)
- Xiaolu Hu
- School of Medicine, South China University of Technology, Guangzhou, China; Department of Cardiology, Guangdong Cardiovascular Institution, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Fan Yang
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Jitao Liu
- Department of Cardiology, Guangdong Cardiovascular Institution, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yuan Liu
- Department of Cardiology, Guangdong Cardiovascular Institution, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Ruixin Fan
- Department of Cardiovascular Surgery, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Jianfang Luo
- School of Medicine, South China University of Technology, Guangzhou, China; Department of Cardiology, Guangdong Cardiovascular Institution, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
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Soleimani M, Deo R, Hudobivnik B, Poyanmehr R, Haverich A, Wriggers P. Mathematical modeling and numerical simulation of arterial dissection based on a novel surgeon's view. Biomech Model Mechanobiol 2023; 22:2097-2116. [PMID: 37552344 PMCID: PMC10613153 DOI: 10.1007/s10237-023-01753-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/16/2023] [Indexed: 08/09/2023]
Abstract
This paper presents a mathematical model for arterial dissection based on a novel hypothesis proposed by a surgeon, Axel Haverich, see Haverich (Circulation 135(3):205-207, 2017. https://doi.org/10.1161/circulationaha.116.025407 ). In an attempt and based on clinical observations, he explained how three different arterial diseases, namely atherosclerosis, aneurysm and dissection have the same root in malfunctioning Vasa Vasorums (VVs) which are micro capillaries responsible for artery wall nourishment. The authors already proposed a mathematical framework for the modeling of atherosclerosis which is the thickening of the artery walls due to an inflammatory response to VVs dysfunction. A multiphysics model based on a phase-field approach coupled with mechanical deformation was proposed for this purpose. The kinematics of mechanical deformation was described using finite strain theory. The entire model is three-dimensional and fully based on a macroscopic continuum description. The objective here is to extend that model by incorporating a damage mechanism in order to capture the tearing (rupture) in the artery wall as a result of micro-injuries in VV. Unlike the existing damage-based model of the dissection in the literature, here the damage is driven by the internal bleeding (hematoma) rather than purely mechanical external loading. The numerical implementation is carried out using finite element method (FEM).
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Affiliation(s)
- Meisam Soleimani
- Institute of Continuum Mechanics, Leibniz University, Hannover, Germany.
| | - Rohan Deo
- Institute of Continuum Mechanics, Leibniz University, Hannover, Germany
| | - Blaz Hudobivnik
- Institute of Continuum Mechanics, Leibniz University, Hannover, Germany
| | - Reza Poyanmehr
- Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Medical School, Hannover, Germany
| | - Axel Haverich
- Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Medical School, Hannover, Germany
| | - Peter Wriggers
- Institute of Continuum Mechanics, Leibniz University, Hannover, Germany
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Bellomo TR, DeCarlo C, Khoury MK, Lella SK, Png CYM, Kim Y, Pendleton AA, Majumdar M, Zacharias N, Dua A. Outcomes of symptomatic penetrating aortic ulcer and intramural hematoma in the endovascular era. J Vasc Surg 2023; 78:1180-1187. [PMID: 37482141 DOI: 10.1016/j.jvs.2023.06.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/10/2023] [Accepted: 06/17/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Although endovascular technology has resulted in a paradigm shift in treatment, medical management remains the standard of care for penetrating aortic ulcer (PAU) and intramural hematoma (IMH). This study aimed to detail the short- and long-term outcomes of symptomatic PAU/IMH. METHODS Institutional data on symptomatic PAU/IMH were gathered (2005-2020). The primary outcome was the composite of recurrent symptoms, radiographic progression, intervention, rupture, and death from related or unknown cause. Factors associated with the primary outcome were determined using a Fine-Gray model with death from an unrelated cause as a competing risk. RESULTS A total of 83 symptomatic patients treated with medical management aside from ruptures and type A dissections: 21 isolated PAU, 30 isolated IMH, and 32 IMH and PAU. Adverse outcomes included symptom recurrence in 14 (16.9%), radiographic progression to dissection or saccular aneurysm in 17 (20.5%), surgery in 20 (24.1%) (17 thoracic endovascular aortic repair, 1 endovascular aortic repair, 1 frozen elephant trunk, and 1 open repair), and rupture in 4 (4.8%). Twenty-seven patients (32.5%) died during follow-up: 6 from IMH treatment complications, 8 from an unknown cause, and 13 from other causes. The 30-day, 1-year, and 5-year cumulative incidences of the primary outcome was 26.5% (95% confidence interval [CI], 16.9%-37.0%), 44.9% (95% CI, 32.8%-56.2%), and 57.5% (95% CI, 42.4%-69.9%), respectively. IMH with PAU was associated with a significantly higher risk of the primary outcome compared with isolated IMH (subdistribution hazard ratio, 2.21; 95% CI, 1.09-4.50; P = .027) and isolated PAU (subdistribution hazard ratio, 3.58; 95% CI, 1.44-8.88; P = .006). CONCLUSIONS Complications from symptomatic PAU and IMH are frequent, with intervention, recurrent symptoms, radiographic progression, rupture, or death affecting 25% of patients at 30 days after diagnosis and almost one-half of patients 1 year after diagnosis. Given the high rate of adverse events in this population, investigation into a more aggressive interventional strategy may warranted, especially in patients with a combined IMH and PAU.
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Affiliation(s)
- Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Srihari K Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Meng D, Gu R, Wang Y, Zhang Z, Xu T, Wang X. Analysis of Short-Term Clinical Outcomes and Influencing Factors in Patients with Acute Type B Aortic Intramural Hematoma Treated with Optimal Medical Therapy. Int Heart J 2023; 64:708-716. [PMID: 37460317 DOI: 10.1536/ihj.23-023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
This study aimed to investigate the short-term predictors of aortic-related adverse events in patients with acute type B aortic intramural hematoma (IMH) initially treated with optimized medical therapy.A total of 157 patients with acute type B IMH were included in this study. These patients were divided into worsening group (n = 45) and stable group (n = 112) based on the incidence of aortic-related adverse events. The clinical data and imaging features of the two groups were compared. Multivariate logistic regression analysis of predictors of aortic-related adverse events in type B IMH was performed. Receiver operating characteristic (ROC) curve was applied to determine the optimal cutoff value for maximum descending aorta diameter (MDAD). Kaplan-Meier survival curve was used to analyze the incidence of aortic-related adverse events.Worsening and stable groups were statistically significant in diuretics, abnormal D-dimer level, observation endpoint systolic blood pressure (SBP), MDAD, aortic atherosclerosis, ulcer-like projection (ULP), and thickness of hematoma (P < 0.05). Multivariate logistic regression showed that abnormal D-dimer level (OR = 12.464, P = 0.025), MDAD (OR = 1.113, P = 0.030), and ULP (OR = 5.849, P = 0.022) were powerful independent risk factors for predicting aortic-related adverse events in type B IMH, and observation endpoint SBP within 100-120 mmHg (OR = 0.225, P = 0.014) was a protective factor for predicting aortic-related adverse events in type B IMH. The cutoff value of MDAD was 35.2 mm.Short-term imaging is recommended for type B IMH patients with abnormal D-dimer level, MDAD > 35.2 mm, and ULP. Blood pressure should also be strictly monitored and controlled during the acute phase of IMH.
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Affiliation(s)
- Dujuan Meng
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
- The General Hospital of Northern Theater Command Training Base for Graduate, Dalian Medical University
| | - Ruoxi Gu
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
| | - Yasong Wang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
| | - Zhiqiang Zhang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
| | - Tianshu Xu
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
| | - Xiaozeng Wang
- National Key Laboratory of Frigid Zone Cardiovascular Disease, Cardiovascular Research Institute and Department of Cardiology, The General Hospital of Northern Theater Command
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Wei C, Li J, Du E, Miao Y, Li P, Guan W. Clinical and imaging differences between Stanford Type B intramural hematoma-like lesions and classic aortic dissection. BMC Cardiovasc Disord 2023; 23:378. [PMID: 37507680 PMCID: PMC10386763 DOI: 10.1186/s12872-023-03413-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/22/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Intramural hematoma (IMH) and Aortic dissection (AD) have overlapping features. The aim of this study was to explore the differences between them by comparing the clinical manifestations and imaging features of patients with acute Stanford type B IMH-like lesions and acute Stanford type B AD (ATBAD). METHODS This study retrospectively analysed the clinical and computed tomography angiography (CTA) imaging data of 42 IMH-like lesions patients with ulcer-like projection (ULP) and 38 ATBAD patients, and compared their clinical and imaging features. RESULTS (1) The IMH-like lesions patients were older than the ATBAD patients (64.2 ± 11.5 vs. 50.9 ± 12.2 years, P < 0.001). The D-dimer level in the IMH-like lesions group was significantly higher than that in the ATBAD group (11.2 ± 3.6 vs. 9.2 ± 4.5 mg/L, P < 0.05). The incidence rate of back pain was significantly higher in the ATBAD group than in the IMH-like lesions group (71.1% vs. 26.2%, P < 0.05). (2) The ULPs of IMH-like lesions and the intimal tears of ATBAD were concentrated in zone 4 of the descending thoracic aorta. The ULPs of IMH-like lesions and the intimal tears of ATBAD were mainly in the upper quadrant outside the lumen (64.3% vs. 65.8%, P > 0.05). (3) The maximum diameter of the ULPs in IMH-like lesions was smaller than that of the intimal tears in ATBAD (7.4 ± 3.4 vs. 10.8 ± 6.8 mm, P = 0.005). The lumen compression ratio in the ULPs plane and the maximum compression ratio of the aortic lumen in the IMH-like lesions group were smaller than that in the ADBAD group (P < 0.05). Fewer aortic segments were involved in IMH-like lesions patients than in ATBAD patients (5.6 ± 2.2 vs. 7.1 ± 1.9 segments, P < 0.005). The IMH-like lesions group had less branch involvement than that of the ATBAD group (P < 0.001). CONCLUSION The degree of intimal tears, lumen compression ratio, extent of lesion involvement, and impact on branch arteries in ATBAD are more severe than that of IMH-like lesions. But for the ULPs of IMH-like lesions and intimal tears of ATBAD, they have astonishing similarities in the location of the partition and the lumen quadrant, we have reason to believe that intimal tear is the initial factor in the pathogenesis of this kind of disease, and their clinical and imaging manifestations overlap, but the severity is different. Concerning similarities between these two conditions, these two may be a spectrum of one disease.
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Affiliation(s)
- Chuanbin Wei
- The Third Clinical College of Xinxiang Medical University, Xinxiang, China
| | - Jinping Li
- Department of Radiology, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Enhui Du
- The Third Clinical College of Xinxiang Medical University, Xinxiang, China
| | - Yulu Miao
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Pinpin Li
- Department of Radiology, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Wenhua Guan
- Department of Radiology, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China.
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10
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di Gioia CRT, Ascione A, Carletti R, Giordano C. Thoracic Aorta: Anatomy and Pathology. Diagnostics (Basel) 2023; 13:2166. [PMID: 37443560 DOI: 10.3390/diagnostics13132166] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
The aorta is the largest elastic artery in the human body and is classically divided into two anatomical segments, the thoracic and the abdominal aorta, separated by the diaphragm. The thoracic aorta includes the aortic root, the ascending aorta, the arch, and the descending aorta. The aorta's elastic properties depend on its wall structure, composed of three distinct histologic layers: intima, media, and adventitia. The different aortic segments show different embryological and anatomical features, which account for their different physiological properties and impact the occurrence and natural history of congenital and acquired diseases that develop herein. Diseases of the thoracic aorta may present either as a chronic, often asymptomatic disorder or as acute life-threatening conditions, i.e., acute aortic syndromes, and are usually associated with states that increase wall stress and alter the structure of the aortic wall. This review aims to provide an update on the disease of the thoracic aorta, focusing on the morphological substrates and clinicopathological correlations. Information on anatomy and embryology will also be provided.
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Affiliation(s)
- Cira Rosaria Tiziana di Gioia
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Andrea Ascione
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Raffaella Carletti
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Carla Giordano
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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11
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Jean-Marie E, Gillombardo CB, Baeza C, Hoit BD. Diffuse Large B-Cell Lymphoma Mimicking Intramural Hematoma of the Thoracic Aorta. JACC Case Rep 2023; 15:101858. [PMID: 37283827 PMCID: PMC10240261 DOI: 10.1016/j.jaccas.2023.101858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 06/08/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is an aggressive lymphoma that is fatal if left untreated. Few cases have been reported of involvement of the aorta. Here we present a case of DLBCL that was diagnosed by periaortic computed tomography-guided biopsy. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Elizabeth Jean-Marie
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Cristian Baeza
- Department of Cardiothoracic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Brian D. Hoit
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Harrington Heart and Vascular Institute, Cleveland, Ohio, USA
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12
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Starrs M, Zafren K. A unique cause of severe chest pain in the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e12982. [PMID: 37260539 PMCID: PMC10227360 DOI: 10.1002/emp2.12982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Affiliation(s)
- Mary Starrs
- Department of Emergency MedicineStanford University Medical CenterPalo AltoCaliforniaUSA
| | - Ken Zafren
- Department of Emergency MedicineStanford University Medical CenterPalo AltoCaliforniaUSA
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13
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Bittner T, Babbush C, Vincent AC, Rokkam V. Spinal cord infarction resulting from intramural haematoma of the thoracic aorta. BMJ Case Rep 2023; 16:e254173. [PMID: 37041042 PMCID: PMC10105982 DOI: 10.1136/bcr-2022-254173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
We present the case of a female patient in her 60s with multiple medical comorbidities who presented to the emergency department with sudden-onset tearing chest, back and abdominal pain in the setting of a hypertensive emergency. Initial CT-angiography demonstrated mild-diffuse thickening of thoracic and abdominal aorta without signs of intramural haematoma or dissection. The patient was subsequently admitted and medically managed. In the days following admission, the patient developed a small bowel obstruction and neurological deficits. Repeat imaging demonstrated an intramural haematoma extending from left subclavian artery to the diaphragm resulting in foci of spinal cord infarction. Instances of spinal cord infarction secondary to aortic intramural haematoma are rare, with a minority of cases reported as of 2020. This case report highlights a non-classic patient presentation of an intramural haematoma, shedding light onto possible clinical outcomes, treatment options and important risk factors.
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Affiliation(s)
- Tyler Bittner
- Department of Medicine, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Connor Babbush
- Department of Medicine, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Ashley Chey Vincent
- Department of Medicine, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Venkata Rokkam
- Department of Medicine, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
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14
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Kinoshita T, Asai T, Suzuki T, Vigers PN. Location of the False Lumen Within the Medial Layer in Acute Intramural Hematoma. Circ J 2023; 87:440-447. [PMID: 36328565 DOI: 10.1253/circj.cj-22-0359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND We compared the location of the false lumen within the medial layer between acute intramural hematoma (AIH) and acute aortic dissection (AAD) using microscopic images of aortic specimens and examined the associations with patient characteristics, CT findings, and late outcomes.Methods and Results: Among 293 patients undergoing surgery for Stanford type A acute aortic syndrome between 2008 and 2018, 45 patients had neither an identifiable intimal tear, flow to the false lumen on preoperative CT or intimal tear by intraoperative observation (AIH group), and 98 patients with patent false lumen were enrolled (AAD group). The AIH group had a significantly thinner outer media thickness (OMT) than the AAD group. The AIH group showed more pericardial effusion, but distal progression of dissection and branch vessel involvement were limited. The change in aortic diameter after surgery was insignificant in the AIH group, whereas in the AAD group it continued to increase. Cumulative incidence of aortic adverse events was significantly higher among AAD patients, but no significant difference was observed in survival between groups. CONCLUSIONS The AIH group had a significantly thinner OMT than the AAD group, which was significantly associated with a large amount of pericardial effusion, greater false lumen diameter, and limited progression of aortic dissection.
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Affiliation(s)
- Takeshi Kinoshita
- Division of Cardiovascular Surgery, Shiga University of Medical Science.,Department of Cardiovascular Surgery, Juntendo University
| | - Tohru Asai
- Division of Cardiovascular Surgery, Shiga University of Medical Science.,Department of Cardiovascular Surgery, Juntendo University
| | - Tomoaki Suzuki
- Division of Cardiovascular Surgery, Shiga University of Medical Science
| | - Piers N Vigers
- Division of Cardiovascular Surgery, Shiga University of Medical Science
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15
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Zhang Z, Lin F, He Z, Wang H, Zhu X, Cheng T. Clinical characteristics and outcomes of Stanford type B aortic intramural hematoma: A single centre experience. Front Surg 2023; 9:1071600. [PMID: 36684296 PMCID: PMC9849559 DOI: 10.3389/fsurg.2022.1071600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023] Open
Abstract
Objective To compare the clinical characteristics of Stanford type B aortic intramural hematoma (IMH) and Stanford type B aortic dissection (AD), and to identify the differences between thoracic endovascular aortic repair (TEVAR) and medical management (MM) in the Stanford type B IMH patients. Methods A retrospective observational study was conducted in patients treated between January 2015 and December 2016. The clinical characteristics and CT images of patients with type B IMH and type B AD were compared, and the clinical characteristics and CT images of patients in the type B IMH group who were treated with TEVAR and MM were compared. Results A total of 176 patients were included in this study, including 62 patients of type B IMH and 114 patients of type B AD. Five patients died in the IMH group and three in the AD group. The proximal hematoma or entry tear in both groups was mainly located in the descending aorta, and the proportion of the iliac artery involved in the AD group was significantly higher than that in the IMH group (31.6% vs. 8.1% P < 0.05). There were 50 MM patients and 12 TEVAR patients in the IMH group. No death occurred in the TEVAR group, while five patients in the MM group died. Seven patients in the MM group had disease progression vs. 12 in the TEVAR group (P < 0.05). The patients in the TEVAR group had more intima lesions than those in the MM group (83.3% vs. 30.0%, P < 0.05). TEVAR group involved more iliac artery hematoma than MM group (33.3% vs. 2.0%, P < 0.05). The maximum thickness of hematoma in TEVAR group was 14.9 ± 3.4 mm, which was significantly larger than that of MM group (10.2 ± 2.8 mm) (P < 0.05). Conclusion In the diagnosis of IMH, patients' symptoms and high-risk signs of CTA should be paid attention to. TEVAR therapy should be actively considered on the basis of effective medical management when there are intima lesions (ULP/PAU), increased aortic diameter and hematoma thickness, extensive hematoma involvement, and pleural effusion.
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Affiliation(s)
- Zhigong Zhang
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China,Correspondence: Zhigong Zhang
| | - Feng Lin
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China,Anhui Public Health Clinical Center, Hefei, China
| | - Zhipeng He
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Haoran Wang
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xingyang Zhu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China,Anhui Public Health Clinical Center, Hefei, China
| | - Tingting Cheng
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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16
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Muacevic A, Adler JR, Jaber J, Fahmi AM, Almasalmeh A, Alnakawa S, Kanaan T. Type A Aortic Dissection With Intramural Hematoma: A Challenging Diagnosis. Cureus 2023; 15:e33300. [PMID: 36741665 PMCID: PMC9893865 DOI: 10.7759/cureus.33300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/04/2023] Open
Abstract
Intramural hematoma (IMH) is considered a part of acute aortic syndromes (AAS), a group of life-threatening aortic diseases with a similar presentation that appears to have different clinical manifestations and pathological and survival characteristics. AAS comprises three major entities, namely, aortic dissection (AD), IMH, and PAU. IMH-like classic AD is classified using Stanford and DeBakey classification systems to indicate the aortic area involved. Early diagnosis and treatment of AAS are crucial for survival; however, diagnosis of IMH may be delayed and challenging due to atypical presentation, investigation findings, and case progression. In this report, we describe a case of delayed and challenging diagnosis of a Stanford type A IMH that was managed surgically with a good outcome.
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17
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Muacevic A, Adler JR, Ahmed-Khan MA, Vargas J. A Rare Initial Presentation of Aortic Intramural Hematoma: A Case Report and Literature Review. Cureus 2022; 14:e32947. [PMID: 36712703 PMCID: PMC9874960 DOI: 10.7759/cureus.32947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2022] [Indexed: 12/28/2022] Open
Abstract
Aortic intramural hematoma (AIH) is a life-threatening emergency that involves aortic wall integrity and is characterized by either a direct rupture of the vasa vasorum or spontaneous bleeding of an arterial plaque located in the tunica media of the aortic wall. A notable difference between AIH and acute aortic dissection is the absence of an intimal flap, a finding discernable on computed tomography angiography (CTA). Follow-up imaging allows for the monitoring of disease progression or early findings of impending complications. While some patients may require surgical intervention, medical management with blood pressure control remains the mainstay in treatment. Our case describes a patient who was found to be in cardiac arrest secondary to ventricular fibrillation and was then found to have presumed Stanford Type A aortic dissection on CTA. After reviewing the scans, the diagnosis was reclassified to AIH due to the absence of an intimal flap, the patient was then managed medically for AIH with antihypertensive medications.
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18
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Warren S, Amsterdam EA, Venugopal S. It Was the Aorta but Not a Dissection: Intramural Aorta Hematoma. Am J Med 2022; 135:1450-1452. [PMID: 35988746 DOI: 10.1016/j.amjmed.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/16/2022] [Accepted: 07/18/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Stephen Warren
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California (Davis), Sacramento
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California (Davis), Sacramento
| | - Sandhya Venugopal
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California (Davis), Sacramento.
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19
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A Woman with Chest Pain and Collapse. Ann Emerg Med 2022; 79:353-387. [PMID: 35337473 DOI: 10.1016/j.annemergmed.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Indexed: 11/22/2022]
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20
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Warner DL, Bhamidipati CM, Abraham CZ. Management of penetrating aortic ulcer and intramural hematoma in the thoracic aorta. Indian J Thorac Cardiovasc Surg 2022; 38:198-203. [PMID: 35463695 PMCID: PMC8980974 DOI: 10.1007/s12055-022-01332-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 10/18/2022] Open
Abstract
Acute aortic syndrome is a broad clinical entity that encompasses several pathologies. Aortic dissection is a well-studied disorder, but the other most prominent disorders within the scope of acute aortic syndrome, penetrating aortic ulcer and intramural hematoma, are more nebulous in terms of their pathophysiology and treatment strategies. While patient risk factors, presenting symptoms, and medical and surgical management strategies are similar to those of aortic dissection, there are indeed nuanced differences unique to penetrating aortic ulcer and intramural hematoma that surgeons and acute care providers must consider while managing patients with these diagnoses. The aim of this review is to summarize patient demographics, pathophysiology, workup, and treatment strategies that are unique to penetrating aortic ulcer and intramural hematoma.
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Affiliation(s)
- David L. Warner
- Department of Surgery, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | | | - Cherrie Z. Abraham
- Division of Vascular Surgery, Department of Surgery, Aortic Program, Knight Cardiovascular Institute, Portland, OR USA
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21
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Wang Y, Li T, Chen Y, Liu J, Shi Q, Yang C, Huang S, Zhou C, Xiong B. Management of spontaneous isolated intramural hematoma of the superior mesenteric artery: a single-center experience. Langenbecks Arch Surg 2022; 407:1217-1224. [PMID: 34994827 DOI: 10.1007/s00423-022-02429-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the clinical course and optimal management for spontaneous isolated intramural hematoma of the superior mesenteric artery (SIHSMA). METHODS From January 2015 to October 2020, a total of 31 consecutive patients with SIHSMA were included in this study. The demographics, clinical features, treatment details, imaging information, and outcomes were reviewed. RESULTS There were 24 males and 7 females, with a mean age of 54.9 years (SD 6.9 years). Seven patients (7/31, 23%) were associated with ulcer-like projection (ULP), one patient (1/31, 3%) with intramural blood pool (IBP), and the remaining twenty-three patients (23/31, 74%) had no ULP or IBP. All patients were initially managed conservatively and underwent a median follow-up of 25.5 months (IQR 14.5, 39.9), which showed 3 patients (3/31, 10%) subsequently underwent stenting (2 within 7 days and 1 after 1.5 months), 1 patient (1/31, 3%) progressed to a localized dissection 7 months later but remained stable and asymptomatic until the time of writing, and the remaining patients (27/31, 87%) had no progression. In the present cohort, the overall survival was 100% (31/31). The free-from progression and stenting rate under conservative treatment was 87% (27/31). The invasive intervention rate was 10% (3/31). The natural complete regression rate of IMH in patients without ULP was higher than those with ULP (91% [21/23] vs. 29% [2/7], p = .003). CONCLUSION The majority of patients with SIHSMA can be managed conservatively. Patients with ULP seemed to have a lower IMH regression rate than those without ULP.
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Affiliation(s)
- Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
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22
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Shehab M, Wolf A, Ajaj M, Greton I, Fajer S, Shehab M. Aortic Intramural Hematoma due to Intercostal Artery Aneurysms. Vasc Endovascular Surg 2021; 56:298-302. [PMID: 34971323 DOI: 10.1177/15385744211068639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BackgroundIntercostal artery aneurysms (ICA) are rare vascular disease. A rupture of ICA is a possible mechanism of intramural aortic hematoma (IH). We report a case with IH and ICAs without clear etiology. Case presentation: A 64-year-old man was admitted to our emergency room with a sudden onset of acute diffused abdominal and chest pain, radiating to the back. Without previous traumatic insult, a computed tomographic angiography scan (CTA) revealed an IH beginning inferior to the left subclavian artery extending to the level of the celiac trunk. Follow-up CTA demonstrated a stable maximal IH thickness diameter of 11 mm, maximal aortic diameter of 40 mm, a new left hemorrhagic pleural effusion, and a focal contrast enhancement at T9 level. Due to these findings, thoracic endovascular aortic repair (TEVAR) was performed. During follow up, T9 focal enhancement continues to grow and an additional one developed. Selective angiography was performed demonstrating a connection to the costal artery and the aortic lumen, confirming ICA. Successful embolization with micro coils was performed. During follow up, additional 2 ICAs developed and treated with embolization. CTA three months later showed a complete resolution of the IH and obliteration of all treated ICAs. Infectious, inflammatory and connective tissue disease investigations were undertaken without a clear etiology. Conclusions: This is a case of IH and ICAs, in the absence of a clear etiology which were successfully treated by endovascular procedures TEVAR and coil embolization. It is not clear whether the hematoma was the source of the ICA or the other way round. Lack of ICAs in the initial CTA might be due to the pressure exerted by the hematoma or that they were too small to be detected but continued to grow on follow up. Rupture of these micro-aneurysms is a possible mechanism of intramural aortic hematoma.
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Affiliation(s)
- Maysam Shehab
- 26745Depratment of Vascular Surgery , Meir Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ammie Wolf
- 26745Depratment of Vascular Surgery , Meir Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mones Ajaj
- 26745Depratment of Vascular Surgery , Meir Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Igal Greton
- 26745Depratment of Vascular Surgery , Meir Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Simmone Fajer
- 26745Depratment of Vascular Surgery , Meir Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maysam Shehab
- 26745Depratment of Vascular Surgery , Meir Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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23
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Steinbrecher KL, Marquis KM, Bhalla S, Mellnick VM, Ohman JW, Raptis CA. CT of the Difficult Acute Aortic Syndrome. Radiographics 2021; 42:69-86. [PMID: 34951836 DOI: 10.1148/rg.210098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute aortic syndrome (AAS) is classically attributed to three underlying pathologic conditions-aortic dissection (AD), intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU). In the majority of cases, the basics of image interpretation are not difficult and have been extensively reviewed in the literature. In this article, the authors extend existing imaging overviews of AAS by highlighting additional factors related to the diagnosis, classification, and characterization of difficult AAS cases. It has been well documented that AAS is caused not only by an AD but by a spectrum of lesions that often have overlap in imaging features and are not clearly distinguishable. Specifically, phase of contrast enhancement, flow artifacts, and flapless AD equivalents can complicate diagnosis and are discussed. While the A/B dichotomy of the Stanford system is still used, the authors subsequently emphasize the Society for Vascular Surgery's new guidelines for the description of acute aortic pathologic conditions given the expanded use of endovascular techniques used in aortic repair. In the final section, atypical aortic rupture and pitfalls are described. As examples of pericardial and shared sheath rupture become more prevalent in the literature, it is important to recognize contrast material third-spacing and mediastinal blood as potential mimics. By understanding these factors related to difficult cases of AAS, the diagnostic radiologist will be able to accurately refine CT interpretation and thus provide information that is best suited to directing management. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Kacie L Steinbrecher
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Kaitlin M Marquis
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Vincent M Mellnick
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - J Westley Ohman
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Constantine A Raptis
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
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24
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King RW, Bonaca MP. Acute aortic syndromes: a review of what we know and future considerations. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:1197-1203. [PMID: 34849689 DOI: 10.1093/ehjacc/zuab106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 12/27/2022]
Abstract
Acute aortic syndromes represent a spectrum of life-threatening aortic pathologies. Prompt diagnosis and proper management of these syndromes are important in reducing overall mortality and morbidity, which remains high. Acute aortic dissections represent most of these aortic wall pathologies, but intramural haematomas and penetrating atherosclerotic ulcers have been increasingly diagnosed. Type A dissections require prompt surgical treatment, with endovascular options on the horizon. Type B dissections can be complicated or uncomplicated, and treatment is determined based on this designation. Complicated Type B dissections require prompt repair with thoracic endovascular aortic repair (TEVAR) becoming the preferred method. Uncomplicated Type B dissections require medical management, but early TEVAR in the subacute setting is becoming more prominent. Proper surveillance for an uncomplicated Type B dissection is crucial in detecting aortic degeneration and need for intervention. Intramural haematomas and penetrating atherosclerotic ulcers are managed similarly to aortic dissections, but more research is needed to determine the proper management algorithms. Multi-disciplinary aortic programmes have been shown to improve patient outcomes and are necessary in optimizing long-term follow-up.
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Affiliation(s)
- R Wilson King
- CPC Clinical Research, 2115 N. Scranton St., Suite 2040 Aurora, CO, USA.,Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Marc P Bonaca
- CPC Clinical Research, 2115 N. Scranton St., Suite 2040 Aurora, CO, USA.,Department of Medicine, University of Colorado, Aurora, CO, USA
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25
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Wang Y, Song S, Zhou C, Zhu W, Liu J, Shi Q, Huang S, Yang C, Li T, Chen Y, Xiong B. Thoracic Endovascular Aortic Repair for Retrograde Type A Intramural Hematoma With Intimal Disruption in the Descending Aorta. J Endovasc Ther 2021; 29:724-730. [PMID: 34852656 DOI: 10.1177/15266028211061268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of thoracic endovascular aortic repair (TEVAR) for retrograde type A intramural hematoma (IMH) with intimal disruption in the descending aorta and report our endovascular therapeutic experience. MATERIALS AND METHODS From January 2014 to October 2020, a total of 24 consecutive patients with retrograde type A IMH with intimal disruption (intimal tear or ulcer-like projection) in the descending aorta underwent TEVAR. The demographics, clinical characteristics, treatment details, imaging information, and follow-up results were reviewed. RESULTS Among all patients with retrograde type A IMH, 13 (54.2%) patients presented with ulcer-like projection and 11 (45.8%) with intimal tear (aortic dissection) in the descending aorta. Successful TEVAR was achieved in all patients. There was no 30-day mortality. During a mean follow-up of 37.5 months, 1 patient (4.2%) developed permanent paralysis, 1 patient (4.2%) underwent reintervention due to the expansion of the aorta distal to the stent resulting from the enlargement of distal intimal tear at the 2 month follow up, and no other adverse events were observed. The latest computed tomographic angiography images showed that the maximum diameter of the ascending aorta and descending aorta significantly decreased after TEVAR (both p<0.001), and the IMH/false lumen in the ascending aorta and the descending thoracic aorta were completely absorbed. CONCLUSION Thoracic endovascular aortic repair for selected patients with retrograde type A intramural hematoma that presented with intimal disruption in the descending aorta is feasible and efficient, but close surveillance is needed to manage aortic-related adverse events.
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Affiliation(s)
- Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Songlin Song
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wenying Zhu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Molecular Imaging, Wuhan, China
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26
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Mehta CK, Son AY, Chia MC, Budd AN, Allen BD, Vassallo P, Hoel AW, Brady WJ, Nable JV. Management of acute aortic syndromes from initial presentation to definitive treatment. Am J Emerg Med 2021; 51:108-113. [PMID: 34735967 DOI: 10.1016/j.ajem.2021.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute aortic syndromes comprise a spectrum of diseases including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcers. Early diagnosis, rapid intervention, and multidisciplinary team care are vital to efficiently manage time-sensitive aortic emergencies, mobilize appropriate resources, and optimize clinical outcomes. OBJECTIVE This comprehensive review outlines the multidisciplinary team approach from initial presentation to definitive interventional treatment and post-operative care. DISCUSSION Acute aortic syndromes can be life-threatening and require prompt diagnosis and aggressive initiation of blood pressure and pain control to prevent subsequent complications. Early time to diagnosis and intervention are associated with improved outcomes. CONCLUSIONS A multidisciplinary team can help promptly diagnose and manage aortic syndromes.
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Affiliation(s)
- Christopher K Mehta
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America.
| | - Andre Y Son
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America
| | - Matthew C Chia
- Division of Vascular Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America
| | - Ashley N Budd
- Department of Anesthesiology, Northwestern Medicine, Chicago, IL, United States of America
| | - Bradley D Allen
- Department of Radiology, Northwestern Medicine, Chicago, IL, United States of America
| | - Patricia Vassallo
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America
| | - Andrew W Hoel
- Division of Vascular Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, IL, United States of America
| | - William J Brady
- Departments of Emergency Medicine and Internal Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Jose V Nable
- Department of Emergency Medicine, MedStar Georgetown University Hospital, Washington D.C., United States of America
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27
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Wortmann M, Peters AS, Erhart P, Körfer D, Böckler D, Dihlmann S. Inflammasomes in the Pathophysiology of Aortic Disease. Cells 2021; 10:cells10092433. [PMID: 34572082 PMCID: PMC8468335 DOI: 10.3390/cells10092433] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 12/27/2022] Open
Abstract
Aortic diseases comprise aneurysms, dissections, and several other pathologies. In general, aging is associated with a slow but progressive dilation of the aorta, along with increased stiffness and pulse pressure. The progression of aortic disease is characterized by subclinical development or acute presentation. Recent evidence suggests that inflammation participates causally in different clinical manifestations of aortic diseases. As of yet, diagnostic imaging and surveillance is mainly based on ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). Little medical therapy is available so far to prevent or treat the majority of aortic diseases. Endovascular therapy by the introduction of covered stentgrafts provides the main treatment option, although open surgery and implantation of synthetic grafts remain necessary in many situations. Because of the risks associated with surgery, there is a need for identification of pharmaceutical targets interfering with the pathophysiology of aortic remodeling. The participation of innate immunity and inflammasome activation in different cell types is common in aortic diseases. This review will thus focus on inflammasome activities in vascular cells of different chronic and acute aortic diseases and discuss their role in development and progression. We will also identify research gaps and suggest promising therapeutic targets, which may be used for future medical interventions.
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28
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Rathore KS. Distal Aortic Remodeling after Type A Dissection Repair: An Ongoing Mirage. J Chest Surg 2021; 54:439-448. [PMID: 34376627 PMCID: PMC8646062 DOI: 10.5090/jcs.21.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/29/2021] [Accepted: 06/03/2021] [Indexed: 11/24/2022] Open
Abstract
Remodeling is a commonly encountered term in the field of cardiothoracic surgery that is often used to describe various pathophysiological changes in the dimension, structure, and function of various cardiac chambers, including the aorta. Stanford type A or DeBakey type 1 aortic dissection (TAAD) is a perplexing pathologic condition that can present surgical teams with the need to navigate a maze of complex decision-making. Ascending or hemi-arch replacement leaves behind a significant amount of distal diseased aortic tissue, which might have a persistent false lumen or primary or secondary intimal tears (or communications between lumina), which can lead to dilatation of the aortic arch. Unfavorable aortic remodeling is a major cause of distal aortic deterioration after the index surgery. Cardiac surgeons are aware of post-surgical cardiac chamber remodeling, but the concept of distal aortic remodeling is still idealized. The contemporary literature from established aortic centers supports aggressive management of the residual aortic pathology during the index surgery, and with continuing technical advancements, endovascular stenting options are readily available for patients with TAAD or for complicated type B aortic dissection cases. This review discusses the pathophysiology and treatment options for favorable distal aortic remodeling, as well as its impact on mid- to long-term outcomes following TAAD repair.
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29
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Harky A, Sokal PA, Hasan K, Papaleontiou A. The Aortic Pathologies: How Far We Understand It and Its Implications on Thoracic Aortic Surgery. Braz J Cardiovasc Surg 2021; 36:535-549. [PMID: 34617429 PMCID: PMC8522328 DOI: 10.21470/1678-9741-2020-0089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Thoracic aortic diseases contribute to a major part of cardiac surgeries. The severity of pathologies varies significantly from emergency and life-threatening to conservatively managed conditions. Life-threatening conditions include type A aortic dissection and rupture. Aortic aneurysm is an example of a conservatively managed condition. Pathologies that affect the arterial wall can have a profound impact on the presentation of such cases. Several risk factors have been identified that increase the risk of emergency presentations such as connective tissue disease, hypertension, and vasculitis. The understanding of aortic pathologies is essential to improve management and clinical outcomes.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,School of Medicine, University of Liverpool, Liverpool, United Kingdom.,Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Khubbaib Hasan
- School of Medicine, University of Liverpool, Liverpool, United Kingdom
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30
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Shilagani C, Lansman S, Gilet A, Flusberg M. IgG4 aortitis of the ascending thoracic aorta: A case report and literature review. J Radiol Case Rep 2021; 15:1-9. [PMID: 34276873 DOI: 10.3941/jrcr.v15i5.3985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
IgG4 aortitis is a recently recognized entity that can have clinical and imaging features that mimic acute aortic syndrome. Therefore, it is imperative for radiologists to be aware of how to potentially differentiate the two. Although this entity has been previously described via case reports and meta-analysis in the context of inflammatory abdominal aortic aneurysm, very few cases of ascending aortic involvement have been reported. In this case report, we present a case of a 60-year-old female transferred from another facility for an initial diagnosis of intramural hematoma of the ascending aorta and later found to have IgG4 aortitis post aortic root repair. This is a histologically confirmed case of multi-segmented IgG4 aortitis with rare involvement of both ascending and infra-renal aorta. We will briefly discuss the pathophysiology of IgG4 aortitis, along with review of literature.
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Affiliation(s)
- Chaitanya Shilagani
- Department of Diagnostic Radiology, Westchester Medical Center, Valhalla, NY, USA
| | - Steven Lansman
- Department of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Anthony Gilet
- Department of Diagnostic Radiology, Westchester Medical Center, Valhalla, NY, USA
| | - Milana Flusberg
- Department of Diagnostic Radiology, Westchester Medical Center, Valhalla, NY, USA
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31
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Gupta AK, Senaratne JM. Type A aortic intramural hematoma. BMJ Case Rep 2021; 14:e240650. [PMID: 33649027 PMCID: PMC7929871 DOI: 10.1136/bcr-2020-240650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Arjun Kumar Gupta
- Division of Cardiology, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Janek Manoj Senaratne
- Division of Cardiology, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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32
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Howard C, Ponnapalli A, Shaikh S, Idhrees M, Bashir M. Non-A non-B aortic dissection: A literature review. J Card Surg 2021; 36:1806-1813. [PMID: 33547714 DOI: 10.1111/jocs.15349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/09/2021] [Indexed: 01/16/2023]
Abstract
Non-A non-B aortic dissections are an infrequent occurrence and represent a small proportion of aortic dissections. Treating this life-threatening medical emergency often requires surgeons to undertake some one of the most challenging surgical or endovascular cases in medicine. This literature review aims to define and classify non-A non-B dissections, describe their epidemiology as well as their pathology. This review also aims to discuss the range of surgical techniques employed in their treatment and management and to investigate the patient outcomes associated with each technique.
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Affiliation(s)
- Callum Howard
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - Anuradha Ponnapalli
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - Safwan Shaikh
- Dentistry and Biomedical Sciences, Queen's University Belfast School of Medicine, Queen's University Belfast, Belfast, UK
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohammad Bashir
- Department of Vascular and Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
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33
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Velez AK, Etchill E, Halushka MK, Schena S. Aortitis masquerading as intramural hematoma: When to observe, when to operate? A case report. J Card Surg 2021; 36:1554-1556. [PMID: 33502772 DOI: 10.1111/jocs.15348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/29/2022]
Abstract
Radiologic evidence of aortic disease is not always consistent with the diagnosis. With a lack of accompanying symptoms or with an atypical presentation, diagnosis, and management of aortic pathology rely greatly on imaging techniques. We report the case of a 58-year-old female who presented with incidental radiographic findings consistent with a type A aortic intramural hematoma and a vague left-sided chest discomfort. After follow-up, imaging was consistent with disease progression and hematoma expansion; the affected segment was resected and pathology reported lymphoplasmacytic aortitis as the underlying etiology of the imaging findings rather than an intramural hematoma. The patient lacked symptoms or serology consistent with the rheumatologic disease, and the postoperative course was uneventful. The management of a suspected ascending intramural hematoma is controversial, especially when the patient presents with atypical signs and symptoms. Features of disease progression may warrant urgent surgical intervention.
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Affiliation(s)
- Ana K Velez
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marc K Halushka
- Division of Cardiovascular Pathology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stefano Schena
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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34
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Jacques F, Gingras M, Lafrenière-Bessi V, Perron J, Dagenais F. Large Intramural Aortic Hematoma with Intimal Tear. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:118-120. [PMID: 33167042 PMCID: PMC7732563 DOI: 10.1055/s-0040-1714058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 72-year-old man presented with excruciating epigastric pain. A chest computed tomography angiography revealed an aortic intramural hematoma. A filling defect within the distal ascending aorta was noted. Images of an intramular hematoma and surgical details of an ascending aortic replacement under deep hypothermic circulatory arrest are provided.
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Affiliation(s)
- Frédéric Jacques
- Departments of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec-IUCPQ, Quebec, QC, Canada
| | - Michel Gingras
- Departments of Medical Imaging, Institut Universitaire de Cardiologie et de Pneumologie de Québec-IUCPQ, Quebec, QC, Canada
| | - Valérie Lafrenière-Bessi
- Departments of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec-IUCPQ, Quebec, QC, Canada
| | - Jean Perron
- Departments of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec-IUCPQ, Quebec, QC, Canada
| | - François Dagenais
- Departments of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec-IUCPQ, Quebec, QC, Canada
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35
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Jen JP, Malik A, Lewis G, Holloway B. Non-traumatic thoracic aortic emergencies: imaging diagnosis and management. Br J Hosp Med (Lond) 2020; 81:1-12. [PMID: 33135923 DOI: 10.12968/hmed.2020.0344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The major component of non-traumatic thoracic aortic emergencies is the acute aortic syndromes. These include acute aortic dissection, intramural haematoma and penetrating atherosclerotic ulcer, grouped together because they are indistinguishable clinically and highly fatal. All three entities involve disruption to the tunica intima and media and may be complicated by rupture, end-organ ischaemia or aneurysmal transformation. Early diagnosis is vital to allow timely and appropriate management. Paired unenhanced and electrocardiogram-gated computed tomography angiography of the chest, extending more distally if required, is recommended for diagnosis. Specific computed tomography features of all three entities are reviewed, with a focus on morphological features associated with complications. Those with type A pathology are usually managed with open surgery because this has a high risk of complication. Patients with uncomplicated type B pathology are usually managed with best medical therapy whereas those with complicated type B pathology are usually offered either surgery or thoracic endovascular aortic repair. The limited evidence regarding the use of thoracic endovascular aortic repair in patients with subacute uncomplicated type B pathology is briefly discussed.
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Affiliation(s)
- Jian Ping Jen
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Akif Malik
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gareth Lewis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Benjamin Holloway
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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36
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Dacie R, Woodhouse L, Mullan D, Lamarca A. Spontaneous Aortic Haematoma in a Patient Receiving Adjuvant Folinic Acid, 5-Fluorouracil, Irinotecan, and Oxaliplatin Chemotherapy Following Resection of a Pancreatic Adenocarcinoma. Cureus 2020; 12:e10908. [PMID: 33194475 PMCID: PMC7657317 DOI: 10.7759/cureus.10908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
This case report describes the finding of a spontaneous aortic haematoma in a patient receiving adjuvant folinic acid, 5-fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) chemotherapy following resection of a pancreatic adenocarcinoma. The haematoma was thought to have arisen secondary to a chemotherapy-induced vasculitis affecting the aorta, as the patient had no other risk factors for de novo aortitis or aortic haematoma. There have been several previously documented cases of associations between chemotherapy agents (in particular platinum-based agents) and vasculitis. This report includes computed tomography (CT) images and a discussion of the literature of related cases. This case is a good example of rare vascular toxicities arising from chemotherapy, the impact such rare complications have upon further chemotherapy options, and how these should be discussed when consenting patients for chemotherapy due to the potentially life-threatening complications.
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37
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Grant J, Allen AZ, Traube L, Levsky JM, Haramati LB. Thoracic aortic dissection classification among radiologists and surgeons and management trends. Emerg Radiol 2020; 28:297-301. [DOI: 10.1007/s10140-020-01861-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/29/2020] [Indexed: 12/26/2022]
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38
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Li Y, Zhang N, Xu S, Fan Z, Zhu J, Huang L, Chen D, Sun Z, Sun L. Acute type A aortic intramural hematoma and type A aortic dissection: correlation between the intimal tear features and pathogenesis. Quant Imaging Med Surg 2020; 10:1504-1514. [PMID: 32676368 DOI: 10.21037/qims-20-191] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background To determine the prevalence, clinical and imaging features of intimal tear detected by ECG-gated multidetector computed tomography (MDCT) and confirmed by surgery in patients with acute type A intramural hematoma (ATAIMH) and acute type A aortic dissection (AAAD). Methods This retrospective study involved analysis of the intimal tear characteristics in 72 consecutive patients with ATAIMH and 209 with AAAD who were diagnosed by MDCT. The size and location of the intimal tear were measured and compared between these two groups of patients. The findings were also compared with those from 28 patients with ATAIMH who underwent surgical treatment to determine the intimal tear features as observed on CT angiography (CTA). Results Patients in the ATAIMH group were significantly older than those in the AAAD group (58.6±11.3 vs. 49.4±12.8 years, P<0.001), and females were predominant in the former category (ATAIMH vs. AAAD: 44.4% vs. 27.8%, P<0.01). Marfan syndrome and pregnancy were associated with most of the occurrences of AAAD. Sixty-four patients (88.9%) with ATAIMH were recognized as having intimal tear in the CTA images. The number of aortic segments in the ATAIMH patients was smaller than that in the AAAD patients (4.45±1.56 vs. 5.04±1.72 segments, P<0.01). The distribution of the intimal tear did not show any difference between the two groups. During the surgery, pericardial hemorrhage was observed in a higher proportion of patients in the ATAIMH than in the AAAD group (60.7% vs. 22.1%; P<0.01). In the former category, all of the intimal tears detected using CTA were confirmed during the operation, and the size was significantly larger than measured on the CTA images (6.95±5.12 vs. 19.59±6.51 mm, P<0.001). Six ATAIMH patients progressed to classical aortic dissection (AD) at surgery. Conclusions Patients with ATAIMH have a high prevalence of intimal tear, which is significantly smaller than that measured in patients with classic AAAD. Just like AD, ATAIMH may also be triggered by intimal tear. Hence, timely surgical repair is needed.
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Affiliation(s)
- Yu Li
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Zhang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shangdong Xu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing, China
| | - Zhanming Fan
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing, China
| | - Lianjun Huang
- Department of Diagnostic and Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dong Chen
- Department of Pathology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhonghua Sun
- Department of Medical Radiation Sciences, Curtin University, Perth, Australia
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing, China
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Chow SCY, Wong RHL, Lakhani I, Wong MV, Tse G, Yu PSY, Ho JYK, Fujikawa T, Underwood MJ. Management of acute type A intramural hematoma: upfront surgery or individualized approach? A retrospective analysis and meta-analysis. J Thorac Dis 2020; 12:680-689. [PMID: 32274133 PMCID: PMC7139001 DOI: 10.21037/jtd.2019.12.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Management of acute type A intramural hematoma (IMH) is a controversial topic. In our study, we aim to analyze the survival outcomes in local patients with acute type A IMH and a meta-analysis on survival in type A IMH treated medically versus surgically was performed. Methods From 2014 to 2019, 65 patients with acute type A IMH were selected for analysis. Primary outcome of interest was 1 year all cause survival. The rate of aortic-related events in the medical group was evaluated. PubMed and Embase were searched for meta-analysis. Results The mean age of our cohort was 61.7±9.7 years. Of the 65 patients, 40% had emergency operation. Overall 1-year survival was 96.9%. The 1-year survival was 94.9% for the medical group. 46.2% of the medical group required aortic intervention at a mean duration of 191±168 days. Maximal aortic diameter (MAD) ≥45 mm was predictive of aortic-related events in the medical group (OR: 7.0; 95% CI, 1.7-29.4; P=0.008). For the meta-analysis, 21 studies were identified, and 900 patients were included. Emergent surgery was associated with improved survival in type A IMH (OR: 0.76; 95% CI, 0.29-1.97, P=0.58; I2=27%). Conclusions The 1-year survival after type A IMH was promising, regardless of approach. The conservative-first approach was found to be safe & feasible, and upfront surgery remained the management of choice in general. Patients with MAD ≥45 mm was associated with subsequent aortic intervention in the medical-first group.
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Affiliation(s)
- Simon C Y Chow
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Ishan Lakhani
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michelle V Wong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Gary Tse
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Peter S Y Yu
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Jacky Y K Ho
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Takuya Fujikawa
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Malcolm J Underwood
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
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Hage F, Hage A, Chu MWA. Hybrid arch frozen elephant trunk repair for acute type A intramural hematoma. Ann Cardiothorac Surg 2019; 8:577-584. [PMID: 31667159 DOI: 10.21037/acs.2019.08.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Fadi Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
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Zoller JK, Gregory SH, Stevens TW, Sanchez LA, Hueneke R. Anesthetic Considerations for Aortic Arch Stenting. J Cardiothorac Vasc Anesth 2019; 33:3163-3175. [DOI: 10.1053/j.jvca.2019.01.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/19/2019] [Accepted: 01/24/2019] [Indexed: 01/16/2023]
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Haensig M. Type B intramural hematoma: focus on reasons for development and overlapping clinical disease. Ann Cardiothorac Surg 2019; 8:494-496. [PMID: 31463214 DOI: 10.21037/acs.2019.06.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Martin Haensig
- Department of Vascular Surgery, University of Leipzig, Leipzig, Germany
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Treatment for acute type B intramural hematoma and patent ductus arteriosus in an adult using a covered stent. Anatol J Cardiol 2019; 21:E13-E14. [PMID: 31142718 PMCID: PMC6683222 DOI: 10.14744/anatoljcardiol.2019.23780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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An unusual cause of pulmonary hypertension; partial anomalous pulmonary venous return to coronary sinus detected on transesophageal echocardiography. Anatol J Cardiol 2019; 21:E14-E15. [PMID: 31142722 PMCID: PMC6683225 DOI: 10.14744/anatoljcardiol.2019.60734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Herrán FL, Bang TJ, Restauri N, Suby-Long T, Alvarez Gómez DI, Sachs PB, Vargas D. CT imaging of complications of aortic intramural hematoma: a pictorial essay. ACTA ACUST UNITED AC 2019; 24:342-347. [PMID: 30373726 DOI: 10.5152/dir.2018.17261] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Aortic intramural hematoma (IMH) is a pathologic process with a clinical presentation identical to aortic dissection and associated with significant morbidity and mortality. Radiologists must be familiar with the imaging appearances of IMH as computed tomography (CT) plays a critical role in both diagnosis and patient management. The course of IMH is variable and the process may regress, remain stable, or progress in extent and therefore imaging findings associated with a negative prognosis must be recognized and included in the formal radiology report. Potentially life-threatening complications and findings associated with IMH include hemopericardium and cardiac tamponade, coexisting aortic dissection, ulcer-like projection, intramural blood pool, and extension of hematoma along the pulmonary or coronary arteries, which are identifiable with aortic protocol CT. The purpose of this pictorial review is to provide the reader with an image-based review of the diagnostic criteria, related complications, and associated critical prognostic features in patients presenting with aortic IMH.
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Affiliation(s)
| | - Tami J Bang
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Colorado, USA
| | - Nicole Restauri
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Colorado, USA
| | - Thomas Suby-Long
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Colorado, USA
| | | | - Peter B Sachs
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Colorado, USA
| | - Daniel Vargas
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Colorado, USA
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Conditional deletion of Rcan1 predisposes to hypertension-mediated intramural hematoma and subsequent aneurysm and aortic rupture. Nat Commun 2018; 9:4795. [PMID: 30442942 PMCID: PMC6237779 DOI: 10.1038/s41467-018-07071-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 10/04/2018] [Indexed: 12/20/2022] Open
Abstract
Aortic intramural hematoma (IMH) can evolve toward reabsorption, dissection or aneurysm. Hypertension is the most common predisposing factor in IMH and aneurysm patients, and the hypertensive mediator angiotensin-II induces both in mice. We have previously shown that constitutive deletion of Rcan1 isoforms prevents Angiotensin II-induced aneurysm in mice. Here we generate mice conditionally lacking each isoform or all isoforms in vascular smooth muscle cells, endothelial cells, or ubiquitously, to determine the contribution to aneurysm development of Rcan1 isoforms in vascular cells. Surprisingly, conditional Rcan1 deletion in either vascular cell-type induces a hypercontractile phenotype and aortic medial layer disorganization, predisposing to hypertension-mediated aortic rupture, IMH, and aneurysm. These processes are blocked by ROCK inhibition. We find that Rcan1 associates with GSK-3β, whose inhibition decreases myosin activation. Our results identify potential therapeutic targets for intervention in IMH and aneurysm and call for caution when interpreting phenotypes of constitutively and inducibly deficient mice.
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Sadamatsu K, Takase S, Sagara S, Ohe K, Nishi JI, Tashiro H, Kosuga T, Yasunaga H. Initial medical management in acute type A aortic dissection patients with a thrombosed false lumen in the ascending aorta combining intramural hematoma and retrograde dissection from the descending to the ascending aorta. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:S13-S20. [PMID: 29781287 DOI: 10.1177/2048872618777724] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The feasibility of medical management for select patients with acute type A aortic dissection has been reported from a few institutions. In this study, we retrospectively investigated the safety and feasibility of our conservative approach for patients with type A aortic dissection in daily practice. METHODS From January 2013 to December 2017, 131 consecutive patients were admitted to our institution for acute aortic dissection, including 58 patients of type A. Initial medical management was attempted in select patients who were clinically stable and had a thrombosed false lumen of the ascending aorta without ulcer-like projections in the ascending aorta. RESULTS Except for nine patients contraindicated for surgery, urgent surgery was performed in 26 patients (SRG group), while 23 patients (MED group) were treated with the initial medical management. The maximum diameter of the ascending aorta was significantly larger in the SRG group than in the MED group. In the MED group, the heart rate and blood pressures were well-controlled at admission to the intensive-care unit, and the systolic blood pressure was further reduced at 24 h after. The in-hospital mortality rates of the MED and SRG groups were 0% and 15%, respectively. During the follow-up period, the survival rate was significantly higher in the MED group than in the SRG group, and the aortic event-free survival at one year was 80%. CONCLUSIONS The initial medical management for select patients with a thrombosed false lumen in the ascending aorta was a safe and feasible strategy in real-world practice.
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Affiliation(s)
- Kenji Sadamatsu
- Department of Cardiology, St. Mary's Hospital, Kurume, Japan
| | - Susumu Takase
- Department of Cardiology, St. Mary's Hospital, Kurume, Japan
| | | | - Kensuke Ohe
- Department of Cardiology, St. Mary's Hospital, Kurume, Japan
| | | | - Hideki Tashiro
- Department of Cardiology, St. Mary's Hospital, Kurume, Japan
| | - Tomokazu Kosuga
- Department of Cardiovascular Surgery, St. Mary's Hospital, Kurume, Japan
| | - Hiroshi Yasunaga
- Department of Cardiovascular Surgery, St. Mary's Hospital, Kurume, Japan
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MacKnight BM, Maldonado Y, Augoustides JG, Cardenas RA, Patel PA, Ghadimi K, Gutsche JT, Ramakrishna H. Advances in Imaging for the Management of Acute Aortic Syndromes: Focus on Transesophageal Echocardiography and Type-A Aortic Dissection for the Perioperative Echocardiographer. J Cardiothorac Vasc Anesth 2016; 30:1129-41. [DOI: 10.1053/j.jvca.2016.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Indexed: 01/16/2023]
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Meyersohn NM, Ghemigian K, Shapiro MD, Shah SV, Ghoshhajra BB, Ferencik M. Role of Computed Tomography in Assessment of the Thoracic Aorta. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:395. [DOI: 10.1007/s11936-015-0395-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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