Acute aortic syndrome: a case presentation and review of the literature

Comparative study on clinical efficacy of different methods for the treatment of intramural aortic hematoma

To explore the difference of curative effect between different treatment modalities, in order to provide reference for the treatment of aortic intramural hematoma (IMH). 168 patients with aortic intramural hematoma diagnosed and treated from January 2010 to July 2020 were selected in the Second Affiliated Hospital of Nanchang University. Among them, 48 patients were diagnosed with Stanford A aortic intramural hematoma and 120 were diagnosed with Stanford B aortic intramural hematoma. According to the therapeutic methods, patients were divided into conservative treatment group and endovascular treatment group (TEVAR). For endovascular treatment group, according to the different timing of surgery, can be divided into acute phase group (onset within 72 h) and non-acute phase group (time of onset > 72 h).The clinical data and follow-up data were collected and analyzed by variance analysis and χ² test. There were 168 patients diagnosed with aortic intramural hematoma 39 of them were (81.25%) Stanford A aortic intramural hematoma patients with pleural or pericardial effusion. For patient with Stanford A aortic intramural hematoma, endovascular treatment was performed in 15 patients (31.2%), and 33 cases (68.8%) for conservative treatment. The average follow-up (24.9 ± 13.9) was months. There were 120 patients with Stanford type B aortic intramural hematoma (71.4%), 60 patients received endovascular treatment (50%), and 60 patients (50%) received conservative treatment, with an average follow-up of (27.8 ± 14.6) months. For Stanford A type aortic intramural hematoma patients when the maximum aortic diameter ≥ 50 mm or hematoma thickness ≥ 11 mm, with high morbidity and mortality, positive endovascular treatment can reduce complications and death. For patients with Stanford type B aortic intramural hematoma, when the maximum aortic diameter ≥ 40 mm or hematoma thickness ≥ 10 mm, with high morbidity and mortality, positive endovascular treatment can reduce complications and death. Both Stanford type A and B aortic intramural hematoma patients could benefit from the endovascular treatment when the initial maximum aortic diameter is ≥ 50 mm or the hematoma thickness is ≥ 11 mm.

Acute aortic dissection (AAD) in the elderly

AAD is a relatively uncommon yet catastrophic disease. Though the relationship between AAD and age has been discussed in several previous studies, many facets of the relationship between AAD and the elderly still remain unclear. From a retrospective review of charts from January 1, 2005 to December 31, 2010, we collected data of 132 spontaneous AAD cases in a medical center in Taiwan, 83 of which were enrolled in our study. We divided patients into two groups: one above 65 years old (elderly), and a second, non-elderly group. Data collected for statistical analysis included: clinical manifestations on arrival, time of onset, type of AAD, width of mediastinum, whether or not the patient underwent an operation, number of days spent hospitalized, and in-hospital mortality rates. We found that in the elderly group there were more instances of hyperglycemia (p=0.0001), more neurologic defects (p=0.001), less chest pain (p=0.001), and less abdominal pain (p=0.003). SBP was also lower in the elderly group (139±48mmHg, p=0.0001), while there was no difference in mediastinal width between these two groups. In both groups, most AAD cases were DeBakey type III, but type I AAD was more commonly seen in the elderly (p=0.0011). We found that there were both lower SBP and higher rate of diabetes in the elderly group. The elderly group also had longer hospital stays (14.6±16.3 days, p=0.0001) and almost twice the mortality rate (31.1% vs. 15.8%, p=0.0001).

Endovascular management of acute aortic syndromes

The term "acute aortic syndrome" (AAS) refers to a spectrum of life-threatening thoracic aortic pathologies including intramural hematoma, penetrating atherosclerotic ulcer, and aortic dissection. Clinically, patients often present with characteristic aortic pain. AAS often leads to aortic rupture. Therefore, recognition of this condition, its prompt diagnosis, and timely treatment is crucial to obtain clinical success and improved overall survival. The management of AAS, however, remains a therapeutic challenge. Endovascular strategies have gained wide acceptance and now represent a minimally invasive alternative to traditional open surgery. Several studies have shown endovascular repair of varying thoracic aortic pathologies to be technically feasible with fewer complications than open surgery. In this review, the authors discuss AAS pathology and its management, with particular attention to the current role of endovascular aortic repair and its treatment.

Acute aortic syndrome: pathology and therapeutic strategies

Acute aortic syndrome (AAS) describes the acute presentation of patients with characteristic "aortic pain" caused by one of several life threatening thoracic aortic pathologies. These include aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer, aneurysmal leak, and traumatic transection. AAS heralds imminent aortic rupture. Highlighting acute aortic pathology as an AAS is therefore important to encourage prompt recognition of this condition and avoid diagnostic delays. The management of AAS remains a therapeutic challenge. The traditional surgical approach to acute "type B" (descending thoracic) aortic pathology is unsatisfactory with high morbidity and mortality. Endovascular aortic stent grafts now represent an alternative minimally invasive approach in these patients who are often poor surgical candidates. Studies show endovascular repair to be technically feasible with fewer complications. This review discusses AAS pathology and in particular assesses the current role for endovascular aortic repair in its treatment.

Staged endovascular treatment for complicated type B aortic dissection

BACKGROUND

A 40-year-old man presented with acute chest and back pain, hypertension and anuria. Two years previously he had been diagnosed with acute uncomplicated type B aortic dissection. Following conservative management, with aggressive antihypertensive therapy and analgesia, he was monitored with 6-monthly surveillance CT scans. These demonstrated a complicated type B dissection with renal and iliac malperfusion.

INVESTIGATIONS

Multislice CT, transthoracic and transesophageal echocardiography, digital subtraction aortography.

DIAGNOSIS

Acute-on-chronic type B aortic dissection, complicated by aneurysmal dilatation of the thoracic aorta and visceral malperfusion.

MANAGEMENT

Antihypertensive therapy; staged thoracoabdominal and branch vessel endoluminal repair (STABLE procedure), with stabilization of the dissection and rescue of renal function; CT imaging surveillance to monitor for any further complications.