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Choi TW, Kwon Y, Kim J, Won JH. [Endovascular Treatment for Vascular Injuries of the Extremities]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:846-854. [PMID: 37559804 PMCID: PMC10407075 DOI: 10.3348/jksr.2023.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/16/2023] [Accepted: 07/08/2023] [Indexed: 08/11/2023]
Abstract
Vascular injuries of the extremities are associated with a high mortality rate. Conventionally, open surgery is the treatment of choice for peripheral vascular injuries. However, rapid development of devices and techniques in recent years has significantly increased the utilization and clinical application of endovascular treatment. Endovascular options for peripheral vascular injuries include stent-graft placement and embolization. The surgical approach is difficult in cases of axillo-subclavian or iliac artery injuries, and stent-graft placement is a widely accepted alternative to open surgery. Embolization can be considered for arterial injuries associated with active bleeding, pseudoaneurysms, and arteriovenous fistula and in patients in whom embolization can be safely performed without a risk of ischemic complications in the extremities. Endovascular treatment is a minimally invasive procedure and is useful as a simultaneous diagnostic and therapeutic approach, which serve as advantages of this technique that is widely utilized for vascular injuries of the extremities.
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Cassidy S, Allouni K, Day C, Wells D, Pherwani A, Ablett D. Blunt Thoracic Aortic Injury and Acute Trauma: The Effect on Aortic Diameter and the Consequences for Stent-graft Sizing. Ann Vasc Surg 2020; 72:563-570. [PMID: 33227478 DOI: 10.1016/j.avsg.2020.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/26/2020] [Accepted: 10/05/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) is associated with a high mortality and large trauma burden. Trauma and resuscitation after injury affect cardiovascular status, which may in turn affect aortic diameter. Measurement of aortic diameter is necessary to guide stent-graft sizing as part of BTAI management. Inaccurate measurement may lead to stent-graft complications. This pilot study aimed to assess the effect of acute major trauma on stent-graft sizing and stent-graft complications, in the context of BTAI and to assess whether any effect could be predicted. METHODS Patients who were admitted to a UK major trauma center between January 2007 and December 2017, and were diagnosed with BTAI, were identified. The thoracic aortic diameter was measured at six points on initial and surveillance computed tomography imaging. Data on patient demographics, admission heart rate, mean arterial pressure (MAP), and serum lactate were gathered. RESULTS Thirty-two patients were identified. Twenty met inclusion criteria. Of these, 12 were managed operatively and eight nonoperatively. The mean age was 40, the mean injury severity score was 43, and 85% were male. A mean increase in diameter between initial trauma scan and surveillance scan was noted throughout the thoracic aorta (P < 0.05). Stent-graft oversizing relative to aortic diameter changed significantly from initial trauma imaging to surveillance imaging (P < 0.05). Admission heart rate, MAP, and serum lactate were not predictive of the percentage change in aortic diameter. There were no complications at surveillance imaging (mean 45 days) or during medium term follow-up (mean 532 days). CONCLUSIONS Aortic diameter is affected by BTAI, acute major trauma, and resuscitation in a significant and variable manner. Measurements of the aorta in a patient with BTAI in the acute trauma setting should be viewed with uncertainty. A lack of complications in the short term is suggestive of a wide tolerance range regarding stent-graft sizing, but long-term results are unknown.
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Affiliation(s)
- Samuel Cassidy
- Keele University Medical School, Stoke-on-Trent, Staffordshire, UK.
| | - Kader Allouni
- Department of Interventional Radiology, Royal Stoke Unviersity Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Christopher Day
- Department of Interventional Radiology, Royal Stoke Unviersity Hospital, Stoke-on-Trent, Staffordshire, UK
| | - David Wells
- Department of Interventional Radiology, Royal Stoke Unviersity Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Arun Pherwani
- Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Daniel Ablett
- Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
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Teraa M, Hazenberg CE, Houben IB, Trimarchi S, van Herwaarden JA. Important issues regarding planning and sizing for emergent TEVAR. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:708-712. [PMID: 32964898 DOI: 10.23736/s0021-9509.20.11571-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In the past decades, treatment of acute thoracic aortic syndrome underwent drastic changes with a central role for thoracic endovascular aortic repair (TEVAR). One of the essential factors in the success of TEVAR is accurate sizing of the endograft, as both under- and oversizing can lead to suboptimal results and disastrous complications. The aim of this review was to give an overview of issues regarding endograft sizing in emergent TEVAR. Sizing of the endograft can be complicated by specific factors related to the underlying disease. For instance, different types of the acute thoracic aortic syndrome, i.e. blunt thoracic injury, thoracic aortic aneurysm or dissection with concomitant rupture are associated with hemorrhagic shock and the need for resuscitation, which leads to profound changes in diameter of the thoracic aorta. These diameter changes should be taken into account during endograft sizing. Measuring the thoracic aorta based on the admission CTA can lead to inaccurate sizing, even if proper centerline-based measurements are performed. The use of real-time imaging, in particular intravascular ultrasound (IVUS), has been shown to provide more accurate endograft sizing in acute thoracic aortic syndromes, especially if associated with hypovolemia. Future research should provide additional data on the exact role of different intra-operative imaging modalities (e.g. IVUS, transesophageal echocardiography [TEE], three dimensional CTA) on endograft sizing and long-term outcomes to ultimately improve patient outcome.
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Affiliation(s)
- Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands -
| | | | - Ignas B Houben
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Santi Trimarchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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4
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Arterial waveform morphomics during hemorrhagic shock. Eur J Trauma Emerg Surg 2019; 47:325-332. [DOI: 10.1007/s00068-019-01140-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/17/2019] [Indexed: 11/26/2022]
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Dobson GP, Arsyad A, Letson HL. The Adenosine Hypothesis Revisited: Modulation of Coupling between Myocardial Perfusion and Arterial Compliance. Front Physiol 2017; 8:824. [PMID: 29104545 PMCID: PMC5654924 DOI: 10.3389/fphys.2017.00824] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/06/2017] [Indexed: 12/25/2022] Open
Abstract
For over four decades the thoracic aortic ring model has become one of the most widely used methods to study vascular reactivity and electromechanical coupling. A question that is rarely asked, however, is what function does a drug-mediated relaxation (or contraction) in this model serve in the intact system? The physiological significance of adenosine relaxation in rings isolated from large elastic conduit arteries from a wide range of species remains largely unknown. We propose that adenosine relaxation increases aortic compliance in acute stress states and facilitates ventricular-arterial (VA) coupling, and thereby links compliance and coronary artery perfusion to myocardial energy metabolism. In 1963 Berne argued that adenosine acts as a local negative feedback regulator between oxygen supply and demand in the heart during hypoxic/ischemic stress. The adenosine VA coupling hypothesis extends and enhances Berne's "adenosine hypothesis" from a local regulatory scheme in the heart to include conduit arterial function. In multicellular organisms, evolution may have selected adenosine, nitric oxide, and other vascular mediators, to modulate VA coupling for optimal transfer of oxygen (and nutrients) from the lung, heart, large conduit arteries, arterioles and capillaries to respiring mitochondria. Finally, a discussion of the potential clinical significance of adenosine modulation of VA coupling is extended to vascular aging and disease, including hypertension, diabetes, obesity, coronary artery disease and heart failure.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Aryadi Arsyad
- Physiology Department, Medical Faculty, Hasanuddin University, Makassar, Indonesia
| | - Hayley L Letson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Nauta FJH, van Bogerijen GHW, Conti M, Trentin C, Moll FL, Van Herwaarden JA, Auricchio F, Trimarchi S. Impact of Thoracic Endovascular Repair on Pulsatile Aortic Strain in Acute Type B Aortic Dissection: Preliminary Results. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2017; 5:42-52. [PMID: 28868315 DOI: 10.12945/j.aorta.2017.16.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 03/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The impact of thoracic endovascular aortic repair (TEVAR) on pulsatile aortic strain remains undetermined in patients with Type B aortic dissection (TBAD). Therefore, we quantified pulsatile aortic strain in TBAD patients and control subjects. METHODS We retrospectively analyzed two TBAD patients from our database with cardiac-gated computed tomography angiography imaging available before and after TEVAR and two control subjects (67- and 76-year-old males). Patient 1 (54-year-old female) presented with acute TBAD, and Patient 2 (55-year-old male) had Marfan syndrome and ruptured acute TBAD. Custom-developed software was used to compute aortic length, diameter, and area during the cardiac cycle. Pulsatile strain was calculated as systolic increments of length and circumference divided by corresponding diastolic values. RESULTS Before TEVAR, pulsatile longitudinal strain of the thoracic aorta was lower in TBAD patients (1.4-1.7%) than in control subjects (2.1-4.5%). After TEVAR, pulsatile longitudinal strain increased proximal to the stent-graft by 65% in the arch of Patient 1 and by 70% in the ascending aorta of Patient 2. Pulsatile circumferential strain was elevated in false lumen patency (4.4-6.2%) compared with thrombosed false lumen (1.4-2.1%) or control subjects (0.9-3.3%). Following TEVAR, circumferential measurements within stented segments were deemed unreliable due to artifacts. CONCLUSIONS TEVAR led to a considerable increase of pulsatile longitudinal strain proximal to the stent-grafts, and TBAD was associated with longitudinally stiffer aortas, which may be part of the pathophysiology of TEVAR-related complications such as retrograde dissection and aneurysmal dilatation. These preliminary data call for larger prospective studies.
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Affiliation(s)
- Foeke J H Nauta
- Thoracic Aortic Research Center, Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy.,Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Guido H W van Bogerijen
- Thoracic Aortic Research Center, Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy.,Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Michele Conti
- Structural Mechanics Division, Department of Civil Engineering and Architecture, University of Pavia, Italy
| | - Chiara Trentin
- CESNA Center for Advanced Numerical Simulations, Istituto Universitario di Studi Superiori di Pavia (IUSS), Pavia, Italy
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Ferdinando Auricchio
- Structural Mechanics Division, Department of Civil Engineering and Architecture, University of Pavia, Italy.,CESNA Center for Advanced Numerical Simulations, Istituto Universitario di Studi Superiori di Pavia (IUSS), Pavia, Italy
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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Irfan H, Ooi GS, Kyin MM, Ho P. Revealing Maximal Diameter of Upper Limb Superficial Vein with an Elevated Environmental Temperature. Int J Chronic Dis 2016; 2016:8096473. [PMID: 27597987 PMCID: PMC5002475 DOI: 10.1155/2016/8096473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 07/03/2016] [Indexed: 11/23/2022] Open
Abstract
Ultrasonography is the primary tool for preoperative analysis of vein morphology for fistula creation in patients with end-stage renal disease. This study examines the effect of environmental temperature on the superficial vein size. Superficial veins of thirteen healthy volunteers were marked at three sites: cephalic vein in left lateral arm near cubital fossa, cephalic vein in left forearm at wrist, and basilic vein in left medial arm near cubital fossa. Mean diameters were recorded using ultrasound probe at 26°C and 43°C. Body temperature was increased using a Bair Hugger blanket. Mean values from the two temperatures were analyzed using paired sample t-test. All three superficial vein sites displayed statistically significant increase in diameter when the temperature was increased from 26°C to 43°C. Paired t-test showed p values of 0.001 for cephalic vein at wrist, 0.01 for cephalic vein near cubital fossa, and 0.01 for basilic vein near cubital fossa. This study proved that environmental temperature exerts a statistically significant effect on vein size measured by ultrasound during preoperative assessment for vascular access. Not to the extent of 43°C, the authors would recommend setting the room temperature higher during ultrasound vascular assessment to avoid underestimating the superficial vein size.
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Affiliation(s)
- Hira Irfan
- Dow University of Health Sciences, Karachi 74200, Pakistan
| | - Guo Shen Ooi
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore 119228
| | - May M. Kyin
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore 119228
| | - Pei Ho
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore 119228
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Trimarchi S, Kamman A, Lomazzi C, Segreti S, Cova M, De Vincentiis C, Frigiola A, Menicanti L, Marrocco-Trischitta MM, Grassi V, Morganti S, Conti M, Auricchio F, Rampoldi V. Activities at Thoracic Aortic Research Center, IRCCS Policlinico San Donato. Eur Heart J Suppl 2016; 18:E57-E63. [PMID: 28533718 DOI: 10.1093/eurheartj/suw015] [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: 11/13/2022]
Abstract
The Thoracic Aortic Research Center (TARC) of the IRCCS Policlinico San Donato (PSD) aims to promote research on thoracic aortic diseases, to disclose the scientific knowledge and clinical experience and to develop new scientific paths within the Hospital and the aortic community, in collaboration with other national and international centres. Thoracic Aortic Research Center collaborates with many centres in both Europe (e.g. University of Utrecht, the Netherlands) and the USA (e.g. University of Michigan). This has led to multiple highly regarded publications in respected cardiovascular journals and has led to several PhD programmes resulting in doctorate degrees. Within Italy, in association with the Bioengineering School of the University of Pavia, TARC has founded the "BETA-lab" (Biomechanics for Endovascular Treatment of the Aorta laboratory), where MDs, Bioengineers, and PhD fellows conduct experimental studies using in vitro/ex vivo models of the physiologic aorta and aortic diseases. Furthermore, a database (iCardiocloud) where the medical imaging of cardiovascular patients from the PSD is structured, for in silico analysis utilizing computational fluid dynamics, and in vitro studies using also 3D printed aortic models. With the role of principal investigator or co-investigator, TARC at PSD has been participating in other several projects, including the International Registry of Acute Aortic Dissection, the International Aortic Arch Surgery Study Group, the European Registry of Endovascular Aortic Repair Complications, the ADSORB and ASSIST trials, and the GREAT registry. International collaborations have included also studies on predictors of aortic growth after dissection with the Yale University and University of Virginia, and on aortic biomarkers with the University of Tokyo.
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Affiliation(s)
- Santi Trimarchi
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Arnoud Kamman
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Chiara Lomazzi
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Sara Segreti
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Marta Cova
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Carlo De Vincentiis
- Section of Cardiac Surgery, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Milan, Italy
| | - Alessandro Frigiola
- Section of Cardiac Surgery, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Milan, Italy
| | - Lorenzo Menicanti
- Section of Cardiac Surgery, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Milan, Italy
| | - Massimiliano M Marrocco-Trischitta
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Viviana Grassi
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Simone Morganti
- Department of Civil Engineering and Architecture, University of Pavia, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Italy
| | | | - Vincenzo Rampoldi
- Section of Vascular Surgery II°, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
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9
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Intravascular ultrasound enhanced aortic sizing for endovascular treatment of blunt aortic injury. J Trauma Acute Care Surg 2015; 79:817-21. [DOI: 10.1097/ta.0000000000000858] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Humphrey JD, Schwartz MA, Tellides G, Milewicz DM. Role of mechanotransduction in vascular biology: focus on thoracic aortic aneurysms and dissections. Circ Res 2015; 116:1448-61. [PMID: 25858068 PMCID: PMC4420625 DOI: 10.1161/circresaha.114.304936] [Citation(s) in RCA: 259] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Thoracic aortic diseases that involve progressive enlargement, acute dissection, or rupture are influenced by the hemodynamic loads and mechanical properties of the wall. We have only limited understanding, however, of the mechanobiological processes that lead to these potentially lethal conditions. Homeostasis requires that intramural cells sense their local chemomechanical environment and establish, maintain, remodel, or repair the extracellular matrix to provide suitable compliance and yet sufficient strength. Proper sensing, in turn, necessitates both receptors that connect the extracellular matrix to intracellular actomyosin filaments and signaling molecules that transmit the related information to the nucleus. Thoracic aortic aneurysms and dissections are associated with poorly controlled hypertension and mutations in genes for extracellular matrix constituents, membrane receptors, contractile proteins, and associated signaling molecules. This grouping of factors suggests that these thoracic diseases result, in part, from dysfunctional mechanosensing and mechanoregulation of the extracellular matrix by the intramural cells, which leads to a compromised structural integrity of the wall. Thus, improved understanding of the mechanobiology of aortic cells could lead to new therapeutic strategies for thoracic aortic aneurysms and dissections.
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MESH Headings
- Aortic Dissection/genetics
- Aortic Dissection/metabolism
- Aortic Dissection/pathology
- Aortic Dissection/physiopathology
- Aortic Dissection/therapy
- Animals
- Aorta, Thoracic/metabolism
- Aorta, Thoracic/pathology
- Aorta, Thoracic/physiopathology
- Aortic Aneurysm, Thoracic/genetics
- Aortic Aneurysm, Thoracic/metabolism
- Aortic Aneurysm, Thoracic/pathology
- Aortic Aneurysm, Thoracic/physiopathology
- Aortic Aneurysm, Thoracic/therapy
- Aortic Rupture/genetics
- Aortic Rupture/metabolism
- Aortic Rupture/pathology
- Aortic Rupture/physiopathology
- Aortic Rupture/therapy
- Biomechanical Phenomena
- Disease Progression
- Extracellular Matrix Proteins/genetics
- Extracellular Matrix Proteins/metabolism
- Genetic Predisposition to Disease
- Hemodynamics
- Humans
- Mechanotransduction, Cellular
- Phenotype
- Stress, Mechanical
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Affiliation(s)
- Jay D Humphrey
- From the Departments of Biomedical Engineering (J.D.H., M.A.S.), Medicine (Cardiology) (M.A.S.), Cell Biology (M.A.S.), and Surgery (G.T.), Yale University, New Haven, CT; and Department of Internal Medicine, University of Texas Health Science Center, Houston (D.M.M.)
| | - Martin A Schwartz
- From the Departments of Biomedical Engineering (J.D.H., M.A.S.), Medicine (Cardiology) (M.A.S.), Cell Biology (M.A.S.), and Surgery (G.T.), Yale University, New Haven, CT; and Department of Internal Medicine, University of Texas Health Science Center, Houston (D.M.M.)
| | - George Tellides
- From the Departments of Biomedical Engineering (J.D.H., M.A.S.), Medicine (Cardiology) (M.A.S.), Cell Biology (M.A.S.), and Surgery (G.T.), Yale University, New Haven, CT; and Department of Internal Medicine, University of Texas Health Science Center, Houston (D.M.M.)
| | - Dianna M Milewicz
- From the Departments of Biomedical Engineering (J.D.H., M.A.S.), Medicine (Cardiology) (M.A.S.), Cell Biology (M.A.S.), and Surgery (G.T.), Yale University, New Haven, CT; and Department of Internal Medicine, University of Texas Health Science Center, Houston (D.M.M.).
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Voitle E, Hofmann W, Cejna M. Aortic emergencies-diagnosis and treatment: a pictorial review. Insights Imaging 2015; 6:17-32. [PMID: 25638646 PMCID: PMC4330229 DOI: 10.1007/s13244-014-0380-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 11/27/2014] [Accepted: 12/16/2014] [Indexed: 12/29/2022] Open
Abstract
Objectives To demonstrate the various presentations of acute aortic pathology and to present diagnostic and therapeutic approaches. Methods Diagnostic imaging is the key to the reliable diagnosis of acute aortic pathology with multi-slice computed tomography angiography (CTA) as the fastest and most robust modality. Endovascular aortic repair (EVAR) with stent grafts and open surgical repair are therapeutic approaches for aortic pathology. Results CTA is reliable in diagnosing and grading aortic trauma, measuring aortic diameter in aortic aneurysms and detecting vascular wall pathology in acute aortic syndrome and aortic inflammation. CTA enables planning the optimal therapeutic approach. Stent graft implantation and/or an open surgical approach can address vascular wall pathology and exclude aortic aneurysms. Conclusion Aortic emergencies have to be detected quickly. CTA is the imaging method of choice and helps to decide whether elective, urgent or emergent treatment is necessary with EVAR and open surgical repair as the main treatment approaches. Teaching Points • To present aortic pathology caused by trauma • To present acute aortic syndrome (aortic dissection, intramural haematoma and penetrating ulcers) • To present symptomatic and ruptured aortic aneurysm • To present infection (mycotic aneurysms/aorto-duodenal fistulae) or iatrogenic injury of the aorta • To understand different presentations for treatment planning (EVAR and open surgery)
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Affiliation(s)
- Esther Voitle
- Institute for Diagnostic and Interventional Radiology, Academic Teaching Hospital LKH Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
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12
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Intravascular ultrasound is a critical tool for accurate endograft sizing in the management of blunt thoracic aortic injury. J Vasc Surg 2014; 61:630-5. [PMID: 25499713 DOI: 10.1016/j.jvs.2014.10.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 10/09/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Accurate measurement of true aortic luminal diameter (ALD) is critical for endograft sizing in endovascular treatment of blunt thoracic aortic injury (BTAI), but ALD is dynamic and changes with respect to patients' hemodynamic status. This study aimed to characterize how ALD at the time of diagnosis of BTAI compares with ALD at the time of endovascular repair and later at follow-up. METHODS This is an Institutional Review Board-approved, single-institution retrospective analysis of prospectively obtained data. Patients were included who presented between July 2007 and December 2012 with computed tomography angiography (CTA)-diagnosed BTAI; who underwent thoracic endovascular aortic repair (TEVAR); and who underwent preoperative CTA, intraoperative intravascular ultrasound (IVUS), and postimplantation CTA. Comparison measurements of the ALD were made among CTA and IVUS images at the level of the left subclavian artery (LSCA) and between initial CTA and postimplantation CTA at 10, 15, and 20 cm distal to the LSCA. Theoretical endograft sizes were determined and compared for each ALD at the LSCA. RESULTS Twenty-two patients were included in the analysis. Mean age was 38 ± 14 years (range, 17-61 years), with 82% men and mean Injury Severity Score of 43 ± 11 (range, 24-66). Mean time from emergency department admission to initial CTA was -1.2 ± 5 hours (range, -13 to 11.5 hours; negative time implies imaging at an outside facility before admission). Mean time from initial CTA to IVUS was 1.2 ± 1.4 days (range, 2.5 hours-5.7 days) and from IVUS to postimplantation CTA 33 ± 45 days (range, 17 hours-169 days). Overall, ALD measured by IVUS was significantly larger than that by initial CTA (Δ2.5 ± 3.1 mm; P < .05). ALD was also larger at 10, 15, and 20 cm distal to the LSCA in comparing the postimplantation CTA with the initial CTA (Δ2.4, 2.0, and 2.0 mm, respectively; all P < .05). More than half the devices would be sized differently with ALD measured by IVUS at the time of TEVAR vs initial CTA. CONCLUSIONS The ALD of patients with BTAI is significantly larger when it is measured by IVUS at the time of TEVAR compared with at the time of initial CTA. This difference in ALD may translate to undersizing of endografts used in TEVAR for BTAI. IVUS at the time of TEVAR provides a more accurate measurement of the actual ALD and should be used for endograft sizing for patients with BTAI.
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13
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Alberta HB, Secor JL, Smits TC, Farber MA, Jordan WD, Azizzadeh A, Rovin JD, Matsumura JS. Comparison of thoracic aortic diameter changes after endograft placement in patients with traumatic and aneurysmal disease. J Vasc Surg 2014; 59:1241-6. [DOI: 10.1016/j.jvs.2013.11.075] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/08/2013] [Accepted: 11/16/2013] [Indexed: 11/28/2022]
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Schlösser FJ, Hogendoorn W, Muhs BE. Commentary: Midterm Results of Thoracic Endovascular Aortic Repair With Periscope Graft Revascularization of the Left Subclavian Artery. J Endovasc Ther 2013; 20:735-7. [DOI: 10.1583/13-4484c.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Schepens MAAM, Van den Brande FGJ. Patient selection for open thoracoabdominal aneurysm repair. Ann Cardiothorac Surg 2013; 1:358-64. [PMID: 23977521 DOI: 10.3978/j.issn.2225-319x.2012.08.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 08/13/2012] [Indexed: 01/15/2023]
Affiliation(s)
- Marc A A M Schepens
- AZ St. Jan, Department of Cardiac Surgery, AZ St. Jan, Ruddershove 10, 8000 Brugge, Belgium
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