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Zhao Y, Liang R, Liang A, Wu Z, Zhang Y, Wu X, Ge G. Effect of TEVAR Combined with Drugs and Drug Therapy Alone on the Efficacy and Safety of Stable Standford B Aortic Dissection. Altern Ther Health Med 2024; 30:146-153. [PMID: 37856806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Objective Stanford type B aortic dissection is a condition in which the intima of the aorta tears, and TEVAR is an interventional treatment to manage this dissection through intimal repair. To evaluate the medium-term clinical efficacy of endovascular repair (TEVAR) for Aortic dissection and drug Conservative management for Stanford B Aortic dissection aneurysms and further explore whether the former is superior to drug Conservative management in the medium-term efficacy. Methods The clinical data of 70 patients with stable Standford type B Aortic dissection admitted to our hospital from March 2016 to March 2020 were retrospectively analyzed. They were divided into the treatment group (n = 47) and the control group (n = 23). The control group patients were treated solely with medication, while the treatment group patients were treated with TEVAR on the basis of the control group patients. The treatment efficacy and safety of the two groups of patients were compared and analyzed. All patients will be followed up once a month for 12 months after discharge and every 2 months thereafter (for a total of 3 years). Results The findings highlight the need to carefully weigh the benefits and harms in the treatment of Stanford type B aortic dissection, especially when considering TEVAR surgery. Future research should focus on reducing postoperative complications to optimize treatment strategies and improve overall patient outcomes.TEVAR surgery significantly reduces hospital mortality, but is also associated with significantly increased postoperative complications, emphasizing the complexity of treatment decisions. This finding provides critical information about weighing the risks and survival benefits of surgery, helping medical teams and patients make informed treatment choices. The hospital mortality rate of patients in the treatment group was 12.77%, while the hospital mortality rate of patients in the control group was 21.74%. The difference between the two groups was statistically significant (P < .05). The incidence of postoperative complications in the treatment group was 23.40%, while the control group did not experience any major complications. The difference between the two groups was statistically significant (P < .05). The mortality rate of patients in the treatment group within 30 days of discharge was 0%, while the mortality rate of patients in the control group within 30 days of discharge was 11.11%. The difference between the two groups was statistically significant (P < .05). The Kaplan Meier curve showed that the survival rates at 3 years of the control and treatment groups were 56.52% and 95.12%, respectively. The log-rank test showed a statistical difference between the two groups. Univariate and multivariate regression analysis showed that postoperative neurological complications (HR = 32.41; P = .00) and preoperative Aortic valve regurgitation (HR = 3.91; P = .00) were risk factors for medium-term death. Conclusion The TEVAR combination drug is a safe and effective treatment for stable Stanford B Aortic dissection. It can reduce mortality. Compared with drug treatment, it has obvious advantages in medium-term treatment effects. Early rising for high-risk patients can make them have better long-term outcomes. Limitations of the study include its retrospective nature and the use of data from only a single medical center, which may limit the external generalizability of the results.
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Zhou M, Zha Z, Zheng Z, Pan Y. Cordycepin suppresses vascular inflammation, apoptosis and oxidative stress of arterial smooth muscle cell in thoracic aortic aneurysm with VEGF inhibition. Int Immunopharmacol 2023; 116:109759. [PMID: 36731150 DOI: 10.1016/j.intimp.2023.109759] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/29/2022] [Accepted: 01/17/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Thoracic aortic aneurysm (TAA) is a type of common and serious vascular disease, in which inflammation, apoptosis and oxidative stress are strongly involved in the progression. Cordycepin, a bioactive compound from Cordyceps militaris, exhibits anti-inflammatory and anti-oxidative activities. This study aimed to address the role and mechanism of cordycepin in TAA. METHODS The thoracic aortas were perivascularly administrated with calcium chloride (CaCl2), and human aortic smooth muscle cells (HASMCs) were incubated with angiotensin II (Ang II) to simulate the TAA model in vivo and in vitro, respectively. The effect and mechanism of cordycepin in TAA were explored by hematoxylin and eosin (HE) staining, immunohistochemistry (IHC), immunofluorescence (IF), western blot, biochemical test, cell counting kit-8 (CCK-8), and terminal deoxynucleotidyl transferase deoxyuridine triphosphate (dUTP) nick end labeling (TUNEL) assays. RESULTS Cordycepin improved the CaCl2-induced the aneurysmal alteration and disappearance of normal wavy elastic structures of the aorta tissues, TAA incidence and thoracic aortic diameter in rats, and Ang II-induced the cell viability of HASMCs. Cordycepin reversed the CaCl2-induced the relative protein expression of cleaved caspase 9, cleaved caspase 3, interleukin (IL)-6, tumor necrosis factor (TNF)-α and IL-1β, and the relative levels of glutathione (GSH), malonaldehyde (MDA) and reactive oxygen species (ROS) in vivo, or Ang II-induced these changes in vitro. Mechanically, cordycepin reduced the relative protein expressions of vascular endothelial growth factor (VEGF), VEGF receptor 2 (VEGFR2), cluster of differentiation 31 (CD31) and endothelial nitric oxide synthase (eNOS) in the Ang II-induced HASMCs. Correspondingly, overexpression of VEGF increased the levels of the indicators involved in apoptosis, inflammation and oxidative stress, which were antagonized with the cordycepin incubation in the Ang II-induced HASMCs. CONCLUSION Cordycepin inhibited apoptosis, inflammation and oxidative stress of TAA through the inhibition of VEGF.
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Affiliation(s)
- Minghe Zhou
- Department of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Zhengbiao Zha
- Department of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Zhi Zheng
- Department of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Youmin Pan
- Department of Cardiovascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China.
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Jadli AS, Ballasy NN, Gomes KP, Mackay CDA, Meechem M, Wijesuriya TM, Belke D, Thompson J, Fedak PWM, Patel VB. Attenuation of Smooth Muscle Cell Phenotypic Switching by Angiotensin 1-7 Protects against Thoracic Aortic Aneurysm. Int J Mol Sci 2022; 23:ijms232415566. [PMID: 36555207 PMCID: PMC9779869 DOI: 10.3390/ijms232415566] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
Thoracic aortic aneurysm (TAA) involves extracellular matrix (ECM) remodeling of the aortic wall, leading to reduced biomechanical support with risk of aortic dissection and rupture. Activation of the renin-angiotensin system, and resultant angiotensin (Ang) II synthesis, is critically involved in the onset and progression of TAA. The current study investigated the effects of angiotensin (Ang) 1-7 on a murine model of TAA. Male 8-10-week-old ApoEKO mice were infused with Ang II (1.44 mg/kg/day) and treated with Ang 1-7 (0.576 mg/kg/day). ApoEKO mice developed advanced TAA in response to four weeks of Ang II infusion. Echocardiographic and histological analyses demonstrated increased aortic dilatation, excessive structural remodelling, perivascular fibrosis, and inflammation in the thoracic aorta. Ang 1-7 infusion led to attenuation of pathological phenotypic alterations associated with Ang II-induced TAA. Smooth muscle cells (SMCs) isolated from adult murine thoracic aorta exhibited excessive mitochondrial fission, oxidative stress, and hyperproliferation in response to Ang II. Treatment with Ang 1-7 resulted in inhibition of mitochondrial fragmentation, ROS generation, and hyperproliferation. Gene expression profiling used for characterization of the contractile and synthetic phenotypes of thoracic aortic SMCs revealed preservation of the contractile phenotype with Ang 1-7 treatment. In conclusion, Ang 1-7 prevented Ang II-induced vascular remodeling and the development of TAA. Enhancing Ang 1-7 actions may provide a novel therapeutic strategy to prevent or delay the progression of TAA.
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Affiliation(s)
- Anshul S. Jadli
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Noura N. Ballasy
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Karina P. Gomes
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Cameron D. A. Mackay
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Megan Meechem
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Tishani Methsala Wijesuriya
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Darrell Belke
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Jennifer Thompson
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Paul W. M. Fedak
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Vaibhav B. Patel
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
- Correspondence: or ; Tel.: +1-(403)-220-3446
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Ninomiya R, Kinehara Y, Tobita S, Konaka H, Jokoji R, Shintani T, Tachibana I. Inflammatory Thoracic Aortic Aneurysm in a Patient with Advanced Lung Adenocarcinoma Treated with Pembrolizumab. Intern Med 2022; 61:2339-2341. [PMID: 35022350 PMCID: PMC9424081 DOI: 10.2169/internalmedicine.8688-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
A 57-year-old man with lung adenocarcinoma was treated with chemotherapy and immune checkpoint blockade. After two cycles of carboplatin, pemetrexed, and pembrolizumab, he developed a persistent fever. Chest computed tomography (CT) suggested inflammation of the aortic wall. We treated the patient with corticosteroids. After four cycles of carboplatin, pemetrexed, and pembrolizumab, chest CT showed an aneurysm in the ascending aorta. We diagnosed him with inflammatory thoracic aortic aneurysm induced by pembrolizumab and performed surgical replacement of the ascending aorta. Although this might be a very rare case, we should be aware of aortitis as a potential adverse effect of pembrolizumab.
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Affiliation(s)
| | | | | | | | - Ryu Jokoji
- Department of Pathology, Nippon Life Hospital, Japan
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Wang X, Zhang X, Qiu T, Yang Y, Li Q, Zhang X. Dexamethasone reduces the formation of thoracic aortic aneurysm and dissection in a murine model. Exp Cell Res 2021; 405:112703. [PMID: 34118251 DOI: 10.1016/j.yexcr.2021.112703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 05/30/2021] [Accepted: 06/05/2021] [Indexed: 12/17/2022]
Abstract
Thoracic aortic aneurysm and dissection (TAAD) is a life-threatening vascular disease with no effective pharmaceutical therapies currently available. Inflammation plays a key role in the progression of aneurysms. Dexamethasone (DEX), a synthetic glucocorticoid, has showed alleviating effects on cells in vitro from TAAD patients. Here we performed a study aiming at investigating the protective role of DEX in a β-aminopropionitrile monofumarate (BAPN)-induced TAAD mouse model. DEX (dose: 0.04 mg/kg/day) treatment significantly reduced the aortic diameter and inhibited TAAD formation. DEX reduced infiltration of macrophages and neutrophils, apoptosis of vascular smooth muscle cells (VSMCs), expression of metalloproteinase 2/9, and extracellular matrix degradation in BAPN-treated TAAD mice. Furthermore, DEX therapy downregulated the expression of p-p65 in macrophages and VSMCs, which suggested that DEX might ameliorate BAPN-induced TAAD by suppressing NF-κB signaling. Therefore, DEX therapy attenuates the progression of BAPN-induced TAAD murine model and could be used as an effective adjuvant therapy for treating TAAD.
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Affiliation(s)
- Xipeng Wang
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, China.
| | - Xiaoping Zhang
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China.
| | - Tao Qiu
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, China.
| | - Yang Yang
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, China.
| | - Qingle Li
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, China.
| | - Xiaoming Zhang
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, China.
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Masaki N, Kumagai K, Sasaki K, Matsuo S, Motoyoshi N, Adachi O, Akiyama M, Kawamoto S, Tabayashi K, Saiki Y. Suppressive effect of pitavastatin on aortic arch dilatation in acute stanford type B aortic dissection: analysis of STANP trial. Gen Thorac Cardiovasc Surg 2018; 66:334-343. [PMID: 29626287 DOI: 10.1007/s11748-018-0916-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/27/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Medical therapy for patients with uncomplicated acute type B aortic dissection (ABAD) is essentially accepted for its excellent early outcome; however, long-term outcomes have not been satisfactory due to aorta-related complications. This trial was performed to investigate the efficacy of a statin as an additive that may enhance the effectiveness of conventional medical treatment in patients with ABAD. METHODS This was a multi-center, prospective, and randomized comparative investigation of patients with uncomplicated ABAD. Fifty patients with ABAD compatible with inclusion criteria were randomly assigned to two groups and then received administration of pitavastatin (group P) or not (group C). We followed up the patients for 1 year from study onset. RESULTS Two patients demised during the follow-up period (both were in group C). In addition, aorta-related interventions were performed in two patients (entry closure for aortic dissection by endovascular repair in one patient in each group). Aortic arch diameters at 1 year in group P tended to be smaller than in group C (P = 0.17), and the rate of change of the aortic arch diameters from onset to 1 year was significantly lower in group P (P = 0.046). Multivariate analysis identified patency of the false lumen was detected as a risk factor for aortic arch dilatation (P = 0.02), and pitavastatin intake was a negative risk factor (P = 0.03). CONCLUSIONS Pitavastatin treatment, in addition to the standard antihypertensive therapy, may have a suppressive effect on aortic arch dilatation in patients with ABAD.
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Affiliation(s)
- Naoki Masaki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan
| | - Kiichiro Kumagai
- Research Division of Sciences for Aortic Disease, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Konosuke Sasaki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan
| | - Satoshi Matsuo
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan
| | - Naotaka Motoyoshi
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan
| | - Osamu Adachi
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan
| | - Masatoshi Akiyama
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan
| | - Shunsuke Kawamoto
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan
| | - Koichi Tabayashi
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan.
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Descaillot L, Lantelme P, Harbaoui B. Trans-oesophageal echocardiography for acute systemic embolism: Check the heart don't forget the aorta. Presse Med 2017; 46:874-876. [PMID: 28619583 DOI: 10.1016/j.lpm.2017.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/25/2016] [Accepted: 05/15/2017] [Indexed: 11/17/2022] Open
Affiliation(s)
- Léonard Descaillot
- Hospices civils de Lyon, hôpital de la Croix-Rousse, cardiology department, 69004 Lyon, France.
| | - Pierre Lantelme
- Hospices civils de Lyon, hôpital de la Croix-Rousse, cardiology department, 69004 Lyon, France; Hospices civils de Lyon, université Claude-Bernard Lyon 1, université de Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, 69100 Lyon, France
| | - Brahim Harbaoui
- Hospices civils de Lyon, hôpital de la Croix-Rousse, cardiology department, 69004 Lyon, France; Hospices civils de Lyon, université Claude-Bernard Lyon 1, université de Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, 69100 Lyon, France
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8
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Todsen T, Lober A, Lyngaard F. [Woman with globulus sensation]. Ugeskr Laeger 2016; 178:V67046. [PMID: 27063200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Abstract
We describe the case of an 83-year-old lady with a known aneurysmal thoracic aorta, developing acute breathlessness and hypoxia, with no pain and unremarkable cardiovascular examination. As D-dimers were raised, she was treated with low-molecular-weight heparin (LMWH) for suspected pulmonary embolism. CT pulmonary angiography showed acutely dissecting, Type-A, thoracic aortic aneurysm. The patient was treated medically with β-blockers. Despite a poor prognosis, she remains well 2 months later. Observational studies of patients over 70 with Type-A dissection show only 75.3% experience pain, are offered surgery less and have higher mortality. d-Dimers are almost always elevated in aortic dissection. No previous studies document breathlessness as the only presenting symptom. This case emphasises the need, in older populations, for a low suspicion threshold for aortic dissection.
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Affiliation(s)
- Jamie Catlow
- Elderly Medicine, North Tyneside General Hospital, Rake Lane North Shields, Tyne and Wear NE29 8NH, UK
| | - Tarquin Cross
- Elderly Medicine, North Tyneside General Hospital, Rake Lane North Shields, Tyne and Wear NE29 8NH, UK
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10
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Abstract
BACKGROUND Thoracic aortic dissection (TAD) is a severe and often lethal complication in people with hypertension. Current practice in the treatment of chronic type B aortic dissections is the use of beta-blockers as first-line therapy to decrease aortic wall stress. Other antihypertensive medications, such as calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), have been suggested for the medical therapy of type B TAD. OBJECTIVES To assess the effects of first-line beta-blockers compared with other first-line antihypertensive drug classes for treating chronic type B TAD. SEARCH METHODS We searched the Database of Abstracts of Reviews of Effects (DARE) for related reviews. We searched the Hypertension Group Specialised Register (1946 to 26 January 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 1), MEDLINE (1946 to 24 January 2014), MEDLINE In-Process, EMBASE (1974 to 24 January 2014) and ClinicalTrials.gov (to 26 January 2014). SELECTION CRITERIA We considered randomized controlled trials (RCTs) comparing different antihypertensive medications in the treatment of chronic type B TAD to be eligible for inclusion. Total mortality rate was the primary outcome of this review. Secondary outcomes included total non-fatal adverse events relating to TADs and number of people not requiring surgical treatment. DATA COLLECTION AND ANALYSIS Two review authors (KC, PL) independently reviewed titles and abstracts and decided on studies to include based on the inclusion criteria. We resolved discrepancies between the two review authors by discussion. MAIN RESULTS After a thorough review of the search results, we identified no studies that met the inclusion criteria. AUTHORS' CONCLUSIONS We did not find any RCTs that compared first-line beta-blockers with other first-line antihypertensive medications for the treatment of chronic type B TAD. Therefore, there is no RCT evidence to support the current guidelines recommending the use of beta-blockers. RCTs are required to assess the benefits and harms of beta-blockers and other antihypertensive medications as first-line treatment of chronic type B TAD.
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Affiliation(s)
- Kenneth K Chan
- University of British ColumbiaFaculty of MedicineVancouverBCCanada
| | - Peggy Lai
- Richmond HospitalLower Mainland Pharmacy Services7000 Westminster HighwayRichmondBCCanadaV6X 1A2
| | - James M Wright
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
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11
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Wheeler JB, Ikonomidis JS, Jones JA. Connective tissue disorders and cardiovascular complications: the indomitable role of transforming growth factor-beta signaling. Adv Exp Med Biol 2014; 802:107-27. [PMID: 24443024 PMCID: PMC4410689 DOI: 10.1007/978-94-007-7893-1_8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Marfan Syndrome (MFS) and Loeys-Dietz Syndrome (LDS) represent heritable connective tissue disorders that cosegregate with a similar pattern of cardiovascular defects (thoracic aortic aneurysm, mitral valve prolapse/regurgitation, and aortic root dilatation with regurgitation). This pattern of cardiovascular defects appears to be expressed along a spectrum of severity in many heritable connective tissue disorders and raises suspicion of a relationship between the normal development of connective tissues and the cardiovascular system. Given the evidence of increased transforming growth factor-beta (TGF-β) signaling in MFS and LDS, this signaling pathway may represent the common link in this relationship. To further explore this hypothetical link, this chapter will review the TGF-β signaling pathway, heritable connective tissue syndromes related to TGF-β receptor (TGFBR) mutations, and discuss the pathogenic contribution of TGF-β to these syndromes with a primary focus on the cardiovascular system.
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MESH Headings
- Adrenergic beta-Antagonists/therapeutic use
- Angiotensin II Type 1 Receptor Blockers/therapeutic use
- Antibodies, Neutralizing/pharmacology
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/genetics
- Aortic Aneurysm, Thoracic/pathology
- Aortic Aneurysm, Thoracic/surgery
- Aortic Valve/pathology
- Aortic Valve/surgery
- Bicuspid Aortic Valve Disease
- Gene Expression Regulation
- Heart Defects, Congenital/drug therapy
- Heart Defects, Congenital/genetics
- Heart Defects, Congenital/pathology
- Heart Defects, Congenital/surgery
- Heart Valve Diseases/drug therapy
- Heart Valve Diseases/genetics
- Heart Valve Diseases/pathology
- Heart Valve Diseases/surgery
- Humans
- Loeys-Dietz Syndrome/drug therapy
- Loeys-Dietz Syndrome/genetics
- Loeys-Dietz Syndrome/pathology
- Loeys-Dietz Syndrome/surgery
- Marfan Syndrome/drug therapy
- Marfan Syndrome/genetics
- Marfan Syndrome/pathology
- Marfan Syndrome/surgery
- Mutation
- Receptors, Transforming Growth Factor beta/genetics
- Signal Transduction/genetics
- Smad Proteins/genetics
- Transforming Growth Factor beta/antagonists & inhibitors
- Transforming Growth Factor beta/genetics
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Affiliation(s)
- Jason B. Wheeler
- Division of Cardiothoracic Surgery, Medical University of South Carolina
| | - John S. Ikonomidis
- Division of Cardiothoracic Surgery, Medical University of South Carolina
| | - Jeffrey A. Jones
- Division of Cardiothoracic Surgery, Medical University of South Carolina
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
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Abstract
A 45 year old executive presents to your office for risk assessment after learning that his sister required an ascending aortic aneurysm repair. He is a well-informed man, concerned about his personal risk for aortic disease, and undergoes a cardiac screen which reveals a dilated ascending aortic aneurysm, measuring a maximal diameter of 4.4 cm. His aortic valve is tricuspid. He is non-Marfanoid and asymptomatic. He realizes that he does not yet meet guideline criteria for aortic surgery, but he is also cognizant of the fact that he is approaching the cut-off for surgical intervention. He wishes to minimize his future risk of aortic rupture, dissection and aortic expansion and seeks your input. Should 'medical treatment' should be employed at this stage? Is there sufficient basis to initiate any form of pharmacotherapy? Would you start a beta-adrenergic receptor blocker, an angiotensin receptor blocker, a matrix metalloproteinase inhibitor (doxycycline), or a statin to reduce his aortic risk for rupture, dissection or need for surgical repair? Does your clinical decision match evidence from existing data? Our paper will address these issues among other questions relevant to the role of medical therapy for thoracic aortic disease.
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Affiliation(s)
- Andrew S Chun
- Yale University School of Medicine, New Haven, CT, USA
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13
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Stein LH, Berger J, Tranquilli M, Elefteraides JA. Effect of statin drugs on thoracic aortic aneurysms. Am J Cardiol 2013; 112:1240-5. [PMID: 24079445 DOI: 10.1016/j.amjcard.2013.05.081] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 05/31/2013] [Accepted: 05/31/2013] [Indexed: 11/15/2022]
Abstract
Pharmacologic interventions for thoracic aneurysms remain poorly characterized. The results of a pilot study by our group suggested improved outcomes among patients with thoracic aortic aneurysm who were taking statins. In the present study, we undertook a comprehensive analysis of a larger cohort of patients from the Database of the Aortic Institute at Yale-New Haven Hospital. A total of 1,560 patients met the inclusion criteria. The adverse events (i.e., death, dissection, or rupture) and surgery rates for patients with (n = 369, 24%) and without (n = 1,191, 76%) statin therapy were compared. We evaluated 3 anatomic components of the aorta: root, ascending and arch, and descending and thoracoabdominal aortic aneurysms. A smaller proportion of the statin group had adverse events: overall, 7% versus 15%; ascending and arch, 6% versus 15%; and descending and thoracoabdominal aortic aneurysms, 8% versus 20%. Also, a smaller proportion of statin patients required surgery: overall, 48% versus 60%; ascending and arch, 51% versus 62%; and descending and thoracoabdominal aortic aneurysms, 36% versus 59% (p <0.001 to 0.01). The protective effect of statins was seen in all segments, except the aortic root. Log-rank evaluation of the interval to an adverse event or surgery was longer among statin-treated patients (p <0.001). Logistic regression analysis found statin use, angiotensin receptor blocker use, and chronic obstructive pulmonary disease were associated with decreased adverse events, and statin use, angiotensin receptor blocker use, β-blocker therapy, and age were associated with a decreased odds of requiring surgery. Multiple logistic regression analysis found only statins were associated with a decreased odds of an adverse event and that statins, coronary artery disease, and chronic obstructive pulmonary disease were associated with a decreased odds of undergoing surgery. In conclusion, these findings provide a medicinal option for the arsenal of treatment options for patients with aneurysms of the thoracic aorta.
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Affiliation(s)
- Louis H Stein
- Aortic Institute, Yale-New Haven Hospital, New Haven, Connecticut
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14
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Abstract
Heritable connective tissue diseases comprise a heterogeneous group of multisystemic disorders that are characterized by significant morbidity and mortality. These disorders do not merely result from defects in the amount or structure of one of the components of the extracellular matrix, as the extracellular matrix also serves other functions, including sequestration of cytokines, such as transforming growth factor beta (TGFβ). Indeed, disturbed TGFβ signaling was demonstrated in several heritable connective tissue diseases, including syndromic forms such as Marfan or Loeys-Dietz syndrome and non-syndromic presentations of thoracic aortic aneurysm/dissection. Because of these findings, new therapeutic targets have been unveiled, leading to the initiation of large clinical trials with angiotensin II type 1 receptor antagonists that also have an inhibiting effect on TGFβ signaling. Here, we present an overview of the clinical characteristics, the molecular findings, and the therapeutic strategies for the currently known syndromic and non-syndromic forms of thoracic aortic aneurysm/dissection.
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Affiliation(s)
- Lut Van Laer
- Center for Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Prins Boudewijnlaan 43, 2650 Antwerp, Edegem Belgium
| | - Dorien Proost
- Center for Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Prins Boudewijnlaan 43, 2650 Antwerp, Edegem Belgium
| | - Bart L. Loeys
- Center for Medical Genetics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Prins Boudewijnlaan 43, 2650 Antwerp, Edegem Belgium
- Department of Human Genetics, Nijmegen Centre for Molecular Life Sciences and Institute for Genetic and Metabolic Disorders, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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15
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Lacro RV, Guey LT, Dietz HC, Pearson GD, Yetman AT, Gelb BD, Loeys BL, Benson DW, Bradley TJ, De Backer J, Forbus GA, Klein GL, Lai WW, Levine JC, Lewin MB, Markham LW, Paridon SM, Pierpont ME, Radojewski E, Selamet Tierney ES, Sharkey AM, Wechsler SB, Mahony L. Characteristics of children and young adults with Marfan syndrome and aortic root dilation in a randomized trial comparing atenolol and losartan therapy. Am Heart J 2013; 165:828-835.e3. [PMID: 23622922 DOI: 10.1016/j.ahj.2013.02.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 02/18/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Pediatric Heart Network designed a clinical trial to compare aortic root growth and other short-term cardiovascular outcomes in children and young adults with Marfan syndrome randomized to receive atenolol or losartan. We report here the characteristics of the screened population and enrolled subjects. METHODS AND RESULTS Between 2007 and 2011, 21 clinical sites randomized 608 subjects, aged 6 months to 25 years who met the original Ghent criteria and had a body surface area-adjusted aortic root diameter z-score >3.0. The mean age at study entry was 11.2 years, 60% were male, and 25% were older teenagers and young adults. The median aortic root diameter z-score was 4.0. Aortic root diameter z-score did not vary with age. Mitral valve prolapse and mitral regurgitation were more common in females. Among those with a positive family history, 56% had a family member with aortic surgery, and 32% had a family member with a history of aortic dissection. CONCLUSIONS Baseline demographic, clinical, and anthropometric characteristics of the randomized cohort are representative of patients in this population with moderate to severe aortic root dilation. The high percentage of young subjects with relatives who have had aortic dissection or surgery illustrates the need for more definitive therapy; we expect that the results of the study and the wealth of systematic data collected will make an important contribution to the management of individuals with Marfan syndrome.
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16
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Nakayama Y, Yamaki F, Matsumura Y. Endovascular aneurysm repair of saccular descending thoracic pseudoaneurysm possibly associated with tuberculosis. Gen Thorac Cardiovasc Surg 2012; 60:501-3. [PMID: 22700454 DOI: 10.1007/s11748-012-0038-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 09/05/2011] [Indexed: 11/26/2022]
Abstract
In 2010, an 84-year-old man underwent thoracic endovascular aneurysm repair (TEVAR) for the saccular descending thoracic pseudoaneurysm (DTAA), which was adherent to the pulmonary lobe and thoracic vertebrae. Past medical history comprised twice anti-tuberculous medications for pulmonary tuberculosis and tuberculous vertebral osteomyelitis. The dilated aorta was detected at the time of medication for tuberculous vertebral osteomyelitis 24 years ago. However, he was not indicated for the operation, and he was lost to follow-up until now. The association of tuberculosis bacilli was suspected through clinical course as an origin of DTAA, although the histopathological examination was not performed because of invasion. TEVAR was performed considering: (1) no preoperative ongoing inflammation, (2) no evidence of tuberculosis recurrence, and (3) risk factors, such as pulmonary impairments and high age. Several months have been passed since the operation, and the patient remains well without perioperative anti-tuberculous medications.
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MESH Headings
- Aged, 80 and over
- Aneurysm, False/diagnosis
- Aneurysm, False/drug therapy
- Aneurysm, False/microbiology
- Aneurysm, False/surgery
- Aneurysm, Infected/diagnosis
- Aneurysm, Infected/drug therapy
- Aneurysm, Infected/microbiology
- Aneurysm, Infected/surgery
- Antitubercular Agents/therapeutic use
- Aortic Aneurysm, Thoracic/diagnosis
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/microbiology
- Aortic Aneurysm, Thoracic/surgery
- Aortography/methods
- Blood Vessel Prosthesis Implantation
- Endovascular Procedures
- Humans
- Male
- Tomography, X-Ray Computed
- Treatment Outcome
- Tuberculosis, Cardiovascular/diagnosis
- Tuberculosis, Cardiovascular/drug therapy
- Tuberculosis, Cardiovascular/microbiology
- Tuberculosis, Cardiovascular/surgery
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Affiliation(s)
- Yuki Nakayama
- Department of Cardiovascular Surgery, Nagano Chuo Hospital, Nishitsuruga, Nagano, Nagano, Japan.
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17
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Rodríguez-Caulo EA, Velázquez CJ, García-Borbolla M, Barquero JM. Mega-aorta syndrome development in giant cell arteritis. A same entity? Ann Vasc Surg 2012; 25:1141.e1-3. [PMID: 22023949 DOI: 10.1016/j.avsg.2011.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 06/22/2011] [Accepted: 07/03/2011] [Indexed: 11/30/2022]
Abstract
Giant cell arteritis (GCA) is the most common form of large vessel arteritis. GCA typically involves the branches of the external carotid artery, but is the leading cause of inflammatory aortitis. However, involvement of the aorta often goes undetected. We present a case of an 81-year-old man, with headache and intense chest pain, who was previously given a diagnosis of GCA with a temporal artery biopsy 6 years ago. Owing to the suspicion of acute aortic syndrome, an emergent computed tomography (CT) was performed. CT showed the development of mega-aorta syndrome, with a diameter of 75.2 mm in the ascending aorta, 61.8 mm in the aortic arch, 76.1 mm in the descending thoracic aorta, and 45.1 mm in the abdominal aorta, presenting a chronic type B aortic dissection. Although there are reported cases secondary to Takayasu arteritis, this is the first case reported in the literature of mega-aorta syndrome associated with GCA in a patient previously diagnosed using temporal artery biopsy.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Aged, 80 and over
- Aortic Dissection/diagnosis
- Aortic Dissection/drug therapy
- Aortic Dissection/etiology
- Aortic Dissection/pathology
- Aorta, Abdominal/diagnostic imaging
- Aorta, Abdominal/pathology
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/pathology
- Aortic Aneurysm, Abdominal/diagnosis
- Aortic Aneurysm, Abdominal/drug therapy
- Aortic Aneurysm, Abdominal/etiology
- Aortic Aneurysm, Abdominal/pathology
- Aortic Aneurysm, Thoracic/diagnosis
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/etiology
- Aortic Aneurysm, Thoracic/pathology
- Aortography/methods
- Biopsy
- Chronic Disease
- Giant Cell Arteritis/complications
- Giant Cell Arteritis/diagnosis
- Giant Cell Arteritis/drug therapy
- Giant Cell Arteritis/pathology
- Humans
- Male
- Temporal Arteries/pathology
- Tomography, X-Ray Computed
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18
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Wang Y, Zhang J, Yin MD, Wang SY, Duan ZQ, Xin SJ. Endovascular repair of a tuberculous aneurysm of descending thoracic aorta. Chin Med J (Engl) 2011; 124:2228-2230. [PMID: 21933632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Tuberculous aortic aneurysm (TBAA) is an extremely rare clinical event with life-threatening implication. Management for this condition is challenging and its therapeutic option has not been yet established. A few recent reports described endovascular repair rather than open surgery as the method for treatment. Although this remains controversial, endovascular exclusion has been gaining acceptance for some surgeons. We present a case of TBAA who was treated by endovascular stent grafting for a descending thoracic aortic aneurysm with simultaneous anti-tuberculous medication. The outcome was favorable.
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Affiliation(s)
- Yong Wang
- Department of Vascular Surgery, First Hospital of China Medical University, Shenyang, Liaoning 110001, China
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19
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Klitfod L, Baekgaard N, Just S, Skøtt P, Jensen LP. [Modern treatment of type B dissections]. Ugeskr Laeger 2008; 170:2858-2863. [PMID: 18796278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Rapid classification is essential in the management of aortic dissections, as Type A dissections require surgery, while the optimal treatment of Type B dissections is controversial. Medical treatment with antihypertensive medication and analgesics has so far been the main treatment of uncomplicated Type B dissections, while surgery has been reserved for complications and persistent pain in spite of medical treatment. Endovascular techniques are less invasive than open repair and show promising early results.
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Affiliation(s)
- Lotte Klitfod
- Karkirurgisk Afdeling B, Gentofte Hospital, DK-2900 Hellerup.
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20
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Xiong W, Knispel RA, Dietz HC, Ramirez F, Baxter BT. Doxycycline delays aneurysm rupture in a mouse model of Marfan syndrome. J Vasc Surg 2008; 47:166-72; discussion 172. [PMID: 18178469 DOI: 10.1016/j.jvs.2007.09.016] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 09/06/2007] [Accepted: 09/07/2007] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Thoracic aneurysms are the main cardiovascular complication of Marfan syndrome (MFS) resulting in premature death. MFS has been associated with mutations of the gene encoding fibrillin-1 (FBN1), a major constituent of the elastic fibers. Matrix metalloproteinases (MMPs) are important in the pathogenesis of abdominal aortic aneurysms but their precise role in MFS is not clear. Doxycycline is a nonspecific MMP inhibitor. The objective of the study was to determine whether docycycline can attenuate matrix degradation and prolong the survival of mice with MFS. METHODS The study employed a well-characterized animal model of MFS, namely fibrillin-1 under-expressing mice (mgR/mgR mice) that die spontaneously from rupture of the thoracic aorta between 2 to 4 months of age. Mutant and wild type mice were given doxycycline in their drinking water at a concentration designed to provide 100 mg/kg/day beginning at postnatal day (PD) 1, whereas control mice were given water. Treated mice were divided into two groups. One group of animals was followed until death or for 7 months to determine lifespan. In the second group of mice, the ascending thoracic aortas were collected for histological analysis (H&E staining, trichrome staining) and zymography for examining MMP-2 and MMP-9 levels at 6 weeks. RESULTS MMP-2 and MMP-9 levels were higher in the thoracic aorta of mgR/mgR mice compared with wild type littermates. Doxycycline-treated mgR/mgR mice lived 132 +/- 14.6 days (n = 16) or significantly longer than untreated mutant mice (79 +/- 6.7 days, n = 30) (P < 0.01). Connective tissue staining showed that doxycycline treatment decreased elastic fiber degradation in mgR/mgR mice. Furthermore, mgR/mgR mice treated with doxycycline had lower MMP-2 and MMP-9 levels compared with untreated mgR/mgR mice. CONCLUSIONS This study demonstrates that doxycycline significantly delays aneurysm rupture in MFS-like mice by inhibiting expression of tissue MMP-2 and MMP-9 and thus, degradation of the elastic matrix. The results suggest that MMPs contribute to the progression of thoracic aneurysm in MFS and that doxycycline has the potential to significantly alter the course of the disease.
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MESH Headings
- Animals
- Aorta, Thoracic/drug effects
- Aorta, Thoracic/enzymology
- Aorta, Thoracic/pathology
- Aortic Aneurysm, Thoracic/complications
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/enzymology
- Aortic Aneurysm, Thoracic/etiology
- Aortic Aneurysm, Thoracic/pathology
- Aortic Rupture/enzymology
- Aortic Rupture/etiology
- Aortic Rupture/pathology
- Aortic Rupture/prevention & control
- Disease Models, Animal
- Disease Progression
- Doxycycline/pharmacology
- Doxycycline/therapeutic use
- Elastic Tissue/metabolism
- Fibrillin-1
- Fibrillins
- Marfan Syndrome/complications
- Marfan Syndrome/drug therapy
- Marfan Syndrome/enzymology
- Marfan Syndrome/pathology
- Matrix Metalloproteinase 2/metabolism
- Matrix Metalloproteinase 9/metabolism
- Matrix Metalloproteinase Inhibitors
- Mice
- Mice, Inbred C57BL
- Mice, Mutant Strains
- Microfilament Proteins/genetics
- Microfilament Proteins/metabolism
- Protease Inhibitors/pharmacology
- Protease Inhibitors/therapeutic use
- Time Factors
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Affiliation(s)
- Wanfen Xiong
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE 68198, USA
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21
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Kwok PCH. Combined endovascular and open treatment for infected pseudoaneurysm of the thoracic aortic arch. Vasc Endovascular Surg 2007; 41:456-9. [PMID: 17942863 DOI: 10.1177/1538574407302851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Infected pseudoaneurysm of the aortic arch is a rare but life-threatening condition. The conventional treatment involves cardiopulmonary bypass, prolonged vascular clamping, and an extensive bypass procedure. We report a case of infected pseudoaneurysm involving the aortic arch. The patient underwent debranching of the supra-aortic arteries and bypass surgery, followed by stent grafting the next day. The patient had good recovery, and the 1-year follow-up computed tomography scan showed resolution of the infected pseudoaneurysm.
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MESH Headings
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/drug therapy
- Aneurysm, False/surgery
- Aneurysm, False/therapy
- Aneurysm, Infected/diagnostic imaging
- Aneurysm, Infected/drug therapy
- Aneurysm, Infected/surgery
- Aneurysm, Infected/therapy
- Anti-Bacterial Agents/therapeutic use
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/surgery
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/surgery
- Aortic Aneurysm, Thoracic/therapy
- Aortography/methods
- Blood Vessel Prosthesis
- Blood Vessel Prosthesis Implantation/instrumentation
- Catheterization, Peripheral/instrumentation
- Combined Modality Therapy
- Female
- Humans
- Middle Aged
- Ofloxacin/therapeutic use
- Stents
- Tomography, X-Ray Computed
- Treatment Outcome
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22
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Tefera G, Acher CW, Hoch JR, Mell M, Turnipseed WD. Effectiveness of intensive medical therapy in type B aortic dissection: A single-center experience. J Vasc Surg 2007; 45:1114-8; discussion 1118-9. [PMID: 17543672 DOI: 10.1016/j.jvs.2007.01.065] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Accepted: 01/31/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although the mainstay of managing acute descending thoracic aortic dissection (ADTAD) remains medical, certain patients will require emergency surgery for complications of rupture or ischemia. This study evaluates factors that affect outcome and determines which patients previously treated surgically would have been eligible for endovascular repair. METHODS A single-institution retrospective study was conducted of patients who presented with clinical signs of ADTAD that was confirmed by magnetic resonance angiography (MRA) or computed tomography (CT). All patients were admitted to the intensive care unit (ICU) and medically managed to maintain systolic blood pressure<120 mm Hg and heart rate<70 beats/min. Two treatment groups were identified: group 1 received medical treatment only; group 2 received medical treatment plus emergency surgery. Patient demographic and clinical data were correlated with 30-day group mortality and morbidity and need for emergency surgery. The MRA and CT scan images of group 2 were retrospectively reviewed to determine if currently available endovascular treatment could have been done. The Fisher exact test was used to compare between the groups, and P<.05 was considered significant. RESULTS Between 1991 and 2005, 83 patients (55 men) were treated for ADTAD. The mean age was 67 years (range, 38 to 85). Sixty-eight patients (82%) had hypertension, three (3.6%) had Marfan syndrome, and 51 (62%) were smokers. Twenty-five (32%) of the patients were receiving beta-blocker therapy before the onset of their symptoms. Back pain was the most common initial symptom (72.2%). Emergency surgery was required in 19 patients (23%): 12 for rupture or impending rupture, four for mesenteric ischemia, and three for lower extremity ischemia. The need for emergency surgery was significantly higher in smokers (P=.03), in patients>70 years old (P=.035), and in patients who were not receiving beta-blocker therapy before the onset of symptoms (P=.023). The combined overall morbidity rate was 33%, and the mortality rate was 9.6%. Morbidity in group 2 was 64% and significantly higher than the 23% in group 1 (P=.00227). The mortality rate was also higher in group 2 at 31.5% compared with group 1 at 1.6% (P=.0004). Factors affecting the overall mortality included age>70 years (P=.057), previous abdominal aortic aneurysm repair (P=.018), tobacco use (P=.039), and the presence of leg pain at initial presentation (P=.013). As determined from the review of radiologic data, 11 of 13 patients with scans available for review in group 2 could have been treated with currently available endovascular grafts. CONCLUSIONS Intensive medical therapies are effective in preventing early mortality associated with ADTAD. Predictably, the need for emergency surgery carries a high morbidity and mortality rate. Most patients in this series requiring emergency surgery could have been candidates for endovascular therapy had it been available.
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Affiliation(s)
- Girma Tefera
- University of Wisconsin School of Medicine and Public Health, Madison 53792, USA.
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23
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Kajimoto M, Shimono T, Hirano K, Miyake Y, Sawada Y, Kato N, Hirata H, Imanaka-Yoshida K, Nishikawa M, Yoshida T, Shimpo H, Horiuchi T, Miyamoto K. Development of a new method for endovascular aortic repair: combination therapy of cell transplantation and stent grafts with a drug delivery system. Circulation 2006; 114:I378-83. [PMID: 16820604 DOI: 10.1161/circulationaha.105.001016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endovascular aortic repair by stent grafts (S/Gs) has been developed as a less invasive treatment for aortic aneurysms. However, some aneurysmal cavities can remain without organization, causing re-expansion. We demonstrated previously that transplantation of a cell combination (myoblasts and fibroblasts) promoted thrombus organization in a rat model. We also developed basic fibroblast growth factor (bFGF) slow-delivery S/Gs coated with elastin and impregnated with bFGF. Here, we evaluated the effects of cell transplantation combined with bFGF slow release on canine thoracic aortic aneurysmal sacs after S/Gs repair. METHODS AND RESULTS Thoracic aortic aneurysms were surgically created with jugular vein patches in 15 beagles. Myoblasts and fibroblasts of autologous skeletal muscle were isolated and cultured for cell transplantation. The S/Gs had 6 holes and produced endoleaks in the excluded cavities. Collagen gel (gel group, n=5) or a mixture of skeletal myoblasts and fibroblasts with collagen gel (cell group, n=5) were injected into the aneurysmal sacs excluded by the S/Gs. We also studied the effects of combined therapy of bFGF slow-release S/Gs and cell transplantation (hybrid group, n=5). After 14 days, histological analyses revealed that the excluded aneurysmal cavities of the gel group were filled with fresh thrombus, whereas the excluded cavities in the cell-transplanted groups were occupied by organized tissue. The percentages of the organized areas relative to the excluded cavities, evaluated by Masson's trichrome staining, were 18.1+/-4.0%, 52.6+/-4.0%, and 77.1+/-6.9% in the gel, cell, and hybrid groups, respectively. Collagen fibers had already appeared, and increased numbers of alpha-smooth muscle actin-positive cells were observed in the hybrid group. CONCLUSIONS Cell transplantation accelerated thrombus organization. Moreover, slow release of bFGF enhanced the effects of cell transplantation. Cell transplantation into unorganized spaces may improve the outcomes of endovascular treatments of aortic aneurysms.
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Affiliation(s)
- Masaki Kajimoto
- Department of Thoracic and Cardiovascular Surgery, Mie University, Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie 514-8507, Japan
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24
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Estrera AL, Miller CC, Safi HJ, Goodrick JS, Keyhani A, Porat EE, Achouh PE, Meada R, Azizzadeh A, Dhareshwar J, Allaham A. Outcomes of Medical Management of Acute Type B Aortic Dissection. Circulation 2006; 114:I384-9. [PMID: 16820605 DOI: 10.1161/circulationaha.105.001479] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Currently, the optimal treatment of acute type B aortic dissection remains controversial. The purpose of this study was to report early clinical outcomes of medical management for acute type B aortic dissection. METHODS AND RESULTS Between January 2001 and March 2005, 129 consecutive patients with the confirmed diagnosis of acute type B aortic dissection were studied. Mean age was 61 years (range, 29 to 94), with 33.3% (43/129) female. Acute type B aortic dissection protocol was instituted with the intent to manage all patients medically. Indications for surgical intervention included rupture, aortic expansion, malperfusion, and intractable pain. All patients were followed-up after discharge. Hospital mortality was 10.1% (13/129), 19% (4/21) when vascular intervention was required, and 8.3% (9/108) when medical management was maintained. Early intervention was required in 21 cases (16.2%), 19 (14.7%) open vascular/aortic cases and 2 cases (1.6%) of percutaneous aortic interventions. Morbidity included rupture (4.7%), stroke (4.7%), paraplegia (8.5%), bowel ischemia (7%), acute renal failure (21%), dialysis requirement (13%), and peripheral ischemia (4.7%). Late vascular-related procedures were performed in 5.2% (6/116) of cases. Univariate risk factors for early mortality were rupture (P<0.0001), need for laparotomy (P<0.008), acute renal failure (P<0.0001), need for dialysis (P<0.0001), and lower extremity ischemia (P<0.0004). The only independent risk factors for hospital mortality by multiple logistic regression was rupture (P<0.0009), and independent risk factors for midterm death were history of chronic obstructive pulmonary disease (P<0.002) and low glomerular filtration rate (<57 mL/min; P<0.0001). CONCLUSIONS Medical management for acute type B aortic dissection is associated acceptable outcomes. Outcomes of other management strategies, eg, endovascular stenting, for acute type B aortic dissection need to be compared with these results.
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Affiliation(s)
- Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas-Houston Medical School, Memorial Hermann Heart and Vascular Institute, 6410 Fannin St, Suite 450, Houston, Texas 77030, USA.
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25
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Villavicencio MA, Orszulak TA, Sundt TM, Daly RC, Dearani JA, McGregor CGA, Mullany CJ, Puga FJ, Zehr KJ, Schaff HV. Thoracic Aorta False Aneurysm: What Surgical Strategy Should Be Recommended? Ann Thorac Surg 2006; 82:81-9; discussion 89. [PMID: 16798195 DOI: 10.1016/j.athoracsur.2006.02.081] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2005] [Revised: 02/18/2006] [Accepted: 02/27/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thoracic aorta false aneurysms (TAFA) are a surgical challenge. The best technical approach remains uncertain. METHODS Between 1981 and 2004, 57 patients underwent operation for TAFA (mean age 57 +/- 18 years; 43 [75%] were male). Symptoms included dyspnea 25 (44%), chest pain 22 (39%), and fever 18 (32%). Twelve (21%) were asymptomatic. Thirty-seven (65%) had undergone previous operation with a mean interval between operations of 80 +/- 90 months. Fifteen (26%) had a mycotic etiology. The TAFA involved the aortic root in 10 (18%), ascending aorta in 28 (49%), arch in 6 (11%), and descending aorta in 13 (32%). Twenty-one (37%) required femorofemoral cannulation and 28 (49%), circulatory arrest. Surgical techniques included graft replacement in 27 (47%), composite root in 10 (18%), patch repair in 10 (18%), and direct suture in 10 (18%). RESULTS Operative mortality was 7% (4 patients). Four of 32 (13%) had massive hemorrhage during redo sternotomy, and all of these had planned extramediastinal cannulation (all survived). Follow-up was 100% for 349 patient-years. Actuarial survival was 77% +/- 6%, 63% +/- 8%, and freedom from recurrent TAFA was 87% +/- 5% and 83% +/- 7%, at 5 and 10 years, respectively. Univariate analysis identified TAFA greater than 55 mm, urgent operation, and NewYork Heart Association functional class III or IV as predictors of hemorrhage during redo sternotomy. Obesity and ejection fraction of 35% or less were predictors of operative death. CONCLUSIONS Thoracic aorta false aneurysm symptoms may be minimal, and consequently a high degree of suspicion plus serial imaging is warranted. Extramediastinal cannulation, deep hypothermia, and circulatory arrest are required for large mediastinal TAFA. Despite serious risks, TAFA correction is possible with good long-term results.
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MESH Headings
- Adult
- Aged
- Aneurysm, False/mortality
- Aneurysm, False/pathology
- Aneurysm, False/surgery
- Aneurysm, Infected/drug therapy
- Aneurysm, Infected/mortality
- Aneurysm, Infected/pathology
- Aneurysm, Infected/surgery
- Anti-Bacterial Agents/therapeutic use
- Aorta, Thoracic/pathology
- Aorta, Thoracic/surgery
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/pathology
- Aortic Aneurysm, Thoracic/surgery
- Aortic Diseases/mortality
- Aortic Diseases/pathology
- Aortic Diseases/surgery
- Blood Loss, Surgical
- Blood Vessel Prosthesis
- Combined Modality Therapy
- Comorbidity
- Emergencies
- Female
- Humans
- Life Tables
- Male
- Middle Aged
- Postoperative Complications/mortality
- Postoperative Complications/pathology
- Postoperative Complications/surgery
- Recurrence
- Retrospective Studies
- Risk Factors
- Sternum/surgery
- Survival Analysis
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Abstract
PURPOSE To evaluate the feasibility and effectiveness of endovascular stent-graft repair of infected aortic and arterial aneurysms. METHODS Eight patients (5 men; mean age 56.6 years, range 30-85) with infected saccular aneurysms in the brachiocephalic artery (n=1), proximal descending thoracic aorta (n=1), infrarenal abdominal aorta (n=3), common iliac artery (n=1), and common femoral artery (n=2) were treated with stent-graft placement and intravenous antibiotic treatment for at least 6 weeks followed by case-specific administration of oral suppressive antibiotics. All patients were considered to be in the high-surgical-risk group. RESULTS Exclusion of the infected aneurysm was successful in all patients. However, 2 patients died within 30 days of uncontrolled sepsis, and 1 patient died at 6 months after rupture of a persistently infected aneurysm (37% mortality rate). Over a follow-up that ranged to 8 years, the 5 survivors showed complete resolution of the infected aneurysms; no stent-graft infection was observed during follow-up. CONCLUSION The acceptable technical and clinical success of endovascular aneurysm repair makes this a promising treatment for infected aortic and arterial aneurysms. However, it is crucial that the infection is treated adequately prior to stent-graft placement.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Aneurysm, Infected/drug therapy
- Aneurysm, Infected/mortality
- Aneurysm, Infected/surgery
- Angioplasty
- Anti-Bacterial Agents/therapeutic use
- Antibiotic Prophylaxis
- Aortic Aneurysm, Abdominal/drug therapy
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/surgery
- Blood Vessel Prosthesis Implantation
- Feasibility Studies
- Female
- Follow-Up Studies
- Humans
- Iliac Aneurysm/drug therapy
- Iliac Aneurysm/mortality
- Iliac Aneurysm/surgery
- Male
- Middle Aged
- Retrospective Studies
- Stents
- Treatment Outcome
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Affiliation(s)
- Kwang-Hun Lee
- Department of Radiology and Research Institute of Radiological Science, Seoul, Republic of Korea
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27
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Mossop PJ, McLachlan CS, Amukotuwa SA, Nixon IK. Staged endovascular treatment for complicated type B aortic dissection. ACTA ACUST UNITED AC 2006; 2:316-21; quiz 322. [PMID: 16265536 DOI: 10.1038/ncpcardio0224] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2005] [Accepted: 04/27/2005] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Peter J Mossop
- Department of Cardiology, St Vincent's Hospital, Melbourne, Australia.
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28
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Honing MLH, Bredie SJH, Smulders YM. [Aortic involvement in patients with temporal arteritis and polymyalgia rheumatica]. Ned Tijdschr Geneeskd 2005; 149:1947-53. [PMID: 16159035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
In 4 patients with temporal arteritis or polymyalgia rheumatica, women aged 60, 57, 83 and 73 years respectively, signs of aortic involvement were established. The first patient presented with signs of systemic inflammation without signs of temporal arteritis or aortitis. In the second, an acute symptomatic thoracoabdominal aneurysm developed. In the third, temporal arteritis was associated with chronic progressive dilatation ofthe thoracic aorta. The fourth developed signs of intermittent claudication of the extremities. The clinical manifestations in all patients were attributed to chronic inflammation of the aorta caused by giant cell arteritis. Aortic giant cell arteritis frequently accompanies temporal arteritis, but is rarely diagnosed. Up to 75% of patients with temporal arteritis may have some degree of aortic involvement. Thoracic aneurysms, complicated by rupture or dissection, are the most serious complications. Aortic disease associated with signs of systemic inflammation should trigger the suspicion of giant cell arteritis. Corticosteroids are the most important part of treatment. Three patients recovered following treatment; the first two received an endoprosthesis; in the woman aged 83 years, this was not technically possible; she died after 1.5 years.
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Affiliation(s)
- M L H Honing
- VU Medisch Centrum, De Boelelaan 1117, 1081 HV Amsterdam
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29
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Roy N, Azakiea A, Moon-Grady AJ, Blurton DJ, Karl TR. Mycotic Aneurysm of the Descending Thoracic Aorta in a 2-kg Neonate. Ann Thorac Surg 2005; 80:726-9. [PMID: 16039245 DOI: 10.1016/j.athoracsur.2004.01.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2003] [Revised: 01/13/2004] [Accepted: 01/28/2004] [Indexed: 11/28/2022]
Abstract
Umbilical artery catheterization is often performed in critically ill neonates. Infection and thromboembolic events are relatively frequent complications, but aneurysm formation is rare. We describe the case of a premature baby who developed a rapidly expanding aneurysm of the descending thoracic aorta, secondary to a highly placed infected umbilical catheter. The rapid progression under medical therapy prompted us to replace the thoracic aorta with an 8-mm polytetrafluoroethylene graft, using extracorporeal circulation and core cooling. The baby had an excellent recovery and was discharged home after a prolonged antibiotic course. He is being followed with repeated imaging studies for a small abdominal aneurysm. We describe a novel approach to this rare and complicated problem and provide a review of the literature on the subject.
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Affiliation(s)
- Nathalie Roy
- Division of Pediatric Cardiothoracic Surgery, Children's Hospital, University of California, San Francisco, California, USA
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30
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Davis DP, Grossman K, Kiggins DC, Vilke GM, Chan TC. The inadvertent administration of anticoagulants to ED patients ultimately diagnosed with thoracic aortic dissection. Am J Emerg Med 2005; 23:439-42. [PMID: 16032607 DOI: 10.1016/j.ajem.2004.10.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Aortic dissection (AD) may present similarly to acute coronary syndrome or pulmonary embolus; however, anticoagulation may be detrimental to patients with AD. METHODS Clinical data were abstracted from medical records of emergency department (ED) patients with nontraumatic AD. Patients administered with anticoagulants were compared with non-anticoagulated patients with regard to presenting symptoms, chest radiograph and electrocardiogram (ECG) findings, and outcome. RESULTS A total of 44 ED patients with nontraumatic AD was identified over a 4-year period; anticoagulants were administered to 9 (21%). Anticoagulated patients had a higher incidence of chest pain without back pain (78% vs 23%; P = .002) and ST elevations or depressions on ECG (89% vs 6%; P < .001) and were less likely to have a widened mediastinum on chest radiograph (0% vs 67%; P < .001). Two ED anticoagulated patients died, one required a second surgery for bleeding complications, and another suffered a stroke after reversal of anticoagulation. CONCLUSIONS There is a clinically significant incidence of anticoagulation administration to ED patients ultimately diagnosed with AD, especially in the presence of ambiguous ECG and radiographic findings.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, University of California, San Diego, CA 92103-8676, USA.
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31
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Nienaber CA, Zannetti S, Barbieri B, Kische S, Schareck W, Rehders TC. INvestigation of STEnt grafts in patients with type B Aortic Dissection: design of the INSTEAD trial--a prospective, multicenter, European randomized trial. Am Heart J 2005; 149:592-9. [PMID: 15990739 DOI: 10.1016/j.ahj.2004.05.060] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE This study describes the design of an ongoing randomized trial initiated to compare the 2-year outcome of uncomplicated type B aortic dissection when treated by endovascular implantation of a Medtronic Talent stent graft adjunctive to best medical treatment versus best medical treatment alone. METHODS Patients older than 18 years with type B aortic dissection as diagnosed by computed tomography or magnetic resonance angiography are randomized to either a thoracic aortic endoprosthesis and antihypertensive treatment, called "stent grafting," or a tailored antihypertensive treatment, called "medical treatment." Only patients in a clinically stable condition and without spontaneous thrombosis of the false lumen after 14 days of the index dissection are considered eligible for study inclusion. RESULTS Primary outcome measure is all-cause mortality. Secondary outcome variables include conversion to stent and/or surgery, induced thrombosis of the false lumen, cardiovascular morbidity, aortic expansion (>5 mm/y of maximum diameter including true and false lumina), quality of life, and length of intensive care unit and hospital stay. The study design calls for 136 patients to be randomized and monitored for 24 months. CONCLUSIONS The INSTEAD trial is the first randomized trial investigating the role of endoluminal treatment of uncomplicated type B aortic dissection. By the end of December 2004, 125 patients were randomized, accounting for 92% of the target. Final results of the INSTEAD trial should be available in 2006.
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Affiliation(s)
- Christoph A Nienaber
- Division of Cardiology and Internal Medicine Department, Rostock University, Germany.
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32
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Abstract
BACKGROUND Aortic aneurysms represent a serious and common condition. Current therapies are based on mechanical treatment. With increased knowledge of the biochemical mechanisms responsible for aneurysm expansion, it may be possible to prevent the growth of small aneurysms. METHODS A series of experiments performed in the investigator's laboratory during the past decade is outlined to show the evolution of our concepts of the processes underlying aneurysm formation and progression. RESULTS Our understanding of aortic aneurysms has changed dramatically. Once thought to represent a simple degenerative process, aneurysm tissue is highly active metabolically with ongoing synthesis and degradation of matrix proteins. Several members of a family of matrix-degrading enzymes play an important role in this process. These enzymes can be inhibited by the antibiotic doxycycline. CONCLUSIONS With a better understanding of aneurysm pathology, it may be possible in the future to inhibit the growth of small aortic aneurysms before they reach a size at which the risk of rupture is significant.
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Affiliation(s)
- B Timothy Baxter
- Department of Surgery, University of Nebraska Medical Center and Methodist Hospital, 8111 Dodge St., Suite 220, Omaha, NE 68114, USA.
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Akutsu K, Nejima J, Kiuchi K, Sasaki K, Ochi M, Tanaka K, Takano T. Effects of the patent false lumen on the long-term outcome of type B acute aortic dissection. Eur J Cardiothorac Surg 2004; 26:359-66. [PMID: 15296897 DOI: 10.1016/j.ejcts.2004.03.026] [Citation(s) in RCA: 154] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2004] [Revised: 03/12/2004] [Accepted: 03/16/2004] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To determine the most effective treatment, we performed a detailed comparative study of the clinical course of patients with type B aortic dissection with a patent or thrombosed false lumen who did not undergo surgery in the acute period. We examined the effect of patency of the false lumen on outcome. METHODS Computed tomography scans of 138 patients with type B acute aortic dissection were reviewed. Of 138 patients, 110 were medically treated and survived the acute period. We focused on the outcome of these 110 patients, 62 with medically treated thrombosed false lumen (thrombosed group) and 48 with medically treated patent false lumen (patent group). We investigated factors influencing outcome among the 110 patients. The follow-up period was up to 10 years after the onset of aortic dissection. The three study endpoints were death from any cause, dissection-related death (aortic rupture, perioperative death, or death due to organ ischemia), and a dissection-related event (aortic rupture or surgery). In the patent group, we investigated factors influencing long-term outcome. RESULTS Patency of the false lumen was an independent risk factor for dissection-related death (P = 0.038, hazard ratio=5.6, confidence interval=1.1-28) and for a dissection-related event (P = 0.000, hazard ratio=7.6, confidence interval=2.7-22) but not for death from any cause (P = 0.769, hazard ratio=1.2, confidence interval=0.45-2.91). In the patent group, location of the most dilated aortic segment at the distal arch was an independent risk factor for dissection-related death (P = 0.026, hazard ratio=13.6, confidence interval=1.4-135) and for a dissection-related event (P = 0.048, hazard ratio=2.6, confidence interval=1.0-6.9). CONCLUSIONS Patency of the false lumen is a strong independent prognostic factor for type B aortic dissection. Location of the most dilated aortic segment at the distal arch is a significant risk factor in the patients with a patent false lumen.
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Affiliation(s)
- Koichi Akutsu
- Intensive and Coronary Care Unit, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
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Abstract
STUDY DESIGN We report on a 54-year-old man with chronic lower back pain after recent streptococcus pneumoniae pulmonary infection, resulting in a mycotic aortic aneurysm and spondylodiscitis of the eighth vertebrae 6 months later. Successful surgical treatment and recurrence-free survival after 4 years are described. SUMMARY OF BACKGROUND DATA Osteomyelitis by Streptococcus pneumoniae of the spine combined with contained rupture of a mycotic aortic aneurysm into lung and spine has not been reported to date. Mycotic aneurysms with pulmonary fistulas are reported to carry a mortality rate of up to 100%. Few cases have been reported with different operative and conservative strategies. METHODS The mycotic aortic aneurysm was excised using extracorporeal circulation and replaced by a Dacron graft. The spondylitic section of the eighth thoracic vertebrae was radically resected, and a tricortical bone block from the iliac crest was inserted into the defect. To keep compartments separated, collagen sponges with antibiotic supplementation were used. A triple antibiotic therapy (Metronidazol 3 x 0.5 g/day, Cefotaxim 3 x 2 g/day, and Flucloxacillin 3 x 2 g/day) was prescribed for 6 weeks and changed to Clindamycin for 1 year thereafter. RESULTS The patient made a good recovery and is free of recurrence 4 years after surgery. CONCLUSIONS Lower back pain might be a projected pain. Particularly in older patients or in the presence of comorbidities resulting in an immunocompromised status, an aggressive workup may be indicated. Radical resection of inflammatory tissues, sparse use of implant material, and prolonged administration of antibiotics proved a successful strategy in this patient.
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MESH Headings
- Aneurysm, Infected/complications
- Aneurysm, Infected/drug therapy
- Aneurysm, Infected/microbiology
- Aneurysm, Infected/surgery
- Anti-Bacterial Agents/therapeutic use
- Aortic Aneurysm, Thoracic/complications
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/microbiology
- Aortic Aneurysm, Thoracic/surgery
- Blood Vessel Prosthesis Implantation
- Cefotaxime/therapeutic use
- Combined Modality Therapy
- Discitis/complications
- Discitis/drug therapy
- Discitis/surgery
- Fistula/diagnostic imaging
- Fistula/etiology
- Fistula/surgery
- Floxacillin/therapeutic use
- Humans
- Ischemia/etiology
- Lung Diseases/diagnostic imaging
- Lung Diseases/etiology
- Lung Diseases/surgery
- Male
- Metronidazole/therapeutic use
- Middle Aged
- Nervous System Diseases/etiology
- Osteomyelitis/drug therapy
- Osteomyelitis/etiology
- Osteomyelitis/microbiology
- Osteomyelitis/surgery
- Pneumococcal Infections/complications
- Pneumococcal Infections/drug therapy
- Pneumococcal Infections/surgery
- Pneumonia, Pneumococcal/complications
- Pneumonia, Pneumococcal/drug therapy
- Postoperative Complications/etiology
- Respiratory Tract Fistula/diagnostic imaging
- Respiratory Tract Fistula/etiology
- Respiratory Tract Fistula/surgery
- Spinal Cord/blood supply
- Spinal Diseases/diagnostic imaging
- Spinal Diseases/etiology
- Spinal Diseases/surgery
- Spondylitis/complications
- Spondylitis/drug therapy
- Spondylitis/surgery
- Streptococcus pneumoniae/isolation & purification
- Thoracic Vertebrae/microbiology
- Thoracic Vertebrae/surgery
- Tomography, X-Ray Computed
- Tracheal Diseases/diagnostic imaging
- Tracheal Diseases/etiology
- Treatment Outcome
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Affiliation(s)
- Carsten Englert
- Department of Trauma and Reconstructive Surgery, University of Regensburg Hospital, Regensburg, Germany.
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Shine TSJ, Greengrass RA, Feinglass NG. Use of Continuous Paravertebral Analgesia to Facilitate Neurologic Assessment and Enhance Recovery After Thoracoabdominal Aortic Aneurysm Repair. Anesth Analg 2004; 98:1640-1643. [PMID: 15155317 DOI: 10.1213/01.ane.0000117149.87018.f2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Neurologic assessment after thoracic aortic aneurysm repair is important for detecting and treating late onset paraplegia. Traditional methods of pain control, such as patient-controlled IV analgesia and epidural analgesia, may interfere with neurologic assessment. We present a case of a patient who received continuous thoracic paravertebral analgesia that provided excellent analgesia while preserving the ability to monitor neurologic function. IMPLICATIONS We provided postoperative continuous paravertebral analgesia in a patient after thoracoabdominal aneurysm repair requiring postoperative neurologic assessment. Paravertebral analgesia provides unilateral analgesia with fewer neurologic and hemodynamic side effects than central neuraxial blockade and should be considered for management of patients undergoing thoracic aortic aneurysm repair.
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Ejiri J, Inoue N, Tsukube T, Munezane T, Hino Y, Kobayashi S, Hirata KI, Kawashima S, Imajoh-Ohmi S, Hayashi Y, Yokozaki H, Okita Y, Yokoyama M. Oxidative stress in the pathogenesis of thoracic aortic aneurysm: protective role of statin and angiotensin II type 1 receptor blocker. Cardiovasc Res 2004; 59:988-96. [PMID: 14553839 DOI: 10.1016/s0008-6363(03)00523-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE The pathogenesis of thoracic aortic aneurysms (TAA) is still unclear. A recent investigation indicated that angiotensin II, a potent activator of NADH/NADPH oxidase, plays an important role in aneurysmal formation. We investigated the potential role of p22phox-based NADH/NADPH oxidase in the pathogenesis of TAA. METHODS Human thoracic aneurysmal (n=40) and non-aneurysmal (control, n=39) aortic sections were examined, and the localization of p22phox, an essential component of the oxidase, and its expressional differences were investigated by immunohistochemistry and Western blot. In situ reactive oxygen species (ROS) generation was examined by the dihydroethidium method, and the impact of medical treatment on p22phox expression was investigated by multiple regression analysis. RESULTS In situ production of ROS and the expression of p22phox increased markedly in TAA throughout the wall, and Western blot confirmed the enhanced expression of p22phox. The expression was more intense in the regions where monocytes/macrophages accumulated. In these inflammatory regions, numerous chymase-positive mast cells and angiotensin converting enzyme-positive macrophages were present. Their localization closely overlapped the in situ activity of matrix metalloproteinase and the expression of p22phox. Multiple regression analysis revealed that medical treatment with statin and angiotensin II type 1 receptor blocker (ARB) suppressed p22phox expression in TAA. CONCLUSION Our findings indicate the role of p22phox-based NADH/NADPH oxidase and the local renin-angiotensin system in the pathogenesis of TAA. Statin and ARB might have inhibitory effects on the formation of aneurysms via the suppression of NADH/NADPH oxidase.
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Affiliation(s)
- Junya Ejiri
- Division of Cardiovascular and Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, chuo-ku, Kobe 650-0017, Japan
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37
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Abstract
BACKGROUND This study reviewed the clinical outcomes of patients with an aortic aneurysm infected with Salmonella treated by a single centre over 6 years. METHODS Data were collected by a retrospective case-note review. RESULTS Between September 1995 and December 2001, 121 patients with non-typhoid Salmonella bacteraemia were treated, of whom 24 patients had an aortic aneurysm infected with Salmonella. Ten had a suprarenal and 14 an infrarenal aortic infection. The most common responsible pathogen was group C Salmonella (12 patients). All of the 20 patients who had combined medical and surgical therapy survived, whereas two of four who had medical therapy alone died. There were two late deaths during a mean follow-up of 23 (range 3-63) months. CONCLUSION The incidence of aortic infection in patients with non-typhoid Salmonella bacteraemia was high in Taiwan. Timely surgical intervention and prolonged intravenous antibiotic therapy resulted in excellent outcomes.
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MESH Headings
- Abdominal Pain/etiology
- Adult
- Aged
- Aged, 80 and over
- Ambulatory Care
- Aneurysm, Infected/drug therapy
- Aneurysm, Infected/surgery
- Aneurysm, Infected/therapy
- Aortic Aneurysm, Abdominal/drug therapy
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Abdominal/therapy
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/surgery
- Aortic Aneurysm, Thoracic/therapy
- Bacteremia/etiology
- Ceftriaxone/therapeutic use
- Cephalosporins/therapeutic use
- Combined Modality Therapy
- Drug Therapy, Combination/therapeutic use
- Female
- Fever/etiology
- Follow-Up Studies
- Hospitalization
- Humans
- Male
- Middle Aged
- Retrospective Studies
- Salmonella Infections/drug therapy
- Salmonella Infections/surgery
- Salmonella Infections/therapy
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Affiliation(s)
- R B Hsu
- Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan 100, Republic of China.
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Kawachi Y, Nakashima A, Kosuga T, Tomoeda H, Toshima Y, Nishimura Y. Comparative study of the natural history and operative outcome in patients 75 years and older with thoracic aortic aneurysm. Circ J 2003; 67:592-6. [PMID: 12845181 DOI: 10.1253/circj.67.592] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Surgery for thoracic aortic aneurysm (TAA) in patients 75 years and older is a high risk, but data for their natural history are not available. In the present study the subjects were 62 patients with TAA aged on average 78 years (range, 75-85 years) enrolled between August 1994 and December 2001: 20 operatively treated patients (OPE) and 42 medically managed patients (MED). All of them had been included in the indication for TAA surgery at the time of consultation. Hospital mortality rates and survival rates (Kaplan-Meier method) were compared among emergency OPE, elective OPE, and MED. There were 136 total patient-years of follow-up. Actuarial survival in MED (ie, the natural history) was 83% at 1 year after consultation and 41% at 3 years. Hospital mortality rates in emergency and elective OPE were 27% (3/11) and 0% (0/9), respectively (p=0.22), and the corresponding 3-year survival rates were 44% and 83% (p=0.019). Actuarial survival in elective OPE was higher than that in MED (p=0.022), but that of emergency OPE was similar to that for MED (p=0.17). Patients aged 75 years and older with TAA should undergo an elective operation if the aneurysm diameter is larger than 6 cm and if the patient is asymptomatic and in good anatomicosurgical, physical, and social condition.
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Affiliation(s)
- Yoshito Kawachi
- Department of Cardiovascular Surgery, Clinical Research Institute, National Kyushu Medical Center, Fukuoka, Japan.
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Sarac TP, Clifford C, Waters J, Clair DG, Ouriel K. Preoperative erythropoietin and blood conservation management for thoracoabdominal aneurysm repair in a Jehovah's Witness. J Vasc Surg 2003; 37:453-5. [PMID: 12563221 DOI: 10.1067/mva.2003.73] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Timur P Sarac
- Department of Vascular Surgery and Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Takeno M, Takagi S, Sakuragi S, Suzuki S, Tsutsumi Y, Nonogi H, Goto Y. Continuous milrinone infusion during preoperative anti-inflammatory therapy in inflammatory aortic aneurysm complicating severe congestive heart failure. Heart Vessels 2002; 17:42-4. [PMID: 12434201 DOI: 10.1007/s003800200041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a 48-year-old man with inflammatory aortic aneurysm in the ascending aorta complicating severe heart failure due to massive aortic regurgitation. Continuous intravenous milrinone infusion was highly effective in reducing pulmonary arterial pressure and improving subjective symptoms during preoperative anti-inflammatory corticosteroid therapy over 7 weeks without any adverse effects or tolerance. Bentall's operation with a valved conduit was successfully performed after complete stabilization of inflammatory markers, and then milrinone was tapered off uneventfully. We consider that continuous milrinone infusion may be suitable for patients with surgically correctable inflammatory cardiovascular diseases complicating severe heart failure in whom maintenance of optimal hemodynamics is necessary for several weeks during preoperative anti-inflammatory corticosteroid therapy.
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Affiliation(s)
- Masayoshi Takeno
- Division of Cardiology, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita 565-8565, Japan
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Fukuda N, Shimohakamada Y, Nakamori Y, Tominaga T, Shinohara K, Takahashi T, Oeda E, Sato Y. [Thoracic aortic aneurysm with chronic disseminated intravascular coagulation treated successfully with orally administered camostat mesilate, warfarin and aspirin]. Rinsho Ketsueki 2002; 43:199-203. [PMID: 11979753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
We describe a case of thoracic aortic aneurysm complicated by chronic disseminated intravascular coagulation (DIC). Initially the DIC was controlled successfully by administration of gabexate mesilate and dalteparin. However, because these drugs were given intravenously, the patient could not be discharged. Subsequently, the DIC was treated successfully by changing to orally administered camostat mesilate, warfarin and aspirin, which allowed the patient to leave hospital.
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Affiliation(s)
- Naofumi Fukuda
- Division of Hematology, Department of Medicine, Yamaguchi Prefecture Central Hospital
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Lin PH, Bush RL, Tong FC, Chaikof E, Martin LG, Lumsden AB. Intra-arterial thrombin injection of an ascending aortic pseudoaneurysm complicated by transient ischemic attack and rescued with systemic abciximab. J Vasc Surg 2001; 34:939-42. [PMID: 11700498 DOI: 10.1067/mva.2001.116968] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Thrombin injection as a means of inducing thrombus formation has recently received wide attention as an alternative treatment for pseudoaneurysm. We present a case of a 67-year-old man in whom a large mycotic pseudoaneurysm developed in the ascending aorta because of sternal osteomyelitis and mediastinitis after coronary artery bypass grafting. Transcatheter intra-arterial thrombin injection was performed, and it successfully induced pseudoaneurysm thrombosis. However, the procedure was complicated by a sudden transient ischemic attack caused by thrombus propagation into the cerebral circulation. Complete thrombus dissolution in the cerebral circulation with the resolution of neurologic symptoms was achieved by means of intravenous abciximab.
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Affiliation(s)
- P H Lin
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Ohara N, Miyata T, Sato O, Oshiro H, Shigematsu H. Aortic aneurysm in patients with autoimmune diseases treated with corticosteroids. INT ANGIOL 2000; 19:270-5. [PMID: 11201597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND Aortic aneurysm is a rare but life-threatening cardiovascular complication in patients with autoimmune disorders. The purpose of this study was to clarify the characteristic clinical features and the pathological mechanism of aneurysmal formation in those patients treated with corticosteroids. METHODS Among 429 patients operated on for abdominal aortic aneurysm during the past 10 years, six patients with autoimmune diseases treated with corticosteroids (one with progressive systemic sclerosis, one with rheumatoid arthritis and four with systemic lupus erythematosus) were reviewed retrospectively. Their data were compared with those of 391 patients with atherosclerotic aneurysms with no autoimmune disorders. The resected aneurysmal walls of the six patients were also compared histopathologically with those of the last six consecutive patients in the control group. RESULTS The average age of the patients with autoimmune disease was younger than that of the control group (53.8+/-16.6 vs 71.8+/-7.8 years; p<0.05). Patients with autoimmune disease had received long-term corticosteroid therapy for 15-32 years; mean 22.2+/-6.5 years. Pathological examination showed that the destructive change of the medial elastic lamina in the autoimmune disease group was wider than that in the controls. Most patients had no complications in the postoperative follow-up period (5.1+/-3.2 years), while one patient died of rupture of a dissecting aneurysm two years after operation. CONCLUSIONS Prolonged corticosteroid treatment probably plays a major role in the disintegration of connective tissue of the media, possibly together with primary aortic wall involvement and/or vasculitic damage in patients with autoimmune disorders, which can result in aortic aneurysmal enlargement.
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Affiliation(s)
- N Ohara
- Department of Surgery, Faculty of Medicine, The University of Tokyo, Japan.
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45
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Weytjens C, Bové T, Van Der Niepen P. Aortic dissection and Turner's syndrome. J Cardiovasc Surg (Torino) 2000; 41:295-7. [PMID: 10901539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Cardiovascular malformations, especially coarctation of the aorta and bicuspid aortic valve, are common in patients with Turner's syndrome. Only 46 patients with aortic dissection and/or rupture have been described. All patients had associated aortic dilation or aneurysm. In all cases except three, involvement of the ascending aorta was present, making surgery often imperative. We describe a rare case of a DeBakey type IIIb aortic dissection (without involvement of the proximal aorta) in a patient with Turner's syndrome mosaicism. The dissection occurred two weeks after a caesarean section because of eclampsia. No aortic dilation or other cardiovascular malformations were found. The distal extension and uncomplicated nature of the dissection indicated medical management. After fifteen months of follow-up, she is clinically doing well and repeated CT scan shows a stable dissection of the descending and abdominal aorta without dilation.
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MESH Headings
- Adult
- Aortic Dissection/diagnosis
- Aortic Dissection/drug therapy
- Aortic Dissection/etiology
- Angiography, Digital Subtraction
- Antihypertensive Agents/therapeutic use
- Aortic Aneurysm, Abdominal/diagnosis
- Aortic Aneurysm, Abdominal/drug therapy
- Aortic Aneurysm, Abdominal/etiology
- Aortic Aneurysm, Thoracic/diagnosis
- Aortic Aneurysm, Thoracic/drug therapy
- Aortic Aneurysm, Thoracic/etiology
- Drug Therapy, Combination
- Echocardiography, Transesophageal
- Female
- Humans
- Tomography, X-Ray Computed
- Turner Syndrome/complications
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Affiliation(s)
- C Weytjens
- Department of Internal Medicine, University Hospital, Vrije Universiteit Brussel, Belgium
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Boyle JR, McDermott E, Crowther M, Wills AD, Bell PR, Thompson MM. Doxycycline inhibits elastin degradation and reduces metalloproteinase activity in a model of aneurysmal disease. J Vasc Surg 1998; 27:354-61. [PMID: 9510291 DOI: 10.1016/s0741-5214(98)70367-2] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Abdominal aortic aneurysms are characterized by degradation of the extracellular matrix, with a reduction in the elastin concentration of the arterial media. These changes are mediated by increased levels of endogenous metalloproteinases (MMPs) within the aorta, which provide a potential therapeutic target for pharmacologic agents aimed at reducing the growth rate of small aneurysms. In this study, the ability of doxycycline--an MMP inhibitor--to reduce matrix degradation was assessed in a previously described model of aneurysmal disease that used a brief pulse of elastase to induce MMP production and elastin degradation in arterial organ cultures. METHODS Porcine aortic segments (n = 8) were preincubated in exogenous pancreatic elastase for 24 hours before culture in standard conditions for 13 days with both 1 and 10 mg/L doxycycline. Control segments were cultured both without doxycycline and without elastase. At the termination of culture, MMPs were extracted from the tissue and quantified by a combination of substrate gel enzymography and immunoblotting. The volume fractions of elastin and collagen were determined by stereologic analysis of sections stained with Miller's elastin and van Gieson's stain. RESULTS Stereologic analysis demonstrated a significant preservation of elastin in aorta treated with doxycycline 10 mg/L (p < 0.001) and demonstrated that this preservation was accompanied by a significant reduction in MMP-9 activity (p < 0.02). Immunoblotting for tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) showed no decreased production in the doxycycline-treated groups. CONCLUSIONS Therapeutic ranges of doxycycline significantly inhibited elastin degradation and MMP-9 production within aortic organ cultures. These data suggest that doxycycline may have a potential application in reducing the growth rates of small abdominal aortic aneurysms.
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Affiliation(s)
- J R Boyle
- Department of Surgery, Leicester University, United Kingdom
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Defraigne JO, Demoulin JC, Detry O, Bertrand O, Limet R. Successful management of acute aortic dissection in a heart transplant recipient. Acta Chir Belg 1997; 97:141-4. [PMID: 9224520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A case of type III aortic dissection which occurred fourteen months after heart transplantation is presented. Medical therapy was instituted to achieve controlled hypotension. The evolution was favorable and the patient could be discharged after one month. Hypertension and increased ejection fraction after transplantation could have been predisposing factors via an increase of the shear stress in the aorta.
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Affiliation(s)
- J O Defraigne
- University Hospital of Liège, Department of Cardiovascular Surgery, Belgium
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Abstract
HISTORY AND CLINICAL FINDINGS A 58-year-old man was admitted after he was found to have a huge aneurysm of the thoracic aorta. 38 months previously he had first experienced subacute pain in the right thorax. After this the aneurysm gradually increased in size. On admission a pulsating mass, 20 cm in diameter, was obvious, having broken through the right ventral thoracic wall. It was causing venous inflow congestion in the upper part of the body. The patient's general condition was poor: he had marked orthopnoea. INVESTIGATIONS Serological tests for syphilis gave the following results: VDRL test, 1:32; FTA-ABS test reactive; TPHA test, 1:8000; treponema-specific IgM negative. Computed tomography with contrast-medium injection exactly defined site and extent of the aneurysm. It started at the aortic root and extended to the aortic arch. Third-degree aortic valvar regurgitation was demonstrated on echocardiography. Pulmonary function tests indicated severe restrictive ventilatory abnormality with clearly reduced respiratory reserve. TREATMENT AND COURSE The symptoms improved after 2 weeks on oral medication of captopril (25 mg/d), furosemide (80 mg/d), spironolactone (100 mg/d), codeine phosphate (90 mg/d) and thick paraffin (20 mg/d as needed). The patient declined further treatment. He died 8 weeks later at home.
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Affiliation(s)
- C Rühlmann
- Medizinische Klinik und Poliklinik I, Zentrum für Radiologie der Universität Leipzig
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Rinaldi RG, Carballido J, Mojica J, Almodovar EA. The use of 25% glutaraldehyde solution to strengthen the aorta of patients with annuloaortic ectasia, ascending and aortic arch aneurysms. J Card Surg 1995; 10:262-3. [PMID: 7626877 DOI: 10.1111/j.1540-8191.1995.tb00607.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Aortic friability is a problem of great concern and frustration for those performing operations on patients with ascending and arch aortic aneurysms, and particularly, on patients with annuloaortic ectasia. We have used 25% glutaraldehyde to successfully strengthen the distal aorta of three such patients. After the application, the aorta wall held sutures without tearing. Postoperative bleeding was minimal in each case. No neurological events were noticed, and all of the patients were discharged home within 2 weeks. The application of this tanning solution to such a friable aortic tissue should be considered as a helpful alternative to reduce postoperative bleeding, which is the most common complication after this type of surgery.
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Affiliation(s)
- R G Rinaldi
- Cardiovascular Institute, Pavia Hospital, San Juan, Puerto Rico
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