Impact of d-Dimer Levels on Admission on Inhospital and Long-Term Outcome in Patients With Type A Acute Aortic Dissection

Limited studies with relatively small sample sizes have reported that elevated d-dimer levels on admission were associated with increased risk of short-term mortality in patients with type A acute aortic dissection (AAD). However, there were unavailable data regarding the impact of admission d-dimer levels on long-term outcomes. Our present study aimed to evaluate the association of admission d-dimer levels with both inhospital and long-term all-cause mortality in patients with type A AAD. A total of 212 consecutive patients with type A AAD were enrolled. d-Dimer levels were measured on admission, and patients were followed up prospectively. The primary end points were inhospital and long-term all-cause mortality. The median length of follow-up was 18.8 months (interquartile range 6.7 to 24.4 months). The inhospital and long-term all-cause mortality rates were 12.7% and 12.4%, respectively. Compared with the survivors, the nonsurvivors had significantly higher d-dimer levels (p <0.001). When divided into 4 groups according to admission d-dimer quartiles, patients in Q4 (>6.10 μg/ml) had the highest inhospital and long-term mortality among groups. After multivariate adjustment, the d-dimer level in Q4 (>6.10 μg/ml) was an independent risk factor for inhospital mortality (hazard ratio [HR] 6.12, 95% confidence interval 1.35 to 27.89, p = 0.019) in addition to surgical treatment; however, this was not an independent predictor for long-term mortality. In conclusion, our study with a relatively large sample size suggested that elevated admission d-dimer levels (>6.10 μg/ml) might be a predictor for increased risk of inhospital mortality, and urgent-emergent surgery might be needed in patients with elevated d-dimer levels on admission. However, d-dimer levels at admission failed to predict long-term mortality.

[Acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult - 2014 AS SMC Guidelines on the classification and diagnosis of aortic diseases]

In addition to organovascular arterial ischemic diseases (cardiovascular, vasculovascular, neurovascular, extre-mitovascular, renovascular, genitovascular, bronchopulmovascular, mesenteriovascular, osteoarthromusculovascular, dermovascular, oculovascular, otovascular, stomatovascular etc.), aortic diseases contribute to the wide spectrum of arterial diseases: aortic aneurysms (AA), acute aortic syndromes (AAS) including aortic dissection (AD), intramural haematoma (IMH), penetrating atherosclerotic ulcer (PAU) and traumatic aortic injury (TAI), pseudoaneurysm, aortic rupture, atherosclerosis, vasculitis as well as genetic diseases (e.g. Turner syndrome, Marfan syndrome, Ehlers-Danlos syndrome) and congenital abnormalities including the coarctation of the aorta (CoA). Similarly to other arterial diseases, aortic diseases may be diagnosed after a long period of subclinical development or they may have an acute presentation. Acute aortic syndrome is often the first sign of the disease, which needs rapid diagnosis and decisionmaking to reduce the extremely poor prognosis. Key clinical-etiology-anatomy-patophysiology (CEAP) diagnostic aspects of aortic diseases are discussed in this document (project Vessels).

Hybrid repair of aortic arch pathology

The objective was to evaluate a 13-year single-centre experience of arch endovascular aortic repair using the hybrid approach. Between 1999 and 2013, 491 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 179 (36.5%) patients (128 men; mean age 70.2 ± 10.8 years, range 27-84). A hybrid approach was performed for all Zone 0 and 1 procedures and in nearly half of Zone 2 procedures. Early and mid-term outcomes were reviewed retrospectively. Overall primary technical success (24 h) was achieved in 162 (90.5%) of the 179 cases; 2 deaths and 15 Type 1 endoleaks were observed. Clinical success at 30 days was achieved in 161 (89.9%) of the 179 patients, with a mortality rate of 4.5% (8/179). Short-term clinical success at 6 months was achieved in 169 (94.4%) of the 179 patients; the rates for the different landing zones did not differ significantly. At a mean follow-up of 27.3 ± 15.7 months (range 1-94), the mid-term clinical success was 165 (92.2%) of the 179 patients; the rates among the different proximal zones did not differ significantly. In selected patients, early and mid-term outcomes of arch endovascular aortic repair using the hybrid approach are promising; however, mortality and morbidity are not negligible. Our results may have practical implications for the ongoing evaluation of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.

Mortality impact of thoracic aortic disease in São Paulo state from 1998 to 2007

BACKGROUND

The epidemiological characteristics of thoracic aortic diseases (TAD) in the State of São Paulo and in Brazil, as well as their impact on the survival of these patients have yet to be analyzed.

OBJECTIVES

To evaluate the mortality impact of TAD and characterize it epidemiologically.

METHODS

Retrospective analysis of data from the public health system for the TAD registry codes of hospitalizations, procedures and deaths, from the International Code of Diseases (ICD-10), registered at the Ministry of Health of São Paulo State from January 1998 to December 2007.

RESULTS

They were 9.465 TAD deaths, 5.500 men (58.1%) and 3.965 women (41.9%); 6.721 dissections (71%) and 2.744. aneurysms. In 86.3% of cases the diagnosis was attained during autopsy. There were 6.109 hospitalizations, of which 67.9% were males; 21.2% of them died (69% men), with similar proportions of dissection and aneurysm between sexes, respectively 54% and 46%, but with different mortality. Men with TAD die more often than women (OR = 1.5). The age distribution for deaths and hospitalizations was similar with predominance in the 6th decade. They were 3.572 surgeries (58% of hospitalizations) with 20.3% mortality (patients kept in clinical treatment showed 22.6% mortality; p = 0.047). The number of hospitalizations, surgeries, deaths of in-patients and general deaths by TAD were progressively greater than the increase in population over time.

CONCLUSIONS

Specific actions for the early identification of these patients, as well as the viability of their care should be implemented to reduce the apparent progressive mortality from TAD seen among our population.

Prevalence of and risk factors for autopsy-determined atherosclerosis among US service members, 2001-2011

CONTEXT

Autopsies of US service members killed in the Korean and Vietnam wars demonstrated that atherosclerotic changes in the coronary arteries can appear early in the second and third decades of life, long before ischemic heart disease becomes clinically apparent.

OBJECTIVE

To estimate the current prevalence of coronary and aortic atherosclerosis in the US armed forces.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of all US service members who died of combat or unintentional injuries in support of Operations Enduring Freedom and Iraqi Freedom/New Dawn between October 2001 and August 2011 and whose cardiovascular autopsy reports were available at the time of data collection in January 2012. Prevalence of atherosclerosis was analyzed by various demographic characteristics and medical history. Classifications of coronary atherosclerosis severity were determined prior to data analysis and designed to provide consistency with previous military studies: minimal (fatty streaking only), moderate (10%-49% luminal narrowing of ≥1 vessel), and severe (≥50% narrowing of ≥1 vessel).

MAIN OUTCOME MEASURES

Prevalence of coronary and aortic atherosclerosis in the US armed forces and by age, sex, self-reported race/ethnicity, education, occupation, service branch and component, military rank, body mass index at military entrance, and International Classification of Diseases, Ninth Revision, Clinical Modification, diagnoses of cardiovascular risk factors.

RESULTS

Of the 3832 service members included in the analysis, the mean age was 25.9 years (range, 18-59 years) and 98.3% were male. The prevalence of any coronary atherosclerosis was 8.5% (95% CI, 7.6%-9.4%); severe coronary atherosclerosis was present in 2.3% (95% CI, 1.8%-2.7%), moderate in 4.7% (95% CI, 4.0%-5.3%), and minimal in 1.5% (95% CI, 1.1%-1.9%). Service members with atherosclerosis were significantly older (mean [SD] age, 30.5 [8.1] years) than those without (mean [SD] age, 25.3 [5.6] years; P < .001). Comparing atherosclerosis prevalence among with those with no cardiovascular risk factor diagnoses (11.1% [95% CI, 10.1%-12.1%]), there was a greater prevalence among those with a diagnosis of dyslipidemia (50.0% [95% CI, 30.3%-69.7%]; age-adjusted prevalence ratio [PR], 2.09 [95% CI, 1.43-3.06]), hypertension (43.6% [95% CI, 27.3%-59.9%]; age-adjusted PR, 1.88 [95% CI, 1.34-2.65]), or obesity (22.3% [95% CI, 15.9%-28.7%]; age-adjusted PR, 1.47 [95% CI, 1.10-1.96]), but smoking (14.1% [95% CI, 8.0%-20.2%]) was not significantly associated with a higher prevalence of atherosclerosis (age-adjusted PR, 1.12 [95% CI, 0.73-1.74]).

CONCLUSION

Among deployed US service members who died of combat or unintentional injuries and received autopsies, the prevalence of atherosclerosis varied by age and cardiovascular risk factors.

Perfection of precise ostial stent placement

Ostial lesions, including aorta-ostial lesions and Medina 001 bifurcation lesions, are known to create difficulty in precise stent placement. There are many techniques used to help in precise ostial stent placement; these include using multiple angiographic views to assist in placement, the use of the Ostial Pro device, the aorta flowing wire technique, Szabo (anchor-wire) techniques, the T-stent and small protrusion (TAP) technique, the cross-over 1-stent technique, and new dedicated ostial stents. In this review, we summarize these different techniques and show that there is no universal technique that allows for perfect ostial stent placement.

[Aortic intramural hematoma type B: images of an entity with different evolution pathways]

The progress in noninvasive imaging techniques for aortic pathology, such as computed tomography (CT), magnetic resonance (MRI) and transesophageal echocardiography (TEE) have facilitated the diagnosis and management of patients with aortic intramural hematoma (IMH). Despite incomplete understanding of their natural history, it is known there is no significant difference between the IMH and classic aortic dissection (AD) on the incidence of major complication or death. In this article, we present images of patient with type B aortic hematoma and different outcomes in their natural evolution.

Acute aortic syndromes and thoracic aortic aneurysm

Acute and chronic aortic diseases have been diagnosed and studied by physicians for centuries. Both the diagnosis and treatment of aortic diseases have been steadily improving over time, largely because of increased physician awareness and improvements in diagnostic modalities. This comprehensive review discusses the pathophysiology and risk factors, classification schemes, epidemiology, clinical presentations, diagnostic modalities, management options, and outcomes of various aortic conditions, including acute aortic dissection (and its variants intramural hematoma and penetrating aortic ulcers) and thoracic aortic aneurysms. Literature searches of the PubMed database were conducted using the following keywords: aortic dissection, intramural hematoma, aortic ulcer, and thoracic aortic aneurysm. Retrospective and prospective studies performed within the past 20 years were included in the review; however, most data are from the past 15 years.

Long-term results with a stentless porcine aortic valve: the Edwards PRIMA model 2500

BACKGROUND AND AIM OF THE STUDY

The study aim was to evaluate the very long-term patient survival, clinical and hemodynamic status after aortic valve replacement (AVR) with the Edwards PRIMA model 2500 stentless porcine aortic valve.

METHODS

A cohort of 50 patients was prospectively followed between September 1991 and November 2006, with clinical evaluation and echocardiography. The mean patient age at implantation was 72.2 +/- 5.2 years, and the mean valve size 24 mm (range: 19-29 mm). Most patients were in NYHA class II or III before valve implantation.

RESULTS

The early mortality was 4% (n=2). Early morbidity included two revisions for bleeding, and thromboembolic events in four patients. A total of 41 patients died during the follow up period; death was cardiac-related or sudden in 19 patients (40%) and undefined in seven (15%). Prosthetic valve endocarditis was diagnosed in five patients, and late thromboembolic events were reported in nine. Bioprosthesis explantation was performed in four patients because of severe structural valve deterioration (SVD). After 10 years, the aortic regurgitation (AR) was grade 1+ or 2+ in 12 of the 17 survivors (71%), and grade > or = 3+ in three (18%); at this time the effective orifice area was 1.81 +/- 0.59 cm2. After 12 years, the aortic regurgitation was grade 1+ or 2+ in two of seven survivors (28%), and grade > or = 3+ in four (57%). Survival of the patients did not differ significantly from that of an age-matched Belgian population.

CONCLUSION

Patient survival was comparable with that of an age-matched population after AVR with the Edwards PRIMA model 2500 valve. SVD was mainly characterized by the development of AR.

Predictors of mortality and reoperation in acute type-a aortic dissection surgery: 18 years of experience

INTRODUCTION AND OBJECTIVES

To describe our experience with acute type-A aortic dissection surgery, including an analysis of the effect of cerebral protection on outcome.

METHODS

Between March 1990 and October 2007, 98 consecutive patients underwent surgery for acute type-A aortic dissection. Of these, 85 had an ascending aorta replacement, while the entire arch was replaced in 13. The aortic valve was replaced in 34 patients but preserved in the rest. An intimal tear was observed in 83 patients.

RESULTS

The in-hospital mortality rate was 15%. Risk factors for in-hospital mortality were age > or = 70 years and preoperative cardiogenic shock (P< .05). Antegrade cerebral perfusion was used in the last 16 consecutive patients, whose in-hospital mortality rate was 6%. The proportions of patients who survived and who did not require reoperation at 1, 5 and 10 years of follow-up were 98.6%+/-1.3%, 86.2%+/-4.6% and 68.2%+/-8.9%, and 97.2%+/-1.9%, 82.5%+/-4.8% and 55.9%+/-7.9% for the two outcomes, respectively. The risk factors for reoperation were found to be severe preoperative aortic regurgitation and preservation of the aortic valve (P< .05). The only risk factor for late mortality was not using antegrade cerebral perfusion (P< .05).

CONCLUSIONS

Despite its seriousness, surgery for acute aortic dissection produces good early and long-term results. Antegrade cerebral perfusion improves the prognosis of these patients and should be the technique of choice for cerebral protection.

No-Clamp Technique for Valve Repair or Replacement in Patients With a Porcelain Aorta

BACKGROUND

Patients requiring valvular heart surgery may have circumferential calcification of the ascending aorta. A variety of creative procedures have been described for managing this "porcelain aorta." We describe a technique based on replacement of the ascending aorta and proximal arch under profound hypothermic circulatory arrest, followed by the valve procedure.

METHODS

Twenty-five consecutive patients with a porcelain aorta were referred for heart valve surgery. In every case the aorta was replaced under circulatory arrest before the valve procedure. Postoperative morbidity, mortality, and univariate risk factors for death were calculated. Fisher's exact test defined significant perioperative variables with a p value less than 0.05.

RESULTS

Of 25 patients, 23 (92%) survived the surgery to hospital discharge. One patient had a stroke (4%) and 2 patients (8%) required reexploration for bleeding. Risk factors for perioperative death by univariate analysis included age more than 78 years (p < 0.009), cardiopulmonary bypass time longer than 200 minutes (p < 0.0001), reexploration for bleeding (p < 0.02), need for intra-aortic balloon pump support (p < 0.001), and postoperative gastrointestinal complications (p < 0.001).

CONCLUSIONS

Valve replacement or repair in the patient with a porcelain aorta can be safely accomplished with a technique based on aortic replacement under circulatory arrest. Elderly patients requiring extensive procedures and prolonged periods on bypass have a substantially increased risk for postoperative complications and death.

[Acute aortic dissection. Differential diagnosis of a thoracic emergency]

Acute aortic dissection is an infrequent but important differential diagnosis of acute chest pain. The variability of presenting symptoms makes it difficult to diagnose correctly. Important clinical indicators - besides chest pain - are symptoms related to acute aortic insufficiency and/or pericardial tamponade, variable acute neurologic alterations, or signs of peripheral or visceral malperfusion. The spontaneous prognosis depends on the location and extent of the dissection, and left untreated dissection carries a high mortality. The key goal of preclinical treatment is stabilization with analgesia, mild sedation (opioids, benzodiazepines) and treatment of hypertension (beta-blockers) or hypotension (fluid administration). If the patient presents with a high probability of dissection, early transfer to a specialized center appears advisable. Initial clinical diagnostic studies include transthoracic echocardiogram and computed tomography. If the ascending aorta is involved (Stanford type A) immediate replacement of the proximal aorta is necessary. Isolated dissections of the descending aorta (type B) require aggressive blood pressure control, but can be managed conservatively in most cases. A high level of vigilance is necessary in all patients to detect and treat visceral ischemia.

Can transthoracic echocardiography with subcostal view predict abdominal aortic atherosclerosis?

BACKGROUND

Prompt detection of atherosclerosis (ATH) may profoundly impact therapy and patient outcome. During transthoracic echocardiography (TTE), subcostal views may suggest abdominal (ABD) aortic (AO) ATH, but this diagnosis may be inaccurate due to suboptimal images, which may in part relate to use of nonlinear probes. Therefore, we investigated the accuracy of TTE assessment of ABD AO ATH relative to transesophageal (TEE) AO images.

METHODS

Routine clinical TTE and TEE studies of 100 patients (44 men), aged 30-92 years old, were reviewed retrospectively and blindly. ABD AO ATH by TTE was graded qualitatively as grade (GR) 0 = smooth wall surface; GR 1, 2, and 3 = mild, moderate, and severe irregularities, respectively; and GR 4 = mobile/complex plaque. TEE images were graded quantitatively as the maximal intimal-medial, or plaque thickness, imaged in the AO arch or descending AO, as: GR 0 <or= 1.5 mm, GR 1 = 1.5-2.4 mm, GR 2 = 2.5-4 mm, GR 3 = >4 mm, or GR 4 = mobile/complex plaque >4 mm. TTE ability to detect the presence (>GR 0) of ABD AO ATH on TEE was measured in terms of sensitivity (SN), specificity (SP), positive (PPV) and negative (NPV) predictive accuracy-in patients with adequate and suboptimal images-compared to TEE.

RESULTS

TTE image quality was adequate in 75 patients and suboptimal in 25. SP and PPV of grading ATH by TTE were directly related to grading by TEE; however, SN and NPV demonstrated an inverse relationship with increasing grading of ATH. TTE correlated with TEE grading with an r = 0.42 (P = 0.0001) for patients (n = 75) with adequate TTE and r = 0.32 (P = 0.001) for all patients (n = 100), including those with suboptimal TTE images.

CONCLUSION

Routine TTE imaging is usually correct in predicting ATH on TEE, but with modest error, it should generally not be relied on as a definitive test for ATH. Adequate image quality improves the correlation of TEE and TTE grading of ABD ATH, and more severe ATH on TTE is more predictive of ATH on TEE.

Traitement endovasculaire percutané des lésions oblitérantes du carrefour aorto-iliaque : résultats chez 28 patients

OBJECTIVE

We conducted a retrospective analysis of short- and mid-term results of endoluminal treatment of obstruction lesions involving the terminal aorta and the initial portions of the iliac arteries in 28 patients.

PATIENTS AND METHODS

Twenty-eight patients (9 women, 19 men, mean age 57.5 Years) presented 52 obstructive atheromatous lesions of the aorto-iliac bifurcation. The lesions were divided into three topographic groups (9 unilateral lesions, 19 bilateral ostial lesions, 5 widespread lesions of the terminal aorta) and identified as simple (44%) or complex (56%, more than 2 cm in length and/or calcified and/or eccentric).

RESULTS

Technical success was achieved in 93% of the cases with only one hematoma of the puncture site. Primary and secondary patencies were 78.9% and 93% after a mean follow-up of 50 Months (range 4-85). Clinical outcome remained good at this term for all cases of technical success but complete resolution of the symptoms was more frequent when a stent was used (84%) than for simple balloon dilatation (49%).

CONCLUSION

Percutaneous treatment of obstructive lesions of the aorto-iliac bifurcation may be proposed when possible as a first-line treatment.

Altered patterns of gene expression distinguishing ascending aortic aneurysms from abdominal aortic aneurysms: complementary DNA expression profiling in the molecular characterization of aortic disease

OBJECTIVES

The purpose of this study was to profile altered patterns of gene expression that characterize degenerative ascending thoracic aortic aneurysms and to compare these patterns with those observed for infrarenal abdominal aortic aneurysms.

METHODS

Full-thickness aortic wall tissues were obtained during surgical repair of degenerative thoracic aortic aneurysms and infrarenal abdominal aortic aneurysms (n = 4 each), with normal thoracic and abdominal aortas from organ transplant donors used as control preparations. Radiolabeled complementary DNA was prepared for each specimen and hybridized to complementary DNA microarrays, and differential levels of gene expression between aneurysmal and normal aortic tissues at each site were assessed by parametric statistics.

RESULTS

Of 1185 genes examined, 112 (9.5%) were differentially expressed (P <.05) between thoracic aortic aneurysms and normal thoracic aorta, with 105 increased and 7 decreased. There were 104 genes (8.8%) differentially expressed between infrarenal abdominal aortic aneurysms and normal abdominal aorta (65 increased and 39 decreased). Quantitative increases in expression for 97 genes were unique to thoracic aortic aneurysms, whereas increases for 61 genes were unique to infrarenal abdominal aortic aneurysms. Although 8 gene products were significantly altered in both thoracic and infrarenal abdominal aortic aneurysms, these changes were directionally concordant for only 4 (matrix metalloproteinase 9/gelatinase B, v-yes-1 oncogene, mitogen-activated protein kinase 9, and intercellular adhesion molecule 1/CD54). Results for 9 genes were independently confirmed by quantitative reverse transcriptase-polymerase chain reaction.

CONCLUSIONS

Thoracic aortic aneurysms and infrarenal abdominal aortic aneurysms exhibit distinct patterns of gene expression relative to normal aorta from the same sites, with most alterations being unique to each disease. Degenerative aneurysms arising in different locations are thus characterized by a high degree of molecular heterogeneity, reflecting different pathophysiologic mechanisms.

Renovascular hypertension - simultaneous aortic and renal artery reconstruction

Despite the enormous progress that has been madein the fields of vascular surgery and intensive care, reconstructive surgery of renal arteries in the presence of arteriosclerosis of the abdominal aorta remains a serious therapeutic problem and is associated with a high rate of complications. The purpose of this study was to analyze the results of treatment of patients with renovascular hypertension and so-called difficult aorta. Surgery was carried out in 68 patients with a critically stenosed renal artery and severe arteriosclerosis of the abdominal aorta. In 53 patients an aortobifemoral prosthetic graft was implanted together with endarterectomy of the renal artery in 23 patients, an aortorenal venous graft in 23 patients and a prosthetic graft in 7 patients. In the remaining 15 patients extra-anatomic anastomoses were performed between the splenic artery and the renal artery (7 patients), hepatic artery and renal artery (6) and between the superior mesenteric and renal artery (2). Postoperatively, the hypertension was cured in 55% of patients, improved in 38% and remained unchanged in 7%. After 1 year the results were respectively 47, 36, and 17%. The patients with an aortorenal prosthetic graft demonstrated a greater tendency for hypertension to recur.

Aortic atheroma. An unknown source of ischemic stroke

Cerebrovascular mortality represents 25% of all cardiovascular mortality. Defining the pathological mechanism of an episode of ischemic stroke is important for epidemiological, prognostic and overall therapeutic purposes. About 1/4 of ischemic strokes are defined as being of unknown cause. The use of transesophageal echocardiography for studying the aortic arch and thoracic aorta, revealed that aortic atheroma can be considered as an embolic source. Retrospective studies documented a significant prevalence of atheroma >4 mm in the aortic arch in patients with previous stroke (15%); while prospective studies documented an increased risk for cardiovascular events in patients with plaque of =/> 4 mm in thickness at the level of the thoracic aorta compared with controls without these lesions: in particular, the incidence of recurrent stroke is 12%/year, while the incidence of cardiovascular events is 26%. Plaques defined unstable and at risk of embolic event are protrudent, >4 mm in thickness, without calcification and have on their surface mobile thrombus. Embolization from a protrudent atheroma can have a iatrogenic cause, that is cardiac catheterization or placement of an intra-aortic balloon- pump or during cardiopulmonary bypass. The management of the subject with aortic atheroma is not well defined. Encouraging dates with the use of statins are from a recent meta-analysis also anticoagulant treatment versus antiplatelet treatment, reduced incidence of stroke in a significant manner. The surgical therapy of aortic endoarterectomy, has, at this moment, a limited indication, because is not without risk. Transesophageal ecocardiography is a method of choice for the study of the aortic atheroma and it should be done in every patient with stroke by unknown cause.

Impact of aortoiliac tortuosity on endovascular repair of abdominal aortic aneurysms: evaluation of 3D computer-based assessment

OBJECTIVE

The purpose of this study was to examine the effect of aortoiliac tortuosity, as assessed by observers and 3-dimensional (3D) computer-based methods, on the conduct and outcome of endovascular repair of abdominal aortic aneurysms.

METHODS

Infrarenal aortoiliac tortuosity was measured in 75 patients (mean follow-up, 14.8 +/- 10.4 months) who underwent endovascular repair of abdominal aortic aneurysms by using the following four methods: (1) grading by 2 experienced observers; (2) tortuosity index measured as the inverse radius of curvature (cm(-1)) at 1-mm intervals along the median luminal centerline (MLC) on 3D reconstructions of computed tomography (CT) angiograms and was calculated as the sum of values greater than 0.3 cm(-1); (3) MLC-straight line length ratio from renal to hypogastric arteries; (4) manual measurement of angles at points of angulation on anteroposterior and lateral projections of 3D CT reconstructions. In evaluating association between these measures, correlation between human observers was accepted as the gold standard.

RESULTS

For rating of overall aortoiliac tortuosity, interobserver correlation (r = 0.67) was comparable with correlation of observers with tortuosity index (r = 0.67 and 0.56), whereas correlations of each observer with MLC-straight line ratio (r = 0.50 and 0.56) and cumulative angulation (r = 0.44 and 0.44) were significant but weaker. For determining the relative tortuosity of right and left aortoiliac access, agreement between observers and tortuosity index (54% and 58%; P < .05; kappa, 0.33 and 0.38) was not as good as between observers (68%; P < .001; kappa, 0.53). This difference was primarily related to evaluation of the aorta, where interobserver correlation (r = 0.71) was better than that between each observer and tortuosity index (r = 0.47 and 0.55), whereas correlations in the iliac arteries were comparable (r = 0.64 and 0.67) (all coefficients P < .01). Increased tortuosity was associated with a more complex endovascular repair, as reflected by longer fluoroscopy time (P = .05), use of more contrast material (P = .03), use of extender modules (P = .04), and more frequent use of arterial reconstruction (P = .01), but was not associated with a higher overall complication rate. Increased tortuosity, when it occurred in the aortic neck, was associated with predischarge endoleak (P = .03) but not with late endoleak, intervention, or aneurysm-related adverse events.

CONCLUSION

Aortoiliac tortuosity is associated with increased complexity of endovascular aneurysm repair and with predischarge endoleak but does not appear to affect intermediate-term results. Computer-based 3D measurement of aortoiliac tortuosity is feasible and clinically meaningful. Its ultimate role in relation to human assessment must be further defined in future studies.

Ultrasonographic demonstration of manipulation-related aortic injuries after cardiac surgery

OBJECTIVES

This study was performed to evaluate the frequency and risk factors associated with new aortal lesions induced by surgical manipulation and their correlation with postoperative stroke.

BACKGROUND

Little is known about the causative mechanism of intraoperative atheroembolism after cardiac surgery.

METHODS

Epiaortic echocardiography was performed before cannulation and after decannulation in 472 patients undergoing cardiac surgery with extracorporeal circulation.

RESULTS

A new lesion in the ascending aortal intima was identified in 16 patients (3.4%) after decannulation. New lesions were severe, with mobile lesions or disruption of the intima in 10 patients. Six of the severe lesions were related to aortic damping and the other four to aortic cannulation. Three patients in this group had postoperative stroke. Univariate analysis identified only the maximal thickness of the atheroma near the aorta manipulation site as a predictor of new lesions. The incidence of new lesions was 11.8% if the atheroma was approximately 3 to 4 mm thick and as high as 33.3% if the atheroma was >4 mm, but only 0.8% when it was <3 mm. Total 10 patients (2.1%) sustained neurological complications. Arteriosclerosis obliterans, atherosclerosis of the aorta and new mobile lesions were identified as predictors of strokes.

CONCLUSIONS

This study demonstrated an association between new lesions created by surgical maneuvers and postoperative stroke. Embolic strokes were more likely to occur if new lesions were complicated with intimal disruption, especially of the mobile type. Modifications in surgical procedures will be needed if thick plaque (especially >4 mm) is noted near the manipulation site.

[Guidelines of the Spanish Society of Cardiology on aortic diseases]

Acute aortic pathology is an urgent clinical situation, of which prognosis mainly related to prompt and accurate diagnosis as well as a quick treatment. In this paper we review the aortic pathology, specially focused on aortic dissection. We review its etiology, clinical presentation and diagnostic methods. In addition the medical therapy and the surgical indications of aortic aneurysm, dissection and aortic intramural haematoma are described.

Comparison between the transabdominal and retroperitoneal approaches for aortic reconstruction in patients at high risk

PURPOSE

The purpose of this study was to compare the transabdominal approach with the retroperitoneal approach for elective aortic reconstruction in the patient who is at high risk.

METHODS

From January 1992 through January 1997, 148 patients underwent aortic operations: 92 of the patients were classified as American Society of Anesthesia (ASA) class IV. Forty-four operations on the patients of ASA class IV were performed with the transabdominal approach (25 for abdominal aortic aneurysms and 19 for aortoiliac occlusive disease), and 48 operations were performed with the retroperitoneal approach (27 for abdominal aortic aneurysms and 21 for aortoiliac occlusive disease). There were no significant differences between the groups for comorbid risk factors or perioperative care.

RESULTS

Among the patients of ASA class IV, eight (8.7%) died after operation (retroperitoneal, 3 [6.26%]; transabdominal, 5 [11.3%]; P =.5). There was no difference between groups in the number of pulmonary complications (retroperitoneal, 23 [47.9%]; transabdominal, 19 [43.2%]; P =.7) or in the development of incisional hernias (retroperitoneal, 6 [12.5%]; transabdominal, 5 [11.3%]; P =.5). The retroperitoneal approach was associated with a significant reduction in cardiac complications (retroperitoneal, 6 [12.5%]; transabdominal, 10 [22.7%]; P =.004) and in gastrointestinal complications (retroperitoneal, 5 [8.3%]; transabdominal, 15 [34.1%]). Operative time was significantly longer in the retroperitoneal group (retroperitoneal, 3.35 hours; transabdominal, 2.98 hours; P =.006), as was blood loss (retroperitoneal, 803 mL; transabdominal, 647 mL; P =.012). The patients in the retroperitoneal group required less intravenous narcotics (retroperitoneal, 36.6 +/- 21 mg; transabdominal, 49.5 +/- 28.5 mg; P =.004) and less epidural analgesics (retroperitoneal, 39.5 +/- 6.4 mg; transabdominal, 56.6 +/- 9.5 mg; P =.004). Hospital length of stay (retroperitoneal, 7.2 +/- 1.6 days; transabdominal, 12.8 +/- 2.3 days; P =.024) and hospital charges (retroperitoneal, $35,587 +/- $980; transabdominal, $54,832 +/- $1105; P =.04) were significantly lower in the retroperitoneal group. The survival rates at the 40-month follow-up period were similar between the groups (retroperitoneal, 81.3%; transabdominal, 78.7%; P =.53).

CONCLUSION

In this subset of patients who were at high risk for aortic reconstruction, the postoperative complications were common. However, the number of complications was significantly lower in the retroperitoneal group. Aortic reconstruction in patients of ASA class IV appears to be more safely and economically performed with the retroperitoneal approach.

The surgical anatomy of the left ventricular outflow tract in hearts with ventricular septal defect and aortic arch obstruction

BACKGROUND

Profound understanding of the left ventricular outflow tract (LVOT) anatomy is crucial to improve surgical results in patients with aortic arch obstruction, ventricular septal defect, and subaortic stenosis.

METHODS

We studied the morphology of the LVOT in 32 postmortem hearts with aortic arch obstruction and a ventricular septal defect. In case of subaortic obstruction, the length of the subaortic muscular component was measured anteriorly and posteriorly within the left ventricle.

RESULTS

Seven of the 32 hearts had no subaortic stenosis. Nine had aortic override, which caused LVOT narrowing. Sixteen hearts contained a subaortic shelf, downstream to the ventricular septal defect, which deviated into the left ventricle in 15. In 10 of these the shelf was muscular; in 6 it was a fibrous ridge. In cases with a muscular shelf, the posterior part was significantly shorter than the anterior part (p < 0.004). In 9 hearts the LVOT was further narrowed because of the abnormal relationship between the mitral valve and the subaortic shelf.

CONCLUSIONS

The present study confirms the complexity of LVOT stenosis in aortic arch obstruction and ventricular septal defect and provides a better understanding of the options to achieve surgical relief.

Assessment of thoracic aortic atheroma by echocardiography: a new classification and estimation of risk of dislodging atheroma during three surgical techniques

A new classification is described to improve precision of thoracic atheroma reporting. In 68 patients, the thoracic aorta was screened with epiaortic and transesophageal echocardiography. The thoracic aorta is divided into 6 zones corresponding to sites of aortic manipulation. Zones 1-3, proximal, mid and distal ascending aorta, Zones 4-5, proximal and distal arch and Zone 6, proximal descending aorta. Each zone is further sub-divided into anterior, left lateral, posterior and right lateral quadrants. There is a marked increase in moderate and severe atheroma between Zones 1-3 and Zone 4-6 (p<0. 001). There is a difference in atheroma by quadrant with the anterior the most frequent. (p<0.001) Once the grade and location of atheroma was classified, a comparison of the estimation of risk of dislodging atheroma during three surgical methods for care, was performed. Of 50 quadrants of atheroma, the composite arterial pedicle Y graft CABG would manipulate 5, Aortocoronary CABG with single aorta cross clamp, 16, and Aortocoronary CABG with aortic partial occlusion clamp, 21. This classification of 6 zones and 4 quadrants within each zone will increase the precision of atheroma reporting and allow better comparison of stroke reduction interventions.

Classification and pathophysiology of enterocutaneous fistulas

Enterocutaneous and aortoenteric fistulas arise from a diverse array of pathophysiologic states. Classification by anatomic, physiologic, and etiologic systems is critical to both nonoperative and operative treatment planning.

Primary leiomyosarcoma of the aorta: report of a case and review of the literature

Leiomyosarcoma of vascular origin is an extremely rare lesion especially when it occurs in the arteries. In the present study, we report a case of such a neoplasm, originating in the wall of the descending aorta and give an ample review of world references on the subjects of primary aortic neoplasm. Wright classified aortic tumors into two categories concerning the site of origin in the aortic wall: the first involves the intima, the second group consists of tumors arising in the media or adventitia. The aspecific clinical findings that characterize these lesions explain the difficulty of a preoperative diagnosis. Very important, therefore, are sonography and CT which point out signs and symptoms which refer to a local and distal diffusion of the tumor. However, even in the cases in which the diagnosis is done before surgery, there is no codified therapeutic management. In fact both surgical and non-surgical methods (radiotherapy, chemotherapy) have poor results with an average survival. Due to the limited prognosis "quoad vitam", the elective therapy must preferably be of conservative type.

A definition of initial, fatty streak, and intermediate lesions of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association

The compositions of lesion types that precede and that may initiate the development of advanced atherosclerotic lesions are described and the possible mechanisms of their development are reviewed. While advanced lesions involve disorganization of the intima and deformity of the artery, such changes are absent or minimal in their precursors. Advanced lesions are either overtly clinical or they predispose to the complications that cause ischemic episodes; precursors are silent and do not lead directly to complications. The precursors are arranged in a temporal sequence of three characteristic lesion types. Types I and II are generally the only lesion types found in children, although they may also occur in adults. Type I lesions represent the very initial changes and are recognized as an increase in the number of intimal macrophages and the appearance of macrophages filled with lipid droplets (foam cells). Type II lesions include the fatty streak lesion, the first grossly visible lesion, and are characterized by layers of macrophage foam cells and lipid droplets within intimal smooth muscle cells and minimal coarse-grained particles and heterogeneous droplets of extracellular lipid. Type III (intermediate) lesions are the morphological and chemical bridge between type II and advanced lesions. Type III lesions appear in some adaptive intimal thickenings (progression-prone locations) in young adults and are characterized by pools of extracellular lipid in addition to all the components of type II lesions.

A definition of initial, fatty streak, and intermediate lesions of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association

The compositions of lesion types that precede and that may initiate the development of advanced atherosclerotic lesions are described and the possible mechanisms of their development are reviewed. While advanced lesions involve disorganization of the intima and deformity of the artery, such changes are absent or minimal in their precursors. Advanced lesions are either overtly clinical or they predispose to the complications that cause ischemic episodes; precursors are silent and do not lead directly to complications. The precursors are arranged in a temporal sequence of three characteristic lesion types. Types I and II are generally the only lesion types found in children, although they may also occur in adults. Type I lesions represent the very initial changes and are recognized as an increase in the number of intimal macrophages and the appearance of macrophages filled with lipid droplets (foam cells). Type II lesions include the fatty streak lesion, the first grossly visible lesion, and are characterized by layers of macrophage foam cells and lipid droplets within intimal smooth muscle cells and minimal coarse-grained particles and heterogeneous droplets of extracellular lipid. Type III (intermediate) lesions are the morphological and chemical bridge between type II and advanced lesions. Type III lesions appear in some adaptive intimal thickenings (progression-prone locations) in young adults and are characterized by pools of extracellular lipid in addition to all the components of type II lesions.

J-shaped relation between change in diastolic blood pressure and progression of aortic atherosclerosis

The J-shaped relation between diastolic blood pressure and mortality from coronary heart disease continues to provoke controversy. We examined the association between diastolic blood pressure and progression of aortic atherosclerosis in a population-based cohort of 855 women, aged 45-64 years at baseline. The women were examined radiographically for calcified deposits in the abdominal aorta, which have been shown to reflect intimal atherosclerosis. After 9 years of follow-up, slight progression of atherosclerosis was noted in 19% of women and substantial progression in 16%. The age-adjusted relative risk of substantial atherosclerotic progression in women with a decrease in diastolic pressure of 10 mm Hg or more was 2.5 (95% CI 1.3-5.6), compared with the reference group of women who had a smaller decrease or no change. The excess risk in this group was confined to women whose increase in pulse pressure was above the median (3.9 [1.5-9.9] vs 1.1 [0.3-4.2] in women with an increase in pulse pressure below the median). The relative risks for women with rises in diastolic pressure of 1-9 mm Hg and 10 mm Hg or more were 2.2 (1.1-4.3) and 3.5 (1.6-8.0), respectively. These findings suggest that a decline in diastolic blood pressure indicates vessel wall stiffening associated with atherosclerotic progression. They support the hypothesis that in low-risk subjects progression of atherosclerosis may be accompanied by a decrease in diastolic blood pressure rather than the opposing idea that low diastolic blood pressure precipitates the occurrence of atherosclerotic events.

Surgical pathology of aorta and arteries of the lower limbs in the elderly

From 1.1.1988 tot 31.8.1991, 42 surgical revascularisations of the aorta and the lower limbs were performed on patients aged 75 and more (men: 24--women: 18; extreme ages: 75-84; average age: 80). In all cases surgery was absolutely indicated: for advanced arteriopathy in the lower limbs (stage III or IV of Fontaine's classification) (37 cases) and ruptured abdominal aortic aneurysm (5 cases). No primary major amputation was performed in the peripheral vascular group stages III and IV. Peripheral vascular occlusive disease (30 cases) was operated under locoregional anaesthesia and consisted of the femoro-distal popliteal bypass with in situ saphenous vein (23 cases). Patients with proximal lesions preferably underwent an extra-anatomic bypass under general anaesthesia (7 cases). Ruptured infrarenal aortic aneurysm also needs a general anesthesia and represents a high surgical risk (5 cases). For the 42 patients, we observed 38 good immediate functional results and 4 peri-operative deaths. Of the 38 immediate good results, we observed 6 secondary obliterations of the bypass within a period of 5 to 18 months, among which 2 were successfully disobliterated. The other 4 patients underwent lower limb amputation.

Segmental analysis of the ascending aorta: definition of normality and classification of aortic dilatation

To better define and classify ascending aortic abnormalities, we adapted the left ventricular dynamic segmental analysis concept to the ascending aorta. Ascending aortic diameters were measured from contrast aortography in 18 normal subjects at the aortic valve (level 1), and 2, 4, and 6 cm above the aortic valve (levels 2, 3, and 4). Diameters greater than two standard deviations (SD) above the mean normal values at any levels were considered abnormal. Aortograms of 102 consecutive patients with abnormal aorta were analyzed. Three patterns of aortic dilatation were identified: I (n = 55), the largest aortic diameter was at level 2 (normal pattern); II (n = 39), the aortic diameters increased from levels 1 to 4; III (n = 8), all aortic diameters were greater than 2 SD above the mean normal values and increased from levels 1 to 4. Segmental analysis of the aorta provides an objective comparative basis for definition and classification of aortic dilatation and aneurysm.

Aortic intimal sarcoma with embolic metastases

A 46-year-old woman died from massive bowel infarction. At autopsy, a primary sarcoma was found growing along the intimal surface of the aorta at the level of the celiac axis. Tumor emboli were found in distal aortic branches and most abdominal organs. Immunoperoxidase for Factor VIII and electron microscopy (EM) did not support an endothelial origin. EM showed myofibroblastic differentiation. Review of the literature yields an array of diagnostic histologic terms for these tumors, hampering case comparison. The literature does suggest, however, that the clinical presentation of these rare neoplasms correlates nicely with the location and gross morphology of the lesion. We therefore propose a clinicopathologic classification, categorizing the lesions as intimal (obstructive and nonobstructive) and mural. The former are typically pleomorphic sarcomas and are probably of myofibroblastic origin, whereas the latter are usually leiomyosarcomas or fibrosarcomas that probably originate in the media or adventitia.

Long-term survival in preductal atresia of the aortic arch

Atresia of the aortic arch is distinguished from complete interruption of the aorta by the presence of a fibrotic strand bridging the 2 discontinuous segments of aorta. Most patients with aortic arch atresia have associated intracardiac defects. There is a high neonatal mortality in this condition, with 95% of the patients dying in the first year of life. The case described herein is the first long-term survivor with atresia of the aortic arch, a patent ductus arteriosus, and an atrial septal defect to reach adulthood. In this patient an extensive collateral network existed in spite of the presence of a patent ductus arteriosus.

Report of Committee on Grading Lesions, Council on Arteriosclerosis, American Heart Association. Grading human atherosclerotic lesions using a panel of photographs

The American Heart Association's Committee on Grading Lesions of the Council on Arteriosclerosis has devised a method of grading the severity of atherosclerosis in human coronary arteries and aortas. The method uses two series of color photographs of arteries arranged in increasing severity of atherosclerosis. The Committee tested the method for inter-observer reproducibility by exhibiting the panel at two national scientific conventions and inviting visitors to grade a set of arteries with the panel. The test demonstrated a reasonable degree of inter-observer reproducibility despite a wide range of experience and disciplinary background. Inter-observer variability decreases with increasing experience in working with atherosclerotic lesions. Training graders who participate in a study may reduce inter-observer bias. For populations with predominantly less or predominantly more atherosclerosis, the investigator should construct special panels with different ranges of severity. The Committee revised the panel in the light of the results of the two exhibits and the comments of users in a field trial. The revised panel provides seven possible scores for each coronary artery and for each aorta. This panel provides a relatively simple and speedy quantitative method of comparing autopsy data on atherosclerosis among many kinds of studies and has the added advantages of facilitating comparisons between different geographic locations and different times.