Cytokine patterns in patients after major vascular surgery, hemorrhagic shock, and severe blunt trauma. Relation with subsequent adult respiratory distress syndrome and multiple organ failure

OBJECTIVE

This study investigates the course of serum cytokine levels in patients with multiple trauma, patients with a ruptured abdominal aortic aneurysm (AAA), and patients undergoing elective AAA repair and the relationship of these cytokines to the development of adult respiratory distress syndrome (ARDS) and multiple organ failure (MOF).

SUMMARY BACKGROUND DATA

Severe tissue trauma, hemorrhagic shock, and ischemia-reperfusion injury are pathophysiologic mechanisms that may result in an excessive uncontrolled activation of inflammatory cells and mediators. This inflammatory response is thought to play a key role in the development of (remote) cell and organ dysfunction, which is the basis of ARDS and MOF.

METHODS

The study concerns 28 patients with multiple trauma, 20 patients admitted in shock because of a ruptured AAA, and 18 patients undergoing elective AAA repair. Arterial blood was serially sampled from admission (or at the start of elective operation) to day 13 in the intensive care unit, and the serum concentrations of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1 beta, and IL-6 were determined.

RESULTS

Twenty-two patients died, 15 within 48 hours and 7 after several weeks, as a result of ARDS/MOF. At hospital admission and after 6 hours, these nonsurvivors had significantly higher plasma TNF-alpha and IL-1 beta levels than did the survivors. At the same measuring points, TNF-alpha and IL-1 beta were significantly more elevated in patients with ruptured AAA than in traumatized patients. However, IL-6 was significantly higher in the traumatized patients. In 10 patients, ARDS/MOF developed, and 41 had an uncomplicated course in this respect. Those with ARDS/MOF exhibited significantly different cytokine patterns in the early postinjury phase. TNF-alpha and IL-1 beta levels were higher mainly on the first day of admission; IL-6 concentrations were significantly elevated in patients with ARDS/MOF from the second day onward. The latter cytokine showed a good correlation with the daily MOF score during the whole 2-week observation period.

CONCLUSIONS

In the early postinjury phase, higher concentrations of these cytokines are associated, not only with an increased mortality rate, but also with an increased risk for subsequent ARDS and MOF. These data therefore support the concept that these syndromes are caused by an overwhelming autodestructive inflammatory response.

Aortic aneurysm and dissection in patients with biopsy-proven giant cell arteritis from northwestern Spain: a population-based study

Most classical manifestations of giant cell arteritis (GCA) are the result of occlusive vascular involvement. However, unlike ischemic manifestations, aortic aneurysmal disease in patients with GCA has been less well described. We assessed the incidence and predictors of aortic aneurysm and dissection in patients with biopsy-proven GCA from the Lugo region of northwestern Spain and compared the results with those in a 2003 report from Olmsted County, MN. We performed a retrospective study of biopsy-proven GCA patients diagnosed from 1981 to 2001 at the single hospital for a well-defined population of almost 250,000 people. Twenty (9.5%) of the 210 biopsy-proven GCA patients diagnosed during the study period developed aortic aneurysmal disease. Sixteen of the 20 patients had thoracic aneurysms and 6 had abdominal aneurysms. The incidence of aortic aneurysm and/or dissection in Lugo (18.9 per 1000 person years at risk) was similar to that reported in Olmsted County (18.7 per 1000 person years at risk). Hypertension (hazard ratio: 4.73) and polymyalgia rheumatica with a marked acute inflammatory response at the time of diagnosis of GCA (hazard ratio: 3.71) were the best predictors of aortic aneurysmal disease. Our present observations suggest that a severe inflammatory response associated with hypertension at the time of diagnosis of GCA may promote the development of aortic aneurysmal disease. GCA patients having these features should be monitored for the existence of aortic aneurysm and dissection.

Value of plasma fibrin D-dimers for detection of acute aortic dissection

OBJECTIVES

The purpose of this research was to assess the value of systemic inflammatory biomarkers in the detection of acute aortic dissection (AD).

BACKGROUND

Rapid diagnosis and initiation of treatment is pivotal for patients with acute AD. So far, there is no laboratory test to aid the diagnosis.

METHODS

Plasma fibrin D-dimers, white blood cell (WBC) count, C-reactive protein (CRP), and fibrinogen were determined in 64 chest-pain (CP) patients (acute AD, n = 16; pulmonary embolism [PE], n = 16; acute myocardial infarction [AMI], n = 16; non-cardiac CP, n = 16); 32 asymptomatic patients with chronic AD served as a control group.

RESULTS

All acute AD patients showed highly elevated D-dimer values that were similar to PE patients (2,238 +/- 1,765 microg/l vs. 1,531 +/- 837 microg/l, p = 0.15) but significantly higher than in chronic AD, AMI, or CP patients (p < 0.001). The WBC count was significantly increased in patients with acute AD compared with the other groups (p < 0.001); in addition, CRP values differed only non-significantly from PE patients(p = 0.71). There were no differences in the fibrinogen levels between the groups.

CONCLUSIONS

D-dimers are highly elevated in both acute PE and acute AD. Patients with acute AD show significant systemic inflammatory reactions. Measurement of D-dimers may be a valuable addition to the current diagnostic work-up of patients with suspected AD.

D-dimer in acute aortic dissection

STUDY OBJECTIVE

Laboratory testing plays a minor role in the assessment of aortic dissection. Its main value is in the exclusion of other diseases. Following an incidental observation, we systematically investigated the relationship between elevated d-dimer levels and acute aortic dissection.

DESIGN

We prospectively tested d-dimer levels in patients with suspected acute aortic dissection (10 patients). In addition, we investigated 14 patients who had received a confirmed diagnosis of thoracic aortic dissection during the previous 5 years, in whom d-dimer testing had been performed for differential diagnosis. Thirty-five patients with acute chest pain of other origin served as a control group.

SETTING

Tertiary referral hospital.

PATIENTS

Twelve patients had type A dissection (Stanford classification), and 12 patients had type B.

MEASUREMENTS AND RESULTS

A d-dimer analysis was performed (Tina-quant assay; Roche Diagnostics; Mannheim, Germany) [normal limit of the assay, 0.5 micro g/mL]. The result of the d-dimer test was positive (ie, > 0.5 micro g/mL) in all patients (sensitivity of the test, 100%) with a mean value of 9.4 micro g/mL and a range of 0.63 to 54.7 micro g/mL. The degree of the elevation was correlated to the delay from the onset of symptoms to laboratory testing (mean, 12.6 h; range, 1 to 120 h) and showed a trend to the extent of the dissection, but not to the outcome (14 patients could be discharged; 10 patients died).

CONCLUSIONS

Based on our observation, we suggest that testing for d-dimer should be part of the initial assessment of patients with chest pain, especially if aortic dissection is suspected. A negative test result makes the presence of the disease unlikely.

Soluble elastin fragments in serum are elevated in acute aortic dissection

OBJECTIVE

We aimed to establish an enzyme-linked immunosorbent assay for measuring soluble elastin fragments (sELAF) in serum and to reveal its usefulness in diagnosing acute aortic dissection (AAD).

METHODS AND RESULTS

An enzyme-linked immunosorbent assay to measure sELAF in serum was developed by using the newly created double monoclonal antibodies, which recognize the different epitopes of human aortic elastin. Twenty-five AAD patients, 50 patients with acute myocardial infarction (AMI), and 474 healthy individuals were enrolled in the study. The sELAF levels from healthy subjects gradually increased with aging. When the cutoff point for positivity was set at the mean+3 SD (ie, 3 SD above the mean in healthy subjects at each age), 16 AAD patients (64.0%) were found be positive, whereas only 1 AMI patient was found to be positive (2.0%). AAD patients with either an open or a partially open pseudolumen were found be 88.9% positive for sELAF, whereas those with its early closure were 0% positive. The difference in the sELAF levels between AAD patients with and without a thrombotic closure of false lumen was significant (60.3+/-15.6 versus 135.4+/-53.2 ng/mL, respectively; P<0.005).

CONCLUSIONS

The sELAF level in serum may be a useful marker for helping in the diagnosis and screening of AAD and may also help to distinguish AAD from AMI.

C-reactive protein and mortality in patients with acute aortic disease

OBJECTIVE

The association of acute-phase reaction and outcome of patients with acute vascular diseases is controversial. The prognostic value of admission C-reactive protein (CRP) in patients with acute aortic aneurysm or dissection has not yet been investigated.

DESIGN AND SETTING

Cohort study including 255 consecutive patients from an aneurysm registry with symptomatic thoracic or abdominal aortic aneurysm and/or dissection in an emergency department of a tertiary care university hospital.

PATIENTS

Patients were included who had symptoms of aortic disease admitted between 1 January 1992 and 31 November 1998 and were followed up until 31 December 1999 for survival.

MEASUREMENTS

Admission CRP (mg/dl) levels were categorized in quartiles: quartile 1, less than 0.5; quartile 2, 0.50-1.30; quartile 3, 1.31-6.30; quartile 4, higher than 6.30. Each group contained about 60 patients.

RESULTS

Cumulative mortality 1, 3, and 6 months after presentation was 32%, 37%, and 40%, respectively. Increased CRP levels were independently associated with mortality, adjusted for age, sex, hemodynamic shock, mechanical ventilation, coronary artery disease, aortic rupture, hemoglobin, diabetes, and treatment strategy (surgery vs. conservative). Hazard ratios in patients with CRP levels in quartiles 2-4 compared to quartile 1 were 0.7, 1.8, and 2.6, respectively.

CONCLUSIONS

Elevated admission CRP values in patients with symptomatic aortic aneurysm/dissection were independently associated with poor prognosis. CRP levels higher than 6.3 mg/dl indicate a high risk for short-term mortality.

D-dimer and BNP levels in acute aortic dissection

Early diagnosis and treatment are pivotal for patients with acute aortic dissection (AAD). D-dimer is a rule-out diagnostic test for pulmonary embolism but there is evidence that it may also be applicable to AAD. We evaluated plasma D-dimer, white cell blood count (WBC), C-reactive protein (CRP) and N-terminal pro-B-type natriuretic peptide (BNP) in 18 consecutive patients with established AAD, 21 consecutive patients with dilated ascending aortas scheduled for elective surgery and 8 normal subjects. Patients with AAD had significantly higher elevated D-dimer, compared to chronic aneurysms and normal controls (p<0.0001). D-dimer level higher than 700 ng/ml had a sensitivity of 94% and specificity of 59% for diagnosis of AAD. The WBC count was also significantly increased compared to the other groups (p<0.01). CRP and BNP values were significantly higher compared to normal controls but these parameters did not distinguish between AAD and chronic aneurysms. D-dimer can be used as a 'rule-out' test in patients with suspected AAD and seems useful in the discrimination between AAD and chronic uncomplicated aneurysms, unlike CRP and BNP plasma levels.

Simple and Useful Tests for Discriminating Between Acute Aortic Dissection of the Ascending Aorta and Acute Myocardial Infarction in the Emergency Setting

BACKGROUND

It is important to rapidly distinguish patients with acute aortic dissection of the ascending aorta (AADa) from those with acute myocardial infarction (AMI), because minimizing the time to initiation of reperfusion therapy leads to maximum benefits for AMI and erroneous reperfusion therapy for AADa can produce harmful outcomes. The aim of this study was to find a simple test to distinguish such patients.

METHODS AND RESULTS

Data were collected from 29 consecutive patients with AADa and 49 consecutive patients with AMI who were admitted within 4 h of the onset of symptoms. The D-dimer concentration and the ratio of the maximum upper mediastinal diameter to the maximum thoracic diameter on plain chest radiograph (M-ratio) in the emergency room were studied retrospectively. Setting the cutoff values of the D-dimer concentration and the M-ratio to 0.8 or 0.9 microg/ml and 0.309, respectively, gave a sensitivity of 93.1% and 93.1% for AADa, respectively, and a sensitivity of 91.8% and 85.7% for AMI, respectively.

CONCLUSIONS

The D-dimer value and the M-ratio, with appropriate cutoff values, have potential as tests that can be routinely used to exclude AADa patients from patients diagnosed with AMI prior to reperfusion therapy.

Serum C-reactive protein elevation predicts poor clinical outcome in patients with distal type acute aortic dissection: association with the occurrence of oxygenation impairment

BACKGROUND

Acute aortic dissection (AAD) is sometimes complicated by respiratory failure due to severe lung oxygenation impairment. Systemic activation of inflammatory system after aortic injury may play some roles in the development of this complication. The aim of this study was to determine the significance of serum C-reactive protein (CRP) elevation in the development of oxygenation impairment and clinical outcome with distal type AAD.

METHODS AND RESULTS

A total of 61 patients, who were admitted with distal type AAD within 24 h from the onset, were examined. Serum CRP levels, white blood cell (WBC) counts and body temperature were measured serially for at least 4 days. Oxygenation impairment, defined as the lowest PaO2/FIO2 ratio < or = 200 mmHg, was noted in 31 patients (51%). In patients with oxygenation impairment, peak CRP levels (20.7+/-7.9 vs. 12.7+/-3.8 mg/dl, P < 0.001), peak WBC counts (14,600+/-3600 vs. 11,800+/-4300/mm3, P = 0.008) and body temperature (38.4+/-0.5 vs. 38.0+/-0.6 degrees C, P = 0.004) were significantly higher than those without. Peak CRP level was inversely correlated with the lowest PaO2/FIO2 (P < 0.001). Patients who underwent urgent surgical treatment and/or died in the hospital had higher peak CRP levels (25.1+/-12.3 vs. 16.1+/-7.4 mg/dl, P = 0.010) than those who did not. Multivariate analysis revealed that a peak CRP level > or = 15 mg/dl (relative risk = 12.6, P < 0.001) was an independent determinant of the development of oxygenation impairment.

CONCLUSION

The greater serum CRP elevation after distal type AAD was associated with a higher incidence of oxygenation impairment and poor clinical outcome. Systemic activation of the inflammatory system after aortic injury may play an important role in the development of oxygenation impairment.

Plasma concentrations of interleukin-6, C-reactive protein, tumor necrosis factor-α and matrix metalloproteinase-9 in aortic dissection

BACKGROUND

The role of inflammation in aortic dissection (AD) has not fully been investigated. We evaluated the potential relationships between interleukin-6 (IL-6), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and matrix metalloproteinase-9 (MMP-9) and AD.

METHODS

Plasma concentrations of IL-6, TNF-α, MMP-9 and CRP were determined in 64 acute AD patients, 42 patients with chronic AD, 98 patients with hypertension alone, and 96 healthy subjects.

RESULTS

IL-6 concentrations were higher in acute AD than that in hypertension and healthy controls (10.98±2.38 vs. 3.79±1.56 and 3.32±1.60 pg/ml, P<0.05, respectively). Increased CRP concentrations were found in acute AD compared with chronic AD and hypertension as well as healthy subjects (13.48±3.74 vs. 4.12±2.99, 1.62±0.65 and 1.12±0.35 mg/l, P<0.001, respectively). Higher MMP-9 concentrations were detected in acute AD, chronic AD and hypertension compared with healthy controls (37.75±9.38, 55.78±6.41 and 31.03±7.94 vs. 21.24±7.28 ng/ml, P<0.05, P<0.001 and P<0.05, respectively), and in the dead compared to the survived (107.29±9.38 vs. 86.80±7.93 ng/ml, P<0.001) among acute AD patients. In acute AD, the time after onset had positive correlation with TNF-α (r=0.497, P=0.000), and negative correlation with CRP (r=-0.424, P=0.000). Plasma CRP levels decreased significantly when the onset time increased (P=0.013). Moreover, in the patients with acute AD who underwent surgery and stenting, plasma MMP-9 concentrations increased immediately after surgical treatment and stenting, and reached the peak values at 24h, then decreased at 1 week (P<0.001).

CONCLUSIONS

Our findings confirmed and extended previous studies that increased plasma inflammatory markers were significantly associated with AD.

Phenotypic variability of cardiovascular manifestations in Marfan Syndrome Possible role of hyperhomocysteinemia and C677T MTHFR gene polymorphism

AIMS

The aim of this study was to evaluate (1) homocysteinemia and the prevalence of the C677T MTHFR polymorphism in Marfan patients and (2) whether the severity of cardiovascular manifestations is associated with homocysteinemia and/or C677T polymorphism.

METHODS AND RESULTS

We studied 107 patients subdivided into three subgroups based on the severity of cardiovascular manifestations: (A) no involvement (n=4); (B) mild involvement (n=45); (C) aortic dilatation or aortic dissection (n=58), and 189 controls. Total homocysteine (tHcy) was significantly higher in subgroup C than in subgroup B. In subgroup C patients with dissection tHcy was higher than in those without dissection. In subgroup C the prevalence of 677T homozygotes was higher, but not significantly, than in the subgroup B. In patients with dissection the prevalence of 677T homozygotes was significantly higher than in those without dissection and than in subgroup B. In the logistic regression analysis, severe cardiovascular manifestations and aortic dissection in Marfan patients were associated with tHcy plasma levels.

CONCLUSIONS

Our data indicate an association between the severity of the cardiovascular manifestations, in particular aortic dissection, and elevated tHcy levels. This suggests an important role for tHcy in determining phenotypic variability in Marfan patients and provides further evidence for the association of homocysteinemia with the damage of the vascular system.

Thoracic aortic aneurysm frequency and dissection are associated with fibrillin-1 fragment concentrations in circulation

RATIONALE

Mutations in fibrillin-1 are associated with thoracic aortic aneurysm (TAA) in Marfan syndrome. Genome-wide association studies also implicate fibrillin-1 in sporadic TAA. Fragmentation of the aortic elastic lamellae is characteristic of TAA.

OBJECTIVE

Immunoassays were generated to test whether circulating fragments of fibrillin-1, or other microfibril fragments, are associated with TAA and dissection.

METHODS AND RESULTS

Plasma samples were obtained from 1265 patients with aortic aneurysm or dissection and from 125 control subjects. Concentrations of fibrillin-1, fibrillin-2, and fibulin-4 were measured with novel immunoassays. One hundred and seventy-four patients (13%) had aneurysms with only abdominal aortic involvement (abdominal aortic aneurysm), and 1091 (86%) had TAA. Of those with TAA, 300 patients (27%) had chronic dissection and 109 (10%) had acute or subacute dissection. Associations of fragment concentrations with TAA (versus abdominal aortic aneurysm) or with dissection (versus no dissection) were estimated with odds ratios (OR) and 95% confidence intervals (CI) adjusted for age, sex, and smoking. Compared with controls, significantly higher percentages of aneurysm patients had detectable levels of fibrillin fragments. TAA was significantly more common (than abdominal aortic aneurysm) in the highest compared with lowest quartile of fibrillin-1 concentration (OR=2.9; 95% CI, 1.6-5.0). Relative to TAA without dissection, acute or subacute dissection (OR=2.9; 95% CI, 1.6-5.3), but not chronic dissection, was more frequent in the highest compared with lowest quartile of fibrillin-1 concentration. Neither TAA nor dissection was associated with fibrillin-2 or fibulin-4.

CONCLUSIONS

Circulating fibrillin-1 fragments represent a new potential biomarker for TAA and acute aortic dissection.

Severe anaphylactic shock due to repeated application of aprotinin in patients following intrathoracic aortic replacement

Aprotinin is known to significantly reduce the incidence of perioperative bleeding complications in cardiac, thoracic and vascular surgery. Despite the wide use of this medication in other surgical fields, there are only a few reports of serious adverse side effects. In this paper we report on two patients with severe anaphylactic shock due to repeated administration of aprotinin, who both required cardiopulmonary resuscitation.

Aprotinin and bleeding in profoundly hypothermic perfusion

Clinical observation led us to believe that aprotinin fails to preserve haemostatic function in patients undergoing deep hypothermic perfusion with or without circulatory arrest. A retrospective study was made of blood loss in 80 consecutive acute Type A dissection patients before and during the aprotinin era (1987-1992). After 1988 all patients were cooled below 20 degrees C pending circulatory arrest. Fourteen patients underwent aortic root replacement and 66 replacements of the ascending aorta. Age distribution (range 22-79 years) and type of operation were similar in the aprotinin and control groups. The impervious Hemashield (Meadox) graft was used for all but five patients. These underwent aortic root replacement with preclotted, valved conduits. Overall the mean blood loss for 27 patients operated without aprotinin was 837 ml per 24 h (standard error +/- 90) and for 53 patients with aprotinin 1,929 ml per 24 h (standard error +/- 90). There was a significant difference between the two groups when profoundly hypothermic perfusion was used, with greater bleeding in aprotinin-treated patients. There were six re-entries in the aprotinin group and none in the control patients. There were ten hospital deaths (11.1%). A greater incidence of bleeding and thrombosis-related deaths was recorded for the aprotinin-treated patients. In addition, four surviving aprotinin patients suffered severe coagulation defect with blood loss greater than 4,500 ml and platelets less than 50 x 10(6). We suggest that aprotinin inhibits the protease enzymes which maintain the fluid state of blood during hypothermic low flow and arrest states. Disseminated intravascular coagulation may consume platelets thereby predisposing to abnormal bleeding and potentially fatal thrombotic events. The use of aprotinin in profoundly hypothermic perfusion should be adopted cautiously.

D-dimer as a biomarker for acute aortic dissection: a systematic review and meta-analysis

To perform a meta-analysis and examine the use of D-dimer levels for diagnosing acute aortic dissection (AAD). Medline, Cochrane, EMBASE, and Google Scholar were searched until April 23, 2014, using the following search terms: biomarker, acute aortic dissection, diagnosis, and D-dimer. Inclusion criteria were diagnosis of acute aortic dissection, D-dimer levels obtained, 2-armed study. Outcome measures were the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of D-dimer level for the diagnosis of AAD. Sensitivity analysis was performed using the leave-one-out approach. Of 34 articles identified, 5 met the inclusion criteria and were included in the analysis. The age of participants was similar between treatments within studies. The number of AAD patients ranged from 16 to 107 (total = 274), and the number of control group patients ranged from 32 to 206 (total = 469). The pooled sensitivity of D-dimer levels in AAD patients was 94.5% (95% confidence interval [CI] 78.1%-98.8%, P < 0.001), and the specificity was 69.1% (95% CI 43.7%-86.5%, P = 0.136). The pooled area under the receiver-operating characteristic curve for D-dimer levels in AAD patients was 0.916 (95% CI 0.863-0.970, P < 0.001). The direction and magnitude of the combined estimates did not change markedly with the exclusion of individual studies, indicating the meta-analysis had good reliability. D-dimer levels are best used for ruling out AAD in patients with low likelihood of the disease.

Significance of serum troponin I elevation in patients with acute aortic dissection of the ascending aorta

OBJECTIVE

This study evaluated the prevalence of increased cardiac troponin I (cTnI) in patients with acute aortic dissection of the ascending aorta (type A).

METHODS AND RESULTS

In 119 consecutive patients with type A acute aortic dissection, serum cardiac troponin I was measured along with clinical, haemodynamic, electrocardiographic and echocardiographic variables obtained on admission. Cardiac troponin I was positive in 28 patients (23.5%; mean +/- SD: 6.1 +/- 14.7 ng/ml) and above the myocardial infarction threshold (1.5 ng/ml) in 12 (10%). Catecholamine infusion (17.9% vs. 4.4%; p = 0.03) and higher value of creatinine (35.7% vs. 15.4%; p = 0.03) were more frequent in patients with elevated troponin. Total mortality was 29.7% (n = 35) and surgical mortality was 16.8% (n = 17). An increased troponin was discriminatory with respect to mortality (OR: 4.1 (1.6-9.9); p = 0.002) in univariate analysis. However, this association was lost when other markers of death (age, stroke, ST-segment elevation, tamponade, catecholamine infusion, renal failure) were added in a multivariate model (OR: 2.2 (0.7-7.4); p = 0.19) indicating that the myocardial loss associated with troponin increase is not in itself a factor of mortality.

CONCLUSIONS

Cardiac troponin I elevation is frequent in patients with type A aortic dissection. It might reflect a higher haemodynamic stress but does not necessarily reflect a negative prognosis.

Determinants of In-Hospital Death and Rupture in Patients With a Stanford B Aortic Dissection

BACKGROUND

In Stanford B acute aortic dissection (AAD), medical treatment is the choice of therapy in the acute phase, however, a portion of patients experience complications caused by serious clinical outcomes including aortic rupture and abdominal visceral ischemia. The objective of this study was to determine the predictors of in-hospital events in an Asian cohort of Stanford type B AAD.

METHODS AND RESULTS

Hospital records were queried to identify patients that met following criteria: (1) AAD presenting within 14 days of symptom onset; and (2) computed tomography (CT) confirmation of a dissected descending aorta not involving the ascending aorta. An in-hospital event was defined as death, rupture/impending rupture, or organ malperfusion. Patient characteristics, inflammatory markers, and CT findings were obtained from clinical case records and retrospectively analyzed. Two hundred and twenty patients with Stanford B AAD were identified. In-hospital events occurred in 15 patients (there were 8 deaths, and 5 patients need to undergo emergent surgery because of impending rupture or rupture, and 4 patients experienced organ malperfusion). In univariate logistic regression analysis, the non-thrombosed type (odds ratio (OR) 3.88, 95% confidence interval (CI) 1.20-12.61, p=0.02) and maximum aortic diameter measured by an initial CT (each having a 5 mm increment: OR 1.61, 95% CI 1.20-2.15, p=0.001) were significant predictors of in-hospital events. In multiple logistic regression analysis, the only significant predictor was maximum aortic diameter measured by an initial CT (each having a 5 mm increment: OR 1.41, 95% CI 1.04-1.92, p=0.03).

CONCLUSION

The results identified a large maximum aortic diameter as the independent predictor of in-hospital events in Stanford type B AAD. The non-thrombosed type might also help differentiate high-risk patients.

Impact of Admission White Blood Cell Count on Short- and Long-term Mortality in Patients With Type A Acute Aortic Dissection: An Observational Study

Studies have shown inflammation is involved in the development of acute aortic dissection (AAD). The hypothesis that white blood cell count (WBCc) on admission may have an impact on the short- and long-term outcomes of type A AAD was tested in a large-scale, prospective observational cohort study.From 2008 to 2010, a total of 570 consecutive patients with type A AAD in Fuwai hospital were enrolled and were followed up. Baseline characteristics and WBCc on admission were collected. The primary outcomes were 30-day and long-term all-cause mortality.During a median of 1.89 years of follow-up, the 30-day and long-term all-cause mortality were 10.7% and 6.5%, respectively. Univariate Cox regression analysis identified admission WBCc as an independent predictor of 30-day mortality when considered as a continuous variable or as a categorical variable using the cutoff of 11.0 × 10 cells/L (all P < 0.05). After adjustment for age, sex, C-reactive protein, D-dimer, and surgical intervention, elevated admission WBCc (>11.0 × 10 cells/L) remained an independent predictor of 30-day mortality of AAD (hazard ratio = 3.31, 95% confidence interval 1.38-7.93, P = 0.007). No impact of admission WBCc was observed on the long-term all-cause mortality.In conclusion, elevated admission WBCc may be valuable as a predictor of 30-day mortality, and may be useful in the risk stratification of type A AAD during hospitalization.

In search of blood tests for thoracic aortic diseases

A number of new diagnostic screening tools have been developed for the assessment of acute and chronic diseases of the thoracic aorta. Although standardized blood-based tests capable of detecting individuals at risk for aortic aneurysm and dissection disease are not yet available, our current knowledge is expanding at a rapid rate and the future is very promising. In this review, an update of the contemporary knowledge on blood tests for detecting thoracic aortic diseases in both preclinical and clinical settings is provided, offering the potential to predict adverse aortic events, such as enlargement, rupture, and dissection.

Clinical characteristics of spontaneous isolated visceral artery dissection

OBJECTIVE

Spontaneous isolated visceral artery dissection (SIVAD) involving the celiac artery or superior mesenteric artery is rare, but it can be fatal. Given its rare incidence, the clinical characteristics of SIVAD are not fully understood. Therefore, the aim of this study was to investigate the clinical characteristics and prognosis of SIVAD.

METHODS

We retrospectively reviewed 39 consecutive patients diagnosed with SIVAD from January 2007 to December 2016. Demographic characteristics, symptoms, vital signs, blood examination results, and computed tomography findings were retrieved through medical record review.

RESULTS

The median age of the patients was 52 years; 94.9% were male, and 64.1% were symptomatic. Median follow-up duration was 11 months. Overall, hypertension (48.7%) and smoking (79.5%) were frequently observed. There were significant differences between symptomatic and asymptomatic patients in white blood cell count and creatine kinase level but not in fibrin degradation products or D-dimer level. There was a significant correlation between symptoms and length of dissection on computed tomography (P < .01). Conservative treatment was performed in 32 patients (82.1%), and only 7 patients required open surgery or intravascular intervention. Notably, the diameter of affected vessels decreased spontaneously with no rupture or symptom recurrence during follow-up, and mortality was 0% at both 30 days and 1 year.

CONCLUSIONS

The utility of blood examination, especially for fibrin degradation products and D-dimer levels, for diagnosis of SIVAD is limited. A high index of suspicion is warranted in patients presenting with persistent severe abdominal pain. Conservative treatment should be considered first-line therapy in patients without any signs of bowel ischemia or rupture.

Changes in coagulation condition, cytokine, adhesion molecule after repair of type A aortic dissection

OBJECTIVE

Because residual dissection often exists even after the repair of a type A dissection, we evaluated coagulation conditions, cytokine levels, and adhesion molecule levels in mid-term follow up after repair of type A dissections.

METHODS

Thrombin-antithrombin III complex (TAT), D-dimer, soluble interleukin-2 receptor (sIL-2R), soluble intercellular adhesion molecule (sICAM)-1, and type III procollagen peptide (PIIIP) were measured in 12 patients (mean age=63 years) following the repair of a type A aortic dissection at 6-82 months after repair (median=33 months).

RESULTS

In the chronic phase, TAT and D-dimer were significantly higher in patients following the repair of a type A dissection compared to healthy controls (TAT; 12+/-8 vs. 2.5+/-1.2 ng/ml, P = 0.0001, D-dimer; 779+/-1384 vs. 104+/-46 U/ml, P = 0.0001). Cytokine was significantly higher in the affected patients (sIL-2R; 556+/-205 vs. 398+/-132 U/ml, P = 0.003, sICAM-1; 255+/-131 vs. 211+/-48 ng/ml, P = 0.136). Collagen turnover (PIIIP) showed a significantly higher value in the affected patients (0.80+/-0.32, vs. 0.58+/-0.13 U/ml, P = 0.002). sIL-2R, sICAM-1 and PIIIP showed a negative correlation with the follow-up period (sIL-2R; r = -0.733, P = 0.0067, sICAM-1; r = -0.61, P = 0.035, PIIIP; r = -0.692, P = 0.0126). We found a positive correlation between aortic size and TAT (r = 0.644, P = 0.0238, n = 12) as well as with D-dimer (r = -0.7831, P = 0.0106, n = 12) and TAT showed significantly higher values in the residual dissection group compared to those without residual dissection (16.6+/-7.9 vs. 7.45+/-4.75 ng/ml, P = 0.035).

CONCLUSION

Hypercoagulation conditions continued even after repair. Both TAT and D-dimer would be good indices for following up patients having repaired aortic dissections. Furthermore, cytokine, adhesion molecules, and collagen turnover would return to a stable state unless impairment and expansion of the vessel wall occurred.

A case–control study found that low albumin and smoking were associated with aortic dissection

OBJECTIVE

Hypertension is a risk factor for aortic dissection. Besides hypertension, associated factors for incidence of aortic dissection are not clear. The aim of this study was to examine whether other factors exist by an epidemiologic case-control approach.

STUDY DESIGN AND SETTING

240 consecutive cases suffering from acute aortic dissection were hospitalized in our university from 1989 to 2000. Blood chemistries and other information obtained immediately after admissions for the first attack were available in 226 patients. A case-control approach was performed by frequency matching age, sex, and history of hypertension in the remaining 226 cases with those of 226 healthy controls drawn from a similar geographic catchment area and all observed in 1989.

RESULTS

The mean albumin (3.6 +/- 0.5 vs. 4.3 +/- 0.2 g/dL: P<.001) level of cases was significantly lower than that of controls (odds ratio: 0.004 per g/dL). The frequency with which cases of current smokers was significantly higher than that of controls (odds ratio: 3.475). The above parameters of cases compared with controls were statistically significant after adjustments for age, sex, and history of hypertension.

CONCLUSION

Low albumin levels and smoking in addition to hypertension are significantly associated with aortic dissection.

Increased interleukin-11 levels in thoracic aorta and plasma from patients with acute thoracic aortic dissection

BACKGROUND

Interleukin (IL) 11 is closely related to tumor and hematological system diseases. Recent studies have demonstrated that IL-11 also participates in cardiovascular diseases, including ischemia-reperfusion mediated heart injury and acute myocardial infarction. This study aimed to investigate whether IL-11 is involved in acute thoracic aortic dissection (TAD).

METHODS

Aortic tissue samples from normal donors and acute TAD patients were collected, and the expression of IL-11 in all aortic tissue was analyzed. In addition, blood samples from patients with chest pain were collected and divided into a non-AD (NAD) group and a TAD group according to the results of computed tomography angiography of the thoracic aorta. The plasma IL-11, IL-17 and interferon (IFN) γ in all blood samples were measured.

RESULTS

Compared with aortic tissue of normal controls, IL-11 was significantly increased in aortic tissue of acute TAD patients, especially in the torn section. The IL-11 was derived from aorta macrophages in TAD. In addition, the plasma IL-11, IL-17 and IFN-γ were significantly higher in acute TAD patients than in NAD patients, and the correlation analysis showed that IL-11 levels were positively correlated with levels of IFN-γ, IL-17, glucose, systolic blood pressure, diastolic blood pressure, white blood cells, C-reactive proteins and D-dimers. Binary logistic regression analyses showed that elevated IL11 in patients who may have diagnostic value of TAD, but less that D-dimer.

CONCLUSION

IL-11 was increased in thoracic aorta and plasma of TAD patients and may be a promising biomarker for diagnosis in patients with TAD.