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This article reviews the recent and relevant literature to the field of aortic surgery. Specific areas highlighted include outcomes of Stanford type A dissection, management of acute aortic syndromes, management of aortic aneurysms, and traumatic aortic injury. Although the focus was on articles from 2023, literature from prior years also was included, given that this article is the first of a series. Notably, the pertinent sections from the 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management Aortic Disease are discussed. [ABSTRACT FROM AUTHOR]

A pulmonary artery periadventitial hematoma is a rare complication of a Stanford type A intramural hematoma. As the proximal ascending aorta and pulmonary artery share a common adventitial layer, extravasated blood from the intramural hematoma in the ascending thoracic aorta may extend to beneath the adventitia of the pulmonary artery. The authors describe a case involving a 66-year-old male with acute chest pain who presented with a pulmonary artery periadventitial hematoma associated with a Stanford type A intramural hematoma. [ABSTRACT FROM AUTHOR]

Aortic dissection is infrequent in everyday practice; however, it can result in life-threatening complications and causes more deaths each year in the UK than road traffic collisions. It is one of the family of acute aortic syndromes, which includes penetrating aortic ulcer (PAU) and intramural haematoma (IMH). Type A aortic dissections involve the ascending aorta and arch and almost invariably require prompt surgical treatment due to exceptionally high early 48-hour mortality without surgery. Many type B aortic dissections (TBAD) are not complicated at presentation and can be treated conservatively in high dependency and discharged without intervention. Complicated aortic dissection requires intervention, often with a thoracic endovascular aortic repair (TEVAR). The survival after TBAD is higher than type A dissection that invariably requires emergency operative intervention, with 65% of patients surviving to 1 year. Following acute aortic syndrome, best medical therapy involves tight blood pressure and heart rate control using beta-blockers or calcium channel blockers. Statin therapy may be of benefit. Regular cross-sectional imaging surveillance is important to detect late complications such as aortic dilatation. In type B aortic dissection, aortic dilatation is a common cause of late rupture with only 50% of patients surviving after 5 years without intervention. One of the most important questions at present is whether people at high risk of further aortic dilatation can be identified and intervened on early to prevent these late complications? [ABSTRACT FROM AUTHOR]

Hybrid approaches involving staged open surgical and percutaneous endovascular procedures are rapidly emerging in the panorama of major aortic disease. The most recent guidelines support progressive expansion and adoption of this approach especially for patients who might not tolerate major aortic surgery. The multidisciplinary context in which these hybrid procedures arise require more comprehensive and integrated anaesthesiology involvement in the in their planning and execution. This review will summarize the key concepts in aortic disease management, the current status of hybrid aortic procedures and focus on the anaesthetic management of thoracic aortic endovascular and hybrid procedures. As utilization of endovascular arch stents is expected to rise, it is crucial that cardiac anaesthesiologists are familiar with their inherent complexities, anaesthetic considerations, and potential complications. [ABSTRACT FROM AUTHOR]

Copyright of Archives Medical Review Journal / Arsiv Kaynak Tarama Dergisi is the property of Cukurova University, Faculty of Medicine and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This study aimed to investigate and compare the discriminative performance and clinical utility of D-dimer and the neutrophil-to-lymphocyte ratio (NLR) in the early differential diagnosis of acute aortic syndrome (AAS). The consecutive patients presenting to Tianjin Chest Hospital for suspected AAS were retrospectively investigated between June 2018 and December 2021. The baseline values of D-dimer and NLR were analyzed and compared in the study population. The discriminative ability of D-dimer and NLR was illustrated and compared using the area under the receiver operating characteristic (ROC) curve (AUC), net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Clinical utility was evaluated by means of decision curve analysis (DCA). In the study period, a total of 697 participants suspected of having AAS were enrolled and 323 had a final diagnosis of AAS. The baseline level of NLR as well as D-dimer was higher in patients with AAS. The use of NLR showed excellent overall diagnostic performance for AAS with a comparable AUC to that of D-dimer (0.845 vs. 0.822, P > 0.05). The reclassification analyses further confirmed that NLR had better discriminative properties for AAS with a significant NRI of 66.1% and IDI of 12.4% (P < 0.001). Moreover, NLR provided higher net benefit than D-dimer as shown by DCA. Similar results were observed in subgroup analyses according to the different classes of AAS. NLR outperformed D-dimer with improved discriminative performance and superior clinical utility in identifying AAS. As a more readily available biomarker, NLR may be a reliable alternative to D-dimer for the screening of suspected AAS in clinical practice. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Acute cardiac emergencies are life threatening. The initial responses to acute cardiac emergencies must be rapid, efficient, skillful, and well-planned. The goal of this article is to provide information that can be used to facilitate the prompt recognition and treatment of the most common acute cardiac emergencies. [ABSTRACT FROM AUTHOR]

Cardiovascular diseases (CVDs) are among the most common causes of access to the Emergency Department and among the leading causes of death worldwide. Accurate diagnostic algorithms are mandatory to ensure a rapid life-saving treatment. However, non-specific clinical presentation and unnecessary referrals to other subspecialties may lead to misinterpretation of the diagnosis and delays. In recent years, the development of imaging technologies has allowed Computed Tomography (CT) to play a prominent role in the concepts of CVD rule-in and rule-out. An optimization strategy for CT protocols is needed to reduce variability and improve image quality. A correct diagnostic suspicion is crucial, as different districts (i.e., heart, aorta and pulmonary circulation) may require different investigation techniques. Additionally, the CVD pre-test probability assessment is highly correlated with CT accuracy. The purpose of this narrative review is to analyze the current role of CT in the approach to the CVDs in the ED, and to analyze the main strategies of CT optimization. [ABSTRACT FROM AUTHOR]

To describe the outcome of open thoracoabdominal aortic aneurysm (TAAA) repair following previous aortic arch repair including elephant trunk (ET) or frozen elephant trunk (FET) for acute and chronic pathologies. This was a retrospective, observational, multicenter study including 32 patients treated between 2006 and 2019 in two aortic centers using identical surgical protocols. Assessment focused on perioperative and long-term outcome, namely in-hospital morbidity and mortality, as well as procedure-related reintervention rate and aortic-related mortality rate. Kaplan-Meier curves with 95% confidence intervals were used to analyze the overall survival after surgery within the cohort. Thirty-two patients (mean age, 45.0 ± 13.6 years; 20 males [62.5%]) were treated because of acute (34.38% [n = 11]) or chronic (65.62% [n = 21]) aortic pathologies, including residual dissection following acute, symptomatic type A dissection (n = 7) and symptomatic mega aortic syndrome (n = 4), as well as post-dissection TAAA (n = 18) and asymptomatic mega aortic syndrome (n = 3). Twenty-eight patients (87.5%) received type II repair, and 4 patients (12.5%) received type III repair after previous ascending aorta and arch repair including ET/FET. Concomitant infrarenal and iliac vessel repair was performed in 38.7% (n = 12) and 29.4% (n = 10), respectively. The in-hospital mortality rate was 18.75% (n = 6). Spinal cord ischemia occurred in two cases, both after one-stage emergency procedure with one case of permanent paraplegia. Temporary acute kidney injury occurred in 41.94% (n = 13). The estimated 1-year survival rate was 78.1% (95% confidence interval, 63.9%-95.6%), with a median follow-up time of 1.29 years (interquartile range, 0.26-3.88 years). No procedure-related reinterventions and one case of aortic-related mortality, namely sepsis because of graft infection, was observed. Open TAAA repair following aortic arch repair including ET or FET because of acute or chronic aortic pathologies is associated with a relevant perioperative morbidity and mortality rate. During follow-up, a low aortic-related mortality rate and procedure-related reintervention rate were observed. [ABSTRACT FROM AUTHOR]

Acute aortic syndrome (AAS) includes the entities of acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. AAS typically presents with sudden onset of severe, tearing, anterior, or interscapular back pain. Symptoms may be dominated by malperfusion syndrome, due to obstruction of the lumen of the aorta and/or a side branch when the intimal and medial layers are separated. Timely diagnosis of AAS is crucial to permit prompt management; for example, early mortality rates are reported to be 1% to 2% per hour after the onset of symptoms for untreated ascending aortic dissection. The appropriateness assigned to each imaging procedure was based on the ability to obtain key information that is used to plan open surgical, endovascular, or medical therapy. This includes, but is not limited to, confirming the presence of AAS; classification; characterization of entry and reentry sites; false lumen patency; and branch vessel compromise. Using this approach, CT, CTA, and MRA are all considered usually appropriate in the initial evaluation of AAS if those procedures include intravenous contrast administration. Ultrasound is also considered usually appropriate if the acquisition is via a transesophageal approach. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]

Aortic dissection is infrequent in everyday practice; however, it can result in life-threatening complications and causes more deaths each year in the UK than road traffic collisions. It is one of the family of acute aortic syndromes, which includes penetrating aortic ulcer (PAU) and intramural haematoma (IMH). Type A aortic dissections involve the ascending aorta and arch and almost invariably require prompt surgical treatment due to exceptionally high early 48-hour mortality without surgery. Many type B aortic dissections (TBAD) are not complicated at presentation and can be treated conservatively in high dependency and discharged without intervention. Complicated aortic dissection requires intervention, often with a thoracic endovascular aortic repair (TEVAR). The survival after TBAD is higher than type A dissection that invariably requires emergency operative intervention, with 65% of patients surviving to 1 year. Following acute aortic syndrome, best medical therapy involves tight blood pressure and heart rate control using beta-blockers or calcium channel blockers. Statin therapy may be of benefit. Regular cross-sectional imaging surveillance is important to detect late complications such as aortic dilatation. In type B aortic dissection, aortic dilatation is a common cause of late rupture with only 50% of patients surviving after 5 years without intervention. One of the most important questions at present is whether people at high risk of further aortic dilatation can be identified and intervened on early to prevent these late complications? [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Markers of serological autoimmunity such as anti-nuclear antibodies (ANA) are noted in approximately 14.01% of the Chinese population. The vast majority will do not have clinical autoimmune disease. However, the possible influence of antinuclear antibodies in acute aortic syndromes (AAS) has not been elucidated. The study group included 77 patients who underwent AAS. Serum levels of antinuclear (ANA) were tested. Patients detailed data on AAS risk factors and markers of subclinical index (including C-reactive protein, D-dimmer, Glucose, Creatine kinase) were available. Results: Of the 77 patients with AAS, 40 had classic acute aortic dissection 29 variants intramural hematoma (IMH) and 8 penetrating atherosclerotic ulcer (PAU). Among the control group, 12/76 (15.8%) were ANA positive. In marked contrast, among the study subjects 30/77 (39.0%) were ANA positive. There is a higher incidence of ANA positivity among the study group than among the control group (p = 0.001). The presence of ANAs was related to the occurrence of AAS (r = 0.224, p = 0.005). Meanwhile, the positive ANAs were correlated with atherosclerosis (r = 0.167, p = 0.039), the red blood cell count (r = −0.245, p = 0.002) and C-reactive protein (r = 0.181, p = 0.042). Our results indicate that ANA positivity is associated with incidence of AAS, especially the incidence of intramural hematoma (IMH), suggesting that mechanisms resulting in ANA production may be involved in the development of AAS. [ABSTRACT FROM AUTHOR]

Penetrating aortic ulcer (AU) is defined as localized disruption of the intimal layer of the aortic wall, resulting in a crater-like lesion outpouching from the vessel contour. AU is a generic term which encompasses a constellation of entities with different etiologies and prognoses and may be a complication of infective, inflammatory, traumatic, iatrogenic, atherosclerotic processes or intramural hematoma. One of the most challenging scenarios of AU for a differential diagnosis, but also for treatment implications, is when they are associated with acute aortic syndrome. Despite advances in the field of aortic disease, lack of consensus defining these lesions and the significant semantic confusion in the medical literature of the acronym PAU (for penetrating aortic ulcer but also for penetrating atherosclerotic ulcer) have given rise to controversy in guidelines and expert consensus, leading to the same treatment being recommended for entities with different etiology and prognosis. Moreover, in the medical literature, most diagnoses were mainly based on imaging techniques which identified AU regardless of clinical symptoms, surrounding imaging findings or dynamic morphologic changes. In this Review, we provide the latest insight into the differential diagnosis between AU, also called penetrating aortic ulcers, based on clinical context and the newest imaging characteristics to aid treatment decision-making. [ABSTRACT FROM AUTHOR]

Objective Type B acute aortic syndrome (AAS) encompasses aortic dissection (AD) and intramural haematoma (IMH), the diagnosis, evolution, and treatment of which are subject to controversies. The aim of this pilot investigation was to assess the ability of specific magnetic resonance imaging (MRI) criteria to differentiate AD from IMH and predict optimal aortic remodeling following AAS. Methods In this retrospective study, all patients presenting between 2008 and 2015 with type B AAS, who had diagnostic MRI following admission, were included. Three MRI criteria were proposed to identify IMH: (i) no visualised entry tear; (ii) no contrast uptake in the aortic lesion on the first pass angiographic run; (iii) no contrast uptake in the aortic lesion on the equilibrium phase T1 sequence. On each patient's diagnostic and follow up imaging studies, the volume of (i) false lumen/IMH, (ii) total aorta, and (iii) true lumen were calculated. Using the Wilcoxon signed rank test, the evolution of these volumes according to the presence or absence of the aforementioned criteria were compared. Results Of 39 patients, in seven all MRI criteria were positive (group IMH) and 32 had one or more negative criteria (group AD). Patients with IMH and AD were similar with respect to sex, age, and delay between onset of symptoms and diagnostic and follow up imaging studies. Eighteen patients had a follow up imaging study after a mean period of 11.2 months: six in the IMH group and 12 in the AD group. Lesion volume decrease and relative true lumen volume increase were statistically significant in group IMH (p =.046 and p =.046, respectively), whereas there was a statistically significant increase of lesion volume (p =.008) in the AD group. Conclusion This pilot study proposed three simple MRI criteria to differentiate between AD and IMH. Once prospectively and clinically validated, this could have substantial therapeutic benefits as IMH are likely to heal spontaneously. [ABSTRACT FROM AUTHOR]

Abstract Objective To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch. Methods Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared. Results The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; P =.115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; P <.001), endovascular treatment (3.5% vs 25.0%; P <.001), and medical management (16.2% vs 51.4%; P <.001). Overall in-hospital mortality was similar (16.7% vs 19.3%; P =.574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; P =.090), and higher after endovascular (25.0% vs 14.3%; P =.597) or medical treatment (24.3% vs 13.9%; P =.191), although the differences were not significant. Conclusions Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection. Graphical abstract [ABSTRACT FROM AUTHOR]

Background: The quality of acute aortic syndrome (AAS) assessment by emergency medical service (EMS) and the incidence and prehospital factors associated with 1-month survival remain unclear.Methods: We retrospectively analyzed the data collected for 94,468 patients with non-traumatic medical emergency excluding out-of-hospital cardiac arrest during the period of 2011-2014.Results: Of these transported by EMS, 22,075 had any of the AAS-related symptoms, and 330 had an EMS-assessed risk for AAS; of these, 195 received an in-hospital AAS diagnosis. Of the remaining 21,745 patients without EMS-assessed risk, 166 were diagnosed with AAS. Therefore, the sensitivity and specificity of our EMS-risk assessment for AAS was 54.0% (195/361) and 99.4% (21,579/21,714), respectively. EMS assessed the risk less frequently when patients were elderly and presented with dyspnea and syncope/faintness. Sign of upper extremity ischemia was rarely detected (6.9%) and absence of this sign was associated with lack of EMS-assessed risk. The calculation of modified aortic dissection detection risk score revealed that rigorous assessment based on this score may increase the EMS sensitivity for AAS. The 1-month survival rate was significantly higher in patients admitted to core hospitals with surgical teams for AAS than in those admitted to all other hospitals [87.5% (210/240) vs 69.4% (84/121); P<0.01]. Multiple logistic regression analysis demonstrated that Stanford type A, Glasgow coma scale ≤14, and admission to core hospitals providing emergency cardiovascular surgery were associated with 1-month survival.Conclusions: Improvement of AAS survival is likely to be affected by rapid admission to appropriate hospitals providing cardiovascular surgery. [ABSTRACT FROM AUTHOR]

To determine whether aortic enlargement in 2 weeks in patients with type B acute aortic syndrome is associated with aorta-related adverse events. This retrospective, single-center study included 183 patients who were diagnosed with uncomplicated type B acute aortic syndrome (classic aortic dissection and intramural hematoma) between 2010 and 2019 and had follow-up computed tomography at second or third week. Aortic diameter was measured at admission and at predischarge follow-up. Aorta-related adverse events were defined by a composite of aortic rupture, surgical or endovascular aortic repair, redissection, severe intestinal malperfusion, and aortic enlargement. The patients whose aortic diameter enlarged ≥2 mm but <5 mm in 2 weeks were categorized as moderate aortic enlargement group. During follow-up, 51 patients (28%) had aorta-related adverse events and 36 patients (20%) had moderate aortic enlargement. Patients with moderate aortic enlargement showed lower aorta-related event-free survival rates than those without moderate enlargement (48 ± 9% vs 90 ± 3% at 1 year, P <.001). On multivariable analysis, moderate aortic enlargement (subhazard ratio, 3.64; 95% confidence interval, 2.08-6.35; P <.001) and aortic diameter ≥40 mm at admission (subhazard ratio, 2.96; 95% confidence interval, 1.60-5.48; P <.001) were associated with aorta-related adverse events. Moderate aortic enlargement in 2 weeks is a significant risk factor of aorta-related adverse events in patients with uncomplicated type B acute aortic syndrome. Patients with moderate aortic enlargement should be followed up carefully and may be candidates for subsequent endovascular treatment. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective/Background The aim of the study was to assess a model of physician modified scalloped stent graft (PMSG) on currently available thoracic aortic devices to extend the proximal landing zone in either zone 2, 1 or 0 of the aortic arch while preserving flow in the supra-aortic vessels on human cadaveric aorta. Methods Fresh human aortas were harvested at autopsy from adult subjects. A proximal scallop was made on the stent grafts based on direct measurements on the aortas to extend the proximal landing zone in zone 0 ( n = 5), zone 1 ( n = 5), and zone 2 ( n = 5). A previously described benchtop closed system pulsatile flow model was used to mimic flow and pressure conditions in the aorta to deploy the stent graft as close to physiological conditions as possible. Deployment accuracy of the scallop opposite the aortic arch branch ostia was assessed by completion angiography and post-procedural analysis of the aortas. Results Fifteen proximal scalloped stent grafts were deployed in the aortic arch of 15 human cadaveric aortas under fluoroscopy. The expected proximal landing zone was achieved in all cases (zone 2 = 5; zone 1 = 5; zone 0 = 5). Post-procedural angiography and direct visual analysis showed supra-aortic vessel patency and deployment of the scallop opposite the aortic arch branch ostia in all cases. Conclusion PMSG to extend the proximal landing zone in zone 2, 1, or 0 in order to treat urgent diseases of the proximal descending aorta or the inner circumference of the aortic arch by a totally endovascular approach while preserving flow in the supra-aortic trunks is experimentally feasible. [ABSTRACT FROM AUTHOR]

Background: Aortic dissection is typically evaluated with computed tomography angiography (CTA). However, the feasibility of using magnetic resonance angiography (MRA) in the ED is unclear. This study examined the indications and outcomes of MRA in suspected aortic dissection evaluation in the ED.Methods: An IRB approved review identified patients who underwent MRA in the ED for acute thoracic aortic dissection from January 2010 to June 2016. Demographics, clinical assessment, CTA contraindications, outcomes, and ED disposition were analyzed.Results: 50 MRAs were ordered for suspected thoracic aortic dissection. 21 (42%) for iodinated contrast allergy, 21 (42%) for renal insufficiency, 2 (4%) due to both, 2 (4%) to spare ionizing radiation, 2 (4%) for further work-up after CTA, and 2 (4%) due to prior contrast enhanced CT within 24h. Median ED arrival to MRA completion time was 311min. 42 studies were fully diagnostic; 7 were limited. One patient could not tolerate the examination. 49 MRAs were completed: 2 (4%) patients had acute dissection on MRA and 47 (96%) had negative exams. 17 (35%) received gadolinium. 18 (37%) patients were discharged home from the ED with a median length of stay of 643min. 2 (4%) were admitted for acute dissection seen on MRA and 29 (59%) for further evaluation.Conclusion: MRA has a clear role in the evaluation for acute thoracic aortic dissection in the ED in patients with contraindications to CTA, and can guide management and facilitate safe discharge to home. [ABSTRACT FROM AUTHOR]

Acute aortic pathologies include acute aortic syndrome (aortic dissection, intramural hematoma, penetrating aortic ulcer), impending rupture, aortic aneurysm rupture and aortic trauma. Acute aortic syndrome, aortic aneurysm rupture and aortic trauma are life-threatening conditions requiring prompt diagnosis and treatment. The basic imaging modality for "acute aorta" is CT angiography with typical findings for these aortic pathologies. Based on the CT, it is possible to classify aortic diseases and anatomical classifications are essential for the planning of treatment. Currently, endovascular treatment is the method of choice for acute diseases of the descending thoracic aorta and is increasingly indicated for patients with ruptured abdominal aortic aneurysms. [ABSTRACT FROM AUTHOR]

Acute aortic syndrome represents a group of potentially lethal aortic diseases, including classic acute aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. Among these conditions, type A aortic dissection is the most common acute presentation. Only surgical interventions are recommended in guidelines as lifesaving procedures for type A dissection. Despite new diagnostic imaging methods, advanced surgical strategy, and improved postoperative management in the over 250-year history of aortic dissection, in-hospital mortality and morbidity rates still remain high. Recently, several new system-based approaches, such as implementation of multidisciplinary experienced high-volume centers and establishment of regional systematic management flow have been reported to improve the outcome. Here, we will describe the pathophysiology, diagnosis, and treatment as well as the new systematic approach to treat acute aortic syndrome. [ABSTRACT FROM AUTHOR]

For the management of acute aortic syndromes, regional treatment networks have been established to coordinate diagnosis and treatment between local emergency rooms and central specialized centers. Triage of acute aortic syndromes requires definitive imaging, resulting in complex data files. Modern information technology network structures, specifically “cloud” technology, coupled with mobile communication, increasingly support sharing of these data in a network of experts using mobile, online access and communication. Although this network is technically complex, the potential benefit of online sharing of data files between professionals at multiple locations within a treatment network appear obvious; however, clinical experience is limited, and further evaluation is needed. [ABSTRACT FROM AUTHOR]

Copyright of West Indian Medical Journal is the property of West Indian Medical Journal (WIMJ) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

It is estimated that 15% of traffic accidents cause trauma to large vessels. In about 70%-95% of cases, aortic rupture took place in the distal ligament of the left subclavian artery, whereas in the remaining cases rupture occurred in the ascending aorta above the aortic valve. Trauma to the aortic sinus and coronary arteries is rarely found in traffic accident victims. Therefore, coronary artery trauma is often misdiagnosed as coronary atherosclerotic heart disease. The present case is a 42 years old male who survived from a traffic accident. He presented with aortic sinus and left coronary artery trauma. He was misdiagnosed as having coronary atherosclerotic heart disease, and therefore wrongly given antiplatelet medicine, such as aspirin, in another hospital. Definite diagnosis was achieved in our hospital, and the patient underwent Bentall and mitral valve replacement, as well as tricuspid valvuloplasty. The aortic occlusion time during surgery was 47 min, and the total cardiopulmonary bypass time was 63 min. After surgery, transthoracic echocardiography confirmed that all the artificial valves worked sufficiently. The patient felt good and symptoms such as asthma and decreased exercise tolerance disappeared. This case taught us that acute aortic syndrome cannot be ignored when patients present with pectoralgia; antiplatelet medication should not be given before definite diagnosis. [ABSTRACT FROM AUTHOR]

The interfacility transfer (IT) of patients with a ruptured abdominal aortic aneurysm (rAAA) occurs not infrequently to allow for a higher level of care. In the present study, we evaluated, using a contemporary administrative database, the effects of IT on mortality after rAAA repair. The Healthcare Cost and Utilization Project Database for New York (2016) and New Jersey, Maryland, and Florida (2016-2017) was queried using the International Classification of Diseases, 10th edition, to identify patients who had undergone open or endovascular repair of AAAs. The hospitals were categorized into quartiles (Qs) per overall volume. The mortality rates for IT vs nontransferred (NT) rAAA patients stratified by treatment modality (open aneurysm repair of an rAAA [rOAR] vs endovascular aneurysm repair of an rAAA [rEVAR]) were compared. A Cox proportional hazard model was used to estimate the hazard ratios (HRs) for mortality. A total of 1476 patients had presented with a rAAA, of whom 673 (45.7%) were not treated. Of the remaining 803 patients, 226 (28.1%) were transferred, of whom 50 (22.1%) had died without repair after IT. The remaining 753 patients (IT, n = 176; NT, n = 576) had undergone rEVAR (n = 492) or rOAR (n = 261). The baseline characteristics were similar between the IT and NT patients, except for a greater proportion of black patients (P =.03), lower income families (P =.049), and rOAR (45.5% vs 31.4%; P =.001) for the IT patients. The overall mortality rates were similar between the NT (30.2%) and IT (27.3%) groups (P =.46). The subgroup analysis revealed that the operative mortality rates after rEVAR were similar between the NT and IT patients, without significant differences among the hospital quartiles. After rOAR, however, the operative mortality rates were lower for the IT patients, largely owing to improved outcomes in the Q4 hospitals (Q4 vs Q1-Q3, P =.001). Cox regression analysis demonstrated that age (HR, 1.03; 95% confidence interval, 1.00-1.06; P =.02) and treatment at a low-volume hospital (Q1-Q3; HR, 1.89; 95% confidence interval, 1.02-3.51; P =.04) were predictors of mortality. The total charges were similar (IT, $286,727; vs NT, $265,717; P =.38). The results from the present study have shown that <30% of rAAA patients deemed a candidate for repair will be transferred. We found that IT did not affect the mortality rates after rEVAR, irrespective of the hospital volume. For rOAR candidates, however, regionalization of care with prompt transfer to a high-volume center could improve the survival benefits without increased healthcare costs. [ABSTRACT FROM AUTHOR]

Background Prompt diagnosis and early referral to specialized centers is critical for patients presenting with cardiovascular emergencies, including acute aortic syndromes (AAS). Prior data has suggested that mobile access to imaging studies with hand-held devices can accelerate diagnosis and management. Objective We conducted a study to determine the diagnostic accuracy of a hand-held device compared to conventional dedicated work-stations for diagnosing a spectrum of cardiovascular emergencies, predominantly acute aortic pathology. Methods This study included 104 cases who underwent computed tomography (CT)-scan during “on-call’’ hours between January, 2013 and August, 2014 for suspected AAS. Assessment was performed on a hand-held device independently by two readers using an iPhone5 connected via secure connection to web-based PACS servers. The subsequent interpretation from a dedicated workstation coupled with the diagnosis at the time of discharge was used as the reference standard for determining the presence or absence of an acute abnormality. Sensitivity and Specificity were calculated on a per patient basis. Results Readers' sensitivity and specificity using the hand-held device to diagnose acute chest pathology were calculated. Hand-held device evaluation was determined to have a sensitivity of 85.2% and a specificity of 98.6% by reader A and a sensitivity of 96.3% and specificity of 100% by reader B. Of 103 cases interpreted by both readers, the readers agreed about the diagnosis in 98 cases (95.1%). Conclusion This study demonstrates that hand-held devices can be a potential useful tool to assist in diagnosis and triage of patients presenting with cardiovascular emergencies. Further studies are needed to assess the impact of screen size and resolution. [ABSTRACT FROM AUTHOR]

Acute aortic syndrome is a relatively recent clinical entity. Non-invasive imaging methods, such as computed tomography and transesophageal echocardiography, have contributed significantly to the diagnosis of variant forms of classic aortic dissection, which have become important disease entities in acute aortic syndrome. Imaging findings may result in risk stratification and application of different treatment options, providing a rational approach to achieve a better outcome of this syndrome. This review will focus on the imaging characteristics of two important variant forms of classic aortic dissection, intramural hematoma and incomplete dissection, and the role of imaging methods in the evaluation of differences in the hemodynamic status of false lumens that contributes to patient prognosis. [ABSTRACT FROM AUTHOR]

Intramural hematoma is the most enigmatic of the 3 lethal entities comprising acute aortic syndrome. Despite being identified almost 100 years ago, there is considerable controversy surrounding the definition, etiology, management, and the very existence of intramural hematoma. The following review outlines these controversies and discusses their effect on management strategies. [ABSTRACT FROM AUTHOR]

Anastomotic pseudoaneurysm remains one of the main life-threatening complications after surgery on the thoracic aorta. We report a case with a history of ascending and aortic arch replacement and a false aneurysm creation at the anastomotic line found at the 2-year follow-up computed tomography. Either, due to incidental and asymptomatic finding and patient negation to any kind of intervention, it has been followed the medical treatment with blood pressure and heart rate control. In this, we discuss also the ways of treatment and the indication of any interventional therapy. Endovascular stent-grafting is a minimal invasive treatment for thoracic aortic aneurysm. However, its clinical usefulness for anastomotic false aneurysm following thoracic aortic surgery is unclear. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To determine the incidence and risk factors for spinal cord ischaemia (SCI) following thoracic and thoracoabdominal aortic intervention. Methods: A prospective database of all thoracic and thoracoabdominal aortic interventions between 2001 and 2009 was used to investigate the incidence of SCI. All elective and emergency cases for all indications were included. Logistic regression was used to investigate which factors were associated with SCI. Results: 235 patients underwent thoracic aortic stent grafting; 111(47%) thoracic aortic stent-grafts alone, with an additional 14(6%) branched or fenestrated thoracic grafts, 30(13%) arch hybrid procedures and 80(34%) visceral hybrid surgical and endovascular procedures. The global incidence of SCI for all procedures was 23/235 (9.8%) and this included emergency indications (ruptured TAAA and acute complex dissections) but the incidence varied considerably between types of procedures. Of the 23 cases, death occurred in 4 patients but recovery of function was seen in 6. Thus, permanent paraplegia occurred in 13/235 (5.5%) patients. Of the nine pre-specified factors investigated for association with SCI, only percentage of aortic coverage was significantly associated with the incidence of SCI; adjusted odds ratio per 10% increase in aorta covered = 1.78[95% CI 1.18–2.71], p = 0.007. The procedures in patients who developed SCI took longer (463.5 versus 307.2 minutes) and utilised more stents (4 versus 2). Conclusion: SCI following thoracic and thoracoabdominal aortic endovascular intervention is associated with the proportion of aorta covered. The degree of risk varies between different types of procedure and this should be carefully considered in both selection and consenting of patients. [ABSTRACT FROM AUTHOR]

Summary: Background: Not only symptoms but electrocardiographic (ECG) changes mimicking acute coronary syndrome as well have been known to develop in acute aortic dissection (AAD). However, detailed information is lacking. Objective: We sought to evaluate incidence, patterns, and underlying mechanisms for acute ECG changes in type A AAD. Methods: Retrospective study in a single tertiary care hospital. A total of 159 cases (mean age 65.1±14.8 years, male/female=67/92) that presented within 12h from the onset were included. Shift of the ST segment ≧0.1mV or changes of the T wave were considered acute ECG changes. Results: Acute and chronic ECG changes were observed in 49.7% and 36.5% cases, respectively. ECG was normal only in 27.0% cases. ST elevation was observed in 8.2% cases and was closely related to direct coronary involvement. ST depression and T wave changes were observed in 34.0% and 21.4% cases, respectively. Cases with ST depression or T wave changes had higher incidence of shock (65.2% vs. 28.8%, p <0.001) and cardiac tamponade (51.2% vs. 15.0%, p <0.001) compared with those without changes. Conclusion: Acute ECG changes were common in type A AAD. Physicians taking care of patients with chest pain and acute ECG changes should consider the possibility of AAD before performing thrombolysis or percutaneous catheter intervention. [Copyright &y& Elsevier]

Abstract: Intramural hematoma (IMH) of the aorta and penetrating aortic ulcer (PAU) are important variant forms of classic double-barrel aortic dissection in patients presenting with acute aortic syndrome. Recent insights provided by modern high-resolution imaging are currently challenging previous pathophysiologic concepts underlying IMH and PAU, suggesting a close relationship of both entities. Thoracic endovascular aortic repair (TEVAR) offers a less invasive approach to the treatment of affected patients with very encouraging early to midterm results. This review discusses current indication for TEVAR in IMH and PAU patients in the view of an improved understanding of these diseases. [Copyright &y& Elsevier]

Acute aortic syndrome (AAS) is a summary term for three life-threatening acute aortic pathologies: aortic dissection, intramural hematoma, and penetrating aortic ulcer. Transthoracic echocardiography (TTE) is a screening tool for assessing chest pain in an emergency setting, diagnosing AAS with suboptimal sensitivity. However, TTE is very important in assessing potentially high-risk AAS features, e.g., pericardial effusion, left ventricular regional wall motion abnormalities, dilated aortic root, and aortic regurgitation; and diagnosing other conditions with similar clinical AAS features, e.g., acute coronary syndrome and acute pulmonary embolism. Computed tomography (CT) is the gold standard for diagnosing AAS. Multidetector CT has higher sensitivity and specificity compared to conventional CT. Transesophageal echocardiography (TEE) is for intraoperative guidance and perioperative monitoring of AAS, and if a local TEE expert is available, diagnosing AAS. [Copyright &y& Elsevier]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Disparities in cardiovascular disease according to socioeconomic factors and ethnicity are a global issue. The indigenous Māori population of New Zealand is not exempt. The aims of the present study were to assess whether ethnic disparities exist in the presentation and outcomes of acute aortic syndrome (AAS), including aortic dissection, intramural hematoma, and penetrating aortic ulcer, in New Zealand. A retrospective observational cohort study of consecutive AAS patients presenting to a tertiary referral center covering the Midland region of New Zealand (population, 816,900; 23.3% Māori) during a 10-year period was completed (2010-2020). Data were assessed by ethnicity (Māori vs non-Māori) and Stanford classification of AAS. The incidence of disease, 30-day mortality, and long-term all-cause and aortic-related mortality were recorded and assessed using logistic regression and Cox proportional hazards models. A total of 250 patients had presented with AAS (Māori, 92 [36.8%]; type A, 144 [57.6%]). The age-standardized rates of AAS were higher in Māori than in non-Māori patients (6.9/100,000 person-years vs 2.0/100,000 person-years; risk ratio, 3.56; 95% confidence interval, 1.50-8.53; P =.002). Māori patients had presented at a younger age for both type A (age, 54.4 ± 12 years vs 66.0 ± 13.2 years; P <.001) and type B (age, 61.3 ± 10.2 years vs 68.8 ± 13.7 years; P =.005) AAS. Mortality at 30 days was higher for those with type A than for those with type B AAS (33.3% vs 13.2%; P <.001) but did not differ by ethnicity in our cohort. On multivariate analysis, no differences were found in 30-day or long-term survival when stratified by ethnicity. The results from the present study have demonstrated that ethnic disparities in AAS exist in New Zealand, with Māori presenting at a younger age and with a greater incidence compared with other ethnicities. Whether this disparity is related to socioeconomic factors, access to preventive care, or other factors remains to be elucidated. Despite these differences in disease presentation, the survival outcomes when stratified by ethnicity were comparable in the present cohort. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to assess the safety and the effectiveness of endovascular stent grafting of chronic aortic dissection (AD) in Marfan patients. Background: The management of chronic AD of the descending thoracic aorta (DTA) is challenging. This is especially true in Marfan patients, who tend to exhibit poor short- and long-term results after conventional surgery. Methods: Fifteen patients with Marfan''s syndrome and chronic AD of the DTA were identified among the 457 patients of the European Talent Registry. All patients underwent endovascular treatment. Results: No major adverse event was encountered during the procedure. Five patients experienced a primary endoleak (type 1, n = 4; type 2, n = 1). Three of them died, and 1 underwent successful conversion to open surgery. Five other patients experienced secondary endoleak (type 1, n = 4; type 3, n = 1). Four of them underwent successful conversion to either open or endovascular reintervention. Two other patients underwent successful conversion to open repair because of secondary aortic enlargement below the stent graft. After a mean follow-up of 2.1 ± 1.4 years, 12 patients are alive. Of these 12, conversion to open repair was successfully performed in 5 patients. In the remaining 7 patients, complete thrombosis of the false lumen was achieved in 6 patients, with partial thrombosis in 1 patient. Conclusions: Endovascular stent grafting of the dissected DTA is feasible in selected Marfan patients with low mortality and morbidity rates. Nevertheless, the rate of primary and secondary endoleak is high. Close imaging surveillance is crucial to detect secondary aortic complications and to assess long-term results. [Copyright &y& Elsevier]

The development of retrospective electrocardiographic (ECG)-gating has proved to be a diagnostic and therapeutic boon for computed tomography (CT) imaging of patients with acute thoracic aortic diseases, such as aortic dissection/intramural hematoma (AD/IMH), penetrating atherosclerotic ulcer (APU), and ruptured/leaking aneurysm. The notorious pulsation motion artifacts in the ascending aorta confounding regular CT scanning can be eliminated, and involvement of the sinuses of Valsalva, the valve cusps, the aortic annulus, and the coronary arteries in aortic dissection can be clearly depicted or excluded. Motion-free images also allow reliable identification of the site of the primary intimal tear, the location, and extent of the intimomedial flap, and branch artery involvement. ECG-gated CTA also allows the detection of more subtle lesions and variants of aortic dissection, which may ultimately expand our understanding of these complex, life-threatening disorders. [Copyright &y& Elsevier]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: The aim of this study was to evaluate mid-term results of endovascular treatment of penetrating aortic ulcers. Methods: Between February 2000 and November 2006, 18 consecutive patients underwent endovascular treatment of the descending thoracic aorta (N =16) and abdominal infrarenal aorta (N =2) for penetrating aortic ulcer, in a single University Hospital. Data were prospectively collected and retrospectively analyzed. Mean follow-up was 41 months (range 4 to 77 months). Results: Technical success was achieved in all patients. No perioperative deaths occurred. No conversion to open repair or secondary procedures were required. Two patients died in the follow-up period for reasons not related to penetrating aortic ulcers. One type II endoleak was observed. It was still present, unchanged, twelve months after the procedure. Conclusion: Endovascular treatment of penetrating aortic ulcers of the descending thoracic and infrarenal aorta were safe and effective in the mid-term in this small series of patients. [Copyright &y& Elsevier]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Thoracic endovascular aortic repair (TEVAR) has undergone rapid evolution and is now applied to a range of aortic pathologies. Imaging plays a vital role in the pre- and postintervention assessment of TEVAR patients. Accurate characterization of pathology and evaluation for high-risk anatomic features are necessary in the planning phase, and careful assessment for graft stability, aortic lumen diameter, and presence of endoleak are paramount in the follow-up period. CTA is the imaging modality of choice for pre- and postintervention assessment, and MRA is an acceptable alternative depending on patient stability and graft composition. Lifelong imaging follow-up is necessary in TEVAR patients because endoleaks may develop at any time. The exact surveillance interval is unclear and may be procedure and patient specific. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]