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OBJECTIVES Ascending aortic length has recently been recognized as a novel predictor of adverse events in aortic diseases, but its prognostic value in type A intramural haematoma is unknown. We aimed to evaluate the association between ascending aortic length and outcomes in patients with type A intramural haematoma initially managed medically. METHODS We retrospectively analysed patients with acute type A intramural haematoma. Ascending aortic length was measured by computed tomography. The primary outcome was aortic progression, defined as aortic intervention or aortic-related death. RESULTS A total of 98 patients were enrolled. During a median follow-up of 2.6 years, aortic progression occurred in 27 patients (27.6%), i.e. 9 events per 100 patient-years. Patients with ascending aortic length ≥11 cm had significantly higher rates of aortic progression [54.2% (20.9 events per 100 patient-years) vs 18.9% (6.1 events per 100 patient-years), P  = 0.001], surgical intervention (45.8% vs 12.2%, P  = 0.001) and presence of ulcer-like projection (25.0% vs 2.7%, P  = 0.002) compared to those with ascending aortic length <11 cm. Kaplan–Meier analysis demonstrated lower progression-free survival in the ascending aortic length ≥11 cm group (P  = 0.0021). Ascending aortic length had a sensitivity of 61.9% and specificity of 77.8% for predicting aortic progression, with an area under the curve of 0.756 (95% confidence interval 0.649–0.862). CONCLUSIONS Ascending aortic elongation may identify a high-risk subgroup of acute type A intramural haematoma patients initially managed medically who could potentially benefit from early surgery. Ascending aortic length should be considered in the risk stratification and management of these patients. [ABSTRACT FROM AUTHOR]

A 54-year-old female presented with recurrent abdominal pain and new onset chest pain. Chest computed-tomography angiogram detected a thoracic aortic aneurysm with suspected Type A intramural hematoma (IMH) versus aortitis. Initially, conservative management was pursued while awaiting a definitive diagnosis. Differential workup was negative, while additional imaging modalities favored IMH, prompting expedited surgical intervention. During ascending aortic and hemiarch replacement, severe aortitis was unexpectedly discovered without evidence of IMH. Histopathological examination of the aortic specimens identified transmural aortic inflammation with lymphoplasmacytic infiltrate and irregular fibrosis. Numerous IgG4-positive plasma cells were present with IgG4/IgG ratio of 40–50% suggesting IgG4-related disease (IgG4-RD). Subsequent analysis revealed B cells positive for clonal IgH gene rearrangement, and bone marrow biopsy then revealed the same clonal B cells. She was ultimately diagnosed with CLL, the most common phenotype of monoclonal B-cell lymphocytosis, thought to account for the IgG4-predominant plasma cells causing aortitis. Although rare, this case highlights the importance of considering IgG4-related disease (IgG4-RD) as a cause of aortitis when assessing symptomatic patients with aortic pathologies, emphasizing the complexities involved in diagnosing due to a variety of imaging presentation, differentiating, and managing large-vessel vasculitides. Moreover, it underscores the importance of Multidisciplinary Aortic Team care and the use of multiple diagnostic modalities in evaluating ambiguous aortic pathologies. [ABSTRACT FROM AUTHOR]

Background: Penetrating aortic ulcers (PAU) are life-threatening conditions which derive from severely advanced atherosclerotic lesions of the aorta. The clinical course is unpredictable; thus clinical vigilance should be maintained. It is very challenging to separate PAU from co-existing AAS as predisposing factors and findings overlap. Case presentation: Case of 58-year-old gentleman, who presented for atypical chest pain in the setting of respiratory tract infection. Computed Tomographic angiography (CTA) of the chest showed a large PAU and intramural hematoma which rapidly progressed into an acute aortic dissection in the emergency department. Close follow up with cardiac point of care ultrasound one hour later detected an intimal flap which was not initially present on CTA. Patient underwent surgical aortic graft replacement and had an uneventful in-hospital stay. Discussion: This case underlines the importance of broadening differential diagnoses in atypical presentations in patients with risk factors. Prompt intervention and careful management are imperative to optimize patient outcomes and prevent complications of aortic lesions. Cardiac point of care ultrasound can help in detecting progression of dynamic atherosclerotic diseases such as acute aortic syndrome. [ABSTRACT FROM AUTHOR]

Background Diagnosis of acute aortic syndrome is challenging and associated with high perihospital mortality rates. The study aim was to evaluate current pathways and understand the chronology of acute aortic syndrome patient care. Method Consecutive patients with acute aortic syndrome imaging diagnosis between 1 January 2018 and 1 June 2021 were identified using a predetermined search strategy and followed up for 6 months through retrospective case note review. The UK National Interventional Radiology Trainee Research and Vascular and Endovascular Research Network co-ordinated the study. Results From 15 UK sites, 620 patients were enrolled. The median age was 67 (range 25–98) years, 62.0% were male and 92.9% Caucasian. Type-A dissection (41.8%) was most common, followed by type-B (34.5%); 41.2% had complicated acute aortic syndrome. Mode of presentation included emergency ambulance (80.2%), self-presentation (16.2%), and primary care referral (3.6%). Time (median (i.q.r.)) to hospital presentation was 3.1 (1.8–8.6) h and decreased by sudden onset chest pain but increased with migratory pain or hypertension. Time from hospital presentation to imaging diagnosis was 3.2 (1.3–6.5) h and increased by family history of aortic disease and decreased by concurrent ischaemic limb. Time from diagnosis to treatment was 2 (1.0–4.3) h with interhospital transfer causing delay. Management included conservative (60.2%), open surgery (32.2%), endovascular (4.8%), hybrid (1.4%) and palliative (1.4%). Factors associated with a higher mortality rate at 30 days and 6 months were acute aortic syndrome type, complicated disease, no critical care admission and age more than 70 years (P < 0.05). Conclusions This study presents a longitudinal data set linking time-based delays to diagnosis and treatment with clinical outcomes. It can be used to prioritize research strategies to streamline patient care. [ABSTRACT FROM AUTHOR]

Abstract A 54-year-old female presented with recurrent abdominal pain and new onset chest pain. Chest computed-tomography angiogram detected a thoracic aortic aneurysm with suspected Type A intramural hematoma (IMH) versus aortitis. Initially, conservative management was pursued while awaiting a definitive diagnosis. Differential workup was negative, while additional imaging modalities favored IMH, prompting expedited surgical intervention. During ascending aortic and hemiarch replacement, severe aortitis was unexpectedly discovered without evidence of IMH. Histopathological examination of the aortic specimens identified transmural aortic inflammation with lymphoplasmacytic infiltrate and irregular fibrosis. Numerous IgG4-positive plasma cells were present with IgG4/IgG ratio of 40–50% suggesting IgG4-related disease (IgG4-RD). Subsequent analysis revealed B cells positive for clonal IgH gene rearrangement, and bone marrow biopsy then revealed the same clonal B cells. She was ultimately diagnosed with CLL, the most common phenotype of monoclonal B-cell lymphocytosis, thought to account for the IgG4-predominant plasma cells causing aortitis. Although rare, this case highlights the importance of considering IgG4-related disease (IgG4-RD) as a cause of aortitis when assessing symptomatic patients with aortic pathologies, emphasizing the complexities involved in diagnosing due to a variety of imaging presentation, differentiating, and managing large-vessel vasculitides. Moreover, it underscores the importance of Multidisciplinary Aortic Team care and the use of multiple diagnostic modalities in evaluating ambiguous aortic pathologies.

Abstract Background Penetrating aortic ulcers (PAU) are life-threatening conditions which derive from severely advanced atherosclerotic lesions of the aorta. The clinical course is unpredictable; thus clinical vigilance should be maintained. It is very challenging to separate PAU from co-existing AAS as predisposing factors and findings overlap. Case presentation Case of 58-year-old gentleman, who presented for atypical chest pain in the setting of respiratory tract infection. Computed Tomographic angiography (CTA) of the chest showed a large PAU and intramural hematoma which rapidly progressed into an acute aortic dissection in the emergency department. Close follow up with cardiac point of care ultrasound one hour later detected an intimal flap which was not initially present on CTA. Patient underwent surgical aortic graft replacement and had an uneventful in-hospital stay. Discussion This case underlines the importance of broadening differential diagnoses in atypical presentations in patients with risk factors. Prompt intervention and careful management are imperative to optimize patient outcomes and prevent complications of aortic lesions. Cardiac point of care ultrasound can help in detecting progression of dynamic atherosclerotic diseases such as acute aortic syndrome.

Introduction: Acute aortic syndrome (AAS) includes the disease processes of aortic dissection, penetrating atherosclerotic ulcer, and intramural hematoma. This case demonstrates an atypical presentation of the disease and offers approaches to potentially prevent missed diagnoses.Case Report: An 87-year-old female with hypertension and Alzheimer’s dementia presented to the emergency department with stable vital signs and a chief complaint of throat pain. Initial work-up was significant for ischemia on electrocardiogram and elevated troponin. Computed tomography of the soft tissue neck revealed evidence of a ruptured aorta.Conclusion: Aortic rupture is a fatal complication of AAS. In an elderly patient with a history of hypertension, ischemic changes on electrocardiogram, and nonspecific pain, AAS should be on the emergency physician’s differential even in the setting of a benign or limited history and exam.

The document titled "2024 ESC Guidelines for the management of peripheral arterial and aortic diseases" is a comprehensive guide that provides recommendations for the evaluation, screening, and treatment of peripheral arterial and aortic diseases. It covers topics such as epidemiology, risk factors, and diagnostic methods for these conditions. The guidelines outline optimal medical treatments, including lifestyle changes and pharmacological therapies, and discuss specific conditions such as peripheral arterial disease and carotid artery disease. The document also addresses aortic diseases, including atheromatous disease and aortic aneurysms, and offers guidance on treatment options such as surgery and endovascular repair. It provides information on genetic and congenital diseases of the aorta, as well as polyvascular peripheral arterial disease. The document concludes with key messages, gaps in evidence, and recommendations for practice, emphasizing the importance of individualized care, multidisciplinary management, and early diagnosis. [Extracted from the article]

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]

In this publication we collected some rare clinical cases referred to surgery in our institution for cardiac surgery over the last ten years. All these patients were previously discussed with our "Heart team": repeated recurrence of a left atrial myxoma; congenital coronary arteriovenous fistulae; cardiac echinococcosis; aortopulmonary fistula in aortic dissection - a rare complication in acute aortic syndrome; ectopic thyroid tumor in the right ventricle. [ABSTRACT FROM AUTHOR]

(1) Background: Identifying acute aortic syndrome (AAS) and thoracic aortic aneurysm (TAA) in busy emergency departments (EDs) is crucial due to their life-threatening nature, necessitating timely and accurate diagnosis. (2) Methods: This retrospective case-control study was conducted in the ED of three hospitals. Adult patients visiting the ED between 1 January 2010 and 1 January 2020 with a chief complaint of chest or back pain were enrolled in the study. The collected chest radiography (CXRs) data were divided into training (80%) and testing (20%) datasets. The training dataset was trained by four different convolutional neural network (CNN) models. (3) Results: A total of 1625 patients were enrolled in this study. The InceptionV3 model achieved the highest F1 score of 0.76. (4) Conclusions: Analysis of CXRs using a CNN-based model provides a novel tool for clinicians to interpret ED patients with chest pain and suspected AAS and TAA. The integration of such imaging tools into ED could be considered in the future to enhance the diagnostic workflow for clinically fatal diseases. [ABSTRACT FROM AUTHOR]

Objectives: Aortic intramural hematoma (IMH) is a rare disease. Thus far, only limited data is available and the indications for conservative and endovascular treatment are not well defined. The aim of this study was to investigate clinical presentation, course, CT imaging features and outcome of patients with type B aortic IMHs. Methods: We included all patients with type B IMHs between 2012 and 2021 in this retrospective monocentric study. Clinical data, localization, thickness of IMHs and the presence of ulcer-like projections (ULPs) was evaluated before and after treatment. Results: Thirty five patients (20 females; 70.3 y ± 11 y) were identified. Almost all IMHs (n = 34) were spontaneous and symptomatic with back pain (n = 34). At the time of diagnosis, TEVAR was deemed indicated in 9 patients, 26 patients were treated primarily conservatively. During the follow-up, in another 16 patients TEVAR was deemed indicated. Endovascularly and conservatively treated patients both showed decrease in thickness after treatment. Patients without ULPs showed more often complete resolution of the IMH than patients with ULPs (endovascularly treated 90.9% (10/11) vs 71.4% (5/7); conservatively treated 71.4% (10/14) vs 33.3% (1/3); P =.207). Complications after TEVAR occurred in 32% and more frequently in patients treated primarily conservatively (37.5% vs 22.2%). No in-hospital mortality was observed during follow-up. Conclusions: Prognosis of IMH seems favourable in both surgically as well as conservatively treated patients. However, it is essential to identify patients at high risk for complications under conservative treatment, who therefore should be treated by TEVAR. In our study, ULPs seem to be an adverse factor for remodeling. [ABSTRACT FROM AUTHOR]

OBJECTIVES Gender difference in the outcome after type A aortic dissection (TAAD) surgery remains an issue of ongoing debate. In this study, we aimed to evaluate the impact of gender on the short- and long-term outcome after surgery for TAAD. METHODS A multicentre European registry retrospectively included all consecutive TAAD surgery patients between 2005 and 2021 from 18 hospitals across 8 European countries. Early and late mortality, and cumulative incidence of aortic reoperation were compared between genders. RESULTS A total of 3902 patients underwent TAAD surgery, with 1185 (30.4%) being females. After propensity score matching, 766 pairs of males and females were compared. No statistical differences were detected in the early postoperative outcome between genders. Ten-year survival was comparable between genders (47.8% vs 47.1%; log-rank test, P  = 0.679), as well as cumulative incidences of distal or proximal aortic reoperations. Ten-year relative survival compared to country-, year-, age- and sex-matched general population was higher among males (0.65) compared to females (0.58). The time-period subanalysis revealed advancements in surgical techniques in both genders over the years. However, an increase in stroke was observed over time for both populations, particularly among females. CONCLUSIONS The past 16 years have witnessed marked advancements in surgical techniques for TAAD in both males and females, achieving comparable early and late mortality rates. Despite these findings, late relative survival was still in favour of males. [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.

Introduction: The in situ fenestration (ISF) technique consists of maintaining the patency of the aortic branch after the endoprosthesis is already in place as a viable, effective, and fast-performing alternative to revascularize the aortic arch arteries. Objective: To report the experience with a series of cases of endovascular treatment of Acute Aortic Syndromes involving the aortic arch, using the ISF technique in a specialized center. Methods: We analyzed data collected from patients treated with ISF during TEVAR for Acute Aortic Syndromes involving the aortic arch from June 2020 to January 2022, assessing perioperative outcomes, including immediate and late success rates, complications, morbidity and mortality, and short and medium term aortic branch patency. Results: Of the 11 patients eligible for the ISF procedure, 9 were successful, with a technical success rate of 81%. No patient had a type 1A endoleak related to fenestration. There was complete thrombosis of the false lumen in the thoracic aorta in 77% cases. No death was related to the fenestration technique. Conclusion: ISF as feasible and with a high rate of technical success and good results in the short and medium term. Prospective studies with long-term clinical follow-up are still needed to fully assess the durability of these unreinforced fenestrations. [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]

Background Tyrosine kinase inhibitors targeting the vascular endothelial growth factor (VEGF) inhibitor pathway with immune checkpoint blockade have shown promising outcomes in managing metastatic renal cancer. However, they increase the risk of a person developing high blood pressure and cardiovascular complications. Case summary In this study, we report the case of a 73-year-old woman on axitinib and pembrolizumab for her Stage 4 renal cell carcinoma. She presented with intractable chest pain and high systolic blood pressure, not responding to opiates. Her computed tomography angiography results showed an acute intra-mural haematoma with a rupture in the descending thoracic aorta. She underwent emergency thoracic endovascular aortic repair. Post-operatively, she recovered fully without any neurological or cardiovascular issues. Discussion The severity of cardiovascular haemodynamic complications arising from the consumption of VEGF inhibitors and from immunotherapy and the lack of anti-hypertensive strategies to adequately manage such events require an unequivocal and urgent assessment of their cardiovascular safety. This case highlights the crucial role of cardiovascular oncology in managing such acute aortic catastrophes. [ABSTRACT FROM AUTHOR]

Acute aortic dissection is often misdiagnosed as a result of its atypical presentations. It affects 4000 patients a year in the UK of all ages, not just older patients, with increasing numbers of cases expected in the future because of the ageing population. Dissection of the aortic wall leads to sudden, severe pain, and commonly end-organ symptoms which must be recognised. Acute aortic dissection can be challenging to diagnose in the emergency department because of the multitude of possible presentations and the need for selective testing with Computed Tomography Angiography (CTA). Clinicians often miss acute aortic dissection because it is not considered in the differential diagnosis, and the challenge lies in identifying acute aortic dissection in a sea of complaints of chest, back and abdominal pain. There are several ways to improve diagnosis, including awareness campaigns, better education about patients in which to consider acute aortic dissection, and improved detection strategies including which patients should receive CTA. Clinical decision tools and biomarkers could help, but further research is required and is a research focus in emergency medicine. Once diagnosed, blood pressure control, analgesia and urgent surgery or transfer to enable this to occur with minimal delay is required. [ABSTRACT FROM AUTHOR]

Purpose: This study reports the outcomes from a Multicenter Registry on unibody stent-graft system for the treatment of spontaneous infrarenal acute aortic syndrome (MURUSSIAS registry). Materials and methods: The retrospective MURUSSIAS registry included spontaneous infrarenal acute aortic dissection (IAAS) managed with the unibody stent-graft system (AFX endovascular AAA system; Endologix Inc., Irvine, California) outside the current instruction for use. IAAS considered aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU). Indications to IAAS treatment were symptoms, associated dilated abdominal aorta (>3 cm), rapidly-growing (>0.5 cm/6 months) aorta, IAAS disease progression. Measured results were technical success, early (within 30 days) and midterm outcomes (after 30 days), including mortality, complications, symptoms recurrence, type I/III endoleak occurrence, stent-graft patency, survival, and freedom from reintervention. The mean follow-up was 22.12 ± 17 months. Results: The MURUSSIAS registry included 83 patients from 7 participating centers. IAAS indication to treatment were symptoms in 42 (51%). In 14 (17%) patients, the infrarenal aortic length was <80 mm, and in 28 (34%), the aortic bifurcation diameter was <16 mm. Technical success was 100%. Mortality occurred early in 1 (1%) and at the midterm in 3 (4%) patients. Complications occurred early in 10 (12%) patients (1 severe, 3 moderates, and 6 mild) and at midterm in 2 (2%) (2 moderate). No symptoms' recurrence or type I/III endoleaks were registered. The 36-month estimated survival and freedom from reinterventions were 89% and 92%, respectively. Conclusions: The MURUSSIAS registry is the largest collection of spontaneous IAAS managed endovascularly using the AFX endovascular AAA system. The IAAS peculiar anatomic features were fitted with the used technique with excellent results. This treatment strategy might be considered in IAAS unless specifically-designed endovascular solutions will be available also in the emergent setting. Further studies are required to assess the longer-term performances and the stability of the reported technique. Clinical Impact: The lack of specifically designed devices for infrarenal acute aortic syndrome (IAAS) disease remains an issue principally for its specific anatomic features. The MURUSSIAS registry retrospectively examined the outcomes of spontaneous IAAS treated using the unibody stent-graft system in a spontaneous national study; and reports the largest available data on this topic. The use of the unibody stent-graft system showed to fit the anatomic peculiarities of IAAS with excellent outcomes. This IAAS treatment strategy should be considered unless specifically designed endovascular solutions will be available. [ABSTRACT FROM AUTHOR]

Background and objectivesAcute aortic syndrome (AAS) is a life-threatening condition in which there is a fracture in the integrity of the aortic wall. gamma-glutamyl transferase to lymphocyte ratio (GLR) is recognized as a risk factor for liver cirrhosis, fibrosis, and hepatocellular carcinoma. However, there are no clinical reports of GLR and AAS. We attempted to determine whether GLR level is associated with AAS in patients from the Chaoshan region of southern China.MethodsA total of 2,384 patients were recruited in this study and were divided into AAS and no-AAS groups according to the results of CT angiography of the thoracoabdominal aorta. Univariate and multivariate logistic regression was performed to identify risk factors for the occurrence of AAS. ROC was applied to assess the value of D-Dimer, GLR alone, or in combination for the diagnosis of AAS. And a 1:1 propensity score-matched analysis was performed.ResultsMultivariate logistics regression analysis indicated that male, age, hypertension, diabetes, creatinine, D-dimer, and GLR were independent risk factors of AAS patients in the before propensity score-matching cohort. After propensity score-matching, it showed that D-dimer, GLR [OR 3.558(1.891, 6.697); p

Abstract Background Acute aortic syndrome (AAS) is a life-threatening condition. Inflammation plays a key role in the pathogenesis, development and progression of AAS, and is associated with significant mortality and morbidity. Understanding the inflammatory responses and inflammation resolutions is essential for an appropriate management of AAS. Method Thirty Chinese cardiovascular centers have collaborated to create a multicenter observational registry (named Chinese Additive Anti-inflammatory Action for Aortopathy & Arteriopathy [5A] registry), with consecutive enrollment of adult patients who underwent surgery for AAS that was started on Jan 1, 2016 and will be ended on December 31, 2040. Specially, the impact of inflammation and anti-inflammatory strategies on the early and late adverse events are investigated. Primary outcomes are severe systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), Sequential Organ Failure Assessment (SOFA) scores at 7 days following this current surgery. Secondary outcomes are SISR, 30-day mortality, operative mortality, hospital mortality, new-onset stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. Discussion The analysis of this multicenter registry will allow our better knowledge of the prognostic importance of preoperative inflammation and different anti-inflammatory strategies in adverse events after surgery for AAS. This registry is expected to provide insights into novel different inflammatory resolutions in management of AAS beyond conventional surgical repair. Trial registration ClinicalTrials.gov Identifier: NCT04398992 (Initial Release: 05/19/2020).

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates. [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]

Spinal cord ischemia leading to paraplegia is a rare, life-limiting complication of acute type B aortic dissection. We report a case of spinal cord ischemia occurred in a young woman treated with endovascular scissor technique in urgent setting. The patient had an uneventful post-procedural course. After 4 months, computed tomography angiography confirmed false lumen reperfusion and major symptoms were regressed. In selected cases, this procedure is a tool to improve false lumen perfusion in type B dissections, and demonstrated to be helpful in our case of spinal cord ischaemia. [ABSTRACT FROM AUTHOR]

Objective. To analyze the epidemiological shifts in the incidence of ascending and arch aortic aneurysms (AA) treated with open surgery in the context of evolving endovascular options on a national basis. Methods. Between 1 January 2009 and 31 December 2018, 4388 cases were admitted to the hospital with either ruptured (r)AA or non-ruptured (nr)AA as the primary or secondary diagnosis. Patients were classified as having AA based on inclusion and exclusion criteria. Results. The age-standardized hospital incidence rates for treatment of nrAA were 7.8 (95% confidence interval (CI): 6.9 to 8.7) in 100,000 men and 2.9 (2.4 to 3.4) in 100,000 women and were stable over time. The overall raw in-hospital mortality rate was 2.0% and was significantly lower in males compared to women (1.6% vs. 2.8%, p = 0.015). Higher van Walraven scores (OR: 1.08 per point; 95%CI: 1.06 to 1.11; p = 0.001) and higher age (OR 1.05 per year; (95%CI: 1.02 to 1.07, p = 0.045) were significantly associated with hospital mortality. Conclusions. Endovascular surgery seems to have no influence on hospital incidence in patients treated with conventional surgery for AA in Switzerland. There was a significant reduction in in-hospital mortality in both men and women, with age and the von Walraven score being independent factors for worse outcomes. [ABSTRACT FROM AUTHOR]

Acute aortic syndrome; includes aortic dissection, intramural hematoma, symptomatic penetrating aortic ulcer. However, these three pathologies form a broad terminology group, including thoracic aortic aneurysm and traumatic aortic rupture, depending on their progression. Aortic dissection is the most common type. Type A aortic dissection requires emergency surgery, while Type B requires endovascular therapy. Intramural hematoma was defined as aortic wall hematoma without intimal flap. The ruptured aorta may progress to aortic dissection, aneurysm or pseudoaneurysm, or it may show complete resolution. It can be divided into proximal (type A) and distal (type B) Acute Aortic Syndrome according to the aortic segment involved surgically and prognostically. Surgical treatment can be recommended in most cases of type A intramural hematomas. In intramural hematomas localized in the descending aorta, there was generally no difference in survival with surgical and medical treatment. Penetrating aortic ulcer; It describes ulceration of an atherosclerotic lesion that progresses to the media layer by perforating the internal elastic lamina. These patients may not progress clinically. Traumatic aortic rupture or transection are also aortic lesions that require early intervention. Treatment methods, surgical or endovascular interventions can be adjusted according to the clinical conditions of the patients. [ABSTRACT FROM AUTHOR]

Background: Distinguishing between large-vessel diseases such as acute aortic syndrome (AAS) and pulmonary embolism (PE), and non-large-vessel diseases, such as acute coronary syndrome (ACS), heart failure (HF), and neurogenic diseases, in patients presenting with chest symptoms remains a challenge, which can result in a significant number of misdiagnoses. Simultaneously distinguishing both AAS and PE is essential because large-vessel diseases require angio-computed tomography (CT) during initial presentation whereas, non-large-vessel diseases do not. This study aimed to determine the optimal method for differentiating between large-vessel and non-large-vessel diseases using D-dimer, troponin I, and pretest probability scores. Methods: From the 11683 patients who presented with chest symptoms including chest pain, discomfort, or dyspnea, this retrospective observational study included 1817 patients who had complete data for essential biomarkers; 105 with AAS, 139 with PE, 1093 with ACS, 451 with HF, and 83 with neurogenic diseases. Results: D-dimer, D-dimer/troponin I ratio (DT ratio), and troponin I results distinguished the 2 groups: D-dimer (>2.38 μg/mL), AUC 0.935; DT ratio, AUC 0.827; and troponin I, AUC 0.653. For predicting AAS, the performances of D-dimer level and aortic dissection detection risk score (ADD-RS) were AUCs of 0.915 (p

Resumen: La fístula aortoentérica es una entidad poco frecuente y con elevada mortalidad, que tratamos en los servicios de cirugía de forma ocasional. Clásicamente el tratamiento propuesto es la corrección mediante cirugía abierta con injerto protésico de Dacron y resección intestinal en el mismo acto. Dados los malos resultados, en los últimos años se han descrito algunos casos de tratamiento endovascular con implante de endoprótesis.Presentamos un caso de fístula aortoentérica resuelta mediante abordaje híbrido con implante de endoprótesis y posterior resección intestinal con sellado de la fístula a través de cirugía abierta. Se trataba de un paciente varón de 75 años que ingresó en nuestro hospital con síntomas de síndrome aórtico agudo y que evidenció en angiotomografía computarizada un aneurisma de aorta abdominal ya conocido de 8,4 × 8,4 × 9,5 cm y luz vascular de 5 × 3,4 cm, así como signos de infiltración de la grasa periaórtica que indicaban rotura de la luz vs. fístula aortoentérica. Dada la inestabilidad hemodinámica del paciente, se decidió implante urgente de endoprótesis con cirugía en un segundo tiempo en vez del abordaje abierto convencional. Se realizó el implante de endoprótesis sin incidencias iniciales, pero con necesidad de resellado por endofuga en el control de imagen posterior. En un segundo tiempo se realizó resección intestinal y cierre de la fístula, ya previamente sellada de forma directa. El paciente evolucionó favorablemente y fue dado de alta.El abordaje híbrido abierto y endovascular en enfermedades complejas y de alta mortalidad como es el caso de la fístula aortoentérica puede ofrecer una supervivencia mayor en pacientes con alta morbilidad. Abstract: Aorto-enteric fistula is a rare entity with high mortality, occasionally surgically treated. Classically, the proposed treatment is open surgical repair with a Dacron prosthetic graft and intestinal resection in the same act. Given the poor results, in recent years some cases of endovascular treatment with stent implantation have been described.We present a case of an aortoenteric fistula resolved by a hybrid approach through stent implantation and intestinal resection with fistulaa sealing by open surgery in a second stage. This is a 75-year-old male patient who was admitted to our hospital with symptoms of acute aortic syndrome. The CT aortogram revealed a known abdominal aortic aneurysm of 8.4 × 8.4 × 9.5 cm and a vascular luz of 5 × 3.4 cm with signs of periaortic fat infiltration suggesting luz rupture vs. aortoenteric fistula. Given the hemodynamic instability of the patient, the team decided on emergent EVAR implantation with intestinal resection surgery in a second stage. The endoprosthesis was implanted without initial incidents but a resealing had to be performed due to endoleak in the subsequent control CT aortogram. In a second stage, the team performed the intestinal resection and closure of the fistula. The patient recovered favorably and was discharged.The hybrid open and endovascular approach in complex pathologies with high mortality, such as aortoenteric fistula, may offer an alternative approach in patients with high morbidity.

(1) Background: Identifying acute aortic syndrome (AAS) and thoracic aortic aneurysm (TAA) in busy emergency departments (EDs) is crucial due to their life-threatening nature, necessitating timely and accurate diagnosis. (2) Methods: This retrospective case-control study was conducted in the ED of three hospitals. Adult patients visiting the ED between 1 January 2010 and 1 January 2020 with a chief complaint of chest or back pain were enrolled in the study. The collected chest radiography (CXRs) data were divided into training (80%) and testing (20%) datasets. The training dataset was trained by four different convolutional neural network (CNN) models. (3) Results: A total of 1625 patients were enrolled in this study. The InceptionV3 model achieved the highest F1 score of 0.76. (4) Conclusions: Analysis of CXRs using a CNN-based model provides a novel tool for clinicians to interpret ED patients with chest pain and suspected AAS and TAA. The integration of such imaging tools into ED could be considered in the future to enhance the diagnostic workflow for clinically fatal diseases.

Abstract Background Intramural hematoma (IMH) and Aortic dissection (AD) have overlapping features. The aim of this study was to explore the differences between them by comparing the clinical manifestations and imaging features of patients with acute Stanford type B IMH-like lesions and acute Stanford type B AD (ATBAD). Methods This study retrospectively analysed the clinical and computed tomography angiography (CTA) imaging data of 42 IMH-like lesions patients with ulcer-like projection (ULP) and 38 ATBAD patients, and compared their clinical and imaging features. Results (1) The IMH-like lesions patients were older than the ATBAD patients (64.2 ± 11.5 vs. 50.9 ± 12.2 years, P 0.05). (3) The maximum diameter of the ULPs in IMH-like lesions was smaller than that of the intimal tears in ATBAD (7.4 ± 3.4 vs. 10.8 ± 6.8 mm, P = 0.005). The lumen compression ratio in the ULPs plane and the maximum compression ratio of the aortic lumen in the IMH-like lesions group were smaller than that in the ADBAD group (P

Penetrating aortic ulcer (PAU) represents a subset of acute aortic syndromes characterized by high rupture risk and management challenges, particularly in elderly patients with significant comorbidities. This case report showcases a 75-year-old patient with a history of coronary artery bypass graft (CABG) and with multiple PAUs involving the aortic arch, deemed unfit for conventional open surgery. A branched aortic endograft with a pre-cannulated side component for the left subclavian artery (LSA) was employed to preserve the patency of the previous CABG. Two computational fluid dynamics (CFD) simulations and a morphological analysis were performed on the pre- and post-intervention aortic configurations to evaluate changes in flow rate and pressure drop at LSA level and differences in the lumen size. The results revealed a decrease in the flow rate equal to 2.38% after the intervention and an increase in pressure drop of 4.48 mmHg, while the maximum differences in LSA cross-sectional areas and diameters were 1.49 cm2 and 0.64 cm, respectively. Minimal alteration in LSA blood flow due to the chosen intervention approach confirmed the effectiveness of the selected unibody design endograft with LSA preservation, ensuring myocardial perfusion. Therefore, CFD simulations demonstrate to be a powerful tool to evaluate the hemodynamic consequences of interventions by accurately estimating the main fluid dynamic parameters.

Background: Acute aortic syndrome (AAS) is a life-threatening condition necessitating timely and accurate diagnosis for appropriate treatment. Currently, the only way to rule out the diagnosis is advanced imaging. The most accessible is computed tomography of the entire aorta. Most scans are negative, exposing patients to radiation, increased time in the emergency department (ED), and non-significant incidental findings. This study investigated whether restricting imaging to the area of aortic-related pain accurately rules out AAS. Methods: A health records review was conducted on consecutive cases from three academic EDs between 2015 and 2020. Data were extracted and verified from multiple sources. Participants included adults diagnosed with AAS based on radiological evidence. The diagnostic performance of the restricted imaging strategy was assessed; sensitivity and likelihood ratios with 95% confidence intervals were calculated. Results: Data from 149 cases of AAS were collected, with the majority presenting with chest pain (46%) or abdominal pain (24%). The restricted imaging strategy demonstrated a sensitivity of 96% (95% CI 91.4–98.5%) in ruling out AAS. In a subset of patients with systolic blood pressure > 90 mmHg and without aortic aneurysm/repair (n = 86), the sensitivity was 100% (95% CI 96–100%). Conclusion: Restricting imaging to the area of pain in hemodynamically stable patients without known aortic aneurysm provides a highly sensitive approach to ruling out AAS. [ABSTRACT FROM AUTHOR]

Type A acute aortic syndrome (urgent AAS, UAAS) has a low incidence and high mortality rate; however, it is often missed or diagnosed late. Our aim was to create a new tool for distinguishing UAAS by using multiple modalities to select patients for CT aortography. This study included 75 patients with UAAS, 77 with acute coronary syndrome (ACS), and 81 with heart failure (HF) who received urgent treatment after propensity matching. Specific symptoms, past medical history, mediastinal width, region of interest (ROI) ratio in the lung base/apex, D-dimers, and troponin I were investigated to differentiate UAAS from ACS and HF. The most significant variables were selected to create a new scoring system. The UAAS score exhibited a performance AUC of 0.982. A simple UAAS score >1, excluding ROI ratios in lung base/apex, showed an AUC of 0.977, a sensitivity of 96%, and specificity of 92.41%. The results were validated using an external data set of 292 patients (simple UAAS score > 1: AUC of 0.966, sensitivity 93.33%, and specificity 95.36%). The simple UAAS score may be a valuable tool for suspecting UAAS and may reduce the likelihood of misdiagnosis or performing unnecessary CT aortography. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Acute aortic syndromes are associated with poor outcomes, despite diagnostic and therapeutic advances. We analysed trends in volumes and outcomes from 2000 to 2021. METHODS The study population includes 494 type A acute aortic syndromes (TAAAS) (54.2%) and 418 type B acute aortic syndromes (TBAAS) (45.8%). Primary outcomes were in-hospital mortality, long-term survival and freedom from aortic reoperation. RESULTS Regardless the type of acute aortic syndrome, patient volumes increased over time. Patients with TBAAS were older, more likely to have comorbid conditions and previous cardiac surgery (P  < 0.001), while cerebrovascular accidents were more frequent in TAAAS (P  < 0.05). Among TAAAS, 143 (28.9%) required total arch and 351 (71.1%) hemiarch replacement. TBAAS management was medical therapy in 182 (43.5%), endovascular in 198 (47.4%) and surgical in 38 (9.1%) cases. Overall in-hospital mortality was 14.6% [18.2% in TAAAS (95% confidence interval (CI) 14.4–21.2%) vs 10.7% in TBAAS (95% CI 7.8%–13.7%); P  = 0.0027]. After propensity score adjustment, in-hospital mortality exhibited a significantly decreasing trend from 2000 to 2021 (P  < 0.001) in TAAAS and TBAAS. 1-, 5- and 10-year survival was 74.2%, 62.2% and 45.5% in TAAAS and 75.4%, 60.7% and 41.0% in TBAAS (P  = 0.975), with no differences among treatment strategies. The adjusted cumulative reoperation risk at 10 years was more than two-fold in TBAAS versus TAAAS (9.5% vs 20.5%, hazard ratio (HR) = 2.30, 95% I 1.31–4.04). CONCLUSIONS In the last decades, better patient triage and surgical/endovascular techniques led to substantial improvements in the management of acute aortic syndrome, with reduction in early mortality and reoperation rate. However, long-term mortality is still >50%. [ABSTRACT FROM AUTHOR]

Aortic dissection is a clinicopathological entity caused by rupture of the intima, leading to a high mortality if not treated. Over time, diagnostic and investigative methods, antihypertensive therapy, and early referrals have resulted in improved outcomes according to registry data. Some data have also emerged from recent studies suggesting a link between Human Cytomegalovirus (HCMV) infection and aortic dissection. Furthermore, the use of microRNAs has also become increasingly widespread in the literature. These have been noted to play a role in aortic dissections with elevated levels noted in studies as early as 2017. This review aims to provide a broad and holistic overview of the role of miRNAs, while studying the role of HCMV infection in the context of aortic dissections. The roles of long non-coding RNAs, circular RNAs, and microRNAs are explored to identify changes in expression during aortic dissections. The use of such biomarkers may one day be translated into clinical practice to allow early detection and prognostication of outcomes and drive preventative and therapeutic options in the future. [ABSTRACT FROM AUTHOR]

Objective: Antithrombotic therapy has the potential to interfere with false lumen thrombosis. In type B acute aortic syndrome, the degree of false lumen thrombosis affects clinical outcomes. We aimed to explore the association of antithrombotic therapy with the prognosis of patients with type B acute aortic syndrome. Methods: We reviewed 406 patients with type B acute aortic syndrome who were discharged alive with and without antithrombotic therapy. The primary outcome was aorta-related adverse events, defined as a composite of aorta-related death, aortic rupture, aortic repair, and progressive aortic dilation. Results: Of the 406 patients, 64 (16%) were discharged with antithrombotic therapy and 342 (84%) were discharged without antithrombotic therapy. A total of 249 patients (61%) presented with intramural hematoma with complete thrombosis of the false lumen, and 157 patients (39%) presented with aortic dissection. During a median follow-up of 4.6 years, 32 patients (50%) in the antithrombotic group and 93 patients (27%) in the nonantithrombotic group had a primary outcome event. Cumulative incidence of aorta-related events at 1 and 3 years with death as the competing risk was higher in the antithrombotic group than in the nonantithrombotic group (19% ± 5% vs 9% ± 2% at 1 year and 40% ± 7% vs 17% ± 2% at 3 years, P

ABSTRACT Today, the issue of the effectiveness of emergency specialized care for patients with acute aortic syndrome (AAS) is extremely relevant in Russian healthcare. Much attention is paid to logistics and management in the AAS. There is a tendency to increase the share of hybrid treatment of aortic pathology due to the rapid development of endovascular technologies in Russian healthcare institutions. This article presents the scheme of logistics at the prehospital stage, perioperative management and options for surgical treatment, including hybrid and endovascular options of AAS. Particular attention is paid to the resolution of the malperfusion syndrome. The main studies were carried out on the basis of SAHI RT Regional Center for Emergency Medical Care.AIM OF STUDY Development of a logistics scheme and tactics for the treatment of patients with acute aortic pathology.MATERIAL AND METHODS This article provides demographic data and incidence statistics. Not only the hospital stage of effective treatment is important, but logistics with routing and anesthesia management as well. Examples of the routing schemes used by us in practice for patients with AAS starting from 2017 are given. Variants of hybrid treatment and resolution of malperfusion syndrome in patients with AAS are shown on the example of clinical cases.CONCLUSION The applied schemes for transporting patients with AAS allowed the optimal treatment strategy to be chosen, where time is of the essence. Proper perioperative management in patients with aortic pathology will allow deaths to be minimized and/or prevented. The options of performed surgical treatment showed a good result, a decrease in mortality. Penn classification, especially in a situation of high perioperative risk, made it possible to predict in-hospital mortality and outcomes of surgical treatment, and also helped choose an adequate treatment strategy

BACKGROUND Acute proximal aortic dissection (Stanford type A) remains the most common fatal pathology of the thoracic aorta. Despite the improvement of surgical technologies, hospital mortality after emergency surgical interventions is 17–25%, in complicated cases it can reach 80–90%.AIM OF STUDY Description of the perioperative treatment tactics adopted at the N.V. Sklifosovsky Research Institute for Emergency Medicine as well as the evolution of approaches that make it possible to obtain satisfactory hospital and long-term results in the treatment of aortic dissection.MATERIAL AND METHODS the study included 278 patients operated on from 2015 to 2021 in the acute stage of aortic dissection (less than 48 hours from the moment of manifestation of the disease). The operated patients were divided into two groups, depending on the presence of complicated forms: group A, 102 patients with uncomplicated course of the disease; group B, 176 patients with complicated course of the disease. Additionally, patients were divided depending on the level of distal reconstruction performed: group I, 83 patients, surgery was limited to prosthetics of the ascending aorta, without removing the clamp; group II, 137 patients who underwent hemi-arch surgery; group III, 58 patients, with distal reconstruction involving the aortic arch.RESULTS Total hospital mortality was 28.1%: 25.3% in group I, 29.1% in group II, 29.3% in group III. In the group of uncomplicated dissection, postoperative mortality was 18.6%, while in the group of complicated dissection it was 33.5%.CONCLUSION An integrated multidisciplinary approach with the formation of an “aortic team”, an individual approach to surgery, depending on the anatomy of the dissection and the clinical status of the patient, will improve the results of the treatment of acute aortic dissection, as the most severe and multiple organ pathology of the aorta.FINDING 1. Hospital mortality of complicated forms of dissection remains significantly higher — 33.5% versus 18.5% of uncomplicated course. 2. The most optimal method of distal reconstruction in patients with the peracute stage of dissection is an open anastomosis with the aorta using the “hemi-arch” technique. 3. If it is necessary to extend the surgical intervention on the aortic arch, a distal anastomosis in areas 0, 1, 2 with the possibility of a subsequent endovascular stage is the priority.

Background: The hybrid aortic repair consisting of root replacement and endovascular arch repair is an optimal alternative for patients unfit for circulatory arrest. However, an artificial aortic valve prosthesis might impede the endovascular procedure. This study aims to present our experience with the branching retrograde externalized guidewire (BREG) technique in such situations, and discuss its utility and efficiency. Methods: From January 2015 to June 2021, a total of 112 patients underwent aortic root/valve replacement combined with aortic arch repair. Among them, the BREG technique was adopted on 24 patients, and the traditional frozen elephant trunk (FET) technique was used for 88 patients. The indication of the BREG was as follows: high-risk patients not suitable for traditional open surgery; meanwhile, the aortic disease required extended repair, and the aortic valve needed to be replaced concomitantly. The data of the 2 groups were compared. Results: The cardiopulmonary bypass time (213.5 ± 73.6 min vs. 246.5 ± 46.2 min, P = 0.046) and cross-clamped time (109.0 ± 27.6 min vs. 139.0 ± 24.6 min, P 0.999). Conclusion: The BREG technique facilitated the advancement of endovascular stent graft, avoided impeding the aortic valve prosthesis in hybrid aortic surgery with aortic valve replacement, and may benefit high-risk patients.

A case of cardioembolic stroke in a patient with sinus of Valsalva aneurysm. The patient presented with chief complaints of syncope, with slurring of speech and a history of deviation of angle of mouth to the right side, which resolved over one day. Examination revealed no focal neurological deficit. CT Brain revealed a lacunar infarct over the left frontal cortex. Echocardiography showed sinus of Valsalva aneurysm of the non-coronary cusp. Hence a diagnosis of cardioembolic stroke secondary to thrombus present in the sinus of Valsalva of the aneurysm was considered. This is a rare presentation of Sinus of Valsalva as a cardioembolic stroke. [ABSTRACT FROM AUTHOR]

Objectives: Matsudaito is a unique surgical sealant with a powerful hemostatic effect that works independent of a patient's blood coagulation function. Because of its mechanism, this sealant is expected to be particularly useful in patients with a poor blood coagulation function, such as in cases of acute aortic syndrome requiring emergency surgery. We, therefore, evaluated the hemostatic static effect of the sealant in both emergency and elective surgery of the thoracic aorta. Methods: We used data obtained from post-marketing surveillance of the sealant. Patients who underwent replacement of the thoracic aorta were enrolled. The hemostatic effect was evaluated as effective if a further hemostatic procedure was not performed after applying the sealant. Results: From 46 hospitals in Japan, a total of 542 patients (327 elective and 215 emergency cases) were enrolled. Hospital mortality was 4.0% and 11.6% in elective and emergency cases, respectively (p < 0.05). Among the 1039 anastomoses (609 elective and 430 emergency cases), effective hemostasis was confirmed in 436 (71.6%) elective and 259 (60.2%) emergency cases. The data from the clinical trial of the sealant showed a hemostatic rate of 44.4% in elective control cases without the sealant. Conclusion: Given that the hemostatic rate in emergency surgery with the sealant seemed to be better than that in elective surgery without the sealant (determined from the clinical trial), we concluded that the sealant was effective in both emergency and elective thoracic surgery of the aorta. [ABSTRACT FROM AUTHOR]

Background: Intramural hematoma (IMH) and Aortic dissection (AD) have overlapping features. The aim of this study was to explore the differences between them by comparing the clinical manifestations and imaging features of patients with acute Stanford type B IMH-like lesions and acute Stanford type B AD (ATBAD). Methods: This study retrospectively analysed the clinical and computed tomography angiography (CTA) imaging data of 42 IMH-like lesions patients with ulcer-like projection (ULP) and 38 ATBAD patients, and compared their clinical and imaging features. Results: (1) The IMH-like lesions patients were older than the ATBAD patients (64.2 ± 11.5 vs. 50.9 ± 12.2 years, P < 0.001). The D-dimer level in the IMH-like lesions group was significantly higher than that in the ATBAD group (11.2 ± 3.6 vs. 9.2 ± 4.5 mg/L, P < 0.05). The incidence rate of back pain was significantly higher in the ATBAD group than in the IMH-like lesions group (71.1% vs. 26.2%, P < 0.05). (2) The ULPs of IMH-like lesions and the intimal tears of ATBAD were concentrated in zone 4 of the descending thoracic aorta. The ULPs of IMH-like lesions and the intimal tears of ATBAD were mainly in the upper quadrant outside the lumen (64.3% vs. 65.8%, P > 0.05). (3) The maximum diameter of the ULPs in IMH-like lesions was smaller than that of the intimal tears in ATBAD (7.4 ± 3.4 vs. 10.8 ± 6.8 mm, P = 0.005). The lumen compression ratio in the ULPs plane and the maximum compression ratio of the aortic lumen in the IMH-like lesions group were smaller than that in the ADBAD group (P < 0.05). Fewer aortic segments were involved in IMH-like lesions patients than in ATBAD patients (5.6 ± 2.2 vs. 7.1 ± 1.9 segments, P < 0.005). The IMH-like lesions group had less branch involvement than that of the ATBAD group (P < 0.001). Conclusion: The degree of intimal tears, lumen compression ratio, extent of lesion involvement, and impact on branch arteries in ATBAD are more severe than that of IMH-like lesions. But for the ULPs of IMH-like lesions and intimal tears of ATBAD, they have astonishing similarities in the location of the partition and the lumen quadrant, we have reason to believe that intimal tear is the initial factor in the pathogenesis of this kind of disease, and their clinical and imaging manifestations overlap, but the severity is different. Concerning similarities between these two conditions, these two may be a spectrum of one disease. [ABSTRACT FROM AUTHOR]

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]

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Iatrogenic aortic dissection is a rare but life-threatening complication of percutaneous coronary intervention (PCI). Emergency surgical treatment is recommended for spontaneous type A aortic dissection, but no specific recommendations have been formulated for iatrogenic dissections. In early studies, the mortality rate of surgically treated patients with iatrogenic aortic dissection was as high as 50%, but according to the currently available registry data, the mortality rate seems comparable to that of patients operated on for spontaneous type A aortic dissection (approximately 16%). However, case reports have been presented of patients successfully treated conservatively with complete healing of the dissection, including cases with extensive aortic wall damage. [ABSTRACT FROM AUTHOR]

Background: Thoracic acute aortic syndrome (AAS) and non-ST elevation myocardial infarction (NSTEMI) have similar clinical presentations, making them difficult to differentiate. This study aimed to identify useful biomarkers for the differential diagnosis of thoracic AAS and NSTEMI. Methods: This was a retrospective observational study. Participants: consecutive adult patients who visited the emergency department for acute chest pain between January 2015 and December 2021 diagnosed with thoracic AAS or NSTEMI. Clinical variables, including D-dimer (μg/mL) and high-sensitivity troponin T (ng/mL, hs-TnT) levels, were compared between the groups. Results: A total of 52 (30.1%) and 121 (69.9%) patients were enrolled in the thoracic AAS and NSTEMI groups, respectively. Logistic regression analysis revealed that the D-dimer to hs-TnT (D/T) ratio (odds ratio (OR), 1.038; 95% confidence interval (CI), 1.020–1.056; p < 0.001) and the thrombolysis in myocardial infarction (TIMI) score (OR, 0.184; 95% CI, 0.054–0.621; p = 0.006) were associated with thoracic AAS. The D/T ratio had an area under the receiver operating characteristic curve (AUC) of 0.973 (95% CI, 0.930–0.998), and the optimal cutoff value was 81.3 with 91.4% sensitivity and 96.2% specificity. The TIMI score had an AUC of 0.769 (95% CI, 0.644–0.812), and the optimal cutoff value was 1.5 with 96.7% sensitivity and 38.5% specificity. Conclusion: the D/T ratio may be a simple and useful parameter for differentiating thoracic AAS from NSTEMI. [ABSTRACT FROM AUTHOR]

Teaching point: While demanding urgent management, limited intimal tear (LIT), a rare subtype of acute aortic syndrome (AAS), poses challenges in terms of accurate and timely diagnosis.