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BACKGROUND Beta-blockers have become the cornerstone for medical management in patients with chronic type B aortic dissection (TBAD). However, the effect of being on and/or receiving intravenous beta-blockers during hospitalization on outcomes of surgical repair of TBAD is not fully described. We sought to investigate this association during open surgical repair (OSR) and endovascular (Endo) intervention for nontraumatic TBAD. METHODS The Premier Healthcare Database was inquired (June/2009-March/2015). Patients with nontraumatic isolated TBAD were identified via ICD-9-CM diagnosis and procedural codes. Patients with codes that indicated TAAD were excluded. In-hospital mortality, cardiac complications (CHF, MI, arrythmia) and stroke were evaluated. Log binomial regression analyses with bootstrapping were performed to assess the relative risk of adverse outcomes. RESULTS A total of 1,752 were admitted for OSR (54.3%) and Endo (45.7%) TBAD repair. Use of oral beta blocker (BB) was 16.0% in OSR and 56.4% in Endo groups. In each arm, patients on BB were more likely to be diabetic, on aspirin or statin and more likely to receive additional IV BB than nonBB patients. There was no significant difference in age, sex, race, or prior history of CHF between BB and nonBB groups. Mortality was proportionally lower in patients on BB in OSR group (7.9% vs. 16.7%; P = 0.006) and Endo (3.3% vs. 9.2%; P < 0.001). The adjusted relative risk for mortality and stroke were significantly lower in oral BB recipients compared with none [aRR (95% CI): 0.53 (0.32-0.90) and 0.46 (0.25-0.87); both P ≤ 0.02]. IV metoprolol was the only IV BB that reduced mortality [aRR (95% CI): 0.62 (0.46-0.85); P = 0.003]. A dose of ≤10 mg was associated with significant mortality reduction: 6.3% (3.0-9.5%) compared with 8.1% (4.6-11.6%) in no IV BB group. Cardiac complications were not affected by BB use. CONCLUSIONS For patients with nontraumatic TBAD, use of oral BB was associated with significant protection against in-hospital mortality and stroke following repair. Metoprolol was the only Intravenous BB type associated with improved survival. Further research is warranted to elucidate the effect of beta-blockers on the long-term surgical outcomes of TBAD.

Approximately one-third of patients with acute Stanford type B or DeBakey type III aortic dissection (TBAD) will develop complications, including persistent symptoms, malperfusion, enlarging aneurysms and impending rupture. In these cases, TBAD becomes a surgical emergency that requires endovascular intervention to complement the medical therapy. The immediate goal of endovascular therapy is to reestablish flow to the true lumen, stabilize the aneurysm and prevent rupture. Long-term goals are the remodeling of the descending thoracic aorta and the prevention of further surgeries in the thoracoabdominal aorta. In this report, we describe our step-by-step endovascular approach to TBAD repair.

OBJECTIVES This study aims to systematically review published literature on male–female differences in presentation, management and outcomes in patients diagnosed with acute thoracic aortic dissection (AD). METHODS A systematic literature search was conducted for studies published between 1 January 1999 and 19 October 2020 investigating mortality and morbidity in adult patients diagnosed with AD. Patient and treatment characteristics were compared with odds ratios (ORs) and standardized mean differences and a meta-analysis using a random-effects model was performed for early mortality. Overall survival and reoperation were visualized by pooled Kaplan–Meier curves. RESULTS Nine studies investigating type A dissections (AD-A), 1 investigating type B dissections (AD-B) and 3 investigating both AD-A and AD-B were included encompassing 18 659 patients. Males were younger in both AD-A (P CONCLUSIONS This systematic review shows male–female differences in AD patient and treatment characteristics, comparable early and overall mortality and inconsistent outcome reporting. As published literature is scarce and heterogeneous, large prospective studies with standardized reporting of male–female characteristics and outcomes are clearly warranted. Improved knowledge of male–female differences in AD will help shape optimal individualized care for both males and females. Clinical registration number PROSPERO, ID number: CRD42020155926.

Several studies have reported lower mortality and morbidity after thoracic endovascular aortic repair (TEVAR) when compared to open surgical repair (OSR) in the treatment of type B aortic dissection (TbAD). However, there are few studies in the literature on the cost of both treatment options. Thus, the aim of this study is to focus on in-hospital outcomes and cost associated with TbAD repair procedures in a national database in the United States.A retrospective review of the Premier Healthcare Database (PHD) between June 2009 and March 2015 was performed. ICD-9-CM codes were used to identify patients who underwent OSR or TEVAR for TbAD. Endpoints included in-hospital adverse events, in-hospital mortality and hospitalization cost. Logistic regression models and generalized linear models were used to assess the impact of treatment type on the main outcomes.Out of 1752 patients with TbAD, 54.3% underwent OSR and 45.7% underwent TEVAR. Patients in the TEVAR group were older [median age, 64 (IQR 54-73) vs. 59 (IQR 49-70), P1] and more likely to have preexisting comorbidities. IAE rates were 78.6% for the OSR group compared to 43.1% for the TEVAR group, P0.001. Patients in the OSR group showed significantly higher in-hospital mortality (15.3% vs. 5.9%, P0.001). After adjusting for potential confounders, OSR was associated with a 5-fold increase in IAE [aOR(95%CI): 4.8 (3.8-6.1), P0.001] and a 3-fold increase in in-hospital mortality [aOR(95%CI): 3.3 (2.1-5.1), P0.001]. In regards to charges related to the hospital stay, total cost was significantly higher among patients undergoing OSR $53,371 ($39,029-$80,471) vs. TEVAR $45,311 ($31,479-$67,960), P0.001.The present study shows that TEVAR presents an advantage in terms of morbidity, mortality and cost when compared to OSR in the treatment of TbAD. However, long-term cost-effectiveness of both procedures remains unknown. Further research is warranted to see whether the superiority of TEVAR is maintained over time.

Acute myocarditis usually presents with a broad spectrum of symptoms and has variable clinical outcomes. A proportion of acute myocarditides may develop into fulminant myocarditis resulting in significant mortality if left untreated. This case report describes an unusual presentation of fatal lymphocytic myocarditis mimicking a thoracic aortic dissection in a previously healthy 45-year-old male. Fulminant myocarditis should be considered as part of the differential diagnosis in an acutely unwell young adult presenting to the Emergency Department with non-specific symptoms.

Acute thoracic aortic dissection is an uncommon, although not rare, life-threatening condition. With protean signs and symptoms that often suggest more common cardiac or pulmonary conditions, it can be difficult to diagnose. Ultrasound has proven useful in making the correct diagnosis. This case demonstrates that training gained using standard ultrasound machines can be easily and successfully adapted to newer handheld ultrasound devices. The examination technique using the handheld device is illustrated with photos and a video.

In recent years, a hybrid approach to the classic two-stage elephant trunk technique has come into favor for treatment of thoracic aortic dissection. During the first stage, inadvertent intraoperative placement of the elephant trunk into the false lumen can occur on rare occasions, resulting in untoward difficulties during the second stage of the procedure. We describe here a snare-assisted technique for endovascular salvage of an elephant trunk that had inadvertently been placed in the false lumen of a chronic aortic dissection.

In recent years, obese patients presenting with acute thoracic aortic dissection have not been uncommon and there are often pulmonary complications among them. Whether a higher body mass index (BMI) is associated with more pulmonary complications or even a higher mortality rate has yet to be determined. This study aimed to evaluate the effects of higher BMI on pulmonary complications and other surgical outcomes.A total of 404 patients who underwent acute thoracic aortic dissection surgery were retrospectively studied. They were divided into three groups based on their BMI: normal weight (BMI 18.5 to25 kg/mNo statistical significance was detected among the groups for postoperative complications, in-hospital mortality and hospital or ICU stay, except for prolonged intubation, the proportion of which was highest in the obese group followed by the overweight and normal groups (40.7% vs 29% vs 11%, respectively; p0.001). Furthermore, logistic regression analysis showed that postoperative renal failure (OR=16.984) and cardiopulmonary bypass time (OR=1.013) were independent risk factors for in-hospital mortality, while higher BMI (OR=7.148 for BMI ≥25 and 18.967 for BMI ≥30), transfused red blood cells (OR=1.004), and postoperative renal failure (OR=7.386) were independent risk factors for prolonged ventilation (p0.05).Body mass index had no effect on in-hospital mortality but may be closely correlated with prolonged intubation for patients undergoing aortic dissection surgery. This finding suggests that these patients should receive more aggressive pulmonary management.

To investigate the discrepancy rate in classification of newly diagnosed aortic dissection (AD) between radiologists and surgeons and explore patient management. 3255 CTs performed for AD from June 2013 to June 2018 at our institution were retrospectively identified. CT reports and charts were reviewed to identify newly diagnosed AD or intramural hematoma (IMH). Radiology reports and electronic health records were reviewed for Stanford type A or B classification and surgical versus medical management. Newly diagnosed AD was diagnosed in 1.9% (62/3255) with one false positive, mean age 60 years. Discrepancy rate was 1.6% (1/61). Type A AD/IMH was treated surgically in 85% (23/27), medically in 15% (4/27). Type B AD/IMH was treated surgically in 56% (19/34) (endovascular 95% (18/19)), medically in 44% (15/34). Discrepancy rate between radiologists and surgeons in Stanford classification of aortic dissection was low. Management of type B AD/IMH was predominantly endovascular, reflecting a shift in practice from the historical binary management strategy of type A dissections being treated surgically and type B dissections medically.

Introduction: Aortic dissection (AD) is the most common aortic emergency, result in a catastrophic outcome. Patients usually asymptomatic, some of them present with sudden severe, tearing or sharp back or anterior chest pain and haemodynamic disturbance. Early and accurate diagnosis and treatment determine the patient outcome.Case Report: A case of 40 years old man complained of acute, sharp, chest pain since 4 days before admission which worsen instead of medical treatment, with a history of smoking since a few years ago. A vital sign was within normal limit. Laboratory result showed high CKMB, troponin T, LDH result. Occasional ventricular extrasystoles and inferior ischaemic was found in the ECG examination. From echocardiography, the patient suspected to have aortic dissection Stanford type A since an intimal flap on ascending aorta was found, with left ventricle hypertrophy, dilatation of right atrium and right ventricle, severe aortic regurgitation, moderate mitral regurgitation, severe tricuspid regurgitation, moderate pulmonary regurgitation and moderate pulmonary hypertension. From plain radiography, the patient showed mediastinum widening and cardiomegaly, CT angiography showed Stanford type A aortic dissection (DeBakey type I). The patient refused to seek further treatment for operation as suggested.Conclusion: It is still challenging to differentiate aortic dissection (AD) and another acute chest emergency. Since clinical presentation and laboratory result may be similar between those illnesses. Therefore careful history taking and further imaging examination should be considered to increase the patient outcome.

Thoracic aortic dissection (TAD) is one of the most lethal aortic diseases due to its acute onset, rapid progress, and high rate of aortic rupture. The pathogenesis of TAD is not completely understood. In this mini-review, we introduce three emerging experimental mouse TAD models using β-aminopropionitrile (BAPN) alone, BAPN for a prolonged duration (four weeks) and then with added infusion of angiotensin II (AngII), or co-administration of BAPN and AngII chronically. We aim to provide insights into appropriate application of these three mouse models, thereby enhancing the understanding of the molecular mechanisms of TAD.

Purpose Thoracic aortic dissection (TAD) is characterized by an inflammatory response. Angiopoietin-like protein 8 (ANGPTL8) is a hormone involved in the regulation of lipid metabolism and inflammation. However, the relationship between ANGPTL8 and TAD remains unknown. Methods This case-control study included 78 TAD patients and 72 controls. The aortic diameter was evaluated by computed tomography and used to assess TAD severity. Circulating ANGPTL8 levels were measured by enzyme-linked immunosorbent assay. Associations of ANGPTL8 with TAD were determined by multivariate logistic regression. Results Serum ANGPTL8 levels were significantly higher in TAD patients compared with controls (562.50 ± 20.84 vs. 419.70 ± 22.65 pg/mL, respectively; P P β = 1.081/100 pg ANGPTL8, 95% CI = 0.075–2.086, P = 0.035) and high-sensitivity C-reactive protein (hs-CRP) (β = 0.845/100 pg ANGPTL8, 95% CI = 0.020–1.480, P = 0.009). The area under the curve (AUC) on receiver operating characteristic (ROC) analysis of the combination of ANGPTL8, hs-CRP, and D-dimer was 0.927, and the specificity and sensitivity were 98.46% and 79.49%, respectively. ANGPTL8 was significantly increased in TAD tissue compared with controls. In vitro, ANGPTL8 was increased in angiotensin II (AngII)-treated macrophages and vascular smooth muscle cells (VSMCs), while ANGPTL8 siRNA-mediated knockdown decreased inflammatory factors in AngII-treated macrophages and decreased apoptosis in AngII-treated VSMCs. Conclusion ANGPTL8 is associated with TAD occurrence and development, which may involve pro-inflammatory effects on macrophages. ANGPTL8 combined with D-dimer and hs-CRP might be a useful clinical predictor of TAD. Trial Registration ChiCTR-COC-17010792 http://www.chictr.org.cn/showproj.aspx?proj=18288

Rupture of ascending thoracic aortic dissection mimicking pulmonary thromboembolism due to pulmonary artery occlusion is rare and should be considered in hypoxic patients with aortic dissection.

Yue Shao,1 Jun Luo,1 Liu Ye,2 Hao-Yu Ran,1 Hao-Ming Shi,1 Cheng Zhang,1 Qing-Chen Wu1 1Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China; 2The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of ChinaCorrespondence: Cheng Zhang; Qing-Chen WuDepartment of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of ChinaEmail zhangchengcqmu@126.com; wuqingchencqmu@126.comBackground: Long non-coding RNAs (lncRNAs) can act as a competitive endogenous RNA (ceRNA) to regulate gene expression by sequestering the microRNA (miRNA). However, the lncRNA-miRNA-mRNA ceRNA network in thoracic aortic dissection (TAD) has been rarely documented.Methods: Three Gene Expression Omnibus (GEO) datasets were used to detect differentially expressed mRNAs, miRNAs, and lncRNAs in TAD. Gene ontology and the Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were conducted for the differentially expressed mRNAs. A protein–protein interaction network for differentially expressed mRNAs was also constructed, and hub genes were identified. We established a ceRNA network of TAD based on the differentially expressed miRNAs, mRNAs and lncRNAs, and verified our results using an independent dataset and quantitative real-time PCR (qRT-PCR).Results: In TAD, 267 lncRNAs, 81 miRNAs, and 346 mRNAs were identified as differentially expressed. The established ceRNA network consisted of seven lncRNA nodes, three mRNA nodes, and three miRNA nodes, and the expression of miRNAs in TAD was opposite to that of lncRNAs and mRNAs. Subsequently, an independent GEO dataset and qRT-PCR were used to validate the expression of three mRNAs. In addition, the expression differences in SLC7A5, associated miRNA and lncRNA were verified. According to gene set enrichment analysis of SLC7A5, the most significant KEGG pathway was considerably enriched in spliceosome and pentose phosphate pathway.Conclusion: We established a novel ceRNA regulatory network in TAD, which provides valuable information for further research in the molecular mechanisms of TAD.Keywords: bioinformatics analysis, ceRNA, expression profile, thoracic aortic dissection

Pregnancy increases aortic wall stress and, for a woman with a chronic dissection, this can lead to extension of the dissection, aortic rupture, and death. We report a pregnancy in a woman with a history of a chronic type B aortic dissection. As a child, she had repeat balloon dilation of aortic coarctation, and one of the procedures was complicated by an iatrogenic dissection at the dilation site. At the age of 27 years, she had a planned pregnancy.

As surgical mortality decreases and endovascular utilization increases, it is unknown whether volume-outcome relationships exist in thoracic aortic dissection repair. We characterized volume-outcome relationships for surgical and endovascular management of thoracic aortic dissection.Patients aged more than 18 years undergoing repair of thoracic aortic dissection in the United States between 2010 and 2014 were identified in seven all-payer state inpatient administrative databases. Patients were divided into groups based on type of repair: surgical repair of type A dissection (TAAD), surgical repair of type B dissection (TBAD), and endovascular repair (TEVAR). Hierarchical logistic regression models evaluated the association between hospital volume and in-hospital mortality.Overall in-hospital mortality rate was 13.4% (890 of 6650), highest after TAAD (463 of 2918, 15.9%), followed by TBAD (270 of 1934, 14.0%) and TEVAR (157 of 1798, 8.7%). Volume-outcome relationships for adjusted in-hospital mortality were demonstrated for TAAD and TBAD (P-trend.001), but not TEVAR (P-trend = .11). Adjusted in-hospital mortality differed most for TAAD (fewer than 3 cases per year: 21%, 95% confidence interval, 18% to 24%; vs 11 or more cases per year: 12%, 95% confidence interval, 8% to 16%; P.001) and TBAD (fewer than 2 cases per year: 18%, 95% confidence interval, 15% to 22%; vs 11 or more cases per year: 9%, 95% confidence interval, 5% to 12%; P.001), whereas TEVAR did not differ between quartiles. Adjusted mortality was lower at centers with 26 or more overall annual thoracic dissection repairs, compared with any of the three lower-volume quartiles (P.001).This study demonstrated lower mortality at high-volume hospitals for overall repair of aortic dissection, persisting separately for surgical repair of TAAD and TBAD, but not TEVAR. As endovascular technology advances and practice patterns consequently change, analyses should focus on understanding the balance between procedural volume, mortality, and access to care for thoracic aortic dissection.

We report a case with rare signs of subcutaneous hematoma, ecchymoses, and pleural effusion resulting from rupture of a thoracic aneurysm and aortic dissection. An 81-year-old woman had a history of aneurysm for 4 years. Ruptured chronic thoracic aortic dissection was diagnosed in the patient. After 2 weeks of medical therapy, the hematoma in the chest wall was absorbed, the pleural effusion almost disappeared, and the patient’s general condition improved. At 6 months follow-up, the patient had no chest discomfort. This case highlights an uncommon sign of ruptured thoracic aneurysm and aortic dissection that clinicians should be aware of.

A 46- year old male, during intense physical activity, sustained malperfusion of the lower extremities from Type A thoracic aortic dissection. We took him to the operating room. emergently and perfusing both lower extremities using a modified straight graft with side to side anastomosis to one limb and end to side anastomoses to the inflow perfusion and contralateral limb. The patient was successfully discharged and remained to be doing well. for four years.

A diagnosis of thoracic aortic dissection should be considered in any patient presenting with chest pain. Thoracic aortic dissection is relatively rare but when undiagnosed, often portends to poor prognosis. Owing to relatively small numbers of patients presenting with aortic dissection, the International Registry of Acute Aortic Dissection was established to better understand aortic dissection pathophysiology, clinical presentation, and, in turn, treatment options. The registry has more recently evaluated differences of clinical presentations, management in outcomes, between sexes. In-hospital complications have occurred with greater frequency in women than men, resulting in higher in-hospital mortality. What causes this disparity? Women tend to have a longer life-expectancy than men. Should this gap affect the criteria in which uncomplicated Type B aortic dissections are treated in women? Women tend to have smaller access vessels and greater angulation of the aortic arch. Should this difference tailor treatment options? This chapter aims to identify the sex differences in clinical presentation, diagnosis, treatment options, and outcomes of thoracic aortic dissections in hopes of identifying opportunities to improve morbidity and mortality in management of this disease.

The trend for medical malpractice claims has increased in recent years, both in the USA and in Europe. Although diagnostic radiology is not considered a high-risk field, malpractice claims in this area follow this general trend. The most common legal action taken against radiologists includes failure to diagnose, poor communication between physicians, failure to supervise technologists properly and improper procedures. Recently, the Italian Civil Supreme Court delivered a judgment (Cass. Civ., N.10158-18) regarding the liability of radiologists, stating that in radiological practice, a correct and timely execution of the diagnostic investigation is required. By contrast, the same judgment states that requesting further clinical consultations and/or the execution of in-depth diagnostic examinations are not within their duties. Considering this judgment, we report two cases of radiologist malpractice and related responsibility for negligent conduct regarding the diagnosis of thoracic aortic dissection and the prevention and management of acute aortic syndrome.

Despite advances in the diagnosis and treatment of thoracic aortic disease, it remains a highly morbid disease with an increased risk of dissection and death from rupture. Most patients with thoracic aneurysms are asymptomatic, with identification of aneurysms occurring through incidental imaging more frequently than symptoms. When considering “what we do not know about women in thoracic aortic disease,” we aim to examine this pathology in the context of what is already known. Beginning with the incidence of thoracic aortic aneurysms and thoracic aortic dissection, we will examine what is known about women in the context of current literature and further opportunities for research in sex-specific risk factors and outcomes in thoracic aortic disease.

Objective: The goal of this chapter is to present the technique and the results associated with the 1-stage open surgical repair (via bilateral anterior thoracotomy) for patients with extensive chronic thoracic aortic dissection.

Background Aortic dissection (AD) is one of the most catastrophic diseases and is associated with high morbidity and mortality. The aim of this study is to investigate the hospital incidence and mortality rates of thoracic AD in Korea using a nationwide database. Methods We conducted a nationwide population-based study using the health claims data of the National Health Insurance Service in Korea. From 2005 to 2016, adult patients newly diagnosed with AD were included. All patients were divided into the following four subgroups by treatment: type A surgical repair (TASR), type B surgical repair (TBSR), thoracic endovascular aortic repair (TEVAR), and medical management (MM). The incidence rate, mortality rate, and risk factors of in-hospital mortality were evaluated. Results In total, 18,565 patients were newly diagnosed with AD (TASR, n = 4,319 [23.3%]; TBSR, n = 186 [1.0%]; TEVAR, n = 697 [3.8%]; MM, n = 13,363 [72.0%]). The overall AD incidence rate was 3.76 per 100,000 person-years and exhibited a gradual increase during the study period (3.29 to 4.82, P < 0.001). The overall in-hospital mortality rate was 10.84% and remained consistent (P = 0.57). However, the in-hospital mortality rate decreased in the TASR subgroup (18.23 to 11.27%, P = 0.046). An older age, the female sex, hypertension, and chronic kidney disease were independent risk factors for in-hospital mortality. Conclusion The incidence of thoracic AD has gradually increased in Korea. The in-hospital mortality in the TASR subgroup decreased over the decade, although the overall mortality of AD patients did not change., Graphical Abstract

Objective: This study is a retrospective study looking at the incidence, management and outcome of patients with thoracic aortic dissection, and the accuracy of emergency physicians in diagnosing thoracic aortic dissection. Background: Thoracic Aortic Dissection (TAD) is associated with a high mortality rate, more so if there is missed or late diagnosis (1-2% per hour). This makes the early diagnosis and prompt management a crucial component in mortality reduction. Methods: A retrospective cross-sectional data analysis of adults presenting to three Monash Health Emergency Departments (ED) suspected for TAD, over a 1-year period from 1st July 2018 to 30th June 2019. Through the presentations, patients with confirmed TAD were identified and demographics, management options as well as outcome were analysed. Results: 16045 adults presented to Monash health EDs with chest pain as their chief complaint over the study period. 68 had been investigated for TAD mainly with CT aortogram. 11 patients had a confirmed TAD (incidence rate of approximately 6.5 in 10000 patients per year), with majority (9 patients) being diagnosed with Stanford Type A dissection. Two patients died in the ED (mortality rate 18%) and others who survived were discharged home and stayed well in 3 months follow up. Conclusion: Thoracic aortic dissection, in particular Type A, remains a condition with a relatively high mortality rate. To reduce this, high index of suspicion and prompt investigation is essential. We demonstrated good accuracy and competency of Emergency physicians in diagnosing and screening for thoracic aortic dissection. Keywords: Aortic dissection; death; dissection; emergency department; TAD; Thoracic aortic dissection

Introduction: Current guidelines recommend patients with thoracic aortic disease (TAD) including inherited aortopathies to avoid heavy exercise. However, evidence supporting the negative advice on exercise is scarce. We aimed to provide an up-to-date systematic review of the available evidence on risks and benefits of exercise and sports participation in TAD patients. Areas covered: A systematic search was performed in Medline, Embase and Web of Science: thoracic aortic aneurysm or thoracic aortic dissection or inheritable aortopathies including Marfan Syndrome (MFS), Loeys-Dietz syndrome, Turner Syndrome, Ehlers-Danlos syndrome, bicuspid aortic valve (BAV) and sports, exercise or athletes. The resulting 1,652 manuscripts were reviewed by two independent observers. Eventually, 26 studies and 12 case-reports were included, reporting on thoracic aortic dimensions in athletes, exercise related acute aortic dissections, and exercise in BAV and MFS patients. Expert opinion: Blood pressure elevation during exercise may be associated with an increased risk of acute aortic dissection; however, no controlled trials have longitudinally evaluated the effect of exercise on survival or the risk of aortic dissection in TAD patients. Mouse-model studies suggest beneficial effects of exercise in the setting of a dilated aorta in MFS. There is a clear need for prospective research in this field.

Background. In families with an inherited form of non-syndromic thoracic aortic disease (TAAD), aortic diameter alone is not a reliable marker for disease occurrence or progression. To identify other parameters of aortic function, we studied aortic stiffness in families with TAAD. We also compared diameter measurements obtained by transthoracic echocardiography (TTE) and magnetic resonance imaging (MRI). Methods. Seven families, including 116 individuals, with non-syndromic TAAD, were studied. The aortic diameter was measured by TTE and MRI. Aortic stiffness was assessed as local distensibility in the ascending aorta and as regional and global pulse wave velocity (PWV). Individuals with a dilated thoracic aorta (n = 21) were compared with those without aortic dilatation (n = 95). Results. Ascending aortic diameter measured by TTE strongly correlated with the diameter measured by MRI (r2 = 0.93). The individuals with dilated aortas were older than those without dilatation (49 vs 37 years old). Ascending aortic diameter increased and distensibility decreased with increasing age; while, PWV increased with age and diameter. Some young subjects without aortic dilatation showed increased aortic stiffness. Individuals with a dilated thoracic aorta had significantly higher PWV and lower distensibility, measured by MRI than individuals without dilatation. Conclusions. Diameters measured with TTE agree with those measured by MRI. Aortic stiffness might be a complementary marker for aortic disease and progression when used with aortic diameter, especially in young individuals. Originally included in thesis in manuscript form.

Introduction Endovascular intervention involving the aortic arch, particularly in thoracic aortic dissection, remains challenging and controversial at current time when there is no commercially suitable grafts on most of the international markets. This study compared two endovascular treatments that maintain left subclavian artery perfusion using two modified techniques for type-B aortic dissection patients. Methods Consecutive cases utilizing chimney or in situ fenestration techniques to preserve left subclavian artery in type B AD from 2006 to 2015 in our single institution were retrospectively reviewed. Statistical analyses were performed with Student t-test, Wilcoxon rank sum, and Fisher exact tests when appropriate. Significant statistical differences were determined with p Results A total of 85 cases, including 67 (79.8%) with chimney and 18 (21.2%) with in situ fenestration techniques were identified in this retrospective study. In chimney group, there were 18 (26.9%) acute, 29 (43.3%) sub-acute, and 20 (29.9%) chronic aortic dissections. We implanted 24 Zenith and 43 Talent aortic endografts along with 55 balloon-expandable bare stents and 12 self-expanding covered stents in chimney group. Whereas in in situ fenestration group, there were four (22.2%) acute, six (33.3%) subacute, and eight (44.5%) chronic aortic dissections, all of which received Zenith endografts with 11 balloon-expandable covered and seven self-expanding covered stents, respectively. Demographic variables were similarly distributed with 100% intraoperative technical overall success in both groups. Comparing to in situ fenestration group, chimney group has shorter procedural and fluoroscopy time, less blood loss, and contrast volume used. All patients were followed-up to 52 months (median 38, range 24–52). Overall group mortality is 3.6% (3/84). All deaths were from chimney group. There was no procedure-related stroke observed within the study series. Primary patency was maintained while aortic remodeling with complete false lumen was achieved in all patients except that there were three (4.55%) Type-I endoleak cases in early post-operative period and one (1.5%) stent compression at 3-months follow-up in chimney group. There were no stent-related complications observed in in situ fenestration group. Conclusion Although there were previous studies describing the similar techniques, this study appears to be the first study to compare in situ fenestration and chimney techniques for aortic dissection involving the left subclavian artery according to the MEDLINE search. Although we are unable to establish the superiority between two approaches due to small sample size and relative short period of follow-up, in situ fenestration may represent a more favorable option, especially among aortic dissections with short proximal landing zones in the study.

BACKGROUND Thoracic aortic aneurysms progressively enlarge and predispose to acute aortic dissections. Up to 25% of individuals with thoracic aortic disease harbor an underlying Mendelian pathogenic variant. An evidence-based strategy for selection of genes to test in hereditary thoracic aortic aneurysm and dissection (HTAAD) helps inform family screening and intervention to prevent life-threatening thoracic aortic events. OBJECTIVES The purpose of this study was to accurately identify genes that predispose to HTAAD using the Clinical Genome Resource (ClinGen) framework. METHODS We applied the semiquantitative ClinGen framework to assess presumed gene-disease relationships between 53 candidate genes and HTAAD. Genes were classified as causative for HTAAD if they were associated with isolated thoracic aortic disease and were clinically actionable, triggering routine aortic surveillance, intervention, and family cascade screening, All gene-disease assertions were evaluated by a pre-defined curator-expert pair and subsequently discussed with an expert panel. RESULTS Genes were classified based on the strength of association with HTAAD into 5 categories: definitive (n = 9), strong (n = 2), moderate (n = 4), limited (n = 15), and no reported evidence (n = 23). They were further categorized by severity of associated aortic disease and risk of progression. Eleven genes in the definitive and strong groups were designated as "HTAAD genes" (category A). Eight genes were classified as unlikely to be progressive (category B) and 4 as low risk (category C). The remaining genes were recent genes with an uncertain classification or genes with no evidence of association with HTAAD. CONCLUSIONS The ClinGen framework is useful to semiquantitatively assess the strength of gene-disease relationships for HTAAD. Gene categories resulting from the curation may inform clinical laboratories in the development, interpretation, and subsequent clinical implications of genetic testing for patients with aortic disease, (C) 2018 the American College of Cardiology Foundation, Published by Elsevier. Alt rights reserved.

Thoracic aortic aneurysms, with an estimated prevalence in the general population of 1%, are potentially lethal, via rupture or dissection. Over the prior two decades, there has been an exponential increase in our understanding of the genetics of thoracic aortic aneurysm and/or dissection (TAAD). To date, 30 genes have been shown to be associated with the development of TAAD and ∼30% of individuals with nonsyndromic familial TAAD have a pathogenic mutation in one of these genes. This review represents the authors' yearly update summarizing the genes associated with TAAD, including implications for the surgical treatment of TAAD. Molecular genetics will continue to revolutionize the approach to patients afflicted with this devastating disease, permitting the application of genetically personalized aortic care.

Introduction Aorto-oesophageal fistula is a rare but life threatening cause of upper gastrointestinal haemorrhage. Severity of presentation and complexity of subsequent management depends on the size of the defect on both the aortic side and oesophagus. Report The patient was a 67 year old Chinese man, who presented initially with a Stanford type A dissection with caudal extension to the right common iliac artery. The patient underwent replacement of the ascending aorta and proximal arch with debranching of the right innominate artery and aortic valve replacement. A follow up computed tomography (CT) aortogram done in the post-operative period showed a stable appearance of the caudal extension of the aortic dissection. The patient was discharged with a plan for future stenting of the thoracic aorta. Three weeks later the patient re-presented with an upper gastrointestinal bleed from an aorto-oesophageal fistula. The patient underwent endovascular stenting of the descending aorta for management of the fistula. Repeat oesophagogastroduodenoscopy showed a small erosion 35 cm from the incisors where the previous bleeding site had been. No further bleeding was seen. Discussion The patient recovered uneventfully after the procedure. Follow up CT aortogram done at 6 weeks demonstrated thrombosis of the false lumen of the descending thoracic aorta. Aorto-oesophageal fistula related to chronic type B aortic dissection is an extremely rare clinical entity and presents a challenge to the treating surgeon. This case demonstrates that selected cases can be judiciously managed by thoracic endovascular aneurysm repair alone., Highlights • Management of aorto-oesophageal fistula may be difficult and associated with significant morbidity. • Most aorto-oesophageal fistulas develop related to, aneurysms or penetrating ulcers, they are rarely related to dissections. • Endovascular management is feasible but still not established as the standard of care. • This case demonstrates successful endovascular management of an aorto-oesophageal fistula related to type B dissection.

Thoracic aortic dissection (TAD) is an aggressive and life-threatening vascular disease and there is no effective means of early diagnosis of dissection. Type IV collagen (Col-IV) is a major component of the sub-endothelial basement membrane, which is initially exposed followed by endothelial injury as early-stage event of TAD. So, we want to build a noninvasive diagnostic method to detect early dissection by identifying the exposed Col-IV via MRI. Methods Col-IV-targeted magnetic resonance/ fluorescence dual probe (Col-IV-DOTA-Gd-rhodamine B; CDR) was synthesized by amide reaction and coordination reaction. Flow cytometry analysis was used to evaluate the cell viability of SMC treated with CDR and fluorescence assays were used to assess the Col-IV targeting ability of CDR in vitro. We then examined the sensitivity and specificity of CDR at different stages of TAD via MRI and bioluminescence imaging in vivo. Results The localization of Col-IV (under the intima) was observed by histology images. CDR bound specifically to Col-IV-expressing vascular smooth muscle cells and BAPN-induced dissected aorta. The CDR signal was co-detected by magnetic resonance imaging (MRI) and bioluminescence imaging as early as 2 weeks after BAPN administration (pre-dissection stage). The ability to detect rupture of dissected aorta was indicated by a strong normalized signal enhancement (NSE) in vivo. Moreover, NSE was negatively correlated with the time of dissection rupture after BAPN administration (r2 = 0.8482). Conclusion As confirmed by in vivo studies, the CDR can identify the exposed Col-IV in degenerated aorta to monitor the progress of aortic dissection from the early stage to the rupture via MRI. Thus, CDR-enhanced MRI proposes a potential method for dissection screening, and for monitoring disease progression and therapeutic response.

Background Stanford acute type A aortic dissection (ATAAD) is a potentially lethal condition. Epidemiology studies show a statistical incidence in Europe of approximately 2–16 cases/100,000 inhabitants/year. In Germany, the estimated incidence (here subsumed under "thoracic aortic dissection" with 4.63 cases/100,000 inhabitants/year) is mainly extracted from medical death certificates by the German Federal Statistical Office. The prehospital incidence of ATAAD deaths is largely unknown. Since patients often die in the pre-hospital setting, the incidence of ATAAD is therefore likely to be higher than current estimates. Material and methods For the period from 2010 to 2014, we retrospectively analyzed all in-hospital ATAAD data from two of the largest cardiac surgical centers that treat ATAAD in the Berlin-Brandenburg region. In addition, autopsy reports of all forensic medicine institutes and of one large pathological provider in the region were analyzed to identify additional non-hospitalized ATAAD patients. Based on these findings, the regional incidence of ATAAD was calculated. Results In addition to in-hospital ATAAD patients ( n =405), we identified additional 145 lethal ATAAD cases among 14,201 autopsy reports. The total of 550 ATAAD cases led to an estimated incidence of 11.9 cases/100,000 inhabitants/year for the whole Berlin-Brandenburg region. Arterial hypertension, pre-existing aortic dilatation, and hereditary connective tissue disorder were found in, respectively, 62.7%, 10%, and 1.8% of patients . Conclusion ATAAD is more frequent than previously reported. Our results show that when patients who die outside of cardiac surgery centers are included, the incidence of ATAAD significantly exceeds the rate reported by the Federal Statistical Office.

Background Results of surgery in descending aortic dissection is usually not safe. Recently after introducing the thoracic endovascular stents the outcome marvelously improved. Our objective was to evaluate the results of our 10 years experience of using the endovascular stents in trauma patients. Methods In Saudi German Hospital in Madinah Munawarah, from 2007 to 2016 13, cases of traumatic aortic dissection were subjected to thoracic endovascular aortic repair (TEVAR). All cases were victims of blunt trauma in road traffic accidents (RTAs). All had descending thoracic aortic dissection just after the left subclavian artery. Medtronic TEVAR was used in all cases. The data of those patients were collected and revised. CT angio, echocardiography and abdominal ultrasonography were the main tools in the diagnosis. Results All cases were males, middle aged, victims of RTAs and all were associated with other injuries.12 cases survived, one died due to major head injury. The survived cases had no paraplegia either before or after stenting. No intra-thoracic bleeding occurred after the procedure. All cases had no coronary artery or valvular involvement. All cases had good landing zones most were within the range of 2 cms or even more. There was no mortality or morbidity related to the procedure. Conclusions The TEVAR is a reliable, safe, convenient and with less complications than the surgical management for traumatic aortic dissection. No incidence of paraplegia was encountered. It is mandatory in all cases presented in RTAs to be surveyed for traumatic aortic dissection.

Background Prediction of the age at aortic dissection for family members of aortic dissection patients would enhance early detection and clinical management. We sought to determine whether these dissections tend to cluster by age in family members of the dissection patients. Methods Ages at dissection were examined, including 51 sporadic dissectors (one dissection in family) and 39 familial dissectors (two or more dissections in family) from 16 families. Differences between sporadic and familial dissectors and relationships between ages at dissection in family members were analyzed by linear regression and clustering analysis. Results Age at dissection was significantly younger in familial versus sporadic dissectors (54.1 ± 15.2 years versus 63.1±12.4 years, p = 0.002). Regression analysis of pairs of family member ages at dissection found a moderately close linear fit (R 2 = 0.35). Cluster analysis indicated that age at onset of family dissectors increases as age of proband dissector increases. More than 50% of familial dissections occurred within 10 years of the median onset age for any given age decade. For familial dissectors with onset age of 30 to 49 years, 71% of other family member dissections also occurred at age 30 to 49 years, and no dissections occurred above the age of 63 years. For familial dissectors with onset age of 60 to 79 years, 80% of other family member dissections occurred beyond the age of 50 years. Conclusions Familial dissections occur earlier than sporadic dissections. Dissections cluster by age in families, and age at onset can predict the age of other dissectors. This finding argues for consideration of prophylactic resection of an aneurysm in family members approaching the age at onset of prior thoracic aortic dissection.

Hemorrhagic cholecystitis is a rare subtype of acute cholecystitis. It is considered a medical emergency, with a morbidity rate of 32% to 58% and a mortality rate of 15% to 20%. It presents with an acute onset of intense abdominal or back pain that can be mistaken for other conditions such as thoracic aortic dissection. Diagnosis hinges on a high index of suspicion and confirmatory studies, such as computed tomography scan or ultrasound. Specific risk factors identified in the literature include a history of trauma and anticoagulant use. We present an atypical case of spontaneous hemorrhagic cholecystitis with no antecedent risk factors.

Nuss procedure, also known as minimally invasive repair of pectus excavatum (MIRPE), is a standard practice in modern surgery. Although initially, this procedure was recommended for the younger age group but nowadays, surgeons also practice in the older age group. Due to little modifications of the original Nuss procedure, the complications rate had markedly reduced. We report a case of 21 years male with pectus excavatum who had traumatic thoracic aortic dissection and fracture of the thoracic spine three years before presentation. He came to our hospital to correct pectus excavatum deformity. At the same time, he was refused by other hospitals due to previous aortic dissection treated with endovascular stent and thoracolumbar spines spine fixed with metallic bars. With a simple modification, MIRPE was performed safely, and the patient was discharged for follow up in outpatient with an excellent outcome.

Acute aortic syndrome and in particular aortic dissection (AAD) persists as a cause of significant morbidity and mortality despite improvements in surgical management. This clinical review aims to explore the risks of misdiagnosis, outcomes associated with misdiagnosis and evaluate current diagnostic methods for reducing its incidence.Due to the nature of the pathology, misdiagnosing the condition and delaying management can dramatically worsen patient outcomes. Several diagnostic challenges exist, including low prevalence, rapidly propagating pathology, non-discrete symptomatology, non-specific signs, analogy with other acute conditions and lack of management infrastructure. A similarity to acute coronary syndromes is a specific concern and risks patient maltreatment. AAD with malperfusion syndromes are both a cause of misdiagnosis and marker of disease complication, requiring specifically tailored management plans from the emergency setting.Despite improvements in diagnostic measures, including imaging modalities and biomarkers, misdiagnosis of AAD remains commonplace and current guidelines are relatively limited in preventing its occurrence. This paper recommends the early use of AAD risk scoring, focused echocardiography and most importantly, fast-tracking patients to cross-sectional imaging where the suspicion of AAD is high. This has the potential to improve the diagnostic process for AAD and limit the risk of misdiagnosis. However, our understanding remains limited by the lack of large patient datasets and an adequately audited processes of emergency department practice.

Objective: Thoracic aortic dissection (TAD) is a fatal disease that leads to aortic rupture and sudden death. However, little is known about the effect and molecular mechanism of S-nitrosylation (SNO) modifications in TAD formation. Approach and Results: SNO levels were higher in aortic tissues from TAD patients than in those from healthy controls, and PLS3 (plastin-3) SNO was identified by liquid chromatography-tandem mass spectrometry analysis. Furthermore, tail vein administration of endothelial-specific adeno-associated viruses of mutant PLS3-C566A (denitrosylated form) suppressed the development of TAD in mice, but the wild-type PLS3 (S-nitrosylated form) virus did not. Mechanistically, Ang II (angiotensin II)–induced PLS3 SNO enhanced the association of PLS3 with both plectin and cofilin via an iNOS (inducible nitric oxide synthase)-dependent pathway in endothelial cells. The formation of PLS3/plectin/cofilin complex promoted cell migration and tube formation but weakened adherens junction formation in Ang II–treated endothelial cells. Interestingly, denitrosylated form of PLS3 partially mitigated Ang II–induced PLS3/plectin/cofilin complex formation and cell junction disruption. Additionally, the inhibition of iNOS attenuated PLS3 SNO and the association of PLS3 with plectin and cofilin, thereby modulating endothelial barrier function. Conclusions: Our data indicate that protein SNO modification in endothelial cells modulates the progression of aortic aneurysm and dissection. The iNOS-mediated SNO of PLS3 at the Cys566 site promoted its interaction with cofilin and plectin, thus contributing to endothelial barrier disruption and pathological angiogenesis in TAD.

Objective This study explored the clinical efficacy and hemodynamic effects of the micropore stent graft (MSG) that could promote aortic remodeling and preserve important organ branches. Methods We conducted a retrospective analysis of 26 patients who underwent endovascular repair using an MSG for DeBakey types I and III TAD at our center between December 2014 and December 2017. The main efficacy parameters were rupture of the false lumen or dissection‐related death, conversion to open repair, secondary reintervention, branch vessel patency, and the hemodynamic effects of TAD at 12 months. Results Dissection rupture, dissection‐related mortality, conversion to open repair, and secondary reintervention rates at 12 months were 0, 3.9, 0, and 0%, respectively. In the 24 patients with more than 6 months of follow‐up, micropore stents were implanted to cover 39 openings in aortic arch branches, 91.7% (22/24) presented with complete thrombosis in the false lumen, 8.3% (2/24) presented with partial thrombosis in the false lumen, 35.2% (6/17) presented with a thrombus in the false lumen that was completely absorbed, and all 39 branches were patent. After surgery, pressure peak value and fluctuation along with the degree and range of unstable blood flow in the aortic lumen decreased. Conclusions For type I and type III thoracic artic dissection, endovascular treatment with an MSG may be a safe and effective treatment option with a good midterm outcome.

Background: Thoracic aortic dissection is an emergent life-threatening condition. Routine screening for genetic variants causing thoracic aortic dissection is not currently performed for patients or family members. Methods: We performed whole exome sequencing of 240 patients with thoracic aortic dissection (n=235) or rupture (n=5) and 258 controls matched for age, sex, and ancestry. Blinded to case-control status, we annotated variants in 11 genes for pathogenicity. Results: Twenty-four pathogenic variants in 6 genes (COL3A1, FBN1, LOX, PRKG1, SMAD3, and TGFBR2) were identified in 26 individuals, representing 10.8% of aortic cases and 0% of controls. Among dissection cases, we compared those with pathogenic variants to those without and found that pathogenic variant carriers had significantly earlier onset of dissection (41 versus 57 years), higher rates of root aneurysm (54% versus 30%), less hypertension (15% versus 57%), lower rates of smoking (19% versus 45%), and greater incidence of aortic disease in family members. Multivariable logistic regression showed that pathogenic variant carrier status was significantly associated with age Conclusions: Clinical genetic testing of known hereditary thoracic aortic dissection genes should be considered in patients with a thoracic aortic dissection, followed by cascade screening of family members, especially in patients with age-of-onset

Analysed herein is efficacy of hybrid intervention according to the 'frozen elephant trunk' procedure in the medium-term period of follow-up in patients operated on for aortic dissection. During the period from 2012 to 2018, a total of 44 'frozen elephant trunk' procedures were carried out for Stanford type A and B thoracic aortic dissections. All interventions were performed in conditions of moderate hypothermic circulatory arrest (25-28 °C) with unilateral cerebral perfusion through the brachiocephalic trunk. The mean diameter of the implanted stent grafts amounted to 27.7±2.8 mm (range 24-30 mm). The distal edge of the stent graft was located at the level below the Th9 in more than 65% of cases (range Th7-Th12). The stent grafts were fixed proximally at the levels Z0-Z3, predominantly in the Z3 zone (72.7%). Thirty-day mortality amounted to 6.8%, with in-hospital mortality of 15.9%. Five-year survival in acute and chronic type A aortic dissection (AD) amounted to 100 and 80%, respectively (p=0.175). In acute type B aortic dissection five-year survival amounted to 62.2%, being 25.0% for chronic AD (p=0.057). Freedom from reinterventions for acute and chronic type A aortic dissection amounted to 100 and 66.7%, respectively (p=0.286). Freedom from aortic reinterventions for acute and chronic type B aortic dissection amounted to 100% and 75%, respectively (p=0.123). Reconstructive operations performed according to the 'frozen elephant trunk' technique appear to be effective surgical treatment in patients with thoracic aortic dissection, yielding satisfactory clinical results during a medium-term follow-up period.Проанализирована эффективность гибридного вмешательства по методике 'замороженный хобот слона' в среднесрочном периоде наблюдения у больных с расслоением аорты. За период 2012–2018 гг. выполнено 44 процедуры по методике 'замороженный хобот слона' при расслоении грудной аорты типов А и В по Стэнфордской классификации. Все вмешательства проводились в условиях умеренной гипотермии (25–28 °C) циркуляторного ареста с унилатеральной перфузией головного мозга через брахиоцефальный ствол. Средний диаметр имплантируемого стент-графта составил 27,7±2,8 мм (диапазон 24–30 мм). Дистальный край стент-графта определялся на уровне ниже Th9 более чем в 65% случаев (диапазон Th7–Th12). Проксимальная фиксация стент-графта выполнялась на уровнях Z0–Z3, преимущественно в зоне Z3 (72,7%). Тридцатидневная летальность составила 6,8%, госпитальная – 15,9%. Пятилетняя выживаемость при остром и хроническом расслоении аорты (РА) типа А достигала 100 и 80% соответственно (p=0,175). При остром РА типа В 5-летняя выживаемость находилась на уровне 62,2%, при хроническом – 25,0% (p=0,057). Свобода от реинтервенций при остром и хроническом РА типа А составила 100 и 66,7% соответственно (p=0,286). При острой форме РА типа В свобода от аортальных реинтервенций достигала 100%, при хронической – 75% (p=0,123). Реконструктивные операции, выполняемые по методике 'замороженный хобот слона', являются эффективным хирургическим лечением больных с расслоением грудной аорты, обеспечивающим удовлетворительный клинический результат в среднесрочном периоде наблюдения.

Abdominal Aortic Aneurysm (AAA) affects 4–5% of men over 65, and Thoracic Aortic Dissection (TAD) is a life-threatening aortic pathology where 75% of patients die within 2-weeks post-onset. Relatively little is known about the underlying mechanisms, which warrants further investigation. Neutrophil Elastase (NE) is an enzyme with roles in priming of the immune system, clearance of large pathogens and remodelling of extra-cellular-matrix proteins, all influential in AAA and TAD. Our recent study suggests a causal role for NE in hyperlipidemia-induced atherosclerosis. However, little is known regarding implications of NE in AAA and TAD. This Study aims to investigate the role of NE within both pathologies. Gene-expression of NE and AAA-associated markers, MMP-2 and MMP-9, were significantly up-regulated by CaCl2-and AngII-treatment in the cultured vascular smooth muscle cells, endothelial cells and macrophages. In both AngII- and CaCl2-induced AAA mouse models, reduction of aortic expansion in NE-knockout mice was observed, compared with wild-type littermates. TAD experiments reaffirmed the functional importance of NE, with significant reduction in death within NE-knockout mice. Histological and Proteomics analysis was carried out in order to determine changes produced by loss of the NE gene within these models. Preliminary translational work is underway, with an Audit of Aneurysm patients’ blood profiles. Additionally, peripheral blood and aortic tissues were harvested from surgical repair patients with AAA for NE expression analysis. Initial results show an alteration in proportions of White Blood cell populations, namely macrophages and lymphocytes within expansive aneurysms and co-localisation of NE with MMPs in AAA human samples. This study suggests NE could be a regulator of aortic expansion and dissection, and therefore a potential target for AAA and TAD treatment. Further work is still needed to elucidate the causal mechanism by which NE takes its effect on AAA and TAD. Conflict of interest no