Acute Aortic Pathology Research Articles

Evaluation of the intraoperative specimens of the thoracic and abdominal aorta

BackgroundLittle is known about the histological patterns of acute and chronic aortic pathology with regard to medial degeneration, atherosclerosis and aortitis as well as their distribution in different age groups. The aim of the study was to evaluate histopathological findings of intraoperatively gained aortic specimens with regard to the incidence of medial degeneration, atherosclerosis and aortitis.MethodsIntraoperatively gained aortic specimens were evaluated in 151 patients including 83 (55%) aortic aneurysms (65 thoracic, 18 abdominal) and 68 (45%) acute type A aortic dissections. Histological stainings used were hematoxylin and eosin, Van Gieson as well as alcian blue. Patients were stratified according to above and below 65 years of age. High grade medial degeneration represented pooling of mucoid material in the whole aortic wall. High grade atherosclerosis represented severe intimal fibrosis, massive accumulation of macrophages and foam cells or massive calcification of the aortic wall.ResultsMedial degeneration was diagnosed in 106 (70%) patients including 55 (52%) aortic aneurysms and 51 (48%) acute type A aortic dissections. High grade medial degeneration was found in 50% of patients with thoracic aortic aneurysms < 65 years of age vs. 44% in patients ≥ 65 years of age (p = 0.64) and in 36% of patients with thoracic aortic dissections < 65 years of age vs. 14% in patients ≥ 65 years of age (p = 0.07). Atherosclerosis was diagnosed in 71 (47%) patients including 46 (65%) aortic aneurysms and 25 (35%) aortic dissections. High grade atherosclerosis was found in 23% of patients with thoracic aneurysms < 65 years of age vs. 36% in patients ≥ 65 years of age (p = 0.24) and in 13% of patients with aortic dissections < 65 years of age vs. 52% in patients ≥ 65 years of age (p < 0.001). Aortitis was rare (n = 2).ConclusionsMedial degeneration was the most frequent diagnosis in this series of aortic specimens. Medial degeneration was equally common in patients above and below 65 years of age. However in cases with acute type A aortic dissections, high grade atherosclerosis was the leading histopathological diagnosis in patients older than 65 years. Acute type A aortic dissections seem to have different underlying pathologies in different age groups.

Hemomediastino por rotura de aneurisma bronquial

Hemomediastinum caused by rupture of a bronchial artery aneurysm is a very infrequent pathology. Clinical presentation can be variable; it can resemble an aortic pathology and be diagnosed in emergency situations. Computerized tomography (CT) of the thorax is the initial test for diagnosis. We present the clinical case of a 70-year-old man with an initial clinical assessment of transfixive thoracic pain resembling an acute aortic pathology. TC was carried out with a diagnosis of suspected mediastinal neoplasia (Hounsfield Units/HU 38 - soft tissue), biopsy sampling was carried out by gastroscopy and broncoscopy with haemorrhagic pap smear, presenting light anemization on admission and remaining haemodynamically stable and asymptomatic. Facing a high clinical suspicion of arterial pathology, CT was repeated in which hemomediastinum was described in resolution, with subsequent confirmation of the existence of ruptured bronchial artery aneurysm through angiography and proceeding to therapeutic embolization.

Diagnosis and treatment planning of acute aortic emergencies using a handheld DICOM viewer

Acute aortic syndromes and traumatic aortic injury are often diagnosed on CT angiography, possibly requiring emergent intervention. Advances in handheld computing have created the possibility of viewing full DICOM datasets from a remote location. We evaluated the ability to diagnose and characterize acute aortic pathologies on CT angiograms of the thorax using an iPhone-based DICOM viewer. This study was performed after Institutional Review Board approval. Fifteen CT angiograms of the thorax in suspected acute aortic syndromes were evaluated by three blinded radiologists on a handheld device using a DICOM viewer. Studies were evaluated for the ability to identify and classify aortic dissection, transection, or intramural hematoma, measure aortic dimensions, and identify mediastinal hematoma, arch variants, and pulmonary pathology. Studies were compared to blinded interpretations on a dedicated PACS workstation. The aortic pathology was correctly identified as aortic transection/pseudoaneurysm (n = 5), type A dissection (n = 2), and type A intramural hematoma (n = 1) by all reviewers, with no false-positive interpretations. This represents a sensitivity and specificity of 100 %. Mediastinal hematoma (n = 6), pneumothorax (five right, three left), and arch vessel involvement (n = 2) were identified in all cases. There was 88.5 % accuracy in identifying arch variants. Measurement of the size of the involved aortic segment was similar on handheld device and PACS workstation; however the adjacent normal aorta was 1.2 ± 1.0 mm larger on the handheld device (p = 0.03). Handheld DICOM viewers may be useful for emergent consultations and triage, and may expedite preprocedure planning to reduce the time interval between diagnostic scan and therapeutic intervention.

In Situ Laser Fenestration During Thoracic Endovascular Aortic Repair Is an Effective Method for Left Subclavian Artery Revascularization

We have previously described our early experience using retrograde laser fenestration to revascularize the left subclavian artery (LSA) during zone II thoracic endovascular aortic repair (TEVAR). This technique uses a relatively simple intraoperative method of endograft modification to revascularize aortic branches for a variety of acute thoracic aortic pathologies. The aim of this study is to present our expanded experience and midterm outcomes of TEVAR with laser fenestration to revascularize the LSA as an alternative to debranching. A retrospective review of the electronic medical records was conducted of all patients who underwent TEVAR with LSA revascularization via laser graft fenestration from September 2009 through August 2012. TEVAR was carried out with deployment of a Dacron endograft over the orifice of the LSA. Through retrograde brachial access, a 0.018-inch guidewire was placed at the ostium of the LSA, followed by laser catheter fenestration of the graft. Balloon-expandable covered stents were deployed through the fenestration to traverse the endograft and LSA; the endograft portion of the covered stent was flared. Routine postoperative follow-up imaging with computed tomography angiography was performed to assess for TEVAR and LSA fenestration patency, endoleak, and aneurysm/dissection exclusion. TEVAR with laser fenestration was successfully performed in 22 patients (12 men; mean age, 57 years; range, 37-83 years) in an urgent or emergency setting secondary to unremitting symptoms. Thirteen patients had large symptomatic thoracic aortic aneurysms (10 secondary to chronic dissection); four patients had acute symptomatic type B aortic dissection, and five patients had intramural hematoma or penetrating aortic ulcer. An average of two endografts (range, 1-4) were placed during TEVAR. LSA-covered stents ranged from 8 to 10 mm in diameter. Mean operative time for TEVAR with laser fenestration was 154 ± 65 minutes. The average hospital length of stay was 12 ± 7 days. There were no fenestration-related complications. One patient developed postoperative paraplegia, and one patient died of massive hemoptysis in the postoperative period, for an in-hospital mortality rate of 4.5%. At a mean follow-up of 8 months (range, 1-32 months), two patients had died (9%) of non–TEVAR-related causes. Follow up computed tomography angiography imaging demonstrated a 100% primary patency for the LSA stents. One patient had an asymptomatic LSA stent stenosis. Two patients had type II endoleaks from the LSA that required reintervention. Both were successfully managed with endovascular coil embolization. There were no fenestration-related type I or III endoleaks. In situ retrograde laser fenestration is a feasible and effective option for LSA revascularization during TEVAR involving a spectrum of acute thoracic aortic pathologies. Laser fenestration provides a rapid, reproducible method of fenestrating the endograft material. The high technical success, low fenestration-related morbidity, and excellent midterm patency support this technique of intraoperative endograft modification. Longer follow-up remains necessary to determine the durability of this technique.

The role of imaging in acute aortic syndromes

The classic entity of life-threatening aortic dissection represents one pathology of a spectrum of acute conditions coined the acute aortic syndrome comprising dissection, intramural haematoma, penetrating atherosclerotic ulcer, and contained aortic rupture of any cause. The common denominator is disruption of the aortic media layers associated with severe pain and a variety of other symptoms. Any clinical suspicion of acute aortic syndrome should prompt immediate action and confirmatory non-invasive imaging; with respect to sensitivity and specificity for acute aortic pathology modern contrast-enhanced CT technology, MR imaging and ultrasound techniques have similar diagnostic accuracy near 100%. Since the prognosis of most patients with acute aortic dissection is related to undelayed diagnosis and (often surgical) treatment swift diagnostic imaging should be the primary goal in the work-up of any patient with suspected acute aortic syndrome; transfer and in-hospital logistics and local expertise for the differential use of various imaging modalities should be constantly improved.

Aortocaval fistula: current management strategies

There has been a trend towards favouring endovascular repair for much acute aortic pathology. We undertook a review of the literature to determine if an endovascular approach could complement the traditional treatment of aortocaval fistula (ACF), a rare complication of abdominal aortic aneurysm. A literature search was undertaken on PubMed using appropriate search terms. Case series and reviews reporting presentation, diagnosis and operative management (open and endovascular techniques) of ACF were selected and discussed. Open surgical treatment of ACF has an associated morbidity and mortality - mainly from excessive blood loss. Open repair mortality rates are reported around 30%, but some centres report far lower rates based on preoperative diagnosis of the ACF. These rates appear to be reduced when using endovascular repair in selected cases, with success rates of up to 96%. Reiteration of the importance of diagnosis of ACF preoperatively was the common denominator with both open and endovascular repair. Endovascular exclusion appears to be an efficacious means of treating ACF and averting the significant blood loss commonly encountered in conventional repair of these lesions. However, some reviews have suggested equal success with open repair. There is limited available published literature on ACF management and outcome, and likely reporting bias attached to both open and endovascular results that are published. With a randomized controlled trial unlikely to occur, a prospective registry may provide better outcome data.

Chronic pericarditis mimicking a pericardial neoplastic mass

A 57-year-old man with a previous history of myocardial infarction was admitted to the emergency department complaining of chest pain, mild dyspnoea, and lower limb oedema. Serum troponin levels were normal. Computed tomography ( Panel A ) excluded any acute aortic or pulmonary pathology, but detected mitral annular calcification (black arrow), coronary artery calcifications (black arrowhead), and a …

Aggressive Progression of Penetrating Atheromatous Ulcer of the Descending Thoracic Aorta

The treatment of acute aortic pathologies continues to evolve with enhanced imaging capabilities. This case report highlights the rapid progression of penetrating atherosclerotic ulcer to pseudoaneurysm development and subsequent treatment with thoracic endovascular stent graft.

Endovascular treatment of acute and chronic aortic pathology in patients with Marfan syndrome

In patients with Marfan syndrome, the complications of aortic degeneration, including dissection, aneurysm, and rupture represent the main cause of mortality. Although contemporary management of ascending aortic disease requires open surgical reconstruction, endovascular repair is now available for management of descending thoracic and abdominal aortic pathology (ie, thoracic endovascular aortic repair [TEVAR], endovascular aneurysm repair [EVAR]). The short- and long-term benefit of endovascular repair in Marfan patients remains largely unproven. We examine our outcomes after EVAR in this patient population. All patients with a diagnosis of Marfan syndrome who were treated with TEVAR/EVAR were evaluated in a retrospective review. Perioperative, procedure-specific and patient covariate data were aggregated. Primary endpoints were overall mortality and procedural success as divided into three categories: (1) successful therapy, (2) primary failure, or (3) secondary failure. Between 2000 and June 2010, 16 patients were identified as having undergone 19 TEVAR/EVAR procedures. These included three emergent operations (two for acute dissection/malperfusion and one for anastomotic disruption early after open repair). All 16 patients had previously undergone at least one (range, 1-5) open operation of the ascending aorta or arch at a time interval from 33 years to 1 week prior to the index endovascular repair. During a median follow-up of 9.3 months (range, 0-46 months), there were four deaths (25%). Six patients (38%) had successful endovascular interventions. Despite early success, there was one death in this group at 1 month postintervention. Seven patients (44%) experienced primary treatment failure with five undergoing open conversion and one undergoing left subclavian coil embolization (the seventh was lost to follow-up and presented 4 months later in cardiac arrest and expired without repair). There were three deaths in the primary treatment failure group. Two patients experienced secondary treatment failure. One underwent the index TEVAR for acute dissection with malperfusion and required a subsequent TEVAR for more distal aortic pathology. He is stable without disease progression. The other patient underwent open conversion after a second EVAR with four-vessel "chimney" stent grafts and is stable with his entire native aorta having been replaced. Aortic disease associated with Marfan syndrome is a complex clinical problem and many patients require remedial procedures. Endovascular therapy can provide a useful adjunct or bridge to open surgical treatment in selected patients. However, failure of endovascular therapy is common, and its use should be judicious with close follow-up to avoid delay if open surgical repair is required.

Single Superior Mesenteric Artery Periscope Grafts to Facilitate Urgent Endovascular Repair of Acute Thoracoabdominal Aortic Pathology

To assess the use of periscope grafts to the superior mesenteric artery (SMA) in extending the distal sealing zone of thoracic stent-grafts. Three patients with ruptured Crawford type I thoracoabdominal aortic aneurysms (TAAA) and 1 patient with a symptomatic type B dissection underwent endovascular repair; the celiac trunk was intraoperatively occluded in all patients. The thoracic stent-graft was extended to immediately above the most cranial renal artery, and the SMA was simultaneously stented from a femoral approach (periscope graft). All 4 periscope grafts were successfully implanted. One patient with rTAAA and intraoperative hemodynamic instability died in the perioperative period with a patent SMA. The other 3 patients had patent SMA periscope grafts and were free from abdominal symptoms at 14, 12, and 7 months; follow-up CT scans showed excluded aneurysms in the 2 TAAAs. The patient with type B dissection became asymptomatic but had persistent retrograde perfusion and expansion of the false lumen. Periscope grafts are a viable option for urgent endovascular repair of acute Crawford type I TAAA. In type B dissections, however, they are at most a bridging solution until more definitive exclusion of the false lumen is achieved.

Multiple Periscope and Chimney Grafts to Treat Ruptured Thoracoabdominal and Pararenal Aortic Aneurysms

To report midterm outcomes after urgent endovascular repair of ruptured pararenal or thoracoabdominal aortic aneurysms using multiple periscope and chimney grafts to preserve renovisceral branch perfusion and facilitate aneurysm exclusion. Nine consecutive men (mean age 72±14 years, range 40-88) presenting with ruptured thoracoabdominal (n = 6), pararenal (n = 2), or infrarenal (n = 1) aortic aneurysm underwent urgent endovascular repair with at least 1 periscope graft delivered via a transfemoral access; chimney grafts were installed from an axillary access. In all, 17 periscope and 7 chimney grafts were used to reperfuse 11 renal and 13 visceral arteries in the 9 patients. The aortic aneurysms were excluded using thoracic devices (n = 7), an aortic extension cuff (n = 1), and bifurcated stent-grafts (n = 2). All procedures were completed without technical complications except for a dislocated stent-graft from the right renal artery; the artery could not be re-accessed, and the right kidney was sacrificed. One patient died of multiple organ failure (11% 30-day mortality). At a mean follow-up of 10 months (range 3-24), 5 of the 9 patients had recovered completely; 3 patients died of unrelated causes. Imaging showed no aneurysm growth in any patient, with a mean 20% shrinkage in aneurysm size. All periscope and chimney grafts remained patent, and no aortic stent-graft migration was observed. Renal function and the glomerular filtration rate remained stable in all patients. The periscope and chimney graft technique provides a simpler, less invasive way to maintain blood flow to the renovisceral arteries during urgent endovascular aortic repairs. The very low 30-day mortality rate and the stability of the repairs in the midterm are encouraging. This technique has the potential to profoundly influence the treatment of acute aortic pathologies.

Mortality and Neurologic Injury After Surgical Repair With Hypothermic Circulatory Arrest in Acute and Chronic Proximal Thoracic Aortic Pathology

Background— The goal of this study was to determine whether advanced age affects mortality and incidence of neurological injury in patients undergoing surgical repair with hypothermic circulatory arrest in acute and chronic thoracic aortic pathology. Methods and Results— A university center audit was done of 523 consecutive patients (median age, 64 years; interquartile range, 56–71 years) between 2005 and 2010. Mortality in acute type A aortic dissection (207 patients) was 9.7%, and in chronic ascending aortic aneurysms (316 patients) was 2.2% ( P &lt;0.001). Neurological injury was observed in 16.9% of patients with acute type A aortic dissection (chronic ascending aortic aneurysms, 7.9%; P =0.002). Multivariable regression analysis revealed hypothermic circulatory arrest &gt;40 minutes (odds ratio [OR], 4.21; 95% confidence interval [CI], 1.60–11.06; P =0.004) and redo surgery (OR, 3.44; 95% CI, 1.11–10.64; P =0.03) but not age (OR, 1.98; 95% CI, 0.73–5.38; P =0.18) as independent predictor of mortality. Emergency surgery (OR, 3.27; 95% CI, 1.31–8.15; P =0.01) and extracardiac arteriopathy (OR, 2.38; 95% CI, 1.26–4.50; P =0.008) but not age (OR, 1.80; 95% CI, 0.93–3.48; P =0.08) were independent predictors of neurological injury. Conclusions— Age is not associated with increased risk for mortality and neurological injury in patients undergoing surgical repair for acute and chronic thoracic aortic pathology with hypothermic circulatory arrest. Extended hypothermic circulatory arrest times, reflecting the extent of disease, and redo surgery predict mortality, whereas emergency surgery and extracardiac arteriopathy predict neurological injury.

Invited Commentary

Invited Commentary

Penetrating Atherosclerotic Ulcerative Disease of the Aorta: Do Emergency Physicians Need to Worry?

BackgroundIn recent years, different aortic pathologies have been grouped together and described in terms of a spectrum of disease referred to as Acute Aortic Syndrome (AAS). Overlapping of these conditions has traditionally introduced discrepancy to the understanding of the pathophysiology and definitive care. Penetrating atherosclerotic ulcer (PAU), an ulceration of an atherosclerotic plaque, has been increasingly recognized as the individual cause of the acute aortic pathology. ObjectiveThe natural evolution and complications of PAU are described, as well as the current diagnostic strategies, definitive management options, and initial care in the emergency department. DiscussionThe natural history of PAU is variable but is generally considered to be an AAS with a high incidence of complications. The clinical differentiation of symptomatic PAU from other causes of AAS is very challenging. Computed tomography imaging has provided additional accuracy with the use of the retrospective electrocardiographic gating technique. Despite traditional surgical therapies for aortic pathology, later studies have demonstrated the success of non-operative management, such as endoluminal grafting. ConclusionThe relative rarity of this disease, the difficulties in its detection, and the lack of precise guidelines about its management may result in diagnostic delays. Asymptomatic patients with well-controlled blood pressure are safely managed as outpatients in close consultation with vascular surgery.

Acute aortic syndrome: surgical, endovascular or medical treatment

Acute aortic syndrome encompasses classic aortic dissection, intramural haematoma, penetrating aortic ulcer, and iatrogenic or traumatic transection of the aorta. These acute aortic pathologies present with characteristic ‘aortic pain’, and are managed by several operative and endovascular techniques.

The implication of vasa vasorum in surgical diseases of the aorta

Vasa vasorum (VV) are microscopic vases that perfuse the vessel's wall; arteries and veins. Many recent researches support the opinion that VV have a significant role in aortic pathology. The VV, or 'the vessels of the vessels', form a network of microvessels that lie in the adventitia and penetrate the outer media of the host vessel wall. Although the importance of the VV in providing nutritional support is not well known, obstruction of blood flow through these vessels has been implicated in the pathogenesis of many cardiovascular diseases such as aortic intramural hematoma, aortic aneurysm, and acute or chronic aortic dissection. Although the proliferation of VV due to atherogenic stimuli is controversial, experimental and clinical studies strongly suggest the potential of VV in vascular proliferative disorders. It seems that the rupture of VV is implicated in intramural hematoma, which can develop in acute aortic dissection. In this review article, we would like to stress the anatomy and mainly the pathophysiology, and the implication of VV in the acute and chronic aortic pathologies.

Endovascular Treatment of Acute and Chronic Aortic Pathology in Patients With Marfan's Syndrome

Endovascular Treatment of Acute and Chronic Aortic Pathology in Patients With Marfan's Syndrome

Thoracic stent grafting – a feasible solution for acute throracic aortic pathology

Background: Endovascular repair of the thoracic aorta has shown to reduce morbidity and mortality when compared with open surgery. The aim of our study was to describe our experience with stent graft treatment for acute thoracic aortic pathology.

Noninvasive Imaging Approaches to Evaluate the Patient With Known or Suspected Aortic Disease

Both chronic and acute aortic conditions are challenges for primary care physicians and cardiac specialists. Longitudinal progression of chronic aortic diseases and appropriate timing of open or endovascular surgery are usually derived from serial noninvasive imaging studies. Rapid imaging is necessary as not to delay the diagnosis of a potentially life-threatening diagnosis. Given the frequency of missed cases of dissection, atypical presentation, and time-dependent morbidity and mortality, imaging is paramount for diagnosis and treatment of any aortic disorder. An ideal imaging modality will precisely, safely, and rapidly confirm suspected acute or chronic aortic pathology with quantitative information on aneurysm formation and progression, as well as on tear location, extent, and type of dissection including evaluation for imminent complications. Today, invasive angiography has been replaced by noninvasive imaging strategies with multislice computed tomography (CT) and MRI for both chronic and acute pathologies; under emergency conditions, acute aortic syndromes can be imaged and confirmed at the bedside by transesophageal echocardiography (TEE), particularly to identify ascending aortic pathology such as type A aortic dissection. According to the International Registry of acute Aortic Dissection (IRAD), as early as 2002, CT was the diagnostic modality of choice for dissection in 63%, followed by TEE in 32%, and angiography and MRI in 4% and 1%, respectively.1 With excellent accuracy and similar sensitivity and specificity CT, MRI, and TEE have become diagnostic options2,3; however, hemodynamic instability of a given patient, and both availability and local expertise, determine the appropriateness of either modality. Whereas invasive angiography visualizes 2D luminograms, noninvasive multidetector CT (MD-CT) is the result of rapid image acquisition and 3D reconstruction in high resolution during brief opacification by intravenous contrast material.4 The technical leap with MD-CT was the creation of a cone-shaped x-ray beam generating image data over a volume, rather than …

Endovascular Repair of Acute Traumatic Thoracic Aortic Transection With Laser-Assisted In-Situ Fenestration of a Stent-Graft Covering the Left Subclavian Artery

To report the use of in-situ laser-assisted endograft fenestration during thoracic endovascular aortic repair (TEVAR). A healthy 26-year-old man presented to the emergency department after sustaining blunt chest trauma. He was hemodynamically stable, although he subjectively complained of tearing chest pain and pleuritic chest wall pain. Radiography revealed a left clavicular fracture, multiple rib fractures, and a widened mediastinum. Imaging showed a partially contained acute aortic transection just distal to the takeoff of the left subclavian artery (LSA); the arch had a bovine configuration, with a shared origin of the right innominate and left common carotid arteries. Endovascular repair was elected, but to avoid sacrificing the LSA, TEVAR with in-situ graft fenestration was performed to reduce the risk of posterior circulation stroke, spinal cord ischemia, and subclavian steal syndrome. A Talent thoracic stent-graft was deployed, with the covered portion of the endograft extending just distal to the shared origin of the innominate and left carotid arteries. A laser catheter was advanced through the LSA to fenestrate the endograft; the fenestration was dilated and stented with an iCast stent, which was flared proximally and distally to effect a seal. At 6 weeks, imaging documented that the repair was patent and secure; the patient continues to do well at his most recent follow-up at 8 months. This technique may provide a means for extending thoracic endografting technology to a greater number of patients with acute thoracic aortic pathology.