Acute Thoracic Aortic Syndromes Research Articles

The Other Aortic Syndrome-Intramural Hematoma and Neurological Deficit: Case Report.

Acute thoracic aortic syndromes are among the most concerning presentations in emergency medicine and are associated with significant morbidity and mortality. Thoracic aortic dissection is most common, followed by penetrating aortic ulcer and, least commonly, intramural hematoma. A 67-year-old woman presented to the emergency department with chest and back pain, and sudden onset of paraparesis. Aortic intramural hematoma was diagnosed, and she underwent spinal drain placement with blood pressure control to optimize spinal cord perfusion. When neurological deficits are present, rapid diagnosis of spinal ischemia and blood pressure optimization is vital. Spinal drains may be considered as an adjunctive treatment.

Trends and Outcomes of Elective Thoracic Aortic Repair and Acute Thoracic Aortic Syndromes in the United States

BackgroundThere is a paucity of data on the contemporary outcomes and trends of elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. MethodsWe queried the National Inpatient Sample (NIS) database years 2012-2016 to identify hospitalizations for elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. The main study outcome was in-hospital mortality. ResultsThe analysis yielded 24,295 hospitalizations for elective thoracic aortic aneurysm repair and 8875 hospitalizations for aneurysm-associated acute aortic syndrome. The number of hospitalizations for elective aortic repair significantly increased from 4375 in 2012 to 5450 in 2016 (Ptrend = .01). The number of hospitalizations for acute aortic syndrome numerically increased from 1545 in 2012 to 2340 in 2016 (Ptrend = .10). Overall in-hospital mortality for elective aortic repair was 2.4% with no change over time. In-hospital mortality for acute aortic rupture was 39.4% and for acute aortic dissection was 6.2% with no change over time. Hospitalizations for elective aortic repair had lower incidence of complications compared with those for aneurysm-associated acute aortic syndrome, including cardiogenic shock, cardiac arrest, acute stroke, and shorter length of stay. Factors associated with higher mortality among admissions undergoing elective aortic repair included older age, heart failure, valvular disease, and chronic kidney disease. Older age, coagulopathy, and fluid/ electrolytes disorders were associated with increased mortality among those with acute aortic syndrome. ConclusionContemporary elective thoracic aortic aneurysm repair is associated with lower in-hospital mortality and morbidity when compared with a clinical presentation for an aneurysm-associated acute aortic syndrome. This should be taken into account when deciding the timing of elective aortic aneurysm repair and balancing the risks and benefits.

Important issues regarding planning and sizing for emergent TEVAR.

In the past decades, treatment of acute thoracic aortic syndrome underwent drastic changes with a central role for thoracic endovascular aortic repair (TEVAR). One of the essential factors in the success of TEVAR is accurate sizing of the endograft, as both under- and oversizing can lead to suboptimal results and disastrous complications. The aim of this review was to give an overview of issues regarding endograft sizing in emergent TEVAR. Sizing of the endograft can be complicated by specific factors related to the underlying disease. For instance, different types of the acute thoracic aortic syndrome, i.e. blunt thoracic injury, thoracic aortic aneurysm or dissection with concomitant rupture are associated with hemorrhagic shock and the need for resuscitation, which leads to profound changes in diameter of the thoracic aorta. These diameter changes should be taken into account during endograft sizing. Measuring the thoracic aorta based on the admission CTA can lead to inaccurate sizing, even if proper centerline-based measurements are performed. The use of real-time imaging, in particular intravascular ultrasound (IVUS), has been shown to provide more accurate endograft sizing in acute thoracic aortic syndromes, especially if associated with hypovolemia. Future research should provide additional data on the exact role of different intra-operative imaging modalities (e.g. IVUS, transesophageal echocardiography [TEE], three dimensional CTA) on endograft sizing and long-term outcomes to ultimately improve patient outcome.

Role of PET/CT in the Evaluation of Aortic Disease.

Positron emission tomography (PET) /computed tomography (CT) has been established as a standard imaging modality in the evaluation of malignancy. Although PET/CT has played a major role in the management of oncology patients, its clinical use has also increased for various disorders other than malignancy. Growing evidence shows that PET/CT images have many advantages in aortic disease as well. This review article addresses the potential role of PET/CT in diseases involving the aorta, emphasizing its usefulness with regard to acute thoracic aortic syndromes, aortic aneurysm, atherosclerotic lesions, aortitis and aortic tumors.

IP087. Midterm Results of Endovascular Stent Graft Implantation for the Treatment of Acute Thoracic Aortic Syndromes

The goal of this study was to evaluate the outcome of thoracic endovascular stent graft implantation (TEVAR) in the treatment of acute aortic syndromes (AAS) of the descending aorta. From June 1997 to December 2016, 141 patients (79% male) with a median age of 61 years (range, 22-88 years) underwent TEVAR for AAS. Aortic pathologies were descending aortic aneurysm (DTA) in 23 (16%), acute type B aortic dissections (TBD) in 54 (38%), perforating aortic ulcer (PAU) in 40 (29%), and acute traumatic aortic transactions (ATAT) in 24 (17%). Thirty-day mortality and overall survival were evaluated for each group. The overall 30 day mortality was 7% (n = 10). No patient died in the PAU group, 5 patients (4%) in the TBD group, 3 (2%) in the aneurysm group, and 2 (1%) in the ATAT group (P = .17). Seven of the 10 deaths were aortic related. Permanent and temporary neurologic dysfunctions were observed in five patients (PAU, n = 2; TBD, n = 2; DTA, n = 1) and nine patients (PAU, n = 3; TBD, n = 3; ATAT, n = 2; DTA, n = 1; P = ns). Early reintervention (within 30 days) was needed in seven patients in the TBD group. The causes were endoleaks in five patients (type Ia, n = 3; type Ib, n = 1; type Ib and II, n = 1), postdilatation in one patient, and repeat dissection in another patient. Six patients underwent a second intervention, and the remaining one had conventional surgery (P < .005 between the treatment groups). The overall rate of persistent primary and secondary endoleaks was 20% and 7%, respectively (P < .05). Overall mortality was 86%, 82%, and 67% at 1, 2, and 5 years with significant differences between the four treatment groups (P < .05; Fig). The treatment of acute aortic syndromes of the descending thoracic aorta with endovascular stent grafts is a feasible and safe technique. It provides low morbidity and mortality rates in the early postoperative period, and midterm results are encouraging. However, long-term studies are needed to evaluate the effectiveness and the durability of this procedure.

MDCT evaluation of acute aortic syndrome (AAS).

Non-traumatic acute thoracic aortic syndromes (AAS) describe a spectrum of life-threatening aortic pathologies with significant implications on diagnosis, therapy and management. There is a common pathway for the various manifestations of AAS that eventually leads to a breakdown of the aortic intima and media. Improvements in biology and health policy and diffusion of technology into the community resulted in an associated decrease in mortality and morbidity related to aortic therapeutic interventions. Hybrid procedures, branched and fenestrated endografts, and percutaneous aortic valves have emerged as potent and viable alternatives to traditional surgeries. In this context, current state-of-the art multidetector CT (MDCT) is actually the gold standard in the emergency setting because of its intrinsic diagnostic value. Management of acute aortic disease has changed with the increasing realization that endovascular therapies may offer distinct advantages in these situations. This article provides a summary of AAS, focusing especially on the MDCT technique, typical and atypical findings and common pitfalls of AAS, as well as recent concepts regarding the subtypes of AAS, consisting of aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer and unstable aortic aneurysm or contained aortic rupture. MDCT findings will be related to pathophysiology, timing and management options to achieve a definite and timely diagnostic and therapeutic definition. In the present article, we review the aetiology, pathophysiology, clinical presentation, outcomes and therapeutic approaches to acute aortic syndromes.

MDCT in diagnosing acute aortic syndromes: reviewing common and less common CT findings

Nontraumatic acute thoracic aortic syndromes (AAS) describe a spectrum of life-threatening aortic pathologies with significant implications on diagnosis, therapy and management. In this context, multidetector computed tomography (MDCT) is the gold standard due to its intrinsic diagnostic value; its performance approaches 100% sensitivity and specificity, and it is accepted as a first-line modality for suspected acute aortic disease. MDCT allows early recognition and characterisation of acute aortic syndromes as well as the presence of any associated complications - findings that are essential for optimising treatment and improving clinical outcomes. Although classic CT findings have long been known, other unusual signs are continually reported in the medical literature. We reviewed the classic and less common CT findings, correlating them with pathophysiology, timing and management options, to achieve a definite and timely diagnostic and therapeutic definition.

Stenting of the descending thoracic aorta: a six-year single-center experience

The aim of this study was to review the six-year results of the endovascular repair of descending thoracic aortic pathologies, reporting the early perioperative outcomes as well as the mid-term follow-up of the treated patients. Fifty-five consecutive patients who underwent endovascular repair for thoracic aortic pathology (32 aneurysms, 17 acute thoracic aortic syndromes, and six traumatic aortic ruptures) during a six-year period were retrospectively reviewed. From these patients, 30 (54.5%) were treated electively and 25 (45.5%) on an emergency basis. In eight cases (14.5%) there was a need for left subclavian artery orifice overstenting. In seven patients (12.7%) an abdominal aortic lesion was simultaneously treated, while three more patients (5.5%) had previously had their abdominal aortic aneurysm repaired. The primary technical success was 92.7%. Seven patients (12.7%) underwent some operation related complication, while postoperative complications occurred in five patients (9.1%), namely four myocardial infarctions, one acute respiratory distress syndrome and two delayed parapareses resulting in an overall incidence of neurological complications of 3.6%. The combined 30-day and in-hospital mortality was 9.1%, exclusively related to patients treated emergently (P = 0.01). In a mean follow-up period of 34 months there were six deaths, and the overall cumulative survival at four years was estimated at 72.6%. Only one type II endoleak was observed one month after the procedure and it spontaneously disappeared 18 months later. The endovascular repair of descending thoracic aortic pathologies seems to be a well-established method, with favorable morbidity and mortality rates, at least for 30 days and in the mid-term. Taking into account the potential of a wide application of the endovascular technique in many vascular centers, stenting of the thoracic aorta might offer an overall better solution for patients suffering from these devastating pathologies.

Acute aortic syndromes: Role of multi-detector row CT

Acute thoracic aortic syndromes encompass a spectrum of emergencies including aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer and aneurysm rupture. All these life-threatening conditions require prompt diagnosis and appropriate management. To date multi-detector row Computed Tomography represents a valuable diagnostic tool especially in the emergency setting. This paper focus on the use of multi-detector row Computed Tomography in the evaluation of acute thoracic aortic syndromes and illustrates the key imaging findings related to each disease.

Long-Term Follow-Up After Endovascular Treatment of Acute Aortic Emergencies

To investigate the long-term outcome and efficacy of emergency treatment of acute aortic diseases with endovascular stent-grafts. From September 1995 to April 2007, 37 patients (21 men, 16 women; age 53.9 +/- 19.2 years, range 18-85 years) with acute complications of diseases of the descending thoracic aorta were treated by endovascular stent-grafts: traumatic aortic ruptures (n = 9), aortobronchial fistulas due to penetrating ulcer or hematothorax (n = 6), acute type B dissections with aortic wall hematoma, penetration, or ischemia (n = 13), and symptomatic aneurysm of the thoracic aorta (n = 9) with pain, penetration, or rupture. Diagnosis was confirmed by contrast-enhanced CT. Multiplanar reformations were used for measurement of the landing zones of the stent-grafts. Stent-grafts were inserted via femoral or iliac cut-down. Two procedures required aortofemoral bypass grafting prior to stent-grafting due to extensive arteriosclerotic stenosis of the iliac arteries. In this case the bypass graft was used for introduction of the stent-graft. A total of 46 stent-grafts were implanted: Vanguard/Stentor (n = 4), Talent (n = 31), and Valiant (n = 11). Stent-graft extension was necessary in 7 cases. In 3 cases primary graft extension was done during the initial procedure (in 1 case due to distal migration of the graft during stent release, in 2 cases due to the total length of the aortic aneurysm). In 4 cases secondary graft extensions were performed--for new aortic ulcers at the proximal stent struts (after 5 days) and distal to the graft (after 8 months) and recurrent aortobronchial fistulas 5 months and 9 years after the initial procedure--resulting in a total of 41 endovascular procedures. The 30-day mortality rate was 8% (3 of 37) and the overall follow-up was 29.9 +/- 36.6 months (range 0-139 months). All patients with traumatic ruptures demonstrated an immediate sealing of bleeding. Patients with aortobronchial fistulas also demonstrated a satisfactory follow-up despite the necessity for reintervention and graft extension in 3 of 6 cases (50%). Two patients with type B dissection died due to mesenteric ischemia despite sufficient mesenteric blood flow being restored (but too late). Two suffered from neurologic complications, 1 from paraplegia and 1 from cerebral ischemia (probably embolic), 1 from penetrating ulcer, and 1 from persistent ischemia of the kidney. Five of 9 (56%) patients with symptomatic thoracic aneurysm demonstrated endoleaks during follow-up and there was an increase in the aneurysm in 1. Endovascular treatment is safe and effective for emergency treatment of life-threatening acute thoracic aortic syndromes. Results are encouraging, particularly for traumatic aortic ruptures. However, regular follow-up is mandatory, particularly in the other pathologies, to identify late complications of the stent-graft and to perform appropriate additional corrections as required.

Multidetector-row CT evaluation of nontraumatic acute thoracic aortic syndromes

Acute thoracic aortic syndromes encompass a spectrum of emergencies presenting with acute chest pain and marked by a high risk of aortic rupture and sudden death. These include nontraumatic disease entities of the thoracic aorta, namely, dissection, intramural haematoma, penetrating atherosclerotic ulcer and aneurysm rupture. In clinical practice, the most frequent imaging procedure used in the diagnostic assessment of these diseases is computed tomography (CT), which, thanks to recent technological developments [multidetector-row computed tomography (MDCT)], affords important diagnostic possibilities and very interesting future perspectives. This paper on the use of MDCT in the evaluation of acute thoracic nontraumatic aortic syndromes illustrates the examination technique and the key imaging findings related to each disease. Moreover, the role of MDCT for planning specific treatment is also highlighted.

Thoracic Stent Grafting for Acute Aortic Pathology

Elective endovascular repair of the thoracic aorta has shown reduced morbidity and mortality when compared with open surgery. The number of studies describing the use of thoracic endovascular stent grafts for acute pathology is limited, however. The purpose of this study was to describe our increasing experience with stent grafting for acute thoracic aortic pathology. Since January 2002, 28 patients underwent endovascular stent graft treatment for various types of acute thoracic aorta diseases, including complicated Stanford type B dissection (n = 12), ruptured descending aorta aneurysms (n = 7), intramural hematoma (n = 4), traumatic rupture of the thoracic aorta (n = 2), aortopulmonary fistula (n = 2), and penetrating aortic ulcer (n = 1). These acute thoracic aortic syndromes were predominantly localized in the proximal descending thoracic aorta (75%). Talent stent grafts were used in 26 patients and Excluder stent grafts in 2 patients. Stent graft deployment at the intended position was successful in all patients. There was 1 intraoperative death (3.6%), due to acute myocardial infarction, after successful exclusion of the lesion with a stent graft. Hospital mortality was 21.4% (n = 6). Four of 6 hospital deaths, however, were directly related to the severely compromised clinical status preoperatively, including extensive bowel ischemia and irreversible cerebral damage after resuscitation. New neurologic symptoms were seen in 4 patients. The majority of the neurologic symptoms improved and faded away during hospital stay. Mean follow-up was 11 months (range, 1 to 31), and all the hospital survivors (n = 22) were alive. There was 1 nonrelated stroke 4 months postoperatively. During follow-up, 2 patients required transposition of the left subclavian artery for malperfusion, and 2 patients required a second stent graft procedure for endoleak. Additionally, 2 patients with early type II endoleaks were treated conservatively, and 1 of them sealed spontaneously at 6 months. Thoracic stent grafting for acute aortic pathology is feasible in critically ill patients. Postoperative morbidity and mortality is predominantly related to the compromised preoperative clinical status, illustrating its use as salvage strategy.

Emergency endovascular stent-graft treatment for acute thoracic aortic syndromes

We report the results of our ongoing experience of urgent and emergency stent-graft implantation in acute thoracic aortic syndromes. In the last 5-years, 19 patients were treated for acute thoracic aortic syndromes. Traumatic rupture was diagnosed in 7 patients, complicated acute type B dissection was present in 5 patients, penetrating ulcer in 4, and symptomatic thoracic aortic aneurysm in 3 patients. There were 17 male patients with a mean age of 54 +/-26 years (range 18-87 ; median 63). Patients were treated in the theatre suite under general anesthesia. Stent-graft placement was technically successful in all patients. The early postoperative mortality was 10.5 %. Neurological events or upper arm ischemia due to overstenting of the left subclavian artery were not observed. Average intensive care unit and hospital stay were 18 and 21 days, respectively. Major complications occurred in 6 patients. Follow-up ranged between 3 and 60 months (mean 25) and included clinical examinations and serial CT-angiography at 1, 4 and 12 months, and every year thereafter. Only one type II endoleak was detected and treated by coil embolization of the left subclavian artery. Our experience suggests emergency stent-graft repair in patients with acute thoracic aortic syndromes is a less-invasive attractive alternative, showing encouraging early and mid-term results.

Thoracic aortic emergencies: impact of endovascular surgery

Background Conventional surgery for thoracic aortic emergencies, such as contained or free rupture of thoracic aortic aneurysms, acute type B dissections, and traumatic rupture of the thoracic aorta, is frequently associated with a high rate of mortality and morbidity. To obviate this risk, endovascular surgery is considered to be a valid alternative procedure. Methods From March 2001 to July 2002, 15 of 22 patients with acute thoracic aortic syndromes were submitted to endovascular surgery: 3 patients (20%) for traumatic rupture, 4 patients (26.7%) for contained or free rupture of thoracic aortic aneurysm, and 8 patients (53.3%) for acute type B dissection evolving to rupture. Computed tomographic scan was diagnostic in all patients. The stent grafts were introduced through the femoral artery. Results In the endovascular group there were no perioperative deaths or open conversions. The intraoperative angiography and computed tomographic scan performed on discharge showed no significant endoleaks and successful sealing of the aortic dissection. Average intensive care unit and hospital stay was 1.7 ± 0.8 and 5.9 ± 3.0 days. Follow-up ranged between 4 and 23 months and included clinical examinations and serial computed tomographic scan at 3, 6, and 12 months, and every 6 months thereafter. One 84-year-old patient with thoracic aortic aneurysm died of pneumonia 78 days after endovascular surgery. Only one type 1 endoleak was noted in the first patient with traumatic rupture, 3 months after the procedure. Conclusions Endovascular surgery is a safe technique, showing encouraging early and midterm results and allowing for prompt treatment of associated lesions in complex multitrauma patients.