Aortic Dissection Type Research Articles

TCTAP C-161 A Case That Liver Function Was Improved by Stent Implantation to Celiac Artery Pressed by False Lumen Caused by Aortic Dissection

### Patient Initials or Identifier Number K.W. ### Relevant Clinical History and Physical Exam A case was 50 years old man, treated with high blood pressure and a bicuspid valve. He had an operation due to Stanford A type aortic dissection. His liver function turned worse with GOT 6662 IU/l, GPT

TCTAP C-159 Hybrid Procedure for Mal-perfusion Syndrome in Complicated Acute Aortic Dissection Type B in a Young Patient Non-marfan Fibrillinopathy

### Patient Initials or Identifier Number 1031234 ### Relevant Clinical History and Physical Exam - Male patient, 36-year-old. - History: Hypertension. No family history. - Complained about the chest and abdominal pain. - Physical exam: Severe pain in the chest and abdominal. Femoral pulse

Long-term survival and frequency of reinterventions after proximal aortic surgery: a retrospective study†.

We sought to analyse perioperative outcome, long-term mortality, frequency and causes of reintervention, and survival benefit in a contemporary cohort of patients undergoing proximal thoracic aortic surgery. Participants comprised all patients undergoing open surgery for proximal thoracic aortic aneurysm (TAA) (n = 319) and thoracic aortic dissection type A (TAD) (n = 229) during 2005-2014 at the Department of Thoracic Surgery, Uppsala University Hospital. Long-term survival was compared to age- and sex-matched controls. Perioperative mortality and morbidity, event-free survival and causes of reoperation were also analysed. Long-term mortality was normalized in patients with TAA, and a survival benefit was seen as early as 20 months when corrected for time lost due to perioperative mortality. Long-term survivors undergoing surgery for TAD, on the other hand, had a 10-year mortality of 130% [95% confidence interval (95% CI) 120-140%] compared to age- and sex-matched controls. Moreover, their event-free survival was half that of patients with TAA (hazard ratio 2.3; 95% CI 1.7-3.2). Reintervention (i.e. reoperation or thoracic endovascular aortic repair) was also twice as common in the TAD patients (odds ratio 2.0; 95% CI 1.1-3.5). The dominant causes for reoperation among TAD patients were aortic insufficiency, aortic arch aneurysm and infection. Surgery for TAA is relatively safe, normalizes long-term mortality and confers an early survival benefit. However, TAD surgery carries a high risk of perioperative mortality and morbidity, as well as increased long-term mortality and risk of reintervention.

Aortic root remodeling in bicuspid and tricuspid aortic valves-long-term results.

Root remodeling is one form of valve-preserving root replacement to treat patients with aortic regurgitation (AR) and root aneurysm. We have consistently used it for patients with and without connective tissue disease and different aortic valve morphologies. The objective of this retrospective study was to review 23years of experience with root remodeling. Between 10/95 and 9/2018, 1004 of 1038 root remodeling procedures were performed in patients with tricuspid (n = 589) or bicuspid (n = 414) anatomy of the aortic valve in our institution. Aortic aneurysm was present in 932 cases, 73 procedures were performed for acute aortic dissection type A. The severity of aortic regurgitation ranged from grade I to grade IV (mean 2.5 ± 0.8). All patients underwent root remodeling, concomitant operations were performed in 433, and cusp repair in 883 instances. Hospital mortality was 2%. Overall freedom from reoperation was 92% at 10years and 89% at 15years. It was 94% for tricuspid valves at 10 and 15years, and 88% for bicuspid aortic valves at 10years and 80% at 15years (p = 0.003). In conclusion, root remodeling is a viable option in valve-preserving root replacement. If combined with careful assessment and, if necessary, correction of aortic valve form reproducible restoration of aortic valve function can be achieved.

Infrarenal versus Suprarenal Abdominal Aortic Aneurysms: Comparison of Associated Aneurysms and Renal Artery Stenosis

The aim of our study is to assess the prevalence of concomitant arterial abnormalities (true aneurysms of iliac, common femoral, renal, visceral arteries and stenoses of iliac and renal arteries) in patients with abdominal aortic aneurysm, and to evaluate whether the type of the aneurysm (suprarenal versus solely infrarenal) is associated with this prevalence. In this retrospective cross-sectional study, we assessed computed tomography angiography scans of 933 patients with abdominal aortic aneurysm, including thoracoabdominal aortic aneurysms type II-IV, with no history of abdominal aortic surgery. We compared 2 groups of patients: group 1 (n=859) with solely infrarenal abdominal aortic aneurysm and group 2 (n=74) with the suprarenal aneurysm component. Patients with history of aortic dissection or thoracoabdominal aortic aneurysms type I and V were excluded from the study. All computed tomography angiography scans were visually assessed by 2 independent experienced physicians. Study group comprised 933 patients with the median age of 73.0years, 83.8% of whom were male. We observed higher prevalence of common iliac artery aneurysms (44.6% vs. 30.6%, P=0.013), internal iliac artery aneurysms (28.4% vs. 18.0%, P=0.03), common femoral artery aneurysms (13.5% vs. 4.4%, P<0.001), visceral artery aneurysms (5.4% vs. 1.2%, P=0.019), renal artery stenosis (20.3% vs. 5.2%, P<0.001), renal atrophy (6.7% vs. 1.1%, P=0.004), and severe chronic kidney disease (14.1% vs. 1.8%, P<0.001) in group 2 compared to group 1. There were no significant differences in the prevalence of iliac arterial stenoses between the groups. Among patients with abdominal aortic aneurysm, concomitant aneurysms and renal artery stenosis are more common in patients with suprarenal component when compared to those with solely infrarenal presentation.

Preoperative dual antiplatelet therapy increases bleeding and transfusions but not mortality in acute aortic dissection type A repair.

Acute aortic dissection type A is a life-threatening condition, warranting immediate surgery. Presentation with sudden chest pain confers a risk of misdiagnosis as acute coronary syndrome resulting in subsequent potent antiplatelet treatment. We investigated the impact of dual antiplatelet therapy (DAPT) on bleeding and mortality using the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database. The NORCAAD database is a retrospective multicentre database where 119 of 1141 patients (10.4%) had DAPT with ASA + clopidogrel (n = 108) or ASA + ticagrelor (n = 11) before surgery. The incidence of major bleeding and 30-day mortality was compared between DAPT and non-DAPT patients with logistic regression models before and after propensity score matching. Before matching, 51.3% of DAPT patients had major bleeding when compared to 37.7% of non-DAPT patients (P = 0.0049). DAPT patients received more transfusions of red blood cells [median 8 U (Q1-Q3 4-15) vs 5.5 U (2-11), P < 0.0001] and platelets [4 U (2-8) vs 2 U (1-4), P = 0.0001]. Crude 30-day mortality was 19.3% vs 17.0% (P = 0.60). After matching, major bleeding remained significantly more common in DAPT patients, 51.3% vs 39.3% [odds ratio (OR) 1.63, 95% confidence interval (CI) 1.05-2.51; P = 0.028], but mortality did not significantly differ (OR 0.88, 95% CI 0.51-1.50; P = 0.63). Major bleeding was associated with increased 30-day mortality (adjusted OR 2.44, 95% CI 1.72-3.46; P < 0.0001). DAPT prior to acute aortic dissection repair was associated with increased bleeding and transfusions but not with mortality. Major bleeding per se was associated with a significantly increased mortality. Correct diagnosis is important to avoid DAPT and thereby reduce bleeding risk, but ongoing DAPT should not delay surgery.

Blood Flow CFD Simulation considering Various Types of Aortic Dissection

Blood Flow CFD Simulation considering Various Types of Aortic Dissection

Virtual Implantation of Stent-graft by Finite Element Simulation and Its Applications in Endovascular Treatment Planning for B Type Aortic Dissection

Virtual Implantation of Stent-graft by Finite Element Simulation and Its Applications in Endovascular Treatment Planning for B Type Aortic Dissection

Successful mechanical thrombectomy via the transbrachial approach for acute ischemic stroke patient with chronic aortic dissection and bovine type aortic arch

Successful mechanical thrombectomy via the transbrachial approach for acute ischemic stroke patient with chronic aortic dissection and bovine type aortic arch

Risk factors of surgical treatment of acute aortic dissection type A (in Russian only)

To evaluate risk factors of surgical treatment of acute aortic dissection type A. Retrospective analysis included 100 patients with acute aortic dissection type A who underwent surgery in 2007-2017. Patients were divided into 2 groups: group I (survivors, n=79) and group II (unfavorable outcomes, n=21). Postoperative in-hospital mortality was 21% (21/100). Preoperative risk factors were cardiac tamponade (p=0.0001), aortic rupture (p=0.0001), impaired coronary blood flow (p=0.0001), renal malperfusion (p=0.0001). Prolonged cardiopulmonary bypass (156.1±37.9 min vs 205.7±91.2 min), surgery time (5.0±1.1 vs. 6.8±2.5 h, p=0.0009) and deep hypothermia (26.1±4.6 min vs 22.4±4.4 min) were the main intraoperative risk factors influencing surgical outcomes in patients who underwent aortic arch repair. Multiple organ failure (p=0.0001), sepsis (p=0.0007), severe postoperative bleeding (p=0.0010) and disseminated intravascular coagulation (p=0.0001) were the main predictors of advanced mortality in postoperative period. Timely surgical treatment in case of cardiac tamponade and aortic rupture is essential to improve survival in patients with acute aortic dissection. Advanced aortic repair including hemi- or total arch replacement should be comprehensively measured because such procedures may be followed by increased postoperative morbidity and mortality after emergency aortic surgery.

IMMEDIATE AND LONGTERM RESULTS OF ENDOVASCULAR STENT-GRAFTING IN DISSECTIONS AND ATHEROSCLEROTIC ANEURYSMS OF THORACIC AORTA

Objective: to analyze the results of endovascular stent-graftingin dissections and atherosclerotic aneurysms of descending part of thoracic aorta.Material and method: in this analysis includes 28 patients with dissections and atherosclerotic aneurysms of descending part of thoracic aorta. Acute aortic dissection type 3 was occurred in 10 patients and two of them were complicated with rupture into the left pleural cavity. 10 patients with chronic aortic dissection type bunderwent operations and one of them was complicated with rupture into the left pleural cavity. Among 8 operated patients due to chronic aneurysms of descending part of thoracic aorta, 4 patients were manifested with symptoms of hemothorax. In 3 patients with aortic dissection type 1 in long-term period, endovascular stent-grafting was performed concerning with the dilatation of descending thoracic aorta and patent false lumen. During in-hospital and long-term periods immediate clinical results, serious clinical complications and long-term survival were compared.Results: technical success of endovascular stent-grafting was achieved in 100 % of cases. In-hospital mortality was 4 (14,2 %) and 30-day mortality was 3 (10,7 %). Events of paraplegia, TIA (Transient Ischemic Attack), prosthetic infection were not found in our research. Two clinical occurrences of vascular approach site complication were found; one case of endoleak type 1 and stent-graft dislocation which required repeated endovascular stent-grafting and one case of endoleak type 2 which was performed subclaviancarotid bypass and ligation of left subclavian artery. Prolong intubation was needed in 5 patients (18,5 %).conclusion: Endovascular stent-grafting in dissections and atherosclerotic aneurysms of descending part of thoracic aorta contributes good immediate clinical results associating with less quantity of serious complications.

Accuracy of deployment of the Relay non-bare stent graft in the aortic arch.

To minimize the complications with thoracic endovascular aortic repair (TEVAR), a new stent graft with no bare ends was developed, namely the Relay non-bare stent (NBS). We hypothesized that the new features of the NBS graft would enable highly accurate deployment and fewer complications. The aim of this study was to analyse the quality of the Relay NBS with respect to its landing precision. Relying on computed tomography angiographs, we evaluated the distance between the stent graft and the target vessel in the proximal landing zone (before and after the intervention as well as the mid-term results). Seventy-eight patients with thoracic aortic pathologies were included. Median computed tomography angiograph follow-up was 16 months. The stent graft was deployable ≤5 mm from the target vessel in 64 (82%) patients; in 14 (18%) of them, the distance to the target vessel was >5 mm. According to the last follow-up computed tomography angiograph, in 35 (55%) patients, the distance to the target vessel was ≤5 mm and in 29 (45%) patients, it was >5 mm. There was no endoleak type Ia immediately after TEVAR or during the follow-up period. A substantial bird beak phenomenon was observed in 3 (4%) and 7 (11%) patients immediately after TEVAR and during the follow-up period, respectively. One patient had a retrograde dissection type A. The Relay NBS graft can be deployed accurately in the aortic arch in most patients. Retrograde aortic dissection type A seldom occurs after TEVAR using the Relay NBS graft. The distance between the NBS graft and the intended target vessel increases during the follow-up period.

Outcome after aortic, axillary, or femoral cannulation for acute type A aortic dissection

ObjectiveThe optimal method for arterial cannulation in acute aortic dissection type A (ADA) remains controversial. The aim of this study was to compare central ascending aortic, axillary, and femoral cannulation in patients who underwent surgery for acute ADA. MethodsBetween 2006 and 2017, 584 patients were operated on for acute ADA. Of those, 355 (61%) underwent ascending aortic, 101 (17%) right axillary, and 128 (22%) femoral cannulation for arterial inflow. Clinical features and outcomes were compared after inverse probability weighting. ResultsAfter inverse probability weighting there were no statistical differences in preoperative characteristics. Operative details differed significantly among the 3 groups: hemiarch replacement was performed more often in the central aortic and the femoral group (P < .001), whereas total arch replacement was performed more often in the axillary group (P < .001). Cardiopulmonary bypass (P = .022) and aortic cross-clamp (P = .021) times were shortest in the aortic cannulation group and longest in the femoral cannulation group. Postoperative morbidities were similar; procedure-related stroke (P = .783) and the need for renal replacement therapy (P = .446). In-hospital mortality (P = .680) and long-term survival were similar (log rank, P = .704). Multilevel multivariate mixed effect logistic regression showed that the cannulation strategy was not associated with in-hospital mortality. ConclusionsCentral ascending aortic cannulation in patients with ADA can be used as safely as axillary or femoral cannulation, providing another option for quick and easy establishment of cardiopulmonary bypass.

Factors limiting physical activity after acute typeA aortic dissection.

SummaryBackgroundAcute type A aortic dissection (AAD) leads to high hospital mortality rates in the first 48 h after the onset of symptoms. Survivors, however, have good long-term perspectives and enhanced survival especially if regaining moderate amounts of physical activity.MethodsThis study analyzed 131 survivors (from 180 consecutive patients, aged 60 years (rande 30–84 years, 71% male) of acute AAD after a median time of 44 months (range 1–147 months). The hospital mortality was 13.5%. The group of physically active patients was compared with those with a sedentary life style. The qualitative and quantitative data on physical activity were correlated with data from an aortic registry.ResultsOverall 87% of patients reported 1 or more types of physical activities after hospital discharge. The most common types were walking (51%), biking (29%), hiking (15%) and gymnastics (14%). Patients with a sedentary life style underwent longer hypothermic circulatory arrest times (39 min, range 8–167 min vs. 47 min, range 27–79 min, p = 0.009), had a longer intensive care unit (ICU) stay (Pearsons r = −0.226 [between length of ICU stay and hours of physical activity after hospital discharge], p = 0.033) and suffered more frequently from postoperative paresis (33.3% vs. 3.8%, p < 0.001) compared with physically active patients. Binary logistic regression analysis showed female gender (p = 0.026) and higher body mass index (p = 0.019) to be independently associated with a reduced amount of physical activity.ConclusionsThis study demonstrate that the majority of survivors of acute aortic dissection type A regain a physically active life including the practice of a variety of sports. Factors predictive of a sedentary life style can be identified. Female patients deserve special attention.

EP39 TYPE A INTRAMURAL HEMATOMA AND PENETRATING ATHEROSCLEROTIC ULCERS OF AORTA: EVALUATION AND MANAGEMENT

Background and Aims: The aim of our study is to report our experience on the surgical treatment of intramural aortic hematoma (IMH) and penetrating atherosclerotic ulcers (PAU), as less common variants of “acute aortic syndromes”. Methods: From 2010 to 2015, 38 patients with a diagnosis of “acute aortic syndrome” underwent emergency surgery at our Center, of which 31 patients (81.57%), suffering from acute aortic dissection type A, 7 patients (18.42%), affected by IMH and a patient (2.63%) affected by IMH + PAU: All the patients affected by IMH and IMH + PAU underwent emergency surgery. We analyzed the following parameters: General and hemodynamic clinical conditions; Presence of spontaneous breath or endotracheal intubation; Neurological conditions; Timing from diagnosis to surgical treatment; Intervention type performed; Time to wake up. Results: Survival at 30 days was 100%: 6 patients were discharged at home, about 3 weeks after surgery and 2 patients were transferred to Cardiorespiratory Rehabilitation Centers about 3 weeks after surgery, in satisfactory general clinical conditions. Conclusions: Preoperative conditions of the patients, early diagnosis and the timeliness of the surgical treatment represent, in our experience, determinant factors about clinical outcomes.

346. Pregnant with Marfan syndrome and aortic root aneurism: Dissection case report for the third quarter

Introduction The main cardiovascular complications of Marfan Syndrome (MS) are valvar disease, heart failure and aortic dissection. Pregnancy in a patient with MS presents greater risk of aortic complications. Aortic root diameter greater than 45 mm is a class IV of modified World Health Organization classification of maternal pregnancy risk (high risk of maternal death or severe morbidity). We discuss a case of aortic dissection in the third trimester in a MS patient with aortic dilation previous to pregnancy. Method Review of medical charts. Case description Patient 40 years old, with MS, previous echocardiogram with aortic root of 54 mm, ascending aorta of 56 mm, and normal aortic arch. She refused therapeutic abortion. During prenatal she remained asymptomatic, under use of metoprolol for 75 mg. A new echocardiogram was made in the second trimester, without alterations. At 30 weeks of gestation, she presented with aortic dissection type Stanford A. A cesarean section was performed under general anesthesia, followed by subtotal hysterectomy, during which the patient remained stable. Subsequently, correction of dissection of the ascending aorta was initiated, with a Benton procedure and right coronary artery bypass. An intraoperative myocardial infarction caused cardiorespiratory arrest reversed during surgery, but a new episode during anesthetic lead to death. The 1370 g live neonate had a good outcome. Discussion Aortic dissection is a severe condition with high rates of mortality. Pregnancy in a patient with aortic dilation is a reason to pregnancy termination, refused by this patient. Even with medical treatment with beta-blocker, she presented a type A aortic dissection, with immediate indication of premature therapeutic cesarean section followed by surgery. Despite prompt diagnosis and treatment, an intraoperative myocardial infarction was the cause of maternal death. This case shows that in spite of optimal care, pregnancy in Marfan syndrome patient with aortic dilation may have a fatal outcome.

Bentall surgery for acute aortic dissection (type-a) in a patient with marfan syndrome

Background: Marfan syndrome is an autosomal-dominant hereditary connective tissue disorder with the clinical manifestations involving the ocular, skeletal, and cardiovascular systems. The cardiovascular manifestations include aortic root dilatation, aortic valvular insufficiency, mitral valve prolapse, mitral regurgitation, aortic dissection and aortic rupture. Acute aortic dissection is one of the most common catastrophes involving the aorta. A high index of suspicion is important in patients who have predisposing risk factors. Classification is based on the location of dissection and its duration. Stanford type A (De bakey type I /type II) dissection should be treated surgically in essentially all cases.Objective: To report our experience in Bentall surgery in Acute aortic dissection (type A ). The efficacy of right axillary artery cannulation was investigated.Materials &amp; Methods: Patient with acute type A aortic dissection involving coronary sinuses with 3 vessels of the arch free of lesions underwent aortic valve with ascending aorta and hemiarch replacement with composite valve graft (Bentall procedure) and reimplantation of coronary arteries under moderate hypothermia. The axillary artery was used for arterial cannulation.Results: Weaning from CPB was smooth. Perioperative period was eventless. Follow-up Echo revealed normal cardiac parameters.Conclusion: Prompt establishment of the diagnosis, through focused physical examination and noninvasive imaging, followed by rapid medical and surgical therapy, are the only effective methods to alter survival in patients with acute aortic dissection.KYAMC Journal Vol. 9, No.-2, July 2018, Page 95-100

OP03-4 - Effects of early use of LPS adsorption filter in acute aortic dissection type A: preliminary results

OP03-4 - Effects of early use of LPS adsorption filter in acute aortic dissection type A: preliminary results

The Relationship Between Renal Artery Involvement in Stanford B-Type Aortic Dissection and the Short-Term Prognosis: A Single-Centre Retrospective Cohort Study

Renal artery involvement has not received sufficient attention despite the fact that aortic computed tomography angiography (CTA) examinations of Stanford B-type aortic dissection patients usually show renal artery involvement [3]. To study the influence of renal artery involvement on aortic dissection, we performed a retrospective study on acute Stanford B-type aortic dissection patients with or without renal artery involvement to investigate its effect on the prognosis of aortic dissection. A total of 221 patients with acute Stanford-B type aortic dissection between January 2012 and January 2014 were enrolled. The patients were divided into a renal artery involvement group and a non-renal artery involvement group based on aortic computed tomography angiography (CTA) results. The clinical data of the two groups were compared. Univariate analyses and multiple logistic regression analyses were performed to determine risk factors related to in-hospital mortality. The effect of renal artery involvement on the prognosis of Stanford B-type aortic dissection patients was analysed. Among the 221 patients with acute Stanford type-B aortic dissection, 100 patients (45.2%) exhibited renal artery involvement. The percentage of patients with a past history of hypertension in the renal artery involvement group was significantly higher than that in the non-renal artery involvement group (84.0% vs. 74.8%, p=0.025). The estimated glomerular filtration rate (eGFR), creatinine level, and urea nitrogen level at admission were not significantly different between the renal artery involvement group and the non-renal artery involvement group. The in-hospital mortality rate in the renal artery involvement group was higher than that in the non-renal artery involvement group; the difference in the percentage of in-hospital mortality between these two groups was statistically significant (12.0% vs. 4.1%, p<0.05). The results of multiple logistic regression analysis showed that renal artery involvement was a risk factor for in-hospital mortality in acute Stanford B-type aortic dissection patients (odds ratio (OR)=3.536 (1.127∼11.095)). In the renal artery involvement group, the in-hospital mortality rate in the conservative treatment group was significantly higher than that in the interventional treatment group (30.8% vs. 5.4%, p=0.001). Although renal artery involvement was not associated with short-term renal function damage, it was a risk factor for in-hospital mortality after acute Stanford B-type aortic dissection.

The ratio between descending aorta and ascending aorta diameter for rapid diagnosis of Stanford type B aortic dissection

Objective To investigate the significance of diameter measurement in descending aorta and ascending aorta as predictors of Stanford B type aortic dissection. Methods A total of 156 patients with chest pain and 100 healthy volunteers as control were enrolled in this study. The descending aorta diameter (dDA) and ascending aorta diameter (dAA) were measured by computed tomography (CT) and CT angiography(CTA), and the ratio of dDA to dAA or to rDA(radius of descending aorta) was calculated. Various metrics were analyzed for their specificity and sensitivity as screening measurements for Stanford B type aortic dissection. Results Fifty-six cases were diagnosed with Stanford B type aortic dissection by CTA with significant increases in dDA and rDA compared with control group(P<0.05). When dDA was ≥30 mm, the sensitivity was 94.6% and specificity was 82.0% for Stanford B type aortic dissection, and when the rDA was ≥0.8, sensitivity and specificity were 96.4% and 91.0%, respectively. Conclusions The dDA≥30 mm and rDA≥0.8 may be used to predict Stanford B type aortic dissection in suspected patients with chest pain, and the latter is more accurate than the former. Key words: Stanford B aortic dissection; Descending aorta diameter; Ascending aorta diameter; Diagnosis