Classic Aortic Dissection Research Articles

Acute aortic syndrome: A systems approach to atime-critical disease.

Acute aortic syndrome represents a group of potentially lethal aortic diseases, including classic acute aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. Among these conditions, type A aortic dissection is the most common acute presentation. Only surgical interventions are recommended in guidelines as lifesaving procedures for type A dissection. Despite new diagnostic imaging methods, advanced surgical strategy, and improved postoperative management in the over 250-year history of aortic dissection, in-hospital mortality and morbidity rates still remain high. Recently, several new system-based approaches, such as implementation of multidisciplinary experienced high-volume centers and establishment of regional systematic management flow have been reported to improve the outcome. Here, we will describe the pathophysiology, diagnosis, and treatment as well as the new systematic approach to treat acute aortic syndrome.

Outcomes and management of type A intramural hematoma.

Initial optimal management of acute type A aortic dissection (ATAAD) with intramural hematoma (ATAIMH) remains controversial, especially between centers in the Eastern vs. Western worlds. We examined the literature and our experience to report outcomes after repair of ATAIMH. We reviewed the hospital, follow-up clinic records and online mortality databases for all patients who presented to our center for open repair of ATAAD between 1999 and 2014. Preoperative characteristics, early and long-term outcomes were compared between classic ATAAD vs. ATAIMH. Survival was analyzed using Kaplan-Meier and log-rank statistics. Of the 523 repaired ATAAD, 101 patients (19%) presented with IMH and 422 (81%) had classic dissection. ATAIMH were significantly older (64.8±12.9 vs. 56.8±14.6 years; P<0.001), more commonly females (39% vs. 26%; P=0.010), had poor baseline renal function (i.e., glomerular filtration rate) (P<0.017), more retrograde dissections (27% vs. 8.3%; P<0.001), and less distal malperfusion (5% vs. 15%; P<0.001). Age greater than 60 years, female sex, retrograde dissection, and Marfan syndrome were strongly correlated with ATAIMH. Time to repair for ATAIMH was longer (median, 55.3 vs. 9.8 hours; P<0.001) with one death in ATAIMH within three days of presentation (0.9% vs. 6%; P=0.040). In all, 30-day mortality in ATAIMH was not different from classic ATAAD (12% vs.16%; P=0.289). A significantly lower incidence of postoperative dialysis in ATAIMH was noted (10% vs. 19%; P=0.034). When adjusted for age and renal function, late survival was improved with IMH (P<0.039). ATAIMH continues to be associated with significant morbidity and mortality, comparable to classic aortic dissection. A multidisciplinary management approach involving aggressive medical management and risk stratification for timely surgical intervention, along with genetic profiling, is recommended for optimal care. Long-term monitoring is mandatory to assess compliance to medical therapy and recognition of evolving complications.

Endovascular Treatment of Two Penetrating Ascending Aortic Ulcers: A Case Report

Endovascular Treatment of Two Penetrating Ascending Aortic Ulcers: A Case Report

Abstract 19354: Management and Outcomes of Acute Type B Dissection in IRAD Treated with Open Surgery, Endovascular Flap Fenestration or TEVAR

Background: The debate for the optimal treatment of complicated Type B Acute Aortic Dissection (TBAAD) is primarily focused upon open surgical intervention versus thoracic endovascular aortic repair (TEVAR). The technique of fenestration with stenting has been proposed to resolve malperfusion. This study evaluated post-procedural outcomes of all three approaches for TBAAD. Methods: TBAAD patients enrolled in the International Registry of Acute Aortic Dissection were stratified by management type: TEVAR, fenestration and stenting, and surgery. Results: Of the 552 patients with TBAAD, 231 (41.8%) underwent TEVAR, 214 (38.8%) standard open surgery, and 107 (19.4%) fenestration and stenting. TEVAR or fenestration and stenting were more likely to be performed in classic double barrel aortic dissection when compared to open surgery (73.2%, 76.6%, 52.8% respectively; p&lt;0.001). Patients treated with open repair were less likely to have distal extension into the abdominal aorta than those with TEVAR or fenestration and stenting (47.7%, 62.7%, 86.4%, respectively; p&lt;0.001). In-hospital mortality was similar between groups (11.7% TEVAR, 14.0% fenestration and stenting, 15.9% surgery). At five years, Kaplan-Meier post-discharge all-cause survival estimates were highest for TEVAR, followed by endovascular fenestration and finally open surgical intervention (85.2%, 78.3%, 67.2%, respectively; p=0.039). Conclusion: Patients treated by endovascular approaches, whether with flap fenestration or thoracic endovascular aortic repair, had lower five year mortality when compared to patients who required open repair in the setting of TBAAD. Either endovascular approach may be helpful in the treatment of TBAAD. Further research is needed to determine how much of the observed difference represents patient selection versus differential effects of treatment.

Endovascular repair of aortic dissection and intramural hematoma: indications and serial changes.

Thoracic aortic dissection (AD) is one of the most common aortic emergencies. It can be fatal if not promptly diagnosed and treated. Intramural hematoma (IMH) of the aorta is recognized as distinct from classic (double-barreled) AD. IMH also frequently leads to aortic emergency, which can be fatal unless rapidly diagnosed and treated.Recently, thoracic endovascular aortic repair (TEVAR) has been used for the treatment of complications caused by AD. TEVAR is also a viable option for the treatment of complicated IHM. In this article, we review the details of TEVAR as treatment options for AD and IMH, including the indications for TEVAR, imaging, and follow-up.

Diagnosis and management of acute aortic syndromes: dissection, intramural hematoma, and penetrating aortic ulcer.

Acute aortic syndromes constitute a spectrum of conditions characterized by disruptions in the integrity of the aortic wall that may lead to potentially catastrophic outcomes. They include classic aortic dissection, intramural hematoma, and penetrating aortic ulcer. Although imaging studies are sensitive and specific, timely diagnosis can be delayed because of variability in presenting symptoms and the relatively low frequency with which acute aortic syndromes are seen in the emergency setting. Traditional classification systems, such as the Stanford system, facilitate early treatment decision-making through recognition of the high risk of death and major complications associated with involvement of the ascending aorta (type A). These patients are treated surgically unless intractable and severe co-morbidities are present. Outcomes with dissections that do not involve the ascending aorta (type B) depend on the presence of acute complications (e.g., malperfusion, early aneurysm formation, leakage), the patency and size of the false lumen, and patient co-morbidities. Patients with uncomplicated type B dissections are initially treated medically. Endovascular techniques have emerged as an alternative to surgery for the management of complicated type B dissections when intervention is necessary. Patients with acute aortic syndromes require aggressive medical care, risk stratification for additional complications and targeted genetic assessment as well as careful long-term monitoring to assess for evolving complications. The optimal care of patients with acute aortic syndrome requires the cooperation of members of an experienced multidisciplinary team both in the acute and chronic setting.

Treatment patterns and their outcomes of acute aortic intramural hematoma in real world: multicenter registry for aortic intramural hematoma.

BackgroundIntramural hematoma of the aorta (IMH), a variant of classic aortic dissection, shows very dynamic process in the early phase. The aim of this study is to evaluate clinical outcomes of patients with acute aortic IMH from real world registry data.MethodsWe analyzed 165 consecutive patients with acute IMH from five medical centers in Korea. All patients were divided into two groups; type A (n = 61, 37.0%) and type B (n = 104, 63.0%) according to the Stanford classification. Clinical outcomes and morphological evolution by CT were analyzed for 2 years.ResultsMost of the patients (77.0% of type A and 99.0% of type B, P < 0.001) were treated medically during their initial hospitalization. There were no significant differences in in-hospital mortality (4.9% vs. 2.9%, P = 0.671) and 2-year mortality (13.1% vs. 11.5%, P = 0.765) between two groups. During the 2-year follow up period, progression to aortic dissection (18.0% vs. 6.7%, P = 0.037) and surgical treatment (29.5% vs. 2.9%, P < 0.001) were higher in type A. For the type A patients, there were no significant difference in in-hospital mortality (7.1% of surgery vs. 4.3% of medical, P = 0.428) and 2-year mortality (7.1% of surgery vs. 14.9% of medical, P = 0.450) in terms of initial treatment strategy.ConclusionFor real world practice in Korea, most of IMH patients were treated medically at presentation and showed favorable outcomes. Thus, even in type A acute IMH, early medical treatment with alternative surgical conversion for selected, complicated cases would be a favorable treatment option.

New vascular ring connectors in surgery for intramural haematoma of the abdominal aorta progressing to rupture : case report - online article

Aortic intramural haematoma is similar to classic aortic dissection, which causes a life-threatening medical condition, and immediate diagnosis and treatment are crucial. The optimal therapy for intramural haematoma of the abdominal aorta remains controversial. Conservative medical management is usually the first choice of treatment for uncomplicated cases. Surgical intervention is usually required for complicated intramural haematomas of the abdominal aorta, including conventional open repair and endovascular treatment with stent-grafts. A new vascular ring connector that achieves a quick, blood-sealed and sutureless anastomosis has been designed for aortic dissection. We herein report a case of intramural haematoma of the abdominal aorta, progressing to rupture on day 14 after onset, which had successful aortic repair with the new vascular ring connector. The new vascular ring connector could be an alternative method for the treatment of complicated intramural haematomas of the abdominal aorta.

Aortic intramural hematoma after thrombolysis in a patient with acute massive pulmonary embolism

Aortic intramural hematoma after thrombolysis in a patient with acute massive pulmonary embolism

Thrombosed Type A Acute Aortic Dissection Quick Overview of a Clinical Variant of Aortic Dissection

Thrombosed type A acute aortic dissection (TA AAD) is a subtype of aortic dissection. The computed tomography shows a crescent-shaped false lumen with neither entry nor blood flow in the false lumen. Clinical characteristics of TA AAD are sometimes different from those of the classical aortic dissection. The worst scenario is the progression to classical aortic dissection, which means recanalization of the false lumen, frank rupture, or aneurysmal formation is worse clinical manifestations. On the other hand, spontaneous regression of the false lumen leading to the disappearance of the aortic dissection is the best course. Optimal strategy for TA AAD still remains debatable. One of the reasons is the international differences in the outcomes of TA AAD. In the Western countries, the patients treated with emergent operation had lower mortality than those treated with medical therapy. On the other hand, in Asian countries, favorable outcomes have been demonstrated in the strategy of medical therapy alone for uncomplicated patients or medical therapy plus timed surgery for complicated patients. On Japanese guidelines for aortic dissection issued in 2011, the surgical treatment for TA AAD is indicated for the patients with cardiac tamponade, aortic regurgitation (AR), large ascending aorta (>50 mm) and thick thrombosed false lumen (>11 mm). The initial medical therapy is selected for patients who do not have the surgical criteria. Once selected, close inspection of the patient and repetitive radiographic follow-up are needed to detect the propagation of aortic dissection rapidly. We should rediscover the fact that thrombosed type A acute aortic dissection belongs to the “acute aortic syndrome” and is likely to progress to the overt aortic dissection or aortic rupture. The optimal selection of the initial treatment according to the risk stratification can improve the outcomes of this unique disease.

Diagnosis of acute aortic syndromes

Acute aortic syndromes are fatal medical conditions including classic acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. Given the nonspecific symptoms and signs, a high clinical index of suspicion followed by an imaging study, namely transesophageal echocardiography, computed tomography, and magnetic resonance imaging (sensitivity 98-100% and specificity 95-100%), is a conditio sine qua non for prompt diagnosis of acute aortic syndromes. This article provides an overview of established and emerging approaches for the assessment of acute aortic syndromes, with focus on imaging and biomarkers. In this regard, D-dimer levels (cut-off: 500 ng/ml) may be useful to rule out aortic dissection, if used within the first 24 h after symptom onset.

A pictorial review of acute aortic syndrome: discriminating and overlapping features as revealed by ECG-gated multidetector-row CT angiography

BackgroundThe term "acute aortic syndrome" (AAS) encompasses a spectrum of life-threatening conditions characterized by acute aortic pain. AAS traditionally embraces three abnormalities including classic aortic dissection, intramural haematoma, and penetrating atherosclerotic ulcer. Although the underlying etiologies and conditions predisposing to AAS are diverse, the clinical features are indistinguishable.MethodsMultidetector-row computed tomography (CT) with electrocardiographic gating (ECG-gated MDCT) has greatly improved imaging of acute thoracic aortic diseases by virtually eliminating pulsation artifacts transmitted from cardiac motion and reveals subtle aortic abnormalities, which have been difficult to recognize by conventional non-gated CT.ResultsWhile these advances in imaging technology provide additional discriminating features of acute aortic diseases, they also reveal a range of overlapping features of these life-threatening conditions that not uncommonly are dynamic and evolving. These overlapping and transitional features may be a major source of misunderstanding, confusion, and controversy for diseases that cause AAS.ConclusionIn this pictorial review, we describe the discriminating and typical imaging features as revealed by modern ECG-gated MDCT angiography. In addition to the discriminating features, recognition of the overlapping and transitional features in AAS will allow a more comprehensive understanding of their underlying pathophysiologic conditions and their natural history, and may improve therapeutic management.Main Messages• The superior visualization of ECG-gated CTA improves the diagnostic accuracy of acute aortic syndrome.• ECG-gated CTA provides discriminating features of underlying pathophysiologic conditions of AAS.• Also, recognition of the overlapping features in AAS will allow a more comprehensive understanding.

The potential value of intravascular ultrasound imaging in diagnosis of aortic intramural hematoma

ObjectiveTo evaluate the potential value of intravascular ultrasound (IVUS) imaging in the diagnosis of aortic intramural hematoma (AIH).MethodsFrom September 2002 to May 2005, a consecutive series of 15 patients with suspected aortic dissection (AD) underwent both IVUS imaging and spiral computed tomography (CT). Six patients diagnosed as acute type B AIH by CT or IVUS composed the present study group.ResultsThe study group consisted of five males and one female with mean age of 66 years old. All of them had chest or back pain. In one patient, CT omitted a localized AIH and an associated penetrating atherosclerotic ulcer (PAU), which were detected by IVUS. In another patient, CT mistaken a partly thrombosed false lumen as an AIH, whereas IVUS detected a subtle intimal tear and slow moving blood in the false lumen. In the four rest patients, both CT and IVUS made the diagnosis of AIH, however, IVUS detected three PAUs in three of them, only one of them was also detected by CT, and two of them escaped initial CT and were confirmed by follow up CT or magnetic resonance imaging.ConclusionsIVUS imaging is a safe examination and has high accuracy in the diagnosis of AIH, particularly for diagnosing localized AIH, distinguishing AIH with thrombosed classic AD and detecting accompanied small PAUs.

Abstract 8789: Serial Measurements of C-Reactive Protein in Predicting Clinical Outcomes in Patients with Acute Aortic Intramural Hematoma

Background: Inflammation is involved in the pathogenesis and progression of acute aortic dissection, and a high circulating C-reactive protein (CRP) level may be a risk factor for adverse events in patients with aortic dissection. However, there is no data regarding time course in CRP levels during acute phase in patients with aortic intramural hematoma (IMH). The aim of this study was to evaluate the prognostic relevance of serial CRP measurements in patients with IMH. Methods: A total of 180 IMH patients (age; 70±11 years, male/female; 105/75) who were admitted to our institution within 48 hours from the onset, were evaluated. CRP data were obtained at admission, 2 days, 1 week, 2 weeks from the onset and maximal values during hospitalization. Patients who underwent surgery within 2 weeks from the onset were excluded. Clinical outcomes were evaluated with a mean follow-up of 5.1±3.9 years. Results: CRP levels were 3.0±4.6, 8.7±5.9, 9.0±5.5, and 5.7±4.5 mg/dL at admission, 2 days, 1 week and 2 weeks, respectively. Maximal value of CRP was 12.4±6.3 mg/dL. There were 23 deaths including 9 cases of aortic rupture, and 23 patients underwent surgical or percutaneous repair during follow-up and 19 patients showed progression to classic aortic dissection or aortic aneurysm without surgery. CRP levels at 2 weeks of patients with aorta-related events were significantly higher than that of patients without the events (8.8±5.2 vs 4.5±3.6; P&lt;0.001). Receiver-operating characteristic curve analysis identified CRP level of 5.0 mg/dL at 2 weeks as a cut off for predicting aorta-related events, with sensitivity, specificity, and positive and negative predictive values of 71%, 66%, 35%, and 86%, respectively. The aorta-related event free survival was significantly higher in patients with lower CRP (≤5.0) at 2 weeks (P&lt;0.001,Figure). Conclusions: Sustained high levels of CRP at 2 weeks from the onset were associated with a progressive disease course in patients with IMH.

Aortic intramural hematoma: aspects of pathogenesis 2011

Non-invasive tomographic imaging modalities have recently contributed to identifying aortic intramural hematoma, a variant form of classic dissection, which is characterized by the absence of an intimal tear and thus the absence of direct flow communication, and which represents an important disease entity in acute aortic syndrome. Clinical investigations have revealed that intramural hematoma has characteristic clinical features and that the natural remodeling process of hematoma is different from that of classic aortic dissection. These findings suggest that intramural hematoma is not just a precursor to aortic dissection, but may be a unique disease entity with a more favorable prognosis compared to aortic dissection. There is regional heterogeneity regarding the relative incidence of this hematoma, with higher incidence seen in Eastern countries. Due to favorable outcomes with medical treatment in Asian patients with type A intramural hematoma, a tailored or individualized approach based on risk stratification using initial clinical information and including imaging studies and timely surgical repair has been suggested in hemodynamically stable patients; however, these results need to be confirmed in other patient populations. The concept of a "micro-tear" which cannot be easily visualized using conventional imaging modalities has been raised: "echo-free space" on transesophageal echocardiography and "focal contrast enhancement" on ultra-fast computerized tomography have drawn many physicians' attention, and the possibility of a pathophysiologic link between classic aortic dissection and intramural hematoma has been discussed. Further investigations are needed to test whether intramural hematoma begins with an initial intimal tear and a different aortic status--characterized by a more rigid and non-compliant aorta associated with old age or long-standing hypertension--and results in an apparently absent intimal flap.

Penetrating aortic ulcer

In addition to classic aortic dissection and intramural hematoma, acute aortic syndrome also includes penetrating aortic ulcers (PAU). The recent advent of highly detailed axial imaging allows closer assessment of PAU and its pathophysiology. However, there is still ongoing discussion about the natural history of the disease, leading to challenging questions concerning the optimal treatment strategy, particularly in asymptomatic patients. In this review, current indications for treatment, with an emphasis on PAU repair in the endovascular era, are discussed.

Strategische Überlegungen bei mit spinaler Ischämie assoziertem intramuralem Hämatom

Intramural hematoma (IMH) forms – along with classic aortic dissection and penetrating aortic ulcer – the entity of acute aortic syndrome. Whereas thoracic pain is a common symptom in these patients, an association of IMH with spinal cord ischemia has been rarely described. We present a case of lower limb paraparesis in a patient with IMH type B. General considerations regarding IMH evaluation and treatment are discussed in the face of spinal cord protection strategies.

64-slice computed tomography as an adjunct to aortography in suspected iatrogenic aortocoronary dissection

Iatrogenic aortic dissection is an uncommon but potentially fatal complication. We present a case of iatrogenic coronary dissection following percutaneous coronary intervention to the right coronary artery. Aortography initially suggested coronary dissection complicated by type A aortic dissection, however, 64-slice computed tomography excluded classical aortic dissection and instead demonstrated widespread pericardial extravasation secondary to coronary perforation/rupture. This article reviews the pathophysiology, diagnosis and management of aorto-coronary dissection.

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.

Penetrating aortic ulcer: Clinical and angiographic characteristics

“Penetrating aortic ulcer,” an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the aortic wall, is rarely considered in the differential diagnosis of patients with sudden onset of severe chest or back pain. It has been suggested that it is a pathologic process that involves elderly hypertensive patients with severe atherosclerosis and rarely has been observed in the ascending aorta. To determine the characteristics of this process, 11 clinical, 2 hemodynamic, 3 angiographic, and 4 surgical variables were compared between 10 consecutive patients with penetrating aortic ulcers and 20 matched patients with classic acute aortic dissection. Clinical and hemodynamic variables were similar in the two compared groups. In the group of patients with penetrating ulcer, mean age was 58±6 years, previous hypertension was observed in six patients and the penetrating ulcer was located in the ascending aorta in six cases. Compared with patients with aortic dissection, more angiographic projections were necessary to obtain the diagnosis in the group of patients with penetrating ulcer (2.4±0.8 vs 1.7±0.6;p<0.05). In addition, the presence of angiographic aortic valve regurgitation was only observed in the group of patients with acute dissection (60% vs 0%;p<0.01). Severe atherosclerosis was not present angiographically in any patient with penetrating ulcer. In conclusion, penetrating aortic ulcer can also affect middle-age patients without severe atherosclerosis and is frequently observed in the ascending aorta. Its form of presentation and clinical characteristics are similar to classic aortic dissection. The lack of confirmatory evidence of dissection with suggestive clinical history should raise the possibility of penetrating aortic ulcer.