Complicated Aortic Dissection Research Articles

Four-dimensional computed tomography assessment of ruptured triple lumen type B aortic dissection: A case report

Abstract Background Few studies have investigated the effect of the intimal morphology of type B aortic dissection(TBAD) on the blood flow after rupture. We report a case of a 30-yar-old male with complicated TBAD, who underwent assessment with four-dimensional computed tomography (4D-CT). Case Summary Patient presented with chest tightness for 14 days, a heart rate of 67 bpm, regular rhythm, and two years of hypertension. Precisely 14 days prior, he had been diagnosed with aortic dissection by ultrasound at another hospital. 4D-CT showed thoracoabdominal aortic dissection (Stanford type B), left haemothorax, multiple dissection tears, an initial tear located at the large curvature side of the aortic arch, a proximal tear entrance >15 mm, and a descending aorta exit >5 mm. 4D-CT analysis and visualisation of the intimal flap showed a parallel three-lumen spatial morphology of true-false-true, and the lumen showed partial thrombosis in the false lumen. Further quantitative analysis of the area of the initial and re-entry tear during the cardiac cycle revealed that the ratio of the initial tear to re-entry tear was consistent with the expansion ratio of the false lumen to the true lumen of the re-entry tear. The patient improved and was discharged one week after undergoing TEVAR for descending aortic dissection. Discussion The complex triple-lumen TBAD, characterized by multiple tears and blood flow channels, poses challenges for thoracic endovascular aortic repair (TEVAR). 4D-CT facilitates the visualization of intimal flap spatial distribution and enables a thorough assessment of interlayer dilation risk within a realistic and complex haemodynamic context, thereby refining the risk stratification for the progression of complicated aortic dissection and its associated complex complications.

Aortic Dissection: Classification, Etiology, Pathogenesis and Clinical Picture

Aortic dissection is a pathological process in which the aortic wall is divided into inner and outer layers under the action of hemodynamic forces. The process can be localized in various parts of the aorta, and also can be cause of blood supply disorders not only of organs which are located along the vessel (orthograde), but also organs which are located retrogradely. Risk factors for aortic dissection may include age, gender, atherosclerosis, inflammatory diseases, chest injuries, heart surgery, hereditary predisposition, congenital defects of the cardiovascular system and hereditary connective tissue disorders. The most often complication of aortic dissection is malperfusion syndrome, which can manifest itself as symptoms of upper and lower limb ischemia, syncope, ischemic stroke, prerenal azotemia (with decreased renal perfusion), abdominal ischemia syndrome (with occlusion of mesenteric arteries), spinal ischemic stroke. Knowledge of the totality of etiological factors, risk factors, pathogenesis, various manifestations and complications of aortic dissection allows you not to miss the beginning of the pathological process and provide timely assistance.

Image detection of aortic dissection complications based on multi-scale feature fusion

BackgroundAortic dissection refers to the true and false two-lumen separation of the aortic wall, in which the blood in the aortic lumen enters the aortic mesomembrane from the tear of the aortic intima to separate the mesomembrane and expand along the long axis of the aorta. PurposeIn view of the problems of individual differences, complex complications and many small targets in clinical aortic dissection detection, this paper proposes a convolution neural network MFF-FPN (Multi-scale Feature Fusion based Feature Pyramid Network) for the detection of aortic dissection complications. MethodsThe proposed model uses Resnet50 as the backbone for feature extraction and builds a pyramid structure to fuse low-level and high-level feature information. We add an attention mechanism to the backbone network, which can establish inter-dependencies between feature graph channels and enhance the representation quality of CNN. ResultsThe proposed method has a mean average precision (MAP) of 99.40% in the task of multi object detection for aortic dissection and complications, which is higher than the accuracy of 96.3% on SSD model and 99.05% on YoloV7 model. It greatly improves the accuracy of small target detection such as cysts, making it more suitable for clinical focus detection. ConclusionsThe proposed deep learning model achieves feature reuse and focuses on local important information. By adding only a small number of model parameters, we are able to greatly improve the detection accuracy, which is effective in detecting small target lesions commonly found in clinical settings, and also performs well on other medical and natural datasets.

Anatomical study of aortic diameter changes after STABILISE for complicated aortic dissections: 2-year results from a comparative study STABILISE versus TEVAR alone

Anatomical study of aortic diameter changes after STABILISE for complicated aortic dissections: 2-year results from a comparative study STABILISE versus TEVAR alone

A hemodynamic analysis of fenestrated physician-modified endograft repair for complicated aortic dissections involving the visceral arteries

ObjectiveThe aim of this study is to perform patient-specific hemodynamic simulations of the patients with complicated aortic dissection underwent Physician-modified endograft (PMEG) and evaluate the treatment outcome. Method12 patient-specific models were reconstructed from computed tomography angiography (CTA) data of 6 patients with complicated aortic dissection before and after the PMEG. Hemodynamic simulations were conducted with the same time-varying volumetric flow rate extracted from the literature and 3-element Windkessel model (3 EWM) boundary conditions were applied at the aortic outlet. Hemodynamic indicators such as time-averaged wall shear stress (TAWSS), relative residence time (RRT) and endothelial cell activation potential (ECAP) were obtained to evaluate the postoperative effect of PMEG. ResultsComparing with the preoperative models, the flow rates of most visceral arteries were increased in the postoperative models (PSMA = 0.012, PRRA = 0.013, and PLRA = 0.005). Pressure and TAWSS in visceral regions were significantly reduced (PP = 0.003 and PTAWSS = 0.017). With the false lumens (FL) covered by the stent grafts, the average TAWSS level increased in the regions of postoperative abdominal aorta (P = 0.002), and the average RRT and ECAP values decreased significantly (PRRT = 0.02 and PECAP = 0.003). ConclusionThis study shows that PMEG, as a new technique for the treatment of complicated aortic dissection involving the distal tears in the visceral region, can effectively restore the abnormal blood supply of the visceral arteries, reduce the risk of aortic rupture, the formation of aortic dissection aneurysm (ADA), and thrombosis. This corresponds well with clinical retrospective studies and 1-year follow-up outcomes. The findings of this study are of great significance for the development of PMEG.

Malperfusion after Aortic Dissection - Management and Techniques

Malperfusion is a common complication of aortic dissection and further increases this deadly disease's mortality. An effective treatment strategy requires a timely diagnosis based on the clinical findings and the available instruments, understanding the disease's pathomechanism, recognising the therapy options recommended by the guidelines, and the diagnostic and therapeutic innovations of the area of research. The final treatment decision should be patient- and case-specific. In this work, we have considered malperfusion after aortic dissection, not only as a complication of aortic dissection but as a separate disease and summarise important information that can contribute to efficient therapy decisions in everyday clinical practice.

The fate of spinal arteries after the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair technique: A case series

We evaluated the patency of the spinal arteries (intercostal and lumbar) after the STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique. A retrospective analysis of all patients with aortic dissection treated with the STABILISE technique between April 2018 and July 2021 was performed. Imaging analysis of the spinal cord vascular supply was accomplished using multiplanar and maximum intensity projection reconstructed images of pre- and postoperative computed tomography angiograms at 1month, 12months, and annually thereafter. Twelve patients were treated for complicated aortic dissection. Primary technical success was 100% and mid-term clinical success, at a mean follow-up of 27± 12months, was 90%. No cases of spinal cord ischemia were identified. One patient died after 1year (non-aortic related), and one patient was lost to follow-up. A significant decrease was found in the mean number of patent spinal arteries in the stent graft area at 1month (P< .001), 1year (P< .001), and 2years (P= .004). However, no significant reduction was found in the number of spinal arteries in either the bare metal stented or nonstented aorta (P > .05). Use of the STABILISE technique decreased intercostal artery patency in the thoracic stent graft area, but spinal artery patency was not significantly affected by the bare metal stent nor its aggressive ballooning. These findings constitute a step toward a better understanding of the safety of this technique.

Abstract 283: Outcomes Among Heart Failure Patients Hospitalized For Aortic Dissection: Insight From The National Inpatient Sample

Background: Aortic dissection is a significant cause of morbidity and mortality among hospitalized patients. Previous studies suggested that heart failure (HF) is a significant complication of aortic dissection which oftentimes lead to poor outcomes due to delays in diagnosis and overall increase disease burden. However, there is paucity of data regarding the outcomes of hospitalized aortic dissection patients with comorbid HF. Methods: We utilized the National Inpatient Sample (NIS) Database of the years 2018-2020 in conducting a retrospective cohort study. All analyses were done through StataBE 17.0. Our outcomes of interests were risk for in-hospital mortality, acute kidney injury (AKI) and hospital length of stay (LOS) among hospitalized aortic dissection patients with comorbid HF. Results: A total of 149,026 hospitalized aortic dissection patients were identified in our study, of which 10.27% (n= 15,305/149,026) had HF. Among those, 6390 met our inclusion criteria. The overall in-hospital mortality among aortic dissection patients was 4.14% (n=6,170/149,026). Among those with concomitant HF, the mortality rate was significantly higher at 6.37%(n=407/6390) (p=0.00). After adjusting for possible patient and hospital level confounders, concomitant HF among aortic dissection patients was deemed to be an independent predictor of overall in-hospital mortality (aOR 2.21; 95% CI, 1.46-3.36; p=0.00) and it was found that systolic (aOR 2.47; 95% CI, 1.42-4.29; p=0.00) and diastolic HF (aOR 2.11; 95% CI, 1.08-4.13; p=0.03) were associated with higher in-hospital mortality compared to those with combined HF (aOR 1.48; 95% CI, 0.44-4.95; p=0.52). Further, concomitant HF increased the risk for the development of in-hospital AKI (aOR 3.16; 95% CI, 2.35-4.24; p=0.00) and longer LOS (aOR 4.16; 95% CI, 2.92-5.40; p=0.00), regardless of HF subtype. Conclusion: Our analysis showed that comorbid HF increased the risk for in-hospital mortality, risk for AKI and longer hospital LOS. On subgroup analysis, systolic and diastolic HF were associated with increased risk for in-hospital mortality and all three HF subtypes increased the risk for AKI and were associated with a longer hospital LOS.

Hotspots and development frontiers of postoperative complications of AD: Bibliometric analysis - a review.

The research on the postoperative complications of aortic dissection (AD) has received great attention from scholars all over the world, and the number of research articles in this field has consistently increased year after year. However, no bibliometric reports have been published yet to analyze the scientific output and the current situation in this field. The Bibliometrix R-package, VOSviewer, and CiteSpace software were used to conduct a bibliometric analysis of the hotspots and development frontiers of AD. A total of 1242 articles were retrieved. The USA, China, and Japan had the highest number of publications. The five keywords with the highest frequency were "analysis," "incidence," "acute type," "graft," and "risk factor." The results also indicated that the research in related fields had shifted from surgical treatment and utilizing experience to the evidence-based exploration of risk factors and the construction of prediction models to help better manage postoperative complications of AD. This is the first bibliometric analysis of global publications on the postoperative complications of AD. The current research hotspots focus on three areas: common postoperative complications of AD, exploration of the related risk factors, and management of complications. Future research could focus on identifying risk factors through meta-analysis and using a multicenter database for AD as well as building relevant models to predict the development of complications to better facilitate the clinical management of AD patients.

Risk Factors Associated with Poor Prognosis in Patients with Stanford Type B Aortic Dissection after Thoracic Endovascular Aortic Repair

To analyze the clinical characteristics of patients with Stanford type B aortic dissection (TBAD) and risk factors after thoracic endovascular aortic repair (TEVAR). Clinical records for patients with TBAD presenting to a medical center between 1 March 2012 and 31 July 2020 were reviewed. Clinical data including demographics, comorbidities, and postoperative complications were obtained from electronic medical records. Comparative analysis and subgroup analysis were performed. A logistic regression model was used to analyze prognostic factors in patients with TBAD after TEVAR. TEVAR was performed on all 170 patients with TBAD, and poor prognosis was identified in 28.2% (48/170) of cases. Patients with a poor prognosis were younger [38.5(32.0, 53.8) years vs.55.0(48.0, 62.0) years, P<0.001], had higher systolic blood pressure (SBP) [138.5 (127.8, 152.8) mmHg vs. 132.0 (120.8, 145.3) mmHg, P=0.013] and more complicated aortic dissection patients [19(60.4) vs. 71(41.8), P =0.029] than those without a poor prognosis. According to the results of binary logic regression analysis, the possibility of a poor prognosis after TEVAR decreased with each ten years increase in age [odds ratio (OR): 0.464, 95% confidence interval (CI): 0.327-0.658, P<0.001]. There is an association between younger age and a poor prognosis after TEVAR in patients with TBAD, with the condition that those with poor prognoses have higher SBP and more complicated cases. In younger patients, postoperative follow-up should be more frequent, and complications should be managed in time.

Acute aortic dissection complicated with hemorrhagic aortopulmonary artery sheath: a review of the literature.

A hemorrhagic aortopulmonary artery sheath (HAPS) is an infrequent and critical complication of aortic dissection (AD), which is caused by a hematoma extending through the ruptured aortic wall into the aortopulmonary artery sheath. The adventitial hematoma might narrow or even occlude the lumen of the pulmonary arteries and extend into the pulmonary interstitium and alveoli. The prompt and accurate recognition of HAPS on computed tomography (CT) is crucial and might assist in the diagnosis of unidentifiable AD. HAPS was manifested as high attenuation areas surrounded the pulmonary arteries without enhancement on CT; even thickened bronchovascular sheath and ground-glass consolidations surrounded bronchovascular distribution, which might be associated with the prognosis. Aggressive and effective surgical treatment is the primary determinant of short-term survival.

In Situ Laser Fenestrations of Aortic Endografts for Emergent Aortic Disease

In situ laser fenestration (ISLF) is a novel endovascular technique which allows customization of a standard stent graft to a patient's anatomy. While most reported cases involve revascularization of the left subclavian artery (LSA), some centers have now reported their initial experience treating branches of the visceral aorta for aortic aneurysms. The aim of this study is to examine the adoption of ISLF in emergent aortic pathology at a specialized aortic center. Between December 2020 and February 2022, all patients who underwent ISLF as part of endovascular intervention for complex aortic pathology at a university hospital were identified. Cases were collected from a prospective aortic database with additional information obtained from a retrospective review of electronic hospital records. Fifteen patients (11 men and 4 women) underwent emergency ISLF, with a median age of 76years. Eleven presented with symptomatic or ruptured aortic aneurysms, three with acute complicated aortic dissections and 1 aortic traumatic transection. Most aortic aneurysms were thoraco-abdominal (n=7), with 1 arch, 1 thoracic, 1 supra-renal, and one-juxta-renal aortic aneurysm. ISLF was performed to revascularize the LSA in 8 cases, and branches of the reno-visceral aorta in 7 cases. All LSA ISLF cases had left brachial artery exposure. Femoral access was percutaneous in 14 of 15 cases. Technical success was 96.3% (26/27)). Median ischemic times were: superior mesenteric artery 7min, renal arteries 22min, and celiac trunk 43.5min. There were 2 early aortic/fenestration related reinterventions. There was no stroke and 1 death caused by heparin-induced thrombocytopenia within 30days. The majority of patients did not require intensive care admission (n=8). The median intensive care unit stay was 0days and hospital length of stay 18days. There was no fenestration endoleak or reintervention post discharge with a median follow-up of 168days. ISLF is a promising new technique that can show excellent technical results in experienced aortic centers, even during the learning curve. While custom-made devices with reinforced fenestrations are preferred in nonemergent situations, ISLF is a feasible option for complex aortic pathology in the acute setting when open surgery is not feasible.

Clinical Identification and Treatment of Aortic Dissection with Pericardial Effusion Before Intravenous Thrombolysis

To detect aortic dissection complicated with pericardial effusion in time before intravenous thrombolysis, to avoid iatrogenic damage and get the rescue time. Methods: The data of 2 patients with aortic dissection complicated by pericardial effusion who entered the stroke greenway in our hospital in 2022 were collected. The literature on the diagnosis and treatment of aortic dissection and cardiac tamponade were reviewed. Results: The clinical features of aortic dissection complicated with pericardial effusion were sudden onset, rapid progression, and high risk of death. The chest CT scan showed linear high-density shadows in the aorta, enlarged cardiac shadows, and pericardial effusion. Echocardiography supported the diagnosis. Conclusion: Neurological deficit is a common complication of aortic dissection, including disturbance of consciousness, and intravenous thrombolysis is not suitable. Chest CT scan and bedside color Doppler ultrasound are important methods to quickly identify aortic dissection and pericardial effusion. Reasonable emergency pericardiocentesis can obtain valuable time for surgical treatment.

Surgical and endovascular repair for type B aortic dissections with mesenteric malperfusion syndrome: A systematic review of in-hospital mortality

ObjectivesMesenteric malperfusion is a feared complication of aortic dissection, with high mortality. The purpose of this study was to systematically review in-hospital mortality (IHM) of endovascular and surgical management of acute and chronic Stanford type B aortic dissections (TBAD) complicated by mesenteric malperfusion (MesMP). MethodsA systematic search of English language articles was conducted in relevant databases. Data on patient demographics, procedure details, and survival outcomes were collected. Reports were classified by type of intervention performed. Studies that failed to report patient-level outcomes based on specific intervention performed or IHM were excluded. Retrospective chart review of previously published data from a single institution was also performed to further identify cases of TBAD that were managed endovascularly. The Fisher exact test was performed to determine statistical significance. ResultsIn total, 37 articles were suitable for inclusion in this systematic review, which yielded 149 patients with a median age 55.0 years (interquartile range, 46.5-65 years) and 79% being male. Overall, in-hospital mortality was 12.8% (19/149) and was similar between endovascular and open surgical interventions (13% vs 11%, P = .99). Among endovascular strategies, IHM was greater, although not statistically significant in the thoracic endovascular aortic repair group compared with the fenestration/stenting without thoracic endovascular aortic repair group (24% vs 11%, P = .15). ConclusionsMultiple strategies exist for the management of TBAD with MesMP; however, a majority of cases were managed endovascularly. Despite advances in therapies, mortality remains high at 13%.

Treatment of acute aortic dissection type A with paraplegia and distal limb ischemia within a hybrid operating room

ObjectiveAcute aortic dissection type A is among the most lethal surgical emergencies. Patients may suffer from occlusion of the aorta or its branches causing end-organ malperfusion complicating the diagnosis and worsening the prognosis. Paraplegia is a rare manifestation that affects less than 5% of patients. If type A aortic dissection and occlusion of the downstream thoraco-abdominal aorta occur simultaneously and require acute treatment, a medical dilemma occurs; what should be treated first?Case reportWe describe a case with an extensive acute type A aortic dissection with signs of consciousness and severe malperfusion syndrome.ResultsThe treatment was successfully performed within a hybrid surgery suite with simultaneous open surgery and endovascular repair techniques supported by cardiopulmonary bypass circulation.ConclusionA hybrid operating room might offer the opportunity to simultaneously repair complicated aortic dissection with malperfusion syndrome, by open aortic surgery and endovascular techniques.

Risk Factors for Incomplete Aortic Remodeling With Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair for Complicated Aortic Dissection: Results of a Multicenter Study

Purpose: The STABILISE technique has extended the treatment of aortic dissection to the thoracoabdominal aorta to achieve complete aortic remodeling. The aim of this multicenter study was to analyze the short- and midterm anatomical results of the STABILISE technique. Materials and Methods: We retrospectively analyzed patients treated with the STABILISE technique for complicated aortic dissection at 3 French academic centers. The aortic diameter at different levels was measured preoperatively, postoperatively, and at 1 year. Results: Between 2018 and 2020, 58 patients, including 47 men (average patient age: 60±11 years), were treated for type B aortic dissection in 34 cases and residual aortic dissection after type A repair in 24 cases. Three (5.2%) patients died postoperatively. Complete aortic remodeling (false lumen thrombosis and complete reapposition of the intimal flap) was achieved in 45/55 patients (81.8%), and false lumen thrombosis in the thoracic aorta was achieved in 52/55 patients (94.5%). At 1 year, with a computed tomographic (CT) scan available for 98.2% (54/55) of patients, we observed a significant decrease in the maximal thoracic aortic diameter and a significant increase in the aortic diameter at the bare-stent level compared with the preoperative CT scan. Severe aortic angulation (p=0.024) was a risk factor for incomplete aortic remodeling and significantly increased the aortic diameter (p=0.032). Chronic aortic dissection was associated with an increased risk of incomplete aortic remodeling (p=0.002). Conclusions: STABILISE for complicated aortic dissection results in false lumen thrombosis, complete reapposition of the intimal flap, and a decrease in the maximum aortic diameter in most cases. Incomplete reapposition of the intimal flap, which is more frequent in cases of chronic aortic dissection and severe aortic angulation, is a risk factor for a significant increase in the aortic diameter at the bare-stent level, and this risk justifies close follow-up and better patient selection. Clinical impact STABILISE technique for complicated aortic dissection results in false lumen thrombosis, complete aortic remodeling and a decrease in the maximum aortic diameter in most cases. At the bare-stent level, incomplete reapposition of the intimal flap, more frequent in chronic aortic dissection and severe aortic angulation, is a risk factor for an increased aortic diameter. This finding justifies close follow-up and better patient selection; thus, the STABILISE technique should be used with care in chronic aortic dissection and severe aortic angulation.

Aortic Dissection Presenting as a STEMI.

This scenario was developed to educate emergency medicine residents on the presentation and management of a patient with a Stanford type A aortic dissection. Chest pain is one of the most common chief complaints seen in the emergency department with a deadly differential diagnosis list. A "can't miss" diagnosis, aortic dissection occurs when an intimal tear creates a false lumen in the aorta, with a variably reported incidence of approximately 2.5-5 per 100,000 person-years.1 This amounts to an estimated 8,000-16,000 cases per year in the United States with a mortality likely underestimated due to prehospital death ranging from 20-40% within 24 hours and 30-50% at 5 years.2,3,4 There is a reported increase in mortality by 1% for every hour the diagnosis is delayed, and half of diagnoses are made greater than 24 hours after presentation.5 The symptoms can range from chest pain to back pain, abdominal pain or extremity pain, to syncope or isolated neurologic deficits, even to shock or cardiac arrest.6 Aortic dissection is most commonly categorized into two groups: Stanford type A, involving the ascending aorta, and Stanford type B, involving only the descending aorta, and are generally managed surgically vs. medically respectively based on this paradigm.7,8 Stanford type A can be complicated by severe aortic regurgitation, pericardial tamponade or coronary artery occlusion mimicking ST-segment elevation myocardial infarction (STEMI). These potentials make it important to switch from heuristic to analytical thinking when developing a differential diagnosis.9 A high index of suspicion with early recognition and management is critical in this catastrophic disease state, especially given the propensity for complications and a wide variety of presentations. At the conclusion of the simulation session or during the debriefing session, learners will be able to: 1) Verbalize the anatomical differences and management of Stanford type A and type B aortic dissections, 2) Describe physical exam findings that may be found with ascending aortic dissections, 3) Describe the various clinical manifestations of the propagation of aortic dissections, 4) Discuss the management of aortic dissection, including treatment and disposition. This session was conducted using a simulation scenario with a high-fidelity manikin as the patient and confederate/actor in the nursing role, followed by a post-scenario debriefing session on the presentation, differential diagnosis, potential physical exam findings, and management of patients with aortic dissection. Debriefing methods may be left to the discretion of the educators, but the authors have utilized advocacy-inquiry techniques.10 This scenario may also be run as an oral board examination case. The residents are provided an electronic survey at the completion of the debriefing session to anonymously rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. Twenty learners completed a feedback form. This session received all 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score. The lowest average score was 6.5 for, "Before the simulation, the instructor set the stage for an engaging learning experience," and the highest average score was 6.84 for, "The instructor identified what I did well or poorly - and why." Feedback from the residents was overwhelmingly positive (available upon request). All groups initially gave aspirin upon identification of the STEMI and several gave heparin. Debriefing topics included STEMI mimics, physical exam findings for aortic dissection, imaging and laboratory workup for aortic dissection, blood pressure and heart rate goals and pharmacologic management, uncomplicated STEMI management, and Type I versus Type II decision-making. This is an easily reproducible method for reviewing management of patients with aortic dissection. There are multiple potential presentations and complications of aortic dissections to further customize the experience for learners' needs. While it was discussed during debriefing that heparin administration was unlikely to cause immediate cardiopulmonary arrest, this state was included to reflect downstream hemorrhagic complications that may occur in the setting of antiplatelet administration for acute aortic dissection. Facilitators may choose to omit the arrest at their discretion. Medical simulation, emergency medicine, aortic dissection, ST-elevation myocardial infarction, cardiovascular emergencies, hypertensive emergencies, STEMI mimics, vascular surgery, cardiothoracic surgery.

Endovascular and Hybrid Repair in Patients with Heritable Thoracic Aortic Disease

In individuals with heritable thoracic aortic disease (HTAD), endovascular repair for treatment of aortic aneurysm and dissection may be lifesaving, but is associated with increased risk of failure of endovascular repair and adverse outcomes. This study reports our experience with early and late outcomes of endovascular aortic and branch vessel repair in patients with HTAD. A retrospective case series was performed by chart review of individuals with HTAD followed at Washington University School of Medicine/Barnes-Jewish Hospital who underwent endovascular aortic and/or branch vessel repair. Clinical features, imaging characteristics, and short- and long-term outcomes were collected. Twenty-nine patients with HTAD (20 male; mean age 45±13years) underwent 37 endovascular procedures between 2006 and 2020 with mean follow up of 54±41months. Seven patients underwent two or more separate endovascular procedures. Each procedure was considered separate for data collection and analysis. Underlying conditions included Marfan syndrome (n=16 procedures), Loeys-Dietz syndrome (n=14 procedures), vascular Ehlers-Danlos syndrome (n=3 procedures), and nonsyndromic HTAD (n=4 procedures). Twenty patients (69%) had prior open surgical aortic repair. Indications for endovascular aortic repair (n=31) included urgent repairs of acute complications of aortic dissection (n=10) or aneurysm rupture (n=3), and elective aortic repair (n=18; 10 chronic dissections and eight chronic aneurysms). Six patients underwent elective endovascular repair of six branch vessel aneurysms or dissections. Six patients underwent hybrid open surgical and endovascular repair. Of the 37 procedures, 25 (68%) proximal landing zones were in the native aorta or branch vessel, 11 (30%) were in a surgical graft or elephant trunk and one was in a previously placed endograft. Thirty-six (97%) procedures were technically successful, and none required emergency surgical conversion. Two patients died: one from sepsis and one from presumed late pseudoaneurysm rupture, for a 5% per-procedure mortality rate. Two procedures were complicated by stroke and one patient developed paraparesis. Of the 31 aortic procedures, seven aortic endografts (23%) developed a stent-induced new entry (SINE) discovered with imaging at 20±15days post-procedure. Seven endografts (23%) developed a Type I endoleak and eight (26%) developed a Type II endoleak. No Type III endoleaks were seen. Within 30days, two endografts (of 37, 5%) required reintervention. After 30days, fifteen additional endografts (of 37, 41%) required reintervention. Two patients (of 6, 33%) who underwent hybrid repair required reintervention. This study is the largest single-center case series examining outcomes of HTAD patients following endovascular repair. Urgent and elective endovascular repairs in patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection with relatively low risk. However, risk of early and late endoleaks and SINE is high. Close post-procedural surveillance is required, and many individuals will require additional interventions. Hybrid repair shows promise and requires further investigation.

Reverse \u201ccheese wire\u201d fenestration for abdominal aortic dissection repair: a case report and literature review

BackgroundAortic dissection is one of the most common emergency condition leading to internal organs or lower limb ischemia and aortic rupture. Herein, we described a reverse “cheese wire” endovascular fenestration repair (CWFER) in a patient with complicated abdominal aortic dissection which had never been reported.Case presentationA 62-year-old male presented abdominal tear-like pain and acute ischemia of the right lower extremity during the endovascular treatment of celiac trunk aneurysms. Computed tomography angiography (CTA) and digital subtraction angiography (DSA) showed abdominal aortic type B dissection with acute ischemia of the right lower extremity preoperatively. After a detailed preoperative examination, the patient then was performed a reverse CWFER. So far, the patient has been followed-up for 6 months, postoperative CTA demonstrated good stent-graft expansion and perfusion of bilateral common iliac arteries; also, no endoleak was detected.ConclusionsThe right iliac artery in this patient supplied by false lumen, which lead to acute ischemia of the right lower extremity, needed to be treated as an emergency and dealt with promptly. CWFER is a very high-risk treatment that requires the rich experience of vascular surgeon and accurate assessment of aortic dissection. After interventional treatment, the patient recovered uneventfully after 6 months’ follow-up.

Dislocation of the Lens Revealing a Complicated Aortic Dissection in a Stable Patient with a Marfan Syndrome

We present the case of a patient admitted for an asymptomatic aortic dissection, complicated and extended to carotid arteries and iliac arteries in a young patient with clinical signs and a family history of Marfan syndrome who came to the emergency room for a sudden vision loss related to lens dislocation without any other associated signs, including no abdominal or thoracic pain or neurological or lower extremity symptoms and with a stable hemodynamic status, with specific morphological abnormalities specific to this syndrome and severe aortic insufficiency. The morality of our work is to show the importance of a the clinical examination of all patients who present clinical signs suggestive of Marfan syndrome during any consultation and the need for a very close follow-up in this population given to the morbidity and high mortality in case of complications.