Diagnosis Of Acute Aortic Syndrome Research Articles

Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.

Acute aortic syndromes (AASs) are rare and severe cardiovascular emergencies with unspecific symptoms. For AASs, both misdiagnosis and overtesting are key concerns, and standardized diagnostic strategies may help physicians to balance these risks. D-dimer (DD) is highly sensitive for AAS but is inadequate as a stand-alone test. Integration of pretest probability assessment with DD testing is feasible, but the safety and efficiency of such a diagnostic strategy are currently unknown. In a multicenter prospective observational study involving 6 hospitals in 4 countries from 2014 to 2016, consecutive outpatients were eligible if they had ≥1 of the following: chest/abdominal/back pain, syncope, perfusion deficit, and if AAS was in the differential diagnosis. The tool for pretest probability assessment was the aortic dissection detection risk score (ADD-RS, 0-3) per current guidelines. DD was considered negative (DD-) if <500 ng/mL. Final case adjudication was based on conclusive diagnostic imaging, autopsy, surgery, or 14-day follow-up. Outcomes were the failure rate and efficiency of a diagnostic strategy for ruling out AAS in patients with ADD-RS=0/DD- or ADD-RS ≤1/DD-. A total of 1850 patients were analyzed. Of these, 438 patients (24%) had ADD-RS=0, 1071 patients (58%) had ADD-RS=1, and 341 patients (18%) had ADD-RS >1. Two hundred forty-one patients (13%) had AAS: 125 had type A aortic dissection, 53 had type B aortic dissection, 35 had intramural aortic hematoma, 18 had aortic rupture, and 10 had penetrating aortic ulcer. A positive DD test result had an overall sensitivity of 96.7% (95% confidence interval [CI], 93.6-98.6) and a specificity of 64% (95% CI, 61.6-66.4) for the diagnosis of AAS; 8 patients with AAS had DD-. In 294 patients with ADD-RS=0/DD-, 1 case of AAS was observed. This yielded a failure rate of 0.3% (95% CI, 0.1-1.9) and an efficiency of 15.9% (95% CI, 14.3-17.6) for the ADD-RS=0/DD- strategy. In 924 patients with ADD-RS ≤1/DD-, 3 cases of AAS were observed. This yielded a failure rate of 0.3% (95% CI, 0.1-1) and an efficiency of 49.9% (95% CI, 47.7-52.2) for the ADD-RS ≤1/DD- strategy. Integration of ADD-RS (either ADD-RS=0 or ADD-RS ≤1) with DD may be considered to standardize diagnostic rule out of AAS. URL: https://www.clinicaltrials.gov. Unique identifier: NCT02086136.

Multislice spiral CT angiography for evaluation of acute aortic syndrome.

To discuss the diagnostic value of multislice CT angiography (MSCTA) in acute aortic syndrome (AAS). The clinical and imaging data of 36 cases diagnosed as AAS by MSCTA were collected. The manifestations of the MSCTA images were reviewed retrospectively, and the average x-ray dose was calculated. Among 36 AAS cases, 16 cases had aortic dissection (AD), 8 cases had penetrating atherosclerotic ulcer (PAU), 7 cases had intramural hematoma (IMH), and 5 cases had unstable thoracic aneurysm (UTA). Of 16 cases with AD, type A and type B accounted for 43.7% (7/16) and 56.3% (9/16), respectively. Of 7 cases with IMH, type A and type B accounted for 42.9% (3/7) and 57.1% (4/7), respectively. In spite of the x-ray radiation, MSCTA proves to be a rapid and noninvasive imaging technique for the diagnosis of AAS.

P097: High-risk clinical features for acute aortic syndrome

Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. The objective of our study was to assess the diagnostic accuracy of high risk historical, examination and basic investigative features for AAS, in confirmed cases of AAS and a low risk control group in order to address the spectrum bias in previous diagnostic accuracy studies. Methods: We performed a historical matched case-control study: participants were adults &amp;gt;18 years old presenting to two tertiary care emergency departments (ED) or one regional cardiac referral center. Cases: new ED or in-hospital diagnosis of non-traumatic AAS confirmed by computed tomography or echocardiography. Controls: triage diagnosis of truncal pain (&amp;lt;14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 4:1 ratio by sex and age. A sample size of 165 cases and 660 controls was calculated based on 80% power and confidence interval of 95% to detect an odds ratio of greater than 2. Results: Data were collected from 2002-2014 yielding 194 cases of AAS and 776 controls (mean age of 65(SD 14.1) and 66.7% male). Of the 194 cases of AAS, 32 (16.5%) were missed on initial assessment. Chest pain unspecified (20.7%), abdominal pain unspecified (9.9%) and acute coronary syndrome (8.7%) were the top diagnoses in the control population. Absence of acute onset pain (Sensitivity 95.9% negative likelihood ratio (LR-) 0.07(0.03-0.14)), and a negative D-dimer (Sensitivity 96.7%, LR- 0.05(0.01-0.18)) can help rule out AAS. Presence of tearing/ripping pain (Specificity 99.7%, LR+42.1 (9.9-177.5), a history of aortic aneurysm (Specificity 97.8%, LR+6.35(3.54-11.42)), hypotension (Specificity 98.7%, LR+ 17.2(8.8-33.6)), pulse deficit (Specificity 99.3, LR+31.1(11.2-86.6)), neurological deficits (Specificity 96.9%, LR+ 5.26(2.9-9.3)), and a new murmur (Specificity 97.8%, LR+ 9.4(5.5-16.2) ) can help rule in the diagnosis of AAS. Conclusion: Patients with one or more high-risk feature should be considered high risk, whereas patients with no high risk and multiple low risk features are at low risk for AAS. Further research should focus on a combination of these factors to guide who warrants further investigation thus reducing miss rate, morbidity and mortality.

Acute Dissection of the Ascending Aorta: A Case Report and Topic Review

ABSTRACTAortic dissection (AD) is a rare entity with an incidence estimated to be 5 to 30 cases per million people per year1 (The Gale Encyclopedia of Medicine, 3rd ed.). It has association with hypertension, connective tissue disorders, congenital aortic stenosis, and bicuspid aortic valve. Spontaneous dissections are rare. It has a high mortality rate when left untreated. Recent advances in imaging have allowed for early and accurate diagnosis of acute aortic syndromes and the options for management are expanding. This case report and review presents the case of a 20-year-old man with Marfan's syndrome with acute type I AD who underwent emergency Bentall's procedure.How to cite this articleChishti MA, Rawat V, Nagarwal P. Acute Dissection of the Ascending Aorta: A Case Report and Topic Review. J Mahatma Gandhi Univ Med Sci Tech 2017;2(1):31-34.

Acute Aortic Dissection and Intramural Hematoma: A Systematic Review.

Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary. To systematically review the current evidence on diagnosis and treatment of AAS. Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed. Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias. Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.

Limiting scan range of cardiac CT and the chance of missed acute aortic syndrome

PurposeRecently, dedicated cardiac computed tomography (CT) has been performed to rule out acute coronary syndrome in patients with chest pain equivalents. However, acute aortic syndrome (AAS) could mimic acute coronary syndrome. We investigated the reliability of CT with a limited scan range for the detection of AAS. MethodsPatients older than 18 years with a diagnosis of AAS were included for a 10-year period. We reviewed all patients' electronic medical record and cardiac CT scan images. The AAS lesions outside of the upper or lower margin of the cardiac CT scan range were measured. Other abnormalities defined as indirect evidence of AAS such as pericardial effusion were also collected. ResultsOf a total of 309 cases, 6 (1.9%; 95% confidence interval, 0.71-4.17) patients had aortic lesions outside of the cardiac CT scan range. One patient had an aortic lesion above the cardiac CT scan range, and 5 patients had aortic lesions below the cardiac CT scan range. ConclusionsAortic lesions outside of the cardiac CT scan range were not rare. Therefore, using a cardiac CT might not guarantee ruling out AAS completely.

Chest radiography in acute aortic syndrome: pearls and pitfalls.

Acute aortic syndrome is a group of life-threatening diseases of the thoracic aorta that usually present to the emergency department. It includes aortic dissection, aortic intramural hematoma, and penetrating aortic ulcer. Rare aortic pathologies of aorto-esophageal fistula and mycotic aneurysm may also be included in this list. All these conditions require urgent treatment with complex clinical care and management. Most patients who present with chest pain are evaluated with a chest radiograph in the emergency department. It is important that maximum diagnostic information is extracted from the chest radiograph as certain signs on the chest radiograph are extremely useful in pointing towards the diagnosis of acute aortic syndrome.

Validation of the diagnostic utility of D-dimer measurement in patients with acute aortic syndrome.

The objective of this study was to evaluate the validity of D-dimer measurements for the diagnosis of acute aortic syndrome in patients admitted to hospital with acute chest pain. A retrospective observational study design was used. Consecutive patients ( n=887) admitted to a tertiary hospital with acute chest pain (acute aortic syndrome, 123; acute pulmonary embolism, 29; and other disease, 735) from the emergency department between January 2011 and April 2014 were assessed to validate the diagnostic value of D-dimer measurements. The D-dimer level was significantly increased in patients with acute aortic syndrome (median (interquartile range) 4.9 (2.0-17.4) µg/ml) compared with control patients (median (interquartile range) 0.6 (0.3-1.4) µg/ml; p<0.001). At a cut-off point of 0.5 μg/ml, the sensitivity for acute aortic syndrome was 0.97 (95% confidence interval 0.92-0.99) and was similar to that for acute pulmonary embolism (0.97 (0.82-0.99)). The age-adjusted D-dimer cut-off point, defined as age × 0.01 μg/ml in patients ⩾50 years, successfully reduced the number of false-positive diagnoses by 13%, while still retaining a high sensitivity (0.96 (0.91-0.99)). The five false-negative diagnoses of acute aortic syndrome included three patients with intramural haematoma, one patient with a penetrating aortic ulcer and one patient with an impending aortic rupture. A combination of probability assessment and the D-dimer approach reduced the number of false-negatives from five patients to two patients. This study demonstrated that the D-dimer test can distinguish acute aortic syndrome from other diseases presenting with acute chest pain with high sensitivity and modest specificity. Using the D-dimer approach presents limitations with some subtypes of acute aortic syndrome, such as intramural haematoma.

Echocardiographic diagnosis of acute aortic syndrome in the emergency department

An 82-year-old woman was admitted to our emergency department in hemodynamically stable condition, 12h after the beginning of severe retrosternal chest pain of 1h duration, not influenced by changes in body position, nor aggravated by breathing and no more repeated. The ECG showed a typical pattern of acute pericarditis with diffuse concave upward ST-segment elevation >1 mm. Cardiac troponin levels, 12h after chest pain, were in the normal range, excluding the diagnosis of acute coronary syndrome. Chest X-ray displayed significant mediastinal enlargement. Transthoracic echocardiography documented mild anterior pericardial effusion (10 mm) and severe aneurysmal dilatation of the ascending aorta (antero-posterior diameter of 7 cm, measured 5 cm above the aortic valve plane) with significant wall thickening and no evidence of intimal flap. In addition, both left and right ventricles showed normal morphology and systolic function; pulmonary artery systolic pressure was 28 mmHg. Transesophageal echocardiography confirmed the significant dilatation of the ascending aorta, with a typical pattern of aortic penetrating ulcer (observed 5 cm above the aortic valve plane) associated with an intramural hematoma of the anterior wall, extended from the level of the sino-tubular junction to 9 cm above the aortic valve plane (acute aortic syndrome, Svensson type II). A diagnosis of acute aortic syndrome was made and, considering the risk for acute aortic dissection or aortic rupture, the patient was quickly transferred to the nearest Cardiac Surgery Center. Computed tomography confirmed the echocardiographic findings and the patient underwent replacement of the ascending aorta with a tubular prosthesis. The present case underlines the great utility of portable echocardiography in the emergency department, for the clinical evaluation of patients with different patterns of chest pain and, particularly, in the differential diagnosis of acute aortic syndromes.

Advances in the diagnosis of acute aortic syndromes: Role of imaging techniques.

Aortic diseases include a wide range of pathological conditions: aortic aneurysms, pseudoaneurysms, acute aortic syndromes, atherosclerotic and inflammatory conditions, genetic diseases and congenital anomalies. Acute aortic syndromes have acute onset and may be life-threatening. They include aortic dissection, intramural haematoma, penetrating aortic ulcer and traumatic aortic injury. Pain is the common denominator to all acute aortic syndromes. Pain occurs regardless of age, gender and other associated clinical conditions. In this review, we deal with the main findings in the clinical setting and the most recent indications for diagnostic imaging, which are aimed to start an appropriate treatment and improve the short- and long-term prognosis of these patients.

Plasma Lactate Dehydrogenase Levels Predict Mortality in Acute Aortic Syndromes: A Diagnostic Accuracy and Observational Outcome Study.

In acute aortic syndromes (AAS), organ malperfusion represents a key event impacting both on diagnosis and outcome. Increased levels of plasma lactate dehydrogenase (LDH), a biomarker of malperfusion, have been reported in AAS, but the performance of LDH for the diagnosis of AAS and the relation of LDH with outcome in AAS have not been evaluated so far.This was a bi-centric prospective diagnostic accuracy study and a cohort outcome study. From 2008 to 2014, patients from 2 Emergency Departments suspected of having AAS underwent LDH assay at presentation. A final diagnosis was obtained by aortic imaging. Patients diagnosed with AAS were followed-up for in-hospital mortality.One thousand five hundred seventy-eight consecutive patients were clinically eligible, and 999 patients were included in the study. The final diagnosis was AAS in 201 (20.1%) patients. Median LDH was 424 U/L (interquartile range [IQR] 367-557) in patients with AAS and 383 U/L (IQR 331-460) in patients with alternative diagnoses (P < 0.001). Using a cutoff of 450 U/L, the sensitivity of LDH for AAS was 44% (95% confidence interval [CI] 37-51) and the specificity was 73% (95% CI 69-76). Overall in-hospital mortality for AAS was 23.8%. Mortality was 32.6% in patients with LDH ≥ 450 U/L and 16.8% in patients with LDH < 450 U/L (P = 0.006). Following stratification according to LDH quartiles, in-hospital mortality was 12% in the first (lowest) quartile, 18.4% in the second quartile, 23.5% in the third quartile, and 38% in the fourth (highest) quartile (P = 0.01). LDH ≥ 450 U/L was further identified as an independent predictor of death in AAS both in univariate and in stepwise logistic regression analyses (odds ratio 2.28, 95% CI 1.11-4.66; P = 0.025), in addition to well-established risk markers such as advanced age and hypotension. Subgroup analysis showed excess mortality in association with LDH ≥ 450 U/L in elderly, hemodynamically stable and in nonsurgically treated patients.Plasma LDH constitutes a biomarker of poor outcome in patients with AAS. LDH is a rapid and universally available assay that could be used to improve risk stratification and to individualize treatment in patient groups where options are controversial.

Management of acute aortic syndrome.

Acute aortic syndrome (AAS) encompasses a group of severe, life-threatening disorders of the aorta, including acute aortic dissection, intramural haematoma (IMH), and penetrating aortic ulcer (PAU). The concept of AAS was developed to enable the early identification and definitive treatment of patients with chest pain from an aortic origin. Aortic dissection is the most common form of AAS, followed by IMH and PAU. Congenital cardiovascular defects, genetic syndromes, and nonsyndromic genetic variants have all been linked with the development of AAS. The diagnosis of AAS in the clinic can be made using imaging modalities such as CT, echocardiography, and MRI. The initial management of patients with AAS is focussed on the control of blood pressure to reduce aortic wall stress. A multidisciplinary team is required to assess each patient and decide whether endovascular or open surgical treatment, or further medical management is indicated. The optimal treatment of patients with AAS remains a challenging clinical dilemma, and further studies are required to fully characterize conditions within the AAS spectrum and to design individualized, patient-centred treatment plans.

Diagnostic value of multi-slice spiral CTA and image-post processing techniques in acute aortic syndrome

Objective To investigate the clinical value of multi-slice spiral CTA （ MSCTA ） and image-post processing techniques in diagnosis of acute aortic syndrome （ AAS） .Methods 71 patients with AAS were scanned by TOSHIBA Aquilion 64-slice spiral CT,the images on axial and 2D/3D were analyzed.Results 71 cases included 48 cases of aortic dissection （ AD） ,10 cases of intramural hematoma （ IMH） and 13 cases of penetrating atheroscle-rotic ulcer （ PAU） .MSCT depicted the imaging features of AAS：AD showed intimal flap and true and false lumens;IMH showed crescent or circular thickening of aortic wall .PAU showed a niche filling with contrast medium and pro-truding the aortic lumen ,where ＂narrow neck sign＂was shown .The location ,radiological diagnosis and complications of AAS were observed in 71 patients.Intervention treatment or surgical treatment was conducted in 27 cases after defi-nite diagnosis .Conclusion MSCT is a fast and noninvasive examination technique , and it can provide important information for the diagnosis and treatment of AAS . Key words: Acute aortic syndrome ; Tomography, X-ray computed ; Angiography

Aortic Intramural Hematoma and Its Complications

> It has long been an axiom of mine that the little things are infinitely the most important.1 > > Sherlock Holmes to Dr Watson > > —Arthur Conan Doyle, > > The Adventures of Sherlock Holmes: A Case of Identity. Case Presentation: A 70-year-old woman with hypertension presents for evaluation of a single episode of nonexertional chest pain of moderate intensity, atypical for myocardial infarction. Clinical signs of acute aortic dissection and cardiac tamponade are absent. A 12-lead ECG and blood test for troponin are negative for acute myocardial infarction. M-mode transthoracic echocardiogram of the aortic root shows dense echoes anteriorly and posteriorly at the level of the aortic valve and a large pericardial effusion (Figure 1A). After discussing a diagnosis of acute aortic syndrome, she asks, “What other tests will I need to confirm the diagnosis? Will I undergo surgery?” Figure 1. A and B , M-mode echocardiogram at the level of the aortic valve. Dense echoes along right and noncoronary sinuses caused by periaortic hematoma from a perforated aortic ulcer (white arrows, A ) compared with a normal echo ( B ). C , Cardiac computed tomography angiography orthogonal view equivalent to transthoracic echocardiographic parasternal long-axis view. This view is optimized to visualize (white arrow) perforated ulcer in the ascending aorta, hemorrhagic pericardial effusion with blood collection along right and noncoronary aortic sinuses correlating with M mode echo at the level of the aortic valve. AV indicates aortic valve; LA, left atrium; LV, left ventricle; PA, pulmonary artery; and RV, right ventricle. Intramural hematoma (IMH) is a life-threatening aortic disease included within acute aortic syndrome, together with aortic dissection and penetrating aortic ulcer (PAU).2,3 IMH is a contained aortic wall hematoma with bleeding within the media but without initial intimal flap formation (Figure 2).3 Its natural history is variable; it may be reabsorbed …

Multi-detector computed tomography in the diagnosis and management of acute aortic syndromes.

Acute aortic syndrome (AAS) is a spectrum of conditions, which may ultimately progress to potentially life-threatening aortic rupture. This syndrome encompasses aortic dissection (AD), intramural haematoma, penetrating atherosclerotic ulcer and unstable thoracic aortic aneurysms. Multi-detector CT (MDCT) is crucial for the diagnosis of AAS, especially in the emergency setting due to its speed, accuracy and ready availability. This review attends to the value of appropriate imaging protocols in obtaining good quality images that can permit a confident diagnosis of AAS. AD is the most commonly encountered AAS and also the one with maximum potential to cause catastrophic outcome if not diagnosed and managed promptly. Hence, this review briefly addresses certain relevant clinical perspectives on this condition. Differentiating the false from the true lumen in AD is often essential; a spectrum of CT findings, e.g., "beak sign", aortic "cobwebs" that allows such differentiation have been described with explicit illustrations. The value of non enhanced CT scans, especially useful in the diagnosis of an intramural hematoma has also been illustrated. Overlap in the clinical and imaging features of the various conditions presenting as AAS is not unusual. However, on most instances MDCT enables the right diagnosis. On select occasions MRI or trans-esophageal echocardiography may be required as a problem solving tool.

Prevalence and factors associated with false positive suspicion of acute aortic syndrome: experience in a patient population transferred to a specialized aortic treatment center.

Acute aortic syndrome (AAS) is a medical emergency that requires prompt diagnosis and treatment at specialized centers. We sought to determine the frequency and etiology of false positive activation of a regional AAS network in a patient population emergently transferred for suspected AAS. We evaluated 150 consecutive patients transferred from community emergency departments directly to our Cardiac Intensive Care Unit (CICU) with a diagnosis of suspected AAS between March, 2010 and August, 2011. A final diagnosis of confirmed acute Type A, acute Type B dissection, and false positive suspicion of dissection was made in 63 (42%), 70 (46.7%) and 17 (11.3%) patients respectively. Of the 17 false positive transfers, ten (58.8%) were suspected Type A dissection and seven (41.2%) were suspected Type B dissection. The initial hospital diagnosis in 15 (88.2%) patients was made by a computed tomography (CT) scan and 10 (66.6%) of these patients required repeat imaging with an ECG-synchronized CT to definitively rule out AAS. Five (29.4%) patients had prior history of open or endovascular aortic repair. Overall in-hospital mortality was 9.3%. The diagnosis of AAS is confirmed in most patients emergently transferred for suspected AAS. False positive activation in this setting is driven primarily by uncertainty secondary to motion-artifact of the ascending aorta and the presence of complex anatomy following prior aortic intervention. Network-wide standardization of imaging strategies, and improved sharing of imaging may further improve triage of this complex patient population.

Acute Aortic Pathology, Munchausen Syndrome, and Confirmation Bias

BackgroundMunchausen syndrome is a psychiatric disease characterized by pathological lying and malingering. Patients who are affected can set up such complex and compelling clinical scenarios that they can lead to a bias in the diagnostic process and even to unnecessary surgery. Case ReportsTwo cases of Munchausen syndrome misrepresenting acute aortic dissection are reported. The two cases occurred at two different institutions where there was considerable expertise in the management of aortic pathology. In both patients, a wrong diagnosis of acute aortic syndrome was made, leading to unnecessary surgery. ConclusionsRetrospective analysis of the clinical events and the diagnostic process suggests that a confirmation bias played a major role in determining the misdiagnosis. The same mistake is likely to have occurred in the only other case reported in the literature.

The role of aortic wall CT attenuation measurements for the diagnosis of acute aortic syndromes

ObjectivesTo determine if measurements of aortic wall attenuation can improve the CT diagnosis of acute aortic syndromes. MethodsCT reports from a ten year period were searched for acute aortic syndromes (AAS). Studies with both an unenhanced and a contrast enhanced (CTA) series that had resulted in the diagnosis of intramural hematoma (IMH) were reviewed. Diagnoses were confirmed by medical records. The attenuation of aortic wall abnormalities was measured. The observed attenuation threshold was validated using studies from 39 new subjects with a variety of aortic conditions. ResultsThe term “aortic dissection” was identified in 1206, and IMH in 124 patients’ reports. IMH was confirmed in 31 patients, 21 of whom had both unenhanced and contrast enhanced images. All 21 had pathologic CTA findings, and no CTA with IMH was normal. Attenuation of the aortic wall was greater than 45 HUs on the CTA images in all patients with IMH. When this threshold was applied to the new group, sensitivity for diagnosing AAS was 100% (19/19), and specificity 94% (16/17). Addition of unenhanced images did not improve accuracy. ConclusionsMeasurements of aortic wall attenuation in CTA have a high negative predictive value for the diagnosis of acute aortic syndromes.

The role of contrast enhanced transesophageal echocardiography in the diagnosis and in the morphological and functional characterization of acute aortic syndromes

The aim of this study is to evaluate the role of contrast transesophageal echocardiography (cTEE) in the diagnostic characterization of acute aortic syndromes (AAS) [aortic dissection, intramural hematoma, penetrating ulcer]. We enrolled 66 non-consecutive patients with clinical suspicion of AAS. Standard transesophageal echocardiography and cTEE were performed prior to gated-CT angiography, which has been assumed as reference standard. cTEE was obtained with a single bolus of contrast agent injection. The definitive diagnosis of AAS was made in 48 patients by gated-CT angiography: 22 aortic dissections, 15 intramural hematomas and 11 penetrating aortic ulcers. Standard TEE and cTEE correctly diagnosed AAS in 87 and 100% (P = 0.03) cases respectively. Standard TEE correctly diagnosed aortic dissection in 20/22 (91%) and cTEE in 22/22 (100 %) (P = 0.5) cases. cTEE was superior than standard TEE in the visualization of false lumen entry tear (22/22 vs. 16/22, P = 0.03). Standard TEE correctly diagnosed intramural hematoma in 11/15 and cTEE 15/15 (P = 0.12) cases. Microtears were identified in 3 patients by cTEE an in 1 patient by standard TEE (P = 0.4). The presence of focal contrast enhancement was identified in 4 and 0 patients by cTEE and standard TEE respectively (P = 0.06). Both standard and cTEE correctly diagnosed penetrating aortic ulcer in 11/11 (100%) (P = 1.0) cases. cTEE provides additional value over standard TEE in the diagnosis and in the anatomic and functional characterization of AAS.

Acute dissection of the descending aorta: a case report and review of the literature.

Cardiovascular disease is the leading cause of death worldwide. Acute aortic syndromes, which include aortic dissection, intramural hematoma, and penetrating aortic ulcer, represent the most morbid presentations of aortic disease and can be difficult to diagnose. Recent advances in imaging have allowed for more rapid and accurate diagnosis of acute aortic syndromes and the options for management are expanding. This case report and review presents the case of a 43-year-old man with acute type B aortic dissection who underwent two endovascular procedures for malperfusion syndrome. The review focuses on the presentation, diagnosis, medical management, and procedural options for acute dissection of the descending aorta.