Aortic Rupture Research Articles

Endovascular Management of Aortic Rupture Secondary to Thoracolumbar Spine Fracture From a Domestic Fall: A Case Report and Clinical Challenges.

Instances of aortic lesions combined with thoracolumbar spine fractures have been rarely described, primarily occurring in high-speed motor vehicle collisions and falls from heights. We present a unique case of a 71-year-old woman with a thoracic aortic rupture caused by a thoracolumbar spine fracture during an accidental domestic fall. She experienced an injury at the level of the celiac trunk on the posterior aspect of the aorta. Hemorrhagic shock and profound hemodynamic instability prompted the swift initiation of a percutaneous endovascular approach, involving the use of REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) followed by the parallel graft technique in a sandwich configuration. Subsequently, thoracolumbar spinal fixation was carefully scheduled and performed 20 days after achieving clinical stabilization. This case underscores the importance of a multidisciplinary approach in managing complex aortic and spinal injuries. The combined use of REBOA and the sandwich graft technique can be life-saving in managing acute thoracic aortic injuries, allowing for the staged stabilization and repair of associated spinal fractures. This case highlights a novel approach to managing a rare thoracic aortic rupture caused by an accidental domestic fall. The application of REBOA for immediate hemodynamic stabilization, combined with the use of a sandwich graft configuration, underscores the adaptability of advanced endovascular techniques in complex, life-threatening situations. These interventions demonstrate the importance of tailoring treatment strategies to individual patient needs, especially in cases involving atypical mechanisms of injury. The findings emphasize the value of early multidisciplinary collaboration and dynamic procedural planning, paving the way for improved outcomes and the refinement of clinical protocols in the management of similar trauma cases.

Estimating nonlinear anisotropic properties of healthy and aneurysm ascending aortas using magnetic resonance imaging.

An ascending aortic aneurysm is an often asymptomatic localized dilatation of the aorta. Aortic rupture is a life-threatening event that occurs when the stress on the aortic wall exceeds its mechanical strength. Therefore, patient-specific finite element models could play an important role in estimating the risk of rupture. This requires not only the geometry of the aorta but also the nonlinear anisotropic properties of the tissue. In this study, we presented a methodology to estimate the mechanical properties of the aorta from magnetic resonance imaging (MRI). As a theoretical framework, we used finite element models to which we added noise to simulate clinical data from real patient geometry and different properties of healthy and aneurysmal aortic tissues collected from the literature. The proposed methodology considered the nonlinear properties, the zero pressure geometry, the heart motion, and the external tissue support. In addition, we analyzed the aorta as a homogeneous material and as a heterogeneous model with different properties for the ascending and descending parts. The methodology was also applied to pre-surgical,in vivo MRI data of a patient who underwent surgery during which an aortic wall sample was obtained. The results were compared with those obtained from ex vivo biaxial test of the patient's tissue sample. The methodology showed promising results after successfully recovering the nonlinear anisotropic material properties of all analyzed cases. This study demonstrates that the variable used during the optimization process can affect the result. In particular, variables such as principal strains were found to obtain more realistic materials than the displacement field.

The frequency of rupture in undiscovered aneurysmsof the abdominal aorta

Background: Abdominal aortic aneurysm rupture remains a major challenge and is one of the most urgent conditions in medicine. The prevalence of abdominal aortic aneurysm is between 4.0%- 8.0% in studies related mainly to men. That is why we perform study to determine the frequency of ruptures in previously unrecognized abdominal aortic aneurysms in the total sample.Material and Methods: The study was designed involving patients of the Clinic for Cardiovascular Surgery at the Clinical Center of the University of Sarajevo, who underwent surgery for rupture of an abdominal aortic aneurysm.Results: Of the total of 71 patients admitted due to a ruptured abdominal aortic aneurysm, in 59 the abdominal aortic aneurysm had not been recognized, that is, 83.1%. The most common rupture position was on the left retroperitoneally, in 45 or 63.4% of cases, then on the right retroperitoneally in 16 or 22.5%. The rarest site was intraperitoneal in 10 or 14.1%. The average size of AAA in the total sample (N=71) was 8.2±1.8 cm.Conclusions: In most patients the abdominal aortic aneurysm had not been previously recognized. In the largest number of patients the position of the rupture was on the left retroperitoneally. Most patients who died had an intraperitoneal rupture.

Endovascular intervention in patients with blunt traumatic thoracic aortic injury: Early results

Aim: Mortality rates are high in thoracic aortic injuries caused by blunt trauma. Thoracic endovascular aortic repair (TEVAR) is the most commonly employed surgical strategy for patients with blunt traumatic thoracic aortic injuries (BTTAI) due to its favorable outcomes. This study aims to present our endovascular experience in treating Type B aortic dissections resulting from blunt trauma. Material and Methods: Our retrospective study included 70 patients who underwent TEVAR for Stanford Type B aortic dissection due to blunt aortic injury. Patients who were under 22 and over 70 years of age, those who underwent emergency TEVAR, died in a hospital emergency, and had penetrating aortic injury, head traumas with neurological symptoms and requiring intervention, aortic pathology other than Type B aortic dissection, or aortic rupture were excluded from the study. Results: Of the patients, 34.3% (n=24) were female, and 65.7% (n=46) were male, with a mean age of 48.54±10.00 years. The most common cause of injury was motor vehicle accidents (81.4%, n=57). No statistically significant difference was found between patients regarding the locations of the landing zones (p>0.05). Conclusion: Early outcomes in selected patients demonstrate high survival rates following TEVAR for trauma-induced Type B dissections.

Endovascular abdominal aortic aneurysm repair (EVAR) outcomes of unibody and single/double docking limb endografts in Medicare beneficiaries between 2012 and 2018.

The evaluation of perioperative and long term outcomes for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) using anatomic (unibody) and proximal neck fixated (docking limbs) endografts across consecutive time cohorts. This study compares the outcomes of EVAR in Medicare patients stratified by mode of fixation. All patients who underwent EVAR between 2012 and 2018 were identified in the Medicare database. Anatomic fixation (AF) and proximal fixation (PF) grafts were differentiated using Current Procedural Terminology (CPT) codes. The AF population was divided into three-time cohorts based on iterative changes in graft design: Cohort 1: (01/01/2012-20/07/2014); Cohort 2: (21/07/2014-09/05/2016); and Cohort 3: (10/05/2016-31/12/2017). The PF cohort was similarly divided into these three periods. Outcomes were evaluated through 31/12/2020 and included all-cause mortality, aortic rupture, and aortic-related reintervention. 32,031 patients underwent EVAR during the study period; 4729 were AF and 27,302 were PF. There were more women (p < .001) and patients with peripheral vascular disease (PVD) (p < .001) in the AF group. There were no group differences in perioperative outcomes. In Cohort 1, there was a higher rate of reintervention (11.9% vs 7.6%; p < .001) and aortic rupture (5.3% vs 4.0%; p = .019) in the AF group compared to the PF group. In Cohort 2, reintervention, aortic rupture, and reintervention rates were similar between the two groups (p = NS). In Cohort 3, the reintervention and aortic rupture rates were similar between the two groups (p = NS). The higher rates of aortic rupture and reintervention seen in the AF group in Cohort 1 when compared with the PF group did not persist in Cohorts 2 and 3. This suggests that improvements in graft design may have led to durability which is similar to that of PF grafts. However, late aneurysm related complications are inherent risks after EVAR and long-term surveillance remains necessary.

Abstract 4138487: A Novel Technique in Managing Equipment Entrapment: A Complicated Case of Aortic Valvuloplasty Balloon Rupture and Detachment

Introduction: A 79-year-old male patient with a history of surgical AVR presented with severe bioprosthetic aortic stenosis requiring valve-in-valve TAVR. The plan was to place an Evolut CoreValve after intentionally fracturing the basal ring of his surgical valve. Through an 18F sheath, a 25mm x 4.5cm True balloon was advanced to the surgical valve over a Lunderquist wire. However, the balloon ruptured immediately after fracturing the valve ring. Decision making: Efforts were made to remove the ruptured True balloon while maintaining the position of the wire, but attempts to withdraw it through the 18F sheath were unsuccessful due to resistance at the distal tip of the sheath. Subsequently, the proximal portion of the balloon catheter was partially detached and removed. An exchange was made to a 22F Gore DrySeal sheath, but again, efforts to withdraw the ruptured balloon were unsuccessful (Figure 1). Various snares were employed, but all attempts to manipulate the balloon into the sheath were ineffective. The ruptured balloon remained in the abdominal aorta and eventually detached from the hypotube. The 22F sheath was then exchanged for a 20F Inari Protrieve sheath. Two Supracore wires were then inserted through the sheath, with one designated for snare delivery and the other for maintaining vessel access. A Tulip snare was guided over one Supracore wire to the descending thoracic aorta, where the snare was opened and the Lunderquist wire was captured at the junction between the stiff and soft parts of the wire (Figure 2). The snared wire and ruptured balloon were retracted into the exposed Nitinol cone of the Inari sheath, successfully engulfing the balloon and compressing it (Figure 3). The sheath, wire, balloon, and snare were then removed as a unit while the wire access was maintained. A new 22F Gore DrySeal sheath was inserted. Inspection confirmed the complete removal of all components of the ruptured True balloon and the catheter. The procedure concluded with the successful deployment of a 29mm Evolut pro CoreValve. The patient made an uneventful recovery and was discharged home the following day. Conclusion: The Inari Protrieve sheath proved valuable in this case of complicated intravascular equipment entrapment. The soft, funnel-shaped nitinol cone aided in capturing and compressing the bulky ruptured balloon, obviating the need for a surgical cutdown.

Abstract 4137925: Long-term Outcome of Initial Thoracic Endovascular Repair or Medical Therapy in Acute Uncomplicated Type B Aortic Dissection: Real-world Data from a Nationwide Claims-Database in Japan.

Introduction: Thoracic endovascular aortic repair (TEVAR) has emerged as a promising treatment option for patients with type B aortic dissection (TBAD). However, there is a lack of evidence regarding the long-term morbidity of initial TEVAR compared to optimal medical therapy (OMT) in acute uncomplicated TBAD (uTBAD). Objective: To evaluate real-world data(RWD) on the long-term outcome of Japanese patients with acute uTBAD using a nationwide claims database. Methods: This retrospective cohort study utilizes JMDC, a nationwide claims database under Japan's universal healthcare system. We included patients who were initially hospitalized with a diagnosis of acute TBAD. We defined acute uTBAD by excluding those who died within one month, suffered aortic rupture, traumatic thoracic aortic injury, underwent open-chest surgery, experienced stroke or paralysis, or had less than six months of history in the JMDC. Patients who underwent TEVAR within three months of the index hospitalization (TEVAR group) were compared with those who received optimal medical therapy (OMT group). Propensity score (PS) matching was performed based on age, sex, and year of hospitalization. Using the Kaplan-Meier method, we calculated the cumulative rate of all-cause mortality and aorta-related events. Results: Of 18,445 patients diagnosed with aortic disease between January 2005 and December 2020, 641 were included in the study (OMT group: n=580, TEVAR group: n=61). After PS-matching, demographics of the groups (OMT_PSM: n=183 vs. TEVAR_PSM: n=61) were female (12.6% vs. 13.1%), median age (54 years [IQR, 48-60] vs. 54 years [IQR, 50-61]) and follow-up time (18 months [8-32] vs. 19 months [9-32]), respectively. Kaplan-Meier curves for the aortic-related events (Figure1, 2) are shown as long-term outcomes. Conclusions: This study successfully demonstrated that the estimated 5-year aortic-related event rate in acute uTBAD patients undergoing OMT is approximately 20%, demonstrating the relevance of the RWD source. However, the number of death events in the TEVAR and OMT groups was not sufficient to provide statistical power. Therefore, further studies are warranted to evaluate the long-term prognosis of initial TEVAR for uTBAD.

Impact of Geometric Attributes on Abdominal Aortic Aneurysm Rupture Risk: An InVivo FSI-Based Study.

Reported in this paper is a cutting-edge computational investigation into the influence of geometric characteristics on abdominal aortic aneurysm (AAA) rupture risk, beyond the traditional measure of maximum aneurysm diameter. A Comprehensive fluid-structure interaction (FSI) analysis was employed to assess risk factors in a range of patient scenarios, with the use of three-dimensional (3D) AAA models reconstructed from patient-specific aortic data and finite element method. Wall shear stress (WSS), and its derivatives such as time-averaged WSS (TAWSS), oscillatory shear index (OSI), relative residence time (RRT) and transverse WSS (transWSS) offer insights into the force dynamics acting on the AAA wall. Emphasis is placed on these WSS-based metrics and seven key geometric indices. By correlating these geometric discrepancies with biomechanical phenomena, this study highlights the novel and profound impact of geometry on risk prediction. This study demonstrates the necessity of a multidimensional assessment approach, future efforts should complement these findings with experimental validations for an applicable approach for clinical use.

Predictors of In-hospital and Short-term Outcomes of Thoracic Endovascular Aortic Repair for Aortic Aneurysm and Aortic Syndrome: A Single-Center Experience

BACKGROUND: Endovascular technique has replaced open repair as primary treatment for different aortic disease indications and was associated with low perioperative mortality and acceptable short-, mid-, and long-term survival. Locally, thoracic endovascular aortic repair (TEVAR) was not widely practiced until year 2017. This study aims to determine the predictors of in-hospital and short-term outcomes of patients who underwent TEVAR for aortic aneurysm and aortic syndrome in a single center and how it compares with local and international data. METHODS: This study is a retrospective analysis of 52 adult patients who underwent TEVAR for the treatment of aortic aneurysm and aortic syndrome. Demographic and clinical data, diagnostic imaging, and procedural details were obtained via inpatient charts at the medical records section and hospital system database archiving. Outcomes at 30 days and 1 year postprocedure were obtained through telephone follow-up after attaining verbal consent. Gathered data were analyzed as to association of different variables with or without the presence of complications. Outcomes reported included in-hospital mortality rate, presence of major adverse events (MAEs), 30-day and 1-year survival rates, and rate of freedom from reintervention. RESULTS: The overall in-hospital mortality was 7.69% (n = 4/52), and complication rate was 32% (n = 20/52), with a survival rate of 92.31% and 87.76% at 30 days and 1 year, respectively. The rates of overall freedom from reintervention were 83.33% and 100% at 30 days and 1 year, respectively. The independent predictors for in-hospital mortality and development of MAEs were increasing weight (odds ratio [OR], 1.0588; 95% confidence interval [CI], 1.003–1.208), preexisting chronic kidney disease (OR, 10.33; 95% CI, 1.1069–96.462), and TEVAR with debranching done as a single procedure (OR, 3.6667; 95% CI, 1.1154–12.054), whereas an estimated glomerular filtration rate of 49.05 ± 19.25 (OR, 0.9402; 95% CI, 0.9019–0.9801) and TEVAR with debranching done as a staged procedure (OR, 0.1624; 95% CI, 0.0321–0.8225) statistically decrease the risk for development of in-hospital mortality and MAEs (P = 0.001 and P = 0.028, respectively). CONCLUSIONS: In this single-center study, indications for TEVAR were fusiform and saccular aneurysm, high-risk intramural hematoma and penetrating aortic ulcer, complicated acute type B dissection, chronic complicated type B dissection with high-risk feature, and aortic rupture. The outcome of this study shows comparable results with other international studies with an acceptable in-hospital mortality rate, complication rate, short-term survival rate, and rate freedom from reintervention at 30 days and 1 year. Increasing weight, preexisting chronic kidney disease, and TEVAR with debranching done as a single setting are independent predictors for developing in-hospital mortality and MAEs, whereas a normal estimated glomerular filtration rate and TEVAR with debranching done as a staged procedure decrease the risk; hence, careful planning and scheduling of procedure among elective and amenable cases could further reduce complication rates of future TEVAR procedures.

Functional features of smooth muscle cells of the human aortic wall and their role in the pathogenesis of aneurysms

BACKGROUND: Thoracic aortic aneurysm is a chronic disease characterized by localized dilation of the vessel, including the ascending, arch and descending parts of the aorta. Aneurysm is one of the most dangerous diseases because aortic dissection or rupture can lead to sudden death. More than 150,000 people worldwide die from aortic aneurysms every year. Despite its prevalence, the cellular mechanisms of its development remain not fully understood. AIM: To evaluate phagocytic activity and proinflammatory activation capability of smooth muscle cells isolated from tunica intima and tunica media of the thoracic part of the human aorta in patients with aneurysm. MATERIALS AND METHODS: The experiments were performed on a culture of primary smooth muscle cells isolated from aneurysm patients. Linear cultures (mesenchymal stem cells ASC52telo, fibroblasts 977hTERT, THP-1, CLTH-CL05008 and EA.hy926) and smooth muscle cells isolated from healthy donors were used as controls. Phagocytic activity was assessed by introducing latex beads to the studied cells, while the ability to internalize low-density lipoprotein was evaluated using the dye BDP 630/650 (Lumiprobe, Russia) and a biochemical method. Pro- and anti-inflammatory activation capability were measured using enzyme-linked immunosorbent assay, quantifying the secretion of cytokines, namely IL-8, IL-6 and IL-10. RESULTS: The study showed that the smooth cells have high phagocytic activity and the ability to internalize low-density lipoprotein. Thus, primary smooth muscle cells from tunica media have greater phagocytic activity than smooth muscle cells obtained from healthy donors (p 0.001). In addition, IL-6 secretion after incubation with latex beads was significantly higher in smooth muscle cells from tunica media compared to those from healthy donors (p 0.001). IL-6 secretion also increased after incubation with low-density lipoprotein in smooth muscle cells from tunica intima compared to cells from healthy donors (p 0.001). CONCLUSION: The absorption of latex beads and low-density lipoprotein stimulates the secretion of proinflammatory IL-6 by primary smooth muscle cells from tunica intima and smooth muscle cells from tunica media, which are part of the aortic wall of patients with aneurysm.

Genetic insights from a Brazilian cohort of aortopathies through targeted next-generation sequencing and FBN1 direct sequencing

Thoracic aortic diseases (or aortopathies) result from complex interactions between genetic and hemodynamic factors. Often clinically silent, these diseases can lead to lethal complications such as aortic dissection or rupture. This study focused on a Brazilian cohort of 79 individuals with thoracic aortic diseases and explored genetic factors through targeted next-generation sequencing (tNGS) of 15 priority genes and FBN1 direct sequencing. The majority of individuals had nonsyndromic aortopathy, with eight diagnosed with Marfan syndrome (MFS). Pathogenic or likely pathogenic variants (PV/LPV) were found in five genes, namely, FBN1, ACTA2, TGFBR2, MYLK, and SMAD3. Notably, novel variants in FBN1 were identified that contributed to Marfan-like phenotypes. The diagnostic yield for isolated aortopathies was 7.1%, which increased to 55.5% for syndromic cases. Variants of uncertain significance (VUS) were identified, emphasizing the need for further research and familial investigations to refine variant classifications. This study provides valuable insights into the genetic landscape of aortopathies in Brazil, aiding early diagnosis and personalized management.

An Umbrella Literature Review on Aortopathy and Fluoroquinolone Use

Background: Aortic dissection and aortic rupture are critical vascular events often predisposed by aneurysmal dilation of the aorta. The use of fluoroquinolone has been associated with aortic dissection and aortic rupture, necessitating a careful clinical review before use. Despite black box warnings, fluoroquinolones continue to be one of the commonly prescribed antibiotics. Critical care providers, specifically those who work in close association with high-volume aortic centers, can play an active role in antibiotic stewardship in the use of fluoroquinolones in patients with a known or predisposition to aortopathy. Aim: This paper provides a brief review of the potential effects of fluoroquinolones on the development of aortic aneurysm, dissection, and or rupture and the cautions to be exercised when using fluoroquinolones, especially in people who are predisposed to developing aortopathies. Methods: A rapid umbrella review was conducted on the effects of fluoroquinolones on aortopathy and the potential for acute aortic events associated with their use. The PICO (Population, Intervention, Comparator, Outcome) strategy coined the research question. It is as follows: In patients with known aortopathy or a known risk of aortopathy, what are the risks of an acute aortic event from taking fluoroquinolones compared to other antibiotics? A meta-analysis was done with selected studies utilizing a random effects model (utilizing Statsdirect software), which showed a pooled effect that favored the association of fluoroquinolones with aortopathy. Findings: Meta-analysis results showed a pooled effect that favored the association of fluoroquinolones with aortopathy. Discussion: Fluoroquinolone use potentiates the risk of developing aortic aneurysm and aortic dissection. Despite published evidence and warnings from manufacturers and regulatory bodies, fluoroquinolone use continues to be a covert contributor to the development of aortopathy. Conclusion: The literature reports multiple instances of fluoroquinolone-induced aortopathy. As such, fluoroquinolones should be reserved for use in situations where their benefits clearly outweigh the risks.

Pulmonary hypertension in patients carrying FLNA loss-of-function variants.

Pulmonary hypertension (PH) is an unusual complication of X-linked disease caused by loss-of-function (LOF) variants in the filamin A (FLNA) gene. Patients with FLNA LOF may also present dysmorphic facial features, aortic dilation, thrombopenia, and periventricular nodular heterotopia (PVNH). We reported clinical, functional, radiologic, and hemodynamic characteristics of patients with FLNA LOF variants and PH from the French PH Network. Nine patients were identified with a female to male ratio of 8:1. PH was diagnosed at a median age of 36 [0-69] years. Associated conditions included epilepsy (n=5), PVNH (n=7), valvular heart disease (n=8), congenital heart diseases (n=4), thrombocytopenia (n=4), and hyperlaxity (n=4). Right heart catheterisation confirmed moderate-to-severe precapillary PH with a median mPAP of 33 [22-49] mmHg and PVR of 4.7 [2.4-8.0] WU. The DLCO was markedly decreased (48 [22-64] %pred) and five patients had obstructive ventilatory disorder. High-resolution CT showed heterogeneous parenchyma (n=8), emphysema (n=3), presence of a peripheral hyperclear band (n=3) and aortic ectasia (n=4). Pathologic assessment available in one patient revealed significant remodelling of small pulmonary arteries, interstitial edema, and irregular alveoli shapes. During follow-up, three patients died, including two from right heart failure. No patient died from aortic rupture. Precapillary PH, likely due to multiple mechanisms, may complicate the course of patients with LOF FLNA variants and may be the presenting symptom leading to diagnosis. The combination of PH with parenchymal involvement and extrapulmonary symptoms (epilepsy, congenital heart diseases, valvular and aortic involvement, thrombocytopenia) should prompt genetic screening for FLNA.

Trem2/Tyrobp Signaling Protects Against Aortic Dissection and Rupture by Inhibiting Macrophage Activation in Mice.

The development of aortic dissection (AD) is closely associated with inflammation. The Trem2 (triggering receptor expressed on myeloid cells 2)/Tyrobp (TYRO protein tyrosine kinase-binding protein) signaling pathway critically regulates innate immunity and has emerged as an important target in cardiovascular diseases; however, its role in AD remains unclear. Transcriptome data from human and mouse ADs were used to perform differentially expressed gene-based protein-protein interaction network analyses. Tyrobp knockout (Tyrobp-/-), myeloid cell-specific Tyrobp-/- (Tyrobpfl/fl Lyz2cre), and Trem2 knockout (Trem2-/-) mice were given β-aminopropionitrile monofumarate in drinking water to induce AD. To dissect the role of macrophages in Tyrobp deficiency-mediated AD progression, macrophages were depleted using clodronate liposomes. Bulk and single-cell RNA sequencing, immunofluorescence staining, and quantitative real-time polymerase chain reaction were performed to assess inflammation and the underlying mechanisms of Tyrobp in AD. Network analysis identified Tyrobp as a hub gene of AD, with elevated levels observed in both human and mouse ADs. Global deletion and myeloid cell-specific deficiency of Tyrobp in mice significantly increased AD incidence and exacerbated extracellular matrix degradation and macrophage infiltration within the aortic wall. Macrophage depletion mitigated the adverse effects of Tyrobp deficiency on AD progression. Additionally, Tyrobp deficiency enhanced TLR (Toll-like receptor)-4 signaling and macrophage activation, which were abrogated by TLR4 inhibitors. Furthermore, deletion of the Tyrobp-associated receptor Trem2 significantly aggravated mouse AD development, whereas Trem2 agonist treatment conferred protection against AD. Our findings suggest a novel role for the Trem2/Tyrobp axis in AD development in mice. Enhancement of Trem2/Tyrobp signaling may represent a promising strategy for the prevention and treatment of AD. Future studies to clarify the role of Trem2/Tyrobp in human AD are warranted.

Local Morphologic and Hemodynamic Analyses for the Prediction of Abdominal Aortic Aneurysm Rupture Based on Patient-Specific CTA and Computational Modeling.

Extensive research has focused on the evaluation of rupture risks in abdominal aortic aneurysms (AAAs) through comprehensive morphologic and hemodynamic analyses, primarily considering the AAA as a whole entity. This study tried to identify the high-risk rupture sites of AAAs more precisely before the fatal process based on morphologic and hemodynamic analyses at the local segment. Computed tomography angiography of a specific AAA patient was conducted at the follow-up 4 months before rupture, 1 day before rupture, the day of the rupture, and 15 days after endovascular aortic repair. The evolution of local morphology and the hemodynamic characteristics at these critical timepoints were investigated based on patient-specific reconstructions and computational fluid dynamics. The morphologic and hemodynamic parameters of the rupture region vary continuously in the process of AAA development and rupture. The surface area and volume of the rupture segment were gradually enlarged at the follow-up 4 months before rupture (47.33 cm2; 67.35 mL), 1 day before rupture (57.23 cm2; 85.24 mL), and on the day of the rupture (62.41cm2; 104.73ml). A prominent decrease in time-averaged wall shear stress and velocity for the rupture segment is observed. The percentages of the lowest time-averaged wall shear stress (<0.1 Pa) area are increased in the AAA region (20.42%, 33.85%, and 53.00%, separately). The results based on precisely rebuilt geometries for the complete follow-ups of patient-specific computed tomography angiography demonstrate that notable morphologic and hemodynamic evolutions have occurred in the local segment of the AAA, which was further proved at the rupture site. The significant changes occurring at the local segment may provide valuable information for the evaluation of aneurysm rupture risk and locate the most probable site of rupture. Capturing the entire process of AAA rupture through CTA imaging is a rare occurrence in clinical practice. The evolution of morphology and hemodynamic characteristics observed in the illustrated results provides valuable insights for clinicians to monitor the state of AAA from a different perspective. These findings suggest that variations in morphology and hemodynamics within the local segment of the AAA might serve as an alternative approach for predicting the rupture risk of AAA.

Aortic Rupture in a Pediatric Patient With Influenza.

Influenza can lead to significant morbidity and mortality in children. Aortopathy tends to occur in adults during influenza season; however, aortic pathology in children with influenza is exceedingly rare. This report describes a child who experienced an aortic rupture during an influenza infection without evidence of secondary bacterial infection or connective tissue disorder.

Study of Risk Factors and Image Findings of Isolated Abdominal Incidentally Detected Aortic Dissection.

Isolated abdominal aortic dissection (IAAD) has been reported to account for 1.1%-4.1% of all aortic dissections. If detected late, it is associated with a risk of aortic rupture. We investigated the risk factors and characteristic imaging findings of incidentally discovered IAAD using abdominal ultrasonography (AUS) during health check-up and hereby report our findings. The study sample included 41 patients with abdominal aortic abnormalities identified by AUS performed during a health check-up at our hospital and who were diagnosed with IAAD by contrast-enhanced computed tomography (CT); in addition, 205 patients were included in the nonevent group. Furthermore, risk factors and characteristic imaging findings of IAAD were examined retrospectively. Compared with the nonevent group, smoking and fatty liver were observed significantly more frequently in the IAAD group. Ultrasound findings indicated an intimal flap in 35 cases (85.4%), whereas CT scan revealed displacement of intimal calcifications in 32 cases (78.0%). Compared with the nonevent group, there were significantly more cases of fatty liver and smoking habits in the IAAD group. In older patients with risk factors for fatty liver and smoking habits, if IAAD is suspected, it is important to monitor the abdominal aorta using ultrasonography during health check-ups.

Aortic rupture – a shift in treatment paradigms

Aortic rupture – a shift in treatment paradigms

GP VI-Mediated Platelet Activation and Procoagulant Activity Aggravate Inflammation and Aortic Wall Remodeling in Abdominal Aortic Aneurysm.

Platelets play an important role in cardiovascular and cerebrovascular diseases. Abdominal aortic aneurysm (AAA) is a highly lethal, atherosclerosis-related disease with characteristic features of progressive dilatation of the abdominal aorta and degradation of the vessel wall, accompanied by chronic inflammation. Platelet activation and procoagulant activity play a decisive role in the AAA pathology as they might trigger AAA development in both mice and humans. The present study investigated the impact of the major platelet collagen receptor GP (platelet glycoprotein) VI in pathophysiological processes underlying AAA initiation and progression. For experimental AAA induction in mice, PPE (porcine pancreatic elastase) and the external PPE model were used. Genetic deletion of GP VI offered protection of mice against aortic diameter expansion in experimental AAA. Mechanistically, GP VI deficiency resulted in decreased inflammation with reduced infiltration of neutrophils and platelets into the aortic wall. Furthermore, remodeling of the aortic wall was improved in the absence of GP VI, as indicated by reduced MMP (matrix metalloproteinase)-2/9 and OPN (osteopontin) plasma levels and an enhanced α-SMA (α-smooth muscle actin) content within the aortic wall, accompanied by reduced cell apoptosis. Consequently, an elevation in intima/media thickness and elastin content was observed in GP VI-deficient PPE mice, resulting in a significantly reduced aortic diameter expansion and reduced aneurysm incidence. In patients with AAA, enhanced plasma levels of soluble GP VI and fibrin, as well as fibrin accumulation within the intraluminal thrombus might serve as new biomarkers to detect AAA early. Moreover, we hypothesize that GP VI might play a role in procoagulant activity and thrombus stabilization via binding to fibrin. In conclusion, our results emphasize the potential need for a GP VI-targeted antiplatelet therapy to reduce AAA initiation and progression, as well as to protect patients with AAA from aortic rupture.

Successful surgical repair of aortic root rupture during transcatheter aortic valve implantation: a case report

BackgroundAortic root rupture is a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Herein, we report a case of aortic root rupture during TAVI that was successfully managed with partial aortic root repair and aortic valve replacement.Case presentationAn 83-year-old woman with severe bicuspid aortic stenosis underwent transfemoral TAVI using a 26 mm SAPIEN 3 Ultra RESILIA valve. Soon after valve implantation, transesophageal echocardiography detected pericardial effusion, which was accompanied by immediate hemodynamic instability. Subxiphoid pericardial drainage was performed, and extracorporeal membrane oxygenation was promptly initiated. Owing to the eruptive hemorrhage, we converted to open-heart surgery. Direct visualization enabled the detection of the aortic root rupture and the performance of partial aortic root repair using bovine pericardium and aortic valve replacement using a 19 mm INSPIRIS RESILIA valve. The patient was transferred to a different hospital 60 days after surgery without complications and is currently doing well as an outpatient.ConclusionsIn the present case, prompt treatment decisions and smooth cooperation among the institutional heart team led to the successful repair of aortic root rupture during TAVI and good clinical outcomes.