Stanford Classification Research Articles

Neurological Manifestations of Aortic Dissection: A Scoping Review.

Aortic dissection (AD) is the most prevalent aortic pathology, with an incidence of 2.6-3.5 cases per 100,000 inhabitants per year with mortality rates as high as 90% at 3 months without proper management. Despite the presence of typical symptoms, it has been reported that up to 38% of cases go unnoticed in the initial evaluation, either due to additional symptomatology or the absence of classic symptoms. In 28% of cases the diagnosis is made post-mortem, highlighting the severity and importance of timely diagnosis. The main goals of this study were to identify the primary neurological manifestations of acute AD and the frequency of these manifestations in type A and B AD according to the Stanford classification. A total of 2,734 records were retrieved from two databases, of which 2,611 were excluded. Therefore, 123 articles were obtained and 88 were evaluated for eligibility. Consequently, 79 articles were included in the review. The abstracts identified in the search were screened by seven blinded independent authors and excluded those who lacked relevance. The authors read the full texts independently to determine inclusion. A third reviewer adjudicated discrepancies when opinions were at odds. There were 169 patients diagnosed with Stanford type A, of which 43.8% displayed quantitative impairment of consciousness. Within this group, transient loss of consciousness was observed in 34.3% of cases. Motor syndrome was present in 54.5%, with 23.7% of patients presenting with hemiparesis or hemiplegia. 3.6% had facial paresis or paralysis and less frequently monoparesis, paraparesis, hyperreflexia, spasticity, and muscle spasms. 7.6% presented with language impairments including Broca's aphasia and dysarthria. Seizures were present in 3.6%. Neuro-ophthalmological symptoms were 2.9%, cortical or cognitive symptoms and headache were 2.3%, cerebellar syndrome was 1.8%, and sensory syndrome was 1.2%. Of 86 patients diagnosed with Stanford type B, 57.0% displayed motor syndrome, with 50.0% being paraparesis or paraplegia, 4.7% monoplegia, and 2.3% hemiplegia or hemiparesis. Additionally, impairment of consciousness was present in 26.7%, sensory syndrome in 12.8%, and language impairments in 3.5%. In the emergency department, understanding the neurological manifestations in both Stanford type A and B dissections emerges as a pivotal cornerstone for conducting precise assessments and efficient patient management. Given the wide spectrum of manifestations, we emphasize the importance of suspecting AD when neurological disorders are associated with the classic symptoms. In these cases, we encourage a complete neurological examination to be performed and a multidisciplinary group assembled to tackle this entity.

An incidental finding of localized aortic arch dissection in a polytraumatized patient. A case report and state of the art of non-A non-B aortic dissection.

Non-A non-B aortic dissection is considered a rare nosological entity, included in the Stanford classification, representing a small percentage of the total aortic dissections that occur annually. Regarding this form, the literature reports a more complicated disease course compared to other types of dissection. We describe the case of a 76-year-old patient who accessed the triage section of an emergency department for a polytrauma picture and, after surgical treatment of a leg fracture, received a diagnosis of non-A non-B aortic dissection, "localized" to the arch and incidentally detected. The angio-computed tomography (CT) showed that the only intimal tear was located in the central portion of the aortic arch, with no exit tear. No signs of malperfusion or clinical symptoms related to the aortic finding were evident. The Aortic Team decided on a conservative approach, whereby the patient was started on medical therapy to control blood pressure in a monitored bed of a semi-intensive care unit. The persistent asymptomatic state, a condition of hemodynamic stability, and an unchanged angio-CT picture enabled discharge on day 7 and the assignment to a close follow-up.

Treatment Strategies for Acute Aortic Dissection With Malperfusion: A Retrospective Study.

Aortic dissection with malperfusion necessitates emergency surgery and is associated with poor outcomes. Therefore, in this study, we analyzed patients' treatment courses from the initial management to hospital discharge in cases of acute aortic dissection (AAD) with malperfusion and investigated the risk factors associated with mortality. We evaluated cases of AAD with malperfusion treated at our institution over a 16-year period from 2007 to 2022. The primary endpoint was in-hospital mortality. The study's primary outcome measure was mortality during hospitalization. We collected and analyzed data encompassing preoperative patient characteristics, Stanford classification, sites of preoperative malperfusion, surgical techniques employed, and postoperative complications. These variables were examined to identify factors associated with in-hospital mortality. During the study period, 366 patients were admitted with AAD, 102 of whom had malperfusion. There were 62 men (61%) and 40 women (39%), with a mean age of 64 ± 13 years (range: 28-87 years). According to the Stanford classification, 75 (74%) and 27 (26%) patients had typeA and B aortic dissection, respectively, and 29 patients (28%) presented with shock. Preoperative malperfusion sites included the brain, coronary arteries, abdominal viscera, limbs, and spinal cord in 40 (39%), 10 (10%), 34 (33%), 52 (51%), and six (6%) patients, respectively. Eleven (11%) patients required immediate intervention in the emergency department. The treatments administered to the patients were as follows: ascending aortic replacement, 30 (29%) patients; aortic arch replacement, 34 (33%) patients; root replacement, three (3%) patients; thoracic endovascular aortic repair (TEVAR), 12 (12%) patients; non-anatomic bypass, five (5%) patients; and conservative management, five (5%) patients. In-hospital mortality occurred in 23 (23%) patients. Multivariate logistic regression analysis identified preoperative coronary malperfusion as an independent risk factor of mortality. Preoperative coronary malperfusion is an independent risk factor for in-hospital mortality in patients with AAD presenting with malperfusion.

Aortic dissection in a renal transplant patient presenting with gastroenteritis: case report

Acute aortic dissection (AD) is a true cardiovascular emergency whose diagnosis and treatment process is very difficult for the patient and the physician, with a mortality rate of 50% in some cases if not intervened within the first 48 hours. AD is classified according to the anatomical region of the aorta affected. Class 1 De Bakey dissection involves the ascending aorta, arcus aorta and descending aorta. Class 2 De Bakey is limited to the ascending aorta, while class 3 De Bakey starts from the descending aorta. According to the Stanford classification, dissection type is divided into A and B. The most common complaints at presentation are predatory chest pain in Type A dissection and low back pain or abdominal pain in Type B dissection.

Impact of age-related arterial degeneration and inflammation on the presentation and etiopathogenesis of acute aortic syndrome

Abstract Funding Acknowledgements None. Background Acute aortic syndrome (AAS) is a critical cardiovascular emergency marked by substantial morbidity and mortality. Both its presentation and accompanying comorbidities hold considerable prognostic and therapeutic implications. Recent observations suggest an age-related increase in the incidence of AAS due to population aging. Nonetheless, the etiopathogenic distinctions between various presentation forms and their connection with age remain enigmatic. Purpose To delineate the forms of presentation of AAS and examine the epidemiological variables according to age, as well as its correlation with the presence of degenerative or inflammatory radiological signs. Methods We analyzed the data from a prospective registry that included all patients with AAS treated at our centre, from 2012 to 2022. The study population was stratified in three age groups: <70 years, 70-80 years and >80 years Three forms of AAS presentation were defined: acute aortic dissection (AAD), intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU). AAS extension was defined by Stanford classification. Degenerative or inflammatory radiological signs were defined as thickening or calcification in the wall of any segment of the aorta or in any of the main arterial territories, regardless of the degree of stenosis. Results 256 patients were included. 156 were <70 years, 63 were 70-80 years, and 37 were >80 years. 195 (76%) had an AAD, 42 (16%) an IMH, 12 (5%) a PAU and 7 (3%) could not be classified. 181 (71%) were type A. AAD were significantly younger than the rest of AAS (61±14 vs 73±10, p<0.0001). Type B AAS occurred at older ages (67±13 vs 63±14, p 0.03). 87% of AAS in patients <70 years were AAD while IMH and PAU increased significantly with age. Active smoking and history of Marfan syndrome were more prevalent in the <70-year-old group. Patients >70 years had more COPD, ischemic heart disease, previous stroke, aortic aneurysm, non-bicuspid aortic valve disease, history of cardiac catheterization and antiplatelet and anticoagulant treatment. Atherosclerotic/inflammatory changes in the aortic wall were present in 46% of AAD versus 63% in the rest of AAS (p 0.068) and in 43% of AAS type A versus 67% of type B (p 0.005). Age was significantly associated with atherosclerotic/inflammatory changes (35% in <70 years, 78% in 70-80 years and 73% in >80 years, p <0.0001) as well as with thickening/calcification of the coronary arteries and the main arterial trunks. See table for more details. Conclusions Age represents a change in trends in terms of the forms of presentation of AAS. AAD are significantly more prevalent in younger patients than the rest of AAS and type B occurs at later ages. Elderly patients are more likely to present IMH and PAU, in percentage detriment of AAD. These epidemiological differences and radiological findings are related to atherosclerotic/inflammatory changes that increase with age, which could justify these findings.Table 1.Representation of the data.

LEFT HEMOTHORAX: UNUSUAL MANIFESTATION OF AORTIC DISSECTION

Aortic dissection is a medical and surgical emergency often revealed by acute chest pain. Its discovery in the context of hemorrhagic pleurisy is rare, and it often poses a diagnostic challenge.We report the case of a 52-year-old patient with a history of chronic smoking, without known arterial hypertension, admitted forexploring a moderately abundant left pleural effusion. Pleural puncture yielded non-coagulable hemorrhagic fluid. Thoracic angio-CT scan revealed a type B aortic dissection (Stanford classification). In the absence of surgical indication, antihypertensive treatment was initiated in this patient, combined with close medical monitoring. The course was marked by the death of the patient after refractory hemorrhagic shock.Aortic dissection should be systematically considered in the presence of any spontaneous hemothorax, even in the absence of suggestive clinical signs.

Participation in outpatient rehabilitation is associated with reduced readmission rates in patients with acute aortic dissection

Abstract Background Patients with acute aortic dissection (AAD) usually require a restriction of physical activity during hospitalisation, which frequently causes difficulty returning to their daily life. Additionally, the increase in the number of older patients with AAD, especially those with frailty, is a crucial problem to worsen clinical outcomes after medical and surgical treatment. Conversely, outpatient cardiovascular rehabilitation is recognized to improve physical function and reduce readmission rates in patients with heart diseases. Although several studies have documented the safety of physical activity intervention after AAD, the relationship between outpatient cardiovascular rehabilitation and clinical outcomes has not been thoroughly evaluated. Purpose This study aimed to examine whether outpatient cardiovascular rehabilitation is associated with clinical outcomes, including readmission rates and mortality, in patients with AAD. Methods This was a single-centre cohort study. We included the patients admitted to a tertiary hospital for treatment of AAD and who received cardiovascular rehabilitation during hospitalisation. Patient characteristics during hospitalisation included age, sex, body mass index, type of AAD as the Stanford classification, treatment information, and comorbidities. We also reviewed whether or not the patients participated in outpatient cardiovascular rehabilitation after discharge. The primary and secondary endpoints were readmission due to cardiovascular disease and all-cause death, respectively. We compared the differences in patient characteristics between the participation in outpatient rehabilitation. The Kaplan–Meier method with log-rank test and multivariate Cox regression analysis were used to examine the association of outpatient rehabilitation participation with the incidences of readmission and death. Results Among the 323 studied patients, 163 participated in outpatient rehabilitation, and 160 did not in. Participants in outpatient rehabilitation showed rates of higher surgical treatment and lower diabetes mellitus as compared with non-participants. There was a significant association between participation in outpatient rehabilitation and lower readmission rates (log-rank: P = 0.045, Figure 1). However, this association was not observed in all-cause death (log-rank: P = 0.063). After adjusting for patient characteristics as confounders, outpatient rehabilitation was significantly associated with lower readmission rates (adjusted hazard ratio [aHR]: 0.63, 95% confidence interval [CI]: 0.41–0.97) and with a tendency of low all-cause death without statistical significance (aHR: 0.51, 95% CI: 0.23–1.10). Conclusions In patients with AAD, participation in outpatient cardiovascular rehabilitation may be beneficial to reduce readmission rates after hospital discharge. Our findings suggest outpatient cardiovascular rehabilitation is one of the treatment options to improve clinical outcomes in these patients.

Acute aortic dissection: Clinical characteristics and outcomes

Background: Acute aortic dissection (AAD) is a serious emergency. This prospective study aims to reveal the clinical characteristics and outcomes of medical and surgical treatments of AAD at the Ibn Al-Bitar Cardiac Centre. Methods: Over a 30-month period ending on Feb 27, 2019, 33 patients (27 males) admitted within 14 days after the onset of AAD symptoms were enrolled. The diagnosis was based on clinical findings and was confirmed by echocardiography and/or CT aortography. Intensive medical therapy was immediately initiated. Stanford classification was applied. Uncomplicated type B aortic dissections (AD) were managed conservatively while complicated type B and all type A dissections were referred for surgery. Perioperative data were entered into a Microsoft Excel-designed database, and the results were collected and statistically analyzed. Results: The male-to-female ratio was 9:2. The age range was 22–75 years, with a mean age of 48.8 ± 13.9 years. The main risk factors were hypertension (66.66%), smoking (42.42%), and Marfan’s syndrome (15.15%). In 84.84% of the cases, chest pain was the presenting symptom. CT aortography revealed dissection of the thoracic aorta in 91% of the cases and the abdominal aorta in 51.5% of the cases. A total of 24 (72.7%) patients had type A AD, and 7 (21.2%) patients had type B AD, whereas two (6.1%) had Non-A Non-B categories. Among those with type B AD, 71.42% had complications. For 48.5% of the patients, surgery was offered. The overall mortality rate was 48.5%, matching the rates that had been already published. Surgery had a lower mortality rate than medical treatment (37.5% vs. 62.5%). The mortality rate of type A was higher than type B (58.3% vs. 28.6%). Conclusions: Urgent surgery performed by expert surgeons is essential to save victims of AAD primarily type A dissection.

Acute Aortic Dissection Masquerading a Rare Type of Congenital Bicuspid Aortic : A Case Report

Acute aortic dissection on bicuspid aortic valve (BAV) type 0 is a rare especially in young masculine. Risk factors like smoking and intensive sport activities can hasten their apparition especially in non-diagnosed population. Trans thoracic echocardiography is very important in the diagnosis of BAV whereas Angio CT scan helps to confirm acute aortic dissection. Treatment is based on surgery for type A Stanford classification for acute aortic dissection. We report a rare case of acute aortic dissection masquerading a rare type of BAV, type 0 in a young sportive male with no history of heart disease who presented for the first-time with acute chest pain after lifting a heavy weight metal at the complex sport center. Patient was initially placed on medical treatment before surgery for heart valve and root replacement (Bentall procedure).

Superior Vena Cava Syndrome and Wallstent: A Systematic Review

Purpose: To elucidate the indication, presentation, demographics, Stanford classification, technical efficacy, morbidity, mortality and long term patency of Wallstent for superior vena cava (SVC) syndrome.Materials and Methods: A systematic review of literature in Pubmed and Embase, CINAHL and Cochrane Library in accordance to PRIMSA was conducted. Retrieval and extraction was performed by two independent reviewers with inter-rater reliability test. The hierarchy of the evidence was assessed through the National Institute for Health and Care Excellence Checklist. Data was subjected to pooled prevalence analysis, Cox regression, Kaplan–Meir survival and test of probability using log rank analytics. This review is registered with International prospective register of systematic review: CRD42021271009.Results: A total of n=701 individuals with n=930 stents with median age of 60 (interquartile range (IQR): 26–89) years and male predominance 3.5 : 1 were identified in n=30 articles. The most common venographic classification was Stanford type II (n=344, 50%) and complete symptomatic resolution was achieved in 48 h. The 30-day morbidity was (n=62, 8%) and mortality was (n=21, 3%). Female gender was associated with higher 30-day morbidity (p<0.03). The cumulative median patency of Wallstent for non-malignant aetiology was [550 days (IQR: 14–1080) vs. 120 days (IQR: 0–925)] for malignancy (p<0.03).Conclusion: The use of Wallstent for resolution of malignancy induced SVC syndrome as a first line therapy is feasible and associated with low mortality. Their use for non-malignant aetiology demands a more in depth review and advocates further investigation.

Is COVID-19 the New Atherosclerosis? Acute Aortic Dissection Type A in the Early Period after COVID -19 Infection

The novel corona virus pandemic has since spread rapidly throughout the world resulting in more than 400 million cases. The clinical manifestations and complications associated with COVID-19 is yet to be elucidated. The clinical presentation may be variable, as it has been previously described. In the published literature many cases of acute aortic dissection caused by COVID-19 infection have been described, but only one in the early period after the resolution of the infection. We present a39year-oldwoman, who was admitted to our department complaining of chest pain after the yoga session. Her past medical history was notable for COVID-19 infection two weeks ago. Her electrocardiogram showed sinus rhythm and mild ST segment elevation in lead a VR, while the transthoracic echocardiogram revealed a dilation of the ascending aorta. After the echocardiographic examination, contrast enhanced computed tomography of aorta was conducted, which revealed an acute aortic dissection (type A- Stanford classification). The patient was admitted for emergent cardiovascular surgery, that was successful and eventually was discharged at the ninth post-operative day.

ГИПОЛИПИДЕМИЧЕСКАЯ ТЕРАПИЯ У ПАЦИЕНТОВ С ХРОНИЧЕСКОЙ СЕРДЕЧНОЙ НЕДОСТАТОЧНОСТЬЮ И ПОСЛЕ ТРАНСПЛАНТАЦИИ СЕРДЦА

This scientific review is devoted to the assessment of the role and effects of statin therapy in the treatment of patients with heart failure (HF). The article overviews the possibilities of using new medications with a profound lipid-lowering effect in patients with HF, belonging to the class of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9). The results of our own research are also presented, the purpose of which was to study the association of statin therapy with the state of the coronary arteries (CA) in the long-term period after heart transplantation (HT). Materials and methods. The data of 75 patients after HT were analyzed. Coronary angiography and intravascular ultrasound were performed to assess coronary artery (CA) damage. The degree of coronary artery disease was determined according to the Stanford classification. In the dynamics of observation, biochemical parameters of blood were assessed. Results and discussion. 7 years (84 months) after HT, patients were divided in 3 groups: 1st with no significant damage to the coronary arteries (n = 38); 2nd with significant damage to the CA (n = 20); 3rd with angiographically significant stenosis of the coronary artery (n = 17). Within 12 months after HT, the groups were comparable in terms of the dose of atorvastatin taken by patients (from 5 to 20 mg). By the 12th month of therapy, the median dose of the medication was significantly lower (5 (5; 10) mg) in group 3 than in groups 1 (20 (10; 40) mg, p = 0.046) and 2 (20 (20; 40) mg, p = 0.008). The dose reduction of the lipid-lowering drug was due to a decrease in the concentration of LDL-C. After 36 months there was a steady increase in the level of LDL-C cholesterol in the blood in group 3. In groups 1 and 2, there were no significant fluctuations in the concentration of LDL cholesterol within the period from 6 to 84 months after HT. Conclusions. In order to prevent the development and progression of coronary artery disease in the long-term period after HT, more aggressive statin therapy is required (at least 20 mg of atorvastatin, even after reaching the target LDL-C level). For patients at high risk of developing coronary heart disease and intolerant to more traditional lipid-lowering treatments, PCSK9 should be considered as a promising alternative.

Automated Stanford classification of aortic dissection using a 2-step hierarchical neural network at computed tomography angiography.

This study aimed to evaluate the feasibility of automatic Stanford classification of classic aortic dissection (AD) using a 2-step hierarchical neural network. Between 2015 and 2019, 130 arterial phase series (57 type A, 43 type B, and 30 negative cases) in aortic CTA were collected for the training and validation. A 2-step hierarchical model was built including the first step detecting AD and the second step predicting the probability (0-1) of Stanford types. The model's performance was evaluated with an off-line prospective test in 2020. The sensitivity and specificity for Stanford type A, type B, and no AD (Sens A, B, N and Spec A, B, N, respectively) and Cohen's kappa were reported. Of 298 cases (22 with type A, 29 with type B, and 247 without AD) in the off-line prospective test, the Sens A, Sens B, and Sens N were 95.45% (95% confidence interval [CI], 77.16-99.88%), 79.31% (95% CI, 60.28-92.01%), and 93.52% (95% CI, 89.69-96.25%), respectively. The Spec A, Spec B, and Spec N were 98.55% (95% CI, 96.33-99.60%), 94.05% (95% CI, 90.52-96.56%), and 94.12% (95% CI, 83.76-98.77%), respectively. The classification rate achieved 92.28% (95% CI, 88.64-95.04%). The Cohen's kappa was 0.766 (95% CI, 0.68-0.85; p < 0.001). Stanford classification of classic AD can be determined by a 2-step hierarchical neural network with high sensitivity and specificity of type A and high specificity in type B and no AD. • The Stanford classification for aortic dissection is widely adopted and divides it into Stanford type A and type B based on the ascending thoracic aorta dissected or not. • The 2-step hierarchical neural network for Stanford classification of classic aortic dissection achieved high sensitivity (95.45%) and specificity (98.55%) of type A and high specificity in type B and no aortic dissection (94.05% and 94.12%, respectively) in 298 test cases. • The 2-step hierarchical neural network demonstrated moderate agreement (Cohen's kappa: 0.766, p < 0.001) with cardiovascular radiologists in detection and Stanford classification of classic aortic dissection in 298 test cases.

747 A Case Report: Spontaneous Recovery of Type B Aortic Dissection

Abstract Introduction An aortic dissection occurs when there is a tear in the intimal and medial layer of the aorta, leading to a false lumen within the media. Type B aortic dissections (TBAD), according to the Stanford Classification are where the entry tear is located distally from the left subclavian artery. Resolution of a Type B aortic dissection (TBAD) by medical therapy is a very rare event. Case Presentation 58-year-old gentleman presented with sudden onset central chest pain. A CTPA was organised following a high d-dimer. This showed a TBAD extending from the origin of the left subclavian artery to the level of the diaphragm. His blood pressure was aggressively controlled with IV labetalol and IV isosorbide dinitrate and was monitored for 2 weeks. He was then discharged home on oral antihypertensive medication. A follow up CT aortogram was done 7 months later which showed that the false lumen of the TBAD has improved from 18mm to 2 mm. Discussion The anti-inotropic effect of beta blockers reduces the stress on the aortic wall and therefore prevents further dilatation. Aggressive control of blood pressure and heart rate comes with its own disadvantages. It had been shown, patients managed conservatively were more likely to develop renal failure (43%) compared to those having endovascular repair. About half of those patients required surgical treatment. There are not many cases in literature where a TBAD had resolved with medication. Conclusions As evident from this case, rigorous management of blood pressure may help with cases of Type B Dissection.

THORACOABDOMINAL AORTIC DISSECTION: ATYPICAL PRESENTATION AND MULTIORGAN DAMAGE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute Aortic Dissection (AoD) is the disruption of the tunica intima and tunica media of the aortic wall forming a blood-filled dissection plane dividing into "true" and "false" lumen. We categorize AoD as Type A and Type B (Stanford classification) based on the part of the aorta involved. However, an accurate diagnosis is difficult due to inconsistent clinical presentations (typically present with tearing chest pain radiating to the back). This is a unique clinical case of an atypical presentation with a complicated clinical course. CASE PRESENTATION: A 53-year-old man with untreated hypertension presented to the emergency room (ER) with worsening right lower extremity (RLE) pain and numbness for 6 days, aggravated with ambulation along with right lower quadrant (RLQ) abdominal pain. He endorses extensive tobacco, alcohol, marijuana, and cocaine use. In the ER, the blood pressure was 275/142 mmHg, biventricular hypertrophy on the EKG. He also had RLQ tenderness and diminished pulses in the RLE. The abdominal computed tomography (CT) discovered a distal abdominal aortic division. The larger false lumen dissected the left renal artery, left common iliac artery, with thrombosis of the left internal iliac artery. The narrow true lumen minimizes perfusion to the RLE and the right kidney. CT angiography of the chest confirmed a Stanford Type B aortic dissection with the intimal tear distal to the left subclavian artery. Intravenous Nicardipine and Esmolol drip controlled the blood pressure, followed by a femorofemoral bypass to improve RLE perfusion. Post-operative contrast nephropathy improved on day 10. Subsequently, a persistent ileus due to poor intestinal perfusion was corrected by transverse loop colostomy on day 15. On day 20, the patient was discharged with oral antihypertensive medications. DISCUSSION: The incidence of AoD is 5-30 per million people per year. 38% of ER presentations are missed; 28% are diagnosed at autopsy. Hypertension, atherosclerosis, cocaine abuse, cardiac surgeries, and systemic inflammatory syndromes can increase risk. Sullivan et al. suggest that a physician suspects AoD in 86% of patients with chest and back pain, 45% with only chest pain, and only 8% with abdominal pain. Our case is a unique combination of an atypical presentation (abdominal pain, leg numbness) with significant malperfusion of RLE, small bowel, and the right kidney (IRAD registry). For Type B dissection, medical management is preferred followed by surgical techniques to improve perfusion. Estimated inpatient mortality is 30% in proximal dissection and 10% in distal dissection. After the acute phase, the 10-year survival rate for AoD is <50%. CONCLUSIONS: Even with atypical symptoms, AoD and associated complications were successfully diagnosed and treated. Even with current surgical and medical advancements, controversies regarding diagnosis, the timing of repair, and type of repair still exist. REFERENCE #1: Cebicci, Huseyin & Salt, Omer & Gurbuz, Sukru & Sahin, Taner & Cumaoglu, Mustafa & Koyuncu, Serhat. (2014). Atypical presentations of aortic dissections: A case series. Acta Medica Mediterranea. 30. 85-90. REFERENCE #2: Sullivan PR, Wolfson AB, Leckey RD, Burke JL. Diagnosis of acute thoracic aortic dissection in the emergency department. Am J Emerg Med. 2000 Jan;18(1):46-50. doi: 10.1016/s0735- 6757(00)90047-0. PMID: 10674531 REFERENCE #3: Crawford, Todd C, et al. "Malperfusion Syndromes in Aortic Dissections." Vascular Medicine, vol. 21, no. 3, 2016, pp. 264–273., doi:10.1177/1358863x15625371 DISCLOSURES: No relevant relationships by Saurabh Chokshi, source=Web Response No relevant relationships by David Goldgrab, source=Web Response No relevant relationships by Devansh Patel, source=Web Response no disclosure on file for Jorge Perez

Ethnic differences in incidence and outcomes of acute aortic syndromes in the Midland region of New Zealand

BackgroundDisparities in cardiovascular disease according to socioeconomic factors and ethnicity are a global issue. The indigenous Māori population of New Zealand is not exempt. The aims of the present study were to assess whether ethnic disparities exist in the presentation and outcomes of acute aortic syndrome (AAS), including aortic dissection, intramural hematoma, and penetrating aortic ulcer, in New Zealand. MethodsA retrospective observational cohort study of consecutive AAS patients presenting to a tertiary referral center covering the Midland region of New Zealand (population, 816,900; 23.3% Māori) during a 10-year period was completed (2010-2020). Data were assessed by ethnicity (Māori vs non-Māori) and Stanford classification of AAS. The incidence of disease, 30-day mortality, and long-term all-cause and aortic-related mortality were recorded and assessed using logistic regression and Cox proportional hazards models. ResultsA total of 250 patients had presented with AAS (Māori, 92 [36.8%]; type A, 144 [57.6%]). The age-standardized rates of AAS were higher in Māori than in non-Māori patients (6.9/100,000 person-years vs 2.0/100,000 person-years; risk ratio, 3.56; 95% confidence interval, 1.50-8.53; P = .002). Māori patients had presented at a younger age for both type A (age, 54.4 ± 12 years vs 66.0 ± 13.2 years; P < .001) and type B (age, 61.3 ± 10.2 years vs 68.8 ± 13.7 years; P = .005) AAS. Mortality at 30 days was higher for those with type A than for those with type B AAS (33.3% vs 13.2%; P < .001) but did not differ by ethnicity in our cohort. On multivariate analysis, no differences were found in 30-day or long-term survival when stratified by ethnicity. ConclusionsThe results from the present study have demonstrated that ethnic disparities in AAS exist in New Zealand, with Māori presenting at a younger age and with a greater incidence compared with other ethnicities. Whether this disparity is related to socioeconomic factors, access to preventive care, or other factors remains to be elucidated. Despite these differences in disease presentation, the survival outcomes when stratified by ethnicity were comparable in the present cohort.

Evaluation of Acute Aortic Dissections in the Emergency Department: A Retrospective Study

Aortic dissection (AD) is a life-threatening emergency that has a mortality rate of around 27% even when optimal conditions are met. Atypical process of the disease which can mimic other critical conditions makes it harder to diagnose. The study aimed to determine Emergency department presentations and factors that influence the diagnostic process, emergency department, and in-hospital mortalities of acute AD patients. This study is a single-centered retrospective observational study. Patients with ICD-10 codes for AD in their digital files were analyzed. Patients were categorized into Stanford Type A or B dissections according to their computerized tomography scans. Also, the patients were compared in terms of survival. Eighty-eight patients had an acute AD and the mean age was 61,90±12,67 years. According to Stanford Classification, 68 patients had Type A dissection. Altered mental status and syncope were detected more in Type A (p=0.003 and p=0.001). Bilateral arm blood pressure readings differential was more in Type A (p=0.007). Blood products were used and endotracheal intubation was performed more in Type A (p=0.002 and p=0.005). Patients who had bilateral arm blood pressure differential had 3.5-fold, who had developed cardiac arrest in ED had 5.07-fold, who got blood product transfusions had 5.41-fold more risk of death. [OR:3.50; (CI 95% 1.36-8.94) p=0.009, OR: 5.07; (CI 95% 1.18-21.39) p=0.027 and OR: 5.41; (CI 95% 1.97-14.78) p=0.001 respectively]. The mortality rates in ED and in-hospital were 12.5% and 61.4% respectively. Aortic dissections will stay as important clinical conditions which management in ED is crucial. Atypical presentation of AD and the nature of the disease cause delays in diagnoses. AD should be considered in the foreground in patients presenting with syncope and altered mental status. When there is a clinical suspicion the scan of the aorta with computerized tomography must be ordered rapidly.

Computed Tomography Angiography Assessment of Acute Aortic Syndromes: Classification, Differentiating Imaging Features, and Imaging Interpretation Pitfalls.

An acute aortic syndrome (AAS) is an important life-threatening condition that requires early detection and management. Acute intramural hematoma (IMH), aortic dissection (AD) and penetrating atherosclerotic ulcer (PAU) are included in AAS. ADs can be classified using the well-known Stanford or DeBakey classification systems. However, these classification systems omit description of arch dissections, anatomic variants, and morphologic features that impact outcome. The Society for Vascular Surgery and Society of Thoracic Surgeons (SVS-STS) have recently introduced a classification system that classifies ADs according to the location of the entry tear (primary intimomedial tear, PIT) and the proximal and distal extent of involvement, but does not include description of all morphologic features that may have diagnostic and prognostic significance. This review describes these classification systems for ADs and other AAS entities as well as their limitations. Typical computed tomography angiography (CTA) imaging appearance and differentiating features of ADs, limited intimal tears (LITs), IMHs, intramural blood pools (IBPs), ulcer-like projections (ULPs), and PAUs will be discussed. Furthermore, this review highlights common imaging interpretation pitfalls, what should be included in a comprehensive CTA report, and provides a brief overview of current management options.

S100A1 as a potential biomarker for the diagnosis of patients with acute aortic dissection.

ObjectiveAcute aortic dissection (AAD) is a common life-threatening cardiovascular disease. This retrospective study was conducted to analyze the plasma concentration of S100A1 and its diagnostic value for AAD through receiver operating characteristic (ROC) curve and logistic regression analyses.MethodsSeventy-eight patients with AAD and 77 healthy controls were included, and the relevant clinical data for each group were collected. According to the Stanford classification, the AAD patients were divided into types A and B. The plasma levels of S100A1, D-dimer, hypersensitive C-reactive protein, and cardiac troponin T were detected by enzyme-linked immunosorbent assays.ResultsThe S100A1 concentrations in the healthy control, Stanford A, and Stanford B groups were 0.7 ± 0.6, 4.9 ± 2.6, and 3.5 ± 2.2 ng/mL, respectively. The concentration of S100A1 was increased in patients with AAD complicated with aortic regurgitation, pericardial effusion, or in-hospital death. ROC curve analysis showed that the area under the curve was 0.89. Logistic regression analysis revealed that the S100A1 level was an important risk factor for the development of AAD.ConclusionPlasma S100A1 is significantly elevated in patients with AAD, and its concentration has potential clinical value for diagnosing AAD.

A New Morphological Variant of Acute Aortic Dissection, Non-A-Non-B Type: Choosing Treatment Strategy

Treatment of acute aortic dissection is determined by the Stanford classification which classifies all cases as type A requiring emergency surgery, and type B managed with antihypertensive therapy, and, more recently, endovascular aneurysm repair. Owing to the introduction of computed tomography (CT) and magnetic resonance imaging (MRI), a new morphological type of the disease has been identified, in which the dissection starts from the aortic arch or the first part of the descending thoracic aorta and spreads retrogradely. A new classification of acute aortic dissection – TEM (T – type, E – entry, M – malperfusion), distinguishes 3 morphological variants of the disease: type A, type B, and non-A-non-B type.&#x0D; The frequency of non-A-non-B type among the other forms of acute aortic dissection is 11%. The existing classifications contain no guidelines on the management of a dissection that starts from or is limited to the aortic arch.&#x0D; The aim. To outline the morphological characteristics of a new, non-A-non-B type of aortic dissection, and to determine acceptable criteria for choosing surgical procedure based on the literature review and 2 observed clinical cases.&#x0D; Material and methods. During 2016-2020, two patients were classified as those having acute non-A-non-B type aortic dissection. Both patients underwent emergency surgery with total aortic arch replacement by a linear graft in one case and by a multi-branch one in the other. The patients were discharged on day 15 and 21 after surgery, respectively, without signs of heart failure or malperfusion, and with healed wounds. In neither of them a complete obliteration of the false lumen of the aorta was achieved; however, the first patient showed marked decrease in the total diameter of the descending thoracic aorta, as well as alleviation of the numbness in the right leg. The expediency of the operation in this type of dissection is explained by the fact that this morphological variant is presumably a local expansion of the type B dissection, the procedure defined as conservative by the Stanford classification. At the same time, the retrograde spreading of the dissection to the arch presents a risk of further involvement of the ascending aorta, which is another indication for surgery. Another variant of acute aortic dissection, which is morphologically similar to the non-A-non-B type, is the retrograde type A, in which surgical treatment is mostly recommended.&#x0D; Conclusions. The non-A-non-B type is one of the morphological variants of acute aortic dissection which is mainly subject to emergency surgery due to the risk of potentially fatal complications. Endovascular aneurysm repair of the entire aortic arch in the non-A-non-B type aims to eliminate the initial tear of the intima. If the intimal tear is located below the orifice of the left subclavian artery, prosthetics of an arch should be supplemented with endovascular repair of the descending aorta.