Treatment Of Acute Aortic Dissection Research Articles

Cannabidiol protects against acute aortic dissection by inhibiting macrophage infiltration and PMAIP1-induced vascular smooth muscle cell apoptosis

Acute aortic dissection (AAD) progresses rapidly and is associated with high mortality; therefore, there remains an urgent need for pharmacological agents that can protect against AAD. Herein, we examined the therapeutic effects of cannabidiol (CBD) in AAD by establishing a suitable mouse model. In addition, we performed human AAD single-cell RNA sequencing and mouse AAD bulk RNA sequencing to elucidate the potential underlying mechanism of CBD. Pathological assays and in vitro studies were performed to verify the results of the bioinformatic analysis and explore the pharmacological function of CBD. In a β-aminopropionitrile (BAPN)-induced AAD mouse model, CBD reduced AAD-associated morbidity and mortality, alleviated abnormal enlargement of the ascending aorta and aortic arch, and suppressed macrophage infiltration and vascular smooth muscle cell (VSMC) apoptosis. Bioinformatic analysis revealed that the pro-apoptotic gene PMAIP1 was highly expressed in human and mouse AAD samples, and CBD could inhibit Pmaip1 expression in AAD mice. Using human aortic VSMCs (HAVSMCs) co-cultured with M1 macrophages, we revealed that CBD alleviated HAVSMCs mitochondrial-dependent apoptosis by suppressing the BAPN-induced overexpression of PMAIP1 in M1 macrophages. PMAIP1 potentially mediates HAVSMCs apoptosis by regulating Bax and Bcl2 expression. Accordingly, CBD reduced AAD-associated morbidity and mortality and mitigated the progression of AAD in a mouse model. The CBD-induced effects were potentially mediated by suppressing macrophage infiltration and PMAIP1 (primarily expressed in macrophages)-induced VSMC apoptosis. Our findings offer novel insights into M1 macrophages and HAVSMCs interaction during AAD progression, highlighting the potential of CBD as a therapeutic candidate for AAD treatment.

Discussion to: Current status of surgical treatment for acute aortic dissection in Japan: Nationwide database analysis

Discussion to: Current status of surgical treatment for acute aortic dissection in Japan: Nationwide database analysis

Current status of surgical treatment for acute aortic dissection in Japan: Nationwide database analysis

ObjectiveTo clarify the current status of surgical treatment of acute aortic dissection (AAD) in Japan through the Japan Cardiovascular Database analysis. MethodsIn total, 7194 patients who underwent surgical treatment for AAD in 2021, including type A (TAAAD) (n = 6416) and type B (TBAAD) (n = 778), were investigated. ResultsThe median age was 70 years, with patients older than age 80 years constituting 21.7% and 23.4% of TAAAD and TBAAD cases. Emergency admission was 88.5% and 78.5%. Shock was found in 11.8% and 6.0%. Rupture/impending rupture occurred in 10.7%/6.0% and 24.0%/11.1%, respectively. Branch malperfusion was complicated in 10.4% and 25.2%. Open repairs were performed in 97.7% and 20.3%, whereas endovascular repairs were performed in 2.3% and 79.7%, respectively. In the increased prevalence of endografting procedures, neurological complications and renal failure occurred frequently after open repair with frozen elephant trunk for 29.9% and 50.3%. The operative mortality rate was 9.8% and 11.5% for open repair and 8.1% and 10.0% for endovascular repair. In patients with TAAAD, age older than 80 years, preoperative critical comorbidities, classical dissection, and coexisting chronic vital organ diseases were independent risk factors for mortality. In frozen elephant trunk procedures, neurologic complications and renal failure were frequent. The operative mortality was higher during the superacute phase within 1 or 2 hours from onset to arrival and between arrival and surgery. ConclusionsThe current status of surgical treatments for AAD including the increased prevalence of endografting of thoracic endovascular aortic repair and frozen elephant trunk were demonstrated with favorable outcomes in the Japan Cardiovascular Database analyses.

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.

Hybrid surgery for aneurysm of the arch and descending part of the aorta. Right-left subclavian bypass as a variant of subtotal debranching

The article presents the experience of our team in various surgical methods of treating aortic pathology. Surgical pathology of the thoracic aorta, namely aneurysms and dissections, remains controversial for the «heart team». In recent years, endovascular aortic replacement (TEVAR) has proven itself as a treatment option for many aortic diseases with a mortality rate up to 7.5 %. According to the latest clinical recommendations, TEVAR has become the method of choice in the treatment of acute aortic dissection, showing better results compared to medical therapy and open surgery. However, the endovascular approach requires certain anatomical features that allow the correct placement of the stent-graft, which is not always possible. Thus, when the brachiocephalic arteries are involved in the pathological process, artificial blood circulation is required with the use of additional methods to protect the brain, such as cerebral perfusion and hypothermia. All these factors increase the risk of intra- and postoperative complications, as well as early mortality. Different methods of open surgery to replace all or most of the thoracic aorta are described, which represent a radical approach and require a high level of professional skills of the surgeon and experience in working with artificial blood circulation.

The Choice of Tactics for Surgical Treatment of Acute De Bakey Type I Aortic Dissection in a Multidisciplinary Surgical Hospital

BACKGROUND Acute proximal aortic dissection (Stanford type A) remains the most common fatal pathology of the thoracic aorta. Despite the improvement of surgical technologies, hospital mortality after emergency surgical interventions is 17–25%, in complicated cases it can reach 80–90%.AIM OF STUDY Description of the perioperative treatment tactics adopted at the N.V. Sklifosovsky Research Institute for Emergency Medicine as well as the evolution of approaches that make it possible to obtain satisfactory hospital and long-term results in the treatment of aortic dissection.MATERIAL AND METHODS the study included 278 patients operated on from 2015 to 2021 in the acute stage of aortic dissection (less than 48 hours from the moment of manifestation of the disease). The operated patients were divided into two groups, depending on the presence of complicated forms: group A, 102 patients with uncomplicated course of the disease; group B, 176 patients with complicated course of the disease. Additionally, patients were divided depending on the level of distal reconstruction performed: group I, 83 patients, surgery was limited to prosthetics of the ascending aorta, without removing the clamp; group II, 137 patients who underwent hemi-arch surgery; group III, 58 patients, with distal reconstruction involving the aortic arch.RESULTS Total hospital mortality was 28.1%: 25.3% in group I, 29.1% in group II, 29.3% in group III. In the group of uncomplicated dissection, postoperative mortality was 18.6%, while in the group of complicated dissection it was 33.5%.CONCLUSION An integrated multidisciplinary approach with the formation of an “aortic team”, an individual approach to surgery, depending on the anatomy of the dissection and the clinical status of the patient, will improve the results of the treatment of acute aortic dissection, as the most severe and multiple organ pathology of the aorta.FINDING 1. Hospital mortality of complicated forms of dissection remains significantly higher — 33.5% versus 18.5% of uncomplicated course. 2. The most optimal method of distal reconstruction in patients with the peracute stage of dissection is an open anastomosis with the aorta using the “hemi-arch” technique. 3. If it is necessary to extend the surgical intervention on the aortic arch, a distal anastomosis in areas 0, 1, 2 with the possibility of a subsequent endovascular stage is the priority.

Rapid detection of two markers of acute aortic dissection based on a lateral flow assay of hollow CdTe/CdS nanospheres

Acute aortic dissection (AAD) is an emergency disease with a high mortality rate, and its characteristics is variable clinical symptoms, complex pathology, high misdiagnosis rate, leading to its frequent confusion with other chest pains of myocardial infarction and chronic emphysema in clinic; Therefore, early diagnosis and treatment of acute aortic dissection is the key to reduce its mortality and improve the prognosis of patients., and timely & rapid diagnosis is crucial for successful treatment. Conventional methods (such as PCR, MRI, and ELISA) cannot be implemented as a rapid point-of-care (POC) test for ADD. Highly fluorescent hollow CdTe/CdS nanospheres (NSs) with the inside size of ∼240 nm and shell thickness of ∼19 nm were prepared via the hydrothermal method, and three color NSs with green, yellow and red fluorescence of wavelength of 535 nm, 580 nm, and 620 nm, respectively, were obtained by changing the preparation temperature. Immunochromatographic (ICG) assay were developed with the prepared yellow CdTe/CdS NSs for the sensitive and qualitative detection of high mobility group box protein B1 (HMGB1). Visual limit of detection of ICG for HMGB1 antigen was 3.13 ng/mL within 15 min, lower than that of normal ELISA. Furthermore, a multichannel lateral flow assays (mLFA) was developed with green and yellow CdTe/CdS NSs for the simultaneous, specific, sensitive, and qualitative detection of HMGB1 and soluble growth stimulating gene 2 (sST2), and visual limits of detection of HMGB1 and sST2 in mLFA were 10 ng/mL and 1.25 ng/mL, respectively. This mLFA of CdTe/CdS NSs with two marker-antibodies first facilitates its application of POC in the early diagnosis on AAD.

Early results of direct true lumen cannulation (samurai technique) in aortic dissection surgery

Aim: The aim of this study was to evaluate and compare the clinical outcomes of Direct True Lumen Cannulation (Samurai Technique), axillary artery cannulation and femoral artery cannulation techniques used in aortic dissection surgery. Materials and methods: The data of 124 patients who underwent surgical treatment for acute aortic dissection between February 2018 and December 2022 were analyzed rectospectively. Patients were divided into Group 1 (samurai technique cannulation group) and Group 2 (axillary and femoral cannulation group). Results: When the results were analyzed, preoperative personal and clinical characteristics were found to be similar between the groups. In the inoperative period, the time from skin incision to CPB, hypothermic circulatory arrest time, and time for cooling were shorter in group 1. While there were no cannulation-related complications in group 1, axillary artery dissection developed in two patients in group 2. No significant difference was observed between the groups in postoperative results. Conclusion: Although there were similar results in the groups in the preoperative and postoperative periods, the more positive results in the surgery show that cannulation with the samurai technique is a preferable method.

Progressive aortic enlargement in medically managed acute type B aortic dissections with visceral aortic involvement.

Aortic remodeling of the thoracic aorta has been studied in patients treated with medical or endovascular therapy for the treatment of acute aortic dissections; however, particular attention has not yet focused on identifying specific growth patterns and rates across all aortic zones. Additionally, previous studies have not delineated between dissections with and without visceral aortic involvement, and we hypothesize that these two cohorts may exhibit distinct differences. The aim of this study is to investigate aortic behavior over time in medically managed acute Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) type B dissections with visceral aortic involvement and identify potential associations of subsequent aortic behavior with clinical outcomes. A single-center retrospective review was performed of all patients between 2010 and 2020 with acute SVS/STS type B aortic dissections with visceral aortic involvement that were not surgically managed. Short-axis centerline measurements of the true/false lumen and total aortic diameter (TAD) were taken at standardized locations relative to aortic anatomy within each aortic zone, including nondissected zones. Measurements were taken at the time of diagnosis and at six subsequent yearly intervals. Diameter changes over time were evaluated using repeated measures mixed models linear growth analysis. Aortic enlargement was classified by growth in TAD ≥5mm in either the thoracic (thoracic segment enlargement [TSE], zone 0-4) or visceral segments (visceral segment enlargement [VSE], zone 5-9). A total of 78 patients were identified with a median length of follow-up of 3.3years (interquartile range [IQR], 1.3-6.6years). Follow-up past 5years was seen in 31% of the cohort. For the entire cohort, mean thoracic growth in TAD was 2.0± 2.0mm/year, and visceral growth in TAD was 2.5± 2.4mm/year. TSE was observed in 65% of patients, with a median time until onset of 0.8years (IQR, 0.4-2.3years). VSE was observed in 57% of the cohort, with a median time until onset of 1.6years (IQR, 0.9-3.3years). Repeat measures mixed models linear growth analysis identified significant predictable linear growth in all aortic zones except for the nondissected zones 0-2. Odds for TSE are significantly increased in patients with known genetically triggered aortic conditions (odds ratio [OR], 2; 95% confidence interval [CI], 1.8-4.5; P= .044) and in cases where the dissection entry tear was in either zone 1 or 2 (OR, 4.8; 95% CI, 1.2-8.4; P= .044). In adjusted regression analysis, odds for intervention in the thoracic aorta were significantly increased in patients with rapid TSE in zone 3 (OR, 3.6; 95% CI, 1.1-8.4; P= .045). Similarly, odds for intervention targeting the visceral aortic segment were significantly increased in patients with zone 9 VSE (OR, 9.3; 95% CI, 1.1-13.3; P= .014). Odds for 5-year all-cause mortality were significantly increased in cases with large thoracic aneurysms (OR, 6.1; 95% CI, 1.1-14.9; P= .042). Aortic enlargement was present in the majority of patients with medically managed acute SVS/STS Type B aortic dissections with visceral aortic involvement, with analysis demonstrating predictable linear growth in all dissected zones. Patients with aortic enlargement demonstrated higher gross changes in diameter in addition to higher yearly rates of change compared with all comers. Odds for enlargement were impacted by both patient demographic and anatomic dissection characteristics. Growth in zone 3 and zone 9 significantly increased odds for aortic intervention. Odds for 5-year mortality were significantly increased in the presence of large thoracic aneurysms. Results highlight risk of progressive degeneration beyond acute phase in SVS/STS Type B aortic dissections with visceral aortic involvement, with life-long surveillance remaining crucial in management of dissections.

Volume Changes in the Descending Aorta after Frozen Elephant Trunk and Conventional Hemi-Arch Repair after Acute Type A Aortic Dissection.

The aim of this study was to compare the mortality rates, re-intervention rates, and volumetric changes in aortas following surgery, in terms of the true lumen and false lumen changes, using conventional hemi-arch repair (CET) and frozen elephant trunk (FET) techniques. During the period from 2015 to 2018, 66 patients underwent surgical treatment for acute aortic dissection (Debakey type 1). Demographic and procedure-related data were evaluated. We measured volumetric change before surgical treatment, at discharge, and at 12- and 24-month time points based on computed tomography angiography. The study cohort was divided into two groups (FET vs. CET). The mean age of the patients was 56.9 ± 9.4 years in the FET group versus 63.6 ± 11 years in the CET group (p = 0.063). The mean follow-up time was 24 ± 6 and 25 ± 5 months for the FET and CET groups, respectively. There were no significant differences between the two groups in terms of the medical histories of the cohorts. The results showed a significant increase in true lumen volume after the FET procedure (within 24 months postoperatively; p = 0.005), and no significant changes in total (p = 0.392) or false lumen (p = 0.659) volumes were noted. After the CET procedure, there were significant increases in total and false lumen volumes (p = 0.013, p = 0.042), while no significant change in true lumen was observed (p = 0.219). The volume increase in true lumen after the FET procedure was higher compared to the CET group at all postoperative time points (at discharge, 12 months, and 24 months) without significant evidence (p = 0.416, p = 0.422, p = 0.268). At two years, the volume increase in false lumen was significantly higher among the CET group compared to the FET group (p = 0.02). The Kaplan–Meier curve analysis showed that patients who underwent the CET procedure underwent significantly more re-interventions due to false lumen expansion of the descending aorta (p = 0.047). Present study results indicate that the true and false lumen changes in the aorta following the FET and CET procedures were different. FET led to a significant increase in true lumen volume, while false lumen volume remained stable; however, after the CET procedure, significant false lumen enlargement was noted at mid-term follow-up time points. The re-intervention rate after CET was higher due to false lumen expansion.

Admission Lysophosphatidic Acid Is Related to Impaired Kidney Function in Acute Aortic Dissection: 2-Year Retrospective Follow-Up Study.

BackgroundDelayed treatment of acute aortic dissection (AAD)-related acute kidney injury (AKI) significantly increases the burden of chronic kidney disease (CKD) and mortality. Lysophosphatidic acid (LPA) is a shared mediator of kidney disease and AAD. Here, we evaluated the relationship between LPA and kidney injury in AAD patients.MethodsWe measured the plasma concentration of LPA in a cohort of 80 patients with AAD. Least Absolute Shrinkage and Selection Operator (LASSO) regression and Logistic regression were used to evaluate the effect and interaction of LPA on AKI. Additive generalized model and penalized spline method were used to describe the non-linear association. Multivariable analyses with the Cox proportional-hazards model were used for subgroup analysis and interaction in LPA and subsequent CKD.ResultsThe participant’s average age was 54.27 ± 11.00 years, 68.75% of them were males, and the incidence of AKI was 43.75%. Patients with AKI had higher levels of LPA on admission, and the more significant the increase, the higher the risk of AKI. There was a non-linear positive correlation between admission LPA and AKI, and the premeditated inflection point was 346.33 (μg/dL) through two-piecewise linear regression and recursive algorithm. Subgroup analysis identified a stronger association between admission LPA and AKI in the elder, female and medically treated patients. The incidence of CKD was 22.67% in the 2-year follow-up. Patients with subsequent CKD had higher LPA levels on admission in the follow-up cohort, and a similar interaction trend was also observed through Cox proportional—hazards model.ConclusionAdmission LPA levels show a non-linear positive correlation with AKI and increase the risk of subsequent CKD, which is more pronounced in elderly, female, and medically treated patients.

Surgical treatment of acute aortic dissection in a patient with SLE and prior antiphospholipid syndrome on therapy for over 30 years: a case report

BackgroundIn patients with systemic lupus erythematosus (SLE), lengthy treatment and long-term steroid use are the main risk factors for developing aortic aneurysms or aortic dissections. In patients with cardiac tamponade, hemodynamic collapse may lead to acute renal and hepatic failure.Case presentationWe report the successful treatment of a 55-year-old woman with SLE since the age of 21. She suddenly felt chest pain approximately 2 weeks before developing fever and vomiting and was admitted to our hospital. Initially, she had severe liver dysfunction and was admitted to the hepatology department, where treatment for fulminant hepatitis was initiated. However, computed tomography (CT) showed an acute aortic dissection (DeBakey type II) and severe bloody pericardial effusion. Therefore, we performed emergency pericardial drainage. Plasma exchange therapy was initiated as emergency aortic surgery was deemed impossible due to impaired liver function tests and coagulation. Ten days later, the patient developed peritonitis due to small bowel perforation, and laparotomy was performed for abscess drainage and perforation closure. She had received steroid pulse therapy at the age of 21. At 40 years of age, she developed deep vein thrombosis due to antiphospholipid antibodies and was prescribed prednisolone. She was ambulatory at 3 months after the onset of acute aortic dissection, and CT revealed a rapidly enlarging true aneurysm in the distal arch. We performed elective aortic surgery. Although there were no antiphospholipid antibodies, surgery could have led to a devastating antiphospholipid syndrome. Therefore, we decided to treat the patient with triple therapy. Methylprednisolone was intravenously administered intraoperatively and at 1 day postoperatively. The patient was discharged without complications after returning to her usual oral prednisolone regimen.ConclusionsThe patient described herein had a systemic circulatory failure due to cardiac tamponade, accompanied by liver failure. This condition is a significant cause of death in patients with aortic dissection-associated SLE and is extremely dangerous. However, multi-specialty intervention helped the patient recover, and she has been attending the outpatient clinic. Aortic surgery requiring hypothermia in SLE patients with antiphospholipid syndrome and a history of thrombocytopenia or thrombosis requires a multi-disciplinary treatment team, including cardiac surgeons and medical experts.

Is TEVAR really needed for uncomplicated type B aortic dissection?

Thoracic endovascular aortic repair (TEVAR) has quickly become the mainstay of treatment for acute aortic dissection, in particular cases of acute complicated Stanford Type B dissection (co-TBAD). Necessarily, TEVAR carries with it the risk of postoperative complications, including stroke and renal failure. As a result, the management of patients with uncomplicated type B aortic dissection (un-TBAD), which is generally accepted as being less severe, is safely managed via optimal medical therapy (OMT) alone. However, despite OMT, patients with un-TBAD are at substantial risk of severe disease progression requiring delayed intervention. The cost-benefit ratio associated with TEVAR for un-TBAD is therefore of key interest. Howard and colleagues produced a fascinating systematic review and meta-analysis investigating the clinical outcomes of TEVAR for complicated and uncomplicated TBAD. Their data suggest that there is no significant difference in in-hospital mortality or 5-year survival between TEVAR for un-TBAD and co-TBAD, although the 30-day mortality rate appeared to be higher in the co-TBAD cohort. Patients with co-TBAD appeared to also be at a higher risk of postoperative stroke and TEVAR endoleak, while un-TBAD patients were at a higher risk of postoperative renal failure. Further prospective research into these relationships is recommended to fully elucidate the comparative efficacies of TEVAR for un-TBAD and co-TBAD.

GUIDANCE ON AREA OF CREATED TEARS FOR AORTIC FENESTRATION TREATMENT BASED ON COMPUTATIONAL FLUID DYNAMICS

Aortic fenestration (AF) uses puncture and a dilation balloon to create a tear in the intimal flap, which can directly relieve ischemia syndrome and reduce hypertension in the false lumen. The selection of a dilation balloon as well as the area of the created tear applied in reality depend on clinical experience, so we aim to provide a quantitative guidance and reference for doctors to better plan the treatment of aortic fenestration. In this study, the area of the created tear was virtually enlarged to at least 10 different values for four cases including one ideal case, and a computational fluid dynamic approach was applied to simulate blood flows in the aorta. The area ratio (AR) between the created tear and entry tear was introduced to express the enlargement of the created tear. The quantitative hemodynamic results indicate that the AR should be controlled to be larger than 7.0, but not too big to obtain the best treatment for acute aortic dissection (AD) case. Additionally, we assessed that AR might also be a risk factor for the prediction of dissection propagation.

Efficiency of atorvastatin on in-hospital mortality of patients with acute aortic dissection (AAD): study protocol for a randomized, open-label, superiority clinical trial

BackgroundDyslipidemia and local inflammation at sites of lipid deposition on blood vessel walls have been demonstrated to be risk factors for patients with acute aortic dissection (AAD). Statins have anti-inflammatory and lipid-lowering effects, which suggest that statins may play an important role in the prevention and treatment of AAD. Some retrospective studies show that statins can protect patients with aortic dissection. However, the effect of statins on the survival of AAD patients has been scarcely investigated, especially in randomized trials. In this study, we will perform a randomized clinical trial to understand whether statins can reduce in-hospital mortality of AAD patients.MethodsA total of 384 subjects diagnosed with AAD in the First Affiliated Hospital of Shantou University Medical College will be recruited. Participants will be randomly divided into an atorvastatin-treated or control group. The primary outcome will be the in-hospital mortality at 30 days.DiscussionThis study is designed to verify the efficacy of atorvastatin on reducing in-hospital mortality of patients with AAD. The aim is to provide a new means of improving survival as a complement to conventional drug therapy.Trial registrationChinese Clinical Trials Registry ChiCTR1900023515. Registered on 1 June 2019.

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.
 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.
 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.
 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.
 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.

Characterization and Significance of Monocytes in Acute Stanford Type B Aortic Dissection.

Acute aortic dissection (AAD) is one of the most common fatal diseases noted in vascular surgery. Human monocytes circulate in dynamic equilibrium and display a considerable heterogeneity. However, the role of monocytes in AAD remains elusive. In our recent study, we firstly obtained blood samples from 22 patients with Stanford type B AAD and 44 age-, sex-, and comorbidity-matched control subjects. And the monocyte proportions were evaluated by flow cytometry. Results showed that the percentage of total CD14+ monocytes in the blood samples of Stanford AAD patients was increased significantly compared with that of normal volunteers (P < 0.0005), and the absolute numbers of CD14brightCD16+ and CD14brightCD16− monocytes both increased significantly regardless of the percentage of PBMC or CD14+ cells, while CD14dimCD16+ monocytes displayed the opposite tendency. However, the percentage of CD14+ cells and its three subsets demonstrated no correlation with D-dimer (DD) and C-reactive protein (CRP). Then, blood mononuclear cell (PBMC) samples were collected by Ficoll density gradient centrifugation, followed with CD14+ magnetic bead sorting. After the purity of CD14+ cells was validated over 90%, AAD-related genes were concentrated in CD14+ monocytes. There were no significant differences observed with regard to the mRNA expression levels of MMP1 (P = 0.0946), MMP2 (P = 0.3941), MMP9 (P = 0.2919), IL-6 (P = 0.4223), and IL-10 (P = 0.3375) of the CD14+ monocytes in Stanford type B AAD patients compared with those of normal volunteers. The expression levels of IL-17 (P < 0.05) was higher in Stanford type B AAD patients, while the expression levels of TIMP1(P<0.05), TIMP2(P<0.01), TGF-β1 (P < 0.01), SMAD3 (P < 0.01), ACTA2 (P < 0.001), and ADAMTS-1 (P < 0.001) decreased. The data suggested that monocytes might play an important role in the development of Stanford type B AAD. Understanding of the production, differentiation, and function of monocyte subsets might dictate future therapeutic avenues for Stanford type B AAD treatment and can aid the identification of novel biomarkers or potential therapeutic targets for decreasing inflammation in AAD.

Surgical Fenestration of the Abdominal Aorta in Patients with Acute and Chronic Aortic Dissection

Introduction - Surgical aortic fenestration for acute and chronic aortic dissection has been used at our institution since 1986. The aim of the study is to define the indications for its use and to evaluate its success at relieving organ or limb malperfusion. Methods - The records of all patients (n=57) who underwent surgical fenestration of abdominal aorta at our department during the past decade (from 2007 to 2017) were identified. Emergency aortic fenestration for treatment of acute aortic dissection underwent 2 patients with type B dissection. Clinical presentation was malperfusion syndrome: 1 patient had bilateral lower limb and renal ischemia and 1 patient had acute renal and mesenteric ischemia. In both cases malperfusion syndrome occurred despite prior proximal descending throracic aortic replacement. The mean interval between malperfusion onset and fenestration was 7 hours (range, 6 - 8 hours). 55 patients underwent elective aortic fenestration for treatment of chronic aortic dissection. 2 patient had type A dissection, and 53 patients had type B dissection. The primary clinical presentation was chronic malperfusion syndrome in all 55 patients and infrarenal aortic aneurysmal disease in 5 patients. Among them 9 patients had lower limb claudication, 41 patients had renal ischemia, and 17 patients had severe refractory renovascular hypertension caused by the compressed true lumen. 7 patients had symptoms related to chronic mesenteric ischemia. 2 patients had prior ascending aortic Bentall procedure and 5 patients - prior proximal descending thoracic aortic replacement. The main condition and indication for surgical aortic fenestration was the absence of aneurysmal enlargement of the abdominal aorta at the para and suprarenal level (aortic diameter less then 5 cm). Abdominal aortic fenestration was performed through longitudinal aortotomy at the para- and suprarenal level by resection of the septum between the false and true lumen. The aortotomy then was sutured and reinforced with strips of Teflon, which resulted in a slightly redused aortic diameter. Concomitant graft replacement for the infrarenal abdominal aorta was done in 14 patients. Results - The malperfusion syndrome was relieved for 55 patients with organ or limb ischemia. Early operative survival from fenestration was 96.5 % (55 /57). In the acute dissection group the operative mortality was 50 % (1/2) and cause of death - anuria and bowel ischemia. In one patient, acute renal and lower limb malperfusion syndrome was successfully relieved. In the chronic dissection group, operative mortality was 1.8 % (1/55), with the cause of death being multi-systemic organ failure. The 54 patients with evidence of chronic malperfusion syndrome had complete relief. None of the patients were seen with complications that called for reoperation. The mean follow-up for 54 survivors was 3 years (range, 3 months to 5 years). All patients remained free from symptomatic recurrence of malperfusion syndrome and had postoperative imaging studies done. Among all patients there was no evidence of aneurysmal formation at the site of aortic fenestration. Conclusion - Surgical fenestration of the abdominal aorta is a safe and effective method for the treatment of ischemic complications associated with the aortic dissection and malperfusion.

Multicentre experience with two frozen elephant trunk prostheses in the treatment of acute aortic dissection†.

The aim of this study was to evaluate early- and mid-term outcome and aortic remodelling in patients undergoing implantation of 2 different frozen elephant trunk prostheses, either the Thoraflex™ hybrid (Vascutek, Inchinnan, UK) and the E-vita Open (Jotec Inc., Hechingen, Germany) for acute aortic dissection. All consecutive patients [n = 88; median age 59 (49-67) years; 69% male] undergoing surgery with a frozen elephant trunk prosthesis for acute aortic dissection from August 2005 until March 2018 were included in this study. The Thoraflex™ device was implanted in 55 patients and the E-vita Open graft in 33 patients. Preoperative characteristics did not differ significantly between groups. There was also no statistically significant difference in postoperative outcome: in-hospital mortality (11% vs 12%; P > 0.99), stroke (18% vs 6%; P = 0.12) and spinal cord injury (6% vs 6%; P > 0.99). While there was no statistically significant difference in the occurrence of distal stent graft-induced new entries (16% vs 18%; P = 0.77), there was a significantly higher rate of secondary endovascular aortic interventions in the Thoraflex™ hybrid group (22% vs 0%; P = 0.003). There was a trend towards a higher rate of false lumen thrombosis at the level of the stent graft (74% vs 95%; P = 0.085) and was comparable at the thoraco-abdominal transition (53% vs 80%; P = 0.36) 1 year after implantation of the prostheses. In this comparison of 2 frozen elephant trunk prostheses, there is no evidence that different surgical techniques influence in-hospital outcome. At 1-year follow-up, patients who underwent implantation of the E-vita Open prosthesis showed a significantly reduced rate of secondary aortic interventions and a trend towards a higher rate of false lumen thrombosis which might be attributed to a longer coverage of the descending aorta due to a longer stent graft design and significantly more frequent implantation in zone 3.

Thoracic Endovascular Aortic Repair for Acute Aortic Dissection.

Thoracic endovascular aortic repair (TEVAR) for thoracic aortic disease constitutes a paradigm shift in the treatment strategy of aortic dissection, as well as thoracic aortic aneurysms. Conventionally, most patients with Stanford type B acute aortic dissection are treated using conservative medical treatment during the acute phase. However, in patients with complicated type B aortic dissection who present with life-threatening complications, TEVAR has been introduced as a novel and less-invasive alternative and has shown better early results than those observed with conventional therapy. Recently, TEVAR was reported to be effective in not only promoting thrombosis of the false lumen but also in preventing aortic enlargement observed at long-term follow-up. TEVAR has been established as first-line therapy for complicated type B aortic dissection. In contrast, a considerable number of patients who received acute phase medical treatment required surgical intervention for chronic dissecting aortic aneurysms. With the increasing popularity of TEVAR for the treatment of complicated type B aortic dissection, prophylactic and pre-emptive TEVAR has been considered in patients with uncomplicated type B aortic dissection. However, supportive evidence for this strategy is limited, and reassessment is mandatory because it is continuously evolving. Although acute type A aortic dissection is a life-threatening condition, the results of open surgery continue to improve in the modern surgical era. Open surgical treatment is well established and recognized as a gold standard even in the endovascular era. Presently, the application of TEVAR for ascending aortic dissection has undergone a change, and TEVAR is considered a viable rescue option for patients with type A aortic dissection who are not eligible for open surgical repair. However, TEVAR for the descending aorta is well-established treatment for retrograde type A dissection. Several conceptual and technical issues remain unresolved, and technological advances would lead to the development of innovative disease-specific devices and solutions in the future for endovascular treatment of acute aortic dissection. (This is a translation of Jpn J Vasc Surg 2018; 27: 337–345.)