Treatment Of Acute Aortic Syndrome Research Articles

Results of the in situ fenestration technique for preservation of the Left subclavian artery in the endovascular repair of acute aortic syndromes in a reference center.

The in situ fenestration (ISF) technique consists of maintaining the patency of the aortic branch after the endoprosthesis is already in place as a viable, effective, and fast-performing alternative to revascularize the aortic arch arteries. To report the experience with a series of cases of endovascular treatment of Acute Aortic Syndromes involving the aortic arch, using the ISF technique in a specialized center. We analyzed data collected from patients treated with ISF during TEVAR for Acute Aortic Syndromes involving the aortic arch from June 2020 to January 2022, assessing perioperative outcomes, including immediate and late success rates, complications, morbidity and mortality, and short and medium term aortic branch patency. Of the 11 patients eligible for the ISF procedure, 9 were successful, with a technical success rate of 81%. No patient had a type 1A endoleak related to fenestration. There was complete thrombosis of the false lumen in the thoracic aorta in 77% cases. No death was related to the fenestration technique. ISF as feasible and with a high rate of technical success and good results in the short and medium term. Prospective studies with long-term clinical follow-up are still needed to fully assess the durability of these unreinforced fenestrations.

Endovascular treatment of acute aortic syndrome

急性主动脉综合征（AAS）是致命性急危重症之一。临床上通常将AAS分为主动脉夹层（AD）、主动脉壁间血肿（IMH）和穿透性溃疡（PAU）等。Stanford A型AAS，因其累及升主动脉而首选外科开放手术。Stanford B型AAS，因不累及升主动脉，如近端锚定区足够，可首选单纯胸主动脉腔内修复术（TEVAR）；如近端锚定区不够，可选择先外科弓上分流而后TEVAR的“杂交”手术，或纯腔内的方式施行烟囱、开窗技术或分支支架置入术。复杂型AAS指患者出现反复疼痛、难以控制的高血压、器官灌注不良、濒临破裂等临床表现，需要急诊手术治疗。而非复杂型AAS可考虑延期至亚急性期进行手术。早期脑脊液引流可改善脊髓缺血患者的预后。术后发热的患者需考虑置入后综合征，抗炎治疗或许有效。.

Diagnosis and Management of Acute Aortic Syndromes: Dissection, Penetrating Aortic Ulcer, and Intramural Hematoma.

Acute aortic syndromes, including aortic dissection, intramural hematoma, and penetrating aortic ulcer, are a group of highly morbid, related pathologies that are defined by compromised aortic wall integrity. The purpose of this review is to summarize current management strategies for acute aortic syndromes. All acute aortic syndromes have potential for high morbidity and mortality and must be quickly identified and managed with the appropriate algorithm to prevent suboptimal outcomes. Recent trials suggest that TEVAR is increasingly useful in stabilizing pathology of the descending thoracic aorta but when possible should be applied in a delayed fashion and with limited coverage to minimize neurologic complications. Treatment for acute aortic syndrome is frequently dictated by the anatomic location and extent of the wall compromise as well as patient comorbidities. Therapy is often individualized and often includes some combination of medical, procedural, and surgical intervention.

Первый опыт эндоваскулярного лечения острого расслоения аорты типа в по Стенфорду

Despite a large body of knowledge about acute thoracic aortic pathology, most physicians do not feel confidentin diagnosing and treating patients with this group of diseases characterized by high mortality. The emergenceof modern high-tech diagnostic methods, such as MSCT angiography, contributed to the early detection of bothacute and latent course of aortic pathology, as well as clearly determine the further treatment tactics. Currently,endovascular techniques are preferred in the treatment of acute thoracic aortic syndrome. This article presentsa case of successful endovascular treatment of acute aortic syndrome in our Republic.

Diagnosis and Management of Acute Aortic Syndrome: A Literature Review

Background : Acute aortic syndrome (AAS) is a potentially fatal disease involving the acute disruption of the aortic wall. Several conditions, such as intramural hematoma (IMH), aortic dissection (AD), penetrating atherosclerotic ulcer (PAU), as well as high mortality rates, are associated with this disease. Hypertension is an essential risk factor, and patients often present with pain. AAS may be challenging to be evaluated, as it has a pre-test probability and several diagnostic tests. Objective : This literature review will discuss the proper diagnosis and management of Acute aortic Syndrome patients. Discussion : Computed Tomography Angiography (CTA) is essential in managing AAS. The significance of prompt diagnosis and treatment of AAS is emphasized further by the current developments in imaging techniques and therapeutic interventions, ultimately leading to increased vigilance of this disease. Management of AAS included initial medical therapy and definitive therapy. Conclusion : In A type AAS, surgical intervention is the definitive therapy, while type B is managed definitively by endovascular or medical treatment

Difficult diagnosis and surgical treatment of acute aortic syndrome.

Difficult diagnosis and surgical treatment of acute aortic syndrome.

Turn down of acute aortic syndrome cases during COVID-19: Results from UK multicentre studies.

ObjectiveThe coronavirus disease 2019 (COVID‐19) pandemic has restructured the healthcare systems, prioritizing resources to treat COVID‐19 patients. The aim of this study was to establish if patients affected by acute aortic syndrome (AAS) had unrestricted access to emergency treatment and evaluate outcome of these patients during the peak of the pandemic.MethodsThis is a retrospective analysis of prospectively collected data between March and June 2020 from 19 participating cardiac surgery centers in the United Kingdom.ResultsAmong 95 patients who presented with an AAS in the participating centers; 85 (89%) underwent surgery, 7 (7%) were turned down for surgery because of their profile of comorbidities, and 3 (3%) died on transfer. Among the patients treated conservatively, three of them (43%) were alive at 30 days. We observed no significant restriction in access to treatment for AAS during the early months of the pandemic.ConclusionServices for life‐threatening aortic surgery patients were maintained during the COVID‐19 period through patient selection and timing of surgery. The rate of surgical turn‐down was comparable to published figures despite the challenges faced during the COVID‐19 pandemic.

Surgical treatment of acute aortic syndrome: an update

The term "acute aortic syndrome" describes a variety of acute and emerging aortic pathologies that include intramural hematoma, penetrating aortic ulcer and acute aortic dissection. However, the acute pathology of the thoracic aorta also includes the contained ruptures of aortic aneurysms, traumatic aortic ruptures and iatrogenic aortic dissections. In all these acute situations, in which emerging surgical treatment is often required, decision-making represents a crucial and extremely important phase, which often affects the patient's prognosis, in the short and long term. This review aims to present an update of the surgical treatment of acute aortic syndrome focusing mainly on the correct decision-making, the factors that influence it and the latest novel surgical techniques and strategies.

Acute aortic dissection case with stroke presentation.

The correct diagnosis of acute aortic syndrome complicated by neurologic symptoms is essential. Performing thrombolytic therapy for acute-stage cerebral infarction would probably be the reason for fatal outcomes. We herein report the case of a 63-year-old man who presented with left hemiparesis and paraparesis. An acute myocardial infarction was excluded by electrocardiography and blood tests. Head computed tomography (CT) showed no remarkable findings. Although there was no chest pain, it was found in CT-angiography that he has an intramural hematoma in the ascending aorta and a severe dissection in the descending aorta. Aortic dissection may mimic acute stroke, in order to make the right decision about the treatment of acute aortic syndrome with neurologic complications, the benefits and risks should therefore be considered in individual patients.

Changes in the diagnosis and management of acute aortic syndrome and associated mortality in the last 20 years

Introduction and objectivesMortality is high in acute aortic syndrome (AAS), which therefore requires early treatment. This study aimed to analyze changes in the diagnosis and treatment of AAS over 20 years at our center. MethodsFrom 1999 to 2018, 451 patients diagnosed with AAS (336 men; mean age, 60.9±12.4 years) were prospectively included (270 type A and 181 type B). Clinical variables, diagnosis, treatment, and in-hospital complications were analyzed. ResultsThe use of computed tomography (CT) as the first-line diagnostic technique increased from 62.8% to 94.2% (P <.001). Surgical treatment of type A AAS rose from 67.4% to 82.5% (P=.09). Mortality from type A AAS decreased significantly from 53.1% to 26.3% (P <.001) as a result of the fall in mortality from surgical treatment (from 45.4% to 17.0%; P <.001). The use of medical treatment alone for type B AAS decreased from 91.8% to 61.7% (P <.001) due to the greater use of endovascular treatment. Mortality from type B AAS showed no significant reduction (16.2% to 10.6%; P=.15). ConclusionsThe diagnosis and treatment of AAS has changed substantially in the last 2 decades. CT has become the first-line diagnostic technique for AAS. In type A AAS, mortality has fallen significantly due to improvements in the results of surgical treatment. In type B AAS, the use of medical treatment alone has decreased due to the expansion of endovascular treatment, although in-hospital mortality has not decreased significantly.

Evolución en el diagnóstico, el tratamiento y la mortalidad del síndrome aórtico agudo en los últimos 20 años

Introduction and objectivesMortality is high in acute aortic syndrome (AAS), which therefore requires early treatment. This study aimed to analyze changes in the diagnosis and treatment of AAS over 20 years at our center. MethodsFrom 1999 to 2018, 451 patients diagnosed with AAS (336 men; mean age, 60.9±12.4 years) were prospectively included (270 type A and 181 type B). Clinical variables, diagnosis, treatment, and in-hospital complications were analyzed. ResultsThe use of computed tomography (CT) as the first-line diagnostic technique increased from 62.8% to 94.2% (P <.001). Surgical treatment of type A AAS rose from 67.4% to 82.5% (P=.09). Mortality from type A AAS decreased significantly from 53.1% to 26.3% (P <.001) as a result of the fall in mortality from surgical treatment (from 45.4% to 17.0%; P <.001). The use of medical treatment alone for type B AAS decreased from 91.8% to 61.7% (P <.001) due to the greater use of endovascular treatment. Mortality from type B AAS showed no significant reduction (16.2% to 10.6%; P=.15). ConclusionsThe diagnosis and treatment of AAS has changed substantially in the last 2 decades. CT has become the first-line diagnostic technique for AAS. In type A AAS, mortality has fallen significantly due to improvements in the results of surgical treatment. In type B AAS, the use of medical treatment alone has decreased due to the expansion of endovascular treatment, although in-hospital mortality has not decreased significantly.

АПОПТОЗ ТА ІМУННЕ ЗАПАЛЕННЯ У ХВОРИХ З ГОСТРИМ АОРТАЛЬНИМ СИНДРОМОМ

&#x0D; &#x0D; &#x0D; The growing number of complicated aneurysms of the aorta requires further study of this pathology, the allocation of major pathophysiological components to improve the quality of treatment, prevention of complications of the disease. An urgent work is under way to detect immune-inflammatory reactions and the effects of apoptosis in complicated aortic aneurysms of different localization, to assess the possibility of their effect on perioperative flow and complications in the course of surgical treatment. The immune system and serotonin apoptotic markers have been analyzed in patients who underwent surgical treatment for acute aortic syndrome.&#x0D; &#x0D; &#x0D;

IP087. Midterm Results of Endovascular Stent Graft Implantation for the Treatment of Acute Thoracic Aortic Syndromes

The goal of this study was to evaluate the outcome of thoracic endovascular stent graft implantation (TEVAR) in the treatment of acute aortic syndromes (AAS) of the descending aorta. From June 1997 to December 2016, 141 patients (79% male) with a median age of 61 years (range, 22-88 years) underwent TEVAR for AAS. Aortic pathologies were descending aortic aneurysm (DTA) in 23 (16%), acute type B aortic dissections (TBD) in 54 (38%), perforating aortic ulcer (PAU) in 40 (29%), and acute traumatic aortic transactions (ATAT) in 24 (17%). Thirty-day mortality and overall survival were evaluated for each group. The overall 30 day mortality was 7% (n = 10). No patient died in the PAU group, 5 patients (4%) in the TBD group, 3 (2%) in the aneurysm group, and 2 (1%) in the ATAT group (P = .17). Seven of the 10 deaths were aortic related. Permanent and temporary neurologic dysfunctions were observed in five patients (PAU, n = 2; TBD, n = 2; DTA, n = 1) and nine patients (PAU, n = 3; TBD, n = 3; ATAT, n = 2; DTA, n = 1; P = ns). Early reintervention (within 30 days) was needed in seven patients in the TBD group. The causes were endoleaks in five patients (type Ia, n = 3; type Ib, n = 1; type Ib and II, n = 1), postdilatation in one patient, and repeat dissection in another patient. Six patients underwent a second intervention, and the remaining one had conventional surgery (P < .005 between the treatment groups). The overall rate of persistent primary and secondary endoleaks was 20% and 7%, respectively (P < .05). Overall mortality was 86%, 82%, and 67% at 1, 2, and 5 years with significant differences between the four treatment groups (P < .05; Fig). The treatment of acute aortic syndromes of the descending thoracic aorta with endovascular stent grafts is a feasible and safe technique. It provides low morbidity and mortality rates in the early postoperative period, and midterm results are encouraging. However, long-term studies are needed to evaluate the effectiveness and the durability of this procedure.

Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).

Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22-92), 443 type A (70.4%) and 186 type B (29.6%). Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th-75th percentiles, 2.7-15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1-3, 2.5-11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.

PP.11.14] PROGNOSTIC SIGNIFICANCE OF SLEEP APNEA SYNDROME ON FALSE LUMEN AORTIC EXPANSION IN POST ACUTE AORTIC SYNDROME

Objective: Good blood pressure control is essential in patients with acute aortic syndrome (AAS). It has been shown that the obstructive sleep apnoea syndrome (OSAS) is a risk factor for resistant arterial hypertension, and aortic dilatation. Here, we assessed benefit of systematic screening for SAS in post AAS.Design and method: We performed a prospective study of patients having undergone surgical treatment for AAS in our university medical centre between January 2010 and June 2014. The patients were screened for OSAS by a polygraphy record in a sleep clinic after the onset of AAS. The severity of OSAS was defined according to the apnoea hypopnoea index (AHI, per hour) and the oxygen desaturation index (ODI, per hour), using the following classes for both index: less than 5: no SAS; 6 to 15: mild SAS; 16 to 30; moderate SAS; upper than30: severe SAS. Blood pressure control was assessed by a 24 hour ambulatory blood pressure monitoring. Results: The population comprised 71 patients (males: 64.7%; median age: 57 [49–64], type A AAS: 49.3%; type B AAS: 50.7%). According to the AHI, 58 patients (81.7%) had OSAS and 31 (43.6%) had severe OSAS. The factors associated with the severity of OSAS were the body mass index (p = 0.0148 for the AHI and 0.009 for the ODI), abdominal perimeter (p = 0.0016 for the AHI and 0.0106 for the ODI). A prognostic analysis revealed a significant increase in the intrathoracic false lumen dilatation rate as a function of OSAS severity (p = 0.0008 for the AHI and p = 0.0284 for the ODI). The median rate of increase was 7.5 mm/year [5–10] in the AHI>30 group and 5.0 mm/year [0–8] in the ODI>30 group. There were no intergroup differences in blood pressure control according AHI category, but a diastolic blood pressure difference was noted for the ODI (p = 0.0008). Conclusions: Our results suggest that systematic screening for OSAS is of value in patients with AAS. The false lumen dilatation rate appears to be related to the severity of OSAS. It remains to be seen whether the treatment OSAS would modify the false lumen dilatation rate.

Acute Aortic Dissection and Intramural Hematoma: A Systematic Review.

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

Controlled Delayed Aortic Repair in Acute Aortic Syndrome and Multiorgan Failure: An Option in Selected Cases.

The factor time plays an important role in diagnosis and treatment of acute aortic syndromes, not only as a short interval between diagnosis and surgical therapy, but also as a delay of definitive therapy in the selected cases. Severe organ damage caused by malperfusion or other mechanisms can be overcome by a surgical delay, improving prognosis. We report a successful attempt of a controlled delayed surgical treatment in a patient with an acute aortic syndrome complicated from multiorgan failure.

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

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

Invited Commentary

There continues to be significant interest in the nonoperative management of intramural hematoma of the ascending aorta, particularly among centers in the Far East. These authors [1Watanabe S. Hanyu M. Arai Y. Nagasawa A. Initial medical treatment for acute type A intramural hematoma and aortic dissection.Ann Thorac Surg. 2013; 96: 2142-2146Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar] have provided us a valuable glimpse into the natural history of this condition, because the preferred treatment algorithm in their center over the study interval was medical management. Only those with frank rupture or uncontrollable malperfusion underwent operation. Even tamponade was managed without operation! The results were remarkably good—at least in the short term. Only 1 patient died within 30 days, and operation had been recommended but declined. A second patient died more than 2 months after admission, again after surgical intervention was recommended and declined. Still, in the long run, 27 of the 59 patients experienced an “aortic event” between 4 days and 3 years after diagnosis. If you see the “glass as half full,” that means that 55% of the patients were spared an operation; if your perspective is the converse, this approach only delayed the inevitable in the other 45%. Either way we are fortunate to have this data set. What do their data mean to surgeons in the rest of the world? For those of us in North America, the appetite for a 1-month hospitalization and half a dozen computed tomographic scans will likely be modest except under the most extraordinary circumstances. Still there may be another lesson here. There are mounting data indicating that surgical outcomes in the treatment of acute aortic syndromes are superior in centers treating the condition more frequently and in the hands of surgeons who do the same [2Chikwe J. Cavallaro P. Itagaki S. Seigerman M. Diluozzo G. Adams D.H. National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality.Ann Thorac Surg. 2013; 95: 1563-1569Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar]. The observation that no patient decompensated in less than 4 days with an intramural hematoma or thrombosed acute dissection supports the argument for regionalization of the treatment of this condition. It is likely that the low-volume dissection surgeon in the low-volume dissection hospital would be quite willing to transfer such patients absent the threat of medicolegal liability. In my opinion, the results of this study support such a practice. Initial Medical Treatment for Acute Type A Intramural Hematoma and Aortic DissectionThe Annals of Thoracic SurgeryVol. 96Issue 6PreviewThere are contradictory reports on outcomes of patients treated for Stanford type A acute intramural hematoma (IMH) and acute aortic dissections (AAD) with thrombosed false lumens. We evaluated short-term clinical outcomes and predictors of adverse outcomes. Full-Text PDF

Acute Aortic Syndromes: New Insights From IRAD and GenTAC Registries

In his presentation entitled “Acute Aortic Syndromes: New Insights from IRAD and GenTAC Registries”, Dr. Eagle will review the latest in the approaches to diagnosis and treatment of acute aortic syndromes and thoracic aortic disease. In particular, new insights as to the underlying causes of aortic syndromes, the optimal use of biomarkers, and the evolving role of genetics as it relates to diagnosis and screening will be emphasized. In addition, recent advances in best medical and interventional therapy for thoracic aortic disease will be discussed. Finally, Dr. Eagle will discuss where translational and imaging research advances are likely to shape the future care for patients with or at risk for thoracic aortic disease.