2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Current approaches to spinal cord protection during open thoracoabdominal aortic aneurysm repair

Spinal cord deficit (SCD) is a feared complication after thoracoabdominal aortic aneurysm repair. Vigilant management throughout the perioperative period is necessary to reduce the risk of SCD. Measures for preventing SCD during the intraoperative period include preoperative optimization and recognizing patients at a higher risk of SCD. In this manuscript, we discuss intraoperative adjuncts including utilization of cerebrospinal fluid drainage, left heart bypass, mild hypothermia, selective reimplantation of intercostal and lumbar arteries, and renal and visceral vessel perfusion. From the operative to the postoperative period, careful attention to avoiding hypotension and anemia is important. If SCD is recognized early, therapeutic intervention may be implemented to mitigate injury.

Safety of cerebrospinal fluid drainage in descending and thoracoabdominal aortic replacement surgery

Background

Spinal cord injury (SCI) remains a significant morbidity of surgical repair of descending thoracic aortic aneurysms (DTAA) and thoracoabdominal aortic aneurysms (TAAA). We present our 17-year experience with cerebrospinal fluid drainage (CSFD) as a protective strategy during open surgical repair of descending and thoracoabdominal aortic disease.

Methods

We conducted a retrospective chart review of 132 patients who underwent open surgical repair of DTAA and TAAA and dissections with concurrent use of CSFD for spinal cord protection. Information regarding survival, postoperative course, and complications related to CSFD use were extracted from electronic health records (EHR) and analyzed.

Results

Mean patient age was 65.4±13.0 years, and 82 (62.1%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay after surgery was 12.2±11.2 days, and in-hospital mortality was 7.6%. Postoperative transient paresis was observed in 5 patients (3.8%), and permanent paraplegia was seen in 4 (3.0%). CSFD related complications were reported in 25 patients (19%). Complications included persistent cerebrospinal fluid (CSF) leakage, blood-tinged CSF (with subdural hematoma reported in 3 patients) and spinal cutaneous fistula in 9 (7%), 14 (11%), and 1 (1%), respectively. Long term survival was 50.9% at 15 years.

Conclusions

CSFD is associated with minor complications, without major sequalae. It is a safe practice and likely contributes innocuously to decreased SCI in patients undergoing open repair of DTAA and TAAA.

Long-Term Outcomes of Patients Undergoing Aortic Root Replacement With Mechanical Versus Bioprosthetic Valves: Meta-Analysis of Reconstructed Time-to-Event Data

Background An aspect not so clear in the scenario of aortic surgery is how patients fare after composite aortic valve graft replacement (CAVGR) depending on the type of valve (bioprosthetic versus mechanical). We performed a study to evaluate the long-term outcomes of both strategies comparatively. Methods and Results Pooled meta-analysis of Kaplan-Meier-derived time-to-event data from studies with follow-up for overall survival (all-cause death), event-free survival (composite end point of cardiac death, valve-related complications, stroke, bleeding, embolic events, and/or endocarditis), and freedom from reintervention. Twenty-three studies met our eligibility criteria, including 11 428 patients (3786 patients with mechanical valves and 7642 patients with bioprosthetic valve). The overall population was mostly composed of men (mean age, 45.5-75.6 years). In comparison with patients who underwent CAVGR with bioprosthetic valves, patients undergoing CAVGR with mechanical valves presented no statistically significant difference in the risk of all-cause death in the first 30 days after the procedure (hazard ratio [HR], 1.24 [95% CI, 0.95-1.60]; P=0.109), but they had a significantly lower risk of all-cause mortality after the 30-day time point (HR, 0.89 [95% CI, 0.81-0.99]; P=0.039) and lower risk of reintervention (HR, 0.33 [95% CI, 0.24-0.45]; P<0.001). Despite its increased risk for the composite end point in the first 6 years of follow-up (HR, 1.41 [95% CI, 1.09-1.82]; P=0.009), CAVGR with mechanical valves is associated with a lower risk for the composite end point after the 6-year time point (HR, 0.46 [95% CI, 0.31-0.67]; P<0.001). Conclusions CAVGR with mechanical valves is associated with better long-term outcomes in comparison with CAVGR with bioprosthetic valves.

A Comprehensive Review of Management Strategies for Bicuspid Aortic Valve (BAV): Exploring Epidemiology, Aetiology, Aortopathy, and Interventions in Light of Recent Guidelines

OBJECTIVE

bicuspid aortic valve (BAV) stands as the most prevalent congenital heart condition intricately linked to aortic pathologies encompassing aortic regurgitation (AR), aortic stenosis, aortic root dilation, and aortic dissection. The aetiology of BAV is notably intricate, involving a spectrum of genes and polymorphisms. Moreover, BAV lays the groundwork for an array of structural heart and aortic disorders, presenting varying degrees of severity. Establishing a tailored clinical approach amid this diverse range of BAV-related conditions is of utmost significance. In this comprehensive review, we delve into the epidemiology, aetiology, associated ailments, and clinical management of BAV, encompassing imaging to aortic surgery. Our exploration is guided by the perspectives of the aortic team, spanning six distinct guidelines.

METHODS

We conducted an exhaustive search across databases like PubMed, Ovid, Scopus, and Embase to extract relevant studies. Our review incorporates 84 references and integrates insights from six different guidelines to create a comprehensive clinical management section.

RESULTS

BAV presents complexities in its aetiology, with specific polymorphisms and gene disorders observed in groups with elevated BAV prevalence, contributing to increased susceptibility to other cardiovascular conditions. The altered hemodynamics inherent to BAV instigate adverse remodelling of the aorta and heart, thus fostering the development of epigenetically linked aortic and heart diseases. Employing TTE screening for first-degree relatives of BAV patients might be beneficial for disease tracking and enhancing clinical outcomes. While SAVR is the primary recommendation for indicated AVR in BAV, TAVR might be an option for certain patients endorsed by adept aortic teams. In addition, proficient teams can perform aortic valve repair for AR cases. Aortic surgery necessitates personalized evaluation, accounting for genetic makeup and risk factors. While the standard aortic replacement threshold stands at 55 mm, it may be tailored to 50 mm or even 45 mm based on patient-specific considerations.

CONCLUSION

This review reiterates the significance of considering the multifactorial nature of BAV as well as the need for further research to be carried out in the field.

Contemporary outcomes of open repair of acute complicated type B aortic dissection

OBJECTIVE

Open repair of acute complicated type B aortic dissection (ACTBAD), required when endovascular repair is not possible, is historically considered high-risk. We analyze our experience with this high-risk cohort compared with the standard cohort.

METHODS

We identified consecutive patients undergoing descending thoracic or thoracoabdominal aortic aneurysm (TAAA) repair from 1997 to 2021. Patients with ACTBAD were compared with those having surgery for other reasons. Logistic regression was used to identify associations with major adverse events (MAEs). Five-year survival and competing risk of reintervention were calculated.

RESULTS

Of 926 patients, 75 (8.1%) had ACTBAD. Indications included rupture (25/75), malperfusion (11/75), rapid expansion (26/75), recurrent pain (12/75), large aneurysm (5/75), and uncontrolled hypertension (1/75). The incidence of MAEs was similar (13.3% [10/75] vs 13.7% [117/851], P = .99). Operative mortality was 5.3% (4/75) vs 4.8% (41/851) (P = .99). Complications included tracheostomy (8%, 6/75), spinal cord ischemia (4%, 3/75), and new dialysis (2.7%, 2/75). Renal impairment, urgent/emergent operation, forced expiratory volume in 1 second ≤50%, and malperfusion were associated with MAEs, but not ACTBAD (odds ratio: 0.48, 95% confidence interval [CI]: [0.20-1.16], P = .1). At 5 and 10 years, there was no difference in survival (65.8% [95% CI: 54.6-79.2] vs 71.3% [95% CI: 67.9-74.9], P = .42, and 47.3% [95% CI: 34.5-64.7] vs 53.7% [95% CI: 49.3-58.4], P = .29, respectively) or 10-year reintervention (12.5% [95% CI: 4.3-25.3] vs 7.1% [95% CI: 4.7-10.1], P = .17, respectively).

CONCLUSIONS

In an experienced center, open repair of ACTBAD can be performed with low rates of operative mortality and morbidity. Outcomes similar to elective repair are achievable even in high-risk patients with ACTBAD. In patients unsuitable for endovascular repair, transfer to a high-volume center experienced in open repair should be considered.

Artificial intelligence-based opportunistic detection of coronary artery stenosis on aortic computed tomography angiography in emergency department patients with acute chest pain

Aims

To evaluate a deep-learning model (DLM) for detecting coronary stenoses in emergency room patients with acute chest pain (ACP) explored with electrocardiogram-gated aortic computed tomography angiography (CTA) to rule out aortic dissection.

Methods and results

This retrospective study included 217 emergency room patients (41% female, mean age 67.2 years) presenting with ACP and evaluated by aortic CTA at our institution. Computed tomography angiography was assessed by two readers, who rated the coronary arteries as 1 (no stenosis), 2 (<50% stenosis), or 3 (≥50% stenosis). Computed tomography angiography was categorized as high quality (HQ), if all three main coronary arteries were analysable and low quality (LQ) otherwise. Curvilinear coronary images were rated by a DLM using the same system. Per-patient and per-vessel analyses were conducted. One hundred and twenty-one patients had HQ and 96 LQ CTA. Sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of the DLM in patients with high-quality image for detecting ≥50% stenoses were 100, 62, 59, 100, and 75% at the patient level and 98, 79, 57, 99, and 84% at the vessel level, respectively. Sensitivity was lower (79%) for detecting ≥50% stenoses at the vessel level in patients with low-quality image. Diagnostic accuracy was 84% in both groups. All 12 patients with acute coronary syndrome (ACS) and stenoses by invasive coronary angiography (ICA) were rated 3 by the DLM.

Conclusion

A DLM demonstrated high NPV for significant coronary artery stenosis in patients with ACP. All patients with ACS and stenoses by ICA were identified by the DLM.

Five-year sex-related outcomes of thoracic endovascular aortic repair in the Global Registry for Endovascular Aortic Treatment

OBJECTIVE

The impact of sex on outcomes of thoracic endovascular aortic repair (TEVAR) represents an area of increased interest over the last decade, and long-term data are lacking. The aim of the present study was to investigate sex-related differences in long-term outcomes after TEVAR using real-world data from the Global Registry for Endovascular Aortic Treatment.

METHODS

Data were obtained retrospectively after querying the multicenter, sponsored Global Registry for Endovascular Aortic Treatment. Patients treated with TEVAR between December 2010 and January 2021 were selected regardless of the type of thoracic aortic disease. The primary outcome was sex-specific all-cause mortality at 5 years and maximum follow-up. Secondary outcomes were sex-specific all-cause mortality at 30 days and 1 year, and aorta-related mortality, major adverse cardiac events, neurological complications, and device-related complications or reinterventions at 30 days, 1 year, 5 years, and maximum follow-up.

RESULTS

A total of 805 patients were analyzed; 535 (66.5%) were males. Females were older (median, 66 years [interquartile range (IQR), 57-75 years] vs 69 years [IQR, 59-78 years], P < .001). Males had more frequently a history of coronary artery bypass grafting and renal insufficiency (8.7% vs 3.7% [P = .010] and 22.4% vs 11.6% [P < .001]). The median follow-up was 3.46 years (IQR, 1.49-4.99 years) for males and 3.18 years (IQR, 1.29-4.86 years) for females. Indications for TEVAR were mostly descending thoracic aortic aneurysms (n = 307 [38.1%]) type B aortic dissections (n = 250 [31.1%]) or others (n = 248 [30.8%]). Freedom from 5-year all-cause mortality was similar for males and females (67% [95% CI, 62.1-72.2] vs 65.9% [95% CI, 58.5-74.2]; P = .847), and there were no differences in secondary outcomes. Multivariable Cox regression showed females to have lower all-cause mortality rates; however, this difference did not reach statistical significance (hazard ratio, 0.97; 95% CI, 0.72-1.30; P = .834). Additional subgroup analyses based on the indication for TEVAR did not identify differences between both sexes for the primary and secondary outcomes except more endoleak type II in females with complicated type B aortic dissection (1.8% vs 12.1%; P = .023).

CONCLUSIONS

The present analysis suggests that long-term outcomes of TEVAR performed irrespective of the type of aortic disease are similar for males and females. Further studies are needed to clarify existing controversies regarding the impact of sex on outcomes of TEVAR.

A Case Report on the Diagnosis of Acute Abdominal Aortic Occlusion Using Point-of-Care Ultrasound in the Emergency Department

Point-of-care ultrasound (PoCUS) can be used to detect and evaluate for an aneurysm and/or a dissection of the abdominal aorta in suspected patients in the Emergency Department (ED). Despite the routine use of PoCUS for the assessment of the abdominal aorta in suspected aortic aneurysms and dissections, there is limited literature regarding its use in the diagnosis of acute abdominal aortic occlusions in the emergency setting. This is a case demonstrating the use of PoCUS in identifying an acute aortic occlusion in a 71-year-old female patient with known hypertension and diabetes mellitus. The patient presented with central abdominal pain and bilateral lower limb weakness to the ED. The patient had multiple differential diagnoses, including a possible acute aortic occlusion of the abdominal aorta. PoCUS of the aorta was utilized to diagnose an acute abdominal aortic occlusion in the ED. The rapid diagnosis expedited the referral to vascular surgeons for definitive management. Acute abdominal aortic occlusion is a time-sensitive and life-threatening emergency. PoCUS of the abdominal aorta to detect acute abdominal occlusions allows for a rapid diagnosis with the potential to improve outcomes. A protocol for detecting acute abdominal aortic occlusion should be included in the standard aorta PoCUS scan.

Aortic size distribution among normal, hypertension, bicuspid, and Marfan populations

Aims

Large-scale investigations on ascending aortic diameter, especially in the Asian population, are lacking. Furthermore, relevant evidence regarding the distribution of hypertension (HP), bicuspid aortic valve (BAV), and Marfan syndrome (MFS) is scarce. We aimed to examine the distribution of ascending aortic diameter in these populations in China.

Methods and results

The data of a total number of 698 795 individuals who underwent cardiac ultrasound were subjected to retrospective analysis. After screening, 647 087 individuals were included in the final analysis. In the normal population, the mean ascending aortic diameter was 28.1 ± 3.2 mm (27.2 ± 3.1 mm in women vs. 29.0 ± 3.1 mm in men) (P < 0.001). Aortic diameter increased gradually with age (P < 0.001). The prevalence of aortic dilation, aneurysm, and dissection in individuals with HP was 12.83%, 2.70%, and 4.77%, respectively. In individuals with MFS, the corresponding rates were 43.92%, 35.31%, and 26.11%. Notably, although BAV patients had high incidences of aortic dilation (37.00%) and aortic aneurysm (16.46%), the incidence of aortic dissection was relatively low (0.74%). Most cases of aortic dissection occurred at an aortic diameter of less than 55 mm. However, in the overall population, the incidence of aortic dissection significantly increased with the increase in the aortic diameter, revealing the existence of an 'aortic paradox'.

Conclusions

(i) The ascending diameter increases with age and is larger in men than in women; (ii) 'Aortic paradox' is explained; (iii) BAV bears a high rate of aortic dilation, but a low incidence of aortic dissection.

A protocol-based treatment for ruptured abdominal aortic aneurysm contributed to improving aorta-related mortality: a retrospective cohort study

BACKGROUND

Recent guidelines state that improving the survival rate of patients with ruptured abdominal aortic aneurysm (rAAA) requires a protocol or algorithm for the emergency management of these patients. We aimed to investigate whether introducing a protocol treatment for rAAA improves clinical outcomes compared with the pre-protocol strategy.

METHODS

At our institution, 92 patients treated for rAAA between June 2008 and August 2022 were retrospectively analyzed. In 2014, the protocol-based treatment was introduced comprising a transfer algorithm to shorten the time to proximal control, use of an endovascular occlusion balloon, strict indications for endovascular aortic aneurysm repair (EVAR) or open surgical repair, and perioperative care, including for abdominal compartment syndrome (ACS). Clinical outcomes were compared between the protocol and pre-protocol group, including operative status, all-cause mortality, and rAAA-related death at 30-day, in-hospital, and 1-year postoperative follow-ups.

RESULTS

Overall, 52 and 40 patients received the protocol-based and pre-protocol treatments, respectively. EVAR was more frequently performed in the protocol group. The rate of achieving time to proximal control was significantly faster, and the transfusion volume was lower in the protocol group. ACS occurred more frequently in the protocol group with a higher EVAR. No difference was found in all-cause mortality between the two groups. The protocol group exhibited fewer rAAA-related deaths than the pre-protocol group during the following time points: 30 days (9.6% vs. 22.5%), during the hospital stay (11.5% vs. 30.0%), and 1 year (14.5% vs. 31.5%).

CONCLUSIONS

The protocol-based treatment improved the survival rate of patients with rAAA.

Value of aortic volumes assessed by automated segmentation of 3D MRI data in patients with thoracic aortic dilatation: A case-control study

PURPOSE

The purpose of this study was to investigate the benefit of aortic volumes compared to diameters or cross-sectional areas on three-dimensional (3D) magnetic resonance imaging (MRI) in discriminating between patients with dilated aorta and matched controls.

MATERIALS AND METHODS

Sixty-two patients (47 men and 15 women; median age, 66 years; age range: 33-86 years) with tricuspid aortic valve and ascending thoracic aorta aneurysm (TAV-ATAA) and 43 patients (35 men and 8 women; median age, 51 years; age range: 17-76 years) with bicuspid aortic valve and dilated ascending aorta (BAV) were studied. One group of 54 controls matched for age and sex to patients with TAV-ATAA (39 men and 15 women; median age, 68 years; age range: 33-81 years) and one group of 42 controls matched for age and sex to patients with BAV (34 men and 8 women; median age, 50 years; age range: 17-77 years) were identified. All participants underwent 3D MRI, used for 3D-segmentation for measuring aortic length, maximal diameter, maximal cross-sectional area (CSA) and volume for the ascending aorta.

RESULTS

An increase in ascending aorta volume (TAV-ATAA: +107%; BAV: +171% vs. controls; P < 0.001) was found, which was three times greater than the increase in diameter (TAV-ATAA: +29%; BAV: +40% vs. controls; P < 0.001). In differentiating patients with TAV-ATAA from their controls, the indexed ascending aorta volume showed better performances (AUC, 0.935 [95% confidence interval (CI): 0.882-0.989]; accuracy, 88.7% [95% CI: 82.9-94.5]) than indexed ascending aorta length (P < 0.001), indexed ascending aorta maximal diameter (P = 0.003) and indexed ascending aorta maximal CSA (P = 0.03). In differentiating patients with BAV from matched controls, indexed ascending aorta volume showed significantly better performances performance (AUC, 0.908 [95% CI: 0.829-0.987]; accuracy, 88.0% [95% CI: 80.9-95.0]) than indexed ascending aorta length (P = 0.02) and not different from indexed ascending aorta maximal diameter (P = 0.07) or from indexed ascending aorta maximal CSA (P = 0.27) CONCLUSION: Aortic volume measured by 3D-MRI integrates both elongation and luminal dilatation, resulting in greater classification performance than maximal diameter and length in differentiating patients with dilated ascending aorta or aneurysm from controls.

"Big Data" Analyses Underlie Clinical Discoveries at the Aortic Institute

This issue of the Yale Journal of Biology and Medicine (YJBM) focuses on Big Data and precision analytics in medical research. At the Aortic Institute at Yale New Haven Hospital, the vast majority of our investigations have emanated from our large, prospective clinical database of patients with thoracic aortic aneurysm (TAA), supplemented by ultra-large genetic sequencing files. Among the fundamental clinical and scientific discoveries enabled by application of advanced statistical and artificial intelligence techniques on these clinical and genetic databases are the following: From analysis of Traditional "Big Data" (Large data sets). 1. Ascending aortic aneurysms should be resected at 5 cm to prevent dissection and rupture. 2. Indexing aortic size to height improves aortic risk prognostication. 3. Aortic root dilatation is more malignant than mid-ascending aortic dilatation. 4. Ascending aortic aneurysm patients with bicuspid aortic valves do not carry the poorer prognosis previously postulated. 5. The descending and thoracoabdominal aorta are capable of rupture without dissection. 6. Female patients with TAA do more poorly than male patients. 7. Ascending aortic length is even better than aortic diameter at predicting dissection. 8. A "silver lining" of TAA disease is the profound, lifelong protection from atherosclerosis. From Modern "Big Data" Machine Learning/Artificial Intelligence analysis: 1. Machine learning models for TAA: outperforming traditional anatomic criteria. 2. Genetic testing for TAA and dissection and discovery of novel causative genes. 3. Phenotypic genetic characterization by Artificial Intelligence. 4. Panel of RNAs "detects" TAA. Such findings, based on (a) long-standing application of advanced conventional statistical analysis to large clinical data sets, and (b) recent application of advanced machine learning/artificial intelligence to large genetic data sets at the Yale Aortic Institute have advanced the diagnosis and medical and surgical treatment of TAA.

Preoperative diameters of aorta influence the remodeling after surgery for type A aortic dissection

Background

Although current research revealed the preoperative diameter of the aorta is related to aortic remodeling, prognosis should consider the true lumen (TL) and false lumen (FL) respectively too.

Methods

The cohort of this retrospective analysis included 161 type A aortic dissection (TAAD) patients who underwent surgery at a single institution from September 1, 2017, to September 1, 2018. Computed tomography angiography (CTA) images were reviewed to assess changes of the diameters of the TL, FL and total aorta at the levels of the stented segment, distal end of the stent, celiac trunk, and below the renal artery.

Results

During the study period, positive remodeling was observed in 33 (20.5%) patients. The probability of negative remodeling far from the stent segment was greater than the aorta close to the stent. Only the TL diameter was associated with each levels' changes and underwent significant change (P<0.05). Multivariate analysis identified aortic regurgitation as a risk factor for remodeling in the distal end of the stent. The maximum diameter of the FL was the only risk factor related to the remodeling type (odds ratio =0.10; 95% confidence interval: 0.01-0.51), a maximum diameter of the FL of >1.28 cm was associated with a higher probability of negative remodeling after surgery (specificity =0.994; sensitivity =0.571; area under the receiver operating characteristic curve =0.76).

Conclusions

The TL and FL diameters on preoperative CTA images can be used to assess the risk of negative remodeling after surgery.

David V procedure and hemiarch replacement in a patient with Loeys-Dietz-Syndrome and beta thalassemia minor: a case report

We report the case of a 36-year-old European female patient presenting with a sinus valsalva aneurysm of 47 mm with moderate aortic regurgitation. Additionally, an aneurysm of the brachiocephalic trunk and multiple aneurysms of the right internal mammary artery were identified. Previous medical history included Loeys-Dietz syndrome (LDS) Type RII due to a TGF-beta receptor mutation, and beta thalassemia minor with a baseline hemoglobin of 9,3 g/dL on admission.Reconstruction of the aortic root and hemiarch replacement was performed in circulatory arrest under moderate hypothermia. During surgery, hypothermia was required as part of the cerebral protection strategy. We aim to highlight special considerations and discuss the effects of cooling, rewarming and the use of cardiopulmonary bypass (CPB) during extensive surgery in a patient with LDS and beta thalassemia minor.

Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation

Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention.

Sex differences in type A acute aortic dissection: a systematic review and meta-analysis

BACKGROUND

In acute aortic dissection (AAD) sex heterogeneity reports are not exhaustive and in part even conflicting.

AIMS

To explore sex differences in clinical features, management, and outcomes among patients with type A AAD.

METHODS AND RESULTS

A systematic review and meta-analysis of the literature were conducted for studies (2004-2022) reporting type A AAD sex differences. Among the 1938 studies retrieved, 16 (16 069 patients, 7142 women, and 8927 men) fulfilled all eligibility criteria. Data were aggregated used the random-effects model as pooled risk ratio and mean difference. Due to information reported by considered manuscripts, analysis were performed only among surgically treated type A AAD patients. At the time of hospital presentation type A AAD women were older than men but had lower body mass index (BMI), body surface area (BSA), and creatinine plasma levels. Active smoking, bicuspid aortic valve, and previous cardiac surgery were less common in women while diabetes mellitus was more frequent. Furthermore, women experienced more frequently pericardial effusion/cardiac tamponade than men. Interestingly, in-hospital surgical mortality did not differ between sexes [risk ratio (RR), 1.02; 95% confidence interval (CI), 0.53-1.99; P = 0.95], whereas 5 (RR 0.94; 95% CI: 0.92-0.97; P < 0.001) and 10-year survival (RR 0.82; 95% CI: 0.74-0.92; P = 0.004) was higher among men. A descriptive analysis of in-hospital outcomes among medically treated type A AAD patients confirmed prohibitive high mortality for both sexes (men 58.6% vs. women 53.8%, P = 0.59).

CONCLUSIONS

A female sex phenotype appears to be evident in type A AAD implying the need for a personalized management patient approach along with tailored preventive strategies.

PROSPERO REGISTRY ID

CRD42022359072.

Genetic Basis, New Diagnostic Approaches, and Updated Therapeutic Strategies of the Syndromic Aortic Diseases: Marfan, Loeys-Dietz, and Vascular Ehlers-Danlos Syndrome

Syndromic aortic diseases (SADs) encompass various pathological manifestations affecting the aorta caused by known genetic factors, such as aneurysms, dissections, and ruptures. However, the genetic mutation underlying aortic pathology also gives rise to clinical manifestations affecting other vessels and systems. As a consequence, the main syndromes currently identified as Marfan, Loeys-Dietz, and vascular Ehlers-Danlos are characterized by a complex clinical picture. In this contribution, we provide an overview of the genetic mutations currently identified in order to have a better understanding of the pathogenic mechanisms. Moreover, an update is presented on the basis of the most recent diagnostic criteria, which enable an early diagnosis. Finally, therapeutic strategies are proposed with the goal of improving the rates of patient survival and the quality of life of those affected by these SADs.

Medical Management of Cardiovascular Disease

We offer an overview of lipid lowering, antiplatelet, antihypertensive, and glucose-lowering therapies for vascular surgeons and their respective medical teams. Further reviews should offer additional guidance on smoking cessation, exercise therapy, and nutritional optimization.

The Fate of Patients Opportunistically Screened for Abdominal Aortic Aneurysms During Echocardiogram or Arterial Duplex Scans

OBJECTIVE

To evaluate the long term outcomes of individuals who attended for transthoracic echocardiograms (TTEs) or lower limb arterial duplex scans (LLADS) and were opportunistically screened for abdominal aortic aneurysms (AAA).

METHODS

Follow up of a prospective single centre pilot cohort study conducted between December 2012 and September 2014 at a tertiary vascular centre in the United Kingdom. Men and Women aged 65 and over were invited to undergo AAA screening when attending hospital for TTE or LLADS. Screening was performed by ultrasonographic examination of the abdomen at the end of their planned scans. AAA was defined as an abdominal aorta outer wall to outer wall anteroposterior diameter of 30 mm or more. Patients were excluded if they had a known AAA or previous abdominal aorta intervention. Follow up outcomes were evaluated in December 2020.

RESULTS

762 patients were enrolled in this study; 486 had TTE and 276 patients had LLADS. The overall incidence of AAA was 54 (7.1%) in the combined cohort, 25 (5.1%) in the TTE group, and 29 (10.5%) in the LLADS group. After a median 7.6 years, two of the 54 AAAs received intervention in the form of endovascular repair. Three others reached treatment threshold but were managed conservatively. The overall intervention rate was 3.7% of detected AAAs. Adjusted mortality rates in those with AAA vs. without was 64.8% and 36%, respectively (hazard ratio [HR] 2.02, p < .001). Diabetes (HR 1.35, p = .015) and older age (HR 1.18, p = .17) were the other factors associated with death.

CONCLUSION

AAA is associated with a significantly increased mortality rate. Populations attending hospital for TTE or LLADS demonstrate a higher prevalence of AAA than population based screening; however, the proportion offered AAA intervention was low. Further research into opportunistic screening should target those more likely to undergo AAA repair, unless other interventions are demonstrated, to reduce the general increased mortality in AAA patients.

The Impact of Shared Decision-Making on the Quality of Decision Making in Aortic Dissection: A before-and-after Comparison Study

Background

Complex surgical plans and consideration of risks and benefits often cause decisional conflicts for decision-makers in aortic dissection (AD) surgery, resulting in decision delay. Shared decision-making (SDM) improves decision readiness and reduces decisional conflicts. The purpose of this study was to investigate the impact of SDM on decision quality in AD.

Methods

One hundred and sixty AD decision-makers were divided into two groups: control (n = 80) and intervention (n = 80). The surgical plan for the intervention group was determined using patient decision aids. The primary outcome was decisional conflict. Secondary outcomes included decision preparation, decision satisfaction, surgical method, postoperative complications, actual participation role, and duration of consultation. The data were analyzed with SPSS 26.0 (IBM Corp., Chicago, IL, USA). p < 0.05 was considered statistically significant.

Results

The decisional conflict score was significantly lower in the intervention group than in the control group (p < 0.001). The decision preparation and decision satisfaction scores in the intervention group were significantly higher than those in the control group (p < 0.001). There were more SDM decision-makers in the intervention group (16 [20%] vs. 42 [52.50%]). There was no statistical significance in the choice of surgical, postoperative complications, duration of consultation, and hospital and post-operative intensive care unit stay time (p = 0.267, p = 0.130, p = 0.070, p = 0.397, p = 0.421, respectively). Income, education level, and residence were the influencing factors of decision-making conflict.

Conclusions

SDM can reduce decisional conflict, improve decision preparation and satisfaction, and help decision-makers actively participate in the medical management of patients with AD without affecting the medical outcome.

Open and endovascular repair of thoracoabdominal aortic aneurysm-a narrative review

Background and Objective

Thoracoabdominal aortic aneurysms (TAAAs) are associated with a high rate of morbidity and mortality when left untreated, yet their repair has been associated considerable risk as well. We aim to present a review of the epidemiology, risk factors, pathophysiology, natural history, management strategies, and current literature on open and endovascular repair of thoracoabdominal aortic aneurysms.

Methods

A narrative review using current search of the most recent literature on this topic.

Key Content and Findings

Indication for surgical repair includes symptomatic aneurysms and those at a size or growth threshold. Open repair is the gold standard for surgical management of TAAA and remains so, however, endovascular repair has an increasingly broad applicability, and technology has correspondingly improved in the two decades since its introduction to clinical practice. Reported contemporary operative mortality has ranged from less than 5% to over 20%. The primary adverse complication of open and endovascular repair is ischemic injury, including renal injury, with reported incidence ranging from 2.8-12.5% in contemporary series, and spinal cord injury, with reported incidence ranging from 2.5% to 7.3% in contemporary series. Cerebrospinal fluid drainage has been shown to be the best-proven mechanism to date to prevent spinal cord injury in both open and endovascular repair.

Conclusions

Endovascular repair is associated with a higher reintervention rate than open repair. Surgeon and center volume and expertise are related to clinical outcomes and should be taken into consideration when deciding on surgical repair.

The Maastricht Acquisition Platform for Studying Mechanisms of Cell-Matrix Crosstalk (MAPEX): An Interdisciplinary and Systems Approach towards Understanding Thoracic Aortic Disease

Current management guidelines for ascending thoracic aortic aneurysms (aTAA) recommend intervention once ascending or sinus diameter reaches 5-5.5 cm or shows a growth rate of >0.5 cm/year estimated from echo/CT/MRI. However, many aTAA dissections (aTAAD) occur in vessels with diameters below the surgical intervention threshold of <55 mm. Moreover, during aTAA repair surgeons observe and experience considerable variations in tissue strength, thickness, and stiffness that appear not fully explained by patient risk factors. To improve the understanding of aTAA pathophysiology, we established a multi-disciplinary research infrastructure: The Maastricht acquisition platform for studying mechanisms of tissue-cell crosstalk (MAPEX). The explicit scientific focus of the platform is on the dynamic interactions between vascular smooth muscle cells and extracellular matrix (i.e., cell-matrix crosstalk), which play an essential role in aortic wall mechanical homeostasis. Accordingly, we consider pathophysiological influences of wall shear stress, wall stress, and smooth muscle cell phenotypic diversity and modulation. Co-registrations of hemodynamics and deep phenotyping at the histological and cell biology level are key innovations of our platform and are critical for understanding aneurysm formation and dissection at a fundamental level. The MAPEX platform enables the interpretation of the data in a well-defined clinical context and therefore has real potential for narrowing existing knowledge gaps. A better understanding of aortic mechanical homeostasis and its derangement may ultimately improve diagnostic and prognostic possibilities to identify and treat symptomatic and asymptomatic patients with existing and developing aneurysms.

Evaluation of microRNA Expression Features in Patients with Various Types of Arterial Damage: Thoracic Aortic Aneurysm and Coronary Atherosclerosis

Circulating serum miRNA are increasingly used as biomarkers and potential treatment targets in several clinical scenarios, including cardiovascular diseases. However, the current data on circulating miRNA in thoracic aorta aneurism (TAA) patients are inconclusive. The aim of the present study is to compare the levels of several circulating miRNA in patients with degenerative TAA, coronary artery disease (CAD), and controls for special profile identification. We have identified several candidates for the role of new biomarkers: miR-143-3p, miR-181-5p, miR-126-3p, miR-126-5p, miR-145-5p, miR-150-5p, and miR-195-5p.

MATERIALS AND METHODS

Serum samples of 100 patients were analyzed, including 388 TAA patients scheduled for elective surgery, 67 patients with stable CAD and 17 controls, were used for miRNA isolation and identification.

RESULTS

More specific for TAA with very high predictive ability in ROC analysis was an increase in the levels of miR-21-5p, miR-29b-5p, miR-126-5p/-3p, miR-181b-5p, and miR-92a-3p, with the latter microRNA being investigated as a novel potential marker of TAA for the first time.

CONCLUSION

TAA and CAD patients demonstrated a significant increase in the levels of circulating miR-126-5p/-3p, miR-181b-5p, and miR-29b-3p. More specific for TAA with very high predictive ability in ROC analysis was an increase in the levels of miR-21-5p, -29b-5p, -126-5p/-3p, 181b-5p, and -92a-3p, with the latter microRNA being investigated as a potential marker of TAA for the first time.

Nonsurgical Repair of the Ascending Aorta: Why Less Is More

Objective: Advanced endovascular options for acute and chronic pathology of the ascending aorta are emerging; however, several problems with stent grafts placed in the ascending aorta have been identified in patients unsuitable for surgical repair, such as migration and erosion at aorta interface. Method: Among the six cases analysed in this report, three were treated with a stent graft in the ascending aorta to manage chronic dissection in the proximal aorta; dimensions of those stent grafts varied between 34 and 45 mm in diameter, and from 77 to 100 mm in length. Three patients, matched by age, sex and their nature of pathology, were subjected to the focal closure of a single communicating entry by the use of an occluding device (Amplatzer ASD and PFO occluders between 14 and 18 mm disc diameter) with similar Charlson comorbidity score. Results: Both conceptually different nonsurgical management strategies were technically feasible; however, with stent grafts, an early or delayed erosion to full re-dissection was documented with stent grafts, in contrast to complete seal, with an induced remodelling and a long-term survival after the successful placing of coils and occluder devices. Moreover, aortic root motion was not impaired by the focal occlusion of a communication with an occluder, while free motion was impeded after stent graft placement. Conclusions: The intriguing observation in our small series was that stent grafts placed in the ascending aorta portends the risk of an either early (post-procedural) or delayed migration and erosion of aortic tissues at the landing site or biological interface between 12 and 16 months after the procedure, a phenomenon not seen with the use of focal occluding devices up to 5 years of follow-up. Obviously, the focal approach avoids the erosion of the aortic wall as the result of minimal interaction with the biological interface, such as a diseased aortic wall. Potential explanations may be related to a reduced motion of the aortic root after the placement of stent graft in the ascending aorta, whereas the free motion of aortic root was preserved with an occluder. The causality of erosion may however not be fully understood, as besides the stiffness and radial force of the stent graft, other factors such as the induced inflammatory reactions of aortic tissue and local adhesions within the chest may also play a role. With stent grafts failing to portend long-term success, they may still have a role as a temporizing solution for elective surgical conversion. Larger datasets from registries are needed to further explore this evolving field of interventions to the ascending aorta.

A Late-Detected Paraganglioma in a Young Patient with Resistant Hypertension and Severe Aortic Regurgitation-A Case Report and Review of the Literature

BACKGROUND

Paraganglioma is a rare neuroendocrine tumor derived from chromaffin cells. The overproduction of catecholamines accounts for the presenting symptoms and cardiovascular complications. The clinical presentation frequently overlaps with the associated cardiac diseases, delaying the diagnosis. Multimodality imaging and a multidisciplinary team are essential for the correct diagnosis and adequate clinical management.

CASE SUMMARY

A 37-year-old woman with a personal medical history of long-standing arterial hypertension and radiofrequency ablation for atrioventricular nodal reentry tachycardia presented with progressive exertional dyspnea and elevated blood pressure values, despite a comprehensive pharmacological treatment with six antihypertensive drugs. The echocardiography showed a bicuspid aortic valve and severe aortic regurgitation. The computed tomography angiography revealed a retroperitoneal space-occupying solid lesion, with imaging characteristics suggestive of a paraganglioma. The multidisciplinary team concluded that tumor resection should be completed first, followed by an aortic valve replacement if necessary. The postoperative histopathology examination confirmed the diagnosis of paraganglioma. After the successful resection of the tumor, the patient was asymptomatic, and the intervention for aortic valve replacement was delayed.

DISCUSSION

This was a rare case of a late-detected paraganglioma in a young patient with resistant hypertension overlapping the clinical presentation and management of severe aortic regurgitation. A multimodality imaging approach including transthoracic and transesophageal echocardiography, computed tomography, and magnetic resonance imaging had an emerging role in establishing the diagnosis and in guiding patient management and follow-up. The resection of paraganglioma was essential for the optimal timing of surgical correction for severe aortic regurgitation. We further reviewed various cardiovascular complications induced by pheochromocytomas and paragangliomas.

Spectrum of ascending aortic aneurysms at a peri-urban tertiary hospital: an echocardiography-based study

Introduction

Thoracic ascending aortic (TAA) aneurysms are an important cause of disability and death and require early detection for effective management. Currently, there is a paucity of data from Africa pertaining to TAA aneurysms. This study describes the spectrum of TAA aneurysms at a peri-urban tertiary hospital.

Methods

A descriptive retrospective study based on clinical and echocardiographic imaging data of patients with TAA aneurysms from October 2017-October 2022. Advanced strain imaging was performed to measure left ventricular (LV) basal, apical, and global longitudinal strain as well as circumferential strain (CS) of the ascending aorta as a proxy measurement of aortic compliance.

Results

The study comprised 139 cases of TAA aneurysms (52.5% females) with a mean age of 50 ± 14.8 years with 45 age and gender matched controls. Most cases (95%) were of African ethnicity. The main etiologies were hypertension (41.7%), HIV (36.6%), connective tissue disease (10.7%), congenital (2.2%) and mixed pathologies (8.6%). Two-thirds of patients (69.7%) presented in heart failure, 10% presented with aortic dissection. Thirty percent of the patients were classified as New York Heart Association (NYHA) class I, 59.7% NYHA II, 8.6% NYHA III and two patients NYHA class IV. Echocardiography revealed enlarged aortic dimensions compared to controls (P < 0.001). TAA aneurysms were complicated by severe aortic regurgitation (AR) in half (50.3%) of patients, moderate AR in 25.8%, and mild AR in 14.3%. The mean LV ejection fraction (46.9 ± 12.7%) was reduced compared to controls (P < 0.001). Aortic CS was reduced compared to controls [4.4 (3.2-6.2) % vs. 9.0 (7.1-13.4) %, P < 0.001]. Aortic stiffness was higher in the aortic aneurysm group compared to controls (15.39 ± 20.65 vs. 5.04 ± 2.09, P = 0.001). LV longitudinal strain (-13.9 ± 3.9% vs. 18.1 ± 6.7%), basal CS (-13.9 ± 5.6% vs. -17.9 ± 5.8%) and apical CS (-8.7 ± 8.5% vs. -30.6 ± 3.8%) were reduced compared to controls (P < 0.001). Most patients were on diuretic and anti-remodeling therapy. Surgery was performed in 29.4% and overall mortality was 7.9%. Mortality for acute aortic dissection was 40%.

Conclusion

TAA aneurysms associated with hypertension and HIV are common in this predominantly African female population and are associated with considerable morbidity and mortality. Two-dimensional echocardiography and advanced strain imaging are potential tools for detecting and risk stratifying TAA aneurysms.

Marfan Syndrome: Enhanced Diagnostic Tools and Follow-up Management Strategies

Marfan syndrome (MFS) is a rare inherited autosomic disorder, which encompasses a variety of systemic manifestations caused by mutations in the Fibrillin-1 encoding gene (FBN1). Cardinal clinical phenotypes of MFS are highly variable in terms of severity, and commonly involve cardiovascular, ocular, and musculoskeletal systems with a wide range of manifestations, such as ascending aorta aneurysms and dissection, mitral valve prolapse, ectopia lentis and long bone overgrowth, respectively. Of note, an accurate and prompt diagnosis is pivotal in order to provide the best treatment to the patients as early as possible. To date, the diagnosis of the syndrome has relied upon a systemic score calculation as well as DNA mutation identification. The aim of this review is to summarize the latest MFS evidence regarding the definition, differences and similarities with other connective tissue pathologies with severe systemic phenotypes (e.g., Autosomal dominant Weill-Marchesani syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome) and clinical assessment. In this regard, the management of MFS requires a multidisciplinary team in order to accurately control the evolution of the most severe and potentially life-threatening complications. Based on recent findings in the literature and our clinical experience, we propose a multidisciplinary approach involving specialists in different clinical fields (i.e., cardiologists, surgeons, ophthalmologists, orthopedics, pneumologists, neurologists, endocrinologists, geneticists, and psychologists) to comprehensively characterize, treat, and manage MFS patients with a personalized medicine approach.

A Case of Type B Aortic Dissection: The Role of Transesophageal Ultrasound Guidance in Thoracic Endovascular Aortic Repair

Thoracic endovascular aortic repair (TEVAR) plays a central role in managing acute and chronic aortic pathologies. With the advancement of transcatheter structural heart procedures, echocardiography has become a key in procedural guidance. Despite consensus on its use for cardiac interventions, ultrasound assistance in aortic procedures is not widely standardized. A 71-year-old obese man with chronic type B aortic dissection underwent a TEVAR procedure, using a single-branched aortic stent graft (Endovastec™ Castor™) and with transesophageal ultrasound guidance. The preprocedural assessment confirmed the presence of aortic dissection of the descending thoracic aorta with a posterior true lumen (TL) and an anterior false lumen (FL), normal aortic valve anatomy and function, normal left ventricular function, absence of intracavity thrombus, and absence of aortic plaques that could prevent the optimal implantation of the stent graft. During the procedure, a transesophageal echocardiogram (TEE) monitored the positioning of the guide wires, the arrival of the catheter of the thoracic endoprosthesis, and then the implantation of this at the level of the aortic arch and the descending thoracic aorta. Postprocedure TEE evaluation underlined full stent-graft deployment without leaks and successful exclusion of FL with the beginning of thrombosis. Angiography confirms the exclusion of the aneurysm and the absence of endoleaks. This clinical case demonstrates how transesophageal echocardiographic guidance can improve the TEVAR procedure by minimizing fluoroscopy time, contrast medium use, and enabling a better assessment of the dissection anatomy with real-time monitoring of both the TL and the FL. In conclusion, TEE can serve as an auxiliary intraoperative imaging tool to provide good information before, during, and after the procedure, increasing the success and safety of the TEVAR.

Serum Sema7A is increased in patients with acute aortic dissection

BACKGROUND

To observe the level of serum Sema7A in acute aortic dissection (AAD) and its diagnostic value for AAD.

RESEARCH DESIGN AND METHODS

Patients with sudden chest pain including AAD, acute myocardial infarction (AMI) or pulmonary embolism (PE) were enrolled. Patients without chest pain or cardiovascular diseases were included as the controls. Serum Sema7A and plasma D-dimer were detected and compared in each group.

RESULTS

85 AAD patients, 55 AMI patients, 15 PE patients, and 30 controls were enrolled. The concentration of Serum Sema7A in the AAD group was significantly higher than that in the control, AMI and PE group. Serum Sema7A was positively correlated with D-dimer. In AAD patients who underwent invasive intervention therapy, serum Sema7A levels were significantly decreased after the intervention. Serum Sema7A was an independent risk factor for the presence of AAD. The areas under the ROC curve of Sema7A and D-dimer for differential diagnosis of AAD from other chest pain disorders were 0.842 (0.776, 0.909) and 0.788 (0.714, 0.862), respectively.

CONCLUSIONS

Sema7A is highly expressed in patients with AAD. Sema7A might be a valuable biomarker for the early diagnosis of AAD and has the potential to differentiate AAD from AMI and PE.

Global trends in research of acute type a aortic dissection: A bibliometric analysis from 2002 to 2022

Background

Acute type A aortic dissection (ATAAD) is life-threatening and needs urgent and highly invasive surgery. So far, there is no comprehensive review of the status quo of ATAAD studies. Therefore, this study aimed to quantify and identify the global trends of ATAAD research over the past two decades through bibliometric analysis and to provide reference for clinical practice, research funding allocation, and decision-making.

Methods

The original research articles and reviews related to ATAAD research were downloaded from the Web of Science Core Collection on March 19, 2023. CiteSpace (6.2.1) and VOSviewer (1.6.18) were used for bibliometric analysis of the number of publications by each country, institution, and authors and the establishment of knowledge maps. The raw data collected were examined using the Online Analysis Platform of Bibliometric to assess the collaboration of countries in the field.

Results

The number of documents on ATAAD research increased continuously. A total of 1,943 publications published from 2002 to 2022 from 66 countries/regions were identified: 637 (32.78%) were conducted in China and 360 (18.53%) in the United States; 152 (cited frequency 941) were conducted by Capital Medical University and 107 (cited frequency 370) by Fujian Medical University. The Journal of Cardiac Surgery was the most frequently published journal (143 publications, cited frequency 695). The highest citation and co-cited journal was the Annals of Thoracic Surgery (cited frequency 3,888, co-cited frequency 6,224). We identified 8,050 authors among which Lizhong Sun (61 publications, cited frequency 721) had the largest number of publications, and Nienaber Christoph A (cited frequency 1,536, co-cited frequency 392) was co-cited most often. Meanwhile, the most common keywords were acute type A aortic dissection (occurrences, 1,211), surgery (occurrences, 657), repair (occurrences, 404), and management (occurrences, 386). The earliest and latest used keywords were "axillary artery" (average publication year: 2011.23) and "inflammation" (average publication year: 2019.09), respectively. The keyword "surgical treatment" (strength 12.31) and the co-cited reference "Evangelista A, 2018, Circulation" (strength 28.55) had the highest citation bursts. The keywords "impact" and "acute kidney injury" remained high citation bursts. The co-cited references with the largest and smallest size clusters were "cerebral protection" (#0, size = 126) and "pregnancy" (#12, size = 11). The reference "Hagan PG, 2000, JAMA" (cited frequency, 350) had the highest co-citations.

Conclusions

The bibliometric and visualized analysis generated objective evidence for a comprehensive understanding and evaluation of ATAAD research.

Macrophage scavenger receptor A1 antagonizes abdominal aortic aneurysm via upregulating IRG1

AIMS

Abdominal aortic aneurysm (AAA) is a common, usually asymptomatic disease with high mortality and limited therapeutic options. Extensive extracellular matrix (ECM) fragmentation and transmural inflammation act as major pathological processes of AAA. However, the underlying regulatory mechanisms remain incompletely understood. Herein, we aimed to investigate the role of scavenger receptor A1 (SR-A1), a key pattern recognition receptor modulating macrophage activity, in pathogenesis of AAA.

METHODS AND RESULTS

The AAA model was generated by administration of angiotensin II (Ang II) into apolipoprotein E knockout mice or peri-arterial application of calcium phosphate in C57BJ/6L mice. We found that SR-A1 was markedly down-regulated in the macrophages isolated from murine AAA aortas. Global or myeloid-specific ablation of SR-A1 aggravated vascular inflammation, loss of vascular smooth muscle cells and degradation of the extracellular matrix. These effects of SR-A1 deficiency on AAA development were mediated by suppressed immunoresponsive gene 1 (IRG1) and increased inflammatory response in macrophages. Mechanically, binding of SR-A1 with Lyn led to STAT3 phosphorylation and translocation into the nucleus, in which STAT3 promoted IRG1 transcription through directly binding to its promoter. Restoration of macrophage SR-A1 in SR-A1-deficient mice by bone marrow transplantation or administration of 4-octyl itaconate, the derivate of IRG1 product itaconate, could relieve murine AAA.

CONCLUSION

Our study reveals a protective effect of macrophage SR-A1-STAT3-IRG1 axis against aortic aneurysm formation via inhibiting inflammation.

Natural History of Truncal Root Dilatation and Truncal Valve Regurgitation in Truncus Arteriosus

BACKGROUND

The natural history of the dilated truncal root in repaired truncus arteriosus (TA) is incompletely understood.

METHODS

A single-center review of patients who underwent TA repair between January 1984 and December 2018 was performed. Echocardiographically determined root diameters and derived z scores were measured at the annulus, sinus of Valsalva (SoV), and sinutubular junction (STJ) immediately before TA repair and throughout follow-up. Linear mixed-effects models assessed trends in root dimensions over time.

RESULTS

Of 193 patients who underwent TA repair at a median age of 12 days (interquartile range, 6-48 days) and survived to discharge, 34 (17.6%), 110 (57.0%), and 49 (25.4%) patients had bicuspid, tricuspid, and quadricuspid truncal valves, respectively. Median postoperative follow-up was 11.6 years (interquartile range, 4.4-22.0 years; range, 0.1-34.8 years). Truncal valve or root intervention was required in 38 patients (19.7%). The mean rates of annular, SoV, and STJ growth were 0.7 ± 0.3 mm/y, 0.8 ± 0.5 mm/y, and 0.9 ± 0.4 mm/y, respectively. Root z scores remained stable with time. At baseline, compared with patients with tricuspid leaflet anatomy, bicuspid patients had larger diameters at the SoV (P = .003) and STJ (P = .029), whereas quadricuspid patients had larger STJ diameters (P = .004). Over time, the bicuspid and quadricuspid cohorts demonstrated comparatively greater annular dilatation (both P < .05). Patients with ≥75th percentile root growth rates had a higher incidence of moderate-severe truncal regurgitation (P = .019) and truncal valve intervention (P = .002).

CONCLUSIONS

Root dilatation in TA persisted for up to 30 years after primary repair. Patients with bicuspid and quadricuspid truncal valves demonstrated greater root dilatation over time and required more valve interventions. Continued longitudinal follow-up is warranted in this higher-risk cohort.

Using computed tomography angiography and computational fluid dynamics to study aortic coarctation in different arch morphologies

Objective

To study the differences in computed tomography angiography (CTA) imaging of gothic arches, crenel arches, and romanesque arches in children with Aortic Coarctation (CoA), and to apply computational fluid dynamics (CFD) to study hemodynamic changes in CoA children with gothic arch aorta.

Methods

The case data and CTA data of children diagnosed with CoA (95 cases) in our hospital were retrospectively collected, and the morphology of the aortic arch in the children was defined as gothic arch (n = 27), crenel arch (n = 25) and romanesque arch (n = 43). The three groups were compared with D1/AOA, D2/AOA, D3/AOA, D4/AOA, D5/AOA, and AAO-DAO angle, TAO-DAO angle, and aortic arch height to width ratio (A/T). Computational fluid dynamics was applied to assess hemodynamic changes in children with gothic arches.

Results

There were no significant differences between D1/AOA and D2/AOA among gothic arch, crenel arch, and romanesque arch (P > 0.05). The differences in D3/AOA, D4/AOA, and D5/AOA among the three groups were statistically significant (P < 0.05), D4/AOA, D5/AOA of the gothic arch group were smaller than the crenel arch group, and the D3/AOA and D5/AOA of the gothic arch group were smaller than the romanesque arch group (P < 0.05). The difference in AAO-DAO angle among the three groups was statistically significant (P < 0.05), and the AAO-DAO angle of gothic arch was smaller than that of romanesque arch and crenel arch group (P < 0.05). There was no significant difference in the TAO-DAO angle between the three groups (P > 0.05). The difference in A/T values among the three groups was statistically significant (P < 0.05), and the A/T values: gothic arch > romanesque arch > crenel arch (P < 0.05). The CFD calculation of children with gothic arch showed that the pressure drop between the distal stenosis and the descending aorta was 58 mmHg, and the flow rate at the isthmus and descending aorta was high and turbulent.

Conclusion

Gothic aortic arch is common in CoA, it may put adverse effects on the development of the aortic isthmus and descending aorta, and its A/T value and AAO-DAO angle are high. CFD could assess hemodynamic changes in CoA.

Thoracic Aorta: Anatomy and Pathology

The aorta is the largest elastic artery in the human body and is classically divided into two anatomical segments, the thoracic and the abdominal aorta, separated by the diaphragm. The thoracic aorta includes the aortic root, the ascending aorta, the arch, and the descending aorta. The aorta's elastic properties depend on its wall structure, composed of three distinct histologic layers: intima, media, and adventitia. The different aortic segments show different embryological and anatomical features, which account for their different physiological properties and impact the occurrence and natural history of congenital and acquired diseases that develop herein. Diseases of the thoracic aorta may present either as a chronic, often asymptomatic disorder or as acute life-threatening conditions, i.e., acute aortic syndromes, and are usually associated with states that increase wall stress and alter the structure of the aortic wall. This review aims to provide an update on the disease of the thoracic aorta, focusing on the morphological substrates and clinicopathological correlations. Information on anatomy and embryology will also be provided.

Anzhen Risk Evaluation System for Acute Aortic Syndrome (AZSCORE-AAS): protocol for a multicentre prospective cohort study in northern China

INTRODUCTION

Acute aortic syndrome (AAS) is a group of acute and critical conditions, including acute aortic dissection (AAD), acute intramural haematoma and penetrating aortic ulcer. High mortality and morbidity rates result in a poor patient prognosis. Prompt diagnoses and timely interventions are paramount for saving patients' lives. In recent years, risk models for AAD have been established worldwide; however, a risk evaluation system for AAS is still lacking in China. Therefore, this study aims to develop an early warning and risk scoring system in combination with the novel potential biomarker soluble ST2 (sST2) for AAS.

METHODS AND ANALYSIS

This multicentre, prospective, observational study will recruit patients diagnosed with AAS at three tertiary referral centres from 1 January 2020 to 31 December 2023. We will analyse the discrepancies in sST2 levels in patients with different AAS types and explore the accuracy of sST2 in distinguishing between them. We will also incorporate potential risk factors and sST2 into a logistic regression model to establish a logistic risk scoring system for predicting postoperative death and prolonged intensive care unit stay in patients with AAS.

ETHICS AND DISSEMINATION

This study was registered on the Chinese Clinical Trial Registry website (http://www. chictr. org. cn/). Ethical approval was obtained from the human research ethics committees of Beijing Anzhen Hospital (KS2019016). The ethics review board of each participating hospital agreed to participate. The final risk prediction model will be published in an appropriate journal and disseminated as a mobile application for clinical use. Approval and anonymised data will be shared.

TRIAL REGISTRATION NUMBER

ChiCTR1900027763.

The anesthesiologist's perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance

The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.

Implications of Bicuspid Aortic Valve Disease and Aortic Stenosis/Insufficiency as Risk Factors for Thoracic Aortic Aneurysm

Bicuspid Aortic Valves (BAV) are associated with an increased incidence of thoracic aortic aneurysms (TAA). TAA are a common aortic pathology characterized by enlargement of the aortic root and/or ascending aorta, and may become life threatening when left untreated. Typically occurring as the sole pathology in a patient, TAA are largely asymptomatic. However, in some instances, they are accompanied by aortic valve (AV) diseases: either congenital BAV or acquired in the form of Aortic Insufficiency (AI) or aortic stenosis (AS). When TAA are associated with aortic valve disease, determining an accurate and predictable prognosis becomes especially challenging. Patients with AV disease and concomitant TAA lack a widely accepted diagnostic approach, one that integrates our knowledge on aortic valve pathophysiology and encompasses multi-modality imaging approaches. This review summarizes the most recent scientific knowledge regarding the association between AV diseases (BAV, AI, AS) and ascending aortopathies (dilatation, aneurysm, and dissection). We aimed to pinpoint the gaps in monitoring practices and prediction of disease progression in TAA patients with concomitant AV disease. We propose that a morphological and functional analysis of the AV with multi-modality imaging should be included in aortic surveillance programs. This strategy would allow for improved risk stratification of these patients, and possibly new AV phenotypic-specific guidelines with more vigilant surveillance and earlier prophylactic surgery to improve patient outcomes.

Perioperative neuromonitoring during thoracoabdominal aortic aneurysm open repair: a systematic review

OBJECTIVES

While open surgical repair remains the gold standard for thoracoabdominal aortic aneurysm (TAAA) treatment, there is still no consensus regarding perioperative neuromonitoring technique for prevention of spinal cord ischaemia.

METHODS

In this systematic review, we aimed to explore the effects and practices of neuromonitoring during the open TAAA repair. A systematic literature search in PubMed, Embase via Ovid, Cochrane library and ClinicalTrialsGov until December 2022 was performed.

RESULTS

A total of 535 studies were identified from the literature search, of which 27 studies including a total of 3130 patients met the eligibility criteria. Most studies (21 out of 27, 78%) investigated the feasibility of motor-evoked potentials (MEP), while 15 analysed somatosensory-evoked potentials (SSEP) and 2 studies analysed near-infrared spectroscopy during open TAAA repair.

CONCLUSIONS

Current literature suggest that rates of postoperative spinal cord ischaemia can be kept at low levels after open TAAA repair with the adequate precautions and perioperative manoeuvres. Neuromonitoring with MEP provides the surgeon objective criteria to direct selective intercostal reconstruction or other protective anaesthetic and surgical manoeuvres. Simultaneous monitoring of MEP and SSEP is a reliable method that can rapidly detect important findings and direct adequate protective manoeuvres during open TAAA repair.

Endovascular repair of a common iliac artery aneurysm with an iliac branch device in a patient with vascular Ehlers-Danlos syndrome due to a null COL3A1 variant

Endovascular repair is avoided in patients with connective tissues disorders due to concerns for stent graft migration and endoleaks. We describe a successful endovascular repair of a common iliac artery aneurysm with a bifurcated aortoiliac stent graft and iliac branch endoprosthesis in a patient with Vascular Ehlers-Danlos syndrome (VEDS) due to a null COL3A1 variant. This case demonstrates that the VEDS genotype is associated with tissue integrity, specifically, individuals with VEDS due to null/haploinsufficiency variants, and adds to our understanding of endovascular repair in this population.

Emergency vascular surgical care in populations with unique physiologic characteristics: Pediatric, pregnant, and frail populations

Vascular surgical emergencies are common in vascular surgical care and require complex decision making and multidisciplinary care. They are especially challenging when they occur in patients with unique physiological characteristics, such as pediatric, pregnant, and frail patients. Among the pediatric and pregnant population, vascular emergencies are rare. This rarity challenges accurate and timely diagnosis of the vascular emergency. This landscape review summarizes these three unique populations' epidemiology and emergency vascular considerations. Understanding the epidemiology is the foundation for accurate diagnosis and subsequent management. Considering each population's unique characteristics is crucial to the emergent vascular surgical interventions decision making. Collaborative and multidisciplinary care is vital in gaining expertise in managing these special populations and achieving optimal patient outcomes.

Current knowledge and contemporary management of non-A non-B aortic dissections

Non-A non-B aortic dissection (AAD) is an infrequently documented condition, comprising of only a small proportion of all AADs. The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD, have led to an ongoing controversy around the topic. It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections, frequently leading to serious complications and thus mandating early intervention. Currently, the available treatment methods in the surgical armamentarium are conventional open, endovascular techniques and combined hybrid methods. The optimum approach is tailored in every individual case and may be determined by the dissection’s location, extent, the aortic diameter, the associated complications and the patient’s status. The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached. In an attempt to provide further insight into this perplexing entity, we performed a minireview of the literature, aiming to elucidate the epidemiology, clinical course and the optimal treatment modality.

Fatigue in patients with syndromic heritable thoracic aortic disease: a systematic review of the literature and a qualitative study of patients' experiences and perceptions

INTRODUCTION

The purpose of this study was to explore the literature on fatigue in patients with syndromic heritable thoracic aortic disease (sHTAD), including Marfan syndrome (MFS), Loeys-Dietz syndrome (LDS), vascular Ehlers Danlos syndrome (vEDS) and other sHTADs, critically appraise and synthesize the relevant literature. We also aimed to investigate how adults with sHTAD experience and perceive fatigue, and to discuss clinical implications and direction for further research.

METHODS

First, a systematic review was performed by searching the published literature in all relevant databases and other sources until 20th October 2022. Second, a qualitative focus group interview study was conducted of 36 adults with sHTADs (LDS n = 11, MFS n = 14, vEDS n = 11).

RESULTS

In the systematic review, 33 articles satisfied the eligibility criteria (3 reviews and 30 primary studies). Of the primary studies: 25 dealt with adults (MFS n = 17, MFS/EDS n = 1, EDS n = 2, LDS/vEDS n = 3, different sHTADs n = 2), 5 with children (MFS n = 4, different sHTADs n = 1). Twenty-two were cross-sectional quantitative studies, 4 prospective and 4 qualitative studies. The quality of the included studies was mostly good, but many had small sample sizes, low response rates and/or participants without verified diagnosis. Despite these limitations, studies indicated high prevalence of fatigue (ranging from 37 to 89%), and fatigue was associated with both health and psychosocial aspects. Few studies found that fatigue was associated with disease-related symptoms. In the qualitative focus groups most of the participants reported that they had experienced fatigue which influenced several aspects of life. Four themes related to fatigue were elucidated: (1) different diagnoses-different fatigue?, (2) the nature of fatigue, (3) searches for causes of fatigue, (4) dealing with fatigue in daily life. The four themes seemed mutually interrelated in terms of barriers, strategies and facilitators for dealing with fatigue. The participants experienced fatigue as a consistent dilemma between self-assertion and inadequacy. Fatigue seems to influence several aspects of daily life and may be one of the most debilitating symptoms of having a sHTAD.

CONCLUSION

Fatigue seems to negatively impact the lives of people with sHTADs and should be recognized as an important aspect in the lifelong follow-up of these patients. The life-threatening complications of sHTADs may result in emotional stress, including fatigue and the risk of developing a sedentary lifestyle. Research and clinical initiatives should consider rehabilitation interventions aiming at postponing the onset or reducing symptoms of fatigue.