A Systematic Review and Meta-analysis of the Incidence of Acute Aortic Dissections in Population-Based Studies

Symptom characteristics in patients undergoing acute type A aortic dissection surgery post-discharge phase: a prospective observational study

OBJECTIVES

In recent years, most studies on symptom characteristics in patients undergoing cardiac surgery have focused on the preoperative and postoperative phases. Relatively little knowledge is available related to the post-discharge phase. In this context, this paper aimed to analyze the symptoms and needs of patients with acute type A aortic dissection (AAAD) during the post-discharge phase.

METHODS

We recruited and studied patients who underwent acute type A aortic dissection surgery at Fujian Heart Medical Center from June 2022 to August 2023. At 3 months following the surgery, these subjects were investigated using the general information questionnaire and relevant symptom assessment scales, including the Mini-Mental State Examination Scale (MMSE), Athens Insomnia Scale (AIS), Hospital Anxiety and Depression Scale (HADS), and Fatigue Severity Scale (FSS). Meanwhile, grip strength and average step per day were measured for the exercise endurance assessment. A latent class analysis (LCA) based on the symptoms was performed, and differences in demographic and disease characteristics among different subgroups of patients were identified and compared using multivariate logistic regression.

RESULTS

A total of 228 patients were enrolled and categorized into three latent classes: fatigue-sleep disturbance (44.3%), anxiety-locomotion decline (16.9%), and high symptom groups (38.8%). Results showed that patients with cardiopulmonary bypass time > 200 min, higher BMI, or decreased grip strength were more likely to be classified as the high symptom group and those were unemployment status have a higher possibility of being defined as the anxiety-locomotion decline group.

CONCLUSIONS

The symptom characteristics in patients with AAAD during the postoperative rehabilitation phrase exhibit heterogeneity. It is suggested that Clinical healthcare personnel improve the identification of symptoms in high-risk patients, particularly patients cardiopulmonary bypass time > 200 min, overweight or obese, unemployed status or decreased grip strength, relevant nursing interventions should be carried out to prevent the occurrence of surgical stress and complications in patients with AAAD early to improve the quality of life of patients.

Impact of Residual Intimal Flap Displacement Post-TEVAR on TBAD Haemodynamics in Compliant, Patient-specific CFD Simulations Informed by MRI

We propose a novel formulation of a moving boundary method to account for the motion of the intimal flap (IF) in a TBAD post-thoracic endovascular aortic repair using patient-specific compliant computational fluid dynamics simulations. The simulations were informed by non-invasive 4D flow MRI sequences. Predicted flow waveforms, aortic wall, and IF displacements were validated against in vivo 4D flow MRI and cine-MRI data. The patient-specific simulation showed that at peak systole, the dynamic interplay between high IF displacement and high transmural pressures promoted true lumen compression and false lumen expansion, whilst luminal patterns were reversed at the deceleration phase. High vorticity and swirling flow patterns were observed throughout the cardiac cycle at the primary entry tear, the descending aorta and proximal to the visceral aortic branches, correlating with high relative residence time, which could indicate an increased localised risk of aortic growth proximal to the IF. A rigid IF simulation revealed significant discrepancies in haemodynamic metrics, highlighting the potential mispredictions when using a rigid wall assumption to assess disease progression. Simulations assuming a more compliant IF highlighted potential increased risks of visceral branches malperfusion and localised aortic wall degeneration. The study underscores the necessity of patient-specific compliant IF simulations for accurate TBAD haemodynamic assessments. These insights can improve disease understanding and inform future treatment strategies.

Aortic Dissections-Postoperative Care and Considerations

Postoperative care following aortic dissection is a multidisciplinary effort, which is enhanced by the presence of an experienced team. Overall outcomes, including survival, are correlated with the early postoperative course and presence of complications such as malperfusion. Despite improvements, in-hospital mortality remains high. Patients who do survive to hospital discharge have a positive prognosis; however, additional interventions for progression of aortic disease may be required. Discharge recommendations for patient care are largely institution and provider dependent due to limited data driven guidelines. Further study is warranted into these areas as well as health related quality of life following aortic dissection.

Related factors affecting misdiagnosis of aortic dissection: a single-center retrospective study

Objective

Aortic dissection (AD) is a life-threatening cardiovascular emergency. Delayed diagnosis frequently leads to treatment delays, elevated mortality, and complications. This study investigates the factors contributing to the misdiagnosis of AD and proposes strategies for improving its early diagnosis.

Methods

A retrospective analysis of 801 patients with AD identified 219 cases for inclusion, which were split into a training set (131 cases) and a validation set (88 cases). A binary logistic regression model was used to identify factors influencing misdiagnosis, while a Nomogram prediction model was developed.

Results

The analysis revealed that factors such as the timing and suddenness of symptom onset, typical back pain, walk-in clinic visits, and laboratory results (D-dimer, fibrinogen, and white blood count) were significant in predicting misdiagnosis. The Nomogram model showed high predictive accuracy with an Area under the ROC curve (AUC) of 0.924 in the training set and 0.912 in the validation set, demonstrating good sensitivity and specificity.

Conclusion

The model offers potential for improving diagnostic accuracy and clinical outcomes in AD cases.

Sex Differences in Peripheral Vascular Disease: A Scientific Statement From the American Heart Association

Sex differences in the risk factors, diagnosis, treatment, and outcomes of patients with cardiovascular disease have been well described; however, the bulk of the literature has focused on heart disease in women. Data on sex differences in peripheral vascular disease are ill defined, and there is a need to report and understand those sex-related differences to mitigate adverse outcomes related to those disparities. Although peripheral vascular disease is a highly diverse group of disorders affecting the arteries, veins, and lymphatics, this scientific statement focuses on disorders affecting the peripheral arteries to include the aorta and its branch vessels. The purpose of this scientific statement is to report the current status of sex-based differences and disparities in peripheral vascular disease and to provide research priorities to achieve health equity for women with peripheral vascular disease.

Aortic Dissection Incidence and Risk Factor Analysis: Findings from the China Kadoorie Biobank

OBJECTIVE

Data on the incidence of aortic dissection (AD) from population based prospective studies are scarce and its risk factors are not well studied in China. The aim of this study was to investigate the relatively accurate incidence of AD in ten regions of China and to identify its potential risk factors using a population based prospective study.

METHODS

Data from a prospective cohort study involving ∼510 000 middle aged adults in ten regions of China from 2004 - 2008 (the China Kadoorie Biobank) were used. The incidence of AD was calculated and the association between potential risk factors (body mass index [BMI], hypertension, and diabetes) and the occurrence of AD was evaluated using competing risk analysis.

RESULTS

The study included 512 724 participants (59.0% female, median age 51.5 years). During a median follow up of 121 months, 119 participants developed AD. The incidence of AD was 2.35 (95% confidence interval [CI] 1.93 - 2.77), 3.97 (95% CI 3.10 - 4.83), and 1.25 (95% CI 0.86 - 1.65) per 100 000 person years for the whole cohort, male participants, and female participants, respectively. Competing risk analysis identified female sex (hazard ratio [HR] 0.35, 95% CI 0.24 - 0.52; p < .001) and hypertension (HR 6.21, 95% CI 3.94 - 9.80; p < .001) as independent predictors of AD. BMI, diabetes, and random blood glucose were not associated with AD.

CONCLUSION

In contrast to previous data and clinical observations, there was no significant correlation between diabetes (or random blood glucose) or BMI and the occurrence of AD. Male sex and hypertension were independently associated with the occurrence of AD.

Through the gap: a case series on managing Type B aortic dissection with multiple lumens and tears

Aortic dissections are classified as Stanford Type A and B based on site of intimal dissection. Management of Type B dissections is guided by risk stratification. Complicated and high-risk Type B aortic dissections are managed either using endovascular or open surgical repair. Uncomplicated Type B dissections are managed medically. The role of the patency of the false lumen and the presence of reentry tears in the dissecting membrane are still contested. Here, we describe two cases of descending aortic dissections with varying anatomical features in the setting of cocaine use and uncontrolled hypertension. The first case uniquely had a triple lumen dissection with two true lumens, while the second case had two distal tears. Both patients initially had signs of reduced end organ perfusion that resolved with control of comorbid conditions. After multidisciplinary discussions, the decision was made to continue with anti-impulse treatment. Due to the radiological and biochemical absence of evidence of end organ injury even while visceral organs were supplied by the false lumen, our multidisciplinary team preferred conservative management with anti-impulse therapy. This serves as a demonstration of individualized management of Type B aortic dissection in patients with multiple comorbidities using carefully analyzed radiographic and biochemical evidence.

Current Status of Treatment for the Acute Type A Aortic Dissection in Japan

Presenting the current status of patient outcomes with acute type A aortic dissection in Japan. The Japanese Association for Thoracic Surgery (JATS), Japanese Registry of All cardiac and Vascular Disease (JROAD), Japan Registry of Acute Aortic Dissection (JRAD), Japan Cardiovascular Surgery Database (JCVSD), National Clinical Database (NCD), The Tokyo acute aortic super network, and J-Open caRdiac aortic arCH DisEase replacement Surgical TheRApy (J-ORCHESTRA) database were used. The incidence of AAD ranged from 10 to 20 per 100,000 population. Thirty percent of patients were older than 70 years. Malperfusion syndrome or ruptured aorta was found in 10-20%. Over 90% of patients had surgery within 24-hour after diagnosis. The mortality tended to be higher in the super-acute phases from onset to surgical treatment. Acute organ malperfusion requires an accurate and prompt diagnosis to proceed with an appropriate intervention before repairing the central aorta. Antegrade cerebral perfusion was used in 70-80% and deep hypothermic circulatory arrest with/without retrograde cerebral perfusion in 20-30%. High-moderate or mild hypothermia was applied in more than 50% of patients. Replacement of the ascending aorta was performed in 70% and total arch replacement in 30%. Treatment with frozen elephant trunk as well as thoracic endovascular aortic repair (TEVAR) has increased. The aortic valve was replaced in 8-10%. Thirty-day mortality was 9.0-10%. The number of operations has increased over time. Stroke occurred in 10-12%. Although the early outcomes are acceptable, there is still room to be improved in patients with preoperative comorbidities.

Association of neutrophil to high density lipoprotein cholesterol ratio with aortic dissection and aneurysm risk: epidemiological insights from prospective cohort study based on UK biobank

BACKGROUND

Neutrophil to high-density lipoprotein cholesterol ratio (NHR) is a metabolic inflammatory biomarker reflecting the balance between pro- and anti-inflammatory responses. Extensive research has revealed that NHR is an effective predictor for cardiovascular risks, such as stroke and myocardial infarction. Nevertheless, the association between NHR and incidence risks of aortic dissection (AD) and aortic aneurysm (AA) remains unclear.

METHODS

This research, designed as a prospective cohort study, enrolled 409,357 participants based on the UK Biobank project. The cut-off value of NHR i.e., 0.205, was determined using a receiver operating characteristic curve for grouping. Participants were divided into two groups: NHR ≤ 0.205 (n = 293,294) and NHR > 0.205 (n = 116,063). The cumulative incidence of outcome, i.e., AD/AA including AD and AA, was calculated using Kaplan-Meier curves. The dose-response relationship between NHR and AD/AA was evaluated using restricted cubic spline (RCS). Multivariable-adjusted Cox proportional hazards regression models, followed by sensitivity analyses and subgroup analyses, were performed to evaluate the association between NHR and AD/AA onset.

RESULTS

A total of 3,408 participants developed AD/AA, including 233 AD cases and 3,259 AA cases, with a median follow-up period of 14.8 years. The incidences of AD/AA, AD and AA were 56.34, 3.85 and 53.87 cases per 100,000 person-years, respectively. A nonlinear relationship between NHR and the incidence risk of AD/AA was documented by RCS (P for nonlinear < 0.001). Participants in the NHR > 0.205 group had a higher risk of developing AD/AA compared to those in the NHR ≤ 0.205 group, with an adjusted HR of 1.47 (95%CI 1.37-1.58). This association was further validated by sensitivity analyses and subgroup analyses.

CONCLUSIONS

NHR is an independent risk factor for AD/AA. The disorder of metabolic inflammation may be a potential pathological mechanism for AD/AA. Tailored assessment and management of NHR may serve as effective strategies for the prevention and prediction of AD/AA.

Losing, regaining, and continuing to build self-confidence - a qualitative, phenomenological study of being physically active with a type B aortic dissection

PURPOSE

To gain a comprehensive understanding of experiences related to being physically active in participants with an uncomplicated type B aortic dissection.

MATERIALS AND METHODS

We performed a qualitative, phenomenological study. First-person accounts of adults, who at least one year ago had an uncomplicated type B aortic dissection, were collected using semi-structured interviews. The audio recordings of the interviews were transcribed verbatim and analyzed with interpretative phenomenological analysis.

RESULTS

We collected, in total, 644 min interview data from 14 participants. Three patterns were interpreted: losing self-confidence, regaining self-confidence, and continuing to build self-confidence. Experiencing symptoms when pushing limits, challenges with energy management, and side effects of medication caused loss of self-confidence. Changes in identity, reaching milestones that reflect improvement, and support from others and tools helped participants regain self-confidence. To continuing to build self-confidence, participants indicated they needed success experiences and activities make life worth living.

CONCLUSIONS

Self-confidence in adults with an uncomplicated type B aortic dissection changes immediately after the diagnosis of the aortic dissection. Rehabilitation professionals can support adults regaining and continuing to build self-confidence, aiming for the perfect balance between blood pressure regulation, quality of life, and being physically active. Implications for rehabilitationRehabilitation professionals should support regaining and continuing to build self-confidence related to being physically active in adults with type B aortic dissection in the early stages of recovery and beyond.Adults with an uncomplicated type B aortic dissection want rehabilitation professionals to tell them primarily what is possible (recommendations) rather than what is not allowed (rules).Rehabilitation professionals should help adults with an uncomplicated type B aortic dissection to explore, push and, ultimately, accept limits related to exercise tolerance.

Development and Validation of a Diagnostic Model for Stanford Type B Aortic Dissection Based on Proteomic Profiling

Purpose

Stanford Type B Aortic Dissection (TBAD), a critical aortic disease, has exhibited stable mortality rates over the past decade. However, diagnostic approaches for TBAD during routine health check-ups are currently lacking. This study focused on developing a model to improve the diagnosis in a population.

Patients and Methods

Serum biomarkers were investigated in 88 participants using proteomic profiling combined with machine learning. The findings were validated using ELISA in other 80 participants. Subsequently, a diagnostic model for TBAD integrating biomarkers with clinical indicators was developed and assessed using machine learning.

Results

Six differentially expressed proteins (DEPs) were identified through proteomic profiling and machine learning in discovery and derivation cohorts. Five of these (GDF-15, IL6, CD58, LY9, and Siglec-7) were further verified through ELISA validation within the validation cohort. In addition, ten blood-related indicators were selected as clinical indicators. Combining biomarkers and clinical indicators, the machine learning-based models performed well (AUC of the biomarker model = 0.865, AUC of the clinical model = 0.904, and AUC of the combined model = 0.909) using relative quantitation. The performance of the three models was verified (AUC of biomarker model = 0.866, AUC of clinical model = 0.868, and AUC of combined model = 0.886) using absolute quantitation. Crucially, the combined models outperformed individual biomarkers and clinical models, demonstrating superior efficacy.

Conclusion

Using proteomic profiling, we identified serum IL-6, GDF-15, CD58, LY9, and Siglec-7 as TBAD biomarkers. The machine-learning-based diagnostic model exhibited significant potential for TBAD diagnosis using only blood samples within the population.

Effect of Statins on the Prognosis After Thoracic Endovascular Aortic Repair for Patients With Acute Type B Aortic Dissection

OBJECTIVE

To analyze the clinical efficacy of long-term statin therapy following thoracic endovascular aortic repair (TEVAR) in patients with acute type B aortic dissection (ATBAD).

METHODS

We retrospectively analyzed data from 645 patients treated between January 2005 and June 2022, dividing them into Statin Group (n=330) and Non-statin Group (n=315) based on whether they received long-term postoperative statin therapy. Patients were further categorized based on median admission low-density lipoprotein cholesterol (LDL-C) levels into High and Low LDL-C Groups to assess the effect of statins on the prognosis of ATBAD patients after TEVAR.

RESULTS

The cohort had an average age of 53.44±11.42 years old, and 81.71% were male. Statin therapy significantly reduced occurrences of all-cause death (3.03% vs 8.57%, p=0.002) and aorta-related death (0.91% vs 3.81%, p=0.015), particularly in patients with high admission LDL-C levels. In addition, patients with statin therapy had a lower incidence of aorta-related adverse events (ARAE) (4.24% vs 11.11%, p=0.001). Kaplan-Meier analysis indicated statins reduced 5-year cumulative incidence rates of all-cause death and ARAE (all Log-rank p<0.05). These trends were sustained after adjustment. Multivariate Cox analysis confirmed that statin therapy was associated with reduced risks of all-cause and aorta-related deaths, as well as ARAE.

CONCLUSION

Long-term statin therapy appears to decrease the risk of all-cause and aorta-related death in ATBAD patients after TEVAR, particularly patients with high admission LDL-C levels. Patients with lower LDL-C levels at admission have a reduction of aorta-related death in the follow-up period. Statin therapy also was associated with a lower incidence of ARAE in follow-up. These findings suggest that statins might be crucial in improving long-term outcomes in this patient population.

CLINICAL IMPACT

Long-term statin therapy administered to patients with acute type B aortic dissection (ATBAD) following thoracic endovascular aortic repair (TEVAR) demonstrates a substantial reduction in both all-cause and aorta-related mortality. Notably, this therapeutic benefit is most evident in patients presenting with elevated low-density lipoprotein cholesterol (LDL-C) levels at admission. Furthermore, statin therapy is associated with a decreased incidence of aorta-related adverse events during follow-up. These findings underscore the pivotal role of statin therapy in enhancing long-term clinical outcomes for ATBAD patients undergoing TEVAR, thereby contributing to improved patient care and prognosis.

Association of triglyceride-glucose index and its combination with obesity indicators in predicting the risk of aortic aneurysm and dissection

Background

The association between the triglyceride-glucose (TyG) index and its combination with obesity indictors in aortic aneurysm and dissection (AAD) remains unclear. We aimed to investigate the association between TyG and TyG-body mass index (TyG-BMI), TyG-waist circumference (TyG-WC), TyG-waist height ratio (TyG-WHtR) and AAD risk.

Methods

This study included 387,483 baseline participants from the UK Biobank with complete data on TyG, TyG-BMI, TyG-WC and TyG-WHtR. Cox proportional hazard models evaluated the relationship between these four indicators and the risk of AAD occurrence. Restricted cubic spline (RCS) examined the non-linear relationship between these indicators and AAD risk, while receiver operating characteristic (ROC) curves assessed the predictive value of these four indicators for AAD risk.

Results

Over a median follow-up of 13.7 years, 3,041 AAD events were recorded. Multivariate Cox regression analysis indicated that for each standard deviation increase, the risk of AAD occurrence increased by 33% (HR: 1.33, 95%CI: 1.29-1.38), 25% (HR: 1.25, 95%CI: 1.21-1.29), 61% (HR: 1.61, 95%CI: 1.56-1.66) and 44% (HR: 1.44, 95%CI: 1.39-1.49) for TyG, TyG-BMI, TyG-WC and TyG-WHtR, respectively. RCS demonstrated a linear relationship between these indicators and AAD risk, with TyG-WC demonstrating the best performance in predicting AAD occurrence based on ROC curves.

Conclusion

The present study, based on a large prospective cohort design, showed that higher TyG index and its combination with obesity indices were significantly associated with the risk of AAD. Moreover, AFT models further showed that elevation of these indicators significantly advanced the onset of AAD. In addition, RCS analyses demonstrated a linear association between these indicators and the risk of AAD, and the TyG-WC showed higher predictive ability for AAD. These findings emphasize the potential application of the TyG index and its combination with obesity indicators in the early identification of AAD.

Epidemiological study of the relationship between meteorological factors and onset of acute aortic dissection in Japan

Several factors influence the onset of acute aortic dissection (AAD). However, few studies have examined AAD onset, weather conditions, and meteorological factors in Japan. This study aimed to identify meteorological factors associated with the onset of AAD in Japan. In this self-controlled study, patients diagnosed with AAD onset from May 1, 2012, to April 30, 2021, at Shizuoka City Shizuoka Hospital (Shizuoka, Japan) were included. Meteorological data from the Shizuoka District Meteorological Office were used. Control days were randomly selected from a 29-day period centered on the day of onset. Conditional logistic regression models were used to obtain odds ratios (ORs) and 95% confidence intervals (CIs) for the onset of AAD relative to the control day due to changes in meteorological factors. In total, 538 patients were included. The meteorological factors associated with the onset of AAD were identified as the daily mean temperature (OR = 1.10; 95% CI = 1.04-1.16), daily minimum temperature (OR = 1.09; 95% CI = 1.03-1.14), daily maximum temperature (OR = 1.05; 95% CI = 1.00-1.10), and the mean of the daily mean temperatures for the previous 7 days (OR = 1.17; 95% CI = 1.07-1.28) with a 1°C decrease in the temperature. The results of this study are expected to help raise awareness in clinical practice and among the general public about the increased risk of AAD associated with a drop in temperature.

Early Diagnosis of an Atypical Type A Aortic Dissection With Point-of-Care Ultrasound: A Case Report

Aortic dissection is a rare but potentially fatal condition, characterized by a high mortality rate where every minute of delay in treatment counts. Its diagnosis remains challenging due to its often atypical clinical presentation. This case report presents an atypical case of type A aortic dissection in a 75-year-old female patient, highlighting the importance of early diagnosis facilitated by point-of-care ultrasound and emphasizing the value of its use in suspected aortic dissection regardless of the clinical probability. Additionally, this report reviews the risk factors for misdiagnosis and underscores the utility of diagnostic scores such as the aortic dissection detection risk score.

Transportation model for acute aortic dissection: implications for reduced treatment centres

OBJECTIVES

The objective of the present study was to model the effects of a reduced number of treatment centres for acute type A aortic dissection on preclinical transportation distance and time. We examined whether treatment in selected centres in Germany would be implementable with respect to time to treatment.

METHODS

For our transportation model, the number of aortic dissections and respective mean annual volume were collected from the annual quality reports (2015-2017) of all German cardiac surgery centres (n = 76). For each German postal code, the fastest and shortest routes to the nearest centre were calculated using Google Maps. Furthermore, we analysed data from the German Federal Statistical Office from January 2005 to December 2015 to identify all surgically treated patients with acute type A aortic dissection (n = 14 102) and examined the relationship between in-hospital mortality and mean annual volume of medical centres.

RESULTS

Our simulation showed a median transportation distance of 27.13 km and transportation time of 35.78 min for 76 centres. Doubling the transportation time (70 min) would allow providing appropriate care with only 12 medical centres. Therefore, a mean annual volume of >25 should be obtained. High mean annual volume was associated with significantly lower in-hospital mortality rates (P < 0.001). A significantly lower mortality rate of 14% was observed (P < 0.001) if a mean annual volume of 30 was achieved.

CONCLUSIONS

Operationalizing the volume-outcome relationship with fewer but larger medical centres results in lower mortality, which outweighs the disadvantage of longer transportation time.

Contemporary nonsurgical management of acute type A aortic dissection: Better outcomes?

OBJECTIVE

The objective of this study was to evaluate outcomes of nonsurgically managed acute type A aortic dissection (ATAAD) in the contemporary era.

METHODS

From January 1996 to December 2021, 999 patients presented with ATAAD at our institution, of whom 839 patients underwent open aortic repair (surgical cohort) whereas 148 patients were managed nonoperatively (nonsurgical cohort) because of severe comorbidities, organ failure from malperfusion syndrome, and patients' wishes. Data were obtained from chart review, the Society of Thoracic Surgeons warehouse, the national death index, and Michigan death index database.

RESULTS

The combined in-hospital + 30-day mortality rate was 9 times higher in the nonsurgical cohort compared with the surgical cohort (70% vs 7.9%). In the nonsurgical cohort, compared with the first decade (1996-2010), patients during the second decade (2011-2021) had a lower in-hospital+30-day mortality rate (58% vs 87%; P<.001); lower incidence of aortic rupture (8% vs 21%; P=.008), and a higher 3-year survival rate (29% vs 13%; P=.005). Within the nonsurgical cohort, compared with patients without malperfusion syndrome, the patients with malperfusion syndrome had similar in-hospital + 30-day mortality but a greater incidence of aortic rupture (21% vs 6.1%, P=.01) with an odds ratio of 4.2 (P=.03); compared with classic type A dissection, the patients with intramural hematoma had a lower in-hospital+30-day mortality rate (52% vs 72%, P=.02) with an odds ratio of 0.36 (P=.02).

CONCLUSIONS

Surgery remained the mainstream treatment for ATAAD. Nonsurgical management still had a role for those who were not surgical candidates because of comorbidities or malperfusion syndrome, especially in those with acute type A intramural hematoma.

Current perspectives in acute type B aortic dissections: a literature review

In this new millennial, endovascular strategies have revolutionized the treatment of acute type B aortic dissection (aTBAD). With reduced in-hospital mortality and good long-term outcomes TEVAR has become the gold standard for the treatment of complicated dissection and is gaining increasing support for its preventive applicability in some uncomplicated dissections. With this new paradigm came a shift of the treatment goal where just covering the entry tear is not enough and instead achieving long-term positive thoracoabdominal remodeling is needed. More extensive approaches with composite device designs (covered stent graft and bare metal stent) emerged to answer this aortic conundrum. At 5-year of follow-up, "Provisional ExTension To Induce COmplete Attachment technique" (PETTICOAT) and its evolution "Stent assisted balloon induced intimal disruption and relamination in aortic dissection repair" (STABILISE) seem to be safe techniques that can allow, when anatomically feasible, excellent aortic remodeling and, in some cases, even the healing of the dissection. Nevertheless, STABILISE results, although promising, are mostly based on small series and therefore need to be validated by analyzing medium-long-term results from the international registry. Given the plethora of new data and the disparity of expert opinions on the best treatment to adopt, in this review we aim to summarize the current knowledge on the results of these different strategies for acute TBAD.

The correlation study between the length and angle of ascending aortic and the incidence risk of acute type A aortic dissection

Objective

This study utilized computed tomography angiography (CTA) to assess the risk of acute type A aortic dissection (ATAAD) by analyzing the imaging morphology indicators of the ascending aorta, along with the relevant risk factors associated with aortic dissection.

Methods

The study utilized a retrospective observational research design. The population consisted of 172 patients who received treatment in the Department of Cardiothoracic Surgery at Qilu Hospital, Shandong University, from January 2018 to December 2022. The patients were divided into two groups: the ATAAD group (n = 97) and the thoracic aortic aneurysm group (TAA, n = 75). Demographic data and ascending aorta CTA measurements were collected from all patients. Single factor and multivariate logistic regression were employed to analyze the statistical differences in clinical data and ascending aorta CTA imaging morphology indicators between the two groups.

Results

The variables were included in logistic multivariate analysis for further screening, indicating that the length of the ascending aorta (LAA) before ATAAD (OR = 3.365; 95% CI :1.742-6.500, P<0.001), ascending arch angle (asc-arch angle, OR = 0.902; 95% CI: 0.816-0.996, P = 0.042) and the maximum aortic diameter (MAD) before ATAAD, (OR = 0.614; 95% CI: 0.507-0.743, P<0.001) showed statistically significant differences.

Conclusions

This study suggests that increased LAA and MAD, as well as a smaller asc-arch angle may be high-risk factors for the onset of ATAAD.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

Population-Based Study of the Incidence and Mortality Rate of Acute Aortic Dissection

BACKGROUND

Acute aortic dissection (AAD) has high morbidity and a high fatality rate for a cardiovascular disease. Recent studies suggested that the incidence of AAD is increasing. However, the actual incidence and mortality rates of AAD are not well known. This study investigated the current epidemiology of AAD within the Yatsushiro medical jurisdictional area.

METHODS AND RESULTS

A population-based review of patients with AAD was performed in a geographically well-defined area. Data were collected retrospectively from January 2011 to December 2020 for a total of 196 patients with AAD (Stanford Type A, n=126 [64.3%]; Stanford Type B, n=70 [35.7%]). The mean patient age was 74.3 years, and 55.6% (109/196) were women. The crude and age-standardized incidence rates of AAD in our medical jurisdictional area were 13.6 and 11.4 per 100,000 inhabitants per year, respectively. The crude and age-standardized 30-day mortality rates of AAD were 4.9 and 4.0 per 100,000 inhabitants per year, respectively. There were upward tendencies for both the incidence and 30-day mortality rate of AAD with age, with both being significantly higher in patients aged ≥85 years (P<0.001).

CONCLUSIONS

This population-based study detected a higher incidence of AAD than previous studies, but reported a lower incidence of AAD in men than in women. Increasing age was associated with an increased incidence and mortality rate of AAD.

Hospital Incidence, Sex Disparities, and Perioperative Mortality in Open Surgically Treated Patients with Aneurysms of the Ascending Aorta and Aortic Arch in Switzerland

OBJECTIVE

To analyze the epidemiological shifts in the incidence of ascending and arch aortic aneurysms (AA) treated with open surgery in the context of evolving endovascular options on a national basis.

METHODS

Between 1 January 2009 and 31 December 2018, 4388 cases were admitted to the hospital with either ruptured (r)AA or non-ruptured (nr)AA as the primary or secondary diagnosis. Patients were classified as having AA based on inclusion and exclusion criteria.

RESULTS

The age-standardized hospital incidence rates for treatment of nrAA were 7.8 (95% confidence interval (CI): 6.9 to 8.7) in 100,000 men and 2.9 (2.4 to 3.4) in 100,000 women and were stable over time. The overall raw in-hospital mortality rate was 2.0% and was significantly lower in males compared to women (1.6% vs. 2.8%, p = 0.015). Higher van Walraven scores (OR: 1.08 per point; 95%CI: 1.06 to 1.11; p = 0.001) and higher age (OR 1.05 per year; (95%CI: 1.02 to 1.07, p = 0.045) were significantly associated with hospital mortality.

CONCLUSIONS

Endovascular surgery seems to have no influence on hospital incidence in patients treated with conventional surgery for AA in Switzerland. There was a significant reduction in in-hospital mortality in both men and women, with age and the von Walraven score being independent factors for worse outcomes.

Underappreciated Relationship: A Case of Type A Aortic Dissection Presented With Atrial Flutter

Aortic dissection (AD) is a life-threatening emergency involving a tear in the aortic intima, leading to a false lumen. Atrial fibrillation (AF) can complicate AD, increasing management challenges and mortality risks. We report a 67-year-old male with no known past medical history who presented with a 1-day history of abdominal pain. Initial examination showed mild hypertension, elevated bilirubin level, and leukocytosis. Imaging studies indicated gallbladder distension with cholelithiasis. Discharged with outpatient follow-up for elective cholecystectomy, the patient returned 2 days later for preoperative clearance, was hypertensive and tachycardic, presented with atrial flutter, and was referred to the emergency department. A 2D echo showed left ventricular ejection fraction (LVEF) 35% to 40% and pericardial effusion. Transesophageal echocardiography (TEE) revealed LVEF 50% to 55% and no thrombus, converting to sinus rhythm postcardioversion. The TEE also suggested type A AD, confirmed by computed tomography (CT) angiography, showing dissection from the aortic valve to the left external iliac artery with pericardial effusion. Emergent surgical repair was performed, and the patient was stabilized and discharged with follow-up. This case illustrates the complexity of diagnosing and managing AD, especially with concurrent AF. Recognizing the association between AD and AF is essential as AF increases in-hospital mortality in AD patients.

Long-term survival and risk analysis of thoracic endovascular aortic repair for type B aortic dissection

To explore the safety and efficacy of thoracic endovascular aortic repair (TEVAR) in the treatment of patients with type B aortic dissection, and to evaluate the risk factors for long-term mortality. Our study retrospectively evaluated 729 patients with type B aortic dissection, who were divided into the thoracic endovascular aortic repair group and the optimal medical treatment group according to their treatment. In-hospital mortality, death within 30 days, and aortic-related mortality were lower in the thoracic endovascular aortic repair group than in the optimal medical treatment group (p < 0.05). The cumulative overall survival rates for the thoracic endovascular aortic repair group at 1 year, 5 years, and 10 years were 92.5%, 84.1%, and 73.5%, respectively. The Cox analysis found that TEVAR was beneficial in reducing mortality and that a vertical length of the dissection exceeding 150 mm was a risk factor for mortality.

Analysis of serum calcium change trajectories and prognostic factors in patients with acute type A aortic dissection

OBJECTIVES

This study aimed to analyze the correlation between serum calcium changes and short-term prognosis of patients with acute type A aortic dissection.

METHODS

Patients who underwent acute type A aortic dissection surgery at Fujian Heart Medical Center between June 2019 and June 2021 were retrospectively analyzed.

RESULTS

A total of 383 patients were enrolled. According to the changing track of serum calcium in patients after acute type A aortic dissection, three potential category tracks were determined: high-level (n = 85), medium-level (n = 259), and continuous low-level groups (n = 39). Using the medium-level group as the control, regression analysis showed that poor prognosis risk was increased in the group with continuous low serum calcium (odds ratio = 2.454, P < 0.05) and in the group with continuous low serum calcium > 48 h (odds ratio = 3.595, P < 0.05). Age (odds ratio = 1.063, P < 0.001), body mass index (odds ratio = 1.138, P < 0.05), hypertension (odds ratio = 3.697, P < 0.05), and the highest lactic acid within 72 h after surgery(odds ratio = 1.093, P < 0.05) were independent risk factors for poor prognosis after aortic dissection.

CONCLUSION

Continuous low serum calcium was an independent predictor of poor prognosis in patients with acute type A aortic dissection.

MiR-590-3p Promotes the Phenotypic Switching of Vascular Smooth Muscle Cells by Targeting Lysyl Oxidase

ABSTRACT

We investigated the clinical characteristics of patients with acute aortic dissection (AAD) and miR-590-3p levels in serum, tissue, and vascular smooth muscle cells. The effect of miR-590-3p on the vascular smooth muscle cell phenotype was assessed, and the regulation of lysyl oxidase by miR-5903p was determined. C57BL/6 mice were used to investigate the incidence of AAD and effects of miR-5903p on AAD. The miR-590-3p levels were measured in the aortae of mice, and hematoxylin and eosin staining and Masson staining were performed to identify the morphological features of the aorta. Comparative analysis revealed significant differences in clinical characteristics between patients with AAD and healthy control subjects, with most patients with AAD exhibiting concomitant hypertension and nearly 50% having atherosclerosis. Lysyl oxidase was a direct target of miR-590-3p. Lysyl oxidase overexpression inhibited switching of the vascular smooth muscle cell phenotype from contractile to synthetic, but miR-590-3p overexpression significantly reversed this change. In the mouse model, miR-590-3p upregulation increased the incidence of AAD to 93.3%, and its incidence decreased to 13.3% after miR-590-3p inhibition. Hematoxylin and eosin and Masson staining revealed that the miR-590-3p agomiR group had a greater loss of the contractile phenotype in the dissected aortic wall and an increased number of muscle fibers in the aortic wall, which contributed to thickening of the aortic wall and the formation of a false lumen in aortic dissection. miR-590-3p might be pivotal in the pathogenesis of AAD. Thus, targeting miR-590-3p or its downstream pathways could represent a therapeutic approach for AAD.

Association of Ductus Diverticulum and Acute Type B Aortic Dissection

RATIONALE AND OBJECTIVES

An anatomic association between ductus diverticulum and the primary entry tear in type B aortic dissection was observed. The aim was to reveal the association between ductus diverticulum and acute type B aortic dissection.

MATERIALS AND METHODS

A matched case-control study was conducted. Case subjects were extracted from consecutive patients with aortic dissection in the emergency department during 2019; the control subjects were extracted from consecutive patients without major aortic disease during 2019. 1:1 matching was performed for age, sex, and comorbidity, the prevalence of ductus diverticulum was compared, and conditional logistic regression was performed to reveal the association of ductus diverticulum and acute type B aortic dissection. In addition, the anatomic association between the ductus diverticulum and the primary entry tear was assessed in extracted cases, and baseline parameters were compared between dissection patients with or without ductus diverticulum.

RESULTS

128 cases and 402 control subjects were extracted. 86 pairs were formed after matching, and the proportion of ductus diverticulum (19.8% vs 1.2%, p < 0.001) was higher in the case group. Conditional logistic regression revealed ductus diverticulum(OR = 22.04, 95%CI: 2.81-172.76, p = 0.003) as an independent predictor for acute type B aortic dissection. Besides, the ductus diverticulum has an anatomic association with the primary entry tear (OR = 4.22, 95%CI: 1.46-12.25, p = 0.008), and dissection patients with ductus diverticulum were younger (47.9 vs 54.4, p = 0.015) than dissection patients without ductus diverticulum.

CONCLUSION

Ductus diverticulum is common in acute type B aortic dissection and is independently associated with acute type B aortic dissection.

Preoperative Immature Neutrophils Predict Clinical Outcomes in Patients with Uncomplicated Type-B Aortic Dissection After Thoracic Endovascular Aortic Repair

Purpose

Inflammation is a hallmark of the initial development and progression of aortic dissection. This study aimed to investigate the predictive value of preoperative neutrophils in aorta-related adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

Patients and Methods

A total of 80 patients with TBAD undergoing TEVAR were enrolled in our hospital. Preoperative inflammatory markers, including white blood cells (WBCs), neutrophils, neutrophil-to-lymphocyte ratio (NLR) and plasma high-sensitivity C-reactive protein (hs-CRP), were measured. Circulating neutrophil subpopulation was determined by flow cytometry. Kaplan-Meier curve was performed to determine whether neutrophil subsets independently predicted aorta-related adverse events (AAEs) after TEVAR.

Results

Compared with control group, the prevalence of hypertension and the levels of inflammatory indicators including WBCs, total neutrophils, NLR, immature neutrophils and hs-CRP were significantly higher in TBAD patients. Receiver operating characteristic (ROC) curve showed that NLR, absolute number of total neutrophils and percent CD10- immature neutrophils had excellent area under curves. During the 18-month follow-up, 16 (20.0%) were reported to occur AAEs, while 4 deaths (5.0%) were documented. Percent immature neutrophil was markedly higher in TBAD patients experiencing AAEs as compared with those without AAEs. Kaplan-Meier curve and Cox regression analysis demonstrated that percent immature neutrophil was the only predictor correlated with the occurrence of AAEs (hazard ratio 7.66, 95% CI: 2.91, 20.17, P = 0.018).

Conclusion

Increased CD10- immature neutrophils could act as a potential biomarker related to long-term adverse outcomes in TBAD patients following TEVAR.

Acute aortic syndrome: nationwide study of epidemiology, management, and outcomes

BACKGROUND

Epidemiological studies on acute aortic syndrome (AAS) have relied largely on unverified administrative coding, leading to wide-ranging estimates of incidence. This study aimed to evaluate the incidence, management, and outcomes of AAS in Aotearoa New Zealand.

METHODS

This was a national population-based retrospective study of patients presenting with an index admission of AAS from 2010 to 2020. Cases from the Ministry of Health National Minimum Dataset, National Mortality Collection, and the Australasian Vascular Audit were cross-verified with hospital notes. Poisson regression adjusted for sex and age was used to investigate trends over time.

RESULTS

During the study interval, 1295 patients presented to hospital with confirmed AAS, including 790 with type A (61.0 per cent) and 505 with type B (39.0 per cent) AAS. A total of 290 patients died out of hospital between 2010 and 2018. The overall incidence of aortic dissection including out-of-hospital cases was 3.13 (95 per cent c.i. 2.96 to 3.30) per 100 000 person-years, and this increased by an average of 3 (95 per cent c.i. 1 to 6) per cent per year after adjustment for age and sex adjustment on Poisson regression, driven by increasing type A cases. Age-standardized rates of disease were higher in men, and in Māori and Pacific populations. The management strategies used, and 30-day mortality rates among patients with type A (31.9 per cent) and B (9.7 per cent) disease have remained constant over time.

CONCLUSION

Mortality after AAS remains high despite advances over the past decade. The disease incidence and burden are likely to continue to increase with an ageing population. There is impetus now for further work on disease prevention and the reduction of ethnic disparities.

Factors Affecting False Lumen Thrombosis In Type B Aortic Dissection

BACKGROUND

Complete thrombosis of the false lumen facilitates remodeling of type B aortic dissection (TBAD). Morphological characteristics affect thrombosis in the false lumen.

OBJECTIVES

Discuss the factors present before admission that influence false lumen thrombosis in patients with TBAD.

METHODS

We studied 282 patients diagnosed with TBAD in our hospital between January 2008 and December 2017. We divided the subjects into a thrombotic group and a non-thrombotic group based on whether any thrombus was detectable in the false lumen. We analyzed the differences between the two groups with respect to clinical data, the vertical length of the dissection, and the diameter of the aorta. P values < 0.05 were considered statistically significantly different.

RESULTS

Significant differences between the thrombotic group and non-thrombotic group were found with respect to age (53.92 ± 11.40 vs. 50.36 ± 10.71, p = 0.009) and proportion of patients with renal insufficiency (7.83% vs. 16.38%, p = 0.026). In zones 3-9, the true lumen diameter of the thrombotic group was significantly larger than in the non-thrombotic group (p < 0.05). Binary logistic regression analysis showed that true lumen diameter in zone 5 and renal insufficiency were independent predictors of false lumen thrombosis.

CONCLUSIONS

Age and renal function were associated with thrombosis in the false lumen. Potentially, the difference between the diameter of the true lumen diameter and that of the false lumen may influence the thrombosis of the false lumen.

Analysis of Inflammation-Related Genes in Patients with Stanford Type A Aortic Dissection

Background: Aortic dissection (AD) is a life-threatening cardiovascular disease. Pathophysiologically, it has been shown that aortic wall inflammation promotes the occurrence and development of aortic dissection. Thus, the aim of the current research was to determine the inflammation-related biomarkers in AD. Methods: In this study, we conducted differentially expressed genes (DEGs) analysis using the GSE153434 dataset containing 10 type A aortic dissection (TAAD) and 10 normal samples downloaded from the Gene Expression Omnibus (GEO) database. The intersection of DEGs and inflammation-related genes was identified as differential expressed inflammation-related genes (DEIRGs). Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were performed for DEIRGs. We then constructed the protein-protein interaction (PPI) network using the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) database and identified hub genes using the Cytoscape plugin MCODE. Finally, least absolute shrinkage and selection operator (LASSO) logistic regression was used to construct a diagnostic model. Results: A total of 1728 DEGs were identified between the TAAD and normal samples. Thereafter, 61 DEIRGs are obtained by taking the intersection of DEGs and inflammation-related genes. The GO indicated that DEIRGs were mainly enriched in response to lipopolysaccharide, in response to molecules of bacterial origin, secretory granule membrane, external side of plasma, receptor ligand activity, and signaling receptor activator activity. KEGG analysis indicated that DEIRGs were mainly enriched in cytokine-cytokine receptor interaction, TNF signaling pathway, and proteoglycans in cancer. We identified MYC, SELL, HIF1A, EDN1, SERPINE1, CCL20, IL1R1, NOD2, TLR2, CD69, PLAUR, MMP14, and HBEGF as hub genes using the MCODE plug-in. The ROC indicated these genes had a good diagnostic performance for TAAD. Conclusion: In conclusion, our study identified 13 hub genes in the TAAD. This study will be of significance for the future development of a preventive therapy of TAAD.

Reintervention of Residual Aortic Dissection after Type A Aortic Repair: Results of a Prospective Follow-Up at 5 Years

Background After a type A aortic dissection repair, a patent false lumen in the descending aorta is the most common situation encountered, and is a well-known risk factor for aortic growth, reinterventions and mortality. The aim of this study was to analyze the long-term results of residual aortic dissection (RAD) at a high-volume aortic center with prospective follow-up. Methods In this prospective single-center study, all patients operated for type A aortic dissection between January 2017 and December 2022 were included. Patients without postoperative computed tomography scans or during follow-up at our center, and patients without RAD were excluded. The primary endpoint was all-cause mortality during follow-up for patients with RAD. The secondary endpoints were perioperative mortality, rate of distal aneurysmal evolution, location of distal aneurysmal evolution, rate of distal reinterventions, outcomes of distal reinterventions, and aortic-related death during follow-up. Results In total, 200 survivors of RAD comprised the study group. After a mean follow-up of 27.2 months (1-66), eight patients (4.0%) died and 107 (53.5%) had an aneurysmal progression. The rate of distal reintervention was 19.5% (39/200), for malperfusion syndrome in seven cases (3.5%) and aneurysmal evolution in 32 cases (16.0%). Most reinterventions occurred during the first 2 years (82.1%). Twenty-seven patients were treated for an aneurysmal evolution of RAD including aortic arch with hybrid repair in 21 cases and branched aortic arch endoprosthesis in six cases. In the hybrid repair group, there was no death, and the rate of morbidity was 28.6% (6/21) (one minor stroke, one pulmonary complication, one recurrent paralysis with complete recovery and three major bleeding events). In the branched endograft group, there was no death, no stroke, and no paraplegia. There was one case (16.7%) of carotid dissection. Complete aortic remodeling or complete FL thrombosis on the thoracic aorta was found in 18 cases (85.7%) and in five cases (83.3%) in the hybrid and branched endograft groups, respectively. Conclusions: Despite a critical course in most cases of RAD, with a high rate of aneurysmal evolution and reintervention, the long-term mortality rate remains low with a close follow-up and a multidisciplinary management in an expert center.

Acute aortic dissection

Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.

Gender differences in acute aortic syndromes

PURPOSE OF REVIEW

Acute aortic syndromes include acute aortic dissection, intramural hematoma, and penetrating aortic ulcer, and are associated with high mortality and morbidity. This review focuses on recent findings and current understanding of gender-related and sex-related differences in acute aortic syndromes.

RECENT FINDINGS

Large international and national registries, population studies, and multicentre national prospective cohort studies show evidence of sex differences in acute aortic syndromes. Recent studies of risk factors, aorta remodelling, and genetics provide possible biological basis for sex differences. The 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management of Aortic Disease revise recommendations for surgical management for aortic root and ascending aorta dilatation, which could impact outcome differences between the sexes.

SUMMARY

Acute aortic syndromes affect men more frequently than women. The prevalence of acute aortic syndromes and prevalence of many risk factors rise sharply with age in women leading to higher age at presentation for women. Times from symptom onset to presentation and presentation to diagnosis are delayed in female patients. Females with type A dissection are also more commonly treated conservatively than male counterparts. These factors likely contribute to higher early mortality and complications in women.

Outcomes of thoracic endovascular aortic repair with fenestrated surgeon-modified stent-graft for type B aortic dissections involving the aortic arch

Objectives

This retrospective analysis aimed to evaluate the early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-graft (f-SMSG) for type B aortic dissections (TBAD) involving the aortic arch.

Methods

From March 2016 to April 2021, 47 consecutive patients were treated using TEVAR with f-SMSG. All patients were diagnosed with TBAD involving the aortic arch.

Results

In total, 47 patients with TBAD involving the aortic arch were treated with f-SMSGs. There were 21 zone 1 and 26 zone 2 TEVAR, and 65 arteries were revascularized successfully with fenestrations. Technical success was achieved in 46 patients (97.88%). The 30-day estimated survival (± SE) and reintervention was 93.6 ± 1.0% (95% Confidence Interval [CI], 92.6-94.6%) and 91.5 ± 1.2% (95% CI, 90.3-92.7%), respectively. During a median follow-up of 51 months (range, 16-71 months), 1 patient died of rupture of aortic dissection (AD) and 3 patients died of non-aortic-related reasons. Reintervention was performed for four patients, including two patients of type IA entry flow and two patients of type IB entry flow. No occlusion of the supra-aortic trunk was observed. The estimated survival and reintervention (± SE) at 4 years was 88.7 ± 1.4% (95% CI, 87.3-90.1%) and 84.8 ± 1.5% (95% CI, 83.3-86.3%), respectively.

Conclusion

Thoracic endovascular aortic repair with f-SMSG is an alternative treatment option for TBAD involving the aortic arch in high-volume centers.

Thoracic Aortic Aneurysm Presenting as a Subacute Cough

The suprasternal aortic notch cardiac point of care ultrasound (POCUS) window is a useful view for evaluating thoracic aortic pathologies. However, it is not routinely included in the standard cardiac POCUS exam despite its ability to capture emergent pathologies such as aortic dissection and thoracic aortic aneurysm (TAA). Ruptured aortic aneurysms can present with sudden, severe chest or back pain, as well as hemodynamic instability, resulting in a high mortality. We present an atypical case of a patient with hemoptysis who was found to have a contained aortic rupture. In this case, POCUS, specifically the suprasternal aortic notch view, was used to expedite definitive care.

Dual-processing theory helps to explain delay in diagnosis of Stanford type A aortic dissection

A woman in her 70s presented with chest pain, which was initially thought to be an acute coronary syndrome but subsequently felt to be pericarditis. Chest radiography and echocardiography demonstrated striking cardiomegaly and marked biatrial dilatation, likely secondary to undiagnosed restrictive cardiomyopathy. The patient remained well on the ward for some days with only mild discomfort and stable haemodynamics. CT of the thorax went on to unexpectedly demonstrate a Stanford type A aortic dissection. The patient was promptly transferred for emergent surgery but sadly died intraoperatively.Delayed or missed diagnosis of acute aortic dissection (AAD) is common. The dual-processing theory (DPT) of human judgement can be applied to medical decision making and used to explain this potential for diagnostic error in AAD diagnosis. A greater awareness of DPT and the role of heuristics and biases in medical decision making may help to reduce medical diagnostic error.