Aortic emergencies

Calcification of the ascending aorta, left heart valves and coronaries: associated diseases and a new classification

Aim: The topography of vascular and valvular calcification could help accurately predict cardiovascular post-operative complications. The data on these calcifications remains scarce. Purpose: Identify the topographic distribution of the ascending aortic, left heart valves and coronary calcifications. Materials & methods: We extracted 26 variables from 557 patients, hospitalized between 2017 and 2020. The topography of calcification was evaluated by thoracic CT scans. Both multivariate logistic regression and classification and regression tree (CART) were used for statistical analysis. Results: Several comorbidities were associated with vascular or valvular calcification. This study proposes a CART tree for patients according to their age, sex, Euroscore and lipid profile. Conclusion: The proposed classification could represent an important clinical tool. More studies are warranted to better prune the current CART algorithm.

A Case of Aortic Dissection Presenting with Atypical Symptoms and Diagnosed with Transthoracic Echocardiography

We present a case of an extensive aortic dissection (AD) identified in a woman with atypical symptoms. Transthoracic echocardiography (TTE) allowed the identification of an intimal flap in multiple locations and resulted in rapid diagnosis and treatment. In most cases, CT angiography is the imaging modality of choice for diagnosis of AD. TTE is rapid and accurate and can be used in kidney failure. Our case highlights the important role of bedside echocardiography in the diagnosis of AD, especially in the patient with a typical symptoms in whom this diagnosis of AD may not be entertained and actually missed leading to negative and possibly deadly consequences.

Hybrid treatment of the ascending aortic aneurysm and "shaggy aorta" syndrome

This case report describes simultaneous approach that enables to replace the ascending aortic aneurysm complicated with atherosclerotic lesions of the descending aorta (the “shaggy aorta” syndrome) using frozen elephant trunk technique.

Abdominal Aortic Emergencies

This article discusses abdominal aortic emergencies. There is a common thread of risk factors and causes of these diseases, including age, male gender, hypertension, dyslipidemia, and connective tissue disorders. The most common presenting symptom of these disorders is pain, usually in the chest, flank, abdomen, or back. Computed tomography scan is the gold standard for diagnosis of pathologic conditions of the aorta in the hemodynamically stable patient. Treatment consists of a combination of blood pressure and heart rate control and, in many cases, emergent surgical intervention.

Aortic emergencies-diagnosis and treatment: a pictorial review

Objectives

To demonstrate the various presentations of acute aortic pathology and to present diagnostic and therapeutic approaches.

Methods

Diagnostic imaging is the key to the reliable diagnosis of acute aortic pathology with multi-slice computed tomography angiography (CTA) as the fastest and most robust modality. Endovascular aortic repair (EVAR) with stent grafts and open surgical repair are therapeutic approaches for aortic pathology.

Results

CTA is reliable in diagnosing and grading aortic trauma, measuring aortic diameter in aortic aneurysms and detecting vascular wall pathology in acute aortic syndrome and aortic inflammation. CTA enables planning the optimal therapeutic approach. Stent graft implantation and/or an open surgical approach can address vascular wall pathology and exclude aortic aneurysms.

Conclusion

Aortic emergencies have to be detected quickly. CTA is the imaging method of choice and helps to decide whether elective, urgent or emergent treatment is necessary with EVAR and open surgical repair as the main treatment approaches.

Teaching Points

• To present aortic pathology caused by trauma

• To present acute aortic syndrome (aortic dissection, intramural haematoma and penetrating ulcers)

• To present symptomatic and ruptured aortic aneurysm

• To present infection (mycotic aneurysms/aorto-duodenal fistulae) or iatrogenic injury of the aorta

• To understand different presentations for treatment planning (EVAR and open surgery)

Rapid detection of aortic occlusion with emergency ultrasonography

The differential diagnosis of aortic emergencies includes abdominal aortic aneurysms and aortic dissection. Aortic occlusion is another rare yet deadly vascular emergency to be wary of. For acute occlusions, definitive management by embolectomy or aortofemoral bypass must be performed promptly. When suspected because of the history and physical examination results, bedside ultrasonography rapidly confirms the diagnosis. We describe 2 very different cases of aortic occlusion both initially detected with bedside ultrasonography in our emergency department.

Methicillin-resistant Staphylococcus aureus aortitis in a cardiac transplant patient

A 57-year-old heart transplant patient presented to the Emergency Department with mild epigastric pain, nausea, and vomiting for two days. Aside from a recent hospitalization for replacement of his hemodialysis catheter, he had otherwise not been ill. He was afebrile, slightly hypertensive, and slightly tachycardic with mild tenderness over the left upper quadrant, but no guarding, rebound tenderness, or masses. His WBC count was elevated at 16.1 (normal: 3.8-10.6). A computed tomography of the abdomen showed an area of low attenuation surrounding the aorta, surrounded more peripherally by an area of higher density. He went urgently to the operating room for a presumed contained rupture of the thoracic aorta. During the operation the surgeons noted inflammatory changes, rather than rupture, and resected and replaced the affected section. Cultures from a peri-aortic swab grew methicillin-resistant Staphylococcus aureus. Among complications of cardiac transplantation, aortic involvement can be a source of significant morbidity and mortality. Primary bacterial aortitis is, however, a rare event with instances of less than 3% in all patients. The presentation of these infections may be subtle, making diagnosis difficult and requiring a high index of suspicion. CT is the initial imaging technique of choice. Therapy frequently involves surgery in addition to broad-spectrum antibiotics. This patient's infection most likely originated from an infected dialysis catheter, the one that had just been replaced, and was probably kept from becoming more symptomatic by the administration of vancomycin during the previous admission.

A case of aortic dissection in a cocaine abuser: a case report and review of literature

Background

Prompt diagnosis and management of aortic dissection are key to reduce patient morbidity and mortality; hence the need to a have a high index of suspicion for this condition. We believe it's important to report this case because it underscores the relationship between cocaine abuse and aortic dissection. In addition it strongly emphasizes basic principles in medicine: patients should not be profiled, and chronic complaints may need reassessment.

Case Presentation

We are presenting a case of Stanford type A aortic dissection in a 46 year old patient with history of cocaine abuse. The aortic dissection presented as worsening of chronic upper abdominal pains he has had for years. He presented to us hours after using crack cocaine.

Conclusion

Aortic dissection associated with cocaine abuse develops at a younger age. Therefore it's crucial to have high index of suspicion for aortic dissection in this subset of patients. Furthermore as this case illustrates, serious diseases can masquerade in old complaints. Patients should never be profiled, and chronic complaints should always be revisited.

Acute aortic dissection in children and adolescents: diagnostic and after-event follow-up obligation to the patient and family

Acute aortic dissection in childhood and adolescence is a rare but life-threatening condition with many known risk factors, most of which are heritable. The importance of determining the presence of any predisposing disorders is stressed, since all close relatives can then be screened for any such inherited trait that would make them at risk for a similar catastrophic event. Even with no obvious predisposing disorder, it may still be prudent to evaluate close kin for the presence of aortic root dilatation, since some genetic disorders have no manifestation other than acute aortic dissection secondary to aortic medial pathology. Close monitoring for at-risk family members, including the index patient, may need to be a life-long process.

Nontraumatic Thoracic Emergencies

Acute chest pain is one of the most common complaints of patients who present to an emergency department, and accounts for up to 5% of all visits. It also is one of the most complex issues in an emergency setting because, although clinical signs and symptoms often are nonspecific, rapid diagnosis and therapy are of great importance. The chest radiograph remains an important component of the evaluation of chest pain, and usually is the first examination to be obtained. Nevertheless, cross-sectional imaging has added greatly to the ability to characterize the wide constellation of clinical findings into a distinct etiology. This article reviews how the various entities that can present as nontraumatic chest pain can manifest radiographically.

Adult surgical emergencies in a developing country: the experience of Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

The goal of this study was to examine the adult surgical emergencies seen at the Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, with a view to proffering preventive solutions where appropriate and improving outcome. From the register of patients seen at the Casualty department and from the operations register in the main operation room of NAUTH, names and hospital numbers of adult patients treated as emergencies over a 5-year period, from 7 September 1998 to 6 September 2003, were obtained. The hospital folders were then retrieved from the Records Department. From each folder, the following details about each patient were extracted: age, sex, diagnosis at presentation, causative factors, treatment given, and outcome. A total of 902 adult patients were treated during the period. The commonest emergency operation was appendectomy for acute appendicitis in 139 patients (97 women and 42 men), followed closely by road traffic accidents (RTAs) involving 137 patients (103 men and 34 women). Gunshot injuries, which resulted mainly from armed robbery attacks, accounted for 127 cases. More men (113) sustained gunshot injuries than women (14). Of the 92 cases of acute intestinal obstruction seen, 62 occurred in women and 30 in men. Some 126 men presented with acute urinary retention, and two others presented with priapism. Governments at various levels should provide modern diagnostic tools for the accurate preoperative diagnosis of surgical emergencies in hospitals. Governments should also inculcate strict discipline into drivers using the highways, particularly in relation to abuse of alcohol and drugs. Good roads and adequate security should be provided for the people. The need for Pre-Hospital Care for the efficient evacuation of accident victims is emphasized. These measures will help to improve the management and outcome of surgical emergencies, and decrease the number of surgical emergencies resulting from RTAs and gunshot wounds.

Case report: aortic dissection and cystic medial degeneration in a 24-year-old without Marfan syndrome

The effective management of aortic dissection relies heavily on a high index of suspicion followed by timely definitive diagnosis. Young adults without a history of blunt trauma who are not at risk for atherosclerotic disease may lower this suspicion. We present a 24-year-old patient with complaints of chest pain who presented in multiple urgent care clinics and emergency departments. With a normal chest radiograph, he was repeatedly discharged home on analgesics until a loud murmur was heard. An echocardiogram revealed a dilated aortic root with an intimal flap consistent with a type II dissection. After surgical aortic repair with a Bentall procedure, he was discharged with complete relief of symptoms. Histologic reports revealed cystic medial degeneration. Physical examinations did not demonstrate the phenotypic manifestations of Marfan syndrome. This case illustrates the importance of cardiac auscultation when assessing an individual with chest pain, even with a low likelihood for alteration in arterial structure, and the maintenance of a high index of clinical suspicion despite a normal chest radiograph. We consider this case to be of interest because of its rarity in a 24-year-old.