Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

Elevated D-dimer increases the risk of dialysis after surgery in patients with Stanford A aortic dissection through the impact of the coagulation system

Background

To investigate whether Elevated D-dimer increases the risk of dialysis after surgery in patients with Stanford A aortic dissection.

Methods

A total of 120 patients with type A aortic dissection who underwent surgery at our institution from August 2014 to December 2015 were enrolled in the study. Acute type A aortic dissection was treated with Sun's operation. Blood samples were collected before anesthesia induction, 4 hours after surgery, and 24 hours after surgery. Patients were divided into two groups according to their D-dimer levels. Group A had D-dimer concentrations below 3,000 µg/L; Group B had D-dimer concentrations above 3,000 µg/L.

Results

Group A (n=99; 82.5% of total patients) had D-dimer levels below 3,000 µg/L. Eighteen patients in Group A (18.18%) died within 30 days after surgery. Group B (n=21; 18.5% of total patients) had D-dimer levels above 3,000 µg/L. Seven patients in Group B (28%) died within 30 days after surgery. A significantly higher percentage of patients in Group B had acute renal failure and the application of continuous renal replacement therapy (P=0.02). There were significant differences between the groups in intraoperative blood loss (P=0.001) and hemostatic drugs administered, such as intraoperative prothrombin complex (P=0.015). The D-dimer (P<0.001), FIB (P=0.008) and FDP (P<0.001) in the B group were significantly higher than those in the A group, but there was no significant difference between the 4 hours after the operation and the 24 hours after the operation. Thromboelastogram (TEG) examination showed that preoperative R in group B was shorter than the A group, 4 hours after operation was still lower in group B than in group A. Through ROC analysis, D-dimer is a prognostic indicator for postoperative renal failure. When cut-off =1,039.00, sensitivity =91.7%, specificity =54.2%. When D-dimer is below 1,039 µg/L, the risk of dialysis after surgery in patients with Stanford A aortic dissection is low. Prognostic value of D-dimer was evaluated using ROC analysis and the results showed that the area under curve (AUC) of D-dimer as prognostic indicator for postoperative renal failure was 0.741 (95% CI, 0.642-0.840; P value<0.001). Stepwise binary logistic regression analysis revealed that total suspended red, wakefulness delayed, D-dimer were independent predictors of dialysis risk after surgery in patients with Stanford A aortic dissection among all the other factors.

Conclusions

D-dimer above 3,000 µg/L increases the risk of dialysis after surgery in patients with Stanford A aortic dissection through the impact of the coagulation system. When D-dimer is below 1,039 µg/L, the risk of dialysis after surgery in patients with Stanford A aortic dissection is low.

At the "threshold" of certainty: Risk stratification and clinical assessment incongruity in the diagnosis of aortic dissection

The use of D-dimer assay to screen for aortic dissection has become routine in clinical practice. Although an uncommon disease entity, aortic dissection is rapidly fatal without prompt diagnosis, and biochemical detection in the proper clinical context is crucial. We performed a retrospective chart review of all aortic dissections presenting to a community tertiary care center between 2000 and 2016 and identified three patients in whom laboratory D-dimer testing was positive and a diagnosis of Stanford Type A aortic dissection was confirmed with computed tomography angiography based on clinical assessment and a newly validated risk stratification tool.

False positive computed tomographic angiography for Stanford type A aortic dissection

BACKGROUND

Computed tomographic angiography (CTA) has emerged as the defacto imaging test to rule out acute aortic dissection; however, it is not without flaws. We report a case of a false-positive CTA with respect to Stanford Type A aortic dissection.

CASE

A 52 year-old male presented with sudden onset shortness of breath. He denied chest pain. Due to severe hypertension and an Emergency Department bedside ultrasound suggesting an intimal flap in the aorta, CTA was requested to better assess the ascending aorta and was interpreted as consistent with Stanford Type A aortic dissection with thrombosis of the false lumen in the ascending aorta. However, intra-operative imaging (TEE and epi-aortic scanning) did not identify an intimal flap or dissection, and neither did definitive surgical inspection of the aorta. The suspected aortic dissection and thrombosed false lumen were not visualized on repeat CTA two days later.

DISCUSSION

False positive diagnosis of Stanford Type A aortic dissection on CTA can be the result of technical factors, streak artifacts, motion artifacts, and periaortic structures. In this case, non-uniform arterial contrast enhancement secondary to unrecognized biventricular dysfunction resulted in the false positive CTA appearance of an intimal flap and mural thrombus. Intra-operative TEE and epi-aortic scanning were proven correct in excluding aortic dissection by the standard of definitive surgical inspection of the aorta.

[When the tissue tolerance fiber tears]

We report a 65 year old patient who presented with both an aneurysm of the axillary artery and, some years later, with an acute aortic dissection type Stanford A. After surgical intervention of the dissection in the further workup, no specific etiology could be found. The most likely reason for the two aneurysms was the inadequately treated hypertension. Therefore, follow-up strategies aim to treat the risk factors which are known to promote aneurysm growth.