Diagnosis and Management of Acute Aortic Dissection,Clinical and Radiological Follow-up

ABSTRACT A clinical series of acute aortic dissections is presented. Twenty cases were of type A and 10 of type B. Acute severe chest pain was common, in type A also blood pressure difference between the arms and aortic regurgitation. The diagnosis was established by echocardiography, computerized tomography and/or aortography. Antihypertensive therapy was instituted immediately after diagnosis and was in type A cases followed by acute surgery unless definite contraindications existed. Of 14 surgically treated type A patients 13 survived the operation. On follow-up 1.5–3.5 years later, 12 patients were still alive and doing well, but the false channel remained open in all cases where it had not been resected totally. Only one of six conservatively treated type A patients survived. Type B dissections were operated on only if conservative therapy failed. Four of five conservatively and two of five surgically treated type B patients survived.     

Trends and Outcomes of Elective Thoracic Aortic Repair and Acute Thoracic Aortic Syndromes in the United States

BackgroundThere is a paucity of data on the contemporary outcomes and trends of elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome.MethodsWe queried the National Inpatient Sample (NIS) database years 2012-2016 to identify hospitalizations for elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. The main study outcome was in-hospital mortality.ResultsThe analysis yielded 24,295 hospitalizations for elective thoracic aortic aneurysm repair and 8875 hospitalizations for aneurysm-associated acute aortic syndrome. The number of hospitalizations for elective aortic repair significantly increased from 4375 in 2012 to 5450 in 2016 (P_trend = .01). The number of hospitalizations for acute aortic syndrome numerically increased from 1545 in 2012 to 2340 in 2016 (P_trend = .10). Overall in-hospital mortality for elective aortic repair was 2.4% with no change over time. In-hospital mortality for acute aortic rupture was 39.4% and for acute aortic dissection was 6.2% with no change over time. Hospitalizations for elective aortic repair had lower incidence of complications compared with those for aneurysm-associated acute aortic syndrome, including cardiogenic shock, cardiac arrest, acute stroke, and shorter length of stay. Factors associated with higher mortality among admissions undergoing elective aortic repair included older age, heart failure, valvular disease, and chronic kidney disease. Older age, coagulopathy, and fluid/ electrolytes disorders were associated with increased mortality among those with acute aortic syndrome.ConclusionContemporary elective thoracic aortic aneurysm repair is associated with lower in-hospital mortality and morbidity when compared with a clinical presentation for an aneurysm-associated acute aortic syndrome. This should be taken into account when deciding the timing of elective aortic aneurysm repair and balancing the risks and benefits.     

B型急性主动脉夹层院内死亡相关危险因素分析

目的：研究B型急性主动脉夹层(acute aortic dissection,AAD)患者住院期间死亡的相关危险因素。方法：回顾性分析2010年1月至2013年12月收治的188例B型急性主动脉夹层患者的住院病例资料。根据住院期间是否发生死亡,分为死亡组与存活组,对部分相关因素进行分析。结果：188例B型主动脉夹层患者,死亡17例(病死率10%)。两组单因素分析提示低血压、肾功能不全及缺血并发症是住院期间死亡的高危因素,中性粒细胞百分数、D二聚体升高有统计学意义。多因素Logistic分析提示肾功能不全、低血压、中性粒细胞百分数升高为患者院内死亡的独立危险因素,手术为保护因素。结论：伴有低血压、肾功能不全、中性粒细胞百分数升高的B型AAD患者住院期间病死率高,在内科治疗基础上手术治疗有助于降低B型AAD患者的病死率。     

Thoracic Aortic Aneurysm and Dissection

Aortic dissection is the most devastating complication of thoracic aortic disease. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta. In this review, we describe normal thoracic aortic size; risk factors for dissection, including genetic and inflammatory conditions; the underpinnings of genetic diseases associated with aneurysm and dissection, including Marfan syndrome and the role of transforming growth factor beta signaling; data on the role for medical therapies in aneurysmal disease, including beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors; prophylactic surgery for aneurysm; surgical techniques for the aortic root; and surgical and endovascular management of aneurysm and dissection for different aortic segments.     

Imaging Modalities in the Diagnosis of Acute Aortic Dissection

The management of patients with acute aortic dissection requires a rapid diagnosis and precise information about the localization and extent of the dissection. Four imaging techniques are currently available to diagnose aortic dissection: aortography; contrast-enhanced computerized tomography (CECT); magnetic resonance imaging (MRI); and transesophageal echocardiography (TEE). All of these techniques have their specific advantages and inherent limitations. Recent studies have demonstrated that MRI may best provide a comprehensive and detailed evaluation of the thoracic aorta, therefore proposing this technique as a "new gold standard" in the diagnosis of acute aortic dissection. TEE, however, may be the best alternative technique, as it combines high sensitivity and specificity with high practicality. The practicality is particularly important in hemodynamically unstable patients in whom a rapid bedside imaging modality is required. CECT might be necessary in selected cases in whom TEE fails to provide a definite diagnosis. Aortography may be necessary in patients in whom clinical signs are suggestive of organ ischemia and in whom coronary anatomy needs to be delineated before operation.     

36例主动脉夹层早期诊断及误诊分析

目的探讨主动脉夹层的临床表现、早期诊断及误诊情况。方法分析36例主动脉夹层临床表现，体检、实验室检查、心电图检查、X线片、超声心动图、CT、MPd等检查结果。结果36例主动脉夹层的临床表现各异，典型撕裂样疼痛22例（61．1％），部分患者以并发症为首发症状，影像学检查能确定诊断。主动脉夹层的临床表现复杂，初诊误诊率50％。结论主动脉夹层临床表现复杂，易误诊，应引起临床医师的高度重视。     

综合超声与磁共振成像对照评价主动脉夹层前瞻性研究

目的：通过与磁共振成像对照研究，评价经胸超声心动图（ＴＴＥ）和经食管超声心动图（ＴＥＥ）在主动脉夹层的应用价值。方法：３９例经手术确诊或经磁共振成像、数字减影血管造影术及ＴＥＥ２种检查方法证实的３９例主动脉夹层患者。结果：ＴＴＥ、ＴＥＥ和磁共振成像诊断主动脉夹层，敏感性分别为９０％、１００％和９７％；特异性分别为９３％、９７％和１００％。ＴＴＥ主要不足在于对降主动脉夹层、原发破口和假腔血栓检出率偏低。ＴＥＥ在夹层破口、假腔血栓、主动脉瓣反流和冠状动脉的检查方面优于磁共振成像。而磁共振成像在头臂动脉及腹主动脉分支的检查方面优于ＴＥＥ。本研究显示主动脉夹层破口血流在收缩期从真腔进入假腔，舒张期又返回真腔。结论：①综合超声心动图和磁共振成像均是理想的主动脉夹层诊断方法；ＴＴＥ适合于筛选检查，ＴＥＥ有确诊价值。②主动脉夹层破口血流方向与真假腔压力变化有关，而与破口部位无关。     

A型急性主动脉夹层患者入院时血小板计数与住院死亡率的相关性研究

目的：探讨A型急性主动脉夹层患者入院时血小板计数与住院死亡率的相关性。方法：连续入选2012-02至2013-05就诊于我院并经计算机断层扫描（CT）证实的A型急性主动脉夹层患者183例,男性126例（68.9%）。分组：①根据患者住院期间是否存活分为存活组（n=157）,死亡组（n=26）;②根据血小板计数五分位值将患者分五组,即血小板计数第1分位（≤119×109/L）组（Q1组,n=36）,血小板计数第2分位（120~149×109/L）组（Q2组,n=37）,血小板计数第3分位（150~173×109/L）组（Q3组,n=36）,血小板计数第4分位（174~228×109/L）组（Q4组,n=37）,血小板计数第5分位（>228×109/L）组（Q5组,n=37）;③按入院时血小板计数分为≤119×109/L组（n=36）和>119×109/L组（n=147）,再根据是否接受手术治疗将其分为≤119×109/L手术者（n=18）、≤119×109/L非手术者（n=18）和>119×109/L手术者（n=96）、>119×109/L非手术者（n=51）。采集患者入院时的基线资料及静脉血标本,检测血小板计数、白细胞、D-二聚体等值。主要终点事件为住院死亡率。结果：183例A型急性主动脉夹层患者总住院死亡率为14.3%。死亡组与存活组比较,血小板计数显著减少、血压较低、D-二聚体水平较高; Q1组患者死亡率（38.9%）显著高于Q2、Q3、Q4和Q5四组（10.8%、11.1%、8.1%和2.7%）,差异均有统计学意义（P<0.001）。Q5组较Q1组死亡风险增加（HR=11.2,95%CI 2.13~123.3,P=0.007）,在调整了年龄、性别等影响预后的因素后,血小板计数≤119×109/L无论在手术治疗进入Cox模型前（HR3.90,95%CI 1.67~9.09, P=0.002）还是进入模型后（HR2.67,95%CI 1.15~6.19,P=0.023）均增加住院死亡风险。结论：A型急性主动脉夹层患者入院时血小板计数≤119×109/L住院死亡率风险明显增加。即使接受手术治疗,血小板计数值较低的患者仍与住院死亡风险相关。     

Fusobacterium necrophorum in an Abdominal Aortic Aneurysm,Treated by Once Daily Ertapenem

Inflammatory aneurysms may make up a small percentage of the total number of abdominal aortic aneurysms, but they present their own unique challenges. We present a case of a 65-year-old man whose aneurysm was found to be colonized by Fusobacterium necrophorum.     

Frozen Elephant Trunk Repair for Descending Thoracic Aortic Dissection in a Man with a Hostile Left Pleural Cavity

The frozen elephant trunk procedure is a hybrid, single-staged alternative to conventional surgery for repairing diffuse pathologic conditions of the thoracic aorta. This approach is particularly advantageous in patients who have pathologic conditions of the left side of the chest, because the descending thoracic aorta can be repaired without entering a hostile pleural cavity.We present the case of a 67-year-old man who had undergone repair of acute type A aortic dissection. He presented with aneurysmal dilation of the descending thoracic aorta secondary to chronic dissection, a large acute dissection of the proximal ascending aorta, and a large paraesophageal hernia that made him a poor candidate for conventional, 2-staged open aortic repair. We describe the hybrid frozen elephant trunk technique that we used to repair the aorta, and its broader advantages.     

D二聚体在急性主动脉夹层诊断和预后中的作用

目的:分析D二聚体水平在急性主动脉夹层(AAD)早期诊断和预后判断中的作用.方法:回顾分析116例AAD患者(AAD组)和132例同期因胸痛就诊的其它患者(对照组),比较两组间包括D二聚体水平在内的各项临床常用指标的差异.结果:D二聚体＞500 μg/L预测AAD的敏感性92.24%,D二聚体＞5 000μg/L预测AAD的特异性为95.45%.DeBakeyⅠ型患者D二聚体水平显著高于其它临床分型,差异具有统计学意义(P＜0.01).2周内死亡的AAD患者D二聚体水平显著高于存活的患者,差异具有统计学意义(P＜0.05).结论:D二聚体的水平与AAD夹层撕裂的程度和范围相关,并可能是AAD患者不良预后的参考指标.     

一种简单易复制的A型主动脉夹层根部处理方式

目的 使用主动脉根部全间断褥式缝合、联合内引流技术治疗A型主动脉夹层,总结早中期结果。方法 回顾2018年6月至2020年12月我科行A型主动脉夹层手术患者46例。根据主动脉根部处理方式分为三组：根部间断缝合组18例,根部置换组（Bentall和Cabrol术组）17例,根部连续缝合组11例。对比三组间术前资料、围术期及随访结果。结果 全组男性32例（69.6%）,年龄（57.2±11.9）岁,发病24h内急诊手术29例（63%）。三组之间性别、年龄无明显差异,手术时机、术前心功能无差异,主动脉根部替换组术前窦部直径显著高于其他两组[置换组（44.2±8.3） mm , 间断组(35.9±3.2)mm ,连续组(35.9±4.0)mm, P<0.01）,主动脉瓣反流程度也更严重。35例患者全弓置换,8例行半弓置换,3例未行弓部手术。主动脉阻断时间（121.5±23.7）min,体外循环时间（262.2±78.8）min,根部置换组时间较长。存活39例（84.8%）,三组之间死亡率、术后ICU停留天数、输血量、术后住院时间无显著差异。随访3月~3年,无轻度以上主动脉瓣反流,心功能良好;随访CTA结果良好。结论 主动脉根部间断缝合联合内引流的方法操作简单、可复制性强,近期手术效果与其他方法相当,可作为现有手术方法的一种补充。     

Transesophageal Echocardiography in the Evaluation of Aortic Trauma

Transesophageal echocardiography (TEE) is superior to other imaging techniques for the diagnosis of aortic trauma. It can accurately, rapidly, and safely diagnose life-threatening conditions such as aortic rupture, pseudoaneurysm, traumatic aortic dissection, and intramural hematoma. TEE is useful for the diagnosis and prevention of iatrogenic aortic trauma induced by cardiovascular surgery, intraaortic procedures, and cardiopulmonary resuscitation.     

术前口服抗血小板药物的急性A型主动脉夹层动脉瘤的临床手术效果分析

目的：急性A型主动脉夹层(Acute type A aortic Disease, ATAAD）是心脏外科常见的需急诊处理的疾病之一,然而,临床中突然的胸痛也可能会误诊为急性冠状动脉综合征（Coronary Artery Diseases, CAD）,并可能在急救过程中给与抗血小板治疗（Antiplatelet therapy,APT）。我们回顾分析了本中心急性主动脉基础患者,研究术前抗血小板治疗对其临床结局的影响。 方法：回顾性分析了中国医科大学2015年至2020年收治的523例主动脉基础患者,其中有31名在术前接受过阿司匹林或氯吡格雷或两者联合使用的抗血小板治疗。在倾向评分匹配之前和之后,通过使用逻辑回归模型比较了APT和非APT患者的并发症发生率和死亡率。 匹配分析后剩余的样本在APT组中为30例,非APT组为80例。 结果：经匹配后APT组患者数为30例,非APT组为80例。我们发现APT组中有10例（33%）既往接受经皮冠状动脉介入治疗（冠状动脉支架植入术）。 APT组的红细胞输入量更大,为8.4±6.05单位;血浆输入量401.67±727 ml,以及血小板输注量（14.07±8.92单位）。 APT组的心包及胸骨后引流量更多（5009.37±2131.44ml,P = 0.004）。 APT组的死亡率相对非APT组较高（26％比10％,P = 0.027）。术前APT是死亡率的独立预测因子（OR 6.808,95％CI1.554-29.828,P = 0.011）。 结论：ATAAD修复前的APT与更多的输血和更高的早期死亡率有关。临床医生应根据患者的状况和外科医生的经验仔细考虑手术时机。     

Mobility of the Intimal Flap and Thrombus Formation in Aortic Dissection: A Transesophageal Echocardiographic Study

The mechanisms of the motion of the intimal flap and of thrombus formation in acute or chronic aortic dissection are not definitively elucidated. Transesophageal echocardiography seems to be a technique of choice to analyze the flow in the true and false lumina. Twenty-one consecutive patients were studied in order to define the mobility of the intimal flap, the color Doppler flow patterns, the presence of spontaneous echocardiographic contrast, and thrombus formation at different levels of the aorta. The results suggest that clotted false lumen is more often seen in chronic aortic dissection at the level of the descending thoracic aorta. However, thrombosed false lumen in the aortic arch is suggestive of a retrograde aortic dissection. In cases of complete obliteration of the false lumen, the differentiation between aortic dissection and aortic ectasia with mural thrombus may be extremely difficult.     

Case Report and Review of Literature: Late Retrograde Type A Aortic Dissection With Rupture after Repair of Type B Aortic Dissection with a GORE TAG Endovascular Prosthesis

Acute aortic dissection is the most common catastrophic condition of the aorta. Treatment options include open surgery and thoracic endovascular aortic reconstruction (TEVAR). We present a late Type A dissection as a complication of the management of descending aortic dissections with TEVAR and a review of the literature. TEVAR of the thoracic aorta is a viable treatment option for the management of complicated descending thoracic aortic dissections. Careful patient selection is necessary as medical therapy successfully treats the majority of uncomplicated Type B dissections. TEVAR should be reserved for patients with complicated Type B dissections or those who fail nonoperative management. Close postoperative monitoring is necessary when TEVAR is performed and should be accompanied by lifelong surveillance. A high level of suspicion is important to identify retrograde Type A dissections in these patients given its rarity and the ambiguity of its clinical presentation.