The relationship between the characteristics of tears and the progression of Stanford type B aortic dissection after endovascular treatment / 中华外科杂志

Endovascular treatment of Stanford type B aortic dissection (type B dissection) has been widely used. There will be complications such as aortic dilatation, which will lead to poor prognosis of some patients. With more in-depth researches, it was found that there was a possible correlation between the prognosis of type B dissection and tears, such as the increasing of aortic diameter would be faster with longer tears, and the location of the tear will affect the thrombosis of the false lumen. Studies on hemodynamics have also found that different characteristics of tears of aortic dissection can cause changes in the pressure, blood flow rate and blood capacity in the true and false lumens recently. The hemodynamic changes can be used to predict the prognosis of type B dissection. The main characteristics of tears included the size, position, number of tears, residual tears and stent graft induced new entry. Describing the effect of tear characteristics on the development of type B dissection, can provide the basis for the clinical treatment and further research of type B dissection.

Effect of out-hospital blood pressure management on prognosis of patients with acute aortic syndrome complicated with hypertension after TEVAR / 中华心血管病杂志

Objective: To investigate the influence of blood pressure control after discharge on prognosis of patients with acute aortic syndrome (AAS) complicated with hypertension who underwent thoracic endovascular aortic repair (TEVAR). Methods: This is a retrospective case analysis. Patients diagnosed with AAS complicated with hypertension and undergoing TEVAR in Northern Theater Command General Hospital from June 2002 to December 2021 were consecutively enrolled. Average systolic blood pressure (SBP) and the occurrence of endpoint events were recorded at one month, one year and every 2 years after TEVAR. According to the patients' average SBP, patients with average SBP<140 mmHg (1 mmHg=0.133 kPa) or<150 mmHg were divided into the target blood pressure achievement group, and the others were divided into target blood pressure non-achievement group. Endpoint events included all-cause death, aortic death, stroke, renal insufficiency, aortic related adverse events and a composite of these events (overall clinical adverse events), and re-accepting TEVAR. The incidence of endpoint events was compared between the two groups at each follow-up period. Results: A total of 987 patients were included, aged (55.7±11.7) years, including 779 male (78.9%). When the cutoff value was 140 mmHg, the rate of average target SBP achievement was 71.2% (703/987) at one month, 66.7% (618/927) during 1st to 12th month and 65.1% (542/832) from the first year to the third year after TEVAR. The proportion of patients taking≥2 antihypertensive agents was higher in the group of target blood pressure non-achievement group than the target blood pressure achievement group after TEVAR at 1 month (74.3% (211/284) vs.65.9% (463/703), P=0.010) and during 1st to 12th month (71.5% (221/309) vs. 63.6% (393/618), P=0.016). There were no statistical differences in the all-cause deaths, stroke, aortic related adverse events, and repeat TEVAR between the two groups (All P>0.05) during above follow-up periods. When the cutoff value was 150 mmHg, the rate of target SBP achievement was 89.3% (881/987) at one month, 85.2% (790/927) during 1st to 12th month and 85.6%(712/832) from the first year to the third year after TEVAR. The incidence of clinical total adverse events (8.8% (12/137) vs. 4.2% (33/790), P=0.021) and repeat TEVAR (4.4% (6/137) vs. 1.0% (8/790), P=0.003) in target blood pressure non-achievement group were significantly higher than the target blood pressure achievement group during 1st to 12th month after TEVAR. The incidence of all-cause deaths (5.8% (7/120) vs. 2.4% (17/712), P=0.037) in the target blood pressure non-achievement group was significantly higher than the target blood pressure achievement group from the first year to the third year follow-up period, but there were no statistical differences in the incidence of clinical total adverse events between the two group (P>0.05). Conclusion: Among TEVAR treated AAS patients complicated with hypertension, the average SBP more than 150 mmHg post discharge is associated with increased risk of adverse events. Ideal blood pressure control should be encouraged to improve the outcome of these patients.

Clinical characteristics and prognostic analysis of female patients with Stanford type B aortic dissection / 中华心血管病杂志

Objective: To explore the clinical characteristics and prognostic factors of female patients with Stanford type B aortic dissection. Methods: This is a single-centre retrospective study. Consecutive patients diagnosed with Stanford type B aortic dissection in General Hospital of Northern Theater Command from June 2002 to August 2021 were enrolled, and grouped based on sex. According to the general clinical conditions and complications of aortic dissection tear, patients were treated with thoracic endovascular aortic repair, surgery, or optimal medication. The clinical characteristics and aortic imaging data of the patients at different stages were collected, adverse events including all-cause deaths, stroke, and occurrence of aortic-related adverse events were obtained during hospitalization and within 30 days and at 1 and 5 years after discharge. According to the time of death, death was classified as in-hospital death, out-of-hospital death, and in-hospital death was divided into preoperative death, intraoperative death and postoperative death. According to the cause of death, death was classified as aortic death, cardiac death and other causes of death. Aortic-related adverse events within 30 days after discharge included new paraplegia, post-luminal repair syndrome, and aortic death; long-term (≥1 year after discharge) aortic-related adverse events included aortic death, recurrent aortic dissection, endoleak and distal ulcer events. The clinical characteristics, short-term and long-term prognosis was compared between the groups. Logistic regression analysis was used to explore the association between different clinical factors and all-cause mortality within 30 days in female and male groups separately. Results: A total of 1 094 patients with Stanford type B aortic dissection were enrolled, mean age was (53.9±12.1) years, and 861 (78.7%) were male and 233 (21.3%) were female. (1) Clinical characteristics: compared with male patients, female patients were featured with older average age, higher proportion of aged≥60 years old, back pain, anemia, optimal medication treatment, and higher cholesterol level; while lower proportion of smoking and drinking history, body mass index, calcium antagonists use, creatine kinase level, and white blood cell count (all P<0.05). However, there was no significant difference in dissection tear and clinical stage, history of coronary heart disease, diabetes, hypertension, and cerebrovascular disease between female and male patients (all P>0.05). (2) Follow-up result: compared with male patients, female patients had a higher rate of 30-day death [6.9% (16/233) vs. 3.8% (33/861), P=0.047], in-hospital death (5.6% (13/233) vs. 2.7% (23/861), P=0.027), preoperative death (3.9% (9/233) vs. 1.5% (12/861), P=0.023) and aorta death (6.0% (14/233) vs. 3.1% (27/861), P=0.041). The 1-year and 5-year follow-up results demonstrated that there were no significant differences in death, cerebrovascular disease, and aorta-related adverse events between the two groups (all P>0.05). (3) Prognostic factors: the results of the univariate logistic regression analysis showed that body mass index>24 kg/m2 (HR=1.087, 95%CI 1.029-1.149, P=0.013), history of anemia (HR=2.987, 95%CI 1.054-8.468, P=0.032), hypertension (HR=1.094, 95%CI 1.047-1.143, P=0.040) and troponin-T>0.05 μg/L (HR=5.818, 95%CI 1.611-21.018, P=0.003)were associated with an increased risk of all-cause mortality within 30 days in female patients. Conclusions: Female patients with Stanford type B aortic dissection have specific clinical characteristics, such as older age at presentation, higher rates of anemia and combined back pain, and higher total cholesterol levels. The risk of death within 1 month is higher in female patients than in male patients, which may be associated with body mass index, hypertension, anemia and troponin-T, but the long-term prognosis for both female and male patients is comparable.

Outcome of surgical repair for aortic coarctation with coexisting descending aortic aneurysm in adult patients / 中华心血管病杂志

Objective: To evaluate the efficacy of surgical treatment of aortic coarctation combined with descending aortic aneurysm in adult patients. Methods: This is a retrospective cohort study. Adult patients with aortic coarctation who were hospitalized in Beijing Anzhen Hospital from January 2015 to April 2019 were enrolled. The aortic coarctation was diagnosed by aortic CT angiography, and the included patients were divided into the combined descending aortic aneurysm group and the uncomplicated descending aortic aneurysm group based on descending aortic diameter. General clinical data and surgery-related data were collected from the included patients, and death and complications were recorded at 30 days after surgery, and upper limb systolic blood pressure was measured in all patients at discharge. Patients were followed up after discharge by outpatient visit or telephone call for their survival and the occurrence of repeat interventions and adverse events, which included death, cerebrovascular events, transient ischemic attack, myocardial infarction, hypertension, postoperative restenosis, and other cardiovascular-related interventions. Results: A total of 107 patients with aortic coarctation aged (34.1±15.2) years were included, and 68 (63.6%) were males. There were 16 cases in the combined descending aortic aneurysm group and 91 cases in the uncomplicated descending aortic aneurysm group. In the combined descending aortic aneurysm group, 6 cases (6/16) underwent artificial vessel bypass, 4 cases (4/16) underwent thoracic aortic artificial vessel replacement, 4 cases (4/16) underwent aortic arch replacement+elephant trunk procedure, and 2 cases (2/16) underwent thoracic endovascular aneurysm repair. There was no statistically significant difference between the two groups in the choice of surgical approach (all P>0.05). In the combined descending aortic aneurysm group at 30 days after surgery, one case underwent re-thoracotomy surgery, one case developed incomplete paraplegia of the lower extremity, and one case died; and the differences in the incidence of endpoint events at 30 days after surgery were similar between the two groups (P>0.05). Systolic blood pressure in the upper extremity at discharge was significantly lower in both groups compared with the preoperative period (in the combined descending aortic aneurysm group: (127.3±16.3) mmHg vs. (140.9±16.3) mmHg, P=0.030, 1 mmHg=0.133 kPa; in the uncomplicated descending aortic aneurysm group: (120.7±13.2) mmHg vs. (151.8±26.3) mmHg, P=0.001). The follow-up time was 3.5 (3.1, 4.4) years. There were no new deaths in the combined descending aortic aneurysm group, no transient ischemic attack, myocardial infarction or re-thoracotomy surgery, and one patient (1/15) suffered cerebral infarction and 10 patients (10/15) were diagnosed with hypertension. The differences in the occurrence of endpoint events during postoperative follow-up were similar between the two groups (P>0.05). Conclusion: In experienced centers, long-term prognosis of patients with aortic coarctation combined with descending aortic aneurysm is satisfactory post surgical intervention.

Aneurisma aórtico torácico com trombose associada em Bugio-preto (Alouatta caraya) / Thoracic aortic aneurysm with associated thrombosis in black-and-gold howler monkey (Alouatta caraya)

O aneurisma é uma dilatação anormal e permanente das artérias, resultante do enfraquecimento da parede do vaso adelgaçamento da camada média e enfraquecimento da camada elástica. Em animais, a maioria dos casos de aneurisma tem origem idiopática e são detectados acidentalmente durante a necropsia. O objetivo deste trabalho é relatar um caso de aneurisma aórtico com trombose associada em Bugio-preto(Alouatta caraya), bem como seus aspectos patológicos. O animal era adulto, macho, pertencente ao Centro Nacional de Primatas (CENP), na cidade de Ananindeua-PA, foi encaminhado para exame necroscópico para investigação da causa mortis. No histórico do animal, não constava qualquer enfermidade. O animal apresentava bom escore de condição corporal com preservação da topografia anatômica dos órgãos. Entretanto, observou-se presença de aumento de volume localizado em aorta torácica, a 1,4 cm da base do coração. Na abertura aórtica foi observado dilatações de tamanhos variados e, no interior da maior dilatação, notou-se uma estrutura de coloração vermelho escuro, aderida, de aspecto seco e superfície áspera, medindo 1,5 cm. Aneurismas aórticos em primatas não humanos não são comuns, porém já foram reportados na literatura. O diagnóstico precoce utilizando exames complementares é importante, porém, ainda há recursos não empregados na rotina veterinária tornando ainda mais difícil o diagnóstico e prevenção. Por isso, na medicina veterinária, os aneurismas são detectados acidentalmente durante a necropsia. Com base nos achados anatomopatológicos, concluiu-se que o animal veio a óbito por trombose associada a aneurisma aórtico.

An aneurysm is an abnormal and permanent dilation of the arteries, resulting from the weakening of the vessel wall.thinning of the middle layer and weakening of the elastic layer. In animals, most cases of aneurysm are idiopathic. This paper aimed to report a case of aortic aneurysm with associated thrombosis in a black-and-gold howler monkey(Alouatta caraya), as well as its pathological aspects. The animal was an adult, male, belonging to the National Primate Center (CENP), in the city of Ananindeua-PA, that was referred for necroscopic examination to investigate the causa mortis. In the animal's history, there was no disease. The animal had a good body condition score with preservation of the anatomical topography of the organs. However, there was an increase in volume located in the thoracic aorta, 1.4 cm from the base of the heart. In the aortic opening, dilations of different sizes were observed, and inside the largest dilatation, a structure of dark red color, adhered, with a dry appearance and rough surface, measuring 1.5 cm was noted in addition to dilations of different sizes. Inside the largest cavitation, a dark red structure was observed, adhered, with a dry appearance and rough surface, measuring 1.5 cm. Aortic aneurysms in non-human primates are incommon, but have been reported in the literature. Early diagnosis using complementary exams is important, however, there are still resources not used in the veterinary routine, making diagnosis and prevention even more difficult. Therefore, in veterinary medicine, aneurysms are accidentally detected during necropsy. Based on the anatomopathological findings, it was concluded that the animal died due to thrombosis associated with an aortic aneurysm.

Aneurisma gigante de aorta torácica. A propósito de un caso clínico / Giant thoracic aortic aneurysm. About a clinical case

El reconocimiento de los aneurismas aórticos torácicos (AAT) es importante ya que pueden tener complicaciones devastadoras si no se diagnostican a tiempo o no se tratan oportunamente. A continuación, se expone un caso clínico de un paciente de 42 años de edad, de sexo masculino, a quien se le diagnosticó un aneurisma gigante de aorta torácica ascendente y arco aórtico, el más grande publicado en la literatura hasta la fecha. La identificación temprana y la derivación para la intervención quirúrgica son vitales para mejorar la morbilidad y la mortalidad de estos pacientes. El objetivo de este artículo es enfatizar en el papel actual de los distintos métodos imagenológicos en la detección y diagnóstico de la patología aórtica. Los aneurismas aórticos torácicos se reconocen cada vez más en angio-TAC, la cual proporciona excelentes detalles de la aorta y sus relaciones con estructuras adyacentes. En la evaluación de la enfermedad aneurismática, las imágenes transversales son particularmente importantes para representar la extensión de la enfermedad, los diámetros aórticos y arteriales totales y la extensión de la formación del trombo mural

Recognition of thoracic aortic aneurysms is important as they can have devastating complications if left undiagnosed or untreated promptly. The following is a clinical case of a 42-year-old male patient, in whom a giant aneurysm of the ascending thoracic aorta and aortic arch was diagnosed, the largest published in the literature to date. Early identification and referral for surgical intervention are vital to improve the morbidity and mortality of these patients. The objective of this article is to emphasize the current role of the different imaging methods in the detection and diagnosis of aortic pathology. Thoracic Aortic Aneurysms are increasingly being recognized on Angio-Tomography, which provides excellent detail of the aorta and its relationships with adjacent structures. In the evaluation of aneurysmal disease, cross-sectional images are particularly important in depicting the extent of disease, total aortic and arterial diameters, and the extent of mural thrombus formation.

Epidemiological analysis of 556 procedures of open thoracoabdominal aortic aneurysm repair in the Public Health System in the largest Brazilian city

ABSTRACT Objective Despite the development of endovascular procedures, open repair remains the gold standard for the treatment of aortic thoracoabdominal aneurysms and some type B dissections, with well-established good outcomes and long-term durability at high-volume centers. The present study described and analyzed public data from patients treated in the public system in a 12-year interval, in a city where more than 5 million inhabitants depend on the Public Health System. Methods Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The variables available in the database include sex, age, elective or emergency hospital admission, number of surgeries, in-hospital mortality, length of stay, and information on reimbursement values. Results A total of 556 procedures were analyzed. Of these, 60.79% patients were men, and 41.18% were 65 years of age or older. Approximately 60% had a residential address registered in the municipality. Of all surgeries, 65.83% were elective cases. There were 178 in-hospital deaths (mortality of 32%). In the elective context, there were 98 deaths 26.78% versus 80 deaths (42.10%) in the emergency context (p=0.174). Mortality was lower in the hospitals that performed more surgeries. A total of USD 3,038,753.92 was paid, an average of USD 5,406.95 for elective surgery and USD 5,074.76 for emergency surgery (p=0.536). Conclusion Mortality was no different between groups, and hospitals with higher volume presented more favorable outcomes. Specialized referral centers should be considered by health policy makers.

Comparison of the outcomes between open and hybrid approaches in the treatment of thoracoabdominal aortic aneurysms repair / 北京大学学报(医学版)

OBJECTIVE@#Thoracoabdominal aortic aneurysm is one of the most challenging aortic diseases. Open surgical repair remains constrained with considerable perioperative morbidity and mortality. The emergence of a hybrid approach utilizing visceral debranching with endovascular aneurysm repair has brought an alternative for high-risk patients. This study aimed to compare the short- and long-term outcomes between hybrid and open repairs in the treatment of thoracoabdominal aortic aneurysms.@*METHODS@#In this retrospectively observational study, patients with thoracoabdominal aortic aneurysm treated in a single center between January 2008 and December 2019 were reviewed, of whom 11 patients with hybrid repair, and 18 patients with open repair were identified. Demographic characteristic, operative data, perioperative morbidity and mortality, freedom from reintervention, and long-term survival were compared between the two groups.@*RESULTS@#In the hybrid repair group, the patients with dissection aneurysm, preoperative combined renal insufficiency, and American Society of Anesthesiologists (ASA) score of 3 or more were significantly overwhelming than in the open repair group. The operation time of debranching hybrid repair was (445±85) min, and the intraoperative blood loss was (955±599) mL. There were 2 cases of complications in the early 30 days after surgery, without paraplegia, and 1 case died. The 30-day complication rate was 18.2%, and the 30-day mortality was 9.1%. The operation time of the patients with open repair was (560±245) min, and the intraoperative blood loss was (6 100±4 536) mL. Twelve patients had complications in the early 30 days after surgery, including 1 paraplegia and 4 deaths within 30 days. The 30-day complication rate was 66.7%, and the 30-day mortality was 22.2%. The bleeding volume in hybrid repair was significantly reduced compared with open repair (P < 0.001). Besides, the incidence of 30-day complications in hybrid surgery was significantly reduced (P=0.011). During the follow-up period, there were 4 reinterventions and 3 deaths in hybrid repair group. The 1-year, 5-year, and 10-year all-cause survival rates were 72%, 54%, and 29%, respectively. In open repair group, reintervention was performed in 1 case and 5 cases died, and the 1-year, 5-year, and 10-year all-cause survival rates were 81%, 71%, and 35%, respectively. There was no significant difference between hybrid repair and open repair in all-cause survival and aneurysm-specific survival.@*CONCLUSION@#Hybrid approach utilizing visceral debranching with endovascular aneurysm repair is a safe and effective surgical method for high-risk patients with thoracoabdominal aortic aneurysms. The incidence of early postoperative complications and mortality is significantly reduced compared with traditional surgery, but the efficacy in the medium and long term still needs to be improved.

The Aortic Pathologies: How Far We Understand It and Its Implications on Thoracic Aortic Surgery

Abstract Thoracic aortic diseases contribute to a major part of cardiac surgeries. The severity of pathologies varies significantly from emergency and life-threatening to conservatively managed conditions. Life-threatening conditions include type A aortic dissection and rupture. Aortic aneurysm is an example of a conservatively managed condition. Pathologies that affect the arterial wall can have a profound impact on the presentation of such cases. Several risk factors have been identified that increase the risk of emergency presentations such as connective tissue disease, hypertension, and vasculitis. The understanding of aortic pathologies is essential to improve management and clinical outcomes.

Exploration of Simplified Intraluminal TEVAR Technique for the Treatment of Aortic Arch Disease

Abstract Objective: The positional relationship between the three branches of the aortic arch was determined in normal people. This study provides data to support the customization of aortic arch stents and simplifies intraluminal treatment. Methods: From January 2019 to August 2019, 120 patients who met the inclusion criteria were examined by CT angiography. The ratio of the distance from the midpoint of the three-branch opening onto the anterior wall to the cross-sectional diameter of the aortic arch was calculated. The positional relationship among the three-branch openings was obtained and the data were analyzed statistically. Results: The three-branch openings were not in a straight line. The positional relationship among the three-branch openings was divided into four types, which were not statistically different between sex and age (P>0.05). Conclusion: By measuring the opening position of the three aortic branches, the positional relationship among the three branches was defined to provide a theoretical basis for the design of intraluminal stents and simplified intracavity thoracic endovascular aortic repair (TEVAR) technology.

Management of acute type A aortic dissection at a public cardiac center in the northeast region of Brazil

Abstract Introduction: Aortic diseases are among the most serious cardiovascular diseases; the overall mortality rate due to diseases such as aneurysms and aortic dissections has been estimated at 2.78 per 100,000 persons in 2010, with a higher mortality rate in men than women. Our objective was to evaluate the epidemiological profile of patients with acute type A aortic dissection at a cardiology referral center. Methods: A retrospective cross-sectional study was performed at a public cardiac center with 24 patients hospitalized from 1/1/2016 to 12/31/2017 with a confirmed diagnosis of acute type A aortic dissection. Results: Twenty (83.3%) out of 24 patients underwent surgery and four (16.7%) did not undergo surgery. Among those who underwent surgery, 10 (50%) died and 10 (50%) were discharged, and all non-operated patients died (P=0.114) (Fisher's exact test). The male gender predominated (n=19, 79.2%), 86.7% (n=13) of the patients presented body mass index > 25 kg/m2, chest pain was found in 91.7% (n=22), and renal failure was present in 45.8% (n=11) of the cases. Hypertension predominated in 91.7% (n=22) and the main exam was aortic angiotomography in 79.2% (n=19) of the cases. Conclusion: The study presented a small sample size, making it impossible to associate the factors, although the service was considered a high-volume referral center. It is possible that the delay in arriving at the service and the accomplishment of invasive imaging with the use of contrast agents have aggravated the patients' condition and have been decisive for the increase in lethality, which requires further studies.

Thoracic aortic aneurysm. An experimental model in pigs

ABSTRACT Purpose To describe an unpublished experimental model of descending thoracic aortic aneurysm in pigs. Methods Ten Landrace female pigs aged 10 to 12 weeks old and with initial weights from 17 to 25 kg were anesthetized and their descending thoracic aortas exposed by fifth intercostal space left thoracotomy. The thoracic aorta was isolated. A 2-cm wide × 2-cm long patch of ready-made bovine pericardium was sewn onto the left anterolateral side of the aorta. After three weeks' follow-up, a control aortography was taken, and the animals were euthanized. The segment of thoracic aorta containing the aneurysm and the adherent tissues were explanted en bloc. The specimens were stained for histological examination. Results One hundred percent of the animals survived the procedure, and after sacrifice a patent aneurysm was observed in all of them. There were no defects on the suture lines. Weight gain during follow-up was normal. All specimens exhibited intense adventitial reaction with myofibroblasts. There were no complications related to the thoracotomy. Conclusions The descending thoracic aortic aneurysms induced experimentally appear to be stable, were of easy execution, with null mortality and no influence on the animals' normal development. Furthermore, they have similar characteristics to those observed in human degenerative aneurysms.

Contained rupture of an aortic arch aneurysm in a patient with syphilitic aortitis. A case report / Ruptura contida de um aneurisma do arco aórtico em paciente com aortite sifilítica. Um relato de caso

Abstract Syphilitic aortitis is a rare complication of tertiary syphilis, which can lead to aortic aneurysm formation, aortic valvular insufficiency, and ostial coronary stenosis. Syphilis has re-emerged worldwide over recent decades and vascular surgeons should be aware of its cardiovascular manifestations. Atypical clinical presentation, such as hemoptysis and a computed tomography angiography pattern of a thicker aneurysmal wall with ulcer-like aneurysm projections, should raise suspicion of syphilitic aortic aneurysm. An early diagnosis and appropriate surgical and medical therapies significantly contribute to successful treatment and favorable prognosis. Herein is reported the case of an 82-year-old male patient, positive for syphilis infection, with impending aortic arch aneurysm rupture treated with a hybrid arch repair. After 7 months, the patient was brought to the emergency room in cardiac arrest. Unsuccessful cardiopulmonary resuscitation maneuvers were performed, and an autopsy showed cardiac tamponade due to rupture of the ascending aorta.

Resumo A aortite sifilítica é uma complicação rara da sífilis terciária, que pode levar a formação de aneurisma aórtico, insuficiência valvar aórtica e estenose ostial coronariana. Ao longo das últimas décadas, a sífilis ressurgiu ao redor do mundo, e os cirurgiões vasculares devem estar atentos às suas manifestações cardiovasculares. Apresentações clínicas atípicas, como a hemoptise, e um padrão na angiotomografia computadorizada de parede aneurismática mais grossa com projeções de aneurisma com aparência de úlcera devem levantar a suspeita de aneurisma sifilítico da aorta. O diagnóstico precoce e terapias cirúrgica e clínica adequadas contribuem significativamente para um tratamento bem-sucedido e prognóstico favorável. Relatamos o caso de um paciente do sexo masculino, de 82 anos, que apresentou infecção por sífilis com ruptura iminente de aneurisma do arco aórtico. Ele foi tratado com reparo híbrido do arco. Após 7 meses, o paciente deu entrada na emergência com parada cardiorrespiratória. As manobras de reanimação cardiopulmonar foram realizadas, mas não obtiveram sucesso, e a autópsia mostrou tamponamento cardíaco devido à ruptura da aorta ascendente.

Epidemiological analysis of 5,595 procedures of endovascular correction of isolated descending thoracic aortic disease over 12 years in the public health system in Brazil

OBJECTIVES: In Brazil, descending thoracic aorta disease, including aneurysms and dissections, is managed preferentially by endovascular treatment, owing to its feasibility and good results. In this study, we analyzed endovascular treatment of isolated descending thoracic aortic disease cases in the Brazilian public health system over a 12-year period. METHODS: Public data from procedures performed from 2008 to 2019 were extracted using web scraping techniques to assess procedure type frequency (elective or urgency), mortality, and governmental costs. RESULTS: A total of 5,595 procedures were analyzed, the vast majority of which were urgent procedures (61.82% vs. 38.18%). In-hospital mortality was lower for elective than for urgent surgeries (4.96 vs.10.32% p=0.008). An average of R$16,845.86 and R$20,012.04 was paid per elective and emergency procedure, respectively, with no statistical difference (p=0.095). CONCLUSION: Elective procedures were associated with lower mortality than urgent procedures. There was no statistically significant difference between elective and urgent procedures regarding costs.

Hemoptisis como signo de alarma de pseudoaneurisma de la aorta torácica: reporte de caso / Hemoptysis as a warning sign of thoracic aorta pseudoaneurysm: a case report

El pseudoaneurisma se define como un hematoma pulsátil repermeabilizado, encapsulado y en comunicación con la luz de un vaso dañado. Se origina cuando hay una disrupción de la pared arterial. La hemoptisis es un signo/síntoma de presentación muy rara de aneurisma aórtico torácico y de pseudoaneurisma aórtico torácico. Hay poca información sobre la hemoptisis asociada con la ruptura del aneurisma aórtico cuyo mecanismo no se explica por la presencia de una fístula aortopulmonar. Entre las hipótesis para explicar este fenómeno, se encuentra la capacidad de las arterias bronquiales de volverse hiperplásicas y tortuosas en presencia de una lesión que modifica la arquitectura pulmonar, siendo más susceptibles a la ruptura. También hay descripciones de lesiones directas del parénquima pulmonar por aneurisma roto. El presente caso nos ilustra que debemos considerar a la hemoptisis como signo de alarma en el diagnóstico diferencial de los aneurismas y pseudoaneurismas aórticos entre otras causas que puede ser fatal en breve tiempo por una hemorragia masiva.

Pseudoaneurysm is defined as a reperfused pulsatile hematoma, encapsulated and communicated with the damaged vessel's lumen. It originates when there is a disruption of the arterial wall. Hemoptysis is a very rare sign/symptom of a thoracic aortic aneurysm or pseudoaneurysm. There is little information on hemoptysis associated with aortic aneurysm rupture, whose mechanisms are not explained by the presence of an aortopulmonary fistula. Among the hypotheses to explain this phenomenon, is the ability of the bronchial arteries to become hyperplasic and tortuous in the presence of a lesion that modifies the pulmonary architecture, being more susceptible to rupture. There are also descriptions of direct lung parenchymal injury from ruptured aneurysm. The present case illustrates that we must consider the hemoptysis as a warning sign in differential diagnosis of aortic aneurysms and pseudo aneurysms, among other causes, that it can be fatal in a short time due to massive hemorrhage.

Thoracic aortic size in Brazilian smokers: measures using low-dose chest computed tomography anatomical and epidemiological assessment

OBJECTIVES: Thoracic aortic aneurysms (TAAs) represent one-third of the hospitalizations for aortic diseases. The prevalence rate depends on the definition of the normal size of the aorta, which is quite variable, depending on the population studied. The aim of this study was to evaluate the characteristics of the thoracic aorta of Brazilian smokers, identifying the normal size of the aorta, presence of anatomical variations, and prevalence of TAA. MATERIALS AND METHODS: A total of 711 patients underwent radiological evaluation with low-dose computed tomography (CT) from January 2013 to July 2014 with the initial objective of lung nodule tracking. Two examiners evaluated these images, and measurements of maximum and serial diameters were performed manually in true orthogonal planes. Serial diameter measurements were taken every 2 cm in the ascending aorta and 5 cm in the descending segment. We searched for anatomical variations, aortic arch type, and correlations between anatomical characteristics, sex, body mass index, and body surface area (BSA). RESULTS: The maximum diameters were 33.61 (standard deviation [SD] 3.88), 28.66 (SD 2.89), and 28.36 mm (SD 3.09) for the ascending segment, aortic arch, and descending segment, respectively. A positive correlation was found between male sex, age, and BSA and aorta diameter. The bovine arch was the most common variation of the aortic arch type, and we found one (0.14%) case of TAA. CONCLUSIONS: This study with low-dose CT allowed the determination of the mean diameters of the ascending aorta, aortic arch, and descending aorta in Brazilian smokers and TAA prevalence.

Endovascular correction of isolated descending thoracic aortic disease: a descriptive analysis of 1, 344 procedures over 10 years in the public health system of São Paulo

OBJECTIVES: In Brazil, descending thoracic aorta disease (TAD), including aneurysms and dissection, are preferentially managed by endovascular treatment (TEVAR) due to the feasibility and good results of this technique. In this study, we analyzed endovascular treatment of isolated TAD (ITAD) in the public health system over a 10-year period in São Paulo, a municipality in Brazil in which more than 5 million inhabitants depend on the governmental health system. METHODS: Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The following types of data were analyzed: demographic data, operative technique, elective or urgent status, number of surgeries, in-hospital mortality, length of hospital stay, mean length of stay in the intensive care unit, and reimbursement values paid by the government. Trauma cases and congenital diseases were excluded. RESULTS: A total of 1,344 procedures were analyzed; most patients were male and aged ≥65 years. Most individuals had a residential address registered in the city. Approximately one-third of all surgeries were urgent cases. There were 128 in-hospital deaths (9.52%), and in-hospital mortality was lower for elective than for urgent surgeries (7.29% vs. 14.31%, p=0.031). A total of R$ 24.766.008,61 was paid; an average of R$ 17.222,98 per elective procedure and R$ 18.558,68 per urgent procedure. Urgent procedures were significantly more expensive than elective surgeries (p=0.029). CONCLUSION: Over a 10-year period, the total cost of ITAD interventions was R$ 24.766.008,61, which was paid from the governmental system. Elective procedures were associated with lower mortality and lower investment from the health system when compared to those performed in an urgent scenario.

Efficacy of endovascular treatment of distal aortic dissection involving abdominal visceral segment with bare-metal stents related technique / 中华心血管病杂志

Objective: To investigate the effect of bare-metal stent related technique on distal aortic dissection involving abdominal visceral segment. Methods: A retrospective analysis was performed on clinical data of 33 patients with distal aortic dissection involved abdominal visceral segment, who hospitalized in the Vascular Surgery Department of Shanghai Changhai Hospital from July 2012 to September 2019. The effect of the treatment was evaluated according to the clinical and preoperative, intraoperative and follow-up imaging data derived from (aorta computed tomography angiography (CTA) and digital subtraction angiography (DSA)) as well as the changes of the maximal diameter of the aorta and the thrombosis of the false lumen of the dissection. The criteria were as follows: the maximum diameter change of aortic dissection<5 mm was defined as stable; the maximum diameter decrease of aortic dissection≥5 mm was defined as effective reduction; the maximum diameter increase of aortic dissection≥5 mm was defined as expansion; the definition of diameter change of false lumen was the same as above. The hospital complications, clinical symptoms and survival were recorded. Results: There were 28 male patients in this cohort, the mean age was (57.6±4.9) years old. Twenty-one patients were treated with bare-metal stent and coils technique, of which 8 patients were jointly treated with stent grafts. Twelve patients were treated with multi-layer bare-metal stent technique, of which 4 patients were jointly treated with stent grafts. Intraoperative DSA image results showed that the visceral arteries were patent during the treatment, and the blood flow velocity of the false lumen was reduced in all 33 patients. There were no adverse events such as distal outflow tract embolism and coil displacement during the operation. During the period of hospitalization, one patient developed intimal rupture of subrenal abdominal aortic dissection on the fourth day after operation and emergency endovascular graft exclusion was performed for abdominal aortic dissection, and the patient recovered well from the emergency operation. The follow-up time was (16.7±14.0) months. One patient died 1 year after surgery due to non-disease-related factors. Follow-up CTA imaging results showed that the maximum diameter of the aorta in abdominal visceral segment tended to be smaller ((39.1±13.4) mm vs. (41.3±11.9) mm, P=0.469), and the maximum diameter of the false lumen was significantly reduced ((16.2±12.9) mm vs. (23.5±10.7) mm, P=0.014). The maximum diameter of the aortic dissection was reduced in 12 cases, stable in 19 cases, expanded in 2 cases. The maximum diameter of the false lumen was effectively reduced in 22 cases, stable in 10 cases, and expanded in 1 case. Four patients developed small endoleak in the false lumen, one of them was nearby the renal artery stent, and the remaining patients experienced complete thrombosis of the false lumen. Conclusions: Endovascular treatment of distal aortic dissection involving abdominal visceral segment with bare-metal stents related technique could promote the shrink and the thrombosis of the false lumen, and slow down the blood flow from the tear into the false lumen in the setting of patency of visceral arteries.

Treatment of thoracoabdominal aortic aneurysm by prosthetic vessel replacement under left heart bypass / 中南大学学报(医学版)

OBJECTIVES@#Thoracoabdominal aortic aneurysm (TAAA) prosthetic vessel replacement is one of the most complex operations in the field of cardiovascular surgery. The key to success of this operation is to prevent and avoid ischemia of important organs while repairing TAAA. This study aims to summarize and analyze the effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA.@*METHODS@#Data of 15 patients with TAAA who underwent prosthetic vessel replacement under left heart bypass in Xiangya Hospital of Central South University were retrospectively analyzed. According to Crawford classification, there were 2 cases of type I, 8 cases of type II, 3 cases of type III, and 2 cases of type V. There were 14 cases of selective operation and 1 case of emergency operation. All operations were performed under left heart bypass, and cerebrospinal fluid drainage was performed before operation. Left heart bypass was established by intubation of left inferior pulmonary vein and distal abdominal aorta or left femoral artery. The thoracoabdominal aorta was replaced segment by segment. After aortic dissection, the kidneys were perfused with cold crystalloid renal protective solution, and the celiac trunk and superior mesenteric artery were perfused with warm blood.@*RESULTS@#One patient with TAAA after aortic dissection of type A died. During the operation, straight blood vessels were used to repair TAAA, and the celiac artery branches were trimmed into island shape and anastomosed with prosthetic vessels. After the operation, massive bleeding occurred at the anastomotic stoma, then anaphylactic reaction occurred during massive blood transfusion, resulting in death. One patient suffered from paraplegia due to ischemic injury of spinal cord. The other patients recovered well and were discharged. The postoperative ventilation time was (16.5±13.8) h and the postoperative hospital stay was (10±4) d. The amount of red blood cell transfusion was (13±9) U. The patients were followed up for 2 months to 2 years, and the recovery was satisfactory.@*CONCLUSIONS@#The effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA is good, which is worthy of clinical promotion.