Ascending aortic rupture incidentally revealed at the cath lab: surprising, rare, and life-threatening.

An 80-year-old woman who was an active smoker with neglected long-term hypertension, but no known previous aortic or connective tissue disorders, presented to the emergency department complaining of sudden chest pain associated with cardiogenic shock.

Proximal false lumen thrombosis is associated with low false lumen pressure and fewer complications in type B aortic dissection.

BACKGROUND: Improved risk stratification is a key priority for type B aortic dissection (TBAD). Partial false lumen thrombus morphology is an emerging predictor of complications. However, partial thrombosis is poorly defined, and its evaluation in clinical studies has been inconsistent. Thus, we aimed to characterize the hemodynamic pressure in TBAD and determine how the pressure relates to the false lumen thrombus morphology and clinical events. METHODS: The retrospective admission computed tomography angiograms of 69 patients with acute TBAD were used to construct three-dimensional computational models for simulation of cyclical blood flow and calculation of pressure. The patients were categorized by the false lumen thrombus morphology as minimal, extensive, proximal or distal thrombosis. Linear regression analysis was used to compare the luminal pressure difference between the true and false lumen for each morphology group. The effect of morphology classification on the incidence of acute complications within 14 days was studied using logistic regression adjusted for clinical parameters. A survival analysis for adverse aortic events at 1 year was also performed using Cox regression. RESULTS: Of the 69 patients, 44 had experienced acute complications and 45 had had an adverse aortic event at 1 year. The mean ± standard deviation age was 62.6 ± 12.6 years, and 75.4% were men. Compared with the patients with minimal thrombosis, those with proximal thrombosis had a reduced false lumen pressure by 10.1 mm Hg (95% confidence interval [CI], 4.3-15.9 mm Hg; P = .001). The patients who had not experienced an acute complication had had a reduced relative false lumen pressure (-6.35 mm Hg vs -0.62 mm Hg; P = .03). Proximal thrombosis was associated with fewer acute complications (odds ratio, 0.17; 95% CI, 0.04-0.60; P = .01) and 1-year adverse aortic events (hazard ratio, 0.36; 95% CI, 0.16-0.80; P = .01). CONCLUSIONS: We found that proximal false lumen thrombosis was a marker of reduced false lumen pressure. This might explain how proximal false lumen thrombosis appears to be protective of acute complications (eg, refractory hypertension or pain, aortic rupture, visceral or limb malperfusion, acute expansion) and adverse aortic events within the first year.

3D Modeling of Blood Flow in Simulated Abdominal Aortic Aneurysm.

BACKGROUND: Besides biological factors, abdominal aortic aneurysm rupture is also caused by mechanical parameters, which are constantly affecting the wall's tissue due to their abnormal values. The ability to evaluate these parameters could vastly improve the clinical treatment of patients with abdominal aortic aneurysms. The objective of this study was to develop and demonstrate a methodology to analyze the fluid dynamics that cause the wall stress distribution in abdominal aortic aneurysms, using accurate 3D geometry and a realistic, nonlinear, elastic biomechanical model using a computer-aided software. METHODS: The geometry of the abdominal aortic aneurysm; was constructed on a 3D scale using computer-aided software SolidWorks (Dassault Systems SolidWorksCorp., Waltham MA). Due to the complex nature of the abdominal aortic aneurysm geometry, the physiological forces and constraints acting on the abdominal aortic aneurysm wall were measured by using a simulation setup using boundary conditions and initial conditions for different studies such as finite element analysis or computational fluid dynamics. RESULTS: The flow pattern showed an increase velocity at the angular neck, followed by a stagnated flow inside the aneurysm sack. Furthermore, the wall shear stress analysis showed to focalized points of higher stress, the top and bottom of the aneurysm sack, where the flow collides against the wall. An increase of the viscosity showed no significant velocity changed but results in a slight increase in overall pressure and wall shear stress. CONCLUSIONS: Conducting computational fluid dynamics modeling of the abdominal aortic aneurysm using computer-aided software SolidWorks (Dassault Systems SolidWorksCorp., Waltham MA) proves to be an insightful approach for the clinical setting. The careful consideration of the biomechanics of the abdominal aortic aneurysm may lead to an improved, case-specific prediction of the abdominal aortic aneurysm rupture potential, which could significantly improve the clinical management of these patients.

The fate of endovascular aortic aneurysm repair after 5 years monitored with duplex ultrasound imaging.

BACKGROUND: Interventions for aortic aneurysm sac growth have been reported across multiple time points after endovascular aortic aneurysm repair (EVAR). We report the long-term outcomes of patients after EVAR monitored with duplex ultrasound (DUS) imaging with respect to the need for and type of intervention after 5 years. METHODS: We report a series of patients who were monitored with DUS imaging for a minimum of 5 years after EVAR. DUS imaging was performed in an accredited noninvasive vascular laboratory, and computed tomography angiography was only performed for abnormal DUS findings. RESULTS: There were 156 patients who underwent EVAR with follow-up >5 years (mean, 7.5 years; range, 5.1-14.5 years). Interventions for endoleak, graft limb stenosis, or thrombosis were performed in 44 patients (28%) at some time during follow-up. Of the 156 patients, 34 (22%) underwent their first intervention during the first 5 years (25 endoleaks, 9 limb stenoses, or occlusions). Four ruptures occurred, all in patients with their first intervention before 5 years. The remaining 10 patients (6%) underwent a first intervention >5 years after implantation: 3 for type I endoleak, 2 for type II endoleak with sac expansion, 2 for combined type I and II endoleaks 2 for type III endoleak, and 1 unknown type. CONCLUSIONS: Long-term follow-up of EVAR (mean, 7.5 years) revealed that approximately one in four patients will require intervention at some point during follow-up. First-time interventions were necessary in 22% of all patients in the first 5 years and in 6% of patients after 5 years, highlighting the need for continued graft surveillance beyond 5 years. All patients who had a first-time intervention after 5 years underwent an endoleak repair; none of these patients had a thrombosed limb or a rupture as a result of the endoleak.

Economic evaluation in the context of rare diseases: is it possible? / Evaluación económica en el contexto de enfermedades raras: ¿es posible? / Avaliação econômica no âmbito das doenças raras: isto é possível?

This study analyzes the available evidence on the adequacy of economic evaluation for decision-making on the incorporation or exclusion of technologies for rare diseases. The authors conducted a structured literature review in MEDLINE via PubMed, CRD, LILACS, SciELO, and Google Scholar (gray literature). Economic evaluation studies had their origins in Welfare Economics, in which individuals maximize their utilities based on allocative efficiency. There is no widely accepted criterion in the literature to weigh the expected utilities, in the sense of assigning more weight to individuals with greater health needs. Thus, economic evaluation studies do not usually weigh utilities asymmetrically (that is, everyone is treated equally, which in Brazil is also a Constitutional principle). Healthcare systems have ratified the use of economic evaluation as the main tool to assist decision-making. However, this approach does not rule out the use of other methodologies to complement cost-effectiveness studies, such as Person Trade-Off and Rule of Rescue.

El objetivo fue sistematizar las evidencias disponibles sobre la pertinencia de utilizar la evaluación económica para la incorporación/exclusión de tecnología en enfermedades raras. Se realizó una revisión sistemática de la literatura en MEDLINE vía PubMed, CRD, LILACS, SciELO y Google Académico (literatura gris). Los estudios de evaluación económica se originan de la Economía del Bienestar, en la que los individuos maximizan sus utilidades, basándose en la eficiencia de asignación. No existe un criterio ampliamente aceptado para examinar las utilidades, a fin de dar más peso a los individuos con mayores necesidades. Generalmente, los estudios no equilibran asimétricamente las utilidades, todas son consideradas iguales, lo que en Brasil es también un principio constitucional. Los sistemas de salud han ratificado el uso de la evaluación económica como la principal herramienta para ayudar en la toma de decisiones. Sin embargo, este abordaje no excluye el uso de otras metodologías complementarias a los estudios de coste-efectividad, como la técnica de compensación personal o la regla del rescate.

O objetivo deste estudo foi analisar as evidências disponíveis sobre a adequação do uso de avaliação econômica sobre incorporação/exclusão de tecnologias para doenças raras. Foi realizada uma revisão estruturada da literatura, nas bases MEDLINE, via PubMed, CRD, LILACS, SciELO e Google Acadêmico (literatura cinzenta). Os estudos de avaliação econômica têm origem na Economia do Bem-Estar, na qual os indivíduos maximizam suas utilidades, fundamentando-se na eficiência alocativa. Não há um critério amplamente aceito para ponderar as utilidades esperadas, no sentido de dar mais peso aos indivíduos com maiores necessidades em saúde. Geralmente não se ponderam assimetricamente as utilidades; todas são tratadas de forma igualitária, que, no caso brasileiro, também é um princípio constitucional. Os sistemas de saúde têm ratificado o uso de avaliação econômica como principal instrumento para auxiliar na tomada de decisão. No entanto, essa postura não exclui o uso de outras metodologias complementares aos estudos de custo-efetividade, como Person Trade-Off e regra de resgate.

The similarities and differences among patients with abdominal aortic aneurysms referred to a tertiary hospital and found at necropsy.

OBJECTIVE: To analyze the characteristics of patients with abdominal aortic aneurysms referred to a tertiary center and to compare with individuals with abdominal aortic aneurysm found at necropsy. METHODS: We have retrospectively analyzed the medical records of 556 patients with abdominal aortic aneurysm and 102 cases abdominal aortic aneurysm found at necropsy. RESULTS: At univariated analysis, hypertension, tobacco use and maximum diameter were significant risk factors for symptomatic aneurysm, while diabetes tended to be a protective factor for rupture. By logistic regression analysis, the largest transverse diameter was the only one significantly associated with abdominal aortic aneurysm rupture (p < .0001, odds ratio 1.7, 95% confidence interval 1.481-1.951). Intact abdominal aortic aneurysm found at necropsy showed similarities with outpatients in relation to abdominal aortic aneurysm diameter and risk factors. CONCLUSION: Intact abdominal aortic aneurysm at necropsy and at outpatients setting showed similarities that confirmed that abdominal aortic aneurysm repair is less offered to women, and they died more frequently with intact abdominal aortic aneurysm from other causes.

Aortic rupture during reoperative bariatric surgery.

Morbid obesity has become a very common problem worldwide, causing severe health-related consequences including cardiovascular or metabolic diseases, arthritis, sleep apnea, or an increased risk of cancer. Bariatric surgery was shown to be the only way to achieve sustainable weight loss and to decrease the frequency and severity of metabolic and cardiovascular comorbidities. The purpose of this article is to present a case of bariatric surgery complicated with lesion of the aorta with a lethal outcome.

Endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval fistula based on aortic and inferior vena cava stent-graft placement.

A ruptured abdominal aortic aneurysm (RAAA), complicated by an aortocaval fistula (ACF), is usually associated with high morbidity and mortality during open operative repair. We report a case of endovascular treatment of an RAAA with ACF. After accessing both common femoral arteries, a bifurcated aortic stent graft was placed. Subsequently, we accessed the fistula from the right femoral vein and a cava vein angiography showed a persistent massive flow from the cava to the excluded aneurysm sac. We proceeded by covering the fistula with an Excluder aortic stent-graft cuff to prevent pressurization of the aneurysm sac and secondary endoleaks. This procedure is feasible and may reduce the chances of posterior endoleaks.

Histologic, histochemical, and biomechanical properties of fragments isolated from the anterior wall of abdominal aortic aneurysms.

OBJECTIVE: To analyze biomechanical, histologic, and histochemical properties of anterior fragments of abdominal aortic aneurysms (AAA) and to correlate them with the maximum transverse diameter (MTD) and symptoms associated to the aneurysms. METHODS: Fragments of the anterior aneurysm wall were obtained from 90 patients submitted to open repair of AAA of degenerative etiology from 2004 to 2009 in the Clinics Hospital of São Paulo University Medical School. Two specimens were produced from the fragments: one for histologic analysis for quantification of collagen fibers, elastic fibers, smooth muscle cells, and degree of inflammatory activity and the other for uniaxial tensile test to assess biomechanical failure properties of the material, such as strength, tension, and stress. Cases were classified according to symptoms and to the AAA MTD. RESULTS: Fragments from AAA with MTD < 5.5 cm showed higher values for biomechanical failure properties than those of AAA with MTD < 5.5 cm (strength, 5.32 ± 2.07 × 4.1 ± 2.41 N; tension, 13.83 ± 5.58 × 10.82 ± 6.48 N/cm; stress, 103.02 × 77.03 N/cm(2); P < .05). No differences were observed between the groups in relation to failure strain (0.41 ± 0.12 × 0.37 ± 0.14; P = .260) and thickness of the fragments (1.58 ± 0.41 × 1.53 ± 0.42 mm; P = .662). The average values of fiber compositions of all the fragments were as follows: collagen fibers, 44.34 ± 0.48% and 61.85 ± 10.14% (Masson trichrome staining and Picrosirius red staining, respectively); smooth muscle cells, 3.46 ± 2.23% (immunohistochemistry/alpha-actin); and elastic fibers, less than 1% (traces) (Verhoeff-van Gieson staining). No differences in fiber percentages (collagen, elastic, and smooth muscle) were observed in fragments from AAA with MTD <5.5 cm and <5.5 cm, but more intense inflammatory activity was seen in larger AAA (grade 3; 70% × 28.6%; P = .011). Compared with asymptomatic aneurysms, symptomatic aneurysms showed no differences in the biomechanical failure properties (strength, 5.32 ± 2.36 × 4.65 ± 2.05 N; P = .155; tension, 14.08 ± 6.11 × 12.81 ± 5.77 N/cm; P = .154; stress, 103.02 × 84.76 N/cm(2); P = .144), strain (0.38 ± 0.12 × 0.41 ± 0.13; P = .287), thickness of the fragments (1.56 ± 0.41 × 1.57 ± 0.41 mm; P = .848), and histologic composition (collagen fibers, 44.67 ± 11.17 × 44.02 ± 13.79%; P = .808; smooth muscle fibers, 2.52 × 2.35%; P = .751; elastic fibers, <1%) CONCLUSIONS: Fragments of the anterior wall from larger aneurysms were more resistant than those from smaller AAA, with no tissue properties that could explain this phenomenon in the histologic or histochemical analyses utilized. CLINICAL RELEVANCE: The fragments of the anterior midsection from larger aneurysms were more resistant than those from smaller abdominal aortic aneurysms, with no tissue properties that could explain this phenomenon in the histologic or histochemical analyses. Larger aneurysms, at least in this place may be stronger than smaller aneurysms. It could point toward regional differences (heterogeneity, localized pathologies) as an important player in aneurysm rupture. Uniaxial strain tests are an important tool for the comprehension of a complex behavior such as that from an aneurysmal aortic wall. However, these tests still have limitations in providing information that would allow the calculation of the risk of rupture for abdominal aortic aneurysms.

Aorta after stent grafting for mycotic aneurysm.

Endovascular stent grafting is applied for the treatment of different aortic pathologies in the current medical era. It may be lifesaving in patients with comorbidities and virtually inoperable when adopting conventional techniques. This manuscript reports on a 40-year-old patient, who was previously treated for a mycotic saccular aneurysm at the aortic arch and who presented with a descending aortic rupture at the mid-term follow-up. The descending aortic rupture was also managed successfully by endovascular measures.

Aorta após endoprótese para aneurisma micótico / Aorta after stent grafting for mycotic aneurysm / Aorta después de endoprótesis para aneurisma micótico

Endopróteses vasculares são atualmente utilizadas no tratamento de diferentes patologias da aorta. Podem salvar a vida de pacientes com comorbidades e virtualmente inoperáveis quando da utilização de técnicas convencionais. Esse manuscrito relata o caso de um paciente de 40 anos, que havia sido previamente tratado de um aneurisma micótico sacular no arco aórtico e que apresentou ruptura da aorta descendente no seguimento de médio prazo. O tratamento da ruptura da aorta descendente também foi realizado através de medidas endovasculares, com sucesso.

Endovascular stent grafting is applied for the treatment of different aortic pathologies in the current medical era. It may be lifesaving in patients with comorbidities and virtually inoperable when adopting conventional techniques. This manuscript reports on a 40-year-old patient, who was previously treated for a mycotic saccular aneurysm at the aortic arch and who presented with a descending aortic rupture at the mid-term follow-up. The descending aortic rupture was also managed successfully by endovascular measures.

Endoprótesis vasculares son actualmente utilizadas en el tratamiento de diferentes patologías de la aorta. Pueden salvar la vida de pacientes con comorbilidades y virtualmente inoperables con la utilización de técnicas convencionales. Este manuscrito relata el caso de un paciente de 40 años, que había sido previamente tratado de un aneurisma micótico sacular en el arco aórtico y que presentó ruptura de la aorta descendente en el seguimiento de medio plazo. El tratamiento de la ruptura de la aorta descendente también fue realizado a través de medidas endovasculares, con éxito.

Tratamiento endovascular de transecciones agudas de la aorta descendente / Endovascular treatment of acute traumatic aortic rupture

Background: Traumatic rupture of the thoracic aorta as a result from high-speed deceleration injury is associated with a mortality rate of 80 percent to 90 percent at the scene of the accident. Survivors usually have life-threatening injuries to other organ systems. Standard open repair is associated with a high penoperative morbidity and mortality. Endografting offers a less invasive alternative to open surgical repair. Aim: To evaluate results of endovascular management of acute traumatic descending thoracic aortic ruptures. Methods: Between August 2002 and March 2010, patients treated for this trauma were reviewed. Results: 16 patients (fourteen males mean age 42.7 +/- 15.8 years, range 24-74) underwent endovascular treatment of an acute aortic rupture. Associated traumas in fifteen patients were: severe brain (7), spleen (4), liver (1), kidney (3) and large bone (9) injuries. Motor vehicle accidents caused 13 of the injuries and fall from height 3. Rupture was diagnosed with admission CT sean and confirmed by intraoperative angiogram. Patients were treated with thoracic aortic endograft, in 11 cases the left subclavian artery was covered with no need for further revascularization. Technical success was 100 percent, no procedure-related mortality or paraplegia was observed. One patient died 5 days after the procedure due to severe associated injuries. During a mean follow-up of 30.8 months (range 1-80), no deaths, complications or need for further interventions presented. Conclusion: Endovascular treatment of acute traumatic aortic isthmic rupture is encouraging and compares favorably to open surgical approach with low morbidity and mortality rates.

Los accidentes por desaceleración súbita se asocian a transección de la aorta torácica, falleciendo 85-90 por ciento de ellos en el sitio del suceso. Los que sobreviven presentan habitualmente politraumatismo asociado grave, teniendo la reparación quirúrgica convencional de la aorta una alta morbimortalidad. La reparación endovascular es una alternativa menos invasiva y de menor morbi-mortalidad. Objetivo: Analizar los resultados de la reparación endovascular de transecciones agudas de la aorta torácica. Pacientes y Métodos: Se revisan los antecedentes de los pacientes tratados entre agosto de 2002 y marzo de 2010. Resultados: Tratamos 16 pacientes (14 hombres, 42,7 +/- 15,8 años, extremos 24-74) con transección traumática aguda de aorta torácica descendente. Quince presentaban lesiones asociadas: traumatismo encéfalo-craneano (7), fractura de huesos largos (9), laceración esplénica (4), hepática (1), renal (3). La causa del accidente fue vehicular en 13 casos y caída de altura en 3. El diagnóstico fue realizado mediante tomograña axial computada al ingreso y luego angiograña en la sala de operaciones. El tratamiento consistió en la cobertura de la zona de transección mediante el implante de una endoprótesis, siendo necesario cubrir la arteria subclavia izquierda en 11 casos, sin requerir revascularización de la extremidad. El éxito técnico fue 100 por ciento, no hubo mortalidad relacionada al procedimiento. No hubo paraplejia. Un paciente de 60 años fallece al 5to día por lesiones asociadas graves. En el seguimiento alejado a 30,8 meses (1-80) no ha habido complicaciones ni reintervenciones. Conclusión: La cirugía endovascular es una alternativa eficaz y con baja morbimortalidad para el tratamiento de transecciones de la aorta torácica.

Prevention of rupture of abdominal aortic aneurysm.

BACKGROUND AND AIMS: Two thirds of patients with an abdominal aortic aneurysm (AAA) have relevant coronary artery disease (CAD). AAAs are prevalent in up to 16% of smokers with CAD. General screening of AAA is controversial. Aim was to assess the potential of finding AAA prior to rupture among patients with known CAD. Main endpoint was whether AAA could have been found during follow-up by sonography or at other time of cardiovascular evaluation. MATERIAL AND METHODS: Retrospective study. 213 consecutive, formerly unknown emergently operated AAAs, treated emergently for symptoms (n = 91) or rupture (n = 122) (rAAA) between January 1998 and June 2005. Patient charts were analysed and primary care physicians contacted. RESULTS: At presentation, mean age was 71 (+/-9) years, twenty (9%) were female. AAA had a mean diameter of 7.6 cm. Two thirds (143) were clinically obese (BMI 27 +/-5). 137 (64%) were active smokers, 32 (15%) had diabetes, 151 (71%) were hypertensive, and 80 (38%) received statin treatment. CAD had been diagnosed in 95 (45%) 9 years earlier and followed up. Thirty-five (16%) had had myocardial infarction. Echocardiography had been performed in 52 (24%). Thirty day mortality after open surgery was 25 (21%). CONCLUSION: All patients with rAAA had been seen by a GP or cardiologist within a year prior to presentation. The cost effectiveness of selective AAA screening should be evaluated in a larger study.

Successful endovascular management of a traumatic aortic rupture in a pediatric patient: case report and literature review.

We report herein an 11-year-old pedestrian struck by a motorcycle, who suffered subdural hematoma and aortic rupture and developed traumatic pseudoaneurysm. He was treated conservatively for the first 24 hours and submitted to stent placement occluding the aneurysm neck. There were no recurrences in the post-procedure period and the child was discharged after 21 days without sequelae. This report also reviews trauma mechanisms and management of such threatening lesions in the pediatric population.

Ruptura da valva aórtica por trauma torácico fechado / Aortic valve rupture due to blunt chest trauma

Relatamos o caso de paciente internado em nossa instituição com ruptura da válvula coronariana direita da valva aórtica, secundária a trauma torácico fechado. O ecocardiograma transesofágico identificou o local da ruptura, permitindo melhor planejamento cirúrgico.

We report a patient admitted to our hospital with aortic valve rupture due to blunt chest trauma. The aortic rupture was accurately identified by the transesophageal echocardiogram, allowing a better surgical approach.

Aortic valve rupture due to blunt chest trauma.

We report a patient admitted to our hospital with aortic valve rupture due to blunt chest trauma. The aortic rupture was accurately identified by the transesophageal echocardiogram, allowing a better surgical approach.