The intraspinal arterial collateral network: a new anatomical basis for understanding and preventing paraplegia during aortic repair

Abstract OBJECTIVES The anatomical distribution pattern of epidural intraspinal arteries is not entirely understood but is likely to substantially impact maintaining perfusion during segmental artery sacrifice when treating acute and chronic thoraco-abdominal aortic diseases. We investigated the anatomical distribution pattern of intraspinal arteries. METHODS Twenty fresh, non-embalmed cadaveric human bodies were studied. Anatomical dissection and investigation of the epidural arterial network were performed according to a standardized protocol. We used a generalized mixed linear model to test whether the presence probability for certain vessels differed between vertebrae/segments. RESULTS There was craniocaudal continuity of all ipsilateral longitudinal connections from T1 to L5 by the anterior radicular artery. The mean [±standard deviation (SD)] number of transverse anastomoses was 9.7 ± 2.1. The presence probability of transverse anastomoses along the spine was different between vertebrae (P < 0.0001). There were 2 distribution peaks along the spine: 1 peak around T4–T6 and 1 around T11. The mean (±SD) number of thoracic and lumbar anterior radiculomedullary arteries (ARMAs) was 3.0 ± 1.1. The probability of the presence of ARMAs along the spine was different for each vertebral segment (P < 0.0001). Between ARMAs there were gaps of up to a maximum of 9 vertebrae. All Adamkiewicz arteries were located caudally to T7. The median segment of the Adamkiewicz presence was T10/11. CONCLUSIONS The epidural collateral network shows craniocaudal continuity. The number of transverse anastomoses is high. The number of ARMAs is low, and there is considerable variation in their distribution and offspring, which is highly likely to impact perfusion during segmental artery sacrifice when treating thoraco-abdominal aortic disease.

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Statins in Aortic Disease

Current Pharmaceutical Design ◽

10.2174/1381612823666171115100829 ◽

2018 ◽

Vol 23 (46) ◽

pp. 7109-7120

Author(s):

Vasiliki Tsigkou ◽

Gerasimos Siasos ◽

Evanthia Bletsa ◽

Maria-Paraskevi Panoilia ◽

Angeliki Papastavrou ◽

...

Keyword(s):

Aortic Valve ◽

Genetic Disorders ◽

Aortic Disease ◽

Current Data ◽

Valve Regurgitation ◽

Aortic Diseases ◽

Cochrane Database ◽

Effect Of Treatment ◽

Pleiotropic Actions ◽

Optimal Type

Background: Numerous studies indicate that statins have multiple beneficial actions (known as ‘pleiotropic actions') on cardiovascular system through the improvement of endothelial dysfunction, inflammation, oxidative stress, excessive arterial thrombosis, and stabilization of the atherosclerotic plaque. Aortic disease primarily consists of aortic valve stenosis, aortic valve regurgitation, aneurysm disease, and genetic disorders such as Marfan syndrome, bicuspid aortic valve and aortic coarctation. Many studies have revealed the cardioprotective actions of statins in aortic disease. Objective: Our aim was to present current data concerning the value of treatment with statins in aortic diseases. Methods: A thorough search of PubMed and the Cochrane Database was conducted to identify the studies and novel articles related to the use of statins in aortic disease. Results: Numerous studies in animals and humans indicate a beneficial effect of treatment with statins in the previous conditions apart from a few conflicting data. Conclusion: There is a need of further investigation in this field, especially for the estimation of the optimal type and dose of statins required in each clinical condition of aortic disease.

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Abdominal Aortic Disease: A Multicase Review

Journal for Vascular Ultrasound ◽

10.1177/1544316719829602 ◽

2019 ◽

Vol 43 (1) ◽

pp. 18-24

Author(s):

Joshua D. Lee ◽

Courtney Webb ◽

Mark W. Fugate

Keyword(s):

Patient Care ◽

Iliac Artery ◽

Endovascular Aneurysm Repair ◽

Artery Aneurysm ◽

Disease Diagnosis ◽

Aortic Disease ◽

Type I ◽

Abdominal Aortic ◽

Type I Endoleak ◽

Vascular Laboratory

Abdominal aortic disease affects more than 3 million people per year. For vascular sonographers, imaging aortic disease can become routine. Therefore, it is necessary to expand the knowledge that we have of aortic disease, diagnosis, and treatment. We present 4 cases with new or worsening conditions diagnosed by duplex ultrasound (DUS). Our first case is a 79-year-old woman returning for surveillance of an endovascular aneurysm repair (EVAR). The DUS findings reveal an increasing abdominal aortic aneurysm (AAA) sac, with evidence of flow originating from an incomplete seal at the attachment suggesting type I endoleak. Next, is a 56-year-old man returning 1 month after type A dissection repair, now presenting with unilateral claudication. The DUS findings of the left lower extremity demonstrated an early systolic deceleration waveform, suggesting more proximal disease. Upon further imaging, an abdominal aortic dissection was identified terminating into the left internal iliac artery, causing the true lumen to be compressed. The third case was a 75-year-old man returning for follow-up of an EVAR and iliac repair. The DUS findings show an increase in iliac artery sac size and anechoic area that was filled with color Doppler flow. These findings are suggestive of type I endoleak involving the distal attachment. The last case is a 56-year-old man returning for EVAR and iliac artery repair surveillance. The common iliac artery aneurysm sac had increased in diameter and length. The distal attachment of the left iliac extension cuff terminated within the aneurysm sac, causing a type I endoleak. Accurate DUS diagnosis of aortic disease is crucial for patient care. Meticulous analysis of the vessels and surrounding structures can make a difference in diagnostic outcomes. Vascular sonographers should continually review and revise vascular laboratory protocols to increase their diagnostic accuracy and improve patient care. It is important to extend the vascular laboratory protocols when complex cases arise to better demonstrate complicated diagnoses and challenging anatomy.

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The relation of anatomical distribution of symptomatic peripheral arterial disease (PAD) with HbA1c level in patients with type 2 diabetes mellitus

Therapeutic Advances in Endocrinology and Metabolism ◽

10.1177/20420188211000504 ◽

2021 ◽

Vol 12 ◽

pp. 204201882110005

Author(s):

Nawaf J. Shatnawi ◽

Nabil A. Al-Zoubi ◽

Hassan M. Hawamdeh ◽

Yousef S. Khader ◽

Mowafeq Heis ◽

...

Keyword(s):

Diabetes Mellitus ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Peripheral Arterial Disease ◽

Hba1c Level ◽

Arterial Disease ◽

Anatomical Distribution ◽

The Mean ◽

Peripheral Arterial

Aims: Increased level of glycated hemoglobin (HbA1c) is associated with an increased prevalence of peripheral arterial disease (PAD). This study aimed to assess the relationship between the anatomical distribution of symptomatic PAD lesions in patients with type 2 diabetes and HbA1c levels at the time of PAD diagnosis. Patients and methods: A retrospective study was conducted at King Abdullah University Hospital during the period August 2011 to December 2015. Consecutive patients with type 2 diabetes presented with symptomatic PAD confirmed by computed tomography-angiography (CTA) were included in this study. CTA images were reviewed. Relevant information including demographic data, PAD symptoms, comorbidities, HbA1c level, lipid profile, C-reactive protein and the mean platelets volume were retrieved from medical records. Results: A total of 332 patients with type 2 diabetes (255 males and 77 females) were included in this study. The mean HbA1c at the time of PAD diagnosis was 8.68% (±2.06%). The prevalence of hemodynamic relevant atherosclerotic lesions of the superficial femoral artery, popliteal artery, leg vessels, femoro-popliteal, and crural segments was significantly higher in patients with HbA1c >7.5% compared with patients with HbA1c ⩽7.5%. Conclusion: The anatomical distribution of symptomatic PAD in patients with type 2 diabetes mellitus differed significantly according to HbA1c level at the time of PAD diagnosis.

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Excess of visceral adipose tissue with or without aortic elongation leads to a steeper heart position

Acta Radiologica ◽

10.1177/02841851211034053 ◽

2021 ◽

pp. 028418512110340

Author(s):

S Petteri Kauhanen ◽

Petri Saari ◽

Tarmo Korpela ◽

Timo Liimatainen ◽

Ritva Vanninen ◽

...

Keyword(s):

Adipose Tissue ◽

Visceral Adipose Tissue ◽

Interquartile Range ◽

Obese Patients ◽

Aortic Diseases ◽

Clinical Value ◽

Abdominal Aortic ◽

History Of ◽

Axial Ct ◽

Visceral Adipose

Background The heart’s position determined as the heart–aorta angle (HAA) has been demonstrated to associate with ascending aortic (AA) dilatation. Visceral adipose tissue (VAT) and aortic elongation may shift the heart to the steeper position. Purpose To investigate whether VAT and aortic length influence the HAA. Material and Methods We examined 346 consecutive patients (58.4% men; mean age = 67.0 ± 14.1 years) who underwent aortic computed tomography angiography (CTA). HAA was measured as the angle between the long axis of the heart and AA midline. The amount of VAT was measured at the level of middle L4 vertebra from a single axial CT slice. Aortic length was measured by combining four anatomical segments in different CTA images. The amount of VAT and aortic length were determined as mild with values in the lowest quartile and as excessive with values in the other three quartiles. Results A total of 191 patients (55.2%) had no history of aortic diseases, 134 (38.7%) displayed AA dilatation, 8 (2.3%) had abdominal aortic aneurysm (AAA), and 13 (3.8%) had both AA dilatation and AAA. There was a strong nonlinear regression between smaller HAA and VAT/height, and HAA and aortic length/height. Median HAA was 124.2° (interquartile range 119.0°–130.8°) in patients with a mild amount of VAT versus 120.5° (interquartile range 115.4°–124.7°) in patients with excessive VAT ( P < 0.001). Conclusion An excessive amount of VAT and aortic elongation led to a steeper heart position. These aspects may possess clinical value when evaluating aortic diseases in obese patients.

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Evaluation of preoperative computed tomography angiography in association with conventional angiography versus computed tomography angiography only, in the endovascular treatment of aortic diseases

Radiologia Brasileira ◽

10.1590/s0100-39842013000500001 ◽

2013 ◽

Vol 46 (5) ◽

pp. 265-272 ◽

Cited By ~ 2

Author(s):

Patrick Bastos Metzger ◽

Eduardo Rafael Novero ◽

Fabio Henrique Rossi ◽

Samuel Martins Moreira ◽

Frederico Augusto Linhares ◽

...

Keyword(s):

Computed Tomography ◽

Retrospective Study ◽

Endovascular Treatment ◽

Computed Tomography Angiography ◽

Therapeutic Intervention ◽

Technical Success ◽

Aortic Diseases ◽

Conventional Angiography ◽

Therapeutic Success ◽

Abdominal Aortic

Objective To evaluate the association of conventional angiography (AG) with computed tomography angiography (CTA) as compared with CTA only, preoperatively, in the treatment of aortic diseases. Materials and Methods Retrospective study involving patients submitted to endovascular treatment of aortic diseases, in the period from January 2009 to July 2010, with use of preoperative CTA + conventional AG or CTA only. The patients were divided into two groups, namely: G1 – thoracic aortic diseases; and G2 – abdominal aortic diseases. G1 was subdivided into 1A (preoperative AG + CTA) and 1B (preoperative CTA). G2 was subdivided into 2C (CTA + AG) and 2D (CTA only). Results The authors evaluated 156 patients. In subgroups 1A and 1B, the rate of technical success was, respectively, 100% and 94.7% (p = 1.0); and the rate of therapeutic success was, respectively, 81% and 58% (p = 0.13). A higher number of complications were observed in subgroup 1B (p = 0.057). The accuracy in the calculation of the prosthesis was higher in subgroup 1A (p = 0.065). In their turn, the rate of technical success in subgroups 2C and 2D was, respectively, 92.3% and 98.6% (p = 0.17). The rate of therapeutic success was 73% and 98.6% (p = 0.79). Conclusion Preoperative conventional AG should be reserved for cases where CTA cannot provide all the information in the planning of a therapeutic intervention.

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Intravenous paracetamol vs. ketoprofen for pain management after the abdominal aortic surgery – pharmacokinetics and therapeutics

Journal of Medical Science ◽

10.20883/jms.2016.176 ◽

2016 ◽

Vol 85 (4) ◽

pp. 254-263

Author(s):

Jowita Rosada-Kurasińska ◽

Alicja Bartkowska-Śniatkowska ◽

Agnieszka Bienert ◽

Małgorzata Grześkowiak ◽

Paweł Sobczyński ◽

...

Keyword(s):

Plasma Concentration ◽

Postoperative Pain ◽

Aortic Surgery ◽

Venous Pressure ◽

Intensive Therapy ◽

University Hospital ◽

Abdominal Aortic Surgery ◽

Abdominal Aortic ◽

Intravenous Paracetamol ◽

The Mean

Introduction. Acute postoperative pain continues to be a dilemma to patients and clinicians.Aim. To define the efficacy, tolerability and pharmacokinetics of paracetamol and ketoprofen in patients after the abdominal aortic surgery. Setting and design in University hospital – intensive therapy unit (clinical part), clinical pharmacy and biopharmacy unit (biochemical part), and pharmaceutical company (statistical part). Prospective randomized study.Material and Methods. 40 adult patients (50–84 years) undergoing abdominal aortic surgery were randomized equally into two groups. After extubation the patients in group 1 (G1) were administered a 1 g paracetamol infusion, and in group 2 (G2) – a 100 mg ketoprofen infusion, both within 15 minutes. All the patients received an epidural infusion of bupivacaine with fentanyl. The following parameters were recorded: mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), plasma concentration of paracetamol and ketoprofen. Postoperative pain was assessed with the visual analogue scale (VAS).Results. The mean values of the MAP, HR and CVP were within normal limits in the both groups. No significant differences were noticed in the assessment of postoperative pain and total use of an opioid. The mean therapeutic plasma concentration of paracetamol and ketoprofen remained up to 180 minutes and up to 120 minutes, respecively.Conclusions. The study enabled us to conclude that intravenous paracetamol as well as ketoprofen have good effectiveness and tolerability. There is no need to modify dosage of these drugs to elderly patients. After paracetamol infusion the therapeutic plasma concentration remains longer than after the ketoprofen infusion.

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Cardiomyopathy in Genetic Aortic Diseases

Frontiers in Pediatrics ◽

10.3389/fped.2021.682390 ◽

2021 ◽

Vol 9 ◽

Author(s):

Laura Muiño-Mosquera ◽

Julie De Backer

Keyword(s):

Marfan Syndrome ◽

Myocardial Dysfunction ◽

Genetic Defect ◽

Positive Family History ◽

Aortic Disease ◽

Aortic Aneurysms ◽

Aortic Diseases ◽

Pathogenic Variants ◽

Fibrillin 1

Genetic aortic diseases are a group of illnesses characterized by aortic aneurysms or dissection in the presence of an underlying genetic defect. They are part of the broader spectrum of heritable thoracic aortic disease, which also includes those cases of aortic aneurysm or dissection with a positive family history but in whom no genetic cause is identified. Aortic disease in these conditions is a major cause of mortality, justifying clinical and scientific emphasis on the aorta. Aortic valve disease and atrioventricular valve abnormalities are known as important additional manifestations that require careful follow-up and management. The archetype of genetic aortic disease is Marfan syndrome, caused by pathogenic variants in the Fibrillin-1 gene. Given the presence of fibrillin-1 microfibers in the myocardium, myocardial dysfunction and associated arrhythmia are conceivable and have been shown to contribute to morbidity and mortality in patients with Marfan syndrome. In this review, we will discuss data on myocardial disease from human studies as well as insights obtained from the study of mouse models of Marfan syndrome. We will elaborate on the various phenotypic presentations in childhood and in adults and on the topic of arrhythmia. We will also briefly discuss the limited data available on other genetic forms of aortic disease.

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Abstract P353: Acute Consumption of Walnuts Increases Ex Vivo Cholesterol Efflux and Postprandial Lipid Response in Overweight and Obese Adults

Circulation ◽

10.1161/circ.125.suppl_10.ap353 ◽

2012 ◽

Vol 125 (suppl_10) ◽

Author(s):

Claire E Berryman ◽

Jessica A Grieger ◽

Sheila G West ◽

George H Rothblat ◽

Jun Zhang ◽

...

Keyword(s):

Cholesterol Efflux ◽

Plasma Lipids ◽

Ex Vivo ◽

Mixed Linear Model ◽

Cvd Risk ◽

Obese Adults ◽

Lipid Response ◽

The Mean ◽

Postprandial Lipid ◽

Cells Cultured

Introduction: Epidemiological and clinical evidence demonstrate benefits of walnuts on cardiometabolic risk factors. Hypothesis: Previously, we conducted a study that evaluated the acute, postprandial effects of walnut components [separated nut skins (5.6 g), de-fatted nutmeat (34 g), and nut oil (51 g)] versus whole walnuts (85 g) on lipid/lipoprotein responses and other measures of CVD risk. The results reported herein are from an ancillary study that compared postprandial whole walnut values to fasting values, to test the hypothesis that the whole walnut treatment would improve reverse cholesterol transport. Methods: A randomized 4-period crossover design was conducted with healthy overweight and obese adults (n=15; 9 women and 6 men) with moderate hypercholesterolemia. Plasma lipids were measured at 0 (fasting), 30, 60, 120, 240, and 360 min post meal consumption; serum for ex vivo cholesterol efflux analysis was collected at 0 and 240 min. The mean fractional efflux of radiolabeled cholesterol was conducted in J774 macrophage cells cultured with 2.5% human serum. Results: A mixed linear model demonstrated an increase in TG postprandially (P < 0.01). TG levels were significantly increased at 120, 240, and 360 min compared to baseline (30.1 ± 5.1 mg/dl, 42.7 ± 5.2 mg/dl, 21.1 ± 5.1 mg/dl, respectively; P < 0.01 for all). HDL-C and the total cholesterol:HDL-C (TC:HDL) ratio also increased postprandially (P = 0.04 and P < 0.01, respectively). HDL-C increased at 60 min (1.8 ± 0.7 mg/dl; P = 0.01) and TC:HDL increased at 120, 240, and 360 min (0.2 ± 0.1, 0.3 ± 0.1, 0.3 ± 0.1, respectively; P < 0.01 for all) compared to baseline. Cholesterol efflux was increased by 3.3 % in cells cultured with postprandial serum relative to fasting baseline (baseline: 18.6 ± 0.3 %, 240 min: 19.2 ± 0.3 %; P = 0.02). Cholesterol efflux correlated positively with plasma HDL-C concentrations (r = 0.43; P = 0.02). Conclusion: Acute consumption of walnuts increased ex vivo cholesterol efflux, suggesting a novel mechanism by which walnut consumption may reduce cardiovascular risk.

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Aortic Aneurysm

10.2310/tywc.4750 ◽

2018 ◽

Author(s):

Christine E Lee ◽

Leily Naraghi ◽

Beatrice Hoffmann

Keyword(s):

Aortic Aneurysm ◽

Aortic Dissection ◽

Intramural Hematoma ◽

Aortic Disease ◽

Magnetic Resonance Images ◽

Aortic Aneurysms ◽

High Morbidity ◽

Aortic Diseases ◽

Decision Algorithm ◽

Type B Dissection

Aortic diseases are relatively rare but are associated with high morbidity and mortality. Emergency physicians (EPs) should consider aortic disease in all patients with pain in the torso, particularly those with other diverse or seemingly unconnected complaints. This review summarizes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with abdominal aortic aneurysms (AAAs), thoracic aortic aneurysms (TAAs), and aortic dissection. Figures show a transverse image of an AAAs with a transmural hematoma, a three-dimensional computed tomographic angiogram (CTA) rendering of a thoracic aneurysm associated with a bicuspid aortic valve in the typical ascending aortic location, a chest x-ray film demonstrating prominent and blurred aortic knob due to TAA, acute aortic dissection subtypes, an electrocardiogram and transesophageal echocardiography of a patient with acute ascending aortic dissection, magnetic resonance images of a patient with dissection of the proximal descending aorta, CT representations of a type A dissection involving a dilated ascending aorta and a type B dissection involving the descending thoracic aorta, and a decision algorithm for evaluation and treatment of a suspected aortic dissection. Tables list normal aortic dimensions by CTA and echocardiography, average annual rate of expansion and rupture of AAA based on current diameter, and the etiology of TAA. Key words: AAA, aorta, aortic dissection, ascending aortic dissection, descending aortic dissection, intimal tear, intramural hematoma, thoracic aortic aneurysm

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Aortic disease: Aneurysm and dissection—role of MSCT

The ESC Textbook of Cardiovascular Imaging ◽

10.1093/med/9780198849353.003.0053 ◽

2021 ◽

pp. 771-780

Author(s):

Rocío Hinojar ◽

Raimund Erbel

Keyword(s):

Aortic Disease ◽

Complete Characterization ◽

Unexpected Finding ◽

Aortic Diseases ◽

Aortic Pathology ◽

Life Threatening ◽

Excellent Spatial Resolution ◽

Widespread Availability

Multislice computed tomography (MSCT) is currently the preferred modality for diagnosis and complete characterization of aortic pathology because of its widespread availability, rapidity, excellent spatial resolution, and excellent accuracy for all aortic segments and different aortic diseases. Aortic disease often remains undiagnosed until a life-threatening complication occurs or the disease is an unexpected finding on imaging studies performed for other purposes. MSCT allows the measurement of the aortic wall and dimension and the evaluation of morphologic features and surrounding structures, even in very sick or unstable patients. It provides not only accurate and highly reproducible aortic measurements but also the evaluation of the wall and contents of an aneurysm, including thrombus, and surrounding structures.

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