Non-traumatic thoracic aortic emergencies: imaging diagnosis and management

2020 ◽  
Vol 81 (10) ◽  
pp. 1-12
Author(s):  
Jian Ping Jen ◽  
Akif Malik ◽  
Gareth Lewis ◽  
Benjamin Holloway
Keyword(s):  
Computed Tomography ◽  
Acute Aortic Dissection ◽  
Thoracic Endovascular Aortic Repair ◽  
Endovascular Aortic Repair ◽  
Type B ◽  
Penetrating Atherosclerotic Ulcer ◽  
Aortic Repair ◽  
Acute Aortic Syndromes ◽  
Best Medical Therapy ◽  
Tunica Intima

The major component of non-traumatic thoracic aortic emergencies is the acute aortic syndromes. These include acute aortic dissection, intramural haematoma and penetrating atherosclerotic ulcer, grouped together because they are indistinguishable clinically and highly fatal. All three entities involve disruption to the tunica intima and media and may be complicated by rupture, end-organ ischaemia or aneurysmal transformation. Early diagnosis is vital to allow timely and appropriate management. Paired unenhanced and electrocardiogram-gated computed tomography angiography of the chest, extending more distally if required, is recommended for diagnosis. Specific computed tomography features of all three entities are reviewed, with a focus on morphological features associated with complications. Those with type A pathology are usually managed with open surgery because this has a high risk of complication. Patients with uncomplicated type B pathology are usually managed with best medical therapy whereas those with complicated type B pathology are usually offered either surgery or thoracic endovascular aortic repair. The limited evidence regarding the use of thoracic endovascular aortic repair in patients with subacute uncomplicated type B pathology is briefly discussed.

Abstract 19354: Management and Outcomes of Acute Type B Dissection in IRAD Treated with Open Surgery, Endovascular Flap Fenestration or TEVAR

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Nathaniel I Costin ◽  
Peter Levanovich ◽  
Eduardo Bossone ◽  
Mark D Peterson ◽  
Truls Myrmel ◽  
...  
Keyword(s):  
Aortic Dissection ◽  
Open Surgery ◽  
Acute Aortic Dissection ◽  
Open Repair ◽  
Surgical Intervention ◽  
Thoracic Endovascular Aortic Repair ◽  
Endovascular Aortic Repair ◽  
Acute Type ◽  
Type B ◽  
Aortic Repair

Background: The debate for the optimal treatment of complicated Type B Acute Aortic Dissection (TBAAD) is primarily focused upon open surgical intervention versus thoracic endovascular aortic repair (TEVAR). The technique of fenestration with stenting has been proposed to resolve malperfusion. This study evaluated post-procedural outcomes of all three approaches for TBAAD. Methods: TBAAD patients enrolled in the International Registry of Acute Aortic Dissection were stratified by management type: TEVAR, fenestration and stenting, and surgery. Results: Of the 552 patients with TBAAD, 231 (41.8%) underwent TEVAR, 214 (38.8%) standard open surgery, and 107 (19.4%) fenestration and stenting. TEVAR or fenestration and stenting were more likely to be performed in classic double barrel aortic dissection when compared to open surgery (73.2%, 76.6%, 52.8% respectively; p<0.001). Patients treated with open repair were less likely to have distal extension into the abdominal aorta than those with TEVAR or fenestration and stenting (47.7%, 62.7%, 86.4%, respectively; p<0.001). In-hospital mortality was similar between groups (11.7% TEVAR, 14.0% fenestration and stenting, 15.9% surgery). At five years, Kaplan-Meier post-discharge all-cause survival estimates were highest for TEVAR, followed by endovascular fenestration and finally open surgical intervention (85.2%, 78.3%, 67.2%, respectively; p=0.039). Conclusion: Patients treated by endovascular approaches, whether with flap fenestration or thoracic endovascular aortic repair, had lower five year mortality when compared to patients who required open repair in the setting of TBAAD. Either endovascular approach may be helpful in the treatment of TBAAD. Further research is needed to determine how much of the observed difference represents patient selection versus differential effects of treatment.

scholarly journals Staged coil embolization after thoracic endovascular stent grafting for aneurysmal chronic type B aortic dissection: A case report

2019 ◽  
Vol 7 ◽  
pp. 2050313X1982890
Author(s):  
Takuya Nakayama ◽  
Koji Hattori ◽  
Takuya Hashizume ◽  
Miki Asano
Keyword(s):  
Computed Tomography ◽  
Aortic Dissection ◽  
Coil Embolization ◽  
False Lumen ◽  
Thoracic Endovascular Aortic Repair ◽  
Endovascular Aortic Repair ◽  
Type B ◽  
Type B Aortic Dissection ◽  
Chronic Type ◽  
Aortic Repair

We herein describe a 38-year-old woman with Marfan syndrome and chronic type A aortic dissection. Computed tomography showed that the sinus of Valsalva and thoracoabdominal aorta had a diameter of 62 and 55 mm, respectively. After 7 months of a Bentall operation and total arch replacement with the elephant trunk technique, we performed thoracic endovascular aortic repair for an aneurysm of the descending aorta, but we preserved the retrograde flow into the false lumen because it supplied vessels perfusing the spinal cord. Computed tomography angiography 14 months after thoracic endovascular aortic repair showed that the thoracic aortic diameter had increased to 68 mm. We then performed partial (proximal only) coil embolization of the false lumen. After 6 months, the thoracic aortic diameter had decreased to 60 mm and the spinal cord remained perfused via the distal false lumen. Staged coil embolization after thoracic endovascular aortic repair for aneurysmal chronic type B aortic dissection is feasible and can be beneficial.

Impact of Preoperative Anemia and Postoperative Hemoglobin Drop on the Incidence of Acute Kidney Injury and In-Hospital Mortality in Patients With Type B Acute Aortic Syndromes Undergoing Thoracic Endovascular Aortic Repair

2017 ◽  
Vol 51 (3) ◽  
pp. 131-138 ◽  
Author(s):  
Riccardo Gorla ◽  
Konstantinos Tsagakis ◽  
Michael Horacek ◽  
Amir-Abbas Mahabadi ◽  
Philipp Kahlert ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Hospital Mortality ◽  
Kidney Injury ◽  
Thoracic Endovascular Aortic Repair ◽  
Endovascular Aortic Repair ◽  
Type B ◽  
Preoperative Anemia ◽  
Aortic Repair ◽  
Acute Aortic Syndromes ◽  
Postoperative Aki

Background: The impact of preoperative anemia and postoperative hemoglobin (Hb) drop on the incidence of acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) for type B acute aortic syndromes (AAS) as well as their prognostic value is unknown. Methods: This retrospective study included 144 patients with type B AAS undergoing TEVAR at our center. Preoperative anemia was classified as no/mild (Hb ≥ 12.0 g/dL in men; ≥11.3 g/dL in women), moderate (Hb 10.80-11.99 g/dL in men; 10.23-11.29 g/dL in women), and severe (<10.80 g/dL in men; <10.23 g/dL in women). Postoperative Hb drop was classified as mild (<2 g/dL), moderate (2-4 g/dL), and severe (>4 g/dL). End points of the study were postoperative AKI and in-hospital mortality. Results: Postoperative AKI was higher in the severe and moderate anemia groups than the no/mild anemia group (63.2%, 52.0%, and 31.0%, respectively, P = .01). In-hospital mortality and AKI were higher in patients with severe postoperative Hb drop (40.9% and 86.4%) than patients with moderate (6.9% and 36.2%) and mild (4.7% and 25.0%) postoperative Hb drop (both P < .001). Postoperative Hb drop (odds ratio [OR]:1.67, P = .036), postoperative Hb levels (OR: 0.57, P = .025), and mesenteric ischemia (OR: 4.65, P = .044) were identified as independent predictors of in-hospital mortality. Preoperative Hb (OR: 0.26, P = .001), postoperative Hb drop (OR: 4.34, P < .001), contrast medium (OR: 1.82, P = .004), and diabetes mellitus (OR: 3.79, P = .001) were independent predictors of AKI. At follow-up, anemia and postoperative Hb drop were not associated with increased mortality. Conclusion: Preoperative Hb and postoperative Hb drop were significant risk factors for AKI. Postoperative Hb drop and Hb levels predicted in-hospital mortality.

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