Application of the Type, Entry Site, and Malperfusion Classification in Treatment of Aortic Dissection.

BACKGROUND: Our goal is to investigate a new practical dissection classification system, including type of dissection, location of the tear of the primary entry, and malperfusion. METHODS: The outcome of 151 patients with aortic dissection between January 2019 and May 2020 retrospectively were analyzed. All cases were classified with the Stanford dissection classification (A and B) by adding type non-A non-B. They were then further classified by the new classification system, including location of the primary Entry (E) and Malperfusion (M). All cases were followed up for six months. RESULTS: The distribution of 151 patients was 53.0%, 27.8%, and 19.2%, respectively, in type A, B, and non-A non-B. The in-hospital mortality rate was 8.8%, 2.4%, and 3.4% in type A, B, and non-A non-B (P < 0.05) and postoperative neurological complications occurred in 33.8%, 7.1%, and 13.8% in type A, B, and non-A non-B (P < 0.05). Total arch replacement was performed in 53.8%, 4.8%, and 13.8% in type A, B, and non-A non-B. The in-hospital mortality rate was 12.0%, 10.4%, and 8.5% in type E1, E2 and E3, while it was 20.0%, 10.4%, and 8.5% in type M1, M2 and M3 (P < 0.05). CONCLUSIONS: The new practical dissection classification system is useful as a supplement to the Stanford dissection classification by regarding the extent of the disease process, aiding in decision-making about the operative indication and plan, and helping in anticipating prognosis.

Expanded Petticoat technique to promote the reduction of contrasted false lumen volume in patients with chronic type B aortic dissection.

OBJECTIVE: This study examined the outcomes of our novel concept of expanded provisional extension to induce complete attachment strategy (Petticoat) for safety, durability, and remodeling of chronic type B dissections. METHODS: Twenty patients with chronic type B aortic dissection with aneurysmal degeneration qualified for an expanded Petticoat strategy (stent graft in the thoracic, plus additional distal bare stent into the abdominal and infrarenal aorta, followed by parallel stent grafts into common iliac arteries). Computed tomography was performed preoperatively and at 1, 6, and 12 months after surgery. RESULTS: The primary technical success was 100%. The 30-day mortality rate was 0%. At 12 months, favorable aortic remodeling and complete false lumen (FL) thrombosis were noted as 100% in the thoracic and infrarenal aorta. The volume of contrast-enhanced FL decreased from 186 ± 75.4 mL all along the dissection preoperatively (range, 70-360 mL), to 6.32 ± 5.4 mL postoperatively (range, 0.0-19.6 mL) and was only observed in the visceral aorta (P = .000089). Despite persistent flow in a small area of the FL, the maximal aortic size was stable in follow-up. Neither paraplegia nor visceral branch occlusion were noted in the follow-up. CONCLUSIONS: The treatment of aortic dissections with an expanded Petticoat strategy seems to be safe and offers good early results. It significantly reduced the volume of contrast enhanced FL. Further investigation of any subsequent results will be necessary.

VI2TA2 S2C2ORE: a new score system for in hospital mortality in acute aortic dissections.

INTRODUCTION: Aortic dissections classification systems have always been an argument of debate. It is well known that none of the described classifications is complete and easy at the same time. While the more used classification is currently the Stanford classification, it is clear that type A and B dissections prognosis can dramatically vary, depending on many different characteristics that they can present. The aim of this study was to propose a new severity score system that could reflect the risk of in hospital mortality of acute aortic dissections. EVIDENCE ACQUISITION: Through a review of the literature, studies describing significant predictors of in hospital mortality of any type of aortic dissection were searched and selected by predefined selection criteria. EVIDENCE SYNTHESIS: Nine studies met the criteria and were finally analyzed. The Odds Ratios of the reported predictors were the basis to the drawing of the score system. Sixteen main in hospital mortality predictors were found, 14 of which described in more than one study. They were combined into a new severity score system that we named VI2TA2 S2C2ORE. CONCLUSIONS: This is a simple risk score that we propose as a first assessment risk-evaluating tool. We look forward to validate it and to describe specific in hospital mortality risk ranges once it will be adopted.

Differences of patients' characteristics in acute type A aortic dissection - surgical data from Belgian and Japanese centers.

BACKGROUND: It is well known that there are major differences between the Japanese and Western population regarding the incidence of ischemic heart disease and stroke. The purpose of this study was to evaluate differences of patients' characteristics between Belgian and Japanese cohort with acute type A aortic dissection. METHODS: In 487 patients (297 male patients, mean age 61.9 ± 12.2 yrs) who underwent surgery for acute type A aortic dissection, baseline preoperative and intraoperative data were collected. Belgian patients (n = 237) were compared to Japanese patients (n = 250). Clinical data included patient demographics, history, status at presentation, imaging study results and intraoperative findings. RESULTS: The Japanese cohort had significantly more women (48.8% vs. 28.7%, p < 0.0001), lower BMI (24.2 vs. 26.4, p < 0.0001) and lower prevalence of hypertension (49.2% vs. 65.8%, p = 0.0002). More DeBakey type I dissections and less type III dissections with retrograde extension were reported in Belgium than in Japan (77.2% vs. 48.4%, p < 0.0001, 3.4% vs. 38.7%, p < 0.0001, respectively). More entries were found in the ascending aorta (78.5% vs. 58.5%, p < 0.0001) and aortic arch (24.9% vs. 13.7%, p = 0.0018) in Belgian patients than in Japanese patients, who had more entries in the descending aorta or undetected entries. CONCLUSIONS: In acute type A aortic dissection, Belgian patients reveal striking differences from Japanese patients regarding gender distribution, entry tear location and type of dissection. Japanese women are more likely to develop acute type A aortic dissection than Belgian women. (234 words).

Machine-learning phenotypic classification of bicuspid aortopathy.

BACKGROUND: Bicuspid aortic valves (BAV) are associated with incompletely characterized aortopathy. Our objectives were to identify distinct patterns of aortopathy using machine-learning methods and characterize their association with valve morphology and patient characteristics. METHODS: We analyzed preoperative 3-dimensional computed tomography reconstructions for 656 patients with BAV undergoing ascending aorta surgery between January 2002 and January 2014. Unsupervised partitioning around medoids was used to cluster aortic dimensions. Group differences were identified using polytomous random forest analysis. RESULTS: Three distinct aneurysm phenotypes were identified: root (n = 83; 13%), with predominant dilatation at sinuses of Valsalva; ascending (n = 364; 55%), with supracoronary enlargement rarely extending past the brachiocephalic artery; and arch (n = 209; 32%), with aortic arch dilatation. The arch phenotype had the greatest association with right-noncoronary cusp fusion: 29%, versus 13% for ascending and 15% for root phenotypes (P < .0001). Severe valve regurgitation was most prevalent in root phenotype (57%), followed by ascending (34%) and arch phenotypes (25%; P < .0001). Aortic stenosis was most prevalent in arch phenotype (62%), followed by ascending (50%) and root phenotypes (28%; P < .0001). Patient age increased as the extent of aneurysm became more distal (root, 49 years; ascending, 53 years; arch, 57 years; P < .0001), and root phenotype was associated with greater male predominance compared with ascending and arch phenotypes (94%, 76%, and 70%, respectively; P < .0001). Phenotypes were visually recognizable with 94% accuracy. CONCLUSIONS: Three distinct phenotypes of bicuspid valve-associated aortopathy were identified using machine-learning methodology. Patient characteristics and valvular dysfunction vary by phenotype, suggesting that the location of aortic pathology may be related to the underlying pathophysiology of this disease.

How Could These Mini Saccular Aneurysms of Ascending Aorta Be Classified?

The wall of a true aneurysm is composed of all histologic layers of the aorta. A false aneurysm represents a small, contained rupture of aorta followed by bulging of the corresponding area that is usually sustained by a fibrous peel. Aortic dissection is defined as a separation of the lamellae of the aortic wall. Herein, we describe an unusual clinical presentation of aortic dissection in a 37-year-old male patient that presented severe aortic regurgitation and unusual bulges with linear intimal fissures in ascending aorta underwent mechanical aortic valve replacement and interposition of tubular vascular graft in ascending aorta.

Acute type a aortic dissection associated with a sporting activity.

PURPOSE: To investigate the clinical characteristics of acute type A aortic dissection (ATAAD) occurring during a sporting activity. METHODS: The subjects of this study were 615 patients who underwent surgery for ATAAD between 1990 and 2015. The patients were divided into two groups according to whether the ATAAD was associated with a sporting activity (sports group: n = 25, mean age 62.3 years; non-sports group: n = 590, mean age 63.7 years). Specific activity was assessed in the sports group, and the characteristics and outcomes were compared between the groups. RESULTS: The sports group accounted for 5% of the patients with daytime onset ATAAD (25/479). The most common sport was golf (n = 8), followed by swimming (n = 4), cycling (n = 4), and weight lifting (n = 3). The average diameter of the ascending aorta on preoperative computed tomography was 4.8 cm. The dissection characteristics of the sports group included DeBakey type I (n = 23, 92%) and malperfusion (n = 9, 36%), which were similar to those of the non-sports group. The 30-day mortality rates were 16% (4/25) for the sports group and 8% (49/590) for the non-sports group (P = 0.33). CONCLUSIONS: The most common sport associated with ATAAD was golf, followed by swimming cycling, and weight lifting. The findings of this study reinforce that sports-related aortic dissection is not a unique clinical condition of young syndromic patients, but can occur in all age groups.

Stent Grafting Acute Aortic Dissection: Comparison of DeBakey Extent IIIA Versus IIIB.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) with stent grafting is effective for acute dissection in selected patients, but most remain at risk for reintervention. The effect of the extent of dissection on outcome is unclear. Objectives of this study were to compare characteristics, outcomes, and aortic remodeling after TEVAR between patients with DeBakey extent IIIA and IIIB dissection. METHODS: From 2005 to 2013, 520 patients presented with acute aortic syndrome. TEVAR was performed in 108 (41 IIIA, 67 IIIB) during the acute phase. Detailed three-dimensional computed tomography imaging analysis was performed in all patients. RESULTS: Patients with IIIA dissection were older (69.9 ± 10 vs 59.5 ± 13 years; p < 0.001) and more likely to have had prior cardiovascular operations (p = 0.01) than IIIB. The most common indication for TEVAR was ischemia in IIIB (66%), and pain (34%) in IIIA. Rupture was more common in IIIA (24.3% vs 1.5%; p < 0.001). Aortic diameters were similar between groups, but IIIB patients had smaller true/false lumen ratio (0.89 ± 1.08 vs 1.76 ± 1.27; p = 0.003). Stent graft coverage was 152 ± 42 mm for IIIA vs 212 ± 85 mm for IIIB (p < 0.001). Additional branch stents were used in 20 IIIB patients (30%), and 7 had infrarenal stenting. Early mortality and complications were similar between groups, except for renal failure (4.4% IIIB vs 0% IIIA; p = 0.04). Mean follow-up was 30 ± 28 months. Estimated survival at 1, 3 and 5 years was 84%, 65%, and 38% for IIIA, and 70%, 66%, and 59% for IIIB, respectively, with no significant difference. Significant expansion of the true lumen occurred in both groups after stenting, and the aortic and false lumen diameter increased only at the level of the abdominal aorta in IIIB patients. The false lumen was thrombosed in 91% of IIIA vs 62% of IIIB patients at the mid-descending aorta. Intervention was required in 15% (6 of 39) of IIIA and in 26% (15 of 58) of IIIB patients. CONCLUSIONS: In patients requiring TEVAR for acute dissection, patient factors and aortic morphology differ by the extent of the dissection. Aortic remodeling after TEVAR was better in patients with limited extent (IIIA) dissection than in than patients with extensive (IIIB) dissection. Despite these differences, very little difference was noted in early and late outcomes, which may be explained by differences in patient characteristics.

Type A Aortic Dissection Occurring After Previous Cardiac Surgery.

BACKGROUND: We retrospectively reviewed our experience of total arch replacement in patients undergoing repair of an ascending aortic dissection following previous cardiac surgery. METHODS: Data were collected for patients with acute type A aortic dissection following previous cardiac surgery between January 2005 and December 2014. Clinical and prognostic features were retrospectively analyzed. RESULTS: Twenty-eight eligible patients (nonelective: 10, elective: 18) were identified. There was a mean period of 44.5 months between the first operation and the subsequent surgery. The overall 30-day mortality rate was 21.4%; 30.0% for nonelective patients and 16.7% for elective patients. Postoperative morbidity rate was higher among nonelective patients versus elective group. During follow-up, two patients died: one from intracranial hemorrhage and the other from a noncardiac cause. One patient received endografting as a result of the true lumen being compressed by the false lumen following aortic repair. CONCLUSIONS: When hemodynamically stable, patients with acute ascending aortic dissection following previous cardiac surgery may have improved outcomes if the surgery can be performed on an elective basis.

Impact of Hemodynamic Instability and Organ Malperfusion in Elderly Surgical Patients Treated for Acute Type A Aortic Dissection.

OBJECTIVE: Recent studies indicate acceptable survival rates in elderly patients treated surgically for acute type A aortic dissection (aTAAD). However, the impact of preoperative hemodynamic compromise or organ malperfusion on outcomes of such patients is still unclear. METHODS: In a retrospective study of 341 patients, 101 qualified as elderly (≥70 years old). Subjects were further grouped by clinical presentation, using the Penn classification. Univariate and multivariable analyses were conducted to identify variables reflecting in-hospital and long-term mortality. RESULTS: Relative to younger subjects, elderly patients showed significantly higher rates of in-hospital mortality (24.8% vs. 14.6%, p = 0.025) and DeBakey type 2 dissections at presentation (40% vs. 18% p < 0.001), with significantly fewer presenting as Penn class Ab (p = 0.010). Penn class Ac was identified as an independent predictor of in-hospital mortality at all ages. Estimated long-term survival was poorer in the elderly (log rank p < 0.001); but in-hospital mortality, based on Penn classification, was similar for both age groups. Survival rates of Penn class Aa subjects at one, five, and 10 years were lower in elderly (vs. younger) patients (79 ± 5.6% vs. 90 ± 2.7%, 68 ± 6.7% vs. 80 ± 3.9%, and 39 ± 10.3% vs. 75 ± 4.6%, respectively; log rank p < 0.001). CONCLUSION: Overall in-hospital mortality is higher in elderly patients surgically treated for aTAAD. Malperfusion and/or hemodynamic instability at presentation confer a dismal prognosis, independent of patient age.

National trends in utilization, mortality, and survival after repair of type B aortic dissection in the Medicare population.

OBJECTIVE: The application of thoracic endovascular aortic repair (TEVAR) has changed treatment paradigms for thoracic aortic disease. We sought to better define specific treatment patterns and outcomes for type B aortic dissection treated with TEVAR or open surgical repair (OSR). METHODS: Medicare patients undergoing type B thoracic aortic dissection repair (2000-2010) were identified by use of a validated International Classification of Diseases, Ninth Revision diagnostic and procedural code-based algorithm. Trends in utilization were analyzed by procedure type (OSR vs TEVAR), and patterns in patient characteristics and outcomes were examined. RESULTS: Total thoracic aortic dissection repairs increased by 21% between 2000 and 2010 (2.5 to 3 per 100,000 Medicare patients; P = .001). A concomitant increase in TEVAR was seen during the same interval (0.03 to 0.8 per 100,000; P < .001). By 2010, TEVAR represented 27% of all repairs. TEVAR patients had higher rates of comorbid congestive heart failure (12% vs 9%; P < .001), chronic obstructive pulmonary disease (17% vs 10%; P < .001), diabetes (8% vs 5%; P < .001), and chronic renal failure (8% vs 3%; P < .001) compared with OSR patients. For all repairs, patient comorbidity burden increased over time (mean Charlson comorbidity score of 0.79 in 2000, 1.10 in 2010; P = .04). During this same interval, in-hospital mortality rates declined from 47% to 23% (P < .001), a trend seen in both TEVAR and OSR patients. Whereas in-hospital mortality rates and 3-year survival were similar between patients selected for TEVAR and OSR, there was a trend toward women having slightly lower 3-year survival after TEVAR (60% women vs 63% men; P = .07). CONCLUSIONS: Surgical treatment of type B aortic dissection has increased over time, reflecting an increase in the utilization of TEVAR. Overall, type B dissection repairs are currently performed at lower mortality risk in patients with more comorbidities.

Acute aortic dissection type A with acute coronary involvement: a novel classification.

BACKGROUND: Acute coronary involvement (ACI) due to acute aortic dissection (AAD) type A is potentially fatal. We examined selected patients with AAD type A, which had evolved over 14 years, and acute coronary involvement. The purpose of this study was to determine the characteristics of patients with ACI due to AAD type A. METHODS: Between 1997 and 2011, we recruited 20 patients (14.1%) with ACI (14 men, 6 women; mean age: 51.8 ± 11.8 years; age range: 35-79 years) from 142 patients who had undergone surgical repair of AAD type A. RESULTS: We propose a novel 4-category classification scheme based on the surgical pathological findings. The right coronary artery was involved in 15 patients, and the left was involved in 5 patients. Fourteen patients had preoperative myocardial ischemia. In the other 6 patients, acute coronary involvement was found intraoperatively. Patients with ACI were significantly younger than those without ACI (51.8 ± 11.8 vs. 61.0 ± 11.8; p = 0.001), a lower prevalence of intramural hematoma (5.0% vs. 32.8%; p = 0.011), a higher aortic regurgitation rate (95.0% vs. 53.5%; p = 0.001). Patients presenting with ACI had an in-hospital mortality rate of 20.0% (4/20), while those without ACI had an in-hospital mortality rate of 19.7% (24/122). CONCLUSIONS: Acute coronary involvement due to AAD type A is not always associated with coronary malperfusion. Patients with ACI were much younger, had a higher aortic regurgitation rate, and, less commonly, had intramural hematoma. This new classification scheme would make it more convenient for surgeons to decide on treatment options for this special cohort.

The IRAD classification system for characterizing survival after aortic dissection.

BACKGROUND: The classification of aortic dissection into acute (<14 days from symptom onset) versus chronic (≥14 days) is based on survival estimates of patients treated decades before modern diagnostic and treatment modalities were available. A new classification of aortic dissection in the current era may provide clinicians with a more precise method of characterizing the interaction of time, dissection location, and treatment type with survival. METHODS: We developed separate Kaplan-Meier survival curves for Type A and Type B aortic dissection using data from the International Registry of Aortic Dissection (IRAD). Daily survival was stratified based on type of therapy provided: medical therapy alone (medical), nonsurgical intervention plus medical therapy (endovascular), and open surgery plus medical therapy (surgical). The log-rank statistic was used to compare the survival curves of each management type within Type A and Type B aortic dissection. RESULTS: There were 1815 patients included, 67.3% male with mean age 62.0 ± 14.2 years. When survival curves were constructed, 4 distinct time periods were noted: hyperacute (symptom onset to 24 hours), acute (2-7 days), subacute (8-30 days), and chronic (>30 days). Overall survival was progressively lower through the 4 time periods. CONCLUSIONS: This IRAD classification system can provide clinicians with a more robust method of characterizing survival after aortic dissection over time than previous methods. This system will be useful for treating patients, counseling patients and families, and studying new diagnostic and treatment methods.

DISSECT: a new mnemonic-based approach to the categorization of aortic dissection.

OBJECTIVE/BACKGROUND: Classification systems for aortic dissection provide important guides to clinical decision-making, but the relevance of traditional categorization schemes is being questioned in an era when endovascular techniques are assuming a growing role in the management of this frequently complex and catastrophic entity. In recognition of the expanding range of interventional therapies now used as alternatives to conventional treatment approaches, the Working Group on Aortic Diseases of the DEFINE Project developed a categorization system that features the specific anatomic and clinical manifestations of the disease process that are most relevant to contemporary decision-making. METHODS AND RESULTS: The DISSECT classification system is a mnemonic-based approach to the evaluation of aortic dissection. It guides clinicians through an assessment of six critical characteristics that facilitate optimal communication of the most salient details that currently influence the selection of a therapeutic option, including those findings that are key when considering an endovascular procedure, but are not taken into account by the DeBakey or Stanford categorization schemes. The six features of aortic dissection include: duration of disease; intimal tear location; size of the dissected aorta; segmental extent of aortic involvement; clinical complications of the dissection, and thrombus within the aortic false lumen. CONCLUSION: In current clinical practice, endovascular therapy is increasingly considered as an alternative to medical management or open surgical repair in select cases of type B aortic dissection. Currently, endovascular aortic repair is not used for patients with type A aortic dissection, but catheter-based techniques directed at peripheral branch vessel ischemia that may complicate type A dissection are considered valuable adjunctive interventions, when indicated. The use of a new system for categorization of aortic dissection, DISSECT, addresses the shortcomings of well-known established schemes devised more than 40 years ago, before the introduction of endovascular techniques. It will serve as a guide to support a critical analysis of contemporary therapeutic options and inform management decisions based on specific features of the disease process.

A new classification system for branch artery perfusion patterns in acute aortic dissection for examining the effects of central aortic repair.

OBJECTIVES: We developed a new classification system for branch perfusion patterns in acute aortic dissection and used it to retrospectively evaluate the perfusion status of whole aortic branches and to examine the effects of central aortic repair. METHODS: Thirty-four consecutive patients with acute type A aortic dissection underwent emergent surgery at our institution between August 2008 and December 2011. A retrospective review of pre- and postoperative computed tomographic angiography was performed. Branch perfusion patterns were categorized into three classes: Class I, dissection involving but not extending into the branch; Class II, dissection extending into the branch and Class III, dissection causing ostial avulsion. RESULTS: In cervical branches (total 169 branches), 70 branches (41%) presented with Class I patterns, 58 (34%) with Class II and none with Class III. In abdominal branches (total 135 branches), 76 branches (56%) presented with Class I patterns, 12 (9%) with Class II and 18 (13%) with Class III. In common iliac arteries (total 68 arteries), 14 arteries (21%) presented with Class I patterns, 24 (35%) with Class II and none with Class III. After repair, among 21 high-risk cervical branches, 14 branches (67%) showed improvement, 3 (14%) preserved distal perfusion supplied through the patent branch false lumen and 4 (19%) showed no improvement in high-risk perfusion pattern or worsened. Among 22 high-risk abdominal branches, 18 branches (82%) showed improvement, 3 (14%) preserved distal perfusion supplied through the patent branch or aortic false lumen and 1 (5%) showed no improvement in high-risk perfusion pattern. CONCLUSIONS: To overcome malperfusion syndromes associated with acute aortic dissection, recognition of diverse branch perfusion patterns through a universal classification system is imperative.

Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection.

BACKGROUND: Cardiac tamponade is associated with fatal outcomes for patients with acute type A aortic dissection, and the presence of cardiac tamponade should prompt urgent aortic repair. However, treatment of the patient with critical cardiac tamponade who cannot survive until surgery remains unclear. We analyzed our experience of controlled pericardial drainage (CPD) managing critical cardiac tamponade. METHODS AND RESULTS: Between September 2003 and May 2011, 175 patients with acute type A aortic dissection were treated surgically, including 43 (24.6%) who presented with cardiac tamponade on arrival. Eighteen patients, who did not respond to intravenous volume resuscitation, underwent CPD in the emergency department. An 8F pigtail drainage catheter was inserted percutaneously, and drainage volume was controlled by means of several cycles of intermittent drainage to maintain blood pressure at ≈90 mm Hg. After CPD, all of the patients were transferred to the operating room, and immediate aortic repair was performed. Systolic blood pressure before CPD was 64.3 ± 8.2 mm Hg and elevated significantly in all of the cases after CPD. Systolic blood pressure after CPD was 94.8 ± 10.5 mm Hg, and increase in systolic pressure was 30.5 ± 11.7 mm Hg. Total volume of aspirated pericardial effusion was 40.1 ± 30.6 mL, and 10 patients required only ≤30-mL aspiration volume. All of the patients underwent aortic repair successfully. In-hospital mortality was 16.7%; however, there was no complications or mortality related to CPD. CONCLUSIONS: Preoperative pericardial drainage with control of volume is a safe and effective procedure for acute type A aortic dissection complicated by critical cardiac tamponade. In our patient population, timely controlled pericardial drainage is warranted.