RESUMEN
BACKGROUND: Acute isolated abdominal aortic dissection (IAAD) is a rare condition and treatment recommendations are lacking. Most previous studies included both symptomatic and asymptomatic patients. The aims were to determine the proportion of IAAD among patients with acute type B aortic dissection as well as to describe patient characteristics, radiological findings, and frequency of early and late complications and to explore sex differences. METHODS: This was a retrospective cohort study including all patients hospitalized with acute symptomatic IAAD in Stockholm County during 2012-2021. RESULTS: A total of 277 patients with acute type B aortic dissection were identified, of whom 10% (n = 28/277) had acute IAAD. Median age was 56 years and 43% (n = 12/28) were women. Hypertension was diagnosed in 46% (n = 13/28) prior to admission. At onset, abdominal pain was the predominant complaint (93%, n = 26/28) and 93% (n = 26/28) were hypertensive on admission. The suprarenal aorta was involved in 39% (n = 11/28) and at least 1 of the iliac arteries in 50% (n = 14/28). All but 1 patient had uncomplicated IAAD (96%, n = 27/28). One patient presented with aortic rupture, treated with open surgical repair. Among patients with primarily uncomplicated IAAD, 7% eventually developed chronic complications (n = 2/27). Median maximum aortic diameter at 1-year follow-up was 21 mm (interquartile range 17-28). Only 1 patient had an aortic diameter exceeding 30 mm. None of the patients died during follow-up; median follow-up was 3.0 years (interquartile range 2-8). CONCLUSIONS: Early and late complications are rare in patients with acute symptomatic IAAD and a conservative approach with antihypertensive treatment and surveillance in uncomplicated cases seems reasonable.
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Aneurisma de la Aorta Abdominal , Disección Aórtica Abdominal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Aguda , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Disección Aórtica Abdominal/diagnóstico por imagen , Disección Aórtica Abdominal/mortalidad , Disección Aórtica Abdominal/cirugía , Disparidades en el Estado de Salud , Hipertensión/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Suecia/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The objective of the study was to assess long-term remodeling, survival, and reintervention outcomes after thoracic endovascular aortic repair (TEVAR) for subacute and chronic type B aortic dissection (TBAD). METHODS: All patients who underwent TEVAR for subacute or chronic TBAD at a tertiary referral center between 1999 and 2015 were included in this cohort study. The primary outcome was aortic remodeling, and secondary outcomes included survival, rate of major complications, and reinterventions. RESULTS: Fifty patients were included, with mean age of 62.4 years, 10 (20%) DeBakey type IIIA and 40 (80%) DeBakey type IIIB dissection; 45 standard TEVAR, 2 branched TEVAR, 3 TEVAR combined with fenestrated or branched EVAR. Indication for TEVAR was intact (n = 40) or ruptured (n = 1) postdissection aneurysm, hypoperfusion (n = 4), treatment-refractory pain (n = 2), or a combination (n = 3). Mean clinical follow-up was 76 months, and median radiological follow-up was 46 months. Thirty-day survival was 96%, stroke 4%, renal failure 0%, paraplegia 0%. Three- and five-year survival was 92% (95% confidence interval (CI) [79; 97]) and 77% (95% CI [61; 87]), respectively. Of 19 late deaths, 6 were confirmed aorta related. Five-year freedom from reintervention was 69% (95% CI [53-80]). Distal stent graft extension due to aortic dilatation composed most reinterventions. Mean maximal aortic diameter was 58.7 mm preoperatively and 51.9 mm on last follow-up (P = 0.003). On thoracic level, true lumen expanded (+10.0 mm, 95% CI [6.4; 13.6]) (P < 0.001) and false lumen decreased (-11.9 mm, 95% CI [-15.2; -8.5]) (P < 0.001) from baseline to the last computed tomography. In the abdominal aorta, true lumen diameter change was +3.1 mm (95% CI [1.4; 4.8]) (P = 0.001); false lumen diameter change was +1.0 mm (95% CI [-1.8; 3.8]) (P = 0.464). CONCLUSIONS: TEVAR for subacute and chronic TBAD results in favorable remodeling of the thoracic but not the abdominal aorta. Five-year survival is almost 80%, but late aortic deaths still occur. Aortic dilatation distal to the treated segment requiring reintervention is common, emphasizing the importance of follow-up.
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Aorta Abdominal/cirugía , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Disección Aórtica/fisiopatología , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/fisiopatología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Enfermedad Crónica , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Reoperación , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Remodelación VascularRESUMEN
AIMS: As large population-based studies of aortic dissection are lacking, the incidence numbers and knowledge about time-trends and sex differences are uncertain. The objective was to describe incidence, temporal trends and outcome of aortic dissection with particular emphasis on sex differences. METHODS AND RESULTS: During the study period 2002-2016, 8057 patients in Sweden were diagnosed with aortic dissection, identified from the National Patient Register and the Cause of Death Register. A total of 5757 (71%) patients were hospitalized, whereas 2300 (29%) patients were deceased without concurrent hospital stay. The annual incidence was 7.2 per 100 000 (9.1 in men and 5.4 in women), decreasing over time in men (P = 0.005). Mean age in the hospitalized patients was 68 years (SD 13), 2080 (36%) were women. Within the first 14 days after onset, 1807 patients (32%) underwent surgical repair. The proportion of surgically treated increased from the 5-year period 2002-2006 to 2012-2016 [27% vs. 35%, odds ratio (OR) 1.61, 95% confidence interval (CI) 1.39-1.86; P < 0.001]. In hospitalized patients, 30-day mortality decreased between the same periods (26% vs. 21%, OR 0.68, 95% CI 0.59-0.80; P < 0.001). Long-term mortality decreased as well (hazard ratio 0.74, 95% CI 0.67-0.82; P < 0.001). Women had higher 30-day mortality than men after acute repair, a sex difference that remained after age adjustment (17% vs. 12%, OR 1.38, 95% CI 1.04-1.82; P = 0.006). CONCLUSION: This population-based study detected a higher incidence of aortic dissection than prior reports, but a decreasing incidence in men. Surgical therapy was increasingly used and with more favourable outcome but was less frequently offered to elderly patients. The sustained sex differences regarding both incidence and outcome require further attention.
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Disección Aórtica , Procedimientos Endovasculares , Anciano , Disección Aórtica/epidemiología , Disección Aórtica/cirugía , Femenino , Humanos , Incidencia , Masculino , Estudios Retrospectivos , Factores de Riesgo , Caracteres Sexuales , Suecia/epidemiología , Resultado del TratamientoRESUMEN
OBJECTIVE: To study functional outcome, mortality, and dialysis free survival in patients undergoing open primary surgical repair of renal artery stenosis (RAS) or aneurysm (RAA). METHODS: This was a retrospective single centre study of patients undergoing open surgical renal artery reconstruction from 1993 to 2007. Blood pressure, renal function, dialysis dependence, vessel patency, and mortality were registered. Survival was investigated by cross matching with the population registry, yielding up to 20 years of follow up. RESULTS: Of the 40 patients operated on, 25 (63%) were women. RAS was the indication for reconstruction in 31 patients; 23 had atherosclerotic aetiology (ARAS), and eight had fibromuscular dysplasia (FMD). Nine patients had RAA. Patients with ARAS were older (p = .008), had more extensive peripheral arterial disease (p = .004), and inferior renal function (p = .003) compared with patients with FMD or RAA. In FMD and RAA, the right renal artery was affected in 13/17 (76%) cases, whereas in ARAS the disease was evenly distributed. In patients with ARAS, 15/25 (60%) stenotic renal arteries (two bilateral procedures) were managed by aorto-renal bypass, and 2/25 (8%) through ilio-renal bypass. In 8/25 (32%) endarterectomy was performed. In FMD, all but one patient underwent aorto-renal bypass. Early mortality was 2.5% (one patient with ARAS). One patient with ARAS required dialysis post-operatively. Systolic blood pressure was significantly reduced in patients with ARAS, from 180 mmHg (median) pre-operatively to 155 mmHg at one month (p = .003) and 160 mmHg at one year (p = .03). Need for medication decreased from three or more drugs to two drugs at one month (p = .01). In FMD, there was a similar tendency. Three patients underwent re-intervention for restenosis: two endovascularly and one by open surgery. The overall 5 year survival was 88%. Median follow up was 10.6 years. CONCLUSION: Open surgical renal arterial reconstruction was performed with low mortality, fairly low morbidity, and excellent durability. Open surgery should still be considered a therapeutic option in complex renal artery disease.
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Aneurisma/cirugía , Obstrucción de la Arteria Renal/cirugía , Arteria Renal/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Adulto , Anciano , Aneurisma/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Obstrucción de la Arteria Renal/mortalidad , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Análisis de Supervivencia , Procedimientos Quirúrgicos Vasculares/mortalidad , Adulto JovenRESUMEN
OBJECTIVES: The aim was to analyse early and late outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for acute or subacute non-traumatic type B aortic dissection (TBAD), with the particular aims of identifying prognostic morphological predictors, and to assess the magnitude of the impact of the timing of TEVAR. METHODS: This was a retrospective, two centre, population based consecutive case series. The study group consisted of all the 53 patients undergoing TEVAR for complicated TBAD in Stockholm during the 12 year period 2004-2015. Demographic data, risk factors, operative, and outcome variables were registered and analysed. The CT scans were thoroughly retrospectively examined. RESULTS: Nearly half (24 patients; 45%) underwent TEVAR within 48 h of the onset of the initial symptoms, another 20 within 2 weeks, and nine in the subacute phase (15-90 days). The median age was 63 years (range 32-88) and 20 patients (38%) were women. The 30 day mortality was 17% (nine patients). Eight of these nine patients were treated within the first 48 h; urgent intervention (0-48 h) was associated with increased mortality (crude OR 14.0; 95% CI 1.6-122). All the nine patients had a false lumen area (FLA) at the level of the tracheal bifurcation exceeding 50% of the aortic cross sectional area at that segment, a finding significantly associated with increased mortality (p = .04), with a 25% 30 day mortality if the FLA > 50% (n = 36) at that segment, but 0% if the FLA was <50%. Overall the one year survival was 79% and five year survival 65%. CONCLUSIONS: All the early deaths demonstrated a FLA >50% of the total aortic cross sectional area at the level of the tracheal bifurcation. Patients needing urgent TEVAR had markedly worse outcome. The first finding may become an additional tool for future risk stratification.
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Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/tendencias , Procedimientos Endovasculares/tendencias , Evaluación de Procesos, Atención de Salud/tendencias , Tiempo de Tratamiento/tendencias , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico , Disección Aórtica/mortalidad , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/mortalidad , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Toma de Decisiones Clínicas , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Suecia/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The objective of this study was to assess long-term outcome after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA). METHODS: All patients who underwent TEVAR for TAA at Uppsala University Hospital from December 1999 to December 2014 were included. Characteristics of the patients and outcome data were collected from medical records, national population registry, and cause of death registry. Perioperative survival was analyzed with the χ2 test, and 5-year survival was estimated with Kaplan-Meier analysis. Predictors of long-term survival were assessed with Cox regression. RESULTS: There were 77 patients included in the study, 49 with intact TAAs (iTAAs) and 28 with ruptured TAAs (rTAAs). Mean follow-up was 83.7 months for iTAA patients and 82.0 months for rTAA patients (P = .853). Mean age was 71.5 years for iTAA patients and 74.8 years for rTAA patients (P = .04). Survival after iTAA repair was 95.9% at 30 days, 91.8% at 90 days, and 62.5% at 5 years. After rTAA repair, survival was 71.4% at 30 days and decreased to 57.1% at 90 days (P < .01), with most deaths after 30 days being related to the aortic event. The 3-year survival rate after rTAA repair was 27.8%, and only one rTAA patient with 5 years of follow-up remained alive. Six aorta-related deaths occurred after 90 days (three iTAA patients, three rTAA patients); five were due to rupture of nontreated aortic segments. The 5-year reintervention rate was 13.2% for iTAA patients and 17.9% for rTAA patients (P = .682). All reinterventions occurred within 14 months of TEVAR. The age-adjusted hazard ratio for long-term mortality was 4.4 after rTAA repair compared with iTAA repair. CONCLUSIONS: TEVAR for iTAA was associated with low perioperative mortality and acceptable 5-year survival at 62.5%. Results were more pessimistic after rTAA repair, however, for which two-thirds of the patients were deceased at 3-year follow-up. Improved selection of patients is necessary to identify patients who are likely to truly benefit from rTAA repair.
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Aneurisma de la Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Anciano , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Hospitales Universitarios , Humanos , Estimación de Kaplan-Meier , Masculino , Registros Médicos , Análisis Multivariante , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Modelos de Riesgos Proporcionales , Sistema de Registros , Retratamiento , Estudios Retrospectivos , Factores de Riesgo , Suecia , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
Purpose Percutaneous remote access for endovascular aortic repair is an advantageous alternative to open access. Previous surgery in the femoral region and the presence of synthetic vascular grafts in the femoral/iliac arteries represent major limitations to percutaneous remote access. The aim of this study was to evaluate an original technique used for enabling percutaneous remote access for thoracic or abdominal endovascular aortic repair in patients with scar tissue and/or a vascular graft in the groin. Methods Twenty-five consecutive patients with a thoracic (11/25; 44%) or an aortic aneurysm (14/25; 66%) and with a synthetic vascular graft in the groin (16/25; 64%) or a redo groin access (9/25; 36%) were managed through the percutaneous remote access. In all patients, a percutaneous transluminal angioplasty balloon was used to predilate the scar tissue and the femoral artery or the synthetic vascular graft after preclosing (ProGlide®; Abbott Vascular, Santa Clara, CA, USA). In 10 patients, requiring a 20 Fr sheath, a 6 mm percutaneous transluminal angioplasty balloon was used; and in the remaining 15, requiring a 24 Fr sheath, an 8 mm percutaneous transluminal angioplasty balloon. Preclosing was exclusively performed using ProGlide®. Mean follow-up was 15 months. Results In all cases, stent-graft deployment was successful. There was one surgical conversion (4%; 1/25) due to bleeding from a femoral anastomosis. Two cases required additional percutaneous maneuvers (postclosing with another system in one patient and endoluminal shielding with stent-graft in the other patient). No pseudoaneurysm or access complication occurred during the follow-up. Conclusions Percutaneous access in redo groins with scar tissue and/or synthetic vascular graft using ultrasound-guided punction, preclosing with ProGlide® system and predilation with percutaneous transluminal angioplasty balloon to introduce large size sheath as used for endovascular aortic repair showed to be feasible, safe and with few local complications.
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Angioplastia de Balón/instrumentación , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Cateterismo Periférico/instrumentación , Cicatriz/etiología , Ingle/irrigación sanguínea , Dispositivos de Acceso Vascular , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/efectos adversos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/métodos , Cicatriz/diagnóstico por imagen , Diseño de Equipo , Femenino , Humanos , Masculino , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
During the last two decades, endovascular technology has revolutionized the management of patients with abdominal aortic aneurysm (AAA). Today, endovascular aortic repair (EVAR) is the treatment of choice for the majority of patients with an AAA. Randomized controlled trials provide robust evidence for the indication of AAA repair and the rationale for the use of EVAR in selected patients. However, despite that, practice varies and several areas need further elucidation. Important future challenges and areas of research include the role of medical therapy in AAA, whether the indication for repair should be any different in women and in the elderly, and long-term follow-up of patients undergoing complex EVAR with adjuncts, both for elective treatment and for ruptured AAA. Continuous rapid technical and clinical development is to be expected. In this paper, we review the current practice and evidence of stenting in AAA.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Aneurisma de la Aorta Abdominal/diagnóstico , Rotura de la Aorta/diagnóstico , Prótesis Vascular/tendencias , Implantación de Prótesis Vascular/tendencias , Diagnóstico Precoz , Procedimientos Quirúrgicos Electivos/métodos , Procedimientos Quirúrgicos Electivos/tendencias , Femenino , Estudios de Seguimiento , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Sistema de Registros , Factores de RiesgoRESUMEN
OBJECTIVE: This study assessed the proportion of previously known abdominal aortic aneurysm (AAA) in patients presenting with a ruptured AAA (rAAA) and analyzed the reasons for nontreatment at the time of the initial AAA diagnosis. METHODS: This retrospective, observational study included all patients with rAAA admitted to a hospital in the counties of Stockholm and Gotland during 2009 to 2013. The patients' records were retrospectively reviewed, with extraction of data on previously detected AAA, demographics, and mortality at 30 and 90 days. RESULTS: We identified 283 patients (76% men) with a mean age of 78.7 years. An AAA had been previously detected in 85 (30%). The overall mortality was higher (68% vs 53%; P = .018) and the intervention rate was lower in patients with a previously detected AAA (59% vs 82%, P < .001). The 90-day mortality rate for all treated rAAA was 43%. Reasons for nontreatment at the initial AAA detection were denial of elective surgery in 31 (36%), patient choice in 15 (18%), size-related in 11 (13%), and surveillance deficiency in 26 (31%). The latter group included patients who failed to comply, missed referral for computed tomography scans, and lack of follow-up of radiology reports. At the time of rupture, 22 patients (85%) were treated, with 30-day and 90-day mortality rates both at 41% (n = 9). CONCLUSIONS: One-third of patients admitted with a rAAA had a previously detected AAA. The surgeons' decision to deny elective surgery and surveillance deficiency were the two main reasons for nontreatment at time of the AAA diagnosis. Improved patient-specific protocols to reduce the surveillance gaps and new methods of determining rupture risk in each case of AAA could be two possible future strategies to reduce the incidence of rupture.
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Aneurisma de la Aorta Abdominal/epidemiología , Rotura de la Aorta/epidemiología , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/terapia , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Rotura de la Aorta/prevención & control , Aortografía/métodos , Angiografía por Tomografía Computarizada , Femenino , Humanos , Incidencia , Masculino , Cooperación del Paciente , Prioridad del Paciente , Valor Predictivo de las Pruebas , Pronóstico , Derivación y Consulta , Negativa al Tratamiento , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Suecia/epidemiología , Factores de Tiempo , Negativa del Paciente al Tratamiento , Espera VigilanteRESUMEN
OBJECTIVES: To describe the incidence of acute aortic dissection in a clearly defined population, to assess onset symptoms and admission biochemical marker levels and to analyse variables potentially associated to mortality. METHODS: Medical records and CT angiograms of all patients hospitalised for acute aortic dissection in the Stockholm County during the 5-year period 2012-2016 were reviewed. The patients were followed until date of death or until 31 December 2020. The annual incidence was determined. Associations between clinical and biochemical variables and 30-day mortality, respectively, were analysed using multivariable logistic regression models. RESULTS: A total of 344 patients were included. The mean annual incidence of acute aortic dissection was 4.1 per 100 000. Median age was 67 years (range 24-91) and 34% (n=118) were women. Type A dissection was predominant; 220 patients (64%) had type A and 124 (36%) had type B. Painless dissection was more common in type A than in type B (18% vs 15%, p=0.003). Type A dissection patients also more commonly had elevated plasma troponin T (44% vs 21%, p<0.001) and thrombocytopenia (26% vs 15%, p=0.010) than type B dissection patients on admission. Overall, 30-day mortality was 28% in type A and 11% in type B (p<0.001). Both painless dissection (OR 4.30, 95% CI 1.80 to 10.28, p=0.001) and elevated troponin T (OR 3.78, 95% CI 2.01 to 7.12, p<0.001), respectively, were associated with increased 30-day mortality in all acute aortic dissection patients. Thrombocytopenia was associated with elevated 30-day mortality only in patients with type A (OR 3.09, 95% CI 1.53 to 6.21, p=0.002). CONCLUSIONS: Nearly two-thirds of acute aortic dissection patients had type A. Levels of troponin T and platelets, respectively, paired with presence or absence of typical symptoms may become useful adjuncts in risk stratification of patients with acute aortic dissection.
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Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Trombocitopenia , Humanos , Femenino , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Masculino , Incidencia , Troponina T , Factores de Riesgo , Resultado del Tratamiento , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/epidemiologíaRESUMEN
PURPOSE: To investigate the long-term morphologic changes of the aorta after thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection and to analyze whether these changes differed between DeBakey class IIIa and IIIb dissections. MATERIALS AND METHODS: During the period 1999-2009, 58 patients with acute complicated type B aortic dissection were treated with TEVAR. Seven patients lacked follow-up data, leaving 51 patients-17 patients with DeBakey IIIa aortic dissection and 34 patients with DeBakey IIIa aortic dissection IIIb-for inclusion in the study. Computed tomography scans performed before and after TEVAR were evaluated. Maximum thoracic and abdominal aortic diameters and diameters of the true lumen and false lumen at the level of the maximum aortic diameter in the thorax and abdomen were analyzed as well as degree of thrombosis of the false lumen. RESULTS: There was an overall significant reduction of the thoracic aortic diameter, increased true lumen diameter, and reduced false lumen diameter (P < .05). Total thrombosis of the false lumen, with or without reintervention, was seen in 53% of all patients, in 41% primarily and in 12% after reintervention. The IIIa group had a higher degree of total false lumen thrombosis. All patients in the IIIb group had total thrombosis of the false lumen along the stent graft. CONCLUSIONS: Long-term follow-up showed favorable aortic remodeling after TEVAR for acute complicated type B aortic dissection. Total thrombosis of the false lumen occurred more often in patients with DeBakey IIIa aortic dissection compared with patients with DeBakey IIIb aortic dissection.
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Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aortografía/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Trombosis/diagnóstico por imagen , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: The purpose of this study was to analyze our experience of thoracic endovascular aortic repair (TEVAR) in patients with traumatic aortic transection. METHODS: This was a single-center consecutive case series that was conducted at the Uppsala University Hospital, Tertiary Referral Center. There were a total of 17 consecutive patients undergoing TEVAR for traumatic thoracic aortic transection. All patients undergoing TEVAR for aortic transection were registered prospectively and their medical records were reviewed regarding technical details, mechanism of injury, and concomitant injuries. Long-term outcome was analyzed with respect to need for reintervention and survival. RESULTS: Between 2001 and 2010, 17 patients underwent TEVAR for traumatic aortic injury. Median age was 42 years (range, 18-77 years), and 15 of 17 patients (88%) were men. Fourteen patients had been involved in motor vehicle accidents, two had fallen from heights, and one fell off a bicycle on a slope. In all cases, the aortic injury was located in the proximity of the origin of the left subclavian artery. All patients had concomitant injuries. In all patients, a single stent graft was sufficient to exclude the injured part of the aorta. The median cover length was 120 mm (range, 100-200 mm). In-hospital mortality was 24% (4 of 17 patients). One patient died perioperatively and three postoperatively, two from brain injuries and one from multiorgan failure. After a median follow-up of 36 months (range, 10-98 months), three patients underwent reintervention (18%), each patient only once; one for a type I endoleak, and two for pseudocoarctation secondary to stent graft infolding. Two were treated endovascularly, and one had a stent graft explantation. CONCLUSIONS: Endovascular repair allows rapid and minimally invasive therapy in patients with traumatic aortic injury with good technical results. The outcome is highly dependent on the severity of other concurrent injuries.
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Aorta Torácica/lesiones , Rotura de la Aorta/terapia , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Heridas no Penetrantes/terapia , Adolescente , Adulto , Anciano , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/mortalidad , Prótesis Vascular , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Stents , Resultado del Tratamiento , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico , Adulto JovenRESUMEN
OBJECTIVES: To describe medical management in aortic dissection (AD) and to analyse the possible associations between antihypertensive, antithrombotic, anticoagulant and statin agents, respectively, and long-term survival. METHODS: From Swedish medical registers, all patients diagnosed with AD in 2006-2015 were identified. Filled prescriptions prior to admission and within 1 year from discharge in patients discharged and alive at 30 days were registered. Associations between pharmacological treatment and long-term survival were analysed using Cox proportional hazards models. RESULTS: Of 3951 patients hospitalised with acute AD, 3046 (77%) were discharged and alive at 30 days. In hospitalised patients, mean age was 66 years (SD 13), and 36% (n=1098) were women. Within 1 year from discharge, 96% (n=2939) had at least one antihypertensive drug. Beta blocker was the most commonly used drug type (90%, n=2741). Statin treatment (47%, n=1418) was associated with higher long-term survival; HR 0.74 (95% CI 0.63 to 0.87, p<0.001). The positive association between statins and long-term survival remained, in subgroup analysis, in medically managed patients (HR 0.72 (95% CI 0.60 to 0.86, p<0.001)), but not in patients undergoing surgical repair (HR 0.82 (95% CI 0.58 to 1.14, p=0.230)). Beta blockers were associated with favourable long-term survival in surgically managed patients (HR 0.58 (95% CI 0.35 to 0.97, p=0.038)) but not in medically managed patients (HR 0.93 (95% CI 0.72 to 1.12, p=0.057)). Neither antiplatelet therapy nor anticoagulants were associated with long-term survival. CONCLUSIONS: Statin treatment was associated with favourable long-term outcome in medically managed AD patients, whereas treatment with beta blocker was associated with higher survival only in surgically managed AD patients. Statin use as well as optimal antihypertensive therapy in the chronic stage of the disease need to be further analysed, preferably in randomised controlled trials.
Asunto(s)
Disección Aórtica , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Humanos , Femenino , Anciano , Masculino , Antihipertensivos/efectos adversos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Resultado del Tratamiento , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/tratamiento farmacológico , Modelos de Riesgos Proporcionales , Antagonistas Adrenérgicos beta/efectos adversosAsunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares/tendencias , Aneurisma de la Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Tecnología Biomédica/tendencias , Prótesis Vascular/tendencias , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/tendencias , Procedimientos Endovasculares/instrumentación , Diseño de Equipo , HumanosRESUMEN
Human dendritic cells were differentiated from blood monocytes and treated with malondialdehyde (MDA) conjugated with human serum albumin (HSA). Autologous T cells from human plaques or blood were co-cultured with the pre-treated dendritic cells or treated directly. MDA modifications were studied by mass spectrometry. MDA-HSA induced a pro-inflammatory DC-mediated T-cell activation and also a strong direct effect on T cells, inhibited by an inhibitor of oxidative stress and antibodies against MDA. Atherogenic heat shock protein-60 was strongly induced in T cells activated by MDA-HSA. Two peptide modifications in atherosclerotic patients' HSA were similar to those present in in vitro MDA-modified HSA.
RESUMEN
BACKGROUND: Low socioeconomic position (SEP) has been demonstrated to negatively influence outcome in several cardiovascular patient groups. The aim of this study was to analyse time trends of incidence of intact abdominal aortic aneurysm (iAAA) and ruptured AAA (rAAA), respectively, and to investigate whether SEP had any influence on the probability to present with rupture and, finally, to determine the impact of SEP on outcome. METHODS: Nationwide population-based study including all individuals with iAAA or rAAA in Sweden during 2001-2015. RESULTS: The number of individuals with an AAA was 41 222; the majority were identified as iAAA 33 254 (80.7%) and 7968 (19.3%) as rAAA. Time trends showed decreasing incidence of rAAA but increase in iAAA during the study period. Individuals with low income or low educational level were more likely to present with a rAAA rather than iAAA: OR 2.16 (95 % CI 1.98 to 2.36, p<0.001) and OR 1.33 (95 % CI 1.21 to 1.46, p<0.001), respectively. Low income was also associated with increased 90-day mortality and 1-year mortality after treatment for rAAA, OR 1.42 (95% CI 1.07 to 1.89, p=0.014) and OR 1.39 (95% CI 1.13 to 1.97, p=0.005). CONCLUSION: This large nationwide study showed a decreasing incidence of rAAA. Individuals with low SEP were found to have an augmented risk of presenting with rAAA rather than iAAA and, in addition, to fare worse after repair. Consequently, SEP should be regarded as a relevant risk factor that should be included in considerations for improved care flow of patients with AAA.
Asunto(s)
Aneurisma de la Aorta Abdominal/epidemiología , Rotura de la Aorta/epidemiología , Clase Social , Aneurisma de la Aorta Abdominal/etiología , Rotura de la Aorta/cirugía , Femenino , Humanos , Incidencia , Masculino , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Sistema de Registros , Factores de Riesgo , Suecia/epidemiologíaRESUMEN
BACKGROUND AND AIMS: IgM antibodies against phosphorylcholine (anti-PC) are negatively associated with atherosclerosis, cardiovascular disease (CVD) and systemic lupus erythematosus (SLE), where the risk of CVD and atherosclerosis is high. We here study the effects of IgM anti-PC immune regulation. METHODS: Mononuclear leukocytes were isolated from peripheral blood (PBMC) obtained from healthy blood donors, six SLE patients with age- and sex-matched controls, and symptom-giving human atherosclerotic plaques. The proportion of Th17 (CD4+CCR6+) and Treg (CD4+CD25+CD127dim/-) cells was determined by flow cytometry in CD4+T cells after 6 days of culture with Th17 or Treg-polarizing cytokines, with PMA and Ionomycin stimulation. IgM anti-PC were extracted from total IgM, with flow-through IgM as controls. Dendritic cells (DC) were differentiated from PBMC. Antibody peptide/protein characterization was done by a proteomics de novo sequencing approach. RESULTS: IgM anti-PC increased significantly the proportion of Tregs from healthy donors, SLE patients and atherosclerotic plaque cells while control antibodies did not. T cells from SLE patients had a significantly lower proportion of Tregs and a higher proportion of Th17 cells as compared to matched controls. IgM anti-PC, but not control antibodies, significantly reduced the production of IL-17 and TNF-α in cell cultures from SLE patients and atherosclerotic plaque cells. IgM anti-PC interacted with CD40 and kept DCs in an immature stage, potentially being tolerogenic. We observed differences in the IgM peptide expression levels in anti-PC compared to control antibodies. CONCLUSIONS: IgM anti-PC promote polarization of Tregs, which could represent a novel protective mechanism in atherosclerosis and autoimmune conditions as SLE.
Asunto(s)
Aterosclerosis/inmunología , Inmunoglobulina M/inmunología , Lupus Eritematoso Sistémico/inmunología , Activación de Linfocitos , Fosforilcolina/inmunología , Placa Aterosclerótica , Linfocitos T Reguladores/inmunología , Aterosclerosis/metabolismo , Aterosclerosis/patología , Aterosclerosis/prevención & control , Autoinmunidad , Estudios de Casos y Controles , Células Cultivadas , Células Dendríticas/inmunología , Células Dendríticas/metabolismo , Femenino , Citometría de Flujo , Humanos , Tolerancia Inmunológica , Interleucina-17/inmunología , Interleucina-17/metabolismo , Lupus Eritematoso Sistémico/diagnóstico , Lupus Eritematoso Sistémico/metabolismo , Lupus Eritematoso Sistémico/prevención & control , Masculino , Persona de Mediana Edad , Fenotipo , Linfocitos T Reguladores/metabolismo , Células Th17/inmunología , Células Th17/metabolismo , Factores de Tiempo , Factor de Necrosis Tumoral alfa/inmunología , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
BACKGROUND: Atherosclerosis is characterized by the presence of activated immune-competent cells including dendritic cells (DCs) and T cells, dead cells, and oxidized low-density lipoprotein. HSP60 (Heat shock protein 60) has been implicated in atherosclerosis. A plasma protein, Annexin A5, has atheroprotective properties. METHODS AND RESULTS: Human DCs differentiated from peripheral blood monocytes were treated with human HSP60 or HSP90 and autologous T cells were cocultured with these pretreated DCs (mDCs). HSP60 induced mDCs and T-cell activation as determined by FACScan (Fluorescence associated cell scan), gene-activation, and cytokine production. HSP60-induced T-cell activation was partly major histocompatibility complex class II-dependent. T cells exposed to HSP60-treated mDCs produced interferon-γ, interleukin-17, but not transforming growth factor-ß. HSP60 did not promote expression of Toll-like receptors 2 or 4. HSP90 promoted mDCs maturation but had no effect on T-cell activation. Annexin A5 inhibited HSP60-proinflammatory Th1/Th17 effects on mDCs and T cells, and partly bound HSP60. Further, Annexin A5 inhibited HSP-induced activation of mDCs and also oxidized low-density lipoprotein-induced HSP-production from mDCs. Experiments on mDCs and T cells derived from carotid atherosclerotic plaques from patients with symptomatic carotid disease gave similar results as from blood donors. CONCLUSIONS: HSP60 induces mDCs activation and partly major histocompatibility complex class II-dependent activation of blood- and plaque-derived T cells, which is mostly of Th1/Th17 type. HSP60 could thus be an important T-cell antigen in plaques, and also mediate oxidized low-density lipoproteins immunogenic effects on DC-T-cell activation, promoting plaque rupture and clinical manifestations of cardiovascular disease. Annexin A5 inhibits both oxidized low-density lipoprotein-induced HSP60, and HSP60-mediated immune activation, which suggests a potential therapeutic role.