Biomarkers in aortic dissection: Diagnostic and prognostic value from clinical research / 中华医学杂志(英文版)

Aortic dissection is a life-threatening condition for which diagnosis mainly relies on imaging examinations, while reliable biomarkers to detect or monitor are still under investigation. Recent advances in technologies provide an unprecedented opportunity to yield the identification of clinically valuable biomarkers, including proteins, ribonucleic acids (RNAs), and deoxyribonucleic acids (DNAs), for early detection of pathological changes in susceptible patients, rapid diagnosis at the bedside after onset, and a superior therapeutic regimen primarily within the concept of personalized and tailored endovascular therapy for aortic dissection.

Disección Aórtica Tipo A como diagnóstico diferencial potencialmente letal de dolor torácico: revisión de casos / Type A Aortic Dissection as a potentially lethal differential diagnosis of chest pain: case Review

Chest pain (CP) is a frequent reason for consultation in emergency departments (ED). It responds to a broad spectrum of pathologies, ranging from banal causes to severe conditions with high mortality. The clinician must be able to distinguish prompt when CP is due to severe pathology and thus make a timely intervention for the patient's benefit. Acute Aortic Syndrome (AAS) is one of the potentially fatal causes of CP. Within this syndrome, we find aortic dissection (AD), intramural hematoma and atherosclerotic penetrating ulcer. AD is the most frequent presentation of AAS. Although it is not a common condition, its high lethality and low suspicion make it of particular interest as a differential diagnosis of CP. The following are two clinical cases of AD of the ascending aortic treated at the Hospital Regional de Talca (HRT) to analyse the clinical characteristics that help to differentiate this condition, the main electrocardiographic and imaging findings, as well as some of its complications and management.

Clinical profiles and outcomes of acute type A aortic dissection and intramural hematoma in the current era: lessons from the first registry of aortic dissection in China / 中华医学杂志(英文版)

BACKGROUND@#Acute type A aortic dissection (ATAAD) and acute type A intramural hematoma (ATAIMH) are life-threatening diseases with high mortality. To better understand their clinical features in the Chinese population, we analyzed the data from the first Registry of Aortic Dissection in China (Sino-RAD) to promote the understanding and management of the diseases.@*METHODS@#All patients with ATAAD and ATAIMH enrolled in Sino-RAD from January 1, 2012 to December 31, 2016 were involved. The data of patients' selection, history, symptoms, management, outcomes, and postoperation complications were analyzed in the study. The continuous variables were compared using the Student's t test for normal distributions and the Mann-Whitney U test for non-normal distributions. Categorical variables were compared using the Chi-square test or Fisher exact test.@*RESULTS@#A total of 1582 patients with ATAAD and 130 patients with ATAIMH were included. The mean age of all patients was 48.4 years. Patients with ATAAD were significantly younger than patients with ATAIMH (48.9 years vs. 55.6 years, P < 0.001). For the total cohort, males were dominant, but the male ratio of patients with ATAAD was significantly higher compared to those with ATAIMH (P = 0.01). The time range from the onset of symptom to hospitalization was 2.0 days. More patients of ATAIMH had hypertension than that of ATAAD (82.3% vs. 67.6%, P < 0.05). Chest and back pain were the most common clinical symptoms. Computerized tomography (CT) was the most common initial diagnostic imaging modality. 84.7% received surgical treatment and in-hospital mortality was 5.3%. Patients with ATAAD mainly received surgical treatment (89.6%), while most patients with ATAIMH received medical treatment (39.2%) or endovascular repair (35.4%).@*CONCLUSIONS@#Our study suggests that doctors should comprehensively use clinical examination and genetic background screening for patients with ATAAD and ATAIMH and further shorten the time range from symptoms onset to intervention, achieving early diagnosis and treatment, thereby reducing the mortality rate of patients with aortic dissection in China. We should standardize the procedures of aortic dissection treatment and improve people's understanding. Meanwhile, the curing and transferring efficiency should also be improved.

Podemos adotar a dosagem sérica da Tenascina-C na avaliação prognóstica do aneurisma e dissecção da aorta? / Could we adopt serum Tenascin-C assays to determine prognosis in aortic aneurysms and dissections?

Resumo O aneurisma da aorta abdominal corresponde a uma dilatação anormal, enquanto a dissecção aórtica aguda é uma delaminação da túnica média com formação de um falso lúmen. A Tenascina-C é uma glicoproteína que pode ser encontrada em situações de lesão tecidual. Nesse sentido, este artigo pretendeu avaliar se a Tenascina-C pode auxiliar na avaliação do prognóstico do aneurisma da aorta abdominal e da dissecção aórtica aguda. Realizou-se uma revisão integrativa da literatura em que foram considerados elegíveis quatro artigos, sendo que dois associaram maiores níveis da Tenascina-C a fatores de proteção e menor risco de lesões, enquanto dois correlacionaram com prognóstico pior. Alguns autores acreditam que a Tenascina-C poderia ser um biomarcador elegível, mas esses estudos ainda são inconclusivos no que diz respeito a seu papel no desfecho clínico dos pacientes com aneurismas.

Abstract Abdominal aortic aneurysm is an abnormal dilatation, while acute aortic dissection is a delamination of the tunica media, forming a false lumen. Tenascin-C is a glycoprotein that can be found in situations involving tissue damage. The objective of this article is to evaluate whether Tenascin-C assays could be of use for predicting prognosis in abdominal aortic aneurysms and acute aortic dissection. We conducted an integrative literature review, for which four articles were considered eligible. Two of these studies associated higher Tenascin-C levels with protective factors and lower risk of injury, whereas the other two correlated them with worse prognosis. Some authors believe that Tenascin-C could be a candidate biomarker, but these studies are still inconclusive with regard to its role in the clinical outcomes of patients with aneurysms.

Cardiac rehabilitation in a patient with DeBakey IIIb aortic disecction case report and literature review / Rehabilitación cardiaca en paciente con disección aortica DeBakey IIIb reporte de caso y revisión de la literatura

Abstract Aortic dissection is one of the three types of acute aortic syndromes, which has a determined mortality rate according to its type. Improvement in survival is possible through diagnostic and treatment advances. However, a great number of these patients frequently experience physical and mental disability after hospital discharge. Thus, we report a case of a woman with aortic dissection diagnosis, who joined a supervised physical training program and a brief review of evidence, demonstrating benefits and safety of cardiac rehabilitation in this pathology.

Resumen La disección aórtica es uno de los tres tipos de los síndromes aórticos agudos, que tienen una tasa de mortalidad determinada según su tipo. La mejora en la supervivencia es posible debido a los avances en el diagnóstico y el tratamiento. Sin embargo, un gran número de estos pacientes, con frecuencia experimentan discapacidad física y mental después del alta hospitalaria. Por lo tanto, se presenta el caso de una mujer con diagnóstico de Disección Aórtica, que se incorporó a un programa de entrenamiento físico supervisado, así como, una breve revisión de la evidencia, demostrando los beneficios y la seguridad de la rehabilitación cardíaca en pacientes con esta patología.

Arc of Buhler: A lifesaving anatomic variation. A case report / Arco de Buhler: uma variação anatômica que salva vidas - relato de caso

Abstract The presence of malperfusion syndrome in cases of complicated acute type B aortic dissection is a negative predictive factor and urgent intervention is indicated. Anatomic variations, such as the Arc of Buhler, contribute anastomotic channels and can preserve the visceral blood supply. In this case report, we describe the overall management of a 54-year-old man who presented with a type B aortic dissection. Initially, conservative management was chosen, as indicated for an uncomplicated type B dissection, but the dissection deteriorated. Despite the fact that severe occlusion of the celiac artery was detected on Computed Tomography (CT) angiography, the Arc of Buhler anatomical variation was present, contributing adequate visceral blood supply. After considering this finding, the patient was treated effectively with thoracic endovascular aortic repair (TEVAR).

Resumo A presença da síndrome de má perfusão em casos de dissecção aórtica aguda do tipo B complicada é um fator preditor negativo, e uma intervenção urgente é indicada. As variações anatômicas, tais como o arco de Buhler, contribuem como canais anastomóticos e podem preservar o suprimento sanguíneo visceral. Neste relato de caso, descrevemos o manejo geral de um paciente do sexo masculino, de 54 anos, que apresentou uma dissecção aórtica do tipo B. Inicialmente, o manejo conservador foi escolhido, conforme indicado para dissecção do tipo B não complicada, mas a dissecção sofreu deterioração. Apesar de uma oclusão grave da artéria celíaca ter sido detectada na angiotomografia computadorizada, a variação anatômica do arco de Buhler estava presente, contribuindo para o suprimento sanguíneo visceral adequado. Após levar em consideração esse achado, o paciente foi tratado de forma efetiva com reparação endovascular da aorta torácica.

Profiles and predictive values of interleukin-6 in aortic dissection: a review

Abstract Aortic dissection (AD) has been recognized to be associated with an inflammatory process. Clinical observations demonstrated that patients with AD had an elevated interleukin (IL)-6 level in comparison to hypertensive or healthy controls. Adverse events such as acute lung injury, postimplantation syndrome, and death are associated with an elevated IL-6 level. Thus, circulating IL-6 could be a reliable biomarker for the diagnosis of AD and for the eveluation of the therapeutic outcomes and the prognosis of AD patients. Therapeutic interventions aiming at attenuating the inflammatory status by IL-6 neutralization could effectively decrease the IL-6 level and thus reverse the progression of the disorder of AD patient. Endovascular aortic repair can effectively control the inflammatory cytokines. Selective antegrade cerebral perfusion with deep hypothermic circulatory arrest during aortic arch replacement shows better neuroprotectve effect with an improved IL-6 level of the cerebrospinal fluid. These results facilitate the understanding of the etiology of AD and guide the directions for the treatment of acute AD in the future. More effective therapeutic agents developed based on the theories of IL-6 signaling involved in the mechasims of AD are anticipated.

Hypoxic hepatitis in an extensive aortic disecction: case report / Hepatitis hipóxica en una disección aórtica extensa: reporte de caso

Hypoxic hepatitis is an uncommon cause of hepatic damage characterized by a centrolobular necrosis. Its pathophysiology remains unclear. Aortic dissection is a rare but frequently catastrophic event. It is caused by an aortic intimal tear with propagation of a false channel in the media. Depending on the site and extension, it can cause hypoperfusion of any organ leading to cellular ischemia and necrosis. We are presenting a case of hypoxic hepatitis in a patient with an extensive aortic dissection who present to the emergency department.

La hepatitis hipóxica es una causa poco frecuente de daño hepático caracterizada por una necrosis centrolobular. Su fisiopatología sigue siendo poco clara. La disección aórtica es un evento raro pero con frecuencia catastrófico. Dependiendo del sitio y la extensión, puede causar hipoperfusión de cualquier órgano lo que conduce a una isquemia celular y necrosis. Nosotros presentamos un caso de hepatitis hipóxica en un paciente con disección aórtica extensa que se presenta al servicio de emergencia.

Dissecção da aorta: manejo clínico e cirúrgico / Aortic dissection: clinical anda surgical management

A dissecção da aorta é uma condição grave cujo diagnóstico preciso precoce é fun-damental para a sobrevida dos pacientes. Dentro do contexto da dor torácica aguda no setor de emergência, seu diagnóstico pode passar despercebido, o que exige um alto índice de suspeição para ser realizado em tempo hábil. A disponibilidade dos métodos de imagem têm contribuído para a prontidão desse diagnóstico. Os objetivos iniciais do tratamento consistem no controle da dor e da pressão arterial através, principalmente, do uso de betabloqueadores endovenosos. Tais medidas diminuem o stress na parede da aorta, minimizando a propagação da delaminação. A identificação da localização do segmento de aorta dissecado é crucial, pois impacta no tratamento e no prognóstico. Pacientes com dissecção tipo B de Stanford e sem complicações podem receber trata-mento medicamentoso exclusivo, enquanto que a dissecção aguda tipo A de Stanford é uma emergência cirúrgica. Em relação à cirurgia, têm-se discutido o benefício da técnica do Frozen Elephant Trunk, a qual corrige uma maior extensão de aorta comprometida, po-dendo beneficiar pacientes com isquemia distal, apesar de apresentar maior complexidade e aumentar o risco de complicações neurológicas. Para as dissecções tipo B, o reparo endovascular tem sido amplamente utilizado e vários especialistas têm sugerido essa abordagem também para os casos não complicados, pois estudos recentes descrevem a influência do tratamento no remodelamento aórtico e, consequentemente, na sobrevida

Aortic dissection is a dramatic condition whose early accurate diagnosis is fundamen-tal for patient survival. Within the context of acute chest pain in the emergency room, its diagnosis can be overlooked, requiring a high level of suspicion to be performed in a timely manner. The availability of imaging methods has contributed to a faster diagnosis. The initial management goal is to control pain and blood pressure, mainly through the use of intra-venous beta-blockers. This strategy decreases shear stress on the aortic wall, minimizing the progression of delamination. Identifying the location of the dissected aortic segment is crucial, as this will impact on the treatment and prognosis. Patients with uncomplicated Stanford type B dissection may receive pharmaceutical treatment alone, while acute type A dissection is a surgical emergency. In relation to surgery, the benefit of the "Frozen Ele-phant Trunk" technique has been discussed, which corrects a greater area of compromised aorta and may benefit patients with distal ischemia, despite adding greater complexity and increasing the risk of neurological complications. For type B dissections, endovascular repair has been widely used, and several experts have also suggested this approach for uncomplicated cases, as recent studies have described the influence of the treatment on aortic remodeling and consequently, on survival

Presentación atípica y diagnóstico tardío de disección aórtica aguda sin tratamiento quirúrgico oportuno: reporte de un caso y revisión de la literatura / Atypical presentation and late diagnosis of acute aortic dissection without timely surgical treatment: case report and literature review

Resumen: El síndrome aórtico agudo incluye un grupo de enfermedades que poseen similitud clínica en su historia natural, siendo la característica más importante su asociación a un alto riesgo vital. Entre estas patologías, el diagnóstico y manejo de la disección aórtica depende del grado de compromiso aórtico según la ubicación de la lesión definida bajo la clasificación de Stanford. Dentro de las manifestaciones clave se considera al dolor torácico como el síntoma cardinal. Sin embargo, existen situaciones que por ambigüedad clínica retrasan el diagnóstico. Se presenta el caso de un paciente que debutó con una disección aórtica Stanford A, con indicación de resolución quirúrgica en fase aguda pero que dado lo inespecífico de su cuadro clínico, no se logró un diagnóstico oportuno. Posterior a reiteradas consultas por cambios en su sintomatología, se determinó el cuadro definitivo a través de estudio imagenológico, evolucionando de forma favorable con terapia ambulatoria.

Abstract: Acute aortic syndrome includes a group of diseases that have clinical similarity in their natural history, the most important characteristic being their association with a high vital risk. The diagnosis and management of aortic dissection depends on the degree of aortic involvement according to the location of the lesion, as defined by the Stanford classification. In this syndrome, chest pain is considered the cardinal symptom; however, there are situations where clinical feedback is difficult. We present the case of a patient who debuted with a Stanford A aortic dissection, with an indication for surgical resolution in the acute phase, but who unexpectedly presented unspecific clinical manifestations. An opportune diagnosis was not obtained. After repeated consultations for changes in his symptoms, the definitive diagnosis was determined through imaging study, evolving favorably with ambulatory therapy.

Dolor abdominal persistente por disección de arteria mesentérica superior y tronco celiaco, que no responde a tratamiento conservador / Persistent abdominal pain caused by superior mesenteric artery and celiac trunk dissection that does not respond to conservative treatment

Reportamos el caso de un paciente varón de 32 años con dolor abdominal recurrente tipo cólico a causa de disección de arteria mesentérica superior (AMS) y tronco celíaco, el cual se resolvió luego de la colocación de 3 stents en AMS. El paciente presentó una clínica atípica lo cual dificultó el diagnóstico. Discutimos la clínica, métodos diagnósticos y alternativas de tratamiento. Iniciamos con un manejo conservador con analgesia, anticoagulación plena, antihipertensivo y control de imágenes, pero al séptimo día luego de reiniciar la vía oral, presenta angina abdominal, por lo cual procedimos a tratamiento endovascular con resultado exitoso y buena evolución, sin eventos, a un seguimiento de 2 años

We report the case of a 32 year old male with recurrent colic abdominal pain due to superior mesenteric artery (SMA) and celiac trunk dissection, which resolved after placing 3 stents in SMA. The patient presented atypical clinical signs and symptoms, which made the diagnosis difficult. Clinical presentation, diagnostic methods and treatment options are discussed. We started with conservative management with pain medication, anticoagulation, antihypertensive drugs and image control, but on the seventh day, after restarting oral ingestion, he presented with abdominal angina, after which we proceeded to endovascular treatment with successful results and with an uneventfully 2 year follow up

Dissecção aórtica aguda: diagnóstico e tratamento / Acute aortic dissection: diagnosis and management

Objetivos: Revisar as evidências atuais sobre diagnóstico e manejo da dissecção aórtica aguda. Métodos: Revisão da literatura por meio de consulta a artigos científicos e diretrizes selecionados nos bancos de dados Medline e PubMed, em junho de 2017, sendo excluídos os estudos publicados antes de 2012. Resultados: O sintoma mais característico é a dor torácica ou dorsal súbita, intensa e migratória. O diagnóstico é feito com exames de imagem como a tomografia computadorizada e a ecocardiografia transesofágica. O tratamento inicial baseia-se na analgesia e no controle da pressão arterial e da frequência cardíaca. O manejo da dissecão aórtica tipo A é cirúrgico ao passo que no tipo B é clínico, salvo na ocorrência de complicações. Conclusões: A dissecção aórtica aguda apresenta alta mortalidade, sendo necessária alta suspeição e diagnóstico precoce. A classificação da dissecção aórtica e as suas manifestações direcionam o tratamento.

Aims: To review the current evidence on diagnosis and management of acute aortic dissection. Methods: Literature review through consultation of articles and guidelines selected in the Medline and PubMed databases, in June 2017, excluding studies published before 2012. Results: The most characteristic symptom is sudden, severe, migratory thoracic or dorsal pain. The diagnosis is made through imaging tests such as computed tomography and transesophageal echocardiography. Initial treatment is based on analgesia and control of blood pressure and heart rate. The management of type A aortic dissection is surgical whereas in type B it is clinical, except in the occurrence of complications. Conclusions: Acute aortic dissection presents high mortality, requiring high suspicion and early diagnosis. The classification of aortic dissection and its manifestations direct the treatment.

Outcomes before and after the Implementation of a Critical Pathway for Patients with Acute Aortic Disease

PURPOSE: Acute aortic diseases, such as aortic dissection and aortic aneurysm, can be life-threatening vascular conditions. In this study, we compared outcomes before and after the implementation of a critical pathway (CP) for patients with acute aortic disease at the emergency department (ED). MATERIALS AND METHODS: This was a retrospective observational cohort study. The CP was composed of two phases: PRE-AORTA for early diagnosis and AORTA for prompt treatment. We compared patients who were diagnosed with acute aortic disease between pre-period (January 2010 to December 2011) and post-period (July 2012 to June 2014). RESULTS: Ninety-four and 104 patients were diagnosed with acute aortic disease in the pre- and post-periods, respectively. After the implementation of the CP, 38.7% of acute aortic disease cases were diagnosed via PRE-AORTA. The door-to-CT time was reduced more in PRE-AORTA-activated patients [71.0 (61.0, 115.0) min vs. 113.0 (56.0, 170.5) min; p=0.026]. During the post-period, more patients received emergency intervention than during the pre-period (22.3% vs. 36.5%; p=0.029). Time until emergency intervention was reduced in patients, who visited the ED directly, from 378.0 (302.0, 489.0) min in the pre-period to 200.0 (170.0, 299.0) min in the post-period (p=0.001). The number of patients who died in the ED declined from 11 to 4 from the pre-period to the post-period. Hospital mortality decreased from 26.6% to 14.4% in the post-period (p=0.033). CONCLUSION: After the implementation of a CP for patients with acute aortic disease, more patients received emergency intervention within a shorter time, resulting in improved hospital mortality.

Evaluación de 200 pacientes pediátricos expuestos al riesgo de contraer rabia / Assessment of 200 pediatric patients exposed to rabies risk

Antecedentes/Objetivo: La rabia continúa siendo un grave problema de salud pública, especialmente en los países subdesarrollados o en vías de desarrollo. El objetivo de este estudio fue investigar las características demográficas y los programas de vacunación de los pacientes ingresados con diagnóstico presuntivo de rabia al Centro de Emergencias Pediátricas de nuestro hospital, que funciona como uno de los centros de vacunación antirrábica de nuestra provincia. Métodos: En este estudio, se analizaron retrospectivamente las historias clínicas de 200 pacientes ingresados al Centro de Emergencias Pediátricas con presunta exposición al virus de la rabia. Resultados: Entre los 200 casos, se halló que el riesgo de contraer rabia era mayor en el grupo de 5 a 9 años. El 68,5% de los casos tenían antecedentes de haber sido mordidos por un perro; el 29,5%, de haber sido rasguñados por un gato; y el 2%, de haber tenido contacto con otros animales. En el 76% de los casos se trataba de animales callejeros, solamente el 11% tenían dueño y habían sido vacunados, y estaban bajo supervisión. Se administró solamente la vacuna antirrábica al 42,5% de los pacientes ingresados, la vacuna antirrábica y la vacuna antitetánica al 51,5%, y la vacuna antirrábica, la vacuna antitetánica y concentrado de inmunoglobulinas antirrábicas al 6%. Se detectó que la profilaxis postexposición se había realizado según las recomendaciones en el 83,5% de los casos. Conclusión: La rabia continúa siendo un problema de salud pública grave en los países en vías de desarrollo, como el nuestro. Consideramos que es necesario sensibilizar a la sociedad; las autoridades locales deben esforzarse por luchar contra los animales callejeros y supervisar los servicios; el personal de la salud involucrado debe actualizarse mediante capacitaciones para reducir los casos de rabia.

Background/Purpose: Rabies is still an important health problem particularly in underdeveloped or developing countries. In this study, the aim was to investigate demographic characteristics and vaccination schedules of cases suspected of having rabies and admitted to the Pediatric Emergency Clinic of our hospital, which serves as one of the Rabies Vaccination Centers in our province. Methods: In our study, medical records of 200 patients admitted to the Pediatric Emergency Clinic with suspicion of risk of contact with the rabies virus were retrospectively analyzed. Results: Of those 200 cases, rabies risk was found to be greater in the 5-9 year old group. There was a history of having been bitten by dogs in 68.5% of cases, cat scratch in 29.5%, and contact with other animals in 2%. While 76% of animals were stray animals, only 11% of them had an owner and had been vaccinated, and were under supervision. Rabies vaccination only had been administered to 42.5% of admitted patients, tetanus and rabies vaccination to 51.5%, tetanus; rabies vaccination and human rabies immune globulin were administered to 6%. Post-exposure prophylaxis was found to have been given as recommended to 83.5% of cases. Conclusion: Rabies remains an important public health problem in developing countries Like ours. We consider that public awareness should be raised; local authorities should devote efforts to control stray animals and supervise such services, and updated guidance and training should be provided to the concerned health staff to reduce the risk of rabies.

Use of real-time three-dimensional transesophageal echocardiography in type A aortic dissections: Advantages of 3D TEE illustrated in three cases.

Stanford type A aortic dissections often present to the hospital requiring emergent surgical intervention. Initial diagnosis is usually made by computed tomography; however transesophageal echocardiography (TEE) can further characterize aortic dissections with specific advantages: It may be performed on an unstable patient, it can be used intra‑operatively, and it has the ability to provide continuous real‑time information. Three‑dimensional (3D) TEE has become more accessible over recent years allowing it to serve as an additional tool in the operating room. We present a case series of three patients presenting with type A aortic dissections and the advantages of intra‑operative 3D TEE to diagnose the extent of dissection in each case. Prior case reports have demonstrated the use of 3D TEE in type A aortic dissections to characterize the extent of dissection and involvement of neighboring structures. In our three cases described, 3D TEE provided additional understanding of spatial relationships between the dissection flap and neighboring structures such as the aortic valve and coronary orifices that were not fully appreciated with two‑dimensional TEE, which affected surgical decisions in the operating room. This case series demonstrates the utility and benefit of real‑time 3D TEE during intra‑operative management of a type A aortic dissection.

Spontaneous perforation and dissection of the sinus of Valsalva and interventricular septum with intracardiac thrombus in a patient with Behcet's disease

No abstract available.