Aortic Arch Calcification as a Predictor of Repeated Arteriovenous Fistula Failure within 1-Year in Hemodialysis Patients.

OBJECTIVES: The aim of the study was to identify the factors associated with repeated arteriovenous fistula (AVF) failure within 1-year, especially the impact of aortic arch calcification (AAC) on patency of AVF. MATERIALS AND METHODS: We retrospectively assessed chest radiography in hemodialysis patients who had undergone initial AVF. The extent of AAC was categorized into four grades (0-3). The association between AAC grade, other clinical variables, and repeated failure of AVF was then analyzed by binary logistic regression analysis. RESULTS: This study included 284 patients (158 males, mean age 61.7 ± 13.1 years). Patients with higher AAC grade were older, had more frequently diabetes mellitus and cardiovascular disease, had lower diastolic blood pressure, and had higher corrected calcium and lower intact parathyroid hormone levels. In multivariate analysis, the presence of higher AAC grade (odds ratio (95% confidence interval): 2.98 (1.43-6.23); p = 0.004), lower mean corrected calcium (p = 0.017), and mean serum albumin level (p = 0.008) were associated with repeated failure of AVF. CONCLUSIONS: The presence of higher AAC grade, lower mean corrected calcium and mean serum albumin level were independently associated with repeated AVF failure within 1 year in hemodialysis patients.

Actualización sobre las características pronósticas y el manejo terapéutico de la úlcera aórtica penetrante / Prognosis and therapeutic management of penetrating aortic ulcer. An update

La úlcera aórtica penetrante es una entidad poco frecuente e infradiagnosticada con características propias respecto la disección clásica. Se presenta una revisión actualizada de la enfermedad centrándose sobre todo en las características pronósticas y el manejo terapéutico

Penetrating aortic ulcer is a rare and underdiagnosed condition, with its own characteristics regarding classical dissection. An updated review is presented, focusing on its prognosis and therapeutic management

Paraparesis after Primary Percutaneous Coronary Intervention for ST-segment Elevation Myocardial Infarction: Combined Uncommon Complications of Acute Aortic Syndrome in a Patient.

Acute aortic syndrome complicated by both ST-segment elevation myocardial infarction (STEMI) and spinal ischemia is exceedingly rare. We herein report the case of a 66-year-old man who presented with paraparesis after primary percutaneous coronary intervention for STEMI. He was found to have an intramural hematoma of the ascending aorta and a severe dissection in the descending aorta, which led to both STEMI and paraparesis.

Diagnóstico diferencial del dolor torácico: un caso de síndrome aórtico agudo / Differential diagnosis of chest pain: a case of acute aortic syndrome

El dolor torácico es uno de los motivos de consulta más frecuentes en cualquier ámbito sanitario, no obstante sigue suponiendo un reto diagnóstico tanto en la consulta del médico de atención primaria como en el ámbito de los médicos que prestan atención en los servicios de urgencias. Describimos un caso de síndrome aórtico agudo que se presentó de forma insidiosa en forma de dolor torácico y síncope de repetición en el que el retraso en el diagnóstico y tratamiento pudo resultar fatal. Hacemos también un breve repaso en la definición, diagnóstico, tratamiento y pronóstico de esta entidad (AU)

Chest pain is one of the most frequent reasons for consulting in any healthcare setting, however its diagnosis remains a challenge for both Primary Care and Emergency Department physicians. We report a case of an Acute Aortic Syndrome which was diagnosed late after an insidious course of chest pain, repetitive syncope, and in which the delay in diagnosis and treatment could be fatal. We also describe the definition, diagnosis, treatment, and outcome of this condition (AU)

[Mid-aortic syndrome in 18 year-old woman with arterial hypertension and bilateral renal artery stenosis]. / Zespól aorty brzusznej u 18-letniej chorej z nadcisnieniem tetniczym i obustronnym zwezeniem tetnic nerkowych.

Mid-aortic syndrome (MAS) is characterised by narrowing of the abdominal aorta, often with involvement of the renal and splanchnic arterial branches. Although uncommon, MAS is an important cause of renovascular hypertension in children and adolescents and should be considered in the differential diagnosis of hypertension . Hypertension is typically severe and often difficult to manage. The management of MAS should always be individualised and may include percutaneous transluminal renal angioplasty, stent implantation or surgical revascularisation. We present a 18 year-old woman with hypertension and MAS coexisting with bilateral renal artery stenosis who underwent left renal artery angioplasty and than was followed-up for one year.

Case report: airway and concurrent hemodynamic management in a neonate with oculo-auriculo-vertebral (Goldenhar) syndrome, severe cervical scoliosis, interrupted aortic arch, multiple ventricular septal defects, and an unstable cervical spine.

We report the challenging case of a 1-week-old, term, 2.4 kg neonate with Goldenhar syndrome (including microcephaly, left microtia, left facial palsy, dextro-scoliosis of the cervical spine, and cervico-thoracic levoscoliosis), multiple ventricular septal defects, a type B interrupted aortic arch, a large patent ductus arteriosis, and radiographic and clinical signs concerning for an unstable cervical spine. Our anesthesia team was consulted for perioperative management of this patient during her surgical repair. This case report describes the use of the Air-Q size 1 laryngeal airway (LA) to assist fiberoptic intubation in an ASA 4 neonate with cardiac disease, an anticipated difficult airway with the addition of an unstable cervical spine, as well as the anesthetic techniques used to maintain hemodynamic stability while the airway was secured.

Embryology and imaging review of aortic arch anomalies.

Congenital malformations of the thoracic aorta can be discovered on chest radiographs when associated with symptoms or found incidentally. We review the imaging anatomy and associations of many of the aortic arch malformations that can be encountered in adults and highlight key points with regard to their treatment and prognoses. An understanding of the normal and abnormal embryologic development of the aortic arch, with knowledge of their imaging features, may be important for improving diagnostic accuracy and patient care.

[CT and MR imaging follow-up of medically treated acute aortic syndrome]. / Comment je surveille un syndrome aortique aigu traité médicalement au scanner ou en IRM?

The follow-up of medically treated acute aortic syndromes relies on CT and MR imaging. Comparison with prior examinations is essential. For aortic dissections, progressive enlargement of the false lumen, visceral hypoperfusion, and extension should be excluded. Mural hematomas and ulcers also undergo close follow-up to detect progression and recanalization. It is important to be familiar with the risk factors of disease progression for medically treated acute aortic syndromes and their management. It is also important to be familiar with the imaging features of disease progression. Acute aortic syndromes managed medically should undergo routine follow-up with CT or MR because these lesions may evolve silently over time and present with complications.

Tratamiento híbrido sobre la zona 0 del arco aórtico / Hybrid treatment on zone 0 of the aortic arch

Introducción. La disección aórtica y los aneurismas de aorta torácica se consideran procesos graves que afectana una población importante. La reparación quirúrgica tradicional supone el empleo de técnicas complejas con unaalta morbimortalidad, mayor aún cuando la enfermedad afecta retrógradamente al arco aórtico. Es posible realizar unprocedimiento endovascular sobre el arco aórtico mediante la asociación de técnicas de revascularización de los troncossupraaórticos con una tasa de éxito aceptable en pacientes que, por su edad o comorbilidad, no son candidatos a una reparaciónquirúrgica convencional. Caso clínico. Presentamos un caso de tratamiento híbrido, quirúrgico y endovascularen un varón con un aneurisma de aorta torácico secundario a disección crónica tipo B, con afectación retrógrada del arcoaórtico. Se consigue la exclusión completa del aneurisma, con permeabilidad de ramas viscerales y reducción significativadel diámetro mayor al año del tratamiento. No se objetivan complicaciones mayores durante el seguimiento y el pacienterealiza una vida activa en la actualidad. Conclusiones. El tratamiento híbrido puede ser una alternativa eficaz con menormorbilidad que la cirugía convencional en pacientes de alto riesgo con patología del cayado aórtico. Se precisan estudiosmás amplios para demostrar la viabilidad, tasas de morbilidad y mortalidad, complicaciones y duración de estas técnicas,ya que los existentes corresponden a series muy cortas de casos seleccionados

Introduction. Aortic dissection and thoracic aortic aneurysms are considered to be serious conditions thataffect a large number of patients. Traditional surgical repair entails the use of complex techniques with high morbidityand mortality rates, which become even higher when the disease affects the aortic arch retrogradely. An endovascularprocedure can be performed on the aortic arch by associating supra-aortic trunk revascularisation techniques, withan acceptable rate of success in patients who, owing to their age or comorbidity, are not suitable candidates forconventional surgical repair. Case report. We report a case of hybrid (surgical and endovascular) treatment in a malepatient with thoracic aortic aneurysm secondary to type B chronic dissection, with retrograde compromise of the aorticarch. Complete exclusion of the aneurysm was achieved, with patency of the visceral branches and a significantreduction in the major diameter at one year after treatment. No important complications were observed during thefollow-up and the patient currently leads an active life. Conclusions. Hybrid treatment can be an effective alternative,with a lower rate of morbidity, than conventional surgery in high risk patients suffering from a pathology affecting theaortic arch. Further studies are needed to show the feasibility, morbidity and mortality rates, complications andduration of these techniques, since those that have been conducted to date included only very short series of selected cases

[Management of acute aortic syndromes]. / Tratamiento de los síndromes aórticos agudos.

Acute aortic syndrome (AAS) describes the acute presentation of patients with characteristic "aortic pain" caused by one of several life threatening thoracic aortic conditions including aortic dissection, intramural hematoma or penetrating atherosclerotic ulcer. Recent advances in imaging and therapeutic techniques have emphasized the importance of early diagnosis of acute aortic syndrome because it is crucial for survival. Not just because the cardiovascular community knows little, the management of AAS remains a therapeutic challenge, while diverse surgical and percutaneous strategies for the treatment of aortic syndromes are continuously evolving. As a result of increasing knowledge and better management strategies in this area, the outcomes of patients treated for acute aortic syndromes have improved. This review discusses the etiology and clinical presentation, but mainly focuses on modern management and both established and emerging therapeutic approaches to acute aortic syndromes.

New device for percutaneous closure of aortopulmonary collaterals.

A 4.5-month-old infant with tetralogy of Fallot, pulmonary atresia, and multiple aortopulmonary collaterals underwent successful occlusion of the collaterals using a new device. This new plug (Amplatzer vascular plug) is a self-expandable cylindrical device made of nitinol wire mesh. The device is available in sizes from 4 to 16 mm in 2 mm increment. The device can be used in patients with aortopulmonary collaterals, pulmonary arteriovenous malformations, venovenous collaterals, shunts, coronary fistulas, and certain type of patent ductus arteriosus.

Associated factors and trends in outcomes of interrupted aortic arch.

BACKGROUND: Interrupted aortic arch (IAA) continues to be associated with important mortality, both before and immediately after repair, with ongoing morbidity during follow-up. We sought to determine trends in presentation, management, outcomes and associated factors. METHODS: We reviewed all consecutive patients (n = 119) presenting from 1975 to 1999, and data were collected regarding demographics, anatomy, management and outcomes. RESULTS: Significant trends over time for patients born in three consecutive periods (1975 to 1984, 1985 to 1993, and 1994 to 1999) demonstrated a smaller proportion of patients with presentation with circulatory collapse (65%, 51%, and 25%, respectively), greater use of prostaglandins (72%, 90%, 100%), fewer deaths without IAA repair (49%, 15%, 13%) and greater use of one-stage repair (68%, 75%, 100%). Independent risk factors for death without IAA repair (p < 0.001) included absence of ventricular septal defect, and the presence of noncardiac anomaly, complex cardiac anomaly, episode of acidosis and earlier birth cohort. Overall survival after repair was 50% at age 1 month, 35% at 1 year, and 34% at 5 years. Early and constant-hazard phases were noted, with incremental risk factors for early phase mortality being cyanosis at presentation, presence of truncus arteriosus or aortic stenosis, an episode of circulatory collapse before repair, earlier date of repair, and lower weight at repair. Greatest survival occurred in those patients with uncomplicated IAA who had repair since 1993 (5 year survival, 83%). Freedom from reintervention for arch obstruction was 60% at 5 years. CONCLUSIONS: While improving, outcomes of IAA remain of concern, especially in patients with associated lesions.

Endovascular stent implantation in patients with stenotic aortoarteriopathies: early and medium-term results.

Data regarding stent implantation for stenotic aortoarteriopathy (SAA) are incomplete. We report on nine patients with this rare syndrome who underwent arterial stent implantation. Indications, results, and complications for patients with SAA were reviewed. Nine patients underwent 11 procedures. Twenty-two stents were implanted in the aorta or brachiocephalic vessels. Five patients had diffuse stenoses, three patients had middle aortic syndrome, and one patient had thoracic and abdominal coarctation. Associated diagnoses included Williams syndrome (2), neurofibromatosis (2), Takayasu's (1), and congenital rubella (1). Median gradient was 60 mm Hg (20-140 mm Hg). Poststent gradient was 15 mm Hg (0-60 mm Hg; P < 0.001). Additional stents were implanted in two patients and five underwent stent redilation. Two patients (22%) were found to have aneurysm formation. Stent implantation effectively provides gradient relief in SAA. Gradient reduction persists or is amenable to redilation. Importantly, however, uncomplicated stent implantation does not preclude aneurysm formation and may be more common than in traditional patient groups.

A case report: first case of filtration leukocytapheresis for a patient of aortitis syndrome associated with ulcerative colitis.

An 18-year-old woman was treated with leukocytapheresis (LCAP) for her combined ulcerative colitis (UC) and aortitis syndrome (AS). Because a close relationship between these two diseases has been suspected based on their etiological and/or pathological findings, we had hypothesized that LCAP, which has satisfactory effects on inflammatory bowel disease such as UC and Crohn's disease might be effective for both her UC and her AS. After informed consent, LCAP therapy was performed once a week for a total of 7 times. Endoscopic remission of the UC was observed. Even though there were no significant improvements in her subjective symptoms of AS such as side-neck pain and dizziness, objective evidence of improvement was obtained when the patient's condition was compared before and after LCAP by angiography, angio-magnetic resonance imaging, and the plethysmogram of her fingertips. These results suggest that LCAP may be valuable as a new adjunct therapy for AS.