Cambios en el tratamiento y disminución de la mortalidad del síndrome aórtico agudo. Lecciones del Registro Español del Síndrome Aórtico Agudo (RESA) / Spanish Registry of Acute Aortic Syndrome (RESA). Changes in therapeutic management and lower mortality in acute aortic syndrome

Introducción y objetivos El Registro Español del Síndrome Aórtico Agudo (RESA) se inició en 2005 para valorar las características del síndrome aórtico agudo (SAA) en nuestro país. El objetivo es analizar las diferencias en las características, el abordaje y el tratamiento y la mortalidad observadas entre las 3 ediciones del RESA. Métodos Se analizaron los datos de los pacientes con SAA incluidos prospectivamente por 24-30 hospitales terciarios en las 3 ediciones: RESA I (2005-2006), RESA II (2012-2013) y RESA III (2018-2019). Resultados Se incluyó a 1.902 pacientes (el 74% varones; media de edad, 60,7± 12,5 años), 1.329 (69,9%) tipo A y 573 (30,1%) tipo B. Comparando los RESAS, la tomografía computarizada aumentó como técnica diagnóstica (el 77,1, el 77,9 y el 84,2% respectivamente; p=0,001). El tratamiento quirúrgico del SAA tipo A aumentó (el 79,6, el 78,7 y el 84,5%; p=0,045) y la mortalidad total disminuyó (el 41,2, el 34,5 y el 31,2%; p=0,002), coincidiendo con una reducción de la mortalidad quirúrgica (el 33,4, el 25,1 y el 23,9%; p=0,003). En el tipo B, el tratamiento endovascular aumentó (el 22,8, el 32,8 y el 38,7%; p=0,006). La mortalidad total del SAA tipo B disminuyó (el 21,6, el 16,1 y el 12,0%; p=0,005) como consecuencia de la reducción de la mortalidad de los tratamientos médico (el 16,8, el 13,8 y el 8,8%; p=0,030) y endovascular (el 27,0, el 18,0 y el 9,2%; p=0,009). Conclusiones El RESA evidencia una disminución de la mortalidad del SAA tipo A coincidiendo con un incremento del tratamiento quirúrgico y una reducción de su mortalidad. En el SAA tipo B, el tratamiento endovascular se asocia con un aumento de la supervivencia, ya que permite una mejor estrategia terapéutica para los pacientes con complicaciones (AU)

Introduction and objectives The Spanish Registry of Acute Aortic Syndrome (RESA) was launched in 2005 to identify the characteristics of acute aortic syndrome (AAS) in Spain. The aim of this study was to analyze the differences in management and mortality in the 3 RESA iterations. Method We analyzed data from patients with AAS prospectively included by 24 to 30 tertiary centers during the 3 iterations of the registry: RESA I (2005-2006), RESA-II (2012-2013), and RESA III (2018-2019). Result AAS was diagnosed in 1902 patients (74% men; age, 60.7±12.5 years): 1329 (69.9%) type A and 573 (30.1%) type B. Comparison of the 3 periods revealed that the use of computed tomography increased as the first diagnostic technique (77.1%, 77.9%, and 84.2%, respectively; P=.001). In type A, surgical management increased (79.6%, 78.7%, and 84.5%; P=.045) and overall mortality decreased (41.2%, 34.5%, and 31.2%; P=.002), due to a reduction in surgical mortality (33.4%, 25.1%, and 23.9%; P=.003). In type B, endovascular treatment increased (22.8%, 32.8%, and 38.7%; P=.006), while medical and surgical treatment decreased. Overall type B mortality also decreased (21.6%, 16.1%, and 12.0%; P=.005) in line with a reduction in mortality with medical (16.8%, 13.8%, and 8.8%, P=.030) and endovascular (27.0%, 18.0%, and 9.2%; P=.009) treatments. Conclusion The iterations of RESA show a decrease in mortality from type A AAS, coinciding with an increase in surgical treatment and a reduction in surgical mortality. In type B, the use of endovascular treatment was associated with improved survival, allowing better management in patients with complications (AU)

Renal Artery Dissection in a Young Woman: Diagnoses Beyond Fibromuscular Dysplasia.

A 31-year-old woman presented at the emergency room after experiencing colic pain in the right iliac fossa for 5 days. She had previously consulted another center, where deterioration of renal function had been identified and abdominal computed tomography (CT) angiography had shown a dissection of the right renal artery, with areas suggestive of infarction in the right kidney, as well as an aneurysm in the left renal artery and a smaller left kidney. The patient had no relevant family or personal history except posttraumatic carotid-cavernous fistula in 2014, which had been treated with embolization. In our hospital, the patient was hypertensive and acute renal failure was confirmed, accompanied by an increase in lactate dehydrogenase and isomorphic microhematuria. After a new CT Scan, in addition to the lesions described in the renal arteries, another aneurysm in the splenic artery and an aneurysm of the right femoral artery were identified. Antihypertensive treatment was initiated with calcium antagonists and anticoagulation. Subsequent renal arteriography confirmed the dissection of the right renal artery, which could not be repaired, and a coated stent was placed in the left renal artery to exclude the aneurysm. The splenic artery lesion was treated 2 months later. The etiological diagnosis in this young woman was challenging. The presence of visceral aneurysms suggested a differential diagnosis comprising fibromuscular dysplasia, vasculitis, and collagenopathies. Using a multidisciplinary approach and directed anamnesis, the presence of frequent sprains, joint hypermobility, and skin fragility was confirmed. Blood immunology and CT angiography including the thoracic and cervical territories were normal. Echocardiography revealed tricuspid insufficiency. All these data suggested the presence of a collagen-like Ehlers-Danlos syndrome (vascular form). The diagnosis was confirmed by the genetic study, which showed a pathogenic mutation in the COL3A1 gene. Currently, the patient is asymptomatic with recovered renal function following treatment with a beta-blocker and antiplatelet therapy.