Postoperative acute kidney injury after thoracic endovascular aortic repair for acute type B aortic dissection.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has evolved as the standard for treating complicated acute type B aortic dissection (ATBAD). Acute kidney injury (AKI) is a common complication in critically ill patients and is commonly observed in patients with ATBAD. The purpose of the study was to characterize AKI after TEVAR. METHODS: All patients who underwent TEVAR for ATBAD from 2011 through 2021 were identified using the International Registry of Acute Aortic Dissection. The primary end point was AKI. A generalized linear model analysis was performed to identify a factor associated with postoperative AKI. RESULTS: A total of 630 patients presented with ATBAD and underwent TEVAR. The indication for TEVAR was complicated ATBAD in 64.3%, high-risk uncomplicated ATBAD in 27.6%, and uncomplicated ATBAD in 8.1%. Of 630 patients, 102 (16.2%) developed postoperative AKI (AKI group) and 528 patients (83.8%) did not (non-AKI group). The most common indication for TEVAR was malperfusion (37.5%). In-hospital mortality was significantly higher in the AKI group (18.6% vs 4%; P < .001). Postoperatively, cerebrovascular accident, spinal cord ischemia, limb ischemia, and prolonged ventilation were more commonly observed in the AKI group. The expected mortality was similar at 2 years between the two groups (P = .51). Overall, the preoperative AKI was observed in 95 (15.7%) in the entire cohort consisting of 60 (64.5%) in the AKI group and 35 (6.8%) in the non-AKI group. A history of CKD (odds ratio, 4.6; 95% confidence interval, 1.5-14.1; P = .01) and preoperative AKI (odds ratio, 24.1; 95% confidence interval, 10.6-55.0; P < .001) were independently associated with postoperative AKI. CONCLUSIONS: The incidence of postoperative AKI was 16.2% in patients undergoing TEVAR for ATBAD. Patients with postoperative AKI had a higher rate of in-hospital morbidities and mortality than those without. A history of CKD and preoperative AKI were independently associated with postoperative AKI.

Proximal false lumen thrombosis is associated with low false lumen pressure and fewer complications in type B aortic dissection.

BACKGROUND: Improved risk stratification is a key priority for type B aortic dissection (TBAD). Partial false lumen thrombus morphology is an emerging predictor of complications. However, partial thrombosis is poorly defined, and its evaluation in clinical studies has been inconsistent. Thus, we aimed to characterize the hemodynamic pressure in TBAD and determine how the pressure relates to the false lumen thrombus morphology and clinical events. METHODS: The retrospective admission computed tomography angiograms of 69 patients with acute TBAD were used to construct three-dimensional computational models for simulation of cyclical blood flow and calculation of pressure. The patients were categorized by the false lumen thrombus morphology as minimal, extensive, proximal or distal thrombosis. Linear regression analysis was used to compare the luminal pressure difference between the true and false lumen for each morphology group. The effect of morphology classification on the incidence of acute complications within 14 days was studied using logistic regression adjusted for clinical parameters. A survival analysis for adverse aortic events at 1 year was also performed using Cox regression. RESULTS: Of the 69 patients, 44 had experienced acute complications and 45 had had an adverse aortic event at 1 year. The mean ± standard deviation age was 62.6 ± 12.6 years, and 75.4% were men. Compared with the patients with minimal thrombosis, those with proximal thrombosis had a reduced false lumen pressure by 10.1 mm Hg (95% confidence interval [CI], 4.3-15.9 mm Hg; P = .001). The patients who had not experienced an acute complication had had a reduced relative false lumen pressure (-6.35 mm Hg vs -0.62 mm Hg; P = .03). Proximal thrombosis was associated with fewer acute complications (odds ratio, 0.17; 95% CI, 0.04-0.60; P = .01) and 1-year adverse aortic events (hazard ratio, 0.36; 95% CI, 0.16-0.80; P = .01). CONCLUSIONS: We found that proximal false lumen thrombosis was a marker of reduced false lumen pressure. This might explain how proximal false lumen thrombosis appears to be protective of acute complications (eg, refractory hypertension or pain, aortic rupture, visceral or limb malperfusion, acute expansion) and adverse aortic events within the first year.

Arc of Buhler: A lifesaving anatomic variation. A case report.

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).

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.

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.

Long-term efficacy of endovascular vs open surgical repair for complicated type-B aortic dissection: a single-center retrospective study and meta-analysis

This study aimed to evaluate the long-term survival and risk factors of traditional open surgical repair (OSR) vs thoracic endovascular aneurysm repair (TEVAR) for complicated type-B aortic dissection (TBAD). A total of 118 inpatients (45 OSR vs 73 TEVAR) with TBAD were enrolled from January 2004 to January 2015. Kaplan-Meier curves and Cox proportional hazards analysis were performed to identify the long-term survival rate and independent predictors of survival, respectively. Meta-analysis was used to further explore the long-term efficacy of OSR and TEVAR in the eight included studies using Review Manager 5.2 software. An overall 10-year survival rate of 41.9% was found, and it was similar in the two groups (56.7% OSR vs 26.1% TEVAR; log-rank P=0.953). The risk factors of long-term survival were refractory hypertension (OR=11.1; 95%CI=1.428-86.372; P=0.021] and preoperative aortic diameter >55 mm (OR=4.5; 95%CI=1.842-11.346; P=0.001). Long-term survival rate did not differ significantly between OSR and TEVAR (hazard ratio=0.87; 95%CI=0.52-1.47; P=0.61). Compared with OSR, TEVAR did not show long-term advantages for patients with TBAD. Refractory hypertension and total aortic diameter >55 mm can be used to predict the long-term survival of TBAD in the Chinese Han population.

Fiebre y disección retrógrada tipo A como complicación de la disección aórtica tipo B / Fever and retrograde type A aortic dissection as complication of type B aortic dissection / Febre e dissecção aórtica retrógrada tipo A como complicação da dissecção aórtica tipo B

La incidencia del síndrome aórtico agudo (disección aórtica, hematoma intramural, úlcera aterosclerótica penetrante y ruptura de la pared vascular) es de 2-3,5 casos por 100.000 habitantes cada año; pero la disección aórtica tipo A retrógrada es poco frecuente y sólo se han reportado casos aislados, en ocasiones como consecuencia de una intervención quirúrgica. Se presenta el caso clínico de un paciente de 62 años de edad, que acudió al cuerpo de guardia por dolor precordial que alivió con analgésicos y tanto la radiografía de tórax como el electrocardiograma eran normales. Al tercer día comenzó con fiebre que duró 4 semanas y desapareció espontáneamente, y fue dado de alta con todos los estudios normales y pancultivos negativos. Dos semanas después ingresa nuevamente por disnea de esfuerzo, que fue progresando. Al ingreso se constata signos clínicos de pericarditis, incluyendo roce pericardio, realizándose ecocardiograma y angio-TAC, donde se evidenció el diagnóstico de disección aórtica tipo B complicada con disección tipo A retrógrada y hemopericardio.

The incidence of acute aortic syndrome (aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer rupture of the vessel wall) is 2-3.5 cases per 100,000 people each year; but the retrograde type A aortic dissection is rare and only isolated cases have been reported, sometimes as a result of surgery. We report a case of a 62-year-old, who came to the emergency for chest pain relieved with analgesics and both chest radiography and electrocardiography were normal. On the third day began with fever that lasted for four weeks and disappeared spontaneously, was discharged with all studies normal and negatives cultives. Two weeks later admitted again by dyspnea on exertion, this was progressing. On admission to hospital clinical signs of pericarditis it is found, including pericardium rubbing, performing echocardiography and CT angiography, where the diagnosis of type B aortic dissection complicated with retrograde type A aortic dissection and hemopericardium was demonstrated.

A incidência de síndrome aórtica aguda (dissecção aórtica, hematoma intramural e penetrante ruptura úlcera aterosclerótica da parede do vaso) é 2-3,5 casos por 100.000 pessoas a cada ano; mas a dissecção aórtica tipo A retrógrada é rara e apenas casos isolados foram relatadas, algumas vezes como resultado da cirurgia. Nós relatamos o caso de um paciente de 62 anos de idade, que veio para a emergência por dor torácica aliviado com analgésicos e tanto a radiografia de tórax e eletrocardiograma eram normais. Ao terceiro dia o paciente começou com febre a qual durou quatro semanas e desapareceu espontaneamente, recebendo alta com todos os estudos normais e pancultivos negativos. Duas semanas mais tarde, ele foi internado no hospital novamente para a dispnéia, que estava progredindo. Na admissão do hospital sinais clínicos de pericardite foram encontrado, incluindo fricção pericárdica, realizando ecocardiografia e angiografia por TC, que revelou o diagnóstico de dissecção aórtica tipo B complicada com dissecção aórtica tipo A retrógrada e hemopericárdio.