Results of the in situ fenestration technique for preservation of the Left subclavian artery in the endovascular repair of acute aortic syndromes in a reference center.

INTRODUCTION: The in situ fenestration (ISF) technique consists of maintaining the patency of the aortic branch after the endoprosthesis is already in place as a viable, effective, and fast-performing alternative to revascularize the aortic arch arteries. OBJECTIVE: To report the experience with a series of cases of endovascular treatment of Acute Aortic Syndromes involving the aortic arch, using the ISF technique in a specialized center. METHODS: We analyzed data collected from patients treated with ISF during TEVAR for Acute Aortic Syndromes involving the aortic arch from June 2020 to January 2022, assessing perioperative outcomes, including immediate and late success rates, complications, morbidity and mortality, and short and medium term aortic branch patency. RESULTS: Of the 11 patients eligible for the ISF procedure, 9 were successful, with a technical success rate of 81%. No patient had a type 1A endoleak related to fenestration. There was complete thrombosis of the false lumen in the thoracic aorta in 77% cases. No death was related to the fenestration technique. CONCLUSION: ISF as feasible and with a high rate of technical success and good results in the short and medium term. Prospective studies with long-term clinical follow-up are still needed to fully assess the durability of these unreinforced fenestrations.

Intramural hematoma and penetrating atherosclerotic ulcers of the aorta: uncertainties and controversies.

The natural histories of intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU) are highly variable as they may progress to aneurysm formation, rupture, or dissection, or even resolve, in the specific case of IMH. Imaging plays an increasingly important role in clinical and surgical management of IMH and PAU. In contrast to ulcer-like projections, images of intramural blood pools have not been widely reported in CT studies of patients with IMH. Understanding the imaging characteristics and the natural course of each of these entities would help clinicians and surgeons to identify patients at greatest risk for bad prognosis and may improve outcomes. This paper discusses the pathophysiology of these entities, the controversies regarding their natural history, and the prognostic factors that should be identified in CT scans.

Características de los pacientes con disección aórtica aguda en Villa Clara: Estudio multicéntrico / Characteristics of patients with acute aortic dissection in Villa Clara: Multicentric study

RESUMEN Introducción: La disección aórtica aguda es considerada como una de las enfermedades cardiovasculares más catastróficas que ocurren en el ser humano, tiene una alta mortalidad que obliga a un diagnóstico y tratamiento precoces. Objetivo: Describir las características de los pacientes con disección aórtica atendidos en 4 instituciones hospitalarias de la provincia de Villa Clara. Método: Se realizó un estudio observacional, descriptivo, de corte transversal, multicéntrico, en 25 pacientes que fueron atendidos con el diagnóstico de disección aórtica en el período comprendido entre enero de 2012 y diciembre de 2017, en 4 centros hospitalarios de nivel secundario de la provincia de Villa Clara, Cuba. Resultados: La media de la edad de los pacientes fue 60,48 ± 13,99 años, 21 fueron del sexo masculino lo que representó el 84,0%. Según la clasificación de Stanford, predominó el tipo A, en 17 pacientes (68,0%). El síntoma más referido fue el dolor torácico anterior y el taponamiento cardíaco fue la complicación más frecuente (28,0%). Conclusiones: Las características de los pacientes con disección aórtica en Villa Clara fueron similares a lo que acontece en el ámbito nacional e internacional, con una elevada mortalidad y una mayor incidencia en hombres, hipertensos y mayores de 65 años de edad. El dolor torácico fue el síntoma cardinal y el taponamiento cardíaco la complicación más temida. La disección aórtica requiere un alto nivel de sospecha por parte del médico para un diagnóstico y un tratamiento tempranos.

ABSTRACT Introduction: Acute aortic dissection is considered one of the most tragic cardiovascular diseases that occur in humans; with high mortality which requires early diagnosis and treatment. Objective: To describe the characteristics of patients with aortic dissection treated in 4 hospital institutions in the province of Villa Clara. Method: An observational, descriptive, cross-sectional, multicenter study was conducted in 25 patients who were treated under the diagnosis of aortic dissection in the period between January 2012 and December 2017, in 4 secondary-level hospital centers in Villa Clara province, Cuba. Results: The mean age of the patients was 60.48 ± 13.99 years, 21 were male, which represented 84.0%. According to the Stanford classification, type A predominated in 17 patients (68.0%). The most common symptom was anterior chest pain while the most frequent complication was cardiac tamponade (28.0%). Conclusions: The characteristics of patients with aortic dissection in the Villa Clara setting manifested in a similar way to those in the national and international sphere. A high level of suspicion is required by the doctor to achieve a timely diagnosis and treatment.

Acute penetrating atherosclerotic ulcer of the ascending aorta.

A 67-year-old man presented with chest pain. Clinical examination revealed hypertension (160/90 mm Hg). Electrocardiogram indicated no acute coronary syndrome and cardiac enzymes were normal. Catheterization was performed owing to the patient's continuing chest pain and ascending aortogram revealed irregular aortic wall. A computed tomography image showed the shape of penetrating ulcer. The patient was taken to the operating room and intraoperative examination confirmed the diagnosis of penetrating atherosclerotic ulcer (PAU). Coronary artery bypass graft and bovine pericardial patch repair of PAU was performed. A bovine pericardial patch was done as aortic root was heavily calcified and was easy to handle and more hemostatic.

Hematoma intramural e úlcera penetrante da aorta: incertezas e controvérsias / Intramural hematoma and penetrating atherosclerotic ulcers of the aorta: uncertainties and controversies

A história natural do hematoma intramural (HI) e da úlcera penetrante (UP) é muito variável, já que podem progredir para a formação de aneurisma, ruptura, dissecção, e podem até mesmo regredir, no caso específico do HI. Exames de imagem têm crescente papel no manejo clínico e operatório da UP e do HI. Ao contrário das projeções semelhantes a úlcera, achados de lagos sanguíneos não são relatados nos estudos tomográficos de pacientes com HI. O entendimento das características da imagem e do curso natural de cada uma dessas entidades ajudará clínicos e cirurgiões a identificar os pacientes com maior risco para um mau prognóstico e pode melhorar os desfechos. A fisiopatologia dessas entidades, as controvérsias no que se refere a suas histórias naturais e os fatores prognósticos das imagens tomográficas são discutidos neste artigo

The natural histories of intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU) are highly variable as they may progress to aneurysm formation, rupture, or dissection, or even resolve, in the specific case of IMH. Imaging plays an increasingly important role in clinical and surgical management of IMH and PAU. In contrast to ulcer-like projections, images of intramural blood pools have not been widely reported in CT studies of patients with IMH. Understanding the imaging characteristics and the natural course of each of these entities would help clinicians and surgeons to identify patients at greatest risk for bad prognosis and may improve outcomes. This paper discusses the pathophysiology of these entities, the controversies regarding their natural history, and the prognostic factors that should be identified in CT scans

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

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.

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.

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.

Experiencia y resultados en cirugía de disección aórtica tipo A durante una década en la Fundación Valle del Lili, Cali, Colombia / Experience and results in surgery of type A aortic dissection during a decade in the Fundación Valle del Lili, Cali, Colombia

Antecedentes: la disección aórtica tipo A continúa siendo una enfermedad con alto riesgo de muerte, que por ende requiere un diagnóstico rápido y manejo quirúrgico inmediato. Objetivo: reportar la experiencia y los resultados en cirugía de disección aórtica tipo A durante una década. Métodos: se realizó un estudio descriptivo, retrospectivo, mediante la revisión de historias clínicas de los pacientes atendidos entre enero de 2001 y diciembre de 2010. Se seleccionaron 58 pacientes con diagnóstico de disección aórtica tipo A, que cumplían con los criterios de inclusión y se analizaron variables demográficas, clínicas, intra y post-operatorias. Resultados: 79,3% de los pacientes fueron hombres; con una mediana de edad de 56 años. Los tiempos promedio para pinza aórtica, bomba y arresto fueron 136, 223 y 39 minutos, respectivamente. Los procedimientos más frecuentes fueron reemplazo de aorta ascendente y cirugía de Bentall en 34,5% de los casos cada uno. La mediana de estancia en la unidad de cuidado intensivo fue de seis y doce días para el total de hospitalización. Se reportaron complicaciones en 36,2% de los casos; la principal fue sepsis de cualquier causa en 20% de los pacientes. La mortalidad intrahospitalaria fue de 24% y la supervivencia a 28 días fue superior a 70%. Conclusiones: según nuestra casuística, la mortalidad observada no difiere mucho a la que se reporta en registros multicéntricos internacionales, en los cuales sigue siendo elevada, lo cual resalta la importancia del diagnóstico temprano y el manejo quirúrgico inmediato, que implica un esfuerzo humano e institucional considerable. Palabras clave: síndrome aórtico agudo, disección de aorta, cirugía cardíaca, mortalidad. Background: type A aortic dissection is still a disease with a high risk of death. Therefore it requires prompt diagnosis and immediate surgical management. Objective: to report our experience and results in surgery of type A aortic dissection during a decade. Methods: a descriptive, retrospective study, by reviewing medical records of patients treated between January 2001 and December 2010 was realized. 58 patients diagnosed as type A aortic dissection who met the inclusion criteria were selected, and demographic, clinical, intra and post-operative variables were analyzed. Results: 79.3% of the patients were men, with a median age of 56 years. The mean times for aortic clamp, pump and arrest were 136, 223 and 39 minutes, respectively. The most frequent procedures were ascending aortic replacement and Bentall surgery in 34.5% of cases each one. The median stay in the ICU was six days and overall hospitalization was twelve days. Complications were reported in 36.2% of cases. The main one was sepsis from any cause in 20% of patients. In-hospital mortality was 24% and survival at 28 days was higher than 70%. Conclusions: according to our casuistics, the observed mortality is not very different to that reported in international multicenter registries which remains still high. This fact highlights the importance of early diagnosis and immediate surgical management, implying a significant human and institutional effort.

Background: type A aortic dissection is still a disease with a high risk of death. Therefore it requires prompt diagnosis and immediate surgical management. Objective: to report our experience and results in surgery of type A aortic dissection during a decade. Methods: a descriptive, retrospective study, by reviewing medical records of patients treated between January 2001 and December 2010 was realized. 58 patients diagnosed as type A aortic dissection who met the inclusion criteria were selected, and demographic, clinical, intra and post-operative variables were analyzed. Results: 79.3% of the patients were men, with a median age of 56 years. The mean times for aortic clamp, pump and arrest were 136, 223 and 39 minutes, respectively. The most frequent procedures were ascending aortic replacement and Bentall surgery in 34.5% of cases each one. The median stay in the ICU was six days and overall hospitalization was twelve days. Complications were reported in 36.2% of cases. The main one was sepsis from any cause in 20% of patients. In-hospital mortality was 24% and survival at 28 days was higher than 70%. Conclusions: according to our casuistics, the observed mortality is not very different to that reported in international multicenter registries which remains still high. This fact highlights the importance of early diagnosis and immediate surgical management, implying a significant human and institutional effort.