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1.
Rev Port Cir Cardiotorac Vasc ; 26(2): 131-137, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31476814

RESUMO

BACKGROUND: Type B aortic dissection (TBAD) is associated with high morbidity and mortality. The DISSECT classification aims to reunite clinical and anatomical characteristics of interest to clinicians involved in its management. This paper aims to characterize a cohort of patients admitted for type B aortic dissection in a tertiary institution. METHODS: This is a retrospective study that included all patients admitted to the hospital due to TBAD from 2006 to 2016. The computerized tomographic angiography that enabled the TBAD diagnosis were reevaluated using DISSECT classification. RESULTS: Thirty-two patients were included in this case series. As to DISSECT classification, 79.3% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental Extent), 28% presented with Complications, and 28% had partial Thrombosis of false lumen. Six patients underwent intervention during the follow-up period. At 12 months, overall survival was 75.4%±8.3% and survival free of aorta-related mortality was 87.0±6.1%. Survival free of aortic dilatation was 82.6±9.5%. In univariate analysis, the presence of complications and chronic kidney disease associated with increased overall and aorta-related mortality rates. Hypertension was associated with aortic dilatation. CONCLUSIONS: The outcomes after TBAD in a Portuguese center are reported. All interventions in TBAD were performed due to complications. The presence of complications and chronic kidney disease was associated with overall mortality and aorta-related mortality and hypertension with aortic dilatation. DISSECT classification was possible to apply in all patients.


Assuntos
Aneurisma Dissecante , Aneurisma da Aorta Torácica , Aneurisma Dissecante/classificação , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/terapia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/terapia , Angiografia por Tomografia Computadorizada , Humanos , Estudos Retrospectivos , Resultado do Tratamento
2.
Medicine (Baltimore) ; 98(32): e16462, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31393350

RESUMO

The outcome of patients with acute type B aortic dissection (BAAD) is largely dictated by whether or not the case is "complicated." The purpose of this study was to investigate the risk factors leading to in-hospital death among patients with BAAD and then to develop a predictive model to estimate individual risk of in-hospital death.A total of 188 patients with BAAD were enrolled. Risk factors for in-hospital death were investigated with univariate and multivariable logistic regression analysis. Significant risk factors were used to develop a predictive model.The in-hospital mortality rate was 9% (17 of 188 patients). Univariate analysis revealed 7 risk factors to be statistically significant predictors of in-hospital death (P < .1). In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: hypotension (odds ratio [OR], 4.85; 95% confidence interval [CI], 1.12-18.90; P = .04), ischemic complications (OR, 8.24; 95% CI, 1.25-33.85; P < .001), renal dysfunction (OR, 12.32; 95% CI, 10.63-76.66; P < .001), and neutrophil percentage ≥80% (OR, 5.76; 95% CI, 2.58-12.56; P = .03). Based on these multivariable results, a reliable and simple prediction model was developed, a total score of 4 offered the best point value.Independent risk factors associated with in-hospital death can be predicted in BAAD patients. The prediction model could be used to identify the prognosis for BAAD patients and assist physicians in their choice of management.


Assuntos
Aneurisma Dissecante/mortalidade , Aneurisma da Aorta Torácica/mortalidade , Mortalidade Hospitalar , Adulto , Idoso , Aneurisma Dissecante/classificação , Aneurisma Dissecante/terapia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/terapia , Comorbidade , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Neutrófilos/metabolismo , Razão de Chances , Fatores de Risco
3.
J Vasc Surg ; 70(1): 53-59, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30591296

RESUMO

OBJECTIVE: To describe index visits for acute aortic dissection (AD) to an academic center and validate the prevailing claims-based methodology to identify and stratify them. METHODS: Inpatient hospitalizations at a single center assigned an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for AD from January 2005 to September 2015 were identified. Diagnoses were verified by review of medical records and imaging studies. All visits were secondarily stratified with the algorithm based on ICD-9 codes. Sensitivity and specificity analyses were conducted to evaluate the ability of the algorithm to correctly identify acute AD by Stanford class and treatment modality (type A open repair [TAOR], type B open repair [TBOR], thoracic endovascular repair [TEVAR], medical management [MM]). RESULTS: In the study interval, there were 1245 visits coded for AD attributed to 968 unique patients. Chart review verification demonstrated that the majority of visits were for AD (79%; n = 981), of which 32% (n = 310) were for an index acute AD event. The true distribution of acute AD visit classifications was TAOR (46.1%; n = 143), TBOR (5.2%; n = 16), TEVAR (7.7%; n = 24), and MM (39.4%; n = 122). The algorithm, which used ICD-9 codes, identified 631 acute visits and stratified them as TAOR (27.1%; n = 171), TBOR (4.1%; n = 26), TEVAR (4.9%; n = 31), and MM (63.9%; n = 403). Analyses demonstrated high specificities, but generally low sensitivities of the algorithm (TAOR: sensitivity, 58%, specificity, 92%; TBOR: sensitivity, 13%, specificity, 98%; TEVAR: sensitivity, 17%, specificity, 98%; MM: sensitivity, 73%, specificity, 72%). CONCLUSIONS: The prevalent claims-based strategy to identify hospitalizations with acute AD is specific, but lacks sensitivity. Caution should be exercised when studying AD with ICD-9 codes and improvements to existing claims-based methodologies are necessary to support future study of acute AD.


Assuntos
Demandas Administrativas em Assistência à Saúde , Algoritmos , Aneurisma Dissecante/terapia , Aneurisma da Aorta Abdominal/terapia , Aneurisma da Aorta Torácica/terapia , Implante de Prótese Vascular , Fármacos Cardiovasculares/uso terapêutico , Mineração de Dados/métodos , Procedimentos Endovasculares , Classificação Internacional de Doenças , Admissão do Paciente , Idoso , Aneurisma Dissecante/classificação , Aneurisma Dissecante/diagnóstico , Aneurisma da Aorta Abdominal/classificação , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico , Implante de Prótese Vascular/classificação , Fármacos Cardiovasculares/classificação , Bases de Dados Factuais , Procedimentos Endovasculares/classificação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos
4.
Radiographics ; 38(7): 1949-1972, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30312138

RESUMO

Treatment of thoracic aortic dissection remains highly challenging and is rapidly evolving. Common classifications of thoracic aortic dissection include the Stanford classification (types A and B) and the DeBakey classification (types I to III), as well as a new supplementary classification geared toward endovascular decision making. By using various imaging techniques, the extent of the dissection, the location of the primary intimal tear, the shape of the aortic arch, and the zonal involvement of the aortic arch-factors that affect the treatment strategy-can easily be identified. Thoracic endovascular aortic repair (TEVAR) is generally performed in two groups of patients: (a) those with a surgically repaired type A dissection, and (b) those with a complicated type B dissection. Several imaging findings can help predict the course of remodeling of the dissected aorta after a repaired type A dissection and TEVAR. A spectrum of imaging findings exist with regard to favorable (positive) or failing (negative) remodeling. A schematic model with imaging support allows the classification of important causes of failing remodeling into proximal and distal groups, on the basis of the origin of the refilling of the false lumen and the underlying pathophysiology of pressurization. Refilling of the false lumen of the aorta after repair of a type A dissection is usually secondary to a persistent intimal tear at the aortic arch, a leak of the distal graft anastomosis, or refilling from the false lumen of a dissected aortic arch vessel. After TEVAR, false lumen refilling is most commonly due to an incomplete seal of the proximal landing related to the aortic tortuosity, an arch branch stump, a supra-arch chimney stent, or the TEVAR technique. Online supplemental material is available for this article. ©RSNA, 2018.


Assuntos
Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares , Aneurisma Dissecante/classificação , Aneurisma da Aorta Torácica/classificação , Humanos , Resultado do Tratamento
5.
Eur J Vasc Endovasc Surg ; 56(6): 818-825, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30241980

RESUMO

AIM: To compare early outcome after complex endovascular aortic repair in octogenarians (age ≥ 80 years) versus non-octogenarians (age < 80 years) treated with fenestrated or branched stent grafts. METHODS: Single centre retrospective analysis from a prospectively collected database of all patients undergoing repair with fenestrated or branched stent grafts for para/suprarenal aortic aneurysm, type Ia endoleak after previous endovascular aortic repair, and thoraco-abdominal aortic aneurysm between January 2015 and December 2017. Early all cause mortality, major adverse events, and need for re-intervention were analysed for non-octogenarians (age < 80 years) and octogenarians (age ≥ 80 years) at the time of repair. RESULTS: 207 patients (58 [28%] females) with a median age of 73 years (IQR 68-78) underwent repair with fenestrated or branched stent grafts. There were 169 (81%) non-octogenarians with a median age of 72 years (IQR 65-76) and 38 (19%) octogenarians with a median age of 82 years (IQR 81-84). The number of patients with chronic kidney disease was significantly higher in the octogenarians (63 [37%] vs. 22 [58%], p = .03]. Nineteen patients (9%) died. The early mortality rate was higher in the octogenarians (12 [7%] vs. 7 [18%], p = .06]. Mortality rate was 4% (6/148) for elective and 22% (13/59) for urgently treated patients. Similar rates of post-operative sepsis, stroke, respiratory problems, need for dialysis, and spinal cord injury were found in both groups. Two patients in each group had early stent graft related re-interventions. The octogenarian group had increased post-operative creatinine values (1.0 [0.8-1.4] vs. 1.4 [1.0-1.9], p = .01). After multiple logistic regression, ASA class ≥4 and rupture were independent factors of early all cause mortality. CONCLUSIONS: Complex endovascular repair in octogenarians has higher early all cause mortality compared with non-octogenarians. Rupture and higher ASA class of ≥4 are independent predictors for early mortality. Age ≥80 years was found to be an independent predictor for higher early all cause mortality.


Assuntos
Fístula Anastomótica/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares/métodos , Stents , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/classificação , Aneurisma da Aorta Torácica/classificação , Ruptura Aórtica/mortalidade , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Complicações Pós-Operatórias , Reoperação , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
6.
Am J Cardiol ; 122(4): 689-695, 2018 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-29970240

RESUMO

The DeBakey classification divides type A acute aortic dissection (AAD) into type I and type II; the latter limited to the ascending aorta. We endeavored to examine differences in DeBakey groups in a contemporary registry. We divided 1,872 patients with noniatrogenic AAD from the International Registry of Acute Aortic Dissection into type I (n = 1691, 90.3%) and type II (n = 181, 9.7%). Patients with type II AAD were older. On presentation, patients with type I AAD reported more back and abdominal pain and were more likely to have pulse deficit. Intramural hematoma was more frequent in type II AAD. Most patients with both types were treated surgically. Lower rates of renal failure, coma, mesenteric and limb ischemia were noted in those with type II AAD. In-hospital death was less frequent (16.6% vs 22.5%) after type II AAD, a trend that did not reach significance. There was no difference in the incidence of new dissection, rapid aortic growth, late aortic intervention or survival at 5 years. In conclusion, AAD limited to the ascending aorta (DeBakey type II) appears to be associated with improved clinical outcomes compared with dissection that extend to the aortic arch or beyond. Although fewer dissection-related complications were noted in patients presenting with type II AAD, as was a trend toward reduced in-hospital mortality, 5-year survival and descending aortic sequelae are not reduced in this contemporary report from International Registry of Acute Aortic Dissection.


Assuntos
Aneurisma Dissecante/classificação , Aneurisma da Aorta Torácica/classificação , Implante de Prótese Vascular/métodos , Sistema de Registros , Stents , Doença Aguda , Idoso , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/cirurgia , Canadá/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
7.
J Thorac Cardiovasc Surg ; 156(1): 27-35.e1, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29709360

RESUMO

OBJECTIVES: We sought to identify the risk factors for abdominal aortic remodeling after thoracic endovascular aortic repair in patients with chronic DeBakey IIIb aneurysm. METHODS: From 2012 to 2016, 70 patients underwent thoracic endovascular aortic repair for chronic DeBakey IIIb aneurysm. The abdominal aortic diameter was measured at 3 different levels (celiac trunk, renal artery, and infrarenal aorta). Abdominal aorta status was classified as expansion or stable. Expansion status was assigned when the abdominal aortic diameter was increased over 5 mm at least 1 level. Otherwise, it was classified as stable status. Forty-six of 70 patients underwent more than 2 postoperative imaging studies. In those patients (n = 46), abdominal aortic volume was measured from celiac trunk to inferior mesenteric artery. A linear mixed-effect model was used to analyze the overall fate of abdominal aortic volume. RESULTS: No in-hospital mortality occurred. The mean follow-up and imaging follow-up duration were 26 and 17 months, respectively. Sixty-one patients (87.1%) demonstrated thoracic false-lumen thrombosis. Although false-lumen thrombosis was achieved, 15 patients (24.6%) demonstrated the expansion status. In volumetric analysis, the total abdominal aortic volume was increasing over time (0.603 cm3/mo; P < .001) and the residual intima tears were identified as an independent anatomic risk factor for an enlarged abdominal aorta. CONCLUSIONS: An enlarged abdominal aorta in chronic DeBakey IIIb aneurysm can be frequently recognized even after successful endovascular treatment. The residual intima tears were the only identified risk factor for change in a dissected abdominal aneurysm. We suggest careful abdominal aorta evaluation and additional procedures on the false lumen if necessary.


Assuntos
Aorta Abdominal/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Remodelação Vascular , Adulto , Idoso , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/fisiopatologia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Doença Crônica , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
8.
Ann Thorac Surg ; 105(6): e239-e241, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29428836

RESUMO

Residual type B aortic dissection following open surgical repair of a type A thoracic aortic dissection can sometimes be complicated by collateral blood supplies, which can impact existing flow patterns and result in progressive aneurysmal dilatation of the thoracic false lumens. We report a unique case that describes the clinical presentation of an infrarenal to innominate artery collateral blood flow that complicated a chronic residual type B dissection, which was diagnosed in a timely manner using multimodality imaging, and successfully managed through an innovative minimally invasive endovascular treatment strategy (without thoracotomy) with no neurological sequela.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Tronco Braquiocefálico , Circulação Colateral , Complicações Pós-Operatórias , Idoso de 80 Anos ou mais , Aneurisma Dissecante/classificação , Aneurisma da Aorta Torácica/classificação , Doença Crônica , Humanos , Masculino , Complicações Pós-Operatórias/classificação
9.
Ann Thorac Surg ; 105(1): 92-99, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29074152

RESUMO

BACKGROUND: The electrocardiogram (ECG) is often used in the diagnosis of patients presenting with chest pain to emergency departments. Because chest pain is a common manifestation of type A acute aortic dissection (TAAAD), ECGs are obtained in much of this population. We evaluated the effect of particular ECG patterns on the diagnosis and treatment of TAAAD. METHODS: TAAAD patients (N = 2,765) enrolled in the International Registry of Acute Aortic Dissection were stratified based on normal (n = 1,094 [39.6%]) and abnormal (n = 1,671 [60.4%]) findings on presenting ECGs and further subdivided according to specific ECG findings. Time data are presented in hours as medians (quartile 1 to quartile 3). RESULTS: Patients with ECGs with abnormal findings presented to the hospital sooner after symptom onset than those with ECGs with normal findings (1.4 [0.8 to 3.3] vs 2.0 [1.0 to 3.3]; p = 0.005). Specifically, this was seen in patients with infarction with new Q waves or ST elevation (1.3 [0.6 to 2.7] vs 1.5 [0.8 to 3.3]; p = 0.049). Interestingly, the time between symptom onset and diagnosis was longer with infarction with old Q waves (6.7 [3.2 to 18.4] vs 5.0 [2.9 to 11.8]; p = 0.034) and nonspecific ST-T changes (5.8 [3.0 to 13.8] vs 4.5 [2.8 to 10.5]; p = 0.002). Surgical mortality was higher in patients with abnormal ECG findings (20.6% vs 11.9%, p < 0.001), especially in those with ischemia by ECG (25.7% vs 16.8%, p < 0.001) and infarction with new Q waves or ST elevation (30.1% vs 17.1%, p < 0.001). CONCLUSIONS: TAAAD patients presenting with abnormal ECG results are sicker, have more in-hospital complications, and are more likely to die. The frequency of nonspecific ST-T abnormalities and its association with delay in diagnosis and treatment presents an opportunity for practice improvement.


Assuntos
Aneurisma Dissecante/fisiopatologia , Aneurisma da Aorta Torácica/fisiopatologia , Eletrocardiografia , Doença Aguda , Idoso , Aneurisma Dissecante/classificação , Aneurisma Dissecante/diagnóstico , Aneurisma Dissecante/terapia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
10.
Ann Thorac Surg ; 105(1): 137-143, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29054307

RESUMO

BACKGROUND: Although surgical outcomes of acute type A aortic dissection (ATAAD) have improved, it is still a high-risk procedure for octogenarians. This study analyzed early and late outcomes of surgical repair of ATAAD among octogenarians. METHODS: From 1990 through 2016, 1,260 consecutive patients with ATAAD were emergently admitted to Jichi Medical University Hospitals. Of them, 1,026 patients who underwent emergency surgery for ATAAD within 48 hours of symptom onset were included in this retrospective study. Of these, 112 were aged 80 years or more (mean, 83.1 ± 2.7) and formed the octogenarian group; and 914 were aged less than 80 years (mean, 62.0 ± 11.4) and formed the control group. Early and late outcomes were compared. RESULTS: The inhospital mortality rate was 6.3% for the octogenarian group and 7.4% for the control group (p = 0.85). No significant difference was observed in the causes of hospital death. Although the overall postoperative complication rate was not different (24.1% versus 23.0%), pneumonia was more frequent among octogenarians (p = 0.03). Multivariate analysis of hospital mortality did not indicate age 80 years or more as a risk factor. Overall postoperative survival for the octogenarian group was 84.6%, 70.5%, and 57.1% at 1, 3, and 5 years, respectively. For the control group, the rates were 89.1%, 85.6%, and 82.1%, respectively. Pneumonia and decrepitude were the major causes of remote death for the octogenarian group. CONCLUSIONS: No significant difference in the hospital mortality rate or the complication rate was observed between the groups. Emergency surgery for ATAAD in octogenarians could be performed with the same low risk observed for younger patients.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Doença Aguda , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma Dissecante/classificação , Aneurisma da Aorta Torácica/classificação , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
11.
Br J Radiol ; 90(1078): 20170417, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28830228

RESUMO

OBJECTIVES: This study analysed CT patterns of the acute dissected aortic arch using original biometric features along with comparison with normal aortas. METHODS: The diagnostic CT scans of 57 patients (42 males, age (mean ± SD: 64.5 ± 13.8 years) admitted with acute Stanford type A dissection involving the aortic arch were analysed by semi-automatic detection protocol of the true lumen of the dissection. We measured the distances from the apex to the ascending and descending aorta, the curvilinear length of the entire arch and of its segments (especially between the brachiocephalic artery trunk and the left subclavian artery), as well as the surface area, angle, height and shift of the arch. These measurements were compared with results previously obtained in a healthy cohort in an analysis adjusted for age, sex and weight. The surface area and rotation of the false lumen were also analysed. RESULTS: Compared to normal aortic arches (N), dissected aortic arches (D) were longer (D: 155 ± 26 mm, N: 135 ± 25 mm, p = 0.002), higher (D: 51 ± 10 mm, N: 45 ± 9 mm, p = 0.04), and with a more anterior apex (shift: D: 1.19 ± 0.56, N: 1.40 ± 0.62, p = 0.007). False lumen occupied between 47-65% of the aorta, turned preferentially clockwise and its rotation decreased progressively along the arch. CONCLUSIONS: The morphology of the dissected aortic arch differs from that of the normal arch. Thus, our compilation of aortic arch measurements may help improve existing endovascular devices and/or design of new endoprostheses. Advances in knowledge: In this article, we provide a comprehensive set of measurements of the dissected aortic arch, and show that dissected aortic arches are longer, higher, and with a more anterior apex than normal arches.


Assuntos
Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/patologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/patologia , Tomografia Computadorizada por Raios X , Doença Aguda , Idoso , Aneurisma Dissecante/classificação , Aneurisma da Aorta Torácica/classificação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
12.
J Thorac Cardiovasc Surg ; 154(4): 1192-1200, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28668458

RESUMO

BACKGROUND: Patients with Stanford type B aortic dissections (ADs) are at risk of long-term disease progression and late complications. The aim of this study was to evaluate the natural course and evolution of acute type B AD and intramural hematomas (IMHs) in patients who presented without complications during their initial hospital admission and who were treated with optimal medical management (MM). METHODS: Databases from 2 aortic centers in Europe and the United States were used to identify 136 patients with acute type B AD (n = 92) and acute type B IMH (n = 44) who presented without complications during their index admission and were treated with MM. Computed tomography angiography scans were available at onset (≤14 days) and during follow-up for those patients. Relevant data, including evidence of adverse events during follow-up (AE; defined according to current guidelines), were retrieved from medical records and by reviewing computed tomography scan images. Aortic diameters were measured with dedicated 3-dimensional software. RESULTS: The 1-, 2-, and 5-year event-free survival rates of patients with type B AD were 84.3% (95% confidence interval [CI], 74.4-90.6), 75.4% (95% CI, 64.0-83.7), and 62.6% (95% CI, 68.9-73.6), respectively. Corresponding estimates for IMH were 76.5% (95% CI, 57.8-87.8), 76.5% (95% CI, 57.8-87.8), and 68.9% (95% CI, 45.2-83.9), respectively. In patients with type B AD, risk of an AE increased with aortic growth within the first 6 months after onset. A diameter increase of 5 mm in the first half year was associated with a relative risk for AE of 2.29 (95% CI, 1.70-3.09) compared with the median 6 months' growth of 2.4 mm. In approximately 60% of patients with IMH, the abnormality resolved within 12 months and in the patients with nonresolving IMH, risk of an adverse event was greatest in the first year after onset and remained stable thereafter. CONCLUSIONS: More than one third of patients with initially uncomplicated type B AD suffer an AE under MM within 5 years of initial diagnosis. In patients with nonresolving IMH, most adverse events are observed in the first year after onset. In patients with type B AD an early aortic growth is associated with a greater risk of AE.


Assuntos
Aneurisma Dissecante , Aneurisma da Aorta Torácica , Doenças da Aorta , Hematoma , Doença Aguda , Idoso , Aneurisma Dissecante/classificação , Aneurisma Dissecante/diagnóstico , Aorta Torácica/crescimento & desenvolvimento , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico , Doenças da Aorta/diagnóstico , Progressão da Doença , Feminino , Hematoma/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos
13.
Ann Thorac Surg ; 104(5): 1577-1582, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28751053

RESUMO

BACKGROUND: The novel Leipzig-Halifax (LH) scorecard for acute aortic dissection type A (AADA) stratifies risk of in-hospital death based on age, malperfusion syndromes, critical preoperative state, and coronary disease. The study aim was to externally validate the LH scorecard performance and, if adequate, propose adjustments. METHODS: All consecutive AADA patients operated on from 1996 to 2016 (n = 509) were included to generate an external validation cohort. Variables related to in-hospital death were analyzed using univariable and multivariable analysis. The LH scorecard was applied to the validation cohort, compared with the original study, and variable selection was adjusted using validation measures for discrimination and calibration. RESULTS: In-hospital mortality rate was 17.7% (LH cohort 18.7%). Critical preoperative state and Penn class non-Aa were independent predictors (odds ratio [OR] 2.42 and 2.45, respectively) of in-hospital death. The LH scorecard was adjusted to include Penn class non-Aa, critical preoperative state, and coronary disease. Assessing discrimination, area under receiver operator characteristic curve for the LH scorecard was 0.61 versus 0.66 for the new scorecard (p = 0.086). In-hospital mortality rates in low-, medium-, and high-risk groups were 14%, 15%, and 48%, respectively (LH scorecard) versus 11%, 23%, and 43%, respectively (new scorecard), and goodness-of-fit p value was 0.01 versus 0.86, indicating better calibration by the new scorecard. A lower Akaike information criterion value, 464 versus 448, favored the new scorecard. CONCLUSIONS: Through adjustment of the LH scorecard after external validation, prognostic performance improved. Further validated, the LH scorecard could be a valuable risk prediction tool.


Assuntos
Aneurisma Dissecante/classificação , Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Mortalidade Hospitalar , Doença Aguda , Idoso , Aneurisma Dissecante/mortalidade , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/mortalidade , Estudos de Coortes , Intervalos de Confiança , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Curva ROC , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Suécia , Resultado do Tratamento
14.
J Thorac Cardiovasc Surg ; 153(6): 1413-1420.e1, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28027791

RESUMO

OBJECTIVE: Low wall shear stress (WSS) has been reported to be associated with accelerated atherosclerosis, aneurysm growth, or rupture. We evaluated the geometry of aortic arch aneurysms and their relationship with WSS by using the 4-dimensional flow magnetic resonance imaging to better characterize the saccular aneurysms. METHODS: We analyzed the geometry in 100 patients using multiplanar reconstruction of computed tomography. We evaluated WSS and vortex flow using 4-dimensional flow magnetic resonance imaging in 16 of them, which were compared with 8 age-matched control subjects and eight healthy young volunteers. RESULTS: Eighty-two patients had a saccular aneurysm, and 18 had a fusiform aneurysm. External diameter/aneurysm length ratio and sac depth/neck width ratio of the fusiform aneurysms were constant at 0.76 ± 0.18 and 0.23 ± 0.09, whereas those of saccular aneurysms, especially those involving the outer curvature, were higher and more variable. Vortex flow was always present in the aneurysms, resulting in low WSS. When the sac depth/neck width ratio was less than 0.8, peak WSS correlated inversely with luminal diameter even in the saccular aneurysms. When this ratio exceeded 0.8, which was the case only with the saccular aneurysms, such correlation no longer existed and WSS was invariably low. CONCLUSIONS: Fusiform aneurysms elongate as they dilate, and WSS is lower as the diameter is larger. Saccular aneurysms dilate without proportionate elongation, and they, especially those occupying the inner curvature, have higher and variable sac depth/neck width ratio. When this ratio exceeds 0.8, WSS is low regardless of diameter, which may explain their malignant clinical behavior.


Assuntos
Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/fisiopatologia , Hemodinâmica , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/patologia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/patologia , Aortografia/métodos , Velocidade do Fluxo Sanguíneo , Angiografia por Tomografia Computadorizada , Dilatação Patológica , Feminino , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Modelos Cardiovasculares , Imagem de Perfusão/métodos , Prognóstico , Fluxo Sanguíneo Regional , Estudos Retrospectivos
15.
Semin Vasc Surg ; 29(1-2): 3-17, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27823587

RESUMO

Management of aortic aneurysm disease has changed in the endovascular era, with the majority of patients opting for stent-graft repair of abdominal and thoracic aneurysms. An understanding of this vascular condition is important for primary care, emergency medicine, medicine specialists, and vascular surgeons alike. Awareness of the patient risk factors for aneurysmal degeneration, sac rupture, and medical management allows physicians to screen appropriate patient populations, which decreases aneurysm-related mortality due to rupture. The evolving endovascular techniques available today have made more patients eligible for this less-invasive repair, which has lower mortality and morbidity compared with open surgery with aorta replacement. This review provides contemporary information on the etiology, natural history, evaluation, and management of aortic aneurysm disease. The complications of prior aortic repair, whether performed via endovascular or open surgery intervention, are equally important to understanding not only for vascular surgeons performing these procedures, but also for primary care, emergency department, and medicine specialists who are evaluating these patients in an office or hospital setting.


Assuntos
Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/terapia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/terapia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares , Aneurisma da Aorta Abdominal/classificação , Aneurisma da Aorta Abdominal/etiologia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/etiologia , Prótese Vascular , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Stents
16.
J Am Coll Cardiol ; 68(10): 1054-65, 2016 09 06.
Artigo em Inglês | MEDLINE | ID: mdl-27585511

RESUMO

We review current knowledge regarding the natural transition of aortic dissection from acute to chronic stages. As this is not well understood, we also bring to bear new data from our institution. Type A dissection rarely transitions naturally into the chronic state; consequently, information is limited. Type B dissections are routinely treated medically and indeed undergo substantial changes during their temporal course. General patterns include: 1) the aorta dilates and, absent surgical intervention, aortic enlargement may cause mortality; 2) continued false lumen patency, particularly with an only partially thrombosed false lumen, increases aortic growth, whereas calcium-channel blockers affect aortic dilation favorably; 3) aortic dilation manifests a temporal dynamic, with early rapid growth and deceleration during transition; 4) the intimal flap dynamically changes over time via thickening, straightening, and loss of mobility; and 5) temporal remodeling, on the cellular level, initially shows a high grade of wall destruction; subsequently, significant fibrosis ensues.


Assuntos
Aneurisma Dissecante/complicações , Aneurisma da Aorta Torácica/complicações , Aneurisma Dissecante/classificação , Aneurisma Dissecante/etiologia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/etiologia , Doença Crônica , Humanos
18.
Ann Thorac Surg ; 100(4): 1444-6, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26434441

RESUMO

Transcatheter aortic valve replacement is being used with increasing frequency in patients with severe aortic stenosis who are otherwise deemed to be at high surgical risk. Aortic dissection is a rare complication of transcatheter aortic valve replacement and poses a unique management dilemma. We describe the treatment of an acute Stanford type A aortic dissection after transcatheter aortic valve replacement with a modified thoracic endovascular stent graft in a 95-year-old woman.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares , Idoso de 80 Anos ou mais , Aneurisma Dissecante/classificação , Aneurisma Dissecante/etiologia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/etiologia , Estenose da Valva Aórtica/cirurgia , Feminino , Próteses Valvulares Cardíacas , Humanos , Desenho de Prótese , Stents , Substituição da Valva Aórtica Transcateter/efeitos adversos
19.
J Endovasc Ther ; 22(6): 938-41, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26384395

RESUMO

PURPOSE: To present a rare case of disseminated intravascular coagulation (DIC) after thoracic endovascular aortic repair (TEVAR) and its novel treatment. CASE REPORT: A 55-year-old man presented with DIC 10 months after TEVAR for chronic type B aortic dissection and descending thoracic aortic aneurysm. He had persistent retrograde flow in the false lumen with a stable aneurysm diameter. The false lumen was embolized with multiple Amplatzer plugs, which promoted false lumen thrombosis. Laboratory evaluation on postoperative day 7 demonstrated resolution of the coagulopathy. Follow-up at 18 months revealed no recurrent DIC; computed tomography angiography showed a stable aortic diameter and excluded thoracic aneurysm sac. CONCLUSION: This case demonstrates an unusual, potentially fatal postoperative complication of endovascular treatment of type B aortic dissections successfully treated with an innovative endovascular solution.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Coagulação Intravascular Disseminada/terapia , Embolização Terapêutica , Procedimentos Endovasculares , Complicações Pós-Operatórias/terapia , Aneurisma Dissecante/classificação , Aneurisma da Aorta Torácica/classificação , Humanos , Masculino , Pessoa de Meia-Idade
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