Viviana Grassi

Importance of Refractory Pain and Hypertension in Acute Type B Aortic Dissection Insights From the International Registry of Acute Aortic Dissection (IRAD)

Background— In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection. Methods and Results— Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. “High-risk” patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P =0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P =0.0003). Mortality rates after surgical (20% versus 28%; P =0.74) or endovascular management (3.7% versus 9.1%; P =0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P =0.041). Conclusions— Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group. # Clinical Perspective {#article-title-24}Background— In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection. Methods and Results— Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. “High-risk” patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P=0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P=0.0003). Mortality rates after surgical (20% versus 28%; P=0.74) or endovascular management (3.7% versus 9.1%; P=0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P=0.041). Conclusions— Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group.

Descending aortic diameter of 5.5 cm or greater is not an accurate predictor of acute type B aortic dissection

OBJECTIVE The risk of acute type B aortic dissection is thought to increase with descending thoracic aortic diameter. Currently, elective repair of the descending thoracic aorta is indicated for an aortic diameter of 5.5 cm or greater. We sought to investigate the relationship between aortic diameter and acute type B aortic dissection, and the utility of aortic diameter as a predictor of acute type B aortic dissection. METHODS We examined the descending aortic diameter at presentation of 613 patients with acute type B aortic dissection who were enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2009, and analyzed the subset of patients with acute type B aortic dissection with an aortic diameter less than 5.5 cm. RESULTS The median aortic diameter at the level of acute type B aortic dissection was 4.1 cm (range 2.1-13.0 cm). Only 18.4% of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection had an aortic diameter of 5.5 cm or greater. Patients with Marfan syndrome represented 4.3% and had a slightly larger aortic diameter than patients without Marfan syndrome (4.68 vs 4.32 cm, P = .121). Complicated acute type B aortic dissection was more common among patients with an aortic diameter of 5.5 cm or greater (52.2% vs 35.6%, P < .001), and the in-hospital mortality for patients with an aortic diameter less than 5.5 cm and 5.5 cm or greater was 6.6% and 23.0% (P < .001), respectively. CONCLUSIONS The majority of patients with acute type B aortic dissection present with a descending aortic diameter less than 5.5 cm before dissection and are not within the guidelines for elective descending thoracic aortic repair. Aortic diameter measurements do not seem to be a useful parameter to prevent aortic dissection, and other methods are needed to identify patients at risk for acute type B aortic dissection.

Circulating transforming growth factor-beta levels in acute aortic dissection

To the Editor: Circulating transforming growth factor (TGF)-beta has received recent attention because it may potentially serve as a biomarker for therapeutic monitoring of aortic remodeling processes in patients with Marfan syndrome ([1,2][1]). TGF-beta and its actions are regulated by the elastic

Descending thoracic and abdominal aortic coarctation in the young: Surgical treatment after percutaneous approaches failure

Descending thoracic and abdominal aortic coarctations are characterized by a segmental narrowing that frequently involves the origin of the visceral and renal arteries. Optimal primary treatment is debated, being reported for both surgical and percutaneous complications. We describe our surgical experience with two youths presenting with failure of distal descending aortic stenting and with abdominal aortic coarctation post-balloon angioplasty, and associated thrombosis of a stented right renal artery and stenosis of the origin of the superior mesenteric artery (SMA). In both cases, a longitudinal aortoplasty was performed with a polytetrafluoroethylene (PTFE) patch, using simple aortic cross-clamping. Renal thrombosis and SMA stenosis were managed with eversion technique. In-hospital course was uneventful. Midterm follow-up showed absence of significant restenosis and better control of hypertension. In order to refrain from operating on these patients as long as possible, and also because of the very high risk of a redo-surgery, we think that an initial balloon angioplasty should be considered. Surgical management can be adopted, even after failure of percutaneous treatments, with satisfactory short- and midterm vessels patency.

Long-term outcomes of surgical aortic fenestration for complicated acute type B aortic dissections

INTRODUCTION Surgical aortic fenestration has been used for treating ischemic complications of acute type B aortic dissection (ABAD). In the current endovascular era, surgical aortic fenestration may serve as an alternative for these patients after percutaneous failure. The purpose of this study is to describe our surgical suprarenal and infrarenal aortic fenestration technique, and to report the long-term outcomes of this approach in the management of complicated ABAD. METHODS We retrospectively analyzed the in-hospital and long-term outcomes of 18 patients treated with either suprarenal (n = 10) or infrarenal surgical fenestration (n = 8) for complicated ABAD between 1988 and 2002. Suprarenal fenestration was performed through a thoracoabdominal incision in the 10th intercostal space, whereas patients treated with infrarenal fenestration underwent a midline laparotomy. A longitudinal aortotomy was performed and the true and false lumens were identified, followed by a wide resection of the intimal membrane. RESULTS Median age was 60 years (range, 48-82 years) and 89% (n = 16) were male. The in-hospital mortality was 22% (n = 4), which included two deaths after suprarenal fenestration and two deaths after infrarenal fenestration. In the remaining patients, full visceral, renal, and lower extremity function was recovered, except for 1 patient with paraplegia at admission in which the neurologic deficit was permanent. Median follow-up of the surviving patients was 10.0 years (interquartile range, 12.5; range, 0.5-20 years). During follow-up, none of the patients developed renal or visceral ischemia, or ischemic complications to the lower extremities, and no significant dilatations of the treated aortic segments were noted. Three of 14 patients with ABAD who were discharged alive expired during the follow-up period due to causes unrelated to the surgical procedure. CONCLUSION Surgical aortic fenestration represents an effective and durable option for treating ischemic complications of ABAD. Actually, this conservative surgical technique may serve as the alternative treatment in case of contraindications or failure of endovascular management of complicated ABAD.

Biomarkers in TAA—The Holy Grail

Thoracic aortic aneurysm (TAA) is a silent disease, often discovered at a time point that dramatic complications, as rupture and dissection, occur. For the detection of asymptomatic TAA and prevention of such complications, it is essential to have an adequate screening tool. Until now, routine laboratory blood tests have played only a minor role in the screening, diagnosis, tracking and prediction of the natural history of TAAs. However, the knowledge about biomarkers is rapidly expanding in the cardiovascular field, and there are several potential biomarkers that might be implemented into TAA clinical practice in the near future. The most important and promising markers for TAA will be discussed in this overview.

Endovascular repair of thoracic aortic disease with the EndoFit stent-graft: short and midterm results from a single center.

Purpose: To analyze the outcomes of endovascular treatment of thoracic aortic pathologies performed at a single center with the EndoFit thoracic stent-graft system. Methods: From January 2002 to January 2007, 41 patients (33 men; mean age 69.3±9.7 years, range 48–84) were treated for thoracic aortic disease with the EndoFit stent-graft system. Patient data were retrieved from a retrospective review of hospital records. Indications for treatment were progression of aneurysm size in atherosclerotic aneurysms (n=24, mean aneurysm diameter 7.19±1.48 cm), acute contained aortic rupture (n=5), aortic dissection (n=6), penetrating atherosclerotic ulcers (n=4), post-traumatic pseudoaneurysm (n=1), and post coarctation repair aneurysm (n=1). Results: The EndoFit stent-graft was successfully deployed in all 41 patients. The inhospital and 30-day mortality rate was 7.3% (3 patients). Three (7.3%) postoperative endoleaks were recorded: a proximal type Ia and a distal Ib both resolved spontaneously at 1 and 3 months, respectively. The third patient had a persistent type Ia endoleak; conversion was necessary after 1 year. There was only 1 case of spinal ischemia, with consequent lower extremity weakness; no paraplegia was observed. During a mean 24.8-month follow-up, 2 secondary type Ia endoleaks were treated with additional stent-grafts. There were 7 (17%) deaths during follow-up. At 2 years, overall patient survival by KaplanMeier analysis was 70%; aneurysm-related survival was 89%. Conclusion: Endovascular treatment of vascular disease involving the descending thoracic aorta can be safely performed with the EndoFit thoracic stent-graft system.

Open fenestration for complicated acute aortic B dissection

Acute type B aortic dissection (ABAD) is a serious cardiovascular emergency in which morbidity and mortality are often related to the presence of complications at clinical presentation. Visceral, renal, and limb ischemia occur in up to 30% of patients with ABAD and are associated with higher in-hospital mortality. The aim of the open fenestration is to resolve the malperfusion by creating a single aortic lumen at the suprarenal or infrarenal level. This surgical procedure is less invasive than total aortic replacement, thus not requiring extracorporeal support and allowing preservation of the intercostal arteries, which results in decreased risk of paraplegia. Surgical aortic fenestration represents an effective and durable option for treating ischemic complications of ABAD, particularly for patients with no aortic dilatation. In the current endovascular era, this open technique serves as an alternative option in case of contraindications or failure of endovascular management of complicated ABAD.

Emergent treatment of aortic rupture in acute type B dissection

Massive left hemothorax is a rare and dramatic complication of acute type B aortic dissection. The primary endpoint is to treat the aortic rupture, stop the bleeding and stabilize the hemodynamic status, with the aim to prevent mortality and major cardiac, cerebral, visceral and renal complications. Thoracic endovascular repair (TEVAR) is the most frequent management, although its planning, in these emergent patients, may be very difficult and sub-optimal imaging may result at post-operative examination (CT and MRI). In case of TEVAR is not the definitive treatment of the aortic disease, a second stage surgical management can be performed in elective status, in a patient with a total clinical recover. In acute and dramatic circumstances, like ruptured type B dissection, TEVAR is a valid and suitable bridge procedure to open surgery, reducing the overall risk for mortality and major complications.

Importance of Refractory Pain and Hypertension in Acute Type B Aortic DissectionClinical Perspective

Background— In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection. Methods and Results— Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. “High-risk” patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P =0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P =0.0003). Mortality rates after surgical (20% versus 28%; P =0.74) or endovascular management (3.7% versus 9.1%; P =0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P =0.041). Conclusions— Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group. # Clinical Perspective {#article-title-24}Background— In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection. Methods and Results— Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. “High-risk” patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P=0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P=0.0003). Mortality rates after surgical (20% versus 28%; P=0.74) or endovascular management (3.7% versus 9.1%; P=0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P=0.041). Conclusions— Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group.