Brief Reports

Prognosis of aortic intramural hemorrhage compared with classic aortic dissection

Acute aortic dissection (AAD) with concurrent ST-segment elevation myocardial infarction (STEMI) is relatively rare and sometimes overlooked. As D-dimer testing has been reported to have high sensitivity to diagnose AAD in a clinical scale, Aortic Dissection Detection Risk Score (ADD-RS), a point-of-care D-dimer analyzer capable of measuring in 10 min would be useful to deny AAD with concurrent STEMI. However, an optimal cut-off value of D-dimer in such population remains unclear. Therefore, the aim of this study was to elucidate the optimal D-dimer threshold in patients clinically diagnosed with STEMI.

This retrospective cohort study was conducted at two tertiary care centers between 2014 and 2019. Patients clinically diagnosed with STEMI who underwent serum D-dimer measurement on hospital arrival were included. The primary outcome was the diagnosis of AAD. The area under the receiver operating characteristic curve (AUROC) for D-dimer values to diagnose AAD was evaluated, particularly in patients with low to moderate risks of AAD (1 of ADD-RS). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with several cut-off values.

A total of 322 patients were included, and 28 were diagnosed with AAD. The AUROC for D-dimer to diagnose AAD was 0.970 (95% confidence interval: 0.948–0.993) in 262 patients with 1 of ADD-RS. If D-dimer ≥750 ng/mL was used as a cut-off value, sensitivity, specificity, PPV and NPV were 100%, 86.4%, 37.7%, and 100%, respectively. AAD could be denied in 209 (79.8%) patients using the cut-off value (D-dimer <750 ng/mL).

Serum D-dimer ≥750 ng/mL exhibited high sensitivity and NPV to diagnose AAD with concurrent STEMI, while the ADD-RS originally utilized ≥500 ng/mL as a cut-off for any suspected AAD. A point-of-care D-dimer measurement with the new cut-off would be useful to rule-out AAD among patients with STEMI.

El hematoma intramural agudo tipo A (HIM-A) constituye una entidad de elevada letalidad, subsidiaria de intervención quirúrgica emergente. No obstante, casos seleccionados (estabilidad clínica/hemodinámica, diámetro < 50 mm, espesor < 11 mm) pueden presentar mejor pronóstico, proponiéndose el manejo conservador como alternativa en estudios asiáticos. Por ello, planteamos realizar un metaanálisis comparando la mortalidad hospitalaria del manejo conservador vs. quirúrgico del HIM-A, así como tendencias temporales y diferencias geográficas. Realizamos una búsqueda en Medline® por palabras clave: «aortic intramural hematoma». Se incluyeron estudios comparativos de ambas alternativas terapéuticas con resultados de mortalidad hospitalaria de pacientes con HIM-A. Se valoró el tamaño del efecto, expresado como riesgo relativo (RR), mediante el test de Mantel-Haenszel y un modelo de efectos fijos o aleatorios según el nivel de heterogeneidad I² < o ≥ 25%, respectivamente. Se incluyeron 46 estudios con 890 pacientes para manejo conservador y 1.071 para quirúrgico. Globalmente, el tratamiento quirúrgico fue superior (RR = 0,65, p = 0,04), y también lo fue en estudios occidentales (RR = 0,57, p = 0,02). Cuando se excluyeron los estudios que asignaron el tratamiento conservador a enfermos rechazados para cirugía, ambas estrategias terapéuticas fueron equivalentes, globalmente (RR = 1,31, p = 0,11) y en el medio occidental (RR = 1,06, p = 0,78), siendo el tratamiento conservador superior en estudios orientales (RR = 2,00, p = 0,03). El análisis de tendencias temporales mostró una progresiva superioridad del manejo conservador electivo, independientemente del medio considerado. Podemos concluir que, aunque el tratamiento de primera elección del HIM-A en nuestro medio es quirúrgico, determinados grupos de pacientes pueden beneficiarse de una estrategia conservadora como puente a una intervención quirúrgica diferida, e incluso como terapia definitiva.

Type A intramural hematoma (IMH-A) is a highly lethal entity where emergent surgical intervention is usually indicated. However, selected cases (clinical/hemodynamic stability, diameter < 50 mm, thickness < 11 mm) may have a better prognosis, and a conservative management as an alternative has been suggested in Asian studies. Thus, we sought to perform a meta-analysis study comparing the hospital mortality of conservative vs. surgical management of HIM-A as well as temporal and geographical trends. We searched studies in Medline® by keywords: “aortic intramural hematoma”. Comparative studies of both therapeutic alternatives that reported hospital mortality of IMH-A patients were included. The effect size, expressed as relative risk (RR), was assessed using the Mantel-Haenszel test using a fixed or random effects model according to the level of heterogeneity I² < or ≥ 25%, respectively. Forty-six studies comprising 890 patients for conservative management and 1,071 for surgery were included. The surgical treatment was superior in the global series (RR = 0.65, P = .04), as well as in western studies (RR = 0.57, P = .02). When the studies that assigned conservative treatment to patients rejected for surgery were excluded, both therapeutic strategies were equivalent, globally (RR = 1.31, P = .11) and in the western environment (RR = 1.06, P = .78). Conversely, conservative treatment was superior in oriental studies (RR = 2.00, P = .03). Temporal trends analysis showed a progressive superiority of elective conservative management regardless of its geographical origin. We can conclude that, although the surgical treatment of IMH-A is the first treatment choice in our environment, selected groups of patients can benefit from a conservative strategy as a bridge to a delayed surgical intervention or even as definitive therapy.

The natural history of penetrating aortic ulcer (PAU) has been variably described and clear guidelines are lacking. We reviewed our experience with PAUs in a tertiary referral center.

Imaging reports from January 2010 to December 2017 were retrospectively searched for the diagnosis of “penetrating aortic ulcer.” Diagnosis was confirmed by review of imaging studies. Patient demographics, presenting symptoms, and anatomic characteristics were collected and analyzed for associations with need for surgical intervention, aortic complication, and overall survival.

One hundred six patients with PAU were identified. Locations included 57 (53.8%) aortic arch, 24 (22.6%) descending thoracic, and 25 (23.5%) abdominal aorta. Dissection was present in 12 (11.4%) and acute rupture in 4 (3.8%) cases. At presentation, 57 (53.8%) patients were symptomatic. Forty-six (43.8%) patients were evaluated by cardiothoracic or vascular surgeons. Thirteen (12.3%) underwent surgical or endovascular repair and 10 (10.4%) had a change in medical management. Long-term follow-up (LTFU) was available in 30 patients for a mean of 36.5 ± 29.2 months. Twenty-one (70%, 21/30) demonstrated disease stability or resolution and 9 (30%, 9/30) worsened with 3 undergoing surgery. No PAU ruptured during follow-up. Patient demographics, presenting symptoms, and PAU morphology did not predict disease progression. Referral to a cardiovascular surgeon at initial presentation was associated with a 40% decreased likelihood of disease progression (P = 0.046) and a 60% survival advantage at LTFU (P = 0.037).

PAU disease progression occurs in 30% of patients at LTFU of 36.5 ± 29.2 months. All patients identified with PAU on diagnostic imaging should be referred for a surgical evaluation and follow-up, as referral to cardiovascular surgeon is associated with improved disease course.

Patients with distal residual after proximal repair of aortic dissection (AD) have shown unsatisfactory long-term prognosis. However, possible mechanisms and risk factors for distal aortic segmental enlargement (DSAE) have been poorly understood.

We analyzed 962 AD patients repaired to the descending aorta between 1999 and 2014. Aortic morphological characteristics of 419 patients (including 75 DSAE and 344 non-DSAE patients) were investigated and compared. Potential risk factors associated with DSAE were explored using logistic regression analysis or natural logarithmic transformation. Logistic multi regress equations were performed to identify independent risk factors.

Independent risk factors of DSAE are listed as follow: more tears in the thoracic descending aorta (odds ratio [OR], 1.65; 95% confidence interval [CI],1.24 to 2.19; P = .0005); fewer tears in the infra-renal abdominal aorta (OR, 3.00; 95% CI,2.04 to 4.55; P < .0001); closer distance of the first intimal tear to the left subclavian artery (OR, 1.51; 95% CI,1.28 to 1.69; P < .0001); larger average distance between tears (OR, 11.81; 95% CI,3.39 to 41.08; P = .0001); larger maximum distance between two tears (OR, 1.79; 95% CI,1.48 to 2.16; P < .0001), and larger area of remained tears (OR, 1.56; 95% CI, 1.38 to 1.76; P < .0001).

The location and size of remained tears are the key risk factors of DSAE patients. Long-segment aortic repair and aggressive exclusion of all distal tears located on the thoracic descending aorta in their initial therapy will be an optimal strategy.

Recently, intramural hematoma (IMH) has been characterized as a rare variant of aortic dissection, falling within the acute aortic syndromes (AAS). Although aortic endovascular treatment seems to provide good results, no consensus has been established regarding the optimal management of IMH affecting the descending thoracic aorta (IMH B). The aim of this study was to assess long-term clinical and morphological results of IMH B treated with a stent graft.

Between 2002 and 2013, 15 of the 423 (3.5%) consecutive patients with AAS were found to have IMH B. During follow-up, complications related to IMH B were observed in 10 patients, including 5 during the acute period (<14 days). Surgical indications were ulcerations, refractory pain, aneurysm evolution, aortic rupture, and pleural effusion. An endovascular approach was taken for all forms with suitable anatomy.

Technical success rate was 100%, with complete exclusion of lesions of the descending thoracic aorta in all cases treated with a stent graft. No neurological complications or deaths occurred within the first 30 postoperative days, nor at the end of the mean follow-up of 46 months (1–137 months). After the aortic stent graft, partial or complete regression of the hematoma was observed in all cases.

IMH B is most often a progressive disease requiring long-term monitoring. In case of complications, stent-graft treatment of the descending thoracic aorta can be performed successfully in most cases. This procedure appears to be a safe technique that provides very good long-term results, with favorable remodeling of the aorta.