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The document titled "2024 ESC Guidelines for the management of peripheral arterial and aortic diseases" is a comprehensive guide that provides recommendations for the evaluation, screening, and treatment of peripheral arterial and aortic diseases. It covers topics such as epidemiology, risk factors, and diagnostic methods for these conditions. The guidelines outline optimal medical treatments, including lifestyle changes and pharmacological therapies, and discuss specific conditions such as peripheral arterial disease and carotid artery disease. The document also addresses aortic diseases, including atheromatous disease and aortic aneurysms, and offers guidance on treatment options such as surgery and endovascular repair. It provides information on genetic and congenital diseases of the aorta, as well as polyvascular peripheral arterial disease. The document concludes with key messages, gaps in evidence, and recommendations for practice, emphasizing the importance of individualized care, multidisciplinary management, and early diagnosis. [Extracted from the article]

Acute Aortic Syndrome (AAS) comprises of three distinct pathological conditions: Aortic Dissection (AD), Penetrating Atherosclerotic Ulcer (PAU), and Intramural Haematoma (IMH). Although AAS and its emergencies are not common occurrences, they are considered highly dangerous and potentially fatal. Clinically, differentiating between the various types of aortic syndromes can be challenging. The prognosis of these conditions significantly depends on speedy and precise analysis. Therefore, present study emphasised the critical role of radiology in the diagnosis of AASs, with Contrast-Enhanced Computed Tomography (CECT) being the quickest and most consistent imaging modality. In this case series, four cases of AASs are presented, comprising three cases of AD and a case of PAU in a patient with infrarenal aortic occlusion. Notably, one of the dissection cases was accompanied by renal ischaemia. Recognising acute aortic emergencies promptly is essential for saving lives.

Acute Aortic Syndrome (AAS) comprises of three distinct pathological conditions: Aortic Dissection (AD), Penetrating Atherosclerotic Ulcer (PAU), and Intramural Haematoma (IMH). Although AAS and its emergencies are not common occurrences, they are considered highly dangerous and potentially fatal. Clinically, differentiating between the various types of aortic syndromes can be challenging. The prognosis of these conditions significantly depends on speedy and precise analysis. Therefore, present study emphasised the critical role of radiology in the diagnosis of AASs, with Contrast-Enhanced Computed Tomography (CECT) being the quickest and most consistent imaging modality. In this case series, four cases of AASs are presented, comprising three cases of AD and a case of PAU in a patient with infrarenal aortic occlusion. Notably, one of the dissection cases was accompanied by renal ischaemia. Recognising acute aortic emergencies promptly is essential for saving lives. [ABSTRACT FROM AUTHOR]

Aims Abdominal aortic aneurysm (AAA) represents a life-threatening condition characterized by medial layer degeneration of the abdominal aorta. Nevertheless, knowledge regarding changes in regulators associated with aortic status remains incomplete. A thorough understanding of cell types and signalling pathways involved in the development and progression of AAAs is essential for the development of medical therapy. Methods and results We harvested specimens of the abdominal aorta with different pathological features in Angiotensin II (AngII)-infused ApoE−/− mice, conducted scRNA-seq, and identified a unique population of interferon-inducible monocytes/macrophages (IFNICs), which were amply found in the AAAs. Gene set variation analysis revealed that activation of the cytosolic DNA sensing cGAS-STING and JAK-STAT pathways promoted the secretion of type I interferons in monocytes/macrophages and differentiated them into IFNICs. We generated myeloid cell-specific deletion of Sting1 (Lyz2 -Cre+/−; Sting1 flox/flox) mice and performed bone marrow transplantation and found that myeloid cell-specific deletion of Sting1 or Ifnar1 significantly reduced the incidence of AAA, aortic rupture rate, and diameter of the abdominal aorta. Mechanistically, the activated pyroptosis- and inflammation-related signalling pathways, regulated by IRF7 in IFNICs, play critical roles in the developing AAAs. Conclusion IFNICs are a unique monocyte/macrophage subset implicated in the development of AAAs and aortic rupture. [ABSTRACT FROM AUTHOR]

Aortic dissection is infrequent in everyday practice; however, it can result in life-threatening complications and causes more deaths each year in the UK than road traffic collisions. It is one of the family of acute aortic syndromes, which includes penetrating aortic ulcer (PAU) and intramural haematoma (IMH). Type A aortic dissections involve the ascending aorta and arch and almost invariably require prompt surgical treatment due to exceptionally high early 48-hour mortality without surgery. Many type B aortic dissections (TBAD) are not complicated at presentation and can be treated conservatively in high dependency and discharged without intervention. Complicated aortic dissection requires intervention, often with a thoracic endovascular aortic repair (TEVAR). The survival after TBAD is higher than type A dissection that invariably requires emergency operative intervention, with 65% of patients surviving to 1 year. Following acute aortic syndrome, best medical therapy involves tight blood pressure and heart rate control using beta-blockers or calcium channel blockers. Statin therapy may be of benefit. Regular cross-sectional imaging surveillance is important to detect late complications such as aortic dilatation. In type B aortic dissection, aortic dilatation is a common cause of late rupture with only 50% of patients surviving after 5 years without intervention. One of the most important questions at present is whether people at high risk of further aortic dilatation can be identified and intervened on early to prevent these late complications? [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Acute aortic syndromes are associated with poor outcomes, despite diagnostic and therapeutic advances. We analysed trends in volumes and outcomes from 2000 to 2021. METHODS The study population includes 494 type A acute aortic syndromes (TAAAS) (54.2%) and 418 type B acute aortic syndromes (TBAAS) (45.8%). Primary outcomes were in-hospital mortality, long-term survival and freedom from aortic reoperation. RESULTS Regardless the type of acute aortic syndrome, patient volumes increased over time. Patients with TBAAS were older, more likely to have comorbid conditions and previous cardiac surgery (P  < 0.001), while cerebrovascular accidents were more frequent in TAAAS (P  < 0.05). Among TAAAS, 143 (28.9%) required total arch and 351 (71.1%) hemiarch replacement. TBAAS management was medical therapy in 182 (43.5%), endovascular in 198 (47.4%) and surgical in 38 (9.1%) cases. Overall in-hospital mortality was 14.6% [18.2% in TAAAS (95% confidence interval (CI) 14.4–21.2%) vs 10.7% in TBAAS (95% CI 7.8%–13.7%); P  = 0.0027]. After propensity score adjustment, in-hospital mortality exhibited a significantly decreasing trend from 2000 to 2021 (P  < 0.001) in TAAAS and TBAAS. 1-, 5- and 10-year survival was 74.2%, 62.2% and 45.5% in TAAAS and 75.4%, 60.7% and 41.0% in TBAAS (P  = 0.975), with no differences among treatment strategies. The adjusted cumulative reoperation risk at 10 years was more than two-fold in TBAAS versus TAAAS (9.5% vs 20.5%, hazard ratio (HR) = 2.30, 95% I 1.31–4.04). CONCLUSIONS In the last decades, better patient triage and surgical/endovascular techniques led to substantial improvements in the management of acute aortic syndrome, with reduction in early mortality and reoperation rate. However, long-term mortality is still >50%. [ABSTRACT FROM AUTHOR]

Background Coronary intramural haematoma from spontaneous coronary artery dissection (SCAD) presents as an acute coronary syndrome, usually in young or middle-aged female patients. Conservative management in the absence of ongoing symptoms is best practice, and the artery eventually heals fully. Case summary A 49-year-old female presented with a non-ST elevation myocardial infarction. Initial angiography and intravascular ultrasound (IVUS) demonstrated typical intramural haematoma of the ostial to mid left circumflex artery. Initial conservative management was selected, but the patient developed further chest pain 5 days later and with worsening electrocardiogram changes. Further angiography was carried out demonstrating near-occlusive disease with organized thrombus in the false lumen. The angioplasty result from this is juxtaposed with another acute SCAD case on the same day with fresh intramural haematoma. Discussion Reinfarction is a common occurrence in SCAD, and little is known about how to predict it. These cases demonstrate the appearance on IVUS of fresh vs. organized thrombus and the relative angioplasty result in each case. Follow-up IVUS due to ongoing symptoms in one patient demonstrated significant stent malapposition, not apparent at the index intervention, in all likeliness due to intramural haematoma regression. [ABSTRACT FROM AUTHOR]

Acute type A aortic syndromes are catastrophic events whose management relies primarily on conventional surgery. For several years, various endovascular attempts have been described; however, long-term data are inexistent. We describe a case of stenting of the ascending aorta for a type A intramural haematoma with survival and freedom from reintervention at >8 years postoperatively. [ABSTRACT FROM AUTHOR]

Objectives: To investigate sex-based differences in presenting characteristics and early outcomes of type A intramural haematoma., Methods: Patients with type A intramural haematoma in an institutional cohort were consecutively enrolled between December 2013 and July 2022. Presenting characteristics, morphological progression and all-cause death during hospitalization were evaluated according to patient sex., Results: Among 473 patients, 48.0% were female. Females were older (65.9 ± 9.1 vs 58.5 ± 11.5 years, P < 0.001) with larger ascending aortic diameters (52.2 ± 6.6 vs 48.3 ± 6.1 mm, P < 0.001), thicker haematomas (11.5 ± 4.9 vs 9.5 ± 3.4 mm, P < 0.001) and more frequent focal intimal disruptions (45.4% vs 29.7%, P < 0.001). Within 30 days of initial medical therapy, 89.8% of males vs 70.1% of females showed morphological regression or stable condition on repeat computed tomography angiography. The in-hospital mortality was 9.7% in females (n = 22) and 2.8% in males (n = 7). Kaplan-Meier analysis revealed higher early mortality in females (P = 0.002). Multivariable Cox regression showed female sex as an independent risk factor for early death (hazard ratio: 2.8, 95% confidence interval: 1.2-6.8, P = 0.021). Subgroup analysis revealed no heterogeneity according to subgroups including older age (71-90 years), ascending aortic diameter ≥50 mm, presence of focal intimal disruption, presence of pericardial effusion, haematoma thickness ≥11 mm and hypertension., Conclusions: Female patients with type A intramural haematoma presented with worse characteristics, higher early morphological progression and an increased risk of early death compared to males., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Acute aortic syndrome (AAS) encompasses a group of severe, life-threatening conditions characterized by impaired aortic wall integrity and possible occurrence of fatal aortic haemorrhage. This group of diseases comprises acute aortic dissection (AAD), intramural haematoma (IMH), penetrating aortic ulcer (PAU), and symptomatic thoracic aorta aneurysm (TAA). Although it is a heterogeneous group of diseases, their common, though non-specific, feature is pain in the chest or back which is manifested at the outset as the chief complaint. Timely and correct diagnosis is essential for an appropriate treatment strategy which involves open surgery in the case of involvement of the ascending aorta, endovascular surgery in the case of complicated involvement of the descending aorta, and conservative medical therapy in uncomplicated cases with involvement of the descending thoracic aorta. Recently, there has also been development of combined, or hybrid, procedures consisting of a surgical and an endovascular part, particularly in conditions with involvement of the aortic arch and ascending aorta. The patient with acute aortic syndrome always requires a diagnostic-therapeutic procedure on an urgent basis and should be referred to specialized centres where multi- disciplinary aortic teams are available. The present paper provides a summary of current knowledge of this issue which represents a serious medical problem, sometimes referred to with some exaggeration as “vascular catastrophe”. [ABSTRACT FROM AUTHOR]

Aortic dissection is infrequent in everyday practice; however, it can result in life-threatening complications and causes more deaths each year in the UK than road traffic collisions. It is one of the family of acute aortic syndromes, which includes penetrating aortic ulcer (PAU) and intramural haematoma (IMH). Type A aortic dissections involve the ascending aorta and arch and almost invariably require prompt surgical treatment due to exceptionally high early 48-hour mortality without surgery. Many type B aortic dissections (TBAD) are not complicated at presentation and can be treated conservatively in high dependency and discharged without intervention. Complicated aortic dissection requires intervention, often with a thoracic endovascular aortic repair (TEVAR). The survival after TBAD is higher than type A dissection that invariably requires emergency operative intervention, with 65% of patients surviving to 1 year. Following acute aortic syndrome, best medical therapy involves tight blood pressure and heart rate control using beta-blockers or calcium channel blockers. Statin therapy may be of benefit. Regular cross-sectional imaging surveillance is important to detect late complications such as aortic dilatation. In type B aortic dissection, aortic dilatation is a common cause of late rupture with only 50% of patients surviving after 5 years without intervention. One of the most important questions at present is whether people at high risk of further aortic dilatation can be identified and intervened on early to prevent these late complications? [ABSTRACT FROM AUTHOR]

Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of—in analogy to the heart team—aortic centre formation and centralization of care, which stimulates continuing development and improves outcome. The next frontier to be explored is the most proximal component of the aorta—the aortic root, in particular in acute type A aortic dissection—which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments. [ABSTRACT FROM AUTHOR]

Dissection of the internal carotid (ICA) and vertebral arteries (VA) is one of the most common causes of ischaemic stroke in younger people. Despite wider use of modern neuroimaging techniques in clinical practice, and greater diagnostic capabilities for assessing structural changes in blood vessels, detection of spontaneous dissection remains low. The aim of the study was to identify patterns of change in the signal characteristics of an intramural haematoma in patients with spontaneous ICA and VA dissection on MRI and MR angiography (MRA), during the first three months after onset of clinical symptoms, as well as to create an optimal scan protocol. Based on changes in the K value and a visual assessment of the signal characteristics of the intramural haematoma, the study found that the signal intensity from the haematoma depends on the time of the examination. In the acute and chronic stages of dissection, the K value approaches 1 under Т1 FS and time-of-flight (TOF) MRA modes, and the intramural hematoma "merges" with the surrounding soft tissues, making it difficult to detect during these periods. Between 7 days and 2 months, the haematoma has a hyperintense signal and the K value is >1 under Т1 FS and TOF-MRA modes (p < 0.05). A comparison of K value data from different time periods made us add the T1 FS mode to the scan protocol for patients with suspected spontaneous dissection, in addition to the standard TOF-MRA, in order to improve the intramural haematoma imaging. [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide Optimal treatment for patients with diseased proximal landing zones in acute/subacute Stanford type B dissection and intramural haematoma remains unclear. This study describes the preliminary outcomes of a localized endovascular treatment [spot-stent grafting (SSG)] of main entries/intramural blood pooling located downstream (aortic zones 4 and 5) using one single short device comprising diseased landing zones, looking particularly at the technical and morphological outcomes. METHODS Patients undergoing thoracic endovascular aortic repair (TEVAR) for acute/subacute aortic dissection Stanford type B/intramural haematoma Stanford type B between 1997 and 2018 were identified from a prospectively maintained institutional database. In a total of 183 cases, 22 patients (7 women; median age 62 years; range 35–79 years) received SSG. The primary study end point was technical success. The primary morphological end point was false lumen thrombosis/aortic remodelling. Secondary end points were TEVAR-related mortality/morbidity and reinterventions. The median follow-up was 28.5 months (5 days–15.6 years). RESULTS The primary technical success rate was 100% (22/22). During follow-up, false lumen thrombosis was seen in 21 patients (95.5%) at a median of 6 days (0 days to 2.7 years) after the index procedure (limited/extended false lumen thrombosis: n  = 9 vs 12). Aortic remodelling was achieved in 15 of 22 patients (68.2%) at a median of 360 days (3 days to 7.2 years). Limited/extended remodelling was observed in 8/15 and 7/15, respectively. Retrograde dissection or stent graft-induced new entry was not observed. No stroke or spinal cord injury occurred. Reinterventions were performed in 4/22 cases. The in-hospital mortality and 30-day mortality were 0%. Overall mortality during the follow-up period was 22.7% (5/22). CONCLUSIONS This study shows favourable technical and morphological results for SSG in selected patients with acute/subacute aortic dissection Stanford type B/intramural haematoma Stanford type B. Patient allocation to SSG remains individual. Prospective large-scale long-term data may allow refinement of the application. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES In this study, we investigated the early and midterm outcomes of initial watch-and-wait strategy for Stanford type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta in patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection in the ascending aorta. METHODS Inpatient and outpatient records were retrospectively reviewed. RESULTS Of the 81 patients with type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta between April 2011 and April 2019, a watch-and-wait strategy was selected in 46 patients. The mean age of the patients was 68 years, and 22 (48%) patients were female. Ten patients underwent emergency pericardial drainage for cardiac tamponade at the time of presentation and 8 patients underwent aortic repair during hospitalization for new ulcer-like projection, re-dissection or rupture. In-hospital mortality occurred in 2 (4%) patients. During follow-up, survival at 1 and 2 years was 95% and 92%, respectively. There was no significant difference in survival or aortic events between patients in whom the watch-and-wait strategy and emergency surgical treatment were indicated. CONCLUSIONS The early and midterm outcomes of the initial watch-and-wait strategy were favourable for type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta in Japanese patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection. Further study is required to show the safety of this strategy. [ABSTRACT FROM AUTHOR]

The current treatment for acute retrograde type A intramural haematoma (IMH) remains challenging. Aortic remodelling in both the ascending aorta (AA) and descending thoracic aorta (DTA) was evaluated and the 30 day and mid term outcomes were determined in patients who underwent thoracic endovascular aneurysm repair (TEVAR) for retrograde type A IMH with a primary intimal tear or ulcer like projection in the DTA This was a retrospective, multicentre observational study. Clinical data, including post-operative mortality and adverse event, aorta related re-intervention, aortic remodelling, and the survival rate of 18 non-consecutive patients with acute retrograde type A IMH undergoing TEVAR between June 2006 and March 2018 were reviewed. The median age at repair was 58.1 years (range 38–86) and 14 (78%) were men. Eight patients (44%) presented with haemopericardium, and 10 (56%) underwent TEVAR within 24 h. The mean IMH thickness and AA diameter were 10.4 ± 3.6 and 45.7 ± 4.6 mm, respectively. Among all patients with acute retrograde type A IMH, 11 patients presented with classical type B aortic dissection and seven with type B IMH. All procedures were technically successful. The median follow up was 28.7 months (range 7–78). No 30 day mortality was observed. Three patients developed post-procedure adverse events. Of these, two patients had neurological events, with one each having cerebrovascular and spinal cord infarction individually, and the third patient required long term haemodialysis with ventilator support. The overall survival rate was 100%. The maximum diameter of the AA and the IMH in the AA significantly decreased after TEVAR. Aortic remodelling was also observed in the DTA along the length of TEVAR coverage. In selected patients with acute retrograde type A IMH, TEVAR offered a treatment alternative to open surgical grafting and medical follow up. [ABSTRACT FROM AUTHOR]

Objective Type B acute aortic syndrome (AAS) encompasses aortic dissection (AD) and intramural haematoma (IMH), the diagnosis, evolution, and treatment of which are subject to controversies. The aim of this pilot investigation was to assess the ability of specific magnetic resonance imaging (MRI) criteria to differentiate AD from IMH and predict optimal aortic remodeling following AAS. Methods In this retrospective study, all patients presenting between 2008 and 2015 with type B AAS, who had diagnostic MRI following admission, were included. Three MRI criteria were proposed to identify IMH: (i) no visualised entry tear; (ii) no contrast uptake in the aortic lesion on the first pass angiographic run; (iii) no contrast uptake in the aortic lesion on the equilibrium phase T1 sequence. On each patient's diagnostic and follow up imaging studies, the volume of (i) false lumen/IMH, (ii) total aorta, and (iii) true lumen were calculated. Using the Wilcoxon signed rank test, the evolution of these volumes according to the presence or absence of the aforementioned criteria were compared. Results Of 39 patients, in seven all MRI criteria were positive (group IMH) and 32 had one or more negative criteria (group AD). Patients with IMH and AD were similar with respect to sex, age, and delay between onset of symptoms and diagnostic and follow up imaging studies. Eighteen patients had a follow up imaging study after a mean period of 11.2 months: six in the IMH group and 12 in the AD group. Lesion volume decrease and relative true lumen volume increase were statistically significant in group IMH (p =.046 and p =.046, respectively), whereas there was a statistically significant increase of lesion volume (p =.008) in the AD group. Conclusion This pilot study proposed three simple MRI criteria to differentiate between AD and IMH. Once prospectively and clinically validated, this could have substantial therapeutic benefits as IMH are likely to heal spontaneously. [ABSTRACT FROM AUTHOR]

Acute aortic emergencies are life-threatening conditions that may require urgent surgical or interventional management. Imaging plays an important role in the diagnosis and planning of the management, and timely intervention helps in reducing mortality and morbidity.

Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adultThe Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)

Acute aortic syndromes (AAS) encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural haematoma, and penetrating atherosclerotic aortic ulcer. Given the non-specific symptoms and physical signs, a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur. In order to reduce the diagnostic time delay, a comprehensive flowchart for decision-making based on pre-test sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases and should be thus applied in the emergency scenario. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken if indicated by a highly specialized aortic team. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) is generally indicated. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts. Finally, it should be highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance. [ABSTRACT FROM AUTHOR]

Indications include such patients with communicating ATAAD, dilated ascending aorta or increased haematoma thickness with noncommunicating ATAAD, or if the patient's family strongly favours surgery. A novel risk score on admission for predicting death or need for surgery in patients with acute type A intramural hematoma receiving medical therapy. Keywords: Stanford type A acute aortic dissection; Noncommunicating aortic dissection; Thrombosed type; Intramural haematoma; Elderly patients; External wrapping EN Stanford type A acute aortic dissection Noncommunicating aortic dissection Thrombosed type Intramural haematoma Elderly patients External wrapping 1 1 1 07/04/23 20230601 NES 230601 We would like to thank Allain I et al. i for acknowledging our study and its clinical implications [[1]]. [Extracted from the article]

Objectives The prognosis of patients with intramural haematoma (IMH) of the aorta beyond the first year after diagnosis remains largely unknown. In particular, patients that do not undergo interventions are lost to follow-up. The aim was to assess medium-term outcome in IMH patients. Methods Post hoc analysis of 63 consecutive patients presenting with IMH between 1999 and 2013 was performed. Patients meeting imaging criteria at the first presentation were included even if follow-up imaging showed evidence of intimal disruption or false lumen flow. Results Eighteen patients presented with type A and 45 with type B IMH (29% vs. 71%, p < .001). The mean age was 71 ± 9.2 years, range 42–88 years. Follow-up was completed in 97% of patients by May 2017 and represents a mean follow-up of 6.3 ± 3.6 years. Freedom from intervention in patients with type B IMH was 40%. TEVAR was performed in 47% because of development, unmasking of an entry tear (57%), progression to acute type B dissection (24%), or subsequent dilation of the affected aortic segments (19%). Open repair was performed in 13% of type B IMH patients because of dilation of the descending aorta. In type A IMH, 89% underwent open repair. Aorta related 30 day, 6 month, 1 year, and late mortality were 1.6%, 6.3%, 6.3%, and 9.5%, respectively, for all IMH patients. All-cause 30 day, 6 month, 1 year, and late mortality were 1.6%, 6.3%, 6.3%, and 47.6%, respectively, for all IMH patients. Late mortality in type B IMH did not differ whether patients underwent TEVAR, open repair, or received best medical treatment only (26% vs. 22%, p = 1.0). Conclusions Late aorta related mortality in IMH was low whereas all-cause mortality was substantial. Aorta related mortality in IMH patients only occurs during the first year after diagnosis. Interventions after the first year are rarely necessary. [ABSTRACT FROM AUTHOR]

Introduction. Intramural haematoma (IMH) and penetrating aortic ulcers (PAU) are the frequent cause of acute aortic syndrome that is disclosed with a rising frequency due to the development of new diagnostic methods. Different symptoms contribute to clinical misdiagnosis, while changeable locations and unpersuasive diameter can lead the radiologists to underestimate such changes. The outcome of PAU and IMH differs, and for the time being there are no data on prognostic factors. The diversity of symptoms and disease course is presented in four cases with different manifestations, treatment and outcome. Outline of Cases. Two patients with IMH were treated conservatively due to the process extensiveness and its morphology. One patient had a complete restitution, while the other had progression of the disease. Other two patients with PAU were treated by surgery (stent graft implantation) according to the morphology and diameter of the aorta. Conclusion. IMH and PAU should be suspected in patients with unclear clinical presentation (back and abdominal pains). Although outcome and complications of these diseases are well known, their incidence has not been fully studied. Endovascular treatment is less invasive and followed by a potentially lower rate of complications. However, usage of this method is justifiable only in patients with associated complications.

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OBJECTIVES: The aim of this study was to investigate the incidence, the biomarker profile and the clinical impact of post-implantation syndrome (PIS) after thoracic endovascular aortic repair (TEVAR) for type B acute aortic syndromes (AASs). METHODS: This retrospective study included 133 patients with type B AASs undergoing TEVAR; PIS was defined as fever >38oC, white blood cells (WBCs) >12.0/nl and C-reactive protein (CRP) >10 mg/dl within 72 h after TEVAR, despite negative blood cultures. Fibrinogen (FBG), D-dimer (D-d) and interleukin 6 (IL-6) were also determined. The clinical endpoints were all-cause mortality and a composite of major adverse events (MAEs such as aortic rupture, need for reintervention and all-cause mortality) at follow-up. RESULTS: PIS was diagnosed in 15.8% of patients and was associated with higher peak values of WBC (17.0±5.1 vs 10.6±3.7/nl, P = 0.002), CRP (22.0±5.4 vs 16.8±8.2 mg/dl, P = 0.03), FBG (779±246 vs 639±225 mg/dl, P = 0.046), D-d (1675±605 vs 1048±639 μg/l, P = 0.003) and IL-6 (192±101 vs 84±34 pg/ml, P = 0.03) than non-PIS patients. All-cause mortality did not significantly differ between PIS and non- PIS patients during the index hospitalization (0.0 vs 6.3%; P = 0.60) and at follow-up (18.8 vs 4.9%; P = 0.086). MAEs were more frequent in the PIS than in the non-PIS group (62.5 vs 25.9%; P = 0.004). PIS (hazard ratio [HR] 3.26, P = 0.022), stroke (HR 3.41, P = 0.004), aortic enlargement (HR 6.88, P = 0.001) and partial thrombosis of the false lumen (HR 6.20, P = 0.003) were independent predictors of MAEs. CONCLUSIONS: PIS occurred in 15.8% of patients with AASs without affecting in-hospital outcome. At follow-up, PIS was associated with increased rates of MAEs, but not mortality. [ABSTRACT FROM AUTHOR]