cardiovascular-agents and Aortic-Aneurysm

Diabetes mellitus (DM) is also a cause of cardiovascular (CV) disease (CVD). Addressing the atherosclerotic CVD (ASCVD) burden in DM should reduce premature death and improve quality of life. Diabetes mellitus-associated ASCVD can lead to complications in all vascular beds (carotids as well as coronary, lower extremity, and renal arteries). This narrative review considers the diagnosis and pharmacological treatment of noncardiac atherosclerotic vascular disease (mainly in patients with DM). Based on current knowledge and the fact that modern DM treatment guidelines are based on CV outcome trials, it should be noted that patients with noncardiac CVD may not have the same benefits from certain drugs compared with patients who predominantly have cardiac complications. This leads to the conclusion that in the future, consideration should be given to conducting well-designed trials that will answer which pharmacological treatment modalities will be of greatest benefit to patients with noncardiac ASCVD.

Topics: Animals; Aortic Aneurysm; Cardiovascular Agents; Diabetes Mellitus; Humans; Hypoglycemic Agents; Peripheral Arterial Disease; Renal Artery Obstruction; Risk Assessment; Risk Factors; Stroke; Treatment Outcome

Aortic aneurysm (AA) remains one of the primary causes of death worldwide. Of the major treatments, prophylactic operative repair is used for AA to avoid potential aortic dissection or rupture. To halt the development of AA and alleviate its progression into aortic dissection, pharmacological treatment has been investigated for years. Currently, β-adrenergic blocking agents, losartan, irbesartan, angiotensin-converting-enzyme inhibitors, statins, antiplatelet agents, doxycycline, and metformin have been investigated as potential candidates for preventing AA progression. However, the paradox between preclinical successes and clinical failures still exists, with no medical therapy currently available for ideally negating the disease progression. This review describes the current drugs used for pharmacological management of AA and their individual potential mechanisms. Preclinical models for drug screening and evaluation are also discussed to gain a better understanding of the underlying pathophysiology and ultimately find new therapeutic targets for AA.

Topics: Animals; Aorta; Aortic Aneurysm; Cardiovascular Agents; Dilatation, Pathologic; Disease Models, Animal; Disease Progression; Humans; Signal Transduction; Treatment Outcome; Vascular Remodeling

Topics: Acute Disease; Analgesics; Aortic Aneurysm; Aortic Dissection; Cardiovascular Agents; Clinical Decision-Making; Consensus; Delphi Technique; Humans; Patient Selection; Postoperative Complications; Risk Assessment; Risk Factors; Thoracic Surgery; Treatment Outcome; Vascular Surgical Procedures

Over the past 4 decades, remarkable progress in understanding the cause, pathogenesis, and management of the MFS has led to an increase in life expectancy to near normal for most patients. Accompanying this increased life span has been the emergence of previously rare or unanticipated clinical problems. Despite much more detailed knowledge of the molecular, cellular, and tissue effects of a mutation in FBN1, targeted, effective therapy remains elusive. Until such precision medicine takes hold, management will depend on early diagnosis, regular scrutiny by imaging, chronic β-blockade, and perhaps ARBs, and prophylactic cardiothoracic surgery. Without question, MFS will remain a fertile subject for basic, translational, and clinical research for the foreseeable future.

Topics: Animals; Aortic Aneurysm; Cardiac Surgical Procedures; Cardiovascular Agents; Disease Progression; DNA Mutational Analysis; Fibrillin-1; Genetic Predisposition to Disease; Humans; Marfan Syndrome; Mutation; Phenotype; Precision Medicine; Predictive Value of Tests; Prognosis; Risk Factors

Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.

Topics: Aortic Aneurysm; Aortic Dissection; Aortography; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Computed Tomography Angiography; Endovascular Procedures; Humans; Risk Factors; Treatment Outcome

Type B aortic dissection is a relatively uncommon and multifaceted disease, whose management is ongoing debated. Its wide range of clinical presentations and anatomical features hamper the early identification and medical management. In the past few years, the introduction of endovascular techniques opened new paradigms in comprehension and management of aortic diseases. Aim of this review is to discuss contemporary therapeutic approaches of acute type B aortic dissections highlighting the growing role of thoracic endovascular aortic repair (TEVAR) in focusing its complex physiopathology.. Prompt medical therapy followed by endovascular repair should be considered as the gold standard in complicated acute type B aortic dissection. Moreover, recent findings also suggest a potential benefit in case of uncomplicated cases.. Management of acute type B aortic dissection is progressively shifting into endovascular approach. However, further studies are warranted to define the optimal treatment strategy in each subset of patients and anatomical features.

Topics: Acute Disease; Aortic Aneurysm; Aortic Dissection; Cardiovascular Agents; Disease Management; Endovascular Procedures; Humans

Aneurysms are common in the abdominal and thoracic regions of the aorta. While generally asymptomatic, progression of aneurysms is associated with the devastating consequences of aortic rupture. Current therapeutic options to prevent rupture are restricted to surgical repair, as there remains a lack of validated pharmaceutical approaches. Absence of proven medical therapies may be a consequence of the paucity of knowledge on mechanisms of aneurysmal initiation, progression and rupture. Many potential therapeutic targets have been identified in several widely used animal models of these diseases. A small number of these targets are currently under clinical evaluation, while many more are in preclinical stages of evaluation. The purpose of this review is to: (1) overview current understanding of mechanisms of aneurysmal initiation and progression and (2) summarise medical therapies that have been investigated clinically, as well as highlight future therapeutic targets.

Topics: Aortic Aneurysm; Aortic Rupture; Asymptomatic Diseases; Cardiovascular Agents; Disease Progression; Drug Evaluation, Preclinical; Drug Therapy; Humans; Metabolism; Translational Research, Biomedical

The scientific literature clearly establishes the occurrence of cardiovascular (CV) accidents and myocardial ischemic episodes is unevenly distributed during the 24 h. Such temporal patterns result from corresponding temporal variation in pathophysiologic mechanisms and cyclic environmental triggers that elicit the onset of clinical events. Moreover, both the pharmacokinetics and pharmacodynamics of many, though not all, CV medications have been shown to be influenced by the circadian time of their administration, even though further studies are necessary to better clarify the mechanisms of such influence on different drug classes, drug molecules, and pharmaceutical preparations. Twenty-four-hour rhythmic organization of CV functions is such that defense mechanisms against acute events are incapable of providing the same degree of protection during the day and night. Instead, temporal gates of excessive susceptibility exist, particularly in the morning and to a lesser extent evening (in diurnally active persons), to aggressive mechanisms through which overt clinical manifestations may be triggered. When peak levels of critical physiologic variables, such as blood pressure (BP), heart rate (HR), rate pressure product (systolic BP × HR, surrogate measure of myocardial oxygen demand), sympathetic activation, and plasma levels of endogenous vasoconstricting substances, are aligned together at the same circadian time, the risk of acute events becomes significantly elevated such that even relatively minor and usually harmless physical and mental stress and environmental phenomena can precipitate dramatic life-threatening clinical manifestations. Hence, the delivery of CV medications needs to be synchronized in time, i.e., circadian time, in proportion to need as determined by established temporal patterns in risk of CV events, and in a manner that averts or minimizes undesired side effects.

Topics: Aortic Aneurysm; Arrhythmias, Cardiac; Blood Pressure; Blood Pressure Monitoring, Ambulatory; Cardiovascular Agents; Cardiovascular Diseases; Circadian Rhythm; Heart Rate; Humans; Myocardial Ischemia; Myocardium; Stroke; Takotsubo Cardiomyopathy; Time Factors

Topics: Aortic Aneurysm; Cardiovascular Agents; Endovascular Procedures; Evidence-Based Medicine; Humans; Lower Extremity; Peripheral Arterial Disease; Risk Factors; Risk Reduction Behavior; Treatment Outcome; Vascular Surgical Procedures

Blunt abdominal aortic injury (BAAI) is a rare injury with less than 200 cases in the current reported world literature, mostly in case report format. We sought to describe the experience of a high-volume trauma center and to provide a contemporary review of the literature to better understand the natural history and management of this injury.. This was a retrospective review of patients with BAAI between 1996 and 2010. Data collected included demographics, mechanism of injury, associated injuries, type of intervention, subsequent imaging, and follow-up. BAAI was classified by the presence of external aortic contour abnormality noted as an intimal tear, large intimal flap, pseudoaneurysm, or free rupture. Abdominal aorta zones of injury were classified by possible surgical approaches as zone I (diaphragmatic hiatus to superior mesenteric artery [SMA]), zone II (includes SMA and renal arteries), and zone III (from the inferior aspect of the renal arteries to the aortic bifurcation).. We identified 28 individuals (68% male) with BAAI (median age, 28.5; range, 6-61 years). The median injury severity score was 45 (range, 16-75), and 39% were hypotensive at presentation. BAAI presented as intimal tear (21%), large intimal flap (39%), pseudoaneurysm (11%), and free rupture (29%). Zone III was the most common location of injury. Management depended on the location and type of injury: nonoperative (32%), open aortic repair (36%), endovascular repair (21%), and multimodality (10%). Overall mortality was 32%. Most deaths occurred during the initial operative exploration. The mortality rate of free aortic rupture was 100%. Intimal tears resolved or remained stable. Median follow-up was 15.5 months (range, 8 days-7.5 years). Vascular complications due to repair included a thrombosed access femoral artery during an endovascular repair and death of a patient who underwent a hybrid repair.. This is the largest BAAI series described in the English literature at one institution. BAAIs range from intimal tears to free rupture, with outcomes and management correlating with type and location of injury. Nonoperative management with blood pressure control using β-blockers coupled with antiplatelet therapy and close follow-up is successful in individuals with intimal tears with minimal thrombus formation because they remain stable or resolve on follow-up. Free rupture remains a devastating injury, with 100% mortality. For all other categories of aortic injury, successful repair correlates with a favorable prognosis.

Topics: Adolescent; Adult; Aneurysm, False; Aorta, Abdominal; Aortic Aneurysm; Aortic Diseases; Aortic Rupture; Aortography; Cardiovascular Agents; Child; Endovascular Procedures; Female; Humans; Incidence; Male; Middle Aged; Predictive Value of Tests; Retrospective Studies; Severity of Illness Index; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Vascular Surgical Procedures; Vascular System Injuries; Washington; Wounds, Nonpenetrating; Young Adult

Aortic dissection represents the most common aortic emergency, affecting 3 to 4 per 100,000 people per year and is still associated with a high mortality. Twenty percent of the patients with aortic dissection die before reaching hospital and 30% die during hospital admission. Aortic dissections may be classified in 3 ways: according to their anatomical extent (the Stanford or DeBakey systems), according to the time from onset (acute or chronic), and according to the underlying pathology (the European Society of Cardiologists' system). Advances in endovascular technology have provided new treatment options. Hybrid endovascular and conventional open surgical repair represent the mainstay of treatment for acute type A dissection. Medical management remains the gold standard for acute and uncomplicated chronic type B dissection, though endovascular surgery offers exciting potential in the management of complicated type B dissection through sealing of the intimal entry tear.

Topics: Acute Disease; Aortic Aneurysm; Aortic Dissection; Cardiovascular Agents; Chronic Disease; Humans; Patient Selection; Predictive Value of Tests; Risk Assessment; Risk Factors; Severity of Illness Index; Treatment Outcome; Vascular Surgical Procedures

Topics: Acute Disease; Aortic Aneurysm; Aortic Dissection; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Endovascular Procedures; History, 18th Century; History, 19th Century; History, 20th Century; History, 21st Century; Humans; Risk Factors; Treatment Outcome

Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality. In this article, the authors review basic biology of the aorta and aortic dissection, epidemiology, clinical presentation, diagnostic approach, emergency stabilization measures, and the latest surgical approach for type B dissection.

Topics: Acute Disease; Adult; Aged; Aortic Aneurysm; Aortic Dissection; Biomarkers; Cardiovascular Agents; Combined Modality Therapy; Diagnostic Imaging; Female; Humans; Male; Middle Aged; Predictive Value of Tests; Risk Factors; Severity of Illness Index; Treatment Outcome; Vascular Surgical Procedures

Topics: Acute Disease; Age Factors; Aged, 80 and over; Animals; Aortic Aneurysm; Aortic Dissection; Cardiovascular Agents; Comorbidity; Contraindications; Critical Care; Heart Valve Prosthesis Implantation; Humans; Risk Factors; Stroke; Time Factors; Treatment Outcome; Vascular Surgical Procedures

Marfan syndrome is a common inherited disorder of connective tissue caused by deficiency of the matrix protein fibrillin-1. Effective surgical therapy for the most life-threatening manifestation, aortic root aneurysm, has led to a nearly normal lifespan for affected individuals who are appropriately recognized and treated. Traditional medical therapies, such as beta-adrenergic receptor blockade, are used to slow pathologic aortic growth and decrease the risk of aortic dissection by decreasing hemodynamic stress. New insights regarding the pathogenesis of Marfan syndrome have developed from investigation of murine models of this disorder. Fibrillin-1 deficiency is associated with excess signaling by transforming growth factor beta (TGFbeta). TGFbeta antagonists have shown great success in improving or preventing several manifestations of Marfan syndrome in these mice, including aortic aneurysm. These results highlight the potential for development of targeted therapies based on discovery of disease genes and interrogation of pathogenesis in murine models.

Topics: Aortic Aneurysm; Cardiovascular Agents; Endocarditis; Humans; Marfan Syndrome

Arterial disease in women will become a major issue in the near future.. A systemic review of existing literature was retrospectively conducted to collect information on the three most common entities of vascular disease: carotid atherosclerotic, abdominal aortic aneurismal, and lower extremity arterial occlusive disease.. Vascular disease is either underdiagnosed or undertreated in women. Whether regarding cerebrovascular disease, aortic aneurysmal disease, or atherosclerosis affecting the lower extremities, natural history, clinical and physiologic patterns are different in women vs men. Current biomedical devices create challenges in endovascular procedures performed in women. Furthermore, indications for treatment of vascular disease are derived from large studies where women are often underrepresented; and, thus, may not be applicable in female vascular patients.. Better understanding of the gender differences in vascular disease with focused randomized trials, biomedical research, and identification of gender specific medical and social risk factors will improve the clinical outcomes in female patients.

Topics: Aortic Aneurysm; Arterial Occlusive Diseases; Cardiovascular Agents; Carotid Stenosis; Estrogen Replacement Therapy; Female; Healthcare Disparities; Humans; Lower Extremity; Peripheral Vascular Diseases; Sex Factors; Vascular Surgical Procedures; Women's Health

Endovascular stent grafting represents a novel concept for type B aortic dissection both in the acute and subacute/chronic setting, with an unknown effect on outcomes.. In a prospective trial 140 patients with stable type B dissection were randomly subjected to elective stent-graft placement in addition to optimal medical therapy (n = 72) or to optimal medical therapy (n = 68) with surveillance (arterial pressure according to World Health Organization guidelines ≤ 120/80 mm Hg). The primary end point was 1-year all-cause mortality, whereas aorta-related mortality, progression (with need for conversion or additional endovascular or open surgical intervention), and aortic remodeling were secondary end points.. There was no difference in all-cause mortality: cumulative survival was 97.0% ± 3.4% with optimal medical therapy versus 91.3% ± 2.1% with thoracic endovascular aortic repair (P = .16). Moreover, aorta-related mortality was not different (P = .42), and the risk for the combined end point of aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgical intervention) was similar (P = .86). Three neurologic adverse events occurred in the thoracic endovascular aortic repair group (1 paraplegia, 1 stroke, and 1 transient paraparesis) versus 1 episode of paraparesis with medical treatment. Finally, aortic remodeling (with true-lumen recovery and thoracic false-lumen thrombosis) occurred in 91.3% with thoracic endovascular aortic repair versus 19.4% with medical treatment (P < .001), which is suggestive of continued remodeling.. In survivors of uncomplicated type B aortic dissection, elective stent-graft placement does not improve 1-year survival and adverse events, despite favorable aortic remodeling.

Topics: Aged; Aortic Aneurysm; Aortic Dissection; Aortography; Blood Pressure; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Chi-Square Distribution; Chronic Disease; Combined Modality Therapy; Elective Surgical Procedures; Europe; Female; Humans; Kaplan-Meier Estimate; Magnetic Resonance Angiography; Male; Middle Aged; Prospective Studies; Risk Assessment; Risk Factors; Stents; Survival Rate; Time Factors; Tomography, X-Ray Computed; Treatment Outcome

Bicuspid aortic valve (BAV) is the most common congenital cardiovascular disease in general population and is frequently associated with the development of thoracic aortic aneurysm (TAA). There is no effective strategy to intervene with TAA progression due to an incomplete understanding of the pathogenesis. Insufficiency of NOTCH1 expression is highly related to BAV-TAA, but the underlying mechanism remains to be clarified.. A comparative proteomics analysis was used to explore the biological differences between non-diseased and BAV-TAA aortic tissues. A microfluidics-based aorta smooth muscle-on-a-chip model was constructed to evaluate the effect of NOTCH1 deficiency on contractile phenotype and mitochondrial dynamics of human aortic smooth muscle cells (HAoSMCs).. Protein analyses of human aortic tissues showed the insufficient expression of NOTCH1 and impaired mitochondrial dynamics in BAV-TAA. HAoSMCs with NOTCH1-knockdown exhibited reduced contractile phenotype and were accompanied by attenuated mitochondrial fusion. Furthermore, we identified that mitochondrial fusion activators (leflunomide and teriflunomide) or mitochondrial fission inhibitor (Mdivi-1) partially rescued the disorders of mitochondrial dynamics in HAoSMCs derived from BAV-TAA patients.. The aorta smooth muscle-on-a-chip model simulates the human pathophysiological parameters of aorta biomechanics and provides a platform for molecular mechanism studies of aortic disease and related drug screening. This aorta smooth muscle-on-a-chip model and human tissue proteomic analysis revealed that impaired mitochondrial dynamics could be a potential therapeutic target for BAV-TAA.. National Key R and D Program of China, National Natural Science Foundation of China, Shanghai Municipal Science and Technology Major Project, Shanghai Science and Technology Commission, and Shanghai Municipal Education Commission.. To function properly, the heart must remain a one-way system, pumping out oxygenated blood into the aorta – the largest artery in the body – so it can be distributed across the organism. The aortic valve, which sits at the entrance of the aorta, is a key component of this system. Its three flaps (or ‘cusps’) are pushed open when the blood exits the heart, and they shut tightly so it does not flow back in the incorrect direction. Nearly 1.4% of people around the world are born with ‘bicuspid’ aortic valves that only have two flaps. These valves may harden or become leaky, forcing the heart to work harder. This defect is also associated with bulges on the aorta which progressively weaken the artery, sometimes causing it to rupture. Open-heart surgery is currently the only way to treat these bulges (or ‘aneurysms’), as no drug exists that could slow down disease progression. This is partly because the biological processes involved in the aneurysms worsening and bursting open is unclear. Recent studies have highlighted that many individuals with bicuspid aortic valves also have lower levels of a protein known as NOTCH1, which plays a key signalling role for cells. Problems in the mitochondria – the structures that power up a cell – are also observed. However, it is not known how these findings are connected or linked with the aneurysms developing. To answer this question, Abudupataer et al. analyzed the proteins present in diseased and healthy aortic muscle cells, confirming a lower production of NOTCH1 and impaired mitochondria in diseased tissues. They also created an ‘aorta-on-a-chip’ model where aortic muscle cells were grown in the laboratory under conditions resembling those found in the body – including the rhythmic strain that the aorta is under because of the heart beating. Abudupataer et al. then reduced NOTCH1 levels in healthy samples, which made the muscle tissue less able to contract and reduced the activity of the mitochondria. Applying drugs that tweak mitochondrial activity helped tissues from patients with bicuspid aortic valves to work better. These compounds could potentially benefit individuals with deficient aortic valves, but experiments in animals and clinical trials would be needed first to confirm the results and assess safety. The aorta-on-a-chip model developed by Abudupataer et al. also provides a platform to screen for drugs and examine the molecular mechanisms at play in aortic diseases.

Topics: Adult; Aged; Aorta; Aortic Aneurysm; Bicuspid Aortic Valve Disease; Cardiovascular Agents; Cell Line; Female; Humans; Lab-On-A-Chip Devices; Male; Middle Aged; Mitochondrial Dynamics; Myocytes, Smooth Muscle; Tissue Array Analysis

Aneurysmal degeneration of medically managed type B aortic dissection (TBAD) can be a life-threatening condition. Preventive thoracic endovascular aorta repair (TEVAR) in patients at risk could potentially be beneficial. The aim of this study was to examine the predictors for late aneurysmal dilatation after TBAD.. A retrospective study was conducted on 82 patients with medically managed acute TBAD for a minimum of 14 days. Relevant demographic, biochemical, and radiographic variables at presentation were studied. The aortic dissection risk calculator tool developed by Sailer et al., predicting the risk of adverse events after aortic dissection based on demographic and radiographic variables at presentation, was tested retrospectively.. With a median follow-up of 36 months (range 13-68), 25 (30.5%) patients underwent surgery (92% TEVAR). A larger initial aortic and false lumen diameter as well as a greater distal extension of the dissection was associated with higher need for surgery (respectively, P = 0.003, P = 0.004, and P = 0.001). We observed higher growth rates of maximum aortic diameter in patients with a greater distal extension of the dissection, larger false lumen diameters and false lumen outflow, and entry tears located at the inner aortic arch (respectively, P = 0.001, P = 0.005, P = 0.001 and P = 0.014). No significant correlations could be found for the risks provided by the calculator tool.. The initial maximum aortic diameter of TBAD is a key predictor for aortic growth. Furthermore, the distal extension of the dissection also seems to play an important role in late aneurysmal degeneration. However, we were not able to confirm the added value of the risk calculator tool in our study group.

Topics: Aged; Aorta, Thoracic; Aortic Aneurysm; Aortic Dissection; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Clinical Decision-Making; Decision Support Techniques; Disease Progression; Endovascular Procedures; Female; Humans; Male; Middle Aged; Predictive Value of Tests; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome

Medical management remains the mainstay of treatment for patients who present with acute Type-B aortic dissections (TBAD). However, it is unclear whether patients maintain adherence to their anti-impulse therapy medication regimen following hospital discharge. This study was designed to evaluate rates and predictors of medication adherence among insured patients treated for acute TBAD.. We used the Truven MarketScan database to identify US patients who presented with an acute TBAD between 2008 to 2017. Patients with continuous health insurance (Commercial or Medicare Part C) for at least 12 months after TBAD diagnosis were stratified by whether they underwent open surgical repair (OPEN), thoracic endovascular aortic repair (TEVAR), or only medication management (MED). Prescriptions for anti-impulse therapy medications were captured and adherence was defined by the medication possession ratio as > 80% fill rate over the follow-up period. Mixed-effects logistic regression models were used to identify predictors for medication adherence.. A total of 6,702 patients were identified that underwent treatment for TBAD (3% TEVAR, 9% OPEN, & 74% MED), whereas 14% received no intervention. The overall mean (±SD) rate of adherence to anti-impulse therapy was 72.6% ( ± 26), and varied based on type of TBAD intervention (73.4% TEVAR, 74.4% OPEN, & 72.4% MED). The majority of patients across all treatment groups were prescribed ≥ 2 agents, with beta-blockers and diuretics being the most common medication classes. The odds of adherence to anti-impulse therapy were significantly lower for patients who were female (OR: 0.93; 95%CI:0.85-0.99; P = 0.03), aged < 45 years (OR: 0.81; 95%CI:0.69-0.96; P < 0.001), nonadherent on preexisting therapy (OR: 0.81; 95%CI: 0.73-0.89; P < 0.001), and when medications were obtained in less than a 90 days supply from retail pharmacies.. Nearly a quarter of patients were nonadherent with anti-impulse therapy prescribed following an acute TBAD, which was more likely among younger female patients not adherent before their event. Adherence was improved among patients who received their medications by mail and when a > 90 days supply was prescribed. These findings may be used by quality improvement initiatives to improve medication adherence following TBAD and help prevent further complications.

Topics: Adolescent; Adrenergic beta-Antagonists; Adult; Age Factors; Aged; Aortic Aneurysm; Aortic Dissection; Cardiovascular Agents; Databases, Factual; Diuretics; Endovascular Procedures; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Medication Adherence; Middle Aged; Patient Discharge; Polypharmacy; Retrospective Studies; Risk Assessment; Risk Factors; Sex Factors; Time Factors; Treatment Outcome; Vascular Surgical Procedures; Young Adult

Management of uncomplicated type B aortic dissection (TBAD) has traditionally been aggressive medical therapy. Recent studies brought about a paradigm shift with evidence to suggest benefits from early endovascular intervention to a high risk subgroup of acute uncomplicated TBAD patients.. We aim to review the effects of aortic remodeling in Asian patients with TBAD with and without endovascular intervention, including maximal aortic diameter, true lumen diameter, and false lumen thrombosis.. This is a single-center retrospective study of a prospective database. Patients who presented to our institution with acute TBAD from January 2008 to December 2015 (n = 44) were evaluated. Eighteen percent (8 patients) presented with complicated TBAD and underwent emergency thoracic endovascular aortic repair (TEVAR) while the remaining 82% (36 patients) were treated with optimal medical therapy (OMT).. Six patients under the conservative arm crossed over to elective TEVAR after 6 weeks because of interval radiological progression of disease. There was no significant difference in the baseline demographics of the TEVAR group and the OMT group. At 24 months, mean maximal aortic diameter difference was -7.7 mm and +1.9 mm (P = 0.077), mean true lumen diameter difference was +10.0 mm and +2.6 mm (P = 0.049), and false lumen thrombosis was 100% and 20% (P = 0.012) for TEVAR and OMT, respectively. Kaplan-Meier analysis showed no significant difference in mortality between the 2 groups at 30 days and 2 years.. Within an Asian population with TBAD, TEVAR with OMT has a significant positive effect on aortic remodeling, compared with OMT-only management.

Topics: Aged; Aorta, Thoracic; Aortic Aneurysm; Aortic Dissection; Asian People; Cardiovascular Agents; Databases, Factual; Emergencies; Endovascular Procedures; Female; Humans; Male; Middle Aged; Retrospective Studies; Risk Factors; Singapore; Time Factors; Treatment Outcome; Vascular Remodeling

The blotchy mouse caused by mutations of ATP7A develops low blood copper and aortic aneurysm and rupture. Although the aortic pathologies are believed primarily due to congenital copper deficiencies in connective tissue, perinatal copper supplementation does not produce significant therapeutic effects, hinting additional mechanisms in the symptom development, such as an independent effect of the ATP7A mutations during adulthood.. We investigated if bone marrow from blotchy mice contributes to these symptoms. For these experiments, bone marrow from blotchy mice (blotchy marrow group) and healthy littermate controls (control marrow group) was used to reconstitute recipient mice (irradiated male low-density lipoprotein receptor -/- mice), which were then infused with angiotensin II (1,000 ng/kg/min) for 4 weeks.. By using Mann-Whitney U test, our results showed that there was no significant difference in the copper concentrations in plasma and hematopoietic cells between these 2 groups. And plasma level of triglycerides was significantly reduced in blotchy marrow group compared with that in control marrow group (P < 0.05), whereas there were no significant differences in cholesterol and phospholipids between these 2 groups. Furthermore, a bead-based multiplex immunoassay showed that macrophage inflammatory protein (MIP)-1β, monocyte chemotactic protein (MCP)-1, MCP-3, MCP-5, tissue inhibitor of metalloproteinases (TIMP)-1, and vascular endothelial growth factor (VEGF)-A production was significantly reduced in the plasma of blotchy marrow group compared with that in control marrow group (P < 0.05). More important, although angiotensin II infusion increased maximal external aortic diameters in thoracic and abdominal segments, there was no significant difference in the aortic diameters between these 2 groups. Furthermore, aortic ruptures, including transmural breaks of the elastic laminae in the abdominal segment and lethal rupture in the thoracic segment, were observed in blotchy marrow group but not in control marrow group; however, there was no significant difference in the incidence of aortic ruptures between these 2 groups (P = 0.10; Fisher's exact test).. Overall, our study indicated that the effect of bone marrow from blotchy mice during adulthood is dispensable in the regulation of blood copper, plasma cholesterol and phospholipids levels, and aortic pathologies, but contributes to a reduction of MIP-1β, MCP-1, MCP-3, MCP-5, TIMP-1, and VEGF-A production and triglycerides concentration in plasma. Our study also hints that bone marrow transplantation cannot serve as an independent treatment option.

Topics: Adenosine Triphosphatases; Angiotensin II; Animals; Aortic Aneurysm; Aortic Rupture; Biomarkers; Bone Marrow; Bone Marrow Transplantation; Cardiovascular Agents; Cation Transport Proteins; Copper; Copper-Transporting ATPases; Cytokines; Disease Models, Animal; Enzymes; Female; Lipids; Male; Mice; Mice, Inbred Strains; Receptors, LDL

Thrombocytopenia and thromboembolism(s) may develop in heparin immune-mediated thrombocytopenia (HIT) patients after reexposure to heparin. At the Onassis Cardiac Surgery Center, 530 out of 17,000 patients requiring heart surgery over an 11-year period underwent preoperative HIT assessment by ELISA and a three-point heparin-induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HIT-reactive antibodies, out of which 46 were also thrombocytopenic (true HIT). Cardiac surgery was performed in HIT-positive patients under heparin anticoagulation and iloprost infusion. A control group of 118 HIT-negative patients received heparin but no iloprost during surgery. For the first 20 patients, the dose of iloprost diminishing the HIPAG test to ≤5% was determined prior to surgery by in vitro titration using the patients' own plasma and donor platelets. In parallel, the iloprost "target dose" was also established for each patient intraoperatively, but before heparin administration. Iloprost was infused initially at 3 ng/kg/mL and further adjusted intraoperatively, until ex vivo aggregation reached ≤5%. As a close correlation was observed between the "target dose" identified before surgery and that established intraoperatively, the remaining 90 patients were administered iloprost starting at the presurgery identified "target dose." This process significantly reduced the number of intraoperative HIPAG reassessments needed to determine the iloprost target dose, and reduced surgical time, while maintaining similar primary clinical outcomes to controls. Therefore, infusion of iloprost throughout surgery, under continuous titration, allows cardiac surgery to be undertaken safely using heparin, while avoiding life-threatening iloprost-induced hypotension in patients diagnosed with HIT-reactive antibodies or true HIT.

Topics: Adult; Aged; Aged, 80 and over; Antibodies; Anticoagulants; Aortic Aneurysm; Blood Platelets; Cardiac Valve Annuloplasty; Cardiovascular Agents; Coronary Artery Bypass; Drug Administration Schedule; Drug Monitoring; Female; Heparin; Humans; Iloprost; Male; Middle Aged; Perioperative Care; Platelet Aggregation; Platelet Count; Thrombocytopenia; Thromboembolism; Treatment Outcome

Endovascular aortic repair has revolutionized the management of traumatic blunt aortic injury (BAI). However, debate continues about the extent of injury requiring endovascular repair, particularly with regard to minimal aortic injury. Therefore, we conducted a retrospective observational analysis of our experience with these patients.. We retrospectively reviewed all BAI presenting to an academic level I trauma center over a 10-year period (2000-2010). Images were reviewed by a radiologist and graded according to Society for Vascular Surgery guidelines (grade I-IV). Demographics, injury severity, and outcomes were recorded.. We identified 204 patients with BAI of the thoracic or abdominal aorta. Of these, 155 were deemed operative injuries at presentation, had grade III-IV injuries or aortic dissection, and were excluded from this analysis. The remaining 49 patients had 50 grade I-II injuries. We managed 46 grade I injuries (intimal tear or flap, 95%), and four grade II injuries (intramural hematoma, 5%) nonoperatively. Of these, 41 patients had follow-up imaging at a mean of 86 days postinjury and constitute our study cohort. Mean age was 41 years, and mean length of stay was 14 days. The majority (48 of 50, 96%) were thoracic aortic injuries and the remaining two (4%) were abdominal. On follow-up imaging, 23 of 43 (55%) had complete resolution of injury, 17 (40%) had no change in aortic injury, and two (5%) had progression of injury. Of the two patients with progression, one progressed from grade I to grade II and the other progressed from grade I to grade III (pseudoaneurysm). Mean time to progression was 16 days. Neither of the patients with injury progression required operative intervention or died during follow-up.. Injury progression in grade I-II BAI is rare (~5%) and did not cause death in our study cohort. Given that progression to grade III injury is possible, follow-up with repeat aortic imaging is reasonable.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aneurysm, False; Aorta, Abdominal; Aorta, Thoracic; Aortic Aneurysm; Aortography; Cardiovascular Agents; Disease Progression; Endovascular Procedures; Female; Humans; Injury Severity Score; Length of Stay; Male; Middle Aged; Retrospective Studies; Risk Factors; Time Factors; Tomography, Spiral Computed; Trauma Centers; Treatment Outcome; Vascular System Injuries; Wounds, Nonpenetrating; Young Adult

Partial thrombosis of the false lumen has been reported as a significant predictor of mortality during follow-up in patients with acute type B aortic dissection. The purpose of this study was to investigate the correlation of false lumen thrombosis and aortic expansion during follow-up in patients with acute type B aortic dissection.. All medically treated patients with acute type B aortic dissection observed in 4 cardiovascular referral centers between 1998 and 2011, with admission and follow-up computed tomography or magnetic resonance imaging scans, were included. Aortic diameters of the dissected aortas were measured at 4 levels on the baseline and follow-up scans, and annual growth rates were calculated. Univariate and multivariate regression analyses were used to investigate the effect of false lumen thrombosis on aortic growth rate.. A total of 84 patients were included, of whom 40 (47.6%) had a partially thrombosed false lumen, 7 (8.3%) had a completely thrombosed false lumen, and 37 (44.0%) had a patent false lumen. A total of 273 of the 336 (81.3%) evaluated aortic levels were dissected segments. Overall, the mean aortic diameter increased significantly at all evaluated levels (P < .001). Univariate analysis showed that annual aortic growth rates were significantly higher in those segments having a false lumen with partial thrombosis (mean, 4.25 ± 10.2) when compared with the patent group (mean, 2.10 ± 5.56; P = .035). In multivariate analysis, partial lumen thrombosis was an independent predictor of higher aortic growth (adjusted mean difference, 2.05 mm/year; 95% confidence interval, 0.10-4.01; P = .040).. In patients with acute type B aortic dissection, aortic segments with a partially thrombosed false lumen have a significantly higher annual aortic growth rate when compared with those presenting with patent or complete thrombosis of the false lumen. Therefore, patients with partial thrombosis require more intensive follow-up and may benefit from prophylactic intervention.

Topics: Aortic Aneurysm; Aortic Dissection; Aortography; Cardiovascular Agents; Connecticut; Disease Progression; Female; Humans; Italy; Linear Models; Magnetic Resonance Angiography; Male; Multivariate Analysis; Netherlands; Predictive Value of Tests; Risk Factors; Thrombosis; Time Factors; Tomography, X-Ray Computed; Treatment Outcome

Topics: Aortic Aneurysm; Aortic Dissection; Cardiomyopathies; Cardiovascular Agents; Cooperative Behavior; Female; Heart Defects, Congenital; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Hypertension, Pulmonary; Infant, Newborn; Interdisciplinary Communication; Pregnancy; Pregnancy Complications, Cardiovascular; Prenatal Diagnosis; Risk Assessment; Venous Thromboembolism

This report describes the case of previous type-A aortic dissection treated with the placement of a termino-terminal prosthesis, which developed a large peri-prosthetic pseudoaneurysmatic sac, detected by CT, performed 2 years after the surgery. This raised the suspicion of a communication between the pseudoaneurysmatic sac and the aortic lumen, but was not able to show it directly. Transthoracic echocardiography confirmed the presence of the fistula, showing a systo-diastolic color Doppler jet signal connecting these two structures.The complementary role of these two diagnostic techniques allowed a complete evaluation of this complex pathology.

Topics: Aged; Aneurysm, False; Aortic Aneurysm; Aortic Dissection; Aortography; Arterio-Arterial Fistula; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Echocardiography, Doppler, Color; Echocardiography, Doppler, Pulsed; Female; Humans; Predictive Value of Tests; Pulmonary Artery; Time Factors; Tomography, X-Ray Computed

Because both endothelin-1 (ET-1) and angiotensin II (AngII) are independent mediators of arterial remodeling, we sought to determine the role of ET receptor inhibition in AngII-accelerated atherosclerosis and aortic aneurysm formation. We administered saline or AngII and/or bosentan, an endothelin receptor antagonist (ERA) for 7, 14, or 28 days to 6-week- and 6-month-old apolipoprotein E-knockout mice. AngII treatment increased aortic atherosclerosis, which was reduced by ERA. ET-1 immunostaining was localized to macrophage-rich regions in aneurysmal vessels. ERA did not prevent AngII-induced aneurysm formation but instead may have increased aneurysm incidence. In AngII-treated animals with aneurysms, ERA had a profound effect on the non-aneurysmal thoracic aorta via increasing wall thickness, collagen/elastin ratio, wall stiffness, and viscous responses. These observations were confirmed in acute in vitro collagen sheet production models in which ERA inhibited AngII's dose-dependent effect on collagen type 1 α 1 (COL1A1) gene transcription. However, chronic treatment reduced matrix metalloproteinase 2 mRNA expression but enhanced COL3A1, tissue inhibitor of metalloproteinase 1 (TIMP-1), and TIMP-2 mRNA expressions. These data confirm a role for the ET system in AngII-accelerated atherosclerosis but suggest that ERA therapy is not protective against the formation of AngII-induced aneurysms and can paradoxically stimulate a chronic arterial matrix remodeling response.

Topics: Angiotensin II; Animals; Antihypertensive Agents; Aorta; Aortic Aneurysm; Apolipoproteins E; Atherosclerosis; Biomechanical Phenomena; Bosentan; Cardiovascular Agents; Cell Adhesion; Collagen; Down-Regulation; Endothelin-1; Integrin beta1; Interferon-gamma; Mice; Mice, Knockout; Stress, Physiological; Sulfonamides; Vasoconstrictor Agents

The increasing life expectancy of the population will likely be accompanied by a rise in the incidence of acute type A aortic dissection. However, because of an increased risk of cardiac surgery in an elderly population, it is important to define when, if at all, the risks of aortic repair outweigh the risk of death from unoperated type A aortic dissection.. We analyzed 936 patients with type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2004. Patients with type A aortic dissection were categorized according to patient age by decade and by surgical versus medical management, and outcomes of both management types were investigated in the different age groups.. The rate of surgical aortic repair decreased progressively with age, whereas surgical mortality significantly increased with age. Age 70 years or more was an independent predictor for mortality (38.2% vs 26.0%; P < .0001, odds ratio 1.73). The in-hospital mortality rate was significantly lower after surgical management compared with medical management until the age of 80 years. For patients aged 80 to 90 years, the in-hospital mortality appeared to be lower after surgical management (37.9% vs 55.2%; P = .188); however, this failed to reach clinical significance owing to the limited patient number in this age group.. Although the surgical mortality significantly increased with increased age, surgical management was still associated with significantly lower in-hospital mortality rates compared with medical management until the age of 80 years. Surgery may decrease the in-hospital mortality rate for octogenarians with type A aortic dissection and might be considered in all patients with type A aortic dissection regardless of age.

Topics: Acute Disease; Age Factors; Aged; Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Asia; Cardiovascular Agents; Chi-Square Distribution; Europe; Hospital Mortality; Humans; Odds Ratio; Patient Selection; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Vascular Surgical Procedures

Topics: Acute Disease; Aortic Aneurysm; Aortic Dissection; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Endovascular Procedures; Hemodynamics; Humans; Ischemia; Time Factors; Treatment Outcome

This paper summarizes the highlights of the 15th International Workshop of Endovascular Surgery, held in Ajaccio in June 2008. This is an annual event that attracts leading endovascular therapists from both sides of the Atlantic Ocean as well as a contingency from down-under. The layout of this meeting followed the previous events with sessions on carotid artery disease and abdominal and thoracic aortic aneurysms topped up with clinical cases, lower limb ischemia and venous disease. Generally the session takes off by summarising new evidence, followed by questions and discussion. This workshops gives the participants an excellent opportunity to get an updated perspective within these fast developing areas.

Topics: Adult; Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Cardiovascular Diseases; Carotid Artery Diseases; Female; Humans; Male; Minimally Invasive Surgical Procedures; Peripheral Vascular Diseases; Renal Artery; Treatment Outcome; Vascular Surgical Procedures; Veins

Impact on survival of different treatment strategies was analyzed in 571 patients with acute type B aortic dissection enrolled from 1996 to 2005 in the International Registry of Acute Aortic Dissection.. The optimal treatment for acute type B dissection is still a matter of debate.. Information on 290 clinical variables were compared, including demographics; medical history; clinical presentation; physical findings; imaging studies; details of medical, surgical, and endovascular management; in-hospital clinical events; and in-hospital mortality.. Of the 571 patients with acute type B aortic dissection, 390 (68.3%) were treated medically, 59 (10.3%) with standard open surgery and 66 (11.6%) with an endovascular approach. Patients who underwent emergency endovascular or open surgery were younger (mean age 58.8 years, p < 0.001) than their counterparts treated conservatively, and had male preponderance and hypertension in 76.9%. Patients submitted to surgery presented with a wider aortic diameter than patients treated by interventional techniques or by medical therapy (5.36 +/- 1.7 cm vs. 4.62 +/- 1.4 cm vs. 4.47 +/- 1.4 cm, p = 0.003). In-hospital complications occurred in 20% of patients subjected to endovascular technique and in 40% of patients after open surgical repair. In-hospital mortality was significantly higher after open surgery (33.9%) than after endovascular treatment (10.6%, p = 0.002). After propensity and multivariable adjustment, open surgical repair was associated with an independent increased risk of in-hospital mortality (odds ratio: 3.41, 95% confidence interval: 1.00 to 11.67, p = 0.05).. In the International Registry of Acute Aortic Dissection, the less invasive nature of endovascular treatment seems to provide better in-hospital survival in patients with acute type B dissection; larger randomized trials or comprehensive registries are needed to access impact on outcomes.

Topics: Acute Disease; Aged; Aortic Aneurysm; Aortic Dissection; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Female; Hospital Mortality; Humans; International Cooperation; Kaplan-Meier Estimate; Logistic Models; Male; Middle Aged; Odds Ratio; Outcome and Process Assessment, Health Care; Patient Selection; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Stents; Treatment Outcome; Vascular Surgical Procedures

Topics: Acute Disease; Aortic Aneurysm; Aortic Dissection; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Disease Progression; Hospital Mortality; Humans; International Cooperation; Outcome and Process Assessment, Health Care; Patient Selection; Registries; Risk Assessment; Risk Factors; Stents; Treatment Outcome; Vascular Surgical Procedures

Earlier studies evaluating long-term survival in type A acute aortic dissection (TA-AAD) have been restricted to a small number of patients in single center experiences. We used data from a contemporary, multi-center international registry of TA-AAD patients to better understand factors associated with long-term survival.. We examined 303 consecutive patients with TA-AAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. We included patients who were discharged alive and had documented clinical follow-up data. Kaplan-Meier survival curves were constructed to depict cumulative survival in patients from date of hospital discharge. Stepwise Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. We found that 273 (90.1%) patients had been managed surgically and 30 (9.9%) were managed medically. Patients who were dead at follow-up were more likely to be older (63.9 versus 58.4 years, P=0.007) and to have had previous cardiac surgery (23.9% versus 10.6%, P=0.01). Survival for patients treated with surgery was 96.1%+/-2.4% and 90.5%+/-3.9% at 1 and 3 years versus 88.6%+/-12.2% and 68.7%+/-19.8% without surgery (mean follow-up overall, 2.8 years, log rank P=0.009). Multivariate analysis identified a history of atherosclerosis (relative risk (RR), 2.17; 95% confidence interval [CI], 1.08 to 4.37; P=0.03) and previous cardiac surgery (RR, 2.54; 95% CI, 1.16 to 5.57; P=0.02) as significant, independent predictors of follow-up mortality.. Contemporary 1- and 3-year survival in patients with TA-AAD treated surgically are excellent. Independent predictors of survival during the follow-up period do not appear to be influenced by in-hospital risks but rather preexisting comorbidities.

Topics: Acute Disease; Age Factors; Aged; Antihypertensive Agents; Aortic Aneurysm; Aortic Dissection; Atherosclerosis; Cardiac Surgical Procedures; Cardiovascular Agents; Case Management; Comorbidity; Europe; Female; Follow-Up Studies; Humans; Hypertension; Japan; Life Tables; Male; Middle Aged; Mortality; Patient Discharge; Postoperative Complications; Proportional Hazards Models; Registries; Risk Factors; Survival Analysis; Treatment Outcome; United States

Acute distal aortic dissection rarely causes spinal cord ischemia presenting with paraplegia or paraparesis. Spinal cord involvement has poor outcomes, and there is no established effective treatment for this disorder. In this report we describe the acute conservative treatment of two cases of paraplegia/paraparesis due to acute type B aortic dissection. Early reversal of lower-limb dysmobility was achieved.

Topics: Aged; Antihypertensive Agents; Aortic Aneurysm; Aortic Dissection; Cardiovascular Agents; Cerebrospinal Fluid; Drainage; Humans; Male; Naloxone; Paraparesis; Spinal Cord Injuries

Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD).. Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustment for age and hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04), predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32% versus 22% in men despite similar delay, surgical technique, and hemodynamics.. Our analysis provides insights into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Cardiac Tamponade; Cardiovascular Agents; Case Management; Combined Modality Therapy; Consciousness Disorders; Europe; Female; Hospital Mortality; Humans; Hypotension; Life Tables; Male; Middle Aged; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Registries; Retrospective Studies; Risk Factors; Sex Factors; Survival Analysis; Treatment Outcome; United States

The phenomenon of delayed neurological deficit after thoracoabdominal aortic aneurysm repair was first reported in the late 1980s. The mechanism may be reduced collateral circulation during periods of hypotension, cord edema, or reperfusion injury. Few patients with delayed-onset neurological deficit have recovered from this devastating complication. The experience with six patients treated with lumbar cerebrospinal fluid (CSF) drainage is reported.. Five patients underwent thoracoabdominal aortic aneurysm repair. Before and immediately after the operation, the patients exhibited no abnormalities in motor or sensory function. Patients presented between 12 and 40 hours postoperatively with rapid motor and sensory loss in their lower extremities. Hypotensive events immediately preceded the onset of deficit in five patients. The sixth patient experienced an acute onset of back pain and was found to have thrombus without evidence of dissection in the descending aorta.. Patients were treated with volume expansion and vasoactive drugs to achieve a mean arterial pressure of more than 70 mm Hg. Lumbar CSF drainage was instituted promptly in four patients; all displayed marked neurological improvement. Two patients underwent CSF drainage several hours after the onset of symptoms and did not improve. The duration of CSF drainage ranged from 15 to 72 hours, with a goal of maintaining the lumbar CSF pressure at less than 10 mm Hg.. The efficacy of CSF drainage may relate to reducing CSF pressure, which may increase spinal cord perfusion. Rapid initiation of CSF drainage with aggressive support of blood pressure may result in neurological improvement in some patients.

Topics: Aged; Aorta, Abdominal; Aorta, Thoracic; Aortic Aneurysm; Blood Pressure; Cardiovascular Agents; Cerebrospinal Fluid; Cerebrospinal Fluid Pressure; Drainage; Female; Humans; Lumbosacral Region; Male; Middle Aged; Nervous System Diseases; Plasma Substitutes; Time Factors; Vascular Surgical Procedures