This study conducts hemodynamic simulations for a total of 20 patients with Type B aortic intramural hematoma (TBIMH) and aims to develop hemodynamic criteria for possible development of intimal tear and indicator for tearing location. The patients are divided into Group A without intimal tear and Group B with progression into tear. The mean oscillatory shear index OSI¯ is calculated based on the wall shear stress (WSS¯) distribution. The blood pressure drop along the main aortic vessel is calculated and the high pressure drop time fraction over one cardiac cycle Td/T is determined, with high pressure drop being defined as the pressure drop larger than half the maximal value. By combining OSI¯ and Td/T at low heart rates 60bpm and 75bpm, we reveal statistically significant correlation between no progression to tear and both low OSI¯<0.121 and low Td/T<0.067, with a pvalue of p=8.7e-5. We also propose a new parameter, namely the magnitude of tangential pressure gradient at aortic wall |∇τp| at the time when the pressure drop is maximal during one cardiac cycle. Comparison with CT imaging reveals that nine out of ten patients in Group B develop intimal tear at the location with elevated |∇τp|. Therefore, the current study provides a two-step procedure for the hemodynamic diagnosis of TBIMH. First, by combining OSI¯ and Td/T those patients with low risk of intimal tear can be excluded. Then, the location of elevated |∇τp| can be adopted as the indicator for possible intimal tear locations.

Acute aortic intramural hematoma (IMH) is a relatively uncommon but potentially life-threatening aortic disease that can occur primarily in hypertensive and atherosclerotic patients. The course of IMH varies widely, with the condition either regressing, remaining stable, or progressing until it leads to outward rupture or intimal layer disruption, eventually resulting in overt aortic dissection. Therefore, poor prognostic computed tomography (CT) features must be promptly recognized and reported by the radiologist. In emergency departments, readily accessible non-invasive CT angiography is crucial for achieving a rapid and accurate diagnosis essential for appropriate management. For Type A and B aortic dissection, surgery is typically recommended in Western countries for patients with Stanford Type A IMH and those experiencing irrepressible pain. For Stanford Type B IMH patients without complications or incessant pain, medical treatment is suggested but with imaging follow-up. In complicated Stanford Type B situations, thoracic endovascular aortic repair (TEVAR) is currently indicated. This review aims to present pathophysiology, CT diagnosis, and IMH fate and provide the reader CT image-based review of the CT diagnostic criteria, complications, and associated critical prognostic findings of this rather rare aortic disease.

Intramural hematoma (IMH) is a serious aortic condition characterized by the presence of a contained hematoma within the aortic media. However, the animal model with a high incidence of IMH was lacking, and the specific pathological characteristics of IMH have not been thoroughly characterized.

We conducted an experimental study using 4-week-old male, 4-week-old female, and 8-week-old male C57BL/6J mice. These mice were subjected to angiotensin II infusion at a rate of 1000 ng/kg/min for a period of 4 days. In situ imaging was performed, and aorta was harvested and serially sectioned. Histological staining and immunostaining techniques were employed, and the subcellular structure was examined using transmission electron microscopy. Our findings revealed that 4-week-old male mice exhibited a higher susceptibility to angiotensin II-induced IMH, characterized by more circumferential appearances and larger affected areas. Furthermore, IMH was more likely to occur in the upper segment of the descending aorta rather than the lower segment. Within the IMH, older fibrinous thrombus was predominantly observed near the adventitia, while younger red thrombus was more prevalent near the lumen. Additionally, platelet activation and degranulation were observed, along with fibrin cross-linking and thrombus organization, indicating a potential relationship between platelet activation and the progression of IMH.

Our study demonstrated that angiotensin II infusion promoted the development of IMH during the early stages, especially in juvenile mice. Furthermore, the presence of platelet activation and thrombus organization suggested their potential involvement in the progression of IMH.

We present a case about a man in his 70s who was admitted to the emergency department, haemodynamically unstable and with complaints of chest pain and dyspnoea. A bedside transthoracic echocardiography showed enlargement of the aorta and pericardial effusion, and a subsequent CT of the aorta showed acute type A intramural haematoma (IMH). Emergency surgery was not possible due to comorbidities, and a wait-and-watch strategy (optimal medical therapy, with blood pressure and pain control and repetitive imaging) was selected. He was hospitalised for a total of 16 days, during which his condition stabilised. A 3-month follow-up CT showed complete regression of both the IMH and haemopericardium.

Ascending aortic length has recently been recognized as a novel predictor of adverse events in aortic diseases, but its prognostic value in type A intramural haematoma is unknown. We aimed to evaluate the association between ascending aortic length and outcomes in patients with type A intramural haematoma initially managed medically.

We retrospectively analysed patients with acute type A intramural haematoma. Ascending aortic length was measured by computed tomography. The primary outcome was aortic progression, defined as aortic intervention or aortic-related death.

A total of 98 patients were enrolled. During a median follow-up of 2.6 years, aortic progression occurred in 27 patients (27.6%), i.e. 9 events per 100 patient-years. Patients with ascending aortic length ≥11 cm had significantly higher rates of aortic progression [54.2% (20.9 events per 100 patient-years) vs 18.9% (6.1 events per 100 patient-years), P = 0.001], surgical intervention (45.8% vs 12.2%, P = 0.001) and presence of ulcer-like projection (25.0% vs 2.7%, P = 0.002) compared to those with ascending aortic length <11 cm. Kaplan-Meier analysis demonstrated lower progression-free survival in the ascending aortic length ≥11 cm group (P = 0.0021). Ascending aortic length had a sensitivity of 61.9% and specificity of 77.8% for predicting aortic progression, with an area under the curve of 0.756 (95% confidence interval 0.649-0.862).

Ascending aortic elongation may identify a high-risk subgroup of acute type A intramural haematoma patients initially managed medically who could potentially benefit from early surgery. Ascending aortic length should be considered in the risk stratification and management of these patients.

Despite key differences in pathological processes, both Intramural Hematomas and Aortic Dissections are Acute Aortic Syndromes repaired with similar surgical technique. The objective of this study was to determine differences in surgical outcomes between patients with Intramural Hematoma versus Type A Aortic Dissection undergoing Ascending Aortic Arch repair.

This retrospective review of prospectively collected data included all patients with acute Intramural Hematoma or Type A Aortic Dissection who underwent emergent Ascending- or Arch Repair from January 2018 to May 2023 at a single academic institution. Primary outcomes included intraoperative mortality, 30-Day mortality, and postoperative stay. Secondary outcomes included postoperative complications. Outcomes were analyzed using Chi-squared, Fisher's Exact, and t-tests, with significance set at p < 0.05.

A total of 107 patients were included, 27 of whom (25%) had Intramural Hematoma and 80 (75%) had Type A Aortic Dissection. There were no differences in preoperative characteristics such as age, gender, and comorbidities, and no differences in perioperative characteristics such as case length, cardiopulmonary bypass, aortic cross-clamp, and circulatory arrest times. When comparing postoperative outcomes, there was a higher rate of postoperative pericardial effusions requiring pericardial window in the Intramural Hematoma cohort compared to the Aortic Dissection cohort (15% [n = 4] vs. 3% [n = 2]; p = 0.02). There were no differences in other primary outcomes such as intraoperative mortality, 30-Day mortality, and postoperative length of stay. There were also no differences in the rates of postoperative complications such as bleeding requiring reoperation, cerebrovascular accident, atrial fibrillation, pleural effusion requiring thoracentesis, and surgery-related Emergency Department visits.

Our analysis demonstrates similar outcomes for patients undergoing Ascending Aortic Arch repair between patients with Intramural Hematoma and Type A Aortic Dissection. Despite the higher rate of required postoperative pericardial windows in the Intramural Hematoma cohort, the overall primary outcomes remained comparable. These findings better elucidate the standard of care for patients with acute Intramural Hematoma undergoing Ascending Aortic Arch repair.

The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years.

IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents.

Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index.

IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.

Type B intramural hematoma (IMH) is often managed medically, yet may progress to dissection, aneurysmal dilation, or rupture. The aim of this study was to report the natural history of medically managed Type B IMH, and factors associated with progression.

We reviewed patients with medically managed Type B IMH between January 1995 to December 2022 at a single center. Any patients with immediate surgical or endovascular intervention were excluded. Demographic profiles, comorbidities, imaging, and follow-up details were reviewed. Patients were divided into two groups: Group 1 had isolated IMH, and Group 2 had IMH along with aneurysm or dissection at the time of presentation. On follow-up, progression was defined as degeneration to aneurysm/dissection or increase in the thickness of IMH in Group 1. In Group 2, progression was an increase in the size of aneurysm or development of new dissection.

Of 104 patients with Type B IMH during the study period, 92 were medically managed. The median age was 77 years, and 45 (48.9%) were females. Comorbidities included hypertension (83.7%), hypercholesterolemia (44.6%), and active smoking (47.8%). Mean Society for Vascular Surger comorbidity score was 6.3. Mean IMH thickness and aortic diameter at presentation were 8.9 mm and 38.3 mm, respectively. Median follow-up was 55 months. Overall survival at 1 year and 5 years was 85.8% and 61.9%, respectively. During follow-up, 19 patients (20.7%) required intervention, more common in Group 2 (Group 1, 8/66; 12.3% vs Group 2, 11/26; 42.3%; P = .001). This resulted in higher freedom from intervention in Group 1 at 1 year (93.5% vs 62.7%) and 5 years (87.5% vs 51.1%; P < .001). Indication for intervention was dissection (n = 4), aneurysm (n = 12), and progression of IMH (n = 3). In Group 1, progression was seen in 25 (37.9%), three (4.5%) remained stable, 29 (43.9%) had complete resolution of IMH, and nine patients were lost to follow-up. In Group 2, 11 patients (42.3%) had progression, seven (26.9%) remained stable, and eight were lost to follow-up. IMH thickness at presentation >7.2 mm is associated with both increased odds of progression (odds ratio, 3.3; 95% confidence interval, 1.2-11.1; P = .03) and intervention (odds ratio, 5.5; 95% confidence interval, 1.3-36.9; P = .03) during the follow-up.

Although many patients with Type B IMH managed medically stabilize or regress, progression or need for intervention can occur in up to 40% of cases. This is associated with the presence of aneurysm, dissection, and IMH thickness. Long-term follow-up is mandatory as late interventions occur, particularly for higher risk patients.

Aortic dissection (AD) remains a difficult diagnosis in the emergency setting. Despite its rare occurrence, it is a life-threatening pathology that, if missed, is typically fatal. Previous studies have documented minimal improvement in timely and accurate diagnoses despite the advancement of computed tomography. Previous literature has highlighted aortic dissections as a major cause of serious misdiagnosis-related harm. The aim of this article is to review the available literature on AD, discussing the diversity in presentations and the prevalence of historical and exam features to better aid in the diagnosis of AD. AD remains a difficult diagnosis, even with the widespread prevalence of computed tomography angiography usage. No single feature of the history or physical examination is enough to raise suspicion. The diagnosis should be strongly considered in any patient with chest pain that is severe and unexplained by other findings or testing. Those who do not present with acute pain are often complicated by neurologic deficits, hypotension, or syncope. These patients suffer from a change in mental status limiting their ability to participate in the history and physical examination and have a higher rate of complications and mortality. An educated understanding of the atypical presentations of aortic dissection helps the clinician to realistically rank it on the differential diagnosis, culminating in judicious use of definitive imaging.

This study is to examine the factors associated with short-term aortic-related adverse events in patients with acute type B aortic intramural hematoma (IMH). Additionally, we develop a risk prediction nomogram model and evaluate its accuracy.

This study included 197 patients diagnosed with acute type B IMH. The patients were divided into stable group (n = 125) and exacerbation group (n = 72) based on the occurrence of aortic-related adverse events. Logistic regression and the Least Absolute Shrinkage and Selection Operator (LASSO) method for variables based on baseline assessments with significant differences in clinical and image characteristics were employed to identify independent predictors. A nomogram risk model was constructed based on these independent predictors. The nomogram model was evaluated using various methods such as the receiver operating characteristic curve, calibration curve, decision analysis curve, and clinical impact curve. Internal validation was performed using the Bootstrap method.

A nomogram risk prediction model was established based on four variables: absence of diabetes, anemia, maximum descending aortic diameter (MDAD), and ulcer-like projection (ULP). The model demonstrated a discriminative ability with an area under the curve (AUC) of 0.813. The calibration curve indicated a good agreement between the predicted probabilities and the actual probabilities. The Hosmer-Lemeshow goodness of fit test showed no significant difference (χ 2 = 7.040, P = 0.532). The decision curve analysis (DCA) was employed to further confirm the clinical effectiveness of the nomogram.

This study introduces a nomogram prediction model that integrates four important risk factors: ULP, MDAD, anemia, and absence of diabetes. The model allows for personalized prediction of patients with type B IMH.

Aortic intramural hematoma (IMH) is a rare disease. Thus far, only limited data is available and the indications for conservative and endovascular treatment are not well defined. The aim of this study was to investigate clinical presentation, course, CT imaging features and outcome of patients with type B aortic IMHs.

We included all patients with type B IMHs between 2012 and 2021 in this retrospective monocentric study. Clinical data, localization, thickness of IMHs and the presence of ulcer-like projections (ULPs) was evaluated before and after treatment.

Thirty five patients (20 females; 70.3 y ± 11 y) were identified. Almost all IMHs (n = 34) were spontaneous and symptomatic with back pain (n = 34). At the time of diagnosis, TEVAR was deemed indicated in 9 patients, 26 patients were treated primarily conservatively. During the follow-up, in another 16 patients TEVAR was deemed indicated. Endovascularly and conservatively treated patients both showed decrease in thickness after treatment. Patients without ULPs showed more often complete resolution of the IMH than patients with ULPs (endovascularly treated 90.9% (10/11) vs 71.4% (5/7); conservatively treated 71.4% (10/14) vs 33.3% (1/3); P = .207). Complications after TEVAR occurred in 32% and more frequently in patients treated primarily conservatively (37.5% vs 22.2%). No in-hospital mortality was observed during follow-up.

Prognosis of IMH seems favourable in both surgically as well as conservatively treated patients. However, it is essential to identify patients at high risk for complications under conservative treatment, who therefore should be treated by TEVAR. In our study, ULPs seem to be an adverse factor for remodeling.

Best medical therapy (BMT) for acute uncomplicated type B intramural hematoma (TBIMH) is the current treatment guideline, but there is considerable controversy about subsequent clinical course and outcome, which may be associated with a significant failure rate. The purpose of this study was to identify potential risk factors for BMT failure and to develop a risk score to guide clinical decision making.

Patients with acute uncomplicated TBIMH between 2011 January and 2020 December were retrospectively studied. Logistic regression was applied to univariately assess potential risk predictors, and multivariable model results were then used to formulate a simplified predictive model for BMT failure.

In a total of 61 patients, the overall rate of BMT failure was 57.4% (35/61), of which 48.6% (17/35) occurred within 28 days of onset. Logistic regression identified maximum descending aortic diameter (HR ​= ​1.99 CI ​= ​1.16-3.40, p ​= ​0.012), initial IMH thickness (HR ​= ​3.29, CI ​= ​1.28-8.46, p ​= ​0.013) and presence of focal contrast enhancement (HR ​= ​3.12, CI ​= ​1.49-6.54, p ​= ​0.003) as potential risk predictors of BMT failure. A risk score was calculated as follows: [Max DTA diameter (mm)∗0.6876 ​+ ​Max IMH thickness (mm)∗1.1918 ​+ ​PAU/ULP ∗1.1369]. Freedom from BMT failure at 1 year was 72% in patients with a risk score ​< ​4.12, compared with only 35.1% in those with a risk score ​≧ ​4.12.

In a substantial proportion of patients with acute uncomplicated TBIMH, initial BMT failed. Based on the three initial computed tomographic imaging variables, this risk score could help stratify patients at high or low risk for BMT failure and provided additional information for early intervention.

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

The acute aortic syndromes (AAS) are life-threatening vascular compromises within the aortic wall. These include aortic dissection (AD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), and blunt traumatic thoracic aortic injury (BTTAI). While patients classically present with chest pain, the presentation may be highly variable. Timely diagnosis is critical to initiate definitive treatment and maximize chances of survival. In high-risk patients, treatment should begin immediately, even while diagnostic evaluation proceeds. The mainstay of medical therapy is acute reduction of heart rate and blood pressure. Surgical intervention is often required but is informed by patient anatomy and extent of vascular compromise.

Aortic aneurysm/dissection (AAD) is a serious cardiovascular condition characterized by rapid onset and high mortality rates. Currently, no effective drug treatment options are known for AAD. AAD pathogenesis is associated with the phenotypic transformation and abnormal proliferation of vascular smooth muscle cells (VSMCs). However, endogenous factors that contribute to AAD progression remain unclear. We aimed to investigate the role of histone deacetylase 9 (HDAC9) in AAD pathogenesis. HDAC9 expression was considerably increased in human thoracic aortic dissection specimens. Using RNA-sequencing (RNA-seq) and chromatin immunoprecipitation, we demonstrated that HDAC9 transcriptionally inhibited the expression of superoxide dismutase 2 and insulin-like growth factor-binding protein-3, which are critically involved in various signaling pathways. Furthermore, HDAC9 triggered the transformation of VSMCs from a systolic to synthetic phenotype, increasing their proliferation and migration abilities and suppressing their apoptosis. Consistent with these results, in vivo experiments revealed that TMP195, a pharmacological inhibitor of HDAC9, suppressed the formation of the β-aminopropionitrile-induced AAD phenotype in mice. Our findings indicate that HDAC9 may be a novel endogenous risk factor that promotes the onset of AAD by mediating the phenotypic transformation of VSMCs. Therefore, HDAC9 may serve as a potential therapeutic target for drug-based AAD treatment. Furthermore, TMP195 holds potential as a therapeutic agent for AAD treatment.

To evaluate outcomes in the follow up of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in patients with acute type B aortic intramural haematoma (IMH).

The following sources were searched for articles meeting the inclusion criteria and published by July 2023: PubMed/MEDLINE, EMBASE, CENTRAL/CCTR (Cochrane Controlled Trials Register).

This systematic review with pooled meta-analysis of time to event data followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and its protocol was registered on the public platform PROSPERO (CRD42023456222). The following were analysed: overall survival (all cause mortality), aortic related mortality, and restricted mean survival time. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool.

Eight studies met the eligibility criteria, including 1 015 patients (440 in the TEVAR group and 575 in the medical therapy group). All studies were observational, and the pooled cohort had a median follow up of 5.1 years. Compared with patients who received medical therapy alone, those who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.44, 95% CI 0.30 - 0.65; p < .001; GRADE certainty: low), lower risk of aortic related death (HR 0.04, 95% CI 0.01 - 0.31; p = .002; GRADE certainty: low) and lifetime gain (restricted mean survival time was overall 201 days longer with TEVAR; p < .001).

Thoracic endovascular aortic repair may be associated with lower risk of all cause and aortic related death compared with medical therapy in patients with acute type B IMH; however, the underlying data are not strong enough to draw robust clinical conclusions. Randomised controlled trials with large sample sizes and longer follow up are warranted to elucidate this question.

The pathophysiology and behavior of acute type B intramural hematoma (TBIMH) is poorly understood. The purpose of this study is to characterize the pathophysiology, fate, and outcomes of TBIMH in the endovascular era.

A retrospective analysis of a US Aortic Database identified 70 patients with TBIMH from 2008 to 2022. Patients were divided into groups and analyzed based upon subsequent management: early thoracic endovascular aortic repair (TEVAR; Group 1) or hospital discharge on optimal medical therapy (OMT) (Group 2).

Of 70 total patients, 43% (30/70) underwent TEVAR (Group 1) and 57% (40/70) were discharged on OMT (Group 2). There were no significant differences in age, demographics, or comorbidities between groups. Indications for TEVAR in Group 1 were as follows: 1) Penetrating atheroscletoic ulcer (PAU) or ulcer-like projection (n = 26); 2) Descending thoracic aortic aneurysm (n = 3); or 3) Progression to type B aortic dissection (TBAD) (n = 2). Operative mortality was zero. No patient suffered a stroke or spinal cord ischemia. During the follow-up period, 50% (20/40) of Group 2 patients required delayed surgical intervention, including TEVAR in 14 patients and open repair in 6 patients. Indications for surgical intervention were as follows: 1) Development of a PAU / ulcer-like projection (n = 13); 2) Progression to TBAD (n = 3), or 3) Concomitant aneurysmal disease (n = 4). Twenty patients did not require surgical intervention. Of the initial cohort, 71% of patients required surgery, 9% progressed to TBAD, and 19% had regression or stability of TBIMH with OMT alone.

The most common etiology of TBIMH is an intimal defect. Progression to TBAD and intramural hematoma regression without an intimal defect occurs in a small percentage of patients. An aggressive strategy with endovascular therapy and close surveillance for TBIMH results in excellent short-term and long-term outcomes.

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

With favorable results of thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated acute type B intramural hematoma (uTBIMH), TEVAR is increasingly utilized in the management of patients with uTBIMH. However, optimal timing for intervention has not been decided. This study aimed to compare the efficacy of acute and delayed TEVAR in patients with uTBIMH.

We included patients with uTBIMH who underwent TEVAR between October 2014 and December 2021. The participants were divided into the acute TEVAR (aTEVAR) and delayed TEVAR (dTEVAR) groups. We analyzed the total aortic diameter (TAD)/true lumen diameter (TLD) ratio on computed tomography angiography (CTA) and aortic-related adverse events and all-cause mortality (AREM).

We included 34 individuals with uTBIMH, among which 20 underwent aTEVAR and 14 underwent dTEVAR. We observed no significant differences in baseline characteristics between both groups. However, compared with the aTEVAR group, better aortic remodeling was achieved in the dTEVAR group before discharge (1.32 ± 0.11 vs. 1.21 ± 0.09, P = 0.005) and at the 1-year follow-up (1.18 ± 0.09 vs. 1.10 ± 0.04, P = 0.034). Although the 30-day and 1-year follow-up outcomes of AREM were not significantly different, the Kaplan-Meier analysis showed that AREM incidence in the dTEVAR group was significantly lower than that in the aTEVAR group (85.7% for dTEVAR vs. 65.0% for aTEVAR, log-rank P = 0.20). Moreover, subgroup analysis revealed a significant difference in the TAD/TLD ratio between the aTEVAR and dTEVAR groups in individuals without a focal intimal disruption (1.33 ± 0.11 vs. 1.17 ± 0.09, P = 0.008).

For individuals with uTBIMH, delaying TEVAR by >7 days improved aortic remodeling and lowered the incidence of early AREM. Additionally, the absence of focal intimal disruption on preoperative CTA supports delayed intervention.

The effect of an initial surgical approach (in comparison with initial medical therapy) in acute type A intramural hematoma remains insufficiently explored. We designed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up for overall survival (all-cause death). Restricted mean survival time was calculated to evaluate lifetime gain or loss. The Risk of Bias in Non-Randomized Studies of Interventions tool (ROBINS-I) was used to assess risk of bias. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to assess certainty of evidence. Eight studies met our eligibility criteria, including a total of 654 patients (311 patients treated with surgery and 343 patients treated with medical therapy alone). All the studies were non-randomized and observational. The median follow-up was 4.6 years (interquartile range 1.0 to 7.7). Patients who underwent surgery had a significantly lower risk of mortality compared with patients receiving medical therapy alone (hazard ratio 0.51, 95% confidence interval 0.35 to 0.74, p <0.001). The restricted mean survival time was overall 1.1 years greater with surgery compared with medical therapy, and this difference was statistically significant (p <0.001), which means that surgery is associated with lifetime gain. The overall risk of bias (ROBINS-I) was considered moderate-to-serious and the certainty of evidence (GRADE) was deemed to be low. In conclusion, in the overall follow-up, surgery as the initial approach was associated with better late survival and lifetime gain in comparison with medical therapy alone in the setting of acute type A aortic intramural hematoma; however, high-quality randomized trials are warranted to establish the efficacy of the surgical strategy.

The indication, timing, and choice of the treatment modality for penetrating aortic ulcers (PAUs) and intramural hematoma (IMH) are frequently challenging. This article reviews these pathologies and their relation to aortic dissection and proposes a diagnostic and treatment algorithm.

A review of literature on diagnosis and treatment of PAU and IMH was conducted. The PubMed database was searched using the terms "penetrating aortic ulcer" and "aortic intramural hematoma". Articles were reviewed and the studies involving diagnosis and management of PAU and IMH were included. We subsequently proposed a management algorithm for PAU and IMH based on available evidence.

PAU and IMH are distinct entities from aortic dissection, although they carry a significant risk of progression into dissection, aneurysm, and rupture. PAU and IMH originating in zone 0 of the aorta generally require surgical treatment. When the origin is beyond zone 0, a trial of medical therapy is recommended. Progression of disease on imaging studies, persistent uncontrolled pain, and certain high-risk features warrant surgery. High-risk features signaling risk of disease progression include PAU with IMH, PAU depth more than 10 mm, PAU diameter more than 20 mm, IMH thickness more than 10 mm, and maximum initial aortic diameter more than 40 mm.

High-quality evidence regarding the treatment of PAU and IMH is lacking. These entities can have a malignant course when they are present with associated symptoms and/or when they have associated high-risk features on imaging. An aggressive surgical approach is necessary in that group of patients.

Background: Surgical patients with aortic dissection often require multiple antihypertensive drugs to control blood pressure. However, the prescription pattern and effectiveness of antihypertensive drugs for these patients are unclear. We aimed to investigate the prescription pattern and effectiveness of different classes of antihypertensive drugs in surgical patients with aortic dissection. Methods: Newly diagnosed aortic dissection patients who underwent surgery, aged >20 years, from 1 January 2012 to 31 December 2017 were identified. Patients with missing data, in-hospital mortality, aortic aneurysms, or congenital connective tissue disorders, such as Marfan syndrome, were excluded. Prescription patterns of antihypertensive drugs were identified from medical records of outpatient visits within 90 days after discharge. Antihypertensive drugs were classified into four classes: 1) β-blockers, 2) calcium channel blockers (CCBs), 3) renin-angiotensin system, and 4) other antihypertensive drugs. Patients were classified according to the number of classes of antihypertensive drugs as follows: 1) class 0, no exposure to antihypertensive drugs; 2) class 1, antihypertensive drugs of the same class; 3) class 2, antihypertensive drugs of two classes; 4) class 3, antihypertensive drugs of three classes; or 5) class 4, antihypertensive drugs of four classes. The primary composite outcomes included rehospitalization associated with aortic dissection, death due to aortic dissection, and all-cause mortality. Results: Most patients were prescribed two (28.87%) or three classes (28.01%) of antihypertensive drugs. In class 1, β-blockers were most commonly used (8.79%), followed by CCBs (5.95%). In class 2, β-blockers+CCB (10.66%) and CCB+RAS (5.18%) were the most common drug combinations. In class 3, β-blockers + CCB+RAS (14.84%) was the most prescribed combination. Class 0 had a significantly higher hazard of the composite outcome (HR, 2.1; CI, 1.46-3.02; p < 0.001) and all-cause mortality (HR, 2.34; CI, 1.56-3.51; p < 0.001) than class 1. There were no significant differences in hazards for rehospitalization associated with aortic dissection among classes. Conclusion: Among operated patients with type A aortic dissection, no specific type of antihypertensive drug was associated with a better outcome, whereas among those with type B aortic dissection, the use of β-blockers and CCBs was related to a significantly lower risk of the composite outcome.

Epidemiological studies on acute aortic syndrome (AAS) have relied largely on unverified administrative coding, leading to wide-ranging estimates of incidence. This study aimed to evaluate the incidence, management, and outcomes of AAS in Aotearoa New Zealand.

This was a national population-based retrospective study of patients presenting with an index admission of AAS from 2010 to 2020. Cases from the Ministry of Health National Minimum Dataset, National Mortality Collection, and the Australasian Vascular Audit were cross-verified with hospital notes. Poisson regression adjusted for sex and age was used to investigate trends over time.

During the study interval, 1295 patients presented to hospital with confirmed AAS, including 790 with type A (61.0 per cent) and 505 with type B (39.0 per cent) AAS. A total of 290 patients died out of hospital between 2010 and 2018. The overall incidence of aortic dissection including out-of-hospital cases was 3.13 (95 per cent c.i. 2.96 to 3.30) per 100 000 person-years, and this increased by an average of 3 (95 per cent c.i. 1 to 6) per cent per year after adjustment for age and sex adjustment on Poisson regression, driven by increasing type A cases. Age-standardized rates of disease were higher in men, and in Māori and Pacific populations. The management strategies used, and 30-day mortality rates among patients with type A (31.9 per cent) and B (9.7 per cent) disease have remained constant over time.

Mortality after AAS remains high despite advances over the past decade. The disease incidence and burden are likely to continue to increase with an ageing population. There is impetus now for further work on disease prevention and the reduction of ethnic disparities.

Survival and aortic-related adverse events after thoracic endovascular aortic repair (TEVAR) for aortic intramural hematoma (IMH) and aortic dissection (AD) are controversial. We aimed to assess the preoperative characteristics and to evaluate TEVAR outcomes of acute type B IMH and AD.

Between June 2002 and May 2021, 83 patients with acute type B IMH and 755 patients with acute type B AD underwent TEVAR at the General Hospital of Northern Theater Command. We retrospectively analyzed data from these patients, including clinical characteristics and follow-up outcomes.

The patients with IMH were significantly older than the ones with AD (P < 0.001). Diabetes mellitus (P = 0.035) and ischemic cerebrovascular disease (P = 0.017) were more common in the IMH group than in the AD group. The results demonstrated a less long-term aortic-related death-free survival rate in the IMH group than the AD group for all the patients (P = 0.014) and the matched patients (P = 0.027). It also presents a lower long-term overall survival rate (P = 0.047) and aortic-related event-free rate (P = 0.048) in the IMH group than in the matched patients.

Compared with AD patients, patients with IMH who underwent TEVAR had a worse long-term outcome of aortic-related survival in all and matched patients.

Computed tomography (CT) has been increasingly used in the diagnosis of acute aortic syndrome, and a number of high-risk CT imaging features have been reported. We aimed to identify CT imaging findings suggesting high-risk for acute aortic syndrome by examining clinical outcomes of patients with acute type A aortic intramural hematoma (TAIMH).

This retrospective study analyzed the relationship of clinical patient characteristics and imaging features with mortality and aortic events in 63 patients receiving initial medical treatment for TAIMH. Multivariate regression analysis was used to determine the predictors of aortic events, and the Kaplan-Meier method was used to analyze survival and aortic events.

During a median follow-up of 4.2 years, 25 patients experienced aortic events and 40% of these occurred within 7 days of admission. In total, 12 patients experienced aortic death and 12 patients underwent open aortic surgery or endovascular stenting for aortic disease. In multivariate regression analysis, penetrating atherosclerotic ulcers (PAUs) or ulcer-like projections (ULPs) (P = 0.04) and pericardial effusion (P = 0.03) were independent predictors of aortic events. In the Cox regression model, PAUs/ULPs (P = 0.04) and pericardial effusion (P = 0.04) were independently associated with lower aortic event-free survival.

Identification of high-risk CT features is important for clinical decision-making during TAIMH treatment. Early and frequent CT imaging follow-up is required in patients receiving medical treatment. PAUs/ULP and pericardial effusion were the strongest predictors of adverse aortic events.

The mortality of acute aortic dissection (AD) can reach 65~70%. However, it is challenging to follow the progress of AD formation. The purpose of this work was to observe the process of dissection development using a novel tear-embedded silicone phantom.

Silicone phantoms were fabricated by embedding a torn area and primary tear feature on the inner layer. CT scanning and laser lightening were conducted to observe the variations in thickness and volume of the true lumen (TL) and false lumen (FL) during development.

The model with a larger interlayer adhesion damage required a lower pressure to trigger the development of dissection. At the initiation stage of dissection, the volume of TL increased by 25.5%, accompanied by a 19.5% enlargement of tear size. The force analysis based on the change of tear size verified the deduction of the process of interlaminar separation from the earlier studies.

The primary tear and the weakening adhesion of the vessel layers are key factors in AD development, suggesting that some forms of primary damage to the arterial wall, in particular, the lumen morphology of vessels with straight inner lumen, should be considered as early risk predictors of AD.

This work aims to review recent literature on penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs), in order to identify clinical and imaging factors connected to aortic-related adverse events (AAE).

We performed a systematic review according to the Preferred Reporting Items for Systematic review and Metanalyses (PRISMA) guidelines. An electronic search was conducted on Medline and Embase databases. We included articles reporting on PAUs and/or IMHs localized in the descending thoracic and/or abdominal aorta and analyzing clinical and/or radiological markers of AAE.

Of 964 records identified through database searching, 17 were incorporated in the present review, including 193 and 1298 patients with type B PAUs and IMHs, respectively. The 30-days aortic-related mortality (ARM) was 4.3% and 3.9% for PAUs and IMHs. A total of 21% of patients with IMHs underwent intervention during the follow-up period, and 32% experienced an AAE. PAU markers of AAE were minimum depth (ranging from 9.5 to 15 mm) and diameter (≥12.5 mm). Maximum aortic diameter (MAD) cut-off values ranging from 38 to 44.75 mm were related to AAE for IMHs, together with ulcer-like projection (ULP) of the aortic wall.

Despite data heterogeneity in the literature, this PAU- and IMH-focused review has highlighted the imaging and clinical markers of disease progression, thus identifying patients that could benefit from an early intervention in order to reduce the AAE rate.

Intramural hematoma (IMH) is one of the acute aortic syndromes along with acute aortic dissection and penetrating aortic ulcer. The three conditions can occur alone or in combination with overlapping presentation. Medical, open surgical, and endovascular treatment is tailored depending on clinical presentation, timing, and location within the aorta. Among patients who present with acute IMH affecting the ascending aorta (Type A), urgent open surgical repair is considered the primary line of treatment in patients who are suitable candidates and unstable. The management of IMH in the descending aorta and aortic arch (Type B) is similar to that applied to treat acute dissections in the same segment. Medical treatment with sequential imaging is recommended in patients with uncomplicated course, and endovascular repair is indicated in patients with rupture, persistent pain, end-organ ischemia, or rapid aortic enlargement. This review discusses the ideal timing for treatment of IMH.

Acute aortic syndrome is a broad clinical entity that encompasses several pathologies. Aortic dissection is a well-studied disorder, but the other most prominent disorders within the scope of acute aortic syndrome, penetrating aortic ulcer and intramural hematoma, are more nebulous in terms of their pathophysiology and treatment strategies. While patient risk factors, presenting symptoms, and medical and surgical management strategies are similar to those of aortic dissection, there are indeed nuanced differences unique to penetrating aortic ulcer and intramural hematoma that surgeons and acute care providers must consider while managing patients with these diagnoses. The aim of this review is to summarize patient demographics, pathophysiology, workup, and treatment strategies that are unique to penetrating aortic ulcer and intramural hematoma.

Acute aortic syndromes, including aortic dissection, intramural hematoma, and penetrating aortic ulcer, are a group of highly morbid, related pathologies that are defined by compromised aortic wall integrity. The purpose of this review is to summarize current management strategies for acute aortic syndromes.

All acute aortic syndromes have potential for high morbidity and mortality and must be quickly identified and managed with the appropriate algorithm to prevent suboptimal outcomes. Recent trials suggest that TEVAR is increasingly useful in stabilizing pathology of the descending thoracic aorta but when possible should be applied in a delayed fashion and with limited coverage to minimize neurologic complications. Treatment for acute aortic syndrome is frequently dictated by the anatomic location and extent of the wall compromise as well as patient comorbidities. Therapy is often individualized and often includes some combination of medical, procedural, and surgical intervention.

The natural history and management of intramural hematoma (IMH) varies significantly worldwide. In this retrospective analysis of our institutional database, we report long-term results from medical and surgical management of types A and B IMH.

CT scan reports completed at our tertiary care hospital from July 2007 to July 2020 were used to identify patients with IMH with thickness >7mm. Those with IMH directly related to trauma, previous aortic surgery, penetrating atheromatous ulcer, dissection flap, iatrogenic source, or who never received any treatment for IMH at the time of presentation were excluded.

A total of 54 patients with IMH met inclusion and exclusion criteria. Twenty-four presented with Stanford type A: 10 were initially managed surgically and 14 were initially managed medically. Two patients in the medical group crossed over to surgery. Thirty patients presented with type B IMH and were initially managed medically, with three eventually receiving surgical intervention. In-hospital survival was 90% for type A IMH treated surgically, 93% for type A IMH treated medically, and 97% for type B IMH treated medically. At last follow-up imaging of medically managed patients, 36% of type A IMH and 31% of type B IMH patients had complete resolution of IMH at 3.7 and 31.5 months respectively, without operative intervention. Development of aortic aneurysm at the site of previous IMH was seen in 18% (2/11) and 12% (3/26) for the type A medical and type B medical cohorts; the overall rate of aortic aneurysm formation in the region of IMH or in another segment was 50%. There was no difference in long-term survival between the three cohorts at a mean follow up of 22.8 months.

There appears to be a role for medical treatment with anti-impulse therapy in appropriately selected patients with type A IMH. These patients must be followed closely clinically and radiographically for signs of deterioration in the short- and long-term phases of their care. They can achieve similar long-term survival compared with surgically treated type A IMH and medically treated type B IMH patients using this algorithm but may require late surgical intervention, especially for aneurysmal disease.