Evaluating the diagnostic accuracy of maximal aortic diameter, length and volume for prediction of aortic dissection
Samuel HeutsBouke P. AdriaansBartosz RylskiCasper MihlSebastiaan C.A.M. BekkersJules R. OlsthoornEhsan NatourHeleen J. BoumanMikołaj BerezowskiKinga KosiorowskaHarry J.G.M. CrijnsJos G. MaessenJoachim E. WildbergerSimon SchallaPeyman Sardari Nia
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Management of thoracic aortic aneurysms (TAAs) comprises regular diameter follow-up until the indication criterion for prophylactic surgery is reached. However, this approach is unable to predict the majority of acute type A aortic dissections (ATAADs). The current study aims to evaluate the diagnostic accuracy of ascending aortic diameter, length and volume for occurrence of ATAAD.This two-centre observational cohort study retrospectively screened 477 consecutive patients who presented with ATAAD between 2009 and 2018. Of those, 25 (5.2%) underwent CT angiography (CTA) within 2 years before dissection onset. Aortic diameter, length and volume of these patients ('pre-ATAAD') were compared with those of TAA controls (n=75). Receiver operating curve analysis was performed to evaluate the predictive accuracy of the three different measurements.96% of patients with pre-ATAAD did not meet the surgical diameter threshold of 55 mm before dissection onset. Maximal aortic diameters (45 (40-49) mm vs 46 (44-49) mm, p=0.075) and volume (126 (95-157) cm3 vs 124 (102-136) cm3, p=0.909) were comparable between patients with pre-ATAAD and TAA controls. Conversely, ascending aortic length (84±9 mm vs 90±16 mm, p=0.031) was significantly larger in patients with pre-ATAAD. All three parameters had an area under the curve of >0.800. At the 55 mm cut-off point, the maximal diameter yielded a positive predictive value (PPV) of 20%. While maintaining same specificity levels, measurements of aortic volume and length showed superior diagnostic accuracy (PPV 55% and 70%, respectively).Measurements of aortic volume and length have superior diagnostic accuracy compared with the maximal diameter and could improve the timely identification of patients at risk for ATAAD.Acute aortic syndrome
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ABSTRACT. Dissection of the aorta is very rare in children, but classically occurs in the presence of Marfan syndrome or other connective tissue disorder. We present a case of spontaneous dissection in a 12‐year‐old boy whose half brother has an idiopathic dilated aorta and whose mother has also required surgery for dissection of a dilated aorta. No features of connective tissue disorder were present in any family member.
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Acute aortic dissection is an uncommon disorder which can have fatal results in the event of treatment delay or misdiagnosis. This case examines a 77-year-old woman presenting with chest pain relieved by nitroglycerin. She was referred to the emergency room with clinical suspicion of acute coronary syndrome (ACS). However, she was later diagnosed with acute aortic dissection and an emergency operation was performed with successful recovery. Aortic dissection may manifest in various ways depending on the site involved and may mimic other disorders such as ACS or pulmonary embolism. Therefore, clinicians must always be aware of aortic dissection and its different clinical manifestations must be understood. Keywords: Aortic Dissection; Acute Coronary Syndrome; Chest Pain; Diagnosis; Symptom
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Aortic dissection most often presents with the severe chest pain and may have variable symptoms including fever. However, fever of unknown origin as the predominant manifestation of aortic dissection seems to be extremely rare. We report the case of a patient who sustained a prolonged spiking fever with unknown origin for 17 days following acute aortic dissection. The case serves as a reminder that prolonged fever may be the principal residual sequelae after aortic dissection.
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Aortic dissection can be a fatal disease and its biomechanics is still unclear. A full study of the dissection of healthy porcine aortas was carried out via two different experimental tests. The study includes the dissection of all layers through different locations of the aorta.
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Angiotensin II-infused ApoE-/- mice are a popular model for aortic aneurysm and
dissection. We have recently demonstrated that the thoraco-abdominal lesions in these
mice start with a medial tear near the ostia of celiac and mesenteric arteries. Given the
location-specific nature of the disease, we hypothesized that the local mechanical
equilibrium may drive disease initiation [1]. In order to investigate this hypothesis we
subsequently developed a novel computational approach to evaluate the in-vivo strain
field in the abdominal aorta. Combining ex vivo synchrotron images with in vivo micro-
CT, we incorporated model features such as non-uniform aortic wall thickness, nonuniform
stretch field and the inclusion of small aortic side branches into our
computational models and showed how these often overlooked features impact the
location of hotspots in the computed strain field [2]. In our current work we validate
these simulations with image-guided histology in order to investigate whether regions
of high strain collocate with sites of micro-structural. N=10 ApoE-/- mice were infused
with Angiotensin-II for 3 days and subsequently underwent a contrast-enhanced micro-
CT scan prior to euthanasia. The aorta was imaged ex-vivo using high-resolution Phasecontrast
X-Ray Microscopy (PCXTM) at 6.5 um isotropic resolution. The same protocol
was followed for n=6 saline-infused controls. An in-house automated framework was
implemented to morph the non-pressurized non-stretched ex-vivo PCXTM geometry
onto the pressurized stretched in-vivo micro-CT geometry [2]. For each animal the
output was a mouse-specific structural finite element simulation. Contrast agent
infiltration in the aortic wall was used to detect the location of micro-ruptures in the
tunica media [1] and image-guided histology was performed to validate and quantify
the vascular damage. Preliminary results show good agreement between hotspots of
early vascular damage and hotspots of computed maximal strain. The highest strain
values occurred invariably in the vicinity of the celiac and mesenteric arteries and
collocated with intramural micro-ruptures and leukocyte infiltration. Moreover, the intersubject
variability of the maximal strain locations (cranial/caudal or right/left of the
ostium) corresponded qualitatively to the inter-subject variability of PCXTM-detected
contrast agent leakage. We conclude that strain concentrations near side branches may
play an important role in disease initiation and could partially explain the focal nature
of the disease.
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Acute aortic dissection is an emergency condition that is often missed during initial assessment. Delay in diagnosis increases mortality, but the presentation can mimic several more common conditions. Emergency practitioners must maintain a high index of suspicion in patients who present with chest or back pain and ensure timely diagnostic testing and interpretation of results if aortic dissection is suspected.
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