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Management of acute aortic syndrome

  • Review Article
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From Nature Reviews Cardiology

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Key Points

  • Acute aortic syndrome (AAS) groups together several severe, aortic, life-threatening conditions, which include acute aortic dissection, intramural haematoma (IMH), and penetrating aortic ulcer (PAU)

  • Aortic dissection is the most common form of AAS, followed by IMH and PAU

  • An abrupt onset of severe pain is the most important symptom the diagnosis of AAS

  • Early and accurate diagnosis of AAS is reliant on the use of CT, echocardiography, or MRI

  • The optimal treatment of patients with AAS remains a challenging clinical dilemma and further studies are required to fully characterize these conditions and design individualized, patient-centred treatment plans

Abstract

Acute aortic syndrome (AAS) encompasses a group of severe, life-threatening disorders of the aorta, including acute aortic dissection, intramural haematoma (IMH), and penetrating aortic ulcer (PAU). The concept of AAS was developed to enable the early identification and definitive treatment of patients with chest pain from an aortic origin. Aortic dissection is the most common form of AAS, followed by IMH and PAU. Congenital cardiovascular defects, genetic syndromes, and nonsyndromic genetic variants have all been linked with the development of AAS. The diagnosis of AAS in the clinic can be made using imaging modalities such as CT, echocardiography, and MRI. The initial management of patients with AAS is focussed on the control of blood pressure to reduce aortic wall stress. A multidisciplinary team is required to assess each patient and decide whether endovascular or open surgical treatment, or further medical management is indicated. The optimal treatment of patients with AAS remains a challenging clinical dilemma, and further studies are required to fully characterize conditions within the AAS spectrum and to design individualized, patient-centred treatment plans.

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Figure 1: Acute aortic syndrome: aortic dissection, intramural haematoma, and penetrating aortic ulcer.
Figure 2: Serial images from the same patient showing progression of penetrating aortic ulcer disease over a 48 h period.
Figure 3: 4D phase contrast MRI from a patient with aortic dissection.

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References

  1. Patel, P. J., Grande, W. & Hieb, R. A. Endovascular management of acute aortic syndromes. Semin. Intervent. Radiol. 28, 10–23 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  2. Brinster, D. R. Endovascular repair of the descending thoracic aorta for penetrating atherosclerotic ulcer disease. J. Card. Surg. 24, 203–208 (2009).

    Article  PubMed  Google Scholar 

  3. Cho, J. R. et al. Clinical characteristics of acute aortic syndrome in Korean patients: from the Korean multi-center registry of acute aortic syndrome. Korean Circ. J. 42, 528–537 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  4. Hagan, P. G. et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 283, 897–903 (2000).

    Article  CAS  PubMed  Google Scholar 

  5. Meszaros, I. et al. Epidemiology and clinicopathology of aortic dissection. Chest 117, 1271–1278 (2000).

    Article  CAS  PubMed  Google Scholar 

  6. Bickerstaff, L. K. et al. Thoracic aortic aneurysms: a population-based study. Surgery 92, 1103–1108 (1982).

    CAS  PubMed  Google Scholar 

  7. Clouse, W. D. et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin. Proc. 79, 176–180 (2004).

    Article  PubMed  Google Scholar 

  8. Coady, M. A. et al. Surgical management of descending thoracic aortic disease: open and endovascular approaches. A scientific statement from the American Heart Association. Circulation 121, 2780–2804 (2010).

    Article  PubMed  Google Scholar 

  9. LeMaire, S. A. & Russell, L. Epidemiology of thoracic aortic dissection. Nat. Rev. Cardiol. 8, 103–113 (2011).

    Article  PubMed  Google Scholar 

  10. Hiratzka, L. F. et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 121, e266–e369 (2010).

    PubMed  Google Scholar 

  11. Wu, D., Shen, Y. H., Russell, L., Coselli, J. S. & LeMaire, S. A. Molecular mechanisms of thoracic aortic dissection. J. Surg. Res. 184, 907–924 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Gravholt, C. H. et al. Clinical and epidemiological description of aortic dissection in Turner's syndrome. Cardiol. Young. 16, 430–436 (2006).

    Article  PubMed  Google Scholar 

  13. Matura, L. A., Ho, V. B., Rosing, D. R. & Bondy, C. A. Aortic dilatation and dissection in Turner syndrome. Circulation 116, 1663–1670 (2007).

    Article  PubMed  Google Scholar 

  14. Loeys, B. L. et al. The revised Ghent nosology for the Marfan syndrome. J. Med. Genet. 47, 476–485 (2010).

    Article  CAS  PubMed  Google Scholar 

  15. Milewicz, D. M. et al. Reduced penetrance and variable expressivity of familial thoracic aortic aneurysms/dissections. Am. J. Cardiol. 82, 474–479 (1998).

    Article  CAS  PubMed  Google Scholar 

  16. Tsai, T. T., Nienaber, C. A. & Eagle, K. A. Acute aortic syndromes. Circulation 112, 3802–3813 (2005).

    Article  PubMed  Google Scholar 

  17. Suzuki, T. et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: Lessons from the International Registry of Aortic Dissection (IRAD). Circulation 108, 312–317 (2003).

    Article  Google Scholar 

  18. von Kodolitsch, Y., Schwartz, A. G. & Nienaber, C. A. Clinical prediction of acute aortic dissection. Arch. Intern. Med. 160, 2977–2982 (2000).

    Article  CAS  PubMed  Google Scholar 

  19. Klompas, M. Does this patient have an acute thoracic aortic dissection? JAMA 287, 2262–2272 (2002).

    Article  PubMed  Google Scholar 

  20. von Kodolitsch, Y. et al. Chest radiography for the diagnosis of acute aortic syndrome. Am. J. Med. 116, 73–77 (2004).

    Article  PubMed  Google Scholar 

  21. Eggebrecht, H. et al. Value of plasma fibrin D-dimers for detection of acute aortic dissection. J. Am. Coll. Cardiol. 44, 804–809 (2004).

    Article  CAS  PubMed  Google Scholar 

  22. Suzuki, T. et al. Diagnosis of acute aortic dissection by D-dimer: the International Registry of Acute Aortic Dissection Substudy on Biomarkers (IRAD-Bio) experience. Circulation 119, 2702–2707 (2009).

    Article  PubMed  Google Scholar 

  23. Gonsalves, C. F. The hyperattenuating crescent sign. Radiology 211, 37–38 (1999).

    Article  CAS  PubMed  Google Scholar 

  24. Evangelista, A. et al. Acute intramural hematoma of the aorta: a mystery in evolution. Circulation 111, 1063–1070 (2005).

    Article  PubMed  Google Scholar 

  25. Evangelista, A. et al. Imaging modalities for the early diagnosis of acute aortic syndrome. Nat. Rev. Cardiol. 10, 477–486 (2013).

    Article  PubMed  Google Scholar 

  26. Becker, H. C. & Johnson, T. Cardiac CT for the assessment of chest pain: imaging techniques and clinical results. Eur. J. Radiol. 81, 3675–3679 (2012).

    Article  PubMed  Google Scholar 

  27. Ketelsen, D. et al. Estimation of radiation exposure of retrospective gated and prospective triggered 128-slice triple-rule-out CT angiography. Acta. Radiol. 52, 762–766 (2011).

    Article  PubMed  Google Scholar 

  28. Troxler, M., Mavor, A. I. & Homer-Vanniasinkam, S. Penetrating atherosclerotic ulcers of the aorta. Br. J. Surg. 88, 1169–1177 (2001).

    Article  CAS  PubMed  Google Scholar 

  29. Tumlin, J. et al. Pathophysiology of contrast-induced nephropathy. Am. J. Cardiol. 98, 14K–20K (2006).

    Article  CAS  PubMed  Google Scholar 

  30. Martin, D. R. & Semelka, R. C. Health effects of ionising radiation from diagnostic CT. Lancet 367, 1712–1714 (2006).

    Article  PubMed  Google Scholar 

  31. Pearce, M. S. et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 380, 499–505 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  32. Ueda, T., Chin, A., Petrovitch, I. & Fleischmann, D. A pictorial review of acute aortic syndrome: discriminating and overlapping features as revealed by ECG-gated multidetector-row CT angiography. Insights Imaging 3, 561–571 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  33. Nienaber, C. A. The role of imaging in acute aortic syndromes. Eur. Heart. J. Cardiovasc. Imaging 14, 15–23 (2013).

    Article  PubMed  Google Scholar 

  34. Baliga, R. R. et al. The role of imaging in aortic dissection and related syndromes. JACC Cardiovasc. Imaging 7, 406–424 (2014).

    Article  PubMed  Google Scholar 

  35. Cecconi, M. et al. The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome. Am. Heart J. 163, 112–118 (2012).

    Article  PubMed  Google Scholar 

  36. Nienaber, C. A. et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N. Engl. J. Med. 328, 1–9 (1993).

    Article  CAS  PubMed  Google Scholar 

  37. Erbel, R. et al. Diagnosis and management of aortic dissection. Eur. Heart J. 22, 1642–1681 (2001).

    Article  CAS  PubMed  Google Scholar 

  38. Sommer, T. et al. Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging. Radiology 199, 347–352 (1996).

    Article  CAS  PubMed  Google Scholar 

  39. Evangelista, A. et al. Diagnosis of ascending aortic dissection by transesophageal echocardiography: utility of M-mode in recognizing artifacts. J. Am. Coll. Cardiol. 27, 102–107 (1996).

    Article  CAS  PubMed  Google Scholar 

  40. Penco, M. et al. Usefulness of transesophageal echocardiography in the assessment of aortic dissection. Am. J. Cardiol. 86, 53G–56G (2000).

    Article  CAS  PubMed  Google Scholar 

  41. Erbel, R. et al. Effect of medical and surgical therapy on aortic dissection evaluated by transesophageal echocardiography. Implications for prognosis and therapy. The European Cooperative Study Group on Echocardiography. Circulation 87, 1604–1615 (1993).

    Article  CAS  PubMed  Google Scholar 

  42. Shiga, T., Wajima, Z., Apfel, C. C., Inoue, T. & Ohe, Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch. Intern. Med. 166, 1350–1356 (2006).

    Article  PubMed  Google Scholar 

  43. Russo, V., Renzulli, M., Buttazzi, K. & Fattori, R. Acquired diseases of the thoracic aorta: role of MRI and MRA. Eur. Radiol. 16, 852–865 (2006).

    Article  PubMed  Google Scholar 

  44. Kramer, C. M., Barkhausen, J., Flamm, S. D., Kim, R. J. & Nagel, E. Standardized cardiovascular magnetic resonance (CMR) protocols 2013 update. J. Cardiovasc. Magn. Reson. 15, 91 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  45. Murray, J. G. et al. Intramural hematoma of the thoracic aorta: MR image findings and their prognostic implications. Radiology 204, 349–355 (1997).

    Article  CAS  PubMed  Google Scholar 

  46. Clough, R. E., Waltham, M., Giese, D., Taylor, P. R. & Schaeffter, T. A new imaging method for assessment of aortic dissection using four-dimensional phase contrast magnetic resonance imaging. J. Vasc. Surg. 55, 914–923 (2012).

    Article  PubMed  Google Scholar 

  47. Shimony, A., Filion, K. B., Mottillo, S., Dourian, T. & Eisenberg, M. J. Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection. Am. J. Cardiol. 107, 1227–1234 (2011).

    Article  CAS  PubMed  Google Scholar 

  48. Newby, L. K. et al. ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J. Am. Coll. Cardiol. 60, 2427–2463 (2012).

    Article  PubMed  Google Scholar 

  49. Parolari, A. et al. Biological features of thoracic aortic diseases. Where are we now, where are we heading to: established and emerging biomarkers and molecular pathways. Eur. J. Cardiothorac. Surg. 44, 9–23 (2013).

    Article  PubMed  Google Scholar 

  50. Milewicz, D. M. et al. Fibrillin-1 (FBN1) mutations in patients with thoracic aortic aneurysms. Circulation 94, 2708–2711 (1996).

    Article  CAS  PubMed  Google Scholar 

  51. Marshall, L. M. et al. Thoracic aortic aneurysm frequency and dissection are associated with fibrillin-1 fragment concentrations in circulation. Circ. Res. 113, 1159–1168 (2013).

    Article  CAS  PubMed  Google Scholar 

  52. Makita, S. et al. Behavior of C-reactive protein levels in medically treated aortic dissection and intramural hematoma. Am. J. Cardiol. 86, 242–244 (2000).

    Article  CAS  PubMed  Google Scholar 

  53. Schillinger, M. et al. C-reactive protein and mortality in patients with acute aortic disease. Intensive Care Med. 28, 740–745 (2002).

    Article  PubMed  Google Scholar 

  54. Nomura, F. et al. Changes in coagulation condition, cytokine, adhesion molecule after repair of type A aortic dissection. Eur. J. Cardiothorac. Surg. 26, 348–350 (2004).

    Article  CAS  PubMed  Google Scholar 

  55. Iyano, K., Kawada, T., Aiba, M. & Takaba, T. Correlation of hemostatic molecular markers and morphology of the residual false lumen in chronic aortic dissection. Ann. Thorac. Cardiovasc. Surg. 10, 106–112 (2004).

    PubMed  Google Scholar 

  56. Shinohara, T. et al. Soluble elastin fragments in serum are elevated in acute aortic dissection. Arterioscler. Thromb. Vasc. Biol. 23, 1839–1844 (2003).

    Article  CAS  PubMed  Google Scholar 

  57. Kodama, K. et al. Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection. Circulation 118, S167–S170 (2008).

    Article  PubMed  Google Scholar 

  58. Feldman, M., Shah, M. & Elefteriades, J. A. Medical management of acute type A aortic dissection. Ann. Thorac. Cardiovasc. Surg. 15, 286–293 (2009).

    PubMed  Google Scholar 

  59. Raymond, C. E. et al. Prevalence and factors associated with false positive suspicion of acute aortic syndrome: experience in a patient population transferred to a specialized aortic treatment center. Cardiovasc. Diagn. Ther. 3, 196–204 (2013).

    PubMed  PubMed Central  Google Scholar 

  60. Landon, B. E., O'Malley, A. J., Giles, K., Cotterill, P. & Schermerhorn, M. L. Volume-outcome relationships and abdominal aortic aneurysm repair. Circulation 122, 1290–1297 (2010).

    Article  PubMed  Google Scholar 

  61. Holt, P. J. et al. Provider volume and long-term outcome after elective abdominal aortic aneurysm repair. Br. J. Surg. 99, 666–672 (2012).

    Article  CAS  PubMed  Google Scholar 

  62. Nienaber, C. A. et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ. Cardiovasc. Interv. 6, 407–416 (2013).

    Article  CAS  PubMed  Google Scholar 

  63. DeBakey, M. E. et al. Surgical management of dissecting aneurysms of the aorta. J. Thorac. Cardiovasc. Surg. 49, 130–149 (1965).

    CAS  PubMed  Google Scholar 

  64. Daily, P. O., Trueblood, H. W., Stinson, E. B., Wuerflein, R. D. & Shumway, N. E. Management of acute aortic dissections. Ann. Thorac. Surg. 10, 237–247 (1970).

    Article  CAS  PubMed  Google Scholar 

  65. Hirst, A. E. Jr, Johns, V. J. Jr & Kime, S. W. Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore) 37, 217–279 (1958).

    Article  Google Scholar 

  66. Booher, A. M. et al. The IRAD classification system for characterizing survival after aortic dissection. Am. J. Med. 126, 730.e19–24 (2013).

    Article  Google Scholar 

  67. Dake, M. D., Thompson, M., van Sambeek, M., Vermassen, F. & Morales, J. P. DISSECT: a new mnemonic-based approach to the categorization of aortic dissection. Eur. J. Vasc. Endovasc. Surg. 46, 175–190 (2013).

    Article  CAS  PubMed  Google Scholar 

  68. Fattori, R. et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J. Am. Coll. Cardiol. 61, 1661–1678 (2013).

    Article  PubMed  Google Scholar 

  69. Fattori, R. et al. Complicated acute type B dissection: is surgery still the best option?: a report from the International Registry of Acute Aortic Dissection. JACC Cardiovasc. Interv. 1, 395–402 (2008).

    Article  PubMed  Google Scholar 

  70. Estrera, A. L. et al. Outcomes of medical management of acute type B aortic dissection. Circulation 114, I384–I389 (2006).

    Article  PubMed  Google Scholar 

  71. Nienaber, C. A. & Powell, J. T. Management of acute aortic syndromes. Eur. Heart J. 33, 26b–35b (2012).

    Article  Google Scholar 

  72. Onitsuka, S. et al. Long-term outcome and prognostic predictors of medically treated acute type B aortic dissections. Ann. Thorac. Surg. 78, 1268–1273 (2004).

    Article  PubMed  Google Scholar 

  73. Tsai, T. T. et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N. Engl. J. Med. 357, 349–359 (2007).

    Article  CAS  PubMed  Google Scholar 

  74. Clough, R. E. et al. A new method for quantification of false lumen thrombosis in aortic dissection using magnetic resonance imaging and a blood pool contrast agent. J. Vasc. Surg. 54, 1251–1258 (2011).

    Article  PubMed  Google Scholar 

  75. Qin, Y. L., Deng, G., Li, T. X., Jing, R. W. & Teng, G. J. Risk factors of incomplete thrombosis in the false lumen after endovascular treatment of extensive acute type B aortic dissection. J. Vasc. Surg. 56, 1232–1238 (2012).

    Article  PubMed  Google Scholar 

  76. Kato, M. et al. Determining surgical indications for acute type B dissection based on enlargement of aortic diameter during the chronic phase. Circulation 92, 107–112 (1995).

    Article  Google Scholar 

  77. Marui, A. et al. Toward the best treatment for uncomplicated patients with type B acute aortic dissection: A consideration for sound surgical indication. Circulation 100, 275–280 (1999).

    Article  Google Scholar 

  78. Song, J. M. et al. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. J. Am. Coll. Cardiol. 50, 799–804 (2007).

    Article  PubMed  Google Scholar 

  79. Trimarchi, S. et al. Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 122, 1283–1289 (2010).

    Article  PubMed  Google Scholar 

  80. Evangelista, A. et al. Long-term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and location. Circulation 125, 3133–3141 (2012).

    Article  PubMed  Google Scholar 

  81. Jonker, F. H. et al. Aortic expansion after acute type B aortic dissection. Ann. Thorac. Surg. 94, 1223–1229 (2012).

    Article  PubMed  Google Scholar 

  82. Karmonik, C. et al. Computational study of haemodynamic effects of entry- and exit-tear coverage in a DeBakey type III aortic dissection: technical report. Eur. J. Vasc. Endovasc. Surg. 42, 172–177 (2011).

    Article  CAS  PubMed  Google Scholar 

  83. Alimohammadi, M., Agu, O., Balabani, S. & Diaz-Zuccarini, V. Development of a patient-specific simulation tool to analyse aortic dissections: assessment of mixed patient-specific flow and pressure boundary conditions. Med. Eng. Phys. 36, 275–284 (2014).

    Article  PubMed  Google Scholar 

  84. Sabik, J. F. et al. Long-term effectiveness of operations for ascending aortic dissections. J. Thorac. Cardiovasc. Surg. 119, 946–962 (2000).

    Article  CAS  PubMed  Google Scholar 

  85. Metcalfe, M. J. et al. The first endovascular repair of an acute type A dissection using an endograft designed for the ascending aorta. J. Vasc. Surg. 55, 220–222 (2012).

    Article  PubMed  Google Scholar 

  86. Sobocinski, J. et al. Endovascular approaches to acute aortic type A dissection: a CT-based feasibility study. Eur. J. Vasc. Endovasc. Surg. 42, 442–447 (2011).

    Article  CAS  PubMed  Google Scholar 

  87. Lyons, O. et al. Endovascular management of Stanford type a dissection or intramural hematoma with a distal primary entry tear. J. Endovasc. Ther. 18, 591–600 (2011).

    Article  PubMed  Google Scholar 

  88. Tsai, T. T. et al. Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection. Circulation 114, 2226–2231 (2006).

    Article  PubMed  Google Scholar 

  89. Acosta, S., Blomstrand, D. & Gottsater, A. Epidemiology and long-term prognostic factors in acute type B aortic dissection. Ann. Vasc. Surg. 21, 415–422 (2007).

    Article  CAS  PubMed  Google Scholar 

  90. Estrera, A. L. et al. Preoperative and operative predictors of delayed neurologic deficit following repair of thoracoabdominal aortic aneurysm. J. Thorac. Cardiovasc. Surg. 126, 1288–1294 (2003).

    Article  PubMed  Google Scholar 

  91. Safi, H. J. et al. Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair. Ann. Thorac. Surg. 80, 2173–2179 (2005).

    Article  PubMed  Google Scholar 

  92. Tsai, T. T. et al. Long-term survival in patients presenting with type B acute aortic dissection: Insights from the International Registry of Acute Aortic Dissection. Circulation 114, 2226–2231 (2006).

    Article  PubMed  Google Scholar 

  93. Svensson, L. G. et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann. Thorac. Surg. 85, S1–S41 (2008).

    Article  PubMed  Google Scholar 

  94. Dake, M. D. et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N. Engl. J. Med. 340, 1546–1552 (1999).

    Article  CAS  PubMed  Google Scholar 

  95. Nienaber, C. A. et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N. Engl. J. Med. 340, 1539–1545 (1999).

    Article  CAS  PubMed  Google Scholar 

  96. Jones, D. W. et al. National trends in utilization, mortality, and survival after repair of type B aortic dissection in the Medicare population. J. Vasc. Surg. 60, 11–19 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  97. Parker, J. D. & Golledge, J. Outcome of endovascular treatment of acute type B aortic dissection. Ann. Thorac. Surg. 86, 1707–1712 (2008).

    Article  PubMed  Google Scholar 

  98. Brunkwall, J., Kasprzak, P., Verhoeven, E., Heijmen, R. & Taylor, P. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur. J. Vasc. Endovasc. Surg. (2014).

  99. Lombardi, J. V. et al. Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design. J. Vasc. Surg. 55, 629–640 (2012).

    Article  PubMed  Google Scholar 

  100. Lombardi, J. V. et al. Aortic remodeling after endovascular treatment of complicated type B aortic dissection with the use of a composite device design. J. Vasc. Surg. 59, 1544–1554 (2014).

    Article  PubMed  Google Scholar 

  101. Kolbel, T. et al. Addressing persistent false lumen flow in chronic aortic dissection: the knickerbocker technique. J. Endovasc. Ther. 21, 117–122 (2014).

    Article  PubMed  Google Scholar 

  102. Knowles, M. et al. The effects of operative indication and urgency of intervention on patient outcomes after thoracic aortic endografting. J. Vasc. Surg. 53, 926–934 (2011).

    Article  PubMed  Google Scholar 

  103. Vilacosta, I. et al. Acute aortic syndrome: a new look at an old conundrum. Heart 95, 1130–1139 (2009).

    CAS  PubMed  Google Scholar 

  104. Knollmann, F. D., Lacomis, J. M., Ocak, I. & Gleason, T. The role of aortic wall CT attenuation measurements for the diagnosis of acute aortic syndromes. Eur. J. Radiol. 82, 2392–2398 (2013).

    Article  PubMed  Google Scholar 

  105. Kitai, T. et al. Detection of intimal defect by 64-row multidetector computed tomography in patients with acute aortic intramural hematoma. Circulation 124, S174–S178 (2011).

    Article  PubMed  Google Scholar 

  106. Kitai, T. et al. Clinical outcomes of medical therapy and timely operation in initially diagnosed type A aortic intramural hematoma: a 20-year experience. Circulation 120, S292–S298 (2009).

    Article  PubMed  Google Scholar 

  107. Song, J. K. et al. Outcomes of patients with acute type A aortic intramural hematoma. Circulation 120, 2046–2052 (2009).

    Article  PubMed  Google Scholar 

  108. Ganaha, F. et al. Prognosis of aortic intramural hematoma with and without penetrating atherosclerotic ulcer: a clinical and radiological analysis. Circulation 106, 342–348 (2002).

    Article  PubMed  Google Scholar 

  109. Kaji, S. et al. Long-term prognosis of patients with type B aortic intramural hematoma. Circulation 108 (Suppl 1), 307–311 (2003).

    Google Scholar 

  110. Sueyoshi, E. et al. New development of an ulcerlike projection in aortic intramural hematoma: CT evaluation. Radiology 224, 536–541 (2002).

    Article  PubMed  Google Scholar 

  111. Robbins, R. C. et al. Management of patients with intramural hematoma of the thoracic aorta. Circulation 88, 1–10 (1993).

    Google Scholar 

  112. Tittle, S. L. et al. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta. J. Thorac. Cardiovasc. Surg. 123, 1051–1059 (2002).

    Article  PubMed  Google Scholar 

  113. Song, J. K. et al. Outcomes of medically treated patients with aortic intramural hematoma. Am. J. Med. 113, 181–187 (2002).

    Article  PubMed  Google Scholar 

  114. Maraj, R., Rerkpattanapipat, P., Jacobs, L. E., Makornwattana, P. & Kotler, M. N. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am. J. Cardiol. 86, 664–668 (2000).

    Article  CAS  PubMed  Google Scholar 

  115. von Kodolitsch, Y. et al. Intramural hematoma of the aorta: predictors of progression to dissection and rupture. Circulation 107, 1158–1163 (2003).

    Article  PubMed  Google Scholar 

  116. Nienaber, C. A. et al. Intramural hemorrhage of the thoracic aorta. Diagnostic and therapeutic implications. Circulation 92, 1465–1472 (1995).

    Article  CAS  PubMed  Google Scholar 

  117. Kan, C. B., Chang, R. Y. & Chang, J. P. Optimal initial treatment and clinical outcome of type A aortic intramural hematoma: a clinical review. Eur. J. Cardiothorac. Surg. 33, 1002–1006 (2008).

    Article  PubMed  Google Scholar 

  118. Ho, H. H. et al. Type A aortic intramural hematoma: clinical features and outcomes in Chinese patients. Clin. Cardiol. 34, E1–E5 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  119. Estrera, A. et al. Acute type A intramural hematoma: analysis of current management strategy. Circulation 120, S287–S291 (2009).

    Article  PubMed  Google Scholar 

  120. Li, D. L. et al. Acute type B aortic intramural hematoma: treatment strategy and the role of endovascular repair. J. Endovasc. Ther. 17, 617–621 (2010).

    Article  PubMed  Google Scholar 

  121. Lavingia, K. S., Ahanchi, S. S., Redlinger, R. E., Udgiri, N. R. & Panneton, J. M. Aortic remodeling after thoracic endovascular aortic repair for intramural hematoma. J. Vasc. Surg. 60, 929–936 (2014).

    Article  PubMed  Google Scholar 

  122. White, C. et al. Endovascular treatment of an acute ascending aortic intramural hematoma. Int. J. Surg. Case Rep. 5, 126–128 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  123. D'Ancona, G. et al. Haemodynamic predictors of a penetrating atherosclerotic ulcer rupture using fluid-structure interaction analysis. Interact. Cardiovasc. Thorac. Surg. 17, 576–578 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  124. Stanson, A. W. et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann. Vasc. Surg. 1, 15–23 (1986).

    Article  CAS  PubMed  Google Scholar 

  125. Quint, L. E. et al. Ulcer-like lesions of the aorta: imaging features and natural history. Radiology 218, 719–723 (2001).

    Article  CAS  PubMed  Google Scholar 

  126. Nathan, D. P. et al. Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease. J. Vasc. Surg. 55, 10–15 (2012).

    Article  PubMed  Google Scholar 

  127. Cho, K. R. et al. Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch. J. Thorac. Cardiovasc. Surg. 127, 1393–1401 (2004).

    Article  PubMed  Google Scholar 

  128. Botta, L. et al. Endovascular repair for penetrating atherosclerotic ulcers of the descending thoracic aorta: early and mid-term results. Ann. Thorac. Surg. 85, 987–992 (2008).

    Article  PubMed  Google Scholar 

  129. Coady, M. A., Rizzo, J. A. & Elefteriades, J. A. Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas. Cardiol. Clin. 17, 637–657 (1999).

    Article  CAS  PubMed  Google Scholar 

  130. Coady, M. A. et al. Penetrating ulcer of the thoracic aorta: what is it? How do we recognize it? How do we manage it? J. Vasc. Surg. 27, 1006–1016 (1998).

    Article  CAS  PubMed  Google Scholar 

  131. Eggebrecht, H. et al. Endovascular stent-graft treatment of penetrating aortic ulcer: results over a median follow-up of 27 months. Am. Heart J. 151, 530–536 (2006).

    Article  PubMed  Google Scholar 

  132. Clough, R. E. et al. Endovascular treatment of acute aortic syndrome. J. Vasc. Surg. 54, 1580–1587 (2011).

    Article  PubMed  Google Scholar 

  133. Scali, S. T. et al. Pathology-specific secondary aortic interventions after thoracic endovascular aortic repair. J. Vasc. Surg. 59, 599–607 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  134. Clough, R. E. et al. Pathology specific early outcome after thoracic endovascular aortic repair. Eur. J. Vasc. Endovasc. Surg. (2014).

  135. National Institute for Health and Care Excellence (NICE). Endovascular stent—graft placement in thoracic aortic aneurysms and dissections. Interventional Procedure Guidance 127 [online], (2005).

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Acknowledgements

R.E.C. is supported by the Academy of Medical Sciences through funding from the Wellcome Trust, Medical Research Council UK, and British Heart Foundation.

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Authors and Affiliations

  1. Department of Vascular Surgery, Division of Imaging Sciences, National Institute for Health Research Biomedical Research Centre of Guy's and St Thomas' National Health Service Foundation Trust and King's College London, London, SE1 7EH, UK

    Rachel E. Clough

  2. Department of Internal Medicine I, Divisions of Cardiology, Pulmonology and Intensive Care Medicine, Heart Centre Rostock, Rostock School of Medicine, University Hospital Rostock, Ernst-Heydemann-Strasse 6, Rostock, 18057, Germany

    Christoph A. Nienaber

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  1. Rachel E. Clough
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Both authors contributed equally to researching data for the article, discussion of content, writing, editing, and reviewing the manuscript before submission.

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Correspondence to Christoph A. Nienaber.

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Clough, R., Nienaber, C. Management of acute aortic syndrome. Nat Rev Cardiol 12, 103–114 (2015). https://doi.org/10.1038/nrcardio.2014.203

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