Acute aortic dissection presents with a wide range of manifestations, and classic findings are often absent. A high clinical index of suspicion is necessary. Despite recent advances, in-hospital mortality rates remain high. Our data support the need for continued improvement in prevention, diagnosis, and management of acute aortic dissection.

Simvastatin and ezetimibe did not reduce the composite outcome of combined aortic-valve events and ischemic events in patients with aortic stenosis. Such therapy reduced the incidence of ischemic cardiovascular events but not events related to aortic-valve stenosis. (ClinicalTrials.gov number, NCT00092677.)

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Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.

Conclusions: During long-term follow-up of patients with asymptomatic carotid stenosis, occlusion and stroke were more common among patients with $70% stenosis. Occlusion is an independent prognostic risk factor for stroke.Summary: In the Asymptomatic Carotid Surgery Trial (ACST), surgery significantly reduced 10-year stroke risk from 16.9% in those allocated to expected management to 10.8% in those treated with carotid endarterectomy (CEA) at the time of study entrance. Half the benefit involved disabling or fatal strokes (Halliday A et al, Lancet 2010;376:1074-84) in patients who had a contralateral occlusion at time of entrance into the ACST-1 trial (8%). There was similar benefit in the annual event rate in the immediate group (1.2%) and the deferred group (2.4%). However, no large-scale prospective studies have investigated stroke risk when high-grade carotid stenosis progresses to occlusion. The ACST-1 trial provided the opportunity to analyze the incidence of new carotid occlusion and stroke in the patients treated with expected management. In this secondary analysis of ACST-1 data, the authors sought to determine the risk of new carotid artery occlusion and associated stroke and to evaluate risk factors predisposing to development of carotid occlusion. In the ACST-1 trial, 3120 patients with high-grade asymptomatic carotid stenosis were randomly assigned to medical treatment alone or to CEA and medications. The analysis excluded 276 patients who had contralateral occlusion at trial entry or incomplete duplex follow-up. Risk of new carotid occlusion and stroke in patients with occlusion was estimated by Kaplan-Meier analysis. Cox proportional hazard regression models were used to determine risk factors for occlusion and stroke. Median follow-up in 2707 patients was 80 months (interquartile range, 52.0-115.0 months). There were new occlusions in 197 patients (1.1% per year). New occlusions were more likely to occur in arteries with tight stenosis and in nonoperated-on patients. Overall risk for stroke was 7.6% (95% confidence interval [CI], 6.6%-8.7%) and 15.5% (95% CI, 13.6%-17.4%) at 5 and 10 years, respectively. For patients with new carotid occlusion, the risk of stroke increased significantly to 17.0% (95% CI, 11.6%-22.4%) and 20.8% (95% CI, 14.1%-26.2%) at 5 and 10 years, respectively (P < .0001). Stroke was also significantly more likely to occur in patients developing occlusion (hazard ratio, 1.78; 95% CI, 1.26-2.51), irrespective of allocated treatment in the ACST-1 study.Comment: The data indicate that new carotid occlusions are infrequent in patients with asymptomatic carotid stenosis but that occlusion and stroke are more common in patients who do not undergo CEA or in whom there is a stenosis of $70% before occlusion. Occlusions occurring in patients who had CEA seemed to be associated with less risk of stroke than occlusions occurring in patients who did not undergo CEA, suggesting that improved collateral circulation within the circle of Willis may decrease the hazards of contralateral occl...