How Does the Ascending Aorta Geometry Change When It Dissects?

Rylski, Bartosz; Blanke, Philipp; Beyersdorf, Friedhelm; Desai, Nimesh D.; Milewski, Rita K.; Siepe, Matthias; Kari, Fabian A.; Czerny, Martin; Carrel, Thierry; Schlensak, Christian; Krüger, Tobias; Mack, Michael J.; Brinkman, William T.; Mohr, Friedrich W.; Etz, Christian D.; Luehr, Maximilian; Bavaria, Joseph E.

doi:10.1016/j.jacc.2013.12.028

Cited by 200 publications

(128 citation statements)

References 22 publications

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“…Interestingly, Rylski et al [17] recently looked at type A dissections in patients who had available CT scan imaging up to 2 years prior to dissection. In 27 patients with spontaneous dissections, the average size of the mid-ascending aorta 2 years before it dissected was 4.3 cm; but this diameter changed to an average of 5.2 cm at the time of dissection.…”

Section: Discussionmentioning

confidence: 99%

Aortic Size Distribution in the General Population: Explaining the Size Paradox in Aortic Dissection

Paruchuri¹,

Salhab

Kuzmik³

et al. 2015

Cardiology

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Background: Current guidelines recommend a diameter of 5-5.5 cm as the threshold for surgery on the ascending aorta. However, a study from the International Registry of Acute Aortic Dissection showed that nearly 60% occurred at <5.5 cm (the ‘aortic size paradox') - leading to a debate whether the size threshold should be lowered. However, the study showing dissection at small size had no knowledge of the population at risk. Herein, we aim to calculate the relative risk of aortic dissection at sizes <5.5 cm by analyzing both the number of occurring dissections (numerator) and the population at risk at each aortic size (denominator). Methods: Using a publicly available database of 3,573 multiethnic subjects (46% male, mean age 60.7 years) from the general population, we plotted a distribution curve of ascending aortic size (by magnetic resonance imaging). The relative risk of aortic dissection was calculated by dividing the proportion of dissections occurring at each size (numerator) by the proportion of aortas of that same size in the general population (denominator). Results: The mean ascending aortic diameter of the reference population was 3.2 cm (±0.4 cm). The largest diameter was 4.9 cm in women and 5.0 cm in men. The proportion of subjects with an aorta <3.5 cm was 79.2%, that of subjects with 3.5-3.9 cm was 18.0%, that of subjects with 4.0-4.4 cm was 2.6%, and that of subjects with ≥4.5 cm was 0.22%. The relative risk of dissection in those categories was found to be 0.055, 2.5, 4.9, and 346.8, respectively. Patients with an aorta ≥4.5 cm were 6,305 times more likely to suffer aortic dissection than those with an aorta <3.5 cm. Conclusions: The normal aorta is deceptively small, most commonly <3.5 cm. The aortic size paradox is a byproduct of the very large number of patients in small size ranges. This study fully supports current recommendations for surgical intervention at 5-5.5 cm.

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Section: Discussionmentioning

confidence: 99%

Aortic Size Distribution in the General Population: Explaining the Size Paradox in Aortic Dissection

Paruchuri¹,

Salhab

Kuzmik³

et al. 2015

Cardiology

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“…The approach in these cases is controversial. Some observational studies have warned about the risk of acute aortic complications in these patients (5)(6)(7). According to them, rupture and/or dissection of the AA are frequent after isolated valve surgery, and they often appear in patients with an AA size lower than indicated for replacement.…”

Section: Review Articlementioning

confidence: 99%

Wrapping of the ascending aorta revisited—is there any role left for conservative treatment of ascending aortic aneurysm?

González-Santos

Arnáiz-García

2017

J. Thorac. Dis.

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Dilatation of the ascending aorta (AA) is a common finding in patients with aortic valve disease.The clinical practice guidelines recommend replacing the AA whenever the diameter exceeds 45 mm.However, no consensus has been reached regarding the approach when the aorta is only moderately dilated.Although the risk in aorta replacement is generally low, it may be higher when associated with other complex surgical procedures or it is carried out in elderly patients or patients with significant comorbidity. This would justify the use of alternative surgical techniques, which reduce surgical risk and guarantee a durable correction of the aortic pathology. Conservative treatment of aneurysms of the AA via wrapping with different synthetic materials has been implemented for many years. The most commonly used technical variant is wrapping the dilated aorta with a vascular prosthesis with a predetermined diameter. When this technique is adequately applied, it immediately reduces the diameter of the AA and, to a lesser degree, the diameter of the aortic root and arch, while at the same time it reinforces the weak aortic wall. These effects lead to a drop-in wall shear stress and in the risk of aortic dissection and rupture, and persist over time. Although the low elasticity of the external support causes significant changes in the histologic structure of the aortic wall, mainly atrophy and alterations typical of a foreign body-induced reaction, this does not seem to involve a higher risk of complications. In some selected patients, this technique may be used in cases other than post-stenotic aortopathy, and also in aortas with a larger diameter.

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“…Appropriate evaluation required consideration of the change in position of the descending aorta to the caudal and cranial direction. Rylski et al also investigated the change in centerline length of the descending aorta after dissection 14. They found that centerline length changed from 253.3 to 261.3 mm, with a change of less than 10 mm, which also appeared to be negligible.…”

Section: Discussionmentioning

confidence: 99%

Equations for Estimating the Predissected Diameter of the Descending Aorta From Computed Tomographic Images at the Onset of Aortic Dissection

Yamauchi

Masai

Takano

et al. 2018

JAHA

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BackgroundEstimation of the predissected descending aortic diameter is important for deciding on the size of a stent graft in cases of acute aortic dissection. However, no equations for estimating this diameter have been previously reported.Methods and ResultsWe developed and validated new equations by investigating computed tomography images that were scanned within 3 years before dissection and those that were scanned immediately after the onset of dissection. Among 1127 patients with acute aortic dissection (425 type A and 702 type B), 36 were matched for the study from October 2005 to March 2017 at 4 centers. New equations were developed in 17 patients and validated in 19 patients. We measured the predissected whole circumference length (CL) and postdissected whole CL, true lumen CL, the major diameter, and the minor diameter of the acutely dissected aorta, followed by calculation of (post‐trueCL+post‐wholeCL)/2 and (post–major diameter+post—minor diameter)/2. Six equations (linear function) and modified equations were derived from each of the above‐mentioned parameters. In the derivation sets, equations that used the parameter of (post‐trueCL+post‐wholeCL)/2 were strongly correlated with pre‐wholeCL (Y=0.9433x+5.0147; R 2=0.9001) and showed significantly less bias compared with the other 5 equations (P<0.0001). In validation sets using this equation, the mean bias of the circumference length and diameter was 2.7±2.8 and 0.85±0.89 mm, respectively. A total of 99.2% of the calculated values were within 3 mm in diameter or less.ConclusionsOur newly developed equations can be used to calculate the predissected aortic diameter in cases of acute aortic dissection and might help to decide the size of the stent graft.

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How Does the Ascending Aorta Geometry Change When It Dissects?

Abstract: Geometry of the thoracic aorta is affected by aortic dissection, leading to an increase in diameter that is most pronounced in the ascending aorta. Both spontaneous and retrograde dissection result in similar aortic geometry changes.

Cited by 200 publications

References 22 publications

Aortic Size Distribution in the General Population: Explaining the Size Paradox in Aortic Dissection

Aortic Size Distribution in the General Population: Explaining the Size Paradox in Aortic Dissection

Wrapping of the ascending aorta revisited—is there any role left for conservative treatment of ascending aortic aneurysm?

Equations for Estimating the Predissected Diameter of the Descending Aorta From Computed Tomographic Images at the Onset of Aortic Dissection

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