Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review

Abstract

Background: Thoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.

Methods: This is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.

Results: There were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.

Conclusion: Acute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.

Keywords: acute aortic syndrome (AAS); hybrid endovascular repair; stent-graft induced new entry tear (SINE); thoracic endovascular aneurysm repair (TEVAR); thoraco-abdominal aorta.

Figure 1

Management of acute aortic syndrome. OMT, Optimal Medical Therapy; TEVAR, Thoracic Endovascular Aneurysm repair; TIGER, STaged HybrId sinGle lumEn Reconstruction.

Figure 2

(A) A 3D reconstruction of type B aortic dissection, starting from the origin of the left subclavian to the distal aorta. (B,C) Depicts an aberrant right subclavian artery that arises from the mid-descending aorta. Note that both common carotids arise from ascending aorta.

Figure 3

(A) CTA axial view illustrates that the aberrant right subclavian artery arises from the compressed true lumen. (B) CTA axial view confirms complex dissection at the level of celiac, superior mesenteric artery (SMA) and right renal artery with dynamic and static occlusion. (C) CTA axial view confirms complex dissection at the level left renal artery with dynamic and static occlusion, with main blood supply arising from false lumen with the hypoperfused left kidney.

Figure 4

(A) 3D reconstruction post sTaged hybrId sinGle lumEn reconstruction (TIGER), demonstrating patient all visceral with left common iliac to left renal artery bypass. (B,C) A 3D reconstruction post-TIGER and thoracic endovascular aortic repair (TEVAR) with Gore C-TAG, with bilateral transposition of both subclavian arteries to both common carotid, demonstrating patent all great vessels of head and neck and all visceral vessels.

Figure 5

(A,B) A 3D reconstruction post-knickerbocker technique to seal distal thoracic aortic aneurysm (TAA) and abolish type IB with gore C-TAG, demonstrating total modulation of TAA.

Figure 6

(A–C) CTA axial views four years post sTaged hybrId sinGle lumEn reconstruction (TIGER) without any evidence of aneurysmal diseases or dissection or stenosis; patients are off all of her antihypertensive medications.

Figure 7

(A–C) Day one post type A aortic dissection, 3D reconstruction confirms that the dissection involves the left subclavian artery and extends to the mid-infra renal aorta, celiac axis, superior mesenteric artery (SMA) and left renal arises from false lumen with hypoperfusion.

Figure 8

(A) CTA axial view depicts that the dissection extends to the left subclavian artery. (B,C) CTA axial views confirm the ominous sign of acute false lumen thrombosis that supplies visceral arteries. (D) CTA Axial view demonstrates that the celiac axis arises from a false lumen.

Figure 9

A 3D reconstruction post sTaged hybrId sinGle lumEn reconstruction (TIGER) demonstrating well-perfused visceral organs.

Figure 10

(A–C) A 3D reconstruction post sTaged hybrId sinGle lumEn reconstruction (TIGER) and thoracic endovascular aortic repair (TEVAR) with a chimney to the left subclavian artery confirming total modulation of the aorta.

Figure 11

(A) CTA sagittal views confirming the patency of the left subclavian chimney and the thoracic endovascular aortic repair (TEVAR) gore C-TAG graft. (B) CTA axial views, five years post sTaged hybrId sinGle lumEn Reconstruction (TIGER), show well-perfused kidneys without any evidence of dissection, aneurysmal dilatation or restenosis.

Figure 12

(A) CTA done at one-hour post-collapse in another institute shows acute aortic hematoma with interscapular pain during the COVID-19 pandemic lockdown. (B) CTA sagittal view done at 20 h post-collapse in another institute confirmed a small bleed into the acute mural hematoma. (C) CTA axial views demonstrated that the hematoma extends proximally and distally.

Figure 13

(A–C) CTA axial views demonstrated rupture of the ascending and descending aorta with acute catastrophic haemorrhage with a terminal event on patient arrival to our institute.

Figure 14

Kaplan Meier Curve displaying combined aneurysm and cardiovascular related mortality (Log-rank test: X² = 0.555 and p = 0.456).

Figure 15

Kaplan Meier Curve displaying all-cause mortality (Log-rank test: X² = 0.545 and p = 0.460).