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Aortic intramural hematoma (IMH) accounts for approximately 10%-25% of acute aortic syndromes (AAS), and multi-slice computed tomography and magnetic resonance imaging are the leading techniques for diagnosis and classification. In this context, endovascular strategies provide a valid alternative to traditional open surgery and transesophageal echocardiography (TEE) could play a role in therapeutic decision-making and in endovascular repair procedure guidance. A 57-year-old female patient with IMH extending from the left subclavian artery to the upper tract of the abdominal aorta, underwent endovascular aortic repair using an unibody single-branched stent grafting in the aortic arch and descending aorta with a side branch inserted in the left common carotid artery. To restore proper flow in the left axillary artery, a carotid-subclavian bypass graft was performed. The procedure was guided by angiography and TEE. Intraoperative TEE revealed aortic IMH with a significant fluid component in the middle tunic of the aorta with a wall thickness of over 13 mm. TEE was useful in monitoring of all steps of the procedure, showing the presence of the guidewires into the true lumen, the advancement of the prosthesis, and the phases of release and anchoring. This case highlights the importance of using multimodality imaging techniques to evaluate AAS and demonstrates the growing potential of TEE in guiding endovascular repairs.

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BACKGROUND: Marfan Syndrome is an autosomal dominant disease caused by pathogenetic variants in the FBN1 gene. The progressive dilatation of the aorta and the potential risk of acute aortic syndromes influence the prognosis of these patients. We aim to describe population characteristics, long-term survival, and re-intervention patterns in patients who underwent aortic surgery with a previously confirmed clinical diagnosis of Marfan Syndrome in a middle-income country. METHODS: A retrospective single-center case series study was conducted. All Marfan Syndrome patients who underwent aortic procedures from 2004 until 2021 were included. Qualitative variables were frequency-presented, while quantitative ones adopted mean ± standard deviation. A subgroup analysis between elective and emergent procedures was conducted. Kaplan-Meier plots depicted cumulative survival and re-intervention-free. Control appointments and government data tracked out-of-hospital mortality. RESULTS: Fifty patients were identified. The mean age was 38.79 ± 14.41 years, with a male-to-female ratio of 2:1. Common comorbidities included aortic valve regurgitation (66%) and hypertension (50%). Aortic aneurysms were observed in 64% without dissection and 36% with dissection. Surgical procedures comprised elective (52%) and emergent cases (48%). The most common surgery performed was the David procedure (64%), and the Bentall procedure (14%). The in-hospital mortality rate was 4%. Complications included stroke (10%), and acute kidney injury (6%). The average follow-up was 8.88 ± 5.78 years. Survival rates at 5, 10, and 15 years were 89%, 73%, and 68%, respectively. Reintervention rates at 1, 2.5, and 5 years were 10%, 14%, and 17%, respectively. The emergent subgroup was younger (37.58 ± 14.49 years), had the largest number of Stanford A aortic dissections, presented hemodynamic instability (41.67%), and had a higher requirement of reinterventions in the first 5 years of follow-up (p = 0.030). CONCLUSION: In our study, surveillance programs played a pivotal role in sustaining high survival rates and identifying re-intervention requirements. However, challenges persist, as 48% of the patients required emergent surgery. Despite not affecting survival rates, a greater requirement for reinterventions was observed, emphasizing the necessity of timely diagnosis. Enhanced educational initiatives for healthcare providers and increased patient involvement in follow-up programs are imperative to address these concerns.

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Aortic intramural hematoma (IMH) is characterized by an aortic wall hematoma without intimal flap and it is a variant of acute aortic syndromes (AAS). This entity may represent 10%-25% of the AAS involving the ascending aorta and aortic arch (Stanford Type A) in 10%-30% of cases and the descending thoracic aorta (Stanford Type B) in 60%-70% of cases. IMH impairs the aortic wall and may progress to either inward disruption of the intima, which finally induces typical dissection or outward rupture of the aorta. The literature describes some clinical reports where Type A aortic dissection mimics a pulmonary embolism but is not described as a case provoked by IMH with outward rupture of the aorta.

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Aortic intramural hematoma (IMH) is characterized by blood spilling through the intimal layer of the aortic wall without any tear within the aortic wall. The condition has been troublesome to analyze until of late. A 55-year-old gentleman with hypertension presented with epigastric pain radiating to the back, he later developed back pain as well as bilateral lower limb numbness and was found to have IMH when a CT angiogram was conducted. Due to the severity of the illness, the patient expired on the 10th day of the admission. It is important for physicians to be aware of atypical presentations of this life-threatening aortic disease.

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Dual-energy computed tomography (DECT) is one of the most promising technological innovations made in the field of imaging in recent years. Thanks to its ability to provide quantitative and reproducible data, and to improve radiologists' confidence, especially in the less experienced, its applications are increasing in number and variety. In thoracic diseases, DECT is able to provide well-known benefits, although many recent articles have sought to investigate new perspectives. This narrative review aims to provide the reader with an overview of the applications and advantages of DECT in thoracic diseases, focusing on the most recent innovations. The research process was conducted on the databases of Pubmed and Cochrane. The article is organized according to the anatomical district: the review will focus on pleural, lung parenchymal, breast, mediastinal, lymph nodes, vascular and skeletal applications of DECT. In conclusion, considering the new potential applications and the evidence reported in the latest papers, DECT is progressively entering the daily practice of radiologists, and by reading this simple narrative review, every radiologist will know the state of the art of DECT in thoracic diseases.

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BACKGROUND: In acute aortic syndrome (AAS) screening, D-dimer is a well-established biomarker whose usefulness has been scarcely studied with respect to its measurement timing. We aimed to evaluate the effectiveness of D-dimer-based AAS screening focused on the time interval between AAS onset and D-dimer measurement. METHODS: We retrospectively analyzed consecutive patients diagnosed with AAS who visited our hospital between 2011 and 2021. For the primary analysis, we divided patients according to the quartiles of the time interval between AAS symptom onset and D-dimer measurement. D-dimer level ≥ 0.5 µg/mL and age-adjusted D-dimer ≥ [age (years) × 0.01] µg/mL (minimum of 0.5 µg/mL) were defined as positive. The primary endpoint was the comparative ability of D-dimer to detect AAS within and between each time quartile. In an exploratory secondary analysis, we reported patient and AAS characteristics in the subgroup of patients who underwent repeat D-dimer measurement within 48 h of the first D-dimer measure. RESULTS: The 273 AAS patients were divided into four groups based on quartiles of the time interval (Group 1, ≤1 h; Group 2, 1-2 h; Group 3, 2-5 h; and Group 4, >5 h). There were no significant differences in D-dimer levels or in the proportions with positive D-dimer (Group 1: 97%, Group 2: 96%, Group 3: 99%, Group 4: 99%; P = 0.76) or positive age-adjusted D-dimer (Group 1: 96%, Group 2: 90%, Group 3: 96%, Group 4: 97%; P = 0.32) between the groups. Of the 147 patients who had D-dimer re-measured, nine had negative D-dimer levels on either the primary or secondary measurement. Of these nine patients, eight had AAS with a thrombosed false lumen and one with a patent false lumen had a short length of dissection. In all nine patients, D-dimer levels remained low (maximum of 1.4 µg/mL). CONCLUSION: D-dimer levels were elevated from the early stages of AAS. The clinical utility of D-dimer is not affected by the time interval from AAS onset to D-dimer measurement, but rather is influenced by AAS characteristics.

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Ruptured abdominal aortic aneurysm (RAAA) is an acute aortic condition that requires emergent intervention and appropriate continuity of care to optimize patient outcomes. We describe the standardized RAAA protocol at the Houston Methodist Hospital Acute Aortic Treatment Center, developed to navigate critical patient transfer periods safely and efficiently, make crucial decisions about surgical intervention, and clearly communicate these plans with other care team providers. Our workflow is organized into five phases: prehospital, preoperative, intraoperative, postoperative, and post-discharge. We identify the transfer center, anesthesia, operating room nursing staff, surgeons, and intensive care unit as key entities of our acute aortic pathology care team. This systematic protocol for the management of acute aortic emergencies such as RAAA identifies critical decision points, potential complications at each stage, and recommendations for best practice.

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We aimed to detect acute aortic syndromes (AAS) on non-contrast computed tomography (NCCT) images using a radiomics-based machine learning model. A total of 325 patients who underwent aortic CT angiography (CTA) were enrolled retrospectively from 2 medical centers in China to form the internal cohort (230 patients, 60 patients with AAS) and the external testing cohort (95 patients with AAS). The internal cohort was divided into the training cohort (n = 135), validation cohort (n = 49), and internal testing cohort (n = 46). The aortic mask was manually delineated on NCCT by a radiologist. Least Absolute Shrinkage and Selection Operator regression (LASSO) was used to filter out nine feature parameters; the Support Vector Machine (SVM) model showed the best performance. In the training and validation cohorts, the SVM model had an area under the curve (AUC) of 0.993 (95% CI, 0.965-1); accuracy (ACC), 0.946 (95% CI, 0.877-1); sensitivity, 0.9 (95% CI, 0.696-1); and specificity, 0.964 (95% CI, 0.903-1). In the internal testing cohort, the SVM model had an AUC of 0.997 (95% CI, 0.992-1); ACC, 0.957 (95% CI, 0.945-0.988); sensitivity, 0.889 (95% CI, 0.888-0.889); and specificity, 0.973 (95% CI, 0.959-1). In the external testing cohort, the ACC was 0.991 (95% CI, 0.937-1). This model can detect AAS on NCCT, reducing misdiagnosis and improving examinations and prognosis.

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Background: Blood-test-based methods of distinguishing between acute aortic syndromes (AASs) and non-ST-elevation myocardial infarction (NSTEMI) during the troponin-blind period of <2-3 h of symptom onset have not been studied previously. We aimed to explore whether routine biomarkers might facilitate differential diagnosis. Methods: Data were retrospectively collected from 178 patients with AASs and 460 patients with NSTEMI within 3 h of onset. Differential risk factors related to AASs were identified by univariate and multivariate logistic regression analyses for patients with onset <2 h and onset ≥2 h, respectively, in the cardiac troponin (cTn) cohort. Nomograms were established in the cTn cohort as a training set and validated in the high-sensitivity cTn cohort. To assess the utility of the models in clinical practice, decision curve analyses were performed. Results: D-dimer, fibrinogen, and age were identified as differential risk factors for AASs with the onset of <2 h. D-dimer at an optimal cutoff level of 281 ng/mL for AASs had a sensitivity of 86.4% and a specificity of 91.3%. A nomogram was developed and validated with areas under the curve (AUC) of 0.934 (95% CI: 0.880-0.988) and 0.952 (95% CI: 0.874-1.000), respectively. D-dimer, neutrophil, bilirubin, and platelet were the differential risk factors for AASs with the onset of ≥2 h. D-dimer at an optimal cutoff level of 385 ng/mL has a sensitivity of 91.8% and a specificity of 91.3%. The AUC of the second nomogram in the training set and the validation set were 0.965 (95% CI: 0.942-0.988) and 0.974 (95% CI: 0.944-1.000), respectively. Conclusion: Time-dependent quality of D-dimer should be considered for discriminating AASs from NSTEMI. Both nomogram models may have a clinical utility for evaluating the probability of AASs.

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Acute aortic syndromes are life-threatening conditions with high morbidity and mortality. The principal pathological feature is acute wall damage with possible evolution towards aortic rupture. Accurate and timely diagnosis is mandatory to avoid catastrophic consequences. Indeed, misdiagnosis with other conditions mimicking acute aortic syndromes is associated with premature death. In this view, cardiovascular imaging is necessary for the correct diagnosis and management. Echocardiography, computed tomography, magnetic resonance imaging, and aortography allow for diagnosis, guarantee immediate treatment, and detect associated complications. Multimodality imaging is essential in the diagnostic work-up to confirm or rule out acute aortic syndromes. The aim of this review is to highlight the contemporary evidence on the role of single cardiovascular imaging techniques and multimodality imaging in the diagnosis and management of acute aortic syndromes.

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This study aimed to assess the diagnostic performance of the aortic dissection detection risk score (ADD-RS) plus D-dimer for acute aortic syndrome (AAS) in Chinese patients. Two hundred and sixty-two and 200 patients with suspected AAS symptoms were enrolled as exploration cohort and validation cohort, respectively. In exploration cohort, ADD-RS plus D-dimer (AUC = 0.929, 95%CI: 0.887-0.971) presented a better diagnostic value for AAS than ADD-RS or D-dimer alone. Meanwhile, ADD-RS > 1 and D-dimer > 2000 ng/mL were the optimal thresholds. Then, a diagnostic model integrating ADD-RS > 1 plus D-dimer > 2000 ng/mL was established, presenting sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 92.5%, 70.3%, 34.9%, and 98.2%, respectively. In validation cohort, the established diagnostic model exhibited a sensitivity, specificity, PPV, and NPV of 93.1%, 70.2%, 34.6%, and 98.4%, respectively, for diagnosing AAS. Summarily, ADD-RS > 1 and D-dimer > 2000 ng/mL are optimal thresholds for diagnosing AAS in the Chinese population. However, confirmative MSCT results are necessary.

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Acute aortic syndromes comprise a range of interrelated conditions including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and contained or not contained aortic aneurysm rupture. These syndromes are potentially life threatening; therefore, a rapid and accurate diagnosis is crucial. A new Clinical Consensus Statement on Aortic and Peripheral Vascular Disease has recently been published, and we will try to highlight the main innovations in the document.

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BACKGROUND: The aim of this study was to define clinical evidence supporting that triple rule-out computed tomography angiography (TRO CTA) is a comprehensive and feasible diagnostic tool in patients with novel coronavirus disease 2019 (COVID-19) who were admitted to the emergency department (ED) for acute chest pain. Optimizing diagnostic imaging strategies in COVID-19 related thromboembolic events, will help for rapid and noninvasive diagnoses and results will be effective for patients and healthcare systems in all aspects. AIM: To define clinical evidence supporting that TRO CTA is a comprehensive and feasible diagnostic tool in COVID-19 patients who were admitted to the ED for acute chest pain, and to assess outcomes of optimizing diagnostic imaging strategies, particularly TRO CTA use, in COVID-19 related thromboembolic events. METHODS: TRO CTA images were evaluated for the presence of coronary artery disease, pulmonary thromboembolism (PTE), or acute aortic syndromes. Statistical analyses were used for evaluation of significant association between the variables. A two tailed P-value < 0.05 was considered statistically significant. RESULTS: Fifty-three patients were included into the study. In 31 patients (65.9%), there was not any pathology, while PTE was diagnosed in 11 patients. There was no significant relationship between the rates of pathology on CTA and history of hypertension. On the other hand, the diabetes mellitus rate was much higher in the acute coronary syndrome group, particularly in the PTE group (8/31 = 25.8% vs 6/16 = 37.5%, P = 0.001). The rate of dyslipidemia was significantly higher in the group with pathology on CTA while compared to those without pathology apart from imaging findings of the pneumonia group (62.5% vs 38.7%, P < 0.001). Smoking history rates were similar in the groups. Platelets, D-dimer, fibrinogen, C-reactive protein, and erythrocyte sedimentation rate values were higher in COVID-19 cases with additional pathologies. CONCLUSION: TRO CTA is an effective imaging method in evaluation of all thoracic vascular systems at once and gives accurate results in COVID-19 patients.

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Intramural hematoma (IMH) and a penetrating aortic ulcer (PAU) are included in a larger category of disorders termed acute aortic syndromes. These disorders typically involve the thoracic aorta, abdominal aorta, or both, and often require emergent evaluation and treatment. Both IMH and PAU, much like aortic dissection, are classified using the Stanford and DeBakey systems to indicate the aortic area involved, with Stanford type A (DeBakey type I and II) necessitating surgical intervention, and Stanford type B sufficing with medical management of blood pressure. While IMH and PAU share many characteristics of aortic dissection in terms of diagnosis and initial management, there is much controversy surrounding ultimate treatment. In this report, we describe a case of a Stanford type A IMH with associated PAU that was managed medically with a good outcome.

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Thoracoabdominal and peripheral vasculature pathologies include a variety of severe and life threatening conditions that may be encountered in the emergent setting. Computed tomography angiography (CTA) is the first-line modality for imaging of the vasculature in this context, but magnetic resonance angiography (MRA) also plays an important and emerging role in the evaluation of carefully selected patients. Intravenous (IV) iodinated contrast is necessary for CTA, although MRA is most useful in patients who cannot receive IV iodinated contrast for reasons including prior severe allergic-like reaction to iodinated contrast, poor IV access, or severe renal insufficiency. Gadolinium-based contrast agents are administered for MRA when possible, as they generally improve the diagnostic quality and shorten the duration of the exam. In most clinical situations, however, noncontrast MRA is sufficient to obtain a diagnostic evaluation. In this review, we discuss the key strengths and limitations of MRA performed in the emergent setting, highlighting the role of MRA in the diagnosis of acute aortic syndromes, aortitis, aortic aneurysm, pulmonary embolism, and peripheral vascular disease.

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Penetrating aortic ulceration (PAU) is an acute aortic syndrome similar to aortic dissection and intramural hematoma. It is the result of a tunica intima ulceration due to atherosclerotic disease. This clinical condition can lead to serious complications and a poor short-term prognosis, especially in high-surgical-risk patients. We report three cases of patients referred to "Ospedale del Cuore" of Massa (Italy) with PAU at the aortic arch-proximal descending aorta level who could not undergo surgical intervention. For the first time in Italy, we successfully treated these patients with a full percutaneous implantation of a Castor branched aortic stent graft. Our case series shows that this type of endovascular graft is an effective, safe, and feasible treatment for PAU involving a distal aortic arch and avoiding surgery and related complications.

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Objective: The optimal treatment modality for retrograde type A intramural hematoma (IMH) remains debatable. This study evaluated and compared surgical outcomes and aortic remodeling after open aortic repair and thoracic endovascular aortic repair (TEVAR) in patients with retrograde type A IMH with a primary intimal tear or ulcer like projection in the descending aorta. Methods: A single center, retrospective observational study was performed on patients with retrograde type A IMH undergoing either open aortic repair and TEVAR. From June 2009 and November 2019, 46 patients with retrograde type A IMH who received either open aortic repair or TEVAR at our institution were reviewed for clinical outcomes, including post-operative mortality/morbidity, re-intervention rate and aortic remodeling. Results: 33 patients underwent open aortic repair and 13 underwent TEVAR. Median age was 68 years (interquartile range [IQR] 15.2 years) and 63 years (IQR 22.5 years) for the open repair group and TEVAR group, respectively. The median duration of follow-up for TEVAR patients was 37.6 months and 40.3 months for open aortic repair. No difference in the 5-year estimated freedom from all-cause mortality (82.1 vs. 87.8%, p = 0.34), re-intervention (82.5 vs. 93.8%, p = 0.08), and aortic-related mortality (88.9 vs. 90.9%, p = 0.88) were observed between the TEVAR and open repair group, respectively; however, the open repair group had a significantly higher 30-day composite morbidity (39.4 vs. 7.7%, p = 0.037). All patients from both treatment groups had complete resolution of the IMH in the ascending aorta. With regard to the descending thoracic aorta, TEVAR group had a significantly greater regression in the diameter of the false lumen or IMH thickness when compared to the open repair group [median 14mm (IQR 10.1) vs. 5mm (IQR 9.5), p < 0.001]. Conclusion: TEVAR and open aortic repair were both effective treatments for retrograde type A IMH, in which no residual ascending aortic IMH was observed during follow-up. TEVAR was also associated with lower post-operative composite morbidities and better descending aortic remodeling. In selected patients with retrograde type A IMH, TEVAR might be a safe, effective alternative treatment modality.