Aortic Dissection


Article Author:
David Levy


Article Editor:
Jacqueline Le


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/14/2018 3:51:17 PM

Introduction

While uncommon, acute aortic dissection (AAD) is an infrequent but catastrophic disorder. Classically described as a patient complaining of an abrupt onset of severe ‘tearing’ chest pain, presentations can often be more subtle. Physicians correctly suspect the diagnosis in as few as 15% to 43% of cases of verified AAD. If left untreated, mortality approaches 50% in the first 48 hours of onset.[1][2][3]

There are two main anatomic classifications used to classify aortic dissection; the DeBakey and Stanford systems. The Stanford system is more frequently employed. It classifies dissections that involve the ascending aorta as type A, regardless of the site of the primary intimal tear, and all other dissections as type B. The DeBakey classification is based upon the site of origin of the dissection. Type 1 originates in the ascending aorta and to at least the aortic arch, while type 2 originates in and is limited to the ascending aorta. Type 3 begins in the descending aorta and extends distally above the diaphragm (type 3a) or below the diaphragm (type 3b). Ascending aortic dissections are almost twice as common as descending dissections.[4]

Etiology

Predisposing high-risk factors for non-traumatic aortic dissection include:

  • Hypertension (occurs in 70% of patients with distal Standford type B AAD).
  • An abrupt, transient, severe increase in blood pressure (e.g., strenuous weight lifting and use of sympathomimetic agents such as cocaine, ecstasy, or energy drinks).
  • Genetic conditions including Marfan syndrome (In an IRAD review, Marfan syndrome was present in 50% of those under age 40, compared with only 2% of older patients), Ehlers-Danlos syndrome, Turner syndrome, and bicuspid aortic valve.
  • Pre-existing aortic aneurysm.
  • Pregnancy and delivery (risk compounded in pregnant women with connective tissue disorders such as Marfan syndrome).
  • Family history.
  • Aortic instrumentation or surgery.
  • Inflammatory or infectious diseases that cause a vasculitis.

Epidemiology

The incidence of aortic dissection is reported to be 5 to 30 cases per 1 million people per year (compared to the much more common condition of acute myocardial infarction, which affects approximately 4400 cases per 1,000,000 person-years). Regarding emergency department presentations, three AADs are ultimately diagnosed out of every 1000 patients presenting with acute back, chest, or abdominal pain. Age is a risk factor for approximately 75% of aortic dissections occurring in patients who are ages 40 to 70 years, with the majority occurring between the ages of 50 and 65 years. However, there are some significant differences between older adult patients and younger patients with dissections involving the ascending aorta. Older patients are significantly more likely to harbor atherosclerosis, prior aortic aneurysm, iatrogenic dissection, or an intramural hematoma. Younger patients are much less likely to have a history of hypertension, and much more likely to suffer from a connective tissue disorder such as Marfan syndrome. Additionally, AAD is three times more common in men than in women, although women tend to present later and experience worse out­comes.[5]

Pathophysiology

The aortic wall consists of three layers: the intima, media, and adventitia. Constant exposure to high pulsatile pressure and shear stress leads to a weakening of the aortic wall in susceptible patients resulting in an intimal tear. Following this rent, blood flows into the space between the intima and adventitia, creating a false lumen. Most of these tears take place in the ascending aorta, usually in the right lateral wall where the greatest shear force on the aorta occurs. An AAD can propagate anterograde and/or retrograde and depending on the direction the dissection travels, cause branch obstruction that produces ischemia of affected territory (coronary, cerebral, spinal, or visceral), and for proximal type, A AADs can instigate acute tamponade, aortic regurgitation or aortic rupture.[6]

History and Physical

Clinically, the presentation of AAD is subject to the extent of the dissection, with complaints corresponding to those affected cardiovascular structures. Three fundamental questions that must be addressed when taking a history of a patient with suspected AAD are the quality, radiation, and intensity of pain at onset. Various studies identified the intensity of onset of pain as the most reliable historical factor.  While increasing the probability of AAD when present, classically cited physical findings, such as a discrepancy of blood pressures in the upper extremities, a pulse deficit, or presence of a diastolic murmur, are present in less than 50% of confirmed cases of AAD.  Additionally, the presence of chest pain with any neurological finding, the combination of chest and abdominal pain, or chest pain accompanied by limb weakness or paresthesia should alert the clinician to the possibility of AAD.

Evaluation

Routine studies like an ECG and chest x-ray can help differentiate other possible causes for chest pain but can be misleading. The presence of ECG findings consistent with an acute myocardial infarction occurs in eight percent of cases of AAD.  Furthermore, while widening of the aortic silhouette increases the likelihood of AAD, its absence does not reliably exclude the diagnosis. Confirmation of AAD requires cardiovascular imaging to identify the presence of an intimal tear, establish the Stanford classification, and detect valvular or branch involvement. Most society guidelines recommend either CT aortography or transesophageal echocardiogram (TEE) for the diagnosis of AAD. Deciding which modality to employ as a first-line screen should be based on institutional availability and expertise. For most emergency departments (EDs), CT angiography will likely be the first advanced imaging technique on account of its widespread availability.[7]

Treatment / Management

Once the diagnosis of AAD is confirmed or highly suspected, urgently consult cardiothoracic or vascular surgery (based on institutional protocols). Acute dissections involving the ascending aorta are considered surgical emergencies. Concurrently commence medical therapy including providing adequate analgesia (morphine is the preferred analgesic, as it decreases sympathetic output as well) and administering a short-acting IV beta-blockers aiming for a heart rate of ~60 bpm (reductions in heart rate and blood pressure reduces aortic wall tension and limit the extent of dissection). If the systolic blood pressure remains elevated, nitroprusside can be added to achieve a systolic blood pressure goal of 100 to 120 mmHg (maintain blood pressure in this range as long as there is no compromise of mentation or urine output).

Surgical therapy for type A AAD involves excision of the intimal tear, obliteration of entry into the false lumen proximally, and reconstitution of the aorta with interposition of a synthetic vascular graft. Surgical intervention for type B AAD tends to be reserved for patients who have a complicated course. Endovascular stent-grafting (TEVAR) has been employed as a less invasive alternative to surgery, primarily for patients with complicated type B dissections.[2][8][9]

Prognosis

Aortic dissection still carries a very high mortality. At least 30% of patients die after reaching the emergency room and even after surgery, the mortality rates vary from 20-30%. For those who survive surgery, the comorbidity also takes a toll and the quality of life is poor. the highest mortality of an acute aortic dissection is within the first 10 days. Patients with a chronic dissection tend to have a better prognosis, but even their life expectancy is shortened compared to the general population.

Complications

  • Multiorgan failure
  • Stroke
  • MI
  • Paraplegia
  • Renal failure
  • Amputation of extremities
  • Bowel ischemia

Postoperative and Rehabilitation Care

  • Once the patient is treated surgically or medically, the blood pressure must be controlled.
  • The patient must be closely monitored for progression of the aortic dissection.
  • Regular CT scan of the chest or MRI are recommended at 3-6 month intervals to check for progression of disease.

Deterrence and Patient Education

  • Controlling blood pressure
  • Avoid use of illicit drugs
  • Maintain a healthy weight
  • Discontinue smoking

Pearls and Other Issues

Despite the best of circumstances, it is next to impossible to diagnose every case of AAD presenting to the ED. Factors contributing to high miss rate include perceived mildness of symptoms in some patients with AAD. A second factor leading to misdiagnosis is clinical symptoms and laboratory findings suggesting an alternative diagnosis such as acute coronary syndrome (ACS). A third factor was the lack of expected results such as a pulse deficit or absence of a widened mediastinum on chest x-ray. Approach every chest pain patient as if they could harbor an ADD, establish a risk factor profile, and remain cognizant of more subtle presentations.

Enhancing Healthcare Team Outcomes

Once the patent with an aortic dissection presents to the emergency room, a standardized system must be in operation to ensure that the diagnosis and management is done without any delay. The triage nurse should be fully aware of the importance of immediate admission of the patient and consult with the emergency physician and cardiac surgeon. The decision on how to make the diagnosis depends on patient stability and availability of imaging tests. The two options include ECHO or a CT scan. An unstable patient should never be sent to the radiology suite. Instead, a cardiologist should be consulted for a bedside echo. [9][10][11] (Level V)

Outcomes

Several studies show that patient outcomes are improved when managed by a multidisciplinary team of healthcare professionals that include a cardiologist, intensivist, pulmonologist, nephrologist, cardiac surgeon, interventional radiologist, and anesthesiologist. In addition, the pharmacist must educate the patient about the importance of blood pressure control and compliance with medications. The outcomes of aortic dissection tend to be better in high volume centers compared to small centers which do less than 5 cases a year. [12][13][14](Level V)


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Aortic Dissection - Questions

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When a transesophageal echocardiogram is done to diagnose an aortic dissection, what is the critical finding that leads to a diagnosis?



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A patient presents to the emergency department with chest pain radiating to the back. The pain started suddenly and has not subsided. The patient is diaphoretic but is not vomiting. Pulses are present and equal. Which test should be used first to confirm the suspected diagnosis?



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A 65-year-old male presents to the emergency department complaining of an acute onset of pain that started in the anterior chest. He says the pain is excruciating and now radiates between his scapula. His respiratory rate is 22, the pulse is 120, and blood pressure is 80/55 mmHg. What is the most likely diagnosis?



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A 65-year-old hypertensive male presents with an acute episode of chest pain that is tearing in nature and radiates to his back. What is the most likely diagnosis?



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Which statement regarding the diagnosis of aortic dissection is not true?



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A 67-year-old female undergoes surgery for an aortic occlusion. Postoperatively, she develops abdominal distension and nausea. A nasogastric tube is inserted which drains about 2 liters per day. Her urine output has been 300 mL per day. What is the next step in the management of this patient?



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A patient who is unconscious following a motor vehicle accident has no focal neurological signs. He has a blood pressure of 130/80 mmHg. A chest x-ray reveals a left pleural collection and a widened mediastinum. Hematuria is present. Which of the following is most necessary for this patient?



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A 71-year-old male is complaining of severe and sharp chest pain radiating down his back after a high-speed motor vehicle accident with airbag deployment. His blood pressure is 190/100 mmHg and his radial pulse is 110 beats/min. Heart tones are muffled. What is the most likely diagnosis?



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Which of the following is the most common site of intimal tears with an aortic dissection?



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Which of the following is not true of aortic dissection?



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Which of the following would be unlikely with dissection of the ascending aorta?



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In which of the following is the preservation of the aortic valve possible?



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During repair of an ascending aortic dissection, which period is associated with the highest risk of malperfusion?



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In an ascending aortic dissection, where is the false lumen generally located?



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A 67-year-old undergoes an elective catheterization for an evaluation of chest pain. During the procedure the cardiologist notices that the guide wire from the femoral artery has caused a small 0.2 cm flap just distal to the left subclavian artery. The patient is stable and has no symptoms. Which of the following is most appropriate for the continued management of this patient?



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A 65-year-old female with a history of hypertension on hydrochlorothiazide presents with severe chest pain that radiates to her back and dyspnea. She is found to have a blood pressure of 205/98 mmHg, pulmonary rales, an ECG with ST changes, and a chest x-ray with a widened mediastinum. What the best initial management?



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A patient with aortic dissection is started on intravenous nitroglycerin. Ten minutes later, the patient develops tachycardia. Which drug should be used to treat the tachycardia?



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Which statement about the elephant trunk is false?



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A tall thin patient with a pectus deformity complains of sudden onset of chest pain radiating to his back. Which condition should be considered first?



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A patient wakes up with chest pain which subsides after 6. Just to make sure everything is okay, he presents to the emergency department. The only significant finding is an absent left radial pulse. Which of the following is the best test to determine his diagnosis?



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Which of the following about aortic dissection is false?



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A tall patient with a pectus deformity presents with chest pain. The pain has been steady for 4 hours. What is the most likely diagnosis?



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A patient awakens with chest pain. He presents to the emergency room with hypotension and diaphoresis. Examination reveals unequal radial pulses. What is the most likely diagnosis?



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Which of the following statements about abdominal aortic dissection is not true?



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After a routine bypass, the patient takes a long time to warm up. The nasopharyngeal temperature is 8 degrees, higher than the bladder temperature. Despite changing the bladder probe and warming for 45 minutes, the bladder temperature fails to rise, but the temperature difference gets wider. Which of the following is the most appropriate response?



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What is the most common cause of aortic dissection in women under 40 years of age?



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A 50-year-old male with a history of hypertension, hyperlipidemia, and poor compliance with his medication is brought to the emergency department with severe chest pain radiating to his back. His blood pressure 200/120 mmHg and EKG is 2 mm ST elevation in the inferior leads. CT confirms dissection of the ascending aorta and minimal pericardial fluid. Select the appropriate treatment.



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Select the patient that does not need endovascular or surgical intervention for aortic dissection.



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Which of the following is a potential clinical presentation of aortic dissection?



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What is not usually seen in aortic dissection?



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Which is usually true concerning aortic dissection?



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Which of the following is a risk factor for aortic dissection?



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Which of the following populations is not at high risk for aortic dissection?



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Which of the following managements is inappropriate for a patient with acute lower extremity ischemia status post-acute aortic dissection?



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Which of the following statements is false regarding aortic dissection?



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Which is most commonly associated with thoracic aortic dissection?



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Extremely severe, central chest pain that radiates to the back and is not aggravated by changes in position or respiration suggests which diagnosis?



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A 65-year-old male presents with back pain. CT scan reveals a dissection of descending aorta. The patient's pain subsides with morphine. What is the next step in the management of this patient?



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You are about to repair a dissection in the descending aorta through a left posterolateral thoracotomy. The dissection starts just adjacent to the takeoff of the left subclavian artery and involves at least 18 cm of the descending aorta above the diaphragm. Which of the following maneuvers may not help you during surgery?



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A patient with aortic dissection feels excruciating pain. The nerve fibers run in what layer of the aorta?



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A 55-year old obese male with a history of uncontrolled hypertension and diabetes mellitus presents with excruciating chest pain that is radiating into his back. The pain has not responded to nitroglycerin. The ECG only reveals non-specific ST segment changes and the first set or cardiac enzymes is within normal limits. Physical exam reveals a male in distress with a BP of 200/100 mmHg, a pulse of 140 bpm and respiratory rate of 22/minute. The patient is sent for a stat CT scan of the chest. Where will his pathology most likely be present?



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A 62-year-old patient wakes up with chest pain but after 6 hours the pain subsides. Just to make sure everything is okay, he presents to the emergency room. The only significant finding is a difference in blood pressure between the right and left arm. His heart rate is 100, blood pressure is 160/95 mmHg, respiratory rate is 18, and pulse oximetry on room air is 96%. All his blood work appears normal. What is the next essential step in his management?



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A middle-aged obese male presents with sudden onset of excruciating chest pain that is now radiating into his back. He has woken up from his sleep 3 hours ago. In the emergency department, he is diaphoretic, anxious, and complaining of chest pain. He is administered nitroglycerin by the triage nurse but this does not provide any relief. Blood pressure on the right arm is 190/90 mmHg and on the left arm, it is 145/75 mmHg. His respiration rate is 28/minute and he is afebrile. His initial set of cardiac enzymes is negative and the ECG reveals non-specific ST changes. In this patient what will most likely hear be heard during auscultation?



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A 59-year-old obese male presents to the emergency department with a 4-hour history of sudden onset of sharp radiating chest pain. The pain he says started in the chest and is now radiating to his arm and lower back. He feels nauseated and feels as if he is going to die. Quick exam reveals a distressed male with right arm blood pressure of 210/110 mmHg and a left arm blood pressure of 140/82 mmHg. He is diaphoretic and extremely anxious. The ECG is unremarkable and the initial set of cardiac enzymes is negative. His pain is not responding to nitroglycerin. In patients with this pathology, what one feature will be seen on the chest x-ray?



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A 63-year old man develops an acute aortic dissection, extending from the ascending aorta to the thoracic abdominal aorta. His creatinine is 2.2 mg/dL and he has diabetes mellitus and hypertension. What is the best management for this patient?



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A 60-year-old male arrives with severe, tearing chest pain that radiates to the upper back. The pain started suddenly, is 10/10, and the patient speaks in a hoarse voice, "Am I going to die? I feel that I will." He is dyspneic, clammy, and cannot lie flat. Radial pulses are absent on the right and bounding (4+) on the left. Blood pressure measured from the right arm is 60/palpable and the left arm is 210/120 mmHg. Pulse rate is 112 beats/min. His past medical history includes diabetes mellitus, poorly controlled hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes a day. What actions are required by the nurse and anticipated provider orders? Select all that apply?



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Stanford type A dissection describes an aortic dissection involving which of the following?



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An aortic dissection that travels distally to the abdominal aorta may affect which of the following?



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A 69-year-old heavy smoker presents to the emergency department with severe knife-like chest pain and diaphoresis that woke him up from his sleep 2 hours ago. He denies being short of breath but claims that the pain is severe, continuous, and radiates to his upper back and shoulders. His past medical history reveals longstanding poorly controlled hypertension, diabetes, and peripheral vascular disease. He is not compliant with his medications, smoked 1 pack of cigarettes daily for the past 30 years, and drinks alcohol regularly. By the time the physical exam is done, the patient’s chest pain has subsided. His blood pressure is 180/90 mm/Hg in his right arm and 120/63 mm/Hg in his left arm, pulse is 110 bpm, respiratory rate is 18 breaths/min, and temperature is 98.8 F. He is alert. His ECG shows T-wave inversions in leads V3 an V4. He undergoes a CT angiogram of the chest depicted in the image. What is the next best step in the management of this patient?

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  • Image 5444 Not availableImage 5444 Not available
    Contributed by chestatlas.com (H. Shulman MD)
Attributed To: Contributed by chestatlas.com (H. Shulman MD)



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Aortic Dissection - References

References

Spinelli D,Benedetto F,Donato R,Piffaretti G,Marrocco-Trischitta MM,Patel HJ,Eagle KA,Trimarchi S, Current evidence in predictors of aortic growth and events in acute type B aortic dissection. Journal of vascular surgery. 2018 Aug 13     [PubMed]
Lau C,Leonard JR,Iannacone E,Gaudino M,Girardi LN, Surgery for Acute Presentation of Thoracoabdominal Aortic Disease. Seminars in thoracic and cardiovascular surgery. 2018 Jul 30     [PubMed]
Wu L, The pathogenesis of thoracic aortic aneurysm from hereditary perspective. Gene. 2018 Jul 17     [PubMed]
Berretta P,Cefarelli M,Montalto A,Savini C,Miceli A,Rubino AS,Troise G,Patanè L,Di Eusanio M, [Surgical indications for thoracic aortic disease: beyond the     [PubMed]
Baliyan V,Parakh A,Prabhakar AM,Hedgire S, Acute aortic syndromes and aortic emergencies. Cardiovascular diagnosis and therapy. 2018 Apr     [PubMed]
Zeng T,Shi L,Ji Q,Shi Y,Huang Y,Liu Y,Gan J,Yuan J,Lu Z,Xue Y,Hu H,Liu L,Lin Y, Cytokines in aortic dissection. Clinica chimica acta; international journal of clinical chemistry. 2018 Aug 4     [PubMed]
Erbel R, [Aortic diseases : Modern diagnostic and therapeutic strategies]. Herz. 2018 May     [PubMed]
Mkalaluh S,Szczechowicz M,Dib B,Weymann A,Szabo G,Karck M, Open surgical thoracoabdominal aortic aneurysm repair: The Heidelberg experience. The Journal of thoracic and cardiovascular surgery. 2018 Jun 6     [PubMed]
Sörelius K,Wanhainen A, Challenging Current Conservative Management of Uncomplicated Acute Type B Aortic Dissections. EJVES short reports. 2018     [PubMed]
Kouchoukos NT, Endovascular surgery in Marfan syndrome: CON. Annals of cardiothoracic surgery. 2017 Nov     [PubMed]
Krol E,Panneton JM, Uncomplicated Acute Type B Aortic Dissection: Selection Guidelines for TEVAR. Annals of vascular diseases. 2017 Sep 25     [PubMed]
Piffaretti G,Bacuzzi A,Gattuso A,Mozzetta G,Cervarolo MC,Dorigo W,Castelli P,Tozzi M, Outcomes Following Non-operative Management of Thoracic and Thoracoabdominal Aneurysms. World journal of surgery. 2018 Aug 20     [PubMed]
Gomibuchi T,Seto T,Komatsu M,Tanaka H,Ichimura H,Yamamoto T,Ohashi N,Wada Y,Okada K, Impact of Frailty on Outcomes in Acute Type A Aortic Dissection. The Annals of thoracic surgery. 2018 Aug 4     [PubMed]
Kim JH,Choi JB,Kim TY,Kim KH,Kuh JH, Simplified surgical approach to improve surgical outcomes in the center with a small volume of acute type A aortic dissection surgery. Technology and health care : official journal of the European Society for Engineering and Medicine. 2018 Jun 15     [PubMed]

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