European Heart Journal (2023) 44, 813–821 STATE OF THE ART REVIEW

https://doi.org/10.1093/eurheartj/ehac757 Cardiac and vascular surgery

Acute aortic dissection:

evidence, uncertainties, and future therapies
1,2
Bartosz Rylski *, Oliver Schilling2,3, and Martin Czerny1,2
1
Department of Cardiovascular Surgery, Heart Centre Freiburg University, Hugstetter Str. 55, 79106 Freiburg, Germany; 2Faculty of Medicine, University of Freiburg, Hugstetter Str. 55,
79106 Freiburg, Germany; and 3Institute for Surgical Pathology, Hugstetter Str. 55, 79106 Freiburg, Germany

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Received 31 March 2022; revised 27 October 2022; accepted 5 December 2022; online publish-ahead-of-print 20 December 2022

Graphical Abstract

The different locations of the primary entry tear and dissection propagation in both retro- and antegrade directions in type A, B, and non-A non-B
dissections. The entry location is described according to the TEM classification. Blue arrows indicate the proximal and distal dissection extensions,
and a white line indicates the dissection flap.

* Corresponding author. Tel: +49 761 270 28180, Fax: +49 761 270 28670, Email: bartosz.rylski@universitaets-herzzentrum.de
© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
814 B. Rylski et al.

Abstract

Remarkable progress has become especially apparent in aortic medicine in the last few decades, leading to essential changes in how thoracic aortic
dissection is understood and treated. This state-of-the-art review article addresses the mechanisms of acute aortic dissection, explaining the role of
its primary entry location, proximal, and distal dissection extension in their clinical presentation and impact on the decision-making process towards
the best treatment approach. The latest evidence on novel treatment methods for acute aortic syndromes is presented, and the diverse dissection
classification systems that remain uncertain are discussed, which reveals the need for shared terminology and more clarity. Finally, future aspects are
discussed in treating acute aortic dissection, such as the endovascular treatment of aortic dissection Type A and biomarkers for acute aortic
syndromes.
.............................................................................................................................................................................................
Keywords Aorta • Aortic dissection • Aortic pathologyIntroduction

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ascending aorta, Type 3a when the descending thoracic aorta is af­
Introduction fected, and Type 3b when the descending thoracic and abdominal aorta
Remarkable progress has become especially apparent in aortic medi­ are involved.12
cine in the last few decades. Aortic dissection is the most frequent acute An acute aortic dissection whose primary entry is in the ascending
aortic disease. It often involves both thoracic and abdominal aortic seg­ aorta is always called aortic dissection Type A. Irrespective of its retro-
ments.1 The spectrum of treatments for this disease was expanded by or antegrade propagation, open surgery is the treatment of choice.1
Volodos’ prosthesis endovascular approach in 1986,2 after which endo­ Retrograde propagation usually involves the non-coronary sinus and of­
vascular techniques became effective treatment methods for many aor­ ten leads to prolapse of the aortic valve commissure between the right
tic diseases, including dissection.3 Parallel open surgery has improved and non-coronary sinus, resulting in aortic valve regurgitation. The dis­
substantially since the introduction of the new hybrid frozen elephant section propagation towards coronary orifices can lead to coronary ob­
trunk (FET) prosthesis and the development of safer neuroprotective struction. The right coronary artery is more frequently involved.
protocols for complex aortic repairs.4–6 This progress in aortic medi­ Frequently observed is pericardial fluid collection due to the transuda­
cine also led to a more multidisciplinary approach to aortic disease,7 tion of fluid across the thin wall of an adjacent false lumen into the peri­
and lowered 30-day mortality to single digits in Type A aortic dissection cardial space. It builds a haemodynamically insignificant pericardial
in certain centres8 and even countries like Japan.9 What has not changed effusion which is diagnosed in a third of patients.13 There is evidence
in the last decades, however, is the stubbornly unchanged rate of aortic that the cardiac tamponade caused by a contained rupture or extensive
dissections among all cardiovascular acute syndromes. transudation occurs in 8%–31% of patients.1
In this state-of-the-art review, we focus on the latest evidence on no­ If the primary entry is in the descending aorta, it is usually a Type B
vel treatment methods for acute aortic pathologies. Furthermore, we aortic dissection. It makes a substantial difference whether (i) a Type B
discuss the diverse dissection classification systems that remain uncer­ dissection course is complicated, (ii) a Type B dissection is initially un­
tain—revealing the need for shared terminology and greater clarity. complicated but its anatomy makes us assume that it will take a compli­
Finally, we discuss future aspects of treating acute aortic dissection, cated course, or (iii) it is an uncomplicated Type B dissection. A
such as the endovascular treatment of aortic dissection Type A and bio­ complicated aortic dissection Type B is defined by malperfusion of
markers for acute aortic syndromes. the spinal cord, gastrointestinal tract, kidney, or extremities.1,14,15
Furthermore, any kind of pleural effusion containing blood, contained
and free ruptures, as well as a maximum aortic diameter >40 mm
and persistent pain, make a dissection a complicated one. There are
Pathophysiology of aortic dissection at least two anatomical risk factors for developing a complicated aortic
The aortic wall consists of three layers: the intima (internal layer), med­ dissection from a primarily uncomplicated one. A dissection with the
ia, and adventitia (external layer). Aortic dissection is an acute process potential to become complicated is one whose primary entry is located
in which a tear in the aorta’s inner lining causes the intima-medial aortic at the lesser curvature and one whose primary entry is located close
laminas to separate from the adventitia. This leads to the formation of (<2 cm) to the left subclavian artery.16–19 An entry location at the less­
an additional aortic lumen (false lumen) to the already existing lumen er curvature is associated with a higher risk of retrograde propagation
(true lumen).7 Patients who suffer an acute aortic dissection usually de­ leading to a Type A dissection due to the lack of an anatomical barrier
scribe an abrupt onset of severe ‘tearing’ and radiating chest pain. An opposing the entries located at the larger curvature, where the
aortic dissection involving the ascending aorta is called a Type A dissec­ supra-aortic vessels may hinder retrograde dissection extension.
tion according to the Stanford classification, regardless of whether or Invasive treatment of acute aortic dissection always includes elimin­
not the aortic arch and descending aorta are involved.10 If the dissection ating the most proximal communication between both lumens, which is
involves the aortic arch but not the ascending aorta, it is called a non-A usually the primary entry.3 There are three strategies to do this: (i) by
non-B aortic dissection.11 A dissection involving only the descending resecting the respective aortic segment and replacing it with the
aorta is designated an aortic dissection Type B. According to the Dacron prosthesis; (ii) it is also achievable via thoracic endovascular
DeBakey classification, Type 1 is when the dissection involves the as­ aortic repair (TEVAR) and stent–graft implantation,3 (iii) finally, such
cending and descending aorta, Type 2 when it involves only the a communication can be eliminated by implanting a hybrid prosthesis,
Acute aortic dissection 815

namely the FET prosthesis (Figure 1).4 Eliminating the most proximal Registry for Acute Type A Aortic Dissection, GERAADA), has helped
communication and approximating the intima-media layers to the ad­ provide a web-based scoring system to predict the 30-day mortality
ventitia leads to decompression of the true lumen, stabilization of the rate in patients undergoing surgery for acute aortic dissection Type
intima-media flap, and ideally to a false lumen thrombosis, at least at A. The risk of mortality is calculated according to age, sex, resuscitation
the level of the stent–graft in TEVAR and FET cases. The number before surgery, previous cardiac surgery, intubation at referral, cate­
and size of persisting communications between both lumens influence cholamines at referral, aortic valve regurgitation, malperfusion status,
the grade of thrombosis of the false lumen and the risk of developing neurological status, and the dissection’s extent. The GERAADA score
new malperfusion. To treat them, extensive TEVAR and the implant­ has been validated by two European centres, which have demonstrated
ation of uncovered stent–grafts in the thoraco-abdominal segment good calibration ability and easy accessibility in daily practice.29,30
may be necessary. Neither of the new tools, the TEM classification and GERAADA
Regardless of the aortic dissection type, its treatment starts with score, should be considered instruments for accepting or rejecting
medical therapy. It is continued after intervention and remains import­ treatment—rather, they serve as useful tools to make the best decision
ant throughout the patients’ life. Its main aim is to reduce shear stress on treatment by relying on having access to the underlying pathology’s

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on the dissected aorta by reducing blood pressure and cardiac con­ entirety, the patient’s preoperative status, dissection anatomy, and
tractility. In the acute phase of dissection, treatment with intravenous being able to anticipate the outcome according to fundamental
beta-blocking agents is recommended to reduce the heart rate and parameters.
lower the systolic blood pressure to 100–120 mmHg. In patients There is obviously an urgent need to extend our surgical armament­
with chronic dissection, blood pressure is recommended to be main­ arium with an effective but less invasive treatment modality for patients
tained below 140/90 mmHg. Lifestyle changes, including moderate who carry such an extremely high mortality risk. Endovascular therapy
physical activity, cessation of smoking, blood pressure control, and a has not yet assumed a strong position in the spectrum of treatment op­
healthy diet, are recommended.1 tions because a tube graft alone is seldom able to alleviate a dissection
involving the ascending aorta with all its sequelae like aortic valve regur­
Aortic dissection Type A gitation, aortic destabilization, and organ malperfusion.27 New ap­
proaches like the Endo-Bentall concept will probably become an
Malperfusion- and anatomy-oriented treatment
endovascular modality.31,32 The Endo-Bentall concept is a single-stage
Replacing the ascending aorta has been the treatment of choice in pa­
procedure including an endovascular valve-carrying conduit for treating
tients with acute aortic dissection Type A for many years. Aortic dissec­
aortic valve and ascending pathologies. This concept is thoroughly dis­
tion therapy has more recently evolved to ‘malperfusion and
cussed below.
anatomy-oriented treatment’.14,20 A mere ascending replacement is
Mortality after surgery for aortic dissection Type A differs between
not an effective treatment option for patients presenting with an entry
countries. Abe et al. 9 recently presented data from a nationwide
in the aortic arch and malperfused visceral arteries due to a true lumen
Japanese database, including almost 12 000 surgically managed patients.
collapse. To distinguish varying forms of aortic dissection requiring dif­
Despite a significant rise in preoperative risk factors, the authors re­
ferent treatments and to clarify the vocabulary employed when report­
ported a drop in mortality down to <8% during the study period. It
ing on aortic dissection, Sievers et al. 14 have proposed a new type entry
seems plausible that the increase in surgeries and better outcomes is
malperfusion (TEM) dissection classification. The TEM classification fo­
attributable to enhanced diagnostic modalities, as Japan reportedly
cusses on the patient’s aortic dissection anatomy and malperfusion sta­
has the highest rate of computed tomography (CT) scanners (111 scan­
tus. The TEM classification is based on the Stanford dissection
ners per million population worldwide, reported in 2019). At the same
classification (A and B) but is supplemented by adding the factors
time, in the USA and Germany, there were 42 and 35 scanners available,
non-A non-B aortic dissection, the primary entry tear’s location (E),
respectively, per million population.33,34
and malperfusion status (M). The entry location ‘0’ is added if the pri­
mary entry tear is not visible; ‘1’ if in the ascending aorta; ‘2’ if in the
arch; and ‘3’ if in the descending aorta (E0, E1, E2, and E3) (Graphical Aortic dissection Type non-A non-B
Abstract). To provide information on the malperfusion status, a ‘0’ is
Among all patients with acute aortic dissection, 7%–11% present an
added if malperfusion is absent; ‘1’ if coronary arteries are affected;
aortic dissection Type non-A non-B, one involving the aortic arch but
‘2’ if supra-aortic vessels are dissected; and ‘3’ if the visceral/renal
not the ascending aorta.11 The most proximal communication between
and/or a lower extremity are affected (M0, M1, M2, and M3). A plus
both lumens is in 50% of non-A non-B dissections the aortic arch (TEM
(+) is added if malperfusion is clinically present and a minus (−) is added
non-A non-B E2) and the descending aorta in another 50% (TEM non-A
if it is a radiological finding14 (Figure 2). Most patients with TEM Type A
non-B E3).11 In all TEM non-A non-B E2 patients, the most proximal
E1 M0 benefit from an ascending replacement, whereas most patients
communication between lumens was located at the larger, and not
with TEM Type A E2 M3 + require aortic arch replacement with FET to
the lesser, aortic arch curvature.11 This interesting observation sup­
eliminate the most proximal communication and address the malper­
ports the notion that an entry location at the lesser curvature is asso­
fused visceral organs.
ciated with a higher risk of retrograde propagation leading to a Type A
dissection caused by the lack of an anatomical barrier.15 It seems that
Operative risk assessment aortic dissection starting at the aortic arch’s lesser curvature extends
The risk of mortality in aortic dissection Type A depends on the pa­ retrogradely into the ascending aorta, leading to aortic dissection
tient’s preoperative condition—it varies enormously between 5% Type A—thus, a TEM non-A non-B E2 with entry at the lesser curva­
and 75%.21–27 The patient’s outcome strongly depends on the previous ture is never observed in clinical practice.
neurological injury, the presence or absence of organ malperfusion, and In a series of 43 non-A non-B dissection patients, the majority
the extent of the underlying disease process.28 The largest multicentre (two-thirds) required aortic repair within 2 weeks of their dissection
register for acute aortic dissection Type A worldwide (German diagnosis.11 A third underwent emergency aortic repair. Interestingly,
816 B. Rylski et al.

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Figure 1 Surgical dacron (A), hybrid frozen elephant trunk (B), and stent–graft prosthesis (C) used in treatment of aortic dissection.

there was no difference in invasive treatment timing between arch en­ in aneurysm formation in up to 60% of patients after dissection onset,36
try (TEM E2) and descending entry (TEM E3) types. In other words, the many patients require reinterventions on the descending aorta, entail­
number of patients needing emergency surgery was not associated with ing aortic replacement all the way down to the aortic bifurcation. The
whether the most proximal communication was in the aortic arch or first reintervention after FET is usually a distal TEVAR extension, a cur­
the descending aorta. Similar results in 31% of emergently treated pa­ rently well-established approach associated with a very low risk of com­
tients were observed in a series of 39 patients with TEM non-A non-B plications such as spinal cord ischaemia, acute kidney failure, or
E2 dissection.35 The most common reason for emergent aortic repair in-hospital death.37 To complete the repair of remaining downstream
was an aortic rupture or end-organ malperfusion. Generally speaking, aortic segments, a third open or endovascular procedure may be neces­
emergent aortic treatment for all non-A non-B aortic dissection pa­ sary. This three-step approach is associated with low-perioperative risk
tients is not recommended and is very controversial. Similar to general and good clinical outcomes.38
recommendations for acute aortic dissection treatment, non-A non-B
dissection patients benefit from eliminating the most proximal commu­
nication between both lumens. Not replacing the aortic segment with Aortic dissection Type B
the most proximal communication will mean that sooner or later, most Acute aortic dissection Type B has long been interpreted as a dissection
such patients will require aortic repair because of rapid aortic enlarge­ carrying a substantially lower risk of an unfavourable clinical outcome
ment or retrograde Type A dissection.11,35 than a Type A dissection. Many patients in the acute phase are managed
Non-A non-B dissection patients carry a substantial risk of retro­ only medically, and their clinical course differs substantially from that of
grade Type A dissection after TEVAR. Spontaneous conversion from those presenting with an aortic dissection Type A, always requiring
Type non-A non-B into Type A is infrequent. Therefore, TEVAR should open aortic repair.39 However, there is recent evidence showing a sig­
be avoided in TEM non-A non-B E2 patients because of the high risk of nificant number of patients needing aortic repair in the acute, subacute,
retrograde Type A dissection (observed in up to 26% of patients after or chronic phases of aortic dissection Type B. In the acute phase (up to
TEVAR).11 14 days after dissection onset), the most common reasons are acute
TEVAR is not usually capable of occluding the most proximal com­ end-organ malperfusion, retrograde propagation, and persisting pain.
munication between both lumens in patients whose entry is in the aor­ In the subacute (15–90 days after dissection onset) and chronic (91
tic arch. An effective invasive treatment option for these patients is FET days after dissection onset and later) phases, the reason for aortic re­
implantation.5,35 In a series of 39 TEM non-A non-B E2 patients, 20 pair is usually an increasing aortic diameter.
(56%) underwent total arch replacement via FET.35 A six of them re­ There is evidence of TEVAR’s positive effect in correcting acute aor­
quired emergency FET. There was no in-hospital mortality among tic dissection Type B with an uncomplicated dissection course. The
non-A non-B dissection patients who underwent FET implantation. prospective randomized Investigation of STEnt Grafts in Aortic
Another important FET advantage is the stent–graft segment of this hy­ Dissection (INSTEAD) trial 34,40 and its long-term observational arm
brid prosthesis, which provides an ideal proximal landing zone for later (INSTEAD-XL trial)41 showed TEVAR’s superior outcomes in conjunc­
TEVAR reinterventions. Since the aortic diameter’s enlargement results tion with the best medical treatment (BMT) approach compared with
Acute aortic dissection 817

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Figure 2 Type entry malperfusion aortic dissection classification.

BMT alone. Patients underwent TEVAR between 2 and 52 weeks after increase and aneurysm formation is an initial descending aorta diameter
their dissection onset. The early benefit of TEVAR was aortic remod­ of >40 mm and a false lumen diameter >22 mm.43,44
elling with true lumen recovery and thoracic false lumen thrombosis,
which occurred in 91% of patients with TEVAR (vs. 19% in the BMT
Future aspects in treating acute aortic
alone group, P < 0.001). At their 5-year follow-up, this difference was
even more pronounced with better aortic-related survival in the dissection
BMT + TEVAR patients.41 The ADSORB trial (Acute Dissection Stent Endovascular approach—the Endo-Bentall concept
Grafting or BMT), with its prospective randomized design, yielded simi­ Understanding the patient’s individual pathology is the conditio sine qua
lar results.42 In that trial, the patients underwent TEVAR in addition to non of developing ground-breaking treatment options. All aortic dissec­
BMT during the acute dissection phase. TEVAR led to positive remod­ tions, regardless of their specific type, involve two fundamental compo­
elling with a false lumen thrombosis and stabilized aortic diameter. nents: a primary entry tear, and retro- and antegrade dissection
Long-term results are not yet available. These results led to a IIA extensions. Both open and endovascular techniques are effective only
Class of recommendation based on evidence Class B for TEVAR in un­ when they lead to eliminating the most proximal communication be­
complicated aortic dissection Type B according to the European tween both lumens, decompressing the true lumen, stabilizing the
Society of Cardiology Aortic Guidelines.1 intima-media flap, and ideally, leading to a false lumen thrombosis.
The optimal acute aortic dissection Type B treatment includes BMT TEVAR is effective in treating acute Type B dissections if the aortic anat­
for all patients. Many of those suffering from a complicated dissection omy enables closure of the most proximal communication between
course can undergo TEVAR successfully. Some of them, in the case both lumens. Such TEVAR efficacy is only possible when the proximal
of a large ascending aorta or aortic arch and the lack of an adequate landing zone is long enough, or if it is realized by transposing the
landing zone may require the FET procedure.5 Endovascular treatment supra-aortic vessels, usually the left subclavian artery. TEVAR applica­
is also recommended for certainly uncomplicated Type B dissections tion in patients presenting an acute Type A aortic dissection is limited
with suitable aortic anatomy.1,40–42 In patients whose dissection course by the absence of an appropriate proximal landing zone, the presence
is at risk of changing from uncomplicated to complicated, invasive aortic of significant aortic regurgitation, and frequently observed tamponade.
treatment can effectively stop or at least slow down the disease’s pro­ Several case reports and small series involving tubular stent grafts for
gress. Included in this group are patients with the most proximal com­ acute ascending aortic dissection treatment have been published
munication between both lumens located at the lesser curvature or (Table 1).45–63 An integrated one-stage concept incorporating an endo­
close to the left subclavian artery, both of whom risk the development vascular valve-carrying conduit (Endo-Bentall) to treat the aortic valve
from malperfusion of retrograde dissection.16–19 The size of the most and ascending aortic dissection has been recently described.32 The
proximal communication is also a predictor of a complicated dissection aim of this device is to close the entry tear in the ascending aorta, ini­
course leading to rapid aortic growth or even rupture if the communi­ tiate true lumen expansion, treat the malperfusion and aortic regurgi­
cation size exceeds 10 mm.18 Another risk factor for an aortic diameter tation, drain any pericardial effusion through a transapical approach,
818 B. Rylski et al.

and to stabilize the aorta. This concept involves three landing zones: (i) At the same time, serum/plasma proteomics faces particular chal­
the aortic valve annulus for stable device fixation, (ii) the sinotubular lenges. Fewer than 15 proteins make up > 90% of the protein content,
junction, and (iii) the distal ascending aorta before the takeoff of the often ‘over-shadowing’ less abundant proteins. Biochemical depletion
brachiocephalic trunk to create a sealing effect between the stent–graft strategies are frequently employed, but they may introduce an addition­
and intima-media flap. It is the valve component’s role to both eliminate al source of technical variation and restrict the comparability of studies.
the valve regurgitation and stabilize the device anchoring in the annulus. In recent investigations, non-depleted, ‘native’ serum/plasma was suc­
The stent–graft component’s role is to cover the most proximal com­ cessfully used for proteome profiling with acceptable proteome cover­
munication between both lumens. Coronary perfusion is enabled by age.70 This example illustrates that serum/plasma proteomics
uncovering the stent–graft portion between landing Zones 1 and (alongside other ‘omics’ approaches) is a growing field of methodo­
2. The ascending aorta’s entry tear is closed by the covered stent–graft logical research. Although it is valuable, this innovative aspect somewhat
portion between landing Zones 2 and 3 (Figure 3). According to an ana­ limits the comparability of different studies.
tomic feasibility study, two-thirds of all aortic dissection Type A pa­ The quantitative composition of serum/plasma proteome reveals
tients are potential candidates for treatment entailing endovascular strong inter-individual heterogeneity and is prone to temporal fluctua­

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valve-carrying conduits.31 The Endo-Bentall concept has not yet been tions. A serum proteome study in a large twin population demon­
tested in the clinical setting due to limited interest in the industry, strated a pronounced genetic impact alongside longitudinal
most probably because of the relatively low market value and high costs variation.71 These aspects need to be considered when researching cir­
associated with developing new medical devices. Aortic dissection Type culating protein markers for aortic diseases. Patient-specific, longitudin­
A patients carrying an increased mortality risk, such as those with al proteome profiling enables us to address this aspect by describing
end-organ malperfusion, are those who above all would benefit from relative changes in patient-specific ‘starting’ concentrations of certain
such new technology. Furthermore, older or multimorbid patients protein markers. Moreover, there is evidence that the biostatistical ana­
not qualified for open cardiac surgery and those with severe neuro­ lysis of proteomic data would benefit from a more unified and informed
logical damage might be candidates for Endo-Bentall surgery. All of approach.72
them would have to fulfil the anatomical criteria for Endo-Bentall treat­ Various working groups have successfully reported on serum/plasma
ment, including (i) the location of the primary entry tears in the ascend­ proteome profiling of aortic diseases, thus highlighting this approach’s
ing aorta distal to the sinotubular junction, and (ii) a distance between feasibility and utility. Circulating, potentially diagnostic proteome pro­
the primary entry tear and the sinotubular junction and innominate ar­ files of acute aortic dissections have begun to emerge, involving compo­
tery measuring at least 1.5 cm. In patients whose entry is in the aortic nents of the extracellular matrix and inflammatory proteins.68,73,74 Less
arch, the Endo-Bentall prosthesis might serve as an optimal proximal frequent are prognostic studies like those in the context of chronic dis­
landing zone for branched aortic arch devices like the Relay sections.75 Consensus findings have yet to emerge, and the clinical util­
branched,64,65 Nexus,66 or Cook devices.67 Since there is no healthy ity of marker candidates must still be established in both settings.
aortic segment in the ascending portion in the vast majority of patients Beyond the aforementioned difficulties associated with plasma/serum
with acute aortic dissection Type A, relying on the ascending aorta as proteomics, it might be advisable to design studies encompassing a
the landing zone for an aortic arch branched device carries the risk of wider spectrum of aortic diseases and compare them to ‘aorta-healthy’
a stent–graft-induced proximal new entry. controls.

Biomarkers of acute aortic syndromes Summary

Circulating, blood-based markers facilitate diagnosis, risk stratification, The most recent research in aortic medicine has provided solid answers
prognosis, and therapy monitoring in many disease settings. A very to many clinically relevant questions. The evidence in aortic medicine
prominent example is troponin as a marker of myocardial damage. In has grown dramatically in different areas: most important, our under­
the context of aortic diseases, research efforts for blood-based biomar­ standing of aortic dissection’s pathophysiology as a process involving
kers largely focus on these two topics: establishing diagnostic markers two main components (i) the primary entry, and (ii) both proximal
helps accelerate the diagnosis of acute aortic syndromes, especially in and distal dissection propagation became clearer. Aortic dissection
the context of non-specific symptoms like acute chest pain. For chronic therapy now concentrates on the entry location and dissection propa­
aortic dissection, prognostic markers may indicate impending disease gation, regardless of whether the patient is undergoing open surgical,
exacerbation, hence enabling timely surgical treatment before an acute endovascular, or hybrid repair. Many uncertainties in aortic medicine
emergency situation arises. Numerous studies have tackled these vari­ have been eliminated through research progress. A good example
ous aspects. For instance, Aggrecan68 has recently been suggested as a thereof is a dissection involving the aortic arch but not the ascending
reliable potential biomarker in plasma samples to detect acute aortic aorta, a factor frequently addressed in reports on aortic dissection
dissection. Its concentration was significantly higher in dissection pa­ Type B. Choosing those patients and reporting on them separately
tients than in those presenting an aortic aneurysm, a myocardial infarc­ has shown that there is a different patient group requiring different
tion, or in healthy volunteers. Furthermore, an interleukin-1 receptor and more frequently invasive treatment than patients presenting
family member, namely soluble ST2, revealed superior overall diagnos­ Type B dissection. There is ongoing discussion on what constitutes
tic performance to D-dimer or cardiac troponin I as a rule-out marker the optimal dissection classification system, and we anticipate inter­
for acute aortic dissection.69 national consensus on this in the near future. The uncertainties remain,
The proteome profiling of serum or plasma has become a key re­ namely long-term outcomes after the most recent treatment methods,
search topic in this field. Thanks to modern equipment, only 10 μL ser­ such as TEVAR for uncomplicated aortic dissection Type B, the extent
um are necessary for the quantitative proteome profiling of several of index surgery in Type A aortic dissection, and the best treatment op­
hundred proteins via liquid chromatography—tandem mass tion for patients with various forms of acute non-A non-B dissection.
spectrometry. Among the more promising aspects of treating acute aortic dissection,
Acute aortic dissection 819

Table 1 Literature review on patients with acute aortic dissection Type A treated with TEVAR zone ‘0’

Authors Year of publication No. of patients Access TF/TA Early open conversion 30-day mortality
......................................................................................................................................................................................
45
Dorros et al. 2000 1 Trans-septal 0/1 0/1
46
Wang et al. 2003 1 1/0 0/1 0/1
47
Ihnken et al. 2004 1 1/0 0/1 0/1
48
Verhoye et al. 2006 1 1/0 0/1 0/1
49
Zimpfer et al. 2006 1 1/0 0/1 0/1
50
Senay et al. 2007 1 1/0 0/1 0/1
51
Ye et al. 2011 6 unknown 0/6 1/6

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52
Metcalfe et al. 2012 1 1/0 0/1 0/1
53
Ronchey et al. 2013 4 4/0 0/4 0/4
54
Lu et al. 2013 5 5/0 0/5 0/5
55
Atianzar et al. 2014 1 1/0 0/1 0/1
Bernardes et al.56 2014 2 2/0 0/2 0/2
Tauchi et al.57 2014 1 Trans-carotid 1/1 0/1
58
Vallabhajosyula et al. 2015 2 0/2 0/2 0/2
59
Roselli et al. 2015 11 5/6 1/11 3/11
60
Wilbring et al. 2015 1 1/0 0/1 0/1
61
Tsilimparis et al. 2016 2 2/0 0/2 1/2
62
Kölbel et al. 2017 2 2/0 0/2 1/2
63
Tsilimparis et al. 2019 16 – – –

TF, transfemoral; TA, transapical.

resulting in products enabling safe endovascular therapy for the acutely

dissected ascending aorta. Finally, we have shown that more intensive
research on ‘troponin’ for acute aortic syndromes has the potential
to accelerate and improve our ability to definitively and more specific­
ally diagnose acute aortic diseases; it might prove to be a useful tool for
following up such patients.

Ethics committee statement

As this is a state-of-the-art review article involving no probands,
Institutional Review Board approval was not required.

Funding
All authors declare no funding for this contribution.

Conflict of interest: M.C. is a consultant to Terumo Aortic, Medtronic,

Endospan and NEOS; received speaking honoraria from Bentley and
Cryolife; and is a shareholder of TEVAR Ltd and Ascense Medical. B.R. is
a consultant to Terumo Aortic and shareholder of Ascense Medical.

Figure 3 Endo-Bentall concept to treat acute aortic dissection Type Data availability
A incorporating a transcatheter aortic valve prosthesis and stent–graft No new data were generated or analysed in support of this research.
with uncovered and covered portions.
References
1. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014
ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering
it is the endovascular repair of acute aortic dissection Type A, including
acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult.
the Endo-Bentall concept, that is expected to be improved upon, The task force for the diagnosis and treatment of aortic diseases of the European
820 B. Rylski et al.

Society of Cardiology (ESC). Eur Heart J 2014;35:2873–2926. https://doi.org/10.1093/ 22. Rylski B, Bavaria JE, Milewski RK, Vallabhajosyula P, Moser W, Kremens E, et al.
eurheartj/ehu281 Long-term results of neomedia sinus valsalva repair in 489 patients with type A aortic
2. Volodos’ NL, Shekhanin VE, Karpovich IP, Troian VI, Gur’ev I. Samofiksiruiushchiĭsia dissection. Ann Thorac Surg 2014;98:582–589. https://doi.org/10.1016/j.athoracsur.
sinteticheskiĭ protez dlia éndoprotezirovaniia sosudov [A self-fixing synthetic blood ves­ 2014.04.050
sel endoprosthesis]. Vestn Khir Im I I Grek 1986;137:123–125. 23. Rylski B, Beyersdorf F, Blanke P, Boos A, Hoffmann I, Dashkevich A, et al. Supracoronary
3. Czerny M, Pacini D, Aboyans V, Al-Attar N, Eggebrecht H, Evangelista A, et al. Current ascending aortic replacement in patients with acute aortic dissection type A: what hap­
options and recommendations for the use of thoracic endovascular aortic repair in pens to the aortic root in the long run? J Thorac Cardiovasc Surg 2013;146:285–290.
acute and chronic thoracic aortic disease: an expert consensus document of the https://doi.org/10.1016/j.jtcvs.2012.07.013
European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, 24. Dumfarth J, Kofler M, Stastny L, Plaikner M, Krapf C, Semsroth S, et al. Stroke after
the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European emergent surgery for acute type A aortic dissection: predictors, outcome and neuro­
Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and logical recovery. Eur J Cardiothorac Surg 2018;53:1013–1020. https://doi.org/10.1093/
the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac ejcts/ezx465
Surg 2021;59:65–73. https://doi.org/10.1093/ejcts/ezaa268 25. Larsen M, Trimarchi S, Patel HJ, DiEusanio M, Greason KL, Peterson MD, et al. Extended
4. Berger T, Kreibich M, Mueller F, Rylski B, Kondov S, Schröfel H, et al. The frozen ele­ versus limited arch replacement in acute type A aortic dissection. Eur J Cardiothorac Surg
phant trunk technique for aortic dissection is safe after previous aortic repair. Eur J 2017;52:1104–1110. https://doi.org/10.1093/ejcts/ezx214
Cardiothorac Surg 2021;59:130–136. https://doi.org/10.1093/ejcts/ezaa288 26. Dumfarth J, Peterss S, Luehr M, Etz CD, Schachner T, Kofler M, et al. Acute type A dis­
5. Kreibich M, Siepe M, Berger T, Kondov S, Morlock J, Pingpoh C, et al. The frozen ele­ section in octogenarians: does emergency surgery impact in-hospital outcome or long-

Downloaded from https://academic.oup.com/eurheartj/article/44/10/813/6948118 by guest on 22 June 2024

phant trunk technique for the treatment of type B and type non-A non-B aortic dissec­ term survival? Eur J Cardiothorac Surg 2017;51:472–477. https://doi.org/10.1093/ejcts/
tion. Eur J Vasc Endovasc Surg 2021;61:107–113. https://doi.org/10.1016/j.ejvs.2020.08. ezw387
040 27. Roselli EE, Hasan SM, Idrees JJ, Aftab M, Eagleton MJ, Menon V, et al. Inoperable patients
6. Kreibich M, Berger T, Morlock J, Kondov S, Scheumann J, Kari FA, et al. The frozen ele­ with acute type A dissection: are they candidates for endovascular repair? Interact
phant trunk technique for the treatment of acute complicated type B aortic dissection. Cardiovasc Thorac Surg 2017;25:582–588. https://doi.org/10.1093/icvts/ivx193
Eur J Cardiothorac Surg 2018;53:525–530. https://doi.org/10.1093/ejcts/ezx281 28. Czerny M, Siepe M, Beyersdorf F, Feisst M, Gabel M, Pilz M, et al. Prediction of mortality
7. Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, et al. Current op­ rate in acute type A dissection: the German Registry for Acute Type A Aortic
tions and recommendations for the treatment of thoracic aortic pathologies involving Dissection score. Eur J Cardiothorac Surg 2020;58:700–706. https://doi.org/10.1093/
the aortic arch: an expert consensus document of the European Association for ejcts/ezaa156
Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery 29. Nežić DG, Živković IS, Miličić MD, Milačić PA, Košević DN, Boričić, et al. On-line risk
(ESVS). Eur J Cardiothorac Surg 2019;55:133–162. https://doi.org/10.1093/ejcts/ezy313 prediction models for acute type A aortic dissection surgery: validation of the
8. De Vos M, Ranschaert W, Vergauwen W, Graulus E, Verrelst P, Schepens M. Acute type German Registry of Acute Aortic Dissection Type A score and the European System
A aortic dissection: timeline between onset and treatment. J Vis Surg 2021;7:24. https:// for Cardiac Operative Risk Evaluation II. Eur J Cardiothorac Surg 2022;61:1068–1075.
doi.org/10.21037/jovs-20-54 https://doi.org/10.1093/ejcts/ezab517
9. Abe T, Yamamoto H, Miyata H, Motomura N, Tokuda Y, Tanemoto K, et al. Patient 30. Luehr M, Merkle-Storms J, Gerfer S, Li Y, Krasivskyi I, Vehrenberg J, et al. Evaluation of
trends and outcomes of surgery for type A acute aortic dissection in Japan: an analysis the GERAADA score for prediction of 30-day mortality in patients with acute type A
of more than 10 000 patients from the Japan Cardiovascular Surgery Database. Eur J aortic dissection. Eur J Cardiothorac Surg 2021;59:1109–1114. https://doi.org/10.1093/
Cardiothorac Surg 2020;57:660–667. https://doi.org/10.1093/ejcts/ezz323 ejcts/ezaa455
10. Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of 31. Kreibich M, Soekeland T, Beyersdorf F, Bavaria JE, Schröfel H, Czerny M, et al. Anatomic
acute aortic dissections. Ann Thorac Surg 1970;10:237–247. https://doi.org/10.1016/ feasibility of an endovascular valve-carrying conduit for the treatment of type A aortic
S0003-4975(10)65594-4 dissection. J Thorac Cardiovasc Surg 2019;157:26–34.e1. https://doi.org/10.1016/j.jtcvs.
11. Rylski B, Reser D, Kari F, Perez V, Beyersdorf F, Siepe M, et al. Acute non A, non B aortic 2018.05.045
dissection: definition, treatment and outcome. Eur J Cardiothorac Surg 2017;52: 32. Rylski B, Szeto WY, Bavaria JE, Branchetti E, Moser W, Milewski RK. Development of a
1111–1117. https://doi.org/10.1093/ejcts/ezx142 single endovascular device for aortic valve replacement and ascending aortic repair. J
12. Debakey ME, Henly WS, Cooley DA, Morris GC Jr, Crawford ES, Beall AC Jr. Surgical Card Surg 2014;29:371–376. https://doi.org/10.1111/jocs.12348
management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg 1965;49: 33. Statista, Health, Pharma & Medtech, Medical Technology. Available from: https://www.
130–149. https://doi.org/10.1016/S0022-5223(19)33323-9 statista.com (accessed 24 Jul 2022).
13. Hayashi T, Tsukube T, Yamashita T, Haraguchi T, Matsukawa R, Kozawa S, et al. Impact 34. Kreibich M, Rylski B. Bringing down mortality to single digits in type A aortic dissection:
of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic Japan can. Eur J Cardiothorac Surg 2020;57:667–668. https://doi.org/10.1093/ejcts/
dissection. Circulation 2012;126:S97–S101. https://doi.org/10.1161/CIRCULATIONA ezz359
HA.111.082685 35. Kosiorowska M, Berezowski M, Widenka K, Beyersdorf F, Czerny M, Rylski B. Non-A
14. Sievers HH, Rylski B, Czerny M, Baier ALM, Kreibich M, Siepe M, et al. Aortic dissection non-B acute aortic dissection with entry tear in the aortic arch. Interact Cardiovasc
reconsidered: type, entry site, malperfusion classification adding clarity and enabling out­ Thorac Surg 2022;34:878–884. https://doi.org/10.1093/icvts/ivab375
come prediction. Interact Cardiovasc Thorac Surg 2020;30:451–457. https://doi.org/10. 36. Fattori R, Cao P, De Rango P, Czerny M, Evangelista A, Nienaber C, et al.
1093/icvts/ivz281 Interdisciplinary expert consensus document on management of type B aortic dissec­
15. Loewe C, Czerny M, Sodeck GH, Ta J, Schoder M, Funovics M, et al. A new mechanism tion. J Am Coll Cardiol 2013;61:1661–1678. https://doi.org/10.1016/j.jacc.2012.11.072
by which an acute type B aortic dissection is primarily complicated, becomes compli­ 37. Kreibich M, Siepe M, Berger T, Kondov S, Morlock J, Pingpoh C, et al. Downstream thor­
cated, or remains uncomplicated. Ann Thorac Surg 2012;93:1215–1222. https://doi. acic endovascular aortic repair following zone 2, 100-mm stent graft frozen elephant
org/10.1016/j.athoracsur.2011.12.020 trunk implantation. Interact Cardiovasc Thorac Surg 2022;34:1141–1146. https://doi.
16. Weiss G, Wolner I, Folkmann S, Sodeck G, Schmidli J, Grabenwoger M, et al. The loca­ org/10.1093/icvts/ivab338
tion of the primary entry tear in acute type B aortic dissection affects early outcome. Eur 38. Berger T, Kreibich M, Rylski B, Kondov S, Fagu A, Beyersdorf F, et al. The 3-step ap­
J Cardiothorac Surg 2012;42:571–576. https://doi.org/10.1093/ejcts/ezs056 proach for the treatment of multisegmental thoraco-abdominal aortic pathologies.
17. Trimarchi S, Jonker FH, van Bogerijen GH, Tolenaar JL, Moll FL, Czerny M, et al. Interact Cardiovasc Thorac Surg 2021;33:269–275. https://doi.org/10.1093/icvts/ivab062
Predicting aortic enlargement in type B aortic dissection. Ann Cardiothorac Surg 2014; 39. Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U, et al.
3:285–291. https://doi.org/10.3978/j.issn.2225-319X.2014.05.01 Insights from the International Registry of Acute Aortic Dissection: a 20 year experience
18. Evangelista A, Salas A, Ribera A, Ferreira-González I, Cuellar H, Pineda V, et al. of collaborative clinical research. Circulation 2018;137:1846–1860. https://doi.org/10.
Long-term outcome of aortic dissection with patent false lumen: predictive role of entry 1161/CIRCULATIONAHA.117.031264
tear size and location. Circulation 2012;125:3133–3141. https://doi.org/10.1161/ 40. Nienaber C, Rousseau H, Eggebrecht H, Kische S, Fattori R, Rehders T, et al. A rando­
CIRCULATIONAHA.111.090266 mized comparison of strategies for noncomplicated type B aortic dissection—the
19. Codner JA, Lou X, Duwayri YM, Chen EP, Binongo JN, Moon R, et al. The distance of the INvestigation of STEnt-grafts in aortic dissection (INSTEAD) trial. Circulation 2009;
primary intimal tear from the left subclavian artery predicts aortic growth in uncompli­ 120:2519–2528. https://doi.org/10.1161/CIRCULATIONAHA.109.886408
cated type B aortic dissection. J Vasc Surg 2019;69:692–700. https://doi.org/10.1016/j.jvs. 41. Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G, et al.
2018.05.245 Endovascular repair of type B aortic dissection: long-term results of the randomized in­
20. Augoustides JG, Szeto WY, Desai ND, Pochettino A, Cheung AT, Savino JS, et al. vestigation of stent grafts in aortic dissection trial. Circ Cardiovasc Intervent 2013;6:
Classification of acute type A dissection: focus on clinical presentation and extent. 407–416. https://doi.org/10.1161/CIRCINTERVENTIONS.113.000463
Eur J Cardiothorac Surg 2011;39:519–522. https://doi.org/10.1016/j.ejcts.2010.05.038 42. Brunkwall J, Kasprzak P, Verhoeven E, Heijmen R, Taylor P; ADSORB Trialists, et al.
21. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic
The international registry of acute aortic dissection (IRAD): new insights into an old dis­ remodeling; 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg 2014;48:
ease. JAMA 2000;283:897–903. https://doi.org/10.1001/jama.283.7.897 285–291. https://doi.org/10.1016/j.ejvs.2014.05.012
Acute aortic dissection 821

43. Ante M, Mylonas S, Skrypnik D, Bischoff MS, Rengier F, Brunkwall J, et al. Prevalence of 59. Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting
the computed tomographic morphological DISSECT predictors in uncomplicated for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg 2015;149:
Stanford type B aortic dissection. Eur J Vasc Endovasc Surg 2018;56:525–533. https:// 144–151. https://doi.org/10.1016/j.jtcvs.2014.07.109
doi.org/10.1016/j.ejvs.2018.06.033 60. Wilbring M, Ghazy T, Matschke K, Kappert U. Complete endovascular treatment of
44. Song JM, Kim SD, Kim JH, Kim MJ, Kang DH, Seo JB, et al. Long-term predictors of des­ acute proximal ascending aortic dissection and combined aortic valve pathology. J
cending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol Thorac Cardiovasc Surg 2015;149:e59–e60. https://doi.org/10.1016/j.jtcvs.2015.01.002
2007;50:799–804. https://doi.org/10.1016/j.jacc.2007.03.064 61. Tsilimparis N, Debus ES, Oderich GS, Haulon S, Terp KA, Roeder B, et al. International
45. Dorros G, Dorros AM, Planton S, O’Hair D, Zayed M. Transseptal guidewire stabiliza­ experience with endovascular therapy of the ascending aorta with a dedicated endo­
tion facilitates stent-graft deployment for persistent proximal ascending aortic dissec­ graft. J Vasc Surg 2016;63:1476–1482. https://doi.org/10.1016/j.jvs.2015.12.027
tion. J Endovasc Ther 2000;7:506–512. https://doi.org/10.1177/152660280000700612 62. Kölbel T, Detter C, Carpenter SW, Rohlffs F, von Kodolitsch Y, Wipper S, et al. Acute
46. Wang ZG, Massimo CG, Li M, Pan SL, Zhang HK, Jing W, et al. Deployment of endograft type A aortic dissection treated using a tubular stent-graft in the ascending aorta and a
in the ascending aorta to reverse type A aortic dissection. Asian J Surg 2003;26:117–119. multibranched stent-graft in the aortic arch. J Endovasc Ther 2017;24:75–80. https://doi.
https://doi.org/10.1016/S1015-9584(09)60232-3 org/10.1177/1526602816680089
47. Ihnken K, Sze D, Dake MD, Fleischmann D, Van der Starre P, Robbins R. Successful 63. Tsilimparis N, Drewitz S, Detter C, Spanos K, von Kodolitsch Y, Rohlffs F, et al.
treatment of a Stanford type A dissection by percutaneous placement of a covered Endovascular repair of ascending aortic pathologies with tubular endografts: a single-
stent graft in the ascending aorta. J Thorac Cardiovasc Surg 2004;127:1808–1810. center experience. J Endovasc Ther 2019;26:439–445. https://doi.org/10.1177/
https://doi.org/10.1016/j.jtcvs.2003.12.019 1526602819852083

Downloaded from https://academic.oup.com/eurheartj/article/44/10/813/6948118 by guest on 22 June 2024

48. Verhoye JP, Sze DY, Ihnken K, Hellinger JC, Robbins RR, Dake MD. Virtual angioscopy in 64. Czerny M, Berger T, Kondov S, Siepe M, Saint Lebes B, et al. Results of endovascular
type-A dissection: ascending aortic stent-graft repair. Ann Thorac Surg 2006;82:347. aortic arch repair using the relay branch system. Eur J Cardiothorac Surg 2021;60:
https://doi.org/10.1016/j.athoracsur.2004.10.045 662–668. https://doi.org/10.1093/ejcts/ezab160
49. Zimpfer D, Czerny M, Kettenbach J, Schoder M, Wolner E, Lammer J, et al. Treatment 65. D’Onofrio A, Caraffa R, Cibin G, Antonello M, Gerosa G. Total endovascular aortic arch
of acute type a dissection by percutaneous endovascular stent-graft placement. Ann repair: from dream to reality. Medicina (Kaunas) 2022;58:372. https://doi.org/10.3390/
medicina58030372
Thorac Surg 2006;82:747–749. https://doi.org/10.1016/j.athoracsur.2005.11.066
66. Planer D, Elbaz-Greener G, Mangialardi N, Lindsay T, D’Onofrio A, Schelzig H, et al.
50. Senay S, Alhan C, Toraman F, Karabulut H, Dagdelen S, Cagil H. Endovascular stent-graft
NEXUS Arch: a multicenter study evaluating the initial experience with a novel aortic
treatment of type A dissection: case report and review of literature. Eur J Vasc Endovasc
arch stent graft system. Ann Surg 2021. https://doi.org/10.1097/SLA.0000000000004843
Surg 2007;34:457–460. https://doi.org/10.1016/j.ejvs.2007.06.015
67. Spanos K, Panuccio G, Rohlffs F, Heidemann F, Tsilimparis N, Kölbel T. Technical as­
51. Ye C, Chang G, Li S, Hu Z, Yao C, Chen W, et al. Endovascular stent-graft treatment for
pects of branched thoracic arch graft implantation for aortic arch pathologies. J
Stanford type A aortic dissection. Eur J Vasc Endovasc Surg 2011;42:787–794. https://doi.
Endovasc Ther 2020;27:792–800. https://doi.org/10.1177/1526602820925443
org/10.1016/j.ejvs.2011.08.015
68. König KC, Lahm H, Dreßen M, Doppler SA, Eichhorn S, Beck N, et al. Aggrecan: a new
52. Metcalfe MJ, Karthikesalingam A, Black SA, Loftus IM, Morgan R, Thompson MM. The
biomarker for acute type A aortic dissection. Sci Rep 2021;11:10371. https://doi.org/10.
first endovascular repair of an acute type A dissection using an endograft designed
1038/s41598-021-89653-y
for the ascending aorta. J Vasc Surg 2012;55:220–222. https://doi.org/10.1016/j.jvs.
69. Wang Y, Tan X, Gao H, Yuan H, Hu R, Jia L, et al. Magnitude of soluble ST2 as a novel
2011.06.116
biomarker for acute aortic dissection. Circulation 2018;137:259–269. https://doi.org/10.
53. Ronchey S, Serrao E, Alberti V, Fazzini S, Trimarchi S, Tolenaar JL, et al. Endovascular
1161/CIRCULATIONAHA.117.030469
stenting of the ascending aorta for type A aortic dissections in patients at high risk 70. Geyer PE, Arend FM, Doll S, Louiset ML, Virreira Winter S, et al. High-resolution serum
for open surgery. Eur J Vasc Endovasc Surg 2013;45:475–480. https://doi.org/10.1016/j. proteome trajectories in COVID-19 reveal patient-specific seroconversion. EMBO Mol
ejvs.2013.01.033 Med 2021;13:e14167. https://doi.org/10.15252/emmm.202114167
54. Lu Q, Feng J, Zhou J, Zhao Z, Bao J, Feng R, et al. Endovascular repair of ascending aortic 71. Liu Y, Buil A, Collins BC, Gillet LC, Blum LC, Cheng LY, et al. Quantitative variability of
dissection: a novel treatment option for patients judged unfit for direct surgical repair. J 342 plasma proteins in a human twin population. Mol Syst Biol 2015;11:786. https://doi.
Am Coll Cardiol 2013;61:1917–1924. https://doi.org/10.1016/j.jacc.2012.08.994 org/10.15252/msb.20145728
55. Atianzar K, Mohamad A, Galazka P, Keller VA, Delafontaine P, Sam AD 2nd. 72. Choi M, Eren-Dogu ZF, Colangelo C, Cottrell J, Hoopmann MR, Kapp EA, et al. ABRF
Endovascular stent-graft repair of ascending aortic dissection with a commercially avail­ Proteome informatics research group (iPRG) 2015 study: detection of differentially
able thoracic endograft. Ann Thorac Surg 2014;98:715–717. https://doi.org/10.1016/j. abundant proteins in label-free quantitative LC-MS/MS experiments. J Proteome Res
athoracsur.2013.09.047 2017;16:945–957. https://doi.org/10.1021/acs.jproteome.6b00881
56. Bernardes RC, Navarro TP, Reis FR, Lima LC, Monteiro EL, Procopio RJ, et al. Early ex­ 73. Lee R, Cassimee I, Huang H, Lapolla P, Ngetich E, Chandrashekar A, et al. Integrated
perience with off-the-shelf endografts using a zone 0 proximal landing site to treat the plasma and tissue proteomics reveals attractin release by intraluminal thrombus of ab­
ascending aorta and arch. J Thorac Cardiovasc Surg 2014;148:105–112. https://doi.org/10. dominal aortic aneurysms and improves aneurysm growth prediction in humans. Ann
1016/j.jtcvs.2013.07.049 Surg 2022;275:1206–1211. https://doi.org/10.1097/SLA.0000000000004439
57. Tauchi Y, Tanioka H, Kondoh H, Satoh H, Matsuda H. Emergency rescue endovascular 74. Xiao Z, Xue Y, Yao C, Gu G, Zhang Y, Zhang J, et al. Acute aortic dissection biomarkers
stent grafting of ascending aorta to relieve life-threatening coronary obstruction in a identified using isobaric tags for relative and absolute quantitation. Biomed Res Int 2016;
case of acute aortic dissection. Ann Thorac Surg 2014;98:e131–e133. https://doi.org/ 2016:6421451. https://doi.org/10.1155/2016/6421451
10.1016/j.athoracsur.2014.08.059 75. Andersen C B, Lindholt JS, Urbonavicius S, Halekoh U, Jensen PS, Stubbe J, et al.
58. Vallabhajosyula P, Gottret JP, Bavaria JE, Desai ND, Szeto WY. Endovascular repair of Abdominal aortic aneurysms growth is associated with high concentrations of plasma
the ascending aorta in patients at high risk for open repair. J Thorac Cardiovasc Surg 2015; proteins in the intraluminal thrombus and diseased arterial tissue. Arterioscler Thromb
149:S144–S150. https://doi.org/10.1016/j.jtcvs.2014.07.063 Vasc Biol 2018;38:2254–2267. https://doi.org/10.1161/ATVBAHA.117.310126