The American journal of emergency medicine · 2025
Relationship of aortic outflow tract size on point-of-care ultrasound to aortic dissection diagnosis.
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Boivin Zachary, Agaraj Irini, Danta Michael, Denkewicz Ryan, Lopez Aisha Droz, Greenstein Daniel, Hesami Mina, Moore Christopher L
Аннотация
INTRODUCTION: Aortic dissection is an uncommon diagnosis with a high mortality rate. Point-of-care ultrasound (POCUS) can serve as an adjunct to computed tomography angiography (CTA) to diagnose aortic dissection. We aimed to determine the association of the aortic outflow tract (AOFT) diameter on POCUS with Stanford type A and type B dissections, along with determining the time to POCUS and CTA.
METHODS: This was a retrospective cross-sectional study of all patients presenting to an Emergency Department (ED) with over 110,000 annual visits between November 1, 2013, and November 30, 2024, found to have an aortic dissection. All ED patients ≥18 years old with an aortic dissection were included based on ICD-10 code. We also separately included 100 random patients for a normal non-dissection cohort who had received a cardiac POCUS. Patients were excluded based on chart review if their chart was unable to be located, if they had an aortic ulceration, abdominal aortic aneurysm, or thoracic aortic dilation without dissection; if they had a previously repaired aortic dissection without acute dissection; if they had a chronic dissection; duplicate visits; or an incorrectly coded visit. Chart review and POCUS image review was conducted by trained study investigators for patient demographics, diagnosis, outcomes, and AOFT diameter measured outside-to-inside. The primary study outcome was the size of AOFT on ED POCUS, while the secondary outcomes were time to CTA in patients who were not transferred with a known dissection comparing both patients who had CTA first versus POCUS first, and comparing those with and without POCUS.
RESULTS: A total of 223 aortic dissection patients plus 100 non-dissection patients were included. There were 132 (59.2 %) type A dissections and 91 (40.8 %) type B dissections, with an overall mortality rate of 21.1 % (47 deaths). Of the 141 patients (63.2 %) with a POCUS performed, there were 98 type A dissections with an average AOFT size of 4.65 cm (median 4.65 cm; IQR 4.05-5.18 cm) and 43 type B dissections with an average AOFT size of 3.94 cm (median 3.85 cm; IQR 3.55-4.36 cm), which was a statistically significant difference (p < 0.001), and significantly greater than the normal cohort AOFT of 3.29 cm (median 3.32 cm; IQR 3.02-3.60 cm). There was no statistically significant difference in time to CTA in both patients who had CTA first versus POCUS first (p = 0.54), and comparing those with and without POCUS (p = 0.67).
CONCLUSION: The average AOFT size was 4.65 cm (median 4.65 cm; IQR 4.05-5.18 cm) for type A dissections and 3.94 cm (median 3.85 cm; IQR 3.55-4.36 cm) for type B dissections, compared to 3.29 cm (median 3.32 cm; IQR 3.02-3.60 cm) in a non-dissection cohort, showing a strong association between aortic dissection and a dilated AOFT in a single center cross-sectional study. AOFT measurement alone should not be used to rule out aortic dissection. Future research should focus on improving specificity of POCUS for aortic dissection through a prospective multicentered validation of AOFT measurements.
METHODS: This was a retrospective cross-sectional study of all patients presenting to an Emergency Department (ED) with over 110,000 annual visits between November 1, 2013, and November 30, 2024, found to have an aortic dissection. All ED patients ≥18 years old with an aortic dissection were included based on ICD-10 code. We also separately included 100 random patients for a normal non-dissection cohort who had received a cardiac POCUS. Patients were excluded based on chart review if their chart was unable to be located, if they had an aortic ulceration, abdominal aortic aneurysm, or thoracic aortic dilation without dissection; if they had a previously repaired aortic dissection without acute dissection; if they had a chronic dissection; duplicate visits; or an incorrectly coded visit. Chart review and POCUS image review was conducted by trained study investigators for patient demographics, diagnosis, outcomes, and AOFT diameter measured outside-to-inside. The primary study outcome was the size of AOFT on ED POCUS, while the secondary outcomes were time to CTA in patients who were not transferred with a known dissection comparing both patients who had CTA first versus POCUS first, and comparing those with and without POCUS.
RESULTS: A total of 223 aortic dissection patients plus 100 non-dissection patients were included. There were 132 (59.2 %) type A dissections and 91 (40.8 %) type B dissections, with an overall mortality rate of 21.1 % (47 deaths). Of the 141 patients (63.2 %) with a POCUS performed, there were 98 type A dissections with an average AOFT size of 4.65 cm (median 4.65 cm; IQR 4.05-5.18 cm) and 43 type B dissections with an average AOFT size of 3.94 cm (median 3.85 cm; IQR 3.55-4.36 cm), which was a statistically significant difference (p < 0.001), and significantly greater than the normal cohort AOFT of 3.29 cm (median 3.32 cm; IQR 3.02-3.60 cm). There was no statistically significant difference in time to CTA in both patients who had CTA first versus POCUS first (p = 0.54), and comparing those with and without POCUS (p = 0.67).
CONCLUSION: The average AOFT size was 4.65 cm (median 4.65 cm; IQR 4.05-5.18 cm) for type A dissections and 3.94 cm (median 3.85 cm; IQR 3.55-4.36 cm) for type B dissections, compared to 3.29 cm (median 3.32 cm; IQR 3.02-3.60 cm) in a non-dissection cohort, showing a strong association between aortic dissection and a dilated AOFT in a single center cross-sectional study. AOFT measurement alone should not be used to rule out aortic dissection. Future research should focus on improving specificity of POCUS for aortic dissection through a prospective multicentered validation of AOFT measurements.