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Combined type B aortic dissection and fusiform abdominal aortic aneurysm. Case reports.

Two patients are described with a combined type B aortic dissection and a fusiform abdominal aortic aneurysm, the dissection not involving the aneurysm. In a seventy-year-old man a type B aortic dissection and a large abdominal aneurysm were found. An infrarenal aortic bifurcation graft was inserted. He died fifteen months later of cardiogenic shock. In a sixty-six-year-old man diagnosis of a primary aortoduodenal fistula was made together with a limited type B dissection. A straight aortic interposition graft was inserted. He died eleven months later of the complications of a secondary aortoduodenal fistula. Although combination of aortic dissection and abdominal aneurysm is a rare occurrence, conservative management of the aortic dissection and interposition graft for the abdominal aneurysm was successful as initial treatment in these 2 patients.

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D-dimers in the emergency department evaluation of aortic dissection.

UNLABELLED: Aortic dissection (AD) is the most common acute aortic condition requiring urgent surgery. AD, if not diagnosed in the emergency department (ED), is frequently fatal. AD is a difficult antemortem diagnosis. OBJECTIVES: To determine if acute AD is associated with an elevation of fibrin degradation products, D-dimers. METHODS: This was a retrospective chart review of patients diagnosed as having AD in the ED in whom a D-dimer determination was obtained in the ED, prior to any therapeutic intervention. The study was conducted in an urban Level I trauma center between October 1996 and September 2000. Exclusion criteria were referred patients with known diagnosis of AD. The D-dimer assay used was the semiquantitative latex agglutination assay, with a normal range up to 0.5 micro g/mL. RESULTS: One hundred fifty-six patients were diagnosed as having AD in the ED. Seven patients had a D-dimer assay during their workup. All seven had a positive test. CONCLUSIONS: All seven patients with an AD who had D-dimer assays performed in the ED had positive results by latex agglutination.

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Surgical therapy of a dissecting aortic aneurysm involving a right-sided aortic arch.

Dissecting aortic aneurysm involving a right-sided aortic arch is apparently quite rare. A patient with this unusual entity is described. By performing an extraanatomic bypass, the aneurysm was excluded between stainless steel staples. The patient was discharged from the hospital 21 days postoperatively. Although the reasons for the extreme rarity of this entity are not clear, precise anatomic definition is required for successful surgical therapy.

Aortic Dissection↗

Aortic dissection with pseudo-aortic regurgitation and transient myocardial ischemia--a case report.

Aortic dissection causes acute aortic regurgitation in one half to two thirds of cases, which is due, mainly, to dilatation of the aortic root. The unsupported intimal flap prolapse, which crosses the aortic valve, rarely produces aortic regurgitation. Moreover, transient myocardial ischemia rarely occurs by malperfusion, which might be due to compression of the ostium of the coronary artery by the false lumen or by the intimal flap. The authors had a rare case of aortic dissection with "pseudo-''aortic regurgitation; ie, regurgitation flow existed just in the area surrounding the intimal flap during diastole and produced transient myocardial ischemia. In this case, the swinging motion of the intimal flap through the aortic valve caused pseudoaortic regurgitation and transient myocardial ischemia, which should be repaired by emergency surgical procedure. Surgery was successful and saved the patient's life.

Aortic Rupture↗

Acute aortic dissection.

Acute aortic dissection is initiated by an intimal tear most often found in the ascending or descending thoracic aorta. A high index of suspicion is necessary to establish diagnosis. In the acute setting, transoesophageal echocardiography is very helpful to confirm the diagnosis, locate the intimal tear and demonstrate the extent of dissection. Acute type A dissection is a surgical emergency contrary to type B dissection which is treated medically unless complications arise. With correct treatment, mortality of these life-threatening disorders has been reduced during the last decade and long-term survival of discharged patients is around 50%. Careful follow-up is necessary to detect late complications, mainly the occurrence of a post-dissection aneurysm.

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[A successful emergency operation of acute aortic dissection (DeBakey I) with aortic root rupture and right coronary avulsion].

We report a successful emergency operation for a patient of acute aortic dissection with cardiogenic shock. A 73-year-old man was admitted to our hospital with a complaint of severe chest pain. The emergency aortography and echocardiography demonstrated aortic dissection (DeBakey I) with aortic valve regurgitation and massive pericardial effusion. The emergency operation started 2 hours after the onset. We performed reconstruction of ascending aorta and aortic valve using composite graft, since the patient had aortic root rupture and right coronary avulsion. Subsequently, the right coronary bypass grafting of saphenous vein was performed in addition to the reimplantation of left coronary artery by carrel patch method. The postoperative course was uneventful and the patient remains asymptomatic.

Acute Disease↗

[Differential diagnostic value of clinical symptoms of aortic dissection].

Acute aortic dissection is a relatively common catastrophic illness, in which the circulation of any major artery arising from the aorta may be compromised and any organ or organ system may become ischemic. Hereby a protean clinical picture may be developed. This disease is characterized by migration of symptoms which may be difficult to evaluate. It is expedient to range the various symptoms produced by aortic dissection among cardiac, pulmonary, cerebral and neurologic, abdominal and renal groups. This may be especially helpful diagnostically if more than one system has been involved. An accurate differential diagnosis can be made if the history and presented signs are carefully evaluated.

Aortic Diseases↗

Acute aortic dissection.

Acute aortic dissection is a surgical emergency which, if not adequately treated, carries a high mortality. With appropriate early intervention, however, a significant percentage of patients can be salvaged. This article discusses how to approach and manage this condition.

Acute Disease↗

Aorta-right atrial fistula: an unusual complication of ascending aortic dissection.

Ascending aortic dissection complicated by aorta-right atrial fistula is a very rare occurrence. The patient may present with atypical clinical findings such as a continuous murmur or atrioventricular block, making the diagnosis difficult. Surgical repair is straightforward unless the correct diagnosis is missed, in which case there may be difficulties during the initial period of cardiopulmonary bypass. This report deals with the successful management of a 67-year-old man with this condition.

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[Common carotid artery dissection propagated from acute aortic dissection: a case successfully treated by PTA].

We reported a rare case, which was successfully treated by PTA, of right common carotid artery dissection propagated from acute aortic dissection (AAD) type A. A 45-year-old male with a past history of hypertension and an artificial graft replacement of the abdominal aorta due to AAD type B, 7 years ago, was brought into our hospital by ambulance 30 minutes after an attack of fainting and left hemiparesis. On admission, the patient complained not of chest pain or left hemiparesis, but nausea. At that time his consciousness level was JCS 1. During examinations, he had the same attack twice and his consciousness level deteriorated to JCS 2. Brain MRI showed no abnormality, but cervical MRA did not visualize the right carotid artery and thoracic CT depicted acute aortic dissection including branches of the aorta. Emergent angiography disclosed that the dissecting 99% stenosis of the right common carotid artery had developed from AAD type A with poor collateral blood flow. PTA was carried out 8 times and reduced the residual stenosis to about 50% with shortened circulation time. The patient's consciousness disturbance improved. After the replacement of the whole aortic arch in an artificial graft, the residual stenosis disappeared. The patient recovered without neurological deficit but right frontal silent embolic infarction caused by the artificial graft replacement was detected. AAD is a catastrophic illness and sometimes accompanied by devastating ischemic cerebral disease (ICD) because of propagation of dissecting to extracranial vessels. This is the first report that shows the efficacy of PTA for treatment of ICD associated with AAD.

Acute Disease↗

[Haustration of the ascending aorta as differential diagnosis of aortic dissection].

Suspected aortic dissection requires undelayed diagnosis by use of imaging modalities such as transesophageal ultrasound, contrast enhanced computed tomography (CT), or magnetic resonance imaging (MRI). This case report describes an asymptomatic man with echocardiographic suspicion of aortic arch dissection. The discordance with the clinical presentation led to CT, MRI, and eventually to contrast angiography, eventually confirming extensive haustration of the thoracic aorta and excluding any acute or chronic dissection. This case demonstrates haustration of the thoracic aorta as a potential differential diagnostic problem when solely using ultrasound techniques.

Aortic Dissection↗

[Acute type A aortic dissection after replacement of descending thoracic aorta for type B aortic dissection].

Two cases of acute type A aortic dissection after replacement of descending thoracic aorta for type B dissection were reported. One case involved a 75-year-old male who had hypertension. The second case involved a 33-year-old female with a familial history of thoracic aneurysms. Both patients underwent simultaneous graft replacement of the ascending aorta and total aortic arch using selective perfusion to the brain. Both patients survived the operations, and the postoperative courses were satisfactory. Acute type A dissection after replacement of descending thoracic aorta for type B dissection is rare, and careful and long-term follow-up is needed for the patients.

Acute Disease↗

[Atherosclerosis-related aortic dissection].

Penetrating atherosclerotic aortic ulcers (PAU) can cause aortic dissection. Of 38 autopsy cases with aortic dissection, 6 (15.8%) had severe atherosclerotic changes, resembling those of PAU, at the site of entry (SE). Clinicopathological data on these patients were compared with those on 32 cases with nonatheromatous dissection (5 with Marfan syndrome or its forme fruste and 27 without Marfan syndrome) and 13 with atherosclerotic saccular aneurysms. For control study, the aorta of a 44-year-old woman who died of pulmonary cancer was used. Compare to nonatheromatous dissection, atherosclerosis-related aortic dissections were found in older women. Four cases were complicated by saccular aneurysms of the aorta. The SE was located in the ascending aorta in 1 and the descending aorta in 5. These sites usually were ulcerated atheromatous plaques or longitudinal fissures rather than transverse tears. Immunohistochemical examination of the SE revealed that MMP-1, 2, 9 and TIMP-2 were expressed in macrophages and/or interstitium, similar to the findings in atheromatous plaque or PAU. We propose that atherosclerosis-related aortic dissection differs from the usual classical aortic dissection. Patients with this lesion have a high risk of re-dissection from the new SE in the same lesion.

Adult↗

Predictors of proximal aortic dissection at the time of aortic valve replacement.

BACKGROUND: Type I aortic dissection develops in 0.6% of patients late after aortic valve replacement (AVR), and 13% of patients with type I aortic dissections have a history of AVR. Predictors of aortic dissection at AVR, however, have not been characterized. METHODS AND RESULTS: A study group of 33 patients with type I aortic dissection had aortic surgery 49+/-55 months after routine AVR. A group of 101 controls, who did not have morphological progression of aortic diameters >/=6 years after AVR, was used to identify predictors of postsurgical dissection. Multivariate analysis identified aortic regurgitation (P<0.002) and fragility (P<0.001) or thinning of the aortic wall (P<0.007) at AVR as predictors, associated with a 14%, 22%, and 7% probability of late aortic dissection, respectively. Clamping times, types of valve prostheses, concomitant coronary artery bypass grafting, and mean ascending aortic diameters of 43+/-10 mm at AVR did not predict late dissection. A separate analysis of 29 nondissecting aneurysms of the ascending aorta developing 104+/-64 months after routine AVR revealed younger age at AVR (P<0.003) and congenitally bicuspid aortic valves (P<0.03) as predictors of late aneurysm formation. CONCLUSIONS: Aortic regurgitation combined with fragile and thinned aortic walls in patients with moderate aortic dilation may reflect aortic root disease, with a high risk for postsurgical aortic sequelae if it is treated incompletely by isolated valve replacement.

Adult↗