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PubMed1999

Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas.

This article confirms the existence of two variants of acute aortic pathology, the penetrating atherosclerotic ulcer (PAU) and the intramural hematoma (IMH), which are radiologically distinct from classic aortic dissection. Table 4 reviews the characteristics distinguishing PAU from classic aortic dissection and IMH. We took as a matter of definition that classic aortic dissection involves a flap which traverses the aortic lumen. We defined PAU and IMH as nonflap lesions, with PAU demonstrating a crater extending from the aortic lumen into the space surrounding the aortic lumen. This categorization can be summarized with the expression, "no flap, no dissection." With these definitions made, re-review of the imaging studies for the present report identified 36 such lesions out of 214 cases originally read as aortic dissection. Therefore, these variant lesions accounted for over 1 out of 8 acute aortic pathologies. Besides confirming the existence of the conditions, PAU and IMH, as distinct radiographic lesions, this series strongly suggests that these two conditions constitute distinct clinical entities as well. Table 4 summarizes the clinical patterns of these two entities as apparent from the present study, and contrasts them with classic aortic dissections. In particular, the following observations, some of which are consonant findings in smaller series, can be made regarding the typical patient profiles of PAU and IMH from the present study: The patients with PAU and IMH are distinctly older than those with type A aortic dissection (74.0 and 73.9 versus 56.5 years, P = 0.0001). Although not statistically significant, PAU and IMH patients tend to be older than patients with type B aortic dissections as well. For PAU and IMH, unlike aortic dissection, the concentration in the elderly is manifested in a very small standard deviation of the mean age (see Fig. 13); these two entities, PAU and IMH, are essentially diseases of the seventh, eighth, and ninth decades of life. Patients with PAU and IMH are almost invariably hypertensive (about 94% of cases). The pain of PAU and IMH mimics that of classic aortic dissection, with anterior symptoms in the ascending aortic lesions and intrascapular or back pain with descending aortic lesions. Unlike classic dissection, PAU and IMH do not produce branch vessel compromise or occlusion and do not result in ischemic manifestations in the extremities or visceral organs. PAU and IMH are more focal lesions than classic aortic dissection, which frequently propagates for much or the entire extent of the thoracoabdominal aorta. PAU is uniformly associated with severe aortic arteriosclerosis and calcification, whereas classic dissection often occurs in aortas with minimal arteriosclerosis and calcification. PAU and IMH tend to occur in even larger aortas than classic aortic dissection (6.2 and 5.5 versus 5.2 cm, P = 0.01). PAU and IMH are strongly associated with AAA, which is seen concomitantly in 42.1% of PAU patients and 29.4% of IMH patients. PAU and IMH are largely diseases of the descending aorta (90% for PAU and 71% for IMH). Although our pathology data is limited, we do feel that an inherent difference in the histologic intramural level of the hematoma may underlie the pathophysiologic process that determines which patient develops a typical dissection and which develops an intramural hematoma. In particular, we feel that the level of blood collection is more superficial, closer to the adventitia, in IMH than in typical aortic dissection. This may explain why the inner layer does not prolapse into the aorta on imaging studies or when the aorta is opened in the operating room. This more superficial location would also explain the high rupture rates as compared to classic aortic dissection (Fig. 14, Table 3). We did find PAU and IMH to behave much more malignantly than typical descending aortic dissection. As seen in Figure 6, the rupture rate is much higher than for aortic dissection. Docume

Aged↗

PubMed2001

Is preservation of the aortic valve different between acute and chronic type A aortic dissections?

OBJECTIVES: In repair of acute type A aortic dissection, the type of proximal repair of the ascending aorta has been of great interest; however, very few reports are available regarding this issue in chronic aortic dissection. The surgical strategies for proximal repair in chronic dissection may not the same as those for acute dissection. We reviewed our 10-year experience of both acute and chronic type A aortic dissections in order to elucidate the validity of valve preservation and the long-term results of aortic regurgitation (AR). METHODS: From 1990 to 1999, 93 patients (55 acute and 38 chronic dissections) underwent operation for type A aortic dissection. Five Marfan patients were included in each group. The degree of AR was evaluated by echocardiography before and after (at hospital discharge and late follow-up) operation. RESULTS: In acute type A aortic dissection (n=55), 16 patients had AR grade II or greater (29%), of whom seven had AR grade III (13%). In 29 patients, dissection was found below the sinotubular junction (STJ) and 14 patients had AR grade II or greater (48%). The aortic valve was replaced in four patients (7%), of whom three had Marfan's syndrome. Only one non-Marfan patient required aortic valve replacement because of valve stenosis. In those whose aortic valve was preserved (n=51), three patients still had AR grade II at hospital discharge, while at late follow-up, AR had deteriorated to grade III in two of them, although no reoperation has been required so far. In chronic type A aortic dissection (n=38), 14 patients had AR grade II or greater (37%), of whom 11 had AR grade III or greater (29% vs. 13% in acute dissection; P=0.051). In 15 patients, dissection was found below the STJ and 12 patients had AR grade II or greater (80% vs. 48% in acute dissection; P=0.043). The aortic valve was replaced in eight patients (21% vs. 7% in acute dissection; P=0.051), including three Marfan patients. Of those whose aortic valve was preserved (n=30), two patients required reoperation for severe AR. The freedom from postoperative AR grade III or greater was 89% at 5 years for operative survivors with acute dissection and 92% for those with chronic dissection, respectively. CONCLUSIONS: This retrospective study suggests that preservation of the aortic valve in acute type A aortic dissection is feasible in non-Marfan patients regardless of the degree of AR. In chronic dissection, aortic root replacement needs to be considered when the degree of AR is greater than moderate because of a dilated STJ and/or annulus. In both acute and chronic dissections, satisfactory mid- to long-term results with a low incidence of reoperation were obtained in those whose aortic valve was preserved.

Acute Disease↗

PubMed2002

The presenting chest roentgenogram in acute type A aortic dissection: a multidisciplinary study.

Acute type A aortic dissection requires early diagnosis and prompt surgical intervention. It is not entirely clear whether patients with this form of dissection have clear-cut chest roentgenogram (CXR) patterns or whether the CXR can guide the physician in directing further workup for acute aortic dissection. The purpose of this study is to evaluate the impact of the initial CXR in arousing suspicion for acute type A aortic dissection. Twelve physicians from four specialties (emergency medicine, radiology, cardiology, and cardiothoracic surgery) evaluated the presenting CXR of ten patients with acute type A aortic dissection and the CXRs of ten normal individuals in a blinded manner. They were asked whether the CXRs were normal or abnormal (part A) and what the findings were and then were asked whether the CXRs were suspicious for acute aortic dissection (part B) and what the findings were. In part A, of the normal CXRs 81 of 120 (68%) readings were recorded as normal. Of the dissection CXRs 112 of 120 (93%) readings were recorded as abnormal (P < 0.001). In part B, the physicians were asked specifically about suspicion for aortic dissection. Of the normal CXRs 101 of 120 (84%) readings were listed as not suspicious for dissection (i.e., 16% of the normal CXRs were listed as supsicious for dissection). Of the dissection CXRs 88 of 120 (73%) readings were recorded as suspicious for dissection (p < 0.001). The most frequent findings on a dissection CXR when physicians were specifically asked about dissection included widened mediastinum in 46 of 120 (38%) followed by not suspicious for dissection in 32 of 120 (27%). Among the physician specialties the only statistically significant finding was that the cardiology group was the most likely group to find an abnormality in a "normal" CXR. This data indicates that the presenting CXR is neither sensitive nor specific for acute type A dissection. In a patient with a suspicious history or physical examination, however, a CXR showing mediastinal widening or other aortic abnormalities should increase the suspicion for dissection and warrant further workup. Furthermore in a patient with a clinical suspicion a normal CXR reading should not delay echocardiography to rule out type A dissection.

Acute Disease↗

PubMedDate not supplied

[Cervical and intracranial arterial dissection: review of the acute clinical presentation and imaging of 48 cases].

INTRODUCTION: Arterial dissections result from longitudinal tear of the vessel wall produced by an intramural haematoma. MATERIAL AND METHODS: We have retrospectively review 48 consecutive patients with 53 arterial dissections diagnosed by cerebral angiography and/or magnetic resonance imaging. RESULTS: Arterial dissections were extracranial in 88% (carotid in 58% and vertebral in 30%) and intracranial in 12% of cases, with 19% of multiple dissections. Extracranial dissections presented with infarct (82%) (major 52%, multifocal 16%, focal 28% e watershed 4%), cervical pain and/or headache (38%) incomplete Horner syndrome (14%). The intracranial dissections presented with infarct, intracranial hypertension and hydrocephalus, subarachnoid hemorrhage and brain haematoma. Most common angiographic findings in the extracranial carotid dissections were stenosis with slow flow (66%), occlusion (34%) and dissecting aneurysm (7%). In the extracranial vertebral dissections the angiograms depicted stenosis with slow flow (82%), occlusion (18%) and dissecting aneurysm (18%). In the intracranial dissections stenosis and dissecting aneurysm were equally found. CONCLUSION: Extracranial arterial dissections have are an important cause of stroke in the younger population. Anti thrombotic drugs are used for the treatment of dissections presenting with infarct. Refractory extracranial dissections and intracranial dissection with haemorrhage presentation and/or dissecting aneurysms should be managed by endovascular treatment.

Acute Disease↗

PubMed1994

[Type B aortic dissections: surgical technique and results].

Between 1978 and 1992, 70 patients were operated for type B aortic dissection (tear in the descending aorta without involvement of the ascending aorta). 15/70 (21%) patients had an acute dissection (onset of symptoms < 24 h), 19/70 (27%) a subacute dissection (onset of symptoms < 14 days), and 36/70 (51) a chronic dissection (onset of symptoms > 14 days). The indications for surgery in cases of acute dissection were: hematothorax, oliguria, leg ischemia and persistent pain. Persistent hypertension was an additional indication in cases of subacute dissection. In large majority (93%) of chronic dissections the indication for surgery was enlarged aortic diameter. In 86% (60/70) graft replacement of the aorta was performed, in 6% (4/70) extra-anatomic bypass, in 3% (2/70) fenestration, in 3% (2/70) thrombendarterectomy, in 3% (2/70). The overall mortality was 17% (12/70); 27% of acute dissection, 26% for subacute dissection, and 8% for chronic dissection. The morbidity for acute dissection was 73%, of subacute dissection 43%, and of chronic dissection 12%. The most frequent complications were: leg ischemia (8 patients), renal failure (4 patients), paraparesis (4 patients) and sepsis (2 patients). No paraparesis was encountered in surgery of the chronic dissection. Conservative treatment was tried in all acute B-dissections, with surgical therapy being reserved for complications of the dissection, such as rupture, such as rupture, risk of rupture (hematothorax, large aortic diameter resp. expansion, persistent hypertension, persistent pain) or ischemia of distal vascular beds. Long-term survival for chronic type B dissections is good. Strong control of risk factors (hypertension) is essential.

Adult↗

PubMed2003

Existence of abdominal aortic aneurysms in patients with thoracic aortic dissections.

OBJECTIVE: The objective of this study was to determine the coexistence or later development of pararenal and infrarenal abdominal aortic aneurysms (AAAs) in patients with thoracic aortic dissections. METHODS: One hundred forty-five patients (95 men, 50 women) encountered from 1992 to 2001 with thoracic aortic dissections-excluding those associated with trauma, those with Marfan's syndrome, and those with thoracoabdominal aortic aneurysms-were studied. The most common risk factors included hypertension (59%) and a history of tobacco use (52%). Type III dissections affected 86 patients (59%), and type I dissections affected the remaining 59 patients (41%). Aortic computed tomography (CT) scans were obtained annually. Data were assessed by univariate and multivariate analyses. RESULTS: Five patients (3%) had a history of AAA repair prior to their thoracic aortic dissection diagnosis-3 were type III dissections and 2 were type I dissections. Twelve patient's (8%) AAAs were diagnosed with the initial CT study of their thoracic aortic dissection. Type III dissections accounted for all but one of these (11 of 12, 92%). Ten additional AAAs (7%) developed in the 128 patients with no initial evidence of an AAA being recognized from 1 to 48 months (average 16 months) after the thoracic aortic dissection was diagnosed. Type III dissections affected 8 of these 10 patients. Among the total 27 AAAs noted in this series, 74% (20 AAAs) were not continuous with the thoracic aortic dissection. In the univariate analysis, age (P =.0002), male gender (P =.044), history of smoking (P =.01), chronic obstructive pulmonary disease (P <.001), duration of dissection (P =.05), and presence of type III dissection (P =.009) were associated with the presence of an AAA. In the multivariate analysis, both chronic obstructive pulmonary disease (odds ratio 5.4, 95% CI, 1.3 to 22.3; P =.02) and age (OR 1.06, 95% CI, 1.02 to 1.11; P =.004) were significant predictors of the development of AAAs. CONCLUSION: This study documented that patients with thoracic aortic dissections are at risk to harbor or develop a later AAA. This finding supports the tenet that abdominal CTs or ultrasound scanning should be mandatory in the follow-up of patients with known thoracic aortic dissections.

Aged↗

PubMed1999

A randomized double-blind controlled trial of automated term dissection.

OBJECTIVE: To compare the accuracy of an automated mechanism for term dissection to represent the semantic dependencies within a compositional expression, with the accuracy of a practicing Internist to perform this same task. We also compare the results of four evaluators to determine the inter-observer variability and the variance between term sets, with respect to the accuracy of the mappings and the consistency of the failure analysis. METHODS: 500 terms, which required a compositional expression to effect an exact match, were randomly distributed into two sets of 250 terms (Set A and Set B). Set A was dissected using the Automated Term Dissection (ATD) Algorithm. A physician specializing in Internal Medicine dissected set B. He had no prior knowledge of the dissection algorithm or how it functioned. In this manuscript, the authors use Human Term Dissection (HTD) to refer to this method. Set A was randomized to two sets of 125 terms (Set A1 and Set A2). Set B was randomized to two sets of 125 terms (Set B1 and Set B2). A new set of 250 terms Set C was created from Set A1 and Set B2. A second new set of 250 terms Set D was created from Set A2 and Set B1. Two expert Indexers reviewed Set C and another two expert Indexers reviewed Set D. They were blinded to which terms were dissected by the clinician and which terms were dissected by the automated term dissection algorithm. The person providing the files for review to the Indexers was also unaware of which terms were dissected by ATD vs. the HTD method. The Indexers recorded whether or not the dissection was the best possible representation of the input concept. If not, a failure analysis was conducted. They recorded whether or not the dissection was in error and if so was a modifier not subsumed or was a Kernel concept subsumed when it should not have been. If a concept was missing, the Indexers recorded whether it was a Kernel concept, a modifier, a qualifier or a negative qualifier. RESULTS: The ATD method was judged to be accurate and readable in 265 out of the 424 terms with adequate content (62.7%). The HTD method was judged to be accurate in 272 out of 414 terms with adequate content (65.7%). There was no statistically significant difference between the rates of acceptability of the ATD and HTD methods (p = 0.33). There was a non-significant trend toward greater acceptability of the ATD method in the subgroup of terms with three or more compositional elements. ATD was acceptable in 53.6% of the terms where the HTD was only acceptable in 43.6% (p = 0.11). The failure analysis showed that both methods misrepresented kernel concepts and modifiers much more commonly than qualifiers (p < 0.001). CONCLUSIONS: There is no statistically significant difference in the accuracy and readability of terms dissected using the automated term dissection method when compared with human term dissection, as judged by four expert medical indexers. There is a non-significant trend toward improved performance of the ATD method in the subset of more complex terms. The authors submit that this may be due to a tendency for users to be less compulsive when the time to complete the task is long. Automated term dissection is a useful and perhaps preferable method for representing readable and accurate compound terminological expressions.

Abstracting and Indexing↗

PubMed2000

The impact of untreated coronary dissections on acute and long-term outcome after intravascular ultrasound guided PTCA.

AIM: Vessel size adapted PTCA results in the use of larger balloons with an increased incidence of severe vascular dissections. The aim of our trial was (a) to evaluate the effect of severe dissections on the acute outcome and (b) to study the natural history of dissections after 1 year. METHODS AND RESULTS: One hundred and seventy-eight patients with 195 lesions underwent vessel size adapted PTCA using intravascular ultrasound. Clinical and angiographic 1 year follow-up was obtained for all patients. Intravascular ultrasound was performed before PTCA to measure the external elastic membrane diameter at the lesion site so that the balloon size could be adopted (external elastic membrane-10%) and post-interventionally to determine the procedural success and the incidence of intracoronary dissections. Stent implantation was reduced to persistently flow limiting dissections (TIMI I, II). Dissections were detected by intravascular ultrasound in 128/195 (66%) lesions (by angiography in 111/195 [58%] lesions) and classified by intravascular ultrasound criteria into four groups: group I: no dissection (67 lesions [34%]), group II: mild dissections (21 lesions [11%]), group III: medium dissections (19 lesions [10%]) and group IV: severe dissections (88 lesions [45%]). Because of threatened vessel closure, GPIIb/IIIa antagonists were used in eight (4.5%) patients and a stent was implanted in two (1. 1%) patients. The cumulative event rate after 1 year was 12% and the global angiographic restenosis rate was 19%. The post-interventional evidence of severe dissections was associated with a decrease in clinical events during long-term follow up (group I: 13 events [19%] vs group IV: seven events [7%];P=0.03). This was also true for the occurrence of restenosis which was significantly lower in patients with severe dissections (group I: 19 [28%] lesions vs group IV:10 [11%] lesions;P=0.01). CONCLUSIONS: According to the theory of 'therapeutic dissections', our data suggest that substantial dissections following PTCA, which do not diminish antegrade blood flow, do not lead to an increase in acute or long-term events. The natural history of vessel injury seems to provide favourable wound healing without increase of restenosis. Thus, stenting for treatment of large dissections without flow limitation does not seem to be mandatory.

Acute Disease↗

PubMed2000

Pain, quality of life, and spinal accessory nerve status after neck dissection.

OBJECTIVE: To assess quality of life (QOL) in patients with head and neck cancer who underwent neck dissection and to compare QOL scores for patients in whom the spinal accessory nerve (CN XI) was resected or preserved. SETTING AND DESIGN AND OUTCOMES MEASURES: Three hundred ninety-seven patients who had undergone treatment for head and neck cancer completed the University of Michigan Head and Neck Quality of Life (HNQOL) instrument, the Medical Outcomes Study SF-12 General Health Survey, and questions on "pain despite pain medications" and headaches. RESULTS: Of the 397 patients, 222 had no neck dissection, 46 had neck dissections resecting CN XI, and 129 had dissection sparing CN XI. Of the latter group, 68 patients had dissections sparing level V and 61 dissections included level V. Age, sex, primary site distribution, and T stage were not different between the groups. Patients who had neck dissections sparing CN XI had better scores on the HNQOL pain domain (P = .002), had less shoulder or neck pain (P = .003), and took pain medications less frequently (P = .0004) compared with patients who had neck dissections sacrificing CN XI. When CN XI was preserved, patients who had no level V dissection had better pain domain scores (P = .03) and eating domain scores (P = .007) on the HNQOL, had less shoulder or neck pain (P = .006), and had less physical problems (P = .03) than patients who had level V dissected. On multivariate analysis, pain-related QOL scores after neck dissection were significantly better (P < .01) if patients had dissections with preservation of CN XI and if level V was not dissected. CONCLUSION: Neck dissections sparing CN XI are associated with better pain scores on the HNQOL, less shoulder and neck pain, and less need for medications. When CN XI is spared, not dissecting level V of the neck is associated with better HNQOL pain scores, less shoulder or neck pain, and fewer physical problems.

Accessory Nerve↗

PubMed2005

Ultrasonically assisted retrohepatic dissection for a liver hanging maneuver.

OBJECTIVE: To establish a safer and technically easier retrohepatic dissection for the liver hanging maneuver with the assistance of intraoperative ultrasound (IOUS). SUMMARY BACKGROUND DATA: The liver hanging maneuver described by Belghiti et al is an innovative suspending technique of the liver and is useful in difficult major right hepatectomies or in donor operations for living donor liver transplantation. The most important complication of this procedure is injury to the short hepatic veins and subsequent massive bleeding with an incidence of 4% to 6%. METHODS: After the cranial dissection of the suprahepatic inferior vena cava (IVC) between the middle and left hepatic veins, a long light curved Kelly clamp is inserted from the caudal edge behind the caudate lobe and passed cranially along the anterior midline of the IVC. On the midway of the dissection, the proper hepatic vein draining the caudate lobe (PrCV) is visualized. A safe dissection path is confirmed by IOUS, identifying the position of the clamp tip, PrCV, and the caudal end of the cranial retrohepatic dissection. When IOUS shows that the clamp tip has reached the caudal end of the cranial dissection, the operator can feel the clamp tip with his/her finger and the retrohepatic dissection is completed. RESULTS: From September 2003 to July 2004, 50 donor operations were performed for adult living donor liver transplantation. Retrohepatic dissection was feasible in 40 cases (80%). Of these, a US-assisted retrohepatic dissection was performed in 34 donors. PrCVs were visualized by IOUS in 48 donors (96%). The location of these PrCVs varied significantly (60 degrees -175 degrees from the right edge of IVC), and there were no distinct landmarks for identifying the location of PrCVs and safe dissecting course (55 degrees -130 degrees ). IOUS found that the dissecting clamp was heading to the PrCV in 3 cases and the direction of dissection was shifted to avoid injury. No substantial bleeding or no other complication related to retrohepatic dissection was encountered in any of the cases. CONCLUSIONS: With the aid of IOUS, the whole course of the blind dissection between the anterior surface of the IVC and the liver could be clearly visualized. IOUS could also identify the PrCV, the most dangerous point in the retrohepatic dissection.

Adult↗

PubMed1997

MRI and MR angiography of vertebral artery dissection.

A review of 4,500 angiograms yielded 11 patients with dissection of the vertebral arteries who had MRI and (in 4 patients) MR angiography (MRA) in the acute phase of stroke. One patient with incidental discovery at arteriography of asymptomatic vertebral artery dissection and two patients with acute strokes with MRI and MRA findings consistent with vertebral artery dissection were included. Dissection occurred after neck trauma or chiropractic manipulation in 4 patients and was spontaneous in 10. Dissection involved the extracranial vertebral artery in 9 patients, the extra-intracranial junction in 1, and the intracranial artery in 4. MRI demonstrated infarcts in the brain stem, cerebellum, thalamus or temporo-occipital regions in 7 patients with extra- or extra-intracranial dissections and a solitary lateral medullary infarct in 4 patients (3 with intracranial and 1 with extra-intracranial dissection). In 2 patients no brain abnormality related to vertebral artery dissection was found and in one MRI did not show subarachnoid haemorrhage revealed by CT. Intramural dissecting haematoma appeared as crescentic or rounded high signal on T1-weighted images in 10 patients examined 3-20 days after the onset of symptoms. The abnormal vessel stood out in the low signal cerebrospinal fluid in intracranial dissections, whereas it was more difficult to detect in extracranial dissections because of the intermediate-to-high signal of the normal perivascular structures and slow flow proximal and distal to the dissection. In two patients examined within 36 h of the onset, mural thickening was of intermediate signal intensity on T1-weighted images and high signal on spin-density and T2-weighted images. MRA showed abrupt stenosis in 2 patients and disappearance of flow signal at and distal to the dissection in 5. Follow-up arteriography, MRI or MRA showed findings consistent with occlusion of the dissected vessel in 6 of 8 patients.

Adult↗

PubMed1998

[The influence of coronary artery dissection on long-term outcome after percutaneous transluminal coronary angioplasty].

UNLABELLED: The influence of a coronary dissection on long-term outcome after PTCA has been controversely discussed in the past. Whereas diverse experimental studies have shown a positive relation between dissection and the incidence of restenosis, clinical trials could not document an influence of dissection on long-term outcome. However, most of the trials did not distinguish between the different morphologic configuration of the vascular dissection. Thus, the aim of the present study was to determine the influence of dissections on restenosis in regard to their amount and morphologic configuration. The prognostic importance of the National Heart, Lung, and Blood Institute classification on dissection as well as the importance of an additional classification of angiographic complications after PTCA were investigated to determine possible pathophysiologic mechanisms of the restenosis process. The study included 141 consecutive patients with 143 stable dissections after PTCA. A follow-up study was performed 13 months in mean after successful PTCA, which included clinical, symptomatic, and functional aspects of patients. In this patient population, type C dissections (Dorros et al.) showed a relevantly increased risk of a clinical adverse event (41.0%), whereas patients with a type A dissection had only a small risk of an adverse event (10.0%) over the investigation period. Type B dissections revealed an intermediate risk (18.0%), and type D dissections showed a risk of 33.3% of an adverse event, which was lower than that observed for type C dissections. The AC-classification of the postinterventional coronary morphology was a stronger predictor of an adverse outcome after PTCA (p = 0.0003) than was the Dorros-classification (p = 0.0056). CONCLUSION: The grade of a coronary dissection was highly, positively related to an ischemic event after PTCA using both the Dorros and the AC-classification (p = 0.0056/p = 0.0003). In regard to the special association of the AC-class with the amount of vascular injury, we conclude that the amount and configuration of coronary dissection correlates with the long-term outcome after PTCA.

Aortic Dissection↗

PubMed1996

Accuracy of biplane and multiplane transesophageal echocardiography in diagnosis of typical acute aortic dissection and intramural hematoma.

OBJECTIVES: The purpose of this study was to evaluate the diagnostic accuracy of biplane and multiplane transesophageal echocardiography in patients with suspected aortic dissection, including intramural hematoma. BACKGROUND: Transesophageal echocardiography is a useful technique for rapid bedside evaluation of patients with suspected acute aortic dissection. The sensitivity of transesophageal echocardiography is high, but the diagnostic accuracy of biplane and multiplane transesophageal echocardiography for dissection and intramural hematoma is less well defined. METHODS: We studied 112 consecutive patients at a major referral center who had undergone biplane or multiplane transesophageal echocardiography to identify aortic dissection. The presence, absence and type of aortic dissection (type A or B, typical dissection or intramural hematoma) were confirmed by operation or autopsy in 60 patients and by other imaging techniques in all. The accuracy of transesophageal echocardiography for ancillary findings of aortic dissection (intimal flap, fenestration and thrombosis) was assessed in the 60 patients with available surgical data. RESULTS: Of the 112 patients, aortic dissection was present in 49 (44%); 10 of these had intramural hematoma (5 with and 5 without involvement of the ascending aorta). Of the remaining 63 patients without dissection, 33 (29%) had aortic aneurysm and 30 (27%) had neither dissection nor aneurysm. The overall sensitivity and specificity of transesophageal echocardiography for the presence of dissection were 98% and 95%, respectively. The specificity for type A and type B dissection was 97% and 99%, respectively. The sensitivity and specificity for intramural hematoma was 90% and 99%, respectively. The accuracy of transesophageal echocardiography for diagnosis of acute significant aortic regurgitation and pericardial tamponade was 100%. CONCLUSIONS: Biplane and multiplane transesophageal echocardiography are highly accurate for prospective identification of the presence and site of aortic dissection, its ancillary findings and major complications in a large series of patients with varied aortic pathology. Intramural hematoma carries a high complication rate and should be treated identically with aortic dissection.

Acute Disease↗

PubMed2006

Neck dissection: then and now.

The significance of metastatic disease in the lymph nodes of the neck as a critical independent prognostic factor in head and neck cancer has long been appreciated. Although 19th century surgeons attempted to remove involved cervical lymph nodes at the time of resection of the primary cancer, a systematic approach to en bloc removal of cervical lymph node disease, described in detail by Jawdyński in 1888 and popularized and illustrated by Crile in the early 20th century, provided consistent and more effective treatment, and forms the basis of our current techniques. During the first half of the 20th century, developments included preservation of the accessory nerve in selected cases, elective neck dissection performed in association with resection of various primary tumors, bilateral neck dissection and limited neck dissection. The greatest impetus to the status of radical neck dissection came from Martin, whose technique consisted of resection of all lymph nodes from level I-V together with the accessory nerve, internal jugular vein, sternocleidomastoid muscle and various other structures in a single block of resected tissue. Martin's technical precepts were followed until the latter part of the 20th century when modifications in technique began to find general acceptance. The first description of an effective technique of modified radical neck dissection was published in Spanish by Suárez, in 1963. This technique, which preserves important structures, such as the internal jugular vein, sternocleidomastoid muscle and accessory nerve, was refined and popularized by various authors who published their results in the English language literature during the period from 1964 through 1990 and beyond. Modified or "functional" neck dissection avoids much of the morbidity of radical neck dissection while achieving equivalent degrees of control of regional disease in properly selected cases. By the late 20th century, the concept of selective neck dissection, consisting of resection of only the nodal groups at greatest risk for metastasis from a given primary site, was studied and developed. These limited dissections are now widely employed for elective, and in properly selected cases, therapeutic treatment and staging of the neck, and have been proposed for limited cervical recurrences after various chemoradiation protocols. Prospective studies have demonstrated similar rates of neck recurrence and survival after elective selective neck dissection compared to elective modified radical neck dissection. Other modifications and factors applied to treatment of cervical lymph node disease include the use of adjuvant and neo-adjuvant radiation and chemotherapy, a revised system for classification of neck dissections, the identification of various adverse prognostic factors such as extracapsular spread and extranodal soft tissue deposits, application of sentinel lymph node biopsy to staging of the neck, the use of immunohistochemical and molecular techniques for identification of lymph node metastases not detectable by light microscopy, and the possibility of endoscopic neck dissection. The authors conclude that neck dissection, as evolved over the past century, is a fundamental tool in management of patients with head and neck cancer, but is still a work in progress.

Head and Neck Neoplasms↗

PubMed1999

Subtypes of acute aortic dissection.

BACKGROUND: This series consists of a 12-year experience with a policy of identifying and replacing the aortic segment containing the primary intimal tear for repair of acute aortic dissection. METHODS: Patients with type A dissection underwent urgent surgery. Patients with type B dissection were referred for surgery based on selective criteria, including aortic dilatation greater than 5 cm. A classification system for acute dissection is described that specifies the site of intimal tear while retaining the clinical relevance of the Stanford system. RESULTS: Of 168 acute dissections, 139 were type A and 29 were type B. The site of intimal tear was as follows: ascending aorta, 83 cases; arch, 32 cases; descending aorta, 29 cases; multiple tears, 11 cases (10 included arch tears); no tear (intramural hematoma), 6 cases; not noted, 7 cases. Only 60% of acute type A dissections arose from solitary intimal tears in the ascending aorta, whereas 30% had arch tears. Hospital mortality for type A dissection was 13.7% (18.8% for arch tears, NS) and 0% for type B. False lumen patency was 57.1% for type A dissection and 18.8% for type B dissection (p = 0.002), yet survival was similar for these groups. Ten-year survival for type A dissection with arch tear (0.51 +/- 0.12) was lower than 10-year survival for type A dissection with ascending tear (0.74 +/- 0.05; p = 0.77), and significantly lower than for type A dissection with descending tear (0.88 +/- 0.12; p = 0.029). CONCLUSIONS: Systematic resection of the primary tear yielded similar hospital mortality, 5-year survival, and aorta-related event-free survival rates for subtypes of acute type A dissection. Excellent results were obtained with a selective approach to type B dissection.

Acute Disease↗

PubMed2000

The effects of intracoronary brachytherapy on the natural history of postangioplasty dissections.

OBJECTIVES: The aim of this study was to determine the natural history of postangioplasty intravascular ultrasound (IVUS)-detected dissections and to assess the influence of intracoronary beta-radiation on dissection resolution. BACKGROUND: Intracoronary radiotherapy is considered to impair exaggerated vessel healing. Conversely, excessive healing impairment may increase the risk of complications due to unhealed dissection. Alternatively, residual dissection may represent an innocent marker of adequate therapy. METHODS: Immediate postangioplasty and six-month follow-up IVUS studies of 94 patients in the IVUS substudy of the MultiVitamins and Probucol (MVP) trial and 26 nonstented patients in the Beta Energy Restenosis Trial (BERT) were analyzed for the presence or absence of dissection. RESULTS: Of the 28 patients with postangioplasty dissections in MVP, only one had evidence of residual dissection at six months (95% confidence interval [CI] for failure rate 0.2%; 20.2%). Conversely, 9 of 16 dissections had healed in BERT (95% CI for failure rate 30.6%; 79.2%) (p < 0.0002). Nevertheless, an index based on dissection arc and length demonstrated improvement in the irradiated patients. Irradiated patients with residual dissections showed significant increase in lumen area at six-months (5.10 +/- 0.98 to 7.11 +/- 2.61 mm2, p < 0.02) not noted when there was resolution of the dissection (6.03 +/- 2.38 to 6.36 +/- 3.33 mm2, p = NS). In both groups the external elastic membrane area was unchanged at follow-up. CONCLUSIONS: Resolution appears to be the natural history of IVUS-detected dissections in most cases. Significant resolution of dissection occurs following intracoronary beta-radiation as reflected in reduced dissection index at six-months in these patients, although significant impairment of vessel wall healing was noted.

Aortic Dissection↗

PubMed1991

Aortic dissection with the entrance tear in the descending thoracic aorta. Analysis of 40 necropsy patients.

Clinical and necropsy findings are described in 40 patients who had aortic dissection with the entrance tear in the descending thoracic aorta. Their ages at death ranged from 39 to 91 years (mean, 66 years); 24 (60%) were men and 16 (40%) were women. Systemic hypertension was present by history in 33 patients (83%) and the hearts were of increased weight in 78%. Of the 40 patients, 31 (78%) had no operative intervention, while 9 (22%) underwent operation for aortic dissection. Of the 31 patients without operative therapy, the diagnosis of aortic dissection was established in life in 9 patients (29%) and at necropsy in 22 (71%). The interval from aortic dissection to death was 30 days or less in 13 patients (42%); rupture of the false channel was the cause of death in 9 patients (69%), renal failure in 2 (15%), and the cause was unclear in 2 (15%). The interval from aortic dissection to death was more than 30 days in 18 (58%) of the 31 patients without operative therapy. The cause of death in these 18 patients was related to the dissection in 11 (61%) (rupture of the false channel in 5; renal failure from dissection in 3, and rupture of the false channel of a second acute dissection in 3), but in the other 7 patients (39%) death was unrelated to the dissection but a nonfatal complication, specifically stenosis of the true channel from compression by a thrombus-filled false channel, occurred in 4 of these 7 patients. Thus only 3 (10%) of the 31 patients without operative therapy had no complications of aortic dissection. All nine patients who underwent operation had had an aortic dissection within 30 days, and the operation was performed because of a major complication of the dissection. Four patients survived 8 to 84 months after the operation. Thus early operative intervention (before the appearance of complications) appears justified in patients with aortic dissection with the entrance tear in the descending thoracic aorta to prevent rupture of the false channel acutely or after initial healing; to prevent renal failure from compression of renal arteries by an aneurysmal false channel; to prevent true channel stenosis from compression by a thrombus-filled false channel; and possibly to prevent the recurrence of acute dissection.

Adult↗

PubMed1999

Quantification of lymph nodes in selective neck dissection.

OBJECTIVES: Provide reference for surgeon and pathologist regarding expected yield from selective neck dissections. Quantify lymph nodes obtained from cadaver dissection based on current nodal classification and compare with clinical series. STUDY DESIGN: 1. Quantification of lymph nodes at levels I-V harvested from human cadavers and correlation with nodal grouping for supraomohyoid (I-III) and lateral (II-IV) neck dissections. 2. Retrospective review of operative specimens from clinical neck dissections for lymph node quantity. METHODS: 1. Twenty radical neck dissection specimens, harvested from 10 fresh human cadavers without evidence of head and neck cancer, were separated by nodal level for gross and microscopic examination by a pathologist. The quantity of nodes obtained per level for each specimen was tabulated. 2. Charts of patients treated with neck dissection for squamous cell carcinoma were reviewed and tabulated for type of dissection and number of lymph nodes reported. RESULTS: In the 20 cadaver neck dissections, the average number of lymph nodes removed for levels I-V was 24, with 13 for levels I-III and 19 for levels II-IV. In the clinical review, 98 total neck dissections were included. In the six supraomohyoid dissections, an average of 20 lymph nodes (range, 14-26) were found, with an average of 30 (range, 15-43) in the 11 lateral compartment specimens. In 81 radical or modified radical dissections, an average of 31 nodes (range, 19-63) was reported. CONCLUSIONS: The number of lymph nodes removed in selective neck dissection should be comparable to that of the corresponding levels in radical neck dissection, provided that strict adherence to surgical boundaries is maintained. Dissection of normal cadavers provides a reference for the surgeon and the pathologist but may under-represent lymph node quantity in the diseased state.

Carcinoma, Squamous Cell↗