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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↗

PubMed1994

Magnetic resonance imaging and dynamic CT scan in cervical artery dissections.

BACKGROUND AND PURPOSE: The typical magnetic resonance imaging picture of arterial dissection, namely, a narrowed eccentric signal void surrounded by a semilunar signal hyper-intensity (corresponding to the mural hematoma) on T1- and T2-weighted images, has been repeatedly reported, but the sensitivity of magnetic resonance imaging for the diagnosis of cervical dissection is poorly known. Another technique, dynamic computed tomography, may provide evidence of mural hematoma, but there has been no systematic evaluation of this technique. The aims of this study were to assess both the sensitivity of routine 0.5-T magnetic resonance imaging for the detection of a typical picture of cervical artery dissection and the value of dynamic computed tomographic scans to provide evidence of dissecting hematoma. METHODS: Fifteen consecutive patients with angiographically confirmed extracranial internal carotid (n = 9) or vertebral (n = 10) dissections were studied using a standardized 0.5-T spin-echo magnetic resonance imaging protocol with axial slices. Twelve of these patients had dynamic computed tomographic scans at the site of the dissection suggested by angiography. RESULTS: A typical magnetic resonance imaging picture of cervical artery dissection was observed in 12 of 15 (80%) patients and in 13 of 19 (68%) dissected vessels. The sensitivity of magnetic resonance imaging was higher in internal carotid (78%) than in vertebral (60%) dissections and in stenotic-type dissections (85%) than in occlusive or aneurysmal-type dissections. The dynamic computed tomographic scan showed the mural hematoma in 11 of the 12 (92%) patients and in 12 of 15 (80%) dissected vessels. CONCLUSIONS: Routine 0.5-T magnetic resonance imaging with axial slices is a sensitive technique for the diagnosis of dissection, but in about 20% of patients with cervical artery dissection magnetic resonance imaging will demonstrate no typical abnormality. Dynamic computed tomographic scans are a sensitive neuroimaging procedure to confirm the presence of the mural hematoma, but it needs to be directed by prior angiography.

Adult↗

PubMed1990

Early diagnosis and surgical intervention of acute aortic dissection by transesophageal color flow mapping.

To determine whether transesophageal color Doppler echocardiography (TEE) is useful for the early diagnosis and surgical intervention in acute aortic dissection, 57 serial patients with acute aortic dissection were examined. These patients were evaluated by TEE with either the single-plane probe (39 patients) or the biplanar probe (18 patients) just after admission. The intimal flap was detected in all patients, and there were 18 patients with type A dissection and 39 patients with type B dissection. The entry was visualized in 83% of type A dissection cases and in 90% of type B dissection cases. In two of 18 patients examined with the biplanar probe technique, the entry was detected in the longitudinal view only. Emergency operations were performed in 18 patients with type A dissection and in 10 patients with ruptured type B dissection. Twenty-nine of 39 patients with type B dissection were treated conservatively. The operative mortality rate of patients with type A dissection was 22%, and that of patients with ruptured type B dissection was 60%. The major advantage of TEE is its ease of application at the bedside or in the operating room, which allows immediate and accurate diagnosis of acute aortic dissection for emergency surgical intervention. Biplanar TEE provides additional acoustic windows, ease of spatial orientation, and more accurate visualization of entry. TEE is a useful and powerful diagnostic tool for acute aortic dissection, and by using this method, one may achieve a more rapid and aggressive surgical approach for patients with acute aortic dissection.

Acute Disease↗

PubMed1979

Dissecting aortic aneurysms: a clinicopathological study. I. Clinical and gross pathological findings.

One hundred and seventy-one patients with dissecting aneurysm seen between 1951 and 1976 at three hospitals in Manchester were studied. There were 60 proximal dissections, 80 distal dissections, 10 abdominal dissections and in 21 the site of origin was uncertain. Pain was the major symptom in 88 per cent of patients; radiation of pain to the interscapular region was much more common in distal dissections. Systemic hypertension was present in 77 per cent, being commoner in distal dissections (83 per cent) than in proximal dissections (70 per cent). Aortic incompetence, hemiplegia and shock were all more common in proximal dissections. Post-mortem examination was performed in 125 patients. Eighty-four per cent of proximal dissections had ruptured, 74 per cent into the pericardium and five per cent into the left pleural cavity. Seventy per cent of distal dissections had ruptured, 11 per cent into the pericardium and 41 per cent into the left pleural cavity. The extent of the dissection was analysed, and it was shown that 25 per cent of distal dissections had extended proximally into the ascending aorta and arch. This implies that diagnosis of the site of origin of dissection from clinical signs and the plain chest-radiograph is inaccurate. Aortography is required for precise assessment. Since treatment often varies with the site of dissection, aortography should be performed in most patients surviving the first few hours. Attention is drawn to the frequency (10.4 per cent) of multiple aortic lesions, and to the occasional aetiological significance of giant-cell arteritis, and, possibly, hypothyroidism.

Adult↗

PubMed1995

[Evaluation of the importance of systematic neck dissection in carcinoma of the oral cavity treated by brachytherapy alone for the primary lesion (apropos of a series of 346 patients)].

UNLABELLED: The study includes 346 carcinomas of the oral cavity (244 mobile tongues and 102 floors of mouth) treated by brachytherapy alone at primary tumor. We noted 199 T1, 131 T2, 14 T3 and 2 TxNx. Among T1, 36 patients had a neck dissection as well as 73 T2. Brachytherapy was performed according to the Paris system. In 59 cases, the curage on the lesion side was a radical neck dissection, in 14 cases a functional neck dissection and in 45 cases a submaxillary and submental dissection. A combined controlateral neck dissection was performed in 20 cases. A complementary irradiation of the node areas was given in 28 cases. RESULTS: for T1, the local control (LC) is 96%, the locoregional control (LRC) 83%, the specific survival (SS) 88%, and the overall survival (OS) 73%. For T2, LC 85%, LRC 70%, SS 75%, OS 52%. For T3, LC 64%, LRC 44%, SS 25%, OS 18%. The difference is very significant between T1 T2 T3 (p < 0.006) for results concerning N0, it is not significant between the N1 in each category, but their number is too low to reach a degree of significancy. In the 36 neck dissection specimens of T1, we found only in 7 cases positive nodes and in the 73 specimens of T2, 24 cases of positive nodes. A detailed study is reported. Tumoral, node or both recurrences are summarized (see table IV). Node recurrences are more frequent in patients without neck dissection than in those with neck dissection for T1, T2, N0, but this is significant only for LRC, SS and OS between patients with negative nodes on neck dissection and those with positive nodes (p < 0.0001). No significant difference was found between OS and SS for patients T1, T2, N0 with positive systematic neck dissection and those with a neck dissection differed until the node recurrence. Among T1, T2, T3, we noted more metastases in patients who presented a recurrence than in others. In conclusion, for patients treated by brachytherapy alone to the primary lesion, it seems desirable to perform a systematic neck dissection if there are adenopathies on initial examination. The dissection can be delayed for small tumors T1 N0 and low T2 N0 if the patients are followed-up regularly. However, a systematic dissection must be advised for high T2 N0 and T3 N0 given the frequency of the node involvement and the risk of metastases.

Brachytherapy↗

PubMed2006

Detection of pelvic lymph node metastases in patients with clinically localized prostate cancer: comparison of [18F]fluorocholine positron emission tomography-computerized tomography and laparoscopic radioisotope guided sentinel lymph node dissection.

PURPOSE: Accurate detection of lymph node metastases in prostate cancer has important implications for prognosis and approach to treatment. We investigated whether preoperative [18F]fluorocholine combined in-line positron emission tomography-computerized tomography and intraoperative laparoscopic radioisotope guided sentinel pelvic lymph node dissection can detect pelvic lymph node metastases in patients with clinically localized prostate cancer as reliably as extended pelvic lymph node dissection. MATERIALS AND METHODS: A total of 20 patients (mean age 63.9 +/- 6.7 years, range 52 to 75) with clinically localized prostate cancer, prostate specific antigen greater than 10 ng/ml, and/or a Gleason score sum of 7 or greater and negative bone scan were enrolled in the study. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was performed before surgery. Sentinel pelvic lymph node dissection preceded extended pelvic lymph node dissection including the area of the obturator fossa, external iliac artery/vein and internal iliac artery/vein up to the bifurcation of the common iliac artery. Laparoscopic radical prostatectomy was performed afterward. RESULTS: In 10 of the 20 patients (50%) lymph node metastases were detected, and were exclusively found outside the obturator fossa in 62%. These metastases would not have been identified with standard lymph node dissection of the obturator fossa only. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was true positive in 1, false-positive in 2, false-negative in 9 and true negative in 8 patients. The largest lymph node metastasis not seen with [18F]fluorocholine combined in-line positron emission tomography-computerized tomography was 8 mm. Laparoscopic sentinel guided lymph node dissection revealed lymph node metastases in 8 of 10 patients. In the other 2 patients sentinel lymph node dissection was not conclusive. In 1 patient normal nodal tissue was completely replaced by cancer and, therefore, there was no tracer uptake in the involved pelvic sidewall/node, and the other patient had no tracer activity at all in the involved pelvic sidewall. Extended pelvic lymph node dissection missed 1 lymph node metastasis (2 mm diameter near pudendal artery) which was detected by sentinel pelvic lymph node dissection only. CONCLUSIONS: Extended pelvic lymph node dissection reveals a higher number of lymph node metastases as described for obturator fossa dissection only. [18F]fluorocholine combined in-line positron emission tomography-computerized tomography is not useful in searching for occult lymph node metastases in clinically localized prostate cancer. Sentinel guided pelvic lymph node dissection allows the detection of even small lymph node metastases. The accuracy of sentinel pelvic lymph node dissection is comparable to that of extended pelvic lymph node dissection when the limitations of the method are taken into consideration.

Aged↗

PubMed2002

Retrospective study of conservation surgery for breast cancer with or without axillary dissection.

BACKGROUND: It is already known that for breast cancer patients, an axillary dissection or locoregional radiation has no major effect on survival with a simple mastectomy. We analyzed whether axillary dissection improved the prognosis for breast conservation surgery. METHODS: From 1982 to 1995, 31 patients underwent axillary dissection and 33 did not in association with breast conservation surgery performed at our institution. Median follow up was at 55 months, ranging from 3 to 210. Survival rates of patients were analyzed retrospectively. RESULTS: In the dissection group, 8 patients had recurrence and 5 died within 3 years, yielding a relapse-free survival rate of 71%. In the non-dissection group, 7 patients had recurrence, 3 died within 3 years, with a relapse-free survival rate of 79%. Figures for overall survival, relapse-free except breast and relapse-free for breast at 5 years were 93%, 73%, and 96% for the dissection group, and 93%, 89%, and 89% for the non-dissection group, respectively. No difference was found in survival rates between the two groups. Adjusted by Cox's regression analysis, survival rates of overall, relapse-free, relapse-free except breast and relapse-free for breast, at 5 years were 86%, 71%, 77%, and 90% for the dissection group, and 100%, 78%, 85%, and 95% for the non-dissection group, respectively. No survival benefit was found in axillary dissection. The first site of recurrence was in the affected breast in 3 patients and in other sites in 5 patients for the dissection group, while for the non-dissection group it was in the affected axilla in 1 patient, the skin of the affected breast in 1 patient, the affected breast in 3 patients, and other sites in 2 patients. In the non-dissection group, a patient who had recurrence on the skin of the affected breast, subsequently had an axillary recurrence on the same side with plexus paresis. CONCLUSION: In breast conservation, prophylactic axillary dissection seems to be omitted, but the axilla of the affected side should be examined for metastasis while treatment is possible.

Adult↗

PubMedDate not supplied

Radical, modified, and selective neck dissection for cutaneous malignant melanoma.

BACKGROUND: The roles of modified and selective neck dissections in treating patients with clinical metastatic melanoma and the place of adjuvant radiotherapy are unclear. In the elective setting, the efficacy of various selective dissections also requires clarification. METHODS: The prospectively documented experience of the senior author (COB) was analyzed. A total of 175 patients had 183 neck dissections and 92 parotidectomies in 6 years. There were 75 therapeutic and 108 elective operations. Modified or selective neck dissections were performed in 58% of patients with clinical neck metastases. Ali but two elective operations were modified or selective dissections. Postoperative radiotherapy was given to 27 dissected necks. Minimum follow-up was 12 months, and 86% of patients were followed up for 2 years or to neck recurrence. RESULTS: Nodes were histologically positive in 80 dissections. The cumulative rate of control of metastatic melanoma in the neck was 86% at 5 years. Neck recurrence developed in 14% of radical dissections, 0% of modified, and 23% of selective dissections performed for clinical disease. Neck recurrence occurred after 5% of elective dissections. Recurrence was 7% among irradiated necks compared to 23% in nonirradiated (p-value not significant). The 5-year survival rate was 50%, and this was significantly worsened by increasing node involvement. CONCLUSIONS: Modified radical neck dissection is highly effective in controlling metastatic melanoma in selected patients. Selective dissections are less effective and need further study. Adjuvant radiotherapy appears to decrease the risk of neck recurrence. In the elective setting, recurrence is uncommon following the selective neck dissections described.

Adolescent↗

PubMed1994

Use of endovascular stents for acute aortic dissection: an experimental study.

This study was designed to evaluate the potential obliteration of an experimental aortic dissection using an intravascular stent introduced via the femoral artery. Twenty-two adult dogs were divided into four groups: in group A (n = 6) a thoracoabdominal aortic dissection was surgically created to observe the natural course of this lesion; in group B (n = 6) a nitinol coil graft was introduced into the aorta via the femoral artery; in group C (n = 3) a nitinol coil graft was introduced via the femoral artery into a dissected aorta in an attempt to obliterate the dissection; and in group D (n = 7) an expandable intraluminal vascular graft (Palmaz stent) was introduced via the femoral artery into a dissected aorta in an attempt to obliterate the dissection. Arteriographic evaluation was performed postoperatively and again 6 weeks later before the aortas were explanted. Gross and light microscopic examinations were performed on all explanted aortas. In group A dissection was achieved and a postoperative aortogram demonstrated evidence of aortic dissection in all animals. Autopsy revealed persistence of dissection with a reentry tear near the celiac axis in five animals. In group B there was incomplete expansion of the nitinol coil graft in five dogs, resulting in aortic thrombosis in one. In group C the nitinol coil graft failed to obliterate the aortic dissection in all animals and resulted in aortic thrombosis in two. In group D placement of a balloon-expandable intraluminal stent solely at entry and reentry sites resulted in only partial obliteration of the dissection (n = 3), but when the entire length of the dissected aorta was treated, the dissection was completely obliterated (n = 3).

Acute Disease↗

PubMed2002

Complications of neck dissection for thyroid cancer.

Prophylactic and therapeutic neck dissections are used to control or eliminate local nodal disease in patients with thyroid cancer. The purpose of this study was to evaluate the results and complications of neck dissection. From 1992 to 1999 a series of 115 consecutive neck dissections were performed in 74 patients (32 men, 42 women; mean age 48 years) with thyroid cancer and nodal metastases. Operations included central compartment, lateral modified, and suprahyoid dissection with and without total or completion thyroidectomy. Sixty-four percent of the patients had papillary, 4% follicular, and 32% medullary thyroid cancer. Complications included transient hypocalcemia (23%) defined by a postoperative serum calcium level of <2.0 mmol/L (8.0 mg/dl), one neck hematoma (0.9%), and one cardiac death (0.9%). There were no permanent recurrent nerve palsies. Hypocalcemia occurred more frequently when neck dissection was combined with total thyroidectomy than without it (p <0.005). In this group, the incidence of hypocalcemia was higher after central, than lateral, neck dissection. When neck dissection was performed without thyroidectomy, there was no difference in the rates of hypocalcemia between central, lateral, or central with lateral neck dissection (p = NS). Hypocalcemia did not increase with repeated neck dissections (p = NS). Permanent hypoparathyroidism occurred in 0.9%. There were no complications after suprahyoid dissection. The median duration of hospitalization was 1 day. Therapeutic neck dissection or repeated neck dissection can be performed relatively safely in patients with thyroid cancer. Hypocalcemia occurs most frequently when neck dissection is combined with total thyroidectomy.

Adolescent↗

PubMed1998

[Aortic valve replacement as an independent predictive factor for later development of aortic dissection].

Dissection of the ascending aorta (type A) following later after aortic valve replacement has been described with increasing frequency. This study analyzes the role of aortic valve replacement for the evolution of late dissection. In a series of 80 consecutive patients with type A dissection, a previous aortic valve replacement had been performed in 12 cases (15%). In addition to arterial hypertension (p < 0.001) and Marfan syndrome (p < 0.01), multivariate analysis identified previous aortic valve replacement (p < 0.01) as an independent predisposing factor for type A dissection. Dissection occurred 3 +/- 4 years after aortic valve replacement with a clinical and anatomical profile similar to classic dissection as proven by comparison to a group of 62 patients with classic dissection associated with arterial hypertension or Marfan syndrome. With 75% and 66%, respectively, 30 day and 1 year survival of patients with dissection following later after aortic valve replacement was similar to patients with classic type A dissection. Extensive thinning and/or fragility (p < 0.05) of the aortic wall in the presence of a mildly dilated aorta (45 +/- 5 mm) at the time of aortic valve replacement was associated with a high risk for late dissection; this finding was substantiated by comparison to a control group of 10 consecutive patients with a similarly dilated aortic root but no dissection. Type and diameter of valve prostheses, cross-clamp time, NYHA functional class, and left ventricular ejection fraction were unrelated to late dissection. Previous aortic valve replacement is an independent predisposing factor for a dissection of the ascending aorta later. At the time of aortic valve replacement, prophylactic replacement or wrapping of the ascending aorta should be considered in patients with a thinned/fragile aortic wall even without a markedly dilated aortic root.

Adult↗

PubMed2006

Predictors of surgical indications for acute type B aortic dissection based on enlargement of aortic diameter during the chronic phase.

OBJECTIVES: Patients with Stanford type B dissection who have been treated successfully with medical hypotensive therapy during the acute phase (< 14 days) have the risk of surgery during the chronic phase because of enlargement of the dissected aorta. The objective of this retrospective analysis is to determine the predictors of surgical indications for acute type B aortic dissection by studying chronic-phase enlargements of aortic dissection in patients treated successfully with medical hypotensive therapy. METHODS: Altogether, 131 patients with type B aortic dissection were treated medically during the acute phase between 1987 and 2004. Multivariate factor analyses were performed to determine the predictors of chronic-phase enlargement (> or = 55 mm, as defined for our surgical criteria) of the dissected aorta. RESULTS: Overall dissection-related mortality was 17.6%. Patency of the false lumen was an independent risk factor for dissection-related death (P = 0.0238, hazard ratio 2.594, confidence interval 1.009-6.122) and for dissection-related events (P = 0.0157, hazard ratio 1.870, confidence interval 1.116-3.133). The incidence of patients treated surgically during the chronic phase was 32.8%. The predictors for aortic enlargement during the chronic phase were the condition of maximum aortic diameter > or = 45 mm with a patent false lumen during the acute phase. The rates of freedom from aortic enlargement (> or = 55 mm) for patients with maximum diameter (> or = 45 mm) with a patent false lumen during the acute phase at 1, 5, and 10 years were 72.6%, 66.0%, and 42.8%, respectively, whereas in patients with a maximum aortic diameter of < 45 mm with a thrombosed false lumen the values were 100%, 94.7%, and 89.2%, respectively (P < 0.005). CONCLUSIONS: These data suggest that patients with acute type B dissection with a patent false lumen or a diameter > or = 45 mm (or both) during the acute phase are at risk for enlargement of the dissecting aorta. The patients with dissecting aortas > or = 45 mm or a patent false lumen (or both) therefore require close follow-up to detect enlargement of the dissecting aorta, whereas patients with a maximum aortic diameter of < 45 mm with a thrombosed false lumen can stay on conservative therapy.

Acute Disease↗

PubMed1990

Aortic dissection with the entrance tear in transverse aorta: analysis of 12 autopsy patients.

Clinical and autopsy findings are described in 12 patients who had fatal aortic dissection with the entrance tear in the transverse aorta. The 12 patients represent 7% of 182 autopsies of spontaneous aortic dissection studied by us. The ages of the 12 patients at death ranged from 37 to 87 years (mean, 67 years). Eight were men; 8 had a history of systemic hypertension, and 10 had hearts of increased weight. Diagnosis of aortic dissection was made during life in only 4 of the 12 patients. All 12 patients died of rupture of the false channel within 2 weeks of onset of signs or symptoms compatible with dissection. The direction of aortic dissection from the entrance tear was entirely retrograde in 4 patients, entirely anterograde in 4 patients, and in both directions in 4 patients. Hemopericardium occurred in the first group, left hemothorax in the second group, and either in the last group. Of the 8 patients in whom the ascending aorta was involved, the retrograde dissection in each extended to the aortic root, 6 had pulmonary adventitial hemorrhage, and 4 had involvement of the arch arteries by dissection. In the 4 patients with strictly anterograde dissection, none had dissection in the arch arteries. Thus, tear in the transverse aorta causes a dissection that is usually fata, that often dissects retrogradely, and that may mimic dissection from a tear in ascending aorta. Aortic dissection from a tear in transverse aorta requires early operative intervention.

Adult↗

PubMed1994

Recurrent spontaneous cervical-artery dissection.

BACKGROUND: Spontaneous dissection of the internal carotid and vertebral arteries is increasingly recognized as a cause of ischemic stroke in young people. An underlying arteriopathy is often suspected in the pathogenesis of such dissection, but the frequency of recurrent dissection is unknown. METHODS: We describe the long-term follow-up of 200 consecutive patients (104 women and 96 men) with spontaneous cervical-artery dissections evaluated at the Mayo Clinic between 1970 and 1990. All diagnoses were confirmed by angiography. RESULTS: The mean age of the patients was 44.9 years (range, 16 to 76). Internal carotid arteries were affected in 150 patients, vertebral arteries in 37, and both in 13. Multivessel dissections were present in 28 percent of the patients. The mean follow-up was 7.4 years. Recurrent dissection occurred only in arteries not previously involved by dissection. A recurrent arterial dissection developed in 16 patients (8 percent)--within a month after the initial dissection in 4 patients (2 percent) and between 1.4 and 8.6 years later in 12 patients (a rate of 1 percent per year). The cumulative rate of recurrent dissection among patients followed for 10 years was 11.9 percent. Younger patients had a greater risk of recurrent dissection. CONCLUSIONS: Although dissections in multiple cervical vessels are common at presentation, after the first month the risk of recurrent dissection is only about 1 percent per year.

Adolescent↗

PubMed1994

Aorta and aortic valve morphologies predisposing to aortic dissection. An in vivo assessment with transoesophageal echocardiography.

Predisposing factors for aortic dissection are well known from necropsy series. To evaluate the frequency of aortic and aortic valve disease in aortic dissection in vivo, 139 patients with acute aortic dissection (96 men, 43 women, mean age 60.5 +/- 15.7 years) were studied by transoesophageal echocardiography (TEE) using 3.5 and 5.0 MHz transducers. Left ventricular hypertrophy by TEE, defined as an end-diastolic wall thickness of the left ventricular septal wall over 1.5 cm, was found in 42 (67.7%) of 62 patients with type I, in 10 (58.8%) of 17 patients with type II and in 46 (76.7%) of 60 patients with type III dissection. The mean value for the aortic root diameter was 3.2 +/- 1.3 cm.m-2 in type I dissection and 2.8 +/- 0.9 cm.m-2(ns) in type II dissection. In the patient group with type III dissection this diameter was significantly smaller (1.8 +/- 0.9 cm.m-2; P < 0.001). Thickening of aortic valve leaflets was demonstrated in six (9.7%) of 62 patients with aortic dissection type I (two of them with mild aortic stenosis), in two (11.8%) of 17 patients with aortic dissection type II and in 15 (25.0%) of 60 patients with aortic dissection type III. A bicuspid aortic valve was diagnosed in five (6.3%) of 79 patients with aortic dissection types I and II and in one (1.7%) of 60 patients with type III dissection. By colour coded Doppler echocardiography, aortic regurgitation was found in 46 (74.2%) of 62 patients with type I, 13 (76.5%) of 17 patients with type II and 23 (38.3%) of 60 patients with type III dissection.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗