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PubMed1979

Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period.

An unselected, consecutive cohort of 125 patients underwent operative repair of acute and chronic aortic dissections with tubular graft interposition over a 16 year span. The absence of remote geographical referral biases and the unselected nature of this series provided a patient population that was representative of the disease process (as assessed heretofore only from autopsy series). Furthermore, this enabled high-risk subsets to be defined by retrospective analysis. Patients were classified according to whether the ascending aorta was involved (type A with involvement, type B without), irrespective of the site of intimal tear, and according to age of the dissection: Fifty-three patients had acute type A (Ac-A), 29 had chronic type A (Ch-A), 20 had acute type B (Ac-B), and 23 had chronic type B (Ch-B) dissections. Fourteen percent (17/125) of the dissections had ruptured. Concomitant aortic valve replacement (AVR) was performed in 11% (6/53) for Ac-A cases and 38% (11/29) of the Ch-A cases. A total of 391 patient-years of follow-up was analyzed; follow-up averaged 4.5 years and extended to 13.7 years. Over-all operative mortality rate was 34% (18/53) for Ac-A, 14% (4/29) for Ch-A, 45% (9/20) for Ac-B, and 22% (5/23) for Ch-B; during the most recent 5 year interval these figures were lower: 27%, 8%, 20%, and 20%, respectively, N = 50. Multiple preoperative variables were found to correlate significantly with both operative death and long-term survival. Operative survivors generally experienced satisfactory functional benefit. Late attrition averaged 8% per year; 61% of all late deaths were related to cardiac or cerebral causes. Over-all actuarial survival (+/- SEM) for the entire cohort was 54% +/- 5% at 5 years and 26% +/- 7% at 10 years; for the 89 patients surviving operation, these figures were 76% +/- 5% and 37% +/- 10%, respectively. No significant differences in long-term survival were evident between the different subgroups. Whether the primary intimal tear had been resected or concomitant AVR had been performed had no statistically significant bearing on operative mortality, functional result, necessity for late reoperation, or late attrition. The long-term "natural" history of surgically treated patients with aortic dissections, as defined in this study, should facilitate comparison with other treatment modalities. Results of the present analysis support immediate operative intervention for patients with Ac-A dissections and probably for those with Ac-B dissections. Additionally, surgical treatment of patients with symptomatic or enlarging Ch-A and Ch-B dissections provides satisfactory rehabilitation and long-term survival. Finally, we re-emphasize our recommendation for simplified classification of aortic dissections, based solely upon the presence or absence of ascending aortic involvement. Pathophysiology and expected biologic behavior pivot on this feature, and appropriate clinical strategy can thereby be defined.

Adult↗

PubMed1979

Aortic dissection: surgical and nonsurgical treatments compared. An analysis of seventy-four cases at the University of Virginia.

During the eleven year period from 1965 to 1976, aortic dissection was diagnosed in seventy-eight patients treated at the University of Virginia Medical Center. The seventy-four cases that comprise the present report were confirmed by aortography, surgery, or autopsy. Forty patients (54 per cent) were surgically treated by interruption of the origin of dissection and insertion of a Dacron prosthesis. The remaining thirty-four (46 per cent) were treated according to the Wheat regimen or by nonspecific supportive measures. The overall survival at one year was 28 per cent. One year survival for patients with type I dissections treated surgically was 19 per cent compared with 8 per cent one year survival for nonsurgically treated patients. Sixty per cent of patients with type II dissections treated surgically were alive at the end of one year, whereas no patients with type II dissection treated nonsurgically survived beyond one year. Half the patients with type III dissections treated surgically were alive at one year compared with 35 per cent of those nonsurgically treated. These data suggest that surgery is the treatment of choice for all types of aortic dissections, but particularly for type II. Patients with type I dissections have a very poor prognosis regardless of therapy.

Aged↗

PubMedDate not supplied

The discovery of the body: human dissection and its cultural contexts in ancient Greece.

In the first half of the third century B.C, two Greeks, Herophilus of Chalcedon and his younger contemporary Erasistratus of Ceos, became the first and last ancient scientists to perform systematic dissections of human cadavers. In all probability, they also conducted vivisections of condemned criminals. Their anatomical and physiological discoveries were extraordinary. The uniqueness of these events presents an intriguing historical puzzle. Animals had been dissected by Aristotle in the preceding century (and partly dissected by other Greeks in earlier centuries), and, later, Galen (second century A.D.) and others again systematically dissected numerous animals. But no ancient scientists ever seem to have resumed systematic human dissection. This paper explores, first, the cultural factors--including traditional Greek attitudes to the corpse and to the skin, also as manifested in Greek sacred laws--that may have prevented systematic human dissection during almost all of Greek antiquity, from the Pre-Socratic philosopher-scientists of the sixth and fifth centuries B.C. to distinguished Greek physicians of the later Roman Empire. Second, the exceptional constellation of cultural, political, and social circumstances in early Alexandria that might have emboldened Herophilus to overcome the pressures of cultural traditions and to initiate systematic human dissection, is analyzed. Finally, the paper explores possible reasons for the mysteriously abrupt disappearance of systematic human dissection from Greek science after the death of Erasistratus and Herophilus.

Animals↗

PubMed1976

The clinical recognition of dissecting aortic aneurysm.

The clinical, roentgenologic and laboratory findings in 124 patients with dissecting aneurysm of the aorta are reported. In 53 patients the dissection occurred in the ascending aorta ("proximal" dissection), and in 71 patients the site of origin was the descending thoracic aorta ("distal" dissection). Certain distinct clinical differences between the groups were apparent. Although hypertension was an important predisposing factor, it was significantly more common in distal dissection, as was atherosclerosis. Back pain and hypertension on hospital presentation characterized patients with distal dissection. Conversely patients with proximal dissection were younger and had a significantly higher incidence of Marfan's syndrome, cystic medial necrosis, anterior chest pain, pulse deficits, neurologic compromise, aortic insufficiency and congestive heart failure. In both groups, syncope appeared to correlate well with the occurrence of cardiac tamponade. Chest roentgenograms almost always showed an abnormal aortic contour. Aortic angiography, when performed, was usually confirmatory of the diagnosis.

Adult↗

PubMed1977

Indications for neck dissection in carcinoma of the lip.

In the past, neck dissections have been recommended only when nodes were clinically palpable or when they became so. A retrospective ten year study of thirty-seven patients with carcinoma of the lip and with an unusually high mortality has allowed reevaluation of indications for neck dissection. (1) Ten of thirty-seven patients died of this disease and nearly all of the ten died with and because of regional metastases. (2) Seven patients with nonpalpable nodes initally had nodal metastases later which, despite neck dissection at that later time, proved lethal. (3) Two patients who, despite nonpalpable nodes, had undergone neck dissections and were found to have occult bilateral nodal metastases were effectively cured with early neck dissection. This suggests that early bilateral supramohyoid neck dissections for small carcinomas of the lip and ipsilateral radical neck dissections for large primaries may yield higher cure rates than currently achieved.

Adult↗

PubMed1992

Ten years of surgery of aortic dissections and aneurysms. Clinical experience and original contributions.

From January '82 to April '91, 117 patients with aortic disease were operated upon at our University Hospital in Genoa, Italy. Thirty-seven had arch dissections or aneurysms; 66 had acute aortic dissection type A and 14 had aortic dissections or aneurysms type B, acute and chronic. Patients with arch or type B aortic pathology but without surgical indication and cases of post-traumatic aortic transections are not included. There were 84 male and 33 female patients with a mean age of 52 (6 min and 74 max). In the acute patients, the mean interval between clinical onset and surgery was 34 hours (6 min-72 max). All patients with primary arch disease had surgical repair with the aid of deep hypothermia and circulatory arrest (17-96 min). Type A dissections were treated with standard CPBP at 28 degrees C. Surgical techniques included direct suture of intimal tear alone, direct suturing of the two aortic stumps; interposition of Dacron tubular prosthesis; Bentall repair; separated valve and aortic replacement; an original aortic bulb aortoplasty with valve repair; arch replacement with resuturing of one or more aortic trunks. Human fibrin glue (Tissucol) was employed either as haemostatic agent, widely spread over the suture lines or as tissue adhesion agent between dissected aortic layers. Human fibrin glue is adopted because it gathers high glueing capacity and maintenance of the elastic property of the vessel wall. Hospital mortality (30 days) has been 25% in ascending aortic dissections (16/66 patients) and 50% in patients with arch disease (18/37 patients) who needed circulatory arrest. Late mortality 5/83 (6%). Reoperations for aortic valve insufficiency or re-dissection have been 7 (8.4%). Early diagnosis (increasing reliability of 2D-Echo and CT scans), aggressive surgery, meticulous myocardial and cerebral protection and introduction in clinical use of biological glues seem to be the milestones of present and further improvements in surgical results.

Acute Disease↗

PubMed1992

[Wallenberg's syndrome due to vertebral artery dissection following minimal neck injury--report of two cases].

We described two cases of the lateral medullary syndrome (Wallenberg's syndrome) due to vertebral artery dissection following minimal neck injuries. The first case was a 45-year-old man, who hit his head and often rotated his head because of posterior neck discomfort. Two years after the injury, he suffered from sudden sharp neck pain, nausea, and vertigo, which was followed by left hand numbness and difficulty in walking due to the right lateral medullary syndrome. Angiography showed right vertebral artery dissection at the fourth segment. The second case, a 48-year-old man, suffered from neck pain immediately after he hyperextended his neck for painting a wall. Within several hours, he experienced left hand numbness and difficulty in walking due to the lateral medullary syndrome. Angiography showed a saccular aneurysm and dissection of the right vertebral artery at the fourth segment. In both cases, minor traumas were thought to be the causes of vertebral artery dissection. We surveyed previously reported 84 cases (men: 50, women: 34) of the vertebral artery dissection due to minor traumas. Seventy per cent of patients were in their third or fourth decade of life. The main causes of trauma preceding the dissection were neck manipulation especially chiropractics (52%). The third segment was most vulnerable. Delay in onset following neck trauma could be more than a week, but in most cases the delay was less than 24 hours. Cervical rotation and extension were thought to precipitate dissection.

Aortic Dissection↗

PubMed1992

[The evaluation of pre and intraoperative factors influencing the false lumen after graft replacement surgery to the extended dissecting aneurysm].

We evaluated the residual false lumen of type I and IIIb dissecting aneurysm by CT, MRI and angiography postoperatively. The 19 patients with type I dissecting aneurysm were included eleven men and eight women, the average age was 55.8 +/- 10.2 years old. The 20 patients with type IIIb dissecting aneurysm were included sixteen men and four women, the average age was 56.2 +/- 8.5 years old. The rate of distal patent false lumen was 52.6% of type I and 35% of type IIIb dissecting aneurysm after graft replacement surgery. In type I dissecting aneurysm, the rate of distal patent false lumen was 40% of acute stage vs 66.7% of chronic stage, 66.7% of ascending and partial arch replacement vs 46.2% of ascending and total arch replacement, and 90% of graft inclusion technique vs 11.1% of graft exclusion technique. The distal patent false lumen was the lowest (12.5%) with type I dissecting aneurysm of ascending and total arch replacement using graft exclusion technique. In type IIIb dissecting aneurysm, the rate of patent false lumen was 66.7% of acute stage vs 29.4% of chronic stage, 30% of graft exclusion technique vs 40% of graft inclusion technique. The size of false lumen preoperatively were larger (11.1 +/- 4.5 cm2) in patients with distal patent false lumen than that (6.7 +/- 3.2 cm2) of in patients with distal occlusive false lumen.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1992

[Diagnostic goals in aortic dissection. Value of transthoracic and transesophageal echocardiography].

The combination of different ultrasound techniques like transthoracic, suprasternal, subcostal and transesophageal echocardiography have a high sensitivity and specificity in the diagnosis of aortic dissection. The limitation of this combined ultrasound technique is related to the visualization of the ascending part of the aortic arch which, cause of the interposition of the trachea, can not be visualized completely. The beginning or the end of a dissection in this part of the aorta may be misinterpreted. False negative results are rare. False positive results due to artefacts resulting from reverberations in an ectatic ascending aorta have to be taken into account. The most important diagnostic aims in acute or chronic aortic dissection can be described: 1. confirmation of the diagnosis by visualization of the intima membrane, 2. the differentiation of the true and false lumen depending on visualization of spontaneous echocardiographic contrast thrombus formation, slow or reduced reversed flow, systolic diameter reduction and signs of entry jet into the false lumen, 3. detection of intimal tear, demonstrating communication by two-dimensional or color Doppler echocardiography, 4. determination of the extent of the dissection with classification according to DeBakey type I, II and III or Stanford A and B with differentiation to communicating or non-communicating dissection, antegrade or retrograde dissection limited to the descending aorta or expanding to the ascending aorta, 5. detection of wall motion abnormalities as a sign of preexisting coronary artery disease or myocardial ischemia due to ostium occlusion by an intimal flap, coronary artery rupture or collapse of the true lumen during diastole, 6. detection and grading of aortic insufficiency, 7. detection of side branch involvement by suprasternal, subcostal and abdominal sonography, which will gain the information which side can be chosen for cannulation or catheterization at the femoral artery, 8. detection of pericardial pleural effusion and mediastinal hematoma as a sign of emergency as rupture can occur within minutes. Without surgical intervention have be performed. Based on these informations, surgery can be performed in all acute situations in type A dissection without further investigations. This decision is particularly important in patients with signs of emergency like pericardial or pleural effusion or mediastinal hematoma.

Aortic Dissection↗

PubMed1978

The effects of extraperiosteal and subperiosteal dissection. II. On fracture healing.

The effects of subperiosteal and extraperiosteal dissection on the healing of tibial osteotomies were studied in fourteen rabbits killed three weeks after the osteotomy. Of the tibiae exposed subperiosteally, 71 per cent healed; of those exposed extraperiosteally, only 7 per cent had solid union. The first group had a significantly lower level of hydroxyproline in the callus and higher values for breaking load, breaking strength, and absorption of energy to failure. In ten animals that also had muscle transection at the osteotomy site, the rate and type of healing was similar whether no dissection, subperiosteal dissection, or extraperiosteal dissection had been done, but the callus showed lower calcium levels and higher hydroxyproline levels than in either of the groups with muscle trauma. This implies retardation of healing caused by muscle injury. Our data suggest that in the absence of muscle damage, subperiosteal dissection results in earlier healing than does extraperiosteal dissection. Muscle transection markedly retards healing; then, after transection, neither type of dissection appears to retard healing more than the other.

Animals↗

PubMed1978

Use of a ringed intraluminal graft in the surgical treatment of dissecting aneurysms of the thoracic aorta. A new technique.

An intraluminal graft made of woven tubular Dacron with cloth-covered grooved rings at both ends is used to repair dissecting aneurysms of the thoracic aorta. Six consecutive white male patients ranging in age from 31 to 69 years with an average age of 55 years were operated upon with the use of this graft. Three patients had a dissecting aneurysm of the ascending aorta and three others had a dissecting aneurysm of the descending aorta. Total cardiopulmonary bypass was utilized in repairing dissecting aneurysms of the ascending aorta and left heart bypass was used in patients with dissecting aneurymsms of the descending aorta. The basic technique consists in inserting the whole ringed graft into the true lumen of the dissected aorta and circumferentially ligating the aorta against the groove in the rings. The proximal ring of the graft effectively stabilized the flail aortic valve in two patients with aortic regurgitation associated with dissection of the ascending aorta. There were no hospital deaths. All patients are doing well 1 year, 1 month to 2 years, 8 months after the operation.

Adult↗

PubMedDate not supplied

Surgical treatment of acute dissecting aneurysm of the ascending aorta.

Since 1959, 51 patients underwent open heart surgery for correction of an acute dissecting aneurysm of the ascending aorta. Upon admission, 33 patients were severely hypotensive or in progressive heart failure. Acute aortic insufficiency was found in 24 patients, and hemiplegia or hemiparesis in four. In 45 patients the ascending aorta was reconstructed with a woven Dacron graft. After excision of the dissected part of the aorta, primary anastomosis or patch aortoplasty was performed in six patients. The aortic valve remained intact in 26 patients, and resuspension of the commissures restored competence of the aortic valve in another nine. Sixteen patients required aortic valve replacement because of disrupture of the commissures. Dissection extended into the coronary ostia in nine cases. Reconstruction of the coronary system was accomplished by reimplantation of the ostia, interposition of a vein graft or aortocoronary bypass. Nine patients died within the early postoperative course from uncontrollable hemorrhage (four), further dissection (three) and myocardial infarction (two). Within the first year after surgery, another five patients died from acute aortic dissection (two), pseudomonas infection causing rupture of the proximal graft anastomosis (one) and myocardial infarction (two). Contraindications of antihypertensive treatment of acute dissection of the ascending aorta are discussed. We recommend prompt surgical intervention in acute dissecting aneurysms of the ascending aorta.

Acute Disease↗

PubMed1975

[Surgical treatment of acute dissection of the ascending aorta (author's transl)].

Since 1959, 51 patients underwent open heart surgery for correction of acute dissection of the ascending aorta. Upon admission 33 patients were severely hypotensive or in porgressive heart failure. Acute aortic insufficiency was found in 24 patients, and hemiplegia or hemiparesis in 4. In 45 patients the ascending aorta was reconstructed with a woven graft. After excision of the dissected part of the aorta primary anastomosis or patch aortoplasty was performed in 6 patients. The aortic valve remained intact in 26 cases, and resuspension of the commissures restored competence of the aortic valve in another 9 patients. Sixteen patients required aortic valve replacement because of disrupture of the commissures. Dissection extended into the coronary ostia in 5 cases. Reconstruction of the coronary system was accomplished by reimplantation of the ostia, interposition of a vein graft or aorto-coronary bypass. Nine patients died within the early postoperative course from uncontrollable hemorrhage (4), further dissection (3) and myocardial infarction (2). Within the first year after surgery another 5 patients died from acute aortic dissection (2), pseudomonas-infection causing rupture of the proximal graft anastomosis (1), and myocardial infarction (2). The contraindications of antihypertensive treatment of actue dissection of the ascending aorta are discussed. We recommend prompt surgical intervention in acute dissecting aneurysm of the ascending aorta.

Aortic Aneurysm↗

PubMed1992

Cervico-thoraco-abdominal (3-field) lymph node dissection for carcinoma in the thoracic esophagus.

The efficacy of an extended radical lymph node dissection for carcinoma in the thoracic esophagus is controversial. Results of a multivariate analysis using clinical data from 127 cases collected from 1982 to 1988 are reported. Twenty-seven of these patients underwent an extended radical (cervico-thoraco-abdominal: 3 fields) lymph node dissection which was recently developed in Japan, while others underwent a standard (thoraco-abdominal: 2 fields) lymph node dissection. They all had a locally-curative resection of the tumor through a right thoracotomy. In this study, 13 factors commonly affecting prognosis were examined: sex, age, cancer location, tumor length, radiographic type, depth of invasion, lymph node metastasis, tumor differentiation, postoperative radiotherapy, chemotherapy, operative risk, postoperative complications, and 3-field or 2-field dissection. Based on the survival-rate curves using Kaplan-Meier's statistics, the 3-field dissection was superior to the 2-field dissection. Moreover, when other prognostic factors were adjusted using Cox's proportional hazards general linear model, the same result was obtained from survival-rate curves. From this analysis, it can be concluded that a 3-field dissection is a better approach for management of carcinoma in the thoracic esophagus.

Abdomen↗

PubMed1975

Control of acute aortic dissection.

An experimental model of acute aortic dissection has been designed in an effort to examine myocardial contractility and systolic arterial pressure as factors influencing the progression of dissection. Thirty mongrel dogs divided into three experimental groups underwent left thoracotomy and construction of a standard intimal tear in the proximal descending aorta. Nine of ten animals in the control group showed progression of the aortic dissection a mean of 81.5 percent of the distance from the aortotomy to the celiac axis. Group II consisted of ten dogs pretreated with propranolol. The myocardial contractility (dp/dt) was significantly depressed in this group without change in systolic pressure. However, progression of dissection occurred in nine of ten animals as in the control group. In Group III, ten dogs were pretreated with trimethaphan lowering the systolic blood pressure to 90 mm. Hg and depressing the dp/dt to levels equal to those of Group II. There was no progression of aortic dissection in any of the animals in this group. The results indicate that, under these experimental conditions, depression of myocardial contractility alone has no inhibitory effect on the progression of dissection. When controlled hypotension is added to myocardial depression, aortic dissection is inhibited completely.

Animals↗

PubMedDate not supplied

[Endo-surgical dissection of the upper urinary tract through the retroperitoneal and transperitoneal route: an experimental study with pigs and cadavers].

In order to define the best method for endosurgical dissection of the upper urinary tract, an experimental study comparing the retroperitoneal and transperitoneal approaches was performed. Between September 1991 and February 1992, 15 female pigs and 8 human cadavres underwent endosurgical dissection of the upper urinary tract. The retroperitoneal approach was used in 8 pigs and 5 cadavres. In the lateral supine position, the retroperitoneum was insufflated at the lower pole of the kidney, via a 2 cm cutaneo-muscular incision, followed by a blind dissection with the finger to create a space in the retroperitoneal fat. Four trocars were inserted into the retroperitoneal space allowing dissection of the ureter, kidney and its vascular pedicle. The renal vessels and the ureter were then clipped or stapled with the endo-GIA then sectioned. The operation was successfully performed in all of the pigs with a mean operating time of 2 hours. Complications were limited to two peritoneal effractions. Retroperitoneal endosurgical dissection was much longer and more difficult to perform on the cadavre (mean operating time: 3 hours). Satisfactory retropneumoperitoneum was never able to be obtained due to the large amount of retroperitoneal fat and the proximity of the twelfth rib and posterior iliac crest interfered with the insertion of the trocars and made dissection more difficult. The transperitoneal approach was performed in 7 pigs and three cadavres. In the lateral supine position, after creating pneumoperitoneum using a Veress needle, 4 trocars were inserted into the peritoneal cavity. Toldt's fascia was gripped and incised allowing retraction of the colon towards the midline, thereby exposing the renal region. The ureter and the renal vessels were dissected. The renal artery and vein were then clipped or stapled with the endo-GIA then sectioned, while the ureter was clipped and sectioned. The complications of the transperitoneal route were: an injury to the small intestine during insertion of a trocar and haemorrhage due to accidental section of a lower pole renal artery, which was able to be controlled by application of clips. In the pig, the transperitoneal approach was as simple to perform as the retroperitoneal approach and the mean operating time was the same (two hours).(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed1977

Renal artery dissections.

Renal artery dissections encountered in 15 patients, aged 3 to 75 years, were categorized as to pathogenesis (blunt abdominal trauma, catheter injury, and spontaneous). Blunt traumatic dissections (seven patients) were characterized by hypertension, gross hematuria, and pain. Catheter-induced dissections (four patients) were asymptomatic, although two exhibited accelerated hypertension. Spontaneous dissections (four patients) were all associated with preexistent arterial disease. Symptoms in these patients were uncommon, despite accelerated hypertension in three cases. Intravenous pyelography lacked specific diagnostic value for renal artery dissections. Early arteriographic examination proved essential in diagnosis and surgical treatment. Criteria for operative intervention included existence of technically correctable dissections causing (1) hemodynamically significant occlusions of the main or major segmental renal arteries, (2) documented renovascular hypertension, or (3) significant deterioration of renal function.

Adult↗

PubMed1978

Results in suprahyoid, modified radical, and standard radical neck dissections for metastatic squamous cell carcinoma: recurrence and survival.

Two hundred sixty-one patients who underwent three types of neck dissection for cervical lymphadenopathy in association with squamous cell cancer of the head and neck are analyzed retrospectively. Patients were grouped into those with histologically negative nodes and those with histologically positive nodes. Statistical analyses for neck recurrence and survival rates were made using the sampled permutation method. The results show that suprahyoid neck dissection is associated with an unusually high recurrence rate in the neck in patients with histologically negative nodes. Modified radical neck dissection and standard radical neck dissection are equivalent with regard to recurrences in the neck and five year survival rates when the disease is above the juguloomohyoid lymph node group. The study suggests that simple upper neck dissection is contraindicated in patients with negative or positive nodes and that modified radical neck dissection can be used in selected patients instead of the formal radical neck operation.

Adult↗