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PubMed1997

[Early results in the surgical treatment of type B aortic dissection].

In contrast to type A aortic dissection, the indication for acute surgical repair as treatment of choice in type B aortic dissection is not the actual dissection, but the complications resulting from the dissection (rupture, potential rupture and ischemic syndromes of the aortic branches). Between 1978 and 1994, 92 patients underwent surgical repair of type B aortic dissection at our institution. Following diagnostic confirmation by echocardiography and/or CT scan, all patients received conservative antihypertensive therapy. 52% of the patients underwent emergency surgical repair. Symptoms prompting surgical repair were: visceral ischemia (23%), pleural effusion (19%), paraparesis (17%), refractory hypertension (12%), further aortic enlargement (12%), and rupture (10%). In chronic type B aortic dissection, the main symptom in 84% of the cases was further enlargement of the aorta. The early mortality decreased in the course of initial treatment from 33% to 16%, and to 8% after exclusion of patients operated on for ruptured aorta. Improved early mortality has led to an increase in acute surgical repair. In cases of chronic dissection, strict antihypertensive therapy is indicated and regular checks on the width of the aorta, as well expeditious diagnostic confirmation of its enlargement, are important.

Acute Disease↗
PubMed1991

Primary malignant fibrous histiocytoma of the aorta associated with aortic dissection.

We report a unique case of primary aortic malignant fibrous histiocytoma presenting clinically as aortic dissection. To our knowledge, this occurrence is the first ever reported. The magnetic resonance imaging technique may provide superiority in the differential diagnosis between tumor and hematoma of aortic dissection. Aortic tumor, although rare, should be included among the causes of aortic dissection.

Aortic Dissection↗
PubMed2006

[Inflow cannula direct insertion into the true lumen of the ascending aorta for an acute aortic dissection patient with intraoperative malperfusion after aortic clamping].

A 47-year old woman, who was diagnosed as Stanford type A acute aortic dissection, underwent an emergent operation. Because of obesity and bleeding, it was impossible to find the right axillary artery. Only we could have for inflow line was the femoral line. After starting cardiopulmonary bypass (CPB) and crossclamping the ascending aorta, mean blood pressure of the right radial artery dropped to 15 mmHg, suggesting the occurrence of malperfusion. The ascending aorta was immediately transected, and the CPB was ceased. Inflow cannula was directly inserted into the true rumen of the ascending aorta, and resumed the CPB. The mean blood pressure rose up to 80 mmHg. Such procedure took about 10 minutes. Abnormal neurological findings were not apparent except for the transient postoperative delirium. The patient was discharged on the 48th day after operation. It is suggested that this method was useful and safe to have the new inflow line when emergently necessary.

Aortic Dissection↗
PubMed1997

Paraparesis due to syphilitic aortic dissection.

A patient is presented who developed an acute spinal cord infarct with paraparesis and segmental pain but no sensory or sphincter involvement. Investigations revealed an extensive dissecting thoracic aortic aneurysm and positive treponemal serologic findings consistent with tertiary cardiovascular syphilis.

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PubMed2002

Does this patient have an acute thoracic aortic dissection?

CONTEXT: The diagnosis of acute thoracic aortic dissection is difficult to make and often missed. OBJECTIVE: To review the accuracy of clinical history taking, physical examination, and plain chest radiograph in the diagnosis of acute thoracic aortic dissection. DATA SOURCES: A comprehensive review of the English-language literature was conducted using MEDLINE for the years 1966 through 2000. Additional sources were identified from the references of retrieved articles. STUDY SELECTION: The search revealed 274 potential sources, which were reviewed for pertinence and quality. Articles included were original investigations describing the clinical findings for 18 or more consecutive patients with confirmed thoracic aortic dissection. Twenty-one studies were identified that met selection criteria. DATA EXTRACTION: Critical appraisal and data extraction were performed by the author. DATA SYNTHESIS: Most patients with thoracic aortic dissection have severe pain (pooled sensitivity, 90%) of sudden onset (sensitivity, 84%). The absence of sudden pain onset lowers the likelihood of dissection (negative likelihood ratio [LR], 0.3; 95% confidence interval [CI], 0.2-0.5). On examination, 49% of patients have an elevated blood pressure, 28% have a diastolic murmur, 31% have pulse deficits or blood pressure differentials, and 17% have focal neurological deficits. Presence of a diastolic murmur does little to change the pretest probability of dissection (positive LR, 1.4; 95% CI, 1.0-2.0), whereas pulse or blood pressure differentials and neurological deficits increase the likelihood of disease (positive LRs, 5.7 and 6.6-33.0, respectively). The plain chest radiograph results are usually abnormal (sensitivity, 90%); hence, the presence of a normal aorta and mediastinum decreases the probability of dissection (negative LR, 0.3; 95% CI, 0.2-0.4). Combinations of findings increase the likelihood of disease. CONCLUSIONS: The presence of pulse deficits or focal neurological deficits increases the likelihood of an acute thoracic aortic dissection in the appropriate clinical setting. Conversely, a completely normal chest radiograph result or the absence of pain of sudden onset lowers the likelihood. Overall, however, the clinical examination is insufficiently sensitive to rule out aortic dissection given the high morbidity of missed diagnosis.

Acute Disease↗
PubMed1989

Magnetic resonance imaging of isolated abdominal aortic dissection.

In the absence of trauma or descending thoracic aortic dissection, abdominal aortic dissection is rare. This report presents a case of "isolated" abdominal aortic dissection. Magnetic resonance imaging may reliably diagnose and characterize these dissections without the use of contrast material.

Aortic Dissection↗
PubMed1999

Endovascular stent-graft placement for the treatment of acute aortic dissection.

BACKGROUND: The standard treatment for acute aortic dissection is either surgical or medical therapy, depending on the morphologic features of the lesion and any associated complications. Irrespective of the form of treatment, the associated mortality and morbidity are considerable. METHODS: We studied the placement of endovascular stent-grafts across the primary entry tear for the management of acute aortic dissection originating in the descending thoracic aorta. We evaluated the feasibility, safety, and effectiveness of transluminal stent-graft placement over the entry tear in 4 patients with acute type A aortic dissections (which involve the ascending aorta) and 15 patients with acute type B aortic dissections (which are confined to the descending aorta). Dissections involved aortic branches in 14 of the 19 patients (74 percent), and symptomatic compromise of multiple branch vessels was observed in 7 patients (37 percent). The stent-grafts were made of self-expanding stainless-steel covered with woven polyester or polytetrafluoroethylene material. RESULTS: Placement of endovascular stent-grafts across the primary entry tears was technically successful in all 19 patients. Complete thrombosis of the thoracic aortic false lumen was achieved in 15 patients (79 percent), and partial thrombosis was achieved in 4 (21 percent). Revascularization of ischemic branch vessels, with subsequent relief of corresponding symptoms, occurred in 76 percent of the obstructed branches. Three of the 19 patients died within 30 days, for an early mortality rate of 16 percent (95 percent confidence interval, 0 to 32 percent). There were no deaths and no instances of aneurysm or aortic rupture during the subsequent average follow-up period of 13 months. CONCLUSIONS: These initial results suggest that stent-graft coverage of the primary entry tear may be a promising new treatment for selected patients with acute aortic dissection. This technique requires further evaluation, however, to assess its therapeutic potential fully.

Acute Disease↗
PubMed1996

Type B aortic dissection involving an isolated right-sided aortic arch.

We report a case of a 48-year-old man in whom type B aortic dissection in the right aortic arch and right descending aorta was diagnosed by transesophageal echocardiography and computed tomographic scan. Angiography was necessary to define the anatomy of the branching vessels. The patient was successfully treated by interposition of a Vascutek 24-mm Dacron woven tube with a right posterolateral thoracotomy approach. Circulatory arrest in profound hypothermia and cerebral retroperfusion were used.

Aortic Dissection↗
PubMed1990

Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum.

Subacute mesenteric ischemia developed 2 months after initial presentation in a patient with a type III aortic dissection. Percutaneous transfemoral fenestration of the septum between the true and false lumens resulted in resolution of clinical, angiographic, and manometric signs of ischemia. Continued expansion of the false lumen required aortic resection and graft replacement of the distal thoracic and abdominal aorta 2 months after the fenestration procedure. At operation, the fenestration site appeared as a 2-cm horizontal tear in the aortic septum, free of adherent thrombus and unrelated to expansion of the false lumen.

Aortic Dissection↗
PubMed1998

Successful surgery for an acute type A aortic dissection following repair of a descending thoracic aortic aneurysm.

Acute type A aortic dissection in the presence of a previously repaired atherosclerotic descending thoracic aortic aneurysm is rarely reported. We experienced a patient who underwent an ascending aortic replacement with reconstruction of the aortic arch 16 months after repair of a descending thoracic aortic aneurysm. We succeeded in the redo operation with comprehensive techniques involving selective cerebral perfusion, deep hypothermia, early antegrade systemic circulation for cerebral protection, and femoro-femoral bypass with occlusion of the descending aorta for lower systemic perfusion as well as renal perfusion. The patient recovered and is doing well one year after the redo operation.

Acute Disease↗
PubMed1989

Radionuclide imaging in diagnosis of aortic dissection.

A case of an aortic dissection occurring in a 69-yr-old woman, 4 yr after aortic valve replacement is presented. The clinical context was one of an acute myocardial infarction. The first-pass and gated blood-pool scintigraphy ordered to evaluate cardiac function disclosed unexpected features of an aortic dissection clinically not suspected.

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PubMed2005

Stenting of a left main coronary artery dissection and stent-graft implantation for acute type a aortic dissection.

PURPOSE: To report successful endovascular repair of Stanford type A acute aortic dissection associated with a proximally extended dissection of the left main coronary artery. CASE REPORT: A 71-year-old man presented with acute type A aortic dissection. One day after admission, dissection of the left main coronary artery accompanied by severe myocardial ischemia prompted Palmaz stent placement. Three days later, a customized stent-graft was placed across the entry site of the dissection in the descending aorta. The false lumen in the ascending aorta, transverse arch, and the descending thoracic aorta thrombosed, and the left coronary artery remained patent. At 14 months after the procedures, the patient is doing well and has had no cardiac event. CONCLUSIONS: This staged procedure may be one option for the management of acute type A aortic dissection complicated by coronary artery dissection.

Acute Disease↗
PubMed1989

Use of surgical glue without replacement in the treatment of type A aortic dissection.

Between 1984 and 1988, 15 patients with type A aortic dissection were treated by direct suturing of the intimal tear and extensive sticking of the dissected aortic layers with surgical (gelatin-resorcin-formaldehyde) glue without prosthetic graft replacement. Aortic incompetence was present in 10 patients, a situation that required valvular replacement in five and valvular repair in five. In 10 patients, the dissection extended to the transverse aortic arch, requiring profound hypothermia and circulatory arrest. All patients survived the operation. Follow-up ranged from 6 to 44 months. All patients were monitored by Doppler echocardiographic studies. In addition, 10 underwent angiography; six, a computed tomographic scan; and five, magnetic resonance imaging. In all patients but two, the ascending aorta and transverse arch had a normal appearance. In three patients, a limited dissection persisted that did not require reoperation. Dissection of the descending aorta was present in 10 patients. One patient required a valvular replacement 18 months after surgery, and one underwent heart transplantation for an associated cardiomyopathy 14 months after surgery. These preliminary results indicate that surgical glue can be used safely and efficiently in type A aortic dissection as an alternative to aortic replacement.

Acute Disease↗
PubMed2004

Aortic dissection: a dreaded disease with many faces.

Aortic dissection is a relatively uncommon but catastrophic illness classically thought to present with acute, sharp, chest pain with radiation to the back. However, aortic dissection can manifest in a number of different ways that include congestive heart failure, inferior myocardial infarction, stroke, focal pulse and neurologic deficits, abdominal pain, or acute renal failure. According to some studies, only about 80% of patients with type A dissection present with severe anterior chest pain, and only about 60% describe their pain as being sharp. Another series reports that treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases. Many patients later found to have aortic dissection are initially suspected to have other conditions such as acute coronary syndrome, pericarditis, pulmonary embolism, or even cholecystitis. In this article we present a case of an unusual presentation of aortic dissection and a review of this condition.

Aortic Dissection↗
PubMed1980

Cineangiography in the diagnosis and evaluation of aortic dissection.

Fourteen patients with suspected aortic dissection were studied with 35-mm biplane cineangiography, and the results were compared with those of previously obtained conventional large-film studies. There was no loss of radiographic information due to the decreased resolution of the cine technique. The detection of initial dissection sites, reentry points, and intimal flaps, and the evaluation of aortic regurgitation and the coronary ostia may be improved with cineangiography. The procedure time was shortened and repeat examinations were eliminated with the cine method. Consideration of this technique in evaluating aortic dissection is recommended.

Aortic Dissection↗
PubMed2001

Aneurysmal degeneration of the aorta after stent-graft repair of acute aortic dissection.

PURPOSE: Stent-graft repair of acute aortic dissection has only recently begun, and the true efficacy and safety of this technique have not yet been clarified. In this report, we describe a significant, previously unreported complication following stent-graft repair of acute aortic dissection. MATERIALS AND METHODS: Fourteen patients with acute aortic dissection underwent stent-graft repair. All of the entry tears were located in the descending thoracic aorta. Five patients had type A aortic dissection, and nine patients had type B aortic dissection. The entry tears were closed with stent-grafts, which were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Stent-graft placement was successfully performed without any complications in all patients. Entry closure was achieved in 13 (93%) of 14 patients. The mean follow-up period was 18 months (range, 9 days to 36 months). During this period, four patients had saccular aneurysms in the proximal descending thoracic aorta. A saccular aneurysm was noted during a mean follow-up period of 63 days (range, 38-99 days). Two of these patients were treated with stent-grafts. Conventional surgical repair is planned in one patient. The other patient is being treated with conservative management. CONCLUSIONS: Stent-graft repair is a technically feasible and effective method for the treatment of acute aortic dissection in selected patients. However, careful follow-up is mandatory to check for the development of saccular aneurysms.

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