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PubMed1998

[Lysis therapy in aortic dissection: by hypertrophic cardiomyopathy simulated myocardial infarct].

A 52-year-old patient presenting with severe thoracic pain of more than 30 minutes duration and ST-segment elevation > 1 mV in leads V1-3 was given 100 mg rt-PA. With persisting thoracic pain and ST-segment elevation, coronary angiography was performed 90 minutes after administration of thrombolytic therapy. Surprisingly, angiography revealed normal coronary arteries in presence of marked hypertrophic cardiomyopathy. New onset of thoracic pain after four hours led to a chest radiograph demonstrating increased mediastinal widening and new pleural effusion as compared to a baseline chest film prior to rt-PA. Spiral computed tomography revealed overt Type B aortic dissection with an intimal flap and communication distal to the origin of the left subclavian artery with signs of a mediastinal hematoma. Immediate cardiac surgery with replacement of the dissected aortic segment was successfully performed. A literature review revealed 4% of aortic dissection to present with electrocardiographic signs of acute myocardial infarction and 13% to have concomitant coronary artery disease; moreover 34 cases of aortic dissection were misdiagnosed as infarction and subjected to thrombolytic agents with a mortality of 64% underlining the importance of exclusion of dissection prior to thrombolytic therapy.

Aortic Dissection↗

PubMed1983

CT recognition of acute aortic dissection.

Twenty-six patients with suspected acute aortic dissection were investigated using computed tomography (CT) as the primary mode of investigation. The diagnosis was controlled by aortography or surgery or both. There were no false-positive or false-negative studies using CT. Aortography was performed on 19 of the 21 patients with aortic dissection and was positive in each instance. However, in two illustrated cases, CT indicated proximal or type A aortic dissection, whereas the corresponding aortograms indicated distal or type B aortic dissection. In two of the 21 acute aortic dissections, only CT was performed, and in both instances surgical confirmation was obtained. The results suggest that CT is at least as accurate as aortography in the diagnosis of acute aortic dissection.

Acute Disease↗

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↗

PubMed1993

Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990).

Acute aortic dissection is the most common fatal condition that involves the aorta; nevertheless, despite major advances in noninvasive diagnosis, the correct antemortem diagnosis is made in less than half the cases. To promote continued improvement in the prompt recognition of aortic dissection, we present a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. Although the clinical features of aortic dissection have gained wider appreciation, the diagnosis still remains unsuspected in a substantial number of patients. In a patient who has a catastrophic illness and unexplained symptoms that could be of vascular origin, especially in the presence of chest pain, aortic dissection should always be included in the differential diagnosis.

Acute Disease↗

PubMed1980

Intimo-intimal intussusception and other unusual manifestations of aortic dissection.

Four cases with unusual aortic dissection found unexpectantly at the time of operation, and their aortographic and anatomic findings and surgical treatment are described. One of the patients had a type I aortic dissection with intimo-intimal intussusception and another had a type I dissection with one portion of the intimal wall unidentifiable up to the origin of the innominate artery. One patient had a type III dissecting aneurysm with retrograde dissection into the aortic arch and ascending aorta, and the fourth patient had a dissecting aneurysm involving the ascending aorta and the innominate, right common carotid, and right vertebral arteries with a re-entry at the aortic arch.

Adult↗

PubMed1990

[Aortic dissecting aneurysm during pregnancy].

Aortic dissecting aneurysm is a rare, serious complication of pregnancy. This condition was diagnosed in a 34-year-old woman in the 38th week of pregnancy. Cesarean section was immediately performed, and was followed by surgical repair of the dissection. A normal male infant was delivered.

Adult↗

PubMed2000

Three-channeled aortic dissection in Marfan syndrome.

Among the various types of aortic dissection, three-channeled aortic dissection, in which two adjacent false lumens are present, is rarely observed. The authors surgically treated 20 Marfan syndrome patients with this type of dissection, who accounted for 29.4% of 68 patients with aortic dissection in Marfan syndrome and who were surgically treated in the authors' institution prior to July 1999. Patient age ranged from 24 to 51 years (mean of 40 years). The male:female ratio was 13:7. Valved conduit procedure had been performed previously in 14 patients. Pain was observed at various times in 13 patients. Computed tomography scanning and magnetic resonance imaging were useful for preoperative diagnosis. The morphology of the first and second false lumens was Stanford type A + type B in 10 patients and type B + type B in 10 patients. Re-entry of the second false lumen was observed in five patients. The descending aorta was replaced in 13 patients, thoracoabdominal aortic replacement was performed in five, extra-anatomic bypass in one patient and iliac artery-superior mesenteric artery bypass in one. Four patients died in hospital. There were three late deaths during a follow-up of 1-208 months (mean of 51 months). When pain recurs in Marfan patients with aortic dissection, three-channeled dissection should be suspected and subsequent surgery is required. The incidence of this dissection is high in patients with Marfan syndrome.

Adult↗

PubMed1994

Atypical patterns in the CT diagnosis of aortic dissection.

Eight cases of aortic dissection with atypical CT appearances are described. Seven were clinical diagnoses, one was confirmed at operation. The findings were those of intramural haematoma, often crescentic and not necessarily compressing the aortic lumen. Evidence is presented to show that some intramural haematomas may subsequently develop ulceration, resulting in the appearances described in penetrating atheromatous ulcer of the aorta.

Acute Disease↗

PubMed2005

[Surgical management for Stanford A aortic dissection].

OBJECTIVE: To summarize the surgical experience for Stanford A aortic dissection. METHODS: Sixty-eight patients with Stanford A aortic dissection underwent surgery from March 1998 to October 2004, acute aortic dissection in 45 cases, chronic aortic dissection in 23 cases. The operation were performed by using moderate hypothermic cardiopulmonary bypass in 53 cases, deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion (RCP) in 11 cases; DHCA with antegrade selective cerebral perfusion (SCP) in 4 cases. Surgical procedures included ascending aortic grafting in 7 cases, ascending and hemiarch grafting in 6, ascending and total arch grafting in 3, ascending and total arch grafting with Frozen elephant trunk procedure in 4. Concomitant procedures included Bentall procedure in 34 cases, Wheat procedure in 12 cases, aortic valvuloplasty in 2 cases, mitral valvuloplasty in 1 cases. Urgent surgery was in 39 cases (emergency surgery in 19). RESULTS: Operative mortality was 7% (urgent surgery mortality was 8%, elective surgery mortality was 7%). Fifty-eight cases were followed up for (37 +/- 22) months. Actuarial survival of 58 cases at 1, 3 and 5 years was 100%, 95% and 86% respectively. CONCLUSION: The choice of surgical procedures depend on the location of intimal tear for Stanford A aortic dissection. Proper surgical indication, technique and brain protections are the key factors of Stanford A aortic dissection surgery.

Adult↗

PubMed2004

Iatrogenic iliac artery rupture and type a dissection after endovascular repair of type B aortic dissection.

We report a case of two iatrogenic complications after endovascular repair of a type B aortic dissection treated for abdominal aortic branch ischemia. A rupture of the common iliac artery occurred first during the procedure. A type A dissection occurred 12 days later. The proximal part of the aortic endovascular graft had created a tear in the aortic wall resulting in a retrograde type A dissection. Although aortic endovascular grafting is apparently associated with less morbidity and mortality, potentially lethal complications, both acute and delayed, may arise.

Aortic Dissection↗

PubMed1992

[A case of acute A type aortic dissection with lower extremity ischemia--percutaneous fenestration of the aortic septum followed by ascending aortic graft replacement by open distal anastomosis and retrograde cerebral perfusion].

A 56-year-old woman with severe back pain and a cold, pulseless right extremity was admitted to our hospital. Angiogram revealed a type A aortic dissection extending from ascending aorta to the aortic bifurcation with no definite re-entry point. The false lumen gave origin to the right renal artery and the right external iliac artery was occluded. Therefore, a catheter was manipulated into the true lumen through a percutaneous right femoral artery approach, and was advanced into the false lumen through the right posterolateral wall of the dissecting aortic septum. Fenestration was then performed with fully dilated angioplasty balloon across the septum. Immediately after the procedure, the patient's symptoms improved. The day after the fenestration, replacement of the ascending aorta with 24 mm woven Dacron graft was followed under the deep hypothermia and the retrograde cerebral perfusion. The patient followed a satisfactory postoperative course and postoperative angiogram showed a complete closure of the entry at the ascending aorta and adequate revascularization of the right renal and external iliac arteries.

Acute Disease↗

PubMed2000

Rapid diagnosis and management of thoracic aortic dissection and intramural haematoma: a prospective study of advantages of multiplane vs. biplane transoesophageal echocardiography.

AIMS: The purposes of this study were to compare the accuracy of multiplane vs. biplane transoesophageal echocardiography (TEE) in the diagnosis of aortic dissection and aortic intramural haematoma, and to test whether these techniques provide all the diagnostic information required to make management decisions. METHODS AND RESULTS: Fifty-eight consecutive patients with clinically suspected aortic dissection were studied with multiplane TEE; all cases who required surgery underwent intraoperative monitoring with multiplane TEE. The following multiplane TEE data were analysed: the angle between current and 0 degrees plane at which each view was obtained; the success rate in the evaluation of true and false lumen, entry tear, coronary artery involvement, aortic regurgitation, pericardial effusion. Advantages of multiplane over biplane TEE have been evaluated by the demonstration of usefulness of views obtained in planes other than 0 degrees-20 degrees or 70 degrees-110 degrees, assuming that with manipulation of a biplane probe a 20 degrees arc could be added to the conventional horizontal and vertical planes. On the basis of TEE findings, aortic dissection was confirmed in 36 cases (18 type A, 12 type B, six intramural haematoma). The specificity and sensitivity of TEE in terms of the presence or absence of aortic dissection or intramural haematoma were 100%. An additional clinical value of multiplane over biplane TEE in the evaluation of ascending aorta, aortic arch, entry tears and coronary artery involvement was demonstrated. All cases with type A aortic dissection or intramural haematoma involving the ascending aorta had an operation that was performed immediately after the diagnosis (hospital mortality, 13%). Patients with type B aortic dissection were treated medically; 25% of these cases were operated later (hospital mortality, 0%). CONCLUSIONS: Multiplane and biplane TEE have excellent and similar accuracies in the evaluation of aortic dissection and intramural haematoma. Multiplane TEE improves the visualization of coronary arteries, aortic arch and entry tears; it appears to be an ideal method as the sole diagnostic approach before surgery in type A aortic dissection.

Adult↗

PubMed1988

[Aorto-caval fistula complicated by a DeBakey IIIb-type dissecting aortic aneurysm: report of a case].

The patient, male and 70 years of age, was suspected of having a ruptured abdominal aortic aneurysm during the laparotomy, and referred to our department. After admission it was found that a ruptured abdominal aortic aneurysm complicated with dissecting aneurysm. Urgent surgical intervention should have been scheduled but an initial conservative control was necessary because of impaired hepato-renal function and hemorrhagic gastroduodenal ulcer. Meanwhile, pleural effusion, edema in lower extremities and abdominal continuous vascular murmur appeared, and cardiac failure symptoms gradually aggravated. The formation of arteriovenous fistula was suspected. Aortography revealed the DeBakey IIIb type dissecting aortic aneurysm complicating an abdominal aneurysmal rupture with the fistula formation to inferior caval vein. Neither enlargement nor progress of a thoracic aortic aneurysm were observed by CT scanning examination and the closure of fistula and Y grafting were performed successfully. So far, only one case of a ruptured abdominal aortic aneurysm forming the aorto-caval fistula and complicating dissecting aortic aneurysm was reported in Japan, and, to the best of our knowledge, this is the first case treated successfully.

Aged↗

PubMed1991

Replacement of the abdominal aorta with an aortic homograft in a patient with an aortic dissection.

The use of aortic and femoral homografts in early vascular surgery has been abandoned for the more successful and abundant synthetic substitutes. With the recent introduction of cryopreservation, homograft use has again met with improved success. A 40-year-old man who had a DeBakey Type I aortic dissection initially underwent replacement of the aortic root with a pulmonary homograft. Subsequently, in the presence of an intraabdominal infectious process, progressive mesenteric and lower limb ischemia was treated by replacing the abdominal aorta with an aortic homograft. Thirty-six months postoperative the patient has a functioning gastrointestinal tract and no vascular insufficiency of the lower extremities and no evidence of degeneration of the homograft. Further laboratory studies should be undertaken using the newer and improved cyropreserved homograft in the presence of, or potential for, an intraabdominal infectious process.

Adult↗

PubMedDate not supplied

Aortic dissection.

Acute and chronic aortic dissection is described in terms of diagnostics, surgical indications and present day operative treatment. The need for prompt decision making and intervention is highlighted. The results to be expected from surgery are outlined.

Acute Disease↗

PubMed1999

Glue containment and anastomosis reinforcement in repair of aortic dissection.

In operations for aortic dissection anastomotic bleeding or secondary anastomosis dehiscence are common problems. The advent of Gelatin-resorcin-formaldehyde-glutaraldehyde (GRF) biologic glue has ameliorated type A dissection operative management. Glue containment is mandatory since detrimental effects of glue migration are described. We herein present a simple technique of anastomosis reinforcement and glue containment that helps in overcoming these complications.

Anastomosis, Surgical↗

PubMed2005

Technetium-99m MAG3 renal scintigraphy with demonstration of aortic dissection.

Demonstration of type B aortic dissection is rare during renal scintigraphy. The discordant radionuclide pattern of asymmetric renal flow with equivalent renal function and excretion has been previously reported in aortic dissection. However, delayed scintigraphic features of the false lumen have not been described. The author presents such a case with persistent technetium-99m MAG3 accumulation in the posterior mediastinum on postvoid planar imaging.

Aged↗

PubMed2003

Preoperative shock determines outcome for acute type A aortic dissection.

BACKGROUND: Acute type A aortic dissection is a life-threatening catastrophe. Surgical results have not improved. METHODS: The charts of all 70 patients surgically treated for acute type A primary aortic dissection during the period of January 1988 through April 2001 were reviewed. RESULTS: Average age was 59 +/- 2 years. Comorbidities included hypertension (66%), coronary artery disease (17%), and Marfan's syndrome (11%). At presentation, 23% were in shock, 17% had neurologic dysfunction, and 36% had coronary ischemia. The aortic valve was preserved in 55. Distal aortic anastomosis was performed under aortic cross-clamp ("closed") in 32 and "open" under circulatory arrest in 38 patients. Operative mortality was 18.6% (13 of 70 patients). Patients in shock had an operative mortality of 50% compared with stable patients of 9% (p = 0.0002). Mortality was similar regardless of technique. Univariate analysis revealed preoperative shock (p = 0.0002), tamponade (p = 0.003), and neurologic deficit (p = 0.02) to be associated with mortality. Multivariate analysis revealed hemodynamic stability (odds ratio = 0.10, p = 0.04) and outside transfer (odds ratio = 0.12, p = 0.03) to be negative predictors of mortality. Of 57 survivors, follow-up was 93% complete for an average of 46 +/- 6 months. The overall late reoperation rate was 24.6% (14 of 57 patients) at 50.3 +/- 12.3 months. Twelve patients (21%) underwent future aortic aneurysmal repair. No difference in reoperation rate was seen comparing "closed" (26%) with "open" (18%; p = 0.46). Of 42 preserved native valves, only 3 (7.1%) needed future valve replacement. CONCLUSIONS: In our experience, operative mortality was determined by preoperative hemodynamic instability. Technique did not impact survival or late reoperation. Early diagnosis and repair is critical to improving survival.

Adolescent↗