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PubMed2001

Clinical features and prognosis of acute aortic intramural hemorrhage compared with those of acute aortic dissection: a single center experience.

The clinical manifestations and natural history of acute aortic intramural hemorrhage are not well characterized. Therefore, we have evaluated the differences in the clinical features and prognosis between acute intramural hemorrhage and acute classic aortic dissection. One hundred two consecutive patients with acute aortic syndrome were diagnosed between November 1994 and May 1999. The clinical features, treatment modalities and survival of these patients were analyzed. Thirty one of the 102 patients (30%) had intramural hemorrhage and 71 (70%) had aortic dissection. Patients with intramural hemorrhage were older than those with aortic dissection (mean ages 67 and 55 years, respectively) (p < 0.001), and intramural hemorrhage showed a lower proportion of type A than did aortic dissection (32% and 58%, respectively) (p = 0.018). The incidence of severe complications was significantly lower in patients with intramural hemorrhage than in those with aortic dissection (19% and 27%, respectively) (p < 0.001). Mean follow-up duration was 23.1+/-16.0 months. The overall death rate for patients with intramural hemorrhage (2 / 31; 6%) tended to be lower than those with aortic dissection (14 / 71; 20%) (p = 0.104). The Stanford classification and treatment modalities were not correlated with death. Late follow-up imaging studies in intramural hemorrhage showed partial to complete resolution of intramural hematoma (9 / 15; 60%). In this study, intramural hemorrhage was fairly common, more frequent among older patients, had a lower proportion of type A, and showed a lower incidence of severe complications and a more favorable prognosis in terms of mortality, than aortic dissection.

Acute Disease↗

PubMed1994

Multiple aneurysms and aortic dissection: an unusual manifestation of Marfan's syndrome.

Annuloaortic ectasia and dissection of the ascending aorta are common cardiovascular complications of Marfan's syndrome. True aneurysms of the subclavian arteries in these patients are rare. We present an unusual case of a 37-year-old woman who over the span of 10 years sequentially developed an aneurysm of the ascending aorta (annuloaortic ectasia), a right subclavian artery aneurysm, a left axillary-subclavian artery aneurysm, and a dissection of the aortic arch. Aside from the aortic dissection, the aneurysms produced no symptoms. All vascular complications were detected with computed tomography and managed successfully. This case emphasizes the need for close postoperative surveillance in patients with Marfan's syndrome who have had one cardiovascular complication of the disease.

Adult↗

PubMed1996

[The shock patients with the cardiac tamponade resulting from acute type A aortic dissection].

Twelve patients with acute type A aortic dissection were admitted at Ohta-Nishinouti Hospital from Jan. 1991 to Mar. 1994. Three of these 12 cases were in shock with cardiac tamponade on arrival at the hospital. Immediate resuscitative management was necessary for these patients, but pericardiocentasis was fruitless in the first case and emergent thoracotomy had led to the aortic rupture. While the second case was the thrombosed type aortic dissection and successfully performed pericardiocentasis, CT findings showed recanalization of the pseudolumen after a day, then we performed the urgent operation. By means of these experiences, the third case was operated quickly in spite of the thrombosed type aortic dissection, and had good result. We concluded that immediate surgical intervention should be taken to the shock patients with cardiac tamponade resulted from acute type A aortic dissection.

Acute Disease↗

PubMed2003

[Familial aortic dissection; cases involving a father, mother, and son].

The occurrence of familial aortic dissection is rare in cases that are not linked to Marfan syndrome. We report the 3 cases of acute aortic dissection, involving both parents and their son. Case 1 (father case): 79-year-old male visited a nearby doctor complaining of severe chest and back pain. He was diagnosed as acute aortic dissection (Stanford type A). An emergency operation was carried out and he had an artificial vascular replacement of ascending aorta and arch portion. Case 2 (mother case): 73-year-old female was treated for hypertension. Suddenly, she had a terrible epigastralgia and back pain. The contrast enhanced chest computed tomography (CT) revealed an acute aortic dissection (Stanford type A). The ascending aortic aneurysm ruptured in the ambulance while she was transferred to our hospital. She arrived at our hospital after cardiac and respiratory arrest. We attempted to perform cardiac massage, but we could not bring her back to life. Case 3 (son case): 48-year-old male was transferred to our hospital diagnosed with acute aortic dissection (Stanford type A). The ascending aorta replacement was performed on the same day. We were able to save cases 1 and 3 by performing surgery. Aortic dissection is thought to be the disease of medial degeneration. Hereditary links to aortic dissection are not well understood, with the exception of Marfan syndrome cases. The investigation of genetic mechanisms related to aortic dissection will be expected in the future.

Acute Disease↗

PubMed1985

Two-dimensional echocardiography for diagnosing acute ascending aortic dissection.

The diagnosis of type A aortic dissection (involving the ascending aorta) can be made with two-dimensional echocardiography, but surgeons usually demand angiographic confirmation. Between January 1983 and February 1984, 10 patients presented at St. Michael's Hospital in Toronto with type A aortic dissection. Six patients underwent two-dimensional echocardiography early in their evaluation. A positive diagnosis was made in four, based upon visualization of an intimal flap or a false lumen. In the other two patients, the findings of an enlarged ascending aorta and pericardial effusion were suggestive but not diagnostic. Three patients survived operation and are alive and well (follow-up ranging from 3 to 5 months). One patient died while awaiting surgery, one died during aortography and one died during operation. All echocardiographic and angiographic findings were confirmed at surgery or at autopsy. It is concluded that two-dimensional echocardiography can diagnose ascending aortic dissection quickly, accurately, easily and without risk to the patient. In selected cases the presence of a false lumen or of an intimal flap makes it possible to proceed with operation without delay or the potential hazards of aortography.

Acute Disease↗

PubMed1998

Outcomes of stent-graft treatment of false lumen in aortic dissection.

BACKGROUND: Stent-graft treatment for aortic disease promises to lead to a less invasive therapy than conventional surgical therapy. However, this treatment has not been established as a therapy for aortic dissection. The aim of this study was to examine the effect of stent-graft treatment of aortic dissection, as measured by follow-up data on entry site closure, clotting in the false lumen, and the outcome of the false lumen from the acute to chronic phase after operation. METHODS AND RESULTS: We used a stent-graft of our own design to close the entry site of aortic dissection in 21 cases: 9 were acute (< 14 days), 8 subacute (< 6 months), and 4 chronic (> 6 months). Nine were type A and 12 were type B. In 15 cases, the stent-graft was inserted through the transverse arch, which had been surgically opened under median sternotomy. In the other 6 cases, the stent-graft was inserted by means of a transcatheter through a femoral artery. Using computed tomographic scans, we followed and examined clot formation in the false lumen and reduction in size of the false lumen at 3 levels: at the level of maximum aortic diameter, at the distal end of the stent-graft, and 50 mm distal to the stent-graft. The entry sites were successfully closed in 19 cases (90.4%); in the remaining 2 (both treated with a transcatheter) there was perigraft leakage into the false lumen. The hospital mortality rate of these stent-graft treatments was 14.3% (3 of 21). At 2 weeks after operation, the false lumen had completely clotted, respectively, in 100%, 77%, and 38% of cases at the 3 measurement levels. Substantial shrinkage (> 50% in diameter) of the false lumen at 6 months after the operation was observed in 72%, 60%, and 38% of cases at the respective levels. Shrinkage of the false lumen was particularly enhanced in patients treated within 6 months from the onset of dissection: The false lumen shrank by > 50% in 93%, 75%, and 50% of patients. CONCLUSIONS: In cases of aortic dissection, the stent-graft is an effective tool for closing the entry site and promoting clot formation in the false lumen and for reducing the size of the false lumen within 6 months of the onset of dissection if the entry site has been closed.

Adult↗

PubMed2001

Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root.

BACKGROUND: Redissection of the aortic root after supracommissural aortic graft replacement with reapproximation of the layers of the dissected aortic root is relatively rare. Causes and surgical treatment of this lesion remain controversial. METHODS: From January 1983 to September 2000, 130 patients had emergency operation for acute type A aortic dissection. Of them, 57 patients underwent root reconstruction using biologic glues and 4 patients (7.0%) developed redissection of the aortic root associated with moderate to severe aortic regurgitation 5 to 27 months after the initial operation. In all patients, the proximal false lumen was obliterated with infusion of gelatin-resorcinol-formaldehyde (GRF) glue or BioGlue and the aorta was reinforced with Teflon felt strip or Surgicel placed on its outside wall. RESULTS: During reoperation, the noncoronary aortic sinus was found to be redissected in all patients with the dissection extending retrogradely to the aortic annulus. This resulted in aortic regurgitation with prolapse of the noncoronary cusp because the proximal suture line dehisced. Histopathology showed disappearance of the nuclei of the medial smooth muscle cells, suggesting tissue necrosis at the site of GRF glue application. The lesions were treated successfully with full root replacement using a freestyle heterograft bioprosthesis or a composite graft prosthesis. CONCLUSIONS: The use of biologic glues for reapproximating the layers of the dissected aortic root is associated with a certain amount of risk of aortic wall necrosis. Therefore, care should be taken to ensure proper use of these glues. Full root replacement could be a preferable technique for treating redissection of the aortic root.

Adult↗

PubMed2006

Echocardiographic findings mimicking type A aortic dissection.

BACKGROUND: Type A aortic dissection is a rare, but life-threatening disease. The prognosis is determined by an accurate and immediate diagnosis. CASE STUDY: A patient with suspected type A dissection based on outward transesophageal echocardiography (TEE) findings is reported. Renewed TEE showed dilation of the ascending aorta with pronounced wall thickness. A membrane-like structure was found in the ascending aorta. M-mode technique revealed movement of the suspected membrane that was partially in parallel to the aortic wall. Thus, there were severe doubts on the presence of type A dissection. By contrast, typical intimal rupture was found in the descending aorta. Computed tomography (CT) and angiography showed aortic dilation and an extended wall hematoma deriving from the entry at the descending part. There was no evidence of type A dissection. CONCLUSION: TEE is a noninvasive diagnostic tool to assess aortic dissection of type A with a sensitivity of 90-98% that is equal to CT or magnetic resonance imaging (MRI) solely. Complementary use of CT or MRI could improve the diagnostic accuracy. False-positive findings could result from echocardiographic artifacts concealing an intimal flap in the ascending aorta. Echo reverberations in dilated or calcified aortas had been judged to account for this phenomenon. In the present case, it could be assumed that the extended wall hematoma in accordance with vessel dilation mimicked the membrane-like structure. Oscillation or flutter of the suspicious intimal flap independently of aortal wall movement seem to be mandatory to avoid false-positive diagnoses. Ancillary findings such as flow signals, intimal fenestration or thrombosis are helpful to enhance the diagnostic specificity of TEE.

Aortic Dissection↗

PubMed1978

The effectiveness of surgical treatment of acute aortic dissection.

Ten consecutive patients have undergone operative repair of acute aortic dissection at St. Thomas Hospital in the last three years. Two died. To assess the status of the residual aorta, all 8 survivors were evaluated by postoperative aortography. Only the patient with a clotted dissection on preoperative study showed no residual dissection of the distal aorta. Analysis of postoperative aortograms suggests that the original dissection reentry points become sites of inflow following removal of the original intimal tear. No death resulted from these residual abnormalities. Retrograde dissection and aortic insufficiency were obliterated. The major sites of aortic rupture were removed. It is concluded that surgical therapy for acute aortic dissection is effective in that it avoids the major sources of mortality. The resultant surviving population must be carefully observed in view of the high frequency of residual aortic abnormality.

Aortic Dissection↗

PubMed1997

Acute aortic dissection complicating pregnancy.

BACKGROUND: Acute aortic dissection occurring during pregnancy represents a lethal risk to both the mother and fetus. Our purpose was to study the prevalence, treatments, and outcome of this rare problem and to suggest therapeutic guidelines. METHODS: During the past 12 years, 6 pregnant women were admitted with an acute aortic dissection. Four had a type A and 2 had a type B dissection (Stanford classification). RESULTS: Two of the 4 patients with a type A dissection underwent a combined emergency operation consisting of first cesarean section and then ascending aortic repair. Cesarean section was carried out 5 days after the emergency procedure on the aorta in the third patient, and 16 weeks later in the fourth patient. All 4 fetuses were delivered alive. One fetus died 6 days later, but the other 3 are alive and well at long-term follow-up. Of the 2 patients with a type B dissection, 1 was operated on for celiac ischemia; the other was treated medically. In both cases the fetus died in utero. There were no maternal deaths in either group. CONCLUSIONS: Cesarean section with concomitant aortic repair is recommended for pregnant women with a type A dissection, depending on the gestational age. The maternal hemodynamic status will determine the sequence of the two procedures. Medical treatment is advised for patients with a type B dissection, but surgical repair is indicated if complications such as bleeding or malperfusion of major side branches occur.

Acute Disease↗

PubMed2005

Preoperative antithrombin III activity predicts outcome after surgical repair of acute type A aortic dissection.

BACKGROUND: Acute Stanford type A aortic dissection is associated with substantial perioperative morbidity and mortality. A sepsis-like state may lead to antithrombin (AT) III consumption and deficiency. The impact of preoperative AT III activity on outcome in patients undergoing emergency surgery is yet unknown. METHODS: We measured preoperative AT III activity in 99 consecutive patients undergoing emergency aortic surgery for Stanford type A aortic dissection during a 4-year period in a retrospective study. Cardiovascular co-morbidities, risk factors and surgical data were recorded and patients were followed for 30-day mortality, and occurrence of multiple organ failure (MOF). RESULTS: During the first 30 days, 15 patients (15%) died, and 8 patients (8%) had MOF. Median AT III levels (IQR) in 30-day non-survivors versus survivors were 64% (52-72) versus 90% (75-97) (p<0.001), and in patients with versus without MOF were 66% (52.3-77.3) versus 88% (72-96) (p=0.018), respectively. Adjusted odds ratios for 30-day mortality and MOF for AT III activity (per % increments) were 0.92 (p=0.007), and 0.96 (p=0.012), respectively, indicating a significant inverse relationship between AT III activity and outcome. CONCLUSION: There is a strong inverse association between preoperative AT III activity and adverse outcome in patients undergoing surgical repair of acute Stanford type A aortic dissection. Larger studies are necessary to determine a cut-off value for AT III and to assess whether patients with low AT III levels benefit targeted therapeutic interventions.

Adult↗

PubMed1993

[Magnetic resonance tomography of chronic aortic dissection].

17 patients with chronic aortic dissection were examined by MRI. In 12 patients, comparison between gradient echo sequences and SE sequences was possible. Gradient echo sequences, unlike SE sequences, permitted evaluation of flow in the true and false lumen, reliable differentiation between thrombus and flowing blood and clear delineation of the intimal flap. An additional comparison between transoesophageal ultrasound and MRT in 15 patients showed significant advantages in favour of MRI. In three patients MRI was able to detect more proximal origins of the dissection. Moreover, MRI allowed evaluation of the major aortic branches and their relation to the dissection; this was not possible with ultrasound. MRI plays an important role in the follow-up of chronic aortic dissections.

Adult↗

PubMed2005

C-reactive protein is related to impaired oxygenation in patients with acute aortic dissection.

Impaired oxygenation sometimes occurs in patients with acute aortic dissection, however, the mechanism has not been fully investigated. We hypothesized that impaired oxygenation is related to inflammation secondary due to aortic dissection. Patients with acute aortic dissection who had received 14 days of conservative treatment were retrospectively examined. Patients who had undergone surgery or died within 14 days were excluded. Patients who had evidence of having pneumonia or pulmonary congestion during this period were also excluded. Twenty-six patients were divided into a preserved oxygenation group (minimum oxygenation index > or = 200, n = 13) and an impaired oxygenation group (minimum oxygenation index < 200, n = 13). Maximum serum C-reactive protein (max CRP) and other factors (age, gender, hypertension, diabetes mellitus, smoking, hyperlipidemia, Stanford type, thrombosed false lumen, pleural effusion, atelectasis, use of intravenous vasodilators) for the two groups were compared. Max CRP was the only predictor for impaired oxygenation as calculated by single/multiple logistic regression analysis. Max CRP was significantly higher in the impaired oxygenation group (20.1 +/- 2.1 mg/dL) than in the preserved oxygenation group (10.5 +/- 1.4 mg/dL, P < 0.05). These results suggest that impaired oxygenation is related to inflammation, which is secondary due to acute aortic dissection.

Acute Disease↗

PubMed1990

Aortic dissection. An autopsy experience.

Aortic dissection was confirmed in 33 patients at autopsy at the University Hospital of the West Indies between 1975 and 1988. Twenty-five cases were acute and 8 chronic and the diagnosis was made antemortem in 5 cases overall. The high risk of rupture of proximal dissections involving the ascending aorta into the pericardial sac is clear, and the overriding importance of systemic hypertension is once again confirmed. An unusual finding was the higher proportion of females to males. A higher index of suspicion should permit an antemortem diagnosis and appropriate therapy in a larger proportion of patients.

Adolescent↗

PubMed2001

Aortic dissection presenting as fever of unknown origin.

Acute aortic dissection may have variable presentations, making the diagnosis clinically challenging. Although fever is a common accompanying feature, it rarely dominates the clinical setting. We report the case of a patient who sustained a prolonged spiking fever with unknown origin following acute aortic dissection. The case serves as a reminder that prolonged fever may be the principal residual sequelae after acute aortic dissection or one of the protean clinical manifestations of painless aortic dissection.

Aortic Dissection↗

PubMedDate not supplied

Increased carotid artery stiffness without atherosclerotic change in patients with aortic dissection.

The arterial properties and pathogenesis of aortic dissection remain obscure. To examine the arterial properties of patients with aortic dissection, the authors studied the ultrasonographic characteristics of the carotid artery in patients with an aortic dissection (AD, n = 86), and compared these findings with data of patients suffering from arteriosclerosis obliterans (ASO, n = 151), coronary artery disease (CAD, n = 163), and with healthy controls (HC, n = 77). Atherosclerotic intimal changes, such as intima-media thickness (IMT) and plaque formation, were milder in AD than in ASO or CAD (IMT: 0.83 +/- 0.16 vs 0.93 +/- 0.20/0.86 +/- 0.17 mm, p < 0.05; plaque number: 0.6 +/- 1.1 vs 2.7 +/- 2.4/2.5 +/- 2.1, p <0.05). Luminal diameter in AD, ASO, and CAD was significantly higher than in HC. The luminal distensibility in AD was decreased compared with HC but was the same as in ASO and CAD. Intra-AD group analysis showed that in patients with an intramural hematoma (IMH) or a dissection with a thrombosed false lumen (TLF) the IMT was higher than in patients with a classic dissection. In addition, plaque formation was more severe in AD patients with a coexisting abdominal aortic aneurysm (AAA). Reduced distensibility without severe intimal disease was found in AD. These findings suggest that patients with AD may have several arterial alterations, including structural abnormalities. Patients with IMH, TFL, or coexisting AAA may differ from patients who have a classic type of dissection or who do not have AAA, in terms of arterial characteristics including intimal disease and wall elastic property, and the initiating cause of the dissection.

Adult↗

PubMed2005

Newly developed aortic dissection in the abdominal aorta after femoral arterial perfusion.

BACKGROUND: Aortic dissection after femoral arterial perfusion has been reported as a dreadful complication. Apart from such a drastic event, using intraoperative transesophageal echocardiography we detected aortic dissection confined to the abdominal aorta that was associated with visceral malperfusion. METHODS: We examined 11 consecutive patients with aortic dissection in whom the abdominal aorta was intact, and surgeries were performed with femoral perfusion. The abdominal aorta and visceral branches were examined for new development of dissection or malperfusion by means of transesophageal echocardiography before, during, and after cardiopulmonary bypass. These echocardiographic findings were then related to the postoperative assessment and midterm results. RESULTS: Aortic dissection was found in 3 of 11 cases (27.2%). Unusual progression of metabolic acidosis (base excess < or =10 mEq/L) occurred, possibly as a result of malperfusion of visceral arteries, in 2 of these 3 cases, whereas none of the 8 cases presented with such findings. The presence of dissection was later confirmed by postoperative computed tomography in all but 1 case. In the midterm follow-up period, aneurysm formation was found in the infrarenal aorta and iliac arteries in 2 of the 3 cases with new aortic dissection but not in any of the remaining 8 cases. CONCLUSIONS: New development of aortic dissection after femoral arterial perfusion was found in 27% of the cases in this series. Although these occurred without dramatic symptoms, this event may be related to unusual metabolic acidosis during cardiopulmonary bypass or to subsequent aneurysmal formation of the infrarenal aorta or iliac arteries, or both.

Acidosis↗

PubMed1996

MRI postoperative monitoring in patients surgically treated for aortic dissection.

In most cases, surgery of aortic dissections repairs only the ascending portion of the aorta, leaving a residual dissection in the arch and descending aorta. We studied 17 patients operated upon for type A aortic dissection. A total of 42 magnetic resonance imaging (MRI) examinations were performed, with two to five studies per patient (mean 2.47). The studies were done between 5 weeks and 47 months (mean 17.5 months) after surgery. The patients were evaluated by MRI using gated spin-echo and gradient-echo sequences on axial and oblique sagittal views, and in selected cases, coronal views. A high incidence of abnormalities was observed. Pericardial hematoma was observed in 11% of cases, aortic and branch involvement in 41%, abdominal aortic branch involvement in 47%, dilatation of native aorta in 58%, and extension of dissection in 10%. New complications were detected during follow-up in 53% of patients. MRI was helpful in the follow-up of patients operated upon for aortic dissections, owing to its noninvasiveness and multiplanarity. By means of this technique, it was possible to obtain information about the natural history of the disease, as well as information useful for subsequent treatment.

Adult↗