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PubMed2002

Operative mortality rate for elective abdominal aortic aneurysm repair is not increased by the presence of a previous or concurrent thoracic or thoracoabdominal aortic dissection.

BACKGROUND: The objective of this study was to determine the likelihood of mortality after abdominal aortic aneurysm (AAA) repair in patients with thoracic or thoracoabdominal aortic dissection. METHODS: Fourteen patients (11 men, three women) with known thoracic or thoracoabdominal aortic dissections underwent elective AAA repair from 1986 to 2001, including three patients with acute dissections (less than 14 days) and 11 patients with chronic dissections (14 days or longer). All 14 patients had type III aortic dissections. Stent graft exclusion of the aortic dissection was performed in one patient before AAA repair. Preoperative patient characteristics, intraoperative events, perioperative complications, and 30-day and 1-year mortality rates were assessed. RESULTS: Elective AAA repair in the setting of thoracic or thoracoabdominal aortic dissection in this series was associated with no 30-day mortality and a 1-year mortality rate of 7.1%. Furthermore, preoperative patient characteristics, intraoperative events, and perioperative complications did not appear to be associated with late, 1-year, mortality. CONCLUSION: Elective AAA repair in the setting of acute or chronic aortic dissection is associated with mortality rates similar to those generally attributed to elective AAA repair without accompanying aortic dissection. Nevertheless, the conduct of the operation is usually complex, especially in the setting of an acute aortic dissection.

Acute Disease↗

PubMed2005

Long-term effectiveness of total arch replacement for type A aortic dissection.

BACKGROUND: With recent improvements in cerebral protection during aortic arch repair, total aortic arch replacement has become an accepted surgical method for acute type A aortic dissection involving the aortic arch. Our surgical strategy is to perform total arch replacement with a branched graft using antegrade selective cerebral perfusion for the patients with type A aortic dissection involving the aortic arch. The objective of this study is to evaluate the effectiveness of this strategy on late outcome. METHODS: From October 1988 to April 2003, 46 patients underwent total arch replacement for acute type A dissection involving the aortic arch. Operations were performed with hypothermic cardiopulmonary bypass, antegrade selective cerebral perfusion during the arch repair, and open distal anastomosis. RESULTS: Hospital mortality was 6.5% (3 patients), and permanent neurologic dysfunction was observed in 1 patient. During the follow-up period (mean, 5.4 years; range, 13 months to 15.6 years), 2 patients died, but the causes were not related to the aorta or aortic valve. Survival rates at 5 and 10 years postoperatively were 89.6% +/- 5.2% and 82.7% +/- 8.2%, respectively. Of the 41 survivors, 3 patients underwent successful reoperation for the distal thoracic aorta. Freedom from reoperation was 93.6% +/- 4.6% and 88.7% +/- 6.5% at 5 and 10 years, respectively. The residual false lumen in the thoracic aorta was frequently thrombosed (76.2%). CONCLUSIONS: Total arch replacement for acute type A dissection may decrease the risk of late complications related to the false lumen and lead to excellent long-term survival.

Acute Kidney Injury↗

PubMed1994

New approach to aortic dissection: development of an insertable aortic prosthesis.

We have developed a new aortic prosthesis with which we can replace or reinforce the aorta using a simple percutaneous technique. We have named the new prosthesis the shape-memory aortic prosthesis (SAP); it consists of a spiral-shaped nitinol stent and polyurethane tube. It can be compressed inside a 14F catheter at a low temperature and regain its original shape at above 30 degrees C. As a preliminary study, SAP sutureless grafting into the descending aorta was performed on 10 mongrel dogs. We found that when the proper diameter of SAP was applied, it functioned satisfactorily for 3 months or more. A percutaneous placement technique pertinent to the SAP also was developed and tried on 4 animals. Our procedure was applied to Stanford type B dissection models to close the entry point successfully. This newly developed SAP has potential to be applied to emergency cases of human aortic dissections.

Aortic Dissection↗

PubMed2000

Detection of false lumen perfusion at the beginning of cardiopulmonary bypass in patients undergoing repair of aortic dissection.

OBJECTIVE: In patients undergoing surgical repair of aortic dissection, false lumen perfusion during cardiopulmonary bypass may produce central nervous system damage, myocardial ischemia, aortic rupture, and death. We describe a method to detect false lumen perfusion at the beginning of retrograde aortic perfusion that may prevent these complications. DESIGN: Sonicated albumin microbubbles (8 mL) were injected through a side branch of the extracorporeal circulation line to detect true lumen and/or false lumen perfusion of the thoracic aorta at the beginning of cardiopulmonary bypass. Transesophageal echocardiography was used to image aortic perfusion. SETTING: The study was performed in a cardiac surgery theater. PATIENTS: A total of 27 consecutive patients undergoing operation for Type I aortic dissection were studied. INTERVENTIONS: All patients underwent surgical repair of aortic dissection and retrograde aortic perfusion through one femoral artery. MEASUREMENTS AND MAIN RESULTS: Patients were divided into three groups: Group I, those having adequate true lumen perfusion: brisk appearance and washout of contrast in the true lumen with no, poor, or delayed opacification of the false lumen; Group II, those having mixed true lumen and false lumen perfusion: simultaneous opacification of both lumens; Group III, those having inappropriate false lumen perfusion: same criteria as for adequate true lumen perfusion applied to the false lumen. The true lumen was perfused in 13 patients, both lumens in 11 patients, and false lumen alone in three patients. In these three patients, cannulation was repeated through the contralateral femoral artery with restoration of true lumen perfusion; the first patient died of diffuse cerebral ischemic damage and renal failure, another one experienced temporary postoperative monoparesis, and the last had no neurologic sequelae. CONCLUSIONS: Contrast echocardiography allows immediate detection of retrograde aortic perfusion during cardiopulmonary bypass and may help prevent neurologic complications and death in patients with Type I dissection.

Adult↗

PubMedDate not supplied

Acute thoracic aortic dissection: the basics.

With an increasing incidence, aortic dissection is the most common acute illness of the aorta. In the setting of chronic hypertension, with or without other risk factors for aortic dissection, this diagnosis should be considered a diagnostic possibility in patients presenting to the emergency department with acute chest or back pain. Left untreated, about 75% of patients with dissections involving the ascending aorta die within 2 weeks of an acute episode. But with successful initial therapy, the 5-year survival rate increases to 75%. Hence, timely recognition of this disease entity coupled with urgent and appropriate management is the key to a successful outcome in a majority of the patients. This article reviews acute thoracic aortic dissection, including ED diagnosis and management.

Acute Disease↗

PubMed1996

[Evolution and recent trends in patient selection and reconstruction method for chronic aortic dissection].

Evolution and recent trends in patient selection and reconstruction method for chronic aortic dissection are reported. Although patient selection and reconstruction method for chronic type A aortic dissection are essentially identical with those for acute type A aortic dissection, chronic dissection frequently necessitates extended reconstruction of the aortic arch. Aortic valve-sparing operation is increasingly applied for associated aortic regurgitation. In chronic type B aortic dissection, operation is indicated when the diameter exceeds 5 cm, if it is symptomatic (i.e. those accompanied with pain or malperfusion of the vital organ), or when it is enlarging rapidly. Operative treatment includes resection of the intimal tear and replacement of the dilated segment. With the advance in diagnosis, methods of organ protection and operative techniques, operative results for chronic aortic dissection had been improving, despite the fact that these complex lesion frequently requires extensive aortic reconstruction with reimplantation of the major aortic branches. Spinal cord protection in extensive thoracoabdominal reconstruction for type B aortic dissection remains an unsolved problem.

Aortic Dissection↗

PubMed1993

[Two cases of Marfan syndrome complicated with aortic dissection during pregnancy].

Two women with Marfan syndrome who developed aortic dissection during pregnancy are reported. Case 1: A 38-year-old woman had experienced severe back pain five years before (at the age of 33) when she was in the 38th week of gestation, followed by labour with no problem. Three years ago, she was examined in our hospital for enlarged thoracic aorta pointed out in a somatoscopy and was diagnosed as having Marfan syndrome and aortic dissection of DeBakey type IIIb. Because her aortic dissection has been growing larger recently, surgical repair is scheduled electively. Case 2: A 32-year-old woman, who had been diagnosed as having Marfan syndrome because of ectopia lentis at 10 years old, was referred to our department for a painful tumor with pulsation which had emerged at the right-hand side of her neck in the 32nd week of gestation. Acute aortic dissection of DeBakey type I complicated with acute aortic regurgitation was diagnosed, and emergency operation (Cesarean section, reconstruction of ascending aorta and aortic arch, replacement of aortic valve and aorto-coronary bypass to right coronary artery) was performed. Post-operative course was uneventful and the patient and her baby were discharged safely. In general, aortic dissection during pregnancy of patients with Marfan syndrome is of poor prognosis. Full consent by the patient and her family is necessary to decide whether the pregnancy should go on, and close cooperation among participating departments is indispensable for the treatment for this condition.

Adult↗

PubMed1991

Usefulness of transesophageal echocardiography in the diagnosis of conditions mimicking aortic dissection.

Between September 1987 and April 1989, forty patients suspected to have aortic dissection were evaluated by transesophageal echocardiography. Aortic dissection was identified in 18 patients. This study evaluated the ability of transesophageal echocardiography in the assessment of the 22 patients in whom aortic dissection was not found. A range of pathologic conditions was diagnosed in these patients. Five patients had ischemic heart disease when they were initially seen. Among the remaining 17 only one patient had a normal aorta. Aortic disease was present in the other 16 patients with aortic dilatation in 10. Atheromas were detected in seven patients with concomitant aortic dilatation in five of them. An extrinsic aortic mass was present in two patients. Transesophageal echocardiography correctly identified an anastomotic leak at the site of left coronary artery implantation in a patient with a recent Bentall procedure, and a large mobile clot within the proximal descending aorta in a patient with blunt chest trauma. These findings obviated the need for other tests in 15 patients and led to surgery in four with no ancillary tests performed in three of them. Thus transesophageal echocardiography has an important role in assessing patients with suspected dissection. Aortic disease is common even in patients in whom aortic dissection is excluded, and some of the conditions can be just as life-threatening as dissection. Transesophageal echocardiography not only reliably identifies dissection but can also detect luminal and extraluminal diseases not adequately visualized by other modalities.

Adult↗

PubMed1990

Optimal diagnostic imaging of aortic dissection.

Without prompt diagnosis and treatment, aortic dissection is rapidly fatal. While standard chest radiography may give clues to the diagnosis of aortic dissection, suspected dissection can be confirmed by only 4 imaging techniques: aortography, echocardiography, computed tomography, and magnetic resonance imaging. The following review discusses each of these methods. It also explains why aortography, the previous diagnostic benchmark, has been replaced by newer techniques and why magnetic resonance imaging has become the diagnostic method of choice for imaging aortic dissection.

Journal Article↗

PubMed1998

[MRI in typical and atypical aortic dissection].

PURPOSE: To determine the value of MRI in typical and atypical aortic dissections. METHODS: MRI investigations on 16 patients with aortic dissections were analysed retrospectively; for 8 patients CT investigations carried out at almost the same time were available for comparison. RESULTS: In all cases the diagnosis of aortic dissection was possible from MRI and CT. If a dissection membrane and a double lumen were present these were detected in all patients by both methods. In three patients with atypical dissections, only an asymmetrical abnormal wall thickening as sole sign for the presence of an aortic dissection was seen. A differentiation between true and false lumen was possible in 16 of 17 MRI investigations and in 5 of 8 CT investigations on the basis of differing blood flow velocities or, respectively, the detection of a thrombus in the false lumen. The relationship of the dissection membrane to the large aortic branches as well as the determination of the branch vessel origin with regard to true or false lumen could be evaluated better with MRI than with CT. CONCLUSIONS: Thus MRI has a significant role in the diagnosis and follow-up of aortic dissections. The advantage in comparison to the alternative spiral CT technique is, in addition to the absence of radiation exposure, the better analysis of the extent of the dissection as a result of the multi-planar slice orientation (especially in the region of the aortic arch and the arch vessel origins) without the necessity to administer iodine-containing contrast media.

Adult↗

PubMed2000

Conservative management for an extensive type A aortic dissection complicating coronary angioplasty.

Aortic dissection is a recognized, though rare complication of percutaneous revascularization procedures. We report a case of an extensive type A dissection that occurred during an attempt to recanalize a chronic total occlusion of a right coronary artery. The patient was treated conservatively and was followed for 36 months, during which he remained well. We conclude that, even though surgery remains the preferred option, conservative management could also be considered in certain patients.

Aortic Dissection↗

PubMed1998

[Late results of extended Stanford type A acute aortic dissection].

From 1978 to July 1997, 140 patients with extended Stanford type A aortic dissection underwent surgical treatment. There were 77 acute and 63 chronic aortic dissections. The follow-up period of the 61 surviving patients in acute aortic dissection ranged from 2 to 164 months (mean, 56 months). During follow-up periods, 6 patients died of no dissection-related causes. The actuarial survival ratios in 77 patients were 77.2% at 3 years, 72.2% at 5 years and 62.6% at 10 years, respectively. There was no significant difference between acute aortic dissection and chronic aortic dissection in actuarial survival ratio. The ratio of the clotted false lumen in the distal aorta was lower and subsequent surgery was more frequent in patients with Marfan syndrome than those with non-Marfan syndrome. In extended type A aortic dissection, the observation of the residual false lumen using body CT scan was very important after surgery, especially in Marfan syndrome. If the false lumen is dilated, a subsequent surgery is needed to get good late results.

Adult↗

PubMed1985

Utility of two-dimensional echocardiography in suspected ascending aortic dissection.

The value of 2-dimensional echocardiography (2-D echo) in patients with suspected ascending aortic dissection was assessed. During a 5.5-year period, 56 consecutive patients underwent bedside 2-D echo for unexplained chest pain possibly due to ascending aortic dissection. Patients with obvious aortic dissection who proceeded directly to aortography were excluded and in all 56 study cases, 2-D echo was the initial diagnostic test. Using standard criteria, 2-D echo correctly identified all 13 patients with ascending aortic dissection. There were 5 false-positive study results and 38 true-negative results, yielding a sensitivity of 100%, specificity of 88% and overall diagnostic accuracy of 91%. In the group of 13 patients with confirmed ascending aortic dissection, 2-D echo identified 4 with pericardial fluid, and 3 of these patients (75%) died within 24 hours. In comparison, 7 patients in the group of 43 without confirmed dissection had pericardial fluid by 2-D echo and only 1 died (p less than 0.001). Finally, in the group of 38 patients with true-negative results, 2-D echo provided useful information in 16 (42%) that assisted or was essential in establishing an alternative diagnosis. However, 5 patients in this group had type III dissection and in none was it identified by 2-D echo. Thus, our data indicate that 2-D echo represents a reliable noninvasive method for rapidly diagnosing ascending aortic dissection at the bedside; offers important prognostic information which is directly related to the presence of pericardial fluid, and provides useful additional information which assists or establishes an alternative diagnosis when ascending aortic dissection is absent.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMedDate not supplied

Aortic dissection after previous coronary artery bypass grafting.

Aortic dissection after coronary artery bypass grafting (CABG) is a rare but potentially fatal complication. The aim of this study was to identify the reasons. Between 1991 and 2000 in our institution CABG was performed on 22,732 patients. In the same time interval 12 (0.5 degree/00) patients presented with an aortic dissection after previous CABG. Age: 59.1 +/- 5.9 years, gender: 10/2, only Stanford A dissections, 4 chronic and 8 acute dissections, mortality: 3, all acute. 2 died of cardiac complications (left heart failure), 1 of other complications (gastrointestinal ischemia). The time interval between CABG and dissection was 2.5 +/- 3.6 years. Two dissections were intraoperative, another 5 were within the first year; the longest time interval was 10 years. In 5 cases the entry originated from a central anastomosis, 1 originated from the aortic cannulation site, and 1 from the site of the cross clamping. In 5 cases the entry was not directly related to the previous operation (1 was located in close proximity to the left coronary ostium, 2 between aortic valve annulus and the coronary ostia and 2 between the distal coronary arteries in the ascending aorta). Pathological changes of the aorta were not described at the time of CABG; only in 1 case a mild aortic regurgitation and dilatation (47 mm) at the time of the first operation was described. As our results suggest an aortic dissection presenting after CABG must be considered to be a rare complication of the previous operation. Considering the severity of this complication satisfying results can be achieved.

Aortic Dissection↗

PubMed1991

Usefulness of transesophageal echocardiography in assessment of aortic dissection.

BACKGROUND: The value of transesophageal echocardiography in the assessment of patients with aortic dissection was studied. METHODS AND RESULTS: Group 1 (34 patients) represented all patients studied at our institution with this technique in whom aortic dissection was proven by aortography, surgery, or autopsy. Group 2 (27 patients) represented all patients studied with this technique at our institution in whom aortic dissection was excluded by aortography. Transesophageal echocardiography made a correct diagnosis of aortic dissection in 33 of 34 patients (sensitivity, 97%; specificity, 100%). It also correctly demonstrated the type of dissection in all 29 patients with aortographic or surgical proof. On the other hand, computed tomography scanning, performed in 24 of 34 patients in group 1, made a correct diagnosis in only 67% of patients and misclassified the type of dissection in 33%. Transesophageal echocardiography correctly identified involvement of the coronary arteries by aortic dissection in six of seven patients as well as absence of both left and right coronary artery involvement in 10 patients with aortic dissection. This technique was also useful in detecting communications between the true and false lumens, presence of thrombi in the false lumen, and, in two patients, localized dissection rupture with formation of a false aneurysm. In both groups 1 and 2, transesophageal echocardiography correctly identified patients with moderate to severe aortic regurgitation. CONCLUSIONS: Transesophageal echocardiography is very useful in the assessment of aortic dissection.

Aortic Dissection↗

PubMed1995

[Cabrol's operation and the aortic arch replacement for Stanford type A dissecting aortic aneurysm].

Replacement of the aortic arch was performed simultaneously with Cabrol's operation utilizing modified selective cerebral perfusion (SCP) in a patient with a Stanford type A dissecting aortic aneurysm. Preoperative arteriography revealed that the dissection involved both common carotid arteries. For this reason, antegrade SCP was performed via the branches attached to the composite graft which were anastomosed to both of the common carotid arteries following clamping under deep hypothermia. The operation was successfully performed, and the patient's postoperative recovery was uneventful. This method of SCP is useful in the treatment of patients with prior difficulty or risk of cannulation.

Adult↗

PubMed2006

[MMP-9 gene -1562C/T polymorphism in aortic dissection in Chinese hypertensive patients].

OBJECTIVE: To investigate the association of matrix metalloproteinase 9 (MMP-9) gene -1562C/T polymorphism with the pathogenesis and site involved range of aortic dissection in Chinese population. METHODS: 142 hypertensive patients with aortic dissection and 130 hypertensive patients without aortic dissection were enrolled. Genomic DNAs were extracted from peripheral blood leucocytes. MMP-9 gene -1562C/T polymorphism was determined with PCR-RFLP. MMP-9 gene -1562C/T genotype and allele frequency were compared between hypertensive patients with aortic dissection and without. In addition, associations of MMP-9 gene -1562C/T polymorphism with clinical aspects were analyzed in hypertensive patients with aortic dissection. RESULTS: There was a significant difference in the T allele frequency of the C-1562T MMP-9 polymorphism between the two groups, with more T allele (17.6%) observed in hypertensive patients with aortic dissection as compared with these without (11.2%) (P = 0.033). The genotype distribution for the MMP-9 -1562C/T polymorphism in hypertensive patients with aortic dissection (-1562CC: 69.0%; -1562 CT: 26.8%; -1562TT: 4.2%) and those without (-1562CC: 79.2%; -1562CT: 19.2%; -1562TT: 1.6%; P = 0.118) showed no remarkable difference, but hypertensive patients with aortic dissection possessing T allele showed a higher odds ratio for involving ascending aorta (OR = 2.063, 95% CI = 0.998 - 4.264, P = 0.049) as compared with those without T allele. CONCLUSIONS: The T variant of MMP-9 gene -1562C/T polymorphism was significantly associated with aortic dissection in hypertensive patients and may represent an important genetic component contributing to aortic dissection susceptibility. Furthermore, hypertensive patients with aortic dissection possessing MMP-9 gene -1562T allele are more prone to involvement of ascending aorta.

Adult↗

PubMed1994

Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful?

BACKGROUND: Cardiac tamponade frequently complicates acute proximal aortic dissection and is one of the most common causes of death from aortic dissection. Well-defined strategies for the management of acute aortic dissection now exist; however, little is known about how best to manage the hemopericardium that may complicate it. METHODS AND RESULTS: Using a computer-based review, we retrospectively identified 10 patients presenting to our hospital over a 13-year period who were diagnosed with both aortic dissection and cardiac tamponade. All 10 had proximal dissections. Three of the 10 presented as the sudden onset of fatal electromechanical dissociation, 6 presented with hypotension, and 1 was normotensive on presentation. Of the 7 hypotensive or normotensive patients diagnosed with cardiac tamponade, 4 underwent successful pericardiocentesis while awaiting surgery. At time intervals of 5 to 40 minutes after their pericardiocenteses, 3 of the 4 patients experienced sudden onset of electromechanical dissociation and death; the fourth patient survived and underwent surgical repair. Of the 3 hypotensive or normotensive patients who had either no pericardiocentesis or an unsuccessful pericardiocentesis, all 3 underwent successful surgical repair and survived. CONCLUSIONS: In this study, patients with an aortic dissection complicated by cardiac tamponade have an early mortality of 60%. While 3 of the 10 died from electromechanical dissociation immediately upon presentation, the 3 other deaths all occurred shortly after successful pericardiocentesis, a procedure undertaken to stabilize them. While the number of patients in this series is small, the observations do raise the possibility that in patients with cardiac tamponade complicating aortic dissection pericardiocentesis could be harmful rather than beneficial. Possible mechanisms for why the performance of pericardiocentesis might destabilize such patients are proposed.

Aged↗