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PubMed1994

[Acute aortic dissection in pregnancy. Report of a clinical case].

Aortic Dissection seldom affects young women. Nevertheless, the structural changes in the arterial wall, that occur during pregnancy, may predispose women to this complication, particularly in the third trimester and peripartum period. Aortic Dissection in gestation is associated specially with the Marfan's syndrome. The authors report a case of a pregnant woman in the 35th week of gestation, without Marfan's disease, admitted to Hospital on suspicious of type A aortic dissection.

Acute Disease↗

PubMed2005

Operative management of ascending aortic dissections.

Surgical management has been the established standard of care for acute ascending aortic dissection (Stanford type A or Debakey type I or II) with a worldwide average operative mortality rate of 23% compared with a 1-month mortality rate of 60% with medical management alone. Improving an institution's operative results depends on the establishment of a comprehensive and specialized team integrating their expertise into a protocol-driven system of care delivery specific for aortic dissections. The operative strategies and techniques for repairing aortic dissections should also be standardized within an institution to optimize outcomes. The primary goals of operative repair of ascending aortic dissection are to restore aortic valvular competency and systemic perfusion, to obliterate false-lumen blood flow, and to prevent rupture, myocardial infarction, stroke, and death. The goals, strategies, and expected outcomes for the operative management of acute ascending aortic dissection are presented.

Aortic Dissection↗

PubMedDate not supplied

Aortic dissection: diagnosis and follow-up with helical CT.

Acute aortic dissection is a cardiovascular emergency that requires prompt diagnosis and treatment. Helical computed tomography (CT) allows diagnosis of acute aortic dissection with a sensitivity and specificity of nearly 100%. With helical CT, a dissection involving the ascending aorta (type A in the Stanford classification) can be differentiated from one distal to the left subclavian artery (type B). Helical CT can also be used to identify atypical forms of aortic dissection such as intramural hematoma, penetrating atherosclerotic ulcer, ruptured type B dissection, and atypical configurations of the intimal flap. Helical CT is useful in follow-up of aortic dissection by allowing assessment of early and late changes after surgery or medical treatment. Such changes include postoperative complications of type A dissection, healing of intramural hematoma, progression of intramural hematoma, and aneurysms of the true or false lumen. Helical CT can also be used to monitor potentially life-threatening ischemic complications of abdominal branch vessels.

Aortic Dissection↗

PubMed1987

[Thrombosis of the false lumen in acute aortic dissection. CT diagnosis].

Three cases are reported of acute aortic dissection with complete thrombosis of the false channel, which is a very uncommon event in De Bakey's I and II type aortic dissections. The 3 patients entered hospital because of severe thoracic pain without any ECG sign of myocardial infarction. Emergency CT showed evidence of pericardial effusion suggesting hemopericardium, enlargement of the ascending aorta and a peripheral semilunar filling defect which caused a slight deformation of the true channel. On precontrast scans, only one case showed inward displacement of peripheral intimal calcifications and high-density aortic wall. No typical signs of aortic dissection were reported, except in the first patient--where a double contrast filled lumen, separated by an intimal flap was seen. CT findings are individually discussed. It is emphasized that in all patients more than one CT sign was present at a time. The correct evaluation of these signs together with the clinical data could lead to the right diagnosis of aortic dissection in spite of the lack of a filled false channel.

Acute Disease↗

PubMed2002

Acute aortic dissection related to crack cocaine.

BACKGROUND: Although single case reports have described acute aortic dissection in relation to cocaine use, this condition is not widely recognized, and the features of cocaine-related aortic dissection have not been defined. METHODS AND RESULTS: We reviewed all available hospital charts from 1981 to 2001 with the ICD-9 diagnosis of aortic dissection. Among the 38 cases of acute aortic dissection, 14 (37%) were related to cocaine use. Crack cocaine was smoked in 13 cases and powder cocaine was snorted in 1 case. The mean interval between cocaine use and the onset of symptoms was 12 hours (range, 0 to 24). Patients with cocaine-related dissection were much younger and more likely to undergo surgery compared with patients with aortic dissection without cocaine use. Most in the cocaine group were black, with a history of untreated hypertension. However, the two groups did not differ in other respects, including dissection type. CONCLUSIONS: In an inner city population, acute aortic dissection in the setting of crack cocaine use is common, presumably as a consequence of abrupt, transient, severe hypertension and catecholamine release. This diagnosis should be considered in cocaine users with severe chest pain.

Acute Disease↗

PubMed2000

Surgery in three-channeled aortic dissection. A 31-patient review.

OBJECTIVE: Three-channeled aortic dissection with 2 adjacent false lumens present is rare. METHODS: The 31 patients whose dissections we treated surgically accounted for 7.3% of the 426 patients with aortic dissection treated surgically between 1978 and May 1999. The 17 men and 14 women ranged in age from 24 to 77 years (mean: 45 +/- 12 years). Marfan syndrome was present in 18. Pain was observed at different times in 20. computed tomography scanning and magnetic resonance image proved useful in preoperative diagnosis. The morphology of the 1st and 2nd false lumens was Stanford type A + B in 13, type B + B in 15, type A + A in 2, and localized abdominal dissection in 1. RESULTS: Descending aortic replacement was done in 18 patients, thoracoabdominal aortic replacement in 7, ascending aortic replacement in 3, and others in 3. Five patients died in hospital and later during follow-up for 1-181 months (mean, 57 +/- 55 months). CONCLUSIONS: Pain recurring in patients with aortic dissection should alert the physician to the possibility of 3-channeled dissection and the necessity of surgery. The incidence of such dissection is high in patients with Marfan syndrome.

Adult↗

PubMed1994

[A two staged extending graft replacement for dissecting aortic aneurysm with Marfan's syndrome].

We experienced four cases of dissecting aortic aneurysms with Marfan's syndrome, in which two staged operations were performed with satisfactory results. The operations performed in the four patients were the replacement of the ascending aorta, transverse aortic arch and the entire descending thoracic aorta in DeBakey type I dissecting aortic aneurysm, replacement of the entire descending thoracic and abdominal aorta in type IIIb, replacement of the aortic valve, ascending aorta, transverse aortic arch, the entire descending thoracic and upper abdominal aorta in type I, and replacement of the total aorta including the aortic valve in type II + IIIb, respectively. There were no operative deaths, but a 42-year-old woman with DeBakey type IIIb died suddenly 2 years 11 months after the second operation. The cause of death was presumed to be due to rupture of a dissecting aneurysm (DeBakey type II). Dissecting aortic aneurysm with Marfan's syndrome must be observed carefully and corrected surgically, because the lesion is progressive and the residual dissecting aneurysm usually dilates eventually. In view of our clinical results, we conclude that the operation for dissecting aortic aneurysm with Marfan's syndrome should be performed as extensively as possible.

Adult↗

PubMed1997

[Acute thoracic aortic dissection with occlusion of the left coronary artery].

Aortic dissection is the most common fatal condition that involves the aorta. Occasionally, symptoms mimic acute myocardial infarction leading to thrombolytic treatment. Accurate diagnosis in patients with chest pain is therefore essential. We describe a case of acute aortic dissection which resulted in myocardial infarction due to obstruction of the left coronary ostium. A 65-year-old female patient with no previous cardiac history was admitted to a local hospital because of severe chest pain of acute onset. Physical examination was normal except for a low blood pressure (90/50 mm Hg), heart rate 45 beats/min and parasthesia in both hands. The ECG showed sinus bradycardia with negative T-wave in VI and with 1 mm ST-segment elevation in V3. A chest X-ray was normal. Five hours later, the patient experienced once more severe chest pain followed by non-sustained polymorphic ventricular tachycardia (Figure 1). Another ECG showed bifascicular bundle branch block (right bundle branch block and left anterior fascicular block). The ECG was interpreted as showing acute myocardial infarction and treatment with intravenous streptokinase started. Since the patient remained severely hypotensive despite infusion of dobutamine, she was intubated, ventilated and transferred to our hospital. Cardiac catheterization showed acute dissection of the ascending aorta with an aortic intimal flap and an occlusion of the left coronary artery (Figures 2a and b). During catheterization, she suffered a cardiac arrest from which she could not be resuscitated. A postmortem examination confirmed the acute aortic dissection which reached to the ostium of the left coronary artery (Figures 3a and b, 4a and b) and an anterior myocardial infarction probably due to intermitted diastolic obstruction of the ostium of the left coronary artery by an aortic intimal flap.

Aged↗

PubMed1993

Aortocameral fistula: a rare complication of aortic dissection.

The false channel of an aortic dissection only rarely ruptures into a cardiac chamber producing an aorto-cameral fistula. Reports of 20 cases have been published, and two distinct clinical patterns have emerged. In nine patients, severe cardiac decompensation associated with chest pain developed abruptly months to years after coronary bypass graft surgery or aortic valve replacement. Continuous murmurs were observed infrequently. In 11 patients, progressive chronic or subacute congestive heart failure developed in patients with aortic dissection known or suspected to have occurred months to years previously. A continuous murmur was almost always present. The frequency with which aortocameral fistula occurred in patients who had undergone cardiac surgery suggests a pathogenetic mechanism. It seems probable that postoperative adhesions favor fistula over free rupture.

Aortic Dissection↗

PubMed1991

Aortic dissection: atypical patterns seen at MR imaging.

Aortic dissection is typically manifested by an intimal flap separating true and false lumens. Atypical patterns lacking an intimal flap can occur, however, and are less well recognized. In this study, the authors review their experience with atypical patterns at magnetic resonance (MR) imaging. They evaluated the T1-weighted and gradient-echo MR images of the entire aorta in 64 patients with aortic dissection. In nine patients (14%) aortic wall thickening was the only sign of dissection in the thorax. In three of these cases, an intimal flap was found in the abdominal aorta; the other six patients had no flap in any region of the aorta, and this led to false-negative angiographic results in three cases. Aortic wall thickening as an atypical sign of dissection was seen more frequently in acute (29%) than in chronic (7%) dissection and was seen in only patients without Marfan syndrome. Two patients with atypical acute dissection at initial examination developed a clearly identifiable intimal flap at follow-up. Aortic wall thickening may represent the only sign of aortic dissection. In some cases, imaging the entire aorta can enable recognition of dissection in atypical cases.

Acute Disease↗

PubMed1990

[Dissecting aortic aneurysm in siblings without Marfan's syndrome].

The occurrence of dissecting aortic aneurysm in 2 or more family members is rare. We reported two cases of dissecting aortic aneurysm in one family. Case 1. Brother. A 49-year-old male, was diagnosed to have acute dissecting aortic aneurysm (DeBakey type I) with mild aortic regurgitation. He was operated on by valvuloplasty and closure of the false lumen, and is alive and well at the present time. Case 2. Sister. A 60-year-old female, was diagnosed to have chronic dissecting aortic aneurysm (DeBakey type II). She underwent replacement of the ascending aorta with a Dacron graft. She is alive and well. Neither of these 2 patients nor other family member had any features of the Marfan's syndrome. Histological examination of 2 cases showed the degeneration of smooth muscle in the media. Among their family, mother died of unidentified heart disease.

Aortic Dissection↗

PubMed1976

Infrarenal mycotic pseudoaneurysm. A late complication of coronary bypass surgery with proximal aortic dissection.

A 62-year-old man developed a mycotic infrarenal pseudoaneurysm at the re-entry site of a previous aortic dissection. The aortic dissection had occurred one year earlier while he was undergoing coronary bypass surgery. The patient was successfully treated with a Dacron bifurcation graft after the mycotic aneurysm had been sterilized. Causes and relationships of the mycotic pseudoaneurysm to aortic dissection and aortic balloon support are discussed.

Aneurysm, Infected↗

PubMedDate not supplied

Management of descending aortic dissection.

The optimal timing of surgery with Stanford type B aortic dissection remains controversal. In acute-phase cases, surgical mortality is so high that medical treatment is preferable unless there are major complications. To guide the choice of medical versus surgical therapy we use survival analysis in patients with acute uncomplicated/complicated and chronic uncomplicated/complicated descending aortic dissection. Between 1992 and 1993 49 patients were diagnosed with Stanford type B aortic dissection. Emergent surgery was performed in 4 patients for rupture or impending rupture, elective surgery was done in 12 patients. The remaining 33 patients were treated medically. Our results support the continued use of medical management as the primary treatment for uncomplicated acute aortic dissection, with surgical therapy being reserved for those patients with complications such as rupture, expansion, continuing pain or ischemia of distal vascular beds.

Aortic Dissection↗

PubMed2002

Does conservative surgical approach improve early and late outcome in patients with acute type A aortic dissection?

OBJECTIVE: Acute type A aortic dissection (AAAD) represents an emergency in cardiac surgery that requires immediate treatment to prevent death due to its fatal complications. The surgical approach is dependent on the involvement of AAAD. METHODS: Sixty-one patients were operated for AAAD at our clinic. 48 (78.7%) were male and 13 (21.3%) were female with a mean age of 51+/-12.3 yr (range, 21-80 yr). Only the ascending aorta was replaced in 33 (54.1%) patients (Group I) and aortic arch replacement was included in 28 (45.9%) patients (Group II). The aortic valve was preserved in 43 (70.5%) patients (Group A) and replaced in 18 (29.5%) patients (Group B). RESULTS: Early mortality rate was 23% (14/61). Multivariate analysis revealed that previous cardiac operations (P=0.048), renal complications (P=0.024), pump time (P=0.024), and cardiac complications (P=0.017) were significantly factors increasing early mortality. Late mortality rate was 8.5% (4/47) and multivariate analysis revealed that pulmonary complication (P=0.015) was the only statistically significant independent risk factor. Arch replacement or aortic valve replacement was not a predictor for early or late mortality. Cumulative survival was 73.8+/-5.63% at 1 yr and 68.3+/-6.46% at 7.5 yr. Cumulative survival was not different between groups (P>0.05). CONCLUSIONS: Both radical and conservative surgical approaches in AAAD do not differ in mean of early or late results. Surgery before development of hemodynamic instability and prevention of other system complications improves the outcome of surgical treatment in AAAD.

Acute Disease↗

PubMed2002

Surgical treatment of complicated distal aortic dissection.

Among the various treatment options for acute distal dissection with aortic branch compromise, we have favored open vascular surgical techniques. Our perspectives with over 500 patients treated during a 30-year period are presented herein.

Acute Disease↗

PubMed1991

Management of thoracoabdominal malperfusion in aortic dissection.

Malperfusion of the thoracoabdominal aorta or its branches is a common complication of aortic dissection, often with a fatal outcome. Since 1985 we saw thoracoabdominal malperfusion in 13 patients with aortic dissection. During repair of an acute type A aortic dissection, the intimal flap was fenestrated in three cases in the abdominal aorta and one within the superior mesenteric artery. In two cases with acute type B aortic dissection fenestration was performed at the level of the aortic bifurcation, and in one the descending aorta was replaced. Six patients had chronic dilatation of a false lumen without distal reentry, compromising the true lumen, with malperfusion of viscera, kidneys, and lower extremities. Three patients underwent replacement of the descending aorta, two of them subsequent abdominal aortic replacement with revascularization of the kidneys. One patient had thoracoabdominal replacement, and in two an extra-anatomic bypass was implanted. Five patients with acute dissection died: two from sequelae of malperfusion, two of myocardial failure, and one late after stroke. Eight patients are alive 1 month to 5 years after operation. In acute aortic dissection fenestration of the intimal flap may relieve thoracoabdominal malperfusion. In chronic aortic dissection, pseudocoarctation is most likely to occur at the diaphragmatic hiatus. This is treated by replacement of the affected aortic segment. In high-risk patients an extra-anatomic bypass is also feasible.

Aortic Dissection↗

PubMed2006

Weight lifting and aortic dissection: more evidence for a connection.

BACKGROUND/AIMS: In 2003, we reported on a small number of patients in whom acute aortic dissection appeared to be causally related to intense weight lifting. If additional cases could be identified, the phenomenon of weight lifting induced aortic dissection would be further substantiated. We now report a substantially larger number of cases in which aortic dissection is associated with intense physical exertion. METHODS: Additional cases of acute aortic dissection occurring at the time of intense physical exertion were accumulated and analyzed. Cases were culled from retrospective review of a large university data base and from reports forwarded to our attention from around the country. We determined type of activity bringing on symptoms, age and sex of the patients, location of the dissection (ascending or descending aorta), aortic size, therapy, and survival. RESULTS: We identified 31 patients in whom acute aortic dissection occurred in the context of severe physical exertion, predominantly weight lifting or similar activities. All patients except one were males. Mean age was 47.3 (range = 19-76). All except four dissections were in the ascending aorta. Only three patients (9.7%) had a family history of aortic disease. Mean aortic diameter on the initial imaging study was 4.63 cm. Twenty-six of the 31 cases were diagnosed ante-mortem and 5 post-mortem. Overall, 10 of the 31 patients (32.2%) died. Of 24 patients reaching surgical therapy, 20 (83.3%) survived. CONCLUSION: Weight lifting related acute aortic dissection appears to be a real phenomenon, with increasing evidence for the association of extreme exertion with this catastrophic aortic event. Moderate aortic dilatation confers vulnerability to exertion-related aortic dissection. Individuals with known aortic dilatation should be cautioned to refrain from weight lifting or strenuous exertion. Routine echocardiographic screening of individuals engaging in heavy strength training should be considered, in order to prevent this tragic loss of life.

Adult↗

PubMed2002

Successful repair of intraoperative aortic dissection detected by transesophageal echocardiography.

Aortic dissection is a rare but devastating complication of cardiac surgery. Early intraoperative diagnosis and management are essential for a favorable outcome. We describe the case of a 69-year-old man with worsening dyspnea who was admitted for mitral valve replacement having previously had a mitral valve repair. Precardiopulmonary bypass transesophageal echocardiography confirmed mitral regurgitation and showed mild atherosclerotic changes in the descending aorta. Following successful replacement of the mitral valve, an attempt to wean from cardiopulmonary bypass failed. This was characterized by acute onset hypovolemia. The transesophageal echocardiography showed the presence of features of acute aortic dissection involving only the descending aorta without identifying the entry point. The tear was successfully repaired by direct suture within the lumen.

Aged↗