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In two patients aortic dissection occurred as a late complication of aortic valve replacement and caused superior vena caval obstruction. The dissection and superior vena caval obstruction were diagnosed by computed tomography.
A 51-year-old woman suffered rapidly irreversible cardiogenic shock with left hemiparesis. Transesophageal echocardiography, which represents an essential imaging tool in the emergency room, ruled out aortic dissection involving branch vessels but did not allow an in vivo diagnosis of spontaneous coronary dissection. The in vivo diagnosis of spontaneous coronary dissection is rather difficult because of the dramatic clinical presentation and selective coronary angiography requirement.
Aortic dissection occurred after aortic valve replacement in two patients with valvular aortic stenosis. Clinical and necropsy findings are described.
The tissue biological adhesive GRF glue has been used in our department to have dissected aortic layers adhered and to reinforce the dissected aortic stumps during surgery for aortic dissection. From May 1992 to August 1993, 12 patients were operated for type A aortic dissection; 4 patients with acute dissection and 8 patients with chronic dissection. There were 5 men and 7 women whose ages ranged from 51 to 69 years with an average of 60.6 years. Replacement of the ascending aorta alone was performed for 6 patients. Replacement of both the ascending aorta and transverse arch was carried out for 4 patients, and replacement of the ascending aorta, transverse arch and the descending aorta was accomplished in 1 patient. Primary repair was performed for 1 patient with intraoperative acute dissection that occurred during surgery for mitral valve. There were no operative or hospital deaths. Preoperative aortic regurgitation was present in 5 patients. Following gluing the aortic root dissection, aortic regurgitation disappeared in all patients confirmed by postoperative aortograms. The use of GRF glue significantly reduced the average amount of intraoperative bleeding from 2893 ml to 1169 ml and also significantly reduced the use of Teflon felt strips for the proximal anastomosis. We believe that use of GRF glue can improve the surgical outcome for acute and chronic aortic dissection.
A case of dissecting aortic aneurysm is reported which occurred without significant pain but was complicated by a subacute pericardial bleeding leading to a large pericardial effusion. The patient was hospitalized because of clinical signs of cardiac tamponade which could be alleviated by pericardiocentesis. Neither 2D-echocardiography nor a portable x-ray of the chest disclosed evidence of aortic dissection. After a symptom-free interval of several hours the patient died because of recurring intractable pericardial tamponade. The differential diagnosis of a large hemorrhagic pericardial effusion should include rupture of a dissecting aortic aneurysm even when typical symptoms are lacking.
Clinical and morphologic observations are described in four patients who had severe aortic regurgitation from severe systemic hypertension unassociated with aortic dissection; each patient underwent aortic valve replacement. Although aortic regurgitation of minimal or mild degree is well recognized to occur in patients with systemic hypertension, severe degrees of aortic regurgitation are rare in such patients; aortic valve replacement in such patients has not previously been reported. Why these four patient had such severe aortic regurgitation was not determined. Although systemic hypertension is rarely a cause, it nevertheless must be added to the list of causes of severe pure aortic regurgitation.
Transesophageal Doppler echocardiography (TEDE) was performed in three patients with proven or suspected DeBakey type I and type III aortic dissection. Case 1: A 66-year-old woman, with DeBakey type I aortic dissection. Clear images of a widened dissected aorta and an intimal flap were obtained in both the ascending and descending aorta, including the aortic arch. The site of an entry into the false lumen was identified by the defect of the intimal flap and the pulsatile entry flow through it. The reentry into the true lumen was also identified near the orifice of the celiac trunk. In this case, the observation was performed using this technique during the operation; i.e., replacement of the ascending aorta with an artificial graft. Case 2: A 77-year-old man, DeBakey type III aortic dissection. The study was performed after surgery which consisted of replacement of the descending aorta with an artificial graft. TEDE provided clear images of the artificial graft, the aorta, and their boundaries. The remaining intimal flap was clearly confirmed. Case 3: An 80-year-old man, DeBakey type III aortic dissection. In this case, though abdominal echography suggested aortic dissection, angiography and X-ray CT failed to facilitate the diagnosis. Only TEDE confirmed the diagnosis. The abnormal flow via the entry directing toward the false lumen was clearly demonstrated on the color Doppler images. We therefore conclude that TEDE is a useful and reliable means of diagnosing dissecting aortic aneurysm.
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There have been few reports of surgical repair of acute aortic dissection in renal transplant recipients. The incidence, operative risk, or perioperative management of aortic dissection with functioning allografts remains unknown. Herein we report our experience in successful treatment of type I dissecting aortic aneurysm in a renal transplant patient. A 35-year-old man was admitted to our hospital complaining of severe chest pain. He had undergone a living renal transplant from his mother for chronic renal failure caused by immunoglobulin A nephropathy 11 years prior to admission. An immunosuppressive regimen had been maintained continuously. Preoperative chest computed tomography demonstrated a thoracic dissecting aortic aneurysm (DeBakey classification type I). An emergent graft replacement for the ascending aorta was placed under circulatory arrest. Although continuous hemodiafiltration was required postoperatively because of deteriorated renal function, he recovered uneventfully and his renal function returned to preoperative values. He was discharged on postoperative day 26 without any complications.
Acute aortic syndromes, including dissections, intramural hematomas and penetrating aortic ulcers, are a catastrophic clinical entity that are relatively uncommon. A high index of clinical suspicion along with proper imaging modalities are critical in making a prompt and accurate diagnosis for immediate management and to improve survival of the patient.
The occurrence of aortic dissection in 2 or more family members is rare. Such occurred, however, in the brothers and elder sister described herein. Case 1: A 54-year-old male had chronic Type I dissecting aortic aneurysm with severe aortic insufficiency and abdominal aortic aneurysm. Case 2: A 57-year-old female had chronic Type II dissecting aortic aneurysm with severe aortic insufficiency. Case 3: A 49-year-old male had chronic Type IIb dissecting aortic aneurysm. Two cases (Case 1 & 3) of them had surgical interventions. The histology showed cystic medial necrosis of aorta. Neither of these 3 patients or other family members had skeletal or ocular features of the Marfan syndrome. The metacarpal indices of them were well within normal. Their parents are cousins. It is, therefore, likely that the occurrence of dissecting aneurysm in the above three cases was due to an underlying hereditary disease. Thus familial dissecting aneurysm is suggested.
The aim of the study was to determine whether digital subtraction angiography (DSA) can be used in the diagnosis of aortic dissection. The study group consisted of six patients with aortic dissection including one of type 2 and five of type 3 by the DeBakey classification. DSA findings were compared to cineangiographic findings. The results were as follows; In all the patients, the diagnosis of aortic dissection was possible using DSA. Especially as to the entry, which was not detected by other non-invasive methods, there was an excellent correlation between cineangiograms and DSA (sensitivity 100%). Of the 20 vessels in the abdomen, which included the celiac, superior mesenteric, and right and left renal arteries, three vessels (15%) were not identified by DSA. Causes of the failure were the low spatial resolution and the artifact due to the motion of the patients and intestinal gas movement. The accuracy rate of the abdominal branch involvement was 70%. While using a prototype equipment, the preliminary study showed that DSA is a safe and very useful method not only for diagnosing aortic dissection, but for evaluation of the entry, extension of the dissection, and involvement of major branches of the abdominal aorta and for a follow-up study.
A 53-year-old male who had been performed aortic valve replacement 15 weeks before was admitted to our hospital because of severe chest pain. Cjest computerized tomography showed dissection of aorta from ascending to descendig aorta and hemorrhage around ascending aorta. An emergency operation was performed under hypothermic circulatory arrest with a selective cerebral perfusion. An entry of dissection was found at posterior wall where was 3 cm upper from an artificial valve. Total arch replacement was successfully performed. There is a few cases of aortic dissection after aortic valve replacement, but careful peri and post operative care is necessary after aortic valve replacement.
The propose of the present work is to study the potential of the 3-D contrast MR-angiography (MRA) in diagnosis of aortic dissection. The studied group consisted of 45 patients who as expected might have aortic dissection. 15 patients was observed in dynamics after surgical treatment. Total number of me performed contrast-MRA was 72. MRA has been performed on 1.5T MR tomograph Magnetom Vision (Siemens) with the of ultrafast sequenses Fisp and turbo-flash. Aortic dissection was diagnosed in 18 patients. The method of ce-MRA enables to make a precise diagnose of acute and chronic aortic dissection. This method is used for a dynamic follow up of the patients after the performed surgery.
Sixteen (47.5%) of 35 patients with acute aortic dissection showed a non-opacified crescent in the aorta on an initial contrast CT. Seven of these 16 patients underwent cineangiography soon after the initial CT, and in all 7 patients, neither an intimal tear nor an intimal flap was obtained. All but one of above 16 patients were followed by CT. Mean duration of follow-up was 9.6 months. In 10 of 15 patients with non-opacified false lumen, the false lumen remained non-opacified until the last examination. Moreover, in 6 of these 10 patients, the false lumen shrunk, and in the other 3, it disappeared completely on follow-up CT. On the other hand, in remaining 5 of these 15 patients who were initially diagnosed to have non-opacified false lumen, the false lumen became opacified and enlarged in size on follow-up CT performed in the first 14 weeks. Moreover, in 4 of these 5 patients, the false lumen became opacified in the only first 6 weeks. No matter how intensive care should be paid at least for the first 6 weeks, it seems that patients with aortic dissection which have non-opacified false lumen had good prognosis in comparison to patients with ordinary aortic dissections which have opacified false lumen. We believe aortic dissection with non-opacified false lumen may consist of two type of aortic dissection, one has no intimal tear, the other has some intimal tears and a thrombosed false lumen. In conclusion, CT is the most useful modality in diagnosing acute aortic dissection. The reasons are the incidence of acute aortic dissection with non-opacified false lumen was high, patients with non-opacified false lumen had good prognosis, and it was difficult to diagnose aortic dissection with non-opacified false lumen by conventional cineangiography and/or DSA.