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At least 721 records · Page 40Linked to original sources

PubMed2003

Dissection of the abdominal aorta in blunt trauma: Endovascular or conventional surgical management?

BACKGROUND: Dissection of the abdominal aorta caused by blunt trauma is a rare injury, often complicated by thrombosis within the true and false lumens and sometimes aortic rupture. The mortality rate with conservative medical management is approximately 75%, whereas it ranges from 18% to 37% with surgical treatment. METHODS: At our institution, 7 of the 87 patients admitted because of blunt aortic trauma, between January 1995 and January 2002, had abdominal aortic dissection. RESULTS: Four patients were treated using endovascular techniques by percutaneous stent placement. The indications for endovascular management were lower limb ischemia in one case and extension of the dissection in two; one patient was asymptomatic. Aortic dissection was complicated by ischemic paraplegia in two patients, and both were treated by conventional operative repair. One patient was managed medically because of a minimal intimal disruption. No deaths were related to the aortic dissection or its treatment. Angiographic and computed tomographic (CT) studies showed thrombosis of the false lumen and complete obliteration of the dissection in the endovascular group. The neurologic condition of the two paraplegic patients either cleared completely or partially improved. CONCLUSION: In the absence of ischemic paraplegia or other injuries that require emergency surgery, endovascular treatment is a safe and efficient method for treating traumatic infrarenal aortic dissection.

Adolescent↗

PubMed1996

Intravascular stenting of traumatic abdominal aortic dissection.

PURPOSE: We describe the case of a 34-year-old man with blunt abdominal trauma. Initial abdominal computed tomography scan showed retroperitoneal hematoma, pancreatic contusion, multiple fractures of the transverse process in the thoraco-lumbar spine, and infrarenal aortic dissection. METHOD: Angiography revealed that the aortic dissection originated proximal to the inferior mesenteric artery and extended down to the left common iliac artery without vascular obliteration. The pancreatic trauma was managed without operation, and the dissection was treated with aortic and left iliac endovascular self-expanding Schneider Wall Stents. RESULT: Immediate angiographic and computed tomography scan examination showed the obliteration of the greater part of the dissection with persistence of a short dissected segment at the level of the aortic bifurcation. Examination a week later showed thrombosis of this false lumen and complete obliteration of the dissection. CONCLUSION: Intravascular stenting allowed treatment of the dissection without open surgical procedures requiring laparotomy and aortic operation.

Abdominal Injuries↗

PubMed1995

Dissection of the external iliac artery in highly trained athletes.

We report a series of four acute external iliac artery dissections occurring in three patients within days of completion of ultraendurance athletic events. Acute dissection of the external iliac artery in highly trained athletes after competition has not been previously documented. A retrospective review of three cases was performed with subsequent follow-up, including imaging and hemodynamic measurements. Dissection was suspected on the basis of duplex imaging results in one case, and arteriography confirmed dissection in all cases. All patients were endurance athletes over the age of 40 years. One patient was found to have bilateral lesions. Treatment in two cases was initiated with percutaneous transluminal angioplasty, one with a successful result and subsequent Plamaz stent placement. In the other case percutaneous transluminal angioplasty was unsuccessful, and operative repair was required with the placement of a graft. The final patient who had bilateral involvement was treated conservatively. At a mean follow-up of 32 months, there have been no complications, and all patients have normal resting hemodynamics. Follow-up duplex imaging shows healing of the dissections in the untreated patient. Histopathologic study in the patient treated with operation disclosed dissection in an otherwise normal arterial wall. Highly trained athletes over the age of 40 are susceptible to external iliac artery dissection, and successful treatment has been achieved by surgical, endovascular, and conservative therapies.

Acute Disease↗

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↗

PubMed1997

Aortic dissection type A versus type B: a different post-surgical death hazard?

OBJECTIVE: Patients with type B aortic dissection differ from patients with type A dissection in age, hypertension prevalence, indications and timing of surgical treatment, yet reported long-term results have been rather similar (see Doroghazi et al. J Am Coll Cardiol 1984;3:1026-1034). METHODS: With the aim of comparing the post-surgical history, we have reviewed our results in 288 dissections, 213 type A and 75 type B, operated consecutively between 1 January 1970 and 31 November 1994. Follow-up was 100% complete. Empirical survival of both groups was interpolated with a fully parametric method and the shape and scale of the hazard function was investigated. RESULTS: Survival was not significantly different between type A and type B. Parametric survival was, respectively, 0.52% (70% C.L.: 0.48-0.55) vs. 0.56% (0.51-0.62) at 5 years, 0.44% (0.40-0.47) vs. 0.28% (0.23-0.25) at 10 years, 0.37% (0.33-0.41) vs. 0.25% (0.19-0.32) at 15 years, and 0.31% (0.26-0.35) vs. 0.24% (0.18-0.31) at 20 years. Following the high perioperative risk phase in type A dissection, the intermediate and late risk remains constant at a rate of 0.0033 events/month (3.9% patient-years (pt.-years)). By contrast, the postoperative course of type B dissection shows an intermediate risk phase between 4 and 10 years with an average linearized risk of 9.3% pt.-years and a peak of 20%. This determined lower survival rates (24 vs. 31% at 20 years, P = NS). CONCLUSIONS: We conclude that patients with type B dissection have a steeper postoperative death hazard as compared to type A dissection patients. Age confounding or late entry do not explain the difference. This could be possibly related to a greater propensity for expansion, higher risk of malperfusion complications or to limitations of our current surgical treatment.

Adult↗

PubMedDate not supplied

Creation of reentry tears in aortic dissection by means of percutaneous balloon fenestration: gross anatomic and histologic considerations.

PURPOSE: To study the safety and efficacy of percutaneous fenestration in aortic dissection, transmural tears in canine and human aortae were created with conventional angioplasty balloons. MATERIALS AND METHODS: Tears created in the aortae of five living dogs were compared with tears created in postmortem specimens. Percutaneous fenestration was performed in a woman with acute type I dissection and ischemic hepatitis who died in multisystem failure, and the balloon tear was documented at autopsy. Additional tears in the human aorta were studied in necropsy specimens of normal, Marfanoid, atherosclerotic, and acutely and chronically dissected thoracic and abdominal aortae. RESULTS: In the canine aorta, transmural balloon tears resulted in rapid death of all five animals, and the tears were approximately 10% longer than tears created post mortem with the same balloon. In human aortic specimens, most transmural and all transseptal tears were linear and were oriented nearly perpendicular to the longitudinal axis of the aorta. Tears that were initiated near calcified plaques or large aortic branches extended in unpredictable directions. The transverse orientation of the tears coincided with the long axis of smooth muscle cells in the media of the intact aorta or the dissection septum. CONCLUSION: Percutaneous balloon fenestration, when performed in areas of the aorta relatively free of atherosclerosis, results in transverse tears in the aortic dissection septum. Percutaneous fenestration of the aortic dissection septum appears feasible and should be considered as a treatment option in carefully selected cases of aortic dissection with ischemic complications. A final conclusion regarding the safety and efficacy of percutaneous fenestration undertaken to relieve organ ischemia requires further clinical experience.

Aged↗

PubMed2001

Dissecting hematoma of intracranial internal carotid artery in an 8-year-old girl.

BACKGROUND: An 8-year-old girl had a minor fall without head trauma and she collapsed the following day while playing. She was awake but mute with focal neurologic signs when admitted to hospital. Radiologic imaging studies showed a progressive left cerebral infarct with left hemisphere vascular narrowing and beading. She died on the third hospital day. METHODS: Autopsy including exploration of neck vessels and neuropathological examination was performed. Postmortem studies included immunostaining for immunoglobulins and fixed complement. RESULTS: Subtotal subintimal dissections of both proximal supraclinoid internal carotid arteries were found microscopically. On the left, the subintimal dissection extended into the major branches of the left internal carotid artery as dissecting hematomas with a major compromise of the arterial lumina. Specific IgM deposition at the dissection sites was found. A literature review shows that subintimal dissection of the intracranial internal carotid artery or its branches occurs rarely, it is often fatal, and it is present in patients with a mean age of 17.5 years in cases studied pathologically. Trauma and physical exertion are the most common associated factors. CONCLUSIONS: Among the causes of ischemic stroke in young individuals, dissecting hematomas of the intracranial portions of the internal carotid artery system rank low. Few reported cases have identifiable pre-existing pathology. The pathogenesis of dissecting hematomas in this region is reviewed and expanded with speculation regarding relevant developmental, anatomical, flow stress and possibly humoral factors that are involved in the disruption of the arterial elastica and subsequent development and extension of a subintimal hematoma resulting in luminal closure and often death.

Carotid Artery, Internal↗

PubMed2002

Carotid dissection: technical factors affecting endovascular therapy.

BACKGROUND AND PURPOSE: To delineate factors associated with the successful endovascular treatment of extracranial carotid dissections, the authors review their management of 13 cases. METHODS: The records of 12 patients with 13 dissections were assessed with reference to mechanism of dissection, preoperative symptoms, presence of a pseudoaneurysm, treatment success, and etiology of treatment failure. Patients were followed prospectively and included six men and six women, ranging in age from 27 to 62 years. RESULTS: Angioplasty and stenting were performed successfully in 11 of 13 procedures (10 of 12 patients). Follow-up in these 10 patients demonstrated excellent patency through the stented segment in nine of the 11 treated vessels. Two patients, both of whom suffered their original dissection as a result of endarterectomy, required further angioplasty and stenting for stenosis outside the previously treated arterial segment. Regarding the treatment failures, a stent deployment device could not navigate a tortuous loop in one, while a microwire could not be advanced beyond a pseudoaneurysm in the second. Six patients had pseudoaneurysms, four of which were treated only with stenting across the dissected arterial segment. All pseudoaneurysms treated in this fashion resolved. No permanent complications occurred as a result of endovascular therapy. CONCLUSIONS: Angioplasty and stenting can be performed safely to manage carotid dissection. A pseudoaneurysm or tortuous anatomy can preclude therapy although the former typically resolves if angioplasty and stenting are feasible. Dissections secondary to endarterectomy may be associated with a higher rate of restenosis after stenting and may require further treatment.

Adult↗

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↗

PubMed2002

Shoulder function and patient well-being after various types of neck dissections.

Preserving the accessory nerve results in a better outcome of the shoulder function after neck dissection. However, little is known about the impact of preserving a cervical contribution to the accessory nerve. This study describes the shoulder function after different types of neck dissections, with the emphasis on the significance of the cervical contribution to the accessory nerve. Fifty-nine patients who underwent neck dissections of various types were included. Thirty-eight patients underwent unilateral radical or modified radical neck dissections, and 21 patients underwent bilateral neck dissections. All the patients were assessed subjectively and objectively, using a questionnaire and an inclinometer. Radical neck dissections inflicted significantly more morbidity than modified radical neck dissections. Preserving a cervical contribution to the accessory nerve did not decrease pain complaints or functional impairment. However, there might be some improvement in range of motion, especially exorotation and anteflexion. Preserving the accessory nerve has a positive influence on shoulder function and complaints. Preserving a cervical contribution does not decrease morbidity significantly.

Accessory Nerve↗

PubMed2001

Pulmonary artery dissection in patients without underlying pulmonary hypertension.

AIMS: Pulmonary artery (PA) dissection is a rare event which usually occurs in patients with underlying pulmonary hypertension. We describe two patients who developed PA dissection without pre-existing pulmonary hypertension and present an extensive review of the literature. METHODS AND RESULTS: In the first patient (a 59-year-old woman), acute-onset dyspnoea was initially thought to have been caused by pulmonary thrombosis, and thromboendarterectomy was performed. Histologically, pulmonary dissection without external rupture was evident, chiefly in the right main PA. In the second patient, an 85-year-old man who had hypergammaglobulinaemia of unknown cause and died from a haemorrhagic gastric ulcer, arterial dissection was detected at autopsy. There was no underlying pulmonary hypertension in either patient. Although the true reason for the development of dissection is unclear, pre-existing inflammation was considered to be related to its formation, at least in the second case. CONCLUSIONS: A literature review indicated that idiopathic and inflammation-related PA dissection is extremely unusual. Since PA dissection is very rare, it is important to be aware of its features in order to make a correct diagnosis.

Aged↗

PubMed2005

Ultrasonographic criteria for diagnosing a dissection of the internal carotid artery.

AIM: To evaluate the usefulness of various sonographic criteria for detecting a dissection of the internal carotid artery (ICA). METHOD: Twenty-three consecutive patients displaying typical clinical symptoms of ICA dissection were identified. The diagnosis of dissection in these cases was confirmed by MRI/MRA or arteriography. The sonographic examination was the first technical investigation and involved the combined use of Doppler and duplex sonography. The value of different sonographic criteria was evaluated for the identification of ICA dissection: 1) Morphological criteria: intramural haematoma or double lumen. 2) Haemodynamic findings of distal stenosis/occlusion in combination with suddenly appearing clinical signs of a space-occupying lesion in the respective region (Horner's syndrome, lower cranial nerve palsies). 3) Haemodynamic signs of distal stenosis/occlusion with ensuing recanalisation within a few weeks. RESULTS: Morphological criteria alone allowed detection of a dissection in 47,8 % of patients. By the combined use of morphological and haemodynamic criteria ICA dissections were identified on admission in 73.9 % and after an average of 4.5 weeks (at the latest after 6 weeks) in 91.3 % of the patients. CONCLUSION: ICA dissections can be identified sonographically with high sensitivity. In some of the cases, however, definite diagnosis can only be provided by follow-up evaluation.

Carotid Artery, Internal↗

PubMed1998

[Dissections of the basilar artery].

PURPOSE: To describe clinical, radiological and pathological-anatomical findings of basilar artery dissections. METHODS: During a period of three years (1994-1996) we observed 4 patients with dissections of the basilar artery, proven by angiography. Angiograms, MRI (n = 2) and autopsy results (n = 1) of these patients were correlated with clinical symptoms and long-term follow-up. RESULTS: In three patients the dissection was confined into the basilar artery. Three patients with vertebrobasilar ischaemia showed irregularities of the vessel wall on angiography, in one of these patients autopsy revealed a haematoma within the vessel wall, located between intima and media. One patient complaining of relapsing headaches had a posttraumatic basilar artery aneurysm. CONCLUSION: Dissections of the basilar artery can be separated in two types. In case of subintimal dissection patients present with vertebrobasilar ischaemia, which in contrast to extracranial dissections usually occurs without temporal delay. A second type of patients presents with subarachnoid haemorrhage. The dissection is subadventitial and pierces through a thin adventitia into the subarachnoid space.

Adult↗

PubMed1998

[Spiral CT and MRT of the operated Stanford-type-A aortic dissection: its course and complications].

PURPOSE: To demonstrate normal postoperative spiral CT and MRI findings and typical complications in patients with aortic repair after Stanford type A aortic dissection. METHODS: 24 patients with aortic repair after Stanford type A aortic dissection were followed up by spiral CT and MRI (0.5 Tesla). Presence of persistent dissection, progressive or new dissection, proximal and distal anastomosis, periprosthetic space, supraaortic vessels, thrombosis and dilatation of the true and false lumen were evaluated. RESULTS: The following postoperative complications were seen: three pseudoaneurysms which developed at the proximal anastomoses of the Dacron prosthesis in two cases and at the insertion site of the reimplanted left coronary artery after implantation of a composite graft (Bentall procedure) in one case; one re-dissection; one perforation of the false lumen; periprosthetic flow in one patient after surgical repair of type A dissection by the graft inclusion technique; progressive dilatation of the false lumen in 4 cases; dilatation of the aortic root in a Marfan patient after replacement of the ascending aorta. CONCLUSION: Precise knowledge of the surgical technique performed is crucial to accurate postoperative imaging evaluation. MRI is the method of choice in the postoperative follow-up of clinically stable patients with aortic dissections.

Aortic Dissection↗

PubMed1996

[Dissection of the carotid artery and vertebral artery--diagnosis and therapy].

Carotid and vertebral artery dissections typically occur in young adults after major trauma, although they can arise spontaneously or after trivial injury. Many patients with carotid dissections have minor symptoms such as a subject bruit or Horner's syndrome. Cephalic pain is also frequent and often inaugural in carotid dissection. However, extracranial dissection is a well recognised cause of ischaemic stroke. The diagnosis of dissection was based on angiographic findings. Noninvasive imaging also allows prompt and reliable diagnosis. Our goal was to demonstrate the spectrum of neuroradiologic (CT, MR and angiographic) findings in craniocervical arterial dissection and compare the diagnostic utility of CT, MR, MR angiography. Clinical data imaging studies, and outcome were reviewed and compared with the results in four patients with carotid artery dissection.

Adolescent↗

PubMed1986

Early and late results following repair of dissections of the descending thoracic aorta.

Management of dissections of the descending thoracic aorta remains controversial, especially with regard to timing and method of repair. To clarify these and other issues we have reviewed our total experience with repair of descending aortic dissections between 1962 and 1983. The 44 men and 20 women had a mean (+/- SEM) age of 59 +/- 2 years (range, 19 to 83 years), and in all patients the dissection originated in and was limited to the aorta distal to the left carotid artery (Stanford type B, DeBakey types IIIa and IIIb). Twenty-nine patients underwent operation within 2 weeks of the onset of symptoms (acute), and the remainder had later repair (chronic). During repair, circulation distal to the aortic cross-clamp was supported with cardiopulmonary bypass or shunt in two thirds of patients. Overall, 18 deaths occurred less than or equal to 30 days postoperatively (operative risk 28%), and risk was higher in acute (45%) than in chronic (14%) dissections. Operative risk was not significantly related to protection of the distal circulation. The most serious postoperative complication was spinal cord ischemia manifested by paraplegia in five patients (8%) and transient or permanent paraparesis in six patients (9%). Risk of spinal cord ischemia was significantly lower in patients who had protection of the distal circulation during operative repair (8% vs. 44%, p = 0.003). Late survival, including hospital deaths, was 49% +/- 7% at 5 years after operation; 22 of the 46 patients who survived repair were found to have aneurysms involving the thoracic and/or abdominal segments of the aorta. Our results indicate that repair of chronic dissection of the thoracic aorta has a lower operative risk than repair of acute dissections, and initial medical management of acute dissection may be indicated if no early complications occur. Risk of spinal cord ischemia is significantly reduced by cardiopulmonary bypass or shunt and is preferred over aortic cross-clamping alone. Finally, these patients require careful long-term follow-up because of the high incidence of residual or recurrent aortic aneurysms.

Acute Disease↗

PubMed2000

Dissection plane of the human vocal fold lamina propria and elastin fibre concentration.

To determine whether a natural plane of dissection occurs in the normal human vocal fold, semi-blunt instruments (Bouchayer laryngeal dissectors) were used to dissect the lamina propria. The depth of the plane of dissection was correlated with the elastin fibre concentration to determine whether the plane occurred at a predictable point in the elastin concentration as it increased between the superficial and middle layers. Eight human larynges were dissected using an operative microscope. The dissection plane consistently occurred between 23-50% depth into the lamina propria. No consistent correlation was found with the elastin fibre concentration. The depth of the plane of dissection has an interesting association with age: dissection planes occurred more superficially in older specimens.

Adolescent↗

PubMed1999

Quantitative analysis of the functionality and efficiency of three surgical dissection techniques: a time-motion analysis.

The increasing technological complexity of surgery demands objective evaluation of surgical techniques. In particular, alternatives for laparoscopic ligation, such as monopolar coagulation and the relatively new bipolar scissors combining dissection with coagulation, should be analyzed and compared. This study tests the efficacy of quantitative time-motion analysis in evaluating and comparing the functionality and efficiency of dissection and ligation techniques in a clinical setting. Standard dissection with ligation of vessels, bipolar scissors, and monopolar coagulation were consecutively applied to dissect 4 of the small bowel mesentery of pigs, in random order. All actions performed were recorded and analyzed, using a standard action list. The efficiency of each technique was expressed in mean dissection time and number of actions, and the safety in occurrence of complications and severity of microscopic damage. Time-motion analysis evaluated the efficiency objectively and reproducibly (ICC 0.98). Bipolar scissors were significantly more efficient (time 7 +/- 2 min, actions 129 +/- 33) than the standard technique (28 +/- 6, 771 +/- 185) and monopolar coagulation (14 +/- 5, 368 +/- 32) (p < 0.01). Furthermore, bipolar coagulation needed significantly less recoagulation of an oozing vessel (0.5% of the total dissected vessels) than did monopolar coagulation (10.4%), and the damaged zone was significantly smaller (p < 0.05). Significantly less time was spent waiting or exchanging instruments with bipolar scissors than with the standard technique (p < 0.05). This time-motion analysis objectively compared the efficiency and functionality of three surgical dissection techniques during clinical use. Bipolar scissors were more efficient than were both other techniques, and they coagulated vessels more safely than did monopolar coagulation.

Animals↗