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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↗

PubMed1986

Aortic dissection: a statistical analysis of the usefulness of plain chest radiographic findings.

Findings on plain chest radiographs of patients with aortic dissection are variable and often overlap those of patients without dissection. To determine which findings were most useful in predicting aortic dissection, plain chest radiographs from 36 patients with aortographically proven aortic dissection and 36 patients from a control population were randomized and analyzed independently by five radiologists for the presence of various radiographic features associated with this condition. A widened aortic knob, widened descending aorta, and widened mediastinum showed the greatest interobserver agreement (p less than .001) although the overall interobserver agreement was poor. The final conclusion of the radiologists was a better predictor of dissection than any of the individual radiographic features alone. Widening of the mediastinum (p less than .001) and widening of the aortic knob (p less than .012) were the only two radiographic features of significance in predicting dissection. In a stepwise multiple logistic regression model, the radiologists achieved an overall accuracy of 85%, a sensitivity of 81%, and a specificity of 89%. Although this illustrates the usefulness of plain chest radiographs in diagnosing aortic dissection, poor interobserver agreement dictates that further definitive investigation be undertaken.

Adolescent↗

PubMed2005

Basilar artery dissection.

OBJECT: Little is understood about the clinical manifestations of basilar artery (BA) dissections, which can present with subarachnoid hemorrhage (SAH), brainstem compression, or ischemia. In any instance, the prognosis seems poorer than that for vertebral artery (VA) dissection. The authors analyzed clinical presentations and radiological features of BA dissection with and without rupture. METHODS: Between 1998 and 2003, the authors treated 10 patients (eight men and two women, ranging in age from 32-78 years; mean age 54 years) with BA dissection. Diagnosis was based on clinical and radiological findings, including those from magnetic resonance imaging and cerebral angiography studies. Of the 10 patients, five had impaired consciousness at disease onset. Among four patients presenting with SAH, two were treated conservatively and had fair outcomes without recurrent hemorrhage. The other two patients with SAH were treated using unilateral endovascular VA occlusion, but one of them subsequently suffered fatal rebleeding. A fifth patient presented with progressive signs of a mass involving the brainstem, whereas the remaining five patients showed brainstem ischemia; all were treated conservatively. Four patients could not return to their previous daily activities. CONCLUSIONS: Basilar artery dissections are rare lesions associated with significant morbidity and death. The natural course of and the treatment options for BA dissection differ considerably from those for VA dissections. Management of these lesions is controversial and difficult, and requires particular care.

Adult↗

PubMedDate not supplied

Treatment of internal carotid artery dissections with endovascular stent placement: report of two cases.

Extracranial carotid artery dissection may manifest as arterial stenosis or occlusion, or as dissecting aneurysm formation. Anticoagulation and/or antiplatelet therapy is the first-line treatment, but because it is effective and less invasive than other procedures, endovascular treatment of carotid artery dissection has recently attracted interest. We encountered two consecutive cases of trauma-related extracranial internal carotid artery dissection, one in the suprabulbar portion and one in the subpetrosal portion. We managed the patient with suprabulbar dissection using a self-expandable metallic stent and managed the patient with subpetrosal dissection using a balloon-expandable metallic stent. In both patients the dissecting aneurysm disappeared, and at follow-up improved luminal patency was observed.

Adult↗

PubMed1994

Ultrasonic features of extracranial carotid dissections: 47 cases studied by angiography.

The purpose of this prospective study was to assess the value of continuous wave Doppler velocimetry, standard duplex scanning and color Doppler flow imaging in the diagnosis of carotid dissections. From 1975 to 1993, 42 patients (mean age, 44 +/- 14 years) were admitted to the University Hospital of Angers for a carotid dissection studied first by ultrasonography, then defined by angiography. Five cases were bilateral. Continuous wave Doppler examination revealed signs of severe obstruction of the carotid arteries in 96% of the cases (occlusion, extensive submandibular tight stenoses, significant slowdowns in the carotid and ophthalmic vessels, retrograde ophthalmic blood flow). Standard duplex scanning suggested dissection in 72% of the cases (tapering stenoses or occlusion, segmental ectasis, tubular vessel, peripheral residual channel, or rare irregular "membrane"). Color Doppler flow imaging suggested a dissection in 82% of the cases. This method has the advantage of underlining the peripheral channel, the double lumen, and the dissecting hematoma, which often is hypoechoic. The ultrasonic methods (continuous wave Doppler combined with color Doppler flow imaging) failed only when they are performed late and when moderate or segmental intrapetrosal dissections were present. These ultrasonic investigations would thus appear to be useful for early diagnosis of carotid dissections.

Adult↗

PubMed2005

B-flow imaging in low cervical internal carotid artery dissection.

OBJECTIVE: Generally, the vascular ultrasonographic examination is the first method in evaluation of internal carotid artery (ICA) dissection. B-flow imaging (BFI), conversely, is a newer method of vascular ultrasonography. The objective of this study was to assess the accuracy and efficacy of BFI for the diagnosis of low cervical ICA dissection. METHODS: Seventeen consecutive patients with 18 angiographically confirmed low cervical ICA dissections and 16 nondissected ICAs were studied with BFI and color Doppler ultrasonography (CDU). The results were compared with those of digital subtraction angiography. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of BFI in diagnosis of low ICA dissection were 94%, 94%, 94%, 94%, and 95%, respectively. Corresponding results for CDU were 83%, 94%, 94%, 83%, and 88%. B-flow imaging more precisely showed the intimal flap and the visualization of flow within the true and false lumens. In dissected carotid arteries, 6 intimal flaps were diagnosed with CDU, and 15 intimal flaps were diagnosed with BFI. The agreement between the observers in determining low cervical ICA dissection by BFI was found to be excellent (kappa = 0.80 for intramural hematoma; kappa = 0.93 for intimal flap). CONCLUSIONS: B-flow imaging seems to be a new reliable vascular ultrasonographic technique for evaluation of low cervical ICA dissection.

Adolescent↗

PubMed1999

Preliminary experience using contrast-enhanced MR angiography to assess vertebral artery structure for the follow-up of suspected dissection.

BACKGROUND AND PURPOSE: Important advances have been made recently in MR angiography with the use of contrast medium injection, which has proved valuable for the imaging of vertebral arteries (VAs) obtained during short scanning times. Our purpose was to assess the feasability of contrast-enhanced fast 3D MR angiography for imaging VAs and to evaluate the long-term follow-up of VA dissections. METHODS: Sixteen consecutive patients with 18 angiographically documented VA dissections (seven occlusive dissections and 11 stenotic dissections, including two each with a pseudoaneurysm) were followed up using both contrast-enhanced 3D MR angiography and cervical T1-weighted MR imaging at a median delay of 22 months. Ten patients underwent MR imaging at the acute phase as well, and nine underwent early follow-up angiography at a median delay of 3 months. MR angiographic findings were determined by consensus, focussing on image quality, presence of residual stenosis, luminal irregularities, and occlusion. RESULTS: Of the 32 VAs, a segment of the artery was not assessable on contrast-enhanced MR angiography in each of four small VAs. A central signal void artifact of cervical arteries was seen in one patient and motion artifacts were seen in two, but images could be interpreted. A venous enhancement was detected in 10 of 16 examinations, but this did not prevent image analysis. Ten of 11 stenotic dissections returned to normal, whereas one stenotic dissection progressed to occlusion. Two pseudoaneurysms detected by initial angiography resolved spontaneously; one was revealed only by delayed MR angiography, and one was detected on an early MR angiogram and proved resolved on a late MR angiogram. Of the seven initially occluded VAs, five reopened, with a hairline residual lumen in each of three. CONCLUSION: This preliminary experience showed that contrast-enhanced MR angiography is a promising tool for imaging VAs; it allows the assessment of VA dissection changes over time. Most lesions tended to heal spontaneously, but persisting occlusion or pseudoaneurysm could be detected during the late course.

Adult↗

PubMed1999

Emergency surgical management of acute aortic dissection: role of transesophageal echocardiography.

The accuracy of transesophageal echocardiography in the diagnosis and surgical management of acute aortic dissection was determined in 54 patients who underwent surgery for acute aortic dissection. Results of the investigations were compared to the surgical assessment. From April 1993 to November 1997, we operated 54 patients (44 male and 10 female) for acute aortic dissection. Mean age was 60 +/- 9 years. At surgery, a De Bakey type I aortic dissection was diagnosed in 30 patients, type II in 23 and type III retrograde in 1. Operating procedures were: replacement of ascending aorta (24 cases), replacement of ascending aorta and aortic arch (17 cases), replacement of ascending aorta and aortic valve replacement (2 cases), Bentall procedure (6 cases) and end-to-end anastomosis of the ascending aorta (4 cases). Initial diagnosis, performed in emergency wards, was done on a clinical basis in 6 patients, on CT scan in 19, on transthoracic echocardiography in 14, and on TEE basis in 12. Three patients underwent angiography before our evaluation. As per our protocol, all patients underwent confirmation of the diagnosis by TEE. Seven patients needed additional instrumental investigations, 2 with CT scan and 5 with angiography. TEE confirmed the diagnosis of aortic dissection in all cases but one. Moreover, it described the site of the intimal tear, the extension of the dissecting process and accessory findings, such as pericardial effusion, aortic incompetence and left ventricular function. The interval between patient presentation and skin incision was a maximum of 70 minutes. At surgery, diagnosis of De Bakey classification was confirmed in 98% of cases; in 90.7% of cases exact location of the entry site was confirmed. In one case, an entry site in the arch diagnosed by TEE but not recognized at surgery, was observed at necropsy. Intraoperatively, we routinely used TEE to monitor retrograde systemic perfusion and correct implant of the vascular prosthesis. One case of malperfusion of the thoracic aorta through the false lumen was observed and managed. In one case we diagnosed acute obstruction of the prosthesis by bleeding in the wrapped aorta, which required reoperation. Assessment of ventricular function was obtained in all patients: in two cases, observation of low right ventricular function led us to perform aortocoronary by-pass to the right coronary artery. In conclusion, the high level of correspondence between TEE diagnosis and surgical anatomy prompted us to perform transesophageal echocardiography as the primary and often sole diagnostic procedure in acute aortic dissection. TEE, in experienced hands, has proven to be a highly reliable, safe and low-cost diagnostic tool. It can be performed at the patient's bedside within just a few minutes of the suspected diagnosis, thereby lowering the mortality rate of the natural history. Again, it can also be used in the operating theatre as an "on-line examination" as well as for assessment of correct surgical repair. Other diagnostic procedures do not yield more information and can cause dangerous delays in intervention.

Adult↗

PubMed2000

A comparison of dissection-method and diathermy tonsillectomies.

OBJECTIVE: To compare the dissection and diathermy methods of tonsillectomy and evaluate their advantages and disadvantages during surgery and convalescence. METHODS AND SETTING: Patients who had tonsillectomy at Aga Khan University Hospital, between January 1994-December 1997. RESULTS: Four year retrospective analysis was done of 200 patients who underwent tonsillectomy by either electrocautery or dissection method. One hundred and eleven underwent tonsillectomy by electrocautery and the other 79 had their tonsils removed by dissection-method and 2 had a combination of both. The average intra-operative blood loss was 10 ml with cautery and 65 ml with dissection method. The average operative time was 15.7 minutes with cautery and 26.9 minutes for dissection. We found higher amounts of blood loss and intra-operative time with dissection method than electrocautery. In comparing diathermy dissection method tonsillectomies, there was marked diffference between two, in peri-operative blood loss and operative time. CONCLUSION: Although post-operative bleeding, pain and infection are complications of both techniques and in our study their incidence in similar in both, but intra-operative blood loss and time are two important factors, based on which we can conclude that electrocautery technique is a more effective technique in our set up.

Adolescent↗

PubMed2000

[Autopsied case of an extracranial internal carotid artery dissecting aneurysm].

An autopsy case of extracranial internal carotid artery (ICA) dissecting aneurysm due to atherosclerosis was reported. A 74-year-old man was admitted to our hospital with the chief complaints of hoarseness and a pulsatile mass below the left mandibular angle. Neurological examination showed no obvious deficits except left recurrent laryngeal nerve palsy. Angiography revealed narrowing of the original segment of left ICA with dissection and aneurysmal dilation at the level of C3 vertebra. Seven days after admission, the patient had a sudden onset of consciousness disturbance. The second angiography showed no obvious changes compared with the first findings except slight narrowing in the distal portion above the aneurysmal dilation. The possible mechanism was thought to be recanalization following transient occlusion of the left ICA caused by extension of dissection or intracranial embolism due to a thrombus within the aneurysm. He was managed conservatively, but unfortunately he died of pneumonia. Macroscopic autopsy showed that the aneurysm was fusiform. Histologically, it demonstrated dissection of the hematoma between the media and adventitia layer. Hemorrhage in the atheromatous plaque with disruption of the elastic lamina were observed along with severe degenerative changes of the intima, media and, in part, adventitia layer due to atherosclerosis. In addition, a dissecting aneurysm of the right iliac artery and severe arteriosclerosis were observed in the systemic arteries. On the basis of these findings, the dissecting aneurysm presumably developed after disruption of a weak portion of the atherosclerotic wall, where intraplaque hemorrhage occurred earlier. We suggest that atherosclerosis be regarded as one of the pathogenic factors capable of causing dissecting aneurysm of the extracranial ICA in elderly patients.

Aged↗

PubMed2000

[Vertebral artery dissections: follow-up with magnetic resonance angiography and injection of gadolinium].

Vertebral artery dissection is a frequent cause of ischemic stroke in young adults but time course of VA dissections remains poorly documented. Angiography was considered as the gold standard for the diagnosis. Recently, non-invasive methods have been developed such as helical CT and magnetic resonance angiography. The purpose of the study was to assess the reliability of a gadolinium-enhanced fast three dimensional (3D) magnetic resonance (MR) angiographic sequence to image vertebral arteries and to assess the long-term follow-up of vertebral artery (VA) dissections. Sixteen consecutive patients with 18 angiographically documented VA dissections were followed-up by gadolinium-enhanced 3D MR angiography and cervical T1-weighted MR imaging at a median delay of 22 months. Ten patients had MR imaging scan at the acute stage as well and nine had early follow-up angiography at a median delay of 3 months. MR angiography was evaluated in a consensus manner including image quality, presence of residual stenosis, luminal irregularities and occlusion. All patients clinically improved. Ten of 11 stenotic dissections returned to normality whereas one stenotic dissection progressed to occlusion. Two pseudoaneurysms detected on the initial angiography resolved spontaneously, one appeared only on a delayed MR angiographic scan and one was detected on early MR angiograms and finally resolved on a late one. Of the seven initially occluded VAs, five reopened with a hairline residual lumen in three. Contrast MR angiography is an interesting tool to assess the late course of VA dissections. Most lesions resolved spontaneously but persisting occlusion or pseudoaneurysm may be found in long term follow-up.

Adult↗

PubMed2000

Radiofrequency induction heating for the treatment of aortic dissection in an animal model.

BACKGROUND: In this study, radiofrequency (RF) induction heating therapy using a self-expanding Gianturco metallic stent (G-EMS) to treat acute aortic dissection was evaluated. METHODS: We evaluated convergent RF induction heating of G-EMS in pigs. In group A (n=3), an aortic dissection was created to determine the natural course of this lesion. In group B (n=4), 0.40 mm stainless steel bare G-EMSs (2.5 cm, 10 bends) were placed in the aorta 5 to 7 days after dissection, and RF induction heating was performed for 30 (n=2) or 45 (n=2) minutes. In group C (n=6), G-EMSs with 0.10 mm ferro-chrome wire mounted on alternating stent legs were placed in the aorta 1 to 7 days after dissection, and RF induction heating was performed for 10 minutes. RESULTS: In group A, 2 pigs died from rupture of the false lumen. In group B, fusion of the dissection flap was confirmed histologically. However, all of the pigs died. In group C, all of the pigs tolerated the procedure, and fusion of the dissection flap was confirmed in all of the pigs. CONCLUSIONS: This experimental animal study suggested that RF induction heating combined with G-EMS, if properly applied, has a potential to treat acute aortic dissection.

Aortic Dissection↗

PubMed2001

A case of intraoperative acute aortic dissection caused by cannulation into an axillary artery.

Severe atherosclerotic disease of the ascending aorta is one of the risk factors of dissection of the ascending aorta and cerebral embolism during cardiac operations with cardiopulmonary bypass. Aortic dissection is rare, but once it happens, the mortality rate is high. For the patient with severely atherosclerotic or strongly calcified aorta, we should avoid cannulation into the aorta or clamping of it. In this case, we experienced aortic dissection although we chose the arterial cannulations into the axillary arteries because of the strong calcification of the ascending aorta and the abdominal aorta. The dissection was caused by the cannulation into the axillary artery. Transesophageal echocardiography (TEE) showed the dissection during the operation and the ascending aorta was replaced soon. Early diagnosis and treatment saved the patient. This case showed the following points: 1) cannulation into an axillary artery is not always safe; 2) TEE is very useful to detect the complicated dissection during operation; 3) replacement of the ascending aorta alone can be one of the choices for the treatment of aortic dissection caused by cannulation into an axillary artery.

Aged↗

PubMed2001

[CT virtual angioscopy in the study of thoracic aortic dissection].

PURPOSE: Virtual endoscopy is a technique in which helical-CT and MR data sets are processed by a special software creating a three-dimensional viewing of the inner surface of hollow viscera that simulates the endoscopic view. We report our 2.5-year experience with virtual intraluminal endoscopy (VIE) in the study of the thoracic aorta in patients with aortic dissection and in patients with normal aorta. MATERIAL AND METHODS: From December 1997 to June 2000, CT angiography (CTA) data sets of the thoracic aorta obtained in a series of 43 patients were retrospectively evaluated. Our series included 23 patients with clinical or radiological suspicion of aortic dissection and 20 patients in whom the study of the thoracic aorta was carried out as a necessary completion of an abdominal aortic disease. CTA data sets were processed with a dedicated software (Navigator); the view point and view direction could be set arbitrarily in the vessel, obtaining an intraluminal endoscopic view of the inner surface of the vessel. Multiple views were obtained and visualised consecutively through a cine-loop technique. The entire thoracic aorta was studied. RESULTS: VIE enabled correct visualisation of the intimal flap in all cases of aortic dissection (=23) and of its origin at the level of the ascending aorta in 16 cases (Stanford A) and in the descending aorta in the remaining 7 patients (Stanford B). In the control group (=20) no signs of intimal flap were identified with the VIE. In all patients with aortic dissection false and true lumen were entirely visualised. VIE allowed the understanding of the relation between false lumen and supraaortic vessels that originated from the true lumen in all cases and were found to be dissected in 6 patients. In 16 cases the dissection included thoracic and abdominal aorta. In some cases the endoscopic view was altered by artifacts related to the selected threshold levels and represented by pierced surface and floating shape artifacts. A correlation with axial and multiplanar (MPR) images allowed the correct interpretation of such artifacts. CONCLUSIONS: According to our experience, virtual endoscopy represents a useful tool in the evaluation of the dissection of the thoracic aorta, allowing a better definition of anatomical details. A correlation with axial images and multiplanar views remains compulsory for a better understanding of VIE findings, which is nevertheless significantly influenced by the operator's experience.

Aortic Dissection↗

PubMed2001

[Dissecting aneurysm of the posterior inferior cerebellar artery--studied by serial angiography].

We report the case of a 34-year-old male with cerebellar hemorrhagic infarction caused by a dissecting aneurysm of the left posterior inferior cerebellar artery (PICA). The patient suffered from a headache and vomiting for two days and was transferred to our hospital with sudden deterioration of consciousness. On admission, he was semicomatose. A CT scan revealed hemorrhagic infarction in the left cerebellum and upward herniation. The emergency operation for posterior fossa decompression was performed. Postoperatively, his consciousness level improved promptly and he had no neurological deficits except for slight gait disturbance. The first vertebral angiography was performed on Day 27. It showed a sausage-like dissecting aneurysm of the left distal PICA. We planned conservative therapy with careful observation because of there being no indication for an operation. Serial angiography was performed and demonstrated the regression of the dissecting aneurysm on Day 258. Dissecting aneurysms of the distal PICA are rare and their natural history is not well understood. Conservative therapy for vertebrobasilar dissecting aneurysms has often been reported. We suggest that conservative therapy with serial angiography is the treatment of choice especially for ischemic-type dissecting aneurysms. We review 17 cases of dissecting aneurysm of the distal PICA in this study.

Adult↗

PubMed2001

[Acute type B aortic dissection treated with endovascular implantation of a stent-graft].

Type B of the Stanford classification of dissection of the aorta is found in one third of patients with dissection of the aorta. The diagnosis of this disease is not simple. The clinical condition of these patients arouses frequently suspicion of other diseases, some diagnostic methods have a low sensitivity, other are frequently unavailable. Treatment of dissection type B may be either conservative or surgical, whereby better short-term and long-term results are recorded according to older reports by conservative methods. During recent years a new therapeutic method in type B dissection of the aorta is endovascular implantation of a stentgraft at the site of the false entry into the lumen. So far there does not exist any long-term investigation of patients with dissection of the aorta type B after stentgraft implantation. According to contemporary knowledge this new method could be used in patients with dissection of the aorta type B and reverse the hitherto adverse course of the disease. Our description of a case draws attention to the difficult diagnosis of this serious disease--dissection of the aorta--and demonstrates at the same time this new therapeutic method.

Acute Disease↗

PubMed2001

[Coronary artery dissection following angioplasty evaluated by fractional flow reserve: report of three cases].

Fractional flow reserve was measured in three patients with coronary artery dissection occurring after percutaneous coronary intervention. In Case 1, fractional flow reserve decreased from 0.88 to 0.73 and angiography showed coronary artery dissection 20 min after balloon angioplasty. In Case 2, angiography showed good results, but the fractional flow reserve decreased to a low value(0.69). Intravascular ultrasonography revealed dissection. In Case 3, angiography clearly showed dissection, but fractional flow reserve remained high(0.91). Stent implantation was performed in all three patients, but might not have been necessary in Case 3. Dissection with low or diminished fractional flow reserve value may cause a pressure gradient in the true lumen. Stent implantation is necessary in such cases. On the other hand, cases of dissection in which the fractional flow reserve value is maintained may also cause a pressure gradient in true lumen, but stent implantation may not be necessary. Fractional flow reserve measurements may be useful for the assessment of coronary artery dissection and evaluating the indications for stent implantation.

Aortic Dissection↗

PubMed2002

Emergency management of spontaneous coronary artery dissection.

Six cases of spontaneous coronary arteries dissection are reported. In one patient, triple vessel spontaneous coronary artery dissection was identified. Another patient presented spontaneous left main coronary artery dissection. In one case we found the spontaneous dissection of the left anterior descending artery associated with distal aortic arch dissection. These conditions are very rare and may present a surgical dilemma. Causative factors and underlying pathology are clarified. Prompt diagnosis and surgical intervention is safe and effective. Early recognition of left main coronary artery dissection or three-vessel dissection is essential because urgent coronary artery bypass grafting may be life saving.

Adult↗