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[The superior vena cava syndrome as a manifestation of dissection of the ascending aorta].

INTRODUCTION: Most clinical manifestations of aortic dissection are due to complications of either ischemic origin or wall rupture of pleural, pericardial, peritoneal or mediastinal cavity. Compression of other blood vessels such as pulmonary artery or superior vena cava is possible, but rarely occurs. CASE REPORT: A 60 year-old patient was admitted to hospital due to severe cyanosis and edema of the face, neck and upper thorax. Ten years ago, due to aortic insufficiency, aortic valve replacement with mechanical prosthesis (St. Jude) was performed. Diagnosis of superior vena cava syndrome was established on the basis of clinical examination, ECG and chest radiography. The etiology was confirmed by echocardiography indicating an enormous dissecting aneurysm of the ascending aorta, 9.2 cm in diameter. Lethal outcome followed 24 h after admission according to the type of electromechanical dissociation. DISCUSSION: The first case of superior vena cava syndrome was described by William Hunter in 1757. This severe disease is caused by tumors which compress or develop inside superior vena cava. In cases of rapid symptom occurrence, thrombosis or compression of vena due to hematoma (trauma, voluminous, dissecting aortic aneurysm) should be considered. Since symptoms of aortic dissection were absent (thoracic pain, aortic regurgitation, pulse asymmetry) the etiologic diagnosis of superior vena cava syndrome was confirmed by echocardiography. Surgical treatment of dissection provides repermeabilization of the superior vena cava and loss of symptoms. CONCLUSION: Superior vena cava syndrome is a rare and slightly known clinical manifestation of ascending aortic dissection. If symptoms rapidly occur, dissection should be considered, particularly in previously surgically treated patients.

Aortic Dissection↗

PubMed2002

High failure rate after valve-sparing aortic root replacement using the "remodeling technique" in acute type A aortic dissection.

BACKGROUND: Valve-sparing surgery including the replacement of the sinus of valsalvae were initially meant to be promising approaches in the treatment of acute type A aortic dissection. However, the long-term outcome after valve-sparing aortic root replacement in acute type A dissection is currently the subject of intense debate, and the evidence reported in the literature is sparse. Here we report on our experience on valve sparing aortic root replacement inpatients with acute type A dissection. METHODS: From August 1995 to November 2000, 30 patients with acute type A dissection received valve-sparing aortic root replacement. Two different techniques were performed: the "remodeling" technique, first described by Yacoub in 1983 (8 patients) and the "reimplantation" technique, initially described by David and Feindel, in 1992 (22 patients). Endpoints of the study were early and late mortality, as well as aortic valve-related complications and reoperations. RESULTS: The mean follow-up time was 22.6+/-15.4 months. The overall 30 day mortality was 17% (5/29) and the late mortality 4% (1/24). During the observation period, 4 patients had to be reoperated (n=3) for acute aortic valve regurgitation after aortic root remodeling and for acute aortic valve endocarditis (n=1) after aortic root reimplantation. In the 3 patients with acute aortic valve regurgitation, symptoms occurred 44, 24, and 17 months after the initial operation in these patients. Intraoperatively prolapsing aortic leaflets because of commissural detachment was found in all 3 cases. In all other patients the latest echocardiographic follow-up examination revealed freedom from aortic regurgitation higher than grade 1. CONCLUSIONS: The high failure rate of aortic root remodeling inpatients with acute type A aortic dissection is discouraging. Whether this technique should be applied in acute type A aortic dissection is questionable. In contrast, aortic root reimplantation lead to favorable midterm outcome. Thus, we recommend consideration of this technique for surgical treatment of patients with acute type A aortic dissection.

Acute Disease↗

PubMed2002

Ascending aortic dissection without intimal tear: a case report.

Aortic dissection may occur without the presence of intimal tear, and it may occur with medial dissection and intramural hematoma. We report a case in which mediastinal enlargement was found in the chest x-ray of a 79-year-old patient with chest and back pain that had started suddenly 1 week before. The patient had a decrease in hematocrit, and transthoracic echocardiography revealed around the heart pericardial fluid 5 cm thick. The ascending aorta could not be evaluated because of the presence of this fluid. The preoperative diagnosis, based on the computerized tomography findings (dissection of ascending aorta and pericardial fluid), was ruptured dissection of the ascending aorta. The patient underwent an emergency operation. Two liters of hemorrhagic fluid was aspirated from the pericardium during the operation. The ascending aorta was opened, but there was no intimal tear. Medial dissection and intramural hemorrhage were seen. The ascending aorta was replaced with a tube graft. Cases such as this, of medial dissection and intramural hematoma in which intimal integrity is preserved, should be approached in the same manner as classical dissections with intimal tear.

Aged↗

PubMed1999

[Selective neck dissection in the treatment of supraglottic carcinoma].

OBJECTIVE: To study the effectiveness of selective neck dissection (upper neck dissection, UND) in the treatment of N0 neck of supraglottic carcinoma. METHOD: The upper neck dissection was designed according to the lymphatic drainage of the supraglottic larynx for the management of N0 neck. The records of the supraglottic carcinoma of T1-4 N0-1 M0 cases (168 patients), who were treated in 1976-1990 at this hospital, were analysed retrospectively. RESULT: In this seires of 168 patients with no neck metastases pathologically a follow-up of five years after an upper neck dissection revealed a neck recurrence rate of 10.1% (17/168), which is comparable with those reported in the literature after selective neck dissection. Five year survival rate was 72.6% (122/168). CONCLUSION: Long-termed observation after UND for supraglottic carcinoma (T1-4 N0-1) resulted in satisfactory survival rates and regional control. It seems justifiable to do a selective neck dissection for N0 and selected N1 patients in order that more patients were exempted from enduring the morbidity following a comprehensive neck dissection.

Adult↗

PubMed2003

[A case of vertebral dissecting aneurysm manifesting as subarachnoid hemorrhage following nuchal pain].

We report a case of subarachnoid hemorrhage (SAH) from vertebral dissecting aneurysm 4 days after first nuchal pain. The patient was a 46-year-old man with a sudden onset of nuchal pain. There were no obvious abnormalities detected on MR images in another hospital. Four days later, however, he was admitted to our hospital because of severe re-attack of nuchal pain. CT demonstrated moderate SAH and cerebral angiograms revealed right vertebral dissecting aneurysm. Proximal occlusion of the vertebral artery including its aneurysmal dilatation was performed using detachable coils. We strongly suspected that his initial symptom of nuchal pain was due to dissection of the vertebral artery itself, since the aneurysmal dilatation accompanied by intramural hematoma had been observed retrospectively in the initial MR imaging. The incidence of the vertebral dissecting aneurysm presenting with nuchal pain alone due to dissection is reported to be 7% in the literature. The prognosis of non-hemorrhagic vertebral dissecting aneurysm followed by delayed SAH is considered to be fatal. Therefore, careful investigations for differential diagnosis should be taken into account since the diagnostic possibility exists that non-hemorrhagic vertebral dissecting aneurysm would be manifested by a symptom of headache/nuchal pain alone.

Aortic Dissection↗

PubMed1992

Ten years of surgery of aortic dissections and aneurysms. Clinical experience and original contributions.

From January '82 to April '91, 117 patients with aortic disease were operated upon at our University Hospital in Genoa, Italy. Thirty-seven had arch dissections or aneurysms; 66 had acute aortic dissection type A and 14 had aortic dissections or aneurysms type B, acute and chronic. Patients with arch or type B aortic pathology but without surgical indication and cases of post-traumatic aortic transections are not included. There were 84 male and 33 female patients with a mean age of 52 (6 min and 74 max). In the acute patients, the mean interval between clinical onset and surgery was 34 hours (6 min-72 max). All patients with primary arch disease had surgical repair with the aid of deep hypothermia and circulatory arrest (17-96 min). Type A dissections were treated with standard CPBP at 28 degrees C. Surgical techniques included direct suture of intimal tear alone, direct suturing of the two aortic stumps; interposition of Dacron tubular prosthesis; Bentall repair; separated valve and aortic replacement; an original aortic bulb aortoplasty with valve repair; arch replacement with resuturing of one or more aortic trunks. Human fibrin glue (Tissucol) was employed either as haemostatic agent, widely spread over the suture lines or as tissue adhesion agent between dissected aortic layers. Human fibrin glue is adopted because it gathers high glueing capacity and maintenance of the elastic property of the vessel wall. Hospital mortality (30 days) has been 25% in ascending aortic dissections (16/66 patients) and 50% in patients with arch disease (18/37 patients) who needed circulatory arrest. Late mortality 5/83 (6%). Reoperations for aortic valve insufficiency or re-dissection have been 7 (8.4%). Early diagnosis (increasing reliability of 2D-Echo and CT scans), aggressive surgery, meticulous myocardial and cerebral protection and introduction in clinical use of biological glues seem to be the milestones of present and further improvements in surgical results.

Acute Disease↗

PubMed1992

[Wallenberg's syndrome due to vertebral artery dissection following minimal neck injury--report of two cases].

We described two cases of the lateral medullary syndrome (Wallenberg's syndrome) due to vertebral artery dissection following minimal neck injuries. The first case was a 45-year-old man, who hit his head and often rotated his head because of posterior neck discomfort. Two years after the injury, he suffered from sudden sharp neck pain, nausea, and vertigo, which was followed by left hand numbness and difficulty in walking due to the right lateral medullary syndrome. Angiography showed right vertebral artery dissection at the fourth segment. The second case, a 48-year-old man, suffered from neck pain immediately after he hyperextended his neck for painting a wall. Within several hours, he experienced left hand numbness and difficulty in walking due to the lateral medullary syndrome. Angiography showed a saccular aneurysm and dissection of the right vertebral artery at the fourth segment. In both cases, minor traumas were thought to be the causes of vertebral artery dissection. We surveyed previously reported 84 cases (men: 50, women: 34) of the vertebral artery dissection due to minor traumas. Seventy per cent of patients were in their third or fourth decade of life. The main causes of trauma preceding the dissection were neck manipulation especially chiropractics (52%). The third segment was most vulnerable. Delay in onset following neck trauma could be more than a week, but in most cases the delay was less than 24 hours. Cervical rotation and extension were thought to precipitate dissection.

Aortic Dissection↗

PubMed1992

[The evaluation of pre and intraoperative factors influencing the false lumen after graft replacement surgery to the extended dissecting aneurysm].

We evaluated the residual false lumen of type I and IIIb dissecting aneurysm by CT, MRI and angiography postoperatively. The 19 patients with type I dissecting aneurysm were included eleven men and eight women, the average age was 55.8 +/- 10.2 years old. The 20 patients with type IIIb dissecting aneurysm were included sixteen men and four women, the average age was 56.2 +/- 8.5 years old. The rate of distal patent false lumen was 52.6% of type I and 35% of type IIIb dissecting aneurysm after graft replacement surgery. In type I dissecting aneurysm, the rate of distal patent false lumen was 40% of acute stage vs 66.7% of chronic stage, 66.7% of ascending and partial arch replacement vs 46.2% of ascending and total arch replacement, and 90% of graft inclusion technique vs 11.1% of graft exclusion technique. The distal patent false lumen was the lowest (12.5%) with type I dissecting aneurysm of ascending and total arch replacement using graft exclusion technique. In type IIIb dissecting aneurysm, the rate of patent false lumen was 66.7% of acute stage vs 29.4% of chronic stage, 30% of graft exclusion technique vs 40% of graft inclusion technique. The size of false lumen preoperatively were larger (11.1 +/- 4.5 cm2) in patients with distal patent false lumen than that (6.7 +/- 3.2 cm2) of in patients with distal occlusive false lumen.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2003

Aortic dissection surgery: experience of 78 cases.

From May 1990 to January 2001, 78 patients underwent surgery for aortic dissection, 68 (87%) of type A. Presentation was acute in 55 patients (71%). For type A dissection, in-hospital mortality was 13% (9 patients) and late mortality was 16%. For type B dissection, in-hospital and late mortality were both 30% (3 patients). The follow-up was complete and medical and imaging controls were performed periodically. Computerized axial tomography has shown persistence of distal aortic dissection in 18 patients, one of whom maintained dissection of the supraaortic trunks with false lumen thrombosis. Six patients maintained signs of dissection in the thoracic and abdominal aorta with patent false lumen. In another eight patients the false lumen was thrombosed. In 3 cases the dissection was located in the abdominal aorta. Two patients developed pseudoaneurysms of the thoracic aorta, one of whom was reoperated due to symptoms of dysphagia and chest pain, with angiographic signs of probable rupture of the aorta. Periodic imaging monitoring is essential, as it allows assessment of the extent of residual aortic disease and its evolution, with early detection of possible complications. This will enable prompt and safe action in those patients who may benefit from reoperation.

Adolescent↗

PubMed1992

[Diagnostic goals in aortic dissection. Value of transthoracic and transesophageal echocardiography].

The combination of different ultrasound techniques like transthoracic, suprasternal, subcostal and transesophageal echocardiography have a high sensitivity and specificity in the diagnosis of aortic dissection. The limitation of this combined ultrasound technique is related to the visualization of the ascending part of the aortic arch which, cause of the interposition of the trachea, can not be visualized completely. The beginning or the end of a dissection in this part of the aorta may be misinterpreted. False negative results are rare. False positive results due to artefacts resulting from reverberations in an ectatic ascending aorta have to be taken into account. The most important diagnostic aims in acute or chronic aortic dissection can be described: 1. confirmation of the diagnosis by visualization of the intima membrane, 2. the differentiation of the true and false lumen depending on visualization of spontaneous echocardiographic contrast thrombus formation, slow or reduced reversed flow, systolic diameter reduction and signs of entry jet into the false lumen, 3. detection of intimal tear, demonstrating communication by two-dimensional or color Doppler echocardiography, 4. determination of the extent of the dissection with classification according to DeBakey type I, II and III or Stanford A and B with differentiation to communicating or non-communicating dissection, antegrade or retrograde dissection limited to the descending aorta or expanding to the ascending aorta, 5. detection of wall motion abnormalities as a sign of preexisting coronary artery disease or myocardial ischemia due to ostium occlusion by an intimal flap, coronary artery rupture or collapse of the true lumen during diastole, 6. detection and grading of aortic insufficiency, 7. detection of side branch involvement by suprasternal, subcostal and abdominal sonography, which will gain the information which side can be chosen for cannulation or catheterization at the femoral artery, 8. detection of pericardial pleural effusion and mediastinal hematoma as a sign of emergency as rupture can occur within minutes. Without surgical intervention have be performed. Based on these informations, surgery can be performed in all acute situations in type A dissection without further investigations. This decision is particularly important in patients with signs of emergency like pericardial or pleural effusion or mediastinal hematoma.

Aortic Dissection↗

PubMed1992

[Result of surgical treatment of true or dissected thoracic aneurysm: determinants analysis in operative mortality and morbidity].

Between 1986 and 1990, 69 patients underwent surgery either for thoracic aneurysm (27 patients) or aortic dissection (42 patients). Sixty one patients (88%) survived and 8 patients (12%) died after surgery. Main determinants of deaths in 4 patients with true arch aneurysm were bleeding from the sites of aortic clamping or anastomosis and intraoperative severe LOS. Three patients with acute type A dissection died from bleeding due to clamp injury or myocardial ischemia. The cause of death in the patient with chronic type B dissection was associated with brain damage due to hypoxia developed during left heart bypass. Postoperative cardiac, pulmonary, hepatic and renal functions were analyzed in the operative survivors. Cardiac functions were maintained well in all patients except two patients with chronic type A dissection. Four patients, one with true arch aneurysm, 2 with chronic type A and one with chronic type B dissection, required tracheostomy. The mean of maximum total serum bilirubin exceeded 4 mg/dl in the patients with true arch aneurysm, acute and chronic type A dissection. The level of serum creatinine showed slight increase in all patients but prophylactic peritoneal dialysis was performed in one patient with chronic type A dissection. In conclusion, the cause of deaths in most patients with thoracic aneurysm was due to inappropriate operative techniques and circulatory supports during surgery. Without the complication described above, the patients could tolerate surgery well.

Aged↗

PubMed2004

[Modified grant method protocol for dissecting and identifying the brachial plexus].

Dissection of the brachial plexus is an important part in the anatomical course, but it is difficult for medical students to identify individual nerves of the brachial plexus due to its complexity and numerous variations. We have recently adopted the Grant method (1991) to guide students in the successful identification of this plexus. However, according to the Grant method the part of the upper limb including the brachial plexus is dissected before the neck part, which makes it impossible to identify the roots, trunks, and cords of the brachial plexus, and to identify the nerve branches extending from the brachial plexus. Here, we propose of anatomical dissection protocol of the brachial plexus a modified Grant method for medical students and instructors. The points of the modified protocols are: (1) to dissect the brachial plexus after the dissection of the neck part, (2) to identify the nerve trunks at the scalenus gap after dissecting the lateral, medial and posterior cords. The modified Grant method can be adapted to any other dissecting protocol of the brachial plexus, and will allow students to cope with many variations of the brachial plexus when they occur.

Anatomy↗

PubMed2004

[Bilateral vertebral artery dissection and its chronological changes detected by MR angiography: a case report].

A case of intracranial bilateral vertebral artery (VA) dissection presenting with ischemic symptoms which following unilateral dissection is presented. A 42-year-old male with an occipital headache was pointed out right vertebral artery stenosis with magnetic resonance (MR) angiography 8 day before admission. He admitted to our hospital complaining of severe vertigo and tinnitus. MR images and cerebral angiograms revealed bilateral VA dissection with infarcts in light lower surface of cerebellum perfused by posterior inferior cerebellar artery and right hypothalamus. Conservative therapy was adopted and serial MR angiography was performed. His symptoms were improved gradually and MR angiograms obtained 2 months later revealed improvement of bilateral VA stenosis. It is generally accepted that VA dissection presenting ischemic symptoms has good outcome by conservative therapy only. However, its pathological process of progression is still unknown. Based on the serial MR findings, we discuss the mechanisms of bilateral VA dissection. In this case, we consider that unilateral VA dissection extended to contralateral vertebral artery through the vertebrobasilar junction. Frequent MR angiography in acute phase could be of great use for monitoring the progression of dissection.

Acute-Phase Reaction↗

PubMed2004

Correlation of hemostatic molecular markers and morphology of the residual false lumen in chronic aortic dissection.

We evaluated our hypothesis that morphological change of the aortic dissection can be predicted by serial measurements of hemostatic molecular markers. Between February 1999 and February 2003, 50 patients with chronic aortic dissection of the descending thoracic aorta were studied at random intervals of 1 to 59 months (mean, 15.4+/-14.3) after onset. Morphologies of the false lumen of the aortic dissection determined by computed tomographic (CT) images were divided into four groups. Twenty-two images had aortic dissection associated with intramural hematoma or a completely thrombosed false lumen without ulcer-like projections (group 1), 14 had a thrombosed false lumen with ulcer-like projections (group 2), 18 had patent, but a partially thrombosed false lumen (group 3), and 15 had a completely patent false lumen (group 4). Blood samples for detection of hemostatic molecular markers were collected on the same day or within 1 month of the CT scan being performed. Thrombin-antithrombin complex (TAT) and D-dimer proved to be significantly higher in group 3 than in group 1. There was no significant correlation between the external diameter and hemostatic molecular markers except for prothrombin fragments 1+2 (PTF1+2). Simultaneous determinations of these hemostatic markers and multiple CT scans were performed more than twice in 19 of the patients. These cases were divided into three groups according to the morphological changes of the false lumen in the interval; morphologically progressive, regressive and no change cases. Five cases showed reduction or disappearance of the false lumen (the regressive cases). Only one case showed that the false lumen progressively enlarged and was partially patent thereafter (the progressive case). Mean plasma levels of TAT and D-dimer were changed correlated with the morphological progressive or regressive changes. The morphology of aortic dissection was correlated with hemostatic molecular markers such as TAT or D-dimer. We concluded that the serial measurement of D-dimer and TAT is useful for predicting morphological changes in chronic aortic dissection, and it can be an alternative way to follow up for patients of aortic dissection.

Adult↗

PubMed1992

Transesophageal echocardiography in the emergency surgical management of patients with aortic dissection.

The diagnostic accuracy and benefit of transesophageal echocardiography were investigated in 32 patients with suspected aortic dissection. Results of transesophageal echocardiography were compared with surgical assessment. The Stanford classification was used for differentiation of dissection type. Examination time was 5 to 15 minutes. Twenty-eight patients were correctly identified to have aortic dissection; four patients had nondissecting aneurysms of the ascending aorta. Both sensitivity and specificity for detection of aortic dissection were 100%. Type of dissection was misdiagnosed in one patient. Classification of dissection type was correct in 96%. The primary entry site was correctly identified in 25 patients (89%). Aortic regurgitation was found in 57% of patients. Pericardial effusion was detected in 21%, with tamponade in one patient. Myocardial infarction was suggested by transesophageal echocardiography in 7%, and 14% had significantly reduced left ventricular function. Eight patients underwent operation based on transesophageal echocardiography alone. Intraoperative transesophageal echocardiography, performed in 20 patients, verified retrograde flow in the true lumen after femoral cannulation. Transesophageal echocardiography documented postrepair persistence of the intimal flap in aortic segments that were not operated on in all patients. Secondary tears and flow in the false lumen were detected in 35% of patients. We conclude that transesophageal echocardiography allows expedient and accurate diagnosis and classification of aortic dissection, and we recommend it as the primary bedside diagnostic modality. It can especially identify patients requiring surgical intervention without further delay caused by other diagnostic procedures.

Adult↗

PubMed1992

[Detection of dissection of the thoracic aorta: improved specificity by magnetic resonance tomography in comparison with echocardiography techniques].

The purpose of this study was to assess the reliability of conventional transthoracic and transoesophageal two-dimensional echocardiography combined with color-coded Doppler flow imaging (TEE) and ECG-triggered magnetic resonance imaging (MRI) for the diagnosis of thoracic aortic dissection and associated epiphenomena. A total of 53 patients with clinically suspected aortic dissection were subjected to a transthoracic and transoesophageal ultrasound examination and magnetic resonance imaging; the results of each imaging modality were compared and validated against the morphological standards of contrast angiography (n = 53) and/or intraoperative findings (n = 27) or autopsy (n = 7). In this series no deleterious events were encountered with either non-invasive imaging method. In contrast to conventional echocardiography the sensitivities of both MRI and TEE were 100% for detecting a dissection of the thoracic aorta, irrespective of its location. However, the specificity of TEE was lower than the specificity of MRI for a dissection (TEE 68.2% versus MRI 100%; p less than 0.005), which resulted from false positive TEE findings mainly confined to the ascending segment of the aorta (specificity of TEE 78.8% versus 100% by MRI; p less than 0.01). In addition, MRI proved to be more sensitive than TEE in detecting the formation of thrombus in the false lumen of both the aortic arch (p less than 0.01) and the descending segment of the aorta (p less than 0.05). There were no discrepancies between the two imaging techniques in detecting the site of entry to a dissection, aortic regurgitation or pericardial effusion. Both MRI and TEE are atraumatic, safe, and highly sensitive methods to identify and classify acute and subacute dissections of the entire thoracic aorta. However, TEE is associated with lower specificity for lesions in the ascending aorta. These results may still favor TEE after a precursory screening transthoracic echogram in suspected aortic dissection, but will establish MRI as an excellent method to avoid false positive findings. Anatomical mapping by MRI may emerge as a promising comprehensive approach and, eventually, as a morphological standard to guide surgical interventions.

Adult↗

PubMed2006

Remodeling of the thoracic aorta after stent grafting of type B dissection: a Swedish multicenter study.

AIM: Endovascular repair of complicated type B dissections has evolved as a promising alternative to open repair. Previous studies have indicated that continued false lumen flow is a predictor of continued aortic dilatation and risk of rupture during follow-up. This multicenter study was conducted to analyze the postoperative changes of the false lumen after endografting of complicated type B dissections. METHODS: All patients treated with endovascular stent grafts for thoracic type B dissections at 5 major Vascular Centers in Sweden were identified through local databases. Review of charts and all available pre- and postoperative CT scans were performed to identify demographics, indications for repair as well as postoperative changes of the aorta and false lumen. RESULTS: A total of 129 patients treated for type B dissections between 1994 and December 2005 were identified. Median radiological follow-up was 14 months. Fourteen patients died perioperatively leaving 115 patients available for analysis. Seventy-four of these had CT imaging of sufficient quality for morphological analysis. The vast majority of acute patients were treated for rupture or end-organ ischemia whereas most chronic patients were treated for asymptomatic aneurysms. In 80% of patients, the false lumen thrombosed along the stent graft but it remained perfused distal to the stent graft fixation in 50% of patients. Only 5% of patients presented with aortic enlargement of the stent grafted area when adequate proximal sealing was achieved. The distal, uncovered aorta displayed expansion in 16% of patients. CONCLUSIONS: The stent grafted thoracic aorta after type B dissection appears to be stabilized by covering the primary entry site with a stent graft in the majority of both acute and chronic dissections. The uncovered portion of the aorta distal to the stent graft, however, remains at risk of continuous dilatation. Stent grafting for complicated type B thoracic dissections seems to be a treatment option with reasonable morbidity and mortality even though the incidence of severe complications is still significant.

Adult↗

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↗