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PubMed1990

[Treatment of type A aortic dissection by exclusive glueing].

From 1984 to 1990, 24 patients suffering from type A aortic dissection were treated by directly suturing the entry orifice of the dissection and glueing (gelatin-resorcin-formaldehyde glue) the dissected aortic tunicae, without any prosthetic replacement. Associated aortic insufficiency in 21 patients was treated by valve replacement (8 patients) or plasty (8 patients). Deep hypothermia with circulatory arrest was required in 13 patients, whose aortic arch was involved by the dissection. All patients survived the operation. All these patients were followed up from 6 to 60 months. All were controlled with Doppler echography. In addition, 21 of them were examined with angiography, 17 with CT and 5 with MRI. 21 patients had an ascending aorta and an apparently normal aortic arch. Limited dissection of the descending aorta, requiring no second surgery, was noted in 2 patients. Persisting dissection of the descending aorta was present in 13 patients. Valve replacement was necessary 18 months later in 1 patient. Heart transplantation was necessary 14 months later in a patient suffering from associated cardiomyopathy. These results demonstrate that aortic glueing is effective and safe in the middle term for the treatment of aortic dissection.

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PubMed1990

[Autotransplantation in the treatment of isolated dissection of the renal artery].

Isolated dissection of renal artery is uncommon; 150 cases were reported in the literature, whose 2/3 diagnosed during patient's life and 1/3 post mortem, during autopsy. From 1976 to 1988 4 cases of isolated dissection of the renal artery were diagnosed and treated in our Institution. Three men and one woman with age ranging from 39 to 46 yrs (mean age 41.75) were seen at our Institution for intense abdominal pain and blood hypertension (mean blood pressure 196.25/113.75 mmHg) of recent occurrence. In 2 cases angiography showed dissection of the left renal artery, with involvement of peripheral branches; in 1 case the dissection involved the right renal artery with complete occlusion of an upper pole branch and upper pole infarction; our youngest patients presented a bilateral dissection, limited to the main trunk on the right side and involving prepelvic and retropelvic branches on the left side. Surgical treatment consisted of renal autotransplantation in the iliac fossa after extracorporeal reconstruction of the arterial pedicule; a branched hypogastric graft was used in 3 patients; in the patient with bilateral dissection an hypogastric graft was used on the right side and a sapehenous graft on the left side (3 months later). Partial nephrectomy was also performed in the patient having right upper pole infarction. Histologic examination showed that dissection always started from lesions of the lamina media. All patient were alive from 6 to 48 months after renal revascularization, with normalization of blood pressure (mean BP 125/80 mmHg); postoperative angiographic control showed thrombosis of 2 small branches in 1 case and partial stenosis of 3 anastomoses in another patient.(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed1990

[Dissection of cervical arteries as a cause of cerebral ischemia or cranial nerve dysfunction].

Nine patients with dissections of the cervical arteries are presented. Dissections cause approximately three per cent of non-haemorrhagic stroke and are usually observed in young and middle-aged patients. Dissections very often give rise to head or neck pain. Carotid artery dissection may lead to lower cranial nerve dysfunction and an incomplete Horner's syndrome in case of subadventitial dissection, and to cerebral ischaemia in case of subintimal spread. Vertebral artery dissection may cause brain stem ischaemia (subintimal dissection) or in rare cases a subarachnoid haemorrhage (subadventitial spread). The history frequently reveals a (trivial) traumatic event. Diagnosis is usually established by angiography or MRI. The prognosis is good and recurrences are rare. Treatment with anticoagulants or acetylsalicylic acid seems recommendable, though scientifically unproven.

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PubMed1990

[Consideration of management of type B dissecting aneurysms of the thoracic aorta: clinical comparative study between surgical and medical treatments].

Between 1970 and 1989, 116 patients with type B dissecting aneurysms of the thoracic aorta were seen in our institution and affiliated hospitals. The patients were classified into 5 groups according to the acuity (acute vs chronic) and modes of therapy (surgical vs medical). Group I: 24 patients with acute B dissection were treated surgically during the acute stage. Group II: 21 patients with acute B dissection were initially treated with intensive medical therapy and followed by elective operation during the subacute stage. Group III: 22 patients with acute B dissection were treated medically. Group IV: 42 patients with chronic dissection were treated surgically. Group V: 7 patients with chronic B dissection were treated medically. The 5-year survival rates including early mortality were 70.5 +/- 9.4% for Group I, 88.9 +/- 7.5% for Group II, 68.3 +/- 11.2% for Group III, 64.6 +/- 8.4% for Group IV and 71.4 +/- 17.1% for Group V. The 5-year survival rates of Group II was significantly better than those of Group I, III and IV, respectively. The present data suggests that acute type B dissection without complications (bleeding, visceral or lower limbs ischemia) should be treated initially with intensive medical therapy and then followed by elective operation during the subacute stage, if the false lumen were not thrombosed.

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PubMedDate not supplied

[The utility of color Doppler in dissecting aortic aneurysm].

We inform about the utility of Color-Doppler to identify dissection in aortic aneurysm. We studied five patients, fourth with dissection and one without dissection. All of them were in the fourth decade of life, except the patient without dissection, who developed symptoms at the age of 62. Two-dimensional echocardiography displayed the alterations of the aorta, such as dilatation of the walls, the presence or absence of dissection and in the cases with dissection the extension of it (three patients had DeBakey Type I, one DeBakey Type III an other DeBakey Type II). In all patients with dissection the Doppler study determined the presence or absence of flow through the false channel, in particular in the second and fifth patient and with Color-Doppler we observed that the flow was bidirectional. Also the degree of aortic incompetence could be quantified. It is concluded that with two-dimentional echocardiography it is possible to identify the anatomical features of aortic aneurysm and that Doppler study gives additional hemodynamic information which has importance in therapy and prognosis.

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PubMed1990

[Treatment of type A aortic dissection by exclusive gluing. Long-term results apropos of 15 patients].

Between 1984 and 1988, 15 patients with a type A aortic dissection were treated with direct suturing of the entry opening of the dissection and gluing of the dissected aortic layers using the GRF glue (gelatine-resorcine-formaldehyde), without prosthetic replacement. An associated aortic insufficiency, in 10 patients, was treated with valve replacement (5 patients) or plasty (5 patients). Deep hypothermia with circulatory arrest were necessary in 10 patients whose dissection reached the ascending aorta. All patients survived the procedure. These patients are followed from 6 to 44 months. They are all controlled by echo-Doppler. In addition, ten had an angiography, 6 a control scan and 5 a NMR. In twelve patients, the ascending aorta as well as the aortic junction are normal. A limited aortic dissection which did not require a secondary procedure, is found in 3 patients. A dissection of the descending aorta is present in 10 patients. Two patients had to be re-operated: one, for a valve replacement, 18 months later; the other, for a myocardiopathy at the terminal stage, 14 months later, requiring an orthotopic transplantation. These results show that gluing of the aorta is an easy and effective treatment in type A aortic dissections.

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PubMed1990

[A case of primary coronary artery dissection].

Primary coronary artery dissection occurring as a spontaneous event and not associated with trauma due to catheter manipulation is rare. We recently experienced (a case of) a 52-year-old man with primary artery dissection. He was admitted to our hospital with severe chest pain as his chief complaint on September 6, 1988. Electrocardiography and laboratory data showed acute inferior myocardial infarction. He was treated with medication and underwent coronary angiograms on October 3, 1988. Right coronary angiogram revealed an intimal flap and false lumen. But right coronary angiograms 6 months after the onset of myocardial infarction revealed progression of stenosis but no intimal flap, and coronary spasm was not evoked after acetylcholine administration. Primary coronary artery dissection has been reported since Pretty's first description of it in 1931. The majority of earlier cases were diagnosed at autopsy, but recently reports of survivors have been increasing due to the progress in and popularization of coronary angiographic technics. This case is the 46th case of primary coronary dissection found by coronary angiography. So it is not extremely rare. In our case the involved artery was the right coronary artery. In survivors, right coronary artery dissection is more frequent than left, because the area supplied by the right coronary artery is smaller than the area supplied by the left one. Although in our case coronary artery stenosis progressed, after a long term resolution of dissection may occur. There are a few cases in which resolution of dissection occurred naturally.(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMedDate not supplied

[Dissecting aneurysm of the aorta associated with local consumption coagulopathy].

Dissecting aneurysm of the aorta associated with local consumption coagulopathy is a rare clinical entity. We report one such case, a 71-year-old man with DeBakey type I aortic dissection and bleeding tendency. This patient had aortic dissection 4 years previous, and had developed a bleeding tendency in the last 2 years. Both computed tomographic scan and digital subtraction angiographic studies revealed DeBakey type I aortic dissection starting at the ascending aorta and extending all the way down to the renal artery, with an inlet at the aortic arch. The area of false lumen was larger than that of the true lumen, and thrombi were noted within the false lumen. A detailed blood coagulation study of this patient showed thrombocytopenia and coagulopathy. Blood coagulation studies in an additional 13 patients, who were seen at NTUH during the past 1 year with aortic dissection, but without the bleeding tendency, revealed no sign of coagulopathy. From analysis of these patients, we note that a large surface area in a false lumen, thrombus formation within a false lumen and blood flow into a false lumen with stasis seem to be the major determinants for causing coagulopathy in patients with aortic dissection. The treatment of aortic dissection with bleeding tendency caused by local consumption coagulopathy is graft replacement of the aneurysm. Hemostatic abnormalities may cause excessive blood loss during surgical operation, and careful and meticulous management of hemostasis are required.

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PubMed1989

[Transesophageal Doppler echocardiography in the diagnosis of dissecting aortic aneurysm].

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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PubMed1989

[Management of acute intrathoracic aortic dissection].

At the intensive care station of the Internal Medicine Department, University Clinic Graz, all patients admitted were promptly and carefully examined in case of suspected acute intrathoracic aortic dissection and immediately treated. In 1987 a total of 4446 patients were referred to this CCU, 893 suffered from acute thoracic pain. In 21 patients of the latter a clinical suspicion of aortic dissection was observed. In 9 patients of these, diagnosis could be established within 5 hours by echocardiography, CT and angiography. 11 patients had no dissection while one positive finding could only be determined by postmortem exam. Retrospectively, these figures for 1982 were 3908 admitted patients, 790 suffering from acute thoracic pain of which only 5 showed suspected dissection. In 3 cases dissection could be confirmed using the same diagnostic procedures, but 2 were without finding. Further 3 patients out of the total series were affected with dissection which could only be determined postmortem. Out of the 9 patients with positive diagnosis, 6 showed Typ I, 1 Typ II and 2 Typ III dissection according to DeBakey (8m, 1f, range 46-78 years). 2 patients underwent surgery immediately after diagnosis, 1 after 12 hours, while 4 cases were conservatively treated. These 7 patients have survived by controlled hypotension up to now (10 to 22 months). Two patients died 2 and 10 hours, respectively, after admission with positive diagnosis. In spite of the severity of this disease prompt and efficient diagnosis and rapid therapeutic management are the key to survival.

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PubMed1988

Primary coronary artery dissection: its incidence, mode of the onset and prognostic evaluation.

The incidence, mode of the onset and prognosis of primary coronary artery dissection in 1,445 consecutive patients with myocardial infarction undergoing coronary angiography were elucidated in the present study. Primary coronary artery dissection was observed in four patients (0.28%). The first case was a 28-year-old man, who developed angina at rest, followed by inferior myocardial infarction. His coronary angiogram showed dual lumina in the proximal to distal segments of the right coronary artery, which were separated by a flap. A left ventriculogram showed severe impairment of contraction (akinesis) in its inferior segment. Six years later, he was classified as New York Heart Association (NYHA) functional class I. The second case, a 54-year-old man, developed vasospastic angina followed by inferior myocardial infarction. His coronary angiogram showed a similar dissection from the proximal to distal segments of the right coronary artery. A left ventriculogram showed akinesis of the inferior segment and a coronary angiogram five years later showed marked resolution of the dissection. Twelve years after the infarction, he was classified as NYHA functional class I. The third case, a 46-year-old woman, experienced sudden onset of inferior myocardial infarction. Her coronary angiogram showed dissection from the middle to distal segments, and the posterior descending branch of the right coronary artery. A left ventriculogram showed akinesis of the inferior segment, and three years later, she was asymptomatic. The fourth case, a 28-year-old woman, developed anterior myocardial infarction following delivery. Her coronary angiogram revealed dissection from the proximal to middle segments of the left anterior descending artery. A left ventriculogram showed akinesis in the anteroseptal segment and dyskinesis in the apical segment. She died suddenly four years after her myocardial infarction. Thus, primary coronary artery dissection is not extremely rare and it may have been associated with coronary vasospasm in at least two of these four cases.

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PubMed1987

Repair of ascending aortic dissection. Influence of associated aortic valve insufficiency on early and late results.

Operative treatment of dissections of the ascending aorta differs from that for the descending aorta, not only because of the need for cardiopulmonary bypass, but also because of the frequent occurrence of aortic valve insufficiency. To determine the early and late results of operative repair, we have reviewed the case histories of 121 consecutive patients who underwent repair of ascending aortic dissections between 1962 and 1985. Ages ranged from 16 to 79 years (mean 56 +/- 14 years); 54 patients had operation within 2 weeks of onset of symptoms (acute), and the remainder had later repair (chronic). Seventy patients (58%) had clinical evidence of aortic insufficiency at the time of admission. During repair of acute dissection, 10 patients (19%) had aortic valve resuspension and 15 patients (28%) had aortic valve replacement. During repair of chronic dissection, eight patients (12%) had resuspension and 43 patients (64%) had replacement. Overall operative mortality was 22%, significantly higher for patients with acute than for those with chronic dissections (39% versus 9%, p less than 0.01). Operative risk was similar for patients who underwent repair of ascending aortic dissections without valve resuspension or replacement (31%) versus those who had repair with aortic valve resuspension (17%) or replacement (17%). During a follow-up period ranging from 1 to 208 months, aortic regurgitation developed in only two patients who did not have aortic insufficiency at the time of repair. Late aortic regurgitation necessitating reoperation developed in one of the 15 survivors who had aortic valve resuspension. Eight patients undergoing aortic valve replacement had complications of their prostheses, including one periprosthetic leak and four mechanical failures. We conclude that resuspension or replacement of the aortic valve does not increase the risk of repair of ascending aortic dissections. Selective management of aortic insufficiency (with valve repair whenever possible) yields satisfactory long-term results.

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PubMed1978

The effects of extraperiosteal and subperiosteal dissection. II. On fracture healing.

The effects of subperiosteal and extraperiosteal dissection on the healing of tibial osteotomies were studied in fourteen rabbits killed three weeks after the osteotomy. Of the tibiae exposed subperiosteally, 71 per cent healed; of those exposed extraperiosteally, only 7 per cent had solid union. The first group had a significantly lower level of hydroxyproline in the callus and higher values for breaking load, breaking strength, and absorption of energy to failure. In ten animals that also had muscle transection at the osteotomy site, the rate and type of healing was similar whether no dissection, subperiosteal dissection, or extraperiosteal dissection had been done, but the callus showed lower calcium levels and higher hydroxyproline levels than in either of the groups with muscle trauma. This implies retardation of healing caused by muscle injury. Our data suggest that in the absence of muscle damage, subperiosteal dissection results in earlier healing than does extraperiosteal dissection. Muscle transection markedly retards healing; then, after transection, neither type of dissection appears to retard healing more than the other.

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PubMed1978

Use of a ringed intraluminal graft in the surgical treatment of dissecting aneurysms of the thoracic aorta. A new technique.

An intraluminal graft made of woven tubular Dacron with cloth-covered grooved rings at both ends is used to repair dissecting aneurysms of the thoracic aorta. Six consecutive white male patients ranging in age from 31 to 69 years with an average age of 55 years were operated upon with the use of this graft. Three patients had a dissecting aneurysm of the ascending aorta and three others had a dissecting aneurysm of the descending aorta. Total cardiopulmonary bypass was utilized in repairing dissecting aneurysms of the ascending aorta and left heart bypass was used in patients with dissecting aneurymsms of the descending aorta. The basic technique consists in inserting the whole ringed graft into the true lumen of the dissected aorta and circumferentially ligating the aorta against the groove in the rings. The proximal ring of the graft effectively stabilized the flail aortic valve in two patients with aortic regurgitation associated with dissection of the ascending aorta. There were no hospital deaths. All patients are doing well 1 year, 1 month to 2 years, 8 months after the operation.

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PubMed1995

Dissection techniques in laparoscopic surgery: a review.

Efficient and safe dissection in laparoscopic surgery consists of the elements of exposure, tissue stabilization and tissue division. Exposure includes bulk exposure of organs and fine exposure of tissues during dissection. In endoscopic surgery this necessarily requires meticulous haemostasis. Tissue stabilization by atraumatic means displays the tissues with appropriate lines of tension to facilitate tissue division. This can be accomplished by a variety of energy types. Besides conventional dissection techniques, technologically advanced dissection systems employing different energy types have been incorporated in laparoscopic surgery. Mechanical energy sources such as ultrasound waves and the kinetic energy of a pressurized water-jet achieve precise dissection without haemostasis. However, thermal energy sources such as high-frequency electrosurgery and lasers achieve haemostatic dissection. Thermal methods generate destructive heat in the body which leads to coagulation or separation of tissues. Surgeons have to be aware of the principles of these dissection techniques, their tissue interactions, their advantages and limitations.

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PubMed1995

[Dissection following balloon angioplasty: predictive possibilities using pre-interventional intravascular ultrasonography].

The purpose of this study was to examine the association between qualitative and quantitative lesion characteristics before and the incidence of dissection after balloon angioplasty as assessed by intravascular ultrasound imaging. Thirty-seven patients (5 women, 32 men, aged 60 +/- 9 years) with 41 dilated lesions were examined with a 3.5 F, 20 MHz rotational tip intravascular ultrasound imaging system before and immediately after coronary balloon angioplasty. Images were assessed for plaque composition, topography and postinterventional effects on the plaque morphology. Quantitative measurements of lumen area, total arterial area and plaque area were performed in the dilated vessel segment. Plaque morphology was concentric in 18 lesions (44%) and eccentric in 23 lesions (56%). Fourteen lesions (34%) showed no calcification, 15 lesions (37%) were superficially and 12 lesions (29%) were deeply calcified. Four distinct changes of the plaque morphology were manifested by ultrasound imaging after balloon angioplasty. Dissection with detachment of the plaque from the underlaying wall was found in 10 lesions, plaque splitting in 9 lesions, superficial tears in 6 lesions, and smooth plaque contours in 16 lesions. The incidence of dissection detected by intravascular ultrasound was significantly greater in eccentric lesions (p = 0.03) and in stenoses with a small total arterial area (p = 0.006). The incidence of dissection was significantly increased in vessels in which balloon cross-sectional area exceeded 50% of the total cross-sectional vessel area as compared to those with a smaller balloon-to-vessel ratio. Preinterventional IVUS imaging provides information about the target stenosis which can be used to assess the risk of postinterventional dissections. In addition to the size of the balloon in relation to vessel cross-sectional area, the features small total vessel cross-sectional area and eccentric stenosis morphology in the preinterventional IVUS study predispose to an increased risk of dissection. Further studies have to elucidate the influence of dissections on late outcome after angioplasty.

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PubMed1994

[Results of surgical treatment of aortic dissections].

From January 1989 to September 1993, 59 consecutive patients (35 males and 24 females, mean age 59.6 years old) underwent surgical repair of aortic dissection on the cardiovascular surgical unit at Takeda Hospital. The type of aortic dissection were classified according to Stanford University criteria. Twenty-two patients had acute type A (Ac-A), 10 had chronic type A (Ch-A), 4 had acute type B (Ac-B), and 23 had chronic type B (Ch-B) dissection. Seventeen dissections (29%) in the entire group of 59 cases had ruptured (including cardiac tamponade, pleural effusion and hemoptysis etc.). Ischemia of lower extremity occurred in 7 patients and ischemia of visceral organs in 3 patients. Type A dissection were approached via a median sternotomy and cardiopulmonary bypass with systemic hypothermia. Type B dissections were approached through a left postrolateral thoracotomy. Left heart bypass (left atrial-femoral in 8 cases) and partial cardiopulmonary bypass (femoral-femoral in 12 cases) generally were utilized. Resection of intimal tear and replacement of aorta with vascular grafts (including aortic arch in 19 cases) were performed in most patients and primary closure of the intimal tear was performed in 9 cases using GRF. The over-all operative mortality rate was 36% (8/22) for Ac-A, 20% (2/10) for Ch-A, 25% (1/4) for Ac-B, 22% (5/23) for Ch-B. Main causes of operative death was perioperative brain damage. It is necessary to improve the operative mortality for Ac-A dissections (especially in replacement of aortic arch and arch vessels). Further researches are needed regarding optimal methods of the cerebral protection during reconstruction of aortic arch.

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PubMed1994

[Doppler transcranial ultrasonography in carotid and vertebral dissections: 36 cases involving angiography].

The aim of this prospective study was to investigate the additional information provided by transcranial pulsed Doppler for the determination of the upper part of dissections of the carotid and vertebral arteries and following-up. Earlier results concerning the role of ultrasound investigations for this indication have been presented elsewhere. Twenty-nine patients were examined (17 females, 12 males; mean age 43 years). All had arterial dissections confirmed by arteriography. There were 24 carotid dissections and 12 vertebral dissections. Investigations were performed during the acute phase and 2 months later. Most of the severe endocranial stenoses were identified by transcranial Doppler: 5 out of 6 severe stenoses of the carotid siphon and 6 out of 7 vertebral stenoses. The haemodynamic effect as measured by sylvian flow was significantly greater (p < 0.01) after a permanent ischaemic event than after temporary events and improved significantly with time (p < 0.008). There was no significant variation in the pulsatility transmission index (PTI), but this index requires a reference artery and is not particularly adapted in cases with bilateral dissection. Collateral perfusion, observed during the acute phase in all cases of occlusion and in 6 of the 8 carotid stenosis, was insufficient in half of the cases. Transcranial pulsed Doppler can be used to guide arteriography and helps determine the length of the dissection. It provides an easy way to assess the haemodynamic consequences of the dissection and is quite useful during follow-up.

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