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PubMed2000

Evolution of aortic dissection after surgical repair.

Patients after aortic dissection repair still have long-term unfavorable prognosis and need careful monitoring. The purpose of this study was to analyze the evolution of aortic dissection after surgical repair in correlation to anatomic changes emerging from systematic magnetic resonance imaging (MRI) follow-up. Between January 1992 and June 1998, 70 patients underwent surgery for type A aortic dissection. Fifty-eight patients were discharged from the hospital (17% operative mortality) and were followed by serial MRI for 12 to 90 months after surgery. In all, 436 postoperative MRI examinations were analyzed. In 13 patients (22.5%) no residual intimal flap was identified, whereas 45 patients (77.5%) presented with distal dissection, with a partial thrombosis of the false lumen in 24. The yearly aortic growth rate was maximum in the descending aortic segment (0.37 +/- 0.43 cm) and was significantly higher in the absence of thrombus in the false lumen (0.56 +/- 0.57 cm) (p <0.05). There were 4 sudden deaths, with documented aortic rupture in 2. Sixteen patients underwent reoperation for expanding aortic diameter. In all but 1 patient, a residual dissection was present (in 13 without any thrombosis of the false lumen). Close MRI follow-up in patients after dissection surgical repair can identify the progression of aortic pathology, providing effective prevention of aortic rupture and timely reoperation. Thrombosis of the false lumen appears to be a protective factor against aortic dilation.

Adult↗

PubMed1977

Pathogenesis of dissecting aneurysm of aorta. Comparative histopathologic study of significance of medial changes.

In previous investigation of the normal aging aorta, the claimed specificity of alterations in the media in the pathogenesis of dissecting aneurysm of the aorta was challenged. The concept was promoted that these changes are nonspecific and caused by general hemodynamic events within the aorta. In this investigation the aortic media was studied in patients with a dilated ascending aorta, whose hemodynamic profile is known to be altered. The results were compared with data obtained from the study of aortas with complete or incomplete dissection and aortas from patients with Marfan's syndrome, a condition known to predispose to dissection. Only quantitative differences were found between the normal "aging" aorta and the overtly abnormal aorta. The pathogenesis of dissected aneurysm, therefore, is considered to be initiated by processes if injury and repair within the aortic wall, consequent to hemodynamic forces. The histologic features of the media previously implicated as the specific underlying defect appear to represent the morphologic substrate of this traumatizing and reparative process. This process may gradually lead to dilatation of the aorta and, according to Laplace's law, a vicious cycle may ensue that may lead to further complications. Local circumstances determine whether a dilated aorta will rupture or whether an incomplete or complete dissection will occur. The fact that the aorta in patients with Marfan's syndrome shows basically the same structural alterations supports the concept proposed. The underlying connective tissue disorder in these patients will lead to complications at an earlier age. Dissecting aneurysm therefore is part of a spectrum of lesions that have as a common denominator the process of injury and repair.

Adolescent↗

PubMed2002

Syncope in acute aortic dissection: diagnostic, prognostic, and clinical implications.

BACKGROUND: Syncope is a well-recognized symptom of acute aortic dissection, often indicating the development of dangerous complications such as cardiac tamponade. SUBJECTS AND METHODS: We identified consecutive patients with acute aortic dissection at 18 referral centers in six countries. Data on key clinical findings and outcomes were collected via extensive questionnaires. Multiple logistic regression models were used to determine the association between syncope and in-hospital mortality, adjusting for demographic characteristics, dissection type, comorbid conditions, and complications (e.g., cardiac tamponade). RESULTS: Syncope was reported in 96 (13%) of 728 patients. Patients with syncope were more likely to die in the hospital (34% [n = 33 deaths]) than were those without syncope (23% [144/632], P = 0.01). They were also more likely to have cardiac tamponade (28% [n = 27] vs. 8% [n = 49], P <0.001), stroke (18% [n = 17] vs. 4% [n = 27], P <0.001), and other neurologic deficits (25% [n = 24] vs. 14% [n = 88], P = 0.005). After multivariate adjustment, clinical factors independently associated with the occurrence of syncope included a proximal dissection (odds ratio [OR] = 5.5; 95% confidence interval [CI]: 2.5 to 12; P <0.001), cardiac tamponade (OR = 3.1; 95% CI: 1.7 to 5.4; P <0.001), and stroke (OR = 3.5; 95% CI: 1.7 to 7.2; P = 0.001). There was a significant association between in-hospital death and syncope after adjustment for demographic characteristics alone (OR = 2.0; 95% CI: 1.2 to 3.5; P = 0.01), but not after adjustment for dissection type, comorbid conditions, and complications. CONCLUSION: Patients with dissections complicated by cardiac tamponade or stroke are significantly more likely to present with syncope. If these complications are excluded, syncope alone does not appear to increase the risk of death independently.

Acute Disease↗

PubMed2002

Advances in the treatment of acute type A dissection: an integrated approach.

BACKGROUND: Acute type A dissections require surgery to prevent death from proximal aortic rupture or malperfusion. Most series over the past decade have reported a death rate in the range of 15% to 30%. The objective of this study is to examine the effect of an integrated surgical approach on the treatment of acute type A dissections. METHODS: From January 1994 to April 2002, 163 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion to replace the aortic arch; HCA established after 3 minutes of electroencephalographic silence in neuromonitored patients (60%) or after 45 minutes of cooling in patients who were not neuromonitored (40%); reinforcement of the residual arch tissue with a Teflon felt "neo-media;" cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension or replacement with a biological or mechanical valved conduit. When HCA times were greater than 50 minutes, antegrade cerebral perfusion is used. Since Februay 1999, BioGlue has been used as an anastomotic adjunct in the repair of type A dissections. RESULTS: Mean age was 62 +/- 14 years, with 68% men and 15% with previous cardiac surgery. Seven percent of patients presented with a preoperative neurologic deficit, and 3% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9.8%. Excluding the patients with preoperative strokes (7%) and those with postoperative stroke (3%), the in-hospital death rate was 6.6%. In 6 patients, prompt changes in circulatory management consisting of switching cannulation sites or cross-clamp release with direct temporary aortic arch fenestration occurred when there were sudden changes in electroencephalogram during cooling. CONCLUSIONS: A standardized approach to the treatment of acute type A dissections has improved outcomes. Our 55% mortality in patients with preoperative cerebral vascular accident (CVA) suggests that this group may be candidates for medical or delayed surgical treatment. Conversely, our 6.6% mortality rate for neurologically intact patients warrants aggressive and expeditious surgical intervention.

Aged↗

PubMed2002

Single-stage reoperative repair of chronic type A aortic dissection using the arch-first technique.

BACKGROUND: Management of the enlarged, chronically dissected aorta after previous repair of acute ascending aortic dissection or after a previous cardiac operation may present a formidable technical challenge and the optimal method of management is not clearly established. METHODS: Twenty-one patients with chronic type A aortic dissection (mean age 57 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. Single-stage replacement with perfusion of the aortic arch first to minimize the duration of brain ischemia and a bilateral anterior thoracotomy (clamshell) incision were used. Fourteen patients had undergone previous repair of acute type A dissection. Seven patients had type A dissection after aortic valve replacement (3 patients) or coronary artery bypass (4 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a two-stage repair. The mean interval between the initial and reoperative procedures was 69 months (range, 5 to 249). RESULTS: There was 1 (4.8%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Ten patients required assisted ventilation for more than 48 hours. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome. There has been 1 late death (mean follow-up 2 years). CONCLUSIONS: The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.

Adult↗

PubMed2003

Optimal treatment of type B acute aortic dissection: long-term medical follow-up results.

BACKGROUND: The aim of this study is to assess the long-term outcome of medical treatment and determine recent surgical indications for type B acute aortic dissection. METHODS: In the last 8 years, 79 patients were admitted to our hospital with type B acute aortic dissection. We medically treated patients at the time of onset, regardless of the aortic diameter and blood patency status in the false lumen. If the maximum diameter of dissected aorta exceeded 60 mm in any stage, early or elective surgery was performed. The mean follow-up duration was 41.2 months. We evaluated operation free rate and actuarial survival rate. RESULTS: Thirteen patients underwent early or elective operations of the descending aorta. At the time of onset, the maximum aortic diameter of these patients was significantly larger than that of medically managed patients (55.8 +/- 4.4 mm vs 44.6 +/- 8.2 mm; p = 0.0004). Two patients underwent emergency axillo-femoral bypass for leg ischemia. Of the other 64 patients, who were medically managed, 2 patients had type A dissection develop during follow-up, 3 died during the initial hospital stay (1 from rupture, 1 from bronchial asthma, and 1 from gut ischemia), and 1 died of pneumonia 6 months after onset. Operation free rate was 98.6% at 1 month, 90.0% at 1 year, 78.7% at 3 years, and 69.5% at 8 years. Actuarial survival rate of medically managed patients was 98.4% at 1 month and 93.5% at 8 years. CONCLUSIONS: Medical treatment of type B acute aortic dissection produced good results. Surgical intervention for type B dissection should be done when the maximum aortic diameter exceeds 60 mm.

Actuarial Analysis↗

PubMed1978

The effectiveness of surgical treatment of acute aortic dissection.

Ten consecutive patients have undergone operative repair of acute aortic dissection at St. Thomas Hospital in the last three years. Two died. To assess the status of the residual aorta, all 8 survivors were evaluated by postoperative aortography. Only the patient with a clotted dissection on preoperative study showed no residual dissection of the distal aorta. Analysis of postoperative aortograms suggests that the original dissection reentry points become sites of inflow following removal of the original intimal tear. No death resulted from these residual abnormalities. Retrograde dissection and aortic insufficiency were obliterated. The major sites of aortic rupture were removed. It is concluded that surgical therapy for acute aortic dissection is effective in that it avoids the major sources of mortality. The resultant surviving population must be carefully observed in view of the high frequency of residual aortic abnormality.

Aortic Dissection↗

PubMed1999

Aortic dissection in Marfan's syndrome.

BACKGROUND: Aortic dissection is the most frequent cause of premature death in Marfan's syndrome. Low-risk elective surgery of the abnormal aortic root has the potential to prevent this complication. METHODS: We examine genetic, structural, and pathophysiological mechanisms of aortic dissection and discuss the surgical methods used when dissection occurs. RESULTS: Abnormal fibrillin disturbs the functional relationship between blood flow and vascular endothelial cell response (mechanotransduction). Decreased arterial distensibility also decreases aortic wall stress, thereby predisposing to dissection in the weakened arterial wall. Radical root and wall surgery and lifelong beta-blockade are required after aortic dissection. CONCLUSIONS: Detailed lifelong medical and surgical treatment can greatly prolong life in Marfan's syndrome. Elective aortic root replacement is paramount in preventing aortic dissection and avoiding subsequent problems in the distal aorta.

Aortic Dissection↗

PubMed1992

Diagnosis of acute thoracic aortic dissection using combined echocardiography and computed tomography.

Acute dissection of the thoracic aorta is a life-threatening emergency requiring a diagnosis which is rapid, accurate and safe, and which will distinguish between dissections involving the ascending and descending aorta. In the absence of any general agreement on the best method of making this diagnosis we studied the use of combined echocardiography and contrast-enhanced computed tomography (CT) to diagnose acute aortic dissection. Over a 3 year period 23 patients were investigated in this way. Aortic dissection was demonstrated in 18 cases, involving the ascending aorta in 15, and the descending aorta alone in three. The diagnosis of aortic dissection was confirmed in 13 patients at surgery, in one at aortography and in one at autopsy. Three patients died without surgery or autopsy being performed to confirm the diagnosis and the subsequently which accounted for their symptoms. This combined approach has proved a valuable and safe means of investigating aortic dissection.

Acute Disease↗

PubMed1999

Three-dimensional partial zona dissection for preimplantation genetic diagnosis and assisted hatching.

OBJECTIVE: To develop a new approach to partial zona dissection of oocytes and embryos for facilitating preimplantation genetic sampling and assisted hatching. DESIGN: Controlled clinical study. SETTING: Preimplantation genetic diagnosis and IVF program, Reproductive Genetics Institute/IVF Illinois, Chicago, Illinois. PATIENT(S): Three hundred forty patients undergoing IVF in whom preimplantation genetic diagnosis or assisted hatching was required. INTERVENTION(S): Three-dimensional partial zona dissection and conventional partial zona dissection were performed, with the use of a simple microneedle, on embryos before preimplantation genetic sampling or on day 3 of embryo development before ET. MAIN OUTCOME MEASURE(S): Pregnancy rate, implantation rate, and ease of preimplantation genetic sampling. RESULT(S): A pregnancy rate of 42% and an embryo implantation rate of 17.6% were obtained in the group in which three-dimensional partial zona dissection was performed, compared with a pregnancy rate of 33% and an implantation rate of 14.7% in the control group, which underwent conventional partial zona dissection. Preimplantation genetic sampling can be performed without distortion of the blastomere configuration in the embryo. CONCLUSION(S): Three-dimensional partial zona dissection is a safe and simple mechanical means of creating an opening sufficient for the atraumatic removal of material from oocytes and embryos for preimplantation genetic diagnosis and assisted hatching.

Dissection↗

PubMed2000

Long-term effectiveness of operations for ascending aortic dissections.

OBJECTIVE: To evaluate long-term effectiveness of a strategy for managing the aortic root and distal aorta according to the pathology in ascending aortic dissection. METHODS: From 1978 to 1995, 208 patients underwent operations for acute (n = 135) and chronic (n = 73) ascending aortic dissection. Surgical strategies included valve resuspension with supracoronary aortic root repair and ascending aortic graft for normal sinuses and valve (n = 135), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 47), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 26). Resection extended into the arch only if the intimal tear originated in or extended to the aortic arch (n = 31). RESULTS: Hospital mortality was 14%. Cardiogenic shock (P =.002) and concomitant coronary artery bypass grafting (P =.001) were associated with increased risk; use of circulatory arrest (P =.0003) decreased risk. Survival was 87%, 68%, and 52% at 30 days, 5 years, and 10 years, respectively. Advanced age, earlier date of operation, composite graft, and arch resection were associated with decreased survival; residual distal dissected aorta was not. Reoperation was required for 5 proximal and 8 distal problems. CONCLUSIONS: In both acute and chronic ascending aortic dissections, (1) circulatory arrest is associated with low early mortality; (2) with normal sinuses and valve, supracoronary repair of the dissected aortic root and valve resuspension is effective long term; and (3) residual distal dissected aorta does not decrease late survival and has a low risk of aneurysmal change and reoperation for at least 10 years.

Adult↗

PubMed2005

[Lateral bulbar infarction due to intracranial dissection and subarachnoid haemorrhage].

INTRODUCTION: Intracranial vertebral artery dissecting aneurysms are a recognized cause of subarachnoid hemorrhage and the hemorrhagic recurrence risk after a first rupture of the dissecting aneurysm is high and of poor prognosis. However, when the dissection is discovered in a patient with vertebrobasilar territory ischemia, little is known about the risk of hemorrhagic rupture risk and there is no consensus on management. OBSERVATION: We report the case of a 49-year-old man who developed subarachnoid hemorrhage 48 hours after the occurrence of a latero-bulbar syndrome caused by a spontaneous dissection with occlusion of the right vertebral artery. The subsequent angiography showed a V4 dissecting aneurysm of the right vertebral artery which was treated by stenting and coiling without any complications. CONCLUSION: This case underlines the hemorrhagic risk of an intradural vertebral artery dissection and its possible progression to aneurysm. Subsequent angiographic imaging must be carefully examined to search for aneurysms which may require early specific treatment because of the high risk of recurrent bleeding.

Brain Infarction↗

PubMed1985

Acute dissections of the aorta. Current surgical treatment.

Tremendous progress has been made in the treatment of acute aortic dissections as a result of advances in surgical, medical, and diagnostic modalities. Rapid clinical diagnosis should be followed by aggressive monitoring, pharmacologic manipulation, and definitive elucidation of the anatomy of the disorder. Ultrasonography and CT scanning may provide valuable information on the anatomy of the dissection, but contrast arteriography remains the preferred method for demonstrating the anatomy. Surgical correction is now recommended for both type A and type B dissections during the acute stage. The exact approach is dictated by the location of the intimal tear and the extent of the dissection. The complexity of the operation may extend from interposing an intraluminal graft to full cardiopulmonary bypass with profound hypothermia, circulatory arrest, and replacement of the ascending aorta, aortic arch, or aortic valve apparatus. The rapid advancement of management techniques for acute aortic dissections now offers patients a reasonable expectation of survival without complications. Future improvements in early, noninvasive, and rapid diagnostic methods, as well as increased utilization of invasive monitoring and nonporous graft materials, promise to increase survival for a patient afflicted with acute aortic dissection.

Acute Disease↗

PubMed2003

En Bloc removal of soft tumors within the brain parenchyma using spoon retractors: traction-dissection method. Technical note.

BACKGROUND: En bloc removal of soft tumors within the brain parenchyma has rarely been performed. We describe a safe technique for en bloc removal of the tumors using a spoon retractor, which enables retraction while holding the soft mass upward. METHODS: Dissection of a tumor mass is performed under traction of the surrounding brain tissue by retracting the mass using a spoon retractor. A dissection plane is first established in a relatively safe area, not opposite the critical area, after a corticotomy. The dissection plane is then extended toward the critical side. After circumferential dissection of the tumor mass, the dissection is continued spirally into deeper regions by retracting and holding the mass upward using a spoon retractor. In this way, the tumor is removed en bloc. CONCLUSIONS: The traction-dissection method using spoon retractors is useful in performing en bloc removal of soft tumors within the brain parenchyma less invasively and provides an appropriate operating field even at depth, reducing intraoperative bleeding, and in vascular rich tumors, possibly preventing tumor seeding in cases of malignant tumors.

Brain Neoplasms↗

PubMed1997

Intracranial dissecting aneurysm causing subarachnoid hemorrhage: the role of computerized tomographic angiography and magnetic resonance angiography.

BACKGROUND: With increasing frequency, dissecting aneurysms of the intracranial arteries are recognized as a possible cause of subarachnoid hemorrhage (SAH). In the presence of a dissecting aneurysm, angiographic changes may be subtle at presentation and correct diagnosis often requires serial angiograms. We report a patient with a dissecting aneurysm of the anterior cerebral artery (ACA) causing SAH, in whom less invasive diagnostic tools, such as high-resolution computerized tomographic angiography (CTA) and magnetic resonance angiography (MRA), were helpful in confirming the diagnosis and in following the evolution of the dissection. CASE PRESENTATION: We present this 51-year old woman who experienced the sudden onset of severe headache without associated neurological deficits. Head CT showed SAH with blood in the interhemispheric fissure, suggesting a ruptured ACA aneurysm. Serial cerebral angiograms failed to demonstrate an aneurysmal sac, but showed evolving irregularities of the ACA consistent with a dissecting aneurysm. These findings were confirmed by CTA and MRA. The patient was treated conservatively and made an excellent recovery. A MRA obtained 2 months later showed slight improvement of the previously visualized ACA dilatation. CONCLUSION: Serial angiograms are often required to confirm the diagnosis and to follow the evolution of an intracranial dissection. With recent advances in neuroradiological techniques, however, critical information can be obtained by less invasive imaging studies, such as CTA and MRA.

Aortic Dissection↗

PubMed1998

[An unknown cause of prolonged fever: apropos of 6 cases of chronic aortic dissection].

PURPOSE: Aortic arch dissection may be sometimes misdiagnosed due to the lack of mild to moderate chest pain. Definite diagnosis is often made while dissection has already occurred more than 15 days ago, being thereafter considered as chronic. Aortic dissection may then present as a prolonged febrile illness with fever and/or inflammation as main symptoms, with little or no pain. METHODS: We retrospectively reviewed cases of chronic aortic dissections seen in a department of internal medicine and a department of neurology between 1975 and 1992. RESULTS: We report six cases of patients presenting with aortic dissection and describe their outcome and treatments after the diagnosis was made based on either thoracic computerized tomography or trans-esophageal echocardiography evidence. Four patients had surgical aortic arch repair while one patient was treated with beta-blockers. CONCLUSION: Chronic aortic dissection has rarely been reported to cause fever or increased sedimentation rate. Treatment has to be discussed between medical and surgical teams involved in the therapeutical management of these unusual patients.

Aged↗

PubMed1997

Renal artery dissection causing renal infarction in otherwise healthy men.

Arterial dissection is usually associated with pathological states such as malignant hypertension, severe atherosclerosis, severe trauma, Marfan syndrome, or Ehlers-Danlos syndrome. However, we report three cases in which renal artery dissection occurred in otherwise healthy, normotensive men. In two cases, the onset of symptoms of renal artery dissection was coincident with an unusual degree of physical activity. In the third case, the symptoms occurred while the patient was sitting but during a stressful business meeting. In each case, the patient experienced severe unilateral flank pain. Urolithiasis was suspected, but intravenous pyelography showed only ipsilateral impaired renal cortical perfusion, and the urinalyses showed no hematuria. The diagnosis of renal artery dissection was established by arteriography in two cases and by nephrectomy in one case. The latter case showed fibromuscular dysplasia by arteriography performed after the nephrectomy. The other two cases showed no evidence of fibromuscular dysplasia. We conclude that spontaneous renal artery dissection can occur in otherwise healthy individuals. Our experience and the reports of others indicate that this condition occurs mainly in men, conservative (nonsurgical) management is generally indicated, and the long-term prognosis is generally excellent. In some patients, an unusual degree of physical exertion might be the cause of renal artery dissection.

Adult↗

PubMed2001

Objective pulsatile tinnitus caused by intrapetrous dissecting aneurysm.

Intrapetrosal dissections is a special kind of intracranial dissection since it is located intracranially but extradurally. Only three reports of spontaneous intrapetrosal dissection have been published so far, the posttraumatic intrapetrosal dissections caused by penetrating or blunt trauma not included. Based on the clinical and radiological presentation a treatment with anticoagulantia (a coumarine derivative) was successfully installed. A short review of the major studies concerning intracranial dissection is presented. Firm guidelines for the treatment cannot be provided based on these data but the etiology of the dissection, whether it was posttraumatic or spontaneous, seems to be important. The diagnostic problem of pulsatile tinnitus is briefly discussed.

Aortic Dissection↗