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PubMed1998

Transient migraine-like symptoms with internal carotid artery dissection.

We report three patients with angiographically confirmed internal carotid artery (ICA) dissection who presented with transient symptoms resembling migraine with aura. Marching impairments from one modality to another preceded recognition of the diagnosis of dissection and were not associated with clinical or radiologic evidence of cerebral infarction. We review the clinical patterns in which ICA dissection may be identified in the setting of migrainous symptoms, given the different therapeutic approaches to migraine and dissection and the non-invasive means to diagnose dissection with magnetic resonance imaging (MRI). We offer mechanisms for recurrent neurologic symptoms in patients with ICA dissection.

Adult↗

PubMed1998

Two cases of unexpected sudden death due to cystic medionecrosis of the aorta associated with bloodless aortic dissection.

The autopsy findings from two rare cases of sudden death concerning a 31- and a 44-year-old woman are reported. Autopsy and morphological examination revealed a dissection of the aorta but no rupture into the pericardial sac. In both cases mucoid deposits in all layers of the media and rarefication of the elastic fibers were found, rendering cystic medionecrosis as the cause of the aortic dissection. In these unusual cases, only a very small intimal tear was present, but no blood in the dissected aortic wall. Evidence of left ventricular hypertrophy and a history of hypertension were reported in both cases. No extension of the aortic dissections into the left or right coronary artery and no other clinical or pathological findings associated with aortic dissection were present. Cystic medionecrosis was the cause of the aortic dissection in these cases. The mechanism of death in both cases is discussed.

Adult↗

PubMed2002

A case of pulmonary artery dissection diagnosed in the Emergency Department.

Pulmonary artery dissections typically occur at the site of a pulmonary artery aneurysm associated with pulmonary hypertension or connective tissue disease. Dyspnea on exertion, retrosternal chest pain, central cyanosis, and sudden hemodynamic decompensation are the four main clinical signs and symptoms associated with a pulmonary artery dissection. Diagnosis of a pulmonary artery dissection frequently occurs postmortem, as many of these patients experience sudden death when the main pulmonary artery dissects into the pericardium, causing acute cardiac tamponade. Pulmonary artery dissection has been diagnosed in living patients using transthoracic echocardiogram, computed tomography (CT) scanning, magnetic resonance imaging (MRI), and angiography. Surgery is curative. Emergency physicians should consider the diagnosis of pulmonary artery dissection in patients presenting with either retrosternal chest pain, dyspnea on exertion, central cyanosis, or sudden hemodynamic decompensation and who have a past medical history of pulmonary hypertension, pulmonary artery surgery, or a disease causing chronic inflammation of myocardial or vascular tissue.

Adult↗

PubMedDate not supplied

Aortic dissection and Turner's syndrome: case report and review of the literature.

Cardiovascular abnormalities are frequently encountered in patients with Turner's syndrome. These include coarctation of the aorta, aortic root dilatation, bicuspid aortic valve, atrial and ventricular septal defects. Aortic dissection is a rare but devastating complication of Turner's syndrome that usually occurs in adulthood. We report a case of Turner's syndrome with coarctation of the aorta and chronic aortic dissection, and review the relevant literature. There have been 21 prior reported cases of aortic dissection in patients with Turner's syndrome. Possible etiologic factors contributing to the occurrence of aortic dissection in this syndrome are protean. They include the presence of cystic medial necrosis, coarctation of the aorta, bicuspid aortic valve, aortic root dilatation, and hypertension, although cases of aortic dissection and Turner's syndrome have been described in patients without any risk factors. As our knowledge of the natural history of congenital heart defects and risk factors for aortic dissection in Turner's syndrome is limited, periodic cardiac evaluation of these patients may be warranted. Early recognition and treatment of this potentially lethal complication of Turner's syndrome is essential.

Adult↗

PubMedDate not supplied

Spectrum of acute dissection of the ascending aorta: a transesophageal echocardiographic study.

Transesophageal echocardiography is an accurate tool for the immediate diagnosis of acute aortic dissection. In addition to establishing the diagnosis of dissection, transesophageal echocardiography provides determination of its extent and detection of complications. The purpose of this study was to delineate the full spectrum of abnormalities present in acute dissection of the ascending aorta as assessed by transesophageal echocardiography. Forty consecutive patients with acute ascending aortic dissection were evaluated. Specific attention was paid to complications of aortic valve insufficiency, pericardial effusion, and left ventricular wall motion abnormalities. The aortic arch and the descending aorta were also evaluated for involvement. Quantitative data included measurement of the aorta at the anulus, sinuses, and tubular portion, as well as the proximal and distal descending aortas. An intimal flap was identified in all patients. This was a simple linear tear in 22 patients (55%) and circumferential in eight (20%). A complex tear was noted in 10 patients (25%). The majority of patients (n = 30; 75%) had extension of the dissection into the descending thoracic aorta. At least one communication between the true and false lumens ("entrance point") was identified in 31 patients (78%). Pericardial effusions were noted in 19 patients (48%), only two of whom had a moderate-size effusion. Moderate or severe aortic insufficiency was seen in 18 patients (45%) and regional wall motion abnormalities in six patients. We conclude that acute dissection of the ascending aorta results in a complex or convoluted flap rather than a simple linear tear in many patients. The complication of clinically significant pericardial effusion was rare. Aortic insufficiency is common and can be attributed to multiple mechanisms.

Acute Disease↗

PubMed1999

Different techniques of distal aortic repair in acute type A dissection: impact on late aortic morphology and reoperation.

OBJECTIVE: To compare three different techniques of distal aortic repair in acute type A (de Bakey type I) aortic dissection and to evaluate their impact on the late morphology of the aortic arch and descending aorta and on the incidence of reoperation. METHODS: From 65 patients operated on due to an acute type A aortic dissection between 1989 and 1993, 54 long-term survivors underwent clinical and radiologic follow-up examination after a mean postoperative interval of 62+/-16 months. The surgical techniques of distal aortic reconstruction included closed repair using Teflon felt reinforcement under moderate hypothermic cardiopulmonary bypass (n = 20) and open repair in deep hypothermic circulatory arrest using either Teflon felt reinforcement (n = 16) or gelatin-resorcin-formaldehyde (GRF) glue (n = 18) to readapt the dissected aortic layers. In all patients, MR imaging was performed on a 1.5-T whole body imaging system for the evaluation of the morphology and function of the heart, aorta and supraaortic branches. RESULTS: Overall hospital mortality following surgical repair of type A aortic dissection was 15.4% during this time period. The highest rate of persistent false lumen perfusion (17/20, 85%) and presence of an intimal flap in the aortic arch (13/20, 65%) was observed in patients following closed repair of acute ascending aortic dissection, whereas the lowest rate of such findings was demonstrated in patients who had undergone open distal aortic repair using biological glue (false lumen perfusion 10/18, 55% and intimal flap in the arch 2/18, 11%). Redo-surgery was significantly reduced in the open repair group using GRF glue (1/18, 5.5%) as compared with the Teflon felt repair group (3/16, 18%) and the closed repair group (6/20, 30%). CONCLUSIONS: In patients with acute type A dissection, open distal aortic repair using GRF-glue favourably influences both (1) the severity of late morphologic alterations in the downstream aorta and (2) the incidence of reoperation.

Aortic Dissection↗

PubMed1999

The use of gelatin-resorcin-formalin glue in acute aortic dissection type A.

OBJECTIVES: The Gelatin-resorcin-formalin (GRF) glue is widely used in the surgical treatment of dissecting aneurysms. This paper is focused on our experience with the GRF glue in cases, operated for acute aortic dissection type A. METHODS: Between September 1990 and December 1997, 164 patients were operated on for acute aortic dissection type A. In 148 patients GRF was used to reinforce the dissected layers proximal (n = 106) or distal (n = 144) of the grafted aortic segment. An intervention at the aortic valve was necessary in 93 instances. In 111 patients, an open distal anastomosis for replacement of the proximal aortic arch was performed. Thirty-seven additional patients underwent subtotal or total aortic arch replacement. RESULTS: Early postoperative mortality was 26.2% (43/164 patients). Another 16 patients died late postoperatively. Actuarial survival rates are 69.9% at 1 year, 62.5% at 3 years, 59.4% at 5 years and 56.1% at 7 years, post-operatively. Twenty-two reoperations were performed in 20 patients (16.5%). Nine of these patients had developed complications in aortic segments that underwent reconstruction by use of GRF during the primary intervention. Aortic root redissection was found in 7/9 patients intraoperatively, whereas 1/9 patients presented with a rupture near the distal graft to aortic anastomosis. CONCLUSIONS: The introduction of GRF glue has greatly facilitated the reconstruction of dissected aortic wall layers adjacent to the vascular graft. However, the use of the adhesive for aortic root reconstruction in acute aortic dissection type A may bear a significant risk of late postoperative proximal aortic redissection. Complications associated with the GRF glue are likely to be due to the toxic effects of the formalin component. Therefore, care should be taken that the amount of formalin administered to the glue components remains as low as possible.

Acute Disease↗

PubMed2005

Dissection with a metal dissector: a useful adjunct to transhiatal oesophagectomy.

OBJECTIVE: Intraoperative cardiovascular instability is frequently observed during blunt finger dissection for transhiatal oesophagectomy. We conducted a prospective study using a metal ring dissector for blunt dissection of the oesophagus to overcome this problem. METHODS: Dissection with a metal ring dissector was used in 30 consecutive patients undergoing transhiatal oesophagectomy for carcinoma of the lower oesophagus (n=26) and oesophagogastric junction (n=4). RESULTS: Dissection of the oesophagus proximal to the growth was quick and straightforward in all instances. The procedure appeared less traumatic than the conventional manual technique and was not associated with any intraoperative cardiovascular instability or intramediastinal bleeding. None of the patients had tracheal injury or recurrent laryngeal nerve paralysis. There was one anastomotic leak and no deaths. CONCLUSION: Oesophageal blunt dissection with a metal ring dissector is safe, easy and quick. The correct plane of dissection minimizes the risk of intramediastinal bleeding and inadvertent trauma to neighbouring structures.

Adult↗

PubMedDate not supplied

The dissected aorta: percutaneous treatment of ischemic complications--principles and results.

PURPOSE: Describe the principles and results of percutaneous treatment of ischemic complications of aortic dissection. MATERIALS AND METHODS: Twenty-four patients with aortic dissection complicated by ischemic compromise of the liver or bowel (n = 15), kidney (n = 18), or lower extremity (n = 13) were evaluated by means of aortography, intravascular ultrasound, and manometry, and were treated percutaneously. Visceral arteries were classified as obstructed or nonobstructed. Obstruction was classified as static, in which the dissecting hematoma extended into and narrowed the lumen of a branch artery, or dynamic, in which the dissection flap prolapsed into the vessel origin or narrowed the true lumen (TL) above it. Treatment consisted of vascular stents alone (n = 4), or balloon fenestration (n = 20) without (n = 8) or with (n = 12) vascular stents. RESULTS: Obstruction was present in 77 arteries and was static in 12 arteries, dynamic in 45 arteries, static and dynamic in 17 arteries, and indeterminate in three arteries. Percutaneous treatment did not alter false lumen (FL) pressure, but reduced the peak systolic interluminal pressure gradient from 28 mm Hg to 2 mm Hg and restored flow in 71 of 77 arteries (92%). Six patients died within 30 days (25% operative mortality), none as a result of the procedure. Two additional patients died in follow-up from complications of an expanding FL. Technical complications in two patients due to altered hemodynamics after initial intervention were recognized and corrected percutaneously during the same procedure. CONCLUSIONS: Percutaneous fenestration and endovascular stent deployment are indicated to restore blood flow to arteries compromised by aortic dissection. The prognosis of patients is related to the ischemic injury sustained prior to the percutaneous interventional procedure and, in patients with acute type I dissection who have not undergone surgery, to the preoperative stability of the FL.

Adult↗

PubMedDate not supplied

Spontaneous coronary artery dissection associated with cocaine use: a case report and brief review.

Isolated, spontaneous dissection of the coronary arteries in the absence of trauma is an unusual but well-documented occurrence. Fewer than 50 cases have been reported in males in the English language literature, and only one case, nonfatal, was associated with cocaine use. We present the second overall and the first fatal case of cocaine-associated spontaneous coronary artery dissection and a brief review of the literature on coronary dissection and the cardiovascular effects of cocaine use. The mechanism of cocaine's toxicity on the heart and vasculature is complex, multifactorial, and predominantly related to cocaine's adrenergic properties. The increased arterial blood pressure from cocaine's inotropic and chronotropic effects combined with its direct vasoconstrictive effect leads to increased shear forces on the coronary endothelium. This elevated stress may be responsible for the formation of an intimal tear and the subsequent dissection of the coronary artery. If the dissected portion of the arterial wall is displaced enough to significantly occlude the true lumen, infarction can result. In light of this possibility, coronary artery dissection must be considered in young patients presenting with symptoms of cardiac ischemia and a history of cocaine use.

Adult↗

PubMedDate not supplied

Short esophagus or bad dissected esophagus? An experimental cadaveric study.

Short esophagus is defined as the inability to reduce the gastroesophageal junction below the diaphragm. One of the factors responsible for this inability can be inadequate esophageal mobilization. We evaluated esophageal lengthening achieved by means of dissection in a cadaveric model. Fifty-one cadavers were dissected (27 transthoracically and 24 transhiatally). Abdominal esophageal length was assessed before and after dissection of the esophagus from the hiatus to the carina. In the transthoracic group, a mean of 1.7+/-1.3 cm (range 0.3 to 5.0 cm) was gained with dissection. In the transhiatal group, a mean of 1.8+/-0.8 cm (range 0 to 3.0 cm) was gained with dissection. In a comparison of results of transthoracic and transhiatal approaches, the difference was not statistically significant. We concluded that a significant increase in esophageal length was achieved after dissection; however, the access route (thorax or abdomen) did not influence the results.

Adult↗

PubMed1997

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) as a consequence of neck dissection.

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) can have multiple causes. Surgical neck dissections may have an association with this syndrome and represent the basis for this study. A retrospective review of 50 patients undergoing neck dissections was performed to evaluate for the development of hyponatraemia as a consequence of SIADH. Based on the results of this review, a prospective study of 20 consecutive patients undergoing 22 neck dissections was performed to determine the incidence of SIADH. A control group of 25 consecutive patients undergoing major non-neck dissection surgery was also studied. SIADH developed in nine of 50 patients (18 per cent) of our retrospective group with a high incidence of development in those who had jugular vein ligation (JVL) (22 per cent), pre-operative radiation therapy (25 per cent) or squamous cell cancers (32 per cent). SIADH developed in six patients undergoing 22 neck dissections (27 per cent) in our prospective group. A high incidence was also noted for those with JVL (42 per cent), pre-operative radiation therapy (67 per cent) or squamous cell cancer (40 per cent). No patients developed symptomatic hyponatraemia. No patients in the prospective control group developed SIADH. Neck dissection surgery is associated with a significant risk for the development of SIADH. Factors such as jugular vein ligation (JVL), pre-operative radiotherapy and squamous cell cancer appear to increase this risk.

Adolescent↗

PubMed2002

"Malignant" carotid artery dissection.

PURPOSE: Carotid artery dissection resulting in occlusion or severe narrowing and massive intracranial embolism can result in life-threatening hemispheric ischemia. Aggressive endovascular and microsurgical measures may be necessary to salvage life and minimize stroke morbidity in this extreme situation. PATIENTS AND METHODS: We have treated two middle-aged women who presented within an hour of spontaneous cervical internal carotid artery (ICA) dissection causing hemiplegia, forced head and eye deviation, and declining consciousness. The first patient had a carotid occlusion through which a catheter could not be passed, so intracranial thrombolysis was achieved through a microcatheter navigated through the posterior circulation. Surgical intimectomy and thrombectomy of the dissected ICA was then carried out using an intraoperative Fogarty arterial embolectomy catheter passed up the dissected ICA, followed by endovascular stenting of the reopened cervical ICA. The second patient underwent intracranial microsurgical embolectomy and, after an unsuccessful attempt of stenting the dissected and severely narrowed cervical ICA, surgical reopening again with a Fogarty catheter. Both patients suffered basal ganglionic infarcts but most of the middle cerebral artery territories were preserved and the patients made satisfactory recoveries. CONCLUSIONS: "Malignant" carotid artery dissection causing occlusion or near occlusion with intracranial embolism is an important cause of severe and life-threatening hemispheric ischemia. Treatment should include aggressive endovascular and microsurgical interventions when the hemisphere is at risk.

Carotid Artery, Internal, Dissection↗

PubMed2000

Paraplegia caused by painless acute aortic dissection.

OBJECTIVES: Painless acute aortic dissection in which paraplegia is the only presenting sign is rare, with limited reported cases. CASE REPORT: The authors report a patient with painless acute aortic dissection who presented with sudden onset paraplegia. Ischemic diseases of the spinal cord were suspected as the cause. MRI revealed extensive acute aortic dissection with an intramural hematoma. The patient was treated conservatively by strictly controlling his blood pressure. The treatment was successful, although the motor function of the lower extremities could not be rescued. Although 3% to 5% of patients with acute aortic dissection present with paraplegia as a result of spinal cord infarction, most of these patients experience severe pain prior to presentation. CONCLUSION: Painless acute aortic dissection in which paraplegia is the only presenting sign is very rare. However, aortic diseases, including acute aortic dissection, should always be considered as a differential diagnosis of patients with sudden onset, painless paraplegia.

Acute Disease↗

PubMedDate not supplied

Endovascular treatment of type B thoracic aortic dissections.

PURPOSE: To evaluate the initial experience of endovascular repair of aortic dissections from a single center. MATERIALS AND METHODS: From June 1999 to March 2002, endovascular stent grafting was performed in 20 high-risk patients (16 to 80 years). Eighteen patients had a type B dissection (14 acute and 4 chronic). Two patients had chronic type A dissection. Preoperative work-up included CT and MRI to evaluate the extent of the dissection, the relation to the left subclavian artery, the size of false and true lumen, and branch complications. RESULTS: Stent-graft deployment was technically successful in all cases. None was converted to open repair. Three patients died within 30 days, i.e., a 15% mortality rate. Four patients (20%) had a perioperative stroke. Paraplegia was observed in one case. No migration of the stent grafts or endoleaks was observed during the mean follow-up period of 13 months. In all but two patient thrombosis of the false lumen was noted. CONCLUSIONS: Endovascular treatment of thoracic dissections is feasible. Early results are encouraging. While endovascular repair with stent-grafts is progressing rapidly as a viable strategy for aortic dissections in selected patients careful investigations must continue to focus on its safety. Randomized controlled trials are urgently needed.

Adolescent↗

PubMed1997

A rare presentation of thoracic aortic dissection as detected by transoesophageal echocardiography.

A case of atypical movement of the intimal flap (tear) during aortic aneurysm dissection is reported. Aortic dissection is caused by the sudden development of a tear in the aortic intima, opening the way for a column of blood driven by the force of the arterial pressure to enter the aortic wall, destroying the media and stripping the intima from the adventitia for variable distance along the length of the aorta. Echocardiographically, aortic dissection is characterized by separation of the normal single dominant echo from the aortic wall in the region of the dissection into two discrete echoes. The inner echo arises from the tunica intima, whereas the outer echo arises from the medial and adventitial structures external to the tear and it is possible to identify two lumens separated by an intimal flap within the aorta. The two echoes generally move in unison with one another, i.e. movement of the flap away from the true lumen during systole and recoil during diastole as the blood flows from true to false lumen. The dissection flap can also move inward during systole owing to the suction caused by high-velocity flow (Venturi effect), as shown in this case report. In any instances, motion of the intimal flap during the cardiac cycle is strong evidence of dissecting aneurysm.

Aged↗

PubMed1998

Headache as the initial manifestation of acute aortic dissection type A.

The most common initial symptom of aortic dissection is chest pain. Other initial symptoms include pain in the neck, throat, abdomen and lower back, syncope, paresis, and dyspnoea. Headache as the initial symptom of aortic dissection has not been described previously. A 61-year-old woman with a history of migraine and arterial hypertension developed continuous bifrontal headache. Two hours later, right-sided thoracic pain and a diastolic murmur were suggestive of aortic dissection that was confirmed by echocardiography and subsequent surgery. The dissection commenced in the ascending aorta and involved all cervical arteries until the base of the skull. Headache as the initial manifestation of aortic dissection was assumed due to either vessel distension or pericarotid plexus ischemia. Aortic dissection has to be considered as a rare differential diagnosis of frontal headache, especially in patients who develop aortic regurgitation or chest pain for the first time.

Aneurysm↗

PubMed1998

Lesion morphology assessed by pre-interventional intravascular ultrasound does not predict the incidence of severe coronary artery dissections.

AIMS: Coronary artery dissections are common findings following percutaneous transluminal coronary angioplasty and occur with an incidence of approximately 20% to 40%. The purpose of this study was to evaluate the impact of intravascular ultrasound for the prediction of severe dissections by pre-interventional analysis of lesion morphology and plaque composition. METHODS AND RESULTS: Pre- and post-interventional intravascular ultrasound was performed in 197 patients with 205 lesions. Using intravascular ultrasound criteria, 24 lesions were classified as soft (hypo- or iso-echogenic), 73 as intermediate (hyper-echogenic) and 108 as calcified (calcific arc > 90 degree of the vessel circumference). Additionally, calcium localization was defined as subendothelial, central or deep. The incidence of dissections was 37.5% in patients with soft lesions, 24.7% in patients with intermediate and 36.1% in patients with calcified lesions. In calcified lesions, the occurrence of severe dissections was not dependent on the localization of calcium deposits. The procedural parameters were similar in all patients. The minimal inflation pressure, however, was significantly higher in calcified lesions (P < 0.01). CONCLUSION: Assessment of lesion morphology by intravascular ultrasound cannot predict the occurrence of severe dissections following percutaneous transluminal coronary angioplasty. Furthermore, despite significantly higher inflation pressures in heavily calcified lesions, the incidence of dissections was found to be comparable in all lesions.

Adult↗