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PubMed1991

[Occlusion of the right pulmonary artery due to acute dissecting aortic aneurysm].

A 58-year-old female was admitted with an abrupt onset of chest and back pain. The CT scan of the chest showed aortic dissection of the ascending aorta and proximal aortic arch, but the false lumen of the aortic dissection had already been occluded by a blood clot. After admission, she complained of chest pain with hemoptysis and presented facial edema and the distention of the neck veins. The pulmonary angiogram showed complete occlusion of the right pulmonary artery at the proximal segment. These findings were interpreted as pulmonary embolism. She was treated with intravenous heparin and urokinase, but these treatments did not demonstrate any improvement. She underwent a surgical exploration on the fourth hospital day. During surgery, the right pulmonary artery was discovered to be compressed and occluded by the large dissecting aneurysm of the ascending aorta. In addition, hematoma was seen between the right pulmonary artery. The ascending aorta and pulmonary trunk, which was injured in the operative procedure, were replaced with an artificial graft successfully. Postoperative pulmonary angiogram showed no stenosis of right pulmonary artery. The occlusion of the pulmonary artery by an acute dissecting aneurysm is an extremely rare complication and it is often wrongly diagnosed as pulmonary embolism. In such cases, the correct diagnosis and prompt surgical treatment is essential and antithrombolytic and anticoagulant therapy should be avoided.

Acute Disease↗
PubMed2000

Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair.

OBJECTIVES: The purpose of this study was to use transesophageal echocardiography (TEE) to define the mechanisms of aortic regurgitation (AR) in acute type A aortic dissection so as to assist the surgeon in identifying patients with mechanisms of AR suitable for valve preservation. BACKGROUND: Significant AR frequently complicates acute type A aortic dissection necessitating either aortic valve repair or replacement at the time of aortic surgery. Although direct surgical inspection can identify intrinsically normal leaflets suitable for repair, it is preferable for the surgeon to correlate aortic valve function with the anatomy prior to thoracotomy. METHODS: We studied 50 consecutive patients with acute type A aortic dissection in whom preoperative TEE findings were considered by the surgeons in planning aortic valve surgery. Six patients did not undergo surgery (noncandidacy or refusal) and one patient had had a prior aortic valve replacement and therefore was excluded from the analysis. RESULTS: Twenty-seven patients had no or minimal AR and 22 had moderate or severe AR. In all, there were 16 with intrinsically normal leaflets who had AR due to one or more correctable aortic valve lesion: incomplete leaflet closure due to leaflet tethering in a dilated aortic root in 7; leaflet prolapse due to disrupted leaflet attachments in 8; and dissection flap prolapse through the aortic valve orifice in 5. Of these 16 patients, 15 had successful aortic valve repair whereas just 1 underwent aortic valve replacement after a complicated intraoperative course (unrelated to the aortic valve). Nine patients underwent aortic valve replacement for nonrepairable abnormalities, including Marfan's syndrome in four, bicuspid aortic valve in four, and aortitis in one. In patients undergoing aortic valve repair, follow-up transthoracic echocardiography at a median of three months revealed no or minimal residual AR, and clinical follow-up at a median of 23 months showed that none required aortic valve replacement. CONCLUSIONS: When significant AR complicates acute type A aortic dissection, TEE can define the severity and mechanisms of AR and can assist the surgeon in identifying patients in whom valve repair is likely to be successful.

Acute Disease↗
PubMed1981

Computed tomography for follow-up of chronic aortic dissections.

Patients who have chronic dissections of the aorta are prone to re-dissection, extension of dissection, aortic aneurysm, and aortic rupture. Computed tomography (CT) with contrast enhancement provides a convenient, noninvasive method for follow-up of these patients. We used CT in a group of twelve patients who were treated for aortic dissection. CT demonstrated re-dissection, aneurysmal dilation of the aorta, and delayed filling of the false lumen. CT also showed persistent patency of the false lumen in almost all of the postoperative cases.

Aortic Dissection↗
PubMed1995

[A case of acute dissecting aortic aneurysm associated with congenital bicuspid aortic valve].

The congenital bicuspid aortic valve is recognized as a cause of aortic dissection. But in Japan, the case of aortic dissection associated with bicuspid aortic valve is rare. A 66-year-old man was referred to our hospital with a diagnosis of acute Stanford A type dissecting aneurysm associated with stenotic bicuspid aortic valve. The chest computed tomography showed thrombosis of the pseudo lumen. An operation consisting of aortic valve replacement and graft replacement of the aneurysm was performed on emergency basis because of remarkable dilation of the ascending aorta. He has been doing well after the operation and discharged from the hospital on the 46th postoperative day. It is though to be important to follow up with special concern about possible dilation of sinus of Valsalva due to intrinsic weakness of the aortic wall.

Aged↗
PubMed1992

[The extension of MR diagnosis in dissecting aortic aneurysms by means of FLASH and snapshot-FLASH sequences].

Using a combination of T1 weighted snapshot-flash sequences and intravenous contrast bolus it was possible to demonstrate intraluminal signal differences in a period of seconds. 5 confirmed aortic lesions were studied; 2 old aortic dissections (with differentiation between the true and false lumen), 1 acute aortic dissection and a partially thrombosed thoracic aortic aneurysm were demonstrated. The advantage of this technique lies in its simplicity and reproducibility. Difficulties in interpreting the intraluminal phases arising from spin echo and flash techniques are made easier by interpreting the available signals from this method.

Aortic Dissection↗
PubMed2007

Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score.

BACKGROUND: Surgical mortality for acute type A aortic dissection is frequently related to preoperative clinical conditions. We report a predictive score to identify risk of death that may be helpful to assist surgeons who are considering whether to proceed with surgical correction in the case of patients in extreme clinical risk. METHODS: Surgical outcome of 682 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2003 was analyzed. Two different models were used. The initial model included only preoperative variables such as demographics, history, symptoms, signs, and diagnostic methods (model 1). The second model also tested intraoperative hemodynamic and surgical variables (model 2). A bedside risk prediction tool to predict operative mortality in individual patients was developed. RESULTS: The overall in-hospital surgical mortality was 23.9%. Independent preoperative predictors of mortality in model 1 were age greater than 70 years, prior cardiac surgery, hypotension (systolic blood pressure less than 100 mm Hg) or shock at presentation, migrating pain, cardiac tamponade, any pulse deficit, and electrocardiogram with findings of myocardial ischemia or infarction. In model 2, other predictors of surgical death were intraoperative hypotension, a right ventricle dysfunction at surgery, and a necessity to perform coronary revascularization. An independent predictor for favorable surgical outcome was right hemiarch replacement. CONCLUSIONS: Surgery in unstable patients with acute type A aortic dissection can be highly unsuccessful. The International Registry of Acute Aortic Dissection risk models predict in-hospital mortality using a multivariable risk prediction tool, useful for surgeons and patients as they consider their surgical risk and the pros and cons of embarking on high-risk surgery.

Acute Disease↗
PubMed1995

[A case report of acute aortic dissection with aortic regurgitation and cardiac tamponade: intimal tear just above commissure of right coronary cusp and left coronary cusp].

A 57-year-old man with acute dissecting aneurysm of the ascending aorta underwent immediate operation. Preoperative study showed aortic regurgitation and cardiac tamponade. The intimal tear originated just above commissure of right coronary cusp and left coronary cusp. The procedure was a combination of direct closure of the entry and dissecting space and resuspension of native aortic valve. It was preferential of simple intervention limited to the ascending aorta without using prosthesis. There was no complication such as aortic valve regurgitation, enlargement of the ascending aorta, or persistent of dissection during follow-up period of 12 months.

Acute Disease↗
PubMed1993

Acute type A dissecting aortic aneurysm requiring emergency arch replacement.

The intimal disruption is located or extends to the aortic arch in 10-20% of acute type A aortic dissections. Multiple tears are extremely rare. The reported mortality rate of emergency arch replacement varies from 25% to 40%, and therefore many surgeons elect to perform ascending aortic replacement only in these cases. However, with such an approach, the operative mortality rate of 10% is followed by a late mortality rate of up to 30% from residual aneurysm formation. Emergency arch replacement was carried out in five of 14 patients with an acute type A aortic dissection in whom the intimal tear either originated or extended into the arch, or in whom multiple tears existed. The ascending dissections were resected under moderate hypothermia, whereas the arch was explored under profound hypothermia, surface cooling and circulatory arrest. None of these five patients died; one developed slight hemiparesis, but no patient developed recurrent aneurysm in the follow-up period. These results appear to justify this aggressive approach, if it can be performed with an acceptable mortality rate < 25%, by avoiding the late deaths associated with more conservative surgical treatment.

Adolescent↗
PubMed2000

Endovascular treatment of aortic dissections and thoracic aortic aneurysms.

Diseases of the thoracic aorta pose a significant challenge to the surgeon because of the complexity of the disease and the characteristics of the patient population. Frequent comorbidities and increasing age account for mortality rates between 5% and 20% for surgical repair of descending thoracic aortic aneurysms and in excess of 50% for Stanford type B aortic dissections, when complicated by preoperative end-organ ischemia. Endovascular techniques of fenestration, stenting, and stent-grafting have emerged as viable alternatives to conventional surgery in these patients. The authors review their experience using endovascular stent-grafts in the treatment of 103 patients with descending thoracic aortic aneurysms and 19 patients with acute aortic dissections. Fenestration and stenting are also addressed as adjuvant therapies in the treatment of complicated aortic dissections. Actuarial survival for aneurysms was 81% +/- 5% at 1 year and 73% +/- 5% at 2 years. Stent-grafting for acute aortic dissections achieved instant relief of symptoms in 71% of cases with an early procedural mortality of 16%, and endovascular revascularization of ischemic beds was achieved in 93% +/- 4% of cases of peripheral or visceral ischemia. The authors' experience supports the use of endovascular techniques in the treatment of thoracic aortic pathologic conditions. Longer follow-up and results of ongoing trials that use newer devices will help define the indications for their future use.

Aged↗
PubMed1992

Surgical reconstruction of an ascending aortic dissection in Takayasu's arteritis.

A 45-year-old Japanese woman with Stanford type A dissecting aortic aneurysm underwent a reconstructive operation on the ascending aorta. Histopathological diagnosis was Takayasu's arteritis in the chronic and inactive phase. It is very rare that a dissecting aortic aneurysm results from Takayasu's arteritis. Long-standing hypertension and fragility of the aortic media due to disruption of elastic fibers were suspected to cause dissection in the entire aorta in this case.

Aortic Dissection↗
PubMed2005

Implications of periaortic hematoma in patients with acute aortic dissection (from the International Registry of Acute Aortic Dissection).

The clinical profiles, presentation, and outcomes of patients with acute aortic dissections and associated periaortic hematomas on aortic imaging have not been described in a large cohort. This study sought to assess the prognostic implications of periaortic hematomas in patients with aortic dissections and to identify factors associated with in-hospital mortality in patients with periaortic hematomas. The study population was 971 patients with acute aortic dissections enrolled in the International Registry of Acute Aortic Dissection with available imaging data on presentation with the presence or absence of periaortic hematomas. Patients with periaortic hematomas (n = 227, 23.4%) were more likely to be women, to have a history of hypertension and atherosclerosis, and to present early to the hospital. At presentation, they had greater frequencies of shock, cardiac tamponade, coma, and/or altered consciousness. Clinical outcomes were significantly worse in patients with periaortic hematomas, including significantly greater mortality (33% vs 20.3%, p <0.001). A multivariate model demonstrated periaortic hematomas to be an independent predictor of mortality in patients with aortic dissections (odds ratio 1.71, 95% confidence interval 1.15 to 2.54, p = 0.007). In conclusion, this study provides insight into the profiles, presentation, and outcomes of patients with periaortic hematomas and acute aortic dissections. The early identification and aggressive management of patients with periaortic hematomas may potentially improve clinical outcomes.

Acute Disease↗
PubMed1998

[Painless aortic dissection late after aortic valve replacement, presenting as superior vena cava syndrome].

A 68-year-old man, who had underwent aortic valve replacement (AVR) with Björk-Shiley disc valve for aortic regurgitation 17 years ago, was transferred to our hospital complaining of facial redness and swelling, without chest or back pain. Preoperative examination revealed DeBakey type II aortic dissection, which caused superior vena cava syndrome (SVC syndrome). Emergent ascending aortic replacement was performed, postoperatively central venous pressure (CVP) decreased from 33 to 9 mmHg, and SVC syndrome was relieved. Painless aortic dissection after AVR, presenting as SVC syndrome, is a rare case, and close follow-up should be performed under consideration of painless aortic dissection late after AVR.

Aged↗
PubMed2004

Extended total arch replacement for type B aortic dissection with ascending aneurysm following healed aortic dissection.

We describe a case of type B aortic dissection with large ascending aortic aneurysm occurring 12.8 years after aortic root replacement (Cabrol procedure) in a non-Marfan patient with cystic medial necrosis of the aorta. We have successfully performed an extended total aortic arch replacement using a four-branched graft through the "L-incision" approach (a combination of a left anterior thoracotomy and upper half median sternotomy). Of note, a histological specimen from the aneurysmal ascending aortic wall revealed "healed aortic dissection" with fibrous tissue replacing the media and intima in addition to multiple foci of cystic medial necrosis.

Aged↗
PubMed1992

[Acute aortic dissection in a patient with Marfan's syndrome and severe pectus excavatum--emergency surgical repairs of ascending aortic dissection and aortic regurgitation complicated by pectus excavatum in Marfan's syndrome].

A case of acute aortic dissection Stanford Type A occurring in a patient with Marfan's syndrome, complicated with aortic regurgitation and severe pectus excavatum, is reported with successful surgical correction. The patient was a 33-year-old woman, who suffered from severe back pain riding to work. An emergency operation consisting of Cabrol's procedure for aortic dissection Stanford Type A and sternal turnover for pectus excavatum was performed simultaneously. Because of the postoperative mediastinal bleeding the implanted sterno-costal complex was removed on the second POD and the prosthetic sternum was reimplanted on the tenth POD. The two-stage operation seems preferable in such an emergency case to avoid postoperative bleeding and infection.

Acute Disease↗
PubMed2000

Proximal aortic dissection late after aortic valve surgery: 119 cases of a distinct clinical entity.

BACKGROUND: Besides systemic hypertension and Marfan syndrome, only previous aortic valve replacement (AVR) is independently associated with proximal (type A) aortic dissection. Little, however, is known to date about the characteristic features of this clinical entity. METHODS: Clinical, prognostic and predisposing profiles in 119 cases of dissection and/or aneurysm occuring 1 month to 16 years after routine AVR were analyzed comprising 62 cases from our database and 57 reported cases. RESULTS: Dissection after AVR has been observed in 0.6% of all routine AVR procedures in the past four decades. With clinical signs, symptoms and anatomical features different from classic aortic dissection post-AVR dissection is a distinct clinical entity with a high intraoperative mortality of 44% and a 30-day and 5-year survival of 62% and 43%, respectively. Aortic regurgitation and a thin and/or fragile aortic wall at AVR, however, predict late dissection. Using a prediction model, the risk of late dissection can be stratified based on information obtained during AVR surgery. CONCLUSIONS: Aortic dissection following AVR is likely to represent a distinct clinical entity which can be predicted and possibly prevented at AVR.

Aged↗
PubMed2006

Plasma levels of metalloproteinases-9 and -2 in the acute and subacute phases of type A and type B aortic dissection.

OBJECTIVES: Aortic dissection is characterized by an acute phase of medial dissection and a subacute-chronic phase of vessel wall repair. Matrix metalloproteinases (MMPs), through degradation of extracellular matrix, may play an important role in these processes. Elevation of MMPs might represent an opportunity to diagnostically characterize acute or chronic aortic processes. We examined the potential diagnostic role of MMP-9 and MMP-2 in different phases of aortic dissection. METHODS: Plasma levels of MMPs were evaluated by enzyme-linked immunosorbent assay technique in 13 patients affected by acute aortic dissection (nine type A, four type B). Ten healthy subjects were used as controls. In patients with type B aortic dissection treated medically, plasma curves (1, 3, 6, 12, 24, 48 and 96 h; 1 and 2 weeks; and 2 months from symptom onset) were also assessed. Aortic tissue samples obtained during surgery were evaluated by immunohistochemistry and western blot for MM-9 and tissue inhibitor of metalloproteinase-1 expression. RESULTS: MMP-9 plasma levels were increased in patients affected by type A and type B aortic dissection presenting within 1 h from onset of symptoms compared to controls (29.3 +/- 16.1 and 16.7 +/- 2.1 ng/ml versus 7.74 +/- 1.6 ng/ml, P < 0.03, respectively). No differences were detected in MMP-2 plasma levels compared to controls (4.84 +/- 1.2 ng/ml for type A and 6.16 +/- 0.6 ng/ml versus 3.17 +/- 1.0 ng/ml for controls, P = NS, respectively). In type B aortic dissection, mean MMP-9 plasma levels increased significantly from hospital admission to 2-month follow-up (16.7 +/- 2.1 ng/ml versus 58.0 +/- 8.2 ng/ml, P < 0.0001). Conversely, no difference in MMP-2 plasma levels was evident during follow-up (6.16 +/- 0.6 ng/ml versus 4.28 +/- 0.4 ng/ml, P = NS, respectively). Low-moderate (+/++) expression of MMP-9 was evident at immunohistochemistry in the acute phase whereas a marked expression (++++) was detected in the subacute phase. CONCLUSIONS: This pilot study suggests that the acute and subacute phase of both type A and type B aortic dissection is characterized by an increase of MMP-9 plasma levels. A marked increase is also evident in the subacute phase of medically treated type B aortic dissection as an expression of aortic wall remodelling. An increase of proteolytic activity could accompany attempts of the dissected aorta to heal itself but such a phenomena might further weaken the aortic wall, predisposing it to dilation and/or rupture.

Acute Disease↗