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PubMed2000

[Abdominal catastrophes and limb arterial occlusions caused by acute aortic dissection. Experiences of a longitudinal population-based study of 28 years].

The authors pursue longitudinal studies since 1972 on a defined population of 106,000 relating to several questions of the aortic dissection. Till now, in 90 patients 93 cases of the aortic dissection were found. In seven patients, the aortic dissection was complicated with the clinical and pathological symptoms of surgical diseases. The vascular complications of the aortic dissection caused obstruction of coecomesenteric arteries with severe ischemic signs in four patients, obstruction of iliac arteries in two patients and the left sublavian artery in one another. In an additional patient with a chronic recurrent pancreatitis, the acute aortic dissection as an acute exacerbation of chronic pancreatitis was considered. It makes known in a short report of cases the clinicopathological features of vascular complications of the thoracoabdominal aortic dissections. Their pathomechanisms as well as the possibilities of their diagnosis and treatment are reviewing in detail.

Abdomen, Acute↗

PubMedDate not supplied

[Cerebral infarction due to spontaneous dissection of the left common carotid artery].

Spontaneous dissection of the extracranial cervicocephalic arteries occurs most often in the internal carotid artery or vertebral artery. Spontaneous dissection of a common carotid artery is rare, with only nine cases having been reported. A 43-year-old man was hospitalized for sudden onset of motor aphasia and right arm weakness due to spontaneous dissection of a left common carotid artery; no sign of aortic disection was evident on aortogram. The most common causes of dissection of the common carotid artery are the extension of an aortic dissection and the complication in an angiogram with direct puncture; spontaneous dissection being very rare. We review the previous literature on this topic.

Adult↗

PubMed2001

A preoperative index of mortality for patients undergoing surgery of type A aortic dissection.

BACKGROUND: The aim of this study was to identify and stratify the most important preoperative factors for in-hospital death after surgery for type A aortic dissection. METHODS: From January 1985 to June 1998, 108 patients underwent surgery for type A aortic dissection. 89.9% of the patients had an acute type A dissection (AD), whereas 11.1% had a chronic dissection (CD). Cardiac tamponade and shock occurred in 22% and 14.8% of the patients, respectively. The location of the primary intimal tear was in the ascending aorta in 71.2% of the cases, in the arch in 16.6% and in the descending aorta in 7.4%. Univariate and multivariate analyses were conducted to identify non-embolic variables independently correlated to in-hospital death. A predictive model of in-hospital mortality was then constructed by means of a mathematical method with the variables selected from logistic regression analysis. RESULTS: The overall in-hospital mortality rate was 20.3% (22/108 patients), being 9% for CD and 21.6% for AD. Emergent procedures had an in-hospital mortality rate of 47.6%, whereas non-emergent operations had an in-hospital mortality rate of 13.7% (p<0.01). Univariate analysis revealed among 39 preoperative and operative variables, age (years), age >70 years, remote myocardial infarction, cerebrovascular dysfunction, diabetes, preoperative renal failure, shock, cardiopulmonary bypass time (minutes), emergency operation as factors associated to in-hospital death (p<0.05). Stepwise logistic regression analysis selected as independent predicting variables (p<0.05), remote myocardial infarction (p=0.006), preoperative renal failure (p=0.032), shock (p=0.001), age >70 years (p=0.007). Finally, a probability table of death risk was obtained with the logistic regression coefficients. The lower death probability (10.6%) was calculated in absence of risk variables; the higher one in presence of all of them (79.7%). Between these extremes, a total of 64 combinations of death risk were obtained. CONCLUSIONS: Increasing age, shock, coronary artery disease and renal failure are variously associated to a high risk of in-hospital death after surgical correction of type A aortic dissection. This predictive model of death probability allows to collocate preoperatively patients with type A aortic dissection at different levels of risk for in-hospital death.

Acute Disease↗

PubMed2001

[A case of iatrogenic carotid artery dissection treated with radial artery graft].

A case of iatrogenic intracranial artery dissection is reported. A 52-year-old female developed severe headache and nausea. Brain CT showed diffuse subarachnoid hemorrhage. On admission, carotid angiography revealed an aneurysm in the right middle cerebral artery and the intact right internal carotid artery. The aneurysm was clipped successfully. Carotid angiography on day 7 revealed dissection in the right internal carotid artery. Repeated angiograms at 10 and 31 days showed progression of the carotid artery dissection. Findings of ECD-SPECT on day 31 (Balloon occlusion test) suggested low perfusion of the right internal carotid artery territory. The patient underwent surgical reconstruction of the right internal carotid artery using a radial artery. She presented with right abducens nerve palsy three days after the radial artery graft. The patency of the radial artery graft was proved by the post-operative angiography. Internal carotid artery dissection may occur spontaneously or as a result of trauma. An iatrogenic dissection is an uncommon complication of cerebral angiography. There are no evidence-based guidelines for the treatment although anticoagulation therapy is most commonly used. The present case emphasizes the usefulness of radial artery graft for traumatic carotid artery dissection.

Carotid Artery, Internal↗

PubMed2001

Vertebral artery dissection due to indirect neck trauma : an underrecognised entity.

Vertebral artery dissection is an important cause of brain stem stroke, especially in the young. Dissections of carotid and vertebral arteries in neck account for about 20% of strokes in young compared with 2.5% in the elderly. Three patients of vertebral artery dissection related to indirect neck trauma are described. The first patient developed the symptoms while dancing, the second after a trivial fall and the third while he was on a dental chair. None of them had a direct severe neck trauma or concomitant risk factor like hypertension, connective tissue disease or migraine. Clinical symptomatology was similar in all the patients and included occipito-nuchal pain, headache and brain stem dysfunction chiefly in the posterior inferior cerebellar artery (PICA) territory. One of the patients also had associated ischaemic myelopathy. MRA and DSA confirmed dissection in all with a predominant steno-occlusive picture. Cases of so called trivial neck movement/torsion related dissection have been described previously but have not received any major importance. Usually classified as 'spontaneous' or 'traumatic', there is a possible ambiguity in literature about appropriate terminology. We emphasise that a history of such subtle precipitating events be taken while diagnosing young patients with brain stem strokes, to recognise this clinical entity. Although mechanisms are not absolutely clear, yet there seems to be an important relationship between arterial dissection and neck movements or minor trauma.

Adult↗

PubMed2001

Dissecting intracranial vertebral artery aneurysms.

Dissecting aneurysms of the intracranial arteries are exceedingly rare vascular lesions that can produce acute cerebral or brain stem infarction in young healthy adults. They carry a high mortality rate. Two cases of dissecting vertebral artery aneurysms that presented with bleed, were successfully operated by trapping and excision of the dissecting segment. Both dissecting aneurysms were located distal to PICA origin. Both the patients developed post operative lower cranial nerve paresis and one developed lateral medullary syndrome, which improved subsequently. Dissecting aneurysms presenting with bleed should be surgically managed by trapping and excising the involved segment sparing the PICA origin or by interventional radiological techniques. Revascularisation procedures should be considered in addition to trapping of the main vertebral segment if PICA is involved in the trapped segment. The diagnostic and therapeutic difficulties associated with dissecting vertebral artery aneurysms and the controversies regarding their management have been reviewed.

Adult↗

PubMed2001

[Endovascular treatment using endoprosthesis and metallic stents for aneurysmal dissection of the intracranial vertebral artery].

Dissecting aneurysms of the intracranial vertebral artery represent a more frequently recognized cause of subarachnoid hemorrhage. The poor natural history of the ruptured dissecting aneurysms indicate a surgical or endovascular treatment. Endovascular treatment usually consists of balloon occlusion of the vertebral artery. This treatment however can lead to hemodynamic complications especially when the treated artery is unique or dominant. We report two cases of ruptured dissecting aneurysms of the intracranial vertebral artery treated by intravascular stent and endosaccular GDC coils. The first patient suffered from bilateral dissection with spontaneous occlusion of the right vertebral artery and development of a pouch on the left side. The second patient suffered from a dissection of the left vertebral artery which was dominant. The stenting-coiling technique was efficient in the two cases. The patients are free of symptoms with a respective follow up of 24 and 8 months. The stenting-coiling association seems to be an interesting therapeutic option in case of intracranial dissecting aneurysms which allows a preservation of the arterial flow and selective occlusion of the aneurysmal pouch.

Adult↗

PubMed2002

[Treatment for the ruptured bilateral vertebral dissecting aneurysms].

We report a case of a bilateral vertebral dissecting aneurysm associated with subarachnoid hemorrhage. Proximal ligation of the vertebral artery on the ruptured side combined with wrapping of the contralateral dissection failed to prevent fatal rebleeding. Since enlargement of the contralateral dissection was observed by postoperative angiography, rupture of the growing contralateral dissecting aneurysm may have caused rebleeding. Hemodynamic changes following the occlusion of one vertebral artery might have led to enlargement and subsequent rupture of the contralateral dissection. Direct wrapping was unable to prevent enlargement of the dissection, so radical surgery including bilateral vertebral artery occlusion combined with vascular reconstruction may be the treatment of choice for this type of lesion.

Aneurysm, Ruptured↗

PubMed2002

Intraoperative aortic dissection--a case report.

Intraoperative aortic dissection is a rare but potentially fatal complication of cardiac surgery. Prompt recognition and repair are necessary to limit the extent of dissection to minimize morbidity and mortality. Here, we present a case of acute type A dissection of ascending aortic artery occurring after removal of aortic cannula at the end of cardiopulmonary bypass. The surgeon immediately recannulated him at the femoral artery and repaired the dissection under deep hypothermia. Ascending aorta was replaced with Hemashield graft and venous graft was reimplanted. Unfortunately, the patient expired the following day due to cardiac tamponade resulting from uncontrolled bleeding. Long-standing severe hypertension, severe atherosclerotic change of the aortic wall, thin and dilating ascending aorta and cystic medial necrosis or collagen vascular disease were thought to predispose him to this complication. Gentle manipulation and surgical discreetness to forestall aoratic injury could minimize the risk of intraoperative aortic dissection. Once aortic dissection has been suspected, prompt application of transesophageal echocardiography to confirm the diagnosis, and rapid as well as appropriate surgical management are necessary to grasp a better outcome.

Aged↗

PubMed2002

Type B aortic dissection with rupture of the left common iliac artery: a case report.

Type B aortic dissection involves the appearance of a false lumen distal to the left subclavian artery and extending distally into the descending thoracic aorta and into the abdominal aorta. Complications of the dissection include rupture of the thoracic aorta, leg ischemia, visceral ischemia, and renal failure. A 37-year-old man presented with complaints of sudden onset of chest pain, left leg pain, and numbness. Examination revealed no femoral, popliteal, or distal pulses with decreased sensory and motor function on the left lower extremity. A CT scan revealed an aortic dissection at the proximal descending aorta extending into the iliac arteries with a left retroperitoneal hematoma at the iliac bifurcation. An MRI confirmed the dissection distal to the left subclavian artery into the iliac artery with a distal occlusion. Exploration revealed rupture of the left iliac artery dissection with arterial occlusion and a contained hematoma. The common iliac artery was ligated and an 8-mm Dacron bypass graft from the right common femoral artery to the left femoral artery was performed. Type B aortic dissection can present as rupture of the common iliac artery. Revascularization of the extremity with a femoral-femoral crossover graft is the recommended procedure in the absence of visceral ischemia. The surgeon should have a keen suspicion of this rare complication and its management.

Adult↗

PubMed2003

Iatrogenic aortic dissection during coronary intervention.

Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare. Localized aortic dissections have been treated by sealing the entry with a coronary stent. Extensive dissections may require a surgical intervention. We describe a coronary dissection with retrograde extension to the ascending aorta that occurred during angioplasty of the right coronary artery. The extensive dissection, which was limited to the ascending aorta, was successfully treated by stenting of the right coronary artery and monitoring the aortic dissection by means of transesophageal echocardiography.

Aortic Dissection↗

PubMed2003

[Endovascular stent-graft exclusion for Stanford B type aortic dissections: a report of 146 patients].

OBJECTIVE: To assess the operation indications, preoperative evaluation, technique essentials and clinical prospect of endovascular stent-graft exclusion for aortic dissection. METHODS: From September 1998 to April 2003, endovascular stent-graft exclusion for aortic dissection (Stanford B) was preformed in 146 patients. CTA or MRA were used as preoperative evaluation methods. Graft was constructed from self-expanding Z-stents covered with a woven Dacron polyester fabric graft (Talent). The stent-grafts were inserted from the femoral or iliac artery to exclude the tear of dissection, and all operations were performed under DSA guidance. RESULTS: The grafts were installed successfully in 145 patients. In 119 patients only proximal tears were excluded, and 26 patients who had both the proximal and distal tears were excluded. The mean follow-up period was 16 months (1 - 54 months). Six patients died within the perioperative period, 2 patients died during the follow-up, 2 patients had recurrence of aortic dissection (Stanford A) and cured by Bentall operation. The others were in good state. No accidents related to the dissection and operation occurred. CONCLUSIONS: Endovascular graft exclusion may be a safe and effective treatment for selected patients with thoracic aortic dissection. Endoleak may lead to aneurysmal expansion and rupture. Further follow-up is necessary to evaluate its long-term effect.

Adult↗

PubMed1992

[Comparison of long-term results of surgical and nonsurgical therapy in acute aortic dissection].

The early and long-term results of both surgical and nonsurgical therapy for 160 patients with acute aortic dissection in our institution were analyzed. Of the 83 patients with acute type A aortic dissection, 47 received surgery during acute stage, 10 received it in the chronic stage, and 26 received nonsurgical therapy. Of the 77 patients with acute type B aortic dissection, 27 received surgery during acute stage, 22 received it in the chronic stage, and 28 received nonsurgical therapy. Ten-year survival rates for patients receiving surgery during the acute stage were 62% for type A and 64% for type B dissection. This survival rate for type A patients was significantly higher than that for type A patients not receiving surgery, but the corresponding difference for type B patients was not significant. Present data indicate that immediate surgical intervention is indicated in patients with acute type A dissection, and elective operation in the subacute stage in patient with uncomplicated type B dissection following medical therapy in the acute stage.

Acute Disease↗

PubMed2003

[Spontaneous intracranial internal carotid artery dissection: 6 case reports and a review of 39 cases in the literature].

Angiographic, CT and MR findings, precipitating factors, and clinical features of spontaneous intracranial internal carotid artery dissection, in particular the terminal segment of the ICA, are described. Patients who had a possible posttraumatic dissection were excluded from the study. Six patients, 3 men and 3 women, mean age 25.8 years, were studied. Spontaneous ICA dissection accounted for 0.63 percent of 797 patients with ischemic stroke and 14 percent of 36 patients with ischemic stroke who were 45 years of age or younger. Headache was absent in two but clearly preceded the onset of cerebral stroke in four patients, the interval ranging from less than a few minutes to 6 hours. Focal cerebral ischemic symptoms were present in all six patients. Four presented with loss of consciousness. Only one patient had a subarachnoid hemorrhage (SAH). Dissection occurred at the level of the carotid knee portion just beyond the origin of the ophthalmic artery in all the patients. Moreover, there was additional involvement of the ipsilateral MCA in four and ipsilateral ACA in three. Angiographic features of the six ICAs that involved dissection were a smooth tapered luminal narrowing or occlusion in two patients, irregular narrowing in three, a pearl and string sign in one, and retention of the contrast media in three. Follow up angiography or magnetic resonance (MR) angiography was performed on all the patients. The interval from the initial to follow-up angiography was one to six months. Stenosis persisted in one artery but was resolved in the other five arteries. MR angiography showed segmental narrowing of the right supraclinoid internal carotid artery in one patient. MR angiographic source images showed a narrow lumen in the right intracavernous portion of the ICA and a crescent-shaped filling defect. Follow-up MR imaging and MR angiography, 6 months after the initial study, showed amelioration of the luminal narrowing and no filling defect. The filling defect is considered to be due to a thrombosed pseudolumen. Treatment consisted of anticoagulation therapy for two patients, hyperbaric therapy for two, and supportive measures only for two. Follow-up ranged from ten months to three years. Of these six patients with completed stroke, four had full recovery, and two some residual neurological deficits. Trivial precipitating events were reported by five of the patients (playing tennis, running, bicycling, and drinking alcohol). Migraine headaches were cited by one patient, use of oral contraceptives by another, and use of tobacco by a third. All the patients were normotensive. In none of them was family history contributory, nor was any underlying arteriopathy identified. Of the six personal cases and the reviewed 25 cases during the last 15 years, represented on the Glasgow Outcome Scale, good recovery was achieved in 61%. The outcomes for these patients was better than previously reported. Spontaneous intracranial ICA dissection may cause ischemic stroke, with or without subarachnoid hemorrhage, especially in young patients.

Adolescent↗

PubMedDate not supplied

Endovascular management of spontaneous bilateral symptomatic vertebral artery dissections.

Extracranial vertebral artery (VA) dissection may lead to significant arterial stenosis, occlusion, or pseudoaneurysm formation with subsequent hemodynamic and embolic infarcts. To prevent thromboembolic complications, anticoagulation with intravenous heparin followed by oral warfarin has been recommended for all patients with acute dissections, regardless of the type of symptoms. Nevertheless, anticoagulation is not innocuous and may be associated with hemorrhagic transformation of a cerebral infarction or may be ineffective to prevent symptoms or dissection progression. We present a case of a bilateral spontaneous extracranial VA dissection presenting with multiple embolic infarctions. The dominant VA was reconstructed with multiple in-tandem stents and the contralateral VA, proved to be the source of emboli, was occluded with coils. Stent-assisted VA angioplasty has rarely been reported in the management of spontaneous dissections and appears to be a safe, effective and immediate method of restoring vessel lumen integrity and should be considered in the therapy of selected cases of VA dissection.

Adult↗

PubMed1992

[The controversy on the treatment of aortic dissection].

It is obvious that there are many controversies regarding to the treatment of aortic dissection. In this report, we discuss following points such as 1) classification, 2) thrombosed type dissection, and 3) simultaneous graft replacement of ascending and aortic arch with the reconstruction of cervical branches. From the patho-morphological status, dissection will be classified into two types, localized and extended types. From the anatomical and surgical points of view, it will be also classified as 1) ascending-arch, 2) descending-thoracoabdominal, and 3) abdominal. With the combination of these two, dissection will be classified more clearly. The thrombosed type will be incorporated into localized type. We have experienced 76 cases of this dissection, and clinical features and outcome by medical treatment only are presented. The simultaneous reconstruction of ascending aorta and aortic arch for the dissection at ascending-arch type was undertaken in total of 35 patients. The surgical results as well as follow up data are presented and the benefit of this extended procedure is presented as well.

Aortic Dissection↗

PubMed1992

[Aortic dissection after aortic valve replacement: clinical and anatomic features].

BACKGROUND: Cardiac surgery has become a possible cause of ascending aortic dissection, particularly in patients who have undergone aortic valve replacement. METHODS: From January 1979 to December 1989, 134 patients with angiographic evidence of aortic dissection, were studied in the Haemodinamic Laboratory of the University of Turin. Twelve of these patients (7 men and 5 women), mean age 51.6 years, had been previously operated for aortic valve replacement. We evaluated incidence, clinical and anatomic features of ascending aortic dissection in this group. RESULTS: A dilated ascending aorta with a mean diameter of 4.92 cm. was noted in all these patients. The interval between valve replacement and diagnosis of aortic dissection was 57 months (range 1 day to 9 years). Reoperation was performed in 11 patients. Four intraoperative deaths occurred and 2 other patients died in the early post-operative period. Survival rate at 12 months was 50%. Our incidence of ascending aortic dissection after aortic valve replacement was 0.66% (10 patients out of 1499 operated for aortic valve replacement) and it is in agreement with reports from other Authors in literature. CONCLUSIONS: Replacement of the ascending aorta must be considered if an important dilatation of aortic root is found at time of aortic valve surgery. New efforts must be undertaken to identify patients at high risk for this complication because an elevated mortality rate is observed in reoperation for aortic dissection.

Adult↗

PubMed1992

Intraoperative echocardiography for diagnosis and treatment of aortic dissection. Utility of color flow mapping for surgical decision making in acute stage.

In the past eight years until July 1992, 92 patients were admitted in the acute state of aortic dissection within two weeks from the onset of symptoms. 41 were diagnosed as Stanford type A and 51 were type B by transthoracic and transesophageal echography, computer tomography, and surgery. Sensitivity of transesophageal echography to detect the intimal flap and the false lumen was 97.6% in patients with Stanford type A and 100% in patients with Stanford type B. The surgical decision making has been mostly depending on the transesophageal echographic diagnosis. When the intimal flap was detected in the ascending aorta (Stanford type A) surgery was performed in emergency regardless of any evidence of rupture, cardiac tamponade, and severe aortic regurgitation. When the aortic dissection was detected only in the descending aorta (Stanford type B) the main course of therapeutic strategy in our institute was medical treatment. Surgery was performed on 37 patients of type A and nine patients of type B with mortality of 18.9% and 55.5% respectively. Four patients of type A and 42 patients of type B were treated medically with a mortality of 75.0% and 2.2% respectively. The relatively large leakages from the anastomosis of the aortic clamp site were repaired secondarily in two patients, and fenestration of the superior mesenteric artery was performed on one patient due to ischemia of the small intestine depending on the intraoperative direct scanning of color flow mapping. Coronary artery involvement of dissection was strongly suspected in two patients by intraoperative transesophageal echography and aortocoronary bypass grafting was performed on these patients. Perfusion problems was encountered in five of 37 patients with type A aortic dissection (13.5%) during cardiopulmonary bypass. Intraoperative transesophageal echography could clearly detect the hemodynamic changes in the descending aorta resulting from inadequate perfusion which was useful for the management of perfusion control during cardiopulmonary bypass. Secondary repair of the aortic arch was required due to ischemia of the aortic arch vessels in two patients after the primary surgery. The extension of the dissection into the aortic arch vessels can be promptly diagnosed with the combination of transesophageal echography and transcutaneous echography. In conclusion, transesophageal Doppler echography is the most rapid diagnostic tool for decision making in acute aortic dissection, and intraoperative transesophageal echo can provide useful information to resolve the perfusion difficulties during cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute Disease↗