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PubMed1993

[A case involving coronary dissection caused after PTCA that was observed with intravascular echocardiography].

We encountered a case that was observed on coronary angiography (CAG) during coronary dissection after coronary angioplasty (PTCA) in which the dissected cavity disappeared on CAG but thrombolytic obstruction in the dissected cavity could be observed by intravascular echocardiography (IVUS). A 67-year-old woman was admitted with a diagnosis of acute myocardial infarction with ST elevation when experiencing chest pain. PTCR was performed for obstruction of the left circumflex artery (LCX) and the stenosis was improved to 90 percent. One month later PTCA was performed on an obstruction lesion in LCX and the feature of the dissected section at the same site was observed by CAG after PTCA. CAG showed that the dissected cavity had disappeared a year and a half later, but IVUS indicated thrombolytic obstruction in the dissected cavity.

Aged↗

PubMed1993

[An experience of dissecting cerebral aneurysm of the anterior cerebral artery].

Intracranial dissecting aneurysms have been reported occasionally in recent years. However, excluding dissecting aneurysms which extend from the proximal intracranial carotid artery, dissecting aneurysms arising merely in ACA are found only rarely. We are reporting here a case of a 42 year-old gentleman who did not present any particular causative etiology such as trauma or other basic diseases causing arteritis. Our patient is the 8th case, as far as we could find in the literature, in which the dissection of the arterial wall originated at the ACA. The patient was thought to have a tiny saccular aneurysm at the A 1-2 junction of the right ACA associated with vasospasm in the distal ACA on the angiogram. The patient had motor weakness on the left side and headache as well as a low density area in the territory of the ACA on the CT scan. A craniotomy was performed verifying the aneurysm to be dissecting in type without any sign of recent subarachnoid hemorrhage in the surrounding structures. No aggressive surgical treatment such as trapping of the aneurysm was done because the collateral blood circulation in that territory of the distal right ACA seemed to be poor and the patient no longer had neurological deficit at the time of operation. The patient was treated successfully with antiplatelet therapy. On the follow-up angiogram performed 3.5 months after the onset of the illness, we noted the disappearance of the abnormal angiographical findings of the dissecting aneurysm and distal arterial narrowing (pearl and string sign).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1995

Dissection of the internal carotid artery: aetiology, symptomatology, clinical and neurosonological follow-up, and treatment in 60 consecutive cases.

We reviewed the medical records of 60 consecutive patients (28 men and 32 women; aged from 13 to 63 years) with the diagnosis of dissection of the internal carotid artery (ICA), and with available clinical and neurosonological follow-up. Ten cases occurred after trauma and 50 cases were spontaneous. Angiographic evidence of fibromuscular dysplasia of the ICA was found in 23% of the cases. Unilateral headaches or neck pain associated with focal cerebral ischemic symptoms or oculosympathetic palsy were the most common findings. Less frequent symptoms such as isolated cranial nerve palsies and pulsating bruits were also observed. Follow-up ranged from 3 to 144 months (mean, 37.5 months). A favourable outcome occurred in 73.7% of the cases with a follow-up of 6 months or more, and seemed to depend on the severity of the ischemic cerebral deficit associated with the ICA dissection. 68% (41/60 cases) of our patients developed stroke and 18% (11/60 cases) experienced a transient ischemic attack, which occurred as the initial manifestation of the ICA dissection in 28.8% (15/52 cases) of the cases, and with a delay (more than 24 hours) in the other cases. Evidence of embolization in the cerebral arteries was found in 36% of the cases with stroke (15/41 cases). Anticoagulant therapy, given in 34 of our patients, seems to be justified by the fact that a considerable risk exists for cerebral emboli in association with ICA dissections; no serious neurological complications were observed in our series as a result of this anticoagulant therapy. Doppler sonography follow-up diagnosed a recanalization in 67.8% of the stenotic or occlusive dissections, most of them being completed within the first 6 months (92%). Recurrence of ICA dissection is exceptional but occurred in one of our 60 cases, 2.5 years after the first event.

Adolescent↗

PubMed1996

[A case of anterior cerebral artery dissecting aneurysm].

The incidence of intracranial dissecting aneurysms is lower than that of berry aneurysms. Following the recent spread of the use of cerebral angiography, however, the number of patients identified as having this type of aneurysm has been increasing. In a majority of cases of intracranial dissecting aneurysms, the aneurysm afflicted the vertebral and basilar arteries. After these, the internal carotid artery and the middle cerebral artery are the next most frequently affected. It is very rare that this type of aneurysm develops in the anterior cerebral artery. According to our search of the literature, only 17 cases of dissecting aneurysm of the anterior cerebral artery have been reported to date (including the case to be presented here). The case we recently encountered was that of a 52-year-old male. On October 25, 1994, the man suddenly developed a headache and strong paresis of the left leg while performing clerical work. The plain head CT, taken next day, revealed low density in the area supplied by the right anterior cerebral artery. An angiogram taken 6 days after onset disclosed characteristic signs of dissecting aneurysm (i.e., double lumen, etc.) at the A2 segment of the right anterior cerebral artery, as well as the presence of non-ruptured berry aneurysms at the bifurcation of the right middle cerebral artery. The non-ruptured berry aneurysms were treated by neck clipping, while the dissecting aneurysms were treated conservatively. The patient was discharged on March 21, 1995, without needing any assistance to walk. We analyzed the 17 reported cases of dissecting aneurysms of the anterior cerebral artery. The cause of this aneurysm was often hypertension, and only 3 of the 17 cases were rated as being idiopathic cases. The site of this aneurysm was often the pericallosal artery (segments A2, A3, etc.). Of the 17 patients, 11 were middle-aged or elderly (over 40). The male-to-female ratio was 13: 4, indicating a predominance of males. The incidence did not differ significantly between the right and left hemispheres. The number of ischemic cases was more than double that of hemorrhagic cases. Most ischemic cases had a good prognosis, even when treated conservatively. All 3 patients with the hemorrhagic type, who were treated conservatively, died.

Aortic Dissection↗

PubMed1996

[Cerebral artery dissection].

The main symptom of arterial dissection is intense acute unilateral headache. The pain is commonly located around the eye, in the temple or the front with a carotid artery dissection [CAD] and in the posterior neck and occiput with a vertebral artery dissection [VAD]. Transient or persistent cerebral ischemic symptoms are similarly frequent but usually occur later in the time course. Horner's syndrome indicating a lesion of perivascular sympathetic fibres represents the third leading symptom and occurs in more than one third of the patients. Compression of local structures such as lower nerve or radicular palsies is rare. This constellation of symptoms in a young patient without vascular risk factors should rise suspicion of a dissection, in particular, if there is a preceding 'trivial' trauma. Characteristic features on Doppler/duplex sonography provide the diagnosis of dissection in almost all CAD and the majority of VAD. MRI demonstrating the mural hematoma allows reliable confirmation of the suspected diagnosis. Angiography is necessary only in selected cases, more often in VAD than in CAD. Brain infarction may be prevented, if premonitory symptoms, which occur in 60 to 80% of the patients, are recognized as such. Therefore, if there is clinical and sonographic suspicion of CAD or VAD, anticoagulation therapy with heparin should should be started before other imaging procedures finally prove the diagnosis. Because immediate anticoagulation may prevent cerebral embolism, this treatment strategy seems appropriate, although its efficacy has not been established by a controlled study. Anticoagulation should be continued until resolution of the dissection.

Adult↗

PubMed1996

[Diagnosis of suspected thoracic aortic dissection. Focused on transesophageal echocardiography].

Over a five-year period (1990-1994), 72 consecutive patients were referred to transoesophageal echocardiography (TEE) on suspicion of thoracic aortic dissection. TEE was performed as the only or last investigation in 42 patients (58%). In 44 patients one or more other investigations were carried out before final clinical decision making: aortography (n = 30), X-ray computer tomography (CT, n = 18), and magnetic resonance imaging (MRI, n = 12). The final diagnosis was based on the combination of clinical information, the available examination results, and findings at surgery or autopsy; 31 of the patients were diagnosed as having aortic dissection. One patient with aortic dissection died during TEE while none of the other patients suffered major complications. The sensitivity (demonstration of dissection including correct classification in type A or B) was 81%, 80%, 45%, and 83% for TEE, aortography. CT, and MRI, respectively. The specificities were 88%, 93%, 71%, and 100%, respectively. Dissection of the thoracic aorta is a life-threatening condition demanding prompt and accurate diagnosis. None of the four techniques employed in the present study is ideal. Although TEE is adequate for immediate bedside examination our results show that more time-consuming and resource demanding investigations are sometimes required. Proper training and improved equipment may, however, increase the usefulness of TEE in patients with suspected aortic dissection.

Adolescent↗

PubMed1996

New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft.

BACKGROUND: To alleviate the invasiveness of surgical treatment for thoracic aortic aneurysm or dissection involving the distal arch, we developed a new method of implanting a graft in the distal anastomotic portion that does not require dissection, suture, or lateral thoracotomy. METHODS AND RESULTS: The tight circumferential attachment between the graft and the aortic inner wall, produced by the hoop strength of a self-expanding (Gianturco) stent that is anchored into the woven polyester graft, takes the place of the conventional anastomotic suture at the distal end of the graft. This new surgical method requires only a median sternotomy and relatively short circulatory arrest time to repair a thoracic aneurysm or dissection involving the distal arch. In a 12-month period in 1994 and 1995, we applied this new method in 10 cases (seven true aneurysms and three dissections). Complete thrombosis of the aneurysms or false lumens surrounding the grafts resulted in all 10. There were no surgical deaths, and the major complications were two cerebral infarctions due to inappropriate protection of the brain and dissecting procedure of an aortic arch, respectively. CONCLUSIONS: These preliminary results indicate that this new graft-implanting method with the stented graft should be considered one of the less-invasive surgical treatments for thoracic aneurysm and dissection involving the distal arch.

Aged↗

PubMed1996

[CT and PRI angiographic findings in dissection of the neck arteries].

PURPOSE: To determine the usefulness of CT angiography (CTA) and MR angiography (MRA) for evaluation of dissection in cervical vessels. MATERIAL AND METHODS: Dissection of cervical vessels was revealed by conventional angiography in 4 patients (two female, two male) of 30-62 years of age. Dissection was located in the carotid artery (n = 3) and in the vertebral artery (n = 1). In two patients CTA and in two patients MRA was performed. RESULTS: Diagnosis of dissection was possible by CTA (internal carotid artery: n = 2) and by MRA (internal carotid artery and vertebral artery). Imaging of the dissection membrane of the vessel wall was possible in one case with MRA. CONCLUSION: CT and MR angiography was successful for detection of typical morphology of dissection in all cases. If results in a greater number can be obtained it seems to be conceivable that both methods can be used in primary diagnosis.

Adult↗

PubMed1996

[Retrograde aortic dissection during cardiopulmonary bypass a case report successfully treated by contralateral femoral cannulation].

Retrograde aortic dissection is the most critical complication associated with femoral perfusion. It may be related to the trauma of femoral cannulation per se or to the jet of retrograde perfusion. We report the successful repair of a retrograde aortic dissection by composite graft replacement of the dissected ascending aorta using contralateral femoral cannulation. A 66-year-old man presented with aortic regurgitation due to annuloaortic ectasia. At the operation, the right common femoral artery was cannulated, and cardiopulmonary bypass was initiated. Within a few minutes after beginning the bypass, we recognized a retrograde dissection showing a tense bluish bulge in the ascending aorta. Bleeding was detected from the dissected aortic root beside the right coronary ostium. The bypass was interrupted, and contralateral femoral cannulation was performed immediately to re-establish the bypass. Composite graft replacement of the aortic root and ascending aorta was successfully performed under hypothermic circulatory arrest using additional retrograde cerebral perfusion. Pathological findings of the aortic wall revealed cystic medionecrosis. When a retrograde aortic dissection occurs, it is essential to establish antegrade flow. If it is impossible to cannulate at the ascending aorta for any reason, a contralateral femoral cannulation can be used successfully to re-establish the cardiopulmonary bypass because of the easy access.

Aged↗

PubMed1996

[Pathology of aortic dissection].

Aortic dissection is not a popular disease but it should be listed in the disease to be excluded especially in acute emergent cases, because of its serious and protean clinical manifestations. While DeBakey classification was used over 30 years. Stanford classification is now widely accepted for its clinical availabilities. The features of the aortic dissection are 1) presence of the intimal tear at the proximal end in almost all cases, 2) its frequent location in the ascending aorta and aortic segment just distal to the left subclavian artery, and 3) the dissected plane at the outer media or medial-adventitial border. Systemic hypertension is frequently noticed in cases with aortic dissection. These features suggest hemodynamic effect as a pathogenic factor in addition to mural fragility of the aorta. Aortic dissection is frequently encountered in Marfan syndrome and other heritable diseases of connective tissue. Concerning Marfan syndrome, mutation of fibrillin gene was confirmed. Fibrillin is a microfibril consisting of glycoprotein closely bound to elastin. Therefore, traditional "cystic medial necrosis" which was referred as a principal morphological change corresponding to aortic dissection is now thought to be a secondary change to the aortic injuries occurred in the aortic wall.

Aortic Dissection↗

PubMed1997

[A case of spontaneous cervical internal carotid artery dissection].

Dissection of the extracranial carotid artery is a recognized cause of ischemia, particularly in young persons who present with acute neurologic deficits, both transient and permanent. We describe a patient with a spontaneous dissection of the cervical internal carotid artery (ICA). A previously healthy 24-year-old man was hospitalized because of a sudden onset of right hemiparesis and consciousness disturbance. In reality, right cervical pain preceded this attack. The first brain MRI revealed a cerebral infarction in the right cerebral hemisphere including basal ganglia. A conventional angiography was performed 1 week later. The following angiographic picture was considered to be consistent with the diagnosis of cervical artery dissection: gradually tapered occlusion beginning distal to the carotid bifurcation. And MRA revealed the same finding. A cervical MRI revealed as an eccentric signal void (corresponding to the residual lumen) surrounded by a semilunar hyperintensity (corresponding to the mural hematoma) on T1- and T2-weighted images. Dynamic CT scan (D-CT) revealed an eccentric and crescent contrast enhancement (corresponding to the residual lumen) surrounded by a relative hypodensity compared with muscle (corresponding to the mural hematoma), itself surrounded by a thin annular enhancement. From these results, we diagnosed this patient with ICA occlusion for dissection of the extracranial carotid artery. But we decided this case contraindication of anastomosis because he had had a major stroke. Our findings suggest that MRA, cervical MRI and DCT provide early recognition of internal carotid artery dissection and monitoring of its resolution. Thus, these studies may guide clinical decisions according to the development of the dissection.

Adult↗

PubMed1997

[Surgical strategy for Stanford type A aortic dissection with Marfan syndrome].

Between January 1979 and May 1996, 23 Marfan patients underwent surgeries for type A aortic dissection; 8 patients with localized type dissection and 15 with extensive type. All of the 23 patients suffered from annuloaortic ectasia (AAE) which was treated by composite graft replacement, 10 of these patients had a concomitant replacement of the aortic arch. The operative mortality rate was 8.7%, and the causes were associated with the methods of coronary artery reattachment to the graft. Of the 15 patients with the extensive type dissection, there were 11 patients who had a non-thrombotic communicating false lumen in the untreated segments of the distal dissected aorta after the first operation and from this group there were seven patients who had anastomotic leakage around the distal suture line of the graft replacement that was demonstrated by aortography. Extensive graft replacement ranging from the entire thoracic aorta to the total aorta were performed in 10 (43.5%). Late deaths occurred in three patients (13.0%) and these causes were LOS and graft infection after the second operation and prosthetic valve endcarditis 6 months after the first operation. The present data indicate that Stanford type A aortic dissection with Marfan syndrome should be undertaken on the basis of a prior achievable plan to perform an entire aortic replacement. The dissection should also be performed using a procedure which doesn't leave distal anastomotic leakage.

Adolescent↗

PubMedDate not supplied

Carotid artery dissection in a young adult: cystic medial necrosis associated with an increased elastase content.

A dissecting aneurysm of the right internal carotid artery was found in a 22-year-old man, who rapidly became unconscious and hemiparetic after an accident occurring during sport. The dissection was limited to the intima and internal elastic lamina. Patterns of cystic medial necrosis with mucoid degeneration were present in the right internal carotid artery proximal to the site of dissection, in the thoracic aorta, and in several visceral arteries. In the region of the right internal carotid artery affected with cystic medial necrosis, calcification and also splitting of the internal elastic lamina was found. Such calcification was also present at the site of the dissection, at the tip of the ruptured and recoiled elastic lamina. These changes, dissection as well as cystic medial necrosis, were associated with an elevated elastase content, a decrease of desmin and an increase of vimentin expression. Ultrastructurally, in areas affected by cystic medial necrosis a corresponding transformation of medial smooth muscle cell phenotype from the contractile to the metabolic state was found. The topographical relation of dissecting aneurysm, cystic medial necrosis, and an increased elastase content is suggestive of a causal relation, and the possibility of common etiological factors is discussed.

Adult↗

PubMed1997

[Peripheral and coronary artery dissections in a young woman. A rare case of type IV Ehlers-Danlos syndrome].

Spontaneous coronary dissection is rare and the diagnosis is usually post-mortem. Less than 60 cases have been diagnosed at coronary angiography. The authors report, to the best of their knowledge, the first case of multiple spontaneous coronary artery dissections in a type IV Ehlers-Danlos syndrome in a young woman admitted to hospital for acute myocardial infarction. She had a previous history of regressive complete tetraplegia due to dissection of the basilar artery and episodes of dizziness related to a dissecting aneurysm of the left vertebral artery. The diagnosis of type IV Ehlers-Danlos syndrome was established after skin biopsy had shown typical histological changes. The patient died several months later after an acute abdominal syndrome probably related to dissection of the aorta. An autopsy was refused by her family. The authors believe this to be the first case of spontaneous coronary dissection related to a type IV Ehlers-Danlos syndrome.

Adult↗

PubMed1976

Neck dissection in the treatment of carcinoma of the anterior two-thirds of the tongue.

The records of 340 patients treated surgically over the 20 year period 1950 through 1969 at this clinic for primary epidermoid carcinoma of the anterior two-thirds of the tongue were reviewed to evaluate the effectiveness of elective versus therapeutic radical neck dissection in their treatment. There has been a change in the clinical presentation of this disease, with more people presenting at an earlier stage, with a smaller primary lesion and fewer cervical node metastases. The over-all survival rate has shown a marked improvement to 69 per cent at five years. The proportion of women afflicted has increased. The status of the cervical nodes is a major prognostic factor, the determining five year survival rate being reduced from 78 to 26 per cent if the nodes are metastatically involved. It cannot be directly proved that removal of occult metastasis to the neck by elective radical neck dissection before nodes are clinically detectable leads to a better survival rate partly because the two groups being compared are selected and not randomly assigned. However, the marked tendency for carcinoma of the tongue to metastasize regionally at some time in its course, the significant error in clinical evaluation of the neck, the significant conversion of clinically negative nodes to positive in patients not treated with radical neck dissection, the poor prognosis after treatment of conversion from clinically negative into positive and the fact that more than half of the deaths are due to uncontrolled disease of the neck alone, make us strongly favor the principle of elective radical neck dissection to enhance the survival time in the group of patients without clinical evidence of nodal involvement. With current surgical expertise, the mortality and morbidity rates of simultaneous radical neck dissection are low, and the potential benefit of the procedure outweighs its potential risks. Obviously, elective radical neck dissection, if beneficial, would most likely be so in patients with the highest likelihood of having occult metastasis.

Carcinoma, Squamous Cell↗

PubMed1997

Aorto-right atrial fistula: a rare complication of aortic dissection type A. A report of two cases.

BACKGROUND: Aortic dissection with rupture into the right atrium is an extremely rare condition and rapidly lethal. The authors report their experience in the treatment of two complicated aortic dissections observed at 85 and 93 months after previous cardiac operations. These were redo mitral valve replacement and saphenous vein coronary artery bypass grafts. METHODS: Both cases underwent hospital admission on an emergency basis because of severe chest pain and cardiac failure. One case had a history of hypertension. The aortography revealed aortic dissection and a fistulous communication into the right atrium. At surgery dissection repair and closure of the fistula was performed. Furthermore in one case vein grafts were reimplanted into the vascular graft. RESULTS: Both patients survived the operation without complications, were rapidly extubated and were asymptomatic and fully active at late follow-up. CONCLUSIONS: In the light of these results we conclude by affirming that aortic dissection with rupture into the right atrium is an extremely rare condition, rapidly lethal. Patient survival is strictly dependent on the time interval between fistulization of the dissection and the operation.

Aged↗

PubMed1998

Spontaneous retrograde dissection of the entire thoracic aorta originating in the abdominal aorta. Case report and review of the literature.

Spontaneous retrograde thoracic extension of the abdominal aortic dissection is extremely rare and difficult to manage. Only five cases have been previously reported in the English literature (dissection reaching the ascending aorta in four, dissection limited in the descending thoracic aorta in one), and all the cases of dissection which reached the ascending aorta were lethal. We herein report one case of a 37-year-old man who was operated on for spontaneous retrograde dissection of the entire thoracic aorta originating in the suprarenal abdominal aorta. Preoperative aortogram revealed the site of the intimal tear just above the celiac artery. He urgently underwent graft replacement of the descending thoracic aorta and the abdominal aorta with reimplantation of the thoracoabdominal visceral arteries. Although the patient had to undergo the second operation for the dissection of the remaining thoracic aorta four months postoperatively, he has been doing well 18 months after the second operation.

Adult↗

PubMedDate not supplied

Aortic dissections: a pathologic study of 35 autopsied cases.

A study of 35 autopsied cases of aortic dissection collected over a period of 12 years was carried out. There were 25 males and 10 females, and the majority of the dissections presented in fourth to fifth decade of life. Thirty-six dissections were present in 35 cases. Type III was the commonest (50.0%), followed by Type I (41.7%) and Type II (8.3%) dissections. Rupture following acute dissection was the cause of death in 15 patients. In chronic types, the causes of death were not related to dissection. Hypertension, connective tissue disorders and trauma were identified as some of the risk factors.

Adolescent↗