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PubMedDate not supplied

Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias.

BACKGROUND CONTEXT: The growing recognition of cervical manipulation as a treatment of neck pain and cervicogenic headaches has lead to increased interest in potential complications that may result from this treatment approach. Recent surveys have reported that many neurologists will encounter cases of vertebral artery dissection that occur at various times after cervical manipulation, whereas most practitioners of spinal manipulation are of the opinion that these events are extremely rare. We asked the question whether these differences in perception could be explained in part by referral or selection bias. PURPOSE: To assess the effect of referral bias on the differences in perceived incidence of vertebral artery dissection after cervical manipulation between neurologists and chiropractors in Canada. STUDY DESIGN: This study was a retrospective review of cases where neurological symptoms consistent with cerebrovascular ischemia were reported by chiropractors in Canada. METHODS: An analysis of data from a chiropractic malpractice insurance carrier (Canadian Chiropractic Protective Association [CCPA]) and results of a survey of chiropractors was performed to determine the likelihood that a vertebral artery dissection after cervical manipulation would be reported to practicing chiropractors. This was compared with the likelihood that a neurologist would be made aware of such a complication. RESULTS: For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime. CONCLUSIONS: The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.

Bias↗

PubMed2002

[Spontaneous dissection of the external iliac artery due to fibromuscular dysplasia].

Spontaneous dissection of the external iliac artery due to fibromuscular dysplasia. A case of spontaneous dissection of the external iliac artery due to fibromuscular dysplasia is presented. In a 45-year-old man with a history of sudden onset of intermittent claudication a dissection of the right external iliac artery was found by duplex ultrasound. The patient, who was first treated with conservative therapy, subsequently required operative treatment because of further progression of the dissection. Considering the age of the patient a retrograde thrombendarterectomy manoeuver over guide wire was performed. Angiographic control at the end of operation demonstrated a good reconstructive result without any changes in the right common iliac artery and the aorta. Histopathological examination of the removed material showed fibromuscular dysplasia of the media. In the postoperative course the patient was clinically asymptomatic with ankle/brachial pressure indices of 1.0 on both legs. But shortly after discharge the intermittent claudication in the right leg recurred. Angiography and duplex ultrasound revealed focal stenosis of the right common iliac artery as well as retrograde dissection of the right common iliac artery extending into the distal aorta. Conservative therapy was recommended to the patient by the local hospital and no further progression of clinical and duplex findings within the last six months was found.

Aortic Dissection↗

PubMed1999

The ophthalmology of internal carotid artery dissection.

PURPOSE: Carotid dissection is an important cause of cerebral and retinal ischemic symptoms, especially in young adults. This article presents a patient material and also includes a review of the ophthalmologic signs and symptoms of carotid dissection. MATERIAL AND METHODS: Twenty-eight patients with spontaneous dissection of the extracranial internal carotid artery dissection underwent a neuro-ophthalmological examination. RESULTS: Twenty-three patients had oculosympathetic paresis. Two experienced transient monocular blindness; in one the episodes were provoked by sitting up from a supine position. One patient presented with a monocular visual field defect, due to posterior ischemic neuropathy, and two others with homonym hemianopia. Diplopia, caused by an incomplete VIth cranial nerve palsy was recognised in one. CONCLUSION: All but one patient presented with detectable ophthalmologic symptoms or signs. Very often the ophthalmologist is the first medical contact for patients with internal carotid artery dissection. The condition is serious, and a prompt evaluation and treatment is indicated to prevent irreversible sequelae.

Abducens Nerve↗

PubMed2000

Anatomy and blood supply of the lower four cranial and cervical nerves: relevance to surgical neck dissection.

This study is a continuation of previous work searching for possible anatomic reasons to explain variable and usually unpredictable postoperative pain and dysfunction after the same nerve losses with similar neck dissection operations. The study consisted of dissections of 19 deceased unpreserved elderly subjects arterially injected with dyed latex. Of the 19 subjects, 14 had brain stem and cervical spinal cord dissections, and all had neck dissections. The findings suggested two possible anatomic reasons for the pain and dysfunction: (i) The intracranial anatomy of the lower four cranial nerves, the glossopharyngeal (IX), the vagus (X), the spinal accessory (XI), and the hypoglossal (XII), was just as variable as the previously reported peripheral spinal accessory nerve plexus; and (ii) Both the intracranial and neck dissections indicated that the blood supply to the lower four cranial and cervical nerves, particularly to the brachial plexus, could be impaired by atherosclerosis and/or neuroforaminal impingement or operative loss. This loss of blood supply theoretically could result in ischemia as another possible cause of postoperative pain and dysfunction. It is concluded that because of the potential importance of each nerve and vessel, often unknown at operation, it is very important to spare as many of them as possible to avoid subsequent painful impairment.

Accessory Nerve↗

PubMed2001

Headache as only symptom in multiple cervical artery dissection.

We describe a patient with atypical headache as the only presenting symptom of spontaneous triple cervical artery dissection. As the patient suffered from arterial hypertension, a causative relation between headache and arterial hypertension was initially taken into consideration. However, four-vessel arteriography disclosed a dissection of both internal carotid arteries and the right vertebral artery. This unique case highlights the value of conventional arteriography for diagnosing cervical artery dissection. Since multiple cervical artery dissections are not rare, all cervical arteries should be examined by means of conventional arteriography when a dissection is suspected.

Aneurysm↗

PubMedDate not supplied

Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections.

PURPOSE: The purpose is to report our experience and revise our previously published results in endovascular repair of short-necked thoracic aortic aneurysms or aortic type B dissections, in which the left subclavian artery (LSA) was occluded by the stent graft intentionally. METHODS: Seven patients with an aortic type B dissection and three patients who had a thoracic aortic aneurysm were treated endovascularly with stent grafts. In all patients the ostium of the LSA was occluded by the stent graft, only in two patients a primary, prophylactic revascularization of the LSA was performed by transposition to the left common carotid artery (LCA). Two types of stent grafts were used: the Talent (Medtronic) and the Excluder (Gore) stent graft. RESULTS: In all patients the sealing of the entry tear in aortic dissections and the exclusion of existing thoracic aortic aneurysms were achieved. No immediate neurological deficit or left arm ischemia occurred. Nevertheless, during a mean follow-up of 18 months (2 to 31 months) in three patients a second surgical intervention had to be performed due to subclavian steal syndrome, left arm ischemia, or continuing perfusion of the dissected false aortic channel. CONCLUSION: Intentional occlusion of the LSA in stent-graft repair of thoracic aortic diseases seems to be a safe procedure. Close follow-up is needed due to arising subclavian steal syndrome, arm ischemia, or persistent perfusion of the false channel via LSA in aortic dissections after patients' discharge, requiring surgical intervention.

Aortic Dissection↗

PubMedDate not supplied

Emergency stent-graft placement in thoracic aortic dissection and evolving rupture.

BACKGROUND: Even with rapid diagnosis and effective medical treatment mortality in type B aortic dissection with evidence of extraaortic leakage of blood remains high. Considering a mortality rate of 29% to 50% associated with emergency surgical repair, the concept of endovascular stent-graft placement may become a life-saving option in impending or evolving rupture by endovascular sealing of the entry tear and subsequent abortion of leakage. METHODS: The concept was tested by comparing short-term and 1-year outcomes of 11 patients after emergency endovascular stent-graft placement with historic-matched control patients subjected to conventional therapy. All patients had acute type B dissection complicated by loss of blood into periaortic spaces. RESULTS: Emergency stent-graft placement was successful without periprocedural morbidity, aborted leakage, and ensured reconstruction of the dissected aorta; at a mean follow-up of 15 +/- 6 months no death had occurred in the stent-graft group whereas four patients had died with conventional treatment (p < 0.05). CONCLUSION: With appropriate logistics and expertise, type B aortic dissection with leakage and evolving rupture may benefit from nonsurgical reconstruction of the dissected segment by endovascular stent grafts.

Acute Disease↗

PubMedDate not supplied

Value of intravascular ultrasound for endovascular stent-graft placement in aortic dissection and aneurysm.

BACKGROUND: Endovascular stent-graft placement is a new concept for the treatment of aortic dissection and aneurysm. Intravascular ultrasound (IVUS) with established diagnostic features may be instrumental in guiding endovascular procedures. METHODS: We performed IVUS and digital angiography before, during, and after implantation of 47 stent grafts in 40 patients with Stanford type B dissection (26 patients, 28 stent grafts), thoracic aneurysm (9 patients, 11 stent grafts), and abdominal aneurysm (5 patients, 8 stent grafts). RESULTS: IVUS could clearly identify the aortic anatomy and differentiate between true and false lumen in all cases of dissection. In four patients with type B dissection extending from the thoracic to the abdominal aorta the true lumen was exclusively identified by IVUS, and thus, essential for safe execution of the procedure. In another patient stent-graft placement in the aorta was optimized by covering a second entry detected by IVUS, but undetected by angiography. The site of stent implantation, the true and false lumen, as well as entry and reentry were always identified in both thoracic and abdominal aorta. In comparison with angiography, IVUS information led to additional balloon molding due to incomplete stent apposition in seven cases. CONCLUSIONS: As an adjunctive imaging modality IVUS is likely to improve stent-graft placement in aortic type B dissection, especially in patients with abdominal extension.

Adult↗

PubMed2006

Detection and monitoring of complications associated with femoral or axillary arterial cannulation for surgical repair of aortic dissection.

OBJECTIVES: Femoral arterial perfusion can be associated with complications, and axillary arterial perfusion is not free from risk. The purpose of this study was to describe the incidence and complications of femoral versus axillary artery cannulation for surgical repair of aortic dissection and to devise a strategy for early detection and monitoring of complications using transesophageal echocardiography, near-infrared spectroscopy, and orbital Doppler. DESIGN: Retrospective and observational. SETTING: University hospital. PARTICIPANTS: Seventy-five consecutive patients with aortic dissection who underwent aortic repair between 1995 and 2004. INTERVENTIONS: Aortic surgery. MEASUREMENTS AND MAIN RESULTS: Among the 44 cases with femoral arterial perfusion, sudden onset of hypotension occurred in 3 cases but was immediately treated based on the TEE diagnosis (collapse of true lumen in the descending aorta). In another case, myocardial ischemia occurred because of occlusion of the coronary artery. These four cases comprised 57.1% of 7 patients with type III dissection with retrograde extension in whom femoral arterial perfusion was used. However, malperfusion was not encountered in 3 cases of the same type of dissection but with axillary arterial perfusion. Axillary artery perfusion (29 cases) led to malperfusion of the right frontal lobe and coronary artery in 1 case each. CONCLUSIONS: Flexible management guided by real-time information is essential. Upon initiating femoral arterial perfusion, malperfusion should first be checked for in the descending aorta and then in the coronary and visceral arteries, especially in cases of type III dissection with retrograde extension. Attention should be paid to cerebral and coronary malperfusion when initiating axillary arterial perfusion.

Adult↗

PubMed2005

Heritable disorders predisposing to aortic dissection.

Heritable disorders of connective tissue often predispose patients to aortic pathology and in particular aortic dissection. The Marfan syndrome, vascular Ehlers-Danlos syndrome, familial forms of thoracic aortic aneurysms or aortic dissection, and bicuspid aortic valve are all examples of heritable disorders that have associated defects affecting the integrity of the aortic wall, posing a risk of both aneurysmal dilation and dissection. The purpose of this review was to outline the phenotypes of the heritable syndromes that predispose to aortic dissection, present a guideline to their management and surveillance, and to offer insight into some of the surgical pitfalls that occur when repairing ascending aortic dissections in these types of patients.

Aortic Dissection↗

PubMed2005

Operative management of ascending aortic dissections.

Surgical management has been the established standard of care for acute ascending aortic dissection (Stanford type A or Debakey type I or II) with a worldwide average operative mortality rate of 23% compared with a 1-month mortality rate of 60% with medical management alone. Improving an institution's operative results depends on the establishment of a comprehensive and specialized team integrating their expertise into a protocol-driven system of care delivery specific for aortic dissections. The operative strategies and techniques for repairing aortic dissections should also be standardized within an institution to optimize outcomes. The primary goals of operative repair of ascending aortic dissection are to restore aortic valvular competency and systemic perfusion, to obliterate false-lumen blood flow, and to prevent rupture, myocardial infarction, stroke, and death. The goals, strategies, and expected outcomes for the operative management of acute ascending aortic dissection are presented.

Aortic Dissection↗

PubMed2005

Indications, timing, and prognosis of operative repair of aortic dissections.

Since the first description of aortic dissection in the 1700s, the understanding and treatment of this catastrophic disease has evolved. Aortic dissections are identified as a tear in the aortic intima and inner layer of the media that allows for blood flow within the aortic wall. The area of the vessel involved determines its classification. The classification, in turn, helps to predict outcomes, which allows for appropriate treatment planning. The goal of this article is to outline the operative indications and timing for Stanford type A and type B dissections, based on prior reported data and our own clinical experience with 176 patients treated surgically at the Yale Center for Thoracic Aortic Disease. With this data we will revisit the importance of looking at each patient individually to devise an appropriate operative plan, with the knowledge that treatment for type A dissections is operative and treatment for type B dissections is medical unless patients present with actual or impending rupture, malperfusion, or failure of medical management.

Adolescent↗

PubMed2005

Chronic descending aortic dissections.

Aortic dissection involving the descending aorta has a predictable and often debilitating course of progressive dilatation that occurs once patients survive the acute phase of the disease. Important factors that impact the rate and degree of dilatation include the persistence of a false lumen channel (and the amount of thrombus), the control of hypertension, and the presence of an underlying connective tissue disorder. The mainstay of management of chronic descending aortic dissections is antihypertensive therapy including beta-blockade until the dissected aorta becomes significantly aneurysmal. Surgical management is recommended at that point. Multiple advances have been made that have improved the results of operative repair of aneurysmal descending aortic dissections including circulation management methodologies, CSF drainage, neurocerebral monitoring, and more recently, endovascular therapies. The presentation, diagnosis and management of chronic descending aortic dissections are discussed.

Aortic Dissection↗

PubMed2002

Treatment of aortic dissections with endovascular stent grafts.

The management of aortic dissections remains controversial. Knowledge regarding the extent and specific pathophysiology of each dissection is critical prior to intervention. Cross-sectional imaging techniques coupled with intravascular ultrasound or hemodynamic measurements are vital. In the setting of ischemia with significant true lumen compromise, the placement of a proximal endovascular graft has a high likelihood of dramatically improving the diameter of the true lumen, alleviating distal ischemia. Caution must be taken when branch vessels are involved in the dissection. Adequate true lumen flow with persistent end-organ ischemia is best handled with branch vessel stenting. Combined true lumen compresssion and branch vessel dissection requires both visceral vessel stenting and proximal endovascular grafting. Using these techniques, we have been able to achieve a mortality rate of less than 35% in a patient population that previously suffered mortality rates in excess of 50%. However, application of these technologies to asymptomatic or nonischemic dissections is not warranted outside the context of investigational trials.

Aortic Dissection↗

PubMed2002

Spontaneous dissection of the infrarenal abdominal aorta.

Spontaneous infrarenal abdominal aortic dissection is rare. We observed enlargement of a spontaneous infrarenal aortoiliac dissection in a 55-year-old hypertensive man. Open surgical repair with a bifurcated polyester graft was successful. A review of the English literature found 41 previously published cases. Mean age was 58 years, 74% of the patients were male, and 62% had hypertension. None had Marfan or Ehlers-Danlos syndrome. More than three fourths of the patients had symptoms, 6 patients (14%) presented with aortic rupture. Dissection was limited to the infrarenal aorta in 50% and extended into the iliac or femoral arteries in 50%. Three patients died before treatment, no death occurred after endovascular repair of after elective open aortic grafting. Mortality following rupture was 67%. Abdominal aortic dissection did not reoccur but 1 patient died at 14 month because of rupture of a thoracic aneurysm. Spontaneous infrarenal abdominal aortic dissections are rare, but usually symptomatic and 14% rupture. Rupture carries high mortality. Elective open repair is recommended, but endovascular repair is a new treatment option for suitable patients.

Aortic Dissection↗

PubMed2002

Neck dissection in oral cancer--clinical review and analysis of prognostic factors.

The purpose of this study was to evaluate the oncologic effectiveness of radical and different types of modified neck dissections with preservation of the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle and to identify prognostic factors for regional control and survival in univariate and multivariate analysis. This retrospective study included 373 patients with squamous cell carcinoma of the oral cavity who underwent 401 neck dissections between January 1986 and December 1997 at the Department for Oral and Maxillofacial Surgery, Hanover Medical School. The actuarial neck control rate after 5 years was estimated with 87%. Neck failure occured only within the first 2 years after neck dissection. The number of positive nodes, macroscopic extracapsular spread, peeling off metastases from carotid artery and cranial base and preoperative radiochemotherapy were significant prognostic factors. Grade of metastases, microscopic extracapsular spread, lymphangiosis carcinomatosa and postoperative radiation showed no prognostic significance. The comparison of neck failures after radical and modified neck dissection demonstrated a tendency to improved regional control after radical neck dissection with increasing extent of neck disease.

Accessory Nerve↗

PubMed2001

Predictability of internal carotid artery (ICA) dissectability in cases showing ICA involvement in parasellar meningioma.

The present study identified predictors for surgical internal carotid artery (ICA) dissection in cases showing ICA involvement in parasellar meningiomas. Twelve cases encountered over the past 4 years were reviewed. Based on MRI findings, patients were divided into two groups; six patients demonstrated complete ICA involvement (encasement) and the other six showed partial ICA involvement (engulfment). The ICA was dissected in all cases in the engulfment group and in four of six cases in the encasement group. The ICA can be dissected even if it is involved at the centre of the tumour if the tumour is soft and can be aspirated. Preservation of the perforating arteries is more important and more difficult. Angiographic finding showing encasement of a long segment of the ICA is unfavourable because of the high possibility that the perforating arteries are involved. Local stenosis of ICA is another unfavourable finding for surgical dissection because tumour invasion of the arterial wall would be suspected. Thus, ICA encasement by the tumour is the less favourable finding for surgery but it is not a decisive predictor. More important findings for ICA dissection in cases showing ICA encasement are involvement of a long segment of the ICA and local ICA stenosis on angiogram.

Aged↗

PubMed2000

[Minimally invasive therapy options in aortic dissections].

Current day therapy for aortic dissection is aimed at the relief of branch vessel ischemia and the prevention of aortic rupture or aneurysm formation. Malperfusion complicating aortic dissection has historically been treated by surgery. Operations in patients with branch-vessel involvement may be technically difficult and the operative mortality is reported to be between 25% and 51%. This may rise to above 70% in patients with critical mesenteric or renal ischemia. Over the past decade, successful relief of such ischemia using the interventional radiological techniques of balloon fenestration, stent implantation and/or thrombolysis has been reported. In addition to being less invasive, this approach is associated with a lower mortality, ranging between 0% and 25%. Patency of the false lumen increases the probability of aortic rupture or aneurysm formation. Recent studies have reported successful closure of the proximal entry site with the help of stent grafts. The aim of the intervention is to initiate a thrombosis of the false lumen and thus stabilize the dissection. Based on a review of the literature and our own experience, we discuss the percutaneous management of branch vessel ischemia complicating aortic dissection as well as the role of stent graft implantation in patients with aortic dissection.

Aortic Dissection↗