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PubMed1997

Pitfalls in the echocardiographic diagnosis of aortic dissection.

The authors studied 25 patients with transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE) for suspected aortic dissection. Of these, aortic dissection was diagnosed correctly in 19 patients, but in 6 the echocardiographic findings for dissection were atypical or false-positive. In patient 1, the TEE revealed a dilatated proximal aortic root. TEE showed a possible flap but was nondiagnostic. The diagnosis was made by computed tomography (CT) and confirmed at surgery to be type 1 dissection. In patient 2, the TTE depicted flail aortic cusps, questionable vegetations, and dilatated aortic root. In patient 3, TTE demonstrated moderate pericardial effusion with hematoma but no dissection. Type 1 dissection was subsequently confirmed at autopsy in both. Patient 4 had TEE diagnosis of type 3 dissection. However, reevaluation of the study by a senior sonographer just prior to surgery led to the correct diagnosis of type 1 dissection. Patients 5 and 6 had dilatated ascending aortas with linear echoes within the lumen on TEE and were reported as having type 1 dissections. CT and/or angiography did not reveal dissection in either patient. In conclusion, TTE and TEE are vaulable tests in diagnosing aortic dissection. However, atypical features, misdiagnosis of the site of dissection, or false-positive studies can occur.

Adult↗

PubMed1992

[Acute and subacute dissection of the thoracic aorta: diagnostic importance of magnetic resonance tomography].

The purpose of this study was to retrospectively assess the reliability of ECG-triggered magnetic resonance imaging (MRI) for the diagnosis of acute and subacute thoracic aortic dissection and associated clinical epiphenomena. 67 patients were subjected to MRI; the diagnostic results were compared with morphological standards. 25 patients had type A, 12 patients type B dissection. In 30 cases a dissection was excluded. 17 patients with aortic dissection had acute onset of symptoms, 10 patients had subacute onset of symptoms. 17 patients revealed thrombosis of the false lumen, which was found in the descending aorta in 59% of the cases. Aortic regurgitation and pericardial effusion was most often associated with type A dissection (Table 1). Three patients were studied while on mechanical ventilation. Scan time for MRI ranged from 15 to 71 minutes with an average of 46 +/- 18 minutes. In this series no deleterious events were encountered related to MRI diagnostics. In contrast to previously published data using other noninvasive techniques the sensitivity of MRI was 100% for detecting a dissection in the ascending segment of the thoracic aorta. Moreover, the specificity of MRI for a dissection was 100% and thus higher than previously published data using transesophageal echocardiography. Sensitivity and specificity for detection and correct classification of type B dissection was 100% and 100% respectively (Table 2). In addition, MRI proved to be sensitive in detecting the formation of thrombus material in the false lumen of the ascending aorta (92%), the aortic arch (100%) and the descending segment (88%). Specificity for exclusion of suspected thrombus material even proved to be slightly higher with 100% in the ascending and descending aorta and 96.1% in the aortic arch (Table 3). The site of entry to a dissection was detected in 78%, with a sensitivity of 76% in the ascending and 92% in the descending aorta. The involvement of side branches in the dissecting process was identified in 60%. There were no false positive findings concerning side branch involvement. Aortic regurgitation and pericardial effusion were detected in 100% and 100%, respectively (Tables 1 and 2). MRI performed even in acute cases proved to be a atraumatic, safe and highly sensitive method to identify and classify acute and subacute dissections of the entire thoracic aorta. Limited patient access was not associated with an increased risk and mechanical ventilation did not interfere with MRI. These results may establish MRI as a valid and promising noninvasive technique to establish the diagnosis in patients with thoracic aortic dissection.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute Disease↗

PubMed1986

[Role of echocardiography in the diagnosis of aortic dissection].

We evaluated sensitivity, specificity and predictive values of echocardiography in detecting aortic dissection. We studied in the same period of time two groups of consecutive patients with good quality echocardiographic examination. Group I, with high prevalence of the disease (76%), was composed of 25 patients; 19 patients with aortic dissection (11 of the type A and 8 of the type B) and 6 patients with clinical and echocardiographic suggestion of aortic dissection which was not confirmed by angiography. Group II, with lower prevalence of the disease (4%), was composed of 382 adult patients who underwent aortic angiography for different reasons. In this second group there were 16 out of the 19 patients of the first group, with aortic dissection, who underwent aortic angiography and the 6 patients with suspicion of aortic dissection which was not confirmed by angiography. Type A dissection: The finding of intimal flap on echocardiography was highly specific (98%) but relatively insensitive (45%); its positive predictive value was low (50% in the first and 34% in the second group). The specificity of increased thickness of aortic wall was lower (89%) and the sensitivity higher (81%); its positive predictive value was satisfactory in the first group (81%) and very low in the second (13%). Aortic root dilatation was fairly specific (76%); the sensitivity of this finding was high (87%) but its positive predictive value was still low (66% in the first and 7% in the second group). To conclude: the positive predictive value of the 3 echocardiographic signs of aortic dissection varied, in relation to the different prevalence of the disease, from 50, 81 and 66% in the first group to 34, 13 and 7% in the second group; the diagnostic utility of the echocardiographic examination appeared limited, in these patients, by the low values of sensitivity and positive predictive values; aortography is still the most valuable technique in the diagnosis of aortic dissection; echocardiography was useful in the early evaluation of some emergency cases (chest pain, shock, collapse...) suggesting sometimes the correct diagnostic hypothesis of aortic dissection; in the presence of a typical clinical picture, the contemporary presence of the 3 echocardiographic signs, though having the lowest sensitivity (36%), was highly predictive of the type A dissection. Type B dissection: In these patients the clinical picture, in contrast with type A dissection, Type A, was not indicating careful and complete echocardiographic aortic scan. Then the echocardiographic examination was even more disappointing: sensitivity 25%.

Adult↗

PubMed1996

[Surgical treatment of aortic dissection with ringed intraluminal graft--late results and fate of the false lumen].

Between April 1981 and March 1992, sixty-nine patients underwent surgery for aortic dissection in our hospital and affiliated hospitals. Of them, 48 patients who survived the operation were followed up 2 months to 11.8 years (mean: 4.6 years). We compared the fate of the false lumen and late results in the 31 patients who underwent ringed intraluminal graft (RIG group) and the 17 patients who underwent conventional graft replacement (GR group). To clarify the status and severity of the dissected aorta, we devised a scoring system (dissection score: DS) to evaluate the long-term changes in the diseased aorta after operation. Of 12 patients (25%) who died of late dissection-related complications, 10 were in the RIG group and 2 in the GR group. The actuarial survival at 5 years was 66 +/- 9% in the RIG group and 88 +/- 8% in the GR group. Late dissection-related events (dissection-related death, redissection, reoperation) were observed in 17 patients, 14 of whom belonged to the RIG group and 3 to the GR group. The dissection-related event-free survival at 5 years was 51 +/- 10% in the RIG group and 88 +/- 8% in the GR group. In 36 (75%) of the 48 patients, including 20 (65%) of the 31 patients in the RIG group and 16 (94%) of the 17 in the GR group (p < 0.05), it was possible to resect the primary intimal tear. The actuarial survival at 5 years was 76 +/- 8% for those 36 cases in which resection of the primary intimal tear was possible and 64 +/- 15% for those in which resection was not possible. The dissection-related event-free survival at 5 years was 72 +/- 8% in the former group and 33 +/- 15% in the latter. The dissection score (DS) decreased from a pre-operative value of 21.5 +/- 8.4 to 12.0 +/- 9.3 postoperatively (p < 0.001). A significant decrease in DS was observed both in the RIG group and the GR group, in the former from 22.1 +/- 7.2 to 13.1 +/- 9.3, and in the latter from 19.9 +/- 11.5 to 9.1 +/- 9.2 (p < 0.01). The DS for those whose primary intimal tear could be resected was significantly decreased postoperatively (pre-operative 20.6 +/- 8.9, post-operative 9.3 +/- 8.4; p < 0.001); but for those whose primary intimal tear could not be resected, there was no difference between the pre- and post-operative DS (pre-operative 23.4 +/- 7.3, post-operative 18.2 +/- 8.7). The percent reduction in DS (%R) was significantly greater in the former group than in the latter one (61% vs. 29%; p < 0.02). DS significantly decreased for those with no late dissection-related events (from 22.4 +/- 9.2 to 10.9 +/- 8.8; p < 0.001) while for those who presented with such events there was no difference between before and after the operation (pre-operative 19.0 +/- 5.7, post-operative 14.9 +/- 10.6). The %R in those with dissection-related events tended to be lower than that in those without such events (33% vs. 58%). Resection of primary intimal tear seemed to be important not only to improve operative results in patients with aortic dissection but also to improve late results. Depending on the site and size of the intimal tear, the ringed intraluminal graft insertion technique often makes intimal tear resection impossible. Indications for this surgical technique are thus quite limited.

Aged↗

PubMedDate not supplied

Prevalence of vertebral artery dissection in Wallenberg syndrome: neuroradiological analysis of 93 patients in the Tohoku District, Japan.

To assess the prevalence of vertebral artery dissection in Wallenberg syndrome (lateral medullary syndrome), records of 93 patients (70 men, 21 women, and 2 patients not identified by gender; mean age at ictus, 58.1 years) with symptoms of Wallenberg syndrome who underwent MRI and/or vertebral angiography were reviewed retrospectively. Study items included the following: (A) headache; (B) arterial intramural hematoma on T1-weighted images as an MR finding; and (C) double lumen, intimal flap, pearl and string sign, and string sign as angiographic findings. These abnormal findings suggesting vertebral artery dissection were scored as 1 or 2 points. According to his or her total score, each patient was classified as "definite dissection." "probable dissection," "suspected dissection," or "no dissection." Twenty-three of 93 patients were classified as "definite dissection," 23 as "probable dissection," 27 as "suspected dissection," and 20 as "no dissection." The frequency of definite or probable dissection in Wallenberg syndrome was estimated at 50% or more. Thus, vertebral artery dissection is a frequent cause of Wallenberg syndrome.

Adult↗

PubMed1998

Axillary lymph node dissection for breast cancer: a decision analysis of T1 lesions.

BACKGROUND: The value of routine axillary dissection for patients with breast cancer is still being debated. The argument centers around whether the information gained by knowing the lymph node status, which aids in making the decision about adjuvant chemotherapy, justifies the morbidity. This study quantitatively analyzes the potential outcomes of routine, selective, and no axillary dissection. METHODS: A decision analysis was performed of the strategies of lumpectomy and radiation versus simple mastectomy followed by no dissection, selective dissection, or routine dissection. Factors included biologic markers to identify high-risk lesions, the morbidity of axillary dissection, the effects of adjuvant chemotherapy on lymph node-negative and lymph node-positive disease, and the life expectancy of patients with high-risk and low-risk node-negative and node-positive lesions. Sensitivity analysis was done to determine threshold levels of these factors in choosing an option. RESULTS: We discovered an advantage in quality-adjusted life expectancy (QALE) for no axillary dissection until the probability of positive lymph nodes reaches >15%; after that, selective node dissection is superior. Selective dissection is superior for lower morbidity rates of axillary dissection. Routine dissection is never a superior strategy. The difference among these strategies is small, however, with no one strategy providing a QALE greater than 1 year longer than any other. CONCLUSIONS: Axillary dissection can be avoided in patients with high-risk lesions who would be candidates for adjuvant chemotherapy regardless of lymph node status, and possibly in patients with low-risk T1a lesions, but it should be recommended for low-risk T1b and T1c lesions for which lymph node status may determine the need for adjuvant chemotherapy.

Axilla↗

PubMed1992

Therapeutic dissection after successful coronary balloon angioplasty: no influence on restenosis or on clinical outcome in 693 patients. The MERCATOR Study Group (Multicenter European Research Trial with Cilazapril after Angioplasty to prevent Transluminal Coronary Obstruction and Restenosis).

OBJECTIVES: The objective of this study was to examine the relation between an angiographically visible coronary dissection immediately after successful coronary balloon angioplasty and a subsequent restenosis and long-term clinical outcome. BACKGROUND: The study population comprised all 693 patients who participated in the MERCATOR trial (randomized, double-blind, placebo-controlled restenosis prevention trial of cilazapril, 5 mg two times a day). METHODS: Cineangiographic films were processed and analyzed at a central angiographic core laboratory, without knowledge of clinical data, with use of an automated interpolated edge detection technique. Dissection was judged according to the National Heart, Lung, and Blood Institute classification. Angiographic follow-up was obtained in 94% of patients with 778 lesions. Two approaches were used to assess the restenosis phenomenon: 1) categoric, using the traditional cutoff criterion of greater than 50% diameter stenosis at follow-up, and 2) continuous, defined as absolute change in minimal lumen diameter (mm) between the postcoronary angioplasty and follow-up, adjusted for the vessel size (relative loss). Clinical outcome was ranked according to the most serious adverse clinical event per patient during the 6-month follow-up period, ranging from death, nonfatal myocardial infarction, coronary revascularization and recurrent angina requiring medical therapy to none of these. RESULTS: Dissection was present in 247 (32%) of the 778 dilated lesions. The restenosis rate was 29% in lesions with and 30% in lesions without dissection (relative risk 0.97; 95% confidence interval 0.77 to 1.23). The relative loss in both groups was 0.10 (mean difference 0; 95% confidence interval -0.03 to 0.03). Clinical outcome ranged from death in 4 patients (0.9%) without dissection and 1 patient (0.4%) with dissection; nonfatal myocardial infarction in 4 (0.9%) without and 8 (3.2%) with dissection; coronary revascularization in 73 (16.6%) without and 32 (12.7%) with dissection; recurrent angina requiring medical therapy in 88 (20%) without and 47 (18.7%) with dissection to no serious adverse event in 272 (61.7%) without and 114 (65.1%) with dissection. CONCLUSIONS: These data indicate that a successfully dilated coronary lesion with an angiographically visible dissection is no more likely to develop restenosis, and is not associated with a worse clinical outcome, at 6-month follow-up than is a dilated lesion without visible dissection on the post-balloon angioplasty angiogram.

Angioplasty, Balloon, Coronary↗

PubMed2000

Judging the therapeutic value of lymph node dissections for melanoma.

BACKGROUND: The management of the regional lymph nodes remains controversial for early-stage melanoma and for those patients with lymph node metastases; American Joint Committee on Cancer stage III. This study examines the importance of quality of the surgical resection measured by the extent of lymph node dissection (quartile of the total number of lymph nodes removed) to determine if this factor is an important prognostic factor for survival. STUDY DESIGN: We reviewed our computer-assisted database of more than 8,700 melanoma patients prospectively collected from 1971 through the present to identify patients who underwent lymph node dissection for stage III melanoma. We included only patients who had their nodal dissections performed at our institute. Patients who underwent sentinel lymph node dissection were excluded. These patients were then analyzed as a group and by individual lymphatic basins: cervical, axillary, and inguinal basins. Univariate and multivariate analyses were used to examine the model that included tumor burden, thickness of the primary melanoma, gender, age, clinical status of the lymph nodes (palpable versus not palpable), and the primary site. The survival and recurrence rates were analyzed using the Cox proportional hazards model. RESULTS: Five hundred forty-eight patients underwent regional lymph node dissections. Of these patients, 214 underwent axillary dissections, 181 inguinal dissections, and 153 cervical dissections. The extent of the nodal dissections was based on the quartile of nodes excised, ranging from 1 to 98 (mean +/- SD = 25.8 +/- 15.8). Patients were stratified by tumor burden and quartile of number of lymph nodes removed. The overall 5-year survival of patients with four or more lymph nodes having tumor and the highest quartile of lymph nodes removed was 44% and was 23% for the lowest quartile of total lymph nodes excised (p = 0.05). By univariate analysis, tumor burden (p = 0.0001), quartile of total lymph nodes removed (p = 0.043), and primary site (p = 0.047) were statistically significant for predicting overall survival. Gender, clinical status of the nodes, primary tumor thickness, age, and dissected basin were not significant (p > 0.05). By multivariate analysis only the tumor burden (p = 0.0001) and quartile of lymph nodes resected (p = 0.044) were statistically significant. CONCLUSIONS: The extent of lymph node dissection for melanoma when analyzed by quartiles is an independent factor in overall survival. This factor appears to be more important with increasing tumor burden in the lymphatic basin. The extent of lymph node dissection should be considered as a prognostic factor in the design of clinical trials that involve stage III melanoma.

Female↗

PubMed2000

Accessory nerve function after modified radical and lateral neck dissections.

OBJECTIVES: Evaluate preoperative and postoperative electrophysiological changes related to the accessory nerve with reference to dissection technique, modified radical neck dissection, and lateral neck dissection. STUDY DESIGN: Prospective electrophysiological analysis of accessory nerve function in a total of 20 laryngeal carcinoma patients after neck dissection, 12 being lateral neck dissection (4 bilateral) and 8 being modified radical neck dissection. METHODS: Distal latencies, compound muscle action potentials, and electromyography findings were investigated before surgery and, in early and late postoperative periods in 20 laryngeal carcinoma patients. Results were evaluated by Student t test and chi2 test for intragroup and intergroup differences. RESULTS: In the lateral neck dissection group, postoperative distal latencies were longer, without statistical significance, whereas in the modified radical neck dissection group postoperative latencies were statistically longer. Postoperative compound muscle action potentials were significantly lower in both groups. Electromyographic work-up showed deterioration in early postoperative periods and improvement in late postoperative periods. When intergroup differences were compared, both postoperative compound muscle action potential and electromyographic findings were worse in the lateral neck dissection group. CONCLUSIONS: The accessory nerve function after modified radical neck dissection is better than function after lateral neck dissection because of increased stress applied to the nerve during retraction of the sternocleidomastoid muscle for achievement of a better exposed surgical field in lateral neck dissection.

Accessory Nerve↗

PubMed2001

Angiographic classification of coronary dissections after plain old balloon angioplasty for prediction of regression at follow-up.

Coronary dissection after plain old balloon angioplasty often shows regression during follow-up. This study sought to determine whether we can predict such phenomenon angiographically. We analyzed 64 patients with 71 type B-D coronary dissections determined by the National, Heart, Lung, and Blood Institute (NHLBI) criteria. Regression was considered present when minimal lumen diameter increased by more than 0.3 mm during follow-up. Dissections were divided into subgroups using the NHLBI criteria and our classification in which type a and b dissections were characterized by the width of a dissection lumen exceeding one quarter of the reference diameter with the outer edge of the dissection lumen within the boundary of reference in type a and beyond it in type b. In type c and type d dissections, the width of the dissection lumen was within one quarter of the reference with its outer edge within the boundary of reference in type c and beyond it in type d. Type e dissection had a protruding flap or spiral appearance. Regression was recognized in 23.9%. The distribution of dissection types was similar in the groups with and without regression by the NHLBI criteria, but type c dissection had regression more frequently than the other types of coronary dissections (p<0.001) using our classification.

Aged↗

PubMed1994

[Mediastinal lymph node dissection improves survival rate in N2(-) non-small cell lung cancer patients].

The effect of mediastinal lymph node dissection on survival rate in clinical N2(-) non-small cell lung cancer patients was assessed. N2(-) was evaluated by both pre-operative computed tomography studies and physical examination during surgery. Systematic mediastinal lymph node dissection, including nodes #1, 2, 3, 3a, 3p, 4, 7, 8 and 9 was performed in 27 patients (T1 or 2, N0 or 1, M0) since 1987 (dissected group). Survival rate and complications were compared with those in 21 patients treated before 1986, in whom mediastinal lymph nodes were not dissected (non-dissected group). 1, 3 and 5 year survival rates in the dissected group were 92.6%, 74.9%, and 74.9%, respectively, which were significantly higher than those in the non-dissected group (71.4%, 61.9% and 41.3%, respectively). Mediastinal lymph node metastases were detected histologically found in three patients, 11% of the dissected group. Respiratory complications showed a significantly higher incidence in the dissected group (p = 0.001). However these complications did not increase the mortality rate in that group. Among elderly patients over 70 years old (8 patients in the dissected group, 7 in the non-dissected group), survival rates were similar in the two groups. In conclusion, systematic mediastinal lymph node dissection significantly improved the survival rate in clinical N2(-) non-small cell lung cancer patients.

Aged↗

PubMed1997

Neck dissection for surgical treatment of lymphnode metastasis in papillary thyroid carcinoma.

In papillary thyroid carcinoma lymphnode metastases at presentation do not seem to adversely affect survival, but do increase the risk of loco-regional tumor recurrence. The value of systematic versus selective lymphadenectomy is far less standardized, whereas the role of postoperative radioiodine in preventing either nodal recurrence or cancer death remains controversial. Clinical data of 36 N+ patients with papillary thyroid carcinoma who had undergone from 1990 to 1996 ipsilateral or bilateral neck dissection were retrospectively reviewed, to analyse the value of systematic lymphadenectomy. In our series of 50 extensive lymph node dissections (levels 2-6), the number of metastases in each specimen (mean value: 5) and the incidence of multiple level metastases (36%) were high. In 37.5% of the metastases at level 6 and in 11.1% at level 4, coexisting nodal involvement at level 2 was observed, without metastasization at intermediate levels. Multiple levels metastases and skip metastases were present in at least one third of the patients and could be excised only performing a complete dissection of the levels 2-6. Extra-capsular spread was found in 56% of the specimens. In 64.3% of these cases a functional neck dissection was performed. A modified radical or radical neck dissection was carried out in the other 35.7% of the cases. These patients received modified radical neck dissection (functional dissection with sacrifice of internal jugular vein) in 60% of the cases and radical neck dissection in the other 40%. In papillary thyroid carcinoma extensive lymphnode dissection at presentation has been stated to offer no advantage versus selective lymphadenectomy, causing increased morbidity. However, experienced surgeons report a low incidence (less than 5%) of accessory spinal nerve and cervical plexus permanent sequelae after functional neck dissection. In our opinion, patients with cervical lymph node metastases require a complete loco-regional neck dissection. Systematic lymphadenectomy, performed by lateral neck plus upper anterior mediastinal dissection, can yield a high disease-free survival. Moreover, this can limit the overall radio-iodine therapeutic dose and the risk of de-differentiation of recurrent tumor to the anaplastic type in patients with a long-term and near normal life-span.

Adult↗

PubMed2000

Arterial dissections complicating cerebral angiography and cerebrovascular interventions.

BACKGROUND AND PURPOSE: Iatrogenic dissections are an uncommon complication of cerebral angiography. We retrospectively reviewed 12 cases of arterial dissections complicating cerebral angiography and cerebrovascular interventions to evaluate the clinical course of these dissections. METHODS: Cases from a large tertiary center performing a large number of neurovascular procedures were collected retrospectively. The patients' medical records and imaging studies were reviewed, with particular attention given to the cause of the dissection, the development of ischemic events resulting from the dissection, and the treatment used. RESULTS: Each of nine dissections affected a vertebral artery, each of two affected an internal carotid artery, and one affected a common carotid artery. The prevalence of iatrogenic dissections was 0.4%. Seven of the dissections were noted at the time of contrast material injection for the filming of cerebral angiograms. The other five dissections occurred during catheter or wire manipulations for interventional neuroradiologic procedures. Five of the patients in our series were treated with IV administered heparin for 24 to 48 hours. The other seven patients had recently suffered acute intracranial hemorrhage or undergone neurosurgery and could not undergo anticoagulant therapy. None of the patients developed symptoms of ischemia, but one was later found to have an asymptomatic infarct in the territory supplied by the dissected artery. CONCLUSION: Arterial dissections are an uncommon complication of cerebral angiography and cerebrovascular interventions and usually have a benign clinical course.

Adult↗

PubMed1997

Expanded application of selective neck dissection with regard to nodal status.

BACKGROUND: The efficacy of extending the application of selective neck dissection to include more-extensive neck disease in patients with squamous carcinoma of the upper aerodigestive tract remains controversial. METHODS: A review of all patients undergoing selective neck dissection at a single institution during a 5-year period was undertaken. The analysis was conducted on 82 patients who received 94 selective neck dissections as part of initial therapy for management of squamous carcinoma of the upper aerodigestive tract, including: oral cavity, oropharynx, larynx, and hypopharynx. RESULTS: Forty-six of the 94 dissected necks were supraomohyoid dissections, and 48 were lateral neck dissections. Sixty-five percent of patients were followed a minimum of 2 years and formed the cohort for final analysis. There were eight regional recurrences, three of which occurred in the contralateral, undissected neck. The regional recurrence rate for all patients undergoing selective neck dissection, with or without radiotherapy, according to pathologic N status was as follows: NO (1/33), 3%; N1 (1/8), 12.5%; and multiple positive nodes (3/26), 11.5%. A comparison of recurrence rates with respect to extent of neck disease (N0-N1 versus multiple positive nodes) for both types of neck dissection did not demonstrate significant differences; supraomohyoid neck dissection, p < .5; lateral neck dissection, p < .25. CONCLUSIONS: There exists an expanded role for selective neck dissection in selected patients with primary squamous cell carcinoma of the upper aerodigestive tract and multiple N+ cervical disease. The selection of patients who are candidates for selective lymphadenectomy should be based on pathoanatomic considerations with reference to the primary site of tumor and demonstrated level(s) of metastatic involvement.

Aged↗

PubMed1995

Coronary artery disease in patients with type A aortic dissection.

The usefulness of preoperative coronary arteriography in patients with type A dissection of the aorta is controversial. To determine the prevalence of arteriosclerotic coronary artery disease in patients with type A dissection of the aorta, we reviewed our experience in 62 patients (42 with acute dissection and 20 with chronic dissection) who underwent operation between January 1, 1986, and December 31, 1993. Among 23 patients with acute dissection who underwent coronary arteriography, 8 (34.8%) had one or more coronary artery lesions causing a greater than 50% narrowing. Among 14 patients with chronic dissection who underwent coronary arteriography, 6 (42.9%) had one or more coronary artery lesions causing a greater than 50% narrowing. There were no fatal complications associated with coronary arteriography. Four patients with acute dissection and 6 patients with chronic dissection underwent coronary artery bypass grafting at the time of operative repair of the aortic dissection, with no operative deaths. On the basis of these findings and the success of combined coronary artery bypass grafting and aortic repair, we recommend that patients with an acute type A dissection who are in stable condition and all patients with a chronic type A dissection of the aorta should undergo preoperative coronary arteriography.

Acute Disease↗

PubMed1997

Angiographic evolution of intracoronary thrombus and dissection following percutaneous transluminal coronary angioplasty (the Thrombolysis and Angioplasty in Unstable Angina [TAUSA] trial).

The evolution and progression of thrombus and dissection after percutaneous transluminal coronary angioplasty (PTCA) are unknown. As part of the protocol of the Thrombolysis and Angioplasty in Unstable Angina (TAUSA) trial, 1 and 15 minutes post-PTCA angiograms were routinely performed and evaluated by the core laboratory for the presence of thrombus and either minor or major dissection. Thrombus was present at 1 minute in 4.4% of culprit lesions. This increased to 16% at 15 minutes (p < 0.005) and was equally seen in patients receiving both urokinase and placebo. Any dissection was noted in 25.2% at 1 minute versus 30.5% at 15 minutes (p < 0.08), and this trend was mainly related to an increase in major dissection with urokinase at 15 minutes versus 1 minute (10.1% vs 5.9%, respectively, p = 0.10). The in-hospital clinical outcome of patients with lesions that did or did not have thrombus or major dissection at 1 and 15 minutes was retrospectively assessed in the placebo group. The presence of either thrombus or major dissection at 1 minute was associated with a subsequent incidence of acute closure of 14% and an incidence of emergency bypass surgery of 11% (p < 0.01 compared with no thrombus or major dissection at 1 minute). The absence of thrombus and major dissection at 15 minutes (n = 173) was associated with no subsequent acute closure or emergency bypass surgery, (p < 0.05 for acute closure vs thrombus or major dissection at 15 minutes). Thrombus evolves progressively over 15 minutes after PTCA in unstable angina, whereas dissection is usually present immediately after PTCA. The absence of thrombus and major dissection at 15 minutes is associated with very low-acute in-hospital complications. Delayed angiograms following standard balloon angioplasty for unstable angina may be predictive of low complications and our study suggests a possible role for their use.

Acute Disease↗

PubMed1994

Classification of neck dissection: variations on a new theme.

BACKGROUND: Commencing in 1984, we initiated a head and neck service surgical database that included a classification system for neck dissection. The aim was to reduce the confusion in terminology resulting from growing interest in modifications of conventional radical neck dissection. METHODS: We considered a neck dissection as radical when four or five lymph node levels were excised; this included patients who had an otherwise classical neck dissection for supraglottic larynx or hypopharyngeal cancer sparing level 1. Lymph-node levels removed, nonlymphatic structures preserved, and excised nonlymphatic structures not ordinarily included in a classical radical neck dissection were all specified by the operating surgeon. We defined as a selective neck dissection any lymphadenectomy that encompassed no more than three nodal levels, usually supraomohyoid (levels 1, 2, 3), or jugular (levels 2, 3, 4). We defined as a limited neck dissection any lymphadenectomy that involved removal of no more than two nodal levels. RESULTS: At the 10-year mark, this database of 10,650 patients now includes 2,635 lymphadenectomies in 2,426 patients, the precise extent of which is accurately described in each patient. CONCLUSIONS: The current classification of neck dissection does not cover all possibilities. If we define as radical those lymphadenectomies that resect four or five nodal levels and specify structures preserved or additional nonlymphatic structures sacrificed, we allow for the possibility that some procedures may be both modified and extended. Selective would describe the standard, three-level dissections (eg, supraomohyoid or jugular node dissections), and the term limited would be introduced to indicate a neck dissection that involves removal of no more than two nodal levels. Such a three-tiered classification would more accurately reflect the time and effort involved and provide a more equitable basis for reimbursement.

Carcinoma, Squamous Cell↗

PubMed1996

Detecting acute thoracic aortic dissection in the emergency department: time constraints and choice of the optimal diagnostic test.

STUDY OBJECTIVES: To compare diagnostic strategies for the emergency assessment of patients with suspected acute thoracic aortic dissection and to measure the effect of delays related to the availability of these tests on the selection of the most appropriate one. METHODS: We carried out a decision analysis representing the risks of performing one or two sequential tests, the tests' accuracy, the risks and benefits of treatment, and the time-dependent mortality rate in untreated patients with dissection (1%/hour). Data were drawn from a Medline search. Our subjects were patients who presented to the emergency department with chest pain in whom acute thoracic aortic dissection was suspected. For different clinical probabilities of aortic dissection, we compared the risks and benefits of testing using the following procedures (alone and in combinations): aortography, computed tomography (CT), magnetic resonance imaging (MRI), and both transesophageal (TEE) and transthoracic echocardiography (TTE). We then measured the effect of delays in these tests on the selection of the appropriate procedure. The outcome studied was 30-day survival. RESULTS: We determined that the "threshold" clinical probability of aortic dissection above which the benefits of testing outweigh its risks is low. It ranges from 2% with the most reliable procedure (MRI) to 9% with the least (TTE). At low probability of dissection (< 15%), the accuracy of all tests except TTE is sufficient to rule out dissection. Delays have negligible effect on these results. When the likelihood of dissection is higher, the preferred option is to order a second diagnostic test if the results of the first are negative. The threshold probabilities above which to order a second test range from 15% (CT, then aortography) to 35% (MRI, then aortography). Excessive delays may affect the selection of tests when the likelihood of dissection is high (eg, 50%). Thus, although it is less accurate, a CT scan obtained within 2 hours or a TEE obtained within 6 hours of presentation to the ED yields a higher survival rate than an MRI obtained within 9 hours. Similarly, the benefits of ordering a second test, if the result of the first are negative, outweigh the risks only if the delay in obtaining the test does not exceed 10 hours. CONCLUSION: All patients in whom aortic dissection is suspected, even if the index of suspicion is very low, should undergo one of the available diagnostic procedures (except TTE). A patient with a moderate to high probability of disease should undergo a second investigation if the findings of the first are negative. When the probability of dissection is high, the physician must consider delays in obtaining specific diagnostic tests and order those that will be the most quickly available.

Aortic Dissection↗