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PubMedDate not supplied

Distal and proximal dissection of an abdominal aortic aneurysm.

A case of abdominal aortic aneurysm in which dissection developed in retrograde fashion into the thoracic aorta is reported. The aortogram showed findings similar to DeBakey Type-IIIb dissection. No intimal tear was seen in the thoracic aorta; however, the origin of the intimal tear was found in the abdominal aorta. Renal hypertension also developed due to distal dissection of the right renal artery. Closure of the primary intimal tear, partial closure of the false channel and removal of the right kidney were performed therefore, reattachment of vessels was not required. This was the first case in which a primary tear was seen in the abdominal aorta in our 37 surgical cases of dissecting aortic aneurysm. Three cases of retrograde dissection of abdominal aortic aneurysm have been reported in the English literature as far as we have determined. The importance of accurate detection of the origin of the intimal tear is emphasized.

Aortic Dissection↗

PubMed1979

Dissecting aortic aneurysms: a clinicopathological study. II. Histopathology of the aorta.

The aortas from 83 patients with dissecting aneurysm were studied histologically. There were two examples of giant-cell arteritis, one of non-specific arteritis and one of syphilis. Apart from these, no constant feature was found in the cases of dissection when compared with 20 controls. In particular there was no difference in the grades of cystic medial necrosis, medionecrosis and fibrosis. Focal fragmentation of elastica was present in the majority of dissections (63 per cent) but similar abnormalities were seen in most controls (85 per cent). The vasa vasorum showed no special features in dissection. Intimal fibrosis and intimal longitudinal muscle were present in both groups studied. Sixteen cases showed 'old' dissections as manifest by either granulation tissue or fibrosis. The histopathological features of the four cases diagnosed clinically as having Marfan's syndrome did not differ from controls.

Adult↗

PubMed1984

Coronary artery dissections.

Isolated spontaneous coronary artery dissections are rare and usually occur in women, the majority of whom are less than 40 years of age. Coronary artery dissection may also be caused by an extension of aortic dissection, especially in Marfan's syndrome. Iatrogenic coronary artery dissections are extremely rare, especially those secondary to coronary catheterization. The consequences of dissection may be fatal; therefore, early recognition and prompt therapy may be lifesaving.

Adolescent↗

PubMed1983

[Dissection of the ascending aorta after aortic valve replacement].

Three patients who underwent aortic valve replacement had dissection of the ascending aorta 7 months, 2 years and 15 years after surgery. This is a rare complication of aortic valve replacement (11 reported cases). Its incidence estimated from the literature would appear to be less than 1% of all aortic valve replacements. It occurs in both cases of stenosis and regurgitation (4 aortic regurgitations, 2 aortic stenosis, 5 mixed aortic valve disease) and is seen in ball and cage (7 cases), tilting disc (3 cases) and bioprosthesis (1 case). Six of these patients had hypertension. The role of the initial surgery for valve replacement in secondary aortic dissection is discussed. Aortic clamping and cannulation can cause immediate dissection but may also damage the aortic wall, leading to the risk of secondary dissection. An aneurysm of the ascending aorta was observed in 5 Cases at surgery; in 3 cases, the aorta was dilated without true aneurysm; in 3 other cases the aorta was considered to be macroscopically normal. The integrity aorta is sometimes difficult to confirm and a macroscopically normal of the aorta may have fragile aortic walls, especially in cases of aortic regurgitation due to valvular dysplasia and forms frustres of Marfan's syndrome, and are associated with a risk of secondary dissection. The appearances of the aorta at aortic valve replacement influence the choice of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1983

[Diagnosis of dissecting aortic aneurysm by digital subtraction angiography].

The aim of the study was to determine whether digital subtraction angiography (DSA) can be used in the diagnosis of aortic dissection. The study group consisted of six patients with aortic dissection including one of type 2 and five of type 3 by the DeBakey classification. DSA findings were compared to cineangiographic findings. The results were as follows; In all the patients, the diagnosis of aortic dissection was possible using DSA. Especially as to the entry, which was not detected by other non-invasive methods, there was an excellent correlation between cineangiograms and DSA (sensitivity 100%). Of the 20 vessels in the abdomen, which included the celiac, superior mesenteric, and right and left renal arteries, three vessels (15%) were not identified by DSA. Causes of the failure were the low spatial resolution and the artifact due to the motion of the patients and intestinal gas movement. The accuracy rate of the abdominal branch involvement was 70%. While using a prototype equipment, the preliminary study showed that DSA is a safe and very useful method not only for diagnosing aortic dissection, but for evaluation of the entry, extension of the dissection, and involvement of major branches of the abdominal aorta and for a follow-up study.

Adult↗

PubMed1982

[A proposition of uniform nomenclature of neck dissection (author's transl)].

There are difficulties in the interpretation of operative-surgical interventions (neck dissection), because the possibility to compare the basic disease is restricted and the operative-surgical procedures are described in a very different way. The neck dissection is carried out in different methods and that is why it must be arranged also in the treatment plan in a different way. Three important facts from the lots of information were used to get comparable informations: 1. The method of neck dissection (I-III), 2. the clinical palpation-statement of the lymphatic nodes of the neck (A, B) and 3. the histological statement of the lymphatic nodes of the neck (1-3). There will result a clear and also international comparable nomenclature of neck dissection. The problematic marking "prophylactic neck dissection" loses its purpose.

Head and Neck Neoplasms↗

PubMed1981

New surgical approach to aortic dissection: flow reversal and thromboexclusion.

With the aim of decreasing the complications and mortality associated with the current techniques for aortic dissections, we have developed an operation which consists of bypassing the dissected aorta and creating flow reversal in the dissected segment. Seven patients with either acute (five) or chronic aortic dissections (two) were operated upon successfully, with no early or late deaths. Three transient postoperative complications were encountered: low cardiac output, hemiparesis, and renal insufficiency. Postoperative arteriography was performed in five patients and demonstrated exclusion of the dissected lesions by thrombosis following flow reversal in the descending aorta. Follow-up is available from 2 to 28 months (average 13 months), with no long-term complications.

Adult↗

PubMedDate not supplied

Dissection of the thoracic aorta. A comparison between medical and surgical treatment.

We have reviewed 113 patients with acute thoracic aortic dissection seen between 1965 and 1979. There were no "diagnostic" symptoms or signs of acute dissection, and diagnosis could only be reliably made by aortography. The latter also allowed typing of the dissection (De Bakey classification) which permitted appropriate therapy to be instituted. Aortography should be performed early because of the high mortality of this condition within the first 24 hours. Early surgery is warranted in all patients with Type I dissection since it significantly increases long term survival: 40% 5 year-survival for surgical treatment compared with 13% survival for medical treatment (p less than 0.01). There is no significant difference in long or short term survival for patients with Type III dissection whether patients are treated medically or surgically.

Adult↗

PubMed1981

Progression of aortic root dissection and cardiac tamponade. Documented by sequential echocardiographic examinations.

The M-mode echocardiographic features of aortic root dissection and its progression to cardiac tamponade in a 68-year-old white man are reported. The diagnosis was confirmed both by angiography and by autopsy. Negative and positive echocardiographic patterns could be obtained at the time of the first clinical diagnosis with slight different angulations of the transducer. Progression of the dissection and evidence of increase of pericardial fluid to cardiac tamponade could then be documented by sequential echocardiograms. M-mode echocardiography is a useful tool in the recognition of aortic dissection. Prolonged and accurate searching of the dissected area is required before a negative echocardiogram is accepted. Multiple sequential echocardiograms must be obtained to eventually detect a progression of the dissection or an increase in pericardial fluid. The possibility to follow the evolution of the disease may be extremely important in the choice of therapeutic intervention.

Aged↗

PubMed1995

Management of aortic dissection.

Patients with aortic dissection are divided into two main groups: those with hypertension and those with syndromes involving hereditary defects of the aortic wall. The common finding in the setting of both Marfan syndrome and hypertension is dilatation of the aorta. The biological events that may lead to dissection are a decrease in the holding power of the internal layer, an increase in blood pressure, or an increase in aortic diameter combined with a decrease in wall thickness. Treatment of established acute type A dissection is still associated with a hospital mortality of greater than 10% and long-term complications from persistent blood flow in the distal false lumen. The main therapeutic challenge is to prevent aortic dissection by screening of aortic root diameter in patients at risk, together with life-long beta-blockade for Marfan patients. In patients with suspected dissection, the preference is for rapid noninvasive diagnosis and early surgical repair to reduce the risk of malperfusion and irreversible organ damage. Results of surgery have improved, with an increasingly conservative approach to repair of the aortic valve with biological glues. Repair is now routinely carried into the aortic arch using improved methods of cerebral protection such as retrograde cerebral perfusion through the superior vena cava. Nevertheless, there remains scope for further innovation in the prevention and treatment of this difficult problem.

Aortic Dissection↗

PubMed1995

Surgical treatment of type A aortic dissections. Results with profound hypothermia and circulatory arrest.

Type A aortic dissection still presents an emergency situation in cardiac surgery that is associated with high morbidity and mortality rates. There has been a significant improvement in the surgical outcome since the introduction of deep hypothermia and circulatory arrest. In this study, we discuss our results after operative repair of ascending aortic dissections, using deep hypothermia and circulatory arrest. This study presents the results of 67 patients (43 men, 24 women) from 18 through 81 years of age (mean, 54 years) who underwent surgery for type A dissecting aneurysm over a period of 4 years. Type A dissection (52 acute and 15 chronic cases) was due to Marfan syndrome in 12 patients, to atherosclerotic disease of the aorta in 27 patients, and to traumatic injury in 1 patient. Hypertension as the only pathologic finding was observed in 27 patients. Deep hypothermia (confirmed by isoelectric electroencephalogram) and circulatory arrest were induced in all patients. Two patients died intraoperatively due to massive bleeding (intraoperative mortality, 3%). The 30-day mortality rate was 30% (n = 20). Causes of perioperative deaths in order of frequency were multi-organ failure (n = 11), myocardial infarction (n = 2), postoperative bleeding (n = 2), cerebrovascular insult (n = 2), and sepsis (n = 1). The mean intensive care unit stay of the surviving 47 patients (72%) was 8 days, followed by a mean of 21 additional days in the hospital. Our experience with profound hypothermia and circulatory arrest, used in combination with coated grafts, supports our conviction that this is the method of choice for the treatment of type A dissecting aneurysm.

Adolescent↗

PubMed1995

Dissecting the pelvic retroperitoneum and identifying the ureters. A laparoscopic technique.

A technique for dissecting the pelvic retroperitoneum and identifying the ureters and uterine arteries is described that makes use of the obliterated hypogastric arteries. The obliterated arteries are readily identified laparoscopically and, as relatively fixed structures, are easily dissected free of the bladder and surrounding areolar tissues. Once freed by blunt dissection, they are traced proximally to where they are joined by the uterine arteries to form the internal iliac arteries. Blunt dissection just proximal and medial to the uterine artery will open the pararectal space, the medial border of which is bounded by the ureter. The uterine arteries are then traced to where they cross the ureters and are freed from them by blunt dissection. The site at which the uterine arteries are divided and the extent to which the extraperitoneal spaces are developed and ureters mobilized off the medial leaf of the broad ligament are tailored to the operation performed.

Dissection↗

PubMed1994

[Nearly total aortic replacement for DeBakey type-I aortic dissection in a patient with Marfan's syndrome].

A successful nearly total aortic replacement for DeBakey type-I aortic dissection in a patient with Marfan's syndrome is reported. A 36-year-old woman developed a DeBakey type-I aortic dissection in October 1987. We replaced the ascending aorta and resuspended the aortic valve urgently, when she had not been diagnosed with Marfan's syndrome. In August 1989, we replaced the distal portion of the descending aorta and the infra-renal abdominal aorta because of dilatation in the diameter of these regions. In September 1990, she had sudden severe chest pain. Computed tomography and Doppler ultrasonography revealed that a new aortic dissection developed in the aortic arch and the descending aorta (three-channeled dissection) and that the new false lumen compressed the true and the old false lumens obstructing the blood flow to the abdominal aorta. She was immediately placed an axilo-femoral bypass, and in January 1991 she underwent the arch and descending aorta replacement using permanent bypass to the supra-aortic branches and partial extracorporeal circulation (first reported by Larmi et al). Postoperative course was satisfactory, and she has been well at 3 years after the operation. Because progressive dilatation of an untreated dissecting aorta is common in patients with Marfan's syndrome, aggressive replacement of the diseased aorta is indicated in these patients.

Adult↗

PubMed1994

[CT evaluation of aortic dissection treated surgically].

A group of 23 patients with aortic dissection submitted for surgical operation was studied by CT (type I-10, type II-7, Type III-6 patients, according to DeBakey classification). In 9 (56.3%) patients with aortic dissection, type I and III, followed up for 3,5-10 years after surgical intervention the signs of aortic dissection were still visible, and 7 (43.7%) patients after 3-9 years developed thrombotic changes of various intensity in the false aortic lumen. In 2 cases a small external leakage and aneurysmal dilatation of the aorta around the implanted prosthesis were found. Five patients with type II dissection showed no signs of the dissection and other complications, whereas two patients developed aneurysmal dilatation of the aorta around the prosthesis.

Adult↗

PubMed1994

[Non-traumatic dissection of the thoracic aorta. A review with special emphasis on postoperative paraplegia].

Non-traumatic dissection of the thoracic aorta is a degenerative vascular disease with a high morbidity and mortality. The main symptom is stabbing thoracic pain, but the diagnosis is made difficult when the clinical picture is dominated by symptoms caused by the aorta's neighbouring structures. The definitive diagnosis is made by aortography. Treatment and prognosis depend on the anatomic placement of the dissection. In dissection of the ascending aorta (type A) the treatment is solely surgical, whereas a combined medical and surgical treatment is recommended for dissections of the descending aorta (type B). The most common postoperative complication in type B dissection is paraplegia, which occurs in up to 40% of cases. The cause of paraplegia is postoperative ischaemia of the spinal medulla. Many methods and treatments have been used to avoid medullary ischaemic damage. The most important ones are reducing the time length of aortic clamping, maintaining an adequate perfusion pressure, and the use of moderate hypothermia. Spinal drainage with or without pharmacological intervention possibly has a preventive effect, but convincing clinical documentation is lacking.

Aortic Dissection↗

PubMedDate not supplied

Acute aortic dissection.

Acute aortic dissection is initiated by an intimal tear most often found in the ascending or descending thoracic aorta. A high index of suspicion is necessary to establish diagnosis. In the acute setting, transoesophageal echocardiography is very helpful to confirm the diagnosis, locate the intimal tear and demonstrate the extent of dissection. Acute type A dissection is a surgical emergency contrary to type B dissection which is treated medically unless complications arise. With correct treatment, mortality of these life-threatening disorders has been reduced during the last decade and long-term survival of discharged patients is around 50%. Careful follow-up is necessary to detect late complications, mainly the occurrence of a post-dissection aneurysm.

Aged↗

PubMed1994

[Vertebral artery dissection. Clinical aspects, non-invasive diagnosis, therapy--observations in 14 patients].

We report 14 patients with so called spontaneous vertebral artery dissection. Dissection site was the atlanto-axial (V3) segment in 12 patients, the intertransverse (V2) in 5 and the intracranial (V4) in 3. Two had additional carotid artery dissection. Typical clinical presentation of symptoms consisted in unilateral, acute, severe neck and occipital head pain (12/14) simultaneously with, or followed by signs of vertebrobasilar ischemia (12/14). The later may be Wallenberg's syndrome (7/14), a cerebellar (5/14) or a vestibular syndrome. When this constellation is present in a young patient and preceded by a "trivial" head or neck trauma dissection should be suspected in cases without vascular risk factors. According to our results, MRI today is the method of choice to confirm diagnosis. Mural hematoma can be shown non invasively (12/13). Angiography is only rarely indicated. Doppler- and duplex sonography of posterior circulation is more difficult and results are less conclusive than with the carotid system. Nevertheless, we found abnormal results in 86% and definite pathologic results in 64% of our patients when combining both methods. Immediate anticoagulation appears to be an adequate treatment when intracranial dissection is excluded. Its effectiveness, however, has not been demonstrated. None of the 12 anticoagulated patients showed deterioration.

Adult↗

PubMed1994

[Calcified false channel wall in aortic dissection].

Chest radiographs and computed tomographic images of 110 patients with chronic aortic dissection were retrospectively reviewed. Among these, calcification of false channel wall was observed in 12 cases (about 10%). Stanford type A dissection was noted in 5 cases and type B in 7 cases. Calcified false channel wall may closely simulate intimal calcification of atherosclerotic aneurysm on chest radiographs and sometimes even on CT. Careful observation of CT images with and without contrast enhancement is helpful to correctly identify the site of calcifications in the false channel wall, true channel wall, and intimal flap in the individual cases. In 3 cases calcification was present mainly in the false channel wall with no or only minimal calcification in the true channel wall. These cases may suggest that the endothelialized false channel lumen may develop atheromatous changes much more rapidly than the true lumen. According to advances in surgical and medical treatment of acute aortic dissection, radiologists may encounter cases of chronic aortic dissection with increasing frequency. Full recognition of this potential pitfall in the diagnosis of aortic dissection is important to avoid confusion.

Aged↗