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PubMed1994

[A case report of successful management of intraoperative aortic dissection during aorta-coronary bypass and aortic valve replacement].

A 70-year-old woman underwent aortic valve replacement and coronary artery bypass surgery with a saphenous vein graft for aortic regurgitation and 99% stenosis in the right coronary artery. During the period of weaning from the cardiopulmonary bypass enlargement of the ascending aorta and bleeding from the suture line were observed. The intraoperative diagnosis of ascending aortic dissection (DeBakey type I) was made with transesophageal and transthoracic echocardiography. Cardiopulmonary bypass was reinstituted and the patients was cooled to 20 degrees C. Under circulatory arrest and continuous retrograde cerebral perfusion through the superior vena cava the intimal tear at the point of infusion cannula was removed and the ascending aorta was reconstructed by direct suture bolstered with Teflon felt strips. Following completion of the repair no further dissection was seen, and the patient was successfully weaned from cardiopulmonary bypass. There were no signs of neurologic complications. Although intraoperative aortic dissection is uncommon, it can be a fatal iatrogenic complication of cardiac operations. Prompt recognition and surgical repair of the injuries are essential to achieve a successful outcome. The combination of transesophageal echocardiography and transthoracic echocardiography permits the immediate diagnosis of aortic dissection. And it is suggested that continuous retrograde cerebral perfusion through the superior vena cava protects the brain for 52 minutes of cerebral circulatory arrest at the lowest nasopharyngeal temperature of 18.7 degrees C. This technique is simple, and required neither special preoperative preparation or special equipment, so that it is suitable especially for intraoperative aortic dissection such as this case.

Aged↗

PubMed1993

[Role of magnetic resonance in the follow-up of surgically treated aortic dissection].

Twenty-one patients were examined with MRI 0.5 to 200 months after surgical aortic dissection. The series included 15 type-I dissections, 1 type-II dissection and 5 complicated type-III dissections. MR images demonstrated the persistence of the intimal flap with patency of both the true and the false lumen in 17 cases, the complete obliteration of the false lumen in 1 case and the partial thrombosis of the false lumen in 3 cases. Coronary artery ostial reimplantation was depicted in all the patients who underwent this kind of surgery; in 1 case, a small hematoma was present at the site of reimplantation. In 3 patients, an organized hematoma was seen between the prosthetic graft and the native aortic wall; in 1 case the aortic lumen was markedly reduced, while in the extant 2 cases, signal intensity features were suggestive of subacute hematoma due to prosthetic graft degeneration. Seven patients underwent two MR exams: the first one immediately after surgery (in most cases) and the second one at 3-11 months. Aortic diameter progressively increased in 4 patients, 3 of them with Marfan syndrome. In conclusion, MRI proved an accurate technique to assess aortic size beyond the prosthetic graft and to demonstrate the residual dissecting process and the postoperative problems in the prosthetic conduit.

Adult↗

PubMed1993

[Emergency surgical salvage for a closing aortic dissection: 2 case reports].

We report here the emergency surgical salvage for closing an aortic dissection in 2 female patients (case 1; 52 years old, case 2; 72 year old). They were admitted to our clinic for severe back pain (case 1) and a loss of consciousness (case 2). Acute aortic dissection (Stanford A type) with cardiac tamponade was confirmed by chest CT, aortography, and cardiac ultrasonography. Diagnosis was determined as a closing aortic dissection from a thrombosed pseudolumen on enhanced chest CT. An emergency operation was performed on the ascending aorta replacement and included resection of the entry port. The postoperative courses were uneventful, except for temporary hemodialysis in case 1. A closing aortic dissection is a new subcategory for an acute aortic dissection. Diagnosis is difficult, but it is regarded as having a good prognosis following timely emergency treatment. However, provided there is no complication, we recommend that surgical treatment should be performed aggressively to avoid rupture and/or cardiac tamponade.

Aged↗

PubMed1993

[A characteristic magnetic resonance image of a dissecting aneurysm in the vertebrobasilar system].

Recently several reports of dissecting aneurysm in the vertebrobasilar system have been published. We report the effectiveness of MRI for the detection of a dissecting aneurysm in the vertebrobasilar distribution system. A 47 year-old male [correction of female] was admitted to our hospital due to right occipitalgia and the right Wallenberg's syndrome. Computed tomography disclosed no abnormalities. Cerebral angiogram showed the pearl and string sign of the right vertebral artery, which suggested a dissecting aneurysm. MRI exhibited the infarct area at the right dorsolateral part of the medulla oblongata, which corresponded to right Wallenberg's syndrome. It disclosed high intensity ring-like findings circumscribing a low intensity spot of the lumen of the right vertebral artery. This high intensity was thought to be the hematoma between the intima and the media at the subacute stage. Its high intensity corresponded to the site of the dissecting aneurysm and of Wallenberg's syndrome. These findings are thought to be useful in the diagnosis of a dissecting aneurysm of the vertebral artery.

Aortic Dissection↗

PubMed1993

[Two cases of Marfan syndrome complicated with aortic dissection during pregnancy].

Two women with Marfan syndrome who developed aortic dissection during pregnancy are reported. Case 1: A 38-year-old woman had experienced severe back pain five years before (at the age of 33) when she was in the 38th week of gestation, followed by labour with no problem. Three years ago, she was examined in our hospital for enlarged thoracic aorta pointed out in a somatoscopy and was diagnosed as having Marfan syndrome and aortic dissection of DeBakey type IIIb. Because her aortic dissection has been growing larger recently, surgical repair is scheduled electively. Case 2: A 32-year-old woman, who had been diagnosed as having Marfan syndrome because of ectopia lentis at 10 years old, was referred to our department for a painful tumor with pulsation which had emerged at the right-hand side of her neck in the 32nd week of gestation. Acute aortic dissection of DeBakey type I complicated with acute aortic regurgitation was diagnosed, and emergency operation (Cesarean section, reconstruction of ascending aorta and aortic arch, replacement of aortic valve and aorto-coronary bypass to right coronary artery) was performed. Post-operative course was uneventful and the patient and her baby were discharged safely. In general, aortic dissection during pregnancy of patients with Marfan syndrome is of poor prognosis. Full consent by the patient and her family is necessary to decide whether the pregnancy should go on, and close cooperation among participating departments is indispensable for the treatment for this condition.

Adult↗

PubMed1993

Aortic dissection: anatomic types and surgical approaches.

Our classification system of acute dissection of the aorta is based on the site of the main intimal tear: Type A: on the ascending aorta; type B: on the transverse aortic arch; type C: on the descending aorta. The extension of the dissecting process is classified as "antegrade" or "retrograde". Acute dissection involving the ascending aorta is an absolute surgical urgency. Any delay in referring the patient to a proper surgical institution or to the operating room increases the risk of death. Fifty per cent of patients, indeed, either untreated or medically supported, die within 48 hours after the onset of symptoms. Surgical therapy is mainly aimed at preventing the patient from dying from intrapericardial rupture of the aorta or from acute massive aortic regurgitation. In type A, it is necessary to replace the ascending aorta with a bloodtight Dacron prosthesis after resecting the entry site, if possible. Downstream, joining the two dissected cylinders by two running sutures and the aid of GRF glue, seals the false lumen. Upstream, the reconstruction of the aortic root and the resuspension of the aortic valve, also by means of running sutures and GRF glue, suppress the aortic valve insufficiency in 90% patients. However, in case of pre-existing annulo-aortic ectasia, the ascending aorta must be replaced by a composite tube according to the Bentail technique. The use of GRF glue since the beginning of 1977, has dramatically improved the immediate and long-term results, accounting for a hospital mortality rate of 10%, in patients less than 65 years old. In type B, resecting the entry site requires that the transverse arch be partially or totally replaced. It is, therefore, mandatory to protect the Central Nervous System. In our experience this is best achieved by perfusing the carotid arteries with cold blood (6 degrees C) during circulatory arrest at moderate core hypothermia (28 degrees C). With this technique of "Cerebroplegia", the hospital mortality rate has been lowered to 28%, higher, though, than in patients undergoing isolated replacement of the ascending aorta. In type C, only the dissections demonstrating symptoms of major complications (rupture or deleterious ischemia) require urgent surgical treatment. In the remaining cases, medical treatment, based on permanent and accurate control of the patient's blood pressure, lead to a good long-term survival rate. Close survey at regular intervals, by means of CT scan or MNR is mandatory to detect any aneurysmal evolution, which may require surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute Disease↗

PubMed1995

[Acute thrombosed aortic dissection--its clinical manifestation and treatment for Stanford A type].

Ten patients (mean age of 63 years old) with acute thrombosed aortic dissection (ATAD) have been evaluated among 31 aortic dissections during past 10 years (from 1985 to 1995). The six cases are Stanford A type and others are Stanford B type. The mean maximal diameter of aorta was 52 +/- 6 mm in Stanford A type and 41 +/- 4 mm in Stanford B type. The ratio of true lumen was 78 +/- 14% to that of whole horizontal section area in thrombosed type and 34 +/- 19% in opacified type dissection. We had chosen conservative treatment for all ATAD. However, five patients with Stanford A type dissection needed to be operated on in short term periods. Three patients were operated upon within three days from onset, and another two patients were operated on 34th and 37th day from onset, respectively. ATAD is firstly treated medically and its prognosis is generally well. However, we proposed here that the conservative treatment for ATAD, especially Stanford A type dissection, must be reconsidered because of our many operations for ATAD in the follow-up periods.

Acute Disease↗

PubMed1996

[Acute aortic dissection with leg ischemia].

From January of 1987 to July of 1994, 83 patients with acute aortic dissection were treated at our institution. Of these, 7 patients (8%) sustained acute leg ischemia. Angiography showed that one patient had arterial occlusion at the abdominal aorta, three had occlusion at the right common iliac artery, and one had severe right common iliac artery stenosis. Four patients with acute type A dissection underwent emergency replacement of the aortic arch and/or ascending aorta. Three of them were discharged, but one patient died due to renal failure and multiple organ failure. In three patients with acute type B dissection, one with aortic rupture was successfully treated by replacement of the descending thoracic aorta; of the other two who received bypass operations for leg ischemia, one died due to myonephropathic metabolic syndrome and sepsis which were caused by a delay in surgery. In conclusion, emergency thoracic aortic repair should be performed in acute type A dissection with leg ischemia, whereas bypass operation for ischemic leg should be considered in patients of acute type B dissection with leg ischemia when they are not complicated with rupture or visceral ischemia.

Acute Disease↗

PubMed1995

Results of long-term medical treatment of patients with arterial hypertension complicated by aortic dissection.

UNLABELLED: The purpose of the study was to analyse results of ambulatory treatment of patients with arterial hypertension complicated by aortic dissection. Twenty patients (19 men, one woman), aged between 39 and 72 years, underwent full physical examination. In all cases the diagnosis of aortic dissection was confirmed by at least two different imaging methods (ultrasonography, digital subtractional angiography, computer tomography or nuclear magnetic resonance). During follow-up (3-75 months, mean 34.3 months), physical examination was performed every 6-8 weeks, chest radiograph was taken once a year. All patients controlled their blood pressure (BP) at home. According to the mean number of in-home BP measurements per month all patients were divided into two groups: group I good (n = 10) and group II bad compliers (n = 10) (28 +/- 30 vs 3 +/- 2 in-home BP measurements a month). Ten patients (6 in group I, 4 in group II) underwent 24 h automatic BP measurement examination. Blood samples were collected for serum cholesterol and uric acid measurements. All patients suffered from arterial hypertension and in five cases at least one parent suffered from this disease. Only three of 20 have never smoked cigarettes. Elevated serum cholesterol was observed in 10 (50%) cases and elevated uric acid in six (30%). Proximal (type A) aortic dissection (DeBakey classification type I and II) was found in 13 patients, distal aortic dissection (type B) in seven patients. All patients were treated with beta-blockers. In 75% of 20 cases three or more hypotensive drugs were used simultaneously to control BP. In the group I lower values of mean of maximal SBP (160 +/- 10 vs 177 +/- 7 mm Hg, P < 0.05) and lower mean circadian heart rate (58.6 +/- 7.5 vs 80.9 +/- 7.9 beats/min, P < 0.005) were observed. The most frequent complaints were intermittent claudication, 9 (45%); angina pectoris 8 (40%), other chest pain, 4 (20%). During follow-up period (3-75 months, mean 34.3 months) five of 20 patients (25%) died (all had proximal, type A dissection) and 15 of 20 patients (75%) are still alive. All deaths in group II were sudden, whereas the only one in group I was because of chronic renal insufficiency. Mortality rate in the two groups were 10% (one of 10) vs 40% (four of 10), respectively, in groups I and II. IN CONCLUSION: patients who control their BP more often have the lower values as well as lower heart rate and therefore a better prognosis.

Adult↗

PubMed1996

[Arterial hypertension complicated by aortic dissection. Clinical analysis, results of conservative treatment].

Detailed analysis of 21 patients suffering from arterial hypertension complicated by aortic dissection, who were treated non-surgically was performed. Signs and symptoms of aortic dissection appeared the most frequently in the age between 50 and 69. In 14 (66.7%) cases proximal (type A) and in 7 (33.3%) distal (type B) dissection were diagnosed. During acute phase 15 patients complained of pain and 6 did not. Smoking and family history of arterial hypertension were the commonest risk factors in this group. Proximal dissection was more frequently connected with painful course of the dissection whereas distal with painless. Detailed analysis of clinical data and non-invasive treatment during acute phase (first 14 days since onset of pain) was performed. During ambulatory observation which lasted 3-75 month (mean 34.3 month) 5 (25%) patients died, 15 (75%) are still alive.

Adult↗

PubMed1996

[Surgical repair of a dissecting aortic aneurysm with entry at proximal descending aorta through left thoracotomy--a case report].

A 45-year-old man underwent a distal arch and descending aortic replacement through a left thoracotomy. His chronic type A dissecting aortic aneurysm had the entry at the proximal descending aorta. After 9 years of his first dissection, he suffered from a second dissection. In computerized tomogram (CT), the ascending and descending aorta enlarged to 6.0 cm and 7.0 cm in diameter, respectively and descending aorta showed a three channeled dissection. The open proximal anastomosis technique was used under the deep hypothermic circulatory arrest (HCA) followed by selective cerebral perfusion (SCP). Surgical repair included the obliteration of the proximal false lumen at the level between the left carotid and subclavian artery. A thrombosed retrograde dissection in the ascending aorta was revealed in postoperative evaluation, and decreased in size at follow up CT.

Aortic Dissection↗

PubMed1995

Multiplane transesophageal echocardiography in traumatic aortic dissection: a case report.

We report a case of a 23 year old male who suffered a traffic accident and had a suspicious widening of the mediastinum on chest x-ray. Computed tomography (CT) failed to demonstrate an aortic dissection. Due to the mechanism of injury and chest X-ray findings, we decided to perform a multiplane transesophageal echocardiogram (MTE). This revealed an aortic dissection of less than one centimeter in length and good heart function. Due to CT evidence of hemoperitoneum, the patient received an emergent laparatomy. A liver laceration and jejunal perforation were found and repaired. An intraabdominal abscess developed, which led to sepsis, multiple organ failure and ultimately death. MTE was used to monitor the status of the dissection and adequacy of heart function during his intensive care unit stay. The dissection extended to 4 cm in length by the second week and then remained stable. There was no thrombus formation within the false lumen by the third month. While the patient unfortunately died from complications related to his abdominal injuries, MTE not only diagnosed the traumatic aortic dissection when CT failed, but allowed easy monitoring of both the rate of extension and the flow patterns within the false lumen. This made prognostication and treatment planning much easier.

Adult↗

PubMed1996

[Directional coronary atherectomy in coronary dissection?].

Significant local dissection at the site of angioplasty remains the most common cause of complications at balloon dilatation. In the past, the only solution was to transfer the patient for emergency coronary artery bypass grafting. Recent improvements in equipment and increasing experience mean that alternative instrumental methods are now available to manage dissection; in particular, by directional atherectomy and stent implantation, thus possibly avoiding surgery. In this article, the use of atherectomy as management for acute local dissection will be discussed, with special reference to the potential difficulties which may be encountered. Data showing that excellent immediate results and good long-term success can be achieved with atherectomy for acute dissection using careful selection criteria will be presented, indicating that atherectomy is a valid alternative instrumental treatment for the management of such dissection.

Aortic Dissection↗

PubMed1996

[Intracerebral hemorrhage secondary to dissecting aneurysm of the anterior cerebral artery].

A case with intracerebral hemorrhage secondary to dissecting aneurysm of the anterior cerebral artery was reported. A 36-year-old male, known to have hypertension, developed somnolence and paresis of the left leg while skiing. There was no evidence of trauma. A plain head CT on admission revealed a high density in the right frontoparietal lobe. Three days after the admission CT revealed low density in the area supplied by the right anterior cerebral artery. An angiogram disclosed a double lumen, suggesting a pathognomonic sign of dissecting aneurysm at the A2 segment of the anterior cerebral artery. In the literature, 18 cases of dissecting aneurysm of the anterior cerebral artery were reported including this case. Eleven of the 17 cases were idiopathic, and 8 of the 11 cases had hypertension. We briefly discussed the relationship between the etiology of dissecting aneurysm and hypertension. Cerebral dissecting aneurysm is rare cause of intracerebral hemorrhage. It should be considered in diagnosis when young individuals develop intracerebral hemorrhage.

Adult↗

PubMed1996

[Recent progress in adjunctive methods during surgery of aortic dissection].

Aortic dissection is severe disease, but recently surgery of aortic dissection is reported in good results. In order to improve results, three adjunctive methods have been progressed recently; intraoperative color Doppler retrograde cerebral perfusion and deep hypothermia. Intraoperative color Doppler reveals dynamic hemodynamics and structural information in aortic dissection in real time which leads to proper surgical treatment to obtain maximum effects with minimum invasiveness. To carry out thrombus obliteration in false lumen by informations of intraoperative color Doppler leads to a healing in aortic dissection. Retrograde cerebral perfusion during surgery of aortic dissection permitted simple procedure and good surgical results with reduced neurological complications. Deep hypothermia for protection of spinal cord and other organs also yielded good operative results and reduced rate of paraplegia.

Aortic Dissection↗

PubMed1996

[The surgical treatment for acute aortic dissection and changing concept of surgical procedures].

The first prominent report on the surgical treatment for acute aortic dissection was published by DeBakey in 1975. Since then, many various techniques have been applied for the surgery on dissection at ascending aorta and aortic arch. The basic understanding for the surgical treatment are focused to the climination of intimal tear as well as resection and closure of dissecting lumen and restore the blood flow only to the true lumen. The associated complications such as acute dissection AR should also be repaired simultaneously. At the present, the graft replacement of ascending aorta has become first choice of procedure. No matter where the intimal tear is located, the simultaneous replacement of assending aorta and aortic arch has been proposed recently as the most radical approach toward Type A dissection, although this extended approach has to be carefully evaluated in the future.

Acute Disease↗

PubMed1996

[Immediate and late results of the surgical treatment of the aneurysms and dissections of the ascending aorta].

PURPOSE: To report our experience and results with the surgical treatment of aortic aneurysms and dissections of the ascending aorta as well as the techniques that have been used. METHODS: Between May 1982-May 1995, 54 patients were operated on and divided in two groups: group A was composed of 25 patients with aneurysms or chronic dissections of the ascending aorta. The Bentall and DeBonno procedure was performed in 18, five were submitted to prosthetic aortic graft associated with aortic valve replacement and two prosthetic aortic graft without aortic valve replacement. Group B had 29 patients with acute dissections of the ascending aorta (type A) who were submitted to 10 prosthetic graft alone, nine Bentall procedures, five prosthetic graft with aortic valve replacement, four aortic repair and one direct suture of the dissection. The survival curve was obtained by the Kaplan-Meier method. RESULTS: Total hospital mortality rate was 13% and the late was 18.5%. Group A-immediate mortality rate was 8% (two patients): Low cardiac output and stroke; late mortality rate was five (20%): sudden death in three, pulmonary embolism one and infectious endocardite one. Group B-hospital mortality rate was five (17.2%) patients: low cardiac output three, multiple organs failure one and stroke with pneumonia one; late mortality rate was five (17.2%), distal redissection in three, sudden death in two. The average survival time was 86 +/- 12 for group A and 75 +/- 13 months for group B. CONCLUSION: The surgery of the aneurysm and dissections of the ascending aorta has shown immediate favorable results and a thorough follow-up to get better late results is needed.

Adult↗

PubMed1997

Opacification of the thoracic aorta after venous injection of sonicated albumin microbubbles. Implications for aortic dissection.

This study was designed to assess the feasibility of thoracic aorta opacification after intravenous injection of sonicated albumin microbubbles in patients with and without aortic dissection. Twenty-one patients were studied by transesophageal echocardiography. In 11 patients without aortic dissection, the opacification of the left ventricular outflow tract, aortic root and descending aorta was evaluated. Ten patients with aortic dissection were studied to assess perfusion of the true and false lumen. The left ventricular outflow tract, aortic root and descending aorta were opacified in all patients, with a systolic increase in contrast at visual analysis and at videodensitometry. The differentiation between false and true lumen was improved and was crucial in 1 case of type A chronic dissection. The intimal tear was detected in 7/9 cases by color Doppler vs 9/9 cases by contrast echocardiography. The noninvasive ultrasound opacification of thoracic aorta is feasible and may improve the diagnosis of aortic dissection.

Adult↗