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PubMed1992

Transesophageal echocardiography in the emergency surgical management of patients with aortic dissection.

The diagnostic accuracy and benefit of transesophageal echocardiography were investigated in 32 patients with suspected aortic dissection. Results of transesophageal echocardiography were compared with surgical assessment. The Stanford classification was used for differentiation of dissection type. Examination time was 5 to 15 minutes. Twenty-eight patients were correctly identified to have aortic dissection; four patients had nondissecting aneurysms of the ascending aorta. Both sensitivity and specificity for detection of aortic dissection were 100%. Type of dissection was misdiagnosed in one patient. Classification of dissection type was correct in 96%. The primary entry site was correctly identified in 25 patients (89%). Aortic regurgitation was found in 57% of patients. Pericardial effusion was detected in 21%, with tamponade in one patient. Myocardial infarction was suggested by transesophageal echocardiography in 7%, and 14% had significantly reduced left ventricular function. Eight patients underwent operation based on transesophageal echocardiography alone. Intraoperative transesophageal echocardiography, performed in 20 patients, verified retrograde flow in the true lumen after femoral cannulation. Transesophageal echocardiography documented postrepair persistence of the intimal flap in aortic segments that were not operated on in all patients. Secondary tears and flow in the false lumen were detected in 35% of patients. We conclude that transesophageal echocardiography allows expedient and accurate diagnosis and classification of aortic dissection, and we recommend it as the primary bedside diagnostic modality. It can especially identify patients requiring surgical intervention without further delay caused by other diagnostic procedures.

Adult↗
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

Use of endovascular stents for acute aortic dissection: an experimental study.

This study was designed to evaluate the potential obliteration of an experimental aortic dissection using an intravascular stent introduced via the femoral artery. Twenty-two adult dogs were divided into four groups: in group A (n = 6) a thoracoabdominal aortic dissection was surgically created to observe the natural course of this lesion; in group B (n = 6) a nitinol coil graft was introduced into the aorta via the femoral artery; in group C (n = 3) a nitinol coil graft was introduced via the femoral artery into a dissected aorta in an attempt to obliterate the dissection; and in group D (n = 7) an expandable intraluminal vascular graft (Palmaz stent) was introduced via the femoral artery into a dissected aorta in an attempt to obliterate the dissection. Arteriographic evaluation was performed postoperatively and again 6 weeks later before the aortas were explanted. Gross and light microscopic examinations were performed on all explanted aortas. In group A dissection was achieved and a postoperative aortogram demonstrated evidence of aortic dissection in all animals. Autopsy revealed persistence of dissection with a reentry tear near the celiac axis in five animals. In group B there was incomplete expansion of the nitinol coil graft in five dogs, resulting in aortic thrombosis in one. In group C the nitinol coil graft failed to obliterate the aortic dissection in all animals and resulted in aortic thrombosis in two. In group D placement of a balloon-expandable intraluminal stent solely at entry and reentry sites resulted in only partial obliteration of the dissection (n = 3), but when the entire length of the dissected aorta was treated, the dissection was completely obliterated (n = 3).

Acute Disease↗
PubMed1988

Mediastinal tumors presenting as spontaneous hemothorax, simulating aortic dissection.

The usual causes of hemomediastinum and hemothorax include chest trauma, rupture of an aortic aneurysm or aortic dissection. We report two patients who presented with a clinical picture of aortic dissection. In both patients, the chest radiograph revealed anterior mediastinal masses. Aortic dissection could not be excluded on the basis of the chest radiograph, and additional investigation by thoracic aortography was performed. The tumors had undergone spontaneous bleeding into the mediastinum and the pleural space, presumably causing the patients pain. The interesting and unusual causes of spontaneous hemomediastinum and hemothorax are reviewed.

Adult↗
PubMed1990

Excision of the aortic wall in the surgical treatment of acute type-A aortic dissection.

Between March 1986 and September 1988, 38 patients underwent extended aortic resection (aortic valve, ascending aorta, and arch) for acute type-A aortic dissection with aortic valve insufficiency; deep hypothermia and circulatory arrest were used. All patients were operated on within 17 hours of the onset of symptoms. In the first 24 patients, operation was performed by the "inclusion technique." In the last 14 patients, the "excision technique" was used: the ascending aorta and arch was excised, and the aorta was transected at the beginning of the descending thoracic tract. Excision and transection were considered essential to prevent back flow from the false lumen, which is the main source of bleeding, and to allow all anastomoses to be constructed beyond the limits of dissection. The only anastomosis to the dissected aorta was at the distal end of the graft. One of the 14 patients died (7.1%). One patient was reopened for bleeding: blood was issuing from the attachment of the carotid trunks, and the defect was repaired by interposing a bifurcated Dacron graft between the arch graft and the carotid arteries. Extended aortic excision meets the principle of either eliminating as far as possible the diseased aorta or controlling intraoperative and postoperative bleeding. An operation of great magnitude can be considered a life-saving procedure when compared with the high risk of acute type-A aortic dissection.

Aortic Dissection↗
PubMed2002

Impact of an aggressive surgical approach on surgical outcome in type A aortic dissection.

BACKGROUND: To evaluate the impact of an aggressive surgical approach on early and late outcome in type A aortic dissection. METHODS: From 1983 to 2001, 240 patients underwent operation for acute (n = 138) and chronic (n = 102) type A aortic dissection. The extent of distal aortic resection included the ascending aorta in 39 (16%) patients, hemiarch (HAR) in 47 (20%), and total arch (TAR) in 154 (64%), including 19 patients who also had their descending aorta replaced (DAR). RESULTS: The in-hospital mortality did not differ between TAR with or without DAR and other more conservative techniques (12.3% versus 16.3%). Actuarial survival at 10 years including in-hospital mortality was 72.4% +/- 3.3% and freedom from reoperation was 77.2% +/- 3.6% for all patients: neither was influenced by the extent of distal aortic resection or acuity of aortic dissection. Multivariate analysis revealed younger age and failure to resect the intimal tear to be independent determinants for late reoperation. However, in contrast to 22 patients who had more conservative operations, none of the patients with TAR required reoperation on the aortic arch through a sternotomy incision. CONCLUSIONS: An aggressive surgical approach did not adversely influence early and late survival following type A aortic dissection; it reduced the necessity of late reoperation and facilitated distal aortic reoperation.

Adult↗
PubMed2000

Long-term effectiveness of operations for ascending aortic dissections.

OBJECTIVE: To evaluate long-term effectiveness of a strategy for managing the aortic root and distal aorta according to the pathology in ascending aortic dissection. METHODS: From 1978 to 1995, 208 patients underwent operations for acute (n = 135) and chronic (n = 73) ascending aortic dissection. Surgical strategies included valve resuspension with supracoronary aortic root repair and ascending aortic graft for normal sinuses and valve (n = 135), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 47), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 26). Resection extended into the arch only if the intimal tear originated in or extended to the aortic arch (n = 31). RESULTS: Hospital mortality was 14%. Cardiogenic shock (P =.002) and concomitant coronary artery bypass grafting (P =.001) were associated with increased risk; use of circulatory arrest (P =.0003) decreased risk. Survival was 87%, 68%, and 52% at 30 days, 5 years, and 10 years, respectively. Advanced age, earlier date of operation, composite graft, and arch resection were associated with decreased survival; residual distal dissected aorta was not. Reoperation was required for 5 proximal and 8 distal problems. CONCLUSIONS: In both acute and chronic ascending aortic dissections, (1) circulatory arrest is associated with low early mortality; (2) with normal sinuses and valve, supracoronary repair of the dissected aortic root and valve resuspension is effective long term; and (3) residual distal dissected aorta does not decrease late survival and has a low risk of aneurysmal change and reoperation for at least 10 years.

Adult↗
PubMed1995

[A surgical case of aortic dissection Stanford type A caused by blunt chest trauma--a report of a successful case].

A case of successfully repaired traumatic aortic dissection was reported. A 66-year-old woman with a blunt chest trauma from the car accident was transferred to our hospital. The radiological examination revealed Stanford type A aortic dissection without aortic regurgitation. Because of disturbance of consciousness and respiratory failure due to the associated blunt lung injury, she was treated in the intensive care unit, and, after 1 month, a graft replacement of the ascending aorta by using deep hypothermia with retrograde cerebral perfusion was carried out. The postoperative course was uneventful. Blunt chest trauma is very rare to cause aortic dissection, and the operative indication should be determined with careful consideration of the associated organ injuries.

Aortic Dissection↗
PubMed1997

Acute aortic dissection and ventricular septal defect repair.

A 37-year-old male with long-standing heart murmur and ventricular septal defect developed acute chest pain and was diagnosed with an aortic dissection and aortic insufficiency. The ventricular septal defect and aortic dissection were repaired successfully as a combined procedure. At late follow-up (three years), he continued to enjoy an excellent result.

Adult↗
PubMed2000

Etiologic factors of acute aortic dissection in children and young adults.

Current concepts in the pathophysiology and predisposing conditions of acute aortic dissection in children, adolescents, and young adults are presented. Timely diagnosis is required for this life-threatening condition. Most children and adolescents with aortic dissection have congenital cardiovascular anomalies. Certain heritable disorders involving connective tissue also predispose to this disorder. Newer associations include cocaine abuse and weight lifting. To facilitate early diagnosis, the salient physical findings of the known predisposing conditions are reviewed. Clinical presentation and diagnostic imaging of aortic dissection are briefly summarized. Physicians working in an acute care setting, particularly in the emergency room, should be aware of disorders predisposing to acute aortic dissection in the pediatric and young adult population. Practitioners conducting school or college preparticipation sports evaluations can make use of such information in their assessment of risk for sudden death.

Acute Disease↗
PubMed2006

Up-regulation of matrix metalloproteinase-2 and membrane-type 1-matrix metalloproteinase were coupled with that of type I procollagen in granulation tissue response after the onset of aortic dissection.

The pathophysiological significance of matrix metalloproteinases (MMPs) in aortic dissection remains poorly understood. The purpose of the present study is to clarify the significance of MMPs in aortic dissection. The activities and distributions of MMP-2, membrane-type 1-MMP (MT1-MMP), and MMP-9 were evaluated by gelatin zymography, immunohistochemistry, and in situ hybridization in 29 patients and seven autopsy cases. To assess if these MMPs are related to a tissue remodeling process, we compared the expression of these MMPs with that of type I procollagen and platelet-derived growth factor receptor beta chain (PDGF Rbeta). Patients were divided into three groups based on histological findings: acute, intermediate, and healed groups. The most remarkable changes were observed in the intermediate group, in which MMP-2 activity peaked and tissue expression of mRNAs for MMP-2 and MT1-MMP were observed in spindle-shaped cells in the neointima, organizing thrombus, and the adventitia. These expression patterns were essentially coupled with those of type I procollagen mRNA and PDGF-Rbeta protein. The association of MMP-2, MT1-MMP, type I procollagen, and PDGF-Rbeta suggests that MMP-2 and MT1-MMP could be involved not only in the degradation of aortic tissue but also in tissue remodeling, which may be associated with the healing process.

Aged↗
PubMed2002

Satisfactory recovery after 45 minutes of resuscitation in acute aortic dissection.

OBJECTIVES: To report the satisfactory recovery of a woman with acute aortic dissection who underwent cardiopulmonary resuscitation out of hospital and to show that there are still chances of recovery for patients with prehospital cardiopulmonary arrest even due to acute aortic dissection. DESIGN: Case report. SETTING: An adult critical care unit of a university hospital. PATIENTS: A 71-yr-old woman who had a cardiopulmonary arrest out of hospital. Cardiopulmonary resuscitation was performed before arriving at the emergency room of our hospital. INTERVENTIONS: Cardiopulmonary resuscitation, echocardiography, computed tomography, aortography, coronary angiography, ascending aortic graft replacement, and brain hypothermia. MEASUREMENT AND MAIN RESULTS: Restoration of spontaneous circulation was gained 45 mins after onset of cardiopulmonary arrest. Echocardiographic and computed tomographic images revealed cardiac tamponade caused by type A acute aortic dissection. Since involuntary movements of the extremities in response to noxious stimulation were observed at 30 mins after restoration of spontaneous circulation, we performed an ascending aortic graft replacement and postoperative mild brain hypothermia. The patient recovered satisfactorily 1 month after the operation. CONCLUSION: The results of this case indicate that there are still chances of recovery for patients with prehospital cardiopulmonary arrest, even due to acute aortic dissection. We propose that an appearance of involuntary movements of the extremities in response to noxious stimulation is one key point that should be considered when deciding whether to perform an emergency operation for this kind of patient.

Aged↗
PubMed2003

A double patch sandwich technique for surgical repair of acute aortic dissection type A.

BACKGROUND: This study compares two groups of patients with acute aortic dissection type A in whom two different techniques of anastomotic reinforcement were used, and evaluates the impact of these two techniques on perioperative blood loss and surgical outcome. METHODS: One hundred eighty-five consecutive patients with acute aortic dissection type A between 1998 and 2002 were grouped according to the technique utilized for reinforcing the aortic anastomotic site. Group A consisted of 21 patients in whom a novel double patch sandwich technique was used, whereas in group B (164 patients) conventional Teflon felt strips served as reinforcement. RESULTS: Preoperative profiles were comparable for both groups. Deep hypothermia and circulatory arrest were used in 180 patients (97%). Retrograde cerebral perfusion and retrograde cardioplegia were used in 70 patients (38%). Hospital mortality for the two groups was 4.7% (1 of 21) and 18% (29 out of 164), p < 0.30, respectively. On average 2 versus 6 U of PRBC (p < 0.21), and 3 versus 5 U of FFP (p < 0.004) were given during operation in groups A and B, respectively, and indicates reduced suture line bleeding in group A. CONCLUSIONS: Modifications in the surgical technique for repair of acute aortic dissection type A, and in anastomotic reinforcement in particular, may lead to substantial reduction of suture line bleeding and diminished blood loss and transfusion requirements, and favorably affects patient outcome. Nevertheless, continued effort is mandatory to further enhance surgical outcome in this patient population.

Acute Disease↗
PubMed1994

[Concomitant graft replacement of the total aortic root and the transverse aortic arch for type A aortic dissection associated with Marfan syndrome: report of a case].

A 25-year-old man of Marfan syndrome with chronic stage aortic dissection of Stanford type A underwent concomitant graft replacement of the total aortic root and transverse aortic arch. The surgical procedure were performed with an aid of extracorporeal circulation, blood cardioplegia, using the techniques of "open distal anastomosis" under the deep hypothermic circulatory arrest and continuous retrograde cerebral perfusion for cerebral protection during circulatory arrest. The operative techniques consisted of total aortic root replacement using a composite graft with Piehler's and Carrel patch technique for left and right coronary artery, and total arch replacement using en bloc distal arch reconstruction and a composite graft replacement for innominate artery. There were no neurological complications. In the case of Marfan syndrome, type A aortic dissection involving aortic arch should be treated by concomitant graft replacement of the total aortic root and the transverse aortic arch in order to reduce the late risk of aortic dissection or annular dilatation.

Adult↗
PubMed1984

Total aortic replacement for chronic aortic dissection occurring in patients with and without Marfan's syndrome.

Total aortic replacement including aortic valve was performed successfully in the two patients in whom this method of treatment was utilized to correct a chronic dissecting aortic aneurysm. Both patients had moderately severe aortic insufficiency producing increasing heart strain and progressive enlargement of the false lumen of aortic dissection involving the entire aorta despite ideal blood pressure control. In addition, one patient had Marfan's syndrome. The surgical treatment for both patients was performed in two stages. At the first operation, cardiopulmonary bypass, profound hypothermia, and circulatory arrest were employed while the aortic valve and the ascending and transverse aortic arch were replaced and the coronary and brachiocephalic vessels were reattached to the composite valve-graft used for replacement. At the second operation, the entire descending thoracic and abdominal aortic segments were replaced with a graft and the intercostal, lumbar, and visceral arteries reattached thereto. Left vocal cord paralysis occurred in both patients and transient mild paraparesis occurred in only one. Both patients are alive and well, one at 13 months and one at 6 weeks. This experience suggests an additional treatment modality for selected patients with complications of chronic aortic dissection.

Aortic Dissection↗
PubMed1990

Aortic dissection with the entrance tear in transverse aorta: analysis of 12 autopsy patients.

Clinical and autopsy findings are described in 12 patients who had fatal aortic dissection with the entrance tear in the transverse aorta. The 12 patients represent 7% of 182 autopsies of spontaneous aortic dissection studied by us. The ages of the 12 patients at death ranged from 37 to 87 years (mean, 67 years). Eight were men; 8 had a history of systemic hypertension, and 10 had hearts of increased weight. Diagnosis of aortic dissection was made during life in only 4 of the 12 patients. All 12 patients died of rupture of the false channel within 2 weeks of onset of signs or symptoms compatible with dissection. The direction of aortic dissection from the entrance tear was entirely retrograde in 4 patients, entirely anterograde in 4 patients, and in both directions in 4 patients. Hemopericardium occurred in the first group, left hemothorax in the second group, and either in the last group. Of the 8 patients in whom the ascending aorta was involved, the retrograde dissection in each extended to the aortic root, 6 had pulmonary adventitial hemorrhage, and 4 had involvement of the arch arteries by dissection. In the 4 patients with strictly anterograde dissection, none had dissection in the arch arteries. Thus, tear in the transverse aorta causes a dissection that is usually fata, that often dissects retrogradely, and that may mimic dissection from a tear in ascending aorta. Aortic dissection from a tear in transverse aorta requires early operative intervention.

Adult↗
PubMed1999

Diagnostic potential of combined transthoracic echocardiography and x-ray computed tomography in suspected aortic dissection.

BACKGROUND: Transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are considered optimal diagnostic methods in the setting of suspected aortic dissection. However, although less sensitive as single modalities, transthoracic echocardiography (TTE) and contrast-enhanced computed tomography (x-ray CT) are more widely available and less costly. HYPOTHESIS: This study was undertaken to compare the diagnostic performance and reliability of the combined use of TTE and x-ray CT with TEE and/or MRI findings in the setting of suspected aortic dissection. METHODS: The diagnostic power of combined TTE and x-ray CT was compared with both single use of TTE and x-ray CT and with TEE and/or MRI in a series of 168 consecutive patients with suspected aortic dissection (AD). Of these, 28 women and 58 men (mean age 53 +/- 16 years) underwent TTE and x-ray CT prior to TEE (n = 52) and/or MRI (n = 69). Diagnostic results of combined TTE/x-ray CT were retrospectively but independently reevaluated in blinded fashion; diagnostic findings were validated by angiography (n = 63), surgery (n = 52), or autopsy (n = 7). RESULTS: Type A dissection was found in 29 patients (34%), type B dissection in 10 (12%), whereas aortic dissection was excluded in 47 (55%). With 95%, the sensitivity of TTE and x-ray CT was significantly enhanced when used in a combined access compared with 67 and 79%, respectively, when used as single methods (95%; p < 0.05). Sensitivity and specificity (95 and 91%, respectively) of combined TTE/x-ray CT evaluation were not different from TEE and/or MRI (100 and 96%, respectively; NS). Thrombus formation, side-branch involvement, aortic regurgitation, pericardial effusion or mediastinal hematoma were also detected with similar sensitivities and specificities both by combined TTE/x-ray CT and TEE and/or MRI. CONCLUSION: This first controlled study comparing the combined information of TTE and x-ray CT with TEE and/or MRI revealed a similar diagnostic potential of both diagnostic strategies in the setting of suspected aortic dissection. Thus, in an environment with access to color Doppler TTE and x-ray CT only, the information from both tests should be combined to decide on diagnostic management of these patients.

Aortic Dissection↗
PubMed1988

Vascular complications associated with spontaneous aortic dissection.

Three hundred twenty-five cases of spontaneous aortic dissection seen at two institutions between 1965 and 1986 were reviewed to assess the incidence, morbid sequelae, and specific management of aortic branch compromise. Noncardiac vascular complications occurred in 33% of the study group, and in these patients the overall mortality rate (51%) was significantly (p less than 0.001) higher than in patients without (29%) such complications. Although aortic rupture was the strongest correlate of mortality (90%), death specifically related to vascular occlusion was common when such occlusion occurred in the carotid, mesenteric, and renal circulation. There was a strong correlation between stroke and carotid occlusion (22/26 cases), yet specific carotid revascularization was only used during the chronic phase of the disease. Similarly, peripheral operation was ineffective in reducing the mortality rate in the setting of mesenteric (87%) and renal (50%) ischemia. Fifteen patients required either fenestration or graft replacement of the abdominal aorta for acute obstruction, rupture, or chronic aneurysm development. Thirty-eight patients (12%) demonstrated some degree of lower extremity ischemia, and one third of these required a direct approach on the abdominal aorta or iliofemoral segments to restore circulation. Selected patients with acute aortic dissection may require peripheral vascular operation in accordance with a treatment strategy that directs initial attention to the immediate life-threatening complications.

Aged↗