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PubMed1998

Clinical and echocardiographic findings in patients with suspected acute aortic dissection.

OBJECTIVES: The objective of this study was to define the range of clinical presentations, echocardiographic findings, and underlying final diagnoses in patients with clinically suspected acute aortic dissection. METHODS AND RESULTS: This study was designed as a retrospective review of clinical and echocardiographic data in consecutive patients evaluated for clinically suspected acute aortic dissection. The study population consisted of 75 studies in 74 consecutive patients referred for urgent or emergency evaluation because of signs and symptoms suggesting acute aortic dissection. A history and physical examination designed to elicit the cause of chest pain, evidence of congestive heart failure, and other cardiovascular abnormalities was performed in each patient. All patients underwent transesophageal echocardiography by experienced operators. Routine 12-lead electrocardiograms and chest radiographs were available for review in the majority of patients. Magnetic resonance imaging or computed tomography was performed in only 5 (6%) and 34 (44%) patients, respectively. Contrast aortography was performed in 21 (27%) patients. For the entire patient cohort, the most prevalent symptom was chest pain alone (n = 31; 41%) or chest pain in conjunction with back pain (n = 23; 31%). Classic "tearing" pain was an infrequent symptom. Syncope or other neurologic findings were present in 15 (20%) patients. Acute aortic dissection was responsible for 34 (45%) of the 75 presentations, with 31 (41% of total evaluations, 92% of dissections) involving the ascending aorta (Stanford type A, DeBakey type 1 or 2). Alternate major cardiovascular diagnoses, including acute myocardial infarction, primary valvular disease, or pericardial disease, were established in 12 (16%) cases. Aortic pathology, other than dissection, was found in 15 (20%) cases. Transesophageal echocardiography established the diagnosis responsible for the symptoms in 61 (81%) cases. CONCLUSIONS: Symptoms in patients with acute aortic dissection are more variable than commonly recognized. Transesophageal echocardiography is an accurate primary diagnostic tool in patients with clinically suspected acute aortic dissection. It allows rapid diagnosis of dissection and can identify alternate cardiovascular pathology responsible for the symptoms in a significant number of patients without acute dissection.

Aged↗
PubMed1995

Operation for type A aortic dissection: introduction of retrograde cerebral perfusion.

Circulatory support during operation for type A aortic dissection is controversial among many medical centers. In the last 21 years, 100 patients with type A aortic dissection underwent 102 operations including 2 reoperations, and 29 patients showed Marfan's syndrome. During operation, no cerebral perfusion technique was used through February 1985 (period I), antegrade cerebral perfusion was applied since March 1985 (period II), and retrograde cerebral perfusion was introduced in November 1990 (period III). Surgical results were compared among these subgroups. Operative mortality was 12.1% in 33 chronic and 57.1% in 7 acute patients in period I, 11.1% in 27 chronic and 54.5% in 11 acute patients in period II, and 6.7% in 15 chronic and 0% in 9 acute patients in period III (period II versus III; p = 0.04). Retrograde cerebral perfusion decreased permanent brain complications. The 5-year actuarial survival was 59.7% in period I and 63.2% in period II (not significant), and the 3-year survival of period III was 91.7%. Actuarial survival of period III was significantly higher than those of periods I and II (p < 0.05). Surgical repair of aortic arch with cerebral perfusion techniques reduced the residual aneurysms. These results show that surgical results of type A aortic dissection in this series improved with the introduction of retrograde cerebral perfusion and extended surgical procedures.

Adult↗
PubMed1997

Intramural hematoma of the thoracic aorta: precursor sign to thoracic aortic dissection.

A 60-year-old man was admitted at his local hospital for persistent chest pain and suspicion of aortic dissection. No evidence of aortic dissection or intimal disruption was noted by means of computed tomography and transesophageal echocardiography. A localized intramural hematoma of the ascending aorta was found. He was first treated medically and remained asymptomatic for 8 days when he developed a new episode of chest pain. He was found to have an acute type A dissection by computed tomography. He underwent graft replacement of the ascending aorta and had an uneventful post-operative course. This case report describes the development of true aortic dissection in a patient who previously had a localized intramural hematoma.

Aortic Dissection↗
PubMed1993

Percutaneous insertion of a jacketed stent to close the entry of dissecting aortic aneurysms of DeBakey types I and II.

As a treatment for dissecting aortic aneurysms of DeBakey Types I and II, a percutaneous insertion method using a new jacketed stent was developed. The efficacy of the method was evaluated in an animal study. We developed a special stent prepared by modifying the original Gianturco self-expandable metallic stent and a fabric patch. A model of a dissecting aortic aneurysm of DeBakey Type I was created in dogs. The device was inserted into the ascending aorta from the left carotid artery through a sheath-introducer system. The aortogram showed the bloodstream through the false lumen before the insertion, but no bloodstream after the stent insertion. The autopsy showed that the entry, the reentry, and the false lumen were completely filled with fresh thrombus. By using this stent, we successfully achieved an interventional treatment for dissecting aortic aneurysms of DeBakey Types I and II.

Aortic Dissection↗
PubMed1981

Clotted false lumen: reappraisal of indications for medical management of acute aortic dissection.

Evidence of a clotted false lumen in patients with acute aortic dissection has been considered to be a primary indication for medical rather than surgical therapy. A review of recent publications shows that 14 of 15 such patients survived with medical management. We present three patients who had radiographic, surgical, or necropsy evidence of acute aortic dissection with a clotted false lumen, who suffered further dissection in spite of adequate medical therapy. Our experience indicates that this condition is not as stable as it has been considered in the past. Consequently, we believe that great caution should be exercised in the application of medical therapy and in the follow-up of patients who demonstrate evidence of a clotted false lumen in an acute aortic dissection. Surgical treatment is indicated at the earliest sign of clinical or radiographic deterioration during medical therapy.

Acute Disease↗
PubMed1990

I-131-orthoiodohippurate renal function test in detection of renal artery occlusion in aortic dissection.

By use of I-131-orthoiodohippurate (I-131-OIH) comprehensive renal function test (CRFT), we studied 4 patients with aortic dissection and various degrees of renal artery obstruction and 39 patients without aortic dissection. Of the 39 patients, 3 had significant renal artery stenosis (RAS group) and 36 had normal renal arteriogram and renal function test (control group). Three of the 4 patients with aortic dissection had complicated renal artery occlusion (RAO group), one had independent RAS. The results indicate that: (1) In the RAO group, the difference in peak time (DPT) between the affected and contralateral kidneys was above 4 minutes: whereas that of the control group was 0-2 minutes (0.5 +/- 0.6 min). (2) In the RAO group, the percent difference of split effective renal plasma flow (%DSERPF) between the 2 kidneys were 29.6% and above or near 80% in patients with incomplete and complete RAO respectively; whereas that of the control group was below 22% (mean = 7.7 +/- 5.7%). In the RAS group, moreover, DPT was 0-2 minutes; and %DSERPF were above and below 22% in 1 case with marked (75% stenosis) and 2 with mild RAS (50-60% stenosis) respectively. The renogram curves were also evaluated. It was found that (1) In the RAO group, 2 cases with complete RAO showed flat shape in the affected kidney (similar to the background surve). The case with incomplete RAO showed markedly delayed rounding peak in phase 2 and slow descent in phase 3. The case with independent RAS showed only impaired phase 3 with saw-tooth waves and less steep slope. (2) In the RAS group, the 2 cases with mild RAS showed normal in one and slightly delayed peak with less steep descent in phase 3 in the other. The case with marked RAS showed reduced and delayed peak in phase 2, and less steep descent in phase 3 with saw-tooth waves and "cross-over" of the two kidney curves. It is concluded that use of I-131-OIH CRFT to evaluate DPT, %DSERPF and the renogram curve may help distinguish amongst RAO (with aortic dissection), RAS and the normal individual in most cases.

Adult↗
PubMed2001

Acute type A aortic dissection: the prognostic impact of preoperative cardiac tamponade.

OBJECTIVE: Acute type A aortic dissection requires emergency surgery and is associated with considerable mortality. The aim of the study was to evaluate whether occurrence of preoperative cardiac tamponade with or without palpable pulses in these patients is associated with higher incidence of multiple organ failure (MOF) and in-hospital mortality. METHODS: A retrospective cohort study included 87 patients with acute type A aortic dissection, who were admitted via an emergency department between December 1991 and December 1999 for emergency surgery. Impending cardiac tamponade (with palpable pulses) and severe cardiac tamponade (without palpable pulses) were recorded and patients were followed for occurrence of MOF and/or in-hospital mortality. RESULTS: Impending cardiac tamponade with palpable pulses was diagnosed in 33 patients (38%), signs of severe cardiac tamponade without palpable pulses were found in seven patients (8%). MOF occurred in 41 patients (47%); 32 patients (37%) died during the present stay, all of them had MOF. Preoperative severe cardiac tamponade without palpable pulses was associated with a significantly increased risk for poor outcome (odds ratio (OR)=16.1, 70% confidence interval (CI) 4.8-71.7, P=0.04), particularly preoperative death (n=6 of 7). Impending cardiac tamponade with palpable pulses (OR=1.6, 70% CI 0.8-3.3, P=0.2) was not associated with the occurrence of MOF/death. Hemodynamic shock (OR=6.5, 70% CI 3.0-13.9, P=0.01) was also associated with poor outcome. CONCLUSION: Patients with acute type A aortic dissection and signs of preoperative cardiac tamponade without palpable pulses had a 16-fold increased risk for poor outcome, particularly preoperative death. In contrast, cardiac tamponade with palpable pulses was not associated with increased frequency of MOF/in-hospital mortality.

Acute Disease↗
PubMed2004

Gender-related differences in acute aortic dissection.

BACKGROUND: Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD). METHODS AND RESULTS: Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustment for age and hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04), predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32% versus 22% in men despite similar delay, surgical technique, and hemodynamics. CONCLUSIONS: Our analysis provides insights into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.

Acute Disease↗
PubMed2002

Endovascular management of renal ischemia in a patient with acute aortic dissection and renovascular hypertension.

We report the endovascular management of a patient with a type B aortic dissection complicated by renal ischemia and resultant severe hypertension. A 69-year-old male presented with acute type B aortic dissection with proximal extension complicated by severe renovascular hypertension secondary to left renal ischemia. Endovascular management consisted of imaging with intravascular ultrasound and left renal artery stenting with balloon-expandable stents. His hypertension subsequently resolved and he was discharged on his baseline two-drug regimen. Management of the ischemic complications of type B aortic dissections may be primarily approached using endovascular methods in stable patients, with open surgery reserved for those patients refractory to these methods. Patients with evidence of decreased renal perfusion represent a select group with an increased risk of associated morbidity and mortality and should therefore be aggressively managed. Accurate information and assessment of anatomy can be obtained with intravascular ultrasound and is therefore an important adjunct to the armamentarium of endovascular specialists managing complications of aortic dissection.

Aged↗
PubMedDate not supplied

Aortic dissection complicating cardiac surgery: diagnosis by intraoperative biplane transesophageal echocardiography.

Aortic dissection is a rare but devastating complication of cardiopulmonary bypass. Intraoperative transesophageal echocardiography can be a useful technique to define the anatomy of the dissection, to evaluate its extension and progression, and to detect the presence of aortic insufficiency. We describe two cases in which transesophageal echocardiography helped in making a rapid diagnosis of aortic dissection during cardiac surgery and demonstrate how it may play a role in therapeutic decision making.

Aged↗
PubMed1992

[Aortic dissection associated with systemic lupus erythematosus].

A 33-year-old female patient, with a 4-year history of hypertension plus a 3-year history of systemic lupus erythematosus, who had been taking high dosages of corticosteroids, has shown repetitive respiratory infections and congestive heart failure for the past 8 months. Angiocardiography confirmed the diagnosis of aortic insufficiency with aneurysmatic dilation of Valsalva's posterior sinus, ascending aorta of normal diameter and normal coronary arteries. Aortic dissection causing aortic insufficiency due to collapse of aortic leaflets was spotted during the surgery and was corrected by a bovine pericardial tube and suspension of aortic valve. The postoperative (PO) period was complicated by left-sided seizures followed by left hemiparesis and respiratory infection. She was discharged on the 25th PO day with mild left hemiparesis and in functional class I (NYHA), using medicines. We emphasize the need to consider the diagnosis of aortic dissection in patients with systemic lupus erythematosus and aortic insufficiency, specially in those who have a history of systemic arterial hypertension and long-term corticosteroid therapy.

Adult↗
PubMed2003

[The application of intravascular ultrasound imaging in the diagnosis of aortic dissection].

OBJECTIVE: To evaluate the role of intravascular ultrasound (IVUS) imaging in the diagnosis of aortic dissection. METHODS: Eighty-two patients with aortic dissection were admitted. The role of IVUS was evaluated and compared with CT, MRI, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), Duplex scanning and digital subtraction angiography (DSA). RESULTS: The different laminar appearance of the outer wall of the true and false lumen, characteristic alterations in the true and false lumen junction and the thrombosis in the false lumen detected by IVUS were useful to differentiate the true from the false lumen. Static and dynamic narrowing, causing visceral ischemia could be detected by IVUS imaging. The detection rate of entry site by IVUS was 100%, higher than CT (28%), MRI (22%), TTE (2%) and TEE (61%), P < 0.01, having no statistic difference with DSA (88%). The detection rate of the distal end of the dissection by IVUS was 100%, higher than Duplex (21%), P < 0.01, but had no statistic difference as compared with CT (89%) and MRI (86%). The detection rate of visceral arteries by IVUS was 98%, higher than CT (56%), MRI (57%), Duplex (17%) and DSA (66%), P < 0.01. The aortic diameter measured by IVUS was correlated well with CT measurement (r = 0.94, P < 0.01). CONCLUSIONS: A full picture of aortic dissection can be obtained using IVUS imaging. It has an advantage over routine examinations in detecting visceral artery origin and clarifying visceral ischemia causes.

Adult↗
PubMed2003

Dissecting aortic aneurysm in computed tomography.

The dissecting aortic aneurysm (DAA) is an emergency, and because of that it requires urgent diagnosis and treatment. Many methods may by used to diagnose dissection, including aortography, CT, MRI, traditional and transesophageal ultrasonography. The computed tomography is often used in diagnostic of DAA, thus the knowledge of morphological characteristic of dissection is very important. The most important features of dissection in CT are presence of dissection of intima and two lumens, true and false. Nevertheless, the CT pictures of dissection not always appears like this, and sometimes the two lumens are identified only by their different rates of opacification with contrast material.

Adult↗
PubMed2002

[Aortic arch replacement with covered stent-graft as elephant trunk for a type A acute aortic dissection].

We report a case of aortic arch replacement with a covered stent-graft as an "elephant trunk". A 54-year-old woman was diagnosed with Stanford type A aortic dissection. The initial intimal tear was located in the distal aortic arch. Under deep hypothermic circulatory arrest and retrograde cerebral perfusion, the distal end of the arch graft, which was turned inside out and reinforced with a Z-stent, was inserted into the distal true lumen as an "elephant trunk". Distal anastomosis was performed between the aortic wall and the inverted external graft. Graft replacement of the aortic arch and ascending aorta was followed by proximal arch grafting. Coronary artery bypass grafting to RCA was performed concomitantly. The postoperative course was uneventful, and the distal false lumen became thrombosed. This procedure is effective for reliable distal anastomosis and prevention of blood leakage into the distal false lumen.

Acute Disease↗
PubMed2000

Aorto-right artrial fistula: a rare complication of aortic dissection.

We describe the successful surgical repair of an acute aortic dissection that had caused an aorto-right atrial fistula in a 67-year-old man. The patient was admitted to the hospital on an emergency basis because of severe heart failure. The diagnosis of acute aortic dissection with rupture into the right atrium was confirmed by use of intraoperative transesophageal echocardiography, although rupture of a sinus of Valsalva aneurysm into the right atrium had been suggested initially by 2-dimensional and Doppler transthoracic echocardiography. At surgery, we found the patient to have aortic arch dissection with complete separation of the right coronary artery from the sinus of Valsalva and a false lumen that had ruptured into the right atrium. The aortic arch was repaired directly. The ascending aorta was successfully replaced with a composite graft. Aortic dissection with rupture into the right atrium is extremely rare and leads to death rapidly. As shown in this case, such a condition might be mistaken for an aneurysmal rupture of the sinus of Valsalva, with use of transthoracic echocardiography alone. Transesophageal echocardiography is a useful noninvasive method to further define or confirm the diagnosis. Early surgical intervention is necessary in patients with this condition to prevent profound shock and end-organ failure.

Aged↗
PubMed2003

Emergency vectorcardiographic study of acute aortic dissection.

There has been no report in the literature of emergency vectorcardiographic study in patients with acute aortic dissection. A total of 135 consecutive patients with suspected coronary artery disease was studied. On admission to the intensive-care unit through the emergency service, each patient was given electrocardiographic and vectorcardiographic examinations, which were repeated at intervals of 24 hours. Fourteen patients (9 type I, 2 type II, and 3 type III according to DeBakey's classification) had acute aortic dissection indicated by clinical symptoms and proven by angiography. The electrocardiograms all revealed abnormal T-wave inversion in limb or precordial leads except 3 patients. Nine (64%) of the 14 patients had abnormal length/width (L/W) ratios of the T-loop in 2 planes of the emergency vectorcardiogram. Two (22%) among these 9 patients died of ventricular tachyarrhythmia. The inscription direction of the T-loop showed abnormality in 4 (29%) of the 14 patients; 2 (50%) among these 4 patients died of ventricular tachyarrhythmia. The de novo occurrence of sustained ventricular tachyarrhythmia after emergency cardiac surgery in patients with acute aortic dissection has been documented in this report. Furthermore, patients with acute aortic dissection who have (1) an abnormal sense of inscription direction of the T-loop in at least 1 of either the horizontal or left sagittal plane, and (2) an abnormal L/W ratio in at least 2 planes in the preoperational emergency vectorcardiogram, have altered ventricular repolarization and thus are at high risk of postoperationally unexpected ventricular tachyarrhythmia. This information is not available from the electrocardiogram.

Adult↗
PubMed2002

[Rupture of type III acute aortic dissection into the bilateral pleural space: report of a case].

Rupture of type III aortic dissection into the bilateral pleural space is very rare. A 62-year-old man was transferred to our department because of aortic dissection for emergency operation. computed tomography (CT) scan revealed rupture of type III aortic dissection into the bilateral pleural space. He underwent successful prosthetic graft replacement through left thoracotomy and removal of a massive amount of blood from the right pleural space by chest tube drainage. The postoperative course was uneventful after 2 days of respiratory support.

Aortic Dissection↗
PubMed2006

Atypical presentation of aortic dissection secondary to a gunshot wound.

We present a case of aortic dissection secondary to a gunshot wound. The traumatic aortic dissection in this patient occurred secondary to the cavitary forces produced by the bullet passing through the patient's chest. This is a rare phenomenon that could easily be missed if attention is placed only on the more obvious injuries.

Adult↗