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PubMed1994

Acute aortic dissection: typical and atypical imaging features.

Acute aortic dissection (AAD) is the most common emergency affecting the aorta. Noninvasive imaging allows prompt and reliable diagnosis of AAD and has largely supplanted aortography. However, atypical imaging features and diagnostic pitfalls can delay lifesaving therapy. An intimal flap is the characteristic feature of AAD. If there is flow within both lumina, typical imaging features are probably present. If the false lumen is thrombosed or there is no intimal tear to permit flow through the false lumen, a distinct intimal flap may not be present. Secondary signs of AAD include an intramural or periaortic acute thrombus, which manifests as a high-attenuation cuff or crescent on unenhanced computed tomographic scans. Other conditions that can reduce the conspicuity of the intimal flap include atypical configurations of the flap, such as seen with short dissections or with multiple false channels, in which case the flaps are complex. Finally, aortic anomalies may cause confusion.

Acute Disease↗
PubMed2002

Predictors of complications in acute type B aortic dissection.

OBJECTIVES: Medical treatment is generally advocated for patients with acute type B aortic dissection without complications. The objective of this retrospective analysis was to determine whether there are any initial findings that can help predict the long-term course of the disease. METHODS: Case records of the 130 patients treated for type B aortic dissection between 1988 and 1997 were reviewed; 41 (31%) were operated on in the acute phase (<14 days), 31 (24%) were operated on in the chronic phase and 58 (45%) were treated medically. RESULTS: Overall acute mortality was 10.8%; 22% for patients operated on in the early phase and 5.6% for medically treated patients. Age (P=0.002), persistent pain (P=0.01) and malperfusion (P=0.001) were significant independent predictors of the need for surgery. Paraplegia/para paresis (P=0.0001), leg ischaemia (P=0.003), pleural effusion (P=0.003), rupture (P=0.0001), shock (P=0.0001), age (P=0.003), cardiac failure (P=0.002) and aortic diameter >4.5 cm (P=0.002) were significant predictors of poor survival. Age and shock also emerged as independent risk factors. Patients without malperfusion (P=0.0001), pleural effusion (P=0.003), rupture (P=0.0001) and shock (P=0.0001) had a significantly better event-free survival (freedom from repeat surgery and death). The actuarial survival rate for high-risk patients (malperfusion, rupture, shock) was 62% at 1 year and 40% at 5 years; the corresponding values for low-risk patients were 94 and 84%, respectively. CONCLUSIONS: Rupture, shock and malperfusion are significant predictors of poor survival in patients with acute type B aortic dissection.

Adult↗
PubMed2002

Thoracoabdominal endaortectomy in case of type B aortic dissection.

Despite remarkable progress in both, diagnostic and therapeutic development in treating aortic dissections, this continues to be one of the most severe vascular disorders and is subject to high mortality rates. While aortic dissections of Type A can be treated surgically today, in the majority of patients with Type B dissections hypotensive treatment is the method of choice, providing a better chance of survival and the effective prevention of aneurysm formation and rupture at the site of the intimal tear. However in certain cases, Type B dissection generates either isthmic aneurysm formation, or, with distal progression, may result in long segmental thoracic, thoraco-abdominal or abdominal deterioration of the aorta and its side branches. The spinal, visceral, renal and lower limb ischemia threatens the viability of these organs and hypotensive medication may enhance this risk. Emergency diagnostic work-up and selective surgical reconstruction could lead to reduced mortality. In our department we have undertaken 33 thoracoabdominal endoaortectomies with meticulous reconstruction of renal and visceral orifices. The mortality rate in this subgroup of patients was 6%. Based on our experience with Type B aortic dissections we recommend open "endoaortectomy" in selected cases in order to improve the long-term outcome.

Aortic Dissection↗
PubMed1998

A surgical case of acute three-channeled aortic dissection in Marfan syndrome.

We surgically treated a 35-year-old male with acute 3-channeled aortic dissection in Marfan syndrome. He had acute type A aortic dissection, and underwent Bentall's type operation, simultaneous graft replacement of the ascending aorta and total aortic arch. Pain recurred 5 years and 9 months after the first operation. CT scan showed two adjacent false lumens in the descending aorta. The morphology of the first and second dissections was Stanford type A + B. The second dissection was acute. In the second false lumen, a re-entry formation was observed in the abdominal aorta. Because severe pain was persistent, we immediately replaced the descending aorta using a femoro-femoral partial cardiopulmonary bypass. The patient was doing well and was discharged. When pain recurs in a Marfan patient with an aortic dissection, a 3-channeled aortic dissection should be suspected, and we recommend emergency surgery.

Adult↗
PubMed1996

Fast CT for aortic dissection.

Results were evaluated in 81 patients with suspected acute aortic dissection who were examined on a fast CT system capable of a 1 s data acquisition time. 17 patients had Type A and nine had Type B dissections. Radiological assessment provided 78 confident reports and expressed some uncertainty about the diagnosis in three patients. Overall sensitivity for aortic dissection was 96.2% and specificity was 96.4%. When 78 confident reports alone were considered, both sensitivity and specificity reached 100%. Reconstruction of data at 100 ms intervals allowed discrimination between artefacts in the ascending aorta and Type A dissections. CT can often be used as the single investigation prior to surgery for acute Type A dissections.

Acute Disease↗
PubMed1994

Intravascular ultrasound imaging in acute aortic dissection.

OBJECTIVES: This study was performed to determine the potential of intravascular ultrasound in the detection and delineation of aortic dissection. BACKGROUND: Intravascular ultrasound is a new technique capable of displaying real-time cross-sectional images of arterial vasculature. Its clinical use has been explored mostly in coronary and peripheral arterial circulation. METHODS: Intravascular ultrasound imaging of the aorta was performed using a 20-MHz ultrasound catheter in 28 patients with suspected aortic dissection. All patients underwent contrast angiography; 7 had computed tomography; and 22 had transesophageal echocardiography. RESULTS: Imaging of the aorta from the root level to its bifurcation was performed in all patients in an average of 10 min. No complications occurred. Dissection was present in 23 patients and absent in 5. In the patients without dissection, intravascular ultrasound revealed normal aortic anatomy. In all 23 patients with dissection, intravascular ultrasound demonstrated the intimal flap and true and false lumena. The longitudinal and circumferential extent of aortic dissection, contents of the false lumen, involvement of branch vessels and the presence of intramural hematoma in the aortic wall could also be identified. In cases where aortography could not define the distal extent of the dissection, intravascular ultrasound did. CONCLUSIONS: Our experience in this series of patients with aortic dissection indicates that intravascular ultrasound could be valuable in the identification and categorization of aortic dissection and in the description of associated pathologic changes that may be clinically important. It can be performed rapidly and safely and could serve as an alternative or adjunct diagnostic procedure in patients with aortic dissection.

Acute Disease↗
PubMed2000

Aortic dissection complicated with aorto-right atrium fistula.

Aorto-right atrium fistula associated with aortic dissection is a very rare complication. Here report a case of successful surgical repair of ascending aortic dissection complicated with aorto-right atrium fistula. A 65-year-old man was presented with sudden chest pain and dyspnea. Fifteen years ago, he had aortic valve replacement. An aortic dissection with fistula to the right atrium was diagnosed by echocardiography and cardiac catheterization. At operation, dense adhesion of the aortic root due to the previous cardiac operation was confirmed, and this was suggested as the cause for this rare complication.

Aged↗
PubMed1994

[Aortic dissection: an incidence study based on hospital cases].

To ascertain the incidence of aortic dissection, we retrospectively studied the data base of our hospital (Ospedale di Treviso-ULSS n 10). The population in the Treviso area is well defined as a geographic settlement and was sufficiently stable from a demographic point of view in the period examined (1976-1988). Patients were selected on the basis of established aortic dissection diagnosed by angiography, surgical inspection or autopsy. One hundred eighty-seven patients were included: 126 of them lived in the hospital-referring area (mean annual population of 239824 people in the study period). The calculated incidence of aortic dissection was 40.4 new cases/million inhabitants/year. This figure is consistently higher than that reported in the literature. The outcome of the study is discussed and data are compared with those of previously published papers.

Adult↗
PubMed1994

Aortic dissection caused by angiographic procedures.

PURPOSE: To describe findings in, and the clinical course and outcome of, aortic dissection (dissecting aneurysm) caused by angiographic procedures. MATERIALS AND METHODS: The records of approximately 15,500 angiographic procedures performed between 1985 and 1991 were reviewed. In the six cases of iatrogenic aortic dissection identified, computed tomography (CT) was performed for diagnosis, follow-up, or both. RESULTS: The type of aortic dissection was Stanford type A in three patients and Stanford type B in three patients. The sites of injury were the abdominal aorta (n = 2), right brachiocephalic artery (n = 2), middle of the thoracic aorta (n = 1), and right common iliac artery (n = 1). One patient had anterograde dissection from the site of injury; two patients, retrograde dissection; and three patients, extensive dissection that extended in both anterograde and retrograde directions. Retrograde dissections decreased in size or disappeared in 1-3 months due to the absence of reentry, whereas anterograde dissections persisted during follow-up (15-27 months). All patient were treated without surgery. CONCLUSION: Angiographers should be aware of this potentially serious complication. The extent and type of the aortic dissection can be determined with CT.

Aged↗
PubMed1993

Anomalous inferior vena cava mimicking aortic dissection on transesophageal echocardiography.

Transesophageal echocardiography (TEE) is considered an excellent method for the diagnosis of aortic dissection, especially that involving the descending aorta. It has also proved useful in the evaluation of conditions mimicking aortic dissection, usually disclosing in these situations other types of severe aortic disease. We are not aware of any report dealing with venous abnormalities which presented diagnostic problems in a patient evaluated with TEE because of a suspected aortic dissection.

Aortic Dissection↗
PubMed1994

[Surgical treatment of acute Stanford Type-A aortic dissection].

Twelve cases of Stanford Type-A aortic dissection were operated in an acute phase. The male vs female ratio was 3:9, and their ages ranged from 47 to 79 (mean 61.3) years old. Most of them complained of chest and/or back pain, and four of them complained of syncope. Eight patients had the history of hypertension. As to the complications of aortic dissection, cardiac tamponade was seen in two cases, myocardial infarction in one, and transient hemiplegia and paraplegia in one case each. In five cases, moderate to severe aortic regurgitation was also noted. All but one case were operated within twenty-four hours after admission. The replacement of the ascending aorta with a tube graft was performed in all cases including the two cases whose entries were located in the aortic arch. CABG was done concomitantly in three cases, and aortic valve replacement and CABG in one case. The open distal anastomosis was carried out under the systemic circulatory arrest combined with the retrograde cerebral perfusion. The systemic perfusion was reinstituted after the distal anastomosis was completed. In cases whose dissecting pseudo-lumen of the distal aorta was not thrombosed, the arterial cannulation site was shifted from the femoral artery to the tube graft. All but two cases were discharged from the hospital in good condition. One case, who had been transferred to the operating room under cardiac massage due to myocardial infarction, was lost by severe LOS three weeks postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed2000

Aortic dissection after ingestion of "ecstasy" (MDMA).

The authors report a case of aortic dissection and cardiac tamponade in a 29-year-old man after ingestion of ecstasy (methylenedioxymethamphetamine, MDMA) at a "rave" party. There was no history of hypertension, myxoid heart disease, or other risk factors for aortic dissection in the deceased, although a minor degree of cystic medial necrosis was noted on histologic examination of the aorta. Autopsy toxicology revealed low residual levels of MDMA in the blood about 48 hours after ingestion of the drug. This case report describes a probable association between MDMA ingestion and aortic dissection in a previously well young adult. The likely mechanisms are discussed, and the difficulties in diagnosing this complication are highlighted.

Adult↗
PubMed2005

Anesthesia and neurocerebral monitoring for aortic dissection.

Patients presenting to the operating room for repair of aortic dissection are challenging in all aspects of their care. Without exception, they require a multidisciplinary team approach. This article will review some of the specific challenges faced by anesthesiologists and neurologists when confronted with such a diagnosis. Specifically, we will discuss the myriad anesthetic issues that present in the preoperative stage and continue into the postoperative period. Neurologic complications during dissection repair result in increased morbidity and mortality. A variety of neurophysiologic monitoring techniques exist that may reduce this risk and will be discussed in detail. Finally, we will present some "controversies in care," emphasizing that our respective fields continue to grow, learn, and improve what information we have on the morbidity and mortality of aortic dissection.

Anesthesia↗
PubMed1978

A simplified plastic repair for aortic dissections.

A simplified plastic repair for aortic dissection is described. The operation consists of noncircumferential resection of the aortic segment containing the intimal tear, leaving the posterior wall intact. The false lumen is obliterated by oversewing both lips of the aortic incision. Aortic continuity is restored either by primary closure or by the insertion of a diamond-shaped prosthetic patch. The simplified plastic procedure shortens cardiopulmonary bypass time and reduces bleeding from suture lines. The operation was employed in 2 patients with success.

Aged↗
PubMed1995

[Aortic dissection demonstrated by ultrasound scanning].

The clinical features of aortic dissection may be nonspecific and confusing. Three patients with different symptomatology diagnosed primarily by ultrasound are reported. In all cases the dissection was confirmed by dynamic CT and arteriography. The sonographic characteristics of aortic dissection are briefly described.

Aged↗
PubMedDate not supplied

Thoracic aortic dissection in a patient with autosomal dominant polycystic kidney disease treated with maintenance hemodialysis.

A patient with autosomal dominant polycystic kidney disease (ADPKD) on maintenance hemodialysis (HD) experienced spreading back pain with a sudden onset, and was diagnosed with thoracic aortic dissection. Reports of ADPKD with aortic dissection are rare. Hypertension, which is essentially universal both among ADPKD and hemodialysis patients, is a known risk factor for aortic dissection. Additionally, some reports have indicated that patients with ADPKD have aortic fragility. We suspect that aortic dissection may be less rare than presently apparent among HD patients with ADPKD.

Aortic Dissection↗
PubMed1979

Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period.

An unselected, consecutive cohort of 125 patients underwent operative repair of acute and chronic aortic dissections with tubular graft interposition over a 16 year span. The absence of remote geographical referral biases and the unselected nature of this series provided a patient population that was representative of the disease process (as assessed heretofore only from autopsy series). Furthermore, this enabled high-risk subsets to be defined by retrospective analysis. Patients were classified according to whether the ascending aorta was involved (type A with involvement, type B without), irrespective of the site of intimal tear, and according to age of the dissection: Fifty-three patients had acute type A (Ac-A), 29 had chronic type A (Ch-A), 20 had acute type B (Ac-B), and 23 had chronic type B (Ch-B) dissections. Fourteen percent (17/125) of the dissections had ruptured. Concomitant aortic valve replacement (AVR) was performed in 11% (6/53) for Ac-A cases and 38% (11/29) of the Ch-A cases. A total of 391 patient-years of follow-up was analyzed; follow-up averaged 4.5 years and extended to 13.7 years. Over-all operative mortality rate was 34% (18/53) for Ac-A, 14% (4/29) for Ch-A, 45% (9/20) for Ac-B, and 22% (5/23) for Ch-B; during the most recent 5 year interval these figures were lower: 27%, 8%, 20%, and 20%, respectively, N = 50. Multiple preoperative variables were found to correlate significantly with both operative death and long-term survival. Operative survivors generally experienced satisfactory functional benefit. Late attrition averaged 8% per year; 61% of all late deaths were related to cardiac or cerebral causes. Over-all actuarial survival (+/- SEM) for the entire cohort was 54% +/- 5% at 5 years and 26% +/- 7% at 10 years; for the 89 patients surviving operation, these figures were 76% +/- 5% and 37% +/- 10%, respectively. No significant differences in long-term survival were evident between the different subgroups. Whether the primary intimal tear had been resected or concomitant AVR had been performed had no statistically significant bearing on operative mortality, functional result, necessity for late reoperation, or late attrition. The long-term "natural" history of surgically treated patients with aortic dissections, as defined in this study, should facilitate comparison with other treatment modalities. Results of the present analysis support immediate operative intervention for patients with Ac-A dissections and probably for those with Ac-B dissections. Additionally, surgical treatment of patients with symptomatic or enlarging Ch-A and Ch-B dissections provides satisfactory rehabilitation and long-term survival. Finally, we re-emphasize our recommendation for simplified classification of aortic dissections, based solely upon the presence or absence of ascending aortic involvement. Pathophysiology and expected biologic behavior pivot on this feature, and appropriate clinical strategy can thereby be defined.

Adult↗
PubMed1998

[Spiral CT and MRT of the operated Stanford-type-A aortic dissection: its course and complications].

PURPOSE: To demonstrate normal postoperative spiral CT and MRI findings and typical complications in patients with aortic repair after Stanford type A aortic dissection. METHODS: 24 patients with aortic repair after Stanford type A aortic dissection were followed up by spiral CT and MRI (0.5 Tesla). Presence of persistent dissection, progressive or new dissection, proximal and distal anastomosis, periprosthetic space, supraaortic vessels, thrombosis and dilatation of the true and false lumen were evaluated. RESULTS: The following postoperative complications were seen: three pseudoaneurysms which developed at the proximal anastomoses of the Dacron prosthesis in two cases and at the insertion site of the reimplanted left coronary artery after implantation of a composite graft (Bentall procedure) in one case; one re-dissection; one perforation of the false lumen; periprosthetic flow in one patient after surgical repair of type A dissection by the graft inclusion technique; progressive dilatation of the false lumen in 4 cases; dilatation of the aortic root in a Marfan patient after replacement of the ascending aorta. CONCLUSION: Precise knowledge of the surgical technique performed is crucial to accurate postoperative imaging evaluation. MRI is the method of choice in the postoperative follow-up of clinically stable patients with aortic dissections.

Aortic Dissection↗