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PubMed2003

Concomitant David's operation and total arch replacement for acute type A aortic dissection.

A 61-year-old man complained of chest pain and developed congestive heart failure due to massive acute aortic regurgitation. Computed tomographic scan demonstrated Stanford type A aortic dissection from the aortic root to common iliac arteries. David's aortic valve sparing operation and total aortic arch replacement were applied to the patient, because the aortic dissection was extended into two aortic commissures and all arch vessels, though the tear was present at the proximal ascending aorta. The surgery was well tolerated without any significant complication.

Aortic Dissection↗
PubMed1999

Axillary artery cannulation in type a aortic dissection operations.

BACKGROUND: Femoral arteries are the preferred site of peripheral cannulation for arterial inflow in type A aortic dissection operations. The presence of aortoiliac aneurysms, severe peripheral occlusive disease, atherosclerosis of the femoral vessels, and distal extension of the aortic dissection may preclude their utilization. Axillary artery cannulation may represent a valid alternative in these circumstances. METHODS: Between January 15, 1989, and August 20, 1998, in our institution, 22 of 152 operations (14.4%) for acute type A aortic dissection were performed with the use of the axillary artery for the arterial inflow. Axillary artery cannulation was undertaken in the presence of femoral arteries bilaterally compromised by dissection in 12 patients (54.5%), abdominal aorta and peripheral aneurysm in 5 patients (22.7%), severe atherosclerosis of both femoral arteries in 3 patients (13. 6%), and aortoiliac occlusive disease in 2 patients (9.1%). In all patients, distal anastomosis was performed with an open technique after deep hypothermic circulatory arrest. Retrograde cerebral perfusion was used in 9 patients (40.9%). RESULTS: Axillary artery cannulation was successful in all patients. The left axillary artery was cannulated in 20 patients (90.9%), and the right axillary artery was cannulated in 2 patients (9.1%). Axillary artery cannulation followed an attempt of femoral artery cannulation in 15 patients (68. 2%). All patients survived the operation, and no patient had a cerebrovascular accident. No axillary artery thrombosis, no brachial plexus injury, and no intraoperative malperfusion were recorded in this series. Two patients (9.1%) died in the hospital of complications not related to axillary artery cannulation. CONCLUSIONS: In patients with type A aortic dissection in whom femoral arteries are acutely or chronically diseased, axillary artery cannulation represents a safe and effective means of providing arterial inflow during cardiopulmonary bypass.

Adolescent↗
PubMed2005

Abdominal Aortic dissections: anatomic and clinical features and therapeutic options.

Isolated abdominal aortic dissections are rare events. Their anatomic and clinical features are different from those of atherosclerotic aneurysms. We report 4 cases of isolated abdominal aortic dissection that were successfully treated with surgical or endovascular intervention. The anatomic and clinical features and a review of the literature are also presented.

Adult↗
PubMed1999

The use of gelatin-resorcin-formalin glue in acute aortic dissection type A.

OBJECTIVES: The Gelatin-resorcin-formalin (GRF) glue is widely used in the surgical treatment of dissecting aneurysms. This paper is focused on our experience with the GRF glue in cases, operated for acute aortic dissection type A. METHODS: Between September 1990 and December 1997, 164 patients were operated on for acute aortic dissection type A. In 148 patients GRF was used to reinforce the dissected layers proximal (n = 106) or distal (n = 144) of the grafted aortic segment. An intervention at the aortic valve was necessary in 93 instances. In 111 patients, an open distal anastomosis for replacement of the proximal aortic arch was performed. Thirty-seven additional patients underwent subtotal or total aortic arch replacement. RESULTS: Early postoperative mortality was 26.2% (43/164 patients). Another 16 patients died late postoperatively. Actuarial survival rates are 69.9% at 1 year, 62.5% at 3 years, 59.4% at 5 years and 56.1% at 7 years, post-operatively. Twenty-two reoperations were performed in 20 patients (16.5%). Nine of these patients had developed complications in aortic segments that underwent reconstruction by use of GRF during the primary intervention. Aortic root redissection was found in 7/9 patients intraoperatively, whereas 1/9 patients presented with a rupture near the distal graft to aortic anastomosis. CONCLUSIONS: The introduction of GRF glue has greatly facilitated the reconstruction of dissected aortic wall layers adjacent to the vascular graft. However, the use of the adhesive for aortic root reconstruction in acute aortic dissection type A may bear a significant risk of late postoperative proximal aortic redissection. Complications associated with the GRF glue are likely to be due to the toxic effects of the formalin component. Therefore, care should be taken that the amount of formalin administered to the glue components remains as low as possible.

Acute Disease↗
PubMed2004

Abdominal CT angiography before surgery as a predictor of postoperative death in acute aortic dissection.

OBJECTIVE: The purpose of our study was to search for a relationship between postoperative death in acute aortic dissection and abdominal helical CT findings before surgery. MATERIALS AND METHODS: We retrospectively included 48 patients admitted to our institution for emergent surgery of acute aortic dissection diagnosed with helical CT angiography. We recorded postoperative deaths and analyzed abdominal helical CT vessels and parenchymal abnormalities, including the presence of dissected abdominal aortic branches, a compressed aortic lumen, and low enhancement of the parenchyma in abdominal organs. RESULTS: Among the 48 patients, 11 died after surgery. Postoperative death occurred in one of five patients with low enhancement of the parenchyma in one abdominal organ and in seven of eight patients with low enhancement of the parenchyma in at least two abdominal organs. The postoperative death rates strongly correlated with the number of low-enhanced abdominal organs per patient (p < 0.00005) but did not correlate with the number of dissected abdominal aortic branches. CONCLUSION: The rate of abdominal organs with low enhancement of the parenchyma seen on CT before surgery is a strong factor in outcome in patients with acute aortic dissection. Additional analysis of low enhancement of the parenchyma in abdominal organs on CT might be a useful tool to detect, before surgery, patients at risk of postoperative death.

Acute Disease↗
PubMed1993

Aortic dissection in the thrombolytic era: early recognition and optimal management is a prerequisite for increased survival.

Based on two case reports, problems of diagnosis and treatment of aortic dissection are discussed. Thrombolytic treatment given to patients with aortic dissection presenting symptoms mimicking acute MI seems to have a fatal outcome. Indications, as well as contra-indications, for thrombolytic therapy are therefore of great importance, when this treatment is given to patients suspected of having acute myocardial infarction, especially where diagnosis is uncertain or as prehospital treatment. In patients with chest pain symptoms without typical history and electrocardiographic changes the diagnosis should be reconsidered within a few hours and, if possible, together with echocardiographic findings. In doing so patients with coronary heart disease will get all the benefits of thrombolytic treatment. Furthermore the importance of quick accurate diagnosis, especially in type A aortic dissection is pointed out, as emergency surgical intervention can be lifesaving. A more aggressive medical and surgical approach has contributed to the improved survival among patients with aortic dissections.

Adult↗
PubMed1992

Outcome of Stanford type B acute aortic dissection.

BACKGROUND: The optimal timing of surgery in patients with Stanford type B aortic dissection remains controversial. This report reviews retrospectively early and long-term outcomes of patients with Stanford type B acute aortic dissections at our institute. METHODS AND RESULTS: From April 1979 through January 1991, 75 patients were diagnosed with Stanford type B aortic dissection, and 58 of them were hospitalized within 2 weeks from onset. They were treated initially as follows: emergent surgery was performed in 13 patients for rupture or impending rupture, and the remaining 45 were treated medically. In the former group, nine patients (69%) died; in the latter, eight (18%) needed surgery because of enlargement or rupture of the aneurysm in the follow-up period, and only one of these (13%) died. Of the other 37 patients treated medically, three (8%) died within 2 weeks and seven died (19%) in the chronic phase, four of them from rupture. Among 42 discharged patients initially treated medically, rupture occurred in 11.9% (five of 42). CONCLUSIONS: In acute-phase cases, surgical mortality is so high that medical treatment is preferable unless there are major complications. However, even in patients who had undergone successful initial medical treatment, expansion of the aneurysm, requiring surgery, often occurred. If careful observation reveals any sign of expansion, because elective surgery can be performed at low risk, it should be considered as soon as possible before a rupture develops.

Actuarial Analysis↗
PubMed1990

[Evaluation of aortic dissection by ultrafast computed tomography].

We report usefulness of ultrafast CT (UFCT) in evaluation of aortic dissection, according to the results of examination of 51 patients. By volume mode study of UFCT, aortic dissection was diagnosed in all patients. Fine structures such as intimal tear and ulcer-like projection were depicted in detail. Pulsatile movement of true and false channels was detected by cine study. Precise flow analysis of both channels was available by flow mode study of UFCT. In morphological and functional assessment of aortic dissection, UFCT is superior to conventional scanners, and may be preferable to DSA or MRI.

Aortic Dissection↗
PubMed1995

Operation for type B aortic dissection: introduction of left heart bypass.

Various support techniques for surgical treatment of type B aortic dissection have been used and recommended in many medical centers. In the last 21 years, 55 patients with type B aortic dissection underwent 65 operations including 10 reoperations, and 10 cases showed Marfan's syndrome. As circulatory support during operation, venoarterial bypass mainly was used until March 1987 (period I) and low-dose heparinized left heart bypass was applied since April 1987 (period II). Surgical results were compared among subgroups by the Kaplan-Meier actuarial method and Cox-Mantel statistical analysis. After the operation, early mortality was 27.3% in 33 patients in period I and 9.4% in 32 patients in period II (p = 0.06). The incidence of fatal hemorrhagic complications was decreased significantly by using the left heart bypass technique (p < 0.02). The 5-year actuarial survival of type B dissection was 60.6% in period I and 79.2% in period II (p = 0.07). These results suggest that surgical results of type B aortic dissection in this series might be improved with the introduction of left heart bypass and extended surgical procedures.

Adult↗
PubMed1980

Aortic dissection manifested as leg ischemia.

The ischemic leg as the only clinical manifestation of an aortic dissection is rare. Without the usual symptoms of an aortic dissection, this diagnosis may easily by overlooked during routine peripheral angiography for the ischemic limb. Three cases are reviewed in which the patient was thought to have a spontaneous peripheral vascular occlusion, but was later found to have an aortic dissection without the usual thoracic or abdominal symptoms. The radiologist should observe carefully for signs of dissection such as fusiform narrowing of a vessel, nonfilling of branches of the aorta, or displacement of the intima into aortic lumen.

Aged↗
PubMed2005

Endoluminal stent-graft stabilization for thoracic aortic dissection.

PURPOSE: To review our experience with thoracic endografting for type B aortic dissection using the TAG Endoprosthesis. METHODS: A retrospective analysis was performed of data collected prospectively from March 2000 to July 2004 under an investigational device exemption protocol for the TAG thoracic endograft. In this time period, 40 patients (29 women; mean age 67 years, range 39-91) were treated with this endograft for type B aortic dissection. RESULTS: Technical success was 95%. There was 1 (2.5%) perioperative death, and 1 (3%) endoleak was treated with an additional graft on postoperative day 2. Fifteen (38%) patients experienced postoperative complications, mainly renal or pulmonary, and 1 (3%) patient developed postoperative paraplegia that did not resolve. The 1-year survival was 85%. Follow-up computed tomography was available for 31 patients with an average 15-month follow-up. There was no significant change in size of the thoracic aorta in 22 patients; 8 aneurysmal segments were significantly reduced in size and 1 thoracic aortic aneurysm expanded. No thoracic aortic ruptures were seen in this series. CONCLUSIONS: These early results indicate type B thoracic aortic dissections can be treated with acceptable morbidity and mortality using endografts. Stent-graft repair of the thoracic aorta may decrease the incidence of thoracic aortic expansion and rupture.

Adult↗
PubMed2002

[Surgical treatment of De Bakey type III aortic dissection].

OBJECTIVE: To summarize the experience in surgical treatment of De Bakey type III aortic dissection and discuss the operative indications, techniques, and methods for spinal cord protection. METHODS: From January 1994 to January 2000, 49 patients with De Bakey type III aortic dissection were operated on. Of these patients, 35 were subjected to partial thoratical aorta replacement, 4 partial thoratical aorta replacement and plasty, 8 total thoratical aorta replacement, and 2 thoracoabdominal aorta replacement. In the 35 patients, the operations were performed by using the technique which preserved blood was transfused back by pump via the femoral artery. RESULTS: Hospital mortality in this group was 6.1% (3/49). Eight patients received emergence operation, and 1 patient died. Paraparesis developed in one patient (2.0%). Other complications included re-exploration for bleeding in 3 patients, and wound infection in 5. CONCLUSIONS: The rate of mortality and complication is high in patients with De Bakey type III aortic dissection. Appropriate operative techniques and methods of spinal cord protection are essential to resolve this problem.

Adult↗
PubMed2004

Elective stent-graft treatment of aortic dissections.

PURPOSE: To retrospectively review 8 years' experience with stent-graft treatment of aortic dissections at a single institution. METHODS: Forty-six patients (31 men; mean age 59 years, range 38-88) underwent stent-graft treatment for 9 Stanford type A and 37 type B aortic dissections (9 acute phase, 13 subacute, 24 chronic). Custom-designed self-expanding stainless steel Z stents covered with polytetrafluoroethylene were used (n=20) until low-profile modular stent-grafts became available for percutaneous delivery (n=26). RESULTS: Endovascular stent-graft deployment was technically successful in 44 (96%) patients; the 2 failed cases owing to intraprocedural migration and graft torsion were converted to surgery. There were 5 type I endoleaks for a clinical success (entry tear exclusion) of 85% (39/46). Complications included 3 cases of transient renal failure, 2 puncture site pseudoaneurysms, 1 guidewire-induced new intimal tear (converted), and 2 cases of stent-induced saccular aneurysms (1 converted). Follow-up at a mean 34 months (range 12-96) showed complete resolution of the thoracic false lumen in 14 (74%) of 19 acute/subacute patients treated successfully; 3 (16%) showed a reduced thoracic false lumen diameter. In the 23 chronic-phase patients treated successfully, 8 (35%) had complete resolution of the thoracic false lumen, and 11 (48%) showed size reduction. Enlargement of the abdominal aortic false lumen due to persistent flow into re-entry tear(s) occurred in 3 (13%). CONCLUSIONS: Stent-graft treatment is a feasible and effective treatment modality in aortic dissection. However, close follow-up is mandatory to monitor new intimal tear, saccular aneurysms, or enlargement of the abdominal aortic false lumen.

Adult↗
PubMedDate not supplied

Aortic dissection in a cardiac allograft recipient: a case report.

Ascending aortic dissection is rare in cardiac allograft recipients. Only two patients with dissection arising from the native aorta have been reported previously and, unfortunately, the diagnosis was made postmortem in each instance. We report the first case of successful surgical treatment of aortic dissection confined to the donor aorta in a recipient of an orthotopic cardiac allograft.

Aortic Dissection↗
PubMed1989

Assessment of transesophageal Doppler echography in dissecting aortic aneurysm.

To assess the clinical value of transesophageal Doppler echography in the diagnosis of dissecting aortic aneurysm, both transesophageal and conventional echograms were performed in 22 cases of dissecting aortic aneurysm. Of the 22 patients, 17 underwent angiography; 8, X-ray computed tomography; 4, both; and 12, surgery. The performance of each method was assessed in the following four segments: A, ascending aorta; B, aortic arch; C, thoracic descending aorta; and D, upper abdominal aorta. The results by angiography were presumed to be correct. In the group of 17 patients who underwent angiography, the rate of correct detection of an intimal flap using the transesophageal approach was 100% in all four segments, significantly better than detection by the conventional approach (segment A, 65%; segment B, 47%; segment C, 35%; segment D, 53%) (p less than 0.01), and the rate of correct detection of the entry sites using the transesophageal approach was 100%, significantly better than that by conventional approach (42%) (p less than 0.05). X-ray computed tomography was not capable of detecting the site of entry in all cases. The presence of thrombus, aortic regurgitation and pericardial hemorrhage were all revealed clearly by the transesophageal approach, and the results were partly proved by other methods. In conclusion, transesophageal Doppler echography provides a rapid and accurate method of diagnosing and evaluating dissecting aortic aneurysm and permits prompt initiation of appropriate treatment.

Adult↗
PubMed2006

Prolapse of aortic intimal flap into the left ventricle: a rare cause of global myocardial ischemia in acute type A aortic dissection.

A 62-year-old woman experienced an acute type A aortic dissection complicated with profound shock caused by acute myocardial ischemia. Intraoperative transesophageal echocardiography (TEE) identified a circumferentially dissected intimal flap at 5.5 cm above the aortic valve, prolapsing into the left ventricle through the aortic valve during diastole and obstructing both coronary ostia. Acute aortic dissection must be kept in mind when presented with myocardial ischemia and TEE is the most useful method for detecting a prolapsing cylindrical intimal flap.

Aortic Dissection↗
PubMed2004

Anterior spinal artery syndrome complicating aortic dissecting aneurysm: case report.

Spinal Cord ischaemia is rare in the absence of trauma. We report a case of a 45 year old known hypertensive for six years, who presented with features of anterior spinal artery syndrome (ASAS) complicating acute dissection of the descending aorta. He developed sudden onset non-traumatic paraparesis, sphincteric dysfunction and dissociated anaesthesia with a sensory level at T6. This was preceded by a two weeks' history of severe, sharp, lancinating, tearing left parasternal chest pain radiating to the back. He was managed conservatively on pentazocine lactate (fortwin), calcium- and beta-blockers, steroids, anti-platelet and free-radical scavengers. On the 8th day of hospitalisation, he had a sudden abdominal distension, bled from the nose and mouth, went into hypovolaemic shock and died within a time frame of two minutes. He was presumed to have had a progression of the aortic dissection with subsequent rupture. Dissecting aortic aneurysm could run a benign asymptomatic or a lethal course and a high index of suspicion is necessary. The lack of exhaustive diagnostic investigative tools as well as surgical intervention in the management of this patient in a developing country was highlighted as was possible that the patient could have been mismanaged.

Aortic Dissection↗
PubMed2005

Peripartum presentation of an acute aortic dissection.

We report the case of an acute type A aortic dissection occurring in a 35-year-old parturient. The initial diagnosis was missed; a subsequent emergency Caesarean section 3 weeks after presentation was followed by the development of left ventricular failure and pulmonary oedema in the early postoperative period. Echocardiography confirmed the diagnosis of aortic dissection and the patient underwent a successful surgical repair.

Acute Disease↗