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PubMed1994

Repair of the aortic arch with fibrin glue in type A aortic dissection.

Location of the intimal tear in the aortic arch in type A aortic dissection is for many authors an indication for replacement of the aortic arch, but this operation has a high in-hospital mortality rate: 20% to 40%. Instead, we suggest repairing the aortic arch by injecting fibrin glue, which contains a human sealer protein concentrate, between the two dissected layers under circulatory arrest while replacing the ascending aorta. To evaluate this technique, we reviewed 45 successive patients operated on for type A acute aortic dissection between January 1989 and July 1993, of which 6 had the intimal tear located on or extending into the aortic arch. Mean age was 71 +/- 4.2 years (range 68 to 74). After proximal supracoronary anastomosis with a collagen-impregnated graft, aortic arch repair was achieved by injecting fibrin glue between the two layers, using circulatory arrest at a mean temperature of 22 degrees C, with a mean duration of 24 minutes. This obliterated the dissection in the arch and also the intimal flap. The distal part of the graft was then anastomosed to the proximal portion of the aortic arch at the origin of the innominate artery under circulatory arrest. There were no early or late deaths. All patients were asymptomatic at a mean follow-up of 2.6 years. Follow-up angioscan showed obliteration of the dissection in the aortic arch in all patients; there were two patients with dilatation of the distal aortic arch of 40 and 45 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed2003

Acute type A aortic dissection with intestinal ischemia predicted by serum lactate elevation.

Mesenteric ischemia can complicate acute aortic dissection. We report a case of acute type A aortic dissection with perioperative intestinal ischemia, which clinically manifested on the second postoperative day. Serial monitoring of serum lactate level by a conventional blood gas analyzer was useful for early diagnosis and for timely treatment of intestinal ischemia. In this report, monitoring of serum lactate level as a key for the successful management of intestinal ischemia is suggested.

Acute Disease↗
PubMed2006

Femoral artery cannulation in Stanford type A aortic dissection operations.

The aim of this study was to evaluate femoral artery cannulation in Stanford type A aortic dissection operations. Between March 1994 and December 2001, 88 patients with Stanford type A aortic dissection underwent surgery with cardiopulmonary bypass and perfusion through the femoral artery; 31 of them had deep-hypothermic circulatory arrest. False lumen perfusion was detected in 8 patients (9.1%). There were 4 (4.5%) cerebral events: 2 patients had diffuse cerebral injury, with one death; and 2 patients had hemiplegia, with one death. Six patients (8.0%) had delayed incision healing, with local infection in one. There was no lower extremity ischemia associated with femoral artery cannulation. It was concluded that retrograde perfusion through the femoral artery was effective for repair of aortic dissection, with a low risk of those cerebral events associated with a high mortality rate.

Adult↗
PubMed1999

Anomalous coronary artery, aortic dissection, and acute myocardial infarction.

The combination of acute coronary occlusion and aortic dissection because of involvement of one or other coronary vessels in the dissection flap is uncommon. Furthermore, the occurrence of an anomalous coronary artery and its involvement in acute myocardial infarction is even more uncommon. We describe a patient with acute myocardial infarction in whom an acute aortic dissection involved the ostium of an anomalous circumflex artery.

Acute Disease↗
PubMed2000

Valve-preserving operation in acute aortic dissection type A.

BACKGROUND: The standard treatment in patients with acute aortic dissection type A (AADA) and aortic regurgitation is either supracommissural aortic or composite replacement of ascending aorta and valve. Valve-preserving surgical procedures provide a promising alternative. We retrospectively analyzed midterm results after these different approaches. METHODS: From October 1995 to December 1999, 52 patients (35 men, 17 women) underwent repair of AADA. Patient ages ranged from 30 to 83 years. Composite replacement was chosen for degenerated aortic valves or prior valve replacement (group A; n = 8). With normal root diameter, supracommissural replacement of the ascending aorta was performed (group B; n = 22). For preexisting root dilatation the aortic root was either remodeled (root diameter 30 to 50 mm, group C; n = 17) or the valve reimplanted within a vascular graft (root diameter more than 50 mm, group D; n = 5). RESULTS: All patients underwent either proximal (n = 46) or total (n = 6) arch replacement under circulatory arrest. Eight patients (15.4%) died (group A: n = 3; group B: n = 3; group C: n = 2). Freedom from aortic regurgitation of grade 2 or more at 2 years was 100% in groups A and D, 90.9% in group C, and 75% following supracommissural replacement. At 2 years freedom from proximal reoperation was 100% in groups A, C, and D and 84.5% in group B. CONCLUSIONS: In AADA valve-preserving root replacement leads to improved stability of aortic valve function without an increased operative risk. Midterm results are promising and may show further superiority over supracommissural aortic replacement in the future.

Acute Disease↗
PubMed1989

Acute renal failure secondary to rhabdomyolysis associated with dissecting aortic aneurysm.

Rhabdomyolysis, a massive necrosis of skeletal muscle, is caused by various traumatic and non-traumatic factors. We report on a 30-year-old male in whom dissecting aortic aneurysm diagnosed by computed tomography was responsible for the generation of rhabdomyolytic acute renal failure. The patient was successfully treated by repeated hemodialyses and corrective surgery for aortic regurgitation and dissecting aortic aneurysm (Bentall's operation).

Acute Kidney Injury↗
PubMed2006

A prospective study of medically treated acute type B aortic dissection.

OBJECTIVE: To study prospectively aneurysm formation, need of surgery, incidence of rupture and mortality in patients with conservatively treated acute type B aortic dissection. METHODS: All patients referred to us with acute type B dissection between January 1990 and December 2001 were candidates for this prospective treatment and follow-up study. Patients deemed not to be in need of acute surgical repair were included after aggressive antihypertensive treatment. The follow-up protocol included close blood pressure control, clinic visits with physical examination, chest x-ray and spiral CT or MRI at 3 and 6 months and annually thereafter. RESULTS: Sixty-six patients were followed for a mean of 79 months (range 22-179). The actuarial survival rate was 82% at 5 years and 69% at 10 years. Eighty-five percent remained free from dissection-related death at 5 years and 82% at 10 years. Ten patients (15%) developed aneurysm (>6 cm) of the dissected aorta. Three of these 10 patients died from aortic rupture and 2 underwent elective surgical repair. Of the 56 patients without aneurysm, one died from rupture and one died suddenly for causes unknown. One patient was treated with endovascular stent-graft. Five patients sustained a new type A aortic dissection which in all but one were fatal. In 26 patients the initial dissection was categorized as intramural hematoma. Twelve of these patients had, in addition to the hematoma, areas with localized dissection/ulcer-like projection. The latter was found to be a predictor of aortic event (dissection-related death, rupture, new type A aortic dissection, aneurysm formation) during follow-up, as was an initial diameter of >4.0 cm at first CT-scan during the acute event. CONCLUSIONS: Conservatively treated acute type B dissection has a low incidence of aneurysm formation and rupture during the chronic phase. These results must be matched or improved upon before endovascular stent-grafting or early aortic surgical repair can be regarded as the primary treatment of choice.

Acute Disease↗
PubMed1999

Dissecting aortic aneurysm in a horse.

A case of dissecting aortic aneurysm in a 4-year-old male thoroughbred horse is reported. The horse had a history of inflammation in the right thigh and a fever 2 weeks before sudden death. At necropsy, aortic aneurysms were observed from the aortic valve to the aortic arch, spreading over a distance of 40 cm. An irregular rupture of the intima of the ascending aorta was located in the cardiac side of a ramification to the tunica branchiocephalicus communis. An intramural haematoma, apparent on the cut surface and in the pericardium, had caused cardiac tamponade and sudden death.

Aortic Dissection↗
PubMed2002

Treatment of aortic dissections with endovascular stent grafts.

The management of aortic dissections remains controversial. Knowledge regarding the extent and specific pathophysiology of each dissection is critical prior to intervention. Cross-sectional imaging techniques coupled with intravascular ultrasound or hemodynamic measurements are vital. In the setting of ischemia with significant true lumen compromise, the placement of a proximal endovascular graft has a high likelihood of dramatically improving the diameter of the true lumen, alleviating distal ischemia. Caution must be taken when branch vessels are involved in the dissection. Adequate true lumen flow with persistent end-organ ischemia is best handled with branch vessel stenting. Combined true lumen compresssion and branch vessel dissection requires both visceral vessel stenting and proximal endovascular grafting. Using these techniques, we have been able to achieve a mortality rate of less than 35% in a patient population that previously suffered mortality rates in excess of 50%. However, application of these technologies to asymptomatic or nonischemic dissections is not warranted outside the context of investigational trials.

Aortic Dissection↗
PubMed2006

Comparison of diagnostic and therapeutic value of transesophageal echocardiography, intravascular ultrasonic imaging, and intraluminal phased-array imaging in aortic dissection with tear in the descending thoracic aorta (type B).

Transesophageal echocardiography (TEE) and conventional intravascular ultrasound (IVUS) have limited capabilities in type B aortic dissection. To evaluate its diagnostic value, intraluminal phased-array imaging (IPAI) was compared with IVUS and TEE. In 23 patients with type B aortic dissection, IPAI was tested with respect to its ability to depict true lumen (TL) and false lumen (FL), to localize which abdominal arteries originate from the TL and FL, and to identify all entries and reentries. After the completion of TEE, 2 additional examiners performed angiography and positioned an AcuNav catheter inside the TL. An IVUS catheter was then introduced into the TL by a fourth examiner. All examiners were blinded to one another. Four additional patients with type B aortic dissection developed peripheral malperfusion due to TL collapse. Transvenous IPAI was used to guide emergency fenestration of the intimal flap. TL and FL could be equally well identified by all diagnostic methods. IPAI detected more entries than IVUS (3.0 +/- 1.2 vs 0.8 +/- 0.5, p <0.001), and thoracic IPAI depicted more entries than TEE (1.8 +/- 1.0 vs 1.2 +/- 0.5, p <0.001). IPAI and IVUS showed >90% of the abdominal side branches. In all patients with peripheral malperfusion, successful emergency intimal flap fenestration was safely guided by IPAI. In conclusion, in the detailed diagnostic evaluation of type B aortic dissection, IPAI is superior to IVUS and TEE in detecting communications between the TL and FL. IPAI is also highly useful as a guiding tool for emergency intimal flap fenestration.

Aortic Dissection↗
PubMed1989

[A successful treatment of Cabrol's procedure for annuloaortic ectasia with an acute aortic dissection (Stanford type A)].

A 67-year-old female who has an Annuloaortic ectasia with an acute aortic dissection was urgently admitted to our hospital. She was also suspected to have developed into an acute cardiac tamponade. An aortic dissection was arised from just above the right coronary artery orific and extended to the innominate artery and the right common carotid artery. In this case Cabrol's procedure with cerebral perfusion technique was considered to be a good indication, but standard Cabrol's procedure provided almost satisfactory results without utilizing a cerebral perfusion technique because disappearance of pressure difference between both hands and the right common carotid artery after reconstruction. Her postoperative course was uneventful and aortography confirmed competence of the prosthetic valve, good patency of the coronary arteries without false aneurysm formation. Cabrol's procedure is a reliable method for Annulo-aortic ectasia especially with an acute aortic dissection of the ascending aorta.

Acute Disease↗
PubMed1997

Treatment of aortic dissection and ruptured abdominal aneurysm with coronary bypass.

We present a patient with a descending aortic dissection and contained rupture of a large abdominal aortic aneurysm with a history of inferior myocardial infarction and right coronary occlusion. The technique of combined repair of the descending thoracic aortic dissection with replacement of the ruptured infrarenal abdominal aorta and coronary artery bypass grafting is described.

Aged↗
PubMed2006

Management of type A aortic dissection and a large pheochromocytoma: a surgical dilemma.

The concomitant presence of an undiagnosed pheochromocytoma at the time of an acute type A aortic dissection creates a difficult management dilemma. The case of a patient with an acute type A aortic dissection and pheochromocytoma was stabilized with catecholamine blockade before undergoing ascending aortic and total arch replacement. Fourteen days later the patient underwent resection of the pheochromocytoma. Temporizing medical stabilization of the pheochromocytoma with catecholamine blockade for a period of 5 days allowed for safe aortic reconstruction and seems to be prudent, provided that the aortic dissection remains relatively stable.

Adrenergic alpha-Antagonists↗
PubMed1999

Surgery for acute type A aortic dissection.

BACKGROUND: Several innovative approaches have been introduced in the surgical treatment of acute type A aortic dissection. This study examines the effects of these new techniques on the early and late outcomes of patients with this disease. METHODS: The records of patients who had surgery for acute type A aortic dissection during an 18 year interval were reviewed. There were 109 patients: 81 men and 28 women, with a mean age of 57 years, range 23 to 80. Most patients were acutely ill and 15 were in shock at the time of surgery. Operations were performed under cardiopulmonary bypass with femoral artery and right atrial cannulation. In 55 patients, the aorta was clamped and retrograde femoral perfusion was used throughout the procedure (group I). In 54 patients, no clamp was used; under circulatory arrest the primary tear was resected whether in the ascending aorta or transverse arch, and antegrade cardiopulmonary bypass was started after completion of the distal anastomosis (group II). Postoperative computed tomographic or magnetic resonance scans were completed annually. RESULTS: There were 16 operative deaths (15%): 11 (20%) in group I, and 5 (9.2%) in group II (p = 0.10). There were 10 strokes: 8 (14.5%) in group I and 2 (3.7%) in group II (p = 0.05). After a mean follow-up time of 59 +/- 45 months for group I, 31 (56%) patients were alive, and after a mean follow-up time of 45 +/- 26 months for group II, 44 (81%) patients were alive. The actuarial survival of group II was higher than group I, but the difference was not significant (p = 0.09). Postoperatively, a patent false lumen was found in 91% of group I patients and in 59% of group II (p = 0.01). CONCLUSIONS: This study suggests that avoidance of aortic clamping, resection of the primary tear in the ascending aorta or transverse arch, and antegrade perfusion after completion of the distal anastomosis improve the early and late outcomes of surgery for acute type A aortic dissection.

Acute Disease↗
PubMed1996

Anaesthesia for caesarean section in a Marfan patient with recurrent aortic dissection.

PURPOSE: We report the anaesthetic management of a 34-yr-old pregnant woman with recurrent aortic dissection and Marfan syndrome for Caesarean section. CLINICAL FEATURES: She presented at 28 wk gestation with recurrent aortic dissection and had undergone aortic valve replacement and coronary ostia reimplantation (Bentall procedure) in the first trimester of pregnancy. She was treated in hospital with labetalol, anticoagulants and steroids and daily echocardiographic examination until 34 wk when caesarean section was planned. After positioning radial artery and CVP catheters and a transoesophageal echocardiographic probe, general anaesthesia was induced with thiopentone and maintained with isoflurane, and endotracheal intubation was facilitated with vecuronium. The site of incision was infiltrated with lidocaine before surgery which was uneventful. The patient was discharged at 10 days. CONCLUSIONS: With appropriate preoperative care and monitoring, uneventful general anaesthesia for caesarean section was achieved in a patient with Marfan syndrome in the presence of recurrent aortic dissection.

Adult↗
PubMed1992

[Comparison of long-term results of surgical and nonsurgical therapy in acute aortic dissection].

The early and long-term results of both surgical and nonsurgical therapy for 160 patients with acute aortic dissection in our institution were analyzed. Of the 83 patients with acute type A aortic dissection, 47 received surgery during acute stage, 10 received it in the chronic stage, and 26 received nonsurgical therapy. Of the 77 patients with acute type B aortic dissection, 27 received surgery during acute stage, 22 received it in the chronic stage, and 28 received nonsurgical therapy. Ten-year survival rates for patients receiving surgery during the acute stage were 62% for type A and 64% for type B dissection. This survival rate for type A patients was significantly higher than that for type A patients not receiving surgery, but the corresponding difference for type B patients was not significant. Present data indicate that immediate surgical intervention is indicated in patients with acute type A dissection, and elective operation in the subacute stage in patient with uncomplicated type B dissection following medical therapy in the acute stage.

Acute Disease↗
PubMed1995

[Takayasu arteritis--a rare differential diagnosis in aortic dissection. A case report].

A 36-year-old woman was delivered to our hospital with suspected aortic dissection from an outlying hospital in May 1994. She reported a history of acute and persistent thoracic and epigastric pain. The physical examination revealed a minor senso-motorical palsy of the left side as residuum after minor strokes occurring 12/93 and 4/94. Also, a marked hypertension (170/100 mm Hg) was present. The hematologic and blood chemical values were normal with a white cell count of 12,000, an erythrocyte sedimentation rate (ESR) of 19 mm/h and a c-reactive protein (CRP) of 2.2 mg/dl. The electrocardiogram was normal. Transthoracic- and transesophageal-echocardiography (TTE, TEE) revealed an eccentric thickening of the whole wall of the descending aorta up to the bifurcation with a stenosis at the side of the diaphragma. Those findings were confirmed by computed tomography. Because of the acute onset of symptoms and the results of the imaging procedures aortic dissection de Bakey type III was diagnosed and the patient was treated with beta-blockers. Symptoms were relieved over the following days. After 2 days a pleuric effusion developed and all inflammatory tests rose (fibrinogen 780 mg/dl, ESR 80 mm/hr, CRP 16 mg/dl). At this time the differential diagnosis of an arteritis was considered. A new TEE-study demonstrated no change, but now more attention was given to the fact that no dissection membrane could be visualized and all wall structures were thickened. In combination with the history of cerebral infarction due to carotid obstruction and the elevated laboratory values the diagnosis of Takayasu-aortitis was established and corticoid therapy was started. Within a few weeks the arterial changes diminshed markedly and the woman became free of symptoms. This case demonstrates the rare situation of an arteritis mimicking aortic dissection, in which the clinical course revealed the true diagnosis.

Adult↗
PubMed2004

Novel intravascular ultrasound-guided method to create transintimal arterial communications: initial experience in peripheral occlusive disease and aortic dissection.

PURPOSE: To report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound (IVUS) transducer to achieve controlled true lumen re-entry in patients undergoing subintimal angioplasty for chronic total occlusions (CTO) or aortic dissections. METHODS: During an 8-month period, 10 patients (6 men; mean age 73.4 years) with lower extremity (LE) ischemia from CTOs (n=7) or true lumen collapse from aortic dissections (n=3) were treated. Subintimal access and controlled re-entry of the CTOs were performed with a commercially available 6.2-F dual-lumen catheter, which contained an integrated 64-element phased-array IVUS transducer and a deployable 24-G needle through which a guidewire was passed once the target lumen was reached. The occluded segments were balloon dilated; self-expanding nitinol stents were deployed. In the aortic dissections, fenestrations were performed using the same device, with the IVUS unit acting as the guide. The fenestrations were balloon dilated and stented to support the true lumen. RESULTS: Time to effective re-entry ranged from 6 to 10 minutes (mean 7) in the CTOs; antegrade flow was restored in all 7 CTOs, and the patients were free of ischemic symptoms at up to 8-month follow-up. In the aortic dissection cases, the fenestrations equalized pressures between the lumens and restored flow into the compromised vessels. There were no complications related to the use of this device in any of the 10 patients. CONCLUSIONS: Our preliminary results demonstrate the feasibility of using this catheter-based system for subintimal recanalization with controlled re-entry in CTOs and for aortic flap fenestrations in aortic dissections. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.

Aged↗