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A patient with Marfan's syndrome and previous Bentall repair for aortic dissection required orthotopic cardiac transplantation for end-stage cardiomyopathy. Postoperatively he suffered recurrent aortic dissection involving the transverse and descending aorta leading to tracheal and esophageal compression. He underwent successful surgical replacement of his ascending aorta, transverse arch, and descending aorta.
We recently reported the existence of a higher risk of acute aortic dissection (AAD) during the winter months. However, it is not known whether this winter peak is affected by climate. To address this issue, we evaluated data from 969 AAD patients who were enrolled at various sites around the globe and who were participating in the International Registry of Acute Aortic Dissection (IRAD). We found a significant (p = 0.001; chi2 test) difference in the number of AAD events occurring during the different seasons of the year, with highest incidence in winter (28.4%) and lowest incidence in summer (19.9%). Furthermore, the winter peak was evident in both cold and temperate climate settings, suggesting that the relative change in temperature, rather than absolute temperature, and/or endogenous annual rhythms are critical mechanistic factors.
Syrian hamsters of the APA strain (APA hamsters) are known to show continuous diabetes accompanied by its complications, such as glomerulosclerosis and atherosclerosis, following a single injection of streptozotocin (SZ). Recently, we observed Stanford type B aortic dissection in three diabetic APA hamsters and histopathological analysis was performed. The histopathologic observations in the false lumen, such as proliferation of granulation tissues, neointima and pseudoneointima, corresponded to the non-thrombosed type of human aortic dissection, and blood clots of the thrombosed type were similar to the remodeling structures of aortic dissection found in human cases. Thus, this model may be useful for investigating the etiology and pathogenesis of aortic dissection accompanying diabetes mellitus in humans.
A 60-year-old patient was referred to the hospital for persisting chest pain. The first transesophageal echocardiogram showed localized hematomas without aortic dissection. Several days later the patient suffered complete paraplegia after a second episode of chest pain. The transesophageal echocardiogram now showed a complete aortic dissection. Thus whether intramural hematomas can be regarded as an early sign of impending aortic dissection needs to be investigated.
BACKGROUND: The surgical treatment of acute complicated type B aortic dissection continues to be a challenge and is still associated with high morbidity and mortality rates. METHODS: Seventy consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure through a median sternotomy during deep hypothermic circulatory arrest. An endoprosthesis that was 22 to 24 mm in diameter was inserted through an incision in the arch and held in place with only proximal sutures. RESULTS: The mean arrest time was 31.4 +/- 8.7 minutes, and it was possible to adequately position the endoluminal graft in every patient. The procedure was done in association with other procedures in 13 patients. There were six in-hospital deaths not related to the endoprosthesis, and four late deaths. Late reoperation was necessary in 6 patients to manage leakage at the proximal suture line. CONCLUSIONS: The insertion of an endoprosthesis through the arch for the management of a complicated acute type B dissection has several advantages over the conventional thoracotomy approach. The hospital mortality rate in this series of 70 patients was 20%, and the actuarial 5-year survival rate was 62.5%. We consider the elephant trunk procedure the treatment of choice in patients with type B acute dissections, regardless of whether the dissection is complicated or not.
Organ malperfusion most commonly occurs in the acute stage of aortic dissection and is associated with a high mortality, but can occur with chronic dissection. We describe a case of a type 3 aortic dissection, which had a stenosed left renal artery originating from the false lumen and causing resistant hypertension. The left renal artery was successfully dilated and stented, with prompt resolution of the patient's hypertension.
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BACKGROUND: The purpose of this preliminary study was to evaluate the effectiveness of our surgical strategy for acute aortic dissection with special emphasis on curative resection of the dissected segments of the aorta. MATERIAL/METHODS: Between January 1995 and April 1999, 29 patients underwent surgery for acute aortic dissection. In 16 patients (Group 1) the dissection was limited to the ascending aorta (8 patients - Group 1a) or involved the ascending aorta and the entire aortic arch (8 patients - Group 1b). Complete resection of all dissected aortic segments (ascending aorta or ascending aorta with complete aortic arch) was performed in these cases, extending to the healthy tissue border. 13 patients (Group 2) presented with dissection of the entire aorta). These patients underwent replacement of the proximal part only of the dissected aorta. RESULTS: Early mortality (within 30 days) and the incidence of perioperative cerebrovascular events was 3.4% and 10.3% respectively. These events all occurred in Group 2. During the follow-up period of up to six years, there were no significant differences between the surviving patients in regards to long-term mortality and morbidity, although a persisting patent false lumen was observed in seven patients from Group 2. CONCLUSIONS: Extension of ascending aorta replacement to include the complete aortic arch can be accomplished in patients amenable to complete resection of the dissected aorta without increasing operative risk and with good mid-term results. We believe that total aortic arch replacement is indicated in these cases.
OBJECTIVE: Although computed tomography, angiography, or magnetic resonance imaging is most commonly used for diagnosing mesenteric ischemia caused by acute aortic dissection, use of these modalities is often limited in the perioperative period. Thus, we have introduced transesophageal echocardiography to cover this deficit. Purpose of this study is to report the feasibility and accuracy of transesophageal echocardiographic diagnosis on mesenteric ischemia. METHODS: The consecutive 24 cases with acute aortic dissection which involved abdominal aorta and underwent surgery were examined. The celiac artery and superior mesenteric artery was visualized with 5 MHz biplane transesophageal echocardiography and was assessed for presence of dissection and blood flow in each of true and false lumen. The transesophageal echocardiographic findings were then correlated to the clinical course, computed tomographic findings, and laboratory data. RESULTS: The celiac artery and superior mesenteric artery was successfully visualized in 24 cases (100%) and 23 cases (95.8%), respectively. Perfusion patterns in superior mesenteric artery were categorized into four patterns: (1) intact artery with adequate perfusion (type A: 14 cases); (2) dissection in the artery but with adequate perfusion in true lumen (type B: 5 cases); (3) dissection in the artery with narrowed true lumen compressed by false lumen without detectable blood flow (type C: 1 case); and (4) obstruction of arterial orifice by the intimal flap with narrowed true lumen in the proximal aorta (type D: 2 cases). One case with immediate postoperative death and another case with unsuccessful visualization of superior mesenteric artery were excluded from the analysis. Clinically apparent intestinal ischemia was present in three cases: one case with type C and two cases with type D, but in none of the remaining 19 cases with type A or type B (both sensitivity and specificity were 100%). The superior mesenteric artery was opacified in all of these three cases with ischemia. CONCLUSIONS: The transesophageal echocardiographic assessment is feasible in nearly all patients and potentially provides correct diagnosis on intestinal ischemia in the perioperative period of acute aortic dissection. Types C and D indicate significant mesenteric malperfusion.
OBJECTIVE: We sought to report the clinical experience with extended total arch replacement for acute type A aortic dissection and to determine the factors that influence early mortality, late survival, and late reoperation. METHODS: Between December 1988 and August 1998, 70 patients underwent emergency graft replacement of both the ascending aorta and the total aortic arch for acute type A aortic dissection. All operations were performed with hypothermic extracorporeal circulation, selective cerebral perfusion for cerebral protection during aortic arch repair, and open distal anastomosis. Concomitant procedures included aortic valve resuspension in 18 patients, composite graft replacement in 10 patients, and coronary artery bypass grafting in 5 patients. RESULTS: The early mortality rate was 16% (11 of 70 patients). Multivariable analysis showed that renal-mesenteric ischemia and coronary artery bypass grafting were independent determinants for early death. Survival rates at 3 and 5 years postoperatively, including the early deaths, were 75% +/- 5% and 73% +/- 6%, respectively. Multivariable analysis showed that renal-mesenteric ischemia and en bloc repair were independent determinants for late death. Freedom from reoperation was 91% +/- 4% and 77% +/- 8% at 3 and 5 years, respectively. Multivariable analysis showed that anastomotic leakage was the only significant determinant for late reoperation. CONCLUSIONS: Extended total arch replacement for acute type A aortic dissection could be justified in properly selected patients.
A case of spontaneous acute infrarenal aortic dissection, with extension to the right common iliac artery and proximally to just below the origin of the renal arteries is presented. This dissection did not involve the visceral vessels nor the iliac system. The diagnosis was made with ultrasonography and computed tomography, without the need for angiography, and confirmed during surgical intervention, in which, prosthetic replacement of the affected segment was carried out.
Forty-seven patients with aortic dissection resulting from a primary tear located in the transverse aortic arch underwent surgical treatment. Twenty-six patients had acute type A, 7 had acute type B, 7 had chronic type A, and 7 had chronic type B aortic dissections. Of the 33 patients with acute dissections, 11 (7 acute type A and 4 acute type B) underwent concomitant arch repair with an operative (less than or equal to 30 days) mortality rate of 55% (35% to 73%, +/- 1 asymmetric 70% confidence limit) (2 of 7 acute type A and 4 of 4 acute type B). Concomitant arch repair was omitted in 22 patients with acute dissections (19 acute type A and 3 acute type B); the operative mortality rate was 41% (29% to 54%) (7 of 19 acute type A and 2 of 3 acute type B) (p = not significant versus arch repair). The overall survival rate for those with arch repair was 45% +/- 15% (+/- 1 standard error of the estimate) at 4 years, compared with 43% +/- 11% for patients without arch repair (p = not significant). Considering the type of dissection, the 4-year survival estimate for patients with acute type A dissections who underwent arch repair (5 hemiarch and 2 total arch) was 71% +/- 17% (versus 44% +/- 12% for acute type A patients without arch repair). There were no survivors among the 4 patients with acute type B dissections who had an arch repair (1 hemiarch and 3 total arch), whereas patients with acute type B dissections who did not undergo concomitant arch repair had a 4-year survival estimate of 33% +/- 27% (p = not significant versus arch repair). Four other patients with acute type B dissections resulting from an arch tear were managed medically and tended to have a slightly better prognosis (2-year survival estimate of 75% +/- 22% versus 14% +/- 13% for all surgically treated acute type B patients), but again this difference was not statistically significant. Multivariate analysis of the 47 surgical patients revealed that advanced age (p = 0.0008), preoperative dissection complications (p = 0.02), and other coexistent medical problems (p = 0.03) were the only significant, independent determinants of overall mortality. Initial arch repair was not a significant predictor. Nine percent (2/22) of patients with acute type A dissections who initially underwent isolated ascending aortic replacement required subsequent arch replacement; 1 died after reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)
OBJECTIVE: We set out to study the efficacy of MRI in the demonstration of residual alterations and postsurgical complications of type A aortic dissection. MATERIALS AND METHODS: From October 1988 to December 1990, 28 patients, 18 patients with type I and 10 with type II aortic dissection, underwent MR examinations for postsurgical evaluation. Features evaluated included caliber of the aorta (a) above and (b) below the prosthesis; (c) redissection; (d) persistent intimal flap; (e) presence of abdominal vessels arising from the false lumen; and (f) status of thoracic supraaortic vessels. RESULTS: Five of 28 patients were considered "normal," due to negative results of the assessed parameters. Dilatation of the aorta was found distal to the graft in seven patients and proximal to the graft in two. Redissection was observed in 2 of 28 patients. Residual intimal flap was seen in 15 of 28 patients; the state of false lumen was well identified in 5 patients using only SE images and in 7 of the remaining 10 using phase imaging. In 25 of 28 patients, supraaortic vessels were well evaluated with involvement seen in 2 cases. In the three other patients, adequate identification was not possible. CONCLUSION: We believe MRI is the technique of choice for monitoring the aorta after surgery in aortic dissection to identify alterations and complications and institute suitable therapy.
OBJECTIVE: The purpose of this study was to assess the ability of gated SE MR to demonstrate entry tears of thoracic aortic dissections and to elucidate their MR appearance. MATERIALS AND METHODS: Gated SE MR images of nine consecutive patients with nonthrombosed aortic dissection on aortography were retrospectively analyzed. RESULTS: Magnetic resonance consistently depicted an intimal flap and a double lumen in all nine patients. A focal intimal flap discontinuity suggesting an intimal tear was shown in eight patients. This intimal flap discontinuity was confirmed to be the entry tear by operation in five patients and by aortography in three. In five of eight patients with a focal intimal flap discontinuity, rapid influx of blood across an intimal defect produced a localized signal void area within the false lumen, which was surrounded by slow flow signal showing even-echo rephasing. This MR sign of a localized jet of flow void within the false lumen was very useful in determining the significance of a focal intimal flap discontinuity. CONCLUSION: Familiarity with these MR appearances of entry tears may enable their preoperative localization in a large proportion of aortic dissections on routine gated SE MRI.
53 cases of aortic dissections were operated on between 1961 and 1975 in the Service of Cardiovascular Surgery at the Broussais Hospital, Paris (Prof. Ch. Dubost). The present study deals with 32 cases operated on in the acute phase. 31 originated in the ascending aorta and 1 in the descending aorta. Operative mortality was 50% (16/32), 4 patients died immediately following sternotomy. Operation consisted in replacement of the ascending aorta for the majority of type I and II dissections. When aortic insufficiency was present, a simple resuspension procedure was effective in 50% of cases. The authors prefer early operative intervention in type I and II dissections and medical treatment in type III dissections.
Between June 1991 and February 1999, three patients suffered ascending aortic dissection as a complication of cardiopulmonary bypass operations with aortic cannulation at our hospital. The dissection occurred during the operation in two of the three patients and several months after the operation in one. Among a total of 2207 cardiac operations performed during this period, the incidence of perioperative ascending aortic dissection was 0.14%. In addition to visual inspection and palpation, either epicardial or transesophageal echocardiography proved extremely useful for establishing an intraoperative diagnosis of ascending aortic dissection as a complication of open cardiac operation. One of the three patients underwent closed plication but subsequently died of vital organ ischemia. In this case, failure of reapproximation of the injured intima by closed plication might have led to extension of the dissection. Despite prolonged cardiopulmonary bypass and myocardial ischemic time, graft replacement of the ascending aorta was successfully carried out in the other two patients. Thus, we believe that graft replacement of the ascending aorta should be performed for patients with extensive aortic dissection complicating an open cardiac operation.
It remains unclear whether or not the infarcted brain caused by aortic dissection should be reperfused when an emergency operation is needed for aortic arch dissection. A 64-year-old woman presented with severe back pain and syncope with a sudden left hemiplegia. CT scan demonstrated an aortic dissection of the entire aorta, obstruction of the right common carotid artery by extended aortic dissection, cerebral infarction of the right middle cerebral artery territory, brain edema and pericardial effusion. Though she was unable to communicate with us, she underwent an emergent aortic arch replacement and ligature of the right common carotid artery nine hours after the onset of stroke, when massive cerebral infarction was established. She survived the operation and regained full consciousness. When brain infarction was established by extended aortic dissection in emergent aortic surgery, concomitant ligature of the responsible artery to the brain infarction may be allowed for avoiding cerebral damage leading to brain death.