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[AORTIC DISSECTIONS].
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Treatment of acute aortic dissection involving the right coronary artery and aortic valve.
A complication of acute dissection of the ascending aorta is involvement of the aortic valve and right coronary artery. A case is presented in which the treatment of this lesion involved placement of a composite valve graft with reattachment of the left main coronary artery using a small Dacron tube graft and a saphenous vein bypass to the right coronary artery.
[Aortic dissection].
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[Tracheo-bronchial stenosis caused by a thrombosed aortic aneurysm after extra-anatomic bypass in a dissecting aortic aneurysm].
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[Is it necessary to increase peripheral resistance in aortic dissection?].
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[Aortic dissection].
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[Diagnostic imaging of aortic dissection].
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[Thrombosed type aortic dissection].
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[Surgical treatment of type A acute aortic dissection--experience of hypothermic circulatory arrest associated with the cerebroplegia].
From 1992 to July 1996, 19 patients (aged 39 to 78 years) were operated on for type A acute aortic dissection. Our operative strategy is that all patients in whom aortic dissection involves the segment of transverse aortic arch should undergo simultaneous replacement or repair of the aortic arch and ascending aorta. Among these 19 patients, 17 were operated on within 24 hours after onset. In 13 patients, graft replacement extended from the ascending aorta to the transverse portion of the arch. The aortic stumps were prepared with the Teflon left both inside and outside of the aortic wall. Recently these were reconstructed with the aid of the Gelatin-Resorcin-Formaling glue, instilled into the false lumen. Cerebral protection was achieved by hypothermic circulatory arrest associated with the cerebroplegia (thiopental, nicradipine and mannitol). In one patient associated with severe aortic regurgitation, a valved conduit was implanted and the coronary arteries were reimplanted. CABG was performed concomitantly in two patients for involvement of the proximal coronary arteries by the dissection process. The hospital mortality rate was 26% (5/19). However, in two of them, death was not directly related to the operative procedure. One patient died of graft versus host disease (GVHD), another patient died of acute epidural hemorrhage which was undetected until the repair was completed. During the postoperative course, in all but two patients, the false lumens of the aortic arch and/or descending thoracic aorta were confirmed to be totally thrombosed by the examination of CT scan and/or aortography. It is concluded that the surgical treatment of type A acute aortic dissection can be successfully performed, even if the graft replacement extended to the transverse aortic arch.
[Total atrioventricular block as the primary clinical manifestation of undiagnosed aortic dissection].
We describe the case of a 54-year-old male who was examined due to light chest pain experienced the previous day. The man was admitted to the cardiology division for the presence of a complete atrioventricular block. On admission the echocardiogram showed a large aortic regurgitation not present two years earlier. Suspecting an aortic dissection we performed a transesophageal echocardiography and a contrast computerized tomography: the two examinations were negative. The next days the patient had two episodes of acute pulmonary edema so he was transferred to the regional reference hospital where an hemodynamic unit and cardiac surgery division were available. There, he repeated a transesophageal echocardiography which was negative. The man had aortic valve replacement without angiography for his very critical condition. The surgeon identified a small aortic dissection, just above the aortic valve plane, which was responsible for valve leaflets prolapse and aortic regurgitation; the hematoma deepened towards the interatrial septum and atrioventricular junction justifying the atrioventricular block. In conclusion, a small aortic dissection can offer an atypical picture, and in this condition even very valuable diagnostic techniques may fail the diagnosis.
Painless acute aortic dissection presenting as echocardiographically diagnosed left ventricular outflow tract obstruction.
We present an unusual case of painless acute aortic dissection with an atypical echocardiographic presentation that could be confused with an aortic stenosis. Transesophageal echocardiography excluded the presence of aortic stenosis and disclosed a systolic anterior movement of the mitral valve as the cause of left ventricular outflow tract obstruction. It also revealed a type A aortic dissection.
Dissecting aortic aneurysm complicated with acute disseminated intravascular coagulation: case report.
Acute disseminated intravascular coagulation (DIC) is a rare complication of aortic aneurysm with or without dissection. We describe an 88-year-old man who presented with severe hemorrhagic diathesis and a pulsating abdominal mass. An abdominal computed tomography (CT) scan revealed a dissecting abdominal aortic aneurysm with thrombus formation, and his coagulation profile showed the features of acute DIC. After he had received blood component therapy, including fresh frozen plasma and cryoprecipitate concentrates, and intravenous heparin infusion (10,000 U/day), the bleeding diathesis and coagulopathy improved. An aneurysmectomy was performed smoothly without excessive bleeding. Coagulation parameters returned to normal after surgery. Dissecting aortic aneurysm should be considered as a possible etiology of acute disseminated intravascular coagulation, even it occurs in rare situations. Surgical intervention is still the main strategy to normalize coagulopathy. Bleeding diathesis must be corrected before surgery in order to prevent massive intraoperative bleeding.
Aortic dissection in a weight lifter with nodular fasciitis of the aorta.
We report a case of spontaneous aortic dissection in a young weight lifter without aortic medial disease but with a myofibroblastic proliferation of the aortic adventitia consistent with nodular fasciitis. Successful treatment included ascending aorta replacement with Dacron graft and aortic valve resuspension. We believe that the underlying aortic pathology most likely contributed to the development of the aortic dissection.
Aortic dissection following coronary arterial bypass graft surgery.
A 60-year-old man underwent coronary arterial bypass graft surgery for unstable angina. After surgery, he developed a widened mediastinum on the chest x-ray film and a murmur consistent with aortic regurgitation. He refused study until the return of his anginal symptoms five years after surgery. At that time the patient had unchanged chest x-ray film and physical findings. Aortograms revealed a large type-1 aortic dissection extending from the aortic root to the descending thoracic aorta. Long-term survival with an aortic dissection after coronary arterial bypass grafting is possible. The pathophysiologic and pathologic findings of a spontaneous type-1 aortic dissection may differ from that of the dissection described herein, and these differences may relate to survival.
Thoracic aortic dissection or aneurysm: clinical presentation, diagnostic imaging and initial management in a tertiary referral centre.
Spontaneous thoracic aortic dissection carries a high mortality despite progress in diagnosis and treatment. Early and accurate diagnosis is paramount and dependent on clinical and diagnostic imaging skills. A retrospective review of 55 consecutive patients referred with suspected thoracic aortic dissection to a medical cardiology department was performed. Clinical follow up was complete to November 1995. Median age was 68 years (range 30-93), with 37 males, 18 females. Presenting complaints included interscapular chest pain in 23 (42 per cent), neurological deficit in 2 (4 per cent), and limb ischaemia in 8 (15 per cent). On examination 34 (62 per cent) patients had hypertension, 5 (9 per cent) a pulse deficit and 10 (18 per cent) aortic incompetence. Electrocardiography confirmed myocardial infarction in 1. Chest X-ray showed a widened mediastinum in 37 (67 per cent) patients. Dissection was confirmed in 35 (64 per cent) patients (13-DeBakey Type I, 6-Type II, 14-Type III); 10 had nondissecting aneurysm. Contrast aortography was equally sensitive (84 per cent) and more specific (100 per cent vs 80 per cent) than computed tomography for detection of dissection. Surgical repair was performed on 24 patients with concomitant coronary artery bypass grafting in 6. At follow up 33 patients were alive. Clinical diagnosis of thoracic aortic dissection or aneurysm may be difficult. Frequently more than one imaging modality may be required in order to provide all of the necessary information for optimal patient management.
Problems encountered during and after stent-graft treatment of aortic dissection.
PURPOSE: The authors report their experiences with the problems encountered during and after stent-graft placement in patients with aortic dissections. MATERIALS AND METHODS: Between July 1994 and December 2003, stent-graft placement was performed in 60 patients with aortic dissections, 9 patients with Stanford type A dissection and 51 patients with type B. Ten patients had acute dissection and 50 patients had chronic dissection. Each patient was followed for 12 to 107 months (mean, 33 mo). All cases were retrospectively reviewed for any problem that occurred during and after the procedure. RESULTS: During the procedure, there were two cases (3%) of stent-graft migration, one case (2%) of stent-graft torsion, two cases (3%) of stent-graft folding due to oversizing, three cases (5%) of persistent thoracic false lumen flow by the appearance of a hidden intimal tear, one case (2%) of new intimal tear that resulted in retrograde type A dissection, and 12 cases (20%) of type I endoleaks on aortograms taken immediately after the procedure. During the follow-up period, one case (2%) of transient cerebral ischemia, six cases (10%) of persistent type I endoleaks, two cases (3%) of type II endoleaks through the intercostal artery, four cases (7%) with progressive dilatation of abdominal false lumen, six cases (10%) of new intimal tears which resulted in saccular aneurysms (n=4) or new dissections (n=2) on either or both ends of the stent-graft, and two cases (3%) of mechanical failure were observed. Overall, five patients (8%) required surgical conversion, and there were no cases of procedure-related mortality. CONCLUSION: Various problems can occur during and after stent-graft placement in aortic dissection. The thorough evaluation of preoperative imaging and close follow-up are mandatory to optimize the management of such problems.
Aortic dissection and Turner's syndrome.
Cardiovascular malformations, especially coarctation of the aorta and bicuspid aortic valve, are common in patients with Turner's syndrome. Only 46 patients with aortic dissection and/or rupture have been described. All patients had associated aortic dilation or aneurysm. In all cases except three, involvement of the ascending aorta was present, making surgery often imperative. We describe a rare case of a DeBakey type IIIb aortic dissection (without involvement of the proximal aorta) in a patient with Turner's syndrome mosaicism. The dissection occurred two weeks after a caesarean section because of eclampsia. No aortic dilation or other cardiovascular malformations were found. The distal extension and uncomplicated nature of the dissection indicated medical management. After fifteen months of follow-up, she is clinically doing well and repeated CT scan shows a stable dissection of the descending and abdominal aorta without dilation.