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PubMed1990

Treatment of patients with aortic dissection presenting with peripheral vascular complications.

The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients.

Adolescent↗
PubMed1988

[Chronic aortic dissection disclosed by pericardial effusion. Apropos of 3 cases].

Three exceptional cases of chronic aortic dissection revealed by a pericardial effusion are reported. The patients were two men and a woman admitted for thoracic pain or fever. Initial diagnoses were myocardial infarction, infective endocarditis and tuberculous pericarditis. The effusions were drained on two occasions. Because the pericardial fluid was a mixture of serum and blood, computerized tomography of the thorax and abdomen was performed. All three cases were then diagnosed as aortic dissection (type II in two cases and type III in one case, with retrograde extension to the ascending aorta). The authors underline the utility of drainage and the need for systematic CT scans in patients with sero-haematic pericardial effusion of uncertain origin.

Aged↗
PubMed1986

Surgical treatment of aortic dissection in 60 patients.

During the years 1964-82 a total of 60 patients underwent surgery for aortic dissection. Forty of them were males, with a mean age of 48.8 years (22 to 69) and 20 were females, with a mean age of 49.0 years (31 to 65). Forty-five patients were operated in an acute stage of aortic dissection and 15 patients in a chronic stage of this disease. The mortality rate of patients operated on for acute dissections was 51.1% and of patients with a chronic dissection 13.3%, the over-all hospital mortality rate being 41.7%. Cardiac and haemorrhagic complications were the commonest cause of death. Among the 35 operative survivors, there were seven late deaths (11.7%); 4 patients died of cardiovascular causes. The mean follow-up time was 6.1 years (2.7 to 13.4). Twenty-six long-term survivors were re-examined in the hospital.

Actuarial Analysis↗
PubMed1993

Ascending aortic dissection causing unilateral absence of perfusion on lung scanning.

A case of an ascending aortic dissection occurring in a patient 8 years after an aortic valve replacement is presented. The patient's initial clinical presentation was thought to be due to pulmonary embolism, and a ventilation-perfusion lung scan demonstrated mismatched absence of perfusion to the entire right lung. Aortography and findings at surgery demonstrated a type A dissection of the ascending aorta. The anatomic relationship of the aorta and pulmonary artery and their common tunica adventitia make the right pulmonary artery susceptible to extrinsic compression after aortic dissection. Although uncommon, dissection of the ascending aorta needs to be considered in patients who have undergone previous aortic valve surgery and demonstrate mismatched unilateral absence of perfusion to the right lung. Because anticoagulation is contraindicated in patients with acute aortic dissection, confirmation of the diagnosis with angiography usually is required.

Aged↗
PubMed2005

How to guide stent-graft implantation in type B aortic dissection? Comparison of angiography, transesophageal echocardiography, and intravascular ultrasound.

BACKGROUND: Despite growing interest in stent-graft implantation for type-B aortic dissection, there are no established recommendations to prepare and perform an implantation procedure. METHODS AND RESULTS: We directly compared angiography (ANGIO), transesophageal echocardiography (TEE), and intravascular ultrasound (IVUS) intraprocedually before and after placement of 48 stent grafts in 42 consecutive patients (12 women, 61+/-11 years of age) with acute and chronic type-B aortic dissection for both usefulness and capability to guide aortic stent-graft implantation. Both IVUS and TEE are superior to ANGIO to identify multiple entries (52 and 43 versus 34; P<0.005 each), to diagnose false-lumen slow flow after stent-graft implantation (32 and 31 versus 24; P<0.005 each) and to detect incomplete stent apposition (18 and 16 versus 8; P<0.005 each). In comparison with ANGIO, guide wire position over the entire length of the aorta was documented more frequently by TEE and IVUS (40 and 42 versus 25; P<0.001 each). In 4 patients with abdominal extension of the dissection, only IVUS was able to accurately identify the false lumen over the entire length of the diseased aorta. TEE was superior to IVUS and ANGIO in the detection of endoleaks (5 versus 0 and 1; P<0.05 each). Intraprocedural ANGIO, TEE, and IVUS had been performed without complications in all patients. CONCLUSIONS: TEE in conjunction with ANGIO appears to be advantageous and adds incremental information to safely guide stent-graft placement in type-B aortic dissection. Additional use of IVUS was found to be helpful in patients with complex anatomy and abdominal extension of the dissection.

Aged↗
PubMed2006

Anomalous origin of the right coronary artery mimicking aortic dissection at transesophageal echocardiography.

Transesophageal echocardiography (TEE) is the most common imaging modality for the detection of acute aortic syndromes. However anomalous anatomic structures may be occasionally misunderstood as pathologic due of lack of familiarity with anatomical variations; false-positive diagnosis can result, potentially leading to unnecessary surgical intervention. It is crucial for echocardiographers to be aware of possible pitfalls which may create false positive findings, since the complementary use of other imaging modalities, such as multislice spiral computed tomography (MSCT), could improve the diagnostic accuracy of TEE. We report a case in which an image resembling an acute aortic dissection (AAD) on transthoracic (TTE) and transesophageal echocardiography was found in a patient with acute chest pain; MSCT detected an anomalous origin of the right coronary artery as cause of false aortic dissection image at echocardiography.

Aortic Dissection↗
PubMed1984

Painless aortic dissection: an unusual cause of syncope.

Presented is a case of syncope as the initial sign of a painless aortic dissection. The patient was stabilized by percutaneous drainage of a hemopericardium, and then underwent angiography and successful operative repair. Although uncommon, painless aortic dissection should be included in the differential diagnosis of a syncopal episode.

Aortic Dissection↗
PubMed1994

The surgical treatment of aortic dissection in a patient with Turner's syndrome: report of a case.

We report herein the successful surgical management of a 42-year-old patient with Turner's syndrome (TS) complicated by Stanford type B aortic dissection. The patient had a single entry in the proximal descending aorta with dissection extending from the entry point to the abdominal aorto-left iliac bifurcation. A patch plasty using felt reinforcement was performed through a left 4th intercostal space thoracotomy. Her postoperative course was uneventful and she has been well during the 3 years since her operation. There have been only nine reports of patients with TS complicated by aortic dissection for whom operations were performed; however, the details of surgical treatment have not been well documented. This paper reports the course of aortic dissection and the surgical methods employed in the treatment of our patient.

Adult↗
PubMed2004

Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients.

AIMS: The purpose of this retrospective study was to assess the risk factors for the early and late outcome of the surgical treatment of acute type A aortic dissection, in terms of mortality and morbidity. METHODS AND RESULTS: From 1976 to 2003, 487 patients with acute type A aortic dissection treated surgically were enrolled. Twenty-five pre-operative and intra-operative variables were analysed to identify conditions influencing early and late morbidity and early mortality. The in-hospital mortality rate including operative death was 22% (107 patients). Multivariable analysis indicated that pre-existing cardiac disease (RR=3.7, 95% CI=1.8-7.4) and cardiopulmonary resuscitation (RR=6.8, 95% CI=2.3-20.2) were independent predictors of in-hospital death. The causes of in-hospital mortality were low cardiac output in 32 patients (6.6%), major brain damage in 24 patients (5.9%), haemorrhage in 11 patients (2.2%), sepsis in nine patients (1.8%), visceral ischaemia in eight patients (1.6%), multiple organ failure in seven patients (1.4%), rupture of the thoracic aorta in six patients (1.2%), respiratory failure in six patients (1.2%), and four intra-operative deaths. The follow-up was 100% complete. The actuarial survival was 94.9+/-1.2% and 88.1+/-2.6%, at 5 and 10 years, respectively. CONCLUSIONS: Patients' pre-operative co-morbidities and dissection-related complications significantly affect early and late survival and morbidity after surgical treatment of acute type A aortic dissection.

Acute Disease↗
PubMed1998

Risk of late reoperations in patients with acute type A aortic dissection: impact of a more radical surgical approach.

OBJECTIVE: To evaluate the incidence and risk factors for reoperations on the pre-isthmic aorta after repair of type A acute aortic dissection. METHODS: From January 1979 to December 1996, 178 patients (125 males and 53 females with a mean age of 57 +/- 9 years) underwent emergency surgery for acute type A aortic dissection with an overall operative mortality rate of 21%. One hundred and forty-one patients (100 males and 41 females, aged 58 +/- 12 years), were discharged after successful replacement of the ascending aorta in 136 cases (96%) with extension to the transverse arch in 22 (16.2%) and associated total root or aortic valve replacement in 31 (22.8%) and 6 (4.4%) cases, respectively. Intimal tear resection and direct primary anastomosis of the aorta were performed in 5 patients (4%). Total follow-up was 690 patient-years, mean 5.1 +/- 4.1 years, with an actuarial survival rate at 5,10 and 15 years of 88%, 73% and 42%, respectively. RESULTS: Nineteen patients (13%), 13 males and 6 females, aged 50 +/- 10 years, required a total of 22 reoperations with an actuarial freedom from reoperation at 5, 10 and 15 years of 94%, 64% and 35%, respectively. Initial repair consisted of replacement of the ascending aorta in 16 (84%) cases, with total root replacement in 2 (12%) and isolated aortic valve replacement in 1 (6%). Three patients (16%) were treated by intimal tear resection and direct primary anastomosis of the aorta. Mean interval between initial repair and reoperation was 5.2 +/- 3.1 years and indication to re-do surgery were severe aortic regurgitation in 2 (11%), aneurysmal evolution of the false lumen in 4 (21%) or both in 13 (68%). Extensive aortic reconstruction comprising simultaneous graft replacement of the aortic root, ascending aorta and aortic arch was necessary in 13 cases (68%), isolated replacement of the ascending aorta in 3 (16%), aortic valve in 2 (11%) and aortic arch in 1 (5%). There were 1 hospital (5%) and 2 late (11%) deaths at a mean follow-up of 2.5 +/- 2.4 years, with an actuarial survival at 5 years of 88%. Retrospective analysis of our total experience revealed that the introduction of the open distal anastomosis technique since 1990, reduced the incidence of reoperation from 11/46 (24%) to 8/95 (8.4%) (P < 0.05). However, also with this strategy 8/73 (11%) patients surviving replacement limited to the ascending aorta required reoperation versus none of the 22 patients surviving repair extended to the aortic arch. Three out of 5 (60%) patients undergoing intimal tear resection and primary anastomosis of the aorta early in our experience, required reoperation. CONCLUSIONS: Management of patients with acute type A aortic dissection may include one or more surgical procedures after the initial emergency repair. Reoperations carry a low operative risk with good long-term survival and their incidence is reduced by routine open distal anastomosis and aggressive replacement of the aortic arch. Intimal tear resection and primary anastomosis of the aorta appear to be associated with increased risk of reoperation.

Acute Disease↗
PubMed2000

Stanford type A aortic dissection in a hypertensive patient with atherosclerosis of aorta and aortitis.

Dissection of aorta is a serious condition; the main factors are hypertension and diseases of the connective tissue or of collagen. Aortitis syndrome in combination with hypertension and atherosclerosis in association with ascending aortic dissection is rarely seen. We present the case of a 53-year-old hypertensive patient whose ascending aortic dissection was associated with pericardial effusion without rupture of the aorta and with pleural effusion. Several unusual aspects of transesophageal echocardiography are described. The intraoperative biopsy revealed inflammatory aortitis with mural hematoma, without giant cells. The literature concerning aortic dissection and aortitis is reviewed.

Aortic Dissection↗
PubMed2006

Painless aortic dissection with bilateral carotid involvement presenting with vertigo as the chief complaint.

A 63 year-old woman was admitted to the emergency department with vertigo, nausea, and vomiting. On arrival, she was fully oriented and cooperative. She denied any pain in her chest, neck, back, or abdomen. A bruit was heard on both sides of her neck. Cranial computed tomography (CT) revealed no abnormality, while thoracic CT disclosed dissection in the ascending aorta, aortic arch, and bilateral common carotid arteries. After several hours, the patient underwent vascular surgery. She had an uneventful course and was discharged without any sequelae after 10 days. Vertigo is a rare presentation of aortic dissection with carotid involvement. Elderly patients presented with vertigo and nausea/vomiting should be evaluated for the condition and carotid dissection should be ruled out. Carotid bruit may be a clue to the diagnosis.

Aortic Dissection↗
PubMed1999

[Surgical management for acute aortic dissection with organ ischemia].

In a series of one hundred and one cases of surgical treatment for acute aortic dissection between January 1986 and September 1997, we evaluated 29 cases presenting with organ ischemia. These consisted of 23 cases of acute type A dissection (type A) and 6 cases of type B dissection (type B). Organ ischemia was diagnosed by (1) aortography, (2) a retrospective review of the history and (3) physical examination or laboratory data. The 23 surgical cases of acute type A dissection consisted of, coronary ischemia 8 cases, cerebral and spinal cord ischemia 9 cases, intestinal ischemia 3 cases, lower extremities ischemia 10 cases, and plural organs ischemia 8 cases. In the 6 cases of acute type B, we noted 4 intestinal ischemias and 2 lower extremities ischemias. The operative mortality rates when subdivided according to ischemic organ were: coronary ischemia 50%, cerebral and spinal cord ischemia 11%, intestinal ischemia type A 33%, type B 50%, and lower extremities ischemia type A 33%, type B 0%. The operative mortality rates, especially for patients presenting with acute myocardial infarction or intestinal ischemia, were relatively high. In cases of acute aortic dissection when organ ischemia occurred, we believed that it was necessary to perform early thoracic aortic repair and reconstruction of the ischemic organ.

Acute Disease↗
PubMed1998

[Determinants of long-term outcome for operative survivors of acute aortic dissection].

Predictability of aorta-related complications and survival was examined in 79 operative survivors of acute aortic dissection. Follow-up was 94.9% complete and totaled 458 patient-years. Actuarial survival was 93 +/- 3% (+/- S.E.) (n = 43) at 5 years, and 74 +/- 8% (n = 13) at 10 years. Survival was significantly lower in patients having neurological complication. Freedom from aorta-related complications was 82 +/- 5% (n = 37) at 5 years, and 67 +/- 8% (n = 11) at 10 years. Multivariate Cox regression analysis identified residual entry and leak on anastomotic site as independent predictors of aorta-related complications. We conclude that in the treatment of acute aortic dissections, reducing the incidence of residual entry and leak on anastomotic site improves long-term outcome.

Acute Disease↗
PubMed2006

Survival and quality of life after repair of acute type A aortic dissection in patients aged 75 years and older justify intervention.

OBJECTIVE: Controversy still exists about averting expenditure of health care resources on the growing elderly population. This study evaluates clinical outcome of patients aged 75 years and older operated upon for acute type A aortic dissection. METHODS: Between January 1990 and April 2004, of 247 patients undergoing emergency operation for acute type A aortic dissection at our Institution, 40 patients (16%) were aged 75 years and older (mean 78+/-3 years, range 75-88 years) and represent the study population. On admission, 9 (22.5%) had cardiogenic shock/hypotension, 20 (50%) cardiac tamponade, 14 (35%) kidney failure, 11 (27.5%) limb ischemia, 3 (7.5%) neurologic deficit, and 1 (2.5%) myocardial ischemia. Surgical procedures included isolated replacement of the ascending aorta in 34 patients (85%), associated with total root replacement in 5 (12.5%), and with aortic valve replacement in 1 (2.5%). Eleven patients (27.5%) underwent aortic arch replacement (hemiarch: n=8, 20%; total arch: n=3, 7.5%). RESULTS: In-hospital mortality was 30% (12 patients). Mortality tended to be higher (8/21, 38% vs 4/19, 21%; p=NS) for patients presenting with any one of the following complications: tamponade, shock, brain and/or myocardial, renal, limb malperfusion. Actuarial survival at 1, 5, and 7 years was 93+/-5%, 80+/-8%, and 80+/-8%, respectively, and freedom from reoperation 97+/-2%, 97+/-2%, and 97+/-2%, respectively. Actuarial event-free rates were 94+/-3%, 90+/-5%, and 90+/-5%. Seventy-four percent of survivors are in NYHA FC I, and quality of life test (RAND SF-36) revealed a generalized perception of independency and well-being, comparable to an age-matched population. CONCLUSIONS: Overall results for emergency repair of acute type A aortic dissection in the elderly justify intervention, particularly in uncomplicated cases. Expeditious referral and intervention by lowering pre-operative dissection-related complications and comorbidities might help to improve results. Survivors show functional status and quality of life similar to contemporary individuals.

Acute Disease↗
PubMed1994

Subtypes of acute aortic dissection.

The technique of open distal anastomosis using deep hypothermic circulatory arrest was used in 69 cases of acute type A aortic dissection. These cases were subcategorized by site of intimal tear, which was found in the ascending aorta in 41 patients (60%), in the arch in 22 patients (32%), and in the descending aorta in 5 patients (7%). Clinical characteristics and complications are described for these subtypes. Hospital mortality, which was 14.5% overall for acute type A dissections, was 14.6% for ascending tears, 18.2% for arch tears, and 0% for descending aortic tears. Six-year survival was 69% +/- 15% for ascending tears, 69% +/- 22% for arch tears, and 80% +/- 25% for descending tears (mean +/- SEM, p = NS). A classification system for aortic dissection is proposed, based on both site of origin and propagation.

Acute Disease↗
PubMed1988

Acute paraplegia: a presenting manifestation of aortic dissection.

Two patients who presented with acute paralysis of the lower extremities as an initial manifestation of aortic dissection are described. The first patient had transient chest pain followed by flaccid paralysis of her lower extremities and severe back pain. In the second patient, sudden paralysis of both legs developed without pain of any sort. The paraplegia completely resolved in a few minutes; however, chest and back pain later ensued. Both patients had a proximal (type I or A) aortic dissection. The first patient's entrance tear in the aortic intima was just above the aortic valve with antegrade propagation, whereas in the second patient, the entrance tear was at the aortic isthmus, with both antegrade and retrograde dissection. Acute cardiac tamponade resulted in sudden deterioration and death in both patients, before any therapeutic intervention could be entertained.

Acute Disease↗
PubMed2003

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm.

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.

Acute Disease↗