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PubMed2005

Surgery for acute type A aortic dissection: the effect of antegrade selective cerebral perfusion on the early outcome of elderly patients.

BACKGROUND: The aim of this study was to evaluate early results and to determine predictive risk factors associated with an adverse outcome in elderly patients after acute type A aortic dissection repair using antegrade selective cerebral perfusion (ASCP). Adverse outcome was defined as the occurrence of death or permanent neurologic dysfunction. METHODS: From October 1995 to March 2002, 178 patients (group A < 75 years, n = 156, 87.6%; group B > 75 years, n = 22, 12.4%) underwent surgery for acute type A aortic dissection using ASCP and moderate hypothermia. An ascending aorta/hemiarch replacement was performed in 128/178 (71.9%) patients (group A 71.2%, group B 77.3%, p = NS), an ascending aorta and arch replacement in 50/178 (28.1%) patients (group A 28.8%, group B 22.7%, p = NS). Associated procedures were performed in 55/178 (20.9%) patients (group A 31.4%, group B 27.3%, p = NS), the arch vessels were reimplanted using the separated graft technique in 32/50 (64.0%) patients (group A 62.2%, group B 80.0%, p = NS). The mean ASCP time was 59 +/- 27 min. RESULTS: The overall adverse outcome rate was 20.8% (group A 21.2%, group B 18.2%, p = NS). The transient neurologic dysfunction rate was 9.5% (group A 9.5%, group B 5.6%, p = NS). A logistic regression analysis revealed cardiopulmonary bypass time (p = 0.045, odds ratio 1.03/min) to be the only independent predictor of adverse outcome in group A. CONCLUSIONS: During type A aortic dissection repair the implementation of ASCP resulted in an acceptable hospital mortality and neurologic outcome. If ASCP is used, the risk of hospital mortality and postoperative morbidity is similar in patients younger and older than 75 years. Duration of cardiopulmonary bypass still remains an important risk factor for hospital mortality and neurologic outcome in elderly patients.

Acute Disease↗
PubMed1995

[The graft replacement of the patient with aortic arch aneurysm and thrombosed aortic dissection].

The patient was male and aged 68 years and complained of dyspnea and chest pain. He was pointed out aortic arch dilatation on chest X-ray and CT demonstrated aortic arch aneurysm accompanied with acute type IIIb aortic dissection. One month later after anti-hypertensive therapy, the false lumen of aortic dissection was closed with thrombus. While we performed the graft replacement to the aortic arch aneurysm, the thrombosed false lumen was recanalized, so it needed the closure of the false lumen reinforced with teflon felt. Postoperative angiography showed no abnormality of anastomosis and complete occlusion of the false lumen.

Aged↗
PubMed1993

Surgical treatment of acute aortic dissection: efficacy of retrograde cardioplegia for myocardial protection.

The operative morbidity and mortality of patients with Stanford type A acute aortic dissection undergoing urgent operation using retrograde cardioplegia for myocardial protection were evaluated to assess the efficacy of such surgery. A total of 18 patients (12 men and six women, 19-71 years of age) were operated on 9-137 h after onset of dissection using cardiopulmonary bypass with deep hypothermia and retrograde cardioplegia. Graft replacement was performed in ten patients, primary anastomosis in three, and Cabrol and Bentall operations in five. All patients were weaned from cardiopulmonary bypass, but four died in hospital (mortality rate 22%). Thirteen patients were in good health at follow-up ranging from 3 to 98 months, and the remaining patient died from rectal cancer 5 months after surgery. It is concluded that urgent operation of patients with Stanford type A acute aortic dissection can be performed with reasonable operative and excellent follow-up results. Retrograde cardioplegia is an easy and reliable method of myocardial protection to repair the fragile aortic wall.

Acute Disease↗
PubMed2000

Recognition and Management of Thrombosed Type of Aortic Dissection With Long-term Follow-up Results.

In a previous report we have stated that two distinct types of aortic dissection exist, namely the opened-communicated type (O-type) which demonstrates communication between the true lumen and the false lumen, and the thrombosed type (T-type, also known as aortic dissecting hematoma or as intramural hematoma). The latter, in its acute phase, shows no opacification of the false lumen through medical imagings such as CT scans or angiography. In previous studies we analyzed the long-term follow-up results of consecutive patients with aortic dissections at our hospital. During the past 14 years a study has been conducted of a total of 466 consecutive patients including 371 who were classified O-type and 95 who were classified as T-type. In 18 T-type patients (19%), complications such as cerebral ischemic episodes were observed. These were, however, transient and not serious, sometimes indicating only minor surgery. Only three T-type patients were indicated for surgery in the follow-up period, two because of the extension of a protruded lesion, and one because of the occurrence of redissection. Three of these died, but the actuarial survival rate of the T-type group was significantly higher than that of the O-type group. In conclusion, it can be stated that at the acute phase, a differentiation between the two types of dissection, ie, T-type and O-type, is important in the deciding of treatment.

Journal Article↗
PubMed2003

Treatment of iatrogenic aortic dissection by percutaneous stent placement.

During elective cardiac catheterization via the right femoral artery, difficulty was encountered advancing the guidewire beyond the aortic arch and the procedure abandoned. The patient later developed back pain and hypotension. A contrast-enhanced spiral computed tomography scan confirmed aortic dissection, extending from an entry point in the external iliac artery to the arch. We hypothesized that the entry site was responsible for filling the dissection in the thoraco-abdominal component. A stent was placed in the iliac artery, occluding the entry point. This is the first report of aortic dissection, a rare complication of angiography, managed by percutaneous stenting of the entry point.

Aortic Dissection↗
PubMedDate not supplied

Aortic dissection presenting as acute pancreatitis: CT diagnosis.

A 42-year-old male developed epigastric pain and elevation of serum amylase of 2045 U/L. A contrast-enhanced abdominal CT disclosed inflammatory changes involving the pancreas and peripancreatic tissues and findings indicative of aortic dissection. The possibility of aortic dissection should be considered in the management of patients with acute pancreatitis.

Adult↗
PubMed2004

Acute type B aortic dissection in elderly patients: clinical features, outcomes, and simple risk stratification rule.

BACKGROUND: The clinical features and outcomes of elderly patients with acute type B aortic dissection (ABAD) are less well known. Accordingly, we sought to evaluate the clinical features and outcomes and derive a simple risk stratification rule for elderly with ABAD. METHODS: We categorized 383 patients with ABAD enrolled in the International Registry of Acute Aortic Dissection into two strata (aged less than 70 years and aged 70 years or more) and compared their clinical features and in-hospital outcomes. Further, we developed a clinical decision rule to risk-stratify elderly with ABAD. RESULTS: Forty-two percent (161 of 383) of patients with ABAD were aged 70 years or more. Hypertension, diabetes, history of prior aortic aneurysm, and arteriosclerosis were more common in the elderly patients, whereas Marfan syndrome and cocaine abuse were less common. The in-hospital complication of hypotension/shock was more common among elderly, and malperfusion of a visceral organ less frequent among elderly patients. In-hospital mortality was higher in the elderly cohort compared with the younger patients (16% versus 10%, p = 0.07). A classification tree identified that elderly patients with hypotension/shock had the highest risk of death (56%). In absence of this, any branch vessel involvement was associated with the next highest mortality rate (28.6%) followed by presence of periaortic hematoma (10.5%). In contrast, elderly patients without any of these three risk factors had an extremely low mortality rate (1.3%). CONCLUSIONS: Our study highlights important differences between older and younger patients with ABAD in their clinical characteristics, management, and outcomes. We also propose a simple decision rule that allows stepwise risk-stratification in elderly patients with ABAD.

Aged↗
PubMed1986

Computed tomography: the investigation of choice for aortic dissection?

Computed tomography has become established as complementary to aortography in the investigation of patients with suspected aortic dissection. Two cases of dissecting aneurysm are reported in which extensive aortography failed to show evidence of dissection. In both cases dissection was demonstrated by computed tomography. The diagnosis was confirmed in one case at operation and in the other case by follow up. It is suggested that computed tomography is the diagnostic method of first choice in aortic dissection.

Aged↗
PubMed1999

Management of aortic dissection that involves the right coronary artery.

A report on the follow-up of 11 patients who suffered from aortic dissection involving the right coronary artery and who underwent surgical treatment is reported. In two patients, the left coronary ostia was also affected. In seven patients, the dissection was acute and in four, chronic. The ascending aorta was substituted by a Dacron graft in all patients, and right coronary artery saphenous vein bypass or Gore-Tex graft to the coronary ostia or right coronary artery was performed in nine, and reimplantation of both dissected coronary in two. There were three early postoperative deaths (27.3%) caused by low-output syndrome and myocardial infarction. There were two late deaths. The six surviving patients were followed-up from 78 to 96 months (mean 83 months). This experience suggests that although carrying a high risk, the involvement of the coronary ostia in aortic dissection can be successfully managed if made before irreversible complications arise.

Acute Disease↗
PubMed1987

Detection of aortic dissection by transoesophageal echocardiography.

The diagnostic value of a combination of transoesophageal and transthoracic echocardiography was evaluated in 21 patients with dissection of the aorta. The results were compared with those of computed tomography, aortography, and with findings at operation or necropsy or both. Transthoracic echocardiography identified three of the four patients with type I dissection, two of the five patients with type II dissection, and one of the 12 patients with type III dissection. When transoesophageal echocardiography was used as well the degree of aortic dissection was identified correctly in all 21 patients. In one patient with type I and in eight patients with type III dissection spontaneous echocardiographic contrast with a mural thrombus within the false lumen could be detected. Computed tomography was unable to demonstrate an intimal flap in one of two patients studied with type I dissection, in two of three patients with type II dissection, and in one of nine patients with type III dissection. Aortography was negative in one of two patients studied with type I dissection, two of four patients with type II dissection, and in one of eight patients with type II dissection. The whole thoracic aorta can be imaged by a combination of transthoracic and transoesophageal echocardiography. The addition of transoesophageal echocardiography to transthoracic echocardiography improves the recognition of aortic dissection. Furthermore, this examination can be performed at the bedside and the findings can be used as a basis for treatment.

Adult↗
PubMed2006

Ruptured giant aneurysm of the ascending aorta caused by chronic aortic dissection.

A 55-year-old man developed acute chest pain and dyspnea. Computed tomography demonstrated a rupture of a giant aneurysm of the ascending aorta. The lesion was 14 cm in diameter--the largest ever reported-and resulted from chronic aortic dissection. The patient did not have aortic insufficiency or aortic dissection around the coronary ostium. Graft replacement of the ascending aorta was performed successfully under deep hypothermia with right hemisphere perfusion.

Aortic Dissection↗
PubMed1993

Inadvertent administration of rtPA to a patient with type 1 aortic dissection and subsequent cardiac tamponade.

Administration of thrombolytic agents to patients with misdiagnosis of acute myocardial infarction can result in serious side effects. A case of aortic dissection that was misdiagnosed as acute myocardial infarction and received rtPA is reported. Within 1 hour of rtPA infusion, the patient developed cardiac tamponade. Type 1 aortic dissection was diagnosed by aortic angiogram. The patient underwent emergency resection of the dissection and evacuation of the pericardial and anterior mediastinal hematoma. Although he required massive transfusion of blood products intraoperatively, he is doing well 22 months after his surgery.

Aged↗
PubMed2001

Scope-guided implantation of a stented elephant trunk in acute aortic dissection.

A reliable guide is essential for implanting a stented graft safely into a recently dissected, fragile aorta. In 4 patients with acute aortic dissection, the implantation of a stented elephant trunk was done safely using an endoscope for direct visualization. In all patients, the operation went well. The placement of a stent appears to enhance the benefit of the elephant trunk, which itself reduces the complications of an arch replacement in acute dissection.

Acute Disease↗
PubMedDate not supplied

Recent advance in treatment of Stanford type A aortic dissection.

During the period between November 1986 and November 1988, 13 consecutive patients with Stanford type A aortic dissection (8 acute and 5 chronic) were treated as follows: (1) urgent operation for cases with pericardial tamponade or severe heart failure, (2) initial medical treatment followed by elective operation for acute but stable cases or chronic cases, and (3) routine use of open distal anastomosis or selective cerebral perfusion. One patient died during medical treatment: 5 patients were operated on emergently. The remaining 2 acute and 5 chronic cases were operated on electively. There were no operative deaths, neurological disturbances, or late deaths. It is suggested that acute dissection of the ascending aorta requires immediate surgical intervention, especially when the entry is in the ascending aorta. On the other hand, it is also suggested that one could avoid emergency operations in selected cases with retrograde extension of the aortic dissection.

Acute Disease↗
PubMed1994

[A case of dissecting aortic aneurysm and presence of anti-Jr(a) antibody].

A 66-year-old woman was diagnosed as a DeBakey type II dissecting aortic aneurysm with angiography and CT. Antibody screening revealed circulating anti-Jr(a) antibody. Preoperatively, erythropoietin was administered twice a week. Over 24 days, a total of 1200 ml of her blood was removed and stored for autologous transfusion. The dissecting ascending aorta was replaced with the aid of cardiopulmonary bypass. The post operative course was uneventful. By using erythropoietin, pre-donated autologous blood, cell saver, aprotinin and transfusion of fresh autologous blood, it was possible to perform cardiovascular surgery on this patient who had an abnormal antibody. This patient is the first case of repair or dissecting aortic aneurysm with anti-Jr(a) antibody in Japan.

Aged↗
PubMed1995

Multiplane transesophageal echocardiography in traumatic aortic dissection: a case report.

We report a case of a 23 year old male who suffered a traffic accident and had a suspicious widening of the mediastinum on chest x-ray. Computed tomography (CT) failed to demonstrate an aortic dissection. Due to the mechanism of injury and chest X-ray findings, we decided to perform a multiplane transesophageal echocardiogram (MTE). This revealed an aortic dissection of less than one centimeter in length and good heart function. Due to CT evidence of hemoperitoneum, the patient received an emergent laparatomy. A liver laceration and jejunal perforation were found and repaired. An intraabdominal abscess developed, which led to sepsis, multiple organ failure and ultimately death. MTE was used to monitor the status of the dissection and adequacy of heart function during his intensive care unit stay. The dissection extended to 4 cm in length by the second week and then remained stable. There was no thrombus formation within the false lumen by the third month. While the patient unfortunately died from complications related to his abdominal injuries, MTE not only diagnosed the traumatic aortic dissection when CT failed, but allowed easy monitoring of both the rate of extension and the flow patterns within the false lumen. This made prognostication and treatment planning much easier.

Adult↗