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PubMed2000

True-lumen collapse in aortic dissection: part I. Evaluation of causative factors in phantoms with pulsatile flow.

PURPOSE: To investigate the causative factors in true-lumen collapse in a model of aortic dissection. MATERIALS AND METHODS: Phantoms with an aortic arch, true and false lumina with abdominal branch vessels, and a distal bifurcation were used to model a Stanford type B aortic dissection. The effects of anatomic factors (entry-tear size, branch-vessel flow distribution, fenestrations, distal reentry communication) and physiologic factors (peripheral resistance in the branch vessels, pump output and rate, vascular compliance) on true-lumen collapse were investigated. The morphology of the true lumen was observed. Branch pressures and flow rates were measured. RESULTS: True-lumen collapse was induced and was exacerbated by an increase in the size of the entry tear, a decrease in the false-lumen outflow caused by occluding the false-lumen branch vessels, and an increase in the true-lumen outflow caused by lowering the peripheral resistance in true-lumen branch vessels. Two kinds of true-lumen collapse depended on pump output. With low pump output and low outflow resistance from the true lumen, the true lumen collapsed. With high pump output and low inflow resistance in the false lumen, the true lumen was compressed. Distal reentry communication between the true and false limbs was more effective than aortic fenestrations in preventing true-lumen collapse. CONCLUSION: True-lumen collapse in this dissection model strongly depends on the difference in the ratios of inflow capacity to outflow capacity in the true and false lumina. Both anatomic and physiologic factors can affect true-lumen collapse.

Aortic Dissection↗
PubMed2004

[Predictors of in-hospital mortality in the surgical management of acute type A aortic dissections: impact of anticoagulant therapies].

OBJECTIVE: The purpose of this investigation was to study the incidence and consequences of anticoagulant therapy in the surgical management of acute aortic dissections. STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: We reviewed all acute type A aortic dissections that were surgically managed in our institution from 1 January 1990 to 31 December 2000. Survival outcome and characteristics potentially associated with survival were abstracted from patient records. We screened preoperative electrocardiograms (ECG) and anticoagulant therapy. RESULTS: ST segment elevation incidence was 14% and preoperative anticoagulant therapy occurred in 63 (20%) cases as follow: aspirin 12%, aspirin + heparin 6%, thrombolysis 1%. Overall mortality was 22%. Time between pain and surgery was not statistically different between anticoagulant therapy and standard group. Administration of antithrombotic agents before admission in -hospital increased significantly mortality (Odds ratio (OR) = 2.02; IC [1.1-3.71]; p = 0.023). Other risk factors for death were preoperative circulatory failure (OR = 8.28 [4.23-16.24], p < 0.0001), preoperative cardiac arrest (OR = 21.92 [7.16-67.14], p < 0.0001), preoperative circulatory arrest (OR = 2.79 [1.60-4.88], p = 0.0003), preoperative cerebral perfusion (OR = 2.45 [1.18-5.05], p = 0.016), postoperative circulatory failure (OR = 3.37 [1.85-6.17], p < 0.0001), postoperative cardiac arrest (OR = 9.92 [3.49-28.21], p < 0.0001), postoperative serum creatinine >150 micromol/l (OR = 4.55 [2.43-8.50], p < 0.0001), postoperative dialysis (OR = 5.63 [2.44-13.20], p < 0.0001), more than 7 days of post-operative ventilation (OR = 23.44 [12.0-45.7], p < 0.0001). DISCUSSION: In our experience, 20% of acute type A aortic dissections had received a preoperative anticoagulant therapy. This event is an independent risk factor of in-hospital death and is more frequent in case of ischaemic ECG abnormalities.

Aged↗
PubMed1987

Visualization of thoracic dissecting aortic aneurysm by transesophageal Doppler color flow mapping.

Real-time color flow mapping by two-dimensional Doppler has now come into widespread use. However, its application via conventional transcutaneous approaches to dissecting aortic aneurysm has some limitations where visualization of the descending aorta is concerned. Its transesophageal approach to this disorder has hitherto remained unreported except by the authors. Transesophageal Doppler color flow mapping has been performed in twelve patients for diagnosis of dissecting aortic aneurysm, and the clinical significance of this method was evaluated. The system used for transesophageal color flow mapping was an Aloka SSD-880 ultrasound scanner with a 5 MHz probe. In all cases, the entire thoracic aorta except for the upper ascending aorta was visualized and both, real-time flow dynamics and structural information, were ascertained. Differentiation of the type of dissection, identification of the entry, and differentiation of the true and false lumina were performed in all cases. Information concerning the reentry was gained in seven cases (58%); aortic regurgitation was graded in three cases, in two of which prolapse of the intimal flap was observed. In five cases, aortography was needed in order to delineate the involvement of aortic branches in the dissection; and in the other seven cases, transesophageal Doppler information was sufficient. In four cases who were operated, the postoperative state was well evaluated. Transesophageal Doppler color flow mapping was found to be a useful method for visualization of the whole thoracic aorta apart from the upper ascending section, and for precise evaluation of the structure and hemodynamics of dissecting aortic aneurysms.

Aortic Dissection↗
PubMed1981

New surgical approach to aortic dissection: flow reversal and thromboexclusion.

With the aim of decreasing the complications and mortality associated with the current techniques for aortic dissections, we have developed an operation which consists of bypassing the dissected aorta and creating flow reversal in the dissected segment. Seven patients with either acute (five) or chronic aortic dissections (two) were operated upon successfully, with no early or late deaths. Three transient postoperative complications were encountered: low cardiac output, hemiparesis, and renal insufficiency. Postoperative arteriography was performed in five patients and demonstrated exclusion of the dissected lesions by thrombosis following flow reversal in the descending aorta. Follow-up is available from 2 to 28 months (average 13 months), with no long-term complications.

Adult↗
PubMed2004

Lethal thrombus in the carotid artery during operation for acute aortic dissection with cerebral malperfusion.

A drowsy patient with acute type A aortic dissection and cerebral malperfusion required emergency operation. Because the right carotid artery was totally obstructed, cerebral perfusion was first restored by cannulating it and the left femoral artery before midline sternotomy. However, a long fresh thrombus was found flowing backward from the obstructed carotid artery. This thrombus was removed, and both arteries were connected through a Y-shaped extracorporeal circulation circuit to reperfuse the brain. During the subsequent aortic procedure, both arteries were used for arterial inflow. Such thrombi can cause grave postoperative neurologic dysfunction. Carotid artery cannulation is mandatory in such cases.

Acute Disease↗
PubMed1996

Surgical implication of aortic dissection on long-term outcome in Marfan patients.

We herein review our 17-year surgical experience for the treatment of ascending aortic aneurysm in patients with Marfan syndrome to clarify the risks of increased mortality and reoperation. The subjects consisted of 15 patients who had all undergone surgery for the aortic root and ascending aorta at Niigata University Hospital between July 1978 and January 1995. Aortic valve replacement and ascending aortic wrapping were performed in 5 patients, Bentall or Cabrol operation in 6, and combined aortic arch reconstruction and Cabrol operation in 2, as the initial surgery. Patients who had an aortic dissection (Stanford type A) at initial surgery were assigned to group I (n = 7), while those with an aortic root aneurysm were assigned to group II (n = 8). In group I, 3 patients required a second operation for the remaining aortic arch aneurysm, and 1 died due to a late rupture of the distal aneurysm. In group II, no patient needed a reoperation; however, 1 died due to an intracranial hemorrhage and another due to composite valve graft failure and distal dissection. The results thus indicate that aortic dissection seems to affect long-term outcome, and therefore the combined repair of the aortic root and transverse arch is recommended in Marfan patients with aortic dissection involving the transverse aortic arch.

Adolescent↗
PubMed1990

Comparison of medical and surgical therapy for uncomplicated descending aortic dissection.

To guide the choice of medical versus surgical therapy for patients with descending (type B) aortic dissection (tear in the descending aorta without involvement of the ascending aorta), multivariate survival analysis was applied to 136 patients admitted to two medical centers between 1975 and 1988 with acute (n = 89) or chronic (n = 47) descending dissection: group 1, all 136 patients; group 2, 106 patients without rupture, pulse loss, or visceral organ compromise; and group 3, 56 patients from group 2 without major cardiac or renal disease (23 surgical and 33 medical). Group 3 medical and surgical subgroups were well matched for baseline characteristics and were potential candidates for either mode of therapy. By Cox model analysis, significant predictors of mortality were pleural rupture, other dissection complications, increasing age, and cardiac disease (all p less than 0.01). Surgical versus medical therapy was not an independent determinant of survival in any of the three groups for acute or chronic dissection. Survival probabilities for all group 3 patients at 1, 5, and 10 years were 0.94, 0.87, and 0.32 (medical) and 0.90, 0.80, and 0.50 (surgical). Despite the limitations of this retrospective study (including the possibility of undefined treatment selection biases), these data suggest that medical or early surgical therapy is associated with equivalent outcome in selected patients with uncomplicated acute or chronic descending aortic dissection.

Adrenergic beta-Antagonists↗
PubMed2004

Thyroid hormone levels in patients with aortic dissection: comparison with controls and correlation with the percentage of the aortic media composed of myxoid deposits.

OBJECTIVE: Deposits of myxoid material, similar to myxedema related to thyroid disease, are described in the medial layer of aortas with dissection. We analyzed the clinical or subclinical thyroid dysfunction of patients with this disease and analyzed whether a correlation exists between serum levels of thyroid-related hormones and the myxoid content of the aortic media. METHODS: We measured, with standard methods, serum levels of triiodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH) in 28 patients who underwent aortic dissection and free T4 in 20 of them. The same hormones were quantified in 20 control patients matched by sex and age. Results were compared by using the Mann-Whitney test. We also measured the percentage of the aortic media occupied by myxoid material in the surgical specimens of 25 of the patients with aortic dissection and analyzed its correlation with hormone levels by using the Pearson test. RESULTS: In the 20 pairs in which the amount of hormones was compared, the mean values for T3, T4, free T4, and TSH were 1.22ng/mL, 9.89mcg/dL, 1.18ng/dL, and 5.45 microIU/mL in study patients and 1.15ng/mL, 8.57mcg/dL, 1.32ng/dL, and 2.15 microIU/mL in controls. Neither these differences nor the correlation between the percentage of myxoid content (mean=30%) and the values for T3, T4, free T4, and TSH (mean 1.22ng/mL, 9.44mcg/dL, 1.20ng/dL, and 5.08 microIU/mL, respectively; n= 25) were significant. CONCLUSION: Our data suggest that serum levels of thyroid hormones have no relation with the myxoid content in the aortic media in cases of aortic dissection.

Adult↗
PubMed2003

Is conservative therapy acceptable for thrombosed type A acute aortic dissection?

OBJECTIVES: The surgical treatment for thrombosed type A dissection is controversial because it has a better prognosis than with conservative therapy. We discuss the validity of conservative therapy for thrombosed type A dissection and examine the relationship between the morphology of the dissecting aorta and its operative indications. METHODS: Subjects were 28 patients with acute type A aortic dissection in which the false lumen was totally thrombosed who were transferred to our hospital in the acute phase between 1990 and 2002. We performed medical therapy on all of them at first. We calculated the ratio of the false lumen and the true lumen (F/T) by enhanced computed tomography scan at the onset. The maximum aneurysmal size was measured approximately every week. RESULTS: Fifteen of them needed surgical repair; six in the acute phase and nine in chronic. One-year and 5-year survival rate for the operative and the non-operative group are 93.3, 80.0 and 92.3, 92.3% respectively. The mean F/T was 30% in the operative group and 50% in the non-operative group (p = 0.04). There was almost no reduction in size in the operative group during the follow up (-0.5 +/- 1.2 mm). CONCLUSIONS: Conservative therapy with frequent imaging follow-up can be a rational option for thrombosed type A acute aortic dissection. A low ratio of the false lumen and the true lumen at the onset and no reduction in the aneurysmal size are the predictive factors by which we should consider surgical repair.

Adult↗
PubMed1993

[Acute aortic dissection during pregnancy. Surgical treatment with maternal and fetal rescue].

Acute aortic dissection (AD) seldom affects young women, but when it occurs it is, in almost one out of two cases, during pregnancy. We report a case of severe AD during pregnancy in which emergency surgery immediately saved the life of the mother and the foetus. The mother died of cardiac complications 13 days after the operation; the condition of the newborn is satisfactory.

Acute Disease↗
PubMed2006

Chemical-induced, nonlethal, developmental model of dissecting aortic aneurysm.

BACKGROUND: A chemical-induced, nonlethal, dissecting aortic aneurysm (DAA) is described following in utero exposure to semicarbazide, an inhibitor of the vascular enzyme semicarbazide sensitive amine oxidase (SSAO). METHODS: Sprague-Dawley rat dams were given semicarbazide (0.096-49.000 mg/kg/day) by IP injection on gestation days (GDs) 14-20, a period of rapid aortic development. Newborn rats (day 1) were killed and their thoracic organs were removed en bloc for near-serial cross sections and routine histopathology, Movat stain for elastin, and immunohistochemistry to differentiate cells involved in the evolution of the DAA. In subsequent experiments, pups from treated dams (0.096-6.125 mg/kg/day) were allowed to survive for 7 or 28 days. RESULTS: DAA occurred in nearly 100% of the rats at all doses except the lowest tested (1.530, 0.096 mg/kg/day). Dissections frequently extended to the carotids and, less frequently, to the abdominal aorta. Remodeling of vascular lesions proceeded by organization of collections of blood in vascular media (the "false lumen"), proliferation of vascular smooth muscle cells, fibrosis, and formation of irregular frayed elastic lamellae in healed vascular media. Biochemical quantitation and Western blot analysis of main extracellular matrix proteins on GD 20 showed no overt difference in expression of collagen type I, fibrillin-1, or elastin. CONCLUSION: This developmental model provides investigators an opportunity to explore the pathologic mechanisms of DAA and to examine the potential long-term effects of vascular remodeling of DAA.

Amine Oxidase (Copper-Containing)↗
PubMed2006

Aorto-carotid bypass for cerebral malperfusion after aortic dissection surgery: a case report.

Malperfusion syndrome may complicate the postoperative course in patients who have undergone surgery for aortic dissection. In these cases, open surgery or endovascular intervention may be required. We present a case of postoperative onset of intermittent severe neurological symptoms after surgery for type A aortic dissection. Progressive dissection of the carotid arteries was diagnosed, and treatment options were discussed. A successful aorto-carotid bypass was performed by cardiac and vascular surgeons in collaboration. All neurological symptoms were completely resolved. We advocate a high degree of vigilance for signs of cerebral malperfusion in the intensive care unit. Early intervention can result in a successful outcome, as illustrated by this case report.

Aortic Dissection↗
PubMed2003

Endovascular treatment of complicated type-B aortic dissection with stent-grafts:: midterm results.

PURPOSE: To report the midterm results of the endovascular treatment of complicated type-B aortic dissection with use of stent-grafts. MATERIALS AND METHODS: Ten patients with acute (n = 4) or chronic (n = 6) complicated type-B dissection were treated with custom-made stent-grafts. Indications for treatment included uncontrollable hypertension with dissection extension (n = 3), renal ischemia (n = 1), and false lumen aneurysm (n = 6). Stainless-steel Z-stents covered with polyester grafts were placed in the initial six patients. Nitinol stents covered with ultrathin polytetrafluoroethylene were used in the remaining four patients. The patients were followed-up with helical computed tomography for a maximum of 30 months (mean, 20 mo). RESULTS: There was one technical failure related to the access site. Early complications included deep venous thrombosis (n = 1) and embolic stroke (n = 1). Complete thrombosis of the thoracic false lumen was achieved in six patients and partial thrombosis was achieved in three. Aneurysms developed at the ends of the stainless-steel stents in two patients, requiring additional stent-graft placement. Despite successful remodeling of the thoracic aorta, three of four patients with distal reentry into the abdominal aorta experienced progressive abdominal aortic aneurysm (AAA). AAA rupture developed in two patients; one rupture was fatal and the other was treated with emergency surgery. CONCLUSIONS: Endovascular treatment of complicated type-B aortic dissection is technically feasible and effective. Closely monitoring the treated aorta is essential to detect early aneurysm formation at the ends of rigid stents. Despite adequate sealing of the tears in the thoracic aorta, dissection with distal reentry phenomenon into the abdominal aorta may evolve into AAA with late rupture.

Alloys↗
PubMed1998

Stanford type A aortic dissection. A new surgical approach.

We describe a new surgical technique adopted for the repair of Stanford type A aortic dissection. In order to minimize the risk of malperfusion caused by retrograde flow during cardiopulmonary bypass, we avoid femoral artery cannulation. On the hypothesis that it is best not to interfere with the hemodynamics of the dissection, we cannulate the dissected ascending aorta, in either the true or false lumen. We here report 2 cases of successful surgical treatment of Stanford type A aortic dissection. In both cases, the false lumen was cannulated under deep hypothermic circulatory arrest, without clamping the aorta. While the patient was cooling, a 10-mm GORE-TEX side arm was sutured to a Dacron graft prosthesis. Repair of the aortic arch was carried out 1st. The aortic cannula was inserted into the GORE-TEX side arm, the tubular prosthesis was cross-clamped, and cardiopulmonary bypass was reinstituted. After this, the aortic bulb was repaired as usual and the tubular prosthesis was sutured to the bulb. No postoperative cerebral complication occurred. Our experience must be confirmed by more cases and a longer follow up.

Aged↗
PubMed2005

Successful surgical treatment for acute aortic dissection in pregnancy with Marfan's syndrome.

A 34-year-old pregnant woman with Marfan's syndrome in the 34th week of gestation was diagnosed with acute DeBakey type I aortic dissection. Immediately after cesarean section, she underwent emergent operation of combined total aortic arch and aortic root replacement using cardiopulmonary bypass, deep hypothermia and antegrade cerebral perfusion. Both maternal and fetal outcomes were good and uneventful. Pregnancy increases the risk of aortic dissection especially for patients with Marfan's syndrome. Moreover it should be noted that cardiac surgery using cardiopulmonary bypass and deep hypothermia generally results in fetal loss. If fetal maturity can be confirmed as in our case, cesarean section should be done before cardiovascular surgery. We describe here a case of successful operation for mother and infant at the 34th week of gestation.

Aortic Dissection↗
PubMed2002

Chronobiological patterns of acute aortic dissection.

BACKGROUND: Chronobiological rhythms have been shown to influence the occurrence of a variety of cardiovascular disorders. However, the effects of the time of the day, the day of the week, or monthly/seasonal changes on acute aortic dissection (AAD) have not been well studied. METHODS AND RESULTS: Accordingly, we evaluated 957 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2000 (mean age 62+/-14 years, type A 61%). A chi2 test for goodness of fit and partial Fourier analysis were used to evaluate nonuniformity and rhythmicity of AAD during circadian, weekly, and monthly periods. A significantly higher frequency of AAD occurred from 6:00 AM to 12:00 noon compared with other time periods (12:00 noon to 6:00 PM, 6:00 PM to 12:00 midnight, and 12:00 midnight to 6:00 AM; P<0.001 by chi2 test). Fourier analysis showed a highly significant circadian variation (P<0.001) with a peak between 8:00 AM and 9:00 AM. Although no significant variation was found for the day of the week, the frequency of AAD was significantly higher during winter (P=0.008 versus other seasons by chi2 test). Fourier analysis confirmed this monthly variation with a peak in January (P<0.001). Subgroup analysis identified a significant association for all subgroups with circadian rhythmicity. However, seasonal/monthly variations were observed only among patients aged <70 years, those with type B AAD, and those without hypertension or diabetes. CONCLUSIONS: Similar to other cardiovascular conditions, AAD exhibits significant circadian and seasonal/monthly variations. Our findings may have important implications for the prevention of AAD by tailoring treatment strategies to ensure maximal benefits during the vulnerable periods.

Aged↗
PubMedDate not supplied

Percutaneous creation of acute type-B aortic dissection: an experimental model for endoluminal therapy.

PURPOSE: To evaluate the feasibility of a percutaneously created type-B aortic dissection as an experimental model for percutaneous therapy. This model was used to evaluate the hemodynamic effects of single-balloon fenestration of the intimal flap. MATERIALS AND METHODS: Acute type-B dissections were created in descending aortae of 15 swine via a femoral (n = 6) or carotid (n = 9) approach. The initial subintimal tear was made with use of a Colapinto needle. The dissections were extended to a predefined position in the aorta. The proximal and distal tears were balloon dilated. The mural flap was balloon fenestrated in six animals, just above the celiac artery. Aortograms were obtained to establish the presence and extent of the dissection. Manometry was performed in both lumina to evaluate the hemodynamics of the dissected aorta and the effects of balloon fenestration in this model. Pathologic specimens were also examined. RESULTS: Creation of dissection was successful in 11 of 15 animals, with six developing true lumen narrowing (group A). The other five animals (group B) had flow in both lumina without evidence of true lumen narrowing. After the creation of a single-balloon fenestration in the group A swine, the arteriograms revealed no evidence of blood admixture between the true and false lumina, and there was no change in the intravascular pressures. Examination of the explanted aortae showed a more extensive circumferential dissection in group A animals as compared with group B. CONCLUSION: The percutaneously created acute type-B aortic dissection is a feasible model for experimentation. The hemodynamics of the aorta did not change after single-balloon fenestration in this model.

Aortic Dissection↗