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PubMed2002

High failure rate after valve-sparing aortic root replacement using the "remodeling technique" in acute type A aortic dissection.

BACKGROUND: Valve-sparing surgery including the replacement of the sinus of valsalvae were initially meant to be promising approaches in the treatment of acute type A aortic dissection. However, the long-term outcome after valve-sparing aortic root replacement in acute type A dissection is currently the subject of intense debate, and the evidence reported in the literature is sparse. Here we report on our experience on valve sparing aortic root replacement inpatients with acute type A dissection. METHODS: From August 1995 to November 2000, 30 patients with acute type A dissection received valve-sparing aortic root replacement. Two different techniques were performed: the "remodeling" technique, first described by Yacoub in 1983 (8 patients) and the "reimplantation" technique, initially described by David and Feindel, in 1992 (22 patients). Endpoints of the study were early and late mortality, as well as aortic valve-related complications and reoperations. RESULTS: The mean follow-up time was 22.6+/-15.4 months. The overall 30 day mortality was 17% (5/29) and the late mortality 4% (1/24). During the observation period, 4 patients had to be reoperated (n=3) for acute aortic valve regurgitation after aortic root remodeling and for acute aortic valve endocarditis (n=1) after aortic root reimplantation. In the 3 patients with acute aortic valve regurgitation, symptoms occurred 44, 24, and 17 months after the initial operation in these patients. Intraoperatively prolapsing aortic leaflets because of commissural detachment was found in all 3 cases. In all other patients the latest echocardiographic follow-up examination revealed freedom from aortic regurgitation higher than grade 1. CONCLUSIONS: The high failure rate of aortic root remodeling inpatients with acute type A aortic dissection is discouraging. Whether this technique should be applied in acute type A aortic dissection is questionable. In contrast, aortic root reimplantation lead to favorable midterm outcome. Thus, we recommend consideration of this technique for surgical treatment of patients with acute type A aortic dissection.

Acute Disease↗
PubMed2004

Spontaneous infrarenal abdominal aortic dissection presenting as claudication: case report and review of the literature.

Spontaneous infrarenal abdominal aortic dissection (SIAAD) is rare. Patients with SIAAD may be asymptomatic or may present with abdominal pain or lower extremity ischemia. We describe a case report of a patient with SIAAD who presented with claudication. We reviewed the English literature on this disorder and specifically evaluated the differences between patients on the basis of their presenting symptoms. Patients who had SIAAD and lower extremity ischemia were more likely to have the dissection process extend into the iliac or femoral artery and were less likely to have an associated abdominal aortic aneurysm. Aortic rupture in the presence of SIAAD was associated with increased risk of death.

Aortic Dissection↗
PubMed2002

Anterior myocardial infarction, acute aortic dissection, and anomalous coronary artery.

Acute dissection of the ascending aorta has, on rare occasions, been accompanied by myocardial infarction due to the compression of the ostium of a coronary artery. Rarer still is the presence of an aortic dissection, myocardial infarction, and an anomalous coronary artery. A case is described of a patient who survived an acute aortic dissection complicated by anterior myocardial infarction due in part to the presence of an anomalous circumflex artery. The anatomy, diagnosis, and consequences of aortic dissection are discussed.

Aorta↗
PubMed2003

Mortality of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis: a population-based study over 50 years.

OBJECTIVE: To determine the mortality of giant cell arteritis (GCA) with large-artery complication compared with that of GCA without large-artery complication. METHODS: An inception cohort of 168 residents of Olmsted County, Minnesota, in whom GCA was diagnosed between January 1, 1950, and December 31, 1999, was followed up. Mortality in patients with incident large-artery complication (aortic aneurysm, aortic dissection, and large-artery stenosis) was determined and compared with that in patients in whom large-artery complication did not develop. RESULTS: No difference in survival was observed between the total group of patients with any type of large-artery complication and patients without large-artery complication or the general population. However, mortality was markedly increased in the 9 patients in whom thoracic aortic dissection developed (median survival 1.1 years [interquartile range 0.2-7.8 years]) compared with that in all other patients with GCA (P < 0.001). No difference in survival was observed between the group of patients with either aortic aneurysm and/or dissection (thoracic and/or abdominal aorta) and the group with GCA without large-artery complication. Survival of patients with GCA and large-artery stenosis was not different from that of patients with GCA without large-artery complication. CONCLUSION: Thoracic aortic dissection in GCA is associated with markedly increased mortality. Overall, mortality in the whole group of patients with GCA with large-artery complication was similar to that in patients with GCA without large-artery complication.

Aortic Dissection↗
PubMed1994

Thoracic aortic dissection with renal artery involvement following blunt thoracic trauma: case report.

Blunt thoracic aortic injury most often occurs beyond the left subclavian artery with subsequent transection and exsanguination. We present a case of an unrestrained driver involved in a high-speed motor vehicle crash who had a traumatic mid-thoracic aortic dissection involving the orifices of both renal arteries, resulting in anuria. This diagnosis should be considered in the presence of anuria following chest trauma.

Aortic Dissection↗
PubMed2005

Surgical results in acute type A aortic dissection.

Currently international registry data present the patient mortality with acute type A aortic dissection managed non-surgically to be 58%, and managed surgically to be 26%. Many articles consistently report the hospital mortality exceeding 20% in western countries. Many factors, such as cardiac tamponade and dissection-related organ malperfusion, contribute to hospital mortality and morbidity. In Japan, the number of patients enrolled in the annual reports has been increasing and the surgical results have been improving year by year. In-hospital mortality has decreased to less than 20% since 1999. Since the beginning of our aortic program, a total of 98 patients underwent emergency operations, and the operative mortality and in-hospital mortality were 5.1% and 6.1%, respectively. In a recent series since 2001, the operative and in-hospital mortalities were remarkably low; 2.8% and 3.2% respectively. We were able to benefit greatly by various innovative technologies which include open distal anastomosis using hypothermic circulatory arrest with antegrade cerebral perfusion, gelatin-resorcin-formaldehyde (GRF) glue, branched presealed Dacron graft, and antegrade arterial perfusion. Our tear-oriented surgery could be justified in many patients in order to improve the surgical results. In patients with preoperative organ malperfusion, it is still challenging to improve the mortality and morbidity.

Acute Disease↗
PubMed2004

Iatrogenic subtle acute aortic dissection during coronary angioplasty for in-stent restenosis. Value of intravascular ultrasound for diagnosis and management.

A patient with a subtle, iatrogenic, type A aortic dissection following a coronary angioplasty is described. Intravascular ultrasound was useful to confirm the diagnosis of the confined aortic dissection and also to guide adequate stent coverage of its coronary entry door. Both transesophageal echocardiography and magnetic resonance imaging failed to detect any significant aortic wall abnormality.

Acute Disease↗
PubMed1981

Renin dependent hypertension by dissecting aortic aneurysm. A case report.

A 49-year-old female patient with dissecting aortic aneurysm and severe hypertension was reported. Aortogram revealed dissection of De Bakey type IIIb, which extended to the iliac artery and caused occlusion of the left renal artery. Peripheral plasma renin activity was extremely elevated and 1-Sar-8-Ile-angiotensin II produced a marked fall in blood pressure. The patient was treated conservatively with antihypertensive agents for about 4 years from July, 1974 to October, 1978 when she died suddenly in an early morning.

Aortic Dissection↗
PubMed1992

The diagnostic value of imaging techniques for aortic dissection.

Previous studies conducted in high-risk populations have reported high predictive values and accuracies for diagnostic imaging techniques for aortic dissection. To see how these techniques perform in low-risk populations, we used Bayes' theorem to calculate predictive values and accuracies for angiography, CT, MRI, and TEE. In high-risk populations (disease prevalence = 50%), positive predictive values were all greater than 85%. In intermediate risk populations (disease prevalence = 10%), positive predictive values were greater than or equal to 90% for CT, MRI, and TEE, but were 65% for angiography. In low-risk populations (disease prevalence = 1%), positive predictive values were 100% for MRI and less than or equal to 50% for angiography, CT, and TEE. In all three populations, negative predictive values and accuracies were greater than or equal to 85%. From these results we conclude that diagnostic imaging techniques for aortic dissection do not perform as well in low-risk populations as they do in high-risk populations.

Aortic Dissection↗
PubMed1997

[Composite valve graft replacement in patients with type A aortic dissection--a modified cabrol procedure].

Composite valve graft replacement of the ascending aorta and aortic valve is indicated for a variety of conditions affecting the aortic root. However, a major drawback in this operation is bleeding from the proximal suture line and coronary anastomosis especially in patient with friable root tissue involved by aortic dissection. We describe here a modified technique to take advantage of the aortic button and cabrol techniques to reattach the coronary artery ostia. We have experienced seven patients with the aortic root replacements for type A dissection using the described technique over the past two years. In view of our favorable experience, we recommend this technique especially for patient with acute dissection involving nondilated aortic annulus, in addition to the patients with Marfan syndrome or annulo-aortic ectasia.

Aged↗
PubMed1997

[Total proximal reconstruction of chronic aortic dissection in patients with Marfan syndrome].

Authors present two patients suffering from Marfan syndrome. Asymptomatically developed serious cardiovascular complications being characteristic of the syndrome itself were revealed at both cases. Type "A" aortic dissection was found at the first, and type "B" aortic dissection involving even the arch as well revealed at the other patient. They were operated on an elective base. Total proximal aortic reconstructions (aortic root-ascending aorta-arch) were performed under deep hypothermia using total circulatory arrest (35 and 87 min). Both patients are doing well without complaints 3-4 months following the surgical interventions. Control angiographic imagination has found normal anatomic conditions at one of the patients. Anastomosis stenosis at the borderline of the arch and descending aorta was revealed at the other case which should be necessary to operate at an later occasion.

Adult↗
PubMed2002

[Clinical effect of femoral cannulation via artificial vessel in operation for aortic dissection].

OBJECTIVE: To evaluate the effect of femoral cannulation via artificial vessel in operation for aortic dissection. METHODS: Operation through femoral cannulation via artificial vessel was performed upon 159 patients with aortic dissection, 89 of Stanford type A and 70 of Stanford type B. An artificial vessel was anastomosed end-to-side to the femural artery. Femoral catheter was inserted via this artificial vessel. Cardiopulmonary bypass was performed in 90 patients, among which 31 had deep hypothermic circulatory arrest. Left heart bypass was performed in 69 patients. RESULTS: False lumen perfusion was detected during cardiopulmonary bypass in 7 patients (4.4%). Cerebral events occurred in 7 patients (two patients with diffused cerebral anoxia with one death, and five patients with cerebral embolism with three deaths). 12 patients suffered from prolonged incision recovery (9.0%), and two from local infection (1.5%). No lower extremity ischemia or femoral thrombosis was found in the cannulation side. CONCLUSION: Femoral cannulation via artificial vessel effectively reduces the incidence of structure of femoral artery, thrombosis, and lower extremity ischemia. Operation through femoral cannulation via artificial vessel is very effective in treatment of aortal dissection. Only a few cases of cerebral events caused by retrograde perfusion through femoral cannulation occurred in this group, however, with high mortality.

Adult↗
PubMed2003

Surgical repair of acute type A aortic dissection: continuous pulmonary perfusion during retrograde cerebral perfusion prevents lung injury in a pilot study.

OBJECTIVE: Postoperative respiratory failure is a frequent and serious complication in patients with type A acute aortic dissection operated on with deep systemic hypothermia. Interaction between neutrophils and pulmonary endothelium along with ischemic insult and reperfusion are the major determinants of lung injury. The aim of this prospective study was to evaluate the effect of continuous pulmonary perfusion during retrograde cerebral perfusion on lung function. METHODS: Twenty-two patients referred for acute type A aortic dissection, who were free from preoperative respiratory dysfunction, were assigned prospectively and alternately to one of 2 treatment groups. Pulmonary perfusion was performed during retrograde cerebral perfusion in group B (11 patients), whereas the conventional Ueda technique was applied in group A (11 patients). Lung function was evaluated on the basis of intubation time, scoring of chest radiographs at 12 hours after cardiopulmonary bypass, and Pao(2)/fraction of inspired oxygen ratio assessed from immediately before the operation to 72 hours after termination of cardiopulmonary bypass. RESULTS: Study groups were homogeneous for age, sex, interval between symptom onset and surgical operation, previous aortic surgery, preoperative ejection fraction and pulmonary gas exchange function, extent of aortic repair, and concomitant procedures. Cardiopulmonary bypass time, length of retrograde cerebral perfusion, operation time, need for blood substitutes, and surgical revision for bleeding did not differ between treatment groups. Postoperative Pao(2)/fraction of inspired oxygen ratios were higher in group B than in group A, and the difference remained statistically significant throughout the study period. The incidence of prolonged ventilator support (>72 hours) and the severity of the radiographic pulmonary infiltrate score were lower in the perfused group (18.2% vs 72.7% [P =.015] and 0.81 +/- 0.75 vs 1.8 +/- 0.78 [P =.028], respectively). CONCLUSIONS: Continuous pulmonary perfusion provided a better preservation of lung function in patients operated on with deep systemic hypothermia.

Acute Disease↗
PubMedDate not supplied

False lumen thrombectomy of the superior mesenteric artery followed by iliomesenteric bypass after Stanford type B aortic dissection.

A 55-year-old man with an acute Stanford type B aortic dissection presented with clinical signs of mesenteric ischemia. Computed tomography (CT) revealed a thrombosed false lumen in the superior mesenteric artery. At laparotomy, the dissection was found to be extending into the jejunal branches and medial colic artery. Thrombus was removed from the false lumen, and perfusion was restored with an iliomesenteric bypass, with the dissected layers tacked together in the suture line. A postoperative CT scan showed a stable diameter of the thoracoabdominal aorta and a patent iliomesenteric bypass.

Aortic Dissection↗
PubMed2002

[Anesthesia for section caesarean with aortic dissection in Marfan Syndrome].

Marfan Syndrome (MFS) is associated with an increased anaesthesia risk because of the pathological manifestations in anaesthesia-relevant organ systems. If, in addition, a typical MFS complication - acute aortic dissection - presents and this in pregnant patients, a high-risk anaesthesia must be assumed. In the case reported, a 30 year old woman in the 35 th week of gestation presented with an acute aortic dissection, initially in the region of the descending aorta and later, in the course of the ascending aorta. An urgent Caesarean section was indicated in order to perform the equally urgent vascular surgery as quickly as possible. The most important goal of the anaesthesia management is to determine an anaesthesia procedure which addresses the combination of aorta dissection, gestation and MFS. On the one hand, the risk of an aorta rupture needs to be kept as low as possible and on the other hand, the vital functions of the baby have to be maintained. A general anaesthesia procedure under mild controlled hypotension was selected. Optimal monitoring and absolute freedom from pain were the prerequisites both for the anaesthesia management of the Caesarean section as well as for the immediate transport to a clinic for further treatment after completion of anaesthesia.

Adult↗
PubMed2003

Left common carotid artery cannulation for type A aortic dissections.

We used left common carotid artery cannulation for repair of type A aortic dissection in 2 patients for whom both femoral artery and axillary artery cannulation were thought to be more dangerous, due to dissection of the brachiocephalic trunk and left subclavian artery in association with abdominal stenosis. Before performing end-to-side anastomosis, we attached a small partial clamp to the left common carotid artery, thereby maintaining adequate cerebral blood flow during perfusion. To date, neither of our patients has experienced neurologic complications related to this procedure. We believe that left common carotid artery cannulation for type A dissections is useful when dissection of the brachiocephalic trunk and left subclavian artery is found in association with abdominal or femoral artery stenosis. To the best of our knowledge, these 2 cases are the 1st described in the medical literature.

Aortic Dissection↗
PubMed1999

Comparative clinical study between retrograde cerebral perfusion and selective cerebral perfusion in surgery for acute type A aortic dissection.

OBJECTIVE: Selection of a brain protection method is a primary concern for aortic arch surgery. We performed a retrospective study to compare the respective advantages and disadvantages of retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) in patients who underwent surgery for acute type A aortic dissection. METHODS: The study reviewed 166 patients who underwent surgery at Nagoya University or its eight branch hospitals between January 1990 and August 1996. There were 91 patients who received SCP and 75 patients who underwent RCP. Results for these two groups were compared. RESULTS: There were no significant differences in age, gender, Marfan syndrome rate, DeBakey classification, or emergency operation rate. Rates of various preoperative complications were similar except for aortic valve regurgitation. Arch replacement was performed more often in SCP than in RCP patients (49% vs. 27%, P = 0.0028). There were no significant differences between groups in cardiac ischemic time or visceral organ ischemic time. However, RCP group showed shorter cardio-pulmonary bypass time (297+/-99 vs. 269+/-112 min, P = 0.013) and lower the lowest core temperature (21.6+/-3.1 degrees C vs. 18.7+/-2.1 degrees C, P = 0.0001). SCP duration was longer than RCP duration (103+/-56 vs. 54+/-24 min, P < 0.0001). Despite these differences, RCP patients were not significantly different from SCP patients with regard to any postoperative complication, neurological dysfunction (16 vs. 19%), or operative mortality (all deaths within the hospitalization; 24 vs. 21%). Regarding neurologic dysfunction, there were six cases of coma, six of motor paralysis, two of paraplegia and one of visual loss among SCP patients, and eight cases of coma, three of motor paralysis, and three of convulsion in the RCP group. The incidence of motor paralysis was higher in the SCP group, while the incidence of coma was higher in the RCP group. CONCLUSIONS: RCP can be performed without clamping or cannulation of the cervical arteries, which is an advantage in reducing the chances of arterial injury or cerebral embolization. RCP is comparable to SCP in terms of clinical outcome.

Acute Disease↗
PubMed1995

[A case of visceral ischemia associated with acute type IIIb aortic dissection].

The case was a 61-year-old man who was transported to our hospital with complaining of severe chest and back pain of sudden onset and diagnosed as acute type IIIb aortic dissection. Inspite of intensive medical treatments, severe abdominal pain with abdominal distension and progressive metabolic acidosis appeared at around 11 hours after admission. Aortogram revealed obstruction of both superior and inferior mesenteric arteries suggesting visceral ischemia associated with acute type IIIb aortic dissection. Emergent operation consisting of bypass grafting for the superior and the inferior mesenteric arteries with saphenous vein, partial resection of small intestine, left hemicolectomy and construction of artificial anus was immediately carried out. The patient had no particular trouble after the operation and returned to the previous job.

Acute Disease↗