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A case of type I (type A) aortic dissection proved by postmortem examination could not be fully delineated relative to the type of dissection by dynamic CT as well as three positive contrast aortograms. Small tears in the ascending aorta and their strategic locations can escape even intensive radiologic evaluation. We present a case in which medical therapy was provided and, inappropriately, surgery was not performed.
The aim of this work was to evaluate the usefulness of angiography, CT scan and MR imaging in the diagnosis of aortic dissection, on the basis of the authors' experience and literature review. Angiographic study is still considered the first choice technique in the diagnosis of aortic dissection, although it is considered not completely safe. CT scan allows to note the early thickening of the vessel walls (due to intraparietal bleeding) and the presence of calcifications in the thrombosed portion of the lesion. MR study allows multiplanar study of the lesions without contrast medium, and best visualization of subendothelial bleeding in dissections without intimal lesion.
A fistula between the aorta and right atrium which communicates with the right ventricle is an extremely rare and rapidly lethal complication of aortic dissection. There are only three previously reported cases of survival after operative repair of aorto-right atrial fistulae in the literature. We describe a patient who experienced acute aortic dissection with fistula formation to the right atrium and to the right ventricle. The patient underwent successful operative repair.
A case of aortic dissection extending to an aberrant right subclavian artery seen at CT and MRI is reported. The clinical and imaging patterns of this rare disease are described and compared with those of the literature. Multiplanar views are, in this particular case, very useful for a precise assessment of the involved aberrant artery.
A 68-year-old man with a DeBakey type II chronic aortic dissection developed bacteremia secondary to a urinary tract infection with the Serratia species. This resulted in an infected thrombus in the false channel and a subsequent rupture of the ascending aorta. An emergency resection of the ascending aorta and a Dacron graft interposition were performed. The patient suffered from severe neurological insufficiency and died of pneumonia 6 months postoperatively. The optimal operation time and surgical options of an infected aortic dissection should be determined.
Three patients presented with a prolonged illness accompanied by fever, weight loss, high ESR, neutrophilia, abnormal liver function tests, urinary abnormalities and, in one case, splinter haemorrhages and impairment of renal function. Aortic dissection was diagnosed 3-12 weeks after the onset of the illness, and probably accounted for the entire syndrome. All abnormalities resolved spontaneously over the following months. There are few similar cases in the literature, and the syndrome could easily pass unrecognized. Aortic dissection should be considered as a possible cause of any systemic illness of sudden onset, but especially if there is an initial history of chest or abdominal pain, or evidence of previous hypertension or other risk factors.
A 56-year-old male was admitted with severe chest and abdominal pain. Enhanced CT revealed type-A acute aortic dissection. Enhancement of false lumen was complete in the aortic arch, but it was incomplete in the ascending and descending aorta. This finding suggested a thrombosing tendency of the false lumen. Marked elevation of Thrombin-Antithrombin III complex (TAT) and Plasmin-alpha 2 Plasmin inhibitor complex (PIC) indicated the activation of both coagulation and fibrinolysis in the false lumen. Aprotinin and Tranexamic acid were used in order to suppress the fibrinolysis. Both TAT and PIC were completely normalized at the 20th hospital day. Enhanced CT on the 40th hospital day showed that the false lumen had disappeared, and the adventitia had thickened. Care should be taken to notice activated coagulation and fibrinolysis in the false lumen. This report appears to be the first statement about the effectiveness of antifibrinolytic therapy to facilitate thrombosing and healing of the false lumen in the treatment of acute aortic dissection.
When the port of entry of acute type-A aortic dissection is at the level of the horizontal portion of the aortic arch, the latter should be replaced by a prosthesis. To avoid performing this difficult procedure in an emergency situation, we place a stent in the aortic arch. Then we replace the ascending aorta by a prosthesis.
Osteogenesis imperfecta (OI) is an inherited connective tissue disorder, a group that includes Ehlers-Danlos syndrome, Marfan's syndrome and pseudoxanthoma elasticum. OI is a heterogeneous disease of collagen I biosynthesis characterized by variable clinical phenotypes, including skeletal and cardiovascular manifestations. A 65-year-old man with OI who had extensive prior successful cardiac valve surgeries is described. He survived for 18 years after his initial valve surgery, but died of multiorgan failure and sepsis after repair of a spontaneous type A aortic dissection. This is the fourth reported case of aortic dissection secondary to OI and illustrates the extensive cardiovascular pathology associated with OI. Aggressive management of arterial dissection risk factors, such as systemic arterial hypertension, is advocated for patients with OI.
Aorta to right ventricular fistula is a rare complication of ascending aortic dissection that has previously been diagnosed ante mortem only by cardiac catheterization. This report describes a patient who had aorta to right ventricular fistula that caused a left-to-right shunt and marked hemodynamic instability. An anatomic diagnosis was made rapidly in this patient by use of echocardiographic techniques. Two-dimensional and Doppler echocardiography have an important role in defining the cause of cardiovascular collapse after aortic dissection.
A 47-year-old man with acute retrograde aortic dissection (Stanford type A) was treated with total aortic arch replacement and endoluminal stent-grafting for an intimal tear in the descending aorta. A stent-graft was introduced into the descending aorta via the transected arch aorta and the entry of the dissecting aneurysm was closed. Open endovascular stent-grafting via the arch aorta is an alternative for repair of acute type A aortic dissection with an intimal tear in the descending aorta, in cases where direct closure of the intimal tear is difficult.
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Between March, 1997 and January, 1999, 11 patients with acute type B aortic dissection underwent doplex scanning evaluation of mesenteric arteries for the early detection of visceral ischemia. Peak systolic velocity (PSV) of the celiac artery (CeA) and superior mesenteric artery (SMA) was measured on their admission. Mean PSV of CeA in the non-ischemic group (8 patients) and in the ischemic group (3 patients) was 1.66 +/- 0.34 m/sec and 3.60 +/- 0.49 m/sec (p = 0.0481), respectively. Mean PSV of the SMA in the non-ischemic group and in the ischemic group was 1.93 +/- 0.52 m/sec and 3.33 +/- 0.37 m/sec (p = 0.00768), respectively. All patients with PSV of the mesenteric arteries above 3.00 m/sec presented visceral ischemia that required emergency operation. If PSV of the mesenteric arteries exceeds 3.00 m/sec, urgent surgical repair should be considered.
OBJECTIVE: To explore the risk factors clinical appearance and examination methods of aortic dissection (AD). METHOD: The clinical data of 106 AD patients admitted from the January, 2001 to July, 2004 were retrospectively reviewed. RESULTS: The symptoms and physical signs of the 106 AD patients were diverse. Chest pain was a common initial symptoms but some patients initial symptoms were atypical. The origins of AD was in ascending aorta when patients had clinical appearance mimicking myocardial infarction, and in descending aorta when patients had pain involving shoulders, dorsum, waist, abdomen or lower limbs. Hypertension was the most important cause of AD. The combination use of echocardiography, CT and MRI may help to make rapid diagnosis. CONCLUSIONS: The symptoms and physical signs of AD were diverse. Clinical symptom had some relationship with the origin of AD, the form of AD and hypertension had obvious relations. An obvious correlation exited between the occurrence of AD and hypertension.
The clinical features, etiologies, pathogenesis, treatment and prognosis of 70 patients with aortic dissecting were studied. Patients with age ranging from 31 to 70 years consisted 93% of the total. The proportion of proximal to distal types is 0.8: 1. Hypertension was present in 67% and Marfan's syndrome 18% of the patients. The pathologic finding was scattered rupture with myxomatous and cystic necrosis of the mecial elastic fibers. 80% of the patients suffered from the disease without any inducing cause. Of the 76% patients had chest pain, it was very severe in 69%. Chest X-ray, ultrasound, computed tomography and magnetic resonance imaging together with clinical manifestations may accurately diagnose the disease. The sensitivity and specificity of the ultrasound are 97% and 94% respectively. The mortality in hospital with surgical and medical therapy of the proximal type was 14% and 22% respectively, while that of the distal type was 63% and 27% respectively. Rupture of the aneurysm was the cause of death in 68% of the patients.
Ten patients underwent surgical treatment for type A aortic dissection from October 1986 to April 1989 using hypothermic cardiopulmonary bypass (CPB) with selective cerebral perfusion (SCP). CPB was begun with femoral artery cannulation. The right axillary artery (RAA) and the left common carotid artery (LCCA) were separately cannulated and perfused with CPB blood by individual pump heads. The average flow to the RAA was 5.4 +/- 1.2 ml/min/kg body weight (mean +/- SD) and 5.6 +/- 2.6 ml/min/kg body weight to the LCCA. The average blood pressure of the superficial temporal artery was 53.1 +/- 15.1 mmHg in the right side and 52.5 +/- 24.7 mmHg in the left. The nasopharyngeal temperature during SCP was maintained at 19.3-24.7 degrees C (mean, 21.1 degrees C). The SCP time ranged from 112 to 197 minutes (mean, 168 +/- 20.8 minutes). There was one operative death. She died of myocardial infarction 3 days after operation. There were two late deaths. One patient died of infection 3 months after operation and another died of cholecystitis 4 months after operation. Cerebral infarction developed in the last patient. Among the 10 patients it was only one neurological sequela, which was surmised to be caused by technical problem in carotid artery cannulation. The good cerebral protection was obtained in our experience by SCP as mentioned above.
BACKGROUND: Postoperative respiratory failure is often encountered in patients suffering from acute aortic dissection (AAD) and is believed to be influenced by release of neutrophil elastase after cardiopulmonary bypass. Sivelestat is a specific neutrophil elastase inhibitor, and this study aims to evaluate the effects of sivelestat on postoperative respiratory failure due to AAD. METHODS AND RESULTS: Patients who were operated for AAD from January 2000 to April 2005 and who had less than 300 mmHg initial postoperative PaO (2)/FiO (2) were investigated retrospectively and divided into two groups. Group 1 (n = 9) received intravenous administration of sivelestat immediately after the operation, while Group II (n = 9) received no sivelestat. There were no significant differences between Group I and II with respect to patients' characteristics or background (age, body weight, operating time, cardiopulmonary bypass time, amount of bleeding, preoperative WBC number and initial PaO (2)/FiO (2)). Though patients in Group I showed a subtle improvement in certain parameters such as PaO (2)/FiO (2), A-aDO (2) and respiratory index (RI) over a 3-day observation period compared to those of Group II, there were no significant differences. Neither postoperative mechanical ventilation time nor ICU stay differed between Group I and II. However, Group I showed a significantly greater improvement in the ratio of RI to initial RI on the 3POD compared to that of Group II (61.6 +/- 44.2 % vs. 111.9 +/- 40.9 %, P = 0.02). CONCLUSION: Inhibiting the activity of the neutrophil elastase may attenuate the postoperative respiratory complications of patients with AAD.
We describe our experience of six patients with clinical suspicion of acute aortic dissection (AAD) who were studied consecutively by transesophageal echocardiography (TEE) from April to July of 1991. All of them were previously submitted to transthoracic echocardiogram. The diagnosis was correctly established by TEE in five cases, confirmed by aortography and/or surgery (four cases), or by autopsy (one case). In one patient the diagnosis of AAD was excluded by TEE, and posteriorly by nuclear magnetic resonance. Four patients had a Stanford type A, and one patient a type B dissection. The site of entry was identified in three cases; the intimal entry tear of the type B dissection, not observed by TEE, was localized in the aortic arch by aortography. In three of the four type A dissection cases, a thrombus in the false lumen and an aortic regurgitation were found. No other noninvasive methods were used after the diagnosis of AAD by TEE. The surgical repair was successful in three cases, one of which, without previous necessity of aortography. In our experience, TEE increased extraordinarily the diagnosis efficacy of AAD, making possible an earlier therapeutic approach, and probably contributing to the improvement of the prognosis of this pathology.