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PubMed2005

Moderate hypothermia (30 degrees C) for surgery of acute type A aortic dissection.

OBJECTIVE: Antegrade cerebral perfusion has proved to be a reliable method of brain protection during surgery of thoracic aneurysms. In addition, the drawbacks of deep hypothermia may be avoided. This study examines the outcome after surgery for acute type A aortic dissections (AAD) using moderate (30 degrees C) systemic hypothermia compared with conventional techniques of cerebral protection. METHODS: Between January 1999 and August 2003, 74 patients underwent repair of acute type A aortic dissection. Moderate systemic hypothermia (30 degrees C) with selective antegrade cerebral perfusion through subclavian artery (group A) was used in 18 patients. Deep hypothermia (20 - 24 degrees C) was employed using either retrograde (18 patients, group B) or antegrade (38 patients, group C) cerebral perfusion. Tube graft replacement was performed in 55, valve-sparing procedure in 8, and composite graft replacement in 11 patients. RESULTS: The 30-day mortality was 5.5 % in group A, 5.5 % in group B, and 15.8 % in group C (A vs. C and B vs. C; p < 0.01). New postoperative permanent neurologic deficit occurred in 5.5 % of patients in group A, 16.7 % in group B, and 13.2 % in group C. Mean chest tube drainage within the first 24 h in groups A, B and C was 703 +/- 338, 1178 +/- 820, and 1447 +/- 802 ml, respectively (A vs. B and A vs. C; p < 0.01). Cardiopulmonary bypass, ICU, and hospital times were significantly shorter in group A. CONCLUSIONS: Selective antegrade cerebral perfusion with moderate systemic hypothermia appears to be a safe and sufficient tool for brain protection during AAD repair. In avoiding deep hypothermia, this technique may help to reduce cardiopulmonary bypass time and hypothermia-related side effects.

Aortic Dissection↗
PubMed1985

Late results of the surgical treatment for aortic dissections.

The results of 32 patients who had undergone surgery for aortic dissections were analyzed. Twenty-six patients were examined in hospital during the follow-up study while one patient refused the examination and 5 others had succumbed. The average follow-up was 42.6 months. Late functional status was generally good. Resuspension of the aortic annulus for incompetent aortic valves in type I and II dissections resulted in grave aortic regurgitation and death in one case, and in mild valvular incompetence in another case, while 5 patients had competent valves after resuspension. Computed tomography (CT) and angiographic studies frequently revealed residual changes such as double lumen of the aorta. Five subsequent aortic aneurysms were discovered, 4 of them having been reoperated after the study was completed. Periodical follow-up and screening of the aorta of operative survivors is recommended.

Adult↗
PubMedDate not supplied

Aortic dissection involving an aberrant right subclavian artery: CT and MR findings.

Three cases of aortic dissection involving an aberrant right subclavian artery are presented. Preoperative diagnosis was made based on CT and MRI. The association of dissection and aberrant right subclavian artery is rarely encountered; however, the diagnostic and therapeutic implications of these associations are important. We describe the chest radiographic, CT, and MR findings of this rare complication of a relatively common congenital vascular anomaly.

Aged↗
PubMed2003

A new approach for proximal anastomosis in type "A" acute aortic dissection: prosthesis eversion.

One of the crucial aspects of surgical repair of type A aortic dissection is to achieve hemostasis of the anastomosis. Furthermore, the possibility of improving the suture with additional stitches is often technically demanding. We, therefore, describe a new surgical technique for the proximal anastomosis, positioning the prosthesis within the left ventricle. We present our series of 6 patients treated with this new technique. The immediate results confirmed the efficacy, speed, and simplicity of the technique. During long-term follow-up no patient showed significant residual aortic valve incompetence.

Acute Disease↗
PubMed2006

Clinical presentation is the main predictor of in-hospital death for patients with acute type A aortic dissection admitted for surgical treatment: a 25 years experience.

BACKGROUND: This retrospective analysis assessed the hypothesis that clinical status on admission more than other variables related to surgical or post-operative management may influence in-hospital mortality after surgical treatment of acute type A aortic dissection. METHODS: Between January 1979 and April 2004, 311 patients, mean age of 59.5+/-13 years (range, 18 to 88 years), with acute type A aortic dissection were referred for surgery. Logistic regression analysis was applied to demographics, etiological, clinical, and surgical variables, to identify independent predictors of in hospital death. RESULTS: In hospital mortality rate was 23%. Univariate analysis showed older age (p=0.03, OR1.02/yrs), cardiac tamponade (p=0.001; OR 2.43), hypotension (p=0.0001; OR 8), myocardial ischemia (p=0.005; OR 7), acute renal failure (p=0.0001; OR 4.16), limb ischemia (p=0.0002; OR 3.3), neurological deficits pre-op (p=0.0001; OR 8.5), and mesenteric ischemia (p=0.003) as independent predictors of in-hospital death. Multivariate analysis identified the following presenting variables as predictors of in-hospital death: hypotension (p=0.003; OR 7.4), myocardial ischemia (p=0.03; OR 5.8), mesenteric ischemia (p=0.009), acute renal failure (p=0.0001; OR 3.9), neurological deficits (p=0.0001; OR 7.7). In-hospital mortality for the group of patients presenting with at least one of the tested pre-operative complications (N=158; 51%) was 33% vs 12% (p=00001). No other variables emerged as significant for in-hospital death. CONCLUSION: In an era of standardized surgical technique, expeditious referral and intervention by lowering preoperative dissection-related complications and co-morbidities might represent the most efficacious tool to improve results.

Acute Disease↗
PubMed1995

Aortic dissection in a healthy 32-year-old man without risk factors.

We report the case of a 32-year-old male who presented to the emergency department with left-sided chest pain associated with burning epigastric discomfort and radiation to the back. Similar symptoms had prompted his visit to another emergency department 1 week earlier. He was discharged from that institution after a negative upper gastrointestinal series. In our emergency department a transoesophageal echocardiograph raised suspicion of a dissection of the thoracic aorta, which was later confirmed by a contrast chest computed tomography scan. The patient was admitted to the intensive care unit but refused surgical intervention at the time of admission. A detailed history failed to uncover any known risk factors for this disease entity. Aortic dissection is rarely seen in young, healthy individuals. Atypical clinical representations are reviewed. The emergency department work-up of aortic dissection is discussed.

Adult↗
PubMed2002

Endoluminal stent graft repair for acute and chronic type B aortic dissection and atherosclerotic aneurysm of the thoracic aorta: an interdisciplinary task.

OBJECTIVE: Endoluminal thoracic aortic stenting is a new therapeutic tool in reducing the operative trauma of the patient. However, the inherent risks of aortic stent grafting are perivascular leakage, stent dislocation, blunt rupture of the aorta, side branch occlusion and neurological sequelae. To reduce these risks, in our institution all stent implantations were performed in close collaboration with our fellow cardiologists under biplane X-ray control supported by simultaneous intravascular and transoesophageal ultrasound imaging. METHODS: Between August 1999 and August 2001, endovascular stent graft repair was performed in 34 patients (27 male, seven female) with a mean age of 68.6+/-7 years (range 58-84). Indication for treatment was an acute Type B aortic dissection in six patients (18%), a symptomatic chronic Type B dissection in 12 patients (35%), a true aneurysm of the descending aorta in seven patients (21%) and an atherosclerotic contained rupture of the descending aorta in nine (26%) patients. Out of six acute type B dissections three patients (8.8%) and one patient (2.9%) out of the chronic dissection group were in severe haemorrhagic shock, ventilated and required high-dose adrenergic support. The others (30 patients, 88.3%) remained symptomatic despite maximum medical treatment. In a special case a combined surgical and endoluminal stent graft repair was performed. Individually manufactured Talent, Medtronic AVE (33), and Gore (1) stents were used. Follow-up examination was performed 1 week after implantation and repeated every 3 months (mean follow-up 8 months, range 1-24). RESULTS: In all patients the aneurysm or the entry of the dissection could be excluded. The observed hospital mortality was 2.9% (one patient). No perivascular leakage, no stent dislocation, no neurological deficit or perfusion impairment was observed. All patients except four were extubated immediately after the procedure and discharged from hospital on postoperative day 2-3. The late procedure-related mortality was 5.8% (two patients) resulting in an overall mortality of 8.8% (three patients). CONCLUSION: Stent graft repair is a safe and feasible treatment option for selected patients, especially in emergency situations, if the aortic lesions can be clearly identified and localized. The use of biplane X-ray control combined with simultaneous intravascular and transoesophageal ultrasound imaging in an interdisciplinary approach enables a more precise targeting of the stent landing zone, resulting in low morbidity and mortality rates.

Acute Disease↗
PubMed2005

Aortic dissection with extension to a patent ductus arteriosus.

An 81-year-old woman presented with shortness of breath and fever of 3 days duration. An enhanced CT of the chest revealed a patent ductus arteriosus (PDA) communicating with the true lumen of an aortic arch dissection. Neither the aortic dissection nor the PDA was suspected. The patient had no history of a connective tissue abnormality or other condition which would predispose to dissection other than systemic hypertension. It is likely that propagation of the aortic dissection partially re-opened the ductus arteriosus.

Aged, 80 and over↗
PubMed2005

Surgical repair and stent positioning for type A acute aortic dissection: a step forward?

We report two cases of type A acute aortic dissection in which the traditional ascending aorta replacement was completed by aortic arch stenting to achieve a complete treatment and to avoid the risks that are connected to aortic arch replacement. Correct deployment of the stent was evaluated through an endoscope inserted in the transverse arch, which avoided fluoroangiography and the involvement of a radiologic team.

Acute Disease↗
PubMed2006

Emergency surgery for acute type a aortic dissection in octogenarians.

BACKGROUND: Emergency surgery for acute type A dissection is associated with a high mortality rate in aged patients. This study was designed to explore perioperative risk factors and prognosis in octogenarians with acute type A aortic dissection. METHODS: Twenty-four octogenarians, of 134 consecutive patients with acute type A dissection between 1995 and 2005 who underwent emergency surgery, were reviewed. The median age was 82 years (80 to 90); the patients were 10 men and 14 women. All 24 patients underwent conservative tear-oriented surgery under deep hypothermic circulatory arrest with cerebral perfusion; the procedures were 23 ascending aortic replacements and one entire arch replacement. RESULTS: The hospital mortality rate was 13% (3 of 24 patients), without statistical significance compared with 6% in patients younger than 80 years. The late mortality rate was 38% (9 of 24 patients), with significance compared with 9% in the other patients. Five- and 10-year survivals ware 55% and 42%, respectively, compared with 83% and 73%, respectively (p = 0.0013), in the other patients. Univariate and multivariate analysis demonstrated that age 80 or greater was not an independent risk factor of hospital death. Risk factors of late death in younger-aged patients were pneumonia and reoperation. CONCLUSIONS: Emergency surgery for octogenarians with acute type A aortic dissection was successfully performed using a conservative intimal tear-oriented procedure, resulting in satisfactory early and late survival. Aggressive surgical treatment is mandatory for improving the outcome of this medical emergency in octogenarians.

Acute Disease↗
PubMed1986

[I.v. DSA in the diagnosis and follow-up of thoracic aortic dissection].

Intravenous DSA was performed in 53 patients with suspected dissection of the thoracic aorta and in 13 patients following surgery for aortic dissection. In 36 patients, the suspected diagnosis could be excluded definitely and, in 14 cases out of 17, a dissection was correctly diagnosed. All 11 type B dissections were correctly diagnosed. Of six type A dissections, only three were adequately demonstrated by IV DSA. In type B dissections, IV DSA is reliable, but in type A dissection with massive aortic insufficiency or pericardial tamponade the findings are not reliable. In all 13 patients who had surgery for dissection, IV DSA proved suitable for showing the anastomosis and progress of the disease.

Aortic Dissection↗
PubMedDate not supplied

Disseminated intravascular coagulopathy associated with thromboexclusion for dissecting aortic aneurysm.

Disseminated intravascular coagulopathy (DIC) was demonstrated in a patient who underwent surgical thromboexclusion by blood flow reversal for dissecting aortic aneurysm. Large clots in the descending thoracic aorta and extra-anatomic bypass grafting might have been causative factors of the consumption coagulopathy. Low-dose heparin together with fresh-frozen plasma was effective; however, extreme caution should be adopted with such patients to minimize the development of DIC, because the factors responsible for the coagulation abnormalities are not removed in patients who undergo the surgical treatment of thromboexclusion.

Aortic Dissection↗
PubMed1999

Surgery for acute type A aortic dissection: the Hopital Foch experience (1977-1998).

BACKGROUND: In 1977, we proposed the use of gelatin-resorcinol-formol (GRF) biological glue during surgery for acute type A aortic dissection. METHODS: From January 1977 to March 1998, 204 patients (146 men and 58 women) aged from 15 to 79 years (mean 54 +/- 11) underwent emergency operation for type A aortic dissection in our institution. One hundred sixty-five patients (84%) were operated on within 48 h after the onset of symptoms. Twenty-eight patients (13.7%) had Marfan's syndrome. In 43 patients (23%), the aortic valve was replaced either independently (6, 3%) or by means of a composite graft (37, 18.1%). Because of the location of the intimal tear, aortic replacement included the transverse arch in 60 patients (29.4%). RESULTS: Hospital mortality was 21% (39 patients): 25% in patients with arch replacement and 19.4% in patients without arch replacement (ns). One hundred sixty-one patients were discharged and followed from 2 months to 21 years postoperatively (mean 85 +/- 66 months). During this interval, 25 patients (15.5%) required reoperation for a total of 33 reoperations. Seven patients (28%) died at reoperation. Upon univariate analysis, presence of Marfan's syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were risk factors for reoperation. Emergency operation (p < 0.01) and thoracoabdominal replacement (p < 0.04) were risk factors for death at reoperation. The actuarial freedom from reoperation (Kaplan-Meier, confidence interval 95%) is 96.1% (90.9%-98.2%) at 1 year, 87.6% (79.8%-92.7%) at 5 years, 80.9% (70.8%-88.1%) at 10 years, and 66.4% (51.1%-78.9%) at 15 years. A total of 39 patients (24.3%) died during follow-up. The presence of Marfan's syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were risk factors for late mortality. The actuarial late survival including hospital mortality is 71.5% (64.3%-77.8%) at 1 year, 66% (58.3%-73%) at 5 years, 56.4% (47.7%-64.7%) at 10 years, and 46.3% (36.4%-56.5%) at 15 years. CONCLUSIONS: The GRF glue has proven extremely useful during emergency initial surgery for acute type A dissection, making the procedure much easier and safer. As a result of this operative improvement, the use of the GRF glue seems to have had a beneficial influence on late results, but these also depend upon the patient's basic condition.

Adolescent↗
PubMed2006

Definitive diagnosis of descending thoracic aortic dissection by real time/live three-dimensional transthoracic echocardiography.

We describe a patient with descending thoracic aortic dissection in whom three- dimensional transthoracic echocardiography was able to clearly visualize the dissection flap en face as a sheet of tissue, as well as demonstrate a large communication between the true and false lumen in three dimensions, enabling a definitive diagnosis of dissection.

Aortic Dissection↗