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We present the case of a middle-aged man who presented with type A aortic dissection, which was resolved spontaneously over 5 weeks time. We also discuss the possible mechanism and the role of conservative management in very selected group of patients.
A 45-year-old man underwent a distal arch and descending aortic replacement through a left thoracotomy. His chronic type A dissecting aortic aneurysm had the entry at the proximal descending aorta. After 9 years of his first dissection, he suffered from a second dissection. In computerized tomogram (CT), the ascending and descending aorta enlarged to 6.0 cm and 7.0 cm in diameter, respectively and descending aorta showed a three channeled dissection. The open proximal anastomosis technique was used under the deep hypothermic circulatory arrest (HCA) followed by selective cerebral perfusion (SCP). Surgical repair included the obliteration of the proximal false lumen at the level between the left carotid and subclavian artery. A thrombosed retrograde dissection in the ascending aorta was revealed in postoperative evaluation, and decreased in size at follow up CT.
A 56 year-old Japanese woman died suddenly after complaining of abdominal pain. Autopsy revealed typical aortic dissection with cardiac tamponade. Histologically, generalized granulomatosis with giant cells resembling sarcoidosis was found. The aorta was most strikingly affected so that granulomatous aortitis was regarded as the cause of the aortic dissection.
We used gelatin-resorcin-form-aldehyde (GRF) glue to fuse the false lumen of type A acute aortic dissection in four patients. All were operated on within 3-24 hours after onset, and gluing of the two cylinders of the dissecting aorta could be done safely in a short time. Initial intimal tears were located in the transverse aorta in three patients and in the proximal descending aorta in one. Simple transection and end-to-end anastomosis of the ascending aorta was done for the first two cases. But in the last two patients, we resected the intimal tear in the transverse aorta and applied GRF glue to the stump of the aortic arch and to that of the aortic root, followed by graft replacement of the ascending aorta. There were no hospital deaths. But we had to reoperate on one patient five months after the first operation due to potentially residual dissection in the aortic root. GRF glue is a very useful adhesive for acute aortic dissection operations, but further refinement of the operative technique using it is necessary.
The finding of a massive unilateral segmental defect with normal ventilation upon lung scanning does not always secure the diagnosis of acute pulmonary embolus. We present a patient whose ventilation-perfusion lung scan suggested a significant embolic phenomenon, but who was subsequently found to have compression of her right pulmonary artery by a dissecting aortic aneurysm. Conditions that present with a unilateral perfusion defect merit further evaluation with pulmonary arteriography.
We experienced a case of acute aortic dissection without an intimal tear. A 55-year-old woman with SLE presented with acute chest pain. TEE study showed dissection of the ascending aorta, and accompanied by pericardial effusion. An emergency operation was performed four hours after onset. Intraoperatively, thrombus was encountered in the false lumen of the ascending aorta and the proximal arch. However, intimal tear was not found. She underwent graft replacement of the ascending aorta and the total aortic arch, and had an uneventful postoperative course. Histological examination of a segment of ascending aorta showed no evidence of mucinous degeneration and pathological rupture of the elastic fiber.
Visceral ischemia is a rare but lethal complication of type III aortic dissection. We report a Marfan patient with such a complication who had a complete resolution of profound visceral ischemia despite a delay in repair of over 48 hours.
The treatment of patients with acute aortic dissection must begin as soon as the diagnosis is first suspected. Aggressive measures to lower the systemic blood pressure and its rate of increase (dP/dt), usually with intravenous beta-blockade in combination with sodium nitroprusside, should be instituted immediately, even before confirmatory imaging studies are performed. Patients with type A dissection are best managed with emergency surgery, whereas patients with type B dissection should be treated medically unless complications intervene. There is a growing experience with catheter-based techniques, including fenestration, stenting, and endoluminal graft insertion, for the management of selected patients with acute dissection. Regardless of the initial treatment strategy adopted, hospital survivors should continue strict antihypertensive therapy, and a schedule of surveillance imaging studies should be established.
Endovascular treatment is becoming the most important treatment modality in the complex management of type B dissection, providing benefits to both acute and chronic patients. Growing technical experience and improving stent-graft devices have resulted in better patient outcome and expanded clinical indications. Nevertheless, similar to any treatment option, this less invasive method has its inherent risks. Several cases of iatrogenic dissection have been reported in the literature, underlying the need for guidelines to minimize this risk and improve procedural safety. Extension of the dissection after endovascular repair of type B dissection does not appear to be device-specific, but related primarily to aortic wall alterations or adverse anatomy that arise most frequently in hypertensive patients or those with challenging aortic configuration. An accurate examination of the aortic wall and dissection anatomy and careful intraprocedural device manipulation and balloon molding may help avoid this potentially life-threatening complication.
A case of acute infrarenal aortic dissection is presented. The diagnosis was confirmed by ultrasonography, CT-scan, arteriography, and at operation. A successful aortobifemoral graft replacement was performed.
We report a case of aorto-iliac occlusion due to descending aortic dissection treated initially with femoro-femoral cross-over bypass and secondarily with unilateral aorto-iliac stenting because of progression of the dissection. A 75-year-old man presented with acute ischemia of the right leg. CT revealed occlusion of the right iliac artery due to descending aortic dissection with a clotted false lumen. Three days after femoro-femoral cross-over bypass, ischemia of both legs developed and angiography demonstrated occlusion of the infrarenal aorta and left common iliac artery. Two overlapping stents were deployed in these vessel segments. Completion angiography confirmed successful recanalization with adequate distal flow and good patency of the cross-over bypass. Peripheral pulses were restored and the patient's symptoms were alleviated. Combined treatment with cross-over bypass and endovascular recanalization may be considered as a viable alternative to open aortic surgery in selected cases of complicated aorto-iliac dissection with bilateral leg ischemia.
The diagnostic value of transoesophageal echocardiography was evaluated in 24 patients with aortic dissection and compared to transthoracic two-dimensional echocardiography, computer tomography, aortography, surgery and autopsy. Using transoesophageal echocardiography we found in 5 patients a type I dissection, in 5 patients a type II and in 14 patients a type III dissection. Transthoracic two-dimensional echocardiography was positive in 3/5 type I, 2/5 in type II and 2/14 in type III dissections. Computer tomography was unable to demonstrate an intimal flap in 1/2 patients with type I, 2/3 type II and 1/11 type III dissections. Aortography was negative in 1/4 type I, 3/5 type II and 3/12 patients with type III dissection. Additional information concerning thrombus formation, localisation of the entry tear, differentiation between true and false lumen, flow dynamics within the true and false lumen as well as accompanying aortic regurgitation may be obtained by transoesophageal echocardiography.
A 78-year-old woman presented to the Emergency Department with spontaneous ecchymosis and swelling of the neck. Ecchymosis was also evident on the posterior pharyngeal wall. A lateral soft tissue radiograph demonstrated a retropharyngeal hematoma, which was confirmed by computed tomography (CT). At this time there was no evidence of airway obstruction and she was admitted for observation. One week after admission she became acutely short of breath, and a chest radiograph at this time showed a large pleural effusion. Pleural drainage confirmed this to be a hemothorax. Subsequent CT revealed a thoracic aortic dissection with blood communicating into both the retropharyngeal space and the pleural cavity. The case highlights both an unusual presentation of thoracic aortic dissection, and also the potential for occult hemorrhage in cases of spontaneous retropharyngeal hematoma.
The usefulness of two dimensional echocardiography in establishing the diagnosis of aortic dissection was evaluated. Forty-two patients were referred for study; 15 had a dissection and 27 did not. Two dimensional echocardiography detected the intimal flap in 12 of 15 patients with a dissection, the three false negative studies were in patients with a localized dissection. There was one false positive study in the 27 patients who did not have a dissection.
In the present study, we report our experience of using three-dimensional reconstruction of transesophageal two-dimensional echocardiographic images in the assessment of aortic dissection (22 patients), aortic rupture (1 patient), aortic aneurysm without dissection (2 patients), and aortic tumor (1 patient).
We report advantages of a temporary mesenteric perfusion method for bowel ischemia with acute type A aortic dissection. The perfusion catheter was inserted from the branch of the superior mesenteric artery. This technique was found to be useful in certain cases that require prompt visceral organ perfusion and proximal aortic repair, which enabled a simultaneous treatment for both lesions and a blood pressure evaluation.
OBJECTIVE: The objective of the present study was to evaluate the outcome of operative treatment for type A aortic dissection during the past 8 year period. PATIENTS AND METHOD: From January 1992 to March 2000, 38 patients (24 men and 14 women) underwent operations for acute (n = 26) and chronic (n = 12) type A aortic dissection. Patient's age ranged from 24 to 82 years (mean age 56 years). Surgical procedures included supracoronary ascending aortic graft for normal sinuses and valve (n = 34) with valve resuspension for commissural detatchment (n = 2), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 1), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 1). Resection was extended into the arch and descending aorta in chronic dissection if there was excessive dilatation of the arch and descending aorta (n = 3). In 28 patients, aortic graft replacement was accomplished by proximal and distal anastomoses during aortic cross-clamping just proximal to the innominate artery. In 10 patients, deep hypothermia and circulatory arrest was used for open distal anastomosis or for arch replacement. Simultaneous coronary artery bypass grafting was performed in 4 patients. Pre-operative risk factors and the condition of the patients were defined and post-operative morbidity and mortality were followed in the early and long term period. RESULTS: There were 2 post-operative deaths (5.2%); one patient died of acute renal failure, the other patient had intra-operative rupture of the heart chamber; both were operated on in the acute phase of dissection. Complications included sternal wound infection in one case, neurological complication in two cases, respiratory problems in three cases, pericardial effusion in one case and post-operative bleeding that required re-operation in five cases. There was no hospital mortality in the group that were operated on in the chronic phase of dissection. Patient follow-up ranged 2 months to 8 years, there were two late mortalities, both, from acute myocardial infarction (at 33 days and 2 years after surgery). Survival rate was 92 per cent and 86 per cent at 30 days and 2 years, respectively. CONCLUSION: The result of repair of type A dissection in both phases was good in our center. The operative mortality was 5.2 per cent. Predictive factors of mortality were pre-operative shock (p=0.021), tamponade (p=0.021) and operation in the acute phase of dissection (p=0.042). In chronic type A dissection, the operative mortality was zero. Coronary artery disease was the most common cause of late deaths. Intermediate term survival in the present series was satisfactory.
OBJECTIVE: In a time when diagnostic methods and above all, surgical as well as interventional radiological treatment for aortic aneurysms and aortic dissections have reached a point nobody could think of a few years back, the present authors feel that it is worth while to remind oneself of the natural course of disease in these conditions. Taking into consideration the high morbidity and mortality rate in surgically treated patients with aortic dissection, and the high complication rate per- and postoperatively, it also seems right to ask if a more expectative and conservative approach to the condition sometimes perhaps may be justified. METHODS AND MATERIAL: Two case reports are given. One was a 15-year-old boy with Stanford (Daily) type B dissection who statistically ought to have a good prognosis, but who died within 2 h after onset of symptoms. The other patient, a middle-aged woman with Stanford type A dissection, survived for 25 years without operation. CONCLUSION: These two cases, though not unique viewed separately, we consider to represent the extremes of the condition and also a natural course of disease, while none of them was operated on.