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Helical (spiral) CT in the evaluation of emergent thoracic aortic syndromes. Traumatic aortic rupture, aortic aneurysm, aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer.

For the near future, CT will play the critical and dominant role in the evaluation of patients presenting with emergent aortic syndromes. Its convenience, accuracy, and utility in the rapid evaluation of not just the aorta, but the entire thorax, make it ideally suited for use in emergency settings. Further benefits are likely to be realized in speed and resolution with multislice CT, although it is as yet not widely available.

Aorta, Thoracic↗

Aortic rupture and aortic smooth muscle tumors in mice. Induction by p-hydrazinobenzoic acid hydrochloride of the cultivated mushroom Agaricus bisporus.

p-Hydrazinobenzoic acid (HBA), an ingredient of the cultivated mushroom Agaricus bisporus, was given in hydrochloride form at a dosage of 0.125% in drinking water for life to randomly bred Swiss mice. Previous studies had demonstrated that either synthetic or naturally occurring hydrazines are carcinogenic in mice with the main tumors so-induced being peripheral angiomas and angiosarcomas. As a result of HBA treatment in the present experiments, smooth muscle cell tumors of the aorta and large arteries were induced in 14% of females and 42% of males, whereas the corresponding frequency of tumors in untreated female and male controls was 0 and 4%, respectively. Tumors were observed as early as at 17 weeks of age. Numerous experimental animals (32% of females and 50% of males) died of aortic rupture. Histopathologically, two major changes were observed to explain both the ruptures and tumors. First, the intimal and inner medial aspect of the aortic walls had undergone effacement with widespread fibrinoid necrosis, accompanied by medial elastinolysis. Second, a proliferation of cells arising in the media, benign in some aortae and frankly malignant in others, was strikingly positive by immunohistochemistry for cytoplasmic actin and myosin, moderately positive for desmin, weakly positive for vimentin, and negative for factor VIII-related antigen. When malignant, the tumors extended into the periaortic adventitial connective tissue. The tumors were classifiable as leiomyomas and leiomyosarcomas. Thus, HBA is an additional carcinogenic ingredient of the widely consumed mushroom, A. bisporus. A continuum from toxic tissue injury to cellular hyperplasia, dysplasia, and ultimate neoplasia is well-illustrated by HBA.

Agaricus↗

[Diagnosis and therapy of acute traumatic aortic rupture].

Aortic transection is defined as complete or partial dehiscence of the aortic wall layers. Aortic transections are seen in 16% of all lethal traffic accidents. The quality of the first emergency care outside hospital and the organization of rescue systems result in an increasing number of patients (espec. with life-threatening multiple injuries incl. atypical aortic lesions) reaching a trauma-center. Guide-lines for surgical indications are: 1. emergency-operation in case of symptomatic transection incl. simultaneous surgery of concommitant lesions. 2. Urgent operation following primary hemodynamic stabilisation in cases of isolated or asymptomatic transection. 3. In cases of concommitant lesions with surgical priority, delayed operation of asymptomatic transection. The perioperative letality claims up to 20%. Next of operative complication paraplegia remains the most deleterious problem. Despite different methods of protection on the spinal cord the incidence of paraplegia persists in the range of 5-10%.

Aorta, Thoracic↗

Pelvic fracture as an indicator of increased risk of thoracic aortic rupture.

Thoracic aortic rupture is a lethal injury associated with severe blunt trauma. Survival is directly related to early diagnosis and operative treatment. Establishing the diagnosis requires a high index of suspicion, recognition of radiologic evidence of mediastinal bleeding, and identification of injuries frequently associated with aortic rupture. A retrospective review of blunt trauma patients at the Washington Hospital Center Trauma Unit and data from the Major Trauma Outcome Study identified a two- to fivefold increase in the incidence of aortic injury among patients with pelvic fracture. Twenty to forty-five per cent of patients with aortic rupture had associated pelvic fracture. Our study documents that pelvic fracture is as reliable an indicator of associated aortic rupture as many currently accepted injuries. Its presence should raise suspicion for aortic injury.

Aorta, Thoracic↗

Percutaneous aortic stent placement for life threatening aortic rupture due to metastatic germ cell tumor.

Patients with testicular carcinoma frequently present with advanced disease and symptoms resulting from metastatic lesions. We report an unusual case of successful emergency management of a massive rupturing aortic pseudoaneurysm midway through systemic chemotherapy for stage III germ cell tumor by percutaneous trans-luminal placement of an aortic bypass stent-graft. Unstable hemorrhage was controlled, allowing our patient to complete chemotherapy and undergo elective retroperitoneal lymph node dissection with resection of the pseudoaneurysm and residual disease after normalization of tumor markers. Final pathological evaluation revealed only fibrosis in the resected tissue. Followup angiography demonstrated a patent stent-graft and the patient was without evidence of disease 1 year after retroperitoneal lymph node dissection.

Adult↗

[Abdominal aortic rupture].

Abdominal aortic rupture is sometimes paroxystic. More often, the rupture process takes hours, even days. Surgical efficiency is dependant on an early diagnosis.

Aneurysm, Ruptured↗

Acute hypertension: its significance in traumatic aortic rupture.

Traumatic aortic rupture is a common occurrence associated with 16 percent of deaths from automobile accidents. Through a review of current literature and two recent cases from The Milton S. Hershey Medical Center, we have attempted to elucidate a common physical finding, acute hypertension associated with blunt chest trauma, and prove its significance as a diagnostic clue to traumatic rupture of the aorta. New laboratory findings of an aortic sympathetic reflex stimulated by stretching the aortic wall in the area of the isthmus provides a physiological explanation for the cause of hypertension after aortic trauma.

Accidents, Traffic↗

Endovascular treatment of aortic rupture during angioplasty for aortic in-stent restenosis in aortoarteritis.

Aortic rupture during balloon angioplasty for in-stent restenosis without attempting to overexpand it is a rarity. We report a case of a young woman with aortoarteritis who had aortic rupture during angioplasty for in-stent restenosis. The balloon used was of the same diameter as the previously implanted stent and was completely within the stent during inflation. The disruption was successfully treated by percutaneous placement of a self-expandable endovascular stent graft.

Adult↗

Nonheparinized partial cardiopulmonary bypass for repair of traumatic aortic rupture.

Traumatic aortic rupture requires rapid, definitive repair for optimal outcome, particularly with respect to distal neurologic function. Over the past 10 years, the R Adams Cowley Shock Trauma Center of the University of Maryland has used partial cardiopulmonary bypass without systemic heparization exclusively for all repairs of the descending aorta. A heparin-bonded circuit allows for controlled distal perfusion and obviates the need for heparinization. Excellent outcome with minimal morbidity has been achieved using this technique. Our protocol and perfusion apparatus are discussed within.

Aorta, Thoracic↗

[Endovascular stent-grafting of ruptured aortic aneurysms].

Ruptured thoracic aortic aneurysms expose the patient to a major risk of death and remain a therapeutic challenge. Hemorrhage control and prevention of fatal bleeding are primary treatment goals in this medical emergency. Early postoperative mortality of surgically treated patients is estimated to be still high. An increasing number of reports on successful endovascular treatment of the ruptured thoracic aortic aneurysms by endovascular stent-grafting have been published, and they provide better early results. Since 2002, 59 patients with thoracic aortic aneurysms have been treated with the endovascular technique using stent-graft in our institute. Initial success of stent-grafting, which means exclusion of the aneurysms without endoleak, were achieved in 98.3%. Treatment using stent-grafting for ruptured thoracic aortic aneurysms (13/ 59) also presented satisfactory early outcome. Endovascular stent-grafting is a low invasive and useful treatment for ruptured thoracic aortic aneurysms, and is strongly recommended if the aneurysms are morphologically susceptible.

Adult↗

[Rational diagnosis of traumatic aortic rupture].

The traumatic aortic rupture has an extremely high spontaneous mortality rate. Important for surviving the trauma is a fast and efficient diagnostic procedure. The suspected diagnosis results from relatively typical criteria in the chest radiograph, especially the continuous widening of the mediastinum. The diagnostic procedure of 26 patients with polytrauma, abnormal chest radiograph and further examinations (intra-arterial digital subtraction angiography [i.a.DSA]: n = 10, contrast-enhanced CT: n = 19, CT and DSA: n = 5) was reviewed. Six patients had an aortic rupture. In 4 patients the diagnosis was confirmed by angiography, in 2 patients by surgery. The specificity was 100% for DSA and 40% for CT. To ensure the suspected diagnosis of a traumatic aortic rupture we therefore primarily recommend angiography. Whenever CT is performed in case of head injury, a CT of the thorax can be added in order to exclude mediastinal bleeding and to reduce the need for angiography.

Adolescent↗

The role of intravascular ultrasound in acute traumatic aortic rupture.

Acute traumatic aortic rupture is a lethal injury and requires immediate diagnosis and surgical repair. The standard of diagnosis for aortic rupture is aortography. In patients in whom the angiographic findings of rupture are subtle or uncertain, intravascular ultrasound (IVUS) imaging of the descending aorta has been useful in confirming or excluding mural injury. However, because IVUS is unable to provide a complete and expeditious survey of the aorta and brachiocephalic arteries, the diagnosis of rupture will continue to rely on aortography or current generation computed tomography.

Acute Disease↗

Little impact of elective surgery on the incidence and mortality of ruptured aortic aneurysms.

Rupture of an abdominal aortic aneurysm is an important cause of death, particularly for men over 60 years of age. The aim of elective surgery for abdominal aortic aneurysms is to prevent future death from rupture of the aneurysm. The present study examines the influence of elective surgery upon the rate of rupture, comparing 1980 when little elective surgery was done and 1989 when considerably more elective surgery was performed in a well defined population. The rate of rupture and death from such a cause was not affected by the increased number of elective operations. It is concluded that the number of operations generally performed is too small to significantly affect the mortality from rupture. In order to decrease this mortality patients with a high risk of rupture should be found and offered elective surgery.

Age Distribution↗

[Endovascular therapy of non-aneurysmatic infrarenal aortic rupture].

INTRODUCTION: Endovascular therapy is being used increasingly also to treat ruptured infrarenal aortic aneurysms. Non-traumatic rupture of non-aneurysmatic infrarenal aorta is an absolute rarity. METHODS: The feasibility of endovascular repair of infrarenal aortic rupture is demonstrated with a case history and a literature review. RESULTS: A 58-year-old male developed spontaneous rupture of his infrarenal aorta after successful chemotherapy resulting in regression of a periaortic tumor. The patient suffered from a sepsis for several days before aortic rupture was discovered during computed tomography for focus search. Immediate endovascular stent-graft repair was performed under emergency conditions. There is no recurrence and the patient is doing well with the stent-graft in place without any pathological finding after a follow-up of 24 months. So far only three further cases have been reported of endovascular repair for penetrating atherosclerotic ulcer with rupture of the infrarenal aorta. DISCUSSION: This is the first report of endovascular repair of aortic rupture due to successful chemotherapy of a periaortic mesothelioma. Furthermore, this is the fourth case of successful stent-graft placement to treat non-aneurysmatic rupture of the infrarenal aorta. Minimally invasive endovascular therapy should become a standard treatment option for aortic rupture.

Angioplasty, Balloon↗

Emergency stent graft deployment for acute aortic rupture following primary stenting for aortic coarctation.

We present a case of endovascular stenting for aortic recoarctation complicated by acute aortic rupture, which was successfully treated by emergency stent graft deployment. This case illustrates the potential serious complication that can occur during aortic stent dilatation and how the prompt deployment of a stent graft helped to change the clinical outcome of this life-threatening situation.

Acute Disease↗

Endovascular repair of aortic rupture.

OBJECTIVES: To report a single centre experience with endovascular repair of ruptures of the descending thoracic and abdominal aorta. DESIGN: Retrospective non-randomised study in a university hospital. MATERIAL AND METHODS: Between February 1997 and October 2002, endovascular repair of the aorta was performed on 125 occasions. In 20 cases, this was done as an emergency (nine ruptured infrarenal aortic aneurysms and 11 descending thoracic aortic ruptures). All patients underwent spiral computed tomographic angiography to assess the feasibility of endovascular repair and the size of the endoprosthesis. RESULTS: Endovascular repair was successfully completed in all patients. Primary conversion to open repair was not necessary. Postoperative 30-day mortality was 5/20 (25%). There were major complications in 12/20 patients. No ruptures of the aneurysms occurred postoperatively. No primary endoleaks occurred, but in 4/20 (20%) secondary surgical interventions were required after a median follow-up of 12 months (range 1-42 months). CONCLUSION: Our early experience shows the feasibility of this technique with early results that compare favourably to those of emergency open repair. Further studies are required to assess the long-term efficacy.

Adult↗