A case of Stanford type A acute aortic dissection associated with a distal aortic arch atherosclerotic aneurysm

We report a rare case of Stanford type A acute aortic dissection associated with a distal aortic arch atherosclerotic aneurysm. A 71-year-old female was referred to us with the diagnosis of thrombosed Stanford type A acute aortic dissection, however on the next day transesophageal echocardiography revealed the false lumen has been recanalized. In the operation, there was a distal aortic arch atherosclerotic aneurysm which was unidentified at the preoperation. It is very rare that the dissection originated from atherosclerotic aneurysm and proceeded to proximal and distal portion of the aorta.     

Two cases of annulo-aortic ectasia with type A aortic dissection reconstructed by reimplantation of the aortic valve

We performed aortic valve sparing operation in two cases of annulo-aortic ectasia combined with Type A aortic dissection. Marfan syndrome was found in one case and the dissection was acutely evolving in another case. The aortic valves were observed as normal configuration in both cases and then reimplanted within the synthetic grafts along with the David's procedure. No aortic regurgitation was found in the acute case but slight regurgitation was checked out in the Marfan case at the discharge. The aortic valve preserving operation for annulo-aortic ectasia was considered much effective in cases with aortic dissection in order to expect the thrombolization in the pseudo lumen.     

An early recrudescent case of Stanford type A closing aortic dissection

A 81-year-old female was hospitalized with chest discomfort. Findings of CT scan revealed Stanford type A acute aortic dissection, but the dissecting lumen had already closed with thrombus. Aortogram showed no intimal tear, intimal flap or ulcer like projection. Under the diagnosis of "closing aortic dissection", conservative treatment was selected. The dissecting lumen was disappearing gradually, but she had a sudden chest pain on hospital day 4 and CT scan demonstrated an enlarged and enhanced dissecting lumen. She underwent an emergency operation and a hemiarch replacement was performed successfully. Her postoperative course was uneventful and she was discharged from the hospital in good health.     

A surgical case of acute three-channeled aortic dissection in Marfan syndrome

We surgically treated a 35-year-old male with acute 3-channeled aortic dissection in Marfan syndrome. He had acute type A aortic dissection, and underwent Bentall's type operation, simultaneous graft replacement of the ascending aorta and total aortic arch. Pain recurred 5 years and 9 months after the first operation. CT scan showed two adjacent false lumens in the descending aorta. The morphology of the first and second dissections was Stanford type A + B. The second dissection was acute. In the second false lumen, a re-entry formation was observed in the abdominal aorta. Because severe pain was persistent, we immediately replaced the descending aorta using a femoro-femoral partial cardiopulmonary bypass. The patient was doing well and was discharged. When pain recurs in a Marfan patient with an aortic dissection, a 3-channeled aortic dissection should be suspected, and we recommend emergency surgery.     

Open distal anastomosis in retrograde cerebral perfusion for repair of ascending aortic dissection

BACKGROUND: In patients with aortic dissection, a patent distal false lumen at long-term follow-up leads to complications. We investigated the feasibility of performing an open distal anastomosis using retrograde cerebral perfusion. METHODS: Over a 10-year period, 41 patients with acute type A aortic dissection underwent 43 surgical repairs. In 1991, an open distal anastomosis using retrograde cerebral perfusion (group 2) was introduced to replace the standard aortic cross-clamp method (group 1). The mean retrograde cerebral perfusion time was 47.3 minutes (range, 22 to 67 minutes), and there were no neurologic sequelae in surviving patients. RESULTS: The operative mortality rate was 18.5% in group 1 and 18.7% in group 2. At long-term follow-up, dilatation of the false lumen (more than 50 mm in diameter) occurred in 9 of 18 patients (50%) in group 1, and 2 patients died of aortic rupture. There were no deaths in group 2, and dilatation of the distal false lumen occurred in only 15.4% of patients (p < 0.05). CONCLUSIONS: The use of retrograde cerebral perfusion in patients with acute aortic dissection provides adequate time to perform a safe, open, distal anastomosis, and could decrease significantly the rate of enlarged, patent, false lumina.     

Right ventricular obstruction in aortic dissection: a mechanism of hemodynamic collapse

The main and right pulmonary arteries may be compressed by the false lumen of a type I aortic dissection. We report a 73-year-old women with a dissection of the aorta in whom echocardiographic examination revealed acute pulmonary arterial compression causing right ventricular failure and hemodynamic collapse.     

Echocardiographic oscillating flap in aortic root dissecting aneurysm

A patient had a history, physical findings, and chest x-ray film suggesting type I aortic dissection. This diagnosis could not be confirmed angiographically. Echocardiographic studies predicted both the presence of dissection and the anatomic findings at surgery. A regularly oscillating echo corresponding to the intimal flap was found in the false lumen. This is suggested as a new echocardiographic finding in dissecting aneurysm.     

Abdominal aortic resection in thoracic dissection

Dissection nearly always begins in the thorax, but it commonly extends into the abdominal aorta, which may become the focal point of the disease. We report five patients who illustrate the surgical management of this disease variant. Clinical manifestations included retroperitoneal rupture, expanding false aneurysm, and lower aortic occlusion. All patients had an aortic bifurcation graft, with reentry of the false lumen at the renal level. Two patients also had thoracic-aortic resection or plasty or both. Although one patient had thoracic aortic rupture at the five-year interval, these abdominal aortic resections provided effective palliation in all. This successful experience in managing complex dissections shows that when aortic dissection extends into the abdomen, resection of the distal aorta with a reentry procedure may be appropriate therapy.     

Extrinsic compression of the left atrium as an infrequent and fatal form of type B aortic dissection: value of ECG]

We present an infrequent case of extrinsic compression of the left atrium caused by a type B aortic dissection diagnosed by echocardiography. The transthoracic echocardiography showed the obliteration of the left atrium by a heterogeneous mass with two circular images of low echogenicity. The TEE study identified the mass as a huge hematoma surrounding the true and false lumen of the aneurysm. The case demonstrated the value of echocardiography in the diagnosis of type B aortic dissection.     

Preliminary clinical results of surgery for type A acute aortic dissections using gelatin-resorcin-formaldehyde glue

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.     

Aortic infarction following dissecting aortic aneurysm

Aortic infarction was observed in 21 of 34 cases of dissecting aortic aneurysm. This lesion occurred as a central zone of necrosis with preserved elastic laminae, sparing media adjacent to the true and false lumens. In cases where the false lumen was occluded, the central infarction extended to this lumen. The infarction followed rather than preceded dissection, took approximately 48 hours to develop, and did not organize with time. The lesion occurred exclusively in the thoracic aorta, and bore no relationship to medial cystic necrosis. Present surgical therapy does not extirpate these areas, and the implication of these lesions in terms of management remains to be determined.     

Thoracic aortic dissection: diagnosis with transesophageal echocardiography versus MR imaging

PURPOSE: To compare transesophageal echocardiography (TEE) and magnetic resonance (MR) imaging in the diagnosis of dissection of the thoracic aorta. MATERIALS AND METHODS: Thirty-one consecutive patients with clinically suspected aortic dissection and 10 postoperative patients underwent transesophageal color Doppler echocardiography and MR imaging. Imaging results were compared at independent double-blind readings. Final diagnosis was obtained from consensual review of all corroborative studies. RESULTS: MR imaging depicted the intimal flap in 95% of aortic dissections; TEE, in 86% (P < .05). In surgical patients, the sensitivity of MR in detection of residual dissection was 100% versus 86% with TEE (P < .05). The inferior extent of the dissected lumen was seen only with MR imaging. False-positive results occurred in two cases with TEE and in one with MR imaging. CONCLUSION: MR imaging is superior to TEE in the evaluation and follow-up of dissection of the thoracic aorta. Because the availability of MR is limited, however, TEE should remain the standard modality for diagnosis.     

Surgical repair of a dissecting aortic aneurysm with entry at proximal descending aorta through left thoracotomy--a case report

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.     

Percutaneous creation of acute type-B aortic dissection: an experimental model for endoluminal therapy

PURPOSE: To evaluate the feasibility of a percutaneously created type-B aortic dissection as an experimental model for percutaneous therapy. This model was used to evaluate the hemodynamic effects of single-balloon fenestration of the intimal flap. MATERIALS AND METHODS: Acute type-B dissections were created in descending aortae of 15 swine via a femoral (n = 6) or carotid (n = 9) approach. The initial subintimal tear was made with use of a Colapinto needle. The dissections were extended to a predefined position in the aorta. The proximal and distal tears were balloon dilated. The mural flap was balloon fenestrated in six animals, just above the celiac artery. Aortograms were obtained to establish the presence and extent of the dissection. Manometry was performed in both lumina to evaluate the hemodynamics of the dissected aorta and the effects of balloon fenestration in this model. Pathologic specimens were also examined. RESULTS: Creation of dissection was successful in 11 of 15 animals, with six developing true lumen narrowing (group A). The other five animals (group B) had flow in both lumina without evidence of true lumen narrowing. After the creation of a single-balloon fenestration in the group A swine, the arteriograms revealed no evidence of blood admixture between the true and false lumina, and there was no change in the intravascular pressures. Examination of the explanted aortae showed a more extensive circumferential dissection in group A animals as compared with group B. CONCLUSION: The percutaneously created acute type-B aortic dissection is a feasible model for experimentation. The hemodynamics of the aorta did not change after single-balloon fenestration in this model.     

Reproducibility of bone height measurements made on serial radiographs

A seventy-three-year-old woman had symptoms of aortic dissection. Initial computed tomographic (CT) scan and angiography showed an extensive intramural hematoma (IMH) of the aortic segment from the ascending aorta to the bulk of the descending aorta without intimal tear or false lumen. Two weeks later the patient's symptoms recurred. A repeat CT demonstrated a classic type A aortic dissection with a false lumen and an intimal defect. The patient underwent a successful hemiarch repair with use of selective cerebral perfusion under profound hypothermic circulatory arrest. This case suggests extensive IMH as an important underlying pathology of the aortic dissection.     

Rupture of an abdominal aortic aneurysm following acute descending thoracic aortic dissection. Case report

The coexistence of an abdominal aortic aneurysm and an acute aortic dissection seems to be rare and only a few reports are to be found in the literature. We report a case of a patient with acute aortic dissection of the descending thoracic aorta that caused rupture of a pre-existing abdominal aortic aneurysm. The literature is also thoroughly reviewed.     

Repair of the aortic arch with fibrin glue in type A aortic dissection

Location of the intimal tear in the aortic arch in type A aortic dissection is for many authors an indication for replacement of the aortic arch, but this operation has a high in-hospital mortality rate: 20% to 40%. Instead, we suggest repairing the aortic arch by injecting fibrin glue, which contains a human sealer protein concentrate, between the two dissected layers under circulatory arrest while replacing the ascending aorta. To evaluate this technique, we reviewed 45 successive patients operated on for type A acute aortic dissection between January 1989 and July 1993, of which 6 had the intimal tear located on or extending into the aortic arch. Mean age was 71 +/- 4.2 years (range 68 to 74). After proximal supracoronary anastomosis with a collagen-impregnated graft, aortic arch repair was achieved by injecting fibrin glue between the two layers, using circulatory arrest at a mean temperature of 22 degrees C, with a mean duration of 24 minutes. This obliterated the dissection in the arch and also the intimal flap. The distal part of the graft was then anastomosed to the proximal portion of the aortic arch at the origin of the innominate artery under circulatory arrest. There were no early or late deaths. All patients were asymptomatic at a mean follow-up of 2.6 years. Follow-up angioscan showed obliteration of the dissection in the aortic arch in all patients; there were two patients with dilatation of the distal aortic arch of 40 and 45 mm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute aortic dissection complicating pregnancy

BACKGROUND: Acute aortic dissection occurring during pregnancy represents a lethal risk to both the mother and fetus. Our purpose was to study the prevalence, treatments, and outcome of this rare problem and to suggest therapeutic guidelines. METHODS: During the past 12 years, 6 pregnant women were admitted with an acute aortic dissection. Four had a type A and 2 had a type B dissection (Stanford classification). RESULTS: Two of the 4 patients with a type A dissection underwent a combined emergency operation consisting of first cesarean section and then ascending aortic repair. Cesarean section was carried out 5 days after the emergency procedure on the aorta in the third patient, and 16 weeks later in the fourth patient. All 4 fetuses were delivered alive. One fetus died 6 days later, but the other 3 are alive and well at long-term follow-up. Of the 2 patients with a type B dissection, 1 was operated on for celiac ischemia; the other was treated medically. In both cases the fetus died in utero. There were no maternal deaths in either group. CONCLUSIONS: Cesarean section with concomitant aortic repair is recommended for pregnant women with a type A dissection, depending on the gestational age. The maternal hemodynamic status will determine the sequence of the two procedures. Medical treatment is advised for patients with a type B dissection, but surgical repair is indicated if complications such as bleeding or malperfusion of major side branches occur.     

Acute aortic dissection and ventricular septal defect repair

A 37-year-old male with long-standing heart murmur and ventricular septal defect developed acute chest pain and was diagnosed with an aortic dissection and aortic insufficiency. The ventricular septal defect and aortic dissection were repaired successfully as a combined procedure. At late follow-up (three years), he continued to enjoy an excellent result.     

A case of aortic dissection after the termination of cardiopulmonary bypass

We report, a case of aortic dissection after the termination of cardiopulmonary bypass (CPB), which was diagnosed by transesophageal echocardiography (TEE). A 70-year old male with aortic regurgitation received aortic valve replacement. After the termination of CPB, the aortic dissection was diagnosed by TEE. Furthermore wall motion abnormality was found by TEE, and aorto-coronary bypass was performed after observation by TEE. This case report suggests that TEE is useful not only for diagnosis but also for therapeutic orientation of aortic dissection.