Type A aortic dissection developed after type B dissection with the presentation of shoulder pain: A case report

BACKGROUNDAortic dissection (AD) is a life-threatening condition with a high mortality rate without immediate medical attention. Early diagnosis and appropriate treatment are critical in treating patients with AD. In the emergency department, patients with AD commonly present with classic symptoms of unanticipated severe chest or back pain. However, it is worth noting that atypical symptoms of AD are easily misdiagnosed.CASE SUMMARYA 51-year-old woman was first diagnosed with scapulohumeral periarthritis due to left shoulder pain. After careful examination of her previous medical history and contrast-enhanced computed tomography angiography, the patient was diagnosed with a new type A AD after chronic type B dissection in the ascending aorta. The patient was successfully treated with surgical replacement of the dissected aortic arch and remains in good health.CONCLUSIONNew retrograde type A AD after chronic type B dissection is relatively rare. It is worth noting that a physician who has a patient with suspected AD should be vigilant. Both patient medical history and imaging tests are crucial for a more precise diagnosis.     

胸主动脉腔内修复术治疗Stanford B型主动脉夹层的长期疗效

目的 观察胸主动脉腔内修复术(TEVAR)在Stanford B型主动脉夹层治疗中的应用效果及其长期疗效.方法 回顾性选取2016年3月至2019年3月文山州人民医院收治的100例Stand ford B型主动脉夹层患者为观察对象,按照治疗方法不同将其分为对照组(n=50)与治疗组(n=50),对照组予以患者传统开放式...     

Total endovascular repair of an intraoperative stent-graft deployed in the false lumen of Stanford type A aortic dissection: A case report

BACKGROUND A 46-year-old male underwent ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection in 2016.However,an intraoperative stent-graft was deployed in the false lumen inadvertently.This caused severe iatrogenic thoracic and abdominal aortic dissection,and the dissection involved many visceral arteries.CASE SUMMARY The patient had pain in the chest and back for 1 mo.A computed tomography scan showed that the patient had secondary thoracic and abdominal aortic dissection.The ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection were performed 2 years prior.An intraoperative stent-graft was deployed in the false lumen.Endovascular aneurysm repair was performed to address this intractable situation.An occluder was used to occlude the proximal end of the true lumen,and a covered stent was used to direct blood flow back to the true lumen.A three-dimensional printing technique was used in this operation to guide prefenestration.The computed tomography scan at the 1stmo after surgery showed that the thoracic and abdominal aortic dissection was repaired,with all visceral arteries remaining patent.The patient did not develop renal failure or neurological complications after surgery.CONCLUSION The total endovascular repair for false lumen stent-graft implantation was feasible and minimally invasive.Our procedures provided a new solution for stent-graft deployed in the false lumen,and other departments may be inspired by this case when they need to rescue a disastrous stent implantation.     

Risk factors of distal segment aortic enlargement after complicated type B aortic dissection

ObjectivesDistal segment aortic enlargement (DSAE) is a common complication that influences the long-term prognosis of type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). In this study, a multivariate analysis was performed to find potential factors predictive of DSAE.MethodsA single-center retrospective study was performed from 1999 to 2016. Included in the study were complicated TBAD patients who underwent TEVAR with uncovered residual tears. Based on the diameter of the distal segment of the uncovered aorta, we assigned patients to an enlargement group and a non-enlargement group. Data extracted from the medical records included demographic and clinical characteristics and follow-up computed tomography angiography data. The primary endpoints were the all-cause mortality and the presumably aortic-related events that required reintervention during the follow-up period.ResultsFor the 333 patients, all-cause mortality was 38 (11.41%), and 76 (22.82%) patients underwent reintervention. A total of 70 (21.02%) patients experienced DSAE, among them were 2 patients who died of aortic rupture and 58 patients who accepted reintervention. Multivariate analysis reviewed independent risk factors of postoperative DSAE, including current smoking, the residual length of the patent false lumen, the postoperative number of dissection tears in the thoracic aorta and type III aortic arch; as well as protective factors, including the application of a restrictive bare stent (RBS), the length of covered stent in the descending thoracic aorta, and the distance from the residual first tear to the left subclavian artery (LSA).ConclusionDSAE after TEVAR for patients with a complicated TBAD can be influenced by their current smoking habit, the residual length of patent false lumen, the postoperative number of dissection tears in the thoracic aorta and the aortic arch type. Meanwhile, RBS usage, the length of the covered stent in the descending thoracic aorta and the distance from the residual first tear to the LSA could have positive effect on the prognosis.     

Management of acute type B aortic dissections

Introduction: For the last several decades, initial management of Stanford type B aortic dissections (DeBakey IIIa or IIIb) has involved medical therapy aimed at reducing blood pressure and impulse stress (Dp/dT). This concept has been indoctrinated into the medical field but is now being challenged with advancements in endovascular therapies and devices. Although there have been advances in the medical management and intensive care unit care, medical modalities alone may still pose a 25 -50% complication rate to the patients, resulting in some physicians seeking alternative approaches to reduce this risk in certain subsets of these patients.

Areas covered: This review will detail the etiology, classification, diagnosis and evolution in treatment of acute type B dissections. We will also review data from recent trials on thoracic endovascular aortic repair and its role in the management of type B aortic dissections to help determine which patients may benefit from placement of a stent graft.

Expert commentary: As we see new technologies develop and obtain long-term results with TEVAR, the paradigm of management may shift toward a more aggressive operative approach to improve on the longterm mortality of patients with type B aortic dissections.     

Acute type B aortic dissection: update on proper management

This study aims to collect and present all current literature data on the diagnostic and therapeutic management of acute type B aortic dissection. It includes a comprehensive literature search utilizing the following keywords: ‘acute aortic dissection’, ‘type B aortic dissection’, ‘conservative management’, ‘endovascular repair’, ‘open surgery’ and ‘diagnosis’. Uncomplicated acute type B aortic dissection can be effectively managed using conservative management, although open repair is indicated only for complicated cases. Endovascular repair shows promising results in selected patients with increased perioperative risk and without contraindications. Recent evidence supports endovascular repair even in uncomplicated cases, although more data on long-term outcomes are needed. Early risk stratification and evaluation of the patient is crucial for selection of optimal management.     

Thoracic endovascular aortic repair versus open chest surgical repair for patients with type B aortic dissection: a systematic review and meta-analysis

Abstract

Aim: This meta-analysis study aimed to compare the efficacy and safety of TEVAR versus OCSR for TBAD patients.

Methods: We systematically searched PubMed, EmBase, and the Cochrane library to identify studies compared the effectiveness of TEVAR and OCSR in TBAD patients from the inception up to July 2019. The summary results were calculated using a random-effects model.

Results: The electronic search identified 1,894 studies, and 18 studies with 9,664 TBAD patients were included. We noted patients received TEVAR were associated with a reduced risk of in-hospital mortality, acute renal failure, respiratory failure, and bleeding as compared with OCSR, whereas no significant differences between groups for the risk of stroke, myocardial infarction, paraplegia, mesenteric ischaemia/infarction, reinterventions, sepsis, and spinal cord ischaemia.

Conclusions: The findings of this meta-analysis study suggested that TEVAR resulted in more short-term survival benefits. Moreover, the reduced risk of acute renal failure, respiratory failure and bleeding was detected in TEVAR group. The treatment effects of TEVAR versus OCSR on specific complications should be further verified by a study with high-level of evidence.

• Key message

• Comprehensive collected studies investigated the treatment effectiveness between TEVAR and OCSR for TBAD patients

• TEVAR resulted in more survival benefits, in addition to lower risk of acute renal failure, respiratory failure and bleeding

• The results of stratified analyses according to patients’ characteristics were conducted

     

Treatment of Stanford type A aortic dissection with triple pre-fenestration,reduced diameter,and three-dimensional-printing techniques: A case report

BACKGROUNDA 63-year-old female was diagnosed with acute Stanford type A aortic dissection. The patient had pain in the chest and back for 1 wk. The computed tomography angiography (CTA) showed Stanford type A aortic dissection (Myla type III aortic arch). The intimal tear was located at the top of the aortic arch and retrograded to the ascending aorta.CASE SUMMARYPreoperatively, a three-dimensional (3D)-printed model of the aortic arch was made according to CTA data. Then, under the guidance of the 3D-printed aortic model, a pre-fenestrated stent-graft was customized, and the diameter of the stent-graft was reduced intraoperatively by surgeons. 3D printing, triple pre-fenestration, and reduced diameter techniques were used during the surgery. The CTA examinations were performed at the 3^rd mo and 1st year after the surgery; the results showed that the aortic dissection was repaired without endoleak, and all three branches of the aortic arch remained unobstructed.CONCLUSIONApplying the triple pre-fenestration technique for aortic arch lesions was feasible and minimally invasive in our case. The technique provides a new avenue for thoracic endovascular aortic repair of Stanford type A aortic dissection.     

Use of three dimensional-printing in the management of floating aortic thrombus due to occult aortic dissection: A case report

BACKGROUNDFloating thrombus within the thoracic aorta is a rare entity but may cause systemic embolism. The pathogenesis of floating aortic thrombi is not yet fully understood. No definitive guidelines are available for the management of floating aortic thrombus.CASE SUMMARYWe report a 48-year-old patient, without a history of trauma and infection, who presented with sudden severe back pain. A floating thrombus within the aortic arch was found by computed tomography angiography (CTA). No evidence of coagulopathies was found. However, with the assistance of a three dimensional-printed model, this floating thrombus was identified to be caused by occult aortic dissection (AD). Subsequently, an emergency thoracic endovascular repair was performed. The patient’s back pain was rapidly alleviated postoperatively. CTA at 1 year showed no filling defect in the stent-graft and aorta.CONCLUSIONOccult AD is a potential factor causing floating aortic thrombi, endovascular stent-graft exclusion may be an optimal therapeutic choice with promising results. Moreover, the combination of CTA and three dimensional-printed models can contribute to the diagnosis and treatment of floating aortic thrombi due to occult AD.     

Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review

BACKGROUNDAcute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis.CASE SUMMARYA 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient’s muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty.CONCLUSIONClinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences.     

Type A aortic dissection following heart transplantation: A case report

BACKGROUNDCardiac transplantation is considered the standard treatment for refractory end-stage heart failure. Worldwide, 5074 heart transplantations were performed in 2015. About 100 heart transplants are performed at the authors’ center each year. The usual complications of heart transplantation include graft rejection, infection, and graft dysfunction. Aortic dissection after heart transplantation is very rare and is a serious complication that requires a hybrid procedure.CASE SUMMARYA 58-year-old female patient was admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology in July 2020 because of unprovoked low back pain without precipitating causes. Magnetic resonance imaging and computed tomography angiography showed type A aortic dissection with an aberrant right subclavian artery. After admission, urapidil was used to control blood pressure. Ten days later, the patient underwent ascending aortic and aortic arch replacement, subclavian artery reconstruction, and endovascular repair of abdominal and thoracic aortic aneurysms. A cardiopulmonary bypass was established through the right femoral artery and femoral vein. The aberrant right subclavian artery, innominate artery, left common carotid artery, and left subclavian artery were blocked, and the left and right common carotid arteries were cannulated for bilateral cerebral perfusion.CONCLUSIONThe right axillary artery could not be selected for cardiopulmonary bypass intubation because of aberrant right subclavian artery.     

Immediate aortic dissection after transcatheter aortic valve replacement: A case report and review of the literature

‐Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67‐year‐old man with symptomatic severe aortic stenosis after TAVR.‐Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.     

Successful treatment of aortic dissection with pulmonary embolism: A case report

BACKGROUNDAortic dissection (AD) and pulmonary embolism (PE) are both life-threatening disorders. Because of their conflicting treatments, treatment becomes difficult when they occur together, and there is no standard treatment protocol.CASE SUMMARYA 67-year-old man fell down the stairs due to syncope and was brought to our hospital as a confused and irritable patient who was uncooperative during the physical examination. Further examination of the head, chest and abdomen by computed tomography revealed a subdural hemorrhage, multiple rib fractures, a hemopneumothorax and a renal hematoma. He was admitted to the Emergency Intensive Care Unit and given a combination of oxygen therapy, external rib fixation, analgesia and enteral nutrition. The patient regained consciousness after 2 wk but complained of abdominal pain and dyspnea with an arterial partial pressure of oxygen of 8.66 kPa. Computed tomography angiograms confirmed that he had both AD and PE. We subsequently performed only nonsurgical treatment, including nasal high-flow oxygen therapy, nonsteroidal analgesia, amlodipine for blood pressure control, beta-blockers for heart rate control. Eight weeks after admission, the patient improved and was discharged from the hospital.CONCLUSIONPatients with AD should be alerted to the possibility of a combined PE, the development of which may be associated with aortic compression. In patients with type B AD combined with low-risk PE, a nonsurgical, nonanticoagulant treatment regimen may be feasible.     

Combined cesarean delivery and repair of acute aortic dissection at 34 weeks of pregnancy during COVID-19 outbreak: A case report

BACKGROUNDSince the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, the exclusion of a patient from COVID-19 should be performed before surgery. However, patients with type A acute aortic dissection (AAD) during pregnancy can seriously endanger the health of either the mother or fetus that requires emergency surgical treatment without the test for COVID-19. CASE SUMMARYA 38-year-old woman without Marfan syndrome was admitted to the hospital because of chest pain in the 34^th week of gestation. She has diagnosed as having a Stanford type-A AAD involving an aortic arch and descending aorta via aortic computed tomographic angiography. The patient was transferred to the isolated negative pressure operating room in one hour and underwent cesarean delivery and ascending aorta replacement. All medical staff adopted third-level medical protection measures throughout the patient transfer and surgical procedure. After surgery, the patient was transferred to the isolated negative pressure intensive care unit ward. The nucleic acid test and anti-COVID-19 immunoglobulin (Ig) G and IgM were performed and were negative. The patient and infant were discharged without complication nine days later and recovered uneventfully. CONCLUSIONThe results indicated that the procedure that we used is feasible in patients with a combined cesarean delivery and surgery for Stanford type-A AAD during the COVID-19 outbreak, which was mainly attributed to rapid multidisciplinary consultation, collaboration, and quick decision-making.     

Successful management of life-threatening aortoesophageal fistula: A case report and review of the literature

BACKGROUNDAortoesophageal fistula (AEF) is a rare but life-threatening cause of upper gastrointestinal bleeding. Only a handful of cases of successful management of AEF caused by esophageal cancer have been reported. The purpose of this study is to report a case of AEF managed by endovascular aortic repair and review the relevant literature.CASE SUMMARYA 66-year-old man with upper gastroenterology bleeding presented at the Emergency Department of our hospital complaining of chest pain, fever and hematemesis for 6 h. He had vomited 400 mL of bright-red blood and experienced severe chest pain 6 h prior. He had a past medical history of advanced esophageal cancer. He received chemoradiotherapy but stopped 8 mo prior because of intolerance. A chest contrast computed tomographic scan revealed communication between the esophagus and the descending aorta as well as a descending aortic pseudoaneurysm. According to the symptoms and imaging findings, AEF was our primary consideration. The patient underwent aortic angiography, which indicated AEF and descending aortic pseudoaneurysm. Emergency percutaneous thoracic endovascular aortic repair (TEVAR) of the descending aorta was performed, and bleeding was controlled after TEVAR. He received antibiotics and was discharged after treatment. However, he died 2 mo after the TEVAR due to cancer progression.CONCLUSIONAlthough AEF is a lethal condition, timely diagnosis and TEVAR may successfully control bleeding.     

Iatrogenic aortic dissection during right transradial intervention in a patient with aberrant right subclavian artery: A case report

BACKGROUNDAberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. When patients having such anomalies receive transradial intervention (TRI), aortic dissection (AD) may occur. Herein, we discuss a case of iatrogenic type B AD occurring during right TRI in an ARSA patient, that was later salvaged by percutaneous angioplasty.CASE SUMMARYA 73-year-old man presented to our hospital with intermittent chest pain. Coronary computed tomography (CT) angiography revealed significant stenosis in the left anterior descending artery. Diagnostic coronary angiography was performed via the right radial artery without difficulty. However, we were unable to advance the guiding catheter past the ostium of the right subclavian artery to the aortic arch for percutaneous coronary intervention, while the guidewire tended to go down the descending aorta. The patient suddenly complained of chest and back pain. Emergent CT aortography revealed type B AD propagating to the left renal artery (RA) with preserved renal perfusion. However, after 2 d, the patient suddenly complained of right lower limb pain where the femoral pulse was suddenly undetectable. Follow-up CT indicated further progression of dissection to the right external iliac artery (EIA) and left RA with limited flow. We performed percutaneous angioplasty of the right EIA and left RA without complications. Follow-up CT aortography at 8 mo showed optimal results.CONCLUSIONA caution is required during right TRI in ARSA to avoid AD. Percutaneous angioplasty can be a treatment option.