Temporary perfusion for mesenteric ischemia with acute type A aortic dissection

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.     

A型主动脉夹层术后并发急性肠系膜上动脉缺血患者的护理

总结1例A型主动脉夹层术后并发急性肠系膜上动脉缺血患者的护理经验。护理要点包括：肠道坏死征象的早期识别与监测、安全转运、分阶段营养支持、谵妄护理、造口渗漏护理、心理支持及出院指导等。患者于入院后25 d病情平稳出院,随访6个月,恢复良好。     

Two-staged repair for an acute type A aortic dissection with visceral ischemia after an aortic valve replacement

There is the consensus that patients with an acute type A aortic dissection (AADA) should undergo urgent surgical treatment. However, we dared to select a two-staged repair in order to relieve the visceral ischemia first. In addition, we selected revascularization using a bypass graft without using a proximal aortic replacement or aortic fenestration, because the reason for the occlusion of the SMA was judged to be an extension of the dissection out along the proximal segment of the SMA. Consequently, we proposed that a two-staged repair of the AADA with visceral ischemia was a useful option.     

Early superior mesenteric artery revascularization for acute type A aortic dissection with cardiac tamponade and mesenteric malperfusion

We report herein the successful treatment of a case of acute type A aortic dissection complicated by cardiac tamponade and mesenteric malperfusion. The patient was a 60-year-old man with back and abdominal pain and in shock, who was transported to our hospital 2 h after symptom onset. Computed tomography revealed DeBakey type I dissection with massive hemopericardium and obstruction of both the celiac artery and superior mesenteric artery. After emergency pericardiotomy and removal of the hematoma, superior mesenteric artery-external iliac artery bypass was constructed with a vein graft, and this restored mesenteric perfusion. Open distal hemiarch replacement was then performed. The postoperative course was uneventful. Superior mesenteric artery revascularization achieved immediately after release of the cardiac tamponade prevented further mesenteric ischemia and paved the way for the aortic repair.     

Treatment strategy for acute type A aortic dissection; how to manage mesenteric ischemia

Mesenteric ischemia is a dreaded complication of acute type A aortic dissection. From January 1994 to December 2004, 134 patients with acute type A aortic dissection were operated. Eleven patients showed postoperative mesenteric ischemia. Mortality of such patients was much higher than that without mesenteric ischemia (81.8 vs. 10.6% , p < 0.0001). Preoperative mesenteric and/or lower extremity ischemia were revealed to be the risk factors of postoperative mesenteric ischemia. Our strategy to manage these patients is as follows; patients who are suffering mesenteric and/or lower extremity ischemia preoperatively, or those whose computed tomography (CT) shows stenosis, obstruction, or dissection of the superior mesenteric artery, should be recognized as high-risk patients of postoperative mesenteric ischemia. Their mesenteric circulation should be examined directly with laparotomy after the central repair. If the mesenteric circulation seems to be suboptimal, iliac artery-superior mesenteric artery bypass should be performed.     

Preoperative fenestration for type A acute aortic dissection with mesenteric malperfusion

We report a case of a 71-year-old man presenting with acute type A aortic dissection and mesenteric ischemia due to extension of the intimal flap to the mesenteric artery. Because of the severity of the abdominal symptoms, surgical correction of the ascending aorta was delayed. Preoperative percutaneous fenestration was performed successfully, allowing ascending aortic replacement 6 days later. Transverse colon stenosis secondary to preoperative ischemia occurred in the postoperative course. The patient was discharged from hospital with normal intestinal transit 72 days later.     

Detection of visceral ischemia with doplex scanning method of mesenteric arteries: in patients with acute type B aortic dissection

Between March, 1997 and January, 1999, 11 patients with acute type B aortic dissection underwent doplex scanning evaluation of mesenteric arteries for the early detection of visceral ischemia. Peak systolic velocity (PSV) of the celiac artery (CeA) and superior mesenteric artery (SMA) was measured on their admission. Mean PSV of CeA in the non-ischemic group (8 patients) and in the ischemic group (3 patients) was 1.66 +/- 0.34 m/sec and 3.60 +/- 0.49 m/sec (p = 0.0481), respectively. Mean PSV of the SMA in the non-ischemic group and in the ischemic group was 1.93 +/- 0.52 m/sec and 3.33 +/- 0.37 m/sec (p = 0.00768), respectively. All patients with PSV of the mesenteric arteries above 3.00 m/sec presented visceral ischemia that required emergency operation. If PSV of the mesenteric arteries exceeds 3.00 m/sec, urgent surgical repair should be considered.     

Delayed visceral malperfusion after Bentall procedure for type A acute aortic dissection

Rapid restoration of flow into the true lumen and obliteration of a false lumen is considered the optimal approach to treating malperfusion syndrome due to acute aortic dissection. However, organ malperfusion can occasionally persist after proximal aortic graft replacement despite redirecting blood flow into the true lumen. A 35-year old man underwent the modified Bentall procedure for Stanford type A acute aortic dissection without organ malperfusion. Ischaemia of the visceral and lower extremities developed on postoperative day 8. Enhanced computed tomography (CT) revealed a thrombus in the false lumen interfering with the true lumen above the celiac trunk. We immediately performed a left axillary-to-bilateral femoral artery bypass. The patient recovered uneventfully and was discharged on postoperative day 28. Although organ malperfusion persisting after proximal aortic graft replacement despite redirecting blood flow into the true lumen is rare, close observation remains imperative after central repair of type A dissection.     

Intraoperative endotoxin adsorption for visceral malperfusion complicating acute type A aortic dissection

A 65-year-old man presenting with visceral malperfusion complicating acute type A aortic dissection underwent emergent surgery. Bypass grafting from the right common iliac artery to the superior mesenteric artery was performed prior to central aortic repair because intestinal ischemia caused hemodynamic instability. Subsequently, the ascending aorta was replaced with a Dacron graft under a condition of circulatory arrest with selective cerebral perfusion. Endotoxin adsorption was carried out intraoperatively in parallel with cardiopulmonary bypass to prevent postoperative end-organ failure. The patient recovered uneventfully and was discharged from our hospital 31 days after surgery.     

Successful right common iliac to superior mesenteric artery bypass for mesenteric ischemia associated with acute aortic dissection: Report of a case

Mesenteric ischemia caused by obstruction of the superior mesenteric artery associated with acute aortic dissection was successfully treated by surgery in a 74-year-old man. The vein graft was effectively bypassed between the right common iliac artery and superior mesenteric artery on the day of onset of acute DeBakey type III b aortic dissection. He is currently well 1 year postoperatively on anti-hypertensive therapy.     

Delayed bowel necrosis due to inferior mesenteric artery occlusion in Stanford type A acute aortic dissection

Although inferior mesenteric artery occlusion due to acute aortic dissection sometimes occurs, it is usually not considered an important finding. Herein, we present an extremely rare case of delayed bowel ischaemia due to inferior mesenteric artery occlusion in Stanford type A acute aortic dissection that highlights the need for cardiac surgeons to be mindful of inferior mesenteric artery occlusion in patients with superior mesenteric artery dissection or vascular anomalies in the mesenteric arteries.     

Superior mesenteric artery dissection: case report

Spontaneous dissections of the superior mesenteric artery are exceptional events because only 26 reports have been published. We present a new case, revealed with an acute abdominal syndrome. Computed tomographic angiography and arteriography allowed a rapid diagnosis and urgent surgical intervention. Progress in imagery makes diagnosis and follow-up examination easier. Surgery is indicated for acute symptomatic forms with suspicion of mesenteric ischemia. In the other cases, a simple follow-up examination may be appropriate.     

Treatment of acute type B aortic dissection with organ ischemia

Nine patients, who suffered from acute type B aortic dissection with organ ischemia, were treated at our hospital from 2004 to 2006. Their mean age was 60.3 (range 37-73) years. Eight of them required surgical intervention. Two patients with mesenteric-ischemia underwent superior mesenteric artery (SMA) bypass surgery and their conditions were relieved. However, 1 of them died of aortic rupture 6 months later. One patient with celiac artery occlusion was at first treated nonsurgically, but was subjected to resection of the small intestine 3 weeks later because of ulcer perforation induced by ischemia. The other 5 patients with lower extremity ischemia underwent bypass surgery and were discharged. Bypass surgery is a reliable procedure for the treatment of acute type B aortic dissection with organ ischemia, allowing prompt resolution of ischemia.     

A simple but useful method of screening for mesenteric ischemia secondary to acute aortic dissection

BACKGROUND: In spite of recent improvements in treatment for acute aortic dissection, mesenteric ischemia secondary to aortic dissection is still challenging. We propose a simple screening method to detect mesenteric ischemia secondary to acute aortic dissection. METHODS: From 1991 to 2002, 245 patients with acute aortic dissection were admitted to our hospital. Nine (3.7%) of those were complicated with mesenteric ischemia. The clinical records of those 9 patients were retrospectively analyzed. The ratios of the diameter of the superior mesenteric vein (SMV) to that of the superior mesenteric artery (SMA) were calculated in patients with mesenteric ischemia (group M) and in patients without mesenteric ischemia (group C). Blood test data, including results of arterial blood gas analysis, in the 2 groups were also compared. RESULTS: The SMV/SMA ratios in groups M and C were 1.16 +/- 0.33 and 1.78 +/- 0.29, respectively (P=.003). A cutoff value of the SMV/SMA ratio was 1.5 (sensitivity, 88.9%; specificity, 88.9%) with an odds ratio of 64.0. Although there were differences between the 2 groups in glutamate oxaloacetate transaminase, lactate dehydrogenase, creatine phosphate kinase, pH, and lactate values, the measurement of lactate was especially useful (P=.002). CONCLUSIONS: The combination of the SMV/SMA ratio and lactate concentration is a useful screening method to detect mesenteric ischemia secondary to acute aortic dissection.     

Surgical strategy for acute type A aortic dissection with cerebral ischemia due to acute occlusion of aortic arch branches

In the treatment of acute type A aortic dissection, it is important to cope effectively with cerebral ischemia due to preoperative acute occlusion of arch branches and intraoperative cerebral malperfusion under extracorporeal circulation. The validity of our surgical strategy for such cases was evaluated. Our surgical strategies are as follow; for cases with preoperative cerebral infarction and disturbance of consciousness total aortic arch replacement is performed after the improvement of brain edema, and for cases of transient cerebral ischemia, emergency operation is performed. In the emergency operation, selective cerebral perfusion through the carotid artery of the diseased side is initiated as soon as possible. In conclusion, our surgical strategy for acute type A aortic dissection with cerebral ischemia due to acute occlusion of aortic arch branches is acceptable. There was no significant difference between the cerebral ischemia group and the control group concerning hospital mortality, cerebral complication and the 5-year survival rate.     

Superior mesenteric artery stent fracture leading to recurrent mesenteric ischemia

We report 2 cases of patients with recurrent symptoms of mesenteric ischemic disease after percutaneous transluminal angioplasty (PTA) and stenting due to superior mesenteric artery stent fracture. Both patients were treated by redo PTA and stenting successfully. Stent fractures, their complications, and management are discussed.     

Perioperative diagnosis of mesenteric ischemia in acute aortic dissection by transesophageal echocardiography

Objective: Although computed tomography, angiography, or magnetic resonance imaging is most commonly used for diagnosing mesenteric ischemia caused by acute aortic dissection, use of these modalities is often limited in the perioperative period. Thus, we have introduced transesophageal echocardiography to cover this deficit. Purpose of this study is to report the feasibility and accuracy of transesophageal echocardiographic diagnosis on mesenteric ischemia. Methods: The consecutive 24 cases with acute aortic dissection which involved abdominal aorta and underwent surgery were examined. The celiac artery and superior mesenteric artery was visualized with 5 MHz biplane transesophageal echocardiography and was assessed for presence of dissection and blood flow in each of true and false lumen. The transesophageal echocardiographic findings were then correlated to the clinical course, computed tomographic findings, and laboratory data. Results: The celiac artery and superior mesenteric artery was successfully visualized in 24 cases (100%) and 23 cases (95.8%), respectively. Perfusion patterns in superior mesenteric artery were categorized into four patterns: (1) intact artery with adequate perfusion (type A: 14 cases); (2) dissection in the artery but with adequate perfusion in true lumen (type B: 5 cases); (3) dissection in the artery with narrowed true lumen compressed by false lumen without detectable blood flow (type C: 1 case); and (4) obstruction of arterial orifice by the intimal flap with narrowed true lumen in the proximal aorta (type D: 2 cases). One case with immediate postoperative death and another case with unsuccessful visualization of superior mesenteric artery were excluded from the analysis. Clinically apparent intestinal ischemia was present in three cases: one case with type C and two cases with type D, but in none of the remaining 19 cases with type A or type B (both sensitivity and specificity were 100%). The superior mesenteric artery was opacified in all of these three cases with ischemia. Conclusions: The transesophageal echocardiographic assessment is feasible in nearly all patients and potentially provides correct diagnosis on intestinal ischemia in the perioperative period of acute aortic dissection. Types C and D indicate significant mesenteric malperfusion.     

An endovascular stent relieves celiac and mesenteric ischemia in acute aortic dissection

We report the case of a 63-year-old patient with bowel ischemia related to an acute type B dissection. The patient was successfully treated with a covered stent graft inserted at the level of the descending thoracic aorta.