Rapid progression of discrete type A intramural hematoma: prevention of a "procedure-related" complication by intraoperative transesophageal echocardiography.

PURPOSE: To report a case illustrating the utility of transesophageal echocardiography (TEE) before planned stent-graft placement for chronic type B aortic dissection. CASE REPORT: A 64-year-old man with acute aortic syndrome and an 8-year-old interposition graft in the distal aortic arch for acute type B dissection was referred for dissection of the descending thoracic aorta down to the aortic bifurcation; the false lumen was dilated to 65 mm and was partially thrombosed. The ascending aorta showed discrete, eccentric, 4-mm wall thickening that was not considered clinically significant. Stent-graft closure of the entry tear in the proximal descending thoracic aorta was elected. However, as the endovascular procedure was about to commence, TEE showed striking eccentric thickening of the aortic wall of up to 18 mm. The endovascular procedure was stopped, as it was decided to urgently replace the ascending aorta. The next day, the patient underwent successful ascending aortic replacement and simultaneous antegrade stent-graft implantation over the descending thoracic aortic entry tear via the open aortic arch. The postoperative course was uncomplicated, and the patient was discharged 19 days after surgery. He remains well at 6 months after the procedure. CONCLUSIONS: Our case demonstrates that dissection of the ascending aorta may occur not only due to endograft-induced intimal injury, but may also occur due to underlying but undiagnosed or underestimated disease of the ascending aorta or arch. Besides procedural guidance, intraoperative TEE is a useful tool to detect such disease to avoid subsequent "procedure-related" complications.     

Palliative stent graft placement combined with subsequent open surgery for retrograde ascending dissection intra-thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) is an effective strategy for type B dissection. Retrograde ascending dissection (RAD) intra-TEVAR is a rare complication on clinic. In this case, a 48-year-old Chinese man with Stanford type B aortic dissection suffered acute RAD during the TEVAR. And palliative stent grafts placement was performed in a local hospital, which earned the time for transfer and subsequent total arch replacement surgery in Zhongshan Hospital Fudan University. This report suggests that the palliative strategy may be an option for RAD in some specific situation.     

三分支支架血管在急性A型主动脉夹层全主动脉弓重建术中的应用

目的探讨应用三分支支架血管进行急性A型主动脉夹层全主动脉弓重建的可行性。方法对3例急性A型主动脉夹层需全主动脉弓重建的患者实施术中直视下三分支支架血管置入。当鼻咽温度降至23℃时,停止下半身灌注,于无名动脉近端横断升主动脉,经此切口将三分支支架血管置入主动脉弓和降主动脉真腔内,并将其分支支架血管依次置入左锁骨下动脉、左颈总动脉和无名动脉。将主干支架血管近端与无名动脉近端的升主动脉切口重建后与替换近端升主动脉的人造血管端端吻合。结果3例患者术中顺利地置入三分支支架血管。术后无并发症,均痊愈出院。术后电子束CT检查结果示：主干支架血管及其分支支架血管通畅,三分支支架血管均无扭曲,三分支支架血管置入部位的主动脉夹层假腔闭合。结论应用三分支支架血管直视置入进行急性A型主动脉夹层患者的全主动脉弓重建是可行的。这种方法避免于常规全主动脉弓替换术中的主动脉弓三分支血管吻合和左锁骨下动脉远端较深部位的远端人造血管一降主动脉的吻合,从而简化了全主动脉弓的重建,并提高了手术的安全性。     

Acute aortic dissection and peripheral ischemia. Diagnostic and therapeutic problems. Remote control using nuclear magnetic resonance

This study concerns 7 cases of acute aortic dissection associated with visceral and/or lower limb ischemia. Only those cases are included which raised diagnostic and therapeutic problems. Patients were excluded who had purely angiographic involvement of an aortic branch and minor rapidly resolving ischemic syndromes. Five of the 7 patients presented type B (type III or distal) and 2 type A (type I or proximal) dissection. All patients received anti-hypertensor medical treatment. All but one had undergone surgery at least once at the acute stage. Five had been followed up and monitored by magnetic resonance imaging (MRI). One type A and 4 type B dissections were thus reviewed between the 15th month and the 9th year. Diagnostically, aortography was found to be inaccurate twice because of incomplete exploration of the thoracoabdominal aorta. Therapeutically, a case of intraoperative death occurred during replacement of the ascending aorta. Thus, out of the 6 patients who survived the acute stage, 4 are alive and asymptomatic, one has been lost sight of and the other died in year 5 after surgery for chronic dissecting aneurysm of the aortic arch. Among the 5 patients examined by MRI, 4 presented aortic ectasia, chronic dissecting aneurysm of the aortic arch and/or a descending aorta with a diameter between 45 and 65 mm. The patient with subnormal aortic diameter had his ascending aorta replaced (the follow-up period at this writing is only 27 months). Among 3 patients who were examined twice, one showed improvement after a year's interval, with a 5-mm increase in the caliber of the dissected aorta.(ABSTRACT TRUNCATED AT 250 WORDS)     

Retrograde type A dissection after endovascular stent grafting of type B dissection

Acute aortic dissection is a disease with high mortality. Whereas acute dissection of the ascending aorta (Standford type A) is treated surgically, acute dissection of Stanford type B (descending aorta) is principally treated conservatively, but surgically in case of complications. Recently, another therapeutical option for the treatment of type B dissection has been developed using endovascular stent-grafts. We report on a 64-year-old woman with typical signs of acute aortic dissection. Computer tomography and transesophageal echocardiography demonstrated Stanford type B dissection. The patient was treated with an endovascular stent-graft, because of malperfusion of the right leg and chest pain. After successful closure of the entry by the stent, the patient developed acute right-sided hemiplegia one day after the intervention due to retrograde dissection into the aortic arch and ascending aorta. Upon immediate operation, the origin of the initially type B dissection was still sufficiently occluded by the endovascular stent-graft; however, there was another entry between the innominate artery and the left carotic artery near one proximal end of the stent's strut. Using deep hypothermia and selective antegrade cerebral perfusion, the ascending aorta and proximal arch were replaced with a 28 mm Dacron-Velour tube and the aortic root was remodelled with a tongue-shaped Dacron graft preserving the valve cusps according to a modified Yacoub procedure. After the operation, neurological symptoms diminished and the patient could walk on the ward on day eleven. This case demonstrates retrograde type A dissection as a complication after interventional treatment of type B dissection using an endovascular stent-graft. The reason for this delayed complication is speculative. Aortic wall damage during stent inserting could be a possible cause. It is also likely that the patient initially had type B dissection with retrograde dissection of the distal part of the aortic arch. Therefore, one of the straight struts of the proximal end of the stent may have caused additional damage to the vulnerable dissected aortic wall in the arch, leading to retrograde type A dissection. Careful patient selection, detailed diagnosis of the aortic arch, improved stent designs and materials, especially regarding the stent's ends and careful insertion of the stent into the aortic arch, could contribute to prevention of the described problems.     

Acute type A aortic dissection in a patient with systemic lupus erythematosus

The case of a 27-year-old Japanese woman with type A acute aortic dissection who had been diagnosed with systemic lupus erythematosus (SLE) is presented. The patient also had aortic regurgitation due to non-infective endocarditis and systemic hypertension, and had been maintained on steroid therapy for 15 years. Her twin sister was also diagnosed with SLE. The patient was admitted to emergency due to severe back pain. A chest x-ray showed enlargement of the upper mediastinum. Echocardiography revealed a thickened and deformed aortic valve with aortic regurgitation and dissection of the ascending aorta, but pericardial effusion was not found. Computed tomography demonstrated aortic dissection extending from the ascending aorta to the abdominal aorta. Graft replacement of the ascending aorta and proximal aortic arch was performed under hypothermic circulatory arrest with retrograde cerebral perfusion. The patient recovered uneventfully. Aortic dissection complicated with SLE is extremely rare, and this is only the 15th case reported in the English or Japanese literature.     

Endovascular treatment of residual type A aortic dissection preserving patency of supra-aortic vessels by implantation of the Djumbodis® system. No more surgery for the aortic arch?

A persistent distal false lumen perfusion--residual type A aortic dissection--is found in 50% to 100% of patients following ascending aorta replacement. Complications of persistent or newly developed dissection of the distal aorta are often fatal and require reoperation, leading to a higher morbidity and mortality rate for these patients than with primary surgery. Thus, many efforts have been done to treat this aortic disease by an endovascular approach. Unfortunately, patency of the supra-aortic vessel still remains an unresolved issue. The present report describes the case of a patient with a residual type A aortic dissection persisting after ascending aorta replacement, successfully treated by implantation of a new endovascular device, the Djumbodis? Dissection System, a bare stent with sufficiently large mesh to join the dissected layers without occluding main vital branches such as supra-aortic arteries.     

Management of intramural hematoma of the ascending aorta and aortic arch: the risks of limited surgery

We present the case of a 57-year-old woman who had an intramural hematoma of the ascending aorta and aortic arch. After initial blood pressure control and imaging studies, the patient underwent limited surgical repair that consisted of ascending aortic replacement. One week postoperatively, the aortic arch hematoma progressed to a full dissection that extended into the proximal descending aorta. Emergent aortic arch replacement was required. Current world medical literature regarding thoracic aortic intramural hematoma is presented. This case supports the treatment of intramural hematomas of the ascending aorta and arch by surgical replacement of both segments with a Dacron graft, with the patient under deep hypothermic circulatory arrest.     

老年主动脉夹层的外科治疗

目的:探讨老年主动脉夹层的外科治疗策略、疗效及预后。方法:回顾性分析本院外科治疗35例老年主动脉夹层患者的临床资料。患者年龄60～77岁,平均(64.9±4.6)岁;男性28例,女性7例;按Debakey分型,Ⅰ型14例,Ⅱ型1例,Ⅲ型20例。结果:全组死亡3例,死亡率8.6%。行降主动脉腔内修复手术18例,杂交手术(即先行主动脉头臂血管转流术,同期行主动脉夹层腔内覆膜支架置入术)3例,均无死亡。开胸手术14例,包括升主动脉置换术2例(同期行主动脉瓣置换1例),升主动脉+半弓置换5例(同期行主动脉瓣置换2例,冠状动脉旁路移植手术1例),升主动脉置换+支架象鼻术2例,升主动脉+全弓置换+支架象鼻术3例,降主动脉置换术2例,共死亡3例,死亡原因为急性肾功能衰竭、多脏器功能不全、心跳骤停及纵隔感染。结论:老年主动脉夹层病情凶险,外科开胸手术治疗死亡率较高,采取杂交手术及微创腔内修复治疗,效果满意。     

Rapid diagnosis and management of thoracic aortic dissection and intramural haematoma: a prospective study of advantages of multiplane vs. biplane transoesophageal echocardiography.

AIMS: The purposes of this study were to compare the accuracy of multiplane vs. biplane transoesophageal echocardiography (TEE) in the diagnosis of aortic dissection and aortic intramural haematoma, and to test whether these techniques provide all the diagnostic information required to make management decisions. METHODS AND RESULTS: Fifty-eight consecutive patients with clinically suspected aortic dissection were studied with multiplane TEE; all cases who required surgery underwent intraoperative monitoring with multiplane TEE. The following multiplane TEE data were analysed: the angle between current and 0 degrees plane at which each view was obtained; the success rate in the evaluation of true and false lumen, entry tear, coronary artery involvement, aortic regurgitation, pericardial effusion. Advantages of multiplane over biplane TEE have been evaluated by the demonstration of usefulness of views obtained in planes other than 0 degrees-20 degrees or 70 degrees-110 degrees, assuming that with manipulation of a biplane probe a 20 degrees arc could be added to the conventional horizontal and vertical planes. On the basis of TEE findings, aortic dissection was confirmed in 36 cases (18 type A, 12 type B, six intramural haematoma). The specificity and sensitivity of TEE in terms of the presence or absence of aortic dissection or intramural haematoma were 100%. An additional clinical value of multiplane over biplane TEE in the evaluation of ascending aorta, aortic arch, entry tears and coronary artery involvement was demonstrated. All cases with type A aortic dissection or intramural haematoma involving the ascending aorta had an operation that was performed immediately after the diagnosis (hospital mortality, 13%). Patients with type B aortic dissection were treated medically; 25% of these cases were operated later (hospital mortality, 0%). CONCLUSIONS: Multiplane and biplane TEE have excellent and similar accuracies in the evaluation of aortic dissection and intramural haematoma. Multiplane TEE improves the visualization of coronary arteries, aortic arch and entry tears; it appears to be an ideal method as the sole diagnostic approach before surgery in type A aortic dissection.     

Unusual complication of aortic dissections: intimo–intimal intussusception

Angiography with a pre-diagnosis of acute coronary syndrome was performed in a 76-year-old female patient presenting to another hospital with symptoms of chest pain and syncope. Upon determination of type III aortic dissection, the patient was referred to our clinic. On CT angiography, the ascending aortic diameter was 57 mm and no dissection flap was observed. There was a filling defect suggestive of intimo–intimal intussusception at the level of the aortic arch, occlusion of the left arteria carotid communis, and a double-channel aorta extending from the left subclavian artery to the iliac artery. On transoesophageal echocardiography, the ascending aorta was seen to be larger than normal and no dissection flap was observed. There were findings suggestive of haematoma and intimo–intimal intussusception at the proximal part of the aortic arch. The dissection flap causing occlusion in the vascular structures was resected. Supracoronary graft replacement of the ascending aorta was performed. Transoesophageal echocardiography is an invasive investigative method with high sensitivity and specificity for the diagnosis of intimo–intimal intussusception.     

Emergent Repair of a Complex Dissecting Aneurysm in the Thoracic Aorta

Endovascular treatment of complex thoracic pathologic conditions involving the aortic arch can often be appropriate and safe; however, minimally invasive procedures are not always feasible, especially in emergent cases. We report the case of a 78-year-old woman who emergently presented in hemorrhagic shock with a ruptured chronic dissecting aneurysm that involved the aortic arch. Eight years earlier, she had undergone aortic valve replacement and plication of the ascending aorta, which was complicated a day later by Stanford type B dissection, malperfusion, and ischemia that required an axillobifemoral bypass. At the current admission, we successfully treated her surgically through a left thoracotomy, using moderate hypothermic extracorporeal circulation and advanced organ-protection methods. We discuss the surgical indications and our operative strategy in relation to open surgical repair versus endovascular treatment in patients with complex conditions.Key words: Aneurysm, dissecting/radiography/surgery; aortic aneurysm, thoracic/radiography/surgery; aortic diseases/surgery; aortic rupture/surgery; treatment outcome; vascular surgical proceduresPathologic involvement of the aortic arch and the presence of dissection are 2 major issues in descending thoracic aortic repair, particularly in emergent settings of aneurysmal rupture. A patient''s comorbidities and older age may contraindicate deep hypothermic circulatory arrest; however, a thoracoabdominal dissection could lead to malperfusion if left-side heart bypass is considered for organ protection. Endovascular or hybrid surgery is a less invasive approach in complex cases; however, a good aneurysmal neck and adequate vascular access for the device are mandatory for technical success. We present the case of an elderly woman with comorbidities who required emergent repair of a complex dissecting thoracic aneurysm.     

Transesophageal Doppler echocardiography in the diagnosis of dissecting aortic aneurysm

Transesophageal Doppler echocardiography (TEDE) was performed in three patients with proven or suspected DeBakey type I and type III aortic dissection. Case 1: A 66-year-old woman, with DeBakey type I aortic dissection. Clear images of a widened dissected aorta and an intimal flap were obtained in both the ascending and descending aorta, including the aortic arch. The site of an entry into the false lumen was identified by the defect of the intimal flap and the pulsatile entry flow through it. The reentry into the true lumen was also identified near the orifice of the celiac trunk. In this case, the observation was performed using this technique during the operation; i.e., replacement of the ascending aorta with an artificial graft. Case 2: A 77-year-old man, DeBakey type III aortic dissection. The study was performed after surgery which consisted of replacement of the descending aorta with an artificial graft. TEDE provided clear images of the artificial graft, the aorta, and their boundaries. The remaining intimal flap was clearly confirmed. Case 3: An 80-year-old man, DeBakey type III aortic dissection. In this case, though abdominal echography suggested aortic dissection, angiography and X-ray CT failed to facilitate the diagnosis. Only TEDE confirmed the diagnosis. The abnormal flow via the entry directing toward the false lumen was clearly demonstrated on the color Doppler images. We therefore conclude that TEDE is a useful and reliable means of diagnosing dissecting aortic aneurysm.     

Outcome of aortic arch surgery in patients aged 70 years or older: axillary artery cannulation and selective cerebral perfusion supports

OBJECTIVES: Axillary artery cannulation, selective cerebral perfusion and replacement of the ascending and arch aorta with an elephant trunk were evaluated to reduce cerebral complications in aortic arch surgery in patients with aortic aneurysm or aortic dissection involving the aortic arch. METHODS AND RESULTS: A total of 45 patients(18 with acute A type aortic dissection and 27 with chronic aortic aneurysm involving the aortic arch) aged 70-92 (mean age 74) years underwent total aortic arch replacement from March 1996 to May 2002. There were three operative deaths in patients with acute A type aortic dissection caused by massive cerebral infarction, bleeding and myocardial infarction, and one hospital death of sepsis. Overall in-hospital mortality was 8.9%(16.7% in A type dissection and 3.7% in chronic aneurysm). Operative complications included mediastinitis in four patients(9%), left recurrent laryngeal nerve palsy in eight(18%), and cerebral infarction in four(9%). Three of the patients with cerebral infarction had associated dissection-related cerebral ischemia before surgery. One patient died, and two needed a walking stick. Twelve of 18 patients(67%) with acute A type aortic dissection and 26 of 27 (96%) with chronic aortic aneurysm were discharged on foot. CONCLUSIONS: Axillary artery cannulation, selective cerebral perfusion and replacement of the ascending and arch aorta with an elephant trunk provided satisfactory operative results in elderly patients aged 70 years or older, especially in patients with chronic aortic aneurysm involving the aortic arch.     

Surgical correction of ascending type a thoracic aortic dissection: simultaneous endoluminal exclusion of the arch and distal aorta.

PURPOSE: To describe repair of an ascending type A dissection combining an open ascending tube graft with simultaneous great vessel transposition and antegrade deployment of an endoluminal graft across the arch and into the descending thoracic aorta. CASE REPORT: A 50-year-old man was evaluated at an outside hospital and transferred to our service for treatment of an ascending aortic dissection with associated lower extremity ischemia. Imaging identified an aortic dissection extending from the aortic root to the aortic bifurcation and into the right common iliac artery. A hybrid procedure incorporating both open and endovascular techniques successfully repaired the dissection and aneurysm and restored blood flow to the extremity. CONCLUSIONS: Although less invasive procedures are sometimes appropriate for repair in the descending thoracic aorta, surgical correction of an ascending dissection and endoluminal exclusion of the arch and distal aorta may form the basis of future treatment strategies for complex aortic pathologies, possibly eliminating the need for hypothermic cardiac arrest.     

Intraoperative echocardiography for diagnosis and treatment of aortic dissection. Utility of color flow mapping for surgical decision making in acute stage.

In the past eight years until July 1992, 92 patients were admitted in the acute state of aortic dissection within two weeks from the onset of symptoms. 41 were diagnosed as Stanford type A and 51 were type B by transthoracic and transesophageal echography, computer tomography, and surgery. Sensitivity of transesophageal echography to detect the intimal flap and the false lumen was 97.6% in patients with Stanford type A and 100% in patients with Stanford type B. The surgical decision making has been mostly depending on the transesophageal echographic diagnosis. When the intimal flap was detected in the ascending aorta (Stanford type A) surgery was performed in emergency regardless of any evidence of rupture, cardiac tamponade, and severe aortic regurgitation. When the aortic dissection was detected only in the descending aorta (Stanford type B) the main course of therapeutic strategy in our institute was medical treatment. Surgery was performed on 37 patients of type A and nine patients of type B with mortality of 18.9% and 55.5% respectively. Four patients of type A and 42 patients of type B were treated medically with a mortality of 75.0% and 2.2% respectively. The relatively large leakages from the anastomosis of the aortic clamp site were repaired secondarily in two patients, and fenestration of the superior mesenteric artery was performed on one patient due to ischemia of the small intestine depending on the intraoperative direct scanning of color flow mapping. Coronary artery involvement of dissection was strongly suspected in two patients by intraoperative transesophageal echography and aortocoronary bypass grafting was performed on these patients. Perfusion problems was encountered in five of 37 patients with type A aortic dissection (13.5%) during cardiopulmonary bypass. Intraoperative transesophageal echography could clearly detect the hemodynamic changes in the descending aorta resulting from inadequate perfusion which was useful for the management of perfusion control during cardiopulmonary bypass. Secondary repair of the aortic arch was required due to ischemia of the aortic arch vessels in two patients after the primary surgery. The extension of the dissection into the aortic arch vessels can be promptly diagnosed with the combination of transesophageal echography and transcutaneous echography. In conclusion, transesophageal Doppler echography is the most rapid diagnostic tool for decision making in acute aortic dissection, and intraoperative transesophageal echo can provide useful information to resolve the perfusion difficulties during cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 400 WORDS)     

Aortic surgery, coarctation of the aorta, and aortic dissection

During the past year, significant advances were made in the insertion of composite valve grafts for the ascending aorta, replacement of the aortic arch, treatment of thoracoabdominal aortic aneurysms, and in the screening of patients with abdominal aortic aneurysms for cardiac disease. Controversy remains as how to best manage patients with aortic coarctation, and a recent symposium reviewed the techniques extensively. Methods of detecting aortic dissection have evolved, with increasing use of advanced technology such as transesophageal echocardiography and magnetic resonance imaging. The management of the aortic arch in patients with acute aortic dissection has been debated.     

Pericardial Effusion Masquerading as an Aortic Dissection

A 24‐year‐old woman with a history of recurrent syncope underwent an echocardiogram that was suspicious for an ascending aortic dissection. Cardiac magnetic resonance imaging was performed which showed no evidence of aortic dissection. However, it did demonstrate a pericardial effusion that extended to the aortic arch. This case shows how pericardial effusions can simulate the appearance of an aortic dissection because of its extension to the aortic arch. (Echocardiography 2011;28:E16‐E18)     

Surgical therapy of thoracic aortic dissection]

Considerable surgical progress of treating aortic dissection has been achieved during the past decade. The emergency indication for acute dissection of the ascending aorta (type A according to the Stanford classification) is unquestioned while surgical treatment for acute dissection of the descending aorta (type B dissection) is mainly reserved for complicated cases. The major complication of acute operations--fatal hemorrhage from the suture line and secondary multi-organ failure--have been successfully reduced by a progress of cardiopulmonary bypass techniques, the introduction of cold cardioplegic myocardial protection, the development of modern suture materials and glues and last not least by a continuous intensive monitoring. Especially the introduction of the so-called french glue safely enabled both the closure of the false lumen as well as the strong reinforcement of the diseased aortic wall and seems to offer a reliable alternative to the application of multi-layered teflon strips. Since the principle of all reconstructive approaches in case of dissection consists of closure of dissected layers and the limited replacement of the segment that is susceptible to a rupture the exact readaptation and reinforcement of the diseased aortic wall represents a fundamental operative step. In type A operations the supracoronary aortic prosthetic replacement or the combined replacement of ascending aorta plus aortic valve followed by the reattachment of coronary arteries has become the standard operative technique. In fact, independently from the location of the primary intimal tear the operation has been traditionally limited to replace the ascending aorta in order to remove an aortic segment that is most likely to rupture. Yet an increasing number of follow-up investigations has demonstrated recurrence of dissection or an aneurysmatical dilatation of the false lumen in about 20% of patients treated with ascending aortic replacement. Consequently, repair of the aortic transverse arch and the radical elimination of the intimal entry is now favoured by an increasing number of surgeons. In addition to these various perioperative and intraoperative adjuncts the introduction of new imaging techniques, especially computerized tomography, magnetic resonance imaging and transesophageal echocardiography allowed to establish adequate therapeutical concepts on a more rational basis. Transesophageal echocardiography as a mobile diagnostic device enables investigators to perform a bed-side dynamic visualization of both the location and extent of a dissection, the evaluation of ventricular performance and aortic competence. Treatment of acute type B dissection is mainly conservative unless complications like intractable pain, aneurysmatic enlargement of the false lumen, ischemia of visceral organs or even rupture occur.(ABSTRACT TRUNCATED AT 400 WORDS)