Spontaneous retrograde dissection of ascending aorta from descending thoracic aorta--a case review

A 56-year-old man with sudden onset chest pain, absent right lower limb pulses and ECG changes suggestive of inferior ST elevation MI underwent coronary angiogram through the right radial artery with a view to primary percutaneous coronary intervention (PCI). The left coronary angiogram demonstrated severe proximal stenotic disease in the left anterior descending and circumflex coronary arteries, but the right coronary artery could not be selectively cannulated. An ascending aortogram to visualise the right coronary artery not only failed to demonstrate it, but revealed, instead, a dissection flap in the ascending aorta, arch and descending thoracic aorta, with moderately severe aortic regurgitation. At operation, the patient was found to have an acute dissection of the ascending aorta, arch and descending aorta with an entry tear in the descending aorta below the left subclavian artery origin. Triple coronary artery bypass grafting with re-suspension of the aortic valve, supracoronary replacement of the ascending aorta and hemiarch and transaortic repair of the descending aortic tear was performed. The patient made an uncomplicated recovery, with the re-appearance of right limb pulses. A postoperative magnetic resonance (MR) scan revealed complete thrombosis of the false channel in the residual arch and a considerably shrunken false channel in the descending aorta and no aortic regurgitation. Retrograde dissection of the ascending aorta from the descending aorta has been reported infrequently in the past. We believe the scale of the problem has been underestimated because of the failure to adopt open distal anastomosis routinely in the past and, hence, failure to inspect the arch and the descending aorta routinely, particularly when the intimal tear was not identified in the ascending aorta. Retrograde dissection of the ascending aorta from an intimal tear in the descending aorta, when identified as such, has been managed, either on the principle of exclusion of the tear in the descending aorta by various elephant trunk procedures and their variants or, alternatively, on the principle of excision of the tear by extended one-stage aortic replacement, usually combined with an elephant trunk procedure. Neither of these procedures is widely adopted, owing to procedural, institutional and outcome considerations. We describe a transaortic repair of the intimal tear in the descending aorta with supracoronary interposition graft replacement of the ascending aorta and hemiarch with excellent clinical and radiological result. We also review the diagnostic and therapeutic approaches to this incompletely understood lethal disease.     

三分支支架血管重建全主动脉弓治疗急性A型主动脉夹层的体外循环策略

目的总结应用三分支支架血管重建全主动脉弓治疗急性A型主动脉夹层的体外循环方法。方法 2008年6月至2009年11月,对30例StanfordA型主动脉夹层患者行升主动脉人造血管替换加三分支支架血管置入,术中采用深低温停循环及选择性脑灌注的体外循环方法。结果 30例患者平均体外循环时间（151.8±16.69）min、心肌缺血时间（84.1±6.97）min、平均选择性脑灌注时间（40.85±3.13）min,平均下半身停止灌注时间（31.17±5.34）min,平均全身停循环时间（2.6±1.09）min。术后转入重症监护病房6小时内全部清醒,无神经系统并发症。平均机械辅助通气时间（17.93±2.35）h,平均重症监护病房观察时间（62.10±9.24）h。目前定期门诊随访中,无死亡和需要再次手术病例。结论 应用三分支支架血管重建全主动脉弓治疗急性A型主动脉夹层术中采用深低温停循环及选择性脑灌注的体外循环方法是安全有效的。     

锁-腹搭桥治疗主动脉夹层的数值模拟实验

主动脉夹层是一种较常见又很凶险的疾病,具有较高的死亡率.旁路搭桥转流术治疗DeBakey Ⅲ型主动脉夹层较一般的胸主动脉置换具有突出的优势,而且对于某些患者而言也是不可避免需要采用的手段.为了探讨锁-腹搭桥对主动脉夹层假腔内血流动力学参数的影响及该术式的有效性,分别构建了DeBakey Ⅲ型主动脉夹层及其锁-腹搭桥的理想化三维几何模型,然后将模型导入ANSYS 11.0中进行有限元分析.数值模拟结果显示,在实施搭桥后假腔入口处和假腔内的血流速度与压力均小于搭桥前.这对于减轻血流对夹层病变的冲击、减缓破裂口的进一步扩大、防止夹层破裂、促进夹层局部病变愈合是非常有利的.所以,锁-腹搭桥是一种在特定情况下治疗DeBakey Ⅲ型主动脉夹层的有效方式,具有一定的临床应用前景.     

Acute aortic dissection mimicking an acute coronary syndrome through occlusion of the right coronary artery

Occlusion of the right coronary artery (RCA) is an uncommon complication of type A aortic dissection. Aortic dissection and acute coronary syndrome (ACS) share a similar pathogenesis in atherosclerosis and hypertension. Consequently a patient with ischaemic risk factors presenting with chest pain and dynamic ECG change may well be incorrectly treated for ACS if careful attention is not paid to the presenting symptoms and signs. This case report describes a 59-year-old man who presented with chest pain, confusion and an ischaemic ECG and was initially treated for ACS. He subsequently deteriorated clinically and imaging confirmed type A aortic dissection complicated by RCA occlusion. Following emergent surgery with aortic root replacement and coronary artery bypass grafting he later made a good recovery.     

Progress in the diagnosis and management of aortic dissection

A 36-year-old man sought medical attention because of pressure in his head and distention of the veins in his neck. Physical examination disclosed a murmur of aortic insufficiency, and a chest roentgenogram showed a dilated ascending aorta. Two-dimensional echocardiography and angiography demonstrated a large intimal tear in the ascending aorta and aortic insufficiency. The patient underwent a surgical procedure, which revealed that his symptoms were caused by compression of the superior vena cava by the dilated ascending aorta. The aortic dissection was successfully repaired by replacement of the aortic root with a composite graft into which the coronary ostia were reimplanted. After further assessment of the patient, including elicitation of a similar history in some paternal relatives, Marfan's syndrome was diagnosed. Physicians should be aware of the clinical manifestations, pathogenesis, and treatment of aortic dissection. With aggressive treatment, 60 to 90% of patients survived aortic dissection in 1985, whereas only 40 years ago, this entity was rarely recognized premortem or treated successfully.     

Percutaneous coronary stenting in guide-induced aortocoronary dissection: angiographic and CT findings

We report here on a case of accidental aortocoronary dissection that occurred during the engagement of a guiding catheter. This resulted in an antegrade dissection into the right coronary artery, and a retrograde extension of the dissection into the Sinus of Valsalva and the ascending aorta up to the aortic arch. It was successfully treated with a stent deployment at the RCA ostium; this restored optimal coronary blood flow and there was a complete resolution of the aortic dissection as was documented by coronary angiography and the follow-up CT scan.     

Arrhythmogenic right ventricular cardiomyopathy with left ventricular involvement and aortic dissection

Ten years ago, a 59-year-old patient presented with ventricular fibrillations. The resting ECG showed findings typical for ARVC. Echocardiography and ventriculography confirmed the diagnosis of ARVC showing a dilated right ventricle with aneurysms. MRI showed additional fatty replacement of the LV. Furthermore, the diagnosis of a chronic aortic dissection was established. Two years after ICD implantation, the patient died of progressive right heart failure. On autopsy, most of the RV and parts of the LV were replaced by fatty tissue, and the media of the aorta showed degenerative changes. A pathogenetic link between the two diseases remains speculative at this time.     

Large atherosclerotic plaque related severe right coronary artery dissection during coronary angiography

Catheter-induced coronary artery dissection and occlusion is a rare but serious complication of diagnostic cardiac angiography. A 50 year-old man presented with unstable angina. ECG, exceptional of bradycardia, was normal (57 beat/min). Selective coronary angiography demonstrated 98% narrowing in the mid-portion of the left anterior descending coronary artery (LAD). During the right coronary angiography, following catheter manipulation in the vicinity of the aortic valve, the patient complained of severe chest discomfort, and he had electrocardiographic evidence of acute inferior wall myocardial infarction. Right coronary artery (RCA) was free of the significant obstruction, and it was observed to be having a dominant artery with a spiral dissection (NHLBI Grade IV) located between ostium and the proximal portion of the posterior descending and posterolateral artery bifurcation. The patient was immediately operated with off-pump coronary artery bypass surgery. Consequently, iatrogenic right coronary dissection that is a very rare condition as a cause of myocardial infarction, is discussed in this case report.     

Impella insertion for residual aortic dissection

Acute aortic dissection with coronary malperfusion is a life‐threatening disease, resulting in demanding postoperative management. We report a successful insertion of percutaneous heart pump Impella through the intact true lumen in a patient with residual aortic dissection after the graft replacement. Careful evaluation of the access site and the Impella size selection is required.     

The application of a modified technique of SCP under DHCA during total aortic arch replacement combined with stented elephant trunk implantation

We reviewed the perfusion experiences of 60 cases with a modified technique of selected cerebral perfusion (SCP) under deep hypothermic circulatory arrest (DHCA) during ascending aorta and total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta for acute and chronic type A aortic dissection. Right auxiliary artery cannulation was routinely used for cardiopulmonary bypass (CPB) and SCP in this procedure. Generally, this technique requires two main pumps for two arterial lines before we applied the modified technique; one for CPB and the other for SCP. In order to simplify the circuit of the extracorporeal circuit (ECC) to operate easily, the arterial line was separated into two branches with a Y-connector on the operating table, one for axillary artery perfusion and the other for graft perfusion connected to the ECC set-up. This method is easy for the perfusionist to install and convenient for the surgeon. This is a safe and simple to use modified technique for SCP under DHCA during ascending aorta and total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta.     

Non-traumatic aortic dissection or rupture as cause of cardiac arrest: presentation and outcome

OBJECTIVE: To evaluate the frequency, presentation and outcome of non-traumatic aortic dissection/rupture as a cause of cardiac arrest. DESIGN: Retrospective analysis of a cardiac arrest registry in a tertiary care hospital emergency department. RESULTS: Over 11.5 years, aortic dissection/rupture was identified as the immediate cause of cardiac arrest in 46 (2,3%) out of 1990 patients with sudden cardiac arrest, primarily affecting the abdominal aorta in 25 and the thoracic aorta in 21 cases. The characteristics of the 46 patients were as follows: male gender (74%), median age 71 years (IQR 59-76), high co-morbidity (89%), previously known aortic aneurysm (33%), pulseless electric activity (70%) as initial cardiac rhythm. When performed, bedside abdominal sonography or echocardiography was almost always diagnostic. Patients with abdominal aortic dissection/rupture had abdominal (52%) and/or flank pain (32%). Patients with thoracic aortic dissection/rupture complained of chest pain (48%) or dyspnoea (19%). Return of spontaneous circulation occurred in 12 (26%) of 46 patients, emergency surgery was performed in eight of these patients, 2 (4%) survived to discharge in good neurological condition. CONCLUSIONS: Cardiac arrest caused by aortic dissection/rupture is rare, and mortality remains very high, even when circulation can be restored initially. Common features such as previously known aortic aneurysm, old age, male gender and pulseless electrical activity as initial cardiac rhythm should increase suspicion of the condition.     

Traumatic rupture of the thoracic aorta.

Our experience with 36 cases of traumatic rupture of the aorta has prompted an aggressive investigative and surgical approach. Age range, mechanism of injury, and associated injuries are quite variable. Aortogram is essential for diagnosis and should be done with any evidence of mediastinal abnormality following a deceleration injury. The preferred method of repair is graft interposition for the transected aorta, using femoral vein to femoral artery bypass with an oxygenator in the system. The salvage rate is good if an aggressive surgical approach is used.     

Asymptomatic dissection of the ascending aorta: diagnosis by transesophageal echocardiography

A young man with marfanoid habitus underwent transesophageal echocardiography to evaluate an aortic root abnormality visualized on transthoracic echocardiography. Transesophageal echo demonstrated a type A aortic dissection traversing across the right sinus of Valsalva but not involving the aortic valve, right coronary artery, or pericardial sac. The aorta was not dilated. This is apparently the first reported case of an asymptomatic and uncomplicated aortic dissection localized to the sinus of Valsalva.     

Endovascular repair of the aortic arch

The aortic arch is a challenging site for endovascular repair. The proximal implantation site is often wide, angulated, conical, and limited in length by the presence of vital branches to the head and arms. The only way to lengthen the implantation site without risking stroke is to provide an alternative source of inflow through endovascular or extravascular bypass. The complexity and stroke risk of branched stent-graft implantation increases exponentially with each additional branch. In our opinion, the safest strategy is to limit the stent graft to a single side branch. This bifurcated stent graft requires multiple bypass grafts in the neck but avoids median sternotomy and partial aortic clamping. Stent-graft implantation through the carotid or innominate artery provides a short, straight route to the proximal ascending aorta and ensures simple accurate placement of the innominate limb. In our experience, the primary limitation has been the anatomy of the ascending thoracic aorta, which may be too short or too wide. Previously created coronary bypass grafts (if patent) may also prevent proximal stent-graft implantation. The bypass grafts and route of access through the neck and groin are created using standard surgical techniques. Both components of the stent graft are implanted during brief periods of cardiac standstill. The tip of the bifurcated stent-graft delivery system is introduced over a curved guidewire into the left ventricle. Otherwise, the endovascular techniques of bifurcated arch repair are essentially those of bifurcated abdominal aortic repair. Despite high flows and wide-diameter components, current experience has shown bifurcated stent grafts of this type to be stable with follow-up over 3 years.     

应用Cabrol手术治疗急性A型主动脉夹层根部病变

目的 Cabrol手术由Cabrol C教授于1981年首创,但至今关于该术式用于治疗A型主动脉夹层的报道并不多。本研究对我中心近7年来应用Cabrol术式治疗急性A型主动脉根部病变的病例进行总结。 方法 2009年1月~2016年12月,共有47例急性A型主动脉夹层的患者在我中心接受Cabrol手术治疗。所有病例术前均经心脏彩超及主动脉增强CT检查确诊。对其根部病变应用Cabrol技术处理,弓部病变采用半弓置换或全弓置换。对所有病例的相关数据进行回顾性分析。 结果 总共纳入47例患者,其中6例为单纯Cabrol手术,13例为Cabrol+右半弓置换,28例为Cabrol+孙氏手术。总的30 d死亡率为10.6%（5/47）。住院期间急性肾功能衰竭发生率25.5%（12/47）,有12.8%（6/47）的病人需要接受连续肾脏替代治疗。中位住院时间为25.5 d（15~128 d）,随访时间6~36月。 结论 Cabrol手术用于急性A型主动脉夹层的病人根部处理安全有效,术中部分技术细节需要注意。       

Aortic dissection and rupture that produce right ventricular perforation: detection by echocardiography and color flow mapping

Aorta to right ventricular fistula is a rare complication of ascending aortic dissection that has previously been diagnosed ante mortem only by cardiac catheterization. This report describes a patient who had aorta to right ventricular fistula that caused a left-to-right shunt and marked hemodynamic instability. An anatomic diagnosis was made rapidly in this patient by use of echocardiographic techniques. Two-dimensional and Doppler echocardiography have an important role in defining the cause of cardiovascular collapse after aortic dissection.     

Diagnosis and therapy of supravalvular aortic dissection (type A)--an interdisciplinary challenge

Acute dissection of the ascending aorta is a life-threatening disease. Successful management requires close teamwork of internal medical specialist, radiologist and cardiovascular surgeon. The diagnostic and therapeutic approach is reviewed on the basis of 18 of our own cases - 15 men and 3 women aged from 42 to 88 years. Peculiarities of history, pain and ECG give valuable clues to the differentiation of aortic dissection from myocardial infarction and massive pulmonary embolism. As a non-invasive rapidly available diagnostic method echocardiography may yield decisive information about the aortic root and the presence of pericardial effusion. Definite confirmation of diagnosis is accomplished by aortography and/or computed tomography. Blood pressure and aortic flow must be decreased to the lowest level tolerated by the patient to prevent pericardial tamponade or rupture into the mediastinum. The urgency of surgical repair is underlined by a median survival time of 12 hours from onset of symptoms to death with conservative treatment. 7 of our patients were operated on. In 6 cases surgery was performed by means of extracorporeal circulation and the ascending aorta was replaced by a graft. 3 patients survived the operation (2 for over 2 years and three died in the postoperative period due to cerebral and pulmonary complications). In one case with inoperable dissection an axillo-femoral bypass was performed for relief of complete ischaemia of the left lower limb. Postoperatively, maintainance of the patient's blood pressure at the low normal level ist mandatory.     

Staphylococcal thoracic aortitis complicated by aortic dissection

BACKGROUND:

The diagnosis of aortitis is often delayed as symptoms are largely non-specific. We report a case of Staphylococcal thoracic aortitis in a 73-year-old Chinese woman complicated by aortic dissection.

METHODS:

The patient presented with pyrexia of unknown origin, and a contrast enhanced computed tomography aortogram revealed a large thrombus at the anterior aspect of the ascending aorta with two large ulcerations as a result of a chronic type A aortic dissection. A hemiarch replacement with a 28 mm Gleweave Vascutek graft was performed with resuspension of aortic valve commisures. Aortic thrombus cultures were positive for coagulase negative Staphylococcus aureaus, and histology showed chronic dissection of the aorta.

RESULTS:

The patient was treated with intravenous cefazolin for a 6-week duration and made good progress.

CONCLUSIONS:

This case highlights Staphylococcal infective aortitis complicated by dissection presenting as fever of unknown origin. Timely diagnosis is essential as progression to catastrophic rupture may occur.KEY WORDS: Aneurysm, Aortic diseases, Endovascular stent, Infected/microbiology, Staphalococcus aureus     

无名动脉插管在主动脉弓部手术中的应用

目的:探讨右无名动脉插管在主动脉弓部手术中的应用。方法:采用右无名动脉插动脉灌注管行主动脉弓部手术26例。结果:全组行Bentall手术21例,Cabro手术1例,Weats手术3例,弓部瘤切除1例;26例病人全弓置换3例,次全弓置换23例。体外循环时间89～167(118±36)min;主动脉阻断时间57～128(89±21)min;深低温停循环时间17～48(29±11)min。病人术后2～10h内全部清醒,无神经系统并发症。本组因术中出血死亡1例,余病人康复出院。结论:右无名动脉插管体外循环技术仅一个切口即可完成弓部手术,在深低温停循环期间可顺利行脑灌注并收到良好的保护效果。     

胸主动脉瘤的外科治疗

目的:总结7例胸主动脉瘤病人的外科治疗经验.方法:7例病人中胸降主动脉瘤2例,主动脉根部瘤(马凡综合征)2例,夹层动脉瘤3例,均为Ⅱ型夹层动脉瘤,其中1例合并冠心痛,前降支单支病变.胸降主动脉瘤在低温体外循环下行人工血管置换术.升主动脉瘤和Ⅱ型夹层动脉瘤在低温体外循环下行Bentall手术,其中1例采用带管道无支架生物瓣,同时行冠脉搭桥手术.结果:6例存活,1例死于低心排综合征.结论:在胸主动脉瘤的外科治疗中,Bentall手术是治疗升主动脉瘤较好的手术方法.外科手术技术是手术成功的重要因素.体外循环管理,良好的心肌保护和血液保护是保证手术成功的重要手段.带管道无支架生物瓣对老年人及抗凝有禁忌或主动脉根部较小者更适宜,对合并冠心病的患者宜同期行冠脉搭桥术.