Dissection of the thoracic aorta following partial clamping

A case is reported in which an extensive dissection of the thoracic aorta was observed after partial clamping during surgery on that blood vessel. The unfavourable outcome of the operation and the accurate investigation of the post-mortem material suggest a lesion of the artery wall secondary to tangential clamping by Satinsky's clamp. The possible pathogenetic mechanisms of lesions induced by vascular clamping are also discussed.     

Dissection of the aorta: a new approach

There are two generally proposed causes of dissection of the aorta: (1) cleavage caused by blood entering the tear; and (2) haemorrhage that dissects the media and tear secondary to the cleavage. Using analysis of pressures and forces, this article shows that, on some occasions, these mechanisms alone cannot be responsible for causing aortic dissection     

Dissection of the aorta complicated by aorto-pulmonary fistula

The authors report the case of chronic dissection of the aorta presenting with congestive cardiac failure. The diagnosis was made for the first time by transoesophageal echocardiography which showed both the dissection of the aorta and its fistulalisation into the pulmonary artery. Aortography confirmed the diagnosis. The patient underwent surgery which consisted of suture of the fistula and replacement of the ascending aorta with a prosthetic tube. The outcome was favourable after 8 months follow-up.     

Dissection of aorta after aortic valve replacement

The authors report 4 cases of aortic dissection after aortic valve replacement. The aorta was dilated in all four cases before surgery. Two patients died within hours of the dissection, illustrating the poor prognosis of this complication and the difficulties of surgical management. The features of these four cases were compared to those of 29 other cases reported in the last ten years. The initial surgical indication for valve replacement was equally divided between aortic stenosis and regurgitation. The onset of dissection after surgery was very variable, ranging from a few hours to several years after valve replacement. Abnormalities of the aortic wall and peroperative trauma play an important role in the pathogenesis of this complication. The prognosis is very poor, which underlines the importance of preventive measures and regular follow-up of these patients.     

Dissection of the aorta associated with congenital malformation of the aortic valve

The association of congenital aortic valve malformation and aortic dissection is analyzed. Over a 30 year period, 186 patients with non-iatrogenic aortic dissection were studied at necropsy. The aortic valve was tricuspid in 170 (91.4%), bicuspid in 14 (7.5%) and unicuspid in 2 (1.1%). Among the 16 patients with aortic dissection and a congenitally malformed valve, the age at death ranged from 17 to 82 years (mean 52) and 13 (81%) were men. The entrance tear of the aortic dissection was located in the ascending aorta in all 16 patients with a malformed valve but in only 68% of those with a tricuspid aortic valve. The aortic valve was stenotic in 6 of the 16 patients with a congenitally malformed valve. Fatal rupture of the false channel occurred after acute ascending aortic dissection in each of the 11 patients (none with healed dissection) who did not have operative therapy for the dissection. Two of the 16 patients with a malformed valve compared with no patient with a tricuspid aortic valve had aortic isthmic coarctation. Histologic sections of aorta from 10 patients disclosed severe degeneration of the elastic fibers of the media in 9 patients. Thus, a congenitally malformed aortic valve appears to be present at least 5 times more frequently in adults with than in those without aortic dissection, and in our patients the entrance tear was always in the ascending aorta, which usually had severe loss of elastic fibers in its media.     

Dissection of the thoracic aorta: Medical or surgical therapy?

Both medical and surgical therapy are available for the treatment of aortic dissection. To help determine which form of treatment is indicated for which patients, all cases of aortic dissection at the Peter Bent Brigham Hospital from 1963 to 1973 were reviewed. The most important feature in determining the patient's clinical status and response to therapy was the site of dissection, that is, the ascending or descending aorta.

Of 31 patients with dissection of the ascending aorta, 26 had one or more of the following contraindications to medical therapy: congestive heart failure (8 patients), hemopericardium (8 patients), new aortic insufficiency (13 patients) or jeopardized carotid or coronary arteries (4 patients). Medical therapy was successful in only 1 of 9 patients with dissection of the ascending aorta; 17 of 22 patients having surgical correction of this lesion did well and were discharged.

The clinical status of the 14 patients with dissection limited to the descending aorta was quite different. None had a contraindication to medical therapy. Medical therapy was instituted in all 14, and was successful in 6; dissection progressed in 8 patients despite medical therapy, and subsequent surgery was successful in only 2.

We conclude that the treatment of choice for dissection of the ascending aorta is prompt surgical therapy. In patients with dissection limited to the descending aorta, medical therapy is usually feasible and often successful.     

Dissection of the ascending aorta in a patient with HLA-B27 associated ankylosing spondylitis

We describe a 38-year-old patient with ankylosing spondylitis complicated by a non-traumatic dissection of the ascending aorta without concomitant Marfan's syndrome.     

Dissection of ascending aorta. Rare complication of aortocoronary venous bypass surgery.

Dissection of the ascending aorta is a rare complication of aortocoronary bypass surgery. A 63-year-old man who had received a double graft was found to have dissection of the ascending aorta, which was shown angiographically four months after operation. Since the patient was asymptomatic, operation was postponed. He has been followed up regularly and two years later his condition is still satisfactory.     

Ascending thoracic aorta dimension and outcomes in acute type B dissection (from the International Registry of Acute Aortic Dissection [IRAD])

It is not well known if the size of the ascending thoracic aorta at presentation predicts features of presentation, management, and outcomes in patients with acute type B aortic dissection. The International Registry of Acute Aortic Dissection (IRAD) database was queried for all patients with acute type B dissection who had documentation of ascending thoracic aortic size at time of presentation. Patients were categorized according to ascending thoracic aortic diameters ≤4.0, 4.1 to 4.5, and ≥4.6 cm. Four hundred eighteen patients met inclusion criteria; 291 patients (69.6%) were men with a mean age of 63.2 ± 13.5 years. Ascending thoracic aortic diameter ≤4.0 cm was noted in 250 patients (59.8%), 4.1 to 4.5 cm in 105 patients (25.1%), and ≥4.6 cm in 63 patients (15.1%). Patients with an ascending thoracic aortic diameter ≥4.6 cm were more likely to be men (p = 0.01) and have Marfan syndrome (p <0.001) and known bicuspid aortic valve disease (p = 0.003). In patients with an ascending thoracic aorta ≥4.1 cm, there was an increased incidence of surgical intervention (p = 0.013). In those with an ascending thoracic aorta ≥4.6 cm, the root, ascending aorta, arch, and aortic valve were more often involved in surgical repair. Patients with an ascending thoracic aorta ≤4.0 were more likely to have endovascular therapy than those with larger ascending thoracic aortas (p = 0.009). There was no difference in overall mortality or cause of death. In conclusion, ascending thoracic aortic enlargement in patients with acute type B aortic dissection is common. Although its presence does not appear to predict an increased risk of mortality, it is associated with more frequent open surgical intervention that often involves replacement of the proximal aorta. Those with smaller proximal aortas are more likely to receive endovascular therapy.     

Cocaine-related Aortic Dissection: Lessons from the International Registry of Acute Aortic Dissection

Background

Acute aortic dissection associated with cocaine use is rare and has been reported predominantly as single cases or in small patient cohorts.

Methods

Our study analyzed 3584 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2012. We divided the population on the basis of documented cocaine use (C+) versus noncocaine use (C-) and further stratified the cohorts into type A (33 C+/2332, 1.4%) and type B (30 C+/1252, 2.4%) dissection.

Results

C+ patients presented at a younger age and were more likely to be male and black. Type B dissections were more common among C+ patients than in C- patients. Cocaine-related acute aortic dissection was reported more often at US sites than at European sites (86.4%, 51/63 vs 13.6%, 8/63; P < .001). Tobacco use was more prevalent in the C+ cohort. No differences were seen in history of hypertension, known atherosclerosis, or time from symptom onset to presentation. Type B C+ patients were more likely to be hypertensive at presentation. C+ patients had significantly smaller ascending aortic diameters at presentation. Acute renal failure was more common in type A C+ patients; however, mortality was significantly lower in type A C+ patients.

Conclusions

Cocaine use is implicated in 1.8% of patients with acute aortic dissection. The typical patient is relatively young and has the additional risk factors of hypertension and tobacco use. In-hospital mortality for those with cocaine-related type A dissection is lower than for those with noncocaine-related dissection, likely due to the younger age at presentation.     

Tandem coarctation of the thoracic aorta with hypoplasia of the abdominal aorta

After resection of the coarctation in a 3-year-old child with end-to-end anastomosis, a second membrane was found 1.5 cm lower. After a successful reoperation with an aortoplasty using Gore-Tex weak femoral pulses persisted. At catheterization, an area of irregular narrowing of the abdominal aorta just distal to the superior mesenteric artery was found with hypoplasia of the iliac and femoral arteries. In addition, this child had a two-sided cheilo-gnatho-palatoschisis, vesicoureteral reflux and absence of gall bladder and hepato-duodenal ligament. It is worthwhile considering that a second or third aortic abnormality can be hidden by a coarctation of the aorta.