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.     

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.     

Coarctation of the aorta and Fallot's tetralogy. Apropos of 2 cases

Two cases of the association of Fallot's tetralogy and coarctation of the aorta are reported. In both cases there was a right aortic arch. In addition, the second case had a cervical aorta and a left subclavian artery isolated from the aorta and vascularised by the left vertebral artery. The two children underwent complete repair: the first patient had a Waterston shunt followed by repair of the Fallot's tetralogy, followed by repair of the coarctation; the second patient first had a Gore-tex tube inserted from the ascending to the descending aorta and then underwent repair of the Fallot's tetralogy. The association of a coarctation with an obstructive lesion of the right heart is very rare; only two cases have previously been reported: one Fallot's tetralogy and one tricuspid atresia with pulmonary stenosis. Both cases also had a right aortic arch. This seems to go against the haemodynamic theory of coarctation: blood flow in the ascending aorta increases while flow in the pulmonary artery decreases. Coarctation could be caused by a partial involution of the terminal segment of the right primitive dorsal aorta as proposed in cases of coarctation with a right sided aortic arch. The second case also presented two uncommon features: a cervical aortic arch and a left subclavian artery isolated from the aorta.     

Intramural hematoma of the ascending aorta

It is reported the case of a 71 year old male patient admitted to the emergency service pale and with systemic arterial hypertension and thoracic pain. In the diagnostic investigation, there was no evidence of compatible with acute myocardial ischemia. The thorax x-ray showed important enlargement of the mediastinum. In the echocardiogram the ascending aorta measured 47 mm, at the level of the pulmonary artery. One day after the echo, submitted to exam of magnetic resonance (RNM), the ascending aorta had a diameter of 62 mm, without false lumen flow or intimal "flap", but showing intramural hematoma envolving the ascending aorta and the proximal portion of the aorta. It was submitted to the surgical correction, being accomplished by resection of the ascending aorta and part of the aortic arch (hemiarch), with preservation of the aortic valve with suspension of the comissures. The patient had uneventful recovery, being discharged in the 9th postoperative day. We emphasized the similarity of the clinical presentation of the intramural hematoma of the aorta with that of aortic dissection, the importance of establishing correct diagnosis and the best treatment.     

Acute retrograde dissection of the ascending thoracic aorta.

The clinical, aortographic and pathologic features of six patients with acute retrograde dissection of the ascending thoracic aorta are presented and appropriate guidelines for surgical treatment are proposed. Although acute dissection of the aorta was the clinical diagnosis in these patients, clinical features were not helpful in identifying the pattern or extent of dissection. Aortography demonstrated that the site or sites of intimal tear occurred adjacent to the origin of the innominate artery (three patients) or left subclavian artery (two patients); an intimal tear was not seen in one patient. Five of the six patients also had acute or chronic (or both) antegrade dissection of the descending thoracic aorta. Retrograde dissection of the ascending aorta occurred in the outer portion of the media. The primary histologic changes were fragmentation of elastic fibers and fibrosis of the media. Three patients died, including two of the five patients who were treated surgically; the other three patients survived. Immediate replacement of the ascending aorta with a Dacron graft is recommended to prevent lethal complications due to extension of retrograde dissection, even though dissection may involve both the ascending and descending aorta and the site of intimai disruption may not be resected. The aortic arch or descending thoracic aorta, or both, can be replaced later, utilizing total body hypothermia and temporary circulatory arrest, if further dis-section or enlargement of the aorta occurs after emergency operation on the ascending aorta.     

Rupture of a thoracic aortic aneurysm after prosthetic bypass from the ascending aorta to the descending aorta in a case of congenital aortic arch hypoplasia

An unusual case of a successfully operated ruptured thoracic aneurysm of the aorta with bleeding into the atelectatic pulmonary left lower lobe and acute occlusion of the prosthesis in a 28-year-old woman is reported. The underlying disease was congenital aortic arch hypoplasia still present following implantation of a prosthetic bypass from the ascending aorta to the descending aorta performed in 1963.     

One-stage repair of a massive aortic arch aneurysm

A 61-year-old woman with a massive aortic aneurysm extending from the aortic root to the proximal descending thoracic aorta required urgent surgical intervention. She underwent successful replacement of her ascending aorta, transverse arch and descending aorta in a single operation.     

Penetrating ulcer of ascending thoracic aorta in syphilis.

Penetrating aortic ulcers (PAUs) are rare exotic pathological entities, classically located in the descending thoracic aorta. Their association with syphilis has never been reported. We describe a first case of a patient with cardiovascular syphilis presenting as PAU in the ascending aorta.     

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.     

Failure of Doppler ultrasound to detect coarctation of the aorta

Normal velocities of flow in the aortic arch were recorded in a patient presenting with clinical signs of aortic coarctation. Angiography demonstrated complete coarctation with extensive collateral supply to the descending aorta: there was a systolic pressure difference of 40 mm Hg between the ascending and descending segments of the aorta. Despite reports of the value of Doppler ultrasound in the diagnosis of coarctation, the finding of normal velocities of flow within the aortic arch does not necessarily exclude the presence of an obstructive lesion.     

Cannulation in the diseased aorta: a safe approach using the Seldinger technique

The Seldinger technique is a method of femoral cannulation that has been used to establish cardiopulmonary bypass. Reports of cannulation of the ascending aorta for antegrade perfusion using the Seldinger method are anecdotal. To the best of our knowledge, the approach described herein for direct cannulation of the ascending aorta with use of the Seldinger technique for antegrade perfusion has not been previously described in the English-language medical literature. This method is helpful when the surgeon is treating a patient who has a calcified ascending aorta, complicated aortic dissection, calcified femoral vessels, or a diseased thoracoabdominal aorta. In such cases, retrograde perfusion has been associated with severe complications as a result of atheromatous embolization from the descending thoracic aorta. Herein, we describe our approach to cannulation for cardiopulmonary bypass, which entails insertion of an aortic cannula into the ascending aorta by means of the Seldinger technique. A soft-tip guidewire is inserted through an arterial entry catheter that has been used to puncture a hole in the wall of the vessel. Then the aortic cannula is introduced into the vessel, sliding along the guidewire. Guided by transesophageal echocardiography, the tip of the cannula is positioned carefully and is then advanced into the descending aorta. This positioning of the cannula decreases the chance of arterial embolization, thereby improving cerebral protection. If cannulation of the ascending aorta is not feasible, the transverse aortic arch or proximal descending aorta can be used.     

Penetrating atheromatous ulcer of ascending aorta: a case report and review of literature

Penetrating atherormatous ulcer (PAU) is the condition in which ulceration of an aortic atherosclerotic lesion penetrates the internal elastic lamina into the media. Penetrating atheromatous ulcers usually involve the descending thoracic aorta and are very uncommon in ascending aorta. Differentiation of PAU from other causes of Acute Aortic Syndrome (AAS) such as intramural haematoma (IMH) and aortic dissection is difficult. The diagnosis of these ulcers is made on computerised tomography (CT) scan, magnetic resonance imaging (MRI), or transoesophageal echocardiography (TOE). Once diagnosed, PAU of ascending aorta should be treated surgically on emergency basis. We report on a patient of penetrating atherosclerotic aortic ulcer in ascending aorta with a review of the natural history, imaging diagnosis and management of the condition. She underwent ascending aortic interposition graft using 26mm Dacron graft successfully.     

Off-pump ascending to descending aorta bypass grafting with descending aneurysm exclusion

We performed an ascending to descending aorta bypass grafting with exclusion of the descending thoracic aortic aneurysm through a median sternotomy incision without cardiopulmonary bypass in a patient with severe chronic obstructive pulmonary disease. The patient was a 75-year-old man who had undergone endovascular stent-graft placement for a descending thoracic aortic aneurysm. The operation became necessary because the aneurysm continued to expand without evidence of endoleak. The postoperative course was uneventful, and without respiratory morbidity.     

Endarterectomy and external prosthetic grafting of the ascending and transverse aorta under hypothermic circulatory arrest

A 78-year-old woman presented with acute pulmonary edema, a blood pressure of 250/160 mmHg, and a 4/6 diastolic murmur of probable aortic origin. Aortography revealed 4+ aortic regurgitation, left ventricular dysfunction, a right coronary artery with good distal run-off but complete proximal occlusion, a fusiform aneurysm of the ascending and transverse aorta (with a transverse dissection in the left anterolateral wall of the upper ascending aorta, but no evidence of intramural lumen), and milder, isolated dilatation of the descending thoracic aorta. Upon operation, on 8 September 1987, I discovered an incompetent aortic valve, advanced atherosclerosis in the ascending and transverse aorta, and a loose intimal flap--but no false lumen--in the upper ascending aorta. After valve replacement and construction of a vein graft to the distal right coronary artery, I decided against replacement of the diseased segment of the ascending and transverse aorta and chose, instead, aortic endarterectomy reinforced by external grafting, as a simpler, quicker, and safer procedure for this patient. Safety was further enhanced by use of profound hypothermia (16 degrees C) to induce total circulatory arrest during the brief period (15 minutes) required for endarterectomy of the arch and approximation of the flap. The patient was discharged 19 days after surgery and continues well and asymptomatic to the present, 21 months after surgery; her milder dilatation of the descending thoracic aorta, which was not treated, is stable and is being monitored.     

Clinical application of intrathecal lidocaine administration in surgery of the descending thoracic aorta

We studied the protective effects of intrathecally administered lidocaine against ischemic spinal cord injury during surgery. Seven patients (mean age 63.7 years, malefemale=61) with descending thoracic aortic aneurysms underwent reconstructive surgery. Following intrathecal lidocaine administration (10 ml), the operation was performed under femorofemoral bypass with an oxygenator. The aorta was cross-clamped at the distal end of the descending thoracic aorta and the proximal end of the lesions. The cross-clamping time was 47.1±23.3 minutes (mean ± SD). The operative procedure was total replacement of the descending thoracic aorta in five cases and patch closure in two. There were no operative deaths but paraparesis developed in two cases of total replacement. Neurological deficit was transient and disappeared in one case. In the other case, with 88 minutes of normothermic aortic cross-clamping, paraparesis gradually improved but was persistent after 7 months of follow-up. Graft anastomosis at the distal aortic arch was time consuming in this case and presumably caused prolonged spinal cord ischemia. Intrathecal administration of lidocaine was likely to reduce ischemic spinal cord injury and increase tolerance of the spinal cord to ischemia caused by prolonged aortic cross-clamping. This method was considered to provide a useful assistance to expand the safety limit of spinal cord ischemia in surgical reconstruction of the descending thoracic aorta requiring aortic occlusion. Tissue protective effects of intrathecal lidocaine administration may be further augmented by combining with deep hypothermia.     

Pseudocoarctation of the aortic arch in a patient with Turner's syndrome

Pseudocoarctation of the aortic arch is a rare congenital anomaly which resembles true coarctation by the presence of a narrowing in the descending thoracic aorta immediately distal to the origin of the left subclavian artery. However, it is differentiated from that entity by the absence of a significant hemodynamic obstruction and by the presence of aneurysmal dilatation proximal and distal to the area of narrowing. As a result, the commonly observed clinical findings of coarctation such as a prominent collateral circulation and decreased blood pressure in the lower extremities are not observed. "Kinking" or "buckling" are common adjectives used to describe the roentgenographic appearance of the aortic arch in this condition. The association of various congenital cardiac abnormalities with pseudocoarctation has been reported, and are similar to those commonly seen with true coarctation. We now present the first reported case of pseudocoarctation associated with a probable bicuspid aortic valve in a patient with Turner's syndrome.     

Dilatation of the entire thoracic aorta in patients with bicuspid aortic valve: a magnetic resonance angiography study

BACKGROUND: The presence of a bicuspid aortic valve (BAV) might be associated with a progressive dilatation of the aortic root and ascending aorta. However, involvement of the aortic arch and descending aorta has not yet been elucidated. PATIENTS AND METHODS: Magnetic resonance angiography (MRA) was used to assess the diameter of the ascending aorta, aortic arch, and descending aorta in 28 patients with bicuspid aortic valves (mean age 30 +/- 9 years). RESULTS: Patients with BAV, but without significant aortic stenosis or regurgitation (n = 10, mean age 27 +/- 8 years, n.s. versus control) were compared with controls (n = 13, mean age 33 +/- 10 years). In the BAV-patients, aortic root diameter was 35.1 +/- 4.9 mm versus 28.9 +/- 4.8 mm in the control group (p < 0.01). The diameter of the ascending aorta was also significantly increased at the level of the pulmonary artery (35.5 +/-5.6 mm versus 27.0 +/- 4.8 mm, p < 0.001). BAV-patients with moderate or severe aortic regurgitation (n = 18, mean age 32 +/- 9 years, n.s. versus control) had a significant dilatation of the aortic root, ascending aorta at the level of the pulmonary artery (41.7 +/- 4.8 mm versus 27.0 +/- 4.8 mm in control patients, p < 0.001) and, furthermore, significantly increased diameters of the aortic arch (27.1 +/- 5.6 mm versus 21.5 +/- 1.8 mm, p < 0.01) and descending aorta (21.8 +/- 5.6 mm versus 17.0 +/- 5.6 mm, p < 0.01). CONCLUSIONS: The whole thoracic aorta is abnormally dilated in patients with BAV, particularly in patients with moderate/severe aortic regurgitation. The maximum dilatation occurs in the ascending aorta at the level of the pulmonary artery. Thus, we suggest evaluation of the entire thoracic aorta in patients with BAV.     

Total aorta replacement in takayasu arteritis presenting as mega aorta

We report a unique case of successful two-stage total aortic replacement from ascending aorta to aortic bifurcation that was done for extensive aneurysmal involvement of the aorta in Takayasu arteritis.     

Interrupted aortic arch in an adult single-stage extra-anatomic repair

Interrupted aortic arch is a rare congenital malformation of the aortic arch that occurs in 3 per million live births. Defined as a loss of luminal continuity between the ascending and descending portions of the aorta, this anomaly entails a very poor prognosis without surgical treatment. To our knowledge, the world medical literature contains only 12 reports of isolated interrupted aortic arch diagnosed in adults. Nine of these patients underwent successful surgical repair, but 1 died during the early postoperative period. We describe a 10th successful surgical repair, which involved a 42-year-old woman who had an asymptomatic type B interrupted aortic arch (characterized by interruption between the left subclavian and left carotid arteries). We performed a single-stage extra-anatomic repair by placing a 16-mm extra-anatomic Dacron graft between the ascending and descending portions of the thoracic aorta and by interposing a 7-mm extra-anatomic Dacron graft between the 16-mm graft and the left subclavian artery. The patient recovered uneventfully and continued to do well 6 months later.     

Retrograde embolism from the descending thoracic aorta causing stroke: An underappreciated clinical condition

The mechanism of retrograde aortic blood flow is a complex and underreported clinical phenomenon. Complex plaques of the aortic arch are considered high-risk sources of cerebral emboli.¹ Aortic plaques situated in the descending thoracic aorta are however often overlooked and in fact can be more frequent potential sources of cerebral embolism through the mechanism of retrograde aortic blood flow. We present the case of an elderly Caucasian female who experienced recurrent posterior circulation embolic strokes where the only possible underlying etiology was found to be an atheroma in the descending thoracic aorta, possibly showering retrograde emboli.