Is Deep Hypothermic Cardiac Arrest Mandatory in Aortic Arch Surgeries?

ABSTRACT Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Preoperative evaluation value of carotid and cerebral arteries by CT angiography in acute type A aortic dissection / 医疗卫生装备

Objective To investigate the feasibility of combined CT angiography(CTA)of head,neck and aorta in acute type A aortic dissection (ATAAD) and whether the incremental craniocervical information benefits the surgeon and leads to improved clinical outcomes.Methods One hundred and twenty ATAAD patients in a CAC group underwent combined aortic CTA and 123 ATAAD patients in a control group underwent conventional aortic CTA.In the CAC group,the image quality was analyzed and critical CTA findings in craniocervical arteries were determined for further surgery procedure.The radiation dose,intraoperative cerebral protection method,and postoperative intensive care units(ICU)time,in-hospital time,neurologic dysfunction(ND)and all-cause mortality were compared between the two groups.Results The CAC group had all the carotid and cerebral arteries diagnosed successfully. There were 13 patients replaced conventional unilateral antegrade selective cerebral perfusion with bilateral one according to the head and neck CTA images in the CAC group. The CAC group had effective radiation dose,postoperative ND,ICU time and in-hospital time significantly lower than those of the control group (P<0.05).There were no statistical differences between the all-cause morbidities of the two groups (P>0.05).Conclusion A combined CTA of head, neck and aorta in ATAAD is feasible. The incremental craniocervical information may lead to improved clinical outcomes.

Significance of the level of B-type natriuretic peptide in acute aortic dissection / 中国综合临床

Objective To investigate the relationship among the levels of B-type natriuretic peptide (BNP) and the extent,prognosis of acute aortic dissection (AAD).Methods The serum levels of BNP were measured in 42 AAD cases.According to the increasing level of BNP,the patients were divided into two groups:group A ( BNP≥ 500 ng/L,n =23 ) and group B ( BNP ＜ 500 ng/L,n =19 ).The extent of the disease and cardiovascular events were compared between the two groups.Results All the patients have elevated levels of BNP.The incidence of lasting aortic dissection (47.83％ vs.15.79％,P =0.048 ) and mortality ( 26.09％ vs.0,P =0.024) were higher in group A compared with those of group B.Conclusion The lasting and higher levels of BNP predict the increasing risk of bad prognosis in acute aortic dissection.

Clinical analysis of obstructive sleep apnea-hypopnea syndrome and aorta dissection / 中国综合临床

Objective To analyze the clinical features of obstructive sleep apnea-hypopnea syndrome(OSAHS)with initial diagnosis of aorta dissection(AD)and therefore to improve its diagnosis.Methods The clinical data of 6 cases of AD with OSAHS were retrospectively analyzed.Results There were six male cases of obesity whose average body mass index(BMI)was 32.72±3.57,with an average age of(43.83±2.14)and the leading symptoms were daytime hypersomnolence,nocturnal wake by suffocation and habitual snoring.ESS was(13.83±2.14),apnea hypopnea index(AHI)was≥62/h[on averaga of(73.35±9.16)/h],the lowest pulse oxygen saturation(LSpO2%)was(58.67±10.95)%,time of oxygen saturation level lower than 90%(min)[T90(min)]was(244.20±144.74)min,the percent of the total time with oxygen saturation level lower than 90%(TS90%)was 54.48±30.18.They had more than two years history of hypertension.Conclusion Severe OSAHS affects the prognosis of AD.Early diagnosis and timely treatment can delay the progress of AD and lower death rate,with an important significance in improving the prognosis of AD.

Primary Stent Placement for Chronic Spontaneous Infrarenal Abdominal Aortic Dissection: A Case Report

Spontaneous infrarenal abdominal aortic dissection (SIAAD) is a rare entity with various clinical presentations. We recently encountered the even rarer condition of a female patient suffering from chronic SIAAD with multiple intimal flaps and prominent lumbar artery collaterals; this all caused stenotic changes of the infrarenal abdominal aorta and produced progressive lower extremity pain and claudication in both her legs. This patient's condition was successfully managed by primary stent placement followed by balloon angioplasty.

Aortic Dissection Presenting with Secondary Pulmonary Hypertension Caused by Compression of the Pulmonary Artery by Dissecting Hematoma: A Case Report

The rupture of an acute dissection of the ascending aorta into the space surrounding the pulmonary artery is an uncommon occurrence. No previous cases of transient pulmonary hypertension caused by a hematoma surrounding the pulmonary artery have been documented in the literature. Herein, we report a case of acute aortic dissection presenting as secondary pulmonary hypertension.

Percutaneous Endovascular Stent-Graft Treatment of Aortic Aneurysms and Dissections: New Techniques and Initial Experience

PURPOSE: To evaluate the feasibility, safety and effectiveness of a newly designed percutaneously implanted separate stent-graft (SSG) for the treatment of aortic aneurysms and dissections. MATERIALS AND METHODS: Using a percutaneous technique, SSG placement (in the descending thoracic aorta in 26 cases and infrarenal abdominal aorta in 24) was attempted in 50 patients with aortic aneurysms (n=27) or dissection (n=23). All SSGs were individually constructed using self-expandable nitinol stents and a Dacron graft, and were introduced through a 12 F sheath and expanded to a diameter of 20-34 mm. In all cases, vascular access was through the femoral artery. The clinical status of each patient was monitored, and postoperative CT was performed within one week of the procedure and at 3-6 month intervals afterwards. RESULTS: Endovascular stent-graft deployment was technically successful in 49 of 50 patients (98%). The one failure was due to torsion of the unsupported graft during deployment. Successful exclusion of aneurysms and the primary entry tears of dissections was achieved in all but three patients with aortic dissection. All patients in whom technical success was achieved showed complete thrombosis of the thoracic false lumen or aneurysmal sac, and the overall technical success rate was 92%. In addition, sixteen patients demonstrated complete resolution of the dissected thoracic false lumen (n=9) or aneurysmal sac (n=7). Immediate post-operative complications occurred at the femoral puncture site in one patient with an arteriovenous fistula, and in two, a new saccular aneurysm developed at the distal margin of the stent. No patient died, and there was no instance of paraplegia, stroke, side-branch occlusion or infection during the subsequent mean follow-up period of 9.4 (range, 2 to 26) months. CONCLUSION: In patients with aortic aneurysm and dissection, treatment with a separate percutaneously inserted stent-graft is technically feasible, safe, and effective.

CT Findings of Aortic Intramural Hematoma with or without associated Penetrating Aortic Ulcer

PURPOSE: To analyze the CT findings of aortic intramural hematoma (IMH) with or without associated penetrating aortic ulcer (PAUH), as seen on initial and follow-up CT scans. MATERIALS AND METHODS: We retrospectively analyzed the CT findings of 36 cases diagnosed clinically and radiologically as IMH (n=7) and PAUH (n=29) after initial and follow-up CT scanning. The period between initial and follow-up scanning-which was performed between two and four times-ranged from 1 week to 91 months (mean: IMH, 18.4 months;PAUH, 16.2 months). RESULTS: With regard to maximal thickness and extension of IMH, maximal diameter of the involved aorta, inward displacement of intimal calcification, Stanford type of IMH, and pleural and pericardial effusion between IMH & PAUH, the results were not statistically significant, but PAUH tends to develop in older patients and shows a more frequent incidence of aortic atherosclerosis. Only PAUH involved abdominal aortic a-neurysm and focal right renal infarction, each in one case. Penetrating aortic ulcers (PAU) were more frequently found in the proximal descending thoracic aorta (n=24) than in the mid(n=11) to distal(n=10) descending thoracic aorta. Among 53 cases of PAU, seven could not be detected on initial CT scans; this was due to excessive scan thickness (n=4) and masking of the aortic ulcer by IMH(n=3), circumstances which were visualized after resolution of IMH. Follow-up CT scanning showed that PAU progressed to fusiform or saccular aortic dilatation (n=15) or localized aortic dissection (n=4), and that in 34 cases, there was no interval change. Follow-up CT findings of IMH in cases of PAUH were as follows: Type A (n=8), with four resolutions after surgery and four after conservative treatment; Type B (n=21), with 21 resolutions after conservative treatment. Follow-up CT findings of IMH were as follows: Type A (n=2), with one resolution after surgery and one after conservative treatment; Type B (n=5), with progression of typical aortic dissection in two cases, and three resolutions after conservative treatment. CONCLUSION: PAUH is characterized by its occurrence in older patients, a more frequent incidence of aortic atherosclerosis and abdominal aortic aneurysm, but no difference in the extension of IMH and other CT findings between PAUH and IMH. Branch vessel involvement was noted in one case of PAUH but not in cases of IMH. Follow-up CT scanning showed that in the absence of surgery, IMH progressed to aortic dissection or resolution. In all patients who did not undergo surgery, PAU progressed to saccular or fusiform aortic dilatation, localized aortic dissection and no interval change, with resolution of IMH after conservative treatment. Initial and follow-up thin-slice spiral CT scanning can provide correct diagnosis and treatment planning (especially ascending aorta is involved), and permit differentiation between PAUH and IMH.

Evaluation of Acute Aortic Dissection by Use with Gadolinium Enhanced MR Angiogra p hy: Comparison withSpin-echo MR Image

PURPOSE: To compare the usefulness of Gadolinium-enhanced MR angiography(Gd-MRA) with spin-echo(SE) MRI forthe evalvation of acute aortic dissection. MATERIALS AND METHODS: During a recent one-year period weretrospectively reviewed the results of SE MRI and Gd-MRA in 14 patients (10 males, 4 females; mean age 57 years)with acute aortic dissection. DeBakey type I was found in six patients, DeBakey type II in one, and DeBakey typeIII in seven. MR techniques were as follows. First, multislice multiphase images were obtained in axial, coronaland oblique sagittal planes using SE T1WI(TR/TE/flip angle=600/14/90; acquisition time=25min), and images ofselected slices were obtained using breath-hold turbo SE T2WI(TR/TE/flip angle=800/76/160). Second, breath-holdGd-MRA imaging (3D-FISP; TR/TE/Flip angle=4.2/1.7/25; acquisition time=1min) was performed, with oblique sagittal(arch view) orientation. We compared 14 SE MRI images with nine thoracic and five abdominal Gd-MRA images,evalvating the presence and extent of intimal flap, entry and reentry tear, thrombus in false lumen (andcomparison to true lumen), the involvement of major branching vessels of the aortic arch, the origin of majorabdominal branching vessels, the presence of hemothorax and hemopericardium. RESULTS: Both SE MRI and Gd-MRA veryaccurately detected the extent of intimal flap, and false lumen status. For detecting the site of entry tear, andthe involvement of major branching vessels at the aortic arch, Gd-MRA(n=12) was more accurate than SE MRI(n=7).When used to image 20 vessels in five patients, Gd-MRA identified with perfect accuracy the origin of majorabdominal branching vessels; SE MRI, however, demonstrated only six of 20 vessels. SE MRI, however, was muchsuperior for the identification of complications such as hemothorax(n=9) and hemopericardium(n=2); in thisrespect, Gd-MRA failed completely. CONCLUSION: For the evaluation of patients with acute aortic dissection, Gd-MRAprovides information regarding site of entry tear and the involvement of major branching vessels very much fasterthan SE-MRI. In such cases, Gd-MRA can therefore be used for initial investigatory imaging.

Postoperative Assessment of Aortic Dissection: The Usefulness of MR Imaging and MR Angiography

PURPOSE: To demonstrate the usefulness of MR imaging and MR angiography in the evaluation of patients whohave undergone surgery for DeBakey type1 or 2 aortic dissection. MATERIALS AND METHODS: Nineteen patients who hadundergone surgery for DeBakey type I(n=13) or type II(n=6) aortic dissection were included in our study. Graftinterposition had been performed in 11 patients, ascending aorta replacement in five, and hemi-arch or total archreplacement in three. MRI was performed 3-40 months(mean:12.5) months after surgery. Twenty(turbo) spin-echo MRimages and 12 contrast-enhanced MR angiographs(3-D FISP) of 19 patients were retrospectively analyzed with regardto perigraft site(perigraft thickness or thrombus), graft site(anastomotic site, deformity of graft), status ofremnant false lumen(remnant intimal flap, flow in false lumen, size, and shape), and involvement of arch vessels. RESULTS: Perigraft sites were demonstrated on spin-echo axial images (9/11), and in no case was theredemonstrable hematoma or perigraft flow. Distal anastomotic sites were identifiable in 17 of 20 cases, and graftredundancy was noted in eight. Remnant false lumen distal to the graft vessel was present in all patients who hadundergone DeBakey type 1 aortic dissection(n=14). Flow in the false lumen was also demonstrated in all DeBakeytype 1 cases on spin-echo images and MR angiography. Remnant false lumen increased in size in six of 14 cases, andtended to show a concave margin to true lumen compared with preoperative imaging. In 8 of 9 patients whose archvessels had been preoperatively involved, intimal flaps in arch vessels remained. CONCLUSION: MR imaging is auseful tool for the postoperative assessment of patients who have undergone aortic dissection. In addition,remnant intimal flap, flow dynamics in false lumen, and involvement of arch vessels can be easily identified by MRangiography.

Helical CT Angiography of the Whole Aorta and Iliac Arteries by Injection of Split Bolus Contrast Media: Comparison with single Bolus Injection Technique

PURPOSE: To compare the efficacy of the split-bolus contrast media injection technique in helical CTangiography(CTA) of the whole aorta and iliac arteries with that of the single-bolus technique. MATERIALS AND METHODS: Using the split bolus technique in 23 patients, 90 ml of contrast medium (Ultravist 300) was injected ata rate of 3ml/sec;this was followed by an 8-sec pause and the subsequent injection of 30ml. Using the single bolustechnique in another 23 patients, 120ml of contrast medium was injected for 40sec. continuously. CT angiography ofthe thoracic aorta (slice thickness/pitch=3mm/2:1) was performed, first followed by an interscan delay of 8sec,and the abdominal aorta and iliac arteries were then scanned(slice thickness/pitch=3mm/2:1 or 5mm/1.5:1). In allpatients, CT density was measured in the aortic lumen at eight levels, from the origin of the aorta to the iliacbifurcation. RESULTS: Using the split bolus technique, visual assessment revealed second density peak in theaortic lumen of the upper abdomen in 15 of 23 patients(65%), while the use of the single bolus technique revealedno second density peak in any patient. CT density in the aortic lumen at the level of the esophagogastricjunction, and at all levels below this except the abdominal aortic bifurcation, was significantly higher using thesplit bolus technique than with the single bolus technique (t-test, p<0.05). CONCLUSION: For CTA of the wholeaorta and iliac arteries, the split bolus technique is more effective than the single bolus technique.

Acute Aortic Intramural Hematoma

PURPOSE: To evaluate the radiologic findings of acute intramural hematoma of the aorta, and the clinical follow up thereof. MATERIALS AND METHODS: Among 34 cases confirmed clinically and radiologically as aortic dissection, an analysis was carried out based on 15 cases in which intramural hematoma without false lumen was demonstrated, on initial CT, 12 cases of in which follow up CT was used and five cases involving an aortogram. Elements such as the shape of the thickened aortic wall, ulcer-like intimal defects, and intimal calcification were examined. Changes in these elements were also examined on follow up CT. RESULTS: DeBackey types I and III accounted for one and 14 cases. respectively. Initial precontrast CT demonstrated continuous, crescentic high attenuation areas along the wall of the descending aorta. In postcontrast scans, the crescentic areas were of relatively lower-attenuation and appeared along the aorta wall. Displaced intimal calcifications were seen in nine of fifteen patients. There was no intimal flap on all five aortogram, while aortic wall thickening and atherosclerotic change were demonstrated in four cases and in one case, case, respectively. Focal ulcers were seen in three cases. Ulcer-like intimal defects were demonstrated in a total of eleven cases (eight on CT, two on aortogram, and one on both). In ten of the twelve cases seen on follow up CT, the thickness of the intramural hematoma was seen to be reduced. Among the 15 cases, the operation was performed in two cases, and the remaining 13 received conservative treatment. In ten cases observed for more than twelve months, a recurrence of symptoms did not occur. CONCLUSION: Eccentric aortic wall thickening in patients who complain of acute chest pain is the result of acute aortic dissection with intramural hematoma, or a penetrating atherosclerotic ulcer of the aorta.The latter may be differentiated from the former by the presence of on ulcer-like intimal defect. When both diseases are limited to the descending aorta, conservative treatment may be effective, unless patients experience persistent or recurrent chest pain, or unless intramural hematoma progresses further.

Aortic Intramural Hematoma: Assessment of Clinical and Radiological Features in Comparison to Acute Aortic Dissection

PURPOSE: To compare the clinical and radiological features of aortic intramural hematoma(IMH) to those of acute aortic dissection(AD). MATERIALS AND METHODS: We analyzed the clinical and radiological features of 12patients with aortic IMH and 43 patients with acute AD. In aortic IMH, the diagnoses were made by means of both CTand transesophageal echocardiography (TEE) and included two surgically proven cases. In acute AD, the diagnoses were made by means of CT and TEE and included 21 surgically proven cases. We com- pared patients ages, etiologies, the extent of the disease, the presence or absence of aortic branch involvement, complications, and outcomes. RESULTS: Aortic IMH tended to develop in older patients (67.8+/-7.9 vs. 50.4+/- 13.4, P.05). In aortic IMH, there was no involvement of aortic branches, whereas in acute AD, 14 (33%) patients showed involvement of one or more aortic branches. Complications of aortic IMH included pericardial effusion (n=2) and pleural effusion (n=4) ; in acute AD, pericardial effusion (n=7), pleural effusion(n=4), aortic insufficiency (n=8), cerebral infarction (n=3), renal infarction (n=4) and spinal infarction (n=1)were seen. There was one (8%) death due to aortic IMH and ten (23%) deaths due to acute AD (p<.01). CONCLUSION: Aortic IMH is characterized by its occurrence in older patients with hypertension, a less frequent incidence of complications, and a more favorable outcome than acute AD.

Prevention of paraplegia after endovascular exclusion for Stanford B thoracic aortic dissection aneurgsm / 介入放射学杂志

Objective To assess the prophylactic measures of paraplegia and paralysis after endovascular graft exclusion(EVE) for Stanford B thoracic aortic dissections(TAD). Methods The records of 116 consecutive patients undergoing endovascular TAD repair from 1998 to 2001 were retrospectively reviewed. Steroids were administrated postoperatively in high risk patients likely to be candidates for paraplegia or paralysis. Results No paraplegia or paralysis occurred postoperatively in all cases, including the patient undengone selective spinal artery angiography (SSAA). Conclusions Transluminal repair can avoid spinal cord ischemia due to aortic cross-clamping, there is still a risk of spinal cord injury caused by occlusion of intercostal arteries under the cover of endograft. A combination of the prophylactic measures, including SSAA and steroids, have been able to reduce the risk of paraplegia and paralysis. A graft-stent of appropriate length is the key point fo this procedure.