Common Presentation of an Uncommon Disease: A Fatal Acute Aortic Dissection in a Young Male

@#Acute aortic dissection (AAD) is rare in the paediatric and young adult population. We present a fatal case of acute aortic dissection Stanford B in a young male diagnosed with hypertension. He presented with severe acute abdominal pain with malignant hypertension. He did not have any trauma to the chest or did not have history of an illicit drug abuse. He had no features suggestive of connective tissue disease as well as other typical signs of aortic dissection. The complain of acute, severe abdominal pain which was out of proportion and required multiple doses of intravenous opioid, raised the suspicion of aortic dissection in this case. Point of care sonography (POC) was done in Emergency Department (ED). However, due to its highly operator dependability, the intimal flap was missed. Computed tomography (CT) scan of abdomen was done and confirmed the diagnosis of AAD. Unfortunately, his clinical condition rapidly deteriorated few hours later with no response to surgical intervention and succumbed within 36 hours of admission. We highlighted the importance of the early recognition of this disease as well as the point of care sonography in ED as a diagnostic tool to tackle this time-sensitive disease.

A Case of Aortic Valve Remodeling Operation for Aortic Localized Dissection / 日本心臓血管外科学会雑誌

A 39-year-old man was admitted to our hospital with symptoms of anterior chest pain and slightly dyspnea. At that time, he had chest discomfort, hypertension, and with enlargement of mediastinal shadow on chest X ray. Medical treatment rapidly improved the hypertension and the other symptoms. Transthoracic echocardiography (TTE) and enhanced chest CT revealed aortic root dilation, and trivial aortic valve regurgitation, but these examinations could not identify the cause of such as typical Stanford type A dissection. Transesophageal echocardiography (TEE) and chest MD-CT were undertaken on 7 days after the admission revealed a localized aortic dissection, intimal flap, and enlargement of sinotubular junction (STJ). An Urgent operation was performed. During the operation, a localized aortic dissection appeared to be above the left coronary cusp through the right coronary cusp of the aortic valve, but the valve findings were normal, so we decided to perform a aortic valve remodeling operation. The aortic sinuses were excised leaving 4 mm of arterial wall attached to the aortic annulus and around the coronary arteries. A Woven Dacron graft of diameter equal to the diameter of the STJ was tailored to recreate three aortic sinuses. The three commissures were suspended into the tailored graft and the neo-aortic sinuses were sutured to the aortic annulus and remnants of arterial wall. The coronary arteries were reimplanted into their respective neo-aortic sinuses and the graft anastomosed to the distal aorta. The postoperative course was uneventful. We concluded that this procedure is useful for a localized aortic dissection around the coronary orifice.

Two-end intimal flap suturing method in establishing stanford B type aortic dissection model in canine / 第二军医大学学报

Objective: To search for a satisfactory method for establishing Stanford B type aortic dissection model in canine. Methods: Totally 12 adult dogs were used in the present study. The proximal descending aorta was clamped partially and laterally after a left thoracotomy; half circumference of the aorta, including the media and adventitia,was cut open transversely, with the intima kept intact. The aortic wall was then separated inferiorly, laterally and superiorly at a special dissecting space with a unique dissecting device. Then the intima at the same site was also cut open transversely and the two ends of the distal intimal flap were sutured to the adjacent aorta to allow blood entry. The distal adventitia and media were sutured to the proximal aorta to close the incision. Follow-up was carried out with pigtail catheter guided digital subtraction angiography (DSA) using omnipaque (16-18 ml/s) via either of the common iliac arteries and color Doppler ultrasound. Results: Formation and distal extension of aortic dissections were observed immediately after the procedure and were further confirmed by intra-operative color Doppler ultrasound, DSA, and post-operative biopsy at different time points. Conclusion: The present two-end intimal flap suturing method can be used for establishing Stanford B type aortic dissection model in canine; the model is similar to human Stanford B type aortic dissection.

Traumatic Dissection of Middle Cerebral Artery with Intimal Flap

No abstract available.

A Case Report of Percutaneous Fenestration of the Intimal Flap for Limb Ischemia in the Aortic Dissection

The residual tense false lumen following surgical repair of aortic dissection remains one of the most difficult and challenging postsurgical problems. Percutaneous fenestration of the dissecting membrane under the guidance of intravascular ultrasound has been recently introduced to depressurize the tense false lumen. A 63-year-old woman who underwent repair of acute type I dissection was readmitted because of claudication and numbness of the left lower extremity. Angiography, computed tomography, and magnetic resonance imaging clearly showed a dissection flap starting from the thoracic aorta distal to the left subclavian artery. Compressed true lumen by the markedly enlarged tense false lumen was also noted in the double-channeled descending thoracoabdominal aorta. Under intravascular ultrasound guidance, the intimal flap was punctured with a Brockenbrough needle advanced to the true lumen through a femoral artery, and then, a balloon catheter was introduced over the guidewire which was placed across the dissection flap. Desired fenestration was obtained successfully by inflation of the balloon without complications. After procedure, symptoms resolved promptly and she is currently(clinical follow-up of 12 months postfenestration) ambulating without claudication. In conclusion, percutaneous fenestration of the intimal flap is a technically feasible and an effective alternative procedure to surgical repair for restoration of perfusion to an ischemic extremity in selected patients complicated with aortic dissection.