Axillary artery cannulation improves operative results for acute type a aortic dissection.

BACKGROUND: This study was undertaken to identify preoperative and postoperative predictors of hospital death of patients with acute type A aortic dissection. METHODS: Between May 1,1992, and July 31, 2004, 106 consecutive patients (59 male and 47 female, mean age 62.2 +/- 12.1 years) with acute type A aortic dissection underwent surgery with open technique and cerebral protection by antegrade selective cerebral perfusion. The external iliac artery or femoral artery alone was used for arterial cannulation in 37 patients; however, the right axillary artery was cannulated in 69 patients. Univariate analysis of potential risk factors was performed to identify risk factors for hospital death and was followed by multivariate analysis by a stepwise logistic regression model to identify independent risk factors. RESULTS: Sixteen patients died postoperatively, and the overall hospital mortality rate was 15.1%. Univariate analysis revealed shock (p = 0.020), visceral ischemia (p = 0.007), root replacement (p = 0.041), and absence of axillary artery perfusion (p = 0.003) as significant risk factors for hospital death. Multivariate analysis revealed visceral ischemia (p = 0.0028, odds ratio 18.4) and absence of axillary artery perfusion (p = 0.0014, odds ratio 8.2) as independent preoperative and intraoperative predictors of hospital death. CONCLUSIONS: Achievement of greater success in the surgical treatment of acute type A dissection will require axillary artery cannulation and measures to prevent visceral malperfusion.

Clinical features and long-term outcome of type A and type B intramural hematoma of the aorta.

OBJECTIVE: Most previous reports on intramural hematoma of the aorta have focused on the initial episode. The purpose of this study was to clarify the long-term outcome of intramural hematoma of the aorta. METHODS: Ninety-four cases of intramural hematoma of the aorta (41 type A and 53 type B) were reviewed. There were 69 male and 25 female patients, and their mean age was 66.7 +/- 8.7 years (range, 46-88 years). RESULTS: Eleven (27%) of the patients with type A hematoma and 1 (2%) of the patients with type B hematoma underwent early surgical intervention. Others were treated medically, and the overall hospital mortality was 7% for patients with type versus 2% for patients with type B intramural hematomas of the aorta (P =.315). Twenty-three patients, 9 (22%) with type A and 14 (26%) with type B intramural hematomas of the aorta, underwent late surgical intervention during the follow-up period, and there were no hospital deaths. A total of 23 patients died during the follow-up period, including 6 of intramural hematoma of the aorta-related deaths (3 in the type A group and 3 in the type B group). The estimated freedom from intramural hematoma of the aorta-related events at 1 and 5 years was 70% +/- 8% and 54% +/- 11% for the type A group versus 73% +/- 6% and 58% +/- 8% for the type B group, respectively (P =.972). After excluding the nonintramural hematoma of the aorta-related deaths, the survival rates at 5 and 10 years were 80% +/- 9% and 80% +/- 9% for the type A group and 91% +/- 8% and 81% +/- 11% for the type B group (P =.211). CONCLUSIONS: Intramural hematoma of the aorta-related events occur equally in both types of intramural hematoma of the aorta. We recommend close follow-up for at least 5 years because most intramural hematoma of the aorta-related events occur during this period.

Intramural hematoma and dissection involving ascending aorta: the clinical features and prognosis.

OBJECTIVE: The clinical features and remedies of acute aortic intramural hemorrhage (IMH) are well discussed. This study prospectively analyzes the features compared with those of Type A aortic dissection, and evaluate the treatment modalities and the prognosis with Type A IMH managed by our original program, Eighty-six consecutive patients consisted of acute type A IMH (n = 36) and dissection (n = 50) were diagnosed between January 1994 and March 2002. Patients with IMH were older (mean 67 and 60, P = 0.0017), more hypertensive (P = 0.0015), not hyperlipidemic (P = 0.0042) than those with dissection. The incidences of preoperative pericardial effusion and aortic regurgitation were significantly lower in patients with intramural hematoma than with dissection, respectively (8:28 versus 22:28, P = 0.0366, 4:32 versus 22:28, P = 0.0011). METHODS: Urgent operation was performed for the patients of IMH with cardiac tamponade or rupture and all dissections. Uncomplicated patients of the patients with IMH were treated medically. Late surgical conversion was applied for the medical treated case on any condition with persistent pain, progression to type A dissection, ruptured aneurysm, or aneurysmal enlargement (>60 mm). Operative mortality, late cardiovascular event, and long-term survival were evaluated statistically. RESULTS: Ten urgent surgical repairs were performed with type A IMH patients and one patient died postoperatively. The rest 26 patients were treated medically. The mean follow up period was 39 +/- 28 months. Among the 26 patients, seven were converted surgical intervention. Cardiovascular event free curve on the 26 patients (Kaplan-Meier, CI: 95%) was 65.6% (45.9-85.3), 59.1% (37.5-80.6) at 2, 4 years. There were six dissection and six IMH patients death during follow up. Two of IMH patients died from cardiovascular event. The actuarial survival rate (Kaplan-Meier, CI: 95%) was 87.5% (76.0-99.1):87.9% (66.2-97.1), 81.7% (66.2-97.1):87.9% (78.8-97.0) at 2, 4 years (P = 0.8393). CONCLUSIONS: Type A IMH tends to occur in older, more hypertensive and not hyperlipidemic patients, showed lower incidences of preoperative aortic valve regurgitation and pericardial effusion than dissection. Medical treatment alone was not enough to manage all type A IMH patients, and 47.2% (17/36) of the patients needed surgical intervention. Urgent surgical repair was not necessary for all type A IMH patients to achieve favorable surgical outcome with careful follow-up using imaging modality.

Management of patients with intramural hematoma involving the ascending aorta.

OBJECTIVE: Although intramural hematoma of the aorta is considered a unique pathologic entity, the management of intramural hematoma involving the ascending aorta (type A) has not been well established. The purpose of this study was to establish the optimal mode of management of type A intramural hematoma. METHODS: We treated patients with type A intramural hematoma as follows. Early operation was carried out only for patients with cardiac tamponade, impending rupture, or rupture. Other patients were treated medically, but patients with progression of intramural hematoma during medical follow-up had their treatment converted to surgery. From February 1992 to March 2001, a total of 33 patients with type A intramural hematoma were treated as described here. Patients were divided according to initial treatment into an early surgery group (n = 9) and a medical treatment group (n = 24). Clinical profiles and in-hospital and long-term survival rates were compared between the groups. RESULTS: Compared with the early surgery group, the medical treatment group was younger (64.2 +/- 7.0 years vs 71.7 +/- 8.5 years, P =.0319) and had a greater number of involved segments (3.6 +/- 0.6 vs 3.0 +/- 0.9, P =.0395). Eight patients in the medical treatment group were switched to surgery during follow-up because of progression of intramural hematoma. In-hospital mortality rates in the early surgery and medical groups were 11% and 5% (P =.477), respectively. Cumulative 1- and 2-year survivals were 89% and 89%, respectively, in the early surgery group, and 92% and 81%, respectively, in the medical group (P =.49). CONCLUSION: We concluded that about 70% of type A intramural hematomas could be managed expectantly, and more than 50% could be treated medically alone.

Spontaneous rupture of coronary artery.

We report a case of spontaneous coronary artery rupture (SCAR) 3 months after descending aortic replacement. Cardiac tamponade was confirmed at first by using echocardiography following emergency pericardial centesis. The patient was denied aortic dissection by computed tomography, thereafter diagnosed as SCAR with selective angiography, which revealed a leakage from the left circumflex branch. The patient underwent successful rupture site isolation by bilateral ligation and distal revascularization with aortocoronary bypass with saphenous vein graft.