Coagulopathy associated with residual dissection after surgical treatment of type A aortic dissection

Relationship of acute type A aortic dissection and disseminated intravascular coagulation

OBJECTIVE

Acute type A aortic dissection (ATAAD) is a critical disease presenting with disseminated intravascular coagulation (DIC). However, the relationship between the degree of DIC and false lumen conditions remains unclear. In the present study, we evaluated the degree of preoperative DIC and the outcomes of ATAAD treatment.

METHODS

A total of 124 patients with ATAAD (70 men and 54 women) treated from January 2012 to January 2020 were included in the present study. The correlation between the preoperative Japanese Association for Acute Medicine (JAAM) DIC score and the false lumen diameter and length, measured using preoperative computed tomography, was examined retrospectively. The correlations were calculated using liner regression analysis. The level of statistical significance was set at P < .05.

RESULTS

The patients were divided into two groups: a low JAAM DIC score group and a high JAAM DIC score group. The preoperative JAAM DIC scores in the high- and low-score groups were 4.8 ± 1.2 and 1.7 ± 2.3, respectively (P < .001). The 5-year survival rates and aortic event-free rates in the low-score group were favorable compared with the high-score group; however, the differences were not statistically significant (80.8% vs 54.5%, P = .065; 63.9% vs 59.8%, P = .15, respectively). The false lumen diameter in the ascending aorta was greater in the high-score group than that in the low-score group (P < .05). The JAAM DIC score correlated significantly with the ascending false lumen diameter and the dissection length (r = 0.32 and P < .001; r = 0.29 and P = .001, respectively). A high JAAM DIC score was associated with communicating-type ATAAD (P < .05).

CONCLUSIONS

Our results suggest that high preoperative JAAM DIC scores are associated with a large false lumen and communicating-type ATAAD.

Use of coagulation-fibrinolysis markers for prognostication of Stanford type A acute aortic dissection

Purpose

Coagulation-fibrinolysis markers are widely used for the diagnosis of Stanford type A acute aortic dissection (SAAAD). However, the role of these markers in estimating prognosis remains unclear.

Methods

A single-center retrospective study was conducted to identify the relationship between preoperative D-dimer and fibrinogen levels on SAAAD postoperative early prognosis.

Results

Of 238 SAAAD patients who underwent surgery between January 2012 and December 2018, 201 (84.5%) and 37 (15.5%) patients constituted the survival and non-survival groups, respectively, 30 days after surgery. D-dimer and fibrinogen levels in the survival and non-survival groups were 45.2 ± 74.3 vs. 91.5 ± 103.6 μg/mL (p = 0.014) and 224.3 ± 95.6 vs. 179.9 ± 96.7 μg/mL (p = 0.012), respectively. According to logistic predictor analysis of 30-day mortality, significant factors showed patent type (OR 10.89, 95% CI 1.66–20.31) and malperfusion (OR 4.63, 95% CI 1.74–12.32). Increasing D-dimer (per +10 μg/mL) and decreasing fibrinogen (per −10 μg/mL) were significantly associated with patent type and malperfusion. Receiver operating characteristic analysis was performed to distinguish between survival and non-survival. The cutoff value of D-dimer was 60 μg/mL (sensitivity 61.1%; specificity 82.5%; area under curve [AUC] 0.713 ± 0.083); fibrinogen was 150 mg/dL (sensitivity 44.4%; specificity 84.0%; AUC 0.647 ± 0.092). Kaplan-Meier survival curve analysis showed that patients with D-dimer levels > 60 μg/mL and fibrinogen levels < 150 mg/dL had significantly low survival rates at 30 days after surgery (60.0%, p < 0.001).

Conclusion

Preoperative coagulation-fibrinolysis markers may be useful for predicting early prognosis in SAAAD.

Effect of massive blood transfusion on late outcomes after surgical repair of acute type A aortic dissection

Massive blood transfusion (MBT) increased mortality and morbidity after cardiac surgery. However, a mid-term follow-up study on repair surgery of acute type A aortic dissection (AAAD) with MBT was lacking. This study aimed to assess the impact of perioperative MBT on late outcomes of surgical repair for AAAD.There were 3209 adult patients firstly received repair surgery for AAAD between 2005 and 2013, were identified using Taiwan National Health Insurance Research Database. Primary interest variable was MBT, defined as transfused red blood cell (RBC) ≥10 units.The outcomes contained in-hospital mortality, surgical-related complications, all-cause mortality, respiratory failure, and chronic kidney disease (CKD) during follow-up period. Higher in-hospital mortality (37.7% vs 11.6%; odds ratio, 4.00; 95% confidence interval [CI], 3.30-4.85), all-cause mortality (26.1% vs 13.0%; hazard ratio [HR], 1.66; 95% CI, 1.36-2.04), and perioperative complications were noted in the MBT group. A subdistribution hazard model revealed higher cumulative incidence of CKD (13.9% vs 6.5%; HR, 1.95; 95% CI, 1.47-2.60) and respiratory failure (7.1% vs 2.7%; HR, 2.34; 95% CI, 1.52-3.61) for the MBT cohort. A dose-dependent relationship between amount of transfused RBC (classified as tertiles) and cumulative incidence of all-cause mortality, incident CKD, and respiratory failure was found (P of trend test <.001).Patients with MBT had worse late outcomes following surgical repair of AAAD. The cumulative incidence of all-cause mortality, incident CKD, and respiratory failure increased with the amount of transfused RBC in a dose-dependent manner.

False Lumen Embolization with the Candy Plug Technique for Consumptive Coagulopathy after Aortic Repair for Chronic Dissection

Introduction

Chronic aortic dissection rarely causes consumptive coagulopathy due to disseminated intravascular coagulation (DIC).

Report

A 69 year old man who had previously undergone total arch replacement with the frozen elephant trunk procedure for chronic aortic dissection was transferred to our hospital because of sudden back pain. He had a bleeding from the right subscapular artery due to consumptive DIC caused by retrograde blood flow into a residual false lumen (FL). Percutaneous transcatheter embolisation was successfully performed, but DIC findings persisted. Thoracic endovascular aortic repair and FL embolisation with the candy plug technique were performed. Subsequently, DIC improved and FL thrombosis was safely accomplished.

Discussion

In this case, FL thrombosis was safely accomplished with the candy plug technique. This strategy expands options in patients with high risk for open repair.

Predictors and impact of massive bleeding in acute type A aortic dissection

Objectives

Bleeding complications associated with acute type A aortic dissection (aTAAD) are a well-known clinical problem. Here, we evaluated predictors of massive bleeding related to aTAAD and associated surgery and assessed the impact of massive bleeding on complications and survival.

Methods

This retrospective study of 256 patients used Blood Conservation Using Antifibrinolytics in a Randomized Trial (BART) criteria to define massive bleeding, which was met by 66 individuals (Group I) who were compared to the remaining patients (Group II). Multivariable logistic regression was used to identify independent predictors of massive bleeding and in-hospital mortality, Kaplan-Meier estimates for analysis of late survival, and Cox regression analysis to evaluate independent predictors of late mortality.

Results

Independent predictors of massive bleeding included symptom duration (odds ratio [OR], 0.974 per hour increment; 95% confidence interval [CI], 0.950-0.999; P  =   0.041) and DeBakey type 1 dissection (OR, 2.652; 95% CI, 1.004-7.008; P  =   0.049). In-hospital mortality was higher in Group I (30.3% vs 8.0%, P  <0.001). Kaplan-Meier estimates of survival indicated poorer survival for Group I at 1, 3 and 5 years (68.8 ± 5.9% vs 92.8 ± 1.9%; 65.2 ± 6.2% vs 85.3 ± 2.7%; 53.9 ± 6.9% vs 82.1 ± 3.3 %, respectively; log rank P  <   0.001). Re-exploration for bleeding was an independent predictor of in-hospital (OR, 3.109; 95% CI, 1.044-9.256; P  =   0.042) and late mortalities (hazard ratio, 3.039; 95% CI, 1.605-5.757; P  =   0.001).

Conclusions

Massive bleeding in patients with aTAAD is prompted by shorter symptom duration and longer extent of dissection and has deleterious effects on outcomes of postoperative complications as well as in-hospital and late mortalities.

Chronic Aortic Dissection Complicated by Disseminated Intravascular Coagulation: Successful Treatment with Endovascular Stent-Grafting

Purpose:

To report endovascular repair of a chronic aortic dissection complicated by disseminated intravascular coagulation (DIC).

Case Report:

A 61-year-old man developed DIC associated with a chronic Stanford type B aortic dissection that occurred during cardiac catheterization 12 years earlier. At the current admission, computed tomography showed a partially thrombosed false lumen extending from the aortic arch to the left common iliac artery. On angiography, entry and re-entry tears were identified at the right subclavian and left common iliac arteries, respectively. After stent-graft implantation at the entry and re-entry sites, not only was the false lumen completely thrombosed but the DIC also resolved. The patient is doing well with no complication at 16 months after treatment.

Conclusions:

Endovascular stent-grafting is an acceptable alternative to surgical repair for aortic dissection accompanied by DIC.

Acute aortic dissection complicated by fistula from aorta to right ventricle through ventricular septum

A case report of aortic dissection (AoD) complicated by a shunt to the right ventricle is presented. Complications, treatment options, and survival of patients with Type A and Type B AoD are reviewed.

Spontaneous healing of a descending aortic dissection

Spontaneous healing of aortic dissection is very rare. A review of the literature has disclosed only four cases [Zeebregts CJAM, Schepens MAAM, Vermeulen FEE. Spontaneous resolution late after aortic dissection: a case report. Eur J Cardiothorac Surg 1997;12:513-515.]. We describe a Type III case in which a spontaneous resolution of the descending aortic dissection was observed.

Deteriorating consumptive coagulopathy with type III endoleak following endovascular repair for abdominal aortic aneurysm associated with liver cirrhosis

PURPOSE

To report a case of deteriorating consumptive coagulopathy with type III endoleak following endovascular aneurysm repair (EVAR) of the abdominal aorta associated with liver cirrhosis.

CASE REPORT

A 72-year-old man with liver cirrhosis developed type III endoleak following EVAR. Spontaneous intramuscular hematoma developed due to deteriorating consumptive coagulopathy induced by type III endoleak and liver dysfunction. Although additional EVAR was performed at 52 months after primary EVAR, the patient died due to multiorgan failure and multifocal hematoma of the muscles and subserosa.

CONCLUSION

EVAR for patients with liver dysfunction and coagulopathy should be considered with great caution. We suggest that prompt and adequate treatment using an endovascular technique or surgical repair should be performed for patients with liver dysfunction, coagulopathy, and turbulent endoleak, even if the coagulopathies are worse compared to before EVAR.

Anesthesia and Neurocerebral Monitoring for Aortic Dissection

Patients presenting to the operating room for repair of aortic dissection are challenging in all aspects of their care. Without exception, they require a multidisciplinary team approach. This article will review some of the specific challenges faced by anesthesiologists and neurologists when confronted with such a diagnosis. Specifically, we will discuss the myriad anesthetic issues that present in the preoperative stage and continue into the postoperative period. Neurologic complications during dissection repair result in increased morbidity and mortality. A variety of neurophysiologic monitoring techniques exist that may reduce this risk and will be discussed in detail. Finally, we will present some "controversies in care," emphasizing that our respective fields continue to grow, learn, and improve what information we have on the morbidity and mortality of aortic dissection.

Simple and Useful Tests for Discriminating Between Acute Aortic Dissection of the Ascending Aorta and Acute Myocardial Infarction in the Emergency Setting

BACKGROUND

It is important to rapidly distinguish patients with acute aortic dissection of the ascending aorta (AADa) from those with acute myocardial infarction (AMI), because minimizing the time to initiation of reperfusion therapy leads to maximum benefits for AMI and erroneous reperfusion therapy for AADa can produce harmful outcomes. The aim of this study was to find a simple test to distinguish such patients.

METHODS AND RESULTS

Data were collected from 29 consecutive patients with AADa and 49 consecutive patients with AMI who were admitted within 4 h of the onset of symptoms. The D-dimer concentration and the ratio of the maximum upper mediastinal diameter to the maximum thoracic diameter on plain chest radiograph (M-ratio) in the emergency room were studied retrospectively. Setting the cutoff values of the D-dimer concentration and the M-ratio to 0.8 or 0.9 microg/ml and 0.309, respectively, gave a sensitivity of 93.1% and 93.1% for AADa, respectively, and a sensitivity of 91.8% and 85.7% for AMI, respectively.

CONCLUSIONS

The D-dimer value and the M-ratio, with appropriate cutoff values, have potential as tests that can be routinely used to exclude AADa patients from patients diagnosed with AMI prior to reperfusion therapy.

D-dimer in acute aortic dissection

STUDY OBJECTIVE

Laboratory testing plays a minor role in the assessment of aortic dissection. Its main value is in the exclusion of other diseases. Following an incidental observation, we systematically investigated the relationship between elevated d-dimer levels and acute aortic dissection.

DESIGN

We prospectively tested d-dimer levels in patients with suspected acute aortic dissection (10 patients). In addition, we investigated 14 patients who had received a confirmed diagnosis of thoracic aortic dissection during the previous 5 years, in whom d-dimer testing had been performed for differential diagnosis. Thirty-five patients with acute chest pain of other origin served as a control group.

SETTING

Tertiary referral hospital.

PATIENTS

Twelve patients had type A dissection (Stanford classification), and 12 patients had type B.

MEASUREMENTS AND RESULTS

A d-dimer analysis was performed (Tina-quant assay; Roche Diagnostics; Mannheim, Germany) [normal limit of the assay, 0.5 micro g/mL]. The result of the d-dimer test was positive (ie, > 0.5 micro g/mL) in all patients (sensitivity of the test, 100%) with a mean value of 9.4 micro g/mL and a range of 0.63 to 54.7 micro g/mL. The degree of the elevation was correlated to the delay from the onset of symptoms to laboratory testing (mean, 12.6 h; range, 1 to 120 h) and showed a trend to the extent of the dissection, but not to the outcome (14 patients could be discharged; 10 patients died).

CONCLUSIONS

Based on our observation, we suggest that testing for d-dimer should be part of the initial assessment of patients with chest pain, especially if aortic dissection is suspected. A negative test result makes the presence of the disease unlikely.

Chronic disseminated intravascular coagulopathy cured by abdominal aortic aneurysm repair

Disseminated intravascular coagulopathy (DIC) may rarely be caused by a previously asymptomatic abdominal aortic aneurysm (AAA). The authors describe a recent case where repair of the AAA provided a complete cure for the patient's bleeding tendency. The multidisciplinary management of this patient is presented, and the evidence for the rare causal role of AAA in DIC is discussed. Coagulation disorders in aneurysm patients are probably under-reported, and warrant careful perioperative assessment.