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Neurological presentation of acute aortic syndrome: Type A intramural haematoma presenting as ischaemic hemisection of the spinal cord. Spinal Cord Ser Cases 2020; 6:57. [PMID: 32632145 DOI: 10.1038/s41394-020-0306-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/15/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Intramural haematoma (IMH) describes the presence of blood within the aortic wall, and is associated with a significant morbidity and mortality. Early diagnosis is essential for institution of medical, and sometimes surgical, management. Neurological complications have rarely been described during the initial presentation of IMH, or other forms of acute aortic syndrome. CASE PRESENTATION We describe a 56-year-old man who presented with sudden onset chest pain and left leg weakness and numbness, and the loss of right leg pain and temperature sensation. CT Angiography showed a Type A intramural haematoma extending from the ascending to the infra-renal aorta. He was managed successfully with cerebrospinal fluid drainage and thoracic endografting to cover the intimal entry lesion. His neurological symptoms improved and he remained well at 3 years with minor residual neurological deficits. DISCUSSION Spinal cord infarction is a rare but documented complication of acute aortic syndrome; Brown-Séquard syndrome typically results from a traumatic injury. To the best of our knowledge, this is the first report of IMH presenting with Brown-Séquard syndrome. This case highlights the need to consider acute aortic syndromes in a patient presenting with chest pain and acute neurological symptoms.
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Li Q, Chen L, Shen Y, Li J, Dong Y. A modified axillo-femoral perfusion for acute type a aortic dissection accompanied with lower limb malperfusion. J Cardiothorac Surg 2020; 15:10. [PMID: 31918763 PMCID: PMC6953259 DOI: 10.1186/s13019-020-1060-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 01/03/2020] [Indexed: 11/25/2022] Open
Abstract
Background Lower limb malperfusion accompanied with acute type A dissection (AAD) is reported to be an independent predictor for mortality. Timely treatment is required. However, staged approach to restore the perfusion of the ischemic leg before aortic repair has a continuously increase risk of aortic rupture. Aortic repair under isolated axillary artery perfusion also has the risk of prolonging leg ischemia. Here we introduce our experience in performing axillo-femoral perfusion, which is supposed to bring benefits for treating lower limb malperfuison. Methods Thirty patients who suffered AAD accompanied by lower limb ischemia enrolled in our study. All patients received aortic repair as soon as possible using the modified axillo-femoral perfusion approach. The cardiopulmonary bypass and cooling started with the right axillary artery perfusion. Then the femoral artery of the ischemic side was exposed and sewn to a graft connected with another inflow cannula. The rectal temperature was about 31 °C when the femoral perfusion started. The perfusion of the ischemic legs preoperative was estimated after the surgery by the clinical signs, the saturation of the distal-limb, and computed tomography scan. Results Twenty-eight patients got good perfusion of the lower body after the surgery. Two patients received femoral-femoral artery bypass immediately after surgery because of the thrombosis in the right common iliac artery, without further injury. No peripheral vessels damage occurred, and no compartment fasciotomy or amputation needed. One patient died for the sepsis and the subsequent multi organ failure 28 days postoperative. Conclusions The modified axllio-femoral perfusion could restore the lower limbs’ perfusion simultaneously during the aortic surgery without neither delaying dissection repair nor prolonging the ischemic time. It is a simple, but safe and effective technique.
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Affiliation(s)
- Qianzhen Li
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian, China.
| | - Liangwan Chen
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yue Shen
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Jiahui Li
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yi Dong
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian, China
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Tsai KT, Ling X. Surgical treatment of Stanford type A dissection for a patient with situs inversus. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_4_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sandhu HK, Charlton-Ouw KM, Jeffress K, Leake S, Perlick A, Miller CC, Azizzadeh A, Safi HJ, Estrera AL. Risk of Mortality After Resolution of Spinal Malperfusion in Acute Dissection. Ann Thorac Surg 2018; 106:473-481. [PMID: 29559376 DOI: 10.1016/j.athoracsur.2018.02.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/12/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) may develop in patients presenting with acute aortic dissection. We sought to determine how SCI and its recovery affect outcomes. METHODS We reviewed patients with SCI in acute type A aortic dissection (ATAAD) and acute type B aortic dissection (ATBAD) from September 1999 to May 2014. SCI was defined as paraplegia or paraparesis present on admission. Monoparesis/plegia, paraesthesia, or numbness was defined as ischemic neuropathy. All ATBAD patients were managed with antiimpulse therapy, with selective intervention for rupture, rapid aortic expansion, malperfusion, or intractable pain. ATAAD patients were managed with urgent proximal aortic replacement. RESULTS Neurologic symptoms were present in 178 (18.2%) of 978 acute dissections (482 ATAAD and 496 ATBAD). Of these 178 patients, SCI presented in 52 patients (29.2%; 80.1% male; mean age, 57 years). On admission paraplegia was present in 24 (46.2%), paraparesis in 10 (19.2%), paresthesia/numbness in 27 (51.9%), and leg ischemia in 25 (48.1%). Aortic operations were performed in 27 SCI patients (51.9%). Symptom resolution was seen in 30 (57.7%). The 30-day mortality was 19.2% and was significantly less in those with resolution of SCI (6.7% vs 36.4%, p = 0.012). When surgical intervention was required in ATBAD with SCI, mortality was 50% (p = 0.039). SCI and symptom resolution significantly affected overall survival. SCI is associated with significantly increased risk of overall mortality (hazard ratio, 2.9; p < 0.001), and SCI resolution completely offsets this risk (hazard ratio, 0.28; p = 0.003). These effects were consistent between ATAAD and ATBAD (p = 0.554). CONCLUSIONS SCI in acute aortic dissection portends a poor prognosis. However, reversal of deficits is associated with a long-term survival outcome comparable to patients unaffected with SCI.
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Affiliation(s)
- Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Kristofer M Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, Texas
| | - Katherine Jeffress
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Samuel Leake
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Alexa Perlick
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, Texas
| | - Ali Azizzadeh
- Division of Vascular Surgery, Department of Surgery for Programmatic Development, Cedars-Sinai, Los Angeles, California
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, Texas
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, Texas.
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Temporary axillofemoral bypass for reperfusion of an ischemic limb complicating type A dissection. J Thorac Cardiovasc Surg 2015; 151:e111-3. [PMID: 26707721 DOI: 10.1016/j.jtcvs.2015.11.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 11/10/2015] [Accepted: 11/18/2015] [Indexed: 11/20/2022]
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Vohra HA, Moorjani N, Armstrong LA, Ohri SK. Extra-anatomic aorto-femoral graft for acute limb ischemia after type a aortic dissection repair. J Card Surg 2011; 26:397-9. [PMID: 21554394 DOI: 10.1111/j.1540-8191.2011.01263.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We report an alternative approach to revascularization of the leg in a patient with acute type A aortic dissection, where other options were not feasible. An aorto-femoral extra-anatomic conduit was used to salvage the leg after major aortic surgery where further surgery or endovascular grafting would have lead to increased morbidity.
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Affiliation(s)
- Hunaid A Vohra
- Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton, United Kingdom.
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Lin PH, Huynh TT, Kougias P, Huh J, LeMaire SA, Coselli JS. Descending Thoracic Aortic Dissection: Evaluation and Management in the Era of Endovascular Technology. Vasc Endovascular Surg 2008; 43:5-24. [DOI: 10.1177/1538574408318475] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute aortic dissection is a relatively uncommon but highly lethal condition. Without proper treatment, devastating consequences can occur due to aortic rupture, cardiac tamponade, or irreversible ischemia involving the spinal cord or the visceral organs. The treatment strategy of this condition is in part influenced by the location and the severity of aortic dissection as immediate surgical intervention is necessary in acute ascending aortic dissection, whereas medical therapy is the initial treatment approach in uncomplicated descending aortic dissection. Recent advances of endovascular technology have broadened the potential application of this catheter-based therapy in aortic pathologies, including descending thoracic aortic dissection. In this article, the etiology, pathogenesis, and classification of this condition are discussed. The diagnostic benefits of various imaging modalities for descending aortic dissection are also discussed. Current treatment strategies, including medical, surgical, and catheter-based interventions, are reviewed. Lastly, clinical experiences of endovascular treatment for descending aortic dissection and various endovascular devices potentially applicable for this condition are discussed.
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Affiliation(s)
- Peter H. Lin
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center,
| | - Tam T. Huynh
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center
| | - Panagiotis Kougias
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center
| | - Joseph Huh
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
| | - Scott A. LeMaire
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
| | - Joseph S. Coselli
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
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Tefera G, Acher CW, Hoch JR, Mell M, Turnipseed WD. Effectiveness of intensive medical therapy in type B aortic dissection: A single-center experience. J Vasc Surg 2007; 45:1114-8; discussion 1118-9. [PMID: 17543672 DOI: 10.1016/j.jvs.2007.01.065] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Accepted: 01/31/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although the mainstay of managing acute descending thoracic aortic dissection (ADTAD) remains medical, certain patients will require emergency surgery for complications of rupture or ischemia. This study evaluates factors that affect outcome and determines which patients previously treated surgically would have been eligible for endovascular repair. METHODS A single-institution retrospective study was conducted of patients who presented with clinical signs of ADTAD that was confirmed by magnetic resonance angiography (MRA) or computed tomography (CT). All patients were admitted to the intensive care unit (ICU) and medically managed to maintain systolic blood pressure<120 mm Hg and heart rate<70 beats/min. Two treatment groups were identified: group 1 received medical treatment only; group 2 received medical treatment plus emergency surgery. Patient demographic and clinical data were correlated with 30-day group mortality and morbidity and need for emergency surgery. The MRA and CT scan images of group 2 were retrospectively reviewed to determine if currently available endovascular treatment could have been done. The Fisher exact test was used to compare between the groups, and P<.05 was considered significant. RESULTS Between 1991 and 2005, 83 patients (55 men) were treated for ADTAD. The mean age was 67 years (range, 38 to 85). Sixty-eight patients (82%) had hypertension, three (3.6%) had Marfan syndrome, and 51 (62%) were smokers. Twenty-five (32%) of the patients were receiving beta-blocker therapy before the onset of their symptoms. Back pain was the most common initial symptom (72.2%). Emergency surgery was required in 19 patients (23%): 12 for rupture or impending rupture, four for mesenteric ischemia, and three for lower extremity ischemia. The need for emergency surgery was significantly higher in smokers (P=.03), in patients>70 years old (P=.035), and in patients who were not receiving beta-blocker therapy before the onset of symptoms (P=.023). The combined overall morbidity rate was 33%, and the mortality rate was 9.6%. Morbidity in group 2 was 64% and significantly higher than the 23% in group 1 (P=.00227). The mortality rate was also higher in group 2 at 31.5% compared with group 1 at 1.6% (P=.0004). Factors affecting the overall mortality included age>70 years (P=.057), previous abdominal aortic aneurysm repair (P=.018), tobacco use (P=.039), and the presence of leg pain at initial presentation (P=.013). As determined from the review of radiologic data, 11 of 13 patients with scans available for review in group 2 could have been treated with currently available endovascular grafts. CONCLUSIONS Intensive medical therapies are effective in preventing early mortality associated with ADTAD. Predictably, the need for emergency surgery carries a high morbidity and mortality rate. Most patients in this series requiring emergency surgery could have been candidates for endovascular therapy had it been available.
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Affiliation(s)
- Girma Tefera
- University of Wisconsin School of Medicine and Public Health, Madison 53792, USA.
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