Medical management of acute type a aortic dissection in association with early open repair of acute limb ischemia may prevent aortic surgery

Improving the Hospital Transfer Process for Acute Type A Aortic Dissections

Patients with acute type A aortic dissection who arrive at hospitals that lack the facilities to treat them must be transferred to a tertiary care facility to receive treatment. The transfer process involves a checkpoint at which the transfer is accepted or denied. Delays in making this decision may lead to suboptimal health outcomes. In light of this, the goal of this project was to devise a way to reduce the time to decision of transfer requests for patients with an acute type A aortic dissection. The project followed the Define-Measure-Analyze-Improve-Control (DMAIC) approach. To better understand the process, data were obtained from the University of Texas Southwestern Medical Center regarding reasons for patient transfer cancellation and the average time until a transfer was denied or accepted. After data analysis, a fishbone diagram was used to display 23 root causes of the delays in time to decision of the transfer request. These were narrowed down to the following four significant causes using a nominal voting technique: (1) no standard on disease-specific information for the handoff, (2) lack of a real-time database, (3) incompatible electronic health record system between facilities, and (4) multiple communication handoffs causing confusion. Solutions to each root cause were evaluated using a solution selection matrix. The final two solutions proposed for implementation were as follows: (1) to establish checklists of required documents and patient transfer criteria and (2) to create a regional database to provide real-time information on hospital capacity.

An atypical presentation of aortic dissection: echocardiography for accurate detection

BACKGROUND

Aortic dissection (AD) is a relatively rare but dreadful illness, often accompanied by severe, sharp (or 'tearing') back pain or anterior chest pain, as well as acute hemodynamic compromise. Painless dissection has also been reported in rare cases. Echocardiography has become the most commonly used imaging test for evaluating cardiovascular disease and, thus, plays an important role in aortic disease diagnosis and follow-up.

CASE PRESENTATION

This paper presents the case of a 63-year-old female presenting a chronic cough for more than 30 days, accompanied by chest pain radiating to the left scapula, a history of chronic hypertension, and recent chest x-ray findings of mediastinal mass on the upper left of the aortic knob. Transthoracic echocardiography (TTE) shows a clear image of a dissection flap on the ascending aorta and abdominal aorta, with a false lumen that is larger than the true lumen and filled with intramural thrombus. A transesophageal echocardiography (TOE) examination performed later shows a clear entry tear near the sinuses of Valsalva directly above the ostium of the right coronary artery (RCA). The patient was diagnosed with AD Stanford A de Bakey Type 1. Computed tomography (CT) focusing on the thoracoabdominal aorta and coronary artery was ordered upon suspicion of RCA ostium obstruction by the dissection flap and to further direct the surgical management. However, later on, the patient refused to undergo surgery, opting instead for conservative medical therapy.

CONCLUSION

The diagnosis of AD is challenging. Our case emphasizes the vital role of TTE in diagnosing AD, particularly in patients with atypical symptoms in which the diagnosis of AD might not be considered. Such missed AD diagnoses can lead to precarious outcomes.

Aortic dissection in Indonesia male: 3 case report

Background

Aortic dissection (AD) is a life-threatening rare condition caused by a tear in the aortic wall which requires urgent surgery.

Case presentation

3 Indonesian males obtained a CT angiography (CTA) showing a picture of AD which was confirmed using the Stanford and De Bakey classification. The patient was successful in undergoing TEVAR and open-heart surgery which 2 patients survived and 1 patient died.

Discussion

The speed of handling in AD is the key to successful management of AD supported by an understanding of the signs and symptoms and results of thoracoabdominal CTA.

Conclusion

The ability to interpret CTA results and understand AD sign symptoms is very helpful in minimizing mortality.

Acute Type A Aortic Dissection Confounded by Aberrant Symptoms

Acute aortic dissection (AAD) is a cardiovascular emergency that requires emergent surgical, endovascular, or medical intervention depending on the portion of the aorta implicated, as dictated by the Stanford classification, and the extent of aortic involvement. Acute chest pain radiating to the back is typically seen in AAD and may be associated with radial pulse deficits. A high index of suspicion is required to diagnose and initiate management of this emergency as early as possible. This is a report of an atypical presentation of an extensive aortic dissection identified in a young man without most of the typical risk factors, but which was promptly diagnosed and treated.

The effect of beta-blockers on hemodynamic parameters in patient-specific blood flow simulations of type-B aortic dissection: a virtual study

Aortic dissection (AD) is one of the fatal and complex conditions. Since there is a lack of a specific treatment guideline for type-B AD, a better understanding of patient-specific hemodynamics and therapy outcomes can potentially control the progression of the disease and aid in the clinical decision-making process. In this work, a patient-specific geometry of type-B AD is reconstructed from computed tomography images, and a numerical simulation using personalised computational fluid dynamics (CFD) with three-element Windkessel model boundary condition at each outlet is implemented. According to the physiological response of beta-blockers to the reduction of left ventricular contractions, three case studies with different heart rates are created. Several hemodynamic features, including time-averaged wall shear stress (TAWSS), highly oscillatory, low magnitude shear (HOLMES), and flow pattern are investigated and compared between each case. Results show that decreasing TAWSS, which is caused by the reduction of the velocity gradient, prevents vessel wall at entry tear from rupture. Additionally, with the increase in HOLMES value at distal false lumen, calcification and plaque formation in the moderate and regular-heart rate cases are successfully controlled. This work demonstrates how CFD methods with non-invasive hemodynamic metrics can be developed to predict the hemodynamic changes before medication or other invasive operations. These consequences can be a powerful framework for clinicians and surgical communities to improve their diagnostic and pre-procedural planning.

A Case of Aortic Dissection Presenting with Atypical Symptoms and Diagnosed with Transthoracic Echocardiography

We present a case of an extensive aortic dissection (AD) identified in a woman with atypical symptoms. Transthoracic echocardiography (TTE) allowed the identification of an intimal flap in multiple locations and resulted in rapid diagnosis and treatment. In most cases, CT angiography is the imaging modality of choice for diagnosis of AD. TTE is rapid and accurate and can be used in kidney failure. Our case highlights the important role of bedside echocardiography in the diagnosis of AD, especially in the patient with a typical symptoms in whom this diagnosis of AD may not be entertained and actually missed leading to negative and possibly deadly consequences.

Aortic Dissection: An Easily Missed Diagnosis when Pain Doesn't Hold the Stage

Case series

Patients: Male, 73-year-old • Female, 70-year-old

Final Diagnosis: Aortic dissection

Symptoms: Paresis

Medication: —

Clinical Procedure: —

Specialty: Neurology

A single-center experience of hemofiltration treatment for acute aortic dissection (Stanford type A) complicated with postoperative acute renal failure

OBJECTIVE

To investigate the effect of continuous venovenous hemofiltration (CVVH) for aortic dissection patients with acute renal failure after surgery in retrospective manner.

METHODS

A total of thirty-seven aortic dissection patients with postoperative acute renal failure accepted CVVH therapy. The effect of CVVH was evaluated by analyzing clinical condition changes and laboratory examination results.

RESULTS

After treatment of CVVH, renal function and clinical symptoms were significantly improved in thirty patients. Eight of the thirty patients got completely renal function recovery within two weeks after CVVH therapy; and twenty-two of the thirty patients got completely renal function recovery within four weeks after CVVH therapy. Nevertheless, seven patients got no benefit from CVVH therapy with poor prognosis.

CONCLUSION

CVVH is an effective treatment to most aortic dissection patients with postoperative acute renal failure. The effect of CVVH was correlated with original renal function, early CVVH therapy, and continuous intensive care.