Intermittent cocaine use associated with recurrent dissection of the thoracic and abdominal aorta

The Use of Intraoperative Transesophageal Echocardiography in Thoracic Aortic Dissection Due to Chronic Cocaine Abuse

Introduction

Aortic dissection is a life threatening disease and is usually accompanied by a high rate of mortality and morbidity. Here we present a case report in which intraoperative tranesophageal echocardiography was used for intraoperative assessments of thoracic aortic dissection due to cocaine abuse.

Case Presentation

A 45- year- old male was admitted to a university hospital due to severe chest pain. He was suffering from severe excruciating chest pain that had started after a psychological stress, leading to heavy cocaine abuse. He was admitted to the emergency department of the hospital, and was then transferred to the cardiac care unit to control the chest pain. The patient underwent emergent surgery. After induction of anesthesia, tranesophageal echocardiography probe was introduced gently and a full exam was done. The surgeon decided to perform a classic Bentall procedure. Cardiopulmonary bypass was started. Everything was acceptable, but bleeding was uncontrolled. The surgical team could not control the bleeding, and he passed away due to bleeding.

Conclusions

This case report stresses the use of IOTEE as a means for more accurate diagnosis of the lesion under general anesthesia, especially when there is not time to do preoperative TEE, or when bedside echocardiography does not give us adequate data.

Cocaine and aortic dissection

Aortic dissection is a rare, potentially catastrophic vascular emergency. Early recognition of the clinical manifestations, rapid confirmation using imaging modalities, urgent administration of appropriate medication and expedient selection of definitive long-term therapy are key to preserving life and reducing morbidity. In recent years it has become increasingly clear that there is a relation between cocaine and aortic dissection. Cocaine serves as both a predisposing factor to aortic dissection due to its effect on aortic connective tissue and as a precipitating factor due to its propensity to produce abrupt and severe hypertension. While similarities exist in the clinical features and diagnostic methods between cocaine-related aortic dissection and aortic dissection unrelated to cocaine use, there are important differences in management between these two syndromes which are rooted in the pharmacology and physiology of cocaine. An understanding of these differences is key to effective early and long-term management of cocaine-related aortic dissection.

Cocaine-related acute aortic dissection: patient demographics and clinical outcomes

BACKGROUND

To compare the demographics, inpatient mortality and short-term survival following hospital discharge between cocaine-using and non-cocaine-using patients presenting with acute aortic dissection.

METHODS

Retrospective analysis of 46 consecutive patients admitted with the diagnosis of acute aortic dissection at the Mount Sinai Hospital (Chicago, USA) between 1996 and 2005. Among these 46 patients, cocaine use was temporally related to the presenting symptom in 13 patients (28%, group 1). Patients who were not cocaine users were grouped into group 2 (33 patients [72%]).

RESULTS

Patients in group 1 were younger than those in group 2 (mean age 38+/-9 years versus 63+/-17 years, P=0.001), more likely to be smokers (13 of 13 patients [100%] versus 15 of 33 patients [45%], P=0.001) and had a higher prevalence of accelerated hypertension (mean blood pressure 210/130 mmHg) compared with group 2 (10 of 13 patients [77%] versus 11 of 33 patients [33%]) (P=0.01). Group 1 patients had a higher prevalence of type B dissection than group 2 (nine of 13 patients [69%] versus one of 33 patients [3%]). After hospital discharge, eight of 13 patients (62%) in the cocaine group continued to use cocaine. Mortality following hospital discharge was significantly higher in cocaine users (nine of 13 patients [69%]) compared with the non-cocaine users (four of 33 patients [12%], P=0.01). Recurrent dissection was the cause of death in five of the 13 deaths (42%) in the cocaine group.

CONCLUSIONS

Patients presenting with acute aortic dissection temporally related to cocaine use are more likely to be younger, smokers, have higher prevalence of hypertensive crises, more likely to have type B aortic dissection and may have a higher mortality following hospital discharge, possibly due to continued cocaine use and recurrent aortic dissection.

Acute aortic dissection associated with use of cocaine

PURPOSE

Cocaine use can result in a variety of cardiovascular complications, including myocardial infarction, arterial thrombosis, coronary dissection, and cardiomyopathy. Cocaine-induced aortic dissection is uncommon and has been described largely in case reports. The purpose of this study was to review our experience with aortic dissection associated with cocaine abuse.

METHODS

A retrospective chart review was performed of all hospital records during a 15-year period in patients diagnosed with aortic dissection. Among the 164 cases of acute aortic dissection, 16 patients (9.8%) had used cocaine or its derivative, crack cocaine, within 24 hours prior to the onset of symptoms. The remaining 148 patients (90.2%) had no history of cocaine usage. Clinical features, management, and outcome in these two groups were compared.

RESULTS

In the cocaine group, powder cocaine was inhaled intranasally in 11 patients (69%) and crack cocaine was smoked in five cases (31%). The mean duration between cocaine use and the onset of aortic dissection was 12.8 hours (range, 4 to 24 hours). Patients in the cocaine group were younger in age and more likely to have a history of polysubstance abuse than the non-cocaine cohort. In the cocaine group, the incidence of DeBakey dissection type I, II, IIIa, and IIIb was 19%, 25%, 38%, and 19%, respectively. In the group without cocaine use, the incidence of DeBakey dissection type I, II, IIIa, and IIIb was 18%, 23%, 39%, and 20%, respectively. Surgical intervention for aortic dissection was performed in 50% of the cocaine group and 45% of the non-cocaine group. In patients who underwent surgical repair, greater pulmonary complications occurred in the cocaine group than the non-cocaine group (n = 0.02). No difference was noted in the hospital length of stay or 30-day operative mortality among the two groups.

CONCLUSIONS

Cocaine-associated aortic dissection occurs in predominantly male patients with illicit drug abuse who were younger than patients with aortic dissection without cocaine use. Greater pulmonary complications can occur in patients with cocaine-related aortic dissection following surgical interventions.

Radiology of Recreational Drug Abuse

Recreational drug abuse is increasing throughout the world. Use of these drugs may result in a diverse array of acute and chronic complications involving almost any body organ, and imaging frequently plays a vital role in detection and characterization of such complications. The nature of the complications depends to a large extent on the drug used, the method of administration, and the impurities associated with the drug. Radiologically demonstrable sequelae may be seen after use of opiates, cocaine, amphetamines and their derivatives such as 3,4-methylenedioxymethamphetamine ("ecstasy"), marijuana, and inhaled volatile agents including amyl nitrite ("poppers") and industrial solvents such as toluene. Cardiovascular complications include myocardial infarction, cardiomyopathy, arterial dissection, false and mycotic aneurysms, venous thromboembolic disease, and septic thrombophlebitis. Respiratory complications may involve the upper airways, lung parenchyma, pulmonary vasculature, and pleural space. Neurologic complications are most commonly due to the cerebrovascular effects of illicit drugs. Musculoskeletal complications are dominated by soft-tissue, bone, and joint infections caused by intravenous drug use. Awareness of the imaging features of recreational drug abuse is important for the radiologist because the underlying cause may not be known at presentation and because complications affecting different body systems may coexist. Intravenous drug abuse in particular should be regarded as a multisystem disease with vascular and infective complications affecting many parts of the body, often synchronously. Discovery of one complication should prompt the radiologist to search for coexisting pathologic conditions, which may alter management.

Cocaine-associated chest pain

Current estimates establish that more than 30 million people in the United States use cocaine. Cardiovascular complaints commonly occur among patients who present to emergency departments(EDs) after cocaine use, with chest pain the most common complaint in several studies. Although myocardial ischemia and infarction account for only a small percentage of cocaine-associated chest-pain, physicians must understand the pathophysiology of cocaine and appropriate diagnostic and treatment strategies to best manage these patients and minimize adverse outcomes. This article reviews the pharmacology of cocaine, its role in the pathogenesis of chest pain with specific emphasis on inducing myocardial ischemia and infarction, and current diagnostic and management strategies for cocaine-associated chest pain encountered in the ED.

Thoracic aortic dissection associated with cocaine abuse

Cardiovascular complications of cocaine abuse include myocardial ischemia and infarction, dysrhythmias, cardiomyopathies and aortic dissection. The case in point pertains to a 26-year-old, Caucasian male, substance abuser who suffered a thoracic aortic dissection following the use of crack cocaine. The autopsy and histological findings showed a connective tissue abnormality including a focal microcystic medial necrosis and a fragmentation of the elastic fibers in the arterial walls. Blood concentrations of cocaine and benzoylecgonine, taken individually, were considered to be within a potentially toxic range. Blood concentrations of methadone also indicated use of this drug at the same time. The small amounts of morphine found in the blood and urine were compatible with heroine or morphine use more than 24 h before death.

Cocaine and the critical care challenge

OBJECTIVE

Cocaine, which first made its appearance >1,000 yrs ago, is now widely used throughout the world. The physiologic responses to cocaine may cause severe pathologic effects. This review highlights the many critical care challenges resulting from these effects.

DESIGN

Historical vignettes, epidemiologic factors, modes of preparation and delivery, and the physiologic and pharmacologic effects of these agents are presented.

SETTING

Cocaine causes intense vasoconstriction, which potentially causes damage to all organ systems. Examples of these toxicities are presented.

PATIENTS

The adverse multisystem responses to cocaine exposure produce organ failure, which challenges diagnostic accuracy and therapeutic intervention. Organ system failure involves the brain, heart, lung, kidneys, gastrointestinal tract, musculature, and other organs. These harmful effects are additive to preexisting organ dysfunction.

INTERVENTION

Recognition of associated cocaine injury alerts the physician that organ dysfunction is more likely to occur and to be more severe. Such anticipation helps plan for therapy in the critical care setting.

RESULTS AND CONCLUSIONS

Cocaine use is an expanding health hazard, despite intense governmental efforts to contain its distribution and use. Recognition of the signs and symptoms of cocaine toxicity help anticipate the subsequent organ dysfunction and implement earlier organ system support.

Thoracic complications of illicit drug use: an organ system approach

Illicit drug use constitutes a major health problem and may be associated with various thoracic complications. These complications vary depending on the specific drug used and the route of administration. Commonly abused drugs that may play a role in causing thoracic disease include cocaine, opiates, and methamphetamine derivatives. Intravenously abused oral medications may contain filler agents that may be responsible for disease. Thoracic complications may be categorized as pulmonary, pleural, mediastinal, cardiovascular, and chest wall complications. Pulmonary complications of drug abuse include pneumonia, cardiogenic edema, acute lung injury, pulmonary hemorrhage, and aspiration pneumonia. Filler agents such as talc may result in panacinar emphysema or high-attenuation upper-lobe conglomerate masses. The primary pleural complication of illicit drug use is pneumothorax. Mediastinal and cardiovascular complications of illicit drug use include pneumomediastinum, cardiomyopathy, myocardial infarction, aortic dissection, and injection-related pseudoaneurysms. Chest wall complications include diskitis and vertebral osteomyelitis, epidural abscess, necrotizing fasciitis, costochondritis, and septic arthritis. Categorization of thoracic complications of illicit drug use may facilitate understanding of these disorders and allow accurate diagnosis.

Acute aortic dissection related to crack cocaine

BACKGROUND

Although single case reports have described acute aortic dissection in relation to cocaine use, this condition is not widely recognized, and the features of cocaine-related aortic dissection have not been defined.

METHODS AND RESULTS

We reviewed all available hospital charts from 1981 to 2001 with the ICD-9 diagnosis of aortic dissection. Among the 38 cases of acute aortic dissection, 14 (37%) were related to cocaine use. Crack cocaine was smoked in 13 cases and powder cocaine was snorted in 1 case. The mean interval between cocaine use and the onset of symptoms was 12 hours (range, 0 to 24). Patients with cocaine-related dissection were much younger and more likely to undergo surgery compared with patients with aortic dissection without cocaine use. Most in the cocaine group were black, with a history of untreated hypertension. However, the two groups did not differ in other respects, including dissection type.

CONCLUSIONS

In an inner city population, acute aortic dissection in the setting of crack cocaine use is common, presumably as a consequence of abrupt, transient, severe hypertension and catecholamine release. This diagnosis should be considered in cocaine users with severe chest pain.

COCAINE USE AND ACUTE MYOCARDIAL INFARCTION

Cocaine use in the United States is widespread, affecting more than 30 million Americans. Although many of these persons do not seek healthcare, the overriding cause for hospitalization is cocaine-associated chest pain. Because only a minority of these patients suffer myocardial injury, it is important to exclude even rarer life-threatening causes for chest pain, such as aortic dissection or pneumothorax. Following that, a thorough knowledge of the pathophysiology and existing literature helps to provide cost-effective care, which focuses resources on those patients most likely to suffer complications. Regardless of the severity of complications, referral to cocaine detoxification programs, counseling, social support, and outpatient follow-up care for modification of cardiac risk factors is a fundamental component of long-term patient care.

Etiologic factors of acute aortic dissection in children and young adults

Current concepts in the pathophysiology and predisposing conditions of acute aortic dissection in children, adolescents, and young adults are presented. Timely diagnosis is required for this life-threatening condition. Most children and adolescents with aortic dissection have congenital cardiovascular anomalies. Certain heritable disorders involving connective tissue also predispose to this disorder. Newer associations include cocaine abuse and weight lifting. To facilitate early diagnosis, the salient physical findings of the known predisposing conditions are reviewed. Clinical presentation and diagnostic imaging of aortic dissection are briefly summarized. Physicians working in an acute care setting, particularly in the emergency room, should be aware of disorders predisposing to acute aortic dissection in the pediatric and young adult population. Practitioners conducting school or college preparticipation sports evaluations can make use of such information in their assessment of risk for sudden death.

Aortic dissection

The presentation of aortic dissection in the emergency department may be more subtle than the classic description of a shocked patient with "ripping" chest pain. The epidemiology, variation in presentation, investigation, and management of aortic dissection are reviewed.

Aortic dissection in young patients with chronic hypertension

We describe four patients aged 14 to 21 years who developed acute aortic dissection. In three of the four patients, the course was fatal, despite aggressive medical and surgical intervention. All four patients had sustained systemic hypertension related to chronic renal insufficiency. The patients had no other identifiable risk factors for aortic dissection, including congenital cardiovascular disease, advanced atherosclerosis, vasculitis, trauma, pregnancy, or family history of aortic dissection. Although aortic dissection is rare in individuals younger than 40 years of age, young patients with sustained systemic hypertension are at increased risk for this serious and often fatal condition. Physicians must be aware of this rare complication of hypertension and consider aortic dissection in the differential diagnosis of unusual chest, abdominal, and back pain in hypertensive children, adolescents, and young adults.

Atypical chest pain

The initial approach to patients with a chief complaint of chest pain is to rule out myocardial ischemia. There are, however, other life-threatening causes of chest pain, including pulmonary emobilism and aortic dissection among many others. This article reviews several of these disease processes.

Evaluation of patients with chest pain after cocaine use

Cocaine remains the most common cause of illicit drug-related visits to emergency departments, 40% of which result from chest pain. It is estimated that over half of the 64,000 patients evaluated annually for cocaine-associated chest pain will be admitted to hospitals for the evaluation of myocardial ischemia or infarction, at a health care cost of over eighty million dollars. Although the link between cocaine use and myocardial ischemia is well established, only about 6% of patients with cocaine-associated chest pain will demonstrate biochemical evidence of myocardial infarction. This article focuses on the evaluation of patients with chest pain following cocaine use, and concentrates on ways to improve diagnosis, management, and utilization of health care services.

Thoracic aortic dissection secondary to crack cocaine ingestion

Thoracic aortic dissection is a rare but recognized complication of crack cocaine inhalation. It is thought to be triggered in some cases by transient severe elevations in blood pressure, causing a shear effect on the thoracic aorta. Unrecognized, it can result in high morbidity and mortality. A case of an unusual presentation of thoracic aortic dissection following crack cocaine ingestion is reported.