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1
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Bidovec J, Risteski P, Stähli BE, Dzemali O, Hofmann M, Stehli J. Case Report: PCI of the left coronary artery after salvage operation in a comatose patient with an acute type A aortic dissection. Front Cardiovasc Med 2025; 12:1516152. [PMID: 39981349 PMCID: PMC11840813 DOI: 10.3389/fcvm.2025.1516152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 01/15/2025] [Indexed: 02/22/2025] Open
Abstract
A 74-year-old female was found hemiplegic in a public restroom. After arrival in our stroke unit, a computed tomography (CT) was performed, and she was diagnosed with bilateral carotid artery and right vertebral artery occlusion due to an acute type A aortic dissection. The patient deteriorated quickly to a GCS of 3 and was brought to the operating room, where a salvage replacement of the ascending aorta and the proximal aortic arch was performed with unilateral antegrade cerebral perfusion. Three days later, a significant decrease in left ventricular function and increase in cardiac biomarkers were observed. Coronary CT displayed residual dissection of the aortic root, extending into the left main coronary artery. The patient underwent an intravascular ultrasound-guided stenting of the left main, resulting in total recovery of heart function. She was extubated on the fourth postoperative day, with no residual neurological impairment. This case report advocates for the proper management of patients with ATAAD with severe neurological impairment, emphasizing the importance of a robust multidisciplinary approach in their care.
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Affiliation(s)
- Jan Bidovec
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, City Hospital Triemli, Zurich, Switzerland
| | - Petar Risteski
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, City Hospital Triemli, Zurich, Switzerland
| | - Barbara E. Stähli
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Omer Dzemali
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, City Hospital Triemli, Zurich, Switzerland
| | - Michael Hofmann
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, City Hospital Triemli, Zurich, Switzerland
| | - Julia Stehli
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
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2
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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3
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He ZY, Yao LP, Wang XK, Chen NY, Zhao JJ, Zhou Q, Yang XF. Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review. World J Clin Cases 2022; 10:8009-8017. [PMID: 36158509 PMCID: PMC9372854 DOI: 10.12998/wjcc.v10.i22.8009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/11/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis.
CASE SUMMARY A 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient’s muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty.
CONCLUSION Clinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences.
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Affiliation(s)
- Zhi-Yang He
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Lin-Peng Yao
- Department of Radiology, The First Affiliated Hospital, Zhejiang University school of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Xiao-Ke Wang
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Nai-Yun Chen
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Jun-Jie Zhao
- Department of Radiology, The First Affiliated Hospital, Zhejiang University school of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Qian Zhou
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Xiao-Feng Yang
- Department of Emergency and Trauma Center, The International Medical Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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Lu Z, Xue Y, Fan F, Cao H, Pan J, Zhou Q, Wang D. Malperfusion syndromes in acute type A aortic dissection do not affect long-term survival in Chinese population: A 10-year institutional experience. J Card Surg 2021; 36:1943-1952. [PMID: 33870559 DOI: 10.1111/jocs.15464] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preoperative malperfusion of acute type A aortic dissection (ATAAD) remains a catastrophic complication that is associated with high postoperative morbidity and mortality. The relationship between malperfusion and long-term survival in the Chinese population is unknown. METHODS A total of 771 patients who underwent ATAAD surgery between January 2009 and December 2018 at our center were included. In-hospital mortality, complications, morbidity, and long-term survival were analyzed. RESULTS Preoperative malperfusion was identified in 292 of 771 patients (37.9%), the in-hospital mortality rate was 20.9% in patients with preoperative malperfusion and 9.2% in those without. Independent predictors of in-hospital mortality included any malperfusion (odds ratio [OR], 5.132; p = .001), pericardial tamponade (OR, 1.808; p = .046), advanced age (OR, 1.028; p = .003), and cardiopulmonary bypass time (OR, 1.008; p = .001). Immediate emergency surgery (OR, 0.492; p = .007) and antegrade cerebral perfusion perioperatively (OR, 0.477; p = .020) were protective against postoperative mortality. The postoperative survival rates at 1, 3, and 5 years were 94.4% ± 1.5%, 91.9% ± 1.8%, and 83.0% ± 3.2% in patients with malperfusion and 94.7% ± 1.1%, 90.2% ± 1.7%, and 84.4% ± 2.7%, respectively, in those without. Preoperative malperfusion did not significantly affect the long-term outcomes of operative survivors (log-rank p = .601). CONCLUSION Malperfusion resulted in an unfavorable prognosis in the short term, but showed almost equal long-term survival in patients without malperfusion of ATAAD. Emergency central repair might be considered to further improve the outcomes of ATAAD with malperfusion.
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Affiliation(s)
- Zirun Lu
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yunxing Xue
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Fudong Fan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Hailong Cao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jun Pan
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
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5
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Jolobe OMP. Important caveats in refractory cardiac arrest. Am J Emerg Med 2020; 46:676-677. [PMID: 32829993 DOI: 10.1016/j.ajem.2020.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/05/2020] [Accepted: 08/11/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Oscar M P Jolobe
- Medical Division, Manchester Medical Society, Simon Building, Brunswick Street, Manchester, M13 9PL, UK.
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6
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Jolobe OMP. Dilemnas raised by implementation of an unqualified STEMI algorithm. Am J Emerg Med 2020; 44:472-473. [PMID: 32690225 DOI: 10.1016/j.ajem.2020.06.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/16/2020] [Accepted: 06/24/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Oscar M P Jolobe
- Medical Division, Manchester Medical Society, Simon Building, Brunswick Street, Manchester M13 9PL, UK.
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7
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Harky A, Singh VP, Khan D, Sajid MM, Kermali M, Othman A. Factors Affecting Outcomes in Acute Type A Aortic Dissection: A Systematic Review. Heart Lung Circ 2020; 29:1668-1681. [PMID: 32798049 DOI: 10.1016/j.hlc.2020.05.113] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/10/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022]
Abstract
Acute type A aortic dissection is a clinical emergency and is associated with significant morbidity and mortality rates if not managed promptly in specialised and high-volume centres. The mortality rate is increased by 1% for each hour delay in management; however, with advancement in clinical practice, diagnostic imaging and clinician awareness, this has been dramatically reduced to below 30% in most international centres. Not only timing of recognition of the pathology, but also other factors can significantly affect outcomes of such critical pathology. This includes, but is not limited to, age, extent of the pathology, existence of connective tissue disorders, hypertension, diabetes mellitus and surgeon experience. This narrative review will focus on current clinical practice and the evidence behind optimising each factor to minimise adverse outcomes in such high-risk cohort.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; School of Medicine, University of Liverpool, Liverpool, UK.
| | | | - Darab Khan
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Muhammed Kermali
- Faculty of Medicine, St. George's, University of London, London, UK
| | - Ahmed Othman
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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8
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Supra-aortic vessel reconstruction in total arch replacement for acute type A dissection: Comparison of en bloc and separate graft techniques. Asian J Surg 2019; 42:482-487. [DOI: 10.1016/j.asjsur.2018.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/19/2018] [Accepted: 09/25/2018] [Indexed: 11/24/2022] Open
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9
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Pacini D, Murana G, Di Marco L, Berardi M, Mariani C, Coppola G, Fiorentino M, Leone A, Di Bartolomeo R. Cerebral perfusion issues in type A aortic dissection. J Vis Surg 2018; 4:77. [PMID: 29780723 DOI: 10.21037/jovs.2018.03.20] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/21/2018] [Indexed: 11/06/2022]
Abstract
Stroke events are very common in acute type A aortic dissection. Cerebral malperfusion could manifest at presentation due to prolonged arch vessels hypoperfusion or develop after surgery for inadequate cerebral protection during arch repair. To reduce this detrimental complication there are several adjuncts that can be adopted for cerebral protection such as direct antegrade or retrograde cerebral perfusion (RCP) and use period of deep to moderate hypothermic circulatory arrest time; however, they are often insufficient as preoperative malperfusion already caused irreversible ischemic damages. The aim of the current review article is to analyze the principal series reporting on neurological injuries during type A aortic dissection to focus on the outcomes according to the type of surgical management and identify possible predictors to better manage this complication.
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Affiliation(s)
- Davide Pacini
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Marianna Berardi
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Carlo Mariani
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giuditta Coppola
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Mariafrancesca Fiorentino
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Leone
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiothoracic Vascular, Cardiac Surgery Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
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10
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Redfern E, Callaway M, Zakkar M, Bryan AJ. Improving outcomes in acute aortic dissection. Br J Hosp Med (Lond) 2017; 78:320-326. [DOI: 10.12968/hmed.2017.78.6.320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Emma Redfern
- Consultant in Accident and Emergency, Department of Accident and Emergency, Bristol Royal Infirmary, Bristol BS2 8HW
| | - Mark Callaway
- Consultant Radiologist, Department of Radiology, Bristol Royal Infirmary, Bristol
| | - Mustafa Zakkar
- Academic Clinical Lecturer in Cardiac Surgery, Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol
| | - Alan J Bryan
- Consultant Cardiac Surgeon, Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol
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11
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Pepper J. Differential aspects of the disease and treatment of Thoracic Acute Aortic Dissection (TAAD)-the European experience. Ann Cardiothorac Surg 2016; 5:360-7. [PMID: 27563549 DOI: 10.21037/acs.2016.06.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The management of patients with acute aortic dissection continues to be a challenge. It is an uncommon but lethal condition which continues to be under-diagnosed and under-treated. In this review, the term acute aortic syndrome is preferred in order to embrace the closely related pathologies of intramural hematoma (IMH) and penetrating aortic ulcer (PAU).
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Affiliation(s)
- John Pepper
- National Institute for Health Research (NIHR), Cardiovascular Biological Research unit (cBRU), Royal Brompton Hospital, London, UK
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12
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Orihashi K. Cerebral malperfusion in acute aortic dissection. Surg Today 2016; 46:1353-1361. [PMID: 27430488 DOI: 10.1007/s00595-016-1381-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 11/30/2015] [Indexed: 11/25/2022]
Abstract
Cerebral malperfusion in association with acute type A aortic dissection is uncommon but can have a considerable effect on the outcome of treatment. Successful treatment requires the individual and effective removal of each of the factors associated with malperfusion. In addition to the conventional surgical procedures, endovascular treatment has become an option for restoring perfusion. However, artificial perfusion and/or surgical procedures can lead to new malperfusion, which is not necessarily apparent to surgeons and which is difficult to predict. Thus, a number of modalities need to be applied to monitoring the current status of perfusion to enable timely treatment. Since each of the diagnostic modalities has its merits and demerits, one should use them effectively while being mindful of the pitfalls. In addition, a delay in the diagnosis in the pre-hospital stage is an important determinant of the surgical outcomes of aortic dissection. Portable echocardiography, which has been recently developed, may be useful for improving this situation. However, an early diagnosis largely depends on the physician's awareness and basic echocardiography skills. Surgeons should make general physicians aware of this message.
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Affiliation(s)
- Kazumasa Orihashi
- Division of Cardiovascular Surgery, Second Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
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13
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Aramendi C, Cubero A, Cortés A, Rivas D, Crespo A, Aramendi JI. Complete carotid and coronary revascularization in brain malperfusion. Asian Cardiovasc Thorac Ann 2016; 24:709-11. [PMID: 26980597 DOI: 10.1177/0218492316639406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 54-year-old man presented with unstable angina and stroke with right hemiplegia and aphasia due to left main coronary plus 3-vessel disease, severe stenosis of bilateral internal carotid, proximal left common carotid, and proximal left subclavian arteries. Simultaneous complete revascularization was undertaken with the use of conventional cardiopulmonary bypass and moderate hypothermia (25℃). The left internal mammary artery and two saphenous vein grafts were used for coronary artery bypass, and brain revascularization consisted of a left aorta-to-common carotid Dacron graft and bilateral carotid endarterectomy. Recovery was good.
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Affiliation(s)
- Claudia Aramendi
- Division of Vascular Surgery, Hospital of Galdakao, Galdakao, Spain
| | - Alain Cubero
- Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Andrés Cortés
- Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Daniel Rivas
- Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Alejandro Crespo
- Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
| | - José I Aramendi
- Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
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14
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Amr G, Boulouis G, Bricout N, Modine T, Fayad G, Aguettaz P, Koussa M. Stroke Presentation of Acute Type A Aortic Dissection with 100% Perfusion-Weighted Imaging-Diffusion-Weighted Imaging Mismatch: A Call for Urgent Action. J Stroke Cerebrovasc Dis 2016; 25:1280-1283. [PMID: 26965469 DOI: 10.1016/j.jstrokecerebrovasdis.2016.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 02/05/2016] [Accepted: 02/06/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Acute stroke in the setting of acute type A aortic dissection is not rare and may contraindicate immediate surgery. Evaluating irreversible brain damage is critical in this setting and magnetic resonance imaging is a key determinant in the decision of selecting surgical over medical treatment for these patients. SUMMARY OF CASES We report herein 2 cases assessed at a tertiary care center for acute stroke. The initial diagnosis workup revealed cerebral hemispheric severe hypoperfusion without any brain infarction. The absence of ischemic lesions prompted surgical repair, despite the severity of clinical symptoms. Both patients demonstrated complete neurological recovery and neuroimaging showed no persistent sequel. CONCLUSION Acute type A aortic dissection is an important differential diagnosis in the causative workup for stroke. Brain hypoperfusion alone should not be a contraindication for urgent surgical treatment, regardless of initial clinical neurological severity.
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Affiliation(s)
- Gilles Amr
- Service de Chirurgie Cardiovasculaire, Hôpital Cardiologique, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Gregoire Boulouis
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Nicolas Bricout
- Department of Neuroradiology, Université Lille Nord de France, Hôpital Roger Salengro, CHRU de Lille, Lille Cedex, France
| | - Thomas Modine
- Service de Chirurgie Cardiovasculaire, Hôpital Cardiologique, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Georges Fayad
- Service de Chirurgie Cardiovasculaire, Hôpital Cardiologique, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Pierre Aguettaz
- Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neuroradiology, Université Lille Nord de France, Hôpital Roger Salengro, CHRU de Lille, Lille Cedex, France; Service de Neuroradiologie Interventionnelle, Hôpital Prive Clairval, Marseille, France
| | - Mohamad Koussa
- Service de Chirurgie Cardiovasculaire, Hôpital Cardiologique, Centre Hospitalier Universitaire de Lille, Lille, France
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Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RSV, Vrints CJM. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2873-926. [PMID: 25173340 DOI: 10.1093/eurheartj/ehu281] [Citation(s) in RCA: 3006] [Impact Index Per Article: 273.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Patients with type A acute aortic dissection presenting with major brain injury: Should we operate on them? J Thorac Cardiovasc Surg 2013; 145:S213-21.e1. [PMID: 23410778 DOI: 10.1016/j.jtcvs.2012.11.054] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 08/15/2012] [Accepted: 11/28/2012] [Indexed: 11/23/2022]
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Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol 2012; 58:2455-74. [PMID: 22133845 DOI: 10.1016/j.jacc.2011.06.067] [Citation(s) in RCA: 168] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 06/07/2011] [Indexed: 01/11/2023]
Abstract
Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.
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Tiwari KK, Granov N, Bevilacqua S, Glauber M. eComment: does coma state really stop from operating type A aortic dissection patients? Interact Cardiovasc Thorac Surg 2010; 10:841-2. [PMID: 20403996 DOI: 10.1510/icvts.2009.228908a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kaushal K Tiwari
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Massa, Italy
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