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Sivadasan PC, Carr CS, Pattath ARA, Hanoura S, Sudarsanan S, Ragab HO, Sarhan H, Karmakar A, Singh R, Omar AS. Incidence and outcome of rhabdomyolysis after type A aortic dissection surgery: A retrospective analysis. World J Crit Care Med 2025; 14:98004. [PMID: 40491885 PMCID: PMC11891855 DOI: 10.5492/wjccm.v14.i2.98004] [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: 06/14/2024] [Revised: 10/27/2024] [Accepted: 12/10/2024] [Indexed: 02/27/2025] Open
Abstract
BACKGROUND Rhabdomyolysis (RML) as an etiological factor causing acute kidney injury (AKI) is sparsely reported in the literature. AIM To study the incidence of RML after surgical repair of an ascending aortic dissection (AAD) and to correlate with the outcome, especially regarding renal function. To pinpoint the perioperative risk factors associated with the development of RML and adverse renal outcomes after aortic dissection repair. METHODS Retrospective single-center cohort study conducted in a tertiary cardiac center. We included all patients who underwent AAD repair from 2011-2017. Post-operative RML workup is part of the institutional protocol; studied patients were divided into two groups: Group 1 with RML (creatine kinase above cut-off levels 2500 U/L) and Group 2 without RML. The potential determinants of RML and impact on patient outcome, especially postoperative renal function, were studied. Other outcome parameters studied were markers of cardiac injury, length of ventilation, length of stay in the intensive care unit), and length of hospitalization. RESULTS Out of 33 patients studied, 21 patients (64%) developed RML (Group RML), and 12 did not (Group non-RML). Demographic and intraoperative factors, notably body mass index, duration of surgery, and cardiopulmonary bypass, had no significant impact on the incidence of RML. Preoperative visceral/peripheral malperfusion, though not statistically significant, was higher in the RML group. A significantly higher incidence of renal complications, including de novo postoperative dialysis, was noticed in the RML group. Other morbidity parameters were also higher in the RML group. There was a significantly higher incidence of AKI in the RML group (90%) than in the non-RML group (25%). All four patients who required de novo dialysis belonged to the RML group. The peak troponin levels were significantly higher in the RML group. CONCLUSION In this study, we noticed a high incidence of RML after aortic dissection surgery, coupled with an adverse renal outcome and the need for post-operative dialysis. Prompt recognition and management of RML might improve the renal outcome. Further large-scale prospective trials are warranted to investigate the predisposing factors and influence of RML on major morbidity and mortality outcomes.
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Affiliation(s)
- Praveen C Sivadasan
- Cardiac Anesthesia and ICU Section, Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Cornelia S Carr
- Department of Clinical Surgery, College of Medicine, Qatar University, Doha 3050, Qatar
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdul Rasheed A Pattath
- Cardiac Anesthesia and ICU Section, Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Samy Hanoura
- Cardiac Anesthesia and ICU Section, Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Anesthesia and Intensive Care, Al-Azhar University, Cairo 11651, Egypt
| | - Suraj Sudarsanan
- Cardiac Anesthesia and ICU Section, Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Hany O Ragab
- Cardiac Anesthesia and ICU Section, Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Anesthesia and Intensive Care, Al-Azhar University, Cairo 11651, Egypt
| | - Hatem Sarhan
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44106, United States
| | - Arunabha Karmakar
- Department of Medical Education, Hamad Medical Corporation, Doha 3050, Qatar
| | - Rajvir Singh
- Department of Medical Research, Hamad Medical Corporation, Doha 3050, Qatar
| | - Amr S Omar
- Cardiac Anesthesia and ICU Section, Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Critical Care Medicine, Beni Suef University, Beni Suef 2722165, Egypt
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Eidt JF, Cha E, Hohmann S, Vasquez J. Midterm Results of the STABILISE Technique in the Treatment of Aortic Dissection. Vasc Endovascular Surg 2025; 59:401-410. [PMID: 39724017 DOI: 10.1177/15385744241312439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2024]
Abstract
Background: Contemporary treatments of acute aortic dissection, including medical, surgical, and endovascular options, are remarkably effective at the management of malperfusion and rupture. Unfortunately, long-term studies indicate that 30%-50% of patients need secondary procedures to treat progressive aneurysmal enlargement of the untreated aorta. The Stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique was introduced to improve long-term outcomes. Purpose: This study aims to investigate the results of the STABILISE technique in patients with aortic dissection. Methods: This is a single-center, retrospective review of all patients treated with the STABILISE technique. There were 12 de novo type B aortic dissection (TBAD) and 7 residual TBAD following type A aortic dissection (TAAD) repair. Results: There was disruption of the dissection membrane and relamination in all or part of the bare metal stent segment in 100% of cases. The average percent attainment of a uni-luminal aorta in comparison to the length with persistent false lumen was 91 ± 12%. Conclusion: Midterm results suggest that the STABILISE technique may improve aortic remodeling after endovascular treatment of acute dissection.
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Affiliation(s)
- John F Eidt
- Baylor Scott and White Heart and Vascular Hospital, Dallas, TX, USA
| | - Erin Cha
- Texas A&M College of Medicine, College Station, TX, USA
| | - Stephen Hohmann
- Baylor Scott and White Heart and Vascular Hospital, Dallas, TX, USA
| | - Javier Vasquez
- Baylor Scott and White Heart and Vascular Hospital, Dallas, TX, USA
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Zedde M, De Falco A, Zanferrari C, Guarino M, Pezzella FR, Haggiag S, Cossu G, Quatrale R, Micieli G, Del Sette M, Pascarella R. Spinal Cord Infarction: Clinical and Neuroradiological Clues of a Rare Stroke Subtype. J Clin Med 2025; 14:1293. [PMID: 40004823 PMCID: PMC11856212 DOI: 10.3390/jcm14041293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2025] [Revised: 02/08/2025] [Accepted: 02/13/2025] [Indexed: 02/27/2025] Open
Abstract
Spinal cord infarction (SCI) of arterial origin is a rare vascular event, and its incidence is probably underestimated. There are no strong epidemiological data, and the diagnostic pathway is complex and sometimes incomplete. Furthermore, many cases may be misdiagnosed as other forms of acute and subacute myelopathies. The focus of this review is the clinical and neuroradiological issues in diagnosing SCI and their respective reliability in a clinical setting. The new proposed diagnostic criteria of SCI, although not covering all aspects, highlight the need for a comprehensive approach, including even atypical cases, as the lack of cord compression on Magnetic Resonance Imaging (MRI) is the only mandatory feature for diagnosis. Some MRI features are supportive of the diagnosis, particularly when the anterior spinal artery territory is involved and diffusion-weighted imaging (DWI) is used. Several etiologies can be considered, considering traditional vascular risk factors and diseases affecting the aorta and its main branches, yet a significant proportion of cases remain without a definite etiology. The strongest predictor of SCI diagnosis is a clinical variable, i.e., a time to nadir of severe deficits < 12 h.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Arturo De Falco
- Neurology and Stroke Unit, Ospedale del Mare, ASL Napoli 1 Centro, 80147 Naples, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Carla Zanferrari
- Neurology and Stroke Unit, ASST Melegnano-Martesana, 20070 Milan, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Maria Guarino
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, 40139 Bologna, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Francesca Romana Pezzella
- Stroke Unit, Dipartimento Di Neuroscienze, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Shalom Haggiag
- Neurology Unit, Dipartimento Di Neuroscienze, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Gianni Cossu
- Neurology Unit, Department of Neuroscience, ARNAS Brotzu, 09047 Cagliari, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Rocco Quatrale
- Dipartimento Di Scienze Neurologiche, UOC di Neurologia—Ospedale dell’Angelo—ULSS 3 Serenissima, 30174 Venezia-Mestre, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Giuseppe Micieli
- Former Department of Emergency Neurology, IRCCS C. Mondino Foundation, 27100 Pavia, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Massimo Del Sette
- Neurology Unit, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
- Associazione Neurologia di Emergenza Urgenza (ANEU), 53100 Siena, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy;
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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: 0.2] [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: 0.4] [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: 1.0] [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: 0.9] [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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