| 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. ( info) |
2/1911. Repair of a pseudoaneurysm of the ascending aorta after aortic valve replacement. An elderly woman underwent an aortic valve replacement and 5 months later developed a pseudoaneurysm from the anterior aspect of the proximal ascending aorta (AA). The pseudoaneurysm was approached through a redo-median sternotomy, on cardiopulmonary bypass (CPB), mild hypothermia, and a beating heart, with a temporary fingertip occlusion of its ostium, and repaired successfully using mattress monofilament sutures enforced by pledgets. The standard approach to such pseudoaneurysms is a CPB and hypothermic circulatory arrest (HCA) prior to mid-sternotomy, and replacement of the AA. But, when a pseudoaneurysm arises from a narrow ostium on the anterior aspect of the AA, as in this case, it can be sutured closed with pledgets under CPB with a mild hypothermia and a beating heart. ( info) |
| A 35-year-old woman presented with dyspnea and chest pain. She had a large aneurysm of the non-coronary sinus of valsalva. Before her scheduled urgent surgery, the patient collapsed and died of cardiac tamponade secondary to intrapericardial rupture of the aneurysm. We would advocate urgent repair of this type of lesion to prevent such an outcome. We are aware of no other specific reports addressing extracardiac rupture of non-coronary cusp aneurysms [corrected]. ( info) |
4/1911. An unusual combination of cardiovascular surgical disorders. A 53-year-year-old man presented with aortic regurgitation, subvalvular and supravalvular aortic stenoses, and aneurysms involving the ascending aorta, the arch, and the innominate, right subclavian, and left common carotid arteries. Surgery consisted of resection of the obstructive lesions, replacement of the aortic valve, graft replacement of the ascending aorta, and the arch resection of innominate and subclavian artery aneurysms and reconstruction with a side limb to which the right carotid artery was anastomosed. The patient has remained asymptomatic with full employment. ( info) |
5/1911. Special problems associated with abdominal aneurysmectomy in spinal cord injury patients. There were 8 patients with spinal cord injury in the last 100 consecutive patients with abdominal aortic aneurysm resected at the Long Beach veterans Administration Hospital. Emphasis is placed upon the problems in management not found in individuals without spinal cord injury. A successful outcome is dependent upon: (a) aggressive control of foci of infection, (b) early diagnosis and planned surgical intervention, (c) continuous intraoperative arterial and central venous pressure monitoring and (d) alertness to the prevention of postoperative complications, with emphasis upon careful tracheal toilet and anticipation of delayed wound healing. ( info) |
6/1911. Aortic dissection in an elderly patient with atrial septal defect. We report a case of acute aortic dissection that occurred in the late course of surgically untreated atrial septal defect. A 60-year-old man with acute aortic dissection and atrial septal defect was operated on successfully, and we discuss the causal relationship between these two unusual conditions. ( info) |
7/1911. Surgical treatment of traumatic aneurysm of the ascending aorta. Traumatic aneurysm of the ascending aorta is a rare event. This case describes a patient with such an aneurysm, resulting from injuries received in a motorcycle accident. The patient was admitted to the emergency room of a local hospital complaining of chest pain, and was subsequently referred to our institution. On admission, a chest x-ray showed mediastinal widening. Computed tomography and aortography revealed an ascending aortic aneurysm and contusion of the upper lobe of the right lung. Due to concerns about bleeding from the lung contusion, surgery was delayed for one week. During surgery, intimal tears were detected at two sites in the ascending aorta. The wall of the ascending aorta was subsequently resected and a prosthetic graft inserted. The postoperative period was uneventful and a postoperative aortogram showed that the graft had molded well. ( info) |
8/1911. Observations on the treatment of dissection of the aorta. The results are presented of treatment in twenty-three patients with dissection of the thoracic aorta, in four of whom it was acute (less than 14 days' duration), and in nineteen chronic (more than 14 days' duration). Sixteen patients had Type I and II dissection (involving the ascending aorta) and five Type III (descending aorta at or distal to the origin of the left subclavian artery); in two, dissection complicated coarctation of the aorta in the usual site. Thirteen patients had aortic regurgitation. Three of the patients with acute dissection were treated medically; two, both with Type I dissection, died, and the third, with Type III, survived. The remaining acute patient was treated surgically and also died. Of the patients with chronic dissection, eight were treated medically and eleven surgically. None of the medical group died in hospital; three died between 3 months and 1 year, and five have survived from periods of 12-72 months. Eleven patients with chronic dissection were treated surgically; four died in hospital at or shortly after operation; and the remaining seven lived for periods of 12-84 months. The presentation, indications for surgical treatment and results are discussed. It is concluded that surgical treatment of chronic dissection may carry a higher initial mortality than medical, but that there may be slightly better overall long term results in the former. As this series was not selected randomly, because patients with complications were selected for surgery, and there are only a few patients in each group, the results do not permit firm conclusion regarding the relative merits of medical and surgical treatment. It is suggested that all patients should initially be treated medically but that surgical treatment should be considered if the dissection continues, if aortic regurgitation is severe, if an aneurysm develops or enlarges, if cardiac tamponade develops or there is evidence of progressive involvement of the branches of the aorta. attention is drawn to the important syndrome of chronic dissecting aneurysm of the ascending aorta with severe aortic regurgitation which requires definitive surgical treatment and aortic valve replacement. The importance of adequate visualization of the origin and extent of the dissection as a preliminary to surgical treatment is stressed. ( info) |
9/1911. Transcatheter gelfoam embolization of posttraumatic bleeding pseudoaneurysms. Diagnostic angiography combined with transcatheter therapeutic embolization is a simple and effective means of treating complex clinical situations associated with posttraumatic hemorrhage. Bleeding pseudoaneurysms, even when large, can be readily managed by this combined modality with resultant decrease in morbidity and hospital stay. Five patients with posttraumatic pseudoaneurysms are presented. All five were treated by transcatheter therapeutic embolization with Gelfoam. Of these five cases, three involved extremities, one involved the retroperitoneal space, and the last was of renal origin. Two of the five cases still required surgical intervention after initial successful therapeutic embolization, one for recurrent bleeding from collaterals and the other for evacuation of a massive pseudoaneurysm which was causing distraction of fracture fragments. The early use of angiography in suspected cases of posttraumatic hemorrhage, together with careful evaluation of potential collateral supply, is stressed. The use of transcatheter therapeutic embolization in the extremities as presented here is yet another example of the ever-broadening applicability of this technique. ( info) |
10/1911. Simultaneous selective cerebral perfusion and systemic circulatory arrest through the right axillary artery for aortic surgery. The duration of safe circulatory arrest for replacement of the ascending aorta for a type A dissection, without additional cerebral perfusion measures, is not clearly defined. If prolonged periods (> 60 minutes) are anticipated, retrograde cerebral perfusion or selective antegrade carotid perfusion may be required. The latter requires separate cannulas with subsequent snaring of the cerebral vessels, which may be time consuming and cumbersome. We propose an alternative method whereby the right axillary artery is cannulated for cardiopulmonary bypass and, when the desired hypothermic temperature is achieved, the flows are turned down to 500 mL/min. The origin of the innominate artery is then occluded establishing selective antegrade right carotid artery perfusion. The distal ascending or aortic arch anastomosis is then performed while the remainder of the body is under selective systemic circulatory arrest. The proximal aortic anastomosis is performed after the graft is clamped proximally and flows return to appropriate perfusion levels. ( info) |