Management of patients with aortic dissection (original) (raw)
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The diagnosis and management of aortic dissection
BMJ, 2011
Aortic dissection is caused by an intimal and medial tear in the aorta with propagation of a false lumen within the aortic media. It is part of the "acute aortic syndrome"an umbrella term for aortic dissection, intramural haematoma, and symptomatic aortic ulcer (table). 1 Acute dissection is the most common aortic emergency, with an annual incidence of 3-4 per 100 000 in the United Kingdom and United States, which exceeds that of ruptured aneurysm. 2 w1 w2 The prognosis is grave, with 20% preadmission mortality and 30% in-hospital mortality. The best treatment depends on the anatomical and temporal classification of the disease. Aortic dissection is therefore categorised according to the site of the entry tear and the time between the onset of symptoms and diagnosis. A dissection is considered "acute" when the diagnosis is made within 14 days of onset, and thereafter it is termed "chronic." The location of the entry tear plays a key role in treatment and outcome, and it is classified by being in the ascending aorta (Stanford type A dissection) or distal to the origin of the left subclavian artery (Stanford type B dissection) . Type A dissection carries a far worse prognosis than type B dissection and urgent surgical intervention is often needed. By contrast, acute type B dissection is usually managed conservatively if uncomplicated and surgically if complicated.
Surgical results in acute type A aortic dissection
Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia, 2005
Currently international registry data present the patient mortality with acute type A aortic dissection managed non-surgically to be 58%, and managed surgically to be 26%. Many articles consistently report the hospital mortality exceeding 20% in western countries. Many factors, such as cardiac tamponade and dissection-related organ malperfusion, contribute to hospital mortality and morbidity. In Japan, the number of patients enrolled in the annual reports has been increasing and the surgical results have been improving year by year. In-hospital mortality has decreased to less than 20% since 1999. Since the beginning of our aortic program, a total of 98 patients underwent emergency operations, and the operative mortality and in-hospital mortality were 5.1% and 6.1%, respectively. In a recent series since 2001, the operative and in-hospital mortalities were remarkably low; 2.8% and 3.2% respectively. We were able to benefit greatly by various innovative technologies which include open...
Outcome of Endovascular Treatment of Acute Type B Aortic Dissection
The Annals of Thoracic Surgery, 2008
Complicated type B aortic dissection is a life-threatening condition. For the last decade, endovascular stent-graft placement has been increasingly used to treat this condition. We undertook a summary analysis of published studies reporting the outcome of stent-grafts to treat complicated type B dissection. Studies were identified from a literature search using the MEDLINE database, and included studies when 10 or more patients were reported and at least in-hospital mortality was presented. A total of 942 patients were included from 29 studies. All patients were reported to have complications requiring intervention (hypotension in 17%). In-hospital mortality was 9% and other major complications (ie, stroke, paraplegia, conversion to type A dissection, bowel infarction, major amputation) occurred in 8.1%. Long-term follow-up was limited to a mean of 20 months. During this time, reintervention was required in 10.4% and aortic rupture was reported in 0.8%. Endovascular treatment of complicated acute type B aortic dissection seems to provide favorable initial outcomes and would seem to be a great addition to the treatment options for this condition. Further study of long-term outcomes is required.
The Annals of Thoracic Surgery, 2002
Methods. One hundred eighty-nine patients with acute type B aortic dissection managed over a 36-year period were analyzed retrospectively for three outcome endpoints: survival; freedom from reoperation, and freedom from late aortic-related complications or late death. Risk factors for death were identified using a multivariable Cox proportional hazards model. Then to account for patient selection bias, heterogeneity of the population, and continuous evolution in techniques, propensity score analysis was used to identify risk-matched cohorts (quintiles I and II) in which the results of medical (n ؍ 111) or surgical (n ؍ 31) therapy were compared more comprehensively.
Own Clinical Observations of Treatment Outcome in Acute Type B Aortic Dissection
Polish Journal of Surgery, 2012
in Wrocław 3 Kierownik: prof. dr hab. m. sąsiadek the aim of the study was to analyse early results of treatment of acute type B aortic dissection. material and methods. 59 patients, treated between 1998 and 2011, were divided into four groups. Group I comprised ten patients in whom hybrid procedures were performed: extra-anatomical bypass graft from the brachio-cephalic trunk to the left carotid artery in six patients, transposition of the left carotid artery to the right one in two patients, and reversed Y prosthesis from the brachio-cephalic trunk to both carotids in the remaining 2 patients, to facilitate stent-grafting. Group II comprised 13 patientsin whom endovascular procedures were performed (stent-grafting). Group III comprised 21 patients in whom conventional surgery was done. Group IV comprised 15 patients who were treated conservatively. Results. In group I, a very good clinical outcome, without complications, was achieved in six patients (60% of cases). The total mortality rate was 40%. One patient died on the operation table, following stent-grafting, due to the rupture of the aortic arch. Two patients died as a result of brain damage (cerebral aneurysm rupture in one, and ischemic stroke in the other). In one patient, an aorto-oesophageal fistula developed. In group II, one patient died during endovascular procedure. Another patient suffered from type 1 endoleak, requiring repeated endovascular surgery.In group III, 15 patients (72%) died. Moreover, four patients required acorrective cardiac surgery (Bentall procedure)which in three patients resulted in death. Thus, the total mortality rate in this group was as high as 85%. In group IV, the mortality rate was13%. Conclusions. We noticed a clear superiority of endovascular procedures over conventional surgeriesfor acute type B aortic dissection. Hybrid procedures for acute, complicated type B aortic dissection evidently reduce mortality and postoperative morbidity. Uncomplicated acute type B aortic dissections should be treated conservatively at intensivecare units.
Acute aortic dissection: Epidemiology and outcomes
International Journal of Cardiology, 2013
Background: Little epidemiological information on acute aortic dissection (AAD) is available in the literature. The objective of the present study was to determine the incidence and mortality rates of AAD in the general population and to analyze its clinical features. Methods: Data from the Emilia-Romagna regional database of hospital admissions was analyzed. Urgent admissions with the diagnosis of dissection of the aorta, dissection of the thoracic aorta and dissection of the thoracoabdominal aorta were selected. Results: Between January 2000 and December 2008, 1499 Emilia-Romagna residents were hospitalized with a diagnosis of AAD. The patients were divided into three groups: Group A, 617 patients (41.2%) surgically treated for type A AAD; Group B, 93 complicated patients (6.2%) with type B AAD treated by endovascular stent-grafting and Group C, 789 patients (52.6%) suffering from any type of AAD medically treated. The overall annual incidence rate was 4.7%/100,000 people and was higher for men than for women (6.7% vs 2.9%).Two hundred ninety-six patients (19.8%) were 80 years of age or older.The overall in-hospital mortality rate was 27.7%, with mortality rates of 21.1%, 26.9% and 33% in Groups A, B and C, respectively. Conclusion: The incidence of AAD is not negligible and a notable rate of patients is ultra-octogenarian. A large number of patients with AAD had no surgery or interventional treatment. The results of surgical treatment for patients with type A dissection are acceptable but the results obtained in patients with complicated type B dissection who were treated with an endoprosthesis are dismal.