Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients

Leontyev, Sergey; Borger, Michael A.; Légaré, Jean‐François; Merk, Denis R.; Hahn, Jochen; Seeburger, Joerg; Lehmann, Sven; Mohr, Friedrich W.

doi:10.1093/ejcts/ezr070

Cited by 86 publications

(91 citation statements)

References 18 publications

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“…8 Other reports have not clearly distinguished acute from chronic cases and intraoperative from postoperative AAD. [20][21][22][23] The underlying pathology and its progression, the symptoms and clinical presentation, and the diagnostic and treatment strategies are all crucial elements in the management and outcome of AAD after cardiac surgery. Realizing the associated high mortality in this patient group, identification of predictive conditions allowing for improved management and outcome are of the upmost importance.…”

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confidence: 99%

Type A Aortic Dissection After Nonaortic Cardiac Surgery

et al. 2013

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A cute type A aortic dissections (AADs) are life-threatening conditions that are conventionally treated with emergency operations. Population-based studies suggest an incidence of ≈20 to 30 cases per million people per year which roughly translates to an estimated >6000 new AAD cases annually in the United States and >14 000 in Europe. [1][2][3][4][5] The clinical presentation, natural history, management, and outcome of spontaneous AADs are well described.2,5-7 Despite improvements in imaging, surgical techniques, and management, the overall in-hospital mortality of patients with spontaneous acute AAD remains high with a range of 15% to 32%, 7-10 with early death resulting mainly from rupture and tamponade. Editorial see p 1593 Clinical Perspective on p 1611AAD can complicate routine cardiac surgery unexpectedly at any time, either intraoperatively and early or late afterward, suddenly converting a low-risk elective procedure into a highrisk situation with excessive operative mortality.11,12 Previous reports suggest that AAD occurs in 0.12% to 0.16% of patients Background-Cardiac surgery with cardiopulmonary bypass is associated with mechanical manipulation of the ascending aorta that occasionally leads to type A aortic dissection (AAD). Methods and Results-One hundred three patients with surgical repair for AAD following nonaortic cardiac surgery were identified. With the use of logistic regression modeling, coronary artery bypass surgery (CABG), either isolated or combined with another procedure in the initial operation, was associated with significantly higher operative mortality in comparison with patients with non-CABG procedures at the time of AAD repair both for all patients (odds ratio, 2.90; 95% confidence interval, 1.09-7.72; P=0.033) and for patients with acute and chronic AAD ≥30 days after the initial operation (odds ratio, 3.62; 95% confidence interval, 1.13-11.54; P=0.03). In patients who developed AAD late after the initial operation, operative mortality was highest in patients without preoperative coronary angiography and appropriate management of their native coronary artery disease and graft disease (odds ratio, 5.36; 95% confidence interval, 1.68-17.0; P=0.002). Nearly all the intimal dissection tears were located at sites of previous surgical trauma. Most of the ascending aortas that had dissected initially had a diameter ≥40 mm with histological evidence of medial degeneration in resected tissue samples. Conclusions-In patients who have undergone previous cardiac surgery, preexisting aortic wall pathology contributes to AAD with typical intimal damage at sites of mechanical trauma. The operative mortality was the highest in patients with previous CABG in comparison with patients with non-CABG procedures. Preoperative coronary angiography and operative management of native coronary and graft disease were significantly associated with outcome in patients with previous CABG. (Circulation. 2013;128:1602-1611.)

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Type A Aortic Dissection After Nonaortic Cardiac Surgery

et al. 2013

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“…4,8 On the other hand, such a complex surgery, coronary or aortic (supracoronary conduit or other techniques), in a patient who is, in many cases, under the influence of strong antithrombotic drugs and has recently experienced a myocardial infarction could have catastrophic results. [1][2][3] However, after following up our patients, the largest series described, for a median of 5 years, we perceived that, after the acute phase, the spontaneous evolution of this complication is excellent. Interestingly, this happened even though the majority of patients presented an acute coronary syndrome, and many continued receiving antithrombotic treatment as indicated in this context, something that would be unthinkable in a spontaneous form or even a postsurgical form.…”

Section: Discussionmentioning

confidence: 92%

“…[1][2][3][4] Although dissection is usually spontaneous, with the introduction of new surgical and interventional procedures, we are witnessing the development of occasional iatrogenic cases, with a profile very dissimilar to that of the classic patient. Because of its low overall frequency, estimated at <0.1% of procedures globally, we have few data available on its natural history and long-term outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3] In 2002, the International Registry of Aortic Dissection reported 26 patients with this type of dissection (69% after a major surgery and 27% catheter derived) of 723 patients included at that time in the registry. 1 Overall, considering the International Registry of Aortic Dissection report, epidemiological features were different from spontaneous forms.…”

Section: Clinical Perspective On P 2119mentioning

confidence: 99%

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Incidence, Management, and Immediate- and Long-Term Outcomes After Iatrogenic Aortic Dissection During Diagnostic or Interventional Coronary Procedures

et al. 2015

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Background-Aortic dissection type A is a disease with high mortality. Iatrogenic aortic dissection after interventional procedures is infrequent, and prognostic data are scarce. Our objective was to analyze its incidence, patient profile, and long-term prognosis. Methods and Results-Between 2000 and 2014, we retrospectively analyzed 74 patients with dissection of the ascending aorta. Clinical and procedural data were reviewed, and later, we performed a prospective clinical follow-up by telephone or in the office. The incidence of aortic dissection was 0.06%. Our patients, predominantly male (67.6%), had a mean age of 66.9±10.8 years. With multiple cardiovascular risk factors, the main reason for cardiac catheterization was an acute coronary syndrome (n=54). The complication was detected acutely in all, trying to engage the right coronary artery in 47 and the left main artery in 30 and after other maneuvers in 2, mostly complex therapeutic procedures (78.4%). A coronary artery was involved in 45 patients (60.8%). Thirty-five patients underwent an angioplasty and stent implantation; 3 had cardiac surgery; and 36 were managed conservatively. Two patients died of cardiogenic shock after the dissection. After a median follow-up of 51.2 months (range, 16.4-104.8 months), none of the remaining patients developed complications as a result of the dissection, progression, ischemia, pain, or dissection recurrence. Conclusions-Iatrogenic catheter dissection of the aorta is a rare complication that carries an excellent short-and longterm prognosis with the adoption of a conservative approach. When a coronary artery is involved as an entry point, it usually can be safely sealed with a stent with good long-term outcomes.

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“…After conservative management of blood pressure and pain, the patient was discharged on post-procedural day 14. To prevent aortic intimal injuries, we note the following potential risk factors: (i) resection of lesions located in the dorsal region of the thoracic part of the esophagus; (ii) gastrointestinal lesions adjacent to pre-existing aortic disease, including atherosclerosis and cystic medial necrosis [3]; (iii) patients with poorly controlled hypertension. Aortic dissection as a result of perforation may be life-threatening if not identified and managed promptly.…”

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A rare and potentially fatal complication of endoscopic submucosal dissection: iatrogenic type B aortic dissection

Tai

Hou³

et al. 2014

Endoscopy

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Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients

Abstract: IAD is a rare but dangerous complication of cardiac surgery and cardiac catheterization, and is frequently associated with pre-existing aortic pathology.

Cited by 86 publications

References 18 publications

Type A Aortic Dissection After Nonaortic Cardiac Surgery

Type A Aortic Dissection After Nonaortic Cardiac Surgery

Incidence, Management, and Immediate- and Long-Term Outcomes After Iatrogenic Aortic Dissection During Diagnostic or Interventional Coronary Procedures

A rare and potentially fatal complication of endoscopic submucosal dissection: iatrogenic type B aortic dissection

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