Transesophageal Echocardiography After Contrast-Enhanced CT Angiography in the Diagnosis of Type A Aortic Dissection

Gologorsky, F.A.S.E. Edward; Karras, Riny; Gologorsky, Angela; Ricci, Marco; Salerno, Tomás A.

doi:10.1111/j.1540-8191.2011.01282.x

Cited by 10 publications

(5 citation statements)

References 12 publications

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“…Once the diagnosis of AAAD is confirmed, the patient should be taken to the OR, and all other information is obtained with TEE. 32,33) However, many surgeons are reluctant to rely on TEE because it necessitates expertise, or they believe that it is not the task of surgeons, but of anesthesiologists or cardiologists. It is the other way around.…”

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confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.Keywords: aortic dissection, malperfusion, complication, echocardiography A cute type A aortic dissection (AAAD) not only causes sudden death at the time of onset but leads to various life-threatening complications. In spite of improved diagnostic imaging and surgical strategies, in-hospital mortality is still high, and patients who have survived often suffer from sequelae that make subsequent quality of life poor. This article is aimed to review the latest literature and ideas to seek the best possible way to minimize undesirable results.Various complications of AAAD caused by separation of the aortic wall to outer and inner layers are summarized as three categories: 1) aortic rupture due to disruption of the outer layer; 2) malperfusion caused by the inner layer, that is, the intimal flap; and 3) aortic regurgitation by a deformed aortic valve, leading to acute heart failure. Approximately 20% of patients instantaneously die due to aortic rupture, 1) and 1 to 2% of the remaining patients die every hour unless appropriately treated. 2) Although surgical outcomes are gradually improving, in-hospital mortality of surgical patients (repair on the aortic root to the arch) in 2009 was as high as around 10%, according to the Japanese database. 3) For the further improvement of outcomes, problems should be solved in each of preonset, pre-hospital, and in-hospital stages. In this review, the latter two stages are discussed first, since most of the literature focuses on these stages. After that, the issue of pre-onset stage, i.e., prevention is discussed. DelayeD DiagnosisIn consideration of the natural history of AAAD, the "chain of onset-to-sur...

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confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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“…While the merits of TOE were acknowledged by a number of reports presenting cases in which false-positive diagnosis of AAD on CT was subsequently corrected by TOE 18 , 19 echocardiography did not yield findings accurate enough to confirm or refute the diagnosis of AAD with a sufficient degree of certainty in our cases.…”

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confidence: 60%

A low threshold to ECG-gated repeat CTA reduces the risk of false-positive diagnosis of type A dissection in interhospital referrals: a case series study

Kornberger¹,

Burck²,

Beyrouti³

et al. 2018

TCRM

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BackgroundFalse-positive diagnosis of acute Stanford type A aortic dissection (AAD) on computed tomography angiography (CTA) is still an issue and may lead to substantial consequences. Given that electrocardiography (ECG)-gated CTA provides greater diagnostic safety, it may be assumed that interhospital referrals with a diagnosis of AAD based on non-ECG-gated pre-referral CTA carry an elevated risk of false-positive diagnosis.Patients and methodsWe reviewed a series of patients in whom a diagnosis of AAD based on non-ECG-gated pre-referral CTA was subsequently proven false by ECG-gated CTA. The artifacts that gave rise to the misdiagnosis, as well as the diagnostic pathways followed and the consequences of false-positive diagnosis were investigated.ResultsIn 5 patients, ECG-gated repeat CTA revealed artifacts in the pre-referral scans that had led to false-positive diagnosis and referral for emergent surgery. In the first case, the patient proceeded to surgery. In 4 subsequent cases, ECG-gated CTA was ordered because a false-positive diagnosis was suspected. We found that ECG-gated CTA rather than echocardiography provided sufficient information to rule out AAD in each of these cases. Comparison between pre-referral non-ECG-gated scans and ECG-gated repeat CTA demonstrated the wide range of artifacts that may give rise to a diagnosis of AAD.ConclusionPatient condition permitting, the threshold to ECG-gated repeat CTA should be low when doubt arises with regard to a diagnosis of AAD based on non-ECG-gated CTA in interhospital referrals.

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“…Even if contrast-enhanced imaging is performed, contrast-enhancement may be poor or false positives may occur due to bloom artifacts. 193 Considering that 90% of the patients survive if they reach invasive treatment (open surgery and SG deployment), it is desirable to avoid misdiagnosis and resulting delays in transportation by performing a quick and simple echographic examination. However, although the diagnostic ability of TEE is comparable to that of CT, 194 it may induce rupture due to the stimulation of insertion, 195,196 and it is not considered optimal for initial diagnosis.…”

Section: ▋ 36 Echographic Examinationmentioning

confidence: 99%

JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection

Ogino,

Iida,

Akutsu

et al. 2023

Circ J

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▋ 1.3.2 Location of AneurysmsAneurysms are classified into thoracic, thoracoabdominal, and abdominal aneurysms, which are further classified as follows: Thoracic: It is further classified into ascending, arch, and descending aortic aneurysms. Thoracoabdominal: The Crawford classification based on the range of replacement in thoracoabdominal aneurysm surgery (Figure 5). Abdominal: Abdominal aortic aneurysms are classified using the renal artery as the reference into the supra-and infra-renal segments. ▋ 1.3.3 CauseBased on the cause of the aneurysm, aortic aneurysms are classified into atherosclerotic, traumatic, inflammatory, infected, congenital, etc. Most of them are atherosclerotic aortic aneurysms. Advance Publication13 JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection is indicated for saccular aneurysms regardless of the size of the thickening (See PQ 1). Inflammatory aortic aneurysm: Aneurysm caused by inflammation. Although, in general, "inflammation" is a concept that includes infection, however, inflammatory aortic aneurysm does not include the aortic aneurysm with infection. Inflammatory periaortitis: A case with inflammation around the aorta but with less aortic dilation that does not meet the criteria of aneurysm. Infected aortic aneurysm: Aneurysm caused by infection. Rupture: Extravascular blood leakage due to damage to the arterial wall. Impending rupture: The absence of damage to the arterial wall despite the presence of aneurysmal pain. ▋ 4.2 Aortic DissectionDissecting aneurysm: Aortic dissection with aneurysmal formation. A general term that was previously used for overall aortic dissection. However, because in many cases with aortic dissection in acute phase does not meet the criteria for an aneurysm, aortic dissection in acute phase is now called, "acute aortic dissection." True lumen: The original arterial cavity. False lumen: A new cavity formed in the arterial wall (the term "dissection cavity" is not appropriate). Dissection flap: The (intima-media) septal wall. It used to be called "intimal dissection." However, it actually consists of intima and a part of the media. Tear: Intimal and medial tears of aortic dissection which is the site of communication between the true lumen and the false lumen. "Intimal tear" is also regularly used as a synonym for "tear". Entry: A site where blood flow enters from the true lumen to the false lumen. Re-entry: A site where blood flow enters from the false lumen to the true lumen. ("communication window" that is also used as a term for both entry and re-entry) Aortic dissection with patent false lumen: It is a synonym for "communicating aortic dissection", a type of aortic dissection in Europe classification. It is also called "classic dissection" or "double barrel aorta." One of the three types of aortic dissection in Japanese Aortic dissection with thrombosed false lumen: It is a synonym for "noncommunicating aortic dissection", a type of aortic dissection in Europe classification. One of the three ty...

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Transesophageal Echocardiography After Contrast-Enhanced CT Angiography in the Diagnosis of Type A Aortic Dissection

Cited by 10 publications

References 12 publications

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

A low threshold to ECG-gated repeat CTA reduces the risk of false-positive diagnosis of type A dissection in interhospital referrals: a case series study

JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection

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