What makes the difference between the natural course of a remaining type B dissection after type A repair and a primary type B aortic dissection?

StreszczenieWstęp: Rozwarstwienie aorty jest ostrym stanem aortalnym stanowiącym zagrożenie życia, wymagającym szybkiej i precyzyjnej diagnostyki. Głównym celem leczenia operacyjnego rozwarstwienia typu A jest wycięcie wrót pierwotnych rozwarstwienia, a w przypadku wewnątrznaczyniowego leczenia rozwarstwienia typu B ich zamknięcie. Celem pracy była ocena wrót pierwotnych i wtórnych w aorcie piersiowej przy użyciu dwuźródłowej tomografii komputerowej (DSCT) bramkowanej EKG u pacjentów z rozwarstwieniem aorty piersiowej. Materiał i metody: Analizie poddano 53 chorych (39 mężczyzn, średnia wieku 55,69 roku) z rozwarstwieniem aorty piersiowej. Bramkowane EKG badania angio-TK aorty wykonywano aparatem dwuźródłowym. Oceniano obecność, lokalizację oraz wielkość wrót pierwotnych oraz występowanie wrót wtórnych w aorcie piersiowej. Obecność i lokalizacja wrót pierwotnych rozwarstwienia była weryfikowana śródoperacyjnie w przypadku pacjentów operowanych lub angiograficznie u pacjentów leczonych wewnątrznaczyniowo. Wyniki: Rozwarstwienie typu A stwierdzono u 42 chorych (79,25%), typu B u 11 (20,75%). Wrota pierwotne uwidoczniono u 98,15% pacjentów, u 41 z rozwarstwieniem typu A i u wszystkich chorych z typem B rozwarstwienia. Nie stwierdzono istotnej statystycznie różnicy wielkości wrót w grupie A i B rozwarstwienia (20.07 vs 12.2 mm, p = 0.14). Wtórne wrota rozwarstwienia w aorcie piersiowej wykryto u 12 (28,5%) chorych z rozwarstwieniem typu A; nie stwierdzono wrót wtórnych w aorcie piersiowej u pacjentów z rozwarstwieniem typu B. Wnioski: DSCT bramkowane EKG pozwala na precyzyjną ocenę lokalizacji i wielkości wrót rozwarstwienia. Wrota pierwotne w obu typach rozwarstwienia mogą być zlokalizowane w łuku aorty. Wielkość wrót w obu typach rozwarstwienia jest podobna. Wrota wtórne w aorcie piersiowej istotnie częściej występują w rozwarstwieniu typu A. Słowa kluczowe: aorta, rozwarstwienie, wrota rozwarstwienia. Kardiochirurgia i Torakochirurgia Polska 2013; 10 (2) 171 DIAGNOSTIC IMAGING AbstractIntroduction: Aortic dissection is an acute life-threatening disorder requiring prompt and precise diagnostic imaging. The main role of surgery in type A dissection is the excision of the primary intimal tear, while in the case of endovascular treatment of type B dissection it is the occlusion of the entry tear. The aim of the study was to assess the initial intimal and additional tears within the thoracic aorta using ECG-gated dual-source computed tomography (DSCT). Material and methods: 53 patients (39 male, mean age 55.69 years) with thoracic aorta dissections were analyzed. The ECG-gated angio-CT was performed using dual-source computed tomography. The presence, location, and measurements of the initial intimal and additional tears in the thoracic aorta were assessed. The CT results were confirmed by surgical reports or by aortographic results in the case of endovascular treatment. Results: Out of 53 patients, 42 (79.25%) had type A dissection, and 11 (20.75%) had type B. The initial tear was detected in 98.15% of patients (in 4...

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“…A remaining patent primary entry tear predicts the need for intervention in patients after surgery for acute type A aortic dissection [9].…”

Section: Discussionmentioning

confidence: 99%

DIAGNOSTIC IMAGING Assessment of intimal tears in thoracic aortic dissection using ECG-gated dual-source computed tomography

Michałowska¹,

Szpakowski²,

Furmanek³

et al. 2013

kitp

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“…Placement of an aortic cross clamp suggests that the primary tear may be left behind (if present in the arch) and is a predictor of aortic dilation (13) and need for reoperation (6,11,14). Lai and colleagues summarize that the open distal anastomosis approach allows for a "sounder and more hemostatic anastomosis [that] can be constructed by avoiding the crowding and distortion introduced by the aortic clamp, clamp injuries to the aorta are avoided, and the friable, dissected aorta under the innominate artery is not left behind" (8).…”

Section: Use Of Deep Hypothermic Circulatory Arrest and The Avoidancementioning

confidence: 99%

The impact of surgical strategy on survival after repair of type A aortic dissection

Lawton

Liu

Kulshrestha

et al. 2015

The Journal of Thoracic and Cardiovascular Surgery

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“…However, a certain percentage of patients will still develop post dissection arch aneurysm despite adequate primary repair. Number and extent of communications between the true and the false channels and evaluation of the functional value of the flow through these communications might help how to decrease the incidence of this problem [13]. Aneurymal degeneration of primary untreated aortic segements was the indication for redo surgery in 13%.…”

Section: Commentmentioning

confidence: 99%

Long-term results after proximal thoracic aortic redo surgery

Czerny¹,

Barchichat²,

Meszaros³

et al. 2013

Thorac cardiovasc Surg

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Objective: To evaluate early and mid-term results in patients undergoing proximal thoracic aortic redo surgery. Methods:We analyzed 60 patients (median age 60 years, median logistic EuroSCORE 40) who underwent proximal thoracic aortic redo surgery between January 2005 and April 2012. Outcome and risk factors were analyzed.Results: In hospital mortality was 13%, perioperative neurologic injury was 7%. Fifty percent of patients underwent redo surgery in an urgent or emergency setting. In 65%, partial or total arch replacement with or without conventional or frozen elephant trunk extension was performed. The preoperative logistic EuroSCORE I confirmed to be a reliable predictor of adverse outcome-(ROC 0.786, 95%CI 0.64-0.93) as did the new EuroSCORE II model: ROC 0.882 95%CI 0.78-0.98. Extensive individual logistic EuroSCORE I levels more than 67 showed an OR of 7.01, 95%CI 1.43-34.27. A EuroSCORE II larger than 28 showed an OR of 4.44 (95%CI 1.4-14.06). Multivariate logistic regression analysis identified a critical preoperative state (OR 7.96, 95%CI 1.51-38.79) but not advanced age (OR 2.46, 95%CI 0.48-12.66) as the strongest independent predictor of in-hospital mortality. Median follow-up was 23 months (1-52 months). One year and five year actuarial survival rates were 83% and 69% respectively. Freedom from reoperation during follow-up was 100%.Conclusions: Despite a substantial early attrition rate in patients presenting with a critical preoperative state, proximal thoracic aortic redo surgery provides excellent early and mid-term results. Higher EuroSCORE I and II levels and a critical preoperative state but not advanced age are independent predictors of in-hospital mortality. As a consequence, age alone should no longer be regarded as a contraindication for surgical treatment in this particular group of patients.

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What makes the difference between the natural course of a remaining type B dissection after type A repair and a primary type B aortic dissection?

Cited by 36 publications

References 20 publications

DIAGNOSTIC IMAGING Assessment of intimal tears in thoracic aortic dissection using ECG-gated dual-source computed tomography

DIAGNOSTIC IMAGING Assessment of intimal tears in thoracic aortic dissection using ECG-gated dual-source computed tomography

The impact of surgical strategy on survival after repair of type A aortic dissection

Long-term results after proximal thoracic aortic redo surgery

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