Related narrative: Aortic Dissection
Aortic dissection can be easily misdiagnosed as limb ischemia, cardiogenic renal failure, stroke etc. depending on the vessels involved. This patient was unusual in not having the typical tearing interscapular pain radiating to the lower back and abdomen. CT scan (especially spiral) is replacing the old gold standard, angiogram for diagnosis. Trans-esophageal echo (TEE) is rapidly gaining popularity as a more rapid assessment tool as well. In addition to the differentiation of type A from type B, it is critical for the cardiac surgeons to have information on the integrity of the aortic valve to anticipate whether a graft incorporating a valve will be necessary. Type B dissection management is changing rapidly. The traditional medical management of hypertension with observation to avoid the severe morbidity and mortality of operative intervention, is now being supplemented with intraluminal stenting.
Dr. Valentine comments:
The case involved acute ischemia of the left leg, and the author did exactly the right thing by performing an extra-anatomic bypass to restore flow to the ischemic leg. He should be encouraged to comment on this, especially since general and vascular surgeons are consulted to manage acute leg/mesenteric/renal ischemia in patients with aortic dissections, which happen up to 30% of the time. Generally speaking, extra-anatomic reconstructions are always appropriate. In Type B dissections, extra-anatomic reconstructions may be the only procedure required, and the aorta can be left alone if no complications such as rupture or expansion intervene.
Was a catheter passed proximally into the artery? If so, how far could it be passed? Were the surgeons tipped off about an acute dissection because the catheter could not be passed?
Dr. Nehler replies:
Yes a catheter was passed, but could not get beyond the common iliac takeoff where the flap was. As soon as I saw the empty artery, I was concerned it was a dissection. The catheter problem verified this.
Rutherford, RB, Vascular Surgery, WB Saunders Co., Phila. 2000, p.1326-1345.
Nehler, MR, Harken, A, Aortic Dissection, in Handbook of Peripheral arterial disease, Regensteiner, JG et. al. Eds. (in press).
Fann JI, Miller DC. Aortic dissection. Ann.Vasc.Surg. 1995; 9:311-323.
Kato M, Bai H, Sato K, et al. Determining surgical indications for acute type B dissection based on enlargement of aortic diameter during the chronic phase. Circulation 1995; 92:II107-II112
Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N.Engl.J.Med. 1999; 340:1546-1552.
Williams GM. Treatment of chronic expanding dissecting aneurysms of the descending thoracic and upper abdominal aorta by extended aortotomy, removal of the dissected intima, and closure. J Vasc Surg 1993; 18: 441-9.
Webb TH, Williams GM. Abdominal aortic tailoring for renal, visceral, and lower extremity malperfusion resulting from acute aortic dissection. J Vasc Surg 1997; 26: 474-81.
Cambria RP, Brewster DC, Gertler J, Moncure AC, et al Vascular complications associated with spontaneous aortic dissection. J Vasc Surg 1988; 7: 199-202.
Slonim SM, Nyman U, Sembra CP, Miller DC, et al. Aortic dissection: Percutaneous management of ischemic complications with endovascular stents and balloon fenestration. J Vasc Surg 1996; 23: 241-53.