Surgery in three-channeled aortic dissection. A 31-patient review

Acute-on-Chronic Aortic Dissection: Management and Outcomes of the Unstable "Triple-Lumen" Aorta

BACKGROUND

The impact of acute aortic dissection of the chronically dissected distal aorta is unknown. This study sought to describe the incidence and characteristics of the triple-lumen aortic dissection and its impact on survival.

METHODS

From 2010 to 2021, a query of a single-institution aortic database identified 1149 patients with chronic distal aortic dissection. Thirty-three (2.9%) patients with at least 3 distinct lumens and 2 separate "primary" intimal tears were identified by analysis of contrast-enhanced cross-sectional imaging. Triple-lumen patients were exactly matched with a cohort of double-lumen patients on a 1:1 ratio using 5 preoperative variables, and outcomes between the groups were assessed.

RESULTS

The median age at time of initial dissection in patients with a triple-lumen dissection was 46 years. Initial dissection was a type A in 33% and a type B in 67% of patients. The median time from initial dissection to triple-lumen diagnosis was 4.2 years. On diagnosis of the triple-lumen aorta, 85% of patients required urgent aortic repair for rapid growth (36%), aortic diameter ≥55 mm (30%), malperfusion (6%), intractable pain (6%), and rupture/type A (6%). Thirty-day mortality after triple lumen dissection was 12%.

CONCLUSIONS

Acute-on-chronic distal dissection resulting in a triple-lumen aorta should be classified as a "complicated" type B dissection as these patients typically have large aneurysms and a high incidence of rapid false lumen expansion requiring urgent surgical repair.

Morphological features and endovascular repair for type B multichanneled aortic dissection: A case report

BACKGROUND

Among the various types of aortic dissection, multichanneled aortic dissection (MCAD) differs from classic double-channeled aortic dissection and involves the formation of an additional false lumen in the aortic wall or the flaps. It is considered a relatively rare condition with high perioperative mortality and morbidity. However, the morphological characteristic and the optimal therapeutic strategy for MCAD has not been fully determined.

CASE SUMMARY

A 64-year-old man presented to our hospital with severe epigastric abdominal pain radiating to the back that was associated with nausea without emesis. A computed tomography angiogram was performed that revealed a type B aortic dissection with multiple channels extending from the level of the left subclavian artery to the bilateral femoral arteries. We used a medical three-dimensional modeling (3D) modeling system to identify the location and extension of multiple lumens from different angles. It also precisely located the two primary entries leading to the false lumens, which helped us to exclude the two false lumens with one stent-graft.

CONCLUSION

By applying medical 3D modeling system, we discover the fragility of aortic wall and the collapse of true lumen caused by the multiple false lumens are the two morphological features of MCAD.

Hemodynamic evaluation using four-dimensional flow magnetic resonance imaging for a patient with multichanneled aortic dissection

The hemodynamic function of multichanneled aortic dissection (MCAD) requires close monitoring and effective management to avoid potentially catastrophic sequelae. This report describes a 47-year-old man who underwent endovascular repair based on findings from four-dimensional (4D) flow magnetic resonance imaging of an MCAD. The acquired 4D flow data revealed complex, bidirectional flow patterns in the false lumens and accelerated blood flow in the compressed true lumen. The collapsed abdominal true lumen expanded unsatisfactorily after primary tear repair, which required further remodeling with bare stents. This case study demonstrates that hemodynamic analysis using 4D flow magnetic resonance imaging can help understand the complex pathologic changes of MCAD.

Three-Channeled Aortic Dissection in a Patient without Marfan Syndrome

A 64-year-old man was admitted for evaluation of back pain. He did not have a Marfan syndrome (MFS)-like appearance, and had a history of a type B aortic dissection and total arch replacement. A connective tissue disorder had been suspected because of the histologic findings of the resected aortic wall. On admission, a computed tomography (CT) scan demonstrated a three-channeled aortic dissection (3ch-AD) measuring 63 mm in diameter. We planned to perform elective surgery during his hospitalization. On the fourth hospital day, he complained of severe back pain, and enhanced CT scan revealed an aortic rupture. The patients with 3ch-AD often have MFS. However, even if they do not have an MFS-like appearance, clinicians should consider fragility of the aortic wall in patients with 3ch-AD. If the aortic diameter is enlarged, early surgery is recommended. In particular, if a connective tissue disorder is obvious or suspected, emergent surgery is warranted.

CT patterns of acute type A aortic arch dissection: longer, higher, more anterior

OBJECTIVES

This study analysed CT patterns of the acute dissected aortic arch using original biometric features along with comparison with normal aortas.

METHODS

The diagnostic CT scans of 57 patients (42 males, age (mean ± SD: 64.5 ± 13.8 years) admitted with acute Stanford type A dissection involving the aortic arch were analysed by semi-automatic detection protocol of the true lumen of the dissection. We measured the distances from the apex to the ascending and descending aorta, the curvilinear length of the entire arch and of its segments (especially between the brachiocephalic artery trunk and the left subclavian artery), as well as the surface area, angle, height and shift of the arch. These measurements were compared with results previously obtained in a healthy cohort in an analysis adjusted for age, sex and weight. The surface area and rotation of the false lumen were also analysed.

RESULTS

Compared to normal aortic arches (N), dissected aortic arches (D) were longer (D: 155 ± 26  mm, N: 135 ± 25  mm, p = 0.002), higher (D: 51 ± 10  mm, N: 45 ± 9  mm, p = 0.04), and with a more anterior apex (shift: D: 1.19 ± 0.56, N: 1.40 ± 0.62, p = 0.007). False lumen occupied between 47-65% of the aorta, turned preferentially clockwise and its rotation decreased progressively along the arch.

CONCLUSIONS

The morphology of the dissected aortic arch differs from that of the normal arch. Thus, our compilation of aortic arch measurements may help improve existing endovascular devices and/or design of new endoprostheses. Advances in knowledge: In this article, we provide a comprehensive set of measurements of the dissected aortic arch, and show that dissected aortic arches are longer, higher, and with a more anterior apex than normal arches.

MDCT in diagnosing acute aortic syndromes: reviewing common and less common CT findings

Nontraumatic acute thoracic aortic syndromes (AAS) describe a spectrum of life-threatening aortic pathologies with significant implications on diagnosis, therapy and management. In this context, multidetector computed tomography (MDCT) is the gold standard due to its intrinsic diagnostic value; its performance approaches 100% sensitivity and specificity, and it is accepted as a first-line modality for suspected acute aortic disease. MDCT allows early recognition and characterisation of acute aortic syndromes as well as the presence of any associated complications - findings that are essential for optimising treatment and improving clinical outcomes. Although classic CT findings have long been known, other unusual signs are continually reported in the medical literature. We reviewed the classic and less common CT findings, correlating them with pathophysiology, timing and management options, to achieve a definite and timely diagnostic and therapeutic definition.