Circumferential intimal tear in type A aortic dissection with intimo-intimal intussusception into left ventricle and left main coronary artery occlusion

Coronary artery involvement in type A aortic dissection: Fate of the coronaries

BACKGROUND

Type A aortic dissection (TAAD) involves a tear in the intimal layer of the thoracic aorta proximal to the left subclavian artery, and hence, carries a high risk of mortality and morbidity and requires urgent intervention. This dissection can extend into the main coronary arteries. Coronary artery involvement in TAAD can either be due to retrograde extension of the dissection flap into the coronaries or compression and/or blockage of these vessels by the dissection flap, possibly causing myocardial ischemia. Due to the emergent nature of TAAD, coronary involvement is often missed during diagnosis, thereby delaying the required intervention.

AIMS

The main scope of this review is to summarize the literature on the incidence, mechanism, diagnosis, and treatment of coronary artery involvement in TAAD.

METHODS

A comprehensive literature search was performed using multiple electronic databases, including PubMed, Ovid, Scopus and Embase, to identify and extract relevant studies.

RESULTS

Incidence of coronary artery involvement in TAAD was seldom reported in the literature, however, some studies have described patients diagnosed either preoperatively, intraoperatively following aortic clamping, or even during autopsy. Among the few studies that reported on this matter, the treatment choice for coronary involvement in TAAD was varied, with the majority revascularizing the coronary arteries using coronary artery bypass grafting or direct local repair of the vessels. It is well-established that coronary artery involvement in TAAD adds to the already high mortality and morbidity associated with this disease. Lastly, the right main coronary artery was often more implicated than the left.

CONCLUSION

This review reiterates the significance of an accurate diagnosis and timely and effective interventions to improve prognosis. Finally, further large cohort studies and longer trials are needed to reach a definitive consensus on the best approach for coronary involvement in TAAD.

Intimal windsock following type A aortic dissection: An intussusception of severe implications

BACKGROUND

A patient has presented with type A aortic dissection and computed tomography aortogram revealed proximal and distal aorta intimointimal intussusception.

MATERIAL & METHODS

The patient has undergone successful aortic root replacement surgery and on the way to his recovery, he developed inferolateral myocardial infarction with the troponin I leak.

RESULTS

The coronary angiogram showed a small contrast leak around the left button with no luminal compromise.

CONCLUSION

An intravascular ultrasound played a major part in the diagnosis of left main coronary artery compression due to the intramural hematoma. A drug-eluting stent was deployed to relieve the compression and to support the dissected layers of the coronary artery.

Stanford type A acute aortic dissection with proximal intimo-intimal intussusception: a case report and literature review

Background

Acute aortic circumferential dissection with proximal intimo-intimal intussusception is a rare and potentially lethal occurrence. We here report a case and review previous works to better understand this particular condition and help surgeons to determine accurate diagnosis and optimal intervention strategies by intraoperative transesophageal echocardiography (TEE).

Case presentation

We report a case of a 46-year-old male who complained of sudden substernal chest pain. Stanford type A acute aortic dissection with proximal intimo-intimal intussusception was confirmed by contrast-enhanced computed tomography (CECT), transthoracic echocardiography (TTE), and TEE. We found the intimal flap prolapsed into the left ventricle outflow tract (LVOT), which caused severe aortic regurgitation (AR) and obstructed the ostia of the coronary arteries. Given the preexisting aneurysmal dilatation of aortic sinus and severity of aortic root and arch dissection, Bentall procedure and Sun’s procedure were performed for our patient.

Conclusions

Intraoperative TEE used by anesthesiologists here played an increasingly valuable role in the determination of acute aortic dissection. Hence, it is necessary that TEE screening is routinely performed in patients with acute aortic dissection to provide valuable information for facilitating surgical strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01581-0.

A Case of Circumferential Type A Aortic Dissection with Intimo-Intimal Intussusception

An 83-year-old woman was referred to our hospital under a diagnosis of acute aortic dissection. Contrast-enhanced computed tomography revealed no intimal flap in the mid-ascending aorta, and the intimal flap was found from the distal ascending aorta to the aortic arch. Operative findings showed that the intima of the mid-ascending aorta was circumferentially dissected and was inverted into the aortic arch. An emergent replacement of the ascending aorta was successfully performed; however, she died of a global intestinal ischemia on the fourth operative day.

Aortic intimal intussusception during acute type B aortic dissection endovascular repair

Aortic intimal intussusception (AoII) is rare, especially during the endovascular repair of acute uncomplicated type B aortic dissection. Here we present a case of 47-year-old man who suffered AoII during the endovascular repair of type B aortic dissection. An abdominal aortic stent was inserted to recanalize the aorta, but failed. He was immediately transferred to our department from the local hospital. Computed tomography angiography confirmed the AoII and showed thrombus in the abdominal aortic stent. Hybrid operation was performed. Final angiography showed patency of the aorta. His postoperative period was uneventful and was discharged on the postoperative 8^th day. No complications happened during the 6^th month follow-up.

Valve-sparing aortic root replacement for extremely localized circumferential aortic dissection associated with intimo-intimal intussusception

Circumferential dissection is a rare clinical condition of aortic dissection, which is also known as intimo-intimal intussusception. In patients with type A aortic dissection with intimo-intimal intussusception, disruption and prolapse of the intimal flap into the left ventricle may occur and cause severe aortic regurgitation or blockage of the coronary artery ostium. A 43-year-old man presented with sudden dyspnea. Echocardiography revealed severe aortic insufficiency. Acute coronary syndrome was also suspected, but coronary angiography showed normal coronary arteries. After medical treatment, elective surgery was performed. The distal aorta beyond the circumferential dissection was intact, and only the aortic root was dissected. The aortic valve could be preserved, because there was little degeneration of the cusps. Here, we report the case of a patient who underwent successful valve-sparing aortic root replacement for extremely localized aortic dissection with intimo-intimal intussusception.

A case of circumferential type A aortic dissection with intimal intussusception diagnosed using repeat transthoracic echocardiography examination

Case

Sometimes it is difficult to diagnose circumferential aortic dissection with enhanced computed tomography alone. A 58-year-old woman presented with sudden-onset chest discomfort and loss of consciousness. Transthoracic echocardiogram showed mild aortic regurgitation. Enhanced computed tomography scans showed no obvious intimal tear or flap at the proximal ascending aorta, but an intimal flap was observed from the aortic arch to both common iliac arteries. Stanford type B dissection was tentatively diagnosed. Repeat detailed transthoracic echocardiography examination showed an intimal tear and flap at the ascending aorta; prolapse into the left ventricle caused severe aortic regurgitation. Type A aortic dissection was definitively diagnosed; emergent operation showed a circumferential intimal tear originating from the ascending aorta.

Outcome

The ascending aorta was replaced; aortic regurgitation disappeared. The patient was discharged in a good condition 58 days postoperatively.

Conclusion

Dynamic evaluations with transthoracic echocardiography should be carried out to diagnose circumferential aortic dissection.

Acute Aortic Dissection With Intussusception of the Partition Between the True and False Channels Leading to Near Total Aortic Occlusion (True Aortic Stenosis)

Described herein are 2 patients with fatal acute aortic dissection resulting in a circumferential intimal-medial tear causing the partition between the true and false channels to roll up and propagate forward as an intra-aortic intussusception (a receiving within).

Echocardiographic detection of intimo-intimal intussusception in a patient with acute Stanford type A aortic dissection

Intimo-intimal intussusception is a very rare and unusual complication of type A dissections, typically noted on TEE exam. It has been reported in a few cases in the cardiothoracic surgical and radiology literature, and even more rarely in the cardiac anesthesia/TEE literature. This uncommon variation occurs in severe, acute, type A dissections when the ascending aortic intima circumferentially strips and detaches from the media and forms a tube-like structure which may either prolapse antegrade into the ascending aortic lumen or retrograde into the left ventricular (LV) outflow tract and LV cavity. Antegrade intussusceptions may be severe enough to partially or completely occlude the ostia of the innominate, left common carotid, and left subclavian arteries producing acute neurologic symptoms. Retrograde intussusceptions may severely impair LV filling in diastole, can worsen aortic insufficiency, mitral regurgitation, as well as produce occlusion of the coronary ostia and acute coronary ischemia. Here, we describe the incidental finding of a retrograde intussusception that was not visualized on computed tomography scan but by intraoperative TEE examination, in a patient with a severe, extensive type A dissection.

Unusual complication of aortic dissections: intimo-intimal intussusception

Angiography with a pre-diagnosis of acute coronary syndrome was performed in a 76-year-old female patient presenting to another hospital with symptoms of chest pain and syncope. Upon determination of type III aortic dissection, the patient was referred to our clinic. On CT angiography, the ascending aortic diameter was 57 mm and no dissection flap was observed. There was a filling defect suggestive of intimo–intimal intussusception at the level of the aortic arch, occlusion of the left arteria carotid communis, and a double-channel aorta extending from the left subclavian artery to the iliac artery. On transoesophageal echocardiography, the ascending aorta was seen to be larger than normal and no dissection flap was observed. There were findings suggestive of haematoma and intimo–intimal intussusception at the proximal part of the aortic arch. The dissection flap causing occlusion in the vascular structures was resected. Supracoronary graft replacement of the ascending aorta was performed. Transoesophageal echocardiography is an invasive investigative method with high sensitivity and specificity for the diagnosis of intimo–intimal intussusception.