Stanford Type A Acute Aortic Dissection with Intimal Intussusception

Surgical choice for the treatment of partial intestinal ischemic necrosis caused by acute type a aortic dissection combined with malperfusion of superior mesenteric artery

Acute type A aortic dissection is a severe cardiovascular disease characterized by rapid onset and high mortality. Traditionally, urgent open aortic repair is performed after admission to prevent aortic rupture and death. However, when combined with malperfusion syndrome, the low perfusion of the superior mesenteric artery can further lead to intestinal necrosis, significantly impacting the surgery's prognosis and potentially resulting in adverse consequences, bringing. This presents great significant challenges in treatment. Based on recent domestic and international research literature, this paper reviews the mechanism, current treatment approaches, and selection of surgical methods for poor organ perfusion caused by acute type A aortic dissection. The literature review findings suggest that central aortic repair can be employed for the treatment of acute type A aortic dissection with inadequate perfusion of the superior mesenteric artery. The superior mesenteric artery can be windowed and (/or) stented, followed by delayed aortic repair. Priority should be given to revascularization of the superior mesenteric artery, followed by central aortic repair. During central aortic repair, direct blood perfusion should be performed on the distal true lumen of the superior mesenteric artery, leading to resulting in favorable therapeutic outcomes. The research results indicate that even after surgical aortic repair, intestinal ischemic necrosis may still occur. In such cases, prompt laparotomy and necessary necrotic bowel resection are crucial for saving the patient's life.

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.

Early and late outcomes of non-total aortic arch replacement for repair of acute Stanford Type A aortic dissection

OBJECTIVE

This study evaluated the early and late outcomes of non-total aortic arch replacement for acute Stanford A aortic dissection.

METHODS

131 cases of acute Stanford Type A aortic dissection with no rupture admitted to our hospital from January 2016 to December 2019 were selected for non-total aortic arch replacement. According to different surgical methods, 51 patients with tear-oriented ascending/hemiarch replacement were included in Group A, and 80 patients who underwent total arch replacement surgery were enrolled in Group B. The perioperative indicators, 30-day mortality rate, and the incidence of postoperative complications were compared between the two groups, and the survival rate of patients were compared by follow-up after discharge.

RESULTS

The cardiopulmonary bypass time, cardiac perfusion time, invasive ventilation and ICU hospitalization in Group A were critically shorter than those in Group B (P<0.05). The incidence of transient cerebral dysfunction in Group A was substantially lower than that in Group B (P<0.05). The difference of comparison in perioperative mortality, incidence of permanent neurological dysfunction, and incidence of acute kidney and liver damage between the two groups was statistically insignificant (P>0.05). In addition, the two groups had statistically insignificant difference in survival during postoperative follow-up (P>0.05).

CONCLUSION

For acute Stanford type A aortic dissection without rupture in aortic arch, the non-total aortic arch replacement has simple surgical method with high perioperative safety and long-term efficacy that similar to total arch replacement.

Aortic Intimo-intimal Intussusception: A Pooled Analysis of Published Reports

AIM

Aortic intimo-intimal intussusception (AoII) is a rare manifestation of aortic dissection with high mortality. This study aimed to obtain a comprehensive understanding of AoII.

METHODS

Three databases (PubMed, Scopus, Embase) were searched with predefined search terms ["intimal intussusception", "aortic intussusception", "(circumferential) AND (intimal dissection)" and "(circumferential) AND (aortic dissection)"]. Demographics, clinical manifestations, imaging methods, therapies, and follow-up data were recorded and analyzed.

RESULTS

The literature search finally identified 81 papers comprising 87 patients (Mean age: 53.7 ± 14.9 years old; male: n = 63). According to morphologic criteria (orientation of AoII intimal flap), patients were divided into three groups: antegrade (n = 37), retrograde (n = 49) and bidirectional (n = 1) orientation. The most frequent symptoms in antegrade group were chest pain (62.2%), syncope (27%), and unconsciousness (21.6%), while in retrograde group, they were chest pain (71.4%), dyspnea (20.4%), and back pain (16.3%). Regarding applied imaging modalities, 67.5% of patients in antegrade group were diagnosed with≥2 methods, comparing with 87.7% in retrograde group. A total of 21 patients (24.1%) with AoII finally died, among which 13.8% (12/87) died before surgery.

CONCLUSION

AoII is a rare form of aortic dissection with high mortality. Antegrade orientation of the intima flap was more accompanied with neurological disorders and asymmetric blood pressure, while retrograde orientation mostly manifested with aortic regurgitation. Application of multiple imaging examinations may detect this rare entity in time.

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.