Showing papers on "Aortic arch published in 1994"
TL;DR: A strong, independent association between atherosclerotic disease of the aortic arch and the risk of ischemic stroke is indicated, particularly strong with thick plaques.
Abstract: Background Atherosclerotic disease of the aortic arch has been suspected to be a potential source of cerebral emboli. We conducted a study to quantify the risk of ischemic stroke associated with atherosclerotic disease of the aortic arch. Methods Using transesophageal echocardiography, we performed a prospective case-control study of the frequency and thickness of atherosclerotic plaques in the ascending aorta and proximal arch in 250 consecutive patients admitted to the hospital with ischemic stroke and 250 consecutive controls, all over the age of 60 years. Results Atherosclerotic plaques ≥ 4 mm in thickness were found in 14.4 percent of the patients but in only 2 percent of the controls. After adjustment for atherosclerotic risk factors, the odds ratio for ischemic stroke among patients with such plaques was 9.1 (95 percent confidence interval, 3.3 to 25.2; P<0.001). Among the 78 patients who had brain infarcts with no obvious cause, 28.2 percent had plaques ≥ 4 mm in thickness, as compared with 8.1 pe...
890 citations
TL;DR: Routine reconstruction of the aSA is recommended to avoid ischemic complications in the vertebrobasilar territory or upper extremity and provision should be made for cardiopulmonary bypass in patients with aneurysm of aSA or associated aortic aneurYSm.
222 citations
TL;DR: In this article, the authors reviewed the prenatal echocardiograms and postnatal outcome of 20 infants (gestational age at initial study 18 to 36 weeks) with coarctation of the aorta established postnatally.
141 citations
TL;DR: A retrospective study examining the echocardiograms of fetuses with a verified aortic arch abnormality and those in whom the diagnosis was suspected prenatally but was not subsequently confirmed found that the most severe forms of coarctation are associated with relative hypoplasia of the left heart structures compared with the right and a correct diagnosis can be made in early pregnancy.
Abstract: OBJECTIVE--To formulate echocardiographic criteria for the prenatal diagnosis of coarctation of the aorta. DESIGN--A retrospective study examining the echocardiograms of fetuses with a verified aortic arch abnormality and those in whom the diagnosis was suspected prenatally but was not subsequently confirmed. SETTING--Tertiary referral centre for fetal echocardiography. PATIENTS--87 fetuses in whom the diagnosis of coarctation was correctly made in 54, suspected but unproved in 24, and overlooked prenatally in nine. MAIN OUTCOME MEASURES--Measurements of left and right ventricular size, the diameters of the great arteries, the diameters of the left and right atrioventricular valvar orifices, the appearance of the aortic arch, and the direction of the flow of blood across the foramen ovale. RESULTS--Measurements of the ventricular widths, diameters of the great arteries, or the diameters of the atrioventricular valvar orifices, did not allow clear distinction between cases that definitely had a coarctation and those in whom the diagnosis was unproved. The appearance of the aortic arch, particularly in the horizontal projection, was more helpful in distinguishing cases of coarctation, although this also was not always diagnostic. A predominantly left to right shunt across the foramen ovale was detected more often in cases with a substantiated coarctation (58%) than in those with an unproved diagnosis (12%). CONCLUSIONS--The most severe forms of coarctation are associated with relative hypoplasia of the left heart structures compared with the right and a correct diagnosis can be made in early pregnancy. The milder forms of coarctation, however, are consistent with a normal early fetal echocardiogram. In late pregnancy it may be impossible to exclude coarctation categorically as the right heart structures may appear larger than the left in the normal fetus. Thus although a combination of echocardiographic features can correctly identify aortic arch anomalies in the fetus, none either alone or in combination, could clearly distinguish between real and false positive cases, particularly in late gestation.
138 citations
TL;DR: The findings from the present study indicate that, currently, early mortality is relatively low for all patients who undergo operations for aneurysm of the aortic arch, unless they are in a critical condition preoperatively orunless they are undergoing a reoperation.
128 citations
TL;DR: A comparison among the various diagnostic techniques used in 12 patients during the last 12 years showed that angiography, magnetic resonance imaging, and computed tomography were the most reliable, as they always accurately delineated the anatomy.
108 citations
TL;DR: It has been shown that transesophageal echocardiography (TEE) is useful in evaluating atheromatous disease of the aortic arch and that such disease is a risk factor for stroke in medical patients.
90 citations
TL;DR: Associated aortic valve disease was strongly correlated with late death and need for reoperation, and both the teardrop-shaped and pantaloon-shaped patch techniques provide excellent long-term relief of localized supravalvular gradients and preservation of aortIC valve competence.
81 citations
TL;DR: Between February 1982 and December 1992, five patients with mycotic aneurysms of the thoracic aorta were operated on, one patient died 4 months postoperatively, the other four patients were without recurrent graft infection and are free of symptoms between 20 months and 5 yearsPostoperatively.
Abstract: Between February 1982 and December 1992 we operated on five patients (three men, two women; aged 40 to 70 years) with mycotic aneurysms of the thoracic aorta. One patient had an aneurysm of the ascending aorta, once the aortic arch and in three cases the descending thoracic aorta were involved. In four of the five patients, excision of the aneurysm and in situ reconstruction of the aorta with a Dacron graft was performed, one patient required a Dacron graft repair and aortic valve replacement. We employed deep hypothermia with circulatory arrest (2), extracorporeal circulation (1), an axillofemoral shunt (1) and a centrifugal pump (1) for cerebral and spinal cord protection. One patient died 4 months postoperatively, the other four patients were without recurrent graft infection and are free of symptoms between 20 months and 5 years postoperatively.
81 citations
TL;DR: It is recommended that descending thoracic aortic dissection extending into the arch or the ascending aorta be managed in accordance with the site of the predominant lesion, which is difficult to achieve through a median sternotomy if the predominant aorti lesion is located in its descending part.
75 citations
TL;DR: With increasing experience in arch reconstructions and improvement in outcome, the indications could be expanded to include all type A aortic dissections with a patent false lumen in the descending aorta.
TL;DR: The results of a 10-year surgical experience with the biventricular repair for double-outlet right ventricle with situs solitus and atrioventricular concordance with preoperative anatomic findings are presented.
TL;DR: Hypothermic circulatory arrest is a valuable adjunct in the management of complex aortic aneurysms through left-sided thoracotomy and its results warrant consideration of its selective use for spinal cord/visceral protection.
Journal Article•
TL;DR: Despite satisfactory early results, the long-term survival of patients with the Marfan syndrome was suboptimal (albeit similar to those without the Mar fan syndrome).
Abstract: Background Aortic dissection is one of the most lethal potential complications in patients with the Marfan syndrome. Methods and results Among 360 patients undergoing operative treatment of aortic dissection between 1963 and 1992, 40 had the Marfan syndrome. There were 24 men and 16 women with a mean age of 35 +/- 9 years (+/- 1 SD; range, 15 to 54 years). These patients included 16 with acute type A, 2 with acute type B, 18 with chronic type A, and 4 with chronic type B aortic dissections. The aortic arch was involved in 29 cases. Preoperative complications included acute aortic valvular insufficiency in 13 patients, rupture into the pericardial space in 3, and loss of peripheral pulses in 9. The site of primary intimal tear was the ascending aorta in 25 patients, the aortic arch in 2, the descending aorta in 7, and not identified in 6. Operations included ascending aortic and aortic valvular replacement (with or without coronary artery reimplantation) in 22 patients, ascending aortic replacement alone in 5, and descending thoracic aortic replacement in 9. Four operative deaths (10 +/- 5% [+/- 70% confidence limits]) occurred in 3 acute patient-years and 1 chronic type A patient-years. Long-term follow-up (216 patient-years; range, 1 month to 22 years; mean, 5.4 years) revealed 15 late deaths, 7 from late aortic sequelae. The overall actuarial survival estimates were 71 +/- 8%, 54 +/- 10%, and 22 +/- 11% at 5, 10, and 15 years, respectively. Twenty late aortic operations were required in 14 patients. Conclusions Despite satisfactory early results, the long-term survival of patients with the Marfan syndrome was suboptimal (albeit similar to those without the Marfan syndrome). Future progress will pivot on reducing the incidence of aortic dissection in these patients with medical therapy and/or earlier surgical intervention and enhanced postoperative serial imaging surveillance of the entire aorta.
TL;DR: It is concluded that regional deep hypothermia of the spinal cord in pigs does provide some protection from ischemic injury during thoracic aortic cross-clamping, and Clinically this may be a useful adjunct for prevention of paraplegia duringThoracicAortic operations.
TL;DR: The present data suggest that simultaneous total arch replacement may be justified in selected patients with acute type A aortic dissection.
TL;DR: Patients with innominate artery compression and pulmonary artery sling with symptomatic vascular rings/slings do well soon after surgery with relief of most of their symptoms, and patients who have persistent symptoms should be further evaluated with PFTs, MRI, and bronchoscopy.
Abstract: Between January 1977 and January 1990, 44 patients with symptomatic vascular rings/slings required surgical intervention at this center. Nineteen patients had double aortic arch (group I); 13 patients had vascular ring consisting of right aortic arch, anomalous origin of the left subclavian artery, and ligamentum arteriosus (group II); eight patients had innominate artery compression (group III); and four patients had pulmonary artery sling (group IV). Three patients had complex congenital heart defect and died secondary to it and are excluded from the study. Follow-up was obtained on 31 patients (76%). The follow-up period ranged from 0.4 years to 10.9 years, with a mean of 3.6 years. Seventy percent of the overall group were asymptomatic, and 30% of patients continued to have upper and lower respiratory symptoms on late follow-up. One third of patients in groups I and II, who underwent surgical repair, continue to have symptoms. Patients who have persistent symptoms should be further evaluated with PFTs, MRI, and bronchoscopy, and may benefit from aortopexy. Patients with innominate artery compression and pulmonary artery sling do well soon after surgery with relief of most of their symptoms.
TL;DR: Two adjunctive techniques for operations involving the aortic arch, retrograde perfusion of cold oxygenated blood through the superior vena cava and establishment of antegrade flow after hypothermic circulatory arrest, are described and may reduce the incidence of brain injury.
TL;DR: The present study aims to examine the results of arterial reconstruction in the medium and long term in patients with histologically proven Takayasu's disease, finding that three patients developed fatal progression of the disease and seven required surgical intervention.
TL;DR: This large animal model demonstrates that long tracheal allografts might be transplanted by means of this direct revascularization and venous drainage technique.
TL;DR: For the whole group, multivariate analysis using stepwise logistic regression showed that operative risk factors were concomitant coronary artery bypass grafting, age (increased), aortic valve regurgitation, and previous cardiac surgery.
TL;DR: Obstructive lesions of the iliofemoral arteries are common after transfemoral BDA of arch obstructions and can be reliably evaluated with gradient MRI, with a significant correlation between the number of balloon catheters used for the angioplasty and severe occlusive changes.
Abstract: BACKGROUNDWe wished to determine the nature and incidence of changes in the iliofemoral arteries after balloon dilation angioplasty (BDA) for aortic arch obstruction in children and to determine the reliability of gradient magnetic resonance imaging (MRI) in their detectionMETHODS AND RESULTSSixty-three children, including 62 with and 1 without arch obstruction, underwent MRI of the iliofemoral vessels Of these, 36 patients had undergone transfemoral BDA (7 after previous transfemoral diagnostic catheterization), 12 had undergone diagnostic transfemoral catheterization but not BDA, and 15 had no history of femoral arterial catheterization The iliofemoral arteries were normal on MRI in all 15 children without catheterization Among the 36 children who had undergone BDA, the ipsilateral iliofemoral artery was normal in 15, mildly narrowing in 7, and severely stenotic or occluded in 14 (39%), including 6 of 9 patients treated for acute femoral artery thrombosis and 8 with no history of femoral artery thro
TL;DR: This method, with its simplified operative procedure using a lateral thoracotomy, supplied oxygen to the brain and protected it during interruption of the cerebral circulation, and careful management of the atherosclerotic aorta is needed.
Abstract: We have devised a simple hypothermic retrograde cerebral circulation technique for protecting the brain during aortic arch surgery. The central venous pressure is simply elevated (15 to 18 mmHg) while the aortic arch is open and the descending aorta occluded, causing oxygen-saturated venous blood from the lower half of the body, which is undergoing deep hypothermic (15°C to 18°C) perfusion, to circulate in the brain in a retrograde fashion, supplying it with oxygen. Twenty-six cases of distal aortic arch aneurysm treated using this method, through a left thoracotomy with femoral vein cannulation, were evaluated. Retrograde cerebral circulation time was 59.6 ± 13.1 minutes (40 to 93 min). Retrograde flow was 43.9 ± 13.0 (25 to 62) mL/min. Significant oxygen and apparent lactate extraction were noted in the brain. Early death resulted in 3 of the first 14 cases (21.4%) from embolism, and in 1 of the other 12 cases (8.3%) from massive bleeding and multiple organ failure. Only one late death occurred. No death was attributed to the method itself. This method, with its simplified operative procedure using a lateral thoracotomy, supplied oxygen to the brain and protected it during interruption of the cerebral circulation. Careful management of the atherosclerotic aorta is needed. (J Card Surg 1994;9:576–583)
Patent•
01 Sep 1994TL;DR: In this paper, an endovascular device for partitioning the ascending aorta and a system for arresting the heart to facilitate the performance of precedures such as heart valve replacement or coronary artery bypass grafting without the need for a thoracotomy.
Abstract: The invention provides an endovascular device (20) for partitioning the ascending aorta and a system for arresting the heart to facilitate the performance of precedures such as heart valve replacement or coronary artery bypass grafting without the need for a thoracotomy. According to the invention, an endovascular device (20) for partitioning a patient's ascending aorta comprises a flexible shaft (22) having a distal end (24), a proximal end (26), and a first inner lumen (29) therebetween with an opening (31) at the distal end (24). The shaft (22) may have a preshaped distal portion (32) with a curvature generally corresponding to the curvature of the patient's aortic arch. Expandable means (28) are disposed near the distal end (24) of the shaft (22) proximal to the opening (31) in the first inner lumen (29) for occluding the ascending aorta so as to block substantially all blood flow therethrough for a plurality of cardiac cycles. Means (90) for delivering cardioplegic fluid may be connected to the proximal end (26) of the device to infuse cardioplegic fluid into the coronary arteries for arresting the heart. The endovascular device of the invention is readily positionable in the ascending aorta, resists displacement caused by systolic blood flow, and maintains axial alignment with the center of the ascending aorta and aortic valve.
TL;DR: Radical arch surgery should be avoided in acute dissections whenever feasible, and the arch should be explored and a blood‐tight distal anastomosis made, going beyond any entry tears encountered in that aortic portion.
Abstract: Operations on the nondissected and dissected aortic arch still pose challenges in terms of the need for and extent of aortic replacement. Our approaches to these lesions are described against the background of 204 operations (58 aneurysms, 54 chronic dissections, and 92 acute dissections), in terms of cerebral protection, procedural choices, and operative technique. Arch anastomoses sparing the supraaortic vessels had shorter periods of circulatory arrest (17.2 min) when compared to tubular arch replacement, with insertion of some or all of these vessels (33.7 min). Early death rates due to cerebral complications were lowest in acute dissections (3/14 fatalities, with two patients showing preoperative cerebral compromise). Based on our experience, we recommend doing subtotal or total arch repiacement in aneurysms regardless of cause. Radical arch surgery should be avoided in acute dissections whenever feasible. instead, the arch should be explored and a blood-tight distal anastomosis made, going beyond any entry tears encountered in that aortic portion. (J Card Surg 1994;9:538–547)
TL;DR: A simplified technique for reversed cerebral perfusion during hypothermic circulatory arrest for transverse aortic arch repair is described and substantial clinical experience indicates the method is clinically safe.
TL;DR: The associated lesions found with aortopulmonary window are seldom encountered with common arterial trunk, suggesting these two arterial lesions have different pathogenesis and are not variants of the same entity.
Abstract: We examined 25 heart specimens with aortopulmonary windows in order to review the variety of the lesion and its associated malformations. Unlike common arterial trunk, the aortopulmonary window involves a deficiency of the wall of the ascending aorta and that of the pulmonary trunk. The window was in proximal position in three specimens, intermediate position in three specimens, distal position in 16 specimens and was confluent in three specimens. The size of the window varied from 27 to 100% of the total length of the pulmonary trunk but size did not bear any apparent relationship to the position of the defect. The shape of the window was tunnel-like in one case. Of the 16 specimens with distal windows, the orifice of the right pulmonary artery arose from the aorta in seven specimens and was overriding the plane of the window in one specimen. The window occurred as an isolated lesion in four specimens. It was associated with interruption of the aortic arch at the isthmus in eight specimens and between the left carotid and left subclavian arteries in three specimens. A further three specimens had isthmal stenosis. Among the other associated defects were complete transposition (two specimens), tetralogy of Fallot (one specimen), and double outlet right ventricle (one specimen). A ventricular septal defect was present in six of the 25 specimens. The associated lesions found with aortopulmonary window are seldom encountered with common arterial trunk, suggesting these two arterial lesions have different pathogenesis and are not variants of the same entity.
TL;DR: Repairs or replacement of the aortic arch using selective cerebral perfusion is a safe procedure with acceptable hospital mortality and there were no significant differences in test scores before or after operation.
TL;DR: To compare the incidence and prognosis of subaortic stenosis associated with a ventricular septal defect and to define the morphological basis of subanatomical stenosis, 202 patients seen at the Royal Liverpool Children's Hospital between 1 January 1960 and 31 December 1991 were reviewed.
Abstract: OBJECTIVE--To compare the incidence and prognosis of subaortic stenosis associated with a ventricular septal defect and to define the morphological basis of subaortic stenosis. DESIGN--Presentation and follow up data on 202 patients with subaortic stenosis seen at the Royal Liverpool Children's Hospital between 1 January 1960 and 31 December 1991 were reviewed. Survivors were traced to assess their current clinical state. Necropsy specimens of 291 patients with lesions associated with subaortic stenosis were also examined. RESULTS--In the clinical study; 65 (32.1%) of the 202 patients with subaortic stenosis had a ventricular septal defect (excluding an atrioventricular septal defect). 32 of these patients had a short segment (fibromuscular) subaortic stenosis. 33 had subaortic stenosis produced by deviation of muscular components of the outflow tracts. In 17 patients (51.5%) this was caused by posterior deviation or extension of structures into the left ventricular outflow tract, resulting in obstruction above the ventricular septal defect. In the other 16 patients (48.5%) there was over-riding of the aorta with concordant ventriculoarterial connections, (without compromise to right ventricular outflow) producing subaortic stenosis below the ventricular septal defect. Additional fibrous obstruction occurred in 39% of the patients with deviated structures. The age at presentation was lower (P < 0.01) in patients with deviated structures (median (range) 0.4 (0 to 9.2) months) than in those with short segment obstruction (median (range) 4.2 (0 to 84.9) months). The incidence of aortic arch obstruction was higher (P < 0.002) in patients with deviated structures than in those with short segment obstruction (38%). In the morphological study 35 pathological specimens showed obstructive muscular structures in the left ventricular outflow tract either above or below the ventricular septal defect. 16 had either posterior deviation of the outlet septum or extension of the right ventriculoinfundibular fold, or both of these together into the left ventricle. 19 had anterior deviation of the outlet septum into the right ventricle with overriding of the aorta (without compromise to right ventricular outflow). The earliest age at which additional fibrous obstruction was seen was 9 months. The aortic valve circumference was small in 18% of specimens. FOLLOW UP--The median (range) duration of follow up in survivors from the clinical study was 6.6 (1 to 25.7) years. 16 patients with deviated musculature (49%) and 16 with short segment fibromuscular stenosis (50%) underwent operation for subaortic stenosis. Patients with deviated structures were younger at operation than those with short segment stenosis (P < 0.005). Patients with posterior deviation or extension of structures into the left ventricular outflow tract underwent operation for subaortic stenosis more frequently (P < 0.05) than those with anterior deviation of the outlet septum and aortic override. The ventricular septal defect required surgical closure more frequently (P < 0.005) in patients with deviation (93.9%) than in those with short segment obstruction (21.9%). There was no significant difference in the mortality between patients with deviation (27%) and those with short segment obstruction (12%). CONCLUSIONS--32% of patients in the clinical study with subaortic stenosis had a ventricular septal defect. Only 51% of these had obstructive and deviated muscular structures in the left ventricular outflow tract. These patients had a significantly higher incidence of aortic arch obstruction and required surgery for subaortic stenosis at a younger age than those with short segment obstruction. The ventricular septal defect also required surgical closure more frequently in those patients with deviation. The morphological study defined the two sites of obstruction. The presence or absence and type of deviation should be clearly defined in all patients with a ventricular septal defect,
TL;DR: The case of a 44-year-old black man who presented with severe dysphagia, cough and chest pain caused by a 12-cm aneurysm developing from a Kommerell's diverticulum at the origin of an aberrant retro-oesophageal left subclavian artery appears to be the first successful operation for this pathology.