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Spontaneous healing of a descending aortic dissection
International Journal of Cardiology 124 (2008) e53 – e55 www.elsevier.com/locate/ijcard
Letter to the Editor
Spontaneous healing of a descending aortic dissection Claudio De Pasquale, Nicola Marraudino, Giovanni Ferlan ⁎ Cardiac Surgery Unit, Department of Organ Transplantation (DETO), University of Bari, Bari, Italy Received 18 October 2006; accepted 21 November 2006 Available online 28 March 2007
Abstract Spontaneous healing of aortic dissection is very rare. A review of the literature has disclosed only four cases [Zeebregts CJAM, Schepens MAAM, Vermeulen FEE. Spontaneous resolution late after aortic dissection: a case report. Eur J Cardiothorac Surg 1997;12:513–515.]. We describe a Type III case in which a spontaneous resolution of the descending aortic dissection was observed. © 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Acute descending aorta dissection; Spontaneous healing
1. Case report A 62-year old man with a long-standing history of hypertension presented in April 2004 with acute dyspnoea and squeezing chest pain localized in the back. Blood pressure was 120/70. Electrocardiography revealed a sinus rhythm at 80 bpm. A contrast computed tomographic scan (CT) showed a dissecting aneurysm involving the descending thoracic aorta and the proximal abdominal aorta (Fig. 1–2). The patient was admitted in the Intensive Care Unit and an antihypertensive therapy was promptly started with betablockers and calcium antagonist i.v. After obtaining a stable clinical course, an oral therapy was instituted, and the patient left the hospital 12 days after the admission. Repeated CT scan was performed at 1 and 3 months from the discharge, which showed a remarkable reduction of false lumen (Fig. 3–4). Lastly, in March 2005, at 1-year follow-up the CT scan revealed a complete resolution of the dissection (Fig. 5–6).
⁎ Corresponding author. U.O. di Cardiochirurgia, DETO, Università di Bari, Policlinico, Piazza G. Cesare, 70100 Bari, Italy. Tel./fax: +390805592379. E-mail address: [email protected] (G. Ferlan). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.11.207
Operations for acute distal aortic dissection carry an overall mortality rate as high as 28–65% [1]; moreover, the risk of paraplegia, even for the most experienced operators [1], is estimated at 30–36% for extensive direct aortic replacement for dissection. These results have therefore suggested to reserve surgical treatment only to those patients presenting with signs of frank (or impending) rupture or vascular occlusion and visceral ischemia. Endovascular stent grafting of the diseased aorta has recently been advocated as an alternative method for the treatment of descending aortic dissection, even in patients with impending or frank rupture [2,3], with better results than with conventional surgery. However, the exact role of this attractive procedure has still to be settled: further studies are needed to determine the long-term efficacy and durability of this innovative technique. So far, medical management of patients presenting with an acute descending aortic dissection is the first choice; it's based on Wheat's concept [4] that decreasing the force of cardiac contraction and the blood pressure with the use of beta-blocking agents and vasodilators would be beneficial for the dissected aorta. Natural history of conservatively treated descending aortic dissection may have a favourable course, with possible late thrombosis, but it may also be complicated by aneurysmal dilatation of the wall of the false
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C. De Pasquale et al. / International Journal of Cardiology 124 (2008) e53–e55
Fig. 1–2. Computed tomography scan performed at the admission, showing a dissecting aneurysm involving the descending thoracic aorta.
Fig. 3–4. CT scan at 1 month from the discharge, which showed a remarkable reduction of false lumen.
Fig. 5–6. At 1-year follow-up computer tomography scan shows no sign of dissection in the descending thoracic aorta.
C. De Pasquale et al. / International Journal of Cardiology 124 (2008) e53–e55
lumen or extension of the dissection. The survival rate and event-free rate in patients with descending aortic dissection with medical treatment were recently analyzed by Kozai et al. [5]. They reported that patients surviving the acute phase had a better survival rate (N 80% at 10 years versus 50%) and a better event-free rate (80% at 10 years versus 70%) if the false lumen was thrombosed or open. Although we do not know the causes that influence the progression of the disease or the thrombosis of the false lumen, a new insight into the phenomenon could probably derive from the studies of Nakajima [6] and Katsuyoshi [7], which have correlated the morphological regression of false lumen in aortic dissection with the plasma level of some hemostatic molecular markers such as thrombin–antithrombin complex and D-dimer. Spontaneous healing of dissection, probably an “extreme” form of a favourable evolution of the disease, is very rare for the aorta. In our patient the resolution of the dissection began very early, and was complete after 12 months. References [1] Elefteriades JA, Lovoulos CJ, Coady MA, Tellides G, Kopf GS, Rizzo JA. Management of descending aortic dissection. Ann Thorac Surg 1999;67:2002–5.
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[2] Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546–52. [3] Nienaber CA, Fattori R, Lund G, et al. Non surgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340:1539–45. [4] Wheat Jr MW, Palmer RF, Bartley TD, Seelman RC. Treatment of dissecting aneurysms of the aorta without surgery. J Thorac Cardiovasc Surg 1965;50:364–71. [5] Kozai Y, Watanabe S, Yonezawa M, et al. Long-term prognosis of acute aortic dissection with medical treatment. A survey of 263 unoperated patients. Jpn Circ J 2001;65:359–63. [6] Nakajima T, Kin H, Minagawa Y, Komoda K, Izumoto H, Kawazoe K. Coagulopathy associated with residual dissection after surgical treatment of type A aortic dissection. J Vasc Surg 1997;26:609–15. [7] Katsuyoshi I, Tadanori K, Masahiro A, Toshihiro T. Correlation of hemostatic molecular markers and morphology of the residual false lumen in chronic aortic dissection. Ann Thorac Cardiovasc Surg 2004;10:106–12.
Letter to the Editor
Spontaneous healing of a descending aortic dissection Claudio De Pasquale, Nicola Marraudino, Giovanni Ferlan ⁎ Cardiac Surgery Unit, Department of Organ Transplantation (DETO), University of Bari, Bari, Italy Received 18 October 2006; accepted 21 November 2006 Available online 28 March 2007
Abstract Spontaneous healing of aortic dissection is very rare. A review of the literature has disclosed only four cases [Zeebregts CJAM, Schepens MAAM, Vermeulen FEE. Spontaneous resolution late after aortic dissection: a case report. Eur J Cardiothorac Surg 1997;12:513–515.]. We describe a Type III case in which a spontaneous resolution of the descending aortic dissection was observed. © 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Acute descending aorta dissection; Spontaneous healing
1. Case report A 62-year old man with a long-standing history of hypertension presented in April 2004 with acute dyspnoea and squeezing chest pain localized in the back. Blood pressure was 120/70. Electrocardiography revealed a sinus rhythm at 80 bpm. A contrast computed tomographic scan (CT) showed a dissecting aneurysm involving the descending thoracic aorta and the proximal abdominal aorta (Fig. 1–2). The patient was admitted in the Intensive Care Unit and an antihypertensive therapy was promptly started with betablockers and calcium antagonist i.v. After obtaining a stable clinical course, an oral therapy was instituted, and the patient left the hospital 12 days after the admission. Repeated CT scan was performed at 1 and 3 months from the discharge, which showed a remarkable reduction of false lumen (Fig. 3–4). Lastly, in March 2005, at 1-year follow-up the CT scan revealed a complete resolution of the dissection (Fig. 5–6).
⁎ Corresponding author. U.O. di Cardiochirurgia, DETO, Università di Bari, Policlinico, Piazza G. Cesare, 70100 Bari, Italy. Tel./fax: +390805592379. E-mail address: [email protected] (G. Ferlan). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.11.207
Operations for acute distal aortic dissection carry an overall mortality rate as high as 28–65% [1]; moreover, the risk of paraplegia, even for the most experienced operators [1], is estimated at 30–36% for extensive direct aortic replacement for dissection. These results have therefore suggested to reserve surgical treatment only to those patients presenting with signs of frank (or impending) rupture or vascular occlusion and visceral ischemia. Endovascular stent grafting of the diseased aorta has recently been advocated as an alternative method for the treatment of descending aortic dissection, even in patients with impending or frank rupture [2,3], with better results than with conventional surgery. However, the exact role of this attractive procedure has still to be settled: further studies are needed to determine the long-term efficacy and durability of this innovative technique. So far, medical management of patients presenting with an acute descending aortic dissection is the first choice; it's based on Wheat's concept [4] that decreasing the force of cardiac contraction and the blood pressure with the use of beta-blocking agents and vasodilators would be beneficial for the dissected aorta. Natural history of conservatively treated descending aortic dissection may have a favourable course, with possible late thrombosis, but it may also be complicated by aneurysmal dilatation of the wall of the false
e54
C. De Pasquale et al. / International Journal of Cardiology 124 (2008) e53–e55
Fig. 1–2. Computed tomography scan performed at the admission, showing a dissecting aneurysm involving the descending thoracic aorta.
Fig. 3–4. CT scan at 1 month from the discharge, which showed a remarkable reduction of false lumen.
Fig. 5–6. At 1-year follow-up computer tomography scan shows no sign of dissection in the descending thoracic aorta.
C. De Pasquale et al. / International Journal of Cardiology 124 (2008) e53–e55
lumen or extension of the dissection. The survival rate and event-free rate in patients with descending aortic dissection with medical treatment were recently analyzed by Kozai et al. [5]. They reported that patients surviving the acute phase had a better survival rate (N 80% at 10 years versus 50%) and a better event-free rate (80% at 10 years versus 70%) if the false lumen was thrombosed or open. Although we do not know the causes that influence the progression of the disease or the thrombosis of the false lumen, a new insight into the phenomenon could probably derive from the studies of Nakajima [6] and Katsuyoshi [7], which have correlated the morphological regression of false lumen in aortic dissection with the plasma level of some hemostatic molecular markers such as thrombin–antithrombin complex and D-dimer. Spontaneous healing of dissection, probably an “extreme” form of a favourable evolution of the disease, is very rare for the aorta. In our patient the resolution of the dissection began very early, and was complete after 12 months. References [1] Elefteriades JA, Lovoulos CJ, Coady MA, Tellides G, Kopf GS, Rizzo JA. Management of descending aortic dissection. Ann Thorac Surg 1999;67:2002–5.
e55
[2] Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546–52. [3] Nienaber CA, Fattori R, Lund G, et al. Non surgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340:1539–45. [4] Wheat Jr MW, Palmer RF, Bartley TD, Seelman RC. Treatment of dissecting aneurysms of the aorta without surgery. J Thorac Cardiovasc Surg 1965;50:364–71. [5] Kozai Y, Watanabe S, Yonezawa M, et al. Long-term prognosis of acute aortic dissection with medical treatment. A survey of 263 unoperated patients. Jpn Circ J 2001;65:359–63. [6] Nakajima T, Kin H, Minagawa Y, Komoda K, Izumoto H, Kawazoe K. Coagulopathy associated with residual dissection after surgical treatment of type A aortic dissection. J Vasc Surg 1997;26:609–15. [7] Katsuyoshi I, Tadanori K, Masahiro A, Toshihiro T. Correlation of hemostatic molecular markers and morphology of the residual false lumen in chronic aortic dissection. Ann Thorac Cardiovasc Surg 2004;10:106–12.