(Circulation. 1999;99:1331-1336.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Intimal Tear Without Hematoma
An Important Variant of Aortic Dissection That Can Elude Current Imaging Techniques
From the Center for Aortic Surgery and Marfan Syndrome Clinic, Divisions of Cardiovascular Surgery (L.G.S.) and Cardiovascular Medicine (S.B.L., A.C.E., J.R.B.), Lahey Hitchcock Clinic, Burlington, Mass.
Correspondence to Lars G. Svensson, MD, PhD, Division of Cardiovascular Surgery, Lahey Hitchcock Clinic, 41 Mall Rd, Burlington, MA 01805.
Background—The modern imaging techniques of transesophageal echocardiography, CT, and MRI are reported to have up to 100% sensitivity in detecting the classic class of aortic dissection; however, anecdotal reports of patient deaths from a missed diagnosis of subtle classes of variants are increasingly being noted.
Methods and Results—In a series of 181 consecutive patients who
had ascending or aortic arch repairs, 9 patients (5%) had subtle
aortic dissection not diagnosed preoperatively. All preoperative
studies in patients with missed aortic dissection were reviewed in
detail. All 9 patients (2 with Marfan syndrome, 1 with Takayasu's
disease) with undiagnosed aortic dissection had undergone 
3 imaging
techniques, with the finding of ascending aortic dilatation (4.7 to 9
cm) in all 9 and significant aortic valve regurgitation
in 7. In 6 patients, an eccentric ascending aortic bulge was
present but not diagnostic of aortic dissection on
aortography. At operation, aortic dissection tears were limited in
extent and involved the intima without extensive undermining of the
intima or an intimal "flap." Eight had composite valve grafts
inserted, and all survived. Of the larger series of 181 patients, 98%
(179 of 181) were 30-day survivors.
Conclusions—In patients with suspected aortic dissection not proven by modern noninvasive imaging techniques, further study should be performed, including multiple views of the ascending aorta by aortography. If patients have an ascending aneurysm, particularly if eccentric on aortography and associated with aortic valve regurgitation, an urgent surgical repair should be considered, with excellent results expected.
Key Words: aorta • dissection • imaging • surgery
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