Question:

It’s very hard to judge the adequacy of care without the whole story, so I will not try to address the specific case and speak in genralities only.

In general, an abnormal test such as a d-dimer should be followed up if there is no obvious cause with additional testing to determine a specific cause, otherwise it should not have been ordered. An abnormal d-dimer in this situation is most commonly used to exclude a pulmonary embolus. This can be done with a CT scan or a V/Q scan. If the CT scan had been ordered, it likely would have found the dissection. If the V/Q scan had been orded a dissection would likely not have been found and most would consider that adequate follow-up of the d-dimer.

Certainly someone 8  days after giving birth would be at high suspicion of a pulmonary embolus and further work up should have been pursued of the abrnomral d-dimer.

Suspicion for dissection remains difficult because of it’s rarity, particularly in the young population. Whether the presentation and symptoms are distinctive enough that it should have a prompted and evaluation for a dissection is highly subjective. As a physician I let people go home all the time from the ER after presenting with chest pain. We ultimately have to play the odds in deciding that the ones we let go are at low risk for a complication. There is no way to reduce that risk to zero. If we scanned everyone with even the slightest chance of a dissection, we would probably kill more people with the cancer caused by the CT scans thn we would save in preventing deaths due to dissection.

On a subject that is perhaps not what you had asked – this is an important time to assess the risk for dissections in your sister-in-laws family. Aortic dissections in young people frequently have a genetic basis. If still possible it is important to gather as much information about your sister-in-laws a condition while things are fresh in everyone’s mind since that information may ultimately prove very useful in deciding who in the family is also at risk and at what level of risk. Information such as CT’s, echoes, descriptions of the location of the origin of the dissection, the size of the aorta and other distinctive findings are important. Pathologic evaluation of the aortic tissue should also be done, although the findings are usually non-specific. If genetic material is still available – tissue(even fixed) or blood – it needs to be preserved for genetic testing now or in the future.

David

Question:

Hi! Brain, My name is Andres, I'm a concern father, my daughter just

Question:

Hi, my name is Walter, I've been diagnosed with a dissending A.D.
since i went to the emergency room 2 weeks ago. It started with pain
in my upper and lower back that was unrelentingly painful. after
stabilizing my blood pressure, messing up my left arm due to not
hitting my vein, thus contaiminating my left arm, I was finally
released after 5 days.....Here's my question...how long is this pain
supposed to last?!! I now have profound respect for the Aorta,
although they say that my Dissection is 4 cm. it almost has me bound
as though I'm in a striaght jacket! I've been on Morphine the whole
time, along with 4 Bp. medications, two of which I take twice a day.
Reading some of the stories on this sight it seems as though most of
you have been down several months, if not years, especially I would
imagine those who have type A dissection. although i didn't need
surgury, it sure feels like i've been through one, and can literally
do nothing outside of extremely menial things. I'm 47 years old but
now feel like I'm 87! I'm married with a small child and I feel
helpless because my wife is doing everything. I hoping I can be healed
in a short time, but I'm finding out that I may be underestimating the
seriousness of this thing.

Answer:

I'm somewhat surprised at the severity of the residual pain. It's not

Question:

Dear Brian,

Answer:

Heidi,

Question:

I am almost 100% positive I asked this before, but it is my understanding that the blood that entered the false lumen clots and remains in the false lumen, encapsulating. My entire family believes the blood will be totally absorbed in 8 or 9 months.

Can you help me with this.

Thanks,

Maurene.

Answer:

The false lumen can end in a dead end. In that case the blood will clot and be reabsorbed over several weeks to months. Frequently though there are holes in the dissection flap so for a portion of the dissection the blood can enter through the initial tear and exit back into the true lumen through one of the downstream tears. In that situation, the portion of the false lumen between the primary tear and the reentry tear will not thrombose and will have continued blood flow.

David

Question:

Dear David,

Do you think I am out of the woods about this possibility?

http://www.allina.com/ac/healthday.nsf/news/4C22FFFEF46205548625732400167731

Thanks, Brian

Answer:

I had sent this article to my surgeon friend and this was his response to me:

The study that you are referring to is somewhat difficult to interpret. The best treatment is beta-blockers. Do you get serial CT scans? At Stanford, I guess? Is your descending aorta enlarged?
In addition, the article you are referring to in the section “Article everyone needs to read” is poorly written. Be careful what you read. The treatment for Type A aortic dissection is surgery, not changing different blood pressure medications. They do not talk about follow-up and how should do it. This is an emergency medicine article they do not care about follow-up.
These are better articles:
Halstead JC, Meier M, Etz C, Spielvogel D, Bodian C, Wurm M, Shahani R, Griepp RB.
The fate of the distal aorta after repair of acute type A aortic dissection.
J Thorac Cardiovasc Surg. 2007 Jan;133(1):127-35. Epub 2006 Dec 4.


Ehrlich MP, Ergin MA, McCullough JN, Lansman SL, Galla JD, Bodian CA, Apaydin A, Griepp RB.
Results of immediate surgical treatment of all acute type A dissections.
Circulation. 2000 Nov 7;102(19 Suppl 3):III248-52.

Thanks Gabe!

Brian Tinsley

More Responses:

This is a very simplistic analysis. It is less the presence of clot,
than how the clotting affects blood flow. In fact there is good data to
suggest that complete trombosis of the false lumen is in fact a good
preditor of better healing of hte dissected aorta. It all depends upon
how the blood clot affects blood flow to the organs.
David L.
--------------------------------------------------------------
Brian
It really depends on two issues. The first is how your operation was performed. Meaining that if the whole ascending aorta was removed and the graft directly to the undersurface or the arch, than you can believe that you won't have a recurrent ascending dissection. In terms of late dilatation of the descending aorta, you are less likely to dilate if your false lumen is clotted off. All said, Five years of no growth is a great sign!
Allan
--------------------------------------------------------------
Absolutley....

If you came this far.....those risks have diminished greatly.
At this point you should be screened for aneurysm formation...which im sure your doctors are doing.


Joe

Dear Joe,
I am coming up on 5 years anniversary on 8/22/2008, do you think I am out of the woods about this?
http://www.allina.com/ac/healthday.nsf/news/4C22FFFEF46205548625732400167731
Thanks,
Brian

 

Question:

I have a question...and I have never really understood it fully. Do you have an aneurysm first and that it turns into a dissection? Or, could you have a ascending aorticdissection without ever having an aneurysm to begin with? Can an AD (ascending) dissection turn into an aneurysm.

Answer:

Brian:


Nice to hear from you. I am writing to answer the question you asked Craig. It is far more likely to dissect an aneurysmal aorta than one of normal caliber. However, size alone cannot predict the incidence of dissection, as many occur below 5cm in maximal diameter. What happens is that force is distributed over a small area (Law of LaPlace). If there is a weakness in that wall, a tear may occur. The reasons vary (i.e. defect in fibrillin-1 gene for Marfan's, absence of matrix metalloproteases in bicupsid valve patients, extreme wall tension in weightlifters, etc). As the aorta grows in size, its ability to handle that force diminishes and the potential for tears to occur increases. There are occasions, such as syphilitic medial necrosis or malignant hypertension where a relatively normal caliber aorta may dissect. That is less common than in those who have at least some degree of dilatation. Hope that answers you question.


Allan Stewart

 

Question:

Brian:

It was been about 2 years since we exchanged e-mails about my wife

Vicki Savage and her descending aortic dissection. It starts at the

subclavian and goes down to the right iliac artery. Maximum width of

the aorta in the midthoracic region is now 5.35. A year ago it was

5.17. The surgeon suggested we could have surgery, but after listening

to the many risks and complications, my wife said I would rather go

when my time goes then to go through all that. She is 69. I noticed in

one of the letters from a member, that you sent her a copy of

"Advances in the Management of Thoracic Aortic Diseases". I couldn't

find that on your web site and wondered if you could refer me to that

article.

Glad to hear you are doing so well. It has been about 7 years since

Vicki's dissection and she has had good health and we are thankful for

that.

Thanks and keep up the good work.

Dick Savage

Answer:

Mr. Savage,

Without having met your wife it is difficult to give very accurate

estimates for the risk of surgery to repair the aneurysm. On average for

someone of your wife's age the risk is not overwhelming, but neither is

it negligible. I'm not sure I would agree with your wife's sentiments

about just waiting until it bursts rather than attempting fix it if she

is otherwise healthy and have a good quality of life.I think I would

recommend waiting though at this stage given the slow growth rate.

Although there si some risk of rupture at this size the risk of surgery

probably still tips the scales in favor of witing. At some point that

scale will probably tip the other way. At that time surgery may be the

better option.

David


 

Question:

Hello,

My name is Carol Glienke and a very good friend, He is male 6'5" not

sure of his weight but a big Viking Looking guy. Pretty healthy

overall, very active a carpenter. He has been diagnosed with Aortic

Dissection. He went into the hospital last Thur to the ER thinking he

threw out his back, luckily they saw other signs and started testing.

In the testing they found his Aorta was dissected in the middle and I

believe after much internet reading that is transverse. So it does not

fir neatly into A or B.Ascending or descending. Although it does

extend pretty far down. Your website looked so interesting but since

he is in intensive care and his wife has not slept in days and hardly

eaten she is unable to search through it.

He was moved from a regular hospital to a Teaching Hospital Christ in

Oak lawn Chicago on Sunday and they put him in a medical induced coma

due to a lack of oxygen, one of the new developments is a Kidney has

failed and now a lung is partially collapsed. Today, Friday they are

testing his lung and took him off a feeding tube due to that. He is

on oxygen and before the lung they were saying if stable they were going to

try him breathing on his own again. I believe they are wanting to get

him "stable" before surgery. My friends wife is spinning and does not

know a few things:

1. How long would he be kept in coma state? They do not tell her

anything about timing, as they may not know.

2. What do they do when the tear is in-between as most everything

talks about Ascending they do immediate surgery and descending they

treat with medication? Some similar cases or writings would be so

helpful.

3. Prognosis long term, if known. Someone told her he will never

work again as he is a master carpenter, if he lives.

My husband and I are Christians and Gunnar is definitely agnostic. We

have been praying for him intensely. When I saw on your site that you

were as well and I saw other good information on the site I sent it to

her.

I appreciate any information or links to better information on his

type of condition.

Thanks,

Carol

Answer:

Dissections typically start just above the aortic valve in the ascending

aorta or just beyond the left subclavian artery past the arch.

Occasionally the dissection will propagate backwards into the arch from

a tear past the arch. I am guessing that this is the situation here.

Most places will watch these types of dissection unless it propages back

to involve the ascending aorta unless the pain can not be controlled or

there are signs of impending rupture.

The management of each case needs to be individualized, so broad

generalizations are difficult. One thing that is worth emphasizing

though is that people do survive dissections and lead long fulfilling

lives afterwards - so there is definitely hope.

David

 

Question:

I just joined your site. My husband survived a type A

aortic dissection that ruptured on May 25th this year. It

took the local emergency room a long time to diagnose this

condition I'd never heard of. Although heart disease runs

in his family, we don't know of anyone with this

condition. He had emergency surgery and received a Dacron

graft and his aortic valve was resuspended. He is doing

well, but the dissection continues down his trunk and

partially into one leg. He's only 55, in pretty good

health, he's on blood pressure medication and will have a

CAT scan every 6 months. My question is how long a life

expectancy does he have? His cardiologist seems so vague

on this point. Thanks.

Priscilla Brandlehner

Answer:

I would probably be vague as well. There's no reason why a person

who has a survivied a dissection shouldn't be able to have a

normal life expectancy. There is higher risk of death from the

residual dissection and possibility of additional repair surgeries

than if you hadn't had a dissection, but there is no set limit on

how long someone can live after surving a dissection.

I guess the analogy - would be that it probably matters little to

any of us whether the normal life expetancy is 65 , 75 or 85

years. We all just do our best to enjoy each day and take care of

ourselves as best we can so we can have as many days ass possible.

The same applies after a dissection. You could live 5 years, 10

years, 20 years or 30 years. No reason to dwell on which it will

be, because no one can predict which it will be. Just have get up

each morning and make the most out of each day.

This isn't really an answer, but quoting statistics would do you

more of disservice than help you. THey are unlikely to represent

any individuals case. Life expectancy is for actuaries and life

insurance salesman.

David

 

Question:

Brian and David,

Thank you very much for your response. I did have both a chest CT and

a "heart" MRI last year, when I was experiencing different type of

chest pain (dull pain) - both came "clear". It got blamed on "nerve

pain" associated with lyme disease. Just getting a bit worried about

missing something that important.

Would you advice asking for a repeat CT?

Thank you for any advice.

Best,

Adrian

Answer:

CT are not without their downside. They involve a fair amount of

radiation, so there needs to be a good reason for doing them, otherwise

they are doing more harm than good.

Chest x-ray nd ECG do not ruel out a dissection, but there are many

other causes of chest more commmond than dissections. You need to

discuss you concerns with your doctor. Ask them why they don't think the

chest pain is due to a dissection and what might be the cause of the

pain. I would do that first before recommending a repeat CT.

David
 

Question:

Brian,

I have a question. My mom was diagnosed with an aortic dissection

(thoratic and abdominal tearing) with blood between the 2nd and

third wall. No surgery will be done b/c mom refused it. She's

taking blood pressure medicines but what is the ratio that it will

burst...I know that you are not a doctor but from your experience,

it would be nice to know. They are saying that she is a 'walking

time bomb' because if her blood pressure goes high it will most

likely rupture the third wall and it will be over for her.

Just wanting your opinion. thanks in advance.

*Corey Sue *

Answer:

If only the descending is involved, we usually manage it without

surgery. The risk of dying in hospital is less than 10% with proper

management. Obviously there are exceptions to the rule and certain

patients will be at higher risk.

There is a risk of rupture even after you leave the hospitalization, but

it is generally low enough that with appropriate monitoring there should

be little risk of unexpected rupture.

If the disection involes the ascending aorta the risk of ruptureis much

higher about 50% during the initial hospitalization and approaching

80-90% by 6 months after the dissection.

David
 

Question:

Hi, Brian! You can't imagine how your site is important to me at

this moment. You don't know me but you've already help me. But I

need some more. I live in Brazil and my father has aortic

dissection, but surprisingly, he has *NO *symptoms. Nothing,

nothing. NO pain at all, normal pulse, everything is normal on him

but the disease is there, on the images of an aortic CT

angiography exam. The dissection afects ascending and descending

aorta and doctors here classified the aortic dissection as type A

(Stanford) or II (deBakey), but didn't appear in the chest x rays.

The CT images show a false channel on the descending aorta and a

trombosis on the ascending aorta.

Because the lack off symptoms, doctors here in Brazil are very

confused about the treatment. One of them said that because the

extent of the disease the surgery is not possible and the only

thing that can be done is to control blood pressure e and avoid

physical exercise but others said that the convencional surgery

will help. We are very confused and anxious. The disease was

discover accidentally during a cardiac catheterism about two

months ago. Since then, our lives has turned into hell. I look to

my father now and he seems normal. After the catheterism, he

stayed at a hospital during a week but he did not feel anything

strange. He is now as he was before the catheterism. So, why do

the surgery? And why NO symptoms?

I want to beg a big favour to you. How can I find help? Maybe, a

expert on USA could help us, see the exams (I don't know how,

email?) ... What do you sugest?

I beg your pardon because of my bad English. I hope I've described

everything on the right way.

Thank you very much

Elis

Answer:

Elis,

Some dissections do occur without pain or in some cases the pain is

atypical and is mistaken for something. The thrombosed false lumen in

the ascending with persistent flow in the descending is suspicious for a

primary tear which started in the descending and then propagated

backward to involve the ascending. In the acute phase this carries

significant risk for rupture into the pericardial sac and death, so we

generally recommend emergency surgery. In your father's case it sounds

as if the dissection may have been there for a while already. The risk

is therefore much lower and medical management may well be appropriate.

The thrombosed part of the dissection may completely resorb over time

and and not require surgery of any kind. The dissected descending

however will require monitoring to watch for progressive enlargement.

I would be happy to review the case, but I will need a copy of the CT

scan(preferably on CD-ROM) along with a description of your father's

overall health, along with the circumstances and date when the

dissection was discovered.

David
 

Question:

Brian,

I'm a 63 year old male with a 1989 implanted mechanical aortic

valve who had an AD in 2006. I was doing 45-60 minutes of

cardio and 90 minutes of relatively heavy resistance exercise

for years before the AD. My cardiologist feels I can do

moderate cardio and light resisitance training but the surgeon

who performed the AD said not to do any exercise. What

information have you been able to acquire on exercise after AD?

Sincerely,

Terry Solomon

Answer:

I would tend to favor the cardiologist's recommendations, but the

details of the state fo the aorta after repair are very relevant to the

recommendation.

David
 

Question:

Brian,


My name is Gerald DuBois. I am thirty-seven years old. I am a
professional chef. About ten years ago, I had a nephrostomy tube
placed in my left kidney. I have a horseshoe kidney that is draped
over my aorta. During the procedure, the radiologist allowed me to
wake up from sedation. I asked him to stop. I was basically held
down and the procedure continued. I was trying to get them to stop
and I am sure I was moving. I was taken to surgery and had
lithotripsy done via the nephrostomy tube. After the surgery I was
in terrible pain. The pain continued for two weeks after the
procedure. I ended up in the emergency room. The doctor treating me
believed I was drug seeking and sent me home. I returned the next
evening, Christmas eve, with chest and abdominal pain. A different
doctor ordered a CT. I was diagnosed with a dissected
thoracoabdominal aneurysm. The tear is through and through.
Therefore, I have a flap of tissue with blood flowing in and out of
it. The dilation of the aorta was 3.5 to 4. It was determined the
DTAA was about two weeks old. I had imaging done before the
nephrostomy placement and kidney stone removal and the DTAA was not
present. The doctors decided to treat me medically.

For the first seven years, I took no medications as I have low
blood pressure and low heart rate naturally. Blood pressure
medication was difficult for me to tolerate. I began taking blood
pressure medication about two years ago. It has been ten years since
the diagnosis. The DTAA has not changed. There have been many, many
studies done over the years. Each one is read differently. The
bottom line is the DTAA has never been determined to be more than
4.5. The radiologist that read the last MRA and CT studies said the
DTAA is unchanged from the initial diagnosis.

When I was sixteen, I was shot in the abdomen. I had a partial
whipple and numerous other abdominal surgeries. Needless to say, my
abdomen is filled with scar tissue. My doctor seems to think I may
have scar tissue surrounding the aorta. My question is as follows:
1) Why have I lasted so long without any change in size or
symptoms. I work full time. I work in the yard. I exercise. I do
what I want within reason. I do not lift heavy items. I do not jog
or allow my blood pressure to stay elevated. I pray a lot. Prayer is
my answer for my resilience.
2) I have low testosterone and growth hormone levels. I take low
dose androgel and was taking HGH for a year. I am not taking HGH
right now but I am in the process of starting this therapy again.
Could the HGH have a positive effect on the aorta. The research I
have done shows improvement in the collagen and elastin in the aorta
as well as increase in the intimal wall size and strength. It has
helped me loose weight and seems to help with blood pressure.
3) I have done a lot of research on stem cell therapy for repairing
vascular tissue. There are some trials going on right now. Do you
think this could help.
4) I have also read about fenestrated stent grafts. MY DTAA involves
the renal arteries and I am not a candidate for the standard
grafts.

I apologize for the length of this e-mail. I have a long history
best shared in conversation. I live with this every day and it is
starting to tax me mentally. Evert time I get a pain in the abdomen
or chest I get scared. Due to my long medical history and many
surgical procedures, I have chronic pain. It is hard to tell if any
pain I have is new or should be considered basis for a trip to the
doctor. I was told by a doctor I could live the rest of my life
without ever having surgery to fix the DTAA. Other doctors feel
differently. I am grateful for the time I have lived so far.
However, I have a family that needs me and I would love to live a
long life. I have had all the surgeries I can stand and I am so
tired of being poked and proded. I need peace. Is there anything I
am neglecting to do. I would appreciate any help or advice you can
give.

Thank you and God Bless,
Chef Gerald DuBois
 

Answer:

Gerald,

You have proven to be quite resilient and I commend you. Your doctor is

correct you may very well go for a whole lifetime and not need to have

your aorta repaired. I certainly wouldn't recommend a branched stent

graft at this time. Why your aorta hasn't dilated so far is anybody's

guess and whether will have further growth of your aorta in the future

is also not certain. Only time will tell. There probably are differences

between the aortas of those that dialte after a dissection and those

that don't. Unfortuantely we don't have the tools yet to tell which

aorta will enlarge and which won't.

At this time we do not know if testosterone or HGH will affect a torn

aorta. The only concern with these agents is their effect on the blood

pressure. Stem cells may have some value in the future, but it will be a

long time before we can control them in a way that will help strengthen

a torn aorta.

As for the pains and how to deal with them - time and experience will

ultimately be your allies in helping you recognize which if the pains

should not cause you concern.

David
 

Question:

My husband Bill had his dissection New Years Eve. Went the full length of the descending aorta. No renal, abdominal, etc damage. It actually narrowed at the lower end. No surgery, they are going to manage by meds, no history of high BP. He was released Jan 9. He had been life-flighted to Parkland Hospital in Dallas.

His combination of meds make him so drowsy and weak. I read in the forums that this is common and hopefully he will get adjusted to them or his dr will be able to adjust them in time. do you know of anyone taking as much as four (4) 200mg Labetalol 3 times a day. that is just one of his meds, he is taking four different BP meds my concern is that his diastolic is in the low 40s and yesterday was in the 30s. I've searched your site but no one mentions the diastolic pressure.

I have printed everything out in chart form for his cardiologist here in Athens, Tx and will call them Mon a.m.

Answer:

That is a large dose of labetalol, but I have seen that much used before. The fatigue is common this soon after a dissection and with the medications. IT should get better. Give it a few more weeks. If doesn’t get better your husbands doctor may be able to adjust the medications to reduce the side effects.

In some cases the very high blood pressure may be due to decreased flow to a kidney. It may bot be bad enough to damage the kidney, but it can cause high blood pressure. If this is the case reestablishing better flow to the kidney may reduce the need for medication considerably.

As for the low diastolic blood pressure – it can be an effect of the medication. It typically does not cause any problems, unless it is a sign of something else like a leaky valve.

David

 

Question:


Hi Brian, This week I had another checkup with my cardioligist who gave me a report on my last echocardiogram which was done in December. It will be 5 years in May that I had my ascending aortic dissection. The membrane and the lining in my aorta was split down to where my kidneys branch off. I questioned the dr. on my prognosis for the future and he really couldn't tell me a whole lot other than we are actually some of the first survivors who will make the 5-7 year mark. I try to walk 5 times a week along with having a fairly active lifestyle: I'm a mother of 5 and also run a parttime home business. I'm 46 years old. I thank God many times over for allowing me to still be here with my family and am thankful for the program I found to boost my energy level because I am on a lot of blood pressure medication and am staying on it for life. Any input you have will be appreciated!
Thanks, Rhoda Sweigart
Answer:

Rhoda,

There is nothing to prevent you from being around for another 30 or 40 years if you are otherwise healthy. There is a chance that the dissected portion of the aorta will enlarge with time, so it needs to be watched and your blood pressure needs to kept in control to decrease the chance of enlargement of the aorta. Even if the aorta does grow in size, it can be repaired successly in the vast majority of the cases, when the repair is performed at a center which is experienced at such repairs.

You mentioned that you just had an echocardiogram. Have you had a CT or MRI in the last year? You should have one at least that frequently, because the echocardiogram cannot see the aortic arch and the descending aorta in the chest clearly.

The other question you should ask your cardiologist is why you had the dissection? Don't accept high blood pressure as the answer unless you have had a history of very elevated blood pressures before the dissection. This is a very important question to ask since you are a mother. Many of the aortic dissections which occur at a young age have a genetic basis. Your children and your siblings should be screened for aortic disease as well. Knowing what caused your aortic dissection should improve the accuracy of the screening.

David

Question:

In 2002 I was in the hospital for over a month and a half. I was

diagnosed with two dissections of left vetebral artery two dissections

of right vetebral artery one dissecton of left carotid artery with berry

anyerism(spelling?) And dissection of rt carotid artery. With further

testing they discovered my right renal artery had dissected. And found

another anyrism in left iliac arteryand stented it closed off again so

they stented three months later two more stents. Two years later blocked off

again couldn't stent because it was in the crook of my leg but has

stayed open since almost a year now.

All my dissections healed except for the right renal it occluded

and the left carotid it occluded. The ironic thing is I only suffered a

small TIA which fixed itself over the hospital stay. another strange thing is

I was also in congestive heart failure. They did all kinds of testing.

Have no diagnosis have been to mayo clinic in rochester MN. They couldn't

diagnose it either .> My question is just resently the left side of my neck has been

tender and painful , concerned that its comming from interal artery dissection.

Do> you feel I should see my doctor for this. I am affraid to go to Doctors

anymore. I have also been getting debilitating migraine headachs 2 to

3 times a week. I have'nt had any real bad ones since the dissections.

at the base of my skull and behind my left eye.

Answer:

Shelly,

You need to see someone right away! Given your history of problems with

your blood vessels, any worsening of headaches needs to be evaluated

carefully for bleeds or new aneurysms.

The diffusenes of your blood vessel problems raises significant red

flags for an underlying weakness of the blood vessels. have you been

evluated for Ehlers-Danlos syndrome Type IV?

David

Question:



Brian, Thank you for forwarding our case to Dr. Liang. We are at a stopping point until we get the other scan run and I dont know when that will be. We have been sent back to the cardio vascular surgeon by the cardiologist, he says this is beyond the heart now and he dosent know what to do so he has sent us back to Dr. Brunsting. Our meeting with him is tomorrow (thursday). Dr. Brunsting is a very good doctor, I just am lost in the dark about what the prognoses is long term. You deal with this type of thing through your sight, have you had anyone with these problems before. How does this type thing usually turn out? My husband was very healthy, 6'1", 205lbs, very active, went to community gym a couple times a week to play B-ball and work out, outside moderately physical work, non-smoker, no history of illinesses, no meds unless he got a cold or something usual like that. Does this help? Can you give me any insight to simular cases. Thank you so much for your time and concern, Elaine Weaver

Answer:

Very hard to say much without knowing more about the whole medical situation. Certainly people do survive and recover from aortic dissections similar to Dan's. We just had a patient under go replacement of pig valve placed during the repair of an aortic dissection which finally wore out after 26 years. The patient is doing fine and over the past 26 years has traveled all over the world, so he got a lot of mileage out of that repair.

The challenge for Dan is getting over the acute issues associated with the dissections and repair. Unfortuantely to give any really useful advice, I need to know more.

David
 

Question:

Dear Brian,
I'm glad you survived your ordeal with aortic dissection. My sister wasn't as lucky. She passed away on Feb. 15, 2006. Her daughter and I feel it may have been Marfan's. My niece and my great niece have had there aortas checked and they both are enlarged. Still the doctors do not want to say it's Marfan's.My niece is six foot tall, with the long fingers and toes, also the severe curvature of the spine. My sister also had these symptoms but was not as tall. My sisters father also died at the age of 24 with a heart attack, that was about 1956. Is there a reason doctors do not want to confirm this disease? I feel that Marfan's is a lot more frequent than is thought.
Good Luck and thanks for your time.
Janet Greenwood
Answer:

Sometimes the diagnosis of Marfan syndrome can be difficult, since there is overlap between the features of Marfan syndrome and other syndromes and the general population. In classic cases the diagnosis is easy, but where the syndrome is not full blown definitive diagnosis is difficult. Genetic testing sometimes can help.

More practically, whether the condition is labeled as Marfan syndrome or not is not always that important. The aorta is clearly diseased in your family and whether it is Marfan syndrome or not, it needs to be watched carefully and replaced when it approaches a size where there is a concern for rupture. Lowering the stress on the aorta with medications called beta-blockers is usually appropriate.

There is early suggestions that a group of drugs called angiotensin receptor blockers may have particular value in some of the aneurysm syndromes. Once the data becomes definitive then it may be more important to differentiate between the causes of aneurysms.

While the data may still be available it is worthwhile to acquire as much information as possible about your sister - where the dissection started, how big was the aorta and any tissue that may still exist should be saved. This information may ultimately be very useful in guiding the care of your nieces.

Your nieces should also be seen by a specialist who is familiar with Marfan syndrome and genetically caused aortic disease. You probably should also be screened.

David Liang

Question:

Hi Brian,

I hope you do not mind if I ask you one more question.

The question is about my 59 year old brother with an aortic dissection with the tear near the heart and dissection that went down to one thigh. It will be one week tomorrow that he was diagnosed.

My mother is telling me that my brother's doctors (cardiologist and internist) are telling them there are no tests available to indicate whether the tear is healing.

I find this hard to believe especially since tests located where the tear is and how far down the dissection ran. They are telling me that the way they can tell that the tear is healing is by monitoring his blood pressure. And then they tell me his blood pressure is being controlled with drugs.

Help! I think I am smart with good common sense . . . are there tests to indicate that the tear is healing?

Hope you are well and that the horrible storm that came through Lavaca County last night did not go through Austin.

Thanks,

Maurene B

Answer:

Maurene,

What you are hearing may not be that far off from what is generally felt

to be appropriate care. I suspect that the dissection does not start

near the heart, or else your brother would have already had surgery. The

dissection likely involves only the part of the aorta which is going

towards the legs. This is usually best handled with medications and

close follow-up. I think in the absence of more precise information, you

will probably have to accept what your brother has decided regarding his

care.

The right aortic arch probably is not a big factor in the dissection

unless there are other malformations to go with it. In any case it

doesn't affect treatment strategy right now.

As for yourself, it probably makes sense to seek counsel about your

risks given the family history. Having the most precise information

possible regarding the case of dissection in the family - scans,

pathology specimens, operative reports etc. will make for the best

possible estimate of your risk and what measures you can do to reduce it.

David

and......

It is rare that a dissection ever completely “heals” itself, i.e. return to it’s state prior to the dissection. In most cases blood continues to flow to some degree in the channel that forms between the layers of the aorta’s walls. The “healing” that does occur is the body laying down scar tissue along this abnormal channel to strengthen it. The thickness of the scar tissue is not enough for us to see it on any scan that we have available now. We have to infer that it is healing by seeing that the aorta is not dilating over time. If it continues to dilate, it suggests that the healing process is inadequate and the aorta then needs to be replaced. If the aorta stabilizes in size then we conclude that the scarring has been adequate in strengthening the aorta, so that we can continue to watch the aorta. It is still necessary to continue to follow the aorta even if appears to stabilize in size, since the growth rate may be very slow and changes may not be apparent over shorter periods.

David

 

Question:

Dear Brian –

I too, a simple man, am a survivor of a Type 1 Aortic Dissection. My story goes that on November 11-12, 2007, I woke up about 12 midnight with what I thought I had some minor indigestion. I took my Prevacid along with some milk and returned back to bed. About 20 minutes later, I arose again with indigestion like symptoms; however, instead of the “feel” of indigestion going up and down, this feeling was going left to right. I woke my wife up and explained to her that I thought I needed to go to the emergency room (in as much as I really love going to the doctor’s office as well as a hospital). She explained that she would get dressed and take me – I told her that I didn’t think I could make it to the car, please dial 911. She did and when they got there the pain was enormous. The paramedics got me on the stretcher and I remember being placed into the ambulance – but – I do not remember anything else for about 3 weeks. There was NO WARNING what was about to happen. The CT technician turned white after the 2nd picture of my chest and told the surgeons to get me to surgery immediately. The surgeons told my wife that I had an EMERGENCY TYPE 1 – AORTIC DISSECTION / ANURSYEM that had exploded and I was rushed into surgery before they could even explain to my wife what was going on. There were 2 heart surgeons that worked on me all night for about 9.5 hours trying to keep me alive. Afterwards, they told my wife that I was not expected to make it since I had been on life support for more than 3 hours and the nature and extend of the aortic dissection was so great – the largest sectional replacement in the history of that hospital (a #24 hemi-shield graft was placed). They also told her that they did not even close me up and could not get me awake. Later the next morning and packed in ice water, they told my wife that she may want to go ahead and make arrangements for my funeral.

My wife, knowing how stubborn I am, told the surgeons that she wanted to see me and that she could wake me up. After about 30 minutes, she got me to respond and the surgeons were notified and took me back into surgery for another approximately 4 hours to complete the repairs. Then to make matters worse, the wires holding my sternum together broke and on January 2nd, they had to go back into my chest and put in steel plates to screw my sternum back into place. Today is the 2 month anniversary of my emergency and I am please to say that I am back to work and feeling fine. It has been a VERY HARD ROAD to travel on – moments of deep depression followed by the courage to continue on with this wonderful life. I no longer have any more medical problems such as high blood pressure, the possible diabetes (never diagnosed officially), but do suffer from severe residual surgical pain in and around where the surgery took place. My doctors said that it will take about 6 months to completely heal and be “normal” again. I keep saying to myself that one day the pain will subside and that I might be able to go back to water skiing again in September – hopefully. Besides some pain relief from my doctor - I only have to take 1 aspirin a day – that’s it (I was taking about 12 pills a day). It has been a very hard road for me and my wife – both emotionally and financially straining, but some how – GOD be with us – we will make it.

GOD kept me alive, I believe, for the simple task of telling people that if you have had high blood pressure, like me for years, PLEASE, oh but PLEASE – go have an MRI done every year from your waste to your head. I had a stress test 2 weeks before all of this happened and everything checked out OK. The aortic dissection did not and will not show up in that type of test – I can not stress to everyone enough – GO GET AN ** MRI ** EVERY YEAR – I am going to from now on even if I must pay for it myself.

If you wish to respond, please feel free to e-mail me at vettejedii@aol.com. And Brian, please tell everyone you know that has high blood pressure to go get an MRI done ASAP.

Thanks for listening

Robert L.

Answer:

Brian,


Mr. Lady seems to have attributed his dissection to high blood pressure. That may be a mistake. Although high blood pressure contributes to the risk of dissection it is seldom the cause of dissection in young people(<65 yrs of age) unless it is extremely high. Frequently surgeons/physicians attribute the dissection to high blood pressure, but in almost all cases in young people there is an inherent weakness in the aorta that may be inherited. The danger in writing the dissection off to high blood pressure is that the risk in family members is not recognized.


I would recommend that Mr. Lady probe further into exactly what was found in the aortic pathology specimen. This should show if there is something inherently weak in the aortic tissue.


David
 

Question:

Hi Brian,

Thanks for the great website.

My 59 year old brother was diagnosed with an aortic dissection last

Thursday after being rushed to the hospital with severe chest and

back pain. There is much confusion with the information I am

getting from my family. I am in Texas and they are in Baton Rouge.

I had suggested they ask for Dr. Coselli to review his records, by

am told they trust their local doctors. This frustrates me.

I am told his his aorta arch's to the right rather to the left. (I

was first told it arched towards his back.) I am being told by

family that the arch to the right put him at a risker risk for a

tear and dissection. Is this true?

I am estranged from most the family, but learned over the weekend

that one of my uncles had either an aortic aneurysm and/or

dissection this summer. My mother seems to think he had his entire

aorta replaced. I cannot see that this would be true and think she

has her facts confused. I also learned that another uncle (brother

to the above mentioned) had an aortic aneurysm in his stomach

leading to the loss of a leg. But, then again, there is confusion

in this stories I am getting.

My brother's tear is near the heart and the dissection traveled into

one of his thighs. I was told it did not go into other veins, but

am getting conflicting information now.

He is being managed with medication and as of yesterday morning I am

told he has a blood clot in one kidney. I am told they will be

moving him out of ICU today or tomorrow and as soon as they can get

him up walking twice they will send him home. This seems premature

to me.

I am on dial up so my research is slow, I thought you might be able

to help me with one statistic. I was wondering how many people are

diagnosed with dissections each year? I did see someone that the

medical community thinks many go undiagnosed after death.

I was also wondering if you would recommend that me and my children

seek genetic counseling on this. I am 58 with boarder line high

blood pressure and am on a drug for it. I also have asthma that has

changed dramatically in the last three years. It is somewhat

controlled, but even with advair I need the nebulizer at least once

a day.

Thanks,

MB

Answer:

Maurene,

What you are hearing may not be that far off from what is generally felt

to be appropriate care. I suspect that the dissection does not start

near the heart, or else your brother would have already had surgery. The

dissection likely involves only the part of the aorta which is going

towards the legs. This is usually best handled with medications and

close follow-up. I think in the absence of more precise information, you

will probably have to accept what your brother has decided regarding his

care.

The right aortic arch probably is not a big factor in the dissection

unless there are other malformations to go with it. In any case it

doesn't affect treatment strategy right now.

As for yourself, it probably makes sense to seek counsel about your

risks given the family history. Having the most precise information

possible regarding the case of dissection in the family - scans,

pathology specimens, operative reports etc. will make for the best

possible estimate of your risk and what measures you can do to reduce it.

David
 

Questions:

How is the dissection of the descending aorta classified? What is the difference in factors between an A dissection and a B dissection? Is one more serious/life-threatening than the other? And lastly, are there more risk factors with an Ascending aortic dissection versus a Descending aortic dissection? Can one lead to another? I mean, do ascending dissections keep on going all the way down, and can descending dissections split upward?
Answers:

There are two primary classification systems for aortic dissections. One is the Stanford system which divides the dissections into Type A if the ascending aorta is involved and Type B if the ascending is not involved. The DeBakey system divides the dissections into Types I, which begin in the ascending aorta and extends into the descending, Type II which involves only the ascending and the Type III which involves only the descending aorta.

The Stanford system is simpler and makes the most important clinical distinction which is whether or not the ascending aorta is involved. Practically Type A dissections need to be emergently treated by surgery due to there very high mortality rate during the first 24 to 48 hours (mortality approaches 70% among medically treated patients in some cases). Type B dissections in the absence of complications are better managed with medication since mortality is about the same for surgical and medical treatment with fewer complications in the medically treated patients.

Occasionally dissections of the descending aorta will propagate retrogradely to involve the ascending aorta, but that is the minority of cases. The majority of ascending aortic dissections will propagate to involve the descending aorta unless they are treated very rapidly.

David

 

Question:

brian what is a thoracic ascending aneurysm and how do you know it has burst
Answer:

The aorta is shaped like a candy cane. It goes up from the heart and then turns downward and goes into the belly. An ascending thoracic aortic aneurysm is an enlargement of the portion of the aorta that is going upwards.

True rupture of an aortic aneurysm is usually quickly fatal. Occasionally it is contained by some of the surrounding tissue. The usual symptom is chest pain. An ascending aortic aneurysm can be evaluated either using a CT scan, an MRI scan or a Tran esophageal echocardiogram.

David
 

Question/Answers:

Q.Why would they have been trying to raise my fathers pressure? He presented with an initial reading of 86/ 37 but was completely lucid, aware, awake etc. The pressure dropped to 78/27 but he still was completely aware, talking with me without any loss of his mental capacities. They inverted him, feet up, head down and were giving him a lot of dopamine. He was complaining that he knew it was wrong, that the inverting was causing him great pain in his chest and that he was much worse with this course of treatment.
[Liang, David]
A: Keeping the blood pressure low is important in treating an aortic dissection, however too low a blood pressure can lead to organ and brain damage. 78/27 is getting very close to where there is danger of inadequate perfusion to the brain and the other organs. So getting your father on Dopamine and such is not necessarily the wrong thing to do.
Q: Can a Patent Foramen Ovale have anything to do with an Aortic Dissection? I have one, that caused me to have a severe embolism after scuba diving. I also had a small "stroke" at 21 years old that they never could figure out. The diving accident came 4 years later. I have been told not to let my children dive without getting tested for PFO because it is genetic. Could my father have had this and is there any possible connection between the two?
[Liang, David]
A: I do not know of any association between patent foramen ovales and aortic dissections.

Q: What can we tell from his chest xray at the earlier hospital visit, where they said he had pneumonia but without any other symptoms besides a sudden cough and upper right chest pain? No fever, no mucus. No normal signs of pneumonia. What should be looked at?
[Liang, David]
A: The chest x-ray may show signs of aortic enlargement, but in most cases the findings of a dissection on CXR are very subtle.

Q: What do blood enzymes do in an aortic dissection case?
[Liang, David]
A: Blood enzymes are usually used to look for a heart attack. There relevance to a case of aortic dissection is that aortic dissections are frequently misdiagnosed initially as heart attacks.

Q: Can someone have a dissection for a year or more and survive without detection and treatment?
[Liang, David]
A: Yes. A small proportion of people with ascending aortic dissections will survive the initial tear.

Q: What tests should be done on myself or my siblings, children, etc. to provide early detection?
[Liang, David]
A: That depends on the precise cause of your fathers dissection. IF the cause was hypertension and/or atherosclerosis treating the BP and the cholesterol are the most important. If the cause is an underlying tissue weakness then if possible the precise tissue weakness should be identified and then precise screening can be done. If no obvious cause is found then at least an echo should be done on you and your siblings. More than one may be necessary since you are younger than the age when your father had his dissection.
 

Question:

My husband suffered an aortic dissection a month ago. Currently, he is taking medication to control his blood pressure. However, he is experiencing numbness in one of his legs and when he tries to walk he gets tired quickly. Is this something you experienced and if so what did you do to overcome it.

I appreciate any information you can provide.

Answer:

Some degree of fatigue after a trauma like a dissection is normal. That should pass with time. The blood pressure medications can also be contributory to the fatigue. With careful adjustment of the medications the fatigue might be mitigated to some degree.

The numbness in the leg may be a sign of decreased blood flow to the leg. Have your doctor check the pulses in both legs and the blood pressure in both legs. If there is obstruction of flow into one of the legs, a simple procedure with a stent can frequently fix the problem.

David
 

Question:

My 48 year old husband had an aortic dissection last October. We have 5 sons. They range from 22 to 2 and one half years. We were advised to have them tested, but not really given any direction. Do you have any suggestions for us?

Answer:

The appropriate screening would depend upon the cause of your husbands aortic aneurysm and dissection. The advice to have the children screened is entirely appropriate since the causes of aortic dissection in younger people are frequently inherited. I would recommend to going to see a specialist who can go beyond simply saying you had a dissection and can try to separate out the potential causes of the aneurysm. Some cases have no identifiable cause but others do and make the process of screening your children much more accurate.

David


 

Question:

Brian: Please tell me what Rosa means......"the tear did not go all

the way through".

Answer:

I am pretty sure that refers tot he dissection. In a dissection a tear occurs in the intima (the inner most layer of the aorta). The blood can then enter between the layers and continue to separate the inner from the outer layers. The outer layers (the adventitia and media) continue to contain the blood. I believe what Rosa means is that the tear didn't go through all the layers.


 

Question:

When one has an aneurysm, doesn't that mean the artery has a bulge in it because the

wall was weakened?

Answer:

Yes.

If this causes the artery wall to tear, doesn't that mean the body is flooded with blood? When an aneurysm occurs, the wall can tear as a single unit which leads to a "rupture". When that happens blood is free to flow into the other cavities. Usually this is catastrophic. Occasionally the blood flows into a small enough space where it may be temporarily contained giving time for surgical intervention. In some cases the blood vessel does not tear as a single unit. In these cases it is usually the inner most layer which tears first. This allows a dissection to occur.


 

Question:

Is this when death is imminent?

Answer:

In either case death can occur suddenly so prompt medical care needs to be sought. In the case of a rupture the cause of death is exsanguination. In the case of a dissection death can be due to propagation of the dissection in to the heart or into the branches leading to the brain or by leading to a rupture.


 

Question:

When a dissection happens, does that mean the 'layers' or inner 'tubes' or walls of the artery are separated because blood has rendered them to split apart though they are still contained in the artery?

Answer:

You are correct.


 

Question:

What occurrence would cause chest pain that would alert a physician that the event

took place: The aneurysm or the dissection ?

Answer:

Usually development of an aneurysm is gradual and does not lead to pain unless it is rapid or it presses against some other structure like the spine. A dissection or a rupture are usually associated with sudden severe pain


 

Question/Answers:

Brian,

I seek the answers that I do not find in any current literature.
1) Average life span of Type A aortic dissection. Average life span of Type B aortic dissection.
[Liang, David] Tough to answer this one. There is some data from the IRAD registry on this, but the outcomes after a dissection depends upon so many things that an average doesn't really mean much. If the repairs is successful though there is no reason why the life expectancy cannot be very near normal with proper care.

2) What are the symptoms of the patient in Type B aortic dissection terminal phase.
[Liang, David] No, such thing as a terminal phase for a type B dissection. Pain is usually the sign that something should be done, but frequently there is no symptom prior to rupture. That's why the aorta needs to be monitored regularly after a dissection.

3) What are the most frequent cause of death of Type B aortic dissection.
[Liang, David] Rupture of the aorta is the most common cause of death.
Thank you
Cynthia Fisher
 

Question:

My father died in December of 2001 after a aortic dissection. This was his second surgery like this and the first one went well. The second, on the other hand, didn't. After his surgery, his kidneys shut down and my father passed away. He was only 57. I'm turning 27 soon and now I am wondering how big of a problem this could be for me. How closely related to genetics is this condition? Should I get checked out, just in case? I appreciate what you are doing for instance like this. Thanks, Nick

Answer:

Nick,

Definitely. Dissection in someone who is relatively young, e.g. less than 65 years old, frequently has a genetic cause or contribution. Usually an echo is a good starting place. In some cases where the dissection started somewhere other than the aortic root, a CT or MRI may also be appropriate.

David

 

Question:

How can our Emergency Room Doctor's better diagnose a potential dissection from a heart attack?

Answer:

The diagnosis of aortic dissection is a particularly difficult one, since it is still relatively rare, yet the consequences of a delay in diagnosis can be disastrous. The frequency of heart attack is still much higher than the frequency of aortic dissection, so thinking of a heart attack in someone with chest pain is still the first instinct. I think the most important thing for the treating physician and what I teach all my residents is to always consider the 3 diagnoses that can kill the patient suddenly which present with chest pain, myocardial infarction, aortic dissection and pulmonary embolus. The physician should, consciously, go over why he/she would exclude each of those diagnoses.

The things that point toward an aortic dissection would be:
1. Very abrupt onset of pain
2. Loss of pulses/perfusion in any extremity
3. Family history of dissection/Marfan syndrome
4. Lack of evidence of the other diagnoses on initial examination in a patient who appears ill.

Unfortunately, these features are far from universally present, which leads to frequent delays in diagnosis of aortic dissection. A CT scan or a transesophageal echocardiogram would certainly have made the diagnosis in John Ritter's case, however doing a scan in every patient with chest pain would not be appropriate for reasons of procedural morbidity, patient discomfort and cost.

One step I would propose would be to increase the use of transthoracic echocardiography in the emergency room. Although, the transthoracic echo is far from definitive in ruling in or ruling out an aortic dissection, it probably does a better job than any of the other available inexpensive noninvasive tests. A transtoracic echocardiogram can also help to confirm one of the others of the 3 diagnosis allowing the physician to be more effective in using CT and TEE in evaluating the remaining patients without firm diagnoses.

With this there will still be missed or delayed diagnoses of aortic dissection. Perhaps a day will come when we can do a 3 minute MRI scan from head to toe. That may be what will be necessary to reach 100% accuracy in the diagnosis of aortic dissection. In the meantime keeping aortic dissection in the minds of emergency physicians is probably the most important step. The important message is that not all chest pain is either a heart attack or it is nothing, the two acutely life threatening diagnoses should always be considered,

David
 

Question:

Is it possible to have an aneursym (ascending, descending, thoracic) and not even know you had it?

Or do these aneursym's have symptoms that they might be ready to blow?

Just so I am clear, you have to have an anuersym first in order to have an aortic dissection. Which I think is a bursting of that anuersym?
Answer:

Brian,

Let's start with the aneurysm vs dissection distinction. That's something that isn't well explained even to many doctors.

An aneurysm is simply an enlargement of a blood vessel.

A dissection implies that there has been a tear in the inner layer of the blood bessel and the layers of the wall of the blood vessel have separated. The tear allows blood to flow into the space created by the separation of the layers. This space is often called the false lumen.

So you can have a dissection without an aneurysm. You can also have an aneurysm without a dissection. An aneurysm usually implies some degree of weakness of the walls of the aorta, so someone with an aneurysm is at a higher risk of a dissection. Conversely, a dissection will weaken the artery thus increasing the tendency for an aneurysm to develop.

I hope this clarifies the distinction and relation between an aneurysm and a dissection.

Now onto the new questions -

An aneurysm is usually assymptommatic until they are quite large, because they are growing slowly. If they start to grow rapidly or start pressing on surrounding structures when they are very large, then symptoms may occur. If they are growing rapidly then the symptom is usually pain. If they are pressing on something, it depends on what they are pressing against. If it is the airway there may be wheezing or coughing. If it is the recurrent laryngeal nerve it may be hoarseness.

David
 

Question:

Brian, my father-in-law was diagnosed Sunday with aortic dissection he under

goed emergency open heart surgery and made it through the surgery. Now five

days has gone by and he has had a fever and now has and bacterial infection

in is lungs and in is bowels could the surgery be a cause of this if you

don't know can you refer me to a doctor or a nurse that i can speak to thank you Dolly

Answer:

Hello,

Sorry to hear about your father-in-law. Repair of an aortic dissection is about as risky a procedure as exists. Even if performed by a very skilled cardiac surgeon, complications are are common. Anyone who undergoes this extensive a procedure is at risk for pneumonia (bacterial infection in the lungs) and other infections. I seriously doubt the infections you describe are the result of the surgery itself. People this ill are usually on a ventilator (life-support), have tubes in their bladders to measure how much urine a person makes, and have large catheters in their veins to give them fluids, antibiotics, etc.

I wish your family well during this tough time. Let me know if you have any more questions-I would be glad to help answer.

Sincerely,

Rob Rogers, M.D.

Assistant Professor of Surgery/Emergency Medicine and Internal Medicine Program Director Combined EMIM Residency University of Maryland School of Medicine


 

Question:

Hope you are your family had a great Thanksgiving-we all have a lot to be thankful for. In Lance's story at the end he said he could heal-this I don't understand. Once you are dissected you are always dissected-at least this is what my surgeon told me. I asked him if he could fix my dissection and he told me he could but it would kill me. The only reason they even operated on me was because the dissection ruined my aorta valve and I had to have it replaced-other wise I don't think they would have done anything to me. Thanks B

Answer:

Hello,

That is a tough question. If your dissection was near/involved your aortic valve, you would have no choice but to have surgery. Type A aortic dissections (where the tear is near the aortic valve-as blood leaves the heart) are for the most part all repaired surgically since they have such a high mortality rate. Type B dissections that begin as the aorta takes a turn and goes down the back aren't typically fixed surgically UNLESS the dissection (or tear) spreads backwards into the part of the aorta above the aortic valve or unless blood flow to a vital organ such as the kidney or intestines is blocked by the dissection. To answer the question, a tear in the aorta can heal but most patients are left with a blood clot within the wall of the aorta. The tear itself can heal.

Hope this helps.

Sincerely,

Rob Rogers, M.D.

Assistant Professor of Surgery/Emergency Medicine and Internal Medicine Program Director Combined EMIM Residency University of Maryland School of Medicine


 

Question:

January 10, 2004

Dear Brian,

In my research I reviewed medical information related to medical products W. L. Gore has developed for use in abdominal aortic. The information is a summary of the medical break through as follows:

"The EXCLUDER Device, Gore's groundbreaking product, is a potential lifesaving endovascular device for patients of abdominal aortic aneurysm (AAA). This minimally invasive tool is especially beneficial to patients whose conditions are too delicate to permit more invasive open surgery."

My question relates to my condition in which I had an acute type 1 aortic dissection ascending in 2002 since then the aorta has expended from 4cm to 5.3 cm.

My doctor informed me surgery would be requiring when the aorta expends to 6cm. He informed me the duration of the operation would be 8 hours with risk at 40% to 60% on a successful operation.

Will the Gore EXCLUDER Device be able to be use on my aorta?

Jan. 10, I will discuss this information with my doctor.

Thank you for your time and consideration with this matter.

Sincerely,



Fred

Answer:

The Gore excluder is currently only approved for use in abdominal aneurysms. We do have investigational stents that can be used in thoracic aneurysms if the anatomy of the aorta is correct.

That said the stent may still not be the right choice even if it can be made to work. Aortic stents are relatively new and there are occasionally issues with the stents migrating or residual leaks. For good operative candidates surgery may still be the right long term answer.

The success rate for surgery quoted to you is quite low. Unless there are a lot of other health issues and assuming you are not in your 80's or 90's, the surgical risks should be significantly less than that quoted to you. For someone in their 50's and 60's who is in otherwise good heatlh the likelihood of a good outcome from surgery to replace the thoracic aorta is closer to 80 to 90% at an experienced center.

Send me your CT's and some background information and I can give you more specific info regarding the therapeutic options.

David


 

Question:

Hi Brian:

Thank you for putting up your website - it has been a helpful resource for me. My mother was diagnosed with Type A Aortic Dissection last week. The length of the dissection is 31 cm and it involves both the ascending and descending aorta. Due to her age and other chronic health problems (she suffered a stroke, which resulted in the diagnosis and has survived lung and kidney cancer) and the location of the tear, she would not survive surgery. They are treating her with various drugs to keep her blood pressure low. The doctors believe that her dissection is chronic rather than acute because a blood clot has formed at the tear which is holding everything together for now. The tear is through the initial and part of the middle layer of the wall.

All of the articles that I have read indicate that the prognosis for the non-surgical treatment of Type A dissections is poor. The majority of articles that I have read indicate that the mortality rates for acute dissections is 90% in 30 days. Does this rate apply to chronic Type A dissections? The only information I could find on chronic dissections is those for Type B, which is different. My mom has come to terms with the diagnosis and has accepted things (she is 76 years old). I know that there is a chance that she may survive for a number of years but would just like to know all the information I can about chronic Type A dissections.

Answer:

Type A dissection are for the most part uniformly fatal. There is, however, a chronic form but not a lot is known about the natural history. I saw a young 45 year-old male on dialysis 2 weeks ago who presented to our ER after a fall and significant head trauma. Only after multiple CAT scans of the head, neck, chest, abdomen, and pelvis (and a review of his medical records) did we discover that he had a chronic Type A dissection (had it for at least 2 1/2 months) The surgeons at our hospital say that he is too ill to repair it. I would consider a type A a major ticking time bomb since it could rupture into the sac around the heart (pericardium) any time. Theoretically, and I emphasize theoretically, a type A could go on for a long while, especially if the blood pressure is controlled. Not a lot is known about it.

Rob Rogers, M.D.

Rob Rogers, M.D.

Assistant Professor of Surgery/Emergency Medicine and Internal Medicine Program Director Combined EMIM Residency University of Maryland School of Medicine


 

Question:

All of the articles that I have read indicate that the prognosis for the non-surgical treatment of Type A dissections is poor. The majority of articles that I have read indicate that the mortality rates for acute dissections is 90% in 30 days. Does this rate apply to chronic Type A dissections? The only information I could find on chronic dissections is those for Type B, which is different. My mom has come to terms with the diagnosis and has accepted things (she is 76 years old). I know that there is a chance that she may survive for a number of years but would just like to know all the information I can about chronic Type A dissections.

Answer:

A chronic type A dissection does not carry the same risk as an acute type A dissection, since much of the risk of death occurs during the first week. There still is significant risk so if the patient is a good operative risk then it is still worth operating. At what point the risk of operation exceeds the risk of waiting is often difficult to decide. Also that decision is also affected by the skill and experience of the available surgeons. In a rare case or two we have even been able to treat Type A dissection with stent graft when the surgical risk is too high.

David

 

Question:

If a person gets a dissected aortic aneurysm and lives through it, what kind of prognosis is given to them ?


Is there a type of medication that would be good for them?


Also, what instructions would they get so that they would survive as long as possible?

Answer:

Prognosis depends on what type of dissection they have. IF the dissection is successfully repaired, the patient should have a fairly good prognosis. Also, it has been shown that mortality rates increase by 1-2 % per hour for every hour the diagnosis is delayed. So, theoretically, if the diagnosis is made after 24 hours the mortality rate is > 24%. Treatment of most cases of dissection involves controlling the patient's blood pressure to a normal level. In cases of hypertension-induced dissection, good control of the blood pressure is a MUST and any agent that would accomplish lower blood pressure would be acceptable. Let me know if you have any more questions.

Rob Rogers, M.D.

Assistant Professor of Surgery/Emergency Medicine and Internal Medicine Program Director Combined EMIM Residency University of Maryland School of Medicine


 

Question:

What is aortic regurgitation?

Answer:

Aortic regurgitation is a fairly common condition and does occur after an episode of rheumatic fever in some cases. The significance of the aortic regurgitation is dependent upon how much leakage is occurring. Small amounts are well tolerated by the heart indefinitely. Larger amounts are also well tolerated for long periods of time, if it starts gradually. If there is a lot of leakage, the heart may eventualy begin to fail. Usually there is still plenty of time to get the valve replaced when heart begins to show signs of failing.

Aortic regurgitation is usually painless. The most common symptom is shortness of breath with exertion.
David Liang

 

Question:

Hi I'm Sue and i live in New Zealand and 37yrs. I and 2 of my 3 kids have marfans. I suffered a dissection just over a year ago and have been left with a false lumen. I haven't had a good read of your site yet but will do tonight when the kids are in bed and i can have a good browse. Marfans isn't very common here but i have a few NZ contacts. GPs here I hope are learning from me ( since I have only known for 2 years i have it) and i hope my surgeon knows what he's doing. I had a bentalls and a mechanical valve put in when i dissected but they want to go back and wrap the remaining aorta soon. Im not keen on more surgery since i have had an attempted stent (which didn't work to close the false lumen ) and recently a hysterectomy because of the warfarin I take. My kids are sick of me being in hosp and recovering all the time and so am I. My false lumen they say has multiple entry and exit points. Any how your site looks good and well done. My email is suzieglassey@hotmail.com
Sue
Answer:

Usually we don't recommend wrap type operations. If a portion of the aorta needs to be repaired, replacement is our preferred option.

The need to surgery on a chronically dissected arch and descending aorta is determined by the size of the aorta, rate of growth and symptoms if any. Also if flow is impeded by the dissection to any part of the body surgery may also be indicated.

I don't know of any surgeons I can recommend in New Zealand. There are some in Australia that I know.

If you wish I can review your CT/MRI scans and at least give you my sense of whether surgery is indicated from those pieces of information.

David

 

Question:

hi, my name is gail .i have just been diagnosed with a 4.3 thoracic aneurysm at the root and ascending aorta..strong family history..mother and brother have died of this and another brother has both thoracic and abd aneurysms...i am a reg. nurse...presently i am waiting to be seen at cleveland clinic...my question is this...is there urgency for me to be seen and if they adopt a "wait and see" approach..should i seek other opinions??..i am a reg nurse...and have had experience in the ER with dissections and ruptures...at age 63 i dont want to wait for mine to do that!!...would appreciate any advice or help you can offer...thank you
Answer:

Gail,

Assuming the 4.3 cm measurement is accurate - and it frequently is not - the aorta is not very enlarged unless you are a very small person. The decision to proceed to immediate surgery, as opposed to waiting depends upon the best guess as to your annual risk of a dissection or rupture. Surgery, especially when valve-sparing methods can be used, has excellent immediate outcome and very little long term morbidity, so we generally aren't willing to tolerate much risk while we wait and watch. Unfortunately figuring out that risk for any given individual can be difficult. We weigh several factors including relative size of the aorta (big people having bigger aortas), rate of growth, presence of symptoms, family history of dissection and presence of a leaky vale to take a best guess at the annual risk. Against that we have to weigh the surgical risk and discomfort, the issues if a artificial valve is needed and the patient's anxiety about surgery and waiting.

The physicians at Cleveland Clinic are very experienced and should provide you with a reasonable recommendation. If there is any doubt when you are done there, we would be happy to review the imaging studies and clinical and family history, and give you our two cents worth.

David

 

Question:

Hello,



Thanks for having this, I'm six months out from my surgery and still have issues of not being able to run, ride a bike without having some muscle constraints in one of my legs. I don't know why this is. The meds I take, lisinprol, metotoprol and some vitamins do seem to cause some energy fatigue in me late in the day. Is all of this normal?



Ron Sonenshine

rsonenshin@att.net

Answer:

Have your cardiologist check the blood flow into the leg. It may be compromised by the dissection. If that is the case a stent may help fix the problem.

If the blood flow is adequate then it is likely an issue of deconditioning. Just remember that you have gone through a major surgery and have not had a chance to exercise for a long period of time so it may take you a little while to get back to your prior level of fitness.

David

 

Question:

have a curious question. I found your website in my research to learn more. Several months ago, my sister called my mother Sunday after church to visit. She found her still in bed asleep and thought this odd. After talking a few minutes she discovered that my mother had been sick through the night with diarrhea and a little vomiting. At this point, she was unclothed asleep in her bed at noon. She was unable to locate her dentures and mentioned not being able to turn off the stove. Scared to death, my sister told her to get her clothes on and sit still until we could get there to see about her. When we arrived, her stove was indeed still on (from the night before) and there was a skillet outside where she had burned her supper beyond recognition. She knew she took the skillet outside but couldn't tell us why. We actually met the EMS there and they delivered her to the ER. A spinal tap was performed to rule out meningitis and blood work was done along with a urinalysis. They did a CT Scan of her brain to rule out stroke. Then they placed her in a regular room for testing and observation. Her chief complaint was terrible headache - which was worsened by them sitting her up immediately after the spinal tap and she had a terrible back pain. They proceeded with many tests - some of which had been performed on her a year earlier in a checkup. When she complained of chest pain - they gave her NTG and then her headache worsened. She mentioned a sensation of "something tearing" in her chest but nothing was done. In your opinion, could this have been prevented in any way? She was in the hospital from a Sunday afternoon around 1:30 pm until she passed away according to the preliminary autopsy with a "ruptured dissecting aortic aneurysm" and a secondary cause of "hemopericardium tamponade" Also, could an abundance of sodium via IV increase the chances of the aneurysm rupturing or could blood thinners? Please advise with what information you can offer. We want to put this to rest in our minds. Thank you for your time.

HBridges

Answer:

I'm sorry to hear about your mother. It's hard to know if her death would be considered a preventable death. Certainly if the diagnosis of a dissection had been made she would have had a chance with surgery. The question really was there any way that her physicians should have reasonably been expected to suspect a dissection given the presentation. That's a tough one to answer. Many of her presenting symptoms were atypical for a dissection. The chest pain would certainly raise the issue of aa dissection, but other causes are still much more likely. It's uncertain how much the tearing sensation was emphasized, because that often makes physicians think about dissections.

The sodium in her IV probably had no effect, but the blood thinners are certainly contraindicated in the setting of a dissection.

I hope this helps.

David

 

Question:

Hello Brian,

My name is Judy. I live in Wisconsin and so does my brother Dave. Dave had Aortic Mechanical Valve Replacement surgery at St. Luke's Hospital in Milwaukee.

I am wondering if you would have any info. on the clicking noise from these devices and the impact on pts. life and quality of life regarding the disturbance from it. If so, I would like to ask if you could send any info. or any sites where the info. may be located. He hasn't been able to find any documents at the hospital where he was.

Sincerely,
Judy
Answer:

The clicking noise is very common with a mechanical aortic valve.. How loud the noise is , is very variable from patient to patient. Typically thin patients will have more audible valves. Almost everyone gets used to the noise over time. The noise will also tend soften a little over time as well. It usually is most annoying when you are in a quiet room, e.g. when you are going to sleep. Just a little background white noise will tend to cover it up quite well.

David

 

Question:

Hello,

I am a recent post op as of Dec14th. my daughter ran across your site and thought it would be beneficial for me.

I was diagnosed with acid Reflux, after I entered the ER with severe burning anterior chest pain.
My daughter was insistant that I be seen by a cardiologist. He ordered an EchoCardiogram which disclosed the disecting aneurysm. I was flown to Rochester on the 14th and had surgery that evening. I was taken back into surgery due to bleeding.

I live 700 miles from Rochester, so I have to cope with post op symptoms with no support system available.

I was startled and scared when I discovered that my legs were cold and clammy around, above and below my knees. I also have Edema of both legs which is lessening, but I still can't get shoes on.

I am an 80 year old retired RN. I was unprepared for the weakness and shortness of breath when I got home.

I eat but do not care much for meat. I prefer fruit, cereal for breakfast and of course I am Diabetic so stick to my diet.

My kids took turns staying with me..until this week I have just checkins by a son who lives 2 doors away.

I still use my walker but go small distances without it. I developed what the therapist called a drop foot which acts more like a paralysis.

I would appreciate any feed back. Thank you. Rosemary M
Answer:

Much of what you describe in your email to Brian Tinsley is

consistent with normal recovery following a very major operation at

age 80. A "foot drop" may take a long time to recovery, or may not

recover. Beyond those generalities, it is difficult to advise you

third-hand by email.

If you tell me where you live, I might be able to suggest a hospital

closer to you than Rochester or follow-up. I'm sure I know your

surgeon in Rochester, and I can help make him aware of your plight.

He may not know your issues. If we continue to correspond, you might

be hearing from me or from Dr. Allan Stewart, who has recently

assumed the leadership of our aortic surgery program.

--

Craig R. Smith, MD
Calvin F. Barber Professor of Surgery
College of Physicians & Surgeons of Columbia University
Chief, Division of Cardiothoracic Surgery
New York Presbyterian Hospital
Milstein Building 7-435
Columbia University Medical Center
177 Fort Washington Avenue
New York, New York 10032
212-305-8312
212-305-0905 fax

 

Question:



Hello Brian,
My name is Harry and I am writing to you from the UK.
I experiencing an extensive aortic dissection in 1996, while undergoing coronary angiogram. The dissection extended from the right femoral artery and exited in the aortic arch. It was decided to treat me conservatively, that it to say wait and see, though the possibility of surgery was discussed.
Having survived this I underwent CABG some 11 months later, I had four grafts, however I am left with what has been described to me as a chronic dissecting thoraco abdominal aortic aneurysm. I have been discharged from all clinics, no prescription medications and have not had a scan since 2001. At the time of the trauma, and after some partial healing I was advised that the residual dissection/aneurysm was almost 4cms in size. I have put on a little weight in the past year, a lot is due to depression, and would be grateful for any advice regarding exercise or treatment. Thank you for the site I don't feel quite so alone.
Yours sincerely,
Harry. (H McManus)
Answer:

The first thing I would do would be to get a CT scan from stem to stern. I generally follow people with chronic thoracoabdominal dissections at yearly intervals after the first year for the rest of their lives, or until they get to an age where the risks of surgery become prohibitive.

If things are stable then a program of mild to moderate aerobic exercise is appropriate. Walking, swimming and bicycling (on flats) are all excellent forms of exercise. It's best to avoid isometric exertion e.g. lifting. As a guideline lifting that forces you to strain at all should be avoided. For most fit men lifting 25-30 pounds should be okay if you want to do something to tone the muscles.

David

 

Question:

Brian,

Your web site has helped me, when no one else could. I need some

advise, I am having a total knee replacement on the 19th. When I

found out that I needed it, my first concern was if there would be any

problems with me having an aortic dissection. I first called my

thoracic surgeon, who referred me to my primary care doctor. He said it

wouldn't be a problem as long as they keep my blood pressure and pulse

low. Now I have found out that I will be treated with blood thinners, I

know that I am not support to take them, as I have not had any surgery

and am just being treated with medications.

To make a long story short, my primary care doc. says I need the

thoracic surgeons approval for that, and the surgeon just puts it back

on the other doc. I don't believe either of them want to make that

decision.. Have you heard of anyone having unrelated surgeries and

having any problems with there dissections. I am starting to have a lot

of stress over this, its not that far away . Thanks for all your support. Pat Ingersoll

Answer:

This is a difficult and not uncommon situation

There is no good data I am aware of in regards to folks with chronic Type B dissections or residual Type A dissections having remote surgery. My guess would be preoperative B-blocker and good BP control would be essential. Good anesthesia is important in controlling your blood pressure as is adequate pain control after surgery. As for "blood thinners" I recognize their role in preventing venous thrombosis and pulmonary embolism after orthopedic surgery. However, ideally no patient with an existing dissection should be treated with long term anticoagulation, especially if their false lumen remains patent (still with blood flow as opposed to thrombus) I guess if you have to have anticoagulation, the shorter term the better. good luck and continue radiologic surveillance of your aorta alan


 

Question:

I was thinking the other day that I wonder if you could find one of the

doctors you are in contact with to list the things that make one's blood pressure

rise. I remember a surgeon friend of mine telling me a few weeks after my

dissection that keeping my blood pressure down was the key to staying alive. I

don't just mean the things we all know like keeping your weight down,

meditating, etc., but things like not drinking too much water, wearing tight garments,

etc. Just a thought, Jane Prugh

Answer:

Nothing really fancy here. Regular mild to moderate aerobic exercise, avoid the salt and watch the weight are the essentials. After that if the blood pressure is not controlled, most people will need medications. There are some other issues that can aggravate the blood pressure - some over the counter medications, alcohol, sleep apnea etc. Also in someone who has had a dissection the blood flow to the kidneys is critical.

david


 

Question:

Brian,
This is the best website I have found about aortic dissections. My mother was diagnosed about 3 weeks ago with this condition. She was sitting in church and suddenly started having severe back pain. We went to the ER and there the ER doctor diagnosed her with thoracic aortic aneurysm. She is now being treated with beta blockers and high blood pressure medicine.
My recently completed several weeks of chemotherapy for reoccurring breast cancer (13 years ago). Did the chemo have anything to do with this? Thank you for an excellent website. Debra
Answer:

There is no known association between chemotherapy and aneurysms. We did have one patient several years ago with Marfan syndrome who had very rapid expansion of her aortic aneurysm after receiving radiation therapy for breast cancer. Whether that was serendipitous or related we don't know.

David

 

Question:

Dear Brian,
After my husbands Aortic Dissection I've notice a change in his personality. He doesn't remember to take his pills everyday, forgets who he was going to call when he picks up the phone, stops home and can't remember why, seems to have lost tactfulness when talking to people, doesn't have patience when dealing with people like he use to before surgery. During the surgery I was told that there was a 3 1/2 minute oxygen loss to his brain when repairing the carotids. Can this behavior be a result of surgery and what can I do to help him?

kklichner@verizon.net
Answer:

How long ago was the surgery? There are many factors that can be contributing. A big traumatic event like dissection by itself can cause a lot of stress. Under stress many people become irritable and forgetful. After cardiac surgery people frequently have brief short term memory loss which can persist for several months. If these are the causes, it should resolve on its own with time.

Depression can also develop around a stress event or a major cardiac surgery. If that is the case medical intervention may be needed if it doesn;t resolve on it's own.

Finally, people can suffer small strokes associated with aortic surgery, but usually the manifestation is not limited to personality changes. The brief period of circulatory arrest is not a problem, since the brain is usually cooled quite a bit during that period. With the brian cooled periods with no circulation up to an hour can be tolerated in some cases.


 

Question:

Brian

Can this EndoSensor when it becomes available be used on someone with Marfan's syndrome? Because of the delicate connective tissue I was of the understanding stent's couldn't be used. What is your thoughts? Thanks!

Hugs, Sherry Heldt

Answer:

We use stents to correct problems with malperfusion after a dissection in patients with Marfan syndrome. We have generally avoided stent graft to treat aneurysms in patients with Marfan syndrome, except in very exceptional situations.

The primary problem is as Sherry mentioned. Most of the stent grafts for treating aneurysms that are currently available are very stiff and with the delicate Marfan tissue there have been some dissections created during the implantation. The long term effects fo the stiff stent in the delicate Marfan aorta are also uncertain.


 

Question:

Dear Brian

First I want to commend you for the valuable information that you are providing for aortic dissection patients. I have reviewed some of your correspondence and I find it most informative. Now for my situation.

Two week ago I had an MRI from my Orthopedic Doctor. In addition to lower back problems the MRI indicated "Double lumen appearance of the abdominal aorta raising the possibility of a focal dissection.".My primary care physician ordered an MRA for my abdominal aorta. The MRA dated April 7, 2005 stated, "Findings are consistent with an aortic dissection. Intimal flap is identified within the distal thoracic aorta and extending into the proximal abdominal aorta and extending down to approximately the level of the renal arteries..A second smaller intimal flap is identified along the right lateral aspect of distal abdominal aorta just proximal to aortic bifurcation." This information was reviewed by my cardiologist and former heart surgeon, He ordered a chest MRA April 22,2005. He advised me that I had a Type B descending aorta dissection.He decided to contact other aorta specialists for consultation and stated he would get back to me on Tuesday, April 26, 2005. I have not reviewed this last report.No further treatment was accorded at that time.

My background is : I am an 80 year old male who had a 4 bypass heart operation on August 1. 2001. The results were excellent and I have had no chest pain or problems since that time that could relate to my heart that I am aware of . Neither the cardiologist nor I can understand why I have had no symptoms or pain before or even now. Had it not been for the MRI taken on March 23, 2005 ordered by my orthopedic doctor, I would not have known about the aorta dissection.

I am patiently waiting for further direction and I would appreciate your comments concerning this issue.

Kindly, Charles A. Allen, Ph.D.
Answer:

Incidentally found aortic dissections are unsuaul, but does happen. The vast majority of patients with aortic dissections have pain, but probably about 5% of people cannot relate a history of pain that might have been when the dissection occurred.

In any case management is probably not changed, Blood pressure needs to be well controlled and the aorta monitored on a regular basis. Generally watchful waiting is the right thing to do for descending aortic dissections. Surgical or stent intervention should only be considered when there are complications e.g. loss of blood flow to organs, excessive growth of the aorta ...

I hope this helps. Please let me know if you have additional questions.

David

 

Question:

Hello Brian,
My husband had a very large Type B aortic dissection three months ago. He is still in a rehab center trying to ambulate. He is being treated with Beta Blockers and Blood pressure meds. He is having a lot of difficulty with his balance. He is on oxygen due to a very low lung capacity. The surgeon here did not want to operate due to the lung problem and also a badly damaged liver. He also has congestive heart failure. He is 73 years of age. He seems very strong from the waist up. He lifts his legs very well with some weights, but is having a lot of problem walking with a walker.

My question is: With the above conditions what is the life expectancy and what should I watch out far if and when he ever comes home?

Thank you for your great web site,
Victoria
Answer:

I suspect the life expectancy will be determined more by the other conditions than by the dissection.

The major things to watch after a dissection are the blood pressure and blood flow to the extremities and internal organs. Lack of blood to the legs generally presents as burning or aching when trying to walk. Problems with blood flow to the internal organs usually manifest as high blood pressure or abdominal pain.

David

 

Question:

Hi Brian,

I am only 31 and not yet married and hoping to have kids within the next couple of years but last Thursday night my new cardiologist who had given me a new cardiology MRI found that my heart murmur that I've had since age 1 is now looking like Dissecting Aortic Aneurysm.

Needless to say, your website has given me the most information out there but I have cried and been depressed since the news last Thursday and am waiting for this dr. to schedule an appointment for me to "simply talk" to a surgeon though she's still encouraging me to have kids within the next couple of years, however, that sounds not only dangerous but just selfish of me.

I am not sure if I qualify for a non invasive vs. open heart surgery but am VERY concerned in reading one of your articles http://www.emedmag.com/html/pre/cov/covers/101504.asp state that even after surgery we're only given 10 years to live??? Please tell me I'm reading this incorrectly as I am so depressed even more now as it's all quite a shock but I felt hopeful as it appears they found it early (I realize your not a dr...)...
With all aortic dissections, patients who survive the initial phase and are discharged from the hospital have a five-year survival rate of up to 80% and a ten-year survival rate of about 50%. Chronic management of patients who have had a dissection involves treatment of the underlying etiology, if possible. In many cases, this translates to aggressive blood pressure management to diminish the pressures exerted on the weakened intimal layer in other segments of the aorta.
Thank you and best of luck to you.
Answer:

Before you jump to any conclusions, I would ask you cardiologist a little more about what was found. Where was the dissection - ascending or descending. How large is the aorta now? What does he think caused the dissection. I have a feeling there may have been some miscommunication - most cardiologists would be very careful about encouraging someone with an aortic dissection to become pregnant.

Also, much of the mortality data for patients with dissections is dominated by an older population of patients who have a lot of other conditions which contributed to the dissection and also contribute to the ultimate cause of death. A dissection by itself in someone who is otherwise healthy definitely does not bring such an ominous prognosis.

Please feel free to contact me directly if you have further questions.

David

 

Question:

What is a Bentalls procedure and where exactly is the aortic root?

Answer:

The Bentall is the very first successful surgery for aortic root replacement. The operation we do currently is frequently called a modified Bentall procedure. The distinction between the modern operation and the classic Bentall is that in the classic Bentall the coronary arteries are left on the aorta and sewed to the graft. In the modern operation the coronary arteries are separated from the aorta and reattached as buttons. Also in the classic Bentall, aorta was left in place and wrapped around the graft at the conclusion of the operation.

The aortic root generally refers to the portion of the aorta just as it leaves the heart. It includes the sinuses of Valsalva.

David

 

Question:

My question to you is: can a dissection be OLD ???? I read that thoracic aortic

dissection is a sudden event???????? I would really appreciate any help you

can give me... She is also having very bad pain in her L12 - which they say is

a compressed fracture ??? Could this be related to the dissection???? Thank

you so much for helping so many people

Answer:

Dissections can be relatively asymptomatic - about 5% or so are picked up incidentally as in your mother's case. The decision to treat will depend on the size of any associated aneurysm and whether blood flow is cut-off to any organs.

The best way to tell if the pain in the back is due to the spine or the aorta is to see if the pain worsens with motion or change of posture. Dissection pain changes very little with position whereas a compression fracture usually makes any motion exquisitely painful.

David


 

Question:

Brian,

Hi, I came across your email address online as I was looking up positive results of the d-dimer test. I am a 32 yr. old female. I started with some severe pains in my left leg, no obvious swelling, but felt warmth in the leg and toes felt numb and cold. I presented to the ER on Friday night 7/8/05. Doctor told me about the d-dimer test they would do to rule out a blood clot, or to indicate an ultra sound would be needed if the result came back positive. Well, low and behold he returned with the results of the d-dimer and said I had a high positive. They then called out for me to have and ultrasound done of the leg, then he returned with the results of that and said that no clot was found. Before results were in, he clearly explained to me that the high d-dimer was a good indication that there may be some clotting. I am just so concerned now that why did the d-dimer return positive, but the ultra sound came back negative. I am really scared, can you please shed some light on this for me. I will go to my family Doctor this week sometime and let him in on what happened, do I have any reason to be terrified till then?? Please respond to me if you can.. Thank you.

Sincerely,

Patricia
7/10/05
Answer:

Unfortunately that is the problem with the d-dimer test. If it is normal then the odds of a blood clot are very low. "False" positives are very frequent though. D-dimers will frequently go up with simle inflammation since the inflammatory process will sometimes activate the coagulation cascade. The description of swelling and warmth along with pain would certainly go with some sort of inflammatory or infectious process, both of which can raise the d-dimer. If the leg is still bothering you it's worthwhile visiting your own doctor for an evaluation. ER's frequently just focus on excluding the things that can kill you and may not try to get a definitive diagnosis.

David

 

Question:

Dear Brian

My daughter, Kim, gave me your email address and said if I had questions,

to write you, and so I hope it's ok with you, Brian.

I feel I have to go into some detail first, before I ask the questions I have concerning blood pressure:

My husband had surgery for an (ascending) aortic anneurysm dissection

last May 2004. The aneursym was located on the arch of the aorta. He

entered the emergency room with 188 (sys) BP reading at that time. At first they said there were no leaks and they could control his condition with meds, but in 2 days made the decision to do the surgery repair, and put in the graft. He was in the hospital in ICU for 31 days

- they had a very difficult time keeping his BP down after the surgery.

He also has a pacemaker - his heart rate

got as low as 27 while in ICU.

Everyone says he is a miracle and he never should have lived through it.

So we feel more than blessed.

He has a second aneurysm just below (or above, I forget) the diaphragm that is in need of repair - the heart surgeon says there is a less invasive surgery for it, entering the groin area with a stent, however, the heart surgeon said my husband's arteries are larger than the normal person and he didn't think they had material yet for his body type??

There is some controversy over the size of this 2nd aneurysm - the radioligist thinks it grew but the heart surgeon disagrees and will do

another CT Scan in December of this year. This 2nd aneurysm is also a

cause for our concern with his current blood pressure readings.

My ultimate question is regarding blood pressure. His blood pressure is all over the place and there seems to be no rhyme or reason to a change from high to low. Because that was the culprit that caused his emergency in the first place, we panic each time his BP reading is high. High being 160's, 170's (systolic) Last week it got as high as 190/125 - it doesn't remain at those HIGHEST levels, however, and fluctuates from 135's to 160's - occasional systolic readings of 117 or under 130's - maybe one or two a day of the low

readings. I just recenlty compared his readings to when he first came

home from the hospital and I don't see where it's significantly different.

The diastolic readings have been as low as 72 to as high as 117 at times, with the exception of the one at 125 (dias) I previously mentioned.

The ultimate questions I have at this time are:

DO WE NEED TO BE IN A PANIC OVER THE ABOVE READINGS?

WHAT IS ACCEPTABLE BP READING, FOR HIM? DID THAT CHANGE DUE TO HIS AORTIC SURGERY? OR HIS LARGER ARTERIES? in other words........IS IT POSSIBLE THOSE READINGS ARE OK FOR MY

HUSBAND?

HOW HIGH IS TOO HIGH BEFORE WE EXPERIENCE PROBLEMS ONCE AGAIN?

HOW LONG CAN HIS BP REMAIN AT HIGH LEVELS BEFORE PROBLEMS BEGIN AGAIN? IS IT POSSIBLE SOMETHING VERY SERIOUS IS GOING ON?

IS IT POSSIBLE THE MEDS ARE CAUSING THE RISE IN BP?

IS HE ON THE RIGHT MEDS?

His current medication for the blood pressure is:

200 mg Toprol XL (the doctor raised the dosage over time, due to the increase in BP levels; started with 50 mg one year ago) 10 mg Felodipine (just switched for the generic from Norvasc) 2 mg Mavik (just added by our doctor a week ago)

In my opinion, It just doesn't seem to matter what meds he is on or how much or even WHEN he takes them (like 1/2 in the morn, 1/2 in the evening or all at once) - the BP seems to keep the same readings.

I apologize for the length of this email, Brian, and thank you in advance

for reading it - and hope you understand our concerns. We would love

another opinion on what's going on with my husband's blood pressure to

ease our minds. I believe you have contact with a Dr Liang that has

been very helpful??

I hope, too, Brian, that you are doing well at this time - I recall when our daughter first had contact with you and wonder if things have improved for you - May God bless you and send His healing touch your way.

Sincerely,

Judy Marvel (husband Bob)

jbmarv1@juno.com

Answer:

Judy,

Unfortunately some of those questions are difficult to answer without more information. To answer the questions about the aneurysms and the aorta's size, I would certainly need to look at the CT scans. I would be happy to do that if you wish to send them to me.

As for the blood pressure, some variation throughout the day is normal The degree of fluctation you report though seems rather extreme. First thing to do is to make sure they are accurate. Confirming the readings of your home monitor in the doctors office is a good way to check. Assuming that the proessures are correct then probably something needs to be done to address the blood pressure swings. Sometime the blood pressure swings are due to releases of various hormaones, e.g. adrenalin, so those levels should be checked. Also if the flow to one of the kidneys is compromised by the aneurysm it can also result in high and fluctuating blood pressures.

My goal with patients with aneurysms is usually to keep the systolic(the upper number) generally lower than 120, if this can be done without too many side effects. Occasional readings up to 150 are unavoidable due to normal fluctuation. The diastolic should ideally stay under 85.

David


 

Question:

Brian:
I actually have two issues that I would like to ask you about.
1) My Grandmother was admitted last week to the hospital with what we thought were complications from her diabetes.
She is 79 years old and has had diabetes for over 20 years. She is on 24 hour oxygen and our family happens to have Ehlers-Danlos that runs in it. And just to make matters worse she also has high cholesterol, high blood pressure and has almost a continual bladder infection.
The week before being admitted she was in a semi-coma state for 5 days after which she woke up with extreme mood swings and aggression. She was also very confused and disoriented not knowing who we were; where she was, etc.
After a 5 day stay in the hospital with low blood sugar; low sodium levels; and a drop in her red blood cells on Saturday she had a scare with either a stroke or a seizure that sent her to the ICU unit.
Upon doing a ton of testing we found out that her creatinin levels had rose to 2.85 over a two day period; she was dizzy and had nausea; complained of back/chest and neck pain. Her red blood cell count dropped to a point where they needed to transfuse her with two pints of blood and her kidney function slowly deteriorated. During the three days in the ICU she was usually very disoriented and actually had a lot of hallucinating.
After being stabilized she was moved out of ICU.
Testing has now found that she has a c-diff infection; a D-Dimmer positive result with a 3.25 outcome. They have done repeated chest x-rays and ultrasounds on her legs and today she was given a lung test with some form of a dye (not ivp - she is allergic plus with her kidneys not putting out urine they did not want to chance it anyway). I was in the room at the time and got to see they photos taken of her lungs. I do not know how to read them but on her right lung it looked to me that there was a large dark spot coming off of her sternum and into her lung. Should I be concerned that this could be a aortic dissection? And if so do I need to notify the Doctor of my suspicion immediately?

2) The second question actually involves myself. I am a 33 year old woman diagnosed with Bicuspid Aortic Stenosis since I was 3 years old and I also have Ehlers-Danlos. With both of these conditions do you think that it would be wise of me to have gene mapping done to see if I carry the certain alleles that would put me at risk for aortic dissection? If I do have the gene mapping done and it comes back that I am at risk what would the preventative treatment include, if any?

Thank you for your time and I apologize for the long message!
Sincerely yours,

Molly Urbanski
urbys@msn.com
Answer:

Molly,

Regarding your grandmother - it's very difficult to tell from the information you have provided precisely what is going on. Obviously your mother's situation is quite complex, with many medical issues. The presentation is certainly not typical for an aortic dissection. Best to discuss your concerns with her doctor, who does have the full set of information.

As for your case - genetic testing is probably not the right answer. There is no genetic testing yet for the more common types of EDS. Except for EDS IV, they are also usually not associated with dissections. EDS IV can usually be excluded on clinical grounds in most patients suspected of having EDS IV. As for bicuspid aortic disease - the gene is not known yet. The best way to risk stratify at this time is probably to start with an echo and move onto a CT or MRi if needed.

David

 

Question:

why the depression med after so long after surgery. What kind of blood pressure med and why so much. my husband is only on 100 mg of loprssor for blood pressure and that is all. what does your dr what your blood pressure and heart rate at. It is really depressing for my husband because when he sees his heart dr whichis new he never had on he asks why are you still living?. my husband also had a aaortic roo9t reconstrustion ascending along with his dissection . how often does your dr give you a xray on your dissection and did you have any problems with your legs.How would I know if my husband needs depression meds.It has only been 8 weeks and he doesnt think he will ever get his strenght back. he tries to walk a mile everyday. any info would be aprreciated
thanks Luci
Answer:

Every patient is an individual so the medications and dosages needs to be adjusted for their need.

The use of a beta-blocker like metoprolol is nearly universal after a dissection to reduce the stress on the aorta. Other blood pressure medications are added if the blood pressure is not adequately controlled.

The frequency of imaging after a dissection - depends state of the aorta after the repair. If there is extensive residual damage left over after the surgery, I usually recommend a scan at 3,6 and 12 months after surgery with annual scans after that if things are stable.

The fatigue and apprehension is not uncommon after a life threatening event like a dissection. The recovery from open heart surgery can take as long as 3 to 6 months, so if your husband is feeling fatigued at 8 weeks that is not surprising. It certainly is worth asking his doctor though if there are other factors that might be contributing - e.g. anmia, depression etc.

The anxiety, unfortunately takes time to resolve. With each day ythat your husband is alive you will feel more confident that he will be with you the next day. With each CT that shows that things are stable , byou will feel more confident that he will be with you next year. Talking to your doctor and others who have had dissections and survivied can help accelerate that process.

David

 

Question:

What is the percentage rate of him developing a blood clot , and if he should be on blood thinners?

Answer:

As for the discrepancies between the various doctors - I would point out to them where there are apparent discrepancies. They may not be as significant as you think and may only represent subtle differences on how to present the information to you. Generally on the major issues the care team needs to come to an agreement before making decisions, so that even if there is some initial disagreement they are usually settled quickly.

Finally - long term follow-up may be with a cardiologist, cardiothoracic surgeon or a vascular surgeon. You just need to make sure whatever type of doctor is chosen that he/she has experience following patients with dissections.

David Liang


 

Question:

Brian:

My husband had 3 arthroscopic back surgeries in 3 months, due to pain in his back and right leg. You need to be awake. During the last

he felt a pain and some real pressure in his heart. They did a scan and found nothing.

He was still having pain in his right leg after 3 surgeries. Found out he had a DVT in his right calf. Took Levinox shots and still on coumadin.

Now he has the same pain in left leg. The doctor gave him Quinine Sulfate which he is not taking.

During some testing they found a 4 centimeter aneurysm in his descending aortic valve. Doctor said all they can do it monitor. Now I read

On AMA site that such a thing can cause leg pain and blood clots. They have not tested his legs for pulse, circulation and have done no

Testing on his left leg to see if there is a clot. Said the treatment is being done (right calf).

How do we know if the surgery caused the blood clots, or if the aneurysm did and is still causing problems with his left leg. He can hardly

Walk and is usually in pain.

What tests can I ask the doctor to do to find out if the aneursym is causing the problems with his legs???

Thank you so much.

Answer:

Hard for me to answer this precisely - aneurysms don't usually cause pain unless they are very large, rapidly expanding or have dissected, so it is hard to blame the pain directly on a 4 cm aortic aneurysm. A 4 cm aneurysm under "usual" circumstances does not warrant immediate intervention and can be safely observed - deferring treatment until there are signs of enlargement.

The pain in the legs may be related to the atherosclerosis that often accompanies the aneurysms, but may also be due to so many things that it is difficult to say where to start in the evaluation of the pain without having seen the leg. I think the best step is to take your concerns to your doctor and ask the same questions you are asking here. If you don't get satisfactory answers then it is time for a second opinion.

David

 

Question:

Hello Brian,

My husband Mark, was just diagnosed with a descending aortic dissection. It runs from just below the arch to the groin area. He has lost blood supply to his right kidney and they can not get his BP down as the kidney is still getting a very small amount of blood.

They are going to take out the right kidney sometime next month. His BP is staying around 140's and does go up to 150 and 160 still. He is on soooo many BP meds 13 different pills, along with all the others for his kidney's and small intestine.

Your website did give us some hope and we are thankful you put it out there for people like us.

I do have some questions though, if you can answer... please

His primary care physician told us yesterday he should apply now for full disability benefits.. he can never lift more than his clothes to put on and not all at one time.

The vascular surgeon hasn't given us any such talk, they more or less said he could go back to work..once the blood pressure is under control.

Are you working again, or do you know of any people that have gone back to work right away after the diagnosis? We don't really know what to expect until after February when we get the next CT Scan... He is very scared and worried of course, but this is making things seem almost hopeless.

Any input would be greatly appreciated. Thank you..

Answer:

Taking the kidney out is probably not warranted, especially if there has been enough flow left to keep the kidney alive. Blood flow to the kidney can usually be reestablished with a stent.

As for activities - during the immediate recovery period - exercise should be limited to walking. After things have stabilized, as long as the aorta is not too dilated, you should be able to return to mild to moderate aerobic exertion. Avoiding isometric is still advisable. If your job does not take you beyond those limits then working in the future is quite realistic. If your requires heavy manual exertion, you may indeed need long term/permanent disability.

[Liang, David] David

 

Question:

I have a few questions though for you. The double barreled aorta thing bothers me, even though the docs think I worry too much. Did you get the same "Oh, well, drugs and mild exercise will control it, and the CT scans will show any beginning problems that need to be addressed".? Call me skeptical, but if they are wrong, it's a bummer day at the office for them, but a little worse for me, you know? And we all know and read about doctors missing the boat when it comes to this disease though.

Have you been told the likelihood for needing surgery? Last March they involved the Baylor Med Center and my cardiothoracic surgeon and some vascular surgeons and they all had a differing idea as to the best way to proceed, or not as it turned out. I can psych myself up to go through that again (except maybe for that damned breathing tube I had to blow in to build lung capacity back up) but it is the not knowing that bugs me the most.

Anyway, Merry Christmas, and Happy New Year. Hope you enjoy yours as much as I am enjoying mine!
Answer:

I certainly understand your concern, but generally medical management and close monitoring is the best way to manage the residual dissected descending aorta after repair of an ascending aortic dissection. There certainly is a chance that the remainder of the aorta will need work in the future (the chances of this are highly dependent on the state of the aorta currently and the underlying cause for the dissection). However, prophylactic replacement of the descending aorta or stent grafting of the descending aorta are generally not considered standard of therapy at this time unless there are features suggestive of a high likelihood of complication in the near future.

The reasons for this include the risk of complications associated with replacement of large portions descending aorta relative to the risk of sudden rupture or other complications during the medical management and monitoring of the descending aorta. The use of stent grafts in aortas for dissections is still in it's infancy and the long term (greater than 10 year) outcome is unknown, therefore it is difficult to justify using stent grafts where the prognosis in that time frame is probably quite good.

I can certainly understand your desire to "just get it fixed", but allow me to present the other side of the argument. You are feeling well now. You can enjoy the opportunity to watch your 5 year old grow up - is it worth risking that in surgery?

David

Question:

For example on the last CT scan report I have it says, "Mural thrombus is seen in the upper abdomen, but the dissection remains apparent. It extend down. In the abdomen the aorta shows no dilatation at the level of the renals but the dissection is still apparent."

I have tried to find the meaning of "mural thrombus" with out much luck. Any ideas?

Answer:

I guess I would have to differ. The severe episode of pain in November 2000 may well have been the time when the dissection occurred. People can survive a descending aortic dissection without medical intervention. Certainly your wife is lucky in that she dodged the acute complications of the dissection.

She may do fine for years to come without further intervention, but close follow-up as you are doing is important especially if the aorta is enlarged to 5.2 cm. I would recommend that you have a cardiologist or a cardiovascular surgeon familiar with dissections involved in your ongoing care, since as you have already found most primary care physicians and even most general cardiologist have very little experience with patients with dissections.

The last point I would make is to emphasize the need to at try to understand why the dissection occurred. This is important both for your wife, but probably more importantly for her family.

David Liang

Question:

Hi Brian,
I saw your site and thought you might be able to help me. I understand this is just your opinion but I really need some guidance and would appreciate any you can give me.
My father suffered two heart attacks two weeks ago and a stroke within two days, though he is stable, he has developed blot clots in his legs and aneursyms behind both knees (5cm) and one near his kidney (9cm). The doctors call it an aortic abdominal aneursym. He is in Florida (Manitee Memorial) and was going to be transferred to a University Hospital to do the surgery but the cardiogist said no way. He said he had to wait 4 weeks with bed rest. My question is, can that aneurysm burst before that and would a vena cavafilter in his leg help with the clots before then and buy some time? Also, are there any options? I respect your opinion and understand the complications this can bring.
Thank you in advance for your reponse.
Answer:

The aneurysms behind the knees, often called popliteal aneurysms, seldom rupture. More frequently they develop blood clots. There is no urgency on those.

The one near his kidney, I presume involves the abdominal aorta. 9 cm certainly carries a significant risk of rupture, probably in excess of 50% per year. So waiting 4 weeks carries about a 4% chance of rupture. Operative mortality for a ruptured abdominal aortic aneurysm has been between 30 and 80% in most series. If the gain in decreased mortality associated with repair of the abdominal aorta is not at least a 2% decrease in operative mortality then it is not worth waiting.

The gain associated with writing the 4 weeks will very much depend upon the size of the heart attacks and the residual cardiac function. Also, they state of the coronary arteries and whether there are additional areas of risk play significant roles in deciding the risk of an operation.

I am guessing that some of your cardiologists desire to wait 4 weeks is old data suggesting that operation within 6 weeks of a heart attack carries a high risk of complications. This data comes from an era when angiograms and angioplasties weren't done routinely for heart attacks. Much of that data comes from an ear when we kept people in the hospital for a month after a heart attack. Now patients are typically sent home within 5 days of an uncomplicated heart attack. While waiting 6 weeks for a truly elective operation still makes sense, a 9 cm aortic aneurysm probably crosses the line of what constitutes an elective surgery.

Has an endovascular stent been considered for your fathers aortic aneurysm. Depending upon the precise location and geometry of the aneurysm an endovascular stent graft may be a good option. Although, it may not be quite as definitive as an open operation, in your father's situation in may be worthwhile to opt for the less definitive, also less invasive option.

Finally, as for inferior vena cava filters - these would only address blood clots in the veins. If you father were not a candidate for blood thinners then the filters would be a reasonable option. Modern filters can be removed later when they are no longer needed. The first choice of therapy though if your father can tolerate it though would be blood thinners such as heparin or coumadin.

David