title: Rapid progression of discrete type A intramural hematoma: prevention of a "procedure-related" complication by intraoperative transesophageal echocardiography.
abstract: OBJECTIVE
  To report a case illustrating the utility of transesophageal echocardiography (TEE) before planned stent-graft placement for chronic type B aortic dissection.
  
  
  METHODS
  A 64-year-old man with acute aortic syndrome and an 8-year-old interposition graft in the distal aortic arch for acute type B dissection was referred for dissection of the descending thoracic aorta down to the aortic bifurcation; the false lumen was dilated to 65 mm and was partially thrombosed. The ascending aorta showed discrete, eccentric, 4-mm wall thickening that was not considered clinically significant. Stent-graft closure of the entry tear in the proximal descending thoracic aorta was elected. However, as the endovascular procedure was about to commence, TEE showed striking eccentric thickening of the aortic wall of up to 18 mm. The endovascular procedure was stopped, as it was decided to urgently replace the ascending aorta. The next day, the patient underwent successful ascending aortic replacement and simultaneous antegrade stent-graft implantation over the descending thoracic aortic entry tear via the open aortic arch. The postoperative course was uncomplicated, and the patient was discharged 19 days after surgery. He remains well at 6 months after the procedure.
  
  
  CONCLUSIONS
  Our case demonstrates that dissection of the ascending aorta may occur not only due to endograft-induced intimal injury, but may also occur due to underlying but undiagnosed or underestimated disease of the ascending aorta or arch. Besides procedural guidance, intraoperative TEE is a useful tool to detect such disease to avoid subsequent "procedure-related" complications.
authors.affiliation: Department of Cardiology, West German Heart Center Essen, University of Duisburg-Essen, Germany. holger.eggebrecht@uni-essen.de
authors.forename: Holger
authors.initials: H
authors.lastname: Eggebrecht
authors.forename: Axel
authors.initials: A
authors.lastname: Schmermund
authors.forename: Ulf
authors.initials: U
authors.lastname: Herold
authors.forename: Alexander
authors.initials: A
authors.lastname: Lind
authors.forename: Thomas
authors.initials: T
authors.lastname: Bartel
authors.forename: Thomas
authors.initials: T
authors.lastname: Buck
authors.forename: Stefan
authors.initials: S
authors.lastname: Martini
authors.forename: Oliver
authors.initials: O
authors.lastname: Kuhnt
authors.forename: Peter
authors.initials: P
authors.lastname: Kienbaum
authors.forename: Jörg
authors.initials: J
authors.lastname: Barkhausen
authors.forename: Heinz
authors.initials: H
authors.lastname: Jakob
authors.forename: Raimund
authors.initials: R
authors.lastname: Erbel
mesh_terms: D000784:Aortic Dissection / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery; D017130:Angioplasty / Q000009:adverse effects; D017545:Aortic Aneurysm, Thoracic / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery; D001019:Aortic Rupture / Q000209:etiology / Q000517:prevention & control*; D002908:Chronic Disease; D017548:Echocardiography, Transesophageal; D006406:Hematoma / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged