Acute Ascending Research Articles

Acute Ascending Flaccid Paralysis in a Healthy 16-year-old.

Acute Ascending Flaccid Paralysis in a Healthy 16-year-old.

Mediastinal Packing for Massive Bleeding Following Acute Ascending Aortic Dissection Surgery: Outcomes and Risk Factors Analysis

Mediastinal Packing for Massive Bleeding Following Acute Ascending Aortic Dissection Surgery: Outcomes and Risk Factors Analysis

Iatrogenic Acute Ascending Aortic Dissection During Combined Heart/Liver Transplant for Amyloidosis

We report a case of iatrogenic acute type A aortic dissection (ATAAD) during a combined heart-liver transplant in a patient with amyloid-associated cardiac and hepatic failure. The patient developed ATAAD of the recipient's aorta during the heart transplantation. Because there was no sign of malperfusion or proximal extension into the donor aorta, we proceeded with the liver transplantation and continued medical management for ATAAD. The patient was discharged uneventfully 30 days after the transplant, and computed tomography coronary angiogram after 4 months showed stable dissection. During a heart transplant, ATAAD of the native aorta without malperfusion syndrome can be managed conservatively with close progress monitoring.

Early Biliary Decompression Reduces Morbidity but Not Mortality in Acute Ascending Cholangitis.

Background Acute ascending cholangitis is a life-threatening infection due to biliary obstruction. Decompression via endoscopic retrograde cholangiography (ERC) or interventional radiologic (IR) drainage controls the source of the sepsis. Numerous studies have been published with conflicting data on whether earlier drainage affects morbidity and mortality. We sought to publish our experience at two Las Vegas community hospitals. Methods After IRB approval, over 4000 inpatient non-elective ERCs were analyzed between 2010 and 2019. Six-hundred and twenty-five patients met the 2018 Tokyo criteria for a "definitive diagnosis" of acute ascending cholangitis. A univariate and multivariate analysis was conducted to identify factors significantly associated with length of stay and mortality. Results On univariate analysis, patients who had drainage conducted within 24 hours had significantly shorter lengths of stay (p = 0.0012 95% CI [-88.1 to -21.8 hrs]), higher mean diastolic blood pressure (p=0.0029 95% CI [1.03 to 5.01 mm Hg]), and lower mean maximum temperature (p=0.0001 95% CI [-0.842 to -0.382oC]) when compared to patients who underwent decompression more than 24 hours after admission. There were no statistically significant differences in mortality between patients who underwent decompression within 24 hours of admission versus patients who underwent decompression beyond 24 hours of admission. On multivariate analysis, earlier decompression reduced the length of stay for patients with mild (p<0.0001), moderate (p<0.0001), and severe cholangitis (p=0.0023). Mortality was significantly associated with the worsening severity of the cholangitis (moderate [p=0.0001] and severe [p<0.0001], but not mild disease) and the use of vasopressors. Conclusions Timely biliary decompression within 24 hours of admission significantly reduces the length of stay, pyrexia, and hemodynamic abnormalities. In addition, our data corroborate the 2018 Tokyo guidelines that correlate the severity of cholangitis with mortality.

The Jigsaw Puzzle of Arch Management in Acute Ascending Aortic Dissection

The Jigsaw Puzzle of Arch Management in Acute Ascending Aortic Dissection

Acute Ascending Necrotizing Myelitis After COVID-19 Infection: A Clinicopathologic Report.

Neurologic manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2, COVID-19) infection are common and varied. The objective of this report was to describe clinicopathologic findings of rare acute ascending necrotizing myelitis (ANM) and briefly summarize similar COVID-19-associated longitudinally extended transverse myelitis cases. We described the clinical presentation, disease course, diagnostic workup, therapeutic measures, and pathologic findings of ANM associated with COVID-19 infection. A 31-year-old previously healthy woman developed a longitudinally extensive lower thoracic myelopathy 3 weeks after COVID-19 infection. The thoracic spinal cord lesion extended to cervical level in 1 week and to the lower medullary level in 2 more weeks. Thoracic laminectomy at T5-T6 level and cord biopsy revealed necrobiotic changes without viral particles or microglial nodules. The clinical deficit stabilized after immunomodulatory and eculizumab therapies. COVID-19 infection can cause ANM. It adds to the spectrum of reported cases of COVID-19 -associated encephalitis and myelitis.

Acute Ascending Sensory Neuropathy Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Disease.

Acute Ascending Sensory Neuropathy Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Disease.

Latent Systemic Lupus Erythematosus Presenting as Acute Ascending Paralysis: A Case Report

Here I report a 29-year old woman who presented with acute ascending paralysis and required mechanical ventila­tion due to severe hypokalaemia. She was found to have normal anion gap metabolic acidosis due to distal renal tu­bular acidosis. She had American College of Rheumatology classification criteria compatible with diagnosis of latent Systemic Lupus Erythematosus (SLE). She was successfully treated with potassium citrate and sodium bicarbonate supplementation. The case is noteworthy as an atypical presentation of SLE.

Open Repair Versus Branched Endograft Repair for Treatment of Residual Chronic Aortic Arch Dissection During Follow-up After Open Type A Acute Ascending Aorta Replacement: Results From an International Multicenter Study.

Open Repair Versus Branched Endograft Repair for Treatment of Residual Chronic Aortic Arch Dissection During Follow-up After Open Type A Acute Ascending Aorta Replacement: Results From an International Multicenter Study.

Management of Acute Ascending Cholangitis with Septic Shock on Top of Altered Anatomy after Old Road Traffic Accident: A Case Report

Management of Acute Ascending Cholangitis with Septic Shock on Top of Altered Anatomy after Old Road Traffic Accident: A Case Report

Octogenarians Experience Outcomes Similar to Other Elderly Patients after Surgery for Acute Ascending Aortic Dissections

Octogenarians Experience Outcomes Similar to Other Elderly Patients after Surgery for Acute Ascending Aortic Dissections

A Rare Case of Acute Abdomen Secondary to Omental Infarction Mimicking Acute Ascending Colitis

A Rare Case of Acute Abdomen Secondary to Omental Infarction Mimicking Acute Ascending Colitis

Fatal and Near Fatal Acute Ascending Aortic Dissection: Two Case Reports with Different Cardiac Manifestations

Acute ascending aortic dissection (AD) is a rare disease and carries a high fatality rate. Its mortality increased with time, 1-2% every hour after symptom onset. Occasionally,&nbsp; the diagnosis of acute AD could be missed or delayed since its&nbsp; presentation can mimic any arterial occlusive diseases including&nbsp; acute coronary syndrome, limb ischemia and stroke. To raise&nbsp; awareness of the medical community, we report on two acute&nbsp; ascending AD patients who presented with different cardiac&nbsp; manifestations.

Activation of the NLRP3 Inflammasome Cascade Amplifies TGFβ Signaling During Acute Ascending Aortic Stress

Activation of the NLRP3 Inflammasome Cascade Amplifies TGFβ Signaling During Acute Ascending Aortic Stress

Acute ascending muscle weakness secondary to medication-induced hyperkalemia.

Secondary hyperkalemic paralysis is an uncommon but potentially life-threatening consequence of drug-induced disease. We report a case of a 53-year-old female with history of chronic kidney disease presenting to the emergency department with a one-day history of upper and lower extremity weakness and paresthesias. Serum potassium concentration on admission was greater than 8 mEq/L, and serum creatinine was elevated above baseline. Electrocardiogram showed first-degree atrioventricular block with peaked T waves. The patient reported compliance with daily lisinopril 10 mg, spironolactone 25 mg, and 40 mEq twice daily of potassium chloride. Symptoms and electrocardiogram returned to baseline within 24 hours of presentation and serum potassium returned to 4.2 mEq/L at approximately 36 hours without the need for dialysis. This case emphasizes the importance of including such a condition in the differential diagnosis of patients with ascending paralysis and the importance of close monitoring of patients placed on potassium-elevating agents.

Acute ascending thrombosis of abdominal and suprarenal aorta.

We report the diagnostic and successful therapeutic images of an acute occlusion of the abdominal and suprarenal aorta. This lesion is a rare but catastrophic pathology which can cause severe ischemic manifestations, depending on the site of obstruction, with high rate of mortality even after treatment. In the majority of cases it represents a surgical emergency. Although the mechanism of the thrombosis has not been delineated, the proposed etiologies include propagation of thrombus from distal artery occlusion, cardiac thromboembolism, dislodgment of a mural thrombus, or coagulation disorders. Frequent risk factors include advanced atherosclerosis combined with a low flow state because of poor cardiac performance. The management of this condition includes immediate intervention with systemic heparinization, improvement of the cardiac condition, and surgical revascularization based on the clinical and anatomical presentation. In this case the authors highlight the importance of an early detection and early intervention to enhance survival rates and reduce morbidity.

CASE 2—2014

ACUTE ASCENDING AORTIC DISSECTION is a serious condition with significant mortality requiring prompt diagnosis and surgical treatment as mortality rates increase hourly without intervention. There are a number of modalities currently used to diagnose aortic dissection, including computed tomography (CT), magnetic resonance imaging (MRI), and transesophageal echocardiography (TEE), each with different strengths and weaknesses in regard to speed, accuracy, and ease of performance. There exists a balance between rapid diagnosis with comprehensive information regarding anatomic detail, vascular branch involvement, false lumen identification, and speed with which the diagnosis can be made to expedite potential surgical treatment. The optimal diagnostic mode for identifying ascending aortic dissection remains controversial. Additionally, the various methods of imaging used to evaluate for aortic dissection all carry potential disadvantages of artifact within the image, complicating the diagnostic process and at times leading to false-positive diagnoses. Managing this balance represents some of the difficulties in identification and treatment of these patients. The authors present a patient who was anesthetized for repair of a suspected ascending aortic dissection based on CT findings, yet subsequent TEE revealed normal anatomy.

Feasibility of Urgent Bedside ERCP without Fluoroscopy in the ICU for Patients with Acute Ascending Cholangitis

Background: Urgent ERCP for patients admitted with acute ascending cholangitis to the intensive care unit (ICU) may be delayed by the availability of fluoroscopy, anesthesia support, or an operating room (OR). Aims: To study 1.) the feasibility of urgent bedside ERCP without fluoroscopy in critically ill patients with suspected acute ascending cholangitis, and 2.) the clinical and endoscopic outcomes of such patients who underwent urgent bedside ERCP in the ICU without fluoroscopy at our institution. Methods: Retrospective case series at a single tertiary academic medical center from December, 2007 to June, 2012. Inclusion criteria: adult patients with suspected acute ascending cholangitis; bedside ERCP in the intensive care unit. Exclusion criteria: use of fluoroscopy; patients who had the index ERCP in the endoscopy unit or operating room. The medical record was reviewed and demographic, clinical, and endoscopic data were collected. Results: Eight patients were identified. Demographics: mean age 67 (range: 38-100; SD±20.4); 75% male. Clinical characteristics: GI bleeding and hemobilia was an additional indication in 50%; organ failure was present in 50% and septic shock and use of vasopressor medications in 25%. Endoscopic outcomes: ERCP with endoscopic stent placement was therapeutically successful in five of six (83%) patients with normal anatomy but failed in the two patients with surgically altered anatomy. Endoscopic hemostasis was successful in three out of four (75%) patients with bleeding. Cannulation of the bile duct without fluoroscopy was facilitated by previous sphincterotomy in three patients. Rescue ERCP with fluoroscopic support was required in one patient and was successful. No patient required rescue percutaneous or surgical intervention. Clinical outcomes: of the five eligible patients, none underwent cholecystectomy due to comorbidities. There was no post-ERCP acute pancreatitis or other procedure-related morbidity in the patients who underwent successful bedside ERCP in the ICU; 7-day mortality was zero and all patients were discharged from hospital. Conclusion: Urgent bedside ERCP with stent placement without fluoroscopy in the ICU is a feasible and effective option in patients with suspected acute ascending cholangitis, particularly in those with a previous sphincterotomy. ERCP without fluoroscopic support may not be feasible in patients with altered anatomy.

Case report and review of the literatureTotal Endovascular Repair of Acute Ascending Aortic Rupture

Thoracic aortic endografting has been successfully implemented to treat aneurysmal disease of the distal aortic arch and descending thoracic aorta. Although there are reports of ascending aortic endovascular interventions, the total endovascular repair of a ruptured ascending aorta secondary to a Type A dissection has not been described. We report the case of a 77-year-old patient who presented with a ruptured ascending aortic aneurysm secondary to degeneration of a Stanford type A aortic dissection. His surgical history was significant for orthotropic heart transplant 19 years prior. The dissection, aneurysm, and rupture occurred in the native aorta distal to the ascending aortic suture line. At presentation, he was hemodynamically unstable with a right hemothorax. We placed 3 Medtronic Talent Thoracic Stent Graft devices (Medtronic Inc, Minneapolis, MN) across the suture line in the ascending aorta, excluding the rupture. The patient survived and has been followed to 25 months.

Neurologic Catastrophe in the Setting of Acute Ascending Aortic Syndromes: A Case for Delayed Surgical Intervention

Neurologic Catastrophe in the Setting of Acute Ascending Aortic Syndromes: A Case for Delayed Surgical Intervention