ACA App
Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 1479 Small font size Default font size Increase font size Print this article Email this article Bookmark this page
 


 

 
     
    Advanced search
 

 
 
     
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1399    
    Printed37    
    Emailed1    
    PDF Downloaded99    
    Comments [Add]    
    Cited by others 2    

Recommend this journal

 


 
Table of Contents
HEART TO HEART BLOG INTERESTING IMAGES  
Year : 2015  |  Volume : 18  |  Issue : 2  |  Page : 227-230
Echocardiographic detection of intimo-intimal intussusception in a patient with acute Stanford type A aortic dissection


1 Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Mayo Clinic Hospital, Phoenix, AZ 85054, USA
2 Department of Anesthesiology, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA

Click here for correspondence address and email

Date of Submission11-Mar-2015
Date of Acceptance17-Mar-2015
Date of Web Publication2-Apr-2015
 

   Abstract 

Intimo-intimal intussusception is a very rare and unusual complication of type A dissections, typically noted on  TEE exam. It has been reported in a few cases in the cardiothoracic surgical and radiology literature, and even more rarely in the cardiac anesthesia/TEE literature. This uncommon variation occurs in severe, acute, type A dissections when the ascending aortic intima circumferentially strips and detaches from the media and forms a tube-like structure which may either prolapse antegrade into the ascending aortic lumen or retrograde into the left ventricular (LV) outflow tract and LV cavity. Antegrade intussusceptions may be severe enough to partially or completely occlude the ostia of the innominate, left common carotid, and left subclavian arteries producing acute neurologic symptoms. Retrograde intussusceptions may severely impair LV filling in diastole, can worsen aortic insufficiency, mitral regurgitation, as well as produce occlusion of the coronary ostia and acute coronary ischemia. Here, we describe the incidental finding of a retrograde intussusception that was not visualized on computed tomography scan but by intraoperative TEE examination, in a patient with a severe, extensive type A dissection.

Keywords: Aortic dissection; ascending; intimo-intimal intussusception; Stanford type A

How to cite this article:
Thunberg CA, Ramakrishna H. Echocardiographic detection of intimo-intimal intussusception in a patient with acute Stanford type A aortic dissection. Ann Card Anaesth 2015;18:227-30

How to cite this URL:
Thunberg CA, Ramakrishna H. Echocardiographic detection of intimo-intimal intussusception in a patient with acute Stanford type A aortic dissection. Ann Card Anaesth [serial online] 2015 [cited 2020 Jan 27];18:227-30. Available from: http://www.annals.in/text.asp?2015/18/2/227/154481



   Introduction Top


An intimo-intimal intussusception (III) is a rare and unusual manifestation of Stanford type A aortic dissection and involves a circular detachment of the intima to form an intimal "cylinder" inside the aorta. In severe cases, the detached intima may prolapse into the LV cavity. We present a patient with acute type A dissection in whom this was an incidental finding during intraoperative transesophageal echocardiography examination.


   Case Report Top


A 58-year-old male with no known medical history developed sudden onset chest pain, dyspnea, and a sensation of fullness in his throat. He was transported to the emergency room where he was found to be hypotensive (82/54 mmHg), bradycardic (40 beats/min), and tachypneic (26 breaths/min). His oxygen saturation was normal, and he was awake and alert and exhibited no neurologic deficits. His electrocardiogram showed normal sinus rhythm without acute ST-T wave changes, and his troponin T was normal. Given the concern for pulmonary embolism, a computed tomography (CT) scan with contrast was obtained. The CT scan revealed acute type A dissection arising from the aortic root and extending to the left iliac system. The left coronary ostium, all three great vessels, the celiac trunk, superior mesenteric artery, and left renal artery appeared to be involved. He was scheduled for emergent aortic reconstruction with deep hypothermic circulatory arrest.

The patient underwent induction of general anesthesia with tracheal intubation. Transesophageal echocardiography (TOE) was subsequently performed, which confirmed the presence of a dissection flap in the ascending aorta [Figure 1]. The flap was observed to prolapse across the aortic valve into the LV outflow tract during diastole [[Figure 2] and Online Video 1]. Remarkably, there was no aortic valve insufficiency [Figure 3], the LV wall motion was normal, and there was no hemopericardium. Following sternotomy and opening of the pericardium, heavy bleeding through the aortic wall was encountered. Cardiopulmonary bypass (CPB) via femoral cannulation was initiated, and the patient was cooled to 18°C. During 37 min of circulatory arrest, the ascending aorta and inside curve of the aortic arch were excised and replaced with vascular graft (hemiarch). The aortic valve and root were replaced with a valved conduit, and the coronary buttons were implanted into the conduit. After the anastomosis of the valved conduit to the hemiarch graft, the patient was separated from CPB, coagulopathy was corrected, the chest was closed, and the patient transported to the intensive care unit intubated and sedated. The patient had a prolonged recovery that was complicated by cognitive impairment and critical illness neuromyopathy.
Figure 1: Midesophageal short axis view of the ascending aorta showing the intimal cylinder in systole (a) and (b) diastole. Arrow: Intimal layer

Click here to view
Figure 2: Midesophageal long axis view of the aortic valve in systole (a) and (b) diastole. Arrow: Intimal layer

Click here to view
Figure 3: Midesophageal long axis view of the aortic valve with color flow Doppler. No aortic regurgitation was evident

Click here to view






   Discussion Top


The term III refers to a circumferential detachment of the intima from the media, forming a loose cylinder inside the aorta. [1],[2],[3],[4] The cylinder typically inverts in an antegrade direction due to forward blood flow and causes vascular complications by obstructing perfusion through the aorta and its branching arteries.

In this case report, we describe the incidental finding by TOE of intimo-intimal intussusception with prolapse into the left ventricle, which has been rarely reported in the literature. [5],[6],[7],[8] In contrast to what one might expect, our case did not exhibit aortic regurgitation. A possible explanation is that the cylinder fell into valvular orifice lopsided, so that the orifice was obstructed during diastole. Although not present in our patient, severe cases of intussusception into the ventricle may be complicated by impaired ventricular filling, acute cardiogenic shock, acute myocardial infarction, mitral regurgitation as well as aortic regurgitation of varying severity. Extensive antegrade III's may present with neurologic events of varying severity- ranging from confusion and vertigo to acute stroke symptomatology.

Given the extent of our patient's dissection, hemiarch reconstruction with a valved conduit during deep hypothermic circulatory arrest was required. III may not be readily apparent on CT or MRI given the nature of the pathophysiology, especially if predominantly retrograde, as seen in our patient.

What must be emphasized is that circumferential dissection of the ascending aorta is a rare phenomenon- one that has been described over 120 years ago in the German literature by Bostroem in 1887. [4],[9] Chiari in 1909 also referenced it in autopsy specimens [10] as an "inversion of the internal cylinder". The phrase intimo-intimal intussusception was first described by Hufnagel et al in 1962, in the surgical literature, where they introduced the concept of aortic luminal obstruction as well as concurrent acute occlusion of the ostia of the supra-aortic vessels. [11] Virtually all of the cases of III have been reported in the surgical and vascular literature with the key presenting symptoms of these patients being chest pain in conjunction with acute neurologic symptoms such as confusion, vertigo and sudden loss of consciousness. [12],[13] III has also been reported in the surgical literature in patients with descending thoracic aortic dissections, where patients have presented with clinical features of "pseudocoarctation"- referring to asymmetric peripheral pulses and asymmetric blood pressures but complete absence of neurologic symptoms. [14],[15] It is important to recognize that patients with III of the aorta may not exhibit the classical imaging findings of the intimal flap in the lumen of the ascending aorta, in fact there may be no CT or MRI features suggestive of aortic dissection- until the patient is placed on cardiopulmonary bypass, or prior to that by aortography as has been described on the literature. [16] Appearance of the flap in III may also be uniquely different, as Touati et al[4] suggest, with a thick and sinuous picture that intussuscepts into the aortic lumen. It is important for the echo cardiographer to also remember that, in cases where aortic dissection is suspected, if TEE does not visualize a flap in the ascending aorta, the aortic arch must be thoroughly imaged in multiple orthogonal views for a circumferential flap. It has been suggested that this combination- of a circumferential flap in the arch in conjunction with the absence of any flap in the ascending aorta is highly predictive of III.

Surgical management can vary based on the location and severity of the III- as Touati et al suggest. [4] Less complex III's can be managed by surgical, manual reduction of the III by returning the prolapsed intimal cylinder into the ascending aorta under deep hypothermic circulatory arrest. Supra-aortic vessel involvement will require partial or greater reconstruction of the innominate, left common carotid and left subclavian ostia and trunks.

 
   References Top

1.
Di Ascenzo L, Angelini A, Thiene G. Images in cardio-thoracic surgery: Intimo-intimal intussusception: A rare complication of Stanford type A acute aortic dissection. Eur J Cardiothorac Surg 2009;35:903.  Back to cited text no. 1
    
2.
Ishii H, Nakamura K, Yano M, Nagahama H, Matsuyama M, Nishimura M, et al. Circumferential dissection of the ascending aorta "intimo-intimal intussusception". Ann Vasc Dis 2012;5:466-8.  Back to cited text no. 2
    
3.
Lijoi A, Scarano F, Canale C, Parodi E, Dottori V, Passerone GC, et al. Circumferential dissection of the ascending aorta with intimal intussusception. Case report and review of the literature. Tex Heart Inst J 1994;21:166-9.  Back to cited text no. 3
    
4.
Touati G, Carmi D, Trojette F, Jarry G. Intimo-intimal intussusception: A rare clinical form of aortic dissection. Eur J Cardiothorac Surg 2003;23:119-21.  Back to cited text no. 4
    
5.
Lajevardi SS, Sian K, Ward M, Marshman D. Circumferential intimal tear in type A aortic dissection with intimo-intimal intussusception into left ventricle and left main coronary artery occlusion. J Thorac Cardiovasc Surg 2012;144:e21-3.  Back to cited text no. 5
    
6.
Nishioka N, Morimoto N, Yoshida M, Mukohara N. Intimointimal intussusception in both the proximal and distal ascending aorta: A rare clinical form of acute type A aortic dissection. Eur J Cardiothorac Surg 2014;45:947.  Back to cited text no. 6
    
7.
Sarikamis C, Yavuz S, Ozturk C, Bozat T, Ozdemir A. Aortic insufficiency caused by a dissecting flap prolapsing into left ventricle. Turk J Thorac Cardiovasc Surg 1997;5:68-9.  Back to cited text no. 7
    
8.
Yavuz S, Elhan K, Eris C, Tugrul Goncu M. Intimo-intimal intussusception: A rare clinical form of aortic dissection. Eur J Cardiothorac Surg 2003;23:850-1.  Back to cited text no. 8
    
9.
Bostroem E. Das geheilte aneurysma dissecans. Deut Arch Klin Med1887;42:1.  Back to cited text no. 9
    
10.
Chiari H. Aneurysma dissecans aortae mit inversion des inneren zylinders. Verh Deut Path Ges 1909;207.  Back to cited text no. 10
    
11.
Hufnagel CA, Conrad PW. Intimo-intimal intussusception in dissecting aneurysms. Am J Surg 1962;103:727.  Back to cited text no. 11
    
12.
Neri E, Capannini G, Caron E. The missing flap: Consideration about a case of aortic intussusception. J Thorac Cardiovasc Surg 1999;117:829-30.  Back to cited text no. 12
    
13.
Goldberg SP, Sanders C, Nanda NC. Aortic dissection with intimal intussusception: diagnosis and management. J Cardiovasc Surg 2000;41:613-5.  Back to cited text no. 13
    
14.
Verdant A, Page A, Blair JF. Diagnostic and therapeutic observations drawn from the surgical experiences of 108 traumatic ruptures of thedescending thoracic aorta. Ann Chir 1998;52:813-20.  Back to cited text no. 14
    
15.
Masiello P, Santoro G, Franzesi E, De Lillo L, Fittipaldi O, Di Benedetto G. Aortic pseudo-coarctation: Spiral volumetric computed tomographyimaging. Ann Thorac Surg 1999;68:1421.  Back to cited text no. 15
    
16.
Lijoi A, Scarano F, Canale C. Circumferential dissection of the ascendingaorta with intimal intussusception. Case report and review of theliterature. Tex Heart Inst J 1994;21:166-169.  Back to cited text no. 16
    

Top
Correspondence Address:
Dr. Harish Ramakrishna
Department of Anesthesiology, 5777 East Mayo Boulevard, Phoenix, AZ 85054
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.154481

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 Advances in Imaging for the Management of Acute Aortic Syndromes: Focus on Transesophageal Echocardiography and Type-A Aortic Dissection for the Perioperative Echocardiographer
Brenda M. MacKnight,Yasdet Maldonado,John G. Augoustides,Ricardo A. Cardenas,Prakash A. Patel,Kamrouz Ghadimi,Jacob T. Gutsche,Harish Ramakrishna
Journal of Cardiothoracic and Vascular Anesthesia. 2016; 30(4): 1129
[Pubmed] | [DOI]
2 Drawing Inferences From Transesophageal Echocardiography
Jelliffe Jeganathan,Ziyad Knio,Feroze Mahmood
Journal of Cardiothoracic and Vascular Anesthesia. 2016; 30(1): 261
[Pubmed] | [DOI]



 

Top