Saudi Journal of Kidney Diseases and Transplantation

BRIEF COMMUNICATION
Year
: 2009  |  Volume : 20  |  Issue : 6  |  Page : 1053--1056

Dissecting aortic aneurysm in maintenance hemodialysis patients


M Ounissi, R Goucha, H Hedri, F Ben Hamida, E Abderrahim, F El Younsi, T Ben Abdallah, H Ben Maiz, A Kheder 
 Department of Internal Medicine and Laboratory of Kidney Diseases, Charles Nicolle's Hospital Tunis, Tunisia

Correspondence Address:
M Ounissi
Department of Internal Medicine, Charle Nicolle«SQ»s Hospital, Boulevard 9 Avril 1938, Tunis
Tunisia

Abstract

The dissecting aortic aneurysm (DAA) is a rare pathology that may result in fatal outcome. We report follow up of three cases of DAA patients undergoing maintenance hemo­dialysis who were managed conservatively.



How to cite this article:
Ounissi M, Goucha R, Hedri H, Hamida F B, Abderrahim E, El Younsi F, Abdallah T B, Maiz H B, Kheder A. Dissecting aortic aneurysm in maintenance hemodialysis patients.Saudi J Kidney Dis Transpl 2009;20:1053-1056


How to cite this URL:
Ounissi M, Goucha R, Hedri H, Hamida F B, Abderrahim E, El Younsi F, Abdallah T B, Maiz H B, Kheder A. Dissecting aortic aneurysm in maintenance hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Nov 18 ];20:1053-1056
Available from: http://www.sjkdt.org/text.asp?2009/20/6/1053/57262


Full Text

 Introduction



Dissecting aortic aneurysm (DAA) is a longi­tudinal tear of the media by a dissecting hema­toma. The cleavage plane is usually situated between the medial and the external thirds of the media and communicates with the aortic lumen via one or more intimo-medial tears or entry points.

Hypertension is usually the cause; however other causes such as congenital aortic deformi­ties, pregnancy and elastic tissue dystrophies (Marfan syndrome, Ehler-Danlos syndrome) are also incriminated.

Many pathologic classifications have been pro­posed to define the dissecting aortic aneurysm in a surgical goal. Stanford classification is the most commonly used: Type A dissection in­cludes the ascending aorta requiring surgical intervention and Type B dissection includes the descending aorta requiring initial medical management. [1],[2]

We report three patients with diagnosis of DAA from our maintenance hemodialysis po­pulation over a period of fifteen years (1992­-2007)

 Patients and Methods



We studied in a retrospective manner three chronically hemodialysed patients in our hemo­dialysis unit for a period of 16 years going from January 1, 1992 to December 31, 2007.

The clinical, biological, and radiological data were collected from the patient's folders and hemodialysis notebooks.

Our centre of interest was directed to the epi­demiologic aspects, to the discovery circums­tances, to the clinical and biological data to the radiological diagnosis, to the therapeutic indi­cations, and to the evolution of the DAA and its impact on the parameters of hemodialysis.

 Results



These include two males and a female who were diagnosed with DAA after initiation of chronic maintenance hemodialysis and followed for an average of 20 (2-48) months. Average age was 50.6 (43-62) years. Etiology of end stage renal disease was type II diabetes mellitus in one patient and undetermined chro­nic kidney disease for the other two patients. Cardiovascular risk factors are represented in [Table 1].

All patients presented with chest pain and two had clear widening of the superior medias­tinum on chest X-ray [Figure 1].

The physical exam revealed hypertension with an average systolic pressure of 160 mmHg and an average diastolic pressure of 95 mmHg.

Two patients had vascular bruits and only one had a reduction in the pulses of the lower limbs.

The laboratory parameters are represented in [Table 2].

The trans-esophageal echocardiography ultra­sound was done in all patients confirming the diagnosis and thoracic abdominal CT scan in two patients and MRI in the third. All the pa­tients had a type B Stanford DAA

The anatomic location is represented by [Table 3] and [Figure 2],[Figure 3] and [Figure 4].

All lesions were supra renal and no dissection of the renal artery was seen.

No surgical intervention was done and pa­tients were managed conservatively. The treat­ment goal was to achieve a systolic blood pre­ssure lower or equal to 110 mmHg and a heart­beat lower or equal to 60 bpm. This goal was met by an adjustment of the dry weight, an in­crease in the number and duration of the hemo­dialysis sessions and an increase of the anti­hypertensive medications (quadruple treatment for two patients and triple treatment for the other).

Anti coagulation during hemodialysis was not modified.

All patients were offered to switch to perito­neal dialysis to avoid hemorrhagic risks and hemodynamic incidents during hemodialysis sessions but the proposal was declined.

The immediate improvement with disappear­rance of chest pain was noted when systolic BP reached around 110 mmHg.

At a follow up of 6 and 12 months no interval change was noted in the radiological studies. All of three patients died after an average of 14 (7-24) months.

The first patient had a sudden cardiac arrest, the second in a road traffic accident, and the third died after a staphylococcus septicaemia.

 Discussion



The DAA is a rare disease among the chronic maintenance dialysis patients. Few reports describe such patients among the dialysis po­pulation.

Takeda reviewed 896 hemodialysis patients over a period of ten years and identified 113 deaths. 5 (5.73%) of these died patients had au­topsy proven aortic dissection as the cause of death. This incidence is much higher than re­ported in the general population (5.37 vs 0.59%, P [3]

In another Japanese study by Tatsuya et al DAA was responsible for 1320 (1.79%) deaths among 73442 autopsies. [4]

Among our 7128 chronic hemodialysis pa­tients over the period from 1992 to 2007; the disease prevalence comes out to be 0.04%.

Commonly hemodialysis patients with DAA present on average after few months of initia­tion of dialysis and have cardiovascular risk factors such as hypertension, dyslipidemia, and vascular calcifications similar to our patients. Two of our patients were smokers also. Our patients had uncontrolled hypertension and evi­dence of volume overload at the time of pre­sentation. The mainstay of treatment is control of BP to less than 110 systolic and a pulse rate less than 60 to avoid shear stress. Our patients did not have any indication for surgery and were successfully managed medically. The cause of death in our patient who died sud­denly could not be blamed on extension of dissection since autopsy was not performed. Cardiovascular and sudden deaths are common among hemodialysis patients and some of these may be due to DAA if not identified early. [3],[5]

In conclusion, DAA is a rare occurrence a­mong chronic hemodialysis patients, however needs high index of suspicion in patients pre­senting with chest pain. Primary medical ma­nagement includes good control of blood pre­ssure and heart rate and surgery when indicated.

References

1Asfoura JY, Vidt DG. Acute aortic dissection. Chest 1991;99:724-9.
2Cambria RP, Brewster DC, Gertler J. Vascular complications associate spontaneous aortic dissection. J Vasc Surg 1988;7:199-209.
3Takeda k, Harada A, Okuda S, et al. Sudden death in chronic dialysis patients. Nephrol Dial Transplant 1997;12:952-5.
4Tatsuya M. Aortic dissection and sudden death: Statistical analysis on 1320 cases autopsied at Tokyo-to Medical Examiner Office. Jpn J Renal Med 1988;42(6):564-77.
5The Japanese Society for dialysis Statistical Investigation Committee. An overview of regular dialysis treatment in Japan. J Jpn Soc Dial Ther 1996;29:1-22.