Aortic dissection surgery: Difference between revisions
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(/* 2010 ACCF/AHA Guideline Recommendations: Perioperative Care for Open Surgical and Endovascular Thoracic Aortic Repairs (DO NOT EDIT) {{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF...) |
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==2010 ACCF/AHA Guideline Recommendations: Perioperative Care for Open Surgical and Endovascular Thoracic Aortic Repairs (DO NOT EDIT) <ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780 }} </ref>== | ==2010 ACCF/AHA Guideline Recommendations: Perioperative Care for Open Surgical and Endovascular Thoracic Aortic Repairs (DO NOT EDIT) <ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780 }} </ref>== | ||
===Recommendations for Preoperative Evaluation=== | |||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In preparation for surgery, imaging studies adequate to establish the extent of disease and the potential limits of the planned procedure are recommended. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki> | |||
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients with thoracic aortic disease requiring a surgical or catheter-based intervention who have symptoms or other findings of myocardial ischemia should undergo additional studies to determine the presence of significant coronary artery disease. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki> | |||
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Patients with unstable coronary syndromes and significant coronary artery disease should undergo revascularization prior to or at the time of thoracic aortic surgery or endovascular intervention with percutaneous coronary intervention or concomitant coronary artery bypass graft surgery. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki> | |||
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==References== | ==References== | ||
Revision as of 20:32, 30 October 2012
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Aortic dissection Microchapters |
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Diagnosis |
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Treatment |
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Special Scenarios |
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Case Studies |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Any dissection that involves the ascending aorta is considered a surgical emergency, and urgent surgical consultation is recommended. There is a 90% 3-month mortality among patients with a proximal aortic dissection who do not undergo surgery. These patients can rapidly develop acute aortic insufficiency (AI), tamponade or myocardial infarction (MI).
Contraindications to the Operative Repair of a Type A Dissection
Even acute MI in the setting of dissection is not a surgical contraindication. Acute hemorrhagic stroke is, however, a relative contraindication, due to the necessity of intraoperative heparinization.
Surgical Indications for Operative Repair of a Type B Dissection
Dissections involving only the descending aorta can generally be managed medically, but indications for surgery include the following:
- Progression of the dissection
- Continued hemorrhage into the pleural or retroperitoneal space
Surgical Complications Following Repair of a Type Be Dissection
- Spinal cord ischemia and paralysis.
Surgical Risk Factors
Risk factors associated with increased surgical mortality include the following:
- Renal insufficiency
- Mesenteric ischemia
- Renal ischemia
- Pericardial tamponade
- Underlying pulmonary disease
Surgical Procedure
Surgical therapy involves excision of the intimal tear, obliteration of the proximal entry site into the false lumen, and reconstitution of the aorta with placement of a synthetic graft. AI can be corrected by resuspension of the native valve, or by aortic valve replacement (AVR).
2010 ACCF/AHA Guideline Recommendations: Evaluation and Management of Acute Thoracic Aortic Disease (DO NOT EDIT) [1]
Recommendations for Definitive Management
| Class I |
| "1. Urgent surgical consultation should be obtained for all patients diagnosed with thoracic aortic dissection regardless of the anatomic location (ascending versus descending) as soon as the diagnosis is made or highly suspected. (Level of Evidence: C) " |
| "2. Acute thoracic aortic dissection involving the ascending aorta should be urgently evaluated for emergent surgical repair because of the high risk of associated life-threatening complications such as rupture. (Level of Evidence: B)" |
Recommendation for Surgical Intervention for Thoracic Aortic Disease
| Class I |
| "1. For patients with ascending thoracic aortic dissection, all aneurysmal aorta and the proximal extent of the dissection should be resected. A partially dissected aortic root may be repaired with aortic valve resuspension. Extensive dissection of the aortic root should be treated with aortic root replacement with a composite graft or with a valve sparing root replacement. If a DeBakey Type II dissection is present, the entire dissected aorta should be replaced. (Level of Evidence: C)" |
2010 ACCF/AHA Guideline Recommendations: Perioperative Care for Open Surgical and Endovascular Thoracic Aortic Repairs (DO NOT EDIT) [1]
Recommendations for Preoperative Evaluation
| Class I |
| "1. In preparation for surgery, imaging studies adequate to establish the extent of disease and the potential limits of the planned procedure are recommended. (Level of Evidence: C) " |
| "2. Patients with thoracic aortic disease requiring a surgical or catheter-based intervention who have symptoms or other findings of myocardial ischemia should undergo additional studies to determine the presence of significant coronary artery disease. (Level of Evidence: C)" |
| "3. Patients with unstable coronary syndromes and significant coronary artery disease should undergo revascularization prior to or at the time of thoracic aortic surgery or endovascular intervention with percutaneous coronary intervention or concomitant coronary artery bypass graft surgery. (Level of Evidence: C)" |
References
- ↑ 1.0 1.1 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE; et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780.