Aortic dissection surgery

Aortic dissection Microchapters
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Case #1

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Any dissection that involves the ascending aorta is considered a surgical emergency. Without surgery, there is a 90% 3-month mortality. These patients can rapidly develop acute aortic insufficiency (AI), tamponade or myocardial infarction (MI). 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.

• Operative mortality for ascending dissections is surgeon dependant, and averages ~ 5 – 20 %. This however, is well below the 50% mortality when these cases are managed with medical therapy.
• Factors that increase surgical risk include renal insufficiency, visceral ischemia, tamponade and underlying pulmonary disease.
• Surgical therapy involves excision of the intimal tear, obliteration of the proximal entry site into the false leumen, 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).
• Dissections involving the descending aorta only can be managed medically unless there is progression or continued hemorrhage into the pleural or retroperitoneal space. The major surgical complication in descending dissections is spinal cord ischemia and paralysis.

ACC/ AHA Guidelines - Recommendation for Surgical Intervention for Thoracic Aortic Disease (DO NOT EDIT)

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)