Aortic dissection surgery

Aortic dissection Microchapters
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Case #1

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 - Recommendations for Definitive Management (DO NOT EDIT)

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)"

2010 ACCF/AHA Guideline Recommendations: Evaluation and Management of Acute Thoracic Aortic Disease - 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)"