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 (DO NOT EDIT)

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)

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)"

Class IIa

"1. Additional testing is reasonable to quantitate the patient’s comorbid states and develop a risk profile. These may include pulmonary function tests, cardiac catheterization, aortography, 24-hour Holter monitoring, noninvasive carotid artery screening, brain imaging, echocardiography, and neurocognitive testing. (Level of Evidence: C)"

"2. For patients who are to undergo surgery for ascending or arch aortic disease, and who have clinically stable, but significant (flow limiting), coronary artery disease, it is reasonable to perform concomitant coronary artery bypass graft surgery. (Level of Evidence: C)"

Class IIb

"1. For patients who are to undergo surgery or endovascular intervention for descending thoracic aortic disease, and who have clinically stable, but significant (flow limiting), coronary artery disease, the benefits of coronary revascularization are not well established. (Level of Evidence: B)"

Recommendations for Choice of Anesthetic and Monitoring Techniques

Class I

"1. The choice of anesthetic techniques and agents and patient monitoring techniques should be tailored to individual patient needs to facilitate surgical and perfusion techniques and the monitoring of hemodynamics and organ function. (Level of Evidence: C) "

Class III (Harm)

"1. Regional anesthetic techniques are not recommended in patients at risk of neuraxial hematoma formation due to thienopyridine antiplatelet therapy, low-molecular-weight heparins, or clinically significant anticoagulation. (Level of Evidence: C)"

"2. Routinely changing double-lumen endotracheal (endobronchial) tubes to single-lumen tubes at the end of surgical procedures complicated by significant upper airway edema or hemorrhage is not recommended. (Level of Evidence: C) "

Class IIa

"1. Transesophageal echocardiography is reasonable in all open surgical repairs of the thoracic aorta, unless there are specific contraindications to its use. Transesophageal echocardiography is reasonable in endovascular thoracic aortic procedures for monitoring, procedural guidance, and/or endovascular graft leak detection. (Level of Evidence: B)"

"2. Motor or somatosensory evoked potential monitoring can be useful when the data will help to guide therapy. It is reasonable to base the decision to use neurophysiologic monitoring on individual patient needs, institutional resources, the urgency of the procedure, and the surgical and perfusion techniques to be employed in the open or endovascular thoracic aortic repair. (Level of Evidence: B)"

Recommendation for Transfusion Management and Anticoagulation in Thoracic Aortic Surgery

Class IIa

"1. An algorithmic approach to transfusion, antifibrinolytic, and anticoagulation management is reasonable to use in both open and endovascular thoracic aortic repairs during the perioperative period. Institutional variations in coagulation testing capability and availability of transfusion products and other prothrombotic and antithrombotic agents are important considerations in defining such an approach. (Level of Evidence: C) "

Recommendations for Brain Protection during Ascending Aortic and Transverse Aortic Arch Surgery

Class I

"1. A brain protection strategy to prevent stroke and preserve cognitive function should be a key element of the surgical, anesthetic, and perfusion techniques used to accomplish repairs of the ascending aorta and transverse aortic arch. (Level of Evidence: B) "

Class III (Harm)

"1. Perioperative brain hyperthermia is not recommended in repairs of the ascending aortic and transverse aortic arch as it is probably injurious to the brain. (Level of Evidence: B)"

Class IIa

"1. Deep hypothermic circulatory arrest, selective antegrade brain perfusion, and retrograde brain perfusion are techniques that alone or in combination are reasonable to minimize brain injury during surgical repairs of the ascending aorta and transverse aortic arch. Institutional experience is an important factor in selecting these techniques. (Level of Evidence: B) "

Recommendations for Spinal Cord Protection during Descending Aortic Open Surgical and Endovascular Repairs

Class I

"1. Cerebrospinal fluid drainage is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury. (Level of Evidence: B) "