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 B 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/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guideline Recommendations: Evaluation and Management of Acute Thoracic Aortic Disease (DO NOT EDIT)

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)"

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)"

Genetic Syndromes (DO NOT EDIT)

Class IIa

"1. It is reasonable to consider surgical repair of the aorta in all adult patients with Loeys-Dietz syndrome or a confirmed TGFBR1 or TGFBR2 mutation and an aortic diameter of 4.2 cm or greater by transesophageal echocardiogram (internal diameter) or 4.4 to 4.6 cm or greater by computed tomographic imaging and/or magnetic resonance imaging (external diameter). (Level of Evidence:C)"

"2. For women with Marfan syndrome contemplating pregnancy, it is reasonable to prophylactically replace the aortic root and ascending aorta if the diameter exceeds 4.0 cm. (Level of Evidence:C)"

"3. If the maximal cross-sectional area in square centimeters of the ascending aorta or root divided by the patient's height in meters exceeds a ratio of 10, surgical repair is reasonable because shorter patients have dissection at a smaller size and 15% of patients with Marfan syndrome have dissection at a size smaller than 5.0 cm. (Level of Evidence:C)"

Preoperative Evaluation (DO NOT EDIT)

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)"

Choice of Anesthetic and Monitoring Techniques (DO NOT EDIT)

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)"

Transfusion Management and Anticoagulation in Thoracic Aortic Surgery (DO NOT EDIT)

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) "

Brain Protection during Ascending Aortic and Transverse Aortic Arch Surgery (DO NOT EDIT)

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) "

Spinal Cord Protection during Descending Aortic Open Surgical and Endovascular Repairs (DO NOT EDIT)

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) "

Class IIa

"1. Spinal cord perfusion pressure optimization using techniques, such as proximal aortic pressure maintenance and distal aortic perfusion, is reasonable as an integral part of the surgical, anesthetic, and perfusion strategy in open and endovascular thoracic aortic repair patients at high risk of spinal cord ischemic injury. Institutional experience is an important factor in selecting these techniques. (Level of Evidence: B) "

"2. Moderate systemic hypothermia is reasonable for protection of the spinal cord during open repairs of the descending thoracic aorta. (Level of Evidence: B) "

Class IIb

"1. Adjunctive techniques to increase the tolerance of the spinal cord to impaired perfusion may be considered during open and endovascular thoracic aortic repair for patients at high risk of spinal cord injury. These include distal perfusion, epidural irrigation with hypothermic solutions, high-dose systemic glucocorticoids, osmotic diuresis with mannitol, intrathecal papaverine, and cellular metabolic suppression with anesthetic agents. (Level of Evidence: B) "

"2. Neurophysiological monitoring of the spinal cord (somatosensory evoked potentials or motor evoked potentials) may be considered as a strategy to detect spinal cord ischemia and to guide reimplantation of intercostal arteries and/or hemodynamic optimization to prevent or treat spinal cord ischemia. (Level of Evidence: B) "

Renal Protection during Descending Aortic Open Surgical and Endovascular Repairs (DO NOT EDIT)

Class III (Harm)

"1. Furosemide, mannitol, or dopamine should not be given solely for the purpose of renal protection in descending aortic repairs. (Level of Evidence: B) "

Class IIb

"1. Preoperative hydration and intraoperative mannitol administration may be reasonable strategies for preservation of renal function in open repairs of the descending aorta. (Level of Evidence: C) "

"2. During thoracoabdominal or descending aortic repairs with exposure of the renal arteries, renal protection by either cold crystalloid or blood perfusion may be considered. (Level of Evidence: B) "