Aortic Dissection - Adrian Manapat,MD
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Transcript Aortic Dissection - Adrian Manapat,MD
Surgery for Aortic
Dissection
Adrian E. Manapat, M.D.
Mortality of Aortic Dissection
Acute aortic dissection
Lindsay, Hurst (1967) :
33% within 24 hrs
50% within 48 hrs
80% within 7 days
95% within 1 month
for Type B 25% at 1 month
Acute/Chronic/A/B
Anagnostopoulos (1972) 70% at 1 week
90% at 3 months
Management of acute aortic
dissection
Type A dissection Surgical repair
(Modes of exit: Cardiac tamponade
MI
Heart failure from AI
Stroke)
Type B dissection Medical > Surgical
Risk of cardiac tamponade 2%
Stanford Duke Collaborative
Study
80
70
60
50
40
Medical
Surgical
30
20
10
0
Life
Other medical Low risk, open
threatening
problems
choice
complications
Management of Type B
dissection
Indications for surgery
1. Life threatening complications of dissection
a) Aortic rupture/leak
b) Infarction/ischemia of major end organ (kidneys,
abdominal viscera, extremities)
2) Progression of dissection during medical treatment
Indications for medical management
1) Elderly
2) Coexisting serious medical problem - cardiac, pulmonary, renal ,
peripheral or cerebrovascular
3) Thrombosed false lumen
4) Primary tear in distal aorta or abdominal aorta
Craig Miller, 1992
Principles of repair
Complete obliteration of the tear of the
ascending aorta
Obliteration of the false lumen
Prevention of rupture of the jeopardized
segment
Correction of aortic regurgitation if present
What is so difficult about repair of
aortic dissection?
Weakened friable aorta does not tolerate
clamping - requires “no touch technique”
Need for deep hypothermic circulatory arrest
Prolonged complex operation
Almost all of them bleed
Potential for multiple organ damage
Possible catastrophic complications
Emergency nature
Deep hypothermic circulatory
arrest (DHCA)
Every 10 o decrease in T causes a 50%
decrease in metabolic rate - protects the organs
from the effects of circulatory arrest
Safe period CA is usually 45 minutes
Disadvantages:
prolonged surgery
bleeding
potential for end organ
damage
Cerebral protection during
circulatory arrest
Cerebral perfusion
Antegrade perfusion via carotid arteries
Retrograde perfusion via superior vena cava
Adjunctive measures:
Head packed in ice
Mannitol, steroids
Sodium pentothal
Trendelenberg position
Surgical options
Supracoronary AA replacement
Bentall procedure (composite ascending aorta
& aortic valve replacement w/ re-implantation
of coronary ostia)
Supracoronary AA replacemnt w/ aortic valve
repair or replacement
Any of the above combined with CABG
Ascending aortic dissection
False and true lumen
Dealing with the aortic valve
Resuspension of the
commissures to repair
the aortic valve
Insertion of a valved
conduit
Proximal graft anastomosis
completed
Aortic graft in place
Ascending aortic replacement
with CABG
Results of Surgical repair
Operative (30-day) mortality
1960’s 30-60%
1990’s to the present 5-30%
Cleveland Clinic experience (208) predictors of mortality:
Earlier operative year
Hypotension
Non-use of DHCA
Composite valve graft
CABG
Late survival (Crawford, 1990)
1 year 78%
5 years 63%
10 years 55%
Acute type A 5 yrs 56%
10 yrs 46%
20 yrs 30%
Long term follow up
Lifelong antihypertensive, B blocker
Anticoagulation for prosthetic valve
Surveillance :
new dissections
aneurysm formation
prosthetic valve function