Surgery for Aortic Dissection Adrian E. Manapat, M.D.

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بسم الله الرحمن الرحيم.

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Presentation transcript:

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 B25% at 1 month Acute/Chronic/A/B Anagnostopoulos (1972) 70% at 1 week 90% at 3 months

Management of acute aortic dissection Type A dissectionSurgical repair (Modes of exit: Cardiac tamponade MI MI Heart failure from AI Heart failure from AI Stroke) Stroke) Type B dissectionMedical > Surgical Risk of cardiac tamponade 2%

Stanford Duke Collaborative Study

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’s30-60% 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 year78%Acute type A 5 yrs 56% 5 years63% 10 yrs 46% 10 years 55% 20 yrs 30%

Long term follow up  Lifelong antihypertensive, B blocker  Anticoagulation for prosthetic valve  Surveillance : new dissections aneurysm formation prosthetic valve function