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The Annals of Thoracic Surgery, Vol 53, 11-20, Copyright © 1992 by The Society of Thoracic Surgeons
JA Elefteriades, J Hartleroad, RJ Gusberg, AM Salazar, HR Black, GS Kopf, JC Baldwin and GL Hammond
We analyzed long-term results in 71 patients (45 men and 26 women) treated
over 17 years for documented descending aortic dissection. Forty-nine
patients were treated medically and 22, surgically. Actuarial survival was
65% at 1 year, 57% at 3 years, 50% at 5 years, and 28% at 10 years for the
whole group. For the group treated medically, survival was 73%, 63%, 58%,
and 25% at 1 year, 3 years, 5 years, and 10 years, respectively, and for
the group treated surgically, 47%, 40%, and 28% at 1 year, 3 years, and 5
years, respectively. Ten (20.4%) of the 49 medically treated patients died
early (5 of rupture), and 14 (28.6%) died late (8 of dissection). Five
medically treated patients crossed over to surgical management for
complications of dissection. Among the surgically treated patients, 6
underwent standard graft replacement of the proximal descending aorta, 8
underwent the fenestration procedure (with a standardized retroperitoneal
abdominal approach), and 4 underwent the thromboexclusion operation.
Specific analysis of fenestration in 14 patients (including some with
persistent descending aortic dissection after replacement of the ascending
aorta for dissection) found it to be safe and effective. Actuarial survival
after fenestration was 77%, 77%, and 53% at 1 year, 3 years, and 5 years,
respectively. Thromboexclusion was found effective, and postoperative
studies confirmed thrombosis of the descending aorta with preservation of
the lowest intercostal arteries. Fifteen of the 21 surviving medically
treated patients agreed to return for follow-up imaging. Nine had
thrombosis of the false lumen. An interesting radiographic finding was that
4 of the 15 restudied patients had a saccular aneurysm in the aorta at the
level of the left subclavian artery. We recommend a complication-specific
approach to the management of descending aortic dissection. Uncomplicated
dissection is treated medically, whereas complicated dissection is treated
surgically, with realized rupture treated by standard graft replacement,
limb ischemia treated by fenestration, and enlargement or impending rupture
treated by thromboexclusion.
ARTICLES
Long-term experience with descending aortic dissection: the complication-specific approach
Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, CT 06510.
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