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Ann Thorac Surg 1999;67:2002-2005
© 1999 The Society of Thoracic Surgeons

Management of descending aortic dissection

^a Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA

Address reprint requests to Dr Elefteriades, Section of Cardiothoracic Surgery, Yale University School of Medicine, 121 FMB, 333 Cedar St, New Haven, CT 06510

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Treatment of descending aortic... Conclusion References

 
Background. Experience with 100 consecutive patients with acute dissection of the descending aorta seen at the Yale Center for Thoracic Aortic Disease over a 10-year period is reported.

Methods. Clinical records from the Yale Center for Thoracic Aortic Disease from 1988 to 1998 were analyzed. This computerized data base included information regarding patients’ demographics, history, presenting symptomatology, diagnostic imaging, early hospital course, treatment strategy, and long term follow up (office visits, echocardiography, computerized tomography, magnetic resonance imaging, and home phone calls).

Results. The average size of the aorta at the time of dissection was 5.05 cm. Nine patients died (six of complications directly related to the thoracic aorta). Sixty of the 91 surviving patients had a benign course, and 31 had a course complicated by rupture (8), vascular occlusion (17), early expansion or extension (12), and continued pain (4); multiple complications were seen in some patients. Forty-two patients came to operation (22 early and 20 late): 32 direct aortic replacements, 6 fenestration procedures, and 4 thromboexclusions. There were six postoperative deaths and six paraplegias. Clinical experience with the alternative procedures of fenestration and thromboexclusion found both procedures safe and effective for selected categories of patients. Review of the literature indicated that direct aortic replacement in the setting of acute descending aortic dissection continues to carry a very high mortality (28%–65%) and paraplegia rate (30%–35%), leaving room for consideration of alternative procedures.

Conclusions. We recommend a "complication-specific" approach to acute descending aortic dissection: medical management with "antiimpulse therapy" for uncomplicated acute descending dissections and surgical intervention for complicated dissections. Surgical therapy varies for the specific complication: for rupture, direct aortic replacement is recommended; for vascular occlusion, fenestration; and for acute expansion or impending rupture, direct aortic replacement, with thromboexclusion as an option. Chronic descending aortic dissection is treated according to general guidelines for descending aortic aneurysms, with operation for symptoms or enlargement > 6.5 cm.

	Introduction

Top Abstract Introduction Treatment of descending aortic... Conclusion References

 
We review herein clinical behavior of 100 consecutive patients presenting to our institution with acute descending aortic dissection between 1988 and 1998. Presenting symptomatology is shown in Table 1: back pain predominated, but many patients also had chest pain, and a small number had symptoms from extremity, abdominal, or spinal cord ischemia. There was a slight male predominance. Average age was 65.5 years, with a range from 20 to 83. Comorbidities are presented in Table 2: hypertension was seen in 80 patients.

Figure 1 presents a flow diagram of the outcome from initial hospitalization for these 100 patients. Nine patients died during the initial hospital admission: six deaths were directly related to the aorta and branch vessel involvement, and three were related to failure of other organ systems (respiratory [2] and brain [1]). These observations parallel reports from other centers [1–4]. Survival rates for initial hospitalization after acute descending aortic dissection range from 80% to 100%, and 6% to 20% of patients require subsequent surgical intervention.

View larger version (41K): [in this window] [in a new window]   Fig 1. Flow diagram of outcome of 100 consecutive patients with acute descending aortic dissection. (A single patient may have more than one complication.)

Thirty-one patients had complications related to the aorta. Eight patients had rupture, diagnosed from imaging studies (computed tomography [CT], magnetic resonance imaging [MRI], echocardiography [ECHO], or angiography) or operative findings; 5 underwent surgery at the time that rupture was recognized, 2 patients refused operation, and 1 had overwhelming comorbidity contraindicating surgery. Seventeen had complications due to occlusion of important branch vessels of the aorta. Five involved the lower extremity, 5 involved the renal vessels, 5 affected the spinal cord, and 2 involved abdominal visceral arteries. Four patients manifested failure to control clinical symptoms (pain) despite maximal medical management. Twelve manifested expansion of the aorta (or other radiologic signs of progression) on early follow-up while still in hospital. Six patients extended the dissection proximally into the aortic arch during the initial admission.

Forty-two of our 100 patients came to operation for the aorta: 22 during the first 30 days, and 20 late after presentation (30 days to 10 years). Thirty-two patients had direct aortic grafts, 6 underwent fenestration of the aorta, and 4 had the thromboexclusion procedure. Six surgical patients died. Nonlethal postoperative surgical complications included paraplegia or paraparesis in 6 patients, and respiratory insufficiency in 12.

This large, highly selected series—all dissectors, all descending, all acute—clearly illustrates the clinical spectrum of presentations and early behavior of this disorder.

	Treatment of descending aortic dissection

Top Abstract Introduction Treatment of descending aortic... Conclusion References

 
Medical treatment
For decades, medical treatment of aortic dissection, either ascending or descending, has followed Wheat’s concept [5] that decreasing the force of cardiac contraction and the ambient blood pressure would be beneficial for the diseased aorta, a concept subsequently supported by both laboratory and clinical observations.

Surgical treatment
Surgical thinking during the 1990s has moved in the direction of avoiding surgical treatment for stable patients with acute descending aortic dissection [6–13]. This practice is supported by our clinical experience: most of our patients with acute descending aortic dissection did well without routine surgical intervention. It has been recognized that descending aortic dissections rupture rarely, much less frequently than ascending dissections.

Direct aortic replacement for acute dissection has significant mortality and complications that far exceed those of aortic replacement in other scenarios [4, 7, 14–19]. Results of recent series of operations for acute dissections of the descending aorta are quite sobering: overall mortality is 28%–65%, with 35% of deaths from bleeding from contiguous or remote aortic segments. Even more sobering is the risk of paraplegia: even the world-class Svennson and Crawford data indicate staggering paraplegia rates of 30%–36% for extensive direct aortic replacement for dissection [19]. These statistics indicate that exploration of creative alternative surgical procedures is appropriate, and that fenestration and thromboexclusion procedures may deserve a place in the aortic surgeon’s armamentarium for selected cases.

In 1992, our group described our institution’s "complication-specific approach," which called for operation only in case of specific categories of complications from acute descending aortic dissection (Fig 2) [20]: realized rupture, vascular occlusion, and impending rupture (early acute dilatation or pain unresponsive to medical management).

View larger version (31K): [in this window] [in a new window]   Fig 2. The "complication-specific" approach to acute descending aortic dissection.

When the complication is organ ischemia from branch vessel occlusion, surgical intervention is almost invariably required, but various surgical therapies have been applied to this subset of the population with acute descending aortic dissection [14, 15, 21]. Perhaps the most commonly utilized approach is replacement of the proximal descending aorta, with reconstitution of the distal layers. The thinking behind this approach is that flow will be redirected into the true lumen, reversing ischemic manifestations: this goal is usually, but not uniformly achieved [7, 12, 21]. Another approach has been direct bypass grafting to the affected tissue, be it limb, kidney, intestine, or other organ.

We have favored a different approach: the fenestration procedure [25]. Cooley and others utilized this procedure in the early years of aortic surgery, and data from our group and from Borst and associates [22] have led to renewed interest in using it to treat malperfusion complicating acute descending aortic dissection. Fenestration is thought to decrease the distention of the false lumen, thus relieving the compression of the ostium of the branch vessel and restoring proper organ blood flow. Through a left flank retroperitoneal incision, the aorta is transected just below the renal arteries. A large window of the intimal layer is excised from the upper aortic segment up to the clamp. In the distal segment, the intimal and adventitial layers are reapproximated with a continuous over-and-over suture, and the upper aortic segment is then anastomosed to the reconstituted lower aorta with a continuous suture. Thus, adventitia above is sewn to the full-thickness aorta below.

Our experience with fenestration has been favorable. The procedure was quickly and safely accomplished. Mortality in the operating room was nil, and overall survival was excellent (62% at 5 years), considering the severity of illness in these patients. Fenestration predictably and consistently restored perfusion to the ischemic organ, whether below (lower limb) or above (kidney) the level of the fenestration. In our experience, the adventitia invariably restrained the bloodstream well, without anastomotic bleeding.

There are limitations to the fenestration procedure. It cannot be entertained with the technique described if the dissection does not reach the infrarenal aorta. Fenestration is appropriate only as an immediate response for early acute dissection: after 24 to 48 hours, clot in the false lumen will likely produce bulging of the false lumen at the branch ostium unresponsive to restored flow in the true lumen.

The third type of complication that may mandate surgical intervention is threatened rupture, rapid enlargement, or distal propagation of the dissected descending aorta. Persistent pain unresponsive to medical management is thought to indicate impending rupture. We repeat aortic imaging (CT or MRI) within 3 to 5 days of presentation with acute descending dissection even in asymptomatic patients who respond well to medical treatment: in a few patients, the thin outer layer of the aorta dilates rapidly, indicating high risk of rupture. We consider early expansion an indication for prompt surgical intervention.

The appropriate surgical procedure for impending rupture is direct aortic replacement, but again a question arises regarding appropriate extent of resection. Some advocate replacement of the proximal descending aorta and reconstitution of layers distally. Svensson and Crawford specify that the proximal half of the descending aorta be replaced [11]. Replacement of a large segment of the aorta raises significant dangers of paraplegia from spinal cord devascularization.

An ingenious alternative surgical procedure for acute descending aortic dissection was recommended by Carpentier and associates in 1981: the "thromboexclusion" procedure [23]. This involves creation of a large-bore, extra-anatomic graft from the ascending aorta to the abdominal aorta via a large sternal notch-to-pubis incision. The extra-anatomic graft provides an alternate route of blood flow, allowing complete, permanent iatrogenic occlusion of the descending aorta just beyond the subclavian artery. The thesis is that the descending aorta becomes a blind pouch, with stagnant flow leading to gradual, progressive thrombosis of the descending aorta. Thrombosis should stop at the site of significant flow through branch vessels (often at the site of a large spinal-perfusing low intercostal vessel at the T8 to L2 level) or at the level of the celiac axis (where run-off is rapid).

Since Carpentier and colleagues’ original report, several groups have reported small series of such operations. Our own data substantiate Carpentier’s thesis: the descending aorta clots predictably and rapidly after total aortic occlusion. Thrombosis begins in the operating room and is complete within days. We have confirmed that the intercostals remain open, that the rate of paraplegia is low, that late rupture is uncommon, and that the benefits are durable. This procedure may be useful as an alternative to direct aortic replacement in a very small minority of patients with acute descending aortic dissection.

Chronic descending aortic dissection
In chronic descending aortic dissection, we employ regular aortic imaging at intervals by CT or MRI. Criteria for intervention parallel those for general descending aortic aneurysm [24]. We operate for symptoms (pain) or for aortic enlargement. Our current size criterion for asymptomatic patients is 6.5 cm, just below 7.0 cm, the size at which our serial statistical data predict a rise in the rupture rate. Operations for chronic dissection pose additional difficulties. Identification of branch vessels can be difficult. The dissected lumen must be opened widely in the abdominal aorta to allow identification and reimplantation of all visceral arteries. In case of less than total replacement of the aorta in chronic dissection, the intimal layer must be resected from the distal aortic cuff and the anastomosis done to the distal advential layer in order to avoid devascularization of organs supplied chronically from the false lumen.

	Conclusion

Top Abstract Introduction Treatment of descending aortic... Conclusion References

 
The vast majority of patients will do well with medical management for acute descending aortic dissection. The minority who develop complications challenge surgical ingenuity. Even with direct replacement procedures, usually limited to the proximal descending aorta, surgery is only palliative: the disease process is not eliminated even with resection of the intimal tear and redirection of blood flow into the true lumen. Most patients have persistence of the false lumen after acute descending aortic dissection. Most are still subject to future complications, including extension, progressive aortic dilatation, and rupture. In view of dauntingly high mortality and paraplegia rates after surgery for acute descending aortic dissection, alternative procedures, especially fenestration, may be of benefit in selected patients with complications.

	References

Top Abstract Introduction Treatment of descending aortic... Conclusion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gary S. Kopf Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Elefteriades, J. A. Articles by Rizzo, J. A. Search for Related Content PubMed PubMed Citation Articles by Elefteriades, J. A. Articles by Rizzo, J. A.