Abstract
Acute aortic syndromes are a constellation of pathologies including acute aortic dissection, intramural hematoma, penetrating atherosclerotic ulcers, and aortic rupture. An acute aortic syndrome involving the ascending aorta is an indication for emergent surgical repair. Acute aortic syndromes involving the descending aorta are typically treated initially with aggressive medical management then repaired through an endovascular or open approach electively. More urgent repair is indicated with rupture, pending rupture, expanding aneurysms, persistent acute pain, and malperfusion syndromes. The goals of open repair of acute ascending aortic syndromes are resolution of cardiac tamponade, malperfusion of end organs, and acute aortic insufficiency, and prevention of aortic rupture. Principles of surgical repair include median sternotomy, excision of the primary entry tear for aortic dissection, followed by reconstruction of the aortic root, ascending aorta, and aortic arch, management of the aortic valve to achieve competency, and ensuring patent coronary arteries and aortic arch vessels to maintain myocardial, cerebral, and upper and lower body perfusion. Venous cannulation is achieved through the right atrium or femoral vein. The most common arterial cannulation strategy is femoral, while alternatives include right axillary artery, intrathoracic right subclavian, innominate, or carotid arteries, and direct modified Seldinger central aortic cannulation of the true lumen. In the setting of acute dissection of the ascending aorta with visceral or extremity malperfusion syndrome, an increasing number of centers perform endovascular fenestration and stenting to restore end-organ perfusion followed by staged open surgical repair of the proximal aorta.
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References
Jabagi H, Brescia AA, Yang B. Type a aortic dissection. In: Brescia AA, Louis C, editors. TSRA review of cardiothoracic surgery. 3rd ed. Chicago: Thoracic Surgery Residents Association; 2022.
Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the international registry of acute aortic dissection: a 20-year experience of collaborative clinical research. Circulation. 2018;137:1846–60.
Rylski B, Pérez M, Beyersdorf F, Reser D, Kari FA, Siepe M, Czerny M. Acute non-A non-B aortic dissection: incidence, treatment and outcome. Eur J Cardiothorac Surg. 2017;52:1111–7.
Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol. 2010;55:e27–e129.
Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(41):2873–926.
Howard DPJ, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM, Oxford Vascular Study. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013;127:2031–7.
Norton EL, Wu X, Farhat L, Kim KM, Patel HJ, Deeb GM, Yang B. Dissection of arch branches alone: an indication for aggressive arch management in type A dissection? Ann Thorac Surg. 2020;109:487–94.
Norton EL, Wu X, Kim KM, Fukuhara S, Patel HJ, Michael Deeb G, Yang B. Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion? J Thorac Cardiovasc Surg. 2021;161:873–884.e2.
Yang B, Rosati CM, Norton EL, et al. Endovascular fenestration/stenting first followed by delayed open aortic repair for acute type A aortic dissection with malperfusion syndrome. Circulation. 2018;138:2091–103.
Deeb GM, Michael Deeb G, Williams DM, Bolling SF, Quint LE, Monaghan H, Sievers J, Karavite D, Shea M. Surgical delay for acute type A dissection with malperfusion. Ann Thorac Surg. 1997;64:1669–77.
Patel HJ, Williams DM, Dasika NL, Suzuki Y, Deeb GM. Operative delay for peripheral malperfusion syndrome in acute type A aortic dissection: a long-term analysis. J Thorac Cardiovasc Surg. 2008;135:1288–95; discussion 1295–6.
Di Eusanio M, Trimarchi S, Patel HJ, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013;145:385–390.e1.
Lauterbach SR, Cambria RP, Brewster DC, Gertler JP, Lamuraglia GM, Isselbacher EM, Hilgenberg AD, Moncure AC. Contemporary management of aortic branch compromise resulting from acute aortic dissection. J Vasc Surg. 2001;33:1185–92.
Midulla M, Renaud A, Martinelli T, Koussa M, Mounier-Vehier C, Prat A, Beregi J-P. Endovascular fenestration in aortic dissection with acute malperfusion syndrome: immediate and late follow-up. J Thorac Cardiovasc Surg. 2011;142:66–72.
Tsagakis K, Konorza T, Dohle DS, Kottenberg E, Buck T, Thielmann M, Erbel R, Jakob H. Hybrid operating room concept for combined diagnostics, intervention and surgery in acute type A dissection. Eur J Cardiothorac Surg. 2013;43:397–404.
Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Management of visceral malperfusion complicated with acute type A aortic dissection. Interact Cardiovasc Thorac Surg. 2015;21:346–51.
Goldberg JB, Lansman SL, Kai M, Tang GHL, Malekan R, Spielvogel D. Malperfusion in type A dissection: consider reperfusion first. Semin Thorac Cardiovasc Surg. 2017;29:181–5.
Brescia AA, Patel HJ, Likosky DS, et al. Volume-outcome relationships in surgical and endovascular repair of aortic dissection. Ann Thorac Surg. 2019;108(5):1299–306.
MacGillivray TE, Gleason TG, Patel HJ, et al. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg. 2022;163:1231–49.
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Brescia, A.A., Yang, B. (2024). Acute Aortic Syndromes. In: Bloom, J.P., Sundt, T.M. (eds) Cardiac Surgery Clerkship. Contemporary Surgical Clerkships. Springer, Cham. https://doi.org/10.1007/978-3-031-41301-8_21
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