July 11, 2009 | In: CARDIOTHORACIC SURGERY
CONTROVERSIES
13. Which is preferred: surgical or medical management of descending dissections?
Show answer
* Initial surgical managementApproximately 25% of patients initially treated medically need an operation eventually.
* Operative mortality is much lower today (20%) than in the past.
* Medical management has the same in-hospital mortality (20%).
* Initial medical managementThis avoids unnecessary operation and its attendant cost and complication rate.
14. What is the preferred management of aortic insufficiency in ascending dissections?
Show answer
* Replacement of aortic valveEasy (valved conduits now available)
* Eliminates aortic insufficiency completely
* Should be done in patients with Marfan syndrome
* Repair of aortic valveWith native valve reconstruction, when done correctly, the need to replace the valve at a later time is only 10%.
* Avoids need for anticoagulation, which is necessary when a mechanical valve is used to replace the aortic valve.
15. What is the preferred repair of descending dissections?
Show answer
1. Partial left atrial-to-femoral artery bypass
For:
* Allows unloading of the heart
* Allows distal perfusion to avoid visceral ischemia
* Allows as much time as needed to complete anastomosis
Against: requires heparinization
2. Simple aortic cross-clamping
For: Fast
Against: Placement of the graft has to be done in < 30 minutes or the complication rate, particularly paraplegia, increases significantly.
16. Are there any other alternatives for the treatment of patients with acute aortic dissection?
Show answer
Although in the early stages of development, the use of endovascular stents may prove to be a useful treatment option. The use of these stents is still considered experimental, and the long-term results are not known.
References
WEB SITE
http://www.acssurgery.com
BIBLIOGRAPHY
1. Barron DJ, Livesey SA, Brown IW, et al: Twenty-year follow-up of acute type A dissection: The incidence and extent of distal aortic disease using magnetic resonance imaging. J Card Surg 12:147-159, 1997. Medline Similar articles
2. Cigarroa JE, Isselbacher EM, DeSanctis RW, Eagle KA: Diagnostic imaging in the evaluation of suspected aortic dissection. Old standards and new directions. N Engl J Med 328:35-43, 1993. Medline Similar articles Full article
3. Glower DD, Fann JI, Speier RH, et al: Comparison of medical and surgical therapy for uncomplicated descending aortic dissection. Circulation 82(suppl IV):39-46, 1990.
4. Khan IA, Nair CK: Clinical, diagnostic, and management perspectives of aortic dissestion. Chest 112:311-328, 2002. Full article
5. Nienaber CA, von Kodolitsch Y, Nicolas V, et al: The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 328:1-9, 1993. Medline Similar articles Full article
6. Okita Y, Takamoto S, Ando M, et al: Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: No relation of early death, stroke, and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg 115:129-138, 1998. Medline Similar articles
7. Safi HJ, Miller CC, Reardon MJ, et al: Operation for acute and chronic aortic dissection: Recent outcome with regard to neurologic deficit and early death. Ann Thorac Surg 66:402-411, 1998. Medline Similar articles Full article
8. Wheat MW Jr, Palmer RF, Bartley TB, Seelman RC: Treatment of dissecting aneurysms of the aorta without surgery. J Thorac Cardiovasc Surg 50:364-373, 1995.
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