CONTROVERSIES

13. Which is preferred: surgical or medical management of descending dissections?

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* 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?

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* 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?

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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?

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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
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