AORTA REPLACEMENT AND REPAIR THORACIC AORTIC DISSECTION

DeBakey classification
Type I - intimal disruption of ascending aorta, which dissects to involve the descending aorta and
abdominal aorta
Type II - involving the ascending aorta only (stops at the innominate artery)
Type III - descending aorta only (distal to left subclavian artery)

Stanford classification
Type A - any dissection that involves ascending aorta
Type B - dissection involves only the descending aorta

Multiple causes
Atherosclerosis
Cystic medial necrosis (i.e. Marfan's syndrome)
Infectious
Trauma
Coarctation
Bicuspid aortic valve, pregnancy
Diagnosis
Is usually made by chest CT or echocardiography

CONSIDERATIONS
Preoperative control of hypertension with beta blockers (+/nitroprusside if necessary) is an essential
part of management
Dissection may advance proximally to disrupt coronary blood flow or induce aortic valve incompetence,
or distally causing stroke, renal failure, intestinal ischemia or leg ischemia

Surgical repair
Operative repair involves replacement of the affected aorta with prosthetic graft
CPB is required for repair of Type A dissections, and hypothermic circulatory arrest is often used for
transverse arch dissections and ascending aorta repairs
Aortic valve replacement and coronary reimplantation may be required for Type A aneurysms that
involve the aortic root
Type B dissections can be medically managed unless expansion, rupture, or compromise of branch
arteries develops or HTN becomes refractory
Post-operative complications include;
renal failure,
intestinal ischemia,
stroke,
paraplegia,
death


THORACIC AORTIC ANEURYSM
Etiology:
medial degeneration,
atherosclerosis,
expansion of chronic dissections

Indications for surgery
ascending aortic aneurysms
Symptomatic, expanding, > 5.5 cm in diameter, or greater than twice the size of the normal
aorta
Aneurysms > 4.5 cm if operation is indicated for aortic regurgitation (annuloaortic ectasia)
all acute type A dissections
mycotic aneurysms
Transverse arch aneurysms
ascending aortic aneurysms that require replacement that also extend into the arch
acute arch dissections
aneurysms > 6 cm in diameter
descending thoracic aorta aneurysms
symptomatic aneurysms
aneurysms > 6 cm
complicated type B dissections

.Catheterization is indicated for patients > 40 years of age or if history of chest pain (to diagnose
coexistent coronary artery disease)

Surgical options
ascending aortic aneurysms
Supracoronary interposition graft placement is performed if the aneurysm does not
involve the sinuses
Bentall procedure (valved conduit) for patients with Marfan's syndrome, if the sinuses
are involved or for annuloaortic ectasia

Transverse arch aneurysms
Hemiarch repair if ascending aorta and proximal arch are involved (graft sewn to the
undersurface of the aorta to leave the brachiocephalic vessels attached to the native aorta)
Extended arch repair involves placement of an interposition graft and reimplantation of
a brachiocephalic island during a period of circulatory arrest (use retrograde SVC perfusion and selective
brachiocephalic perfusion to minimize cerebral complications)

Descending thoracic aorta aneurysms
Interposition graft placement
To ensure spinal cord and kidney perfusion, consider using femoral-femoral bypass
(femoral artery and vein cannulation, with arterial blood pumped retrograde into femoral artery for
cephalad aortic blood flow)

TRAUMATIC AORTIC DISRUPTION
1. This injury results from deceleration injury, and usually occurs just distal to the left subclavian
artery at the level of the ligamentum arteriosum

2. Chest radiograph findings include widened mediastinum, pleural capping, associated first and
second rib fractures, loss of the aortic knob, hemothorax, deviation of the trachea or NG tube,
and associated thoracic injuries (scapular fracture, clavicular fracture)

3. Definitive diagnosis is made by aortagram, but chest CT and TEE also aid in the diagnosis

4. Imperative that immediate life-threating injuries (i.e. positive diagnostic peritoneal lavage) be
treated prior to repair