Evolution of surgical therapy for Stanford acute type A aortic dissection

Abstract

Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small?The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.

Postoperative care in patients with DeBakey type I aortic dissection: criteria of aortic remodeling and risk factors of disease progression

“…За прошедшие десятилетия тактика его лечения претерпела значительные изменения. Однако даже в настоящее время, несмотря на наличие в арсенале междисциплинарных команд по лечению заболеваний аорты таких современных методик, как операция «Хобот слона» (Elephant Trunk) и гибридные вмешательства, в ряде клиник при лечении расслоения всей аорты выполняют протезирование лишь проксимальных отделов аорты [2], хотя известно, что подобный подход ассоциирован с 20-30% вероятностью повторных и дополнительных операций (в течение 4,7±2,8 года после первой операции) [3].…”

Una strana colica renale destra

“…4 Per il tipo A è necessario un trattamento chirurgico in urgenza, mentre per il tipo B è possibile procedere inizialmente con una terapia medica a meno che non ci siano complicanze. 5 Nel nostro caso clinico ci trovavamo di fronte ad una dissecazione aortica di tipo B per la quale si è reso necessario un’intervento chirurgico in urgenza visto il quadro di grave insufficienza renale acuta con cui si è presentato il paziente. Le arterie renali sono tra i vasi periferici più frequentemente colpiti da dissecazione, ma le forme spontanee sono comunque rare.…”

Noteworthy Literature Published in 2016 for Cardiac Surgery

“…The full arch replacement will most likely be program specific as the traditional approach of living to fight another day has saved many patients over the years. 22,23 However, there remains a subset of patients that could avoid obligatory secondary intervention with a more aggressive arch replacement up front, and it is up to those of us caring for these patients to figure out those patients that benefit most.…”