Update in the Management of Aortic Dissection
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Vascular Disease (H Gornik and E Kim, Section Editors)
Update in the Management of Aortic Dissection Jip L. Tolenaar, MD1 Guido H. W. van Bogerijen, MD1 Kim A. Eagle, MD, FACC2 Santi Trimarchi, MD, PhD1,* Address *,1Thoracic Aortic Research Center, IRCCS Policlinico San Donato, Cardiovascular Center E. Malan, University of Milan, Via Morandi, 30, 20097, San Donato Milanese, MI, Italy Email: [email protected] 2 University of Michigan Health System, Ann Arbor, MI, USA
Published online: 10 January 2013 * Springer Science+Business Media New York 2013
Keywords Thoracic/aortic I Thoracic aortic dissection I TEVAR (thoracic endovascular repair) Cardiopulmonary bypass I Open surgical repair I Medical treatment
I
Opinion statement Recent improvements in diagnosis, peri-operative management, surgical techniques and postoperative care have resulted in decreased mortality and morbidity in acute aortic dissections (AAD). The classic treatment algorithm indicates that type A patients require direct surgical intervention and type B patients should be treated medically, in absence of complications. Initial medical treatment is adopted in all AAD patients, as it reduces propagation of the dissection and aortic rupture. In type A aortic dissection (TAAD) several techniques have contributed to major changes in the surgical approach, such as cerebral protection using moderate circulatory arrest, selective cerebral perfusion, and aortic valve sparing with root replacement. In TAAD with involvement of the descending aorta, thoracic endovascular aortic repair (TEVAR) can be performed as a part of a complex hybrid procedure, in which surgical ascending/arch repair is combined with the placement of a stent graft in the descending aorta. Future developments in stent graft technologies might broaden the usefulness of TEVAR for the total endovascular repair of TAAD. In complicated type B aortic dissection (TBAD), the use of TEVAR has become the therapy of first choice. By covering the proximal entry tear, the stent graft reduces the pressurization of the false lumen, treating malperfusion and inducing favorable aortic remodeling. In uncomplicated TBAD, TEVAR has been used to prevent long term complications, such as aortic aneurysm, but this concept is not yet routinely recommended. Regardless of their initial treatment, all AAD patients should be administered with strict antihypertensive management combined with imaging surveillance and careful periodic clinical follow-up.
Update in the Management of Aortic Dissection
Tolenaar et al.
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Introduction Acute aortic dissection is a life-threatening disease with an increasing incidence up to 14 per 100.000 people/year, due to aging population and improved imaging modalities [1]. Prognosis of aortic dissection in untreated patients is poor, with a mortality of 20–30 % before hospital admission and 50 % will expire within the first 48 hours [1, 2]. The Stanford classification is most commonly used and classifies dissections into TAAD involving the ascending aorta and TBAD, without as
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