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The Journal of Thoracic and Cardiovascular Surgery, Vol 97, 334-341, Copyright © 1989 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
SL Lansman, S Raissi, MA Ergin and RB Griepp
Surgical intervention is generally accepted for acute type A dissection,
but little is published regarding therapy for acute dissection of the
transverse portion of the aortic arch, though involved in approximately 15%
of cases. Often, surgical treatment is withheld if aortography suggests a
primary tear in the aortic arch. Similarly, resection is limited to the
ascending aorta despite intimal tears within the transverse portion of the
arch. This work reports a 9- year experience with a policy of emergency
resection for all acute aortic dissections involving the aortic arch.
Intensive "antiimpulse" therapy is instituted and aortic angiograms are
obtained. Type A dissections are resected under moderate hypothermia and,
if the primary tear extends into the arch or is not found in the ascending
aorta, the arch is explored during a brief period of deep hypothermia and
circulatory arrest. If necessary, the arch is replaced during circulatory
arrest, the patient's head is packed in ice, steroids are administered, and
a barbiturate coma is induced. If arch replacement is anticipated
preoperatively, surface cooling is also employed. Sixteen acute (up to 14
days) and three subacute (15 to 28 days) transverse arch dissections were
treated in this manner between May 1979 and May 1988, with four (21%)
hospital deaths (25%, acute; 0%, subacute). Mortality was related to left
main coronary dissection with extensive myocardial infarction in two of our
four cases, a third death was related to persistent seizures in a renal
transplant patient requiring hemodialysis who had lupus cerebritis, and the
fourth resulted from rupture of the descending aorta 15 days after arch
replacement.(ABSTRACT TRUNCATED AT 250 WORDS)
ARTICLES
Urgent operation for acute transverse aortic arch dissection
Division of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, N.Y. 10029.
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