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Long-term experience with descending aortic dissection: the complication-specific approach
J A Elefteriades1, J Hartleroad, R J Gusberg
1Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, CT 06510.
Insights
This study on descending aortic dissection found that a complication-specific approach improves outcomes. Surgical interventions like fenestration and thromboexclusion are effective for complicated cases, while medical management is suitable for uncomplicated dissections.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Thoracic Surgery
Background:
- Descending aortic dissection is a life-threatening condition requiring careful management.
- Long-term outcomes for medical versus surgical treatment remain a critical area of study.
Purpose of the Study:
- To analyze long-term results of medical and surgical treatments for descending aortic dissection.
- To evaluate the effectiveness of specific surgical techniques including fenestration and thromboexclusion.
Main Methods:
- Retrospective analysis of 71 patients with descending aortic dissection treated over 17 years.
- Comparison of actuarial survival rates between medically and surgically treated groups.
- Detailed assessment of surgical procedures: graft replacement, fenestration, and thromboexclusion.
Main Results:
- Overall 10-year survival was 28%. Medical management showed 10-year survival of 25%, while surgical management had 5-year survival of 28%.
- Fenestration demonstrated 5-year survival of 53% and was found safe and effective.
- Thromboexclusion was effective in achieving thrombosis of the false lumen.
Conclusions:
- A complication-specific approach to descending aortic dissection management is recommended.
- Uncomplicated dissection should be treated medically.
- Complicated dissections require surgical intervention tailored to the specific complication.
Abstract:
We analyzed long-term results in 71 patients (45 men and 26 women) treated over 17 years for documented descending aortic dissection. Forty-nine patients were treated medically and 22, surgically. Actuarial survival was 65% at 1 year, 57% at 3 years, 50% at 5 years, and 28% at 10 years for the whole group. For the group treated medically, survival was 73%, 63%, 58%, and 25% at 1 year, 3 years, 5 years, and 10 years, respectively, and for the group treated surgically, 47%, 40%, and 28% at 1 year, 3 years, and 5 years, respectively. Ten (20.4%) of the 49 medically treated patients died early (5 of rupture), and 14 (28.6%) died late (8 of dissection). Five medically treated patients crossed over to surgical management for complications of dissection. Among the surgically treated patients, 6 underwent standard graft replacement of the proximal descending aorta, 8 underwent the fenestration procedure (with a standardized retroperitoneal abdominal approach), and 4 underwent the thromboexclusion operation. Specific analysis of fenestration in 14 patients (including some with persistent descending aortic dissection after replacement of the ascending aorta for dissection) found it to be safe and effective. Actuarial survival after fenestration was 77%, 77%, and 53% at 1 year, 3 years, and 5 years, respectively. Thromboexclusion was found effective, and postoperative studies confirmed thrombosis of the descending aorta with preservation of the lowest intercostal arteries. Fifteen of the 21 surviving medically treated patients agreed to return for follow-up imaging. Nine had thrombosis of the false lumen. An interesting radiographic finding was that 4 of the 15 restudied patients had a saccular aneurysm in the aorta at the level of the left subclavian artery. We recommend a complication-specific approach to the management of descending aortic dissection. Uncomplicated dissection is treated medically, whereas complicated dissection is treated surgically, with realized rupture treated by standard graft replacement, limb ischemia treated by fenestration, and enlargement or impending rupture treated by thromboexclusion.