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Surgery_Schwartz. most of the transverse aortic arch, except for the dorsal segment containing the brachiocephalic arteries, is removed. An appropriately sized, sealed (with collagen or gelatin) polyester tube graft is selected, and the beveled distal anastomosis is made with continuous 3-0 or 4-0 monofilament suture; the potential space between the true and false lumen can be obliterated with a small amount of surgical adhesive or by using a strip of Teflon felt. To improve hemostasis, the distal anastomosis can be reinforced by placing interrupted mattress sutures with felt pledgets. D. After cardiopulmonary bypass is resumed and a cross-clamp is applied to the hemiarch replacement graft, the aortic valve is assessed. Disrupted commissures are resuspended with pledgeted mattress sutures to restore valvular competence. E. The aorta is generally transected at the sinotubular junction, and a very small amount of surgical adhesive can be applied between the true and false lumens, or more commonly, the


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Surgery_Schwartz. competence. E. The aorta is generally transected at the sinotubular junction, and a very small amount of surgical adhesive can be applied between the true and false lumens, or more commonly, the false lumen within the proximal aortic stump is obliterated by inserting a semicircle of felt within the false lumen of the noncoronary sinus. The trimmed edges are brought together by using 6-0 polypropylene sutures. F. The proximal anastomosis is carried out at the sinotubular junction, incorporating the distal margin of the commissures. G. In patients with residual distal aortic dissection (such as in DeBakey type I aortic dissection), hemiarch repair can be extended with antegrade stent delivery to the descending thoracic aorta. (Used with permission of Baylor College of Medicine.)ACFGDEBBrunicardi_Ch22_p0853-p0896.indd 88301/03/19 5:42 PM 884SPECIFIC CONSIDERATIONSPART IIrecommendation for this subset of patients.204 Another alter-native employs separate grafts: a standard polyester


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Surgery_Schwartz. 88301/03/19 5:42 PM 884SPECIFIC CONSIDERATIONSPART IIrecommendation for this subset of patients.204 Another alter-native employs separate grafts: a standard polyester graft to replace the ascending aorta and proximal hemiarch, and a stent graft delivered antegrade into the descending thoracic aorta (Fig. 22-23G). Although this procedure differs from a formal “frozen elephant trunk” repair in that it does not replace the entire arch, it is meant to achieve the same goal: promoting remodeling of the dissected descending aortic segment.Chronic Dissection Occasionally, patients with ascending aor-tic dissection present for repair in the chronic phase. In most respects, the operation is similar to that for acute dissection repair. One notable difference is that the tissue is stronger in chronic dissection than in acute dissection, which makes sutur-ing safer. In addition, the false lumen is not obliterated at the distal anastomosis; instead, the dissecting membrane is fenes-trated into


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Surgery_Schwartz. dissection than in acute dissection, which makes sutur-ing safer. In addition, the false lumen is not obliterated at the distal anastomosis; instead, the dissecting membrane is fenes-trated into the arch to assure perfusion of both lumens and to prevent postoperative malperfusion complications. Unlike operations for acute dissection, operations for chronic dissec-tion are often aggressive repairs that extend into the arch and root because the tissues are much less fragile.Treatment of Descending Aortic Dissection Nonoperative Management Nonoperative, pharmacologic management of acute descending aortic dissection results in lower morbidity and mortality rates than traditional open surgi-cal treatment does.174 The most common causes of death during nonoperative treatment are aortic rupture and end-organ malp-erfusion. Therefore, patients are continually reassessed for new complications. Serial CT scans are generally obtained during the index hospitalization—usually on day 2 or 3 and on


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Surgery_Schwartz. and end-organ malp-erfusion. Therefore, patients are continually reassessed for new complications. Serial CT scans are generally obtained during the index hospitalization—usually on day 2 or 3 and on day 8 or 9 of treatment—and compared with the initial scan to rule out significant aortic expansion.Once the patient’s condition has been stabilized, phar-macologic management is gradually shifted from IV to oral medications. Oral therapy, usually including a b-antagonist, is initiated when systolic pressure is consistently between 100 and 110 mmHg and the neurologic, renal, and cardiovascular systems are stable. Many patients can be discharged after their blood pressure is well controlled with oral agents and after serial CT scans confirm the absence of aortic expansion.Long-term pharmacologic therapy is important for patients with chronic aortic dissection. b-Blockers remain the drugs of choice.205 In a 20-year follow-up study, DeBakey and col-leagues206 found that inadequate blood


Surgery_Schwartz

Surgery_Schwartz. therapy is important for patients with chronic aortic dissection. b-Blockers remain the drugs of choice.205 In a 20-year follow-up study, DeBakey and col-leagues206 found that inadequate blood pressure control was associated with late aneurysm formation. Aneurysms developed in only 17% of patients with “good” blood pressure control, compared with 45% of patients with “poor” control.Aggressive imaging follow-up is recommended for all patients with chronic aortic dissection.207 Both contrast-enhanced CT and MRA scans provide excellent aortic imag-ing and facilitate serial comparisons to detect progressive aortic expansion. The first surveillance scan is obtained approximately 6 weeks after the onset of dissection. Subsequent scans are obtained at 3 to 6 months and then at 1 year after onset. If the aorta appears to be stable, imaging is obtained annually there-after. Scans are obtained more frequently in high-risk patients, such as those with Marfan or Loeys-Dietz syndrome, and in those


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Surgery_Schwartz. If the aorta appears to be stable, imaging is obtained annually there-after. Scans are obtained more frequently in high-risk patients, such as those with Marfan or Loeys-Dietz syndrome, and in those in whom significant aortic expansion is detected. For patients who have undergone graft repair of descending aor-tic dissection, annual CT or MRA scans are also obtained to detect false aneurysm formation or dilatation of unrepaired seg-ments of aorta. Early detection of worrisome changes allows timely, elective intervention before rupture or other complica-tions develop; rupture of the distal aorta is relatively common in patients with chronic aortic dissection and often results in death.192Indications for Open Surgery In the acute phase of descend-ing aortic dissection, open surgery has been traditionally reserved for patients who experience complications.208 Compli-cated acute distal aortic dissections are those with aortic rupture, increasing periaortic or pleural fluid volume, rapidly


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Surgery_Schwartz. traditionally reserved for patients who experience complications.208 Compli-cated acute distal aortic dissections are those with aortic rupture, increasing periaortic or pleural fluid volume, rapidly expanding aortic diameter, uncontrolled hypertension, and persistent pain despite adequate medical therapy and malperfusion. In general terms, emergency open operations were originally intended to prevent or repair rupture and relieve life-threatening ischemic manifestations. However, open operation is associated with high morbidity in such cases; now that stent graft technology is available, endovascular surgical intervention is recommended for patients with complicated acute distal aortic dissection.Acute dissection superimposed on a preexisting aneu-rysm is considered a life-threatening condition and is therefore another indication for operation. Finally, patients who have a history of noncompliance with medical therapy may ultimately benefit more from surgical intervention if they are


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Surgery_Schwartz. and is therefore another indication for operation. Finally, patients who have a history of noncompliance with medical therapy may ultimately benefit more from surgical intervention if they are otherwise reasonable operative candidates.In the chronic phase, the indications for open surgical inter-vention for aortic dissection are similar to those for degenerative thoracic aortic aneurysm, although a slightly lower threshold of repair is now recommended. Guidelines for thoracic aortic disease44 recommend elective operation in otherwise healthy patients when the affected segment has reached a diameter of 5.5 cm, especially in patients with heritable disorders. Rapid aortic enlargement and other factors that increase the likelihood of aortic rupture may also be considered.Endovascular Treatment Malperfusion Syndrome Endovascular therapy is routinely used in patients with descending aortic dissection complicated by visceral malperfusion.209 Abdominal malperfusion syn-drome often is fatal;


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Surgery_Schwartz. Syndrome Endovascular therapy is routinely used in patients with descending aortic dissection complicated by visceral malperfusion.209 Abdominal malperfusion syn-drome often is fatal; prompt identification of visceral ischemia and expedited treatment to restore hepatic, gastrointestinal, and renal perfusion are imperative for a positive outcome. As described in a later section, several open surgical techniques can be used to reestablish blood flow to compromised organs. However, in acute cases, open surgery is associated with poor outcomes. Therefore, endovascular intervention is the pre-ferred initial approach in such cases. In one endovascular tech-nique known as endovascular fenestration, a balloon is used to create a tear in the dissection flap, which allows blood to flow in both the true and false lumens. Although endovascular fen-estration was commonly used in the past, its use has declined in recent years as direct aortic and branch-vessel stenting tech-niques have evolved and


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Surgery_Schwartz. true and false lumens. Although endovascular fen-estration was commonly used in the past, its use has declined in recent years as direct aortic and branch-vessel stenting tech-niques have evolved and gained favor. Placing a stent graft in the true lumen of the aorta can resolve a “dynamic” malperfu-sion. Occasionally, a small stent must be placed directly in the lumen of a visceral or renal artery because the dissection has propagated into the branch, resulting in “static” malperfusion at the origin.209Iliofemoral malperfusion causing limb-threatening leg ischemia also can be treated via an endovascular approach. Limb malperfusion usually resolves after the endovascular repair of acute descending thoracic aortic dissection. If the malperfusion does not resolve, then a femoral-to-femoral arterial bypass graft is an effective option.Brunicardi_Ch22_p0853-p0896.indd 88401/03/19 5:42 PM 885THORACIC ANEURYSMS AND AORTIC DISSECTIONCHAPTER 22Acute Dissection Although surgery has been


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Surgery_Schwartz. arterial bypass graft is an effective option.Brunicardi_Ch22_p0853-p0896.indd 88401/03/19 5:42 PM 885THORACIC ANEURYSMS AND AORTIC DISSECTIONCHAPTER 22Acute Dissection Although surgery has been traditionally recommended for patients with complicated acute descending aortic dissection, many centers have shifted toward using endo-vascular stent grafts as the preferred approach in these cases because of the high morbidity associated with the open opera-tion. Evidence suggests that emergent endovascular repair in patients with true lumen collapse and complications such rupture or dynamic malperfusion may be lifesaving in these difficult-to-treat patients. However, these patients remain at risk of further complication or future reintervention. Although endovascular repair in patients with heritable aortic disorders is generally not recommended, this technique can be used as a bridge to later, definitive repair in such life-threatening circumstances.66Controversy exists regarding the


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Surgery_Schwartz. heritable aortic disorders is generally not recommended, this technique can be used as a bridge to later, definitive repair in such life-threatening circumstances.66Controversy exists regarding the use of endovascular stent grafts to treat uncomplicated acute descending dissection; some encouraging data have been published in the last couple of years.210 The goal of this treatment strategy is to use the stent graft to cover the intimal tear, seal the entry site of the dis-section, and eventually cause thrombosis of the false lumen to aid in aortic remodeling and reduce late aortic expansion. Such procedures take place in a hybrid operating room. After the true lumen is accessed through the femoral arteries, an aor-togram is taken, and the intimal tear is identified. Note that the diameter of the true lumen is measured on the preoperative contrast-enhanced CT scan. The use of IVUS is encouraged to help access the true lumen, verify navigation of the wire inside the true lumen, and


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Surgery_Schwartz. of the true lumen is measured on the preoperative contrast-enhanced CT scan. The use of IVUS is encouraged to help access the true lumen, verify navigation of the wire inside the true lumen, and confirm measurements. For these cases, a stent graft is selected with a diameter no more than 10% greater than that of the true lumen. Unlike stents deployed to treat most descending thoracic aortic aneurysms, stents deployed to treat descending thoracic aortic dissections must not be ballooned, because ballooning can cause a new intimal tear, retrograde dissection into the ascending aorta, or even aortic rupture. The ideal length of the descending thoracic aorta that should be cov-ered in patients with acute distal descending dissection remains unclear. Close monitoring with serial imaging is necessary after endovascular repair because the false lumen remains at risk for retrograde perfusion or pressurization.Chronic Dissection Endovascular treatment of chronic descend-ing aortic dissection


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Surgery_Schwartz. after endovascular repair because the false lumen remains at risk for retrograde perfusion or pressurization.Chronic Dissection Endovascular treatment of chronic descend-ing aortic dissection is supported by the 5-year data of the INSTEAD-XL trial, which showed that endovascular repair com-bined with optimal medical treatment was associated with slower disease progression and greater aorta-specific survival than opti-mal medical treatment alone.211 Importantly, patients in the trial had dissections in the early chronic phase, many within 10 to 12 weeks of onset and all within 1 year of onset. Endovascular repair of chronic dissection is particularly challenging because the rela-tive rigidity of the dissecting membrane—which increases over time during the chronic phase—and the presence of multiple reen-try sites make it difficult to exclude the false lumen.Penetrating Aortic Ulcer Patients with PAUs appear to be good candidates for endovascular intervention. Covering the focal


Surgery_Schwartz

Surgery_Schwartz. of multiple reen-try sites make it difficult to exclude the false lumen.Penetrating Aortic Ulcer Patients with PAUs appear to be good candidates for endovascular intervention. Covering the focal ulceration with a stent graft has been shown to be an effec-tive treatment.212 In a recent study by Patel and colleagues,213 endovascular repair of PAU was associated with better early outcomes than open repair. However, when PAU was associ-ated with adjacent hematoma within the aortic wall, rates of subsequent reintervention were increased.Open Repair Acute Dissection In patients with acute aortic dissection, open surgical repair of the descending thoracic or thoracoabdominal aorta has been traditionally associated with high morbidity and mortality.174 Therefore, surgery was generally only performed to prevent fatal rupture or to restore branch-vessel perfusion in patients with complicated dissection.208 With the evolution of endovascular technology, open repair has fallen out of favor in


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Surgery_Schwartz. to prevent fatal rupture or to restore branch-vessel perfusion in patients with complicated dissection.208 With the evolution of endovascular technology, open repair has fallen out of favor in recent years.Malperfusion Syndrome In patients with malperfusion, when an endovascular approach is unavailable or unsuccessful, open surgery is necessary. Lower-extremity ischemia can be readily addressed with surgical extra-anatomic revascularization techniques, such as femoral-to-femoral bypass grafting. In patients with abdominal organ ischemia, flow to the compromised bed must be reestab-lished swiftly. Although they are considered second-line therapies, multiple techniques are available, including graft replacement of the aorta (with flow redirected into the true lumen), open aortic fenestration, and visceral or renal artery bypass.Chronic Dissection A more aggressive replacement usually is performed during elective aortic repairs in patients with chronic dissection. In many regards, the


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Surgery_Schwartz. and visceral or renal artery bypass.Chronic Dissection A more aggressive replacement usually is performed during elective aortic repairs in patients with chronic dissection. In many regards, the operative approach used in these patients is identical to that used for descending thoracic and tho-racoabdominal aortic aneurysms, as described in the first half of this chapter (Fig. 22-24). One key difference is the need to excise as much dissecting membrane as possible to clearly identify the true and false lumens and to locate all important branch vessels. When the dissection extends into the visceral or renal arteries, the membrane can be fenestrated, or the false lumen can be obliter-ated with sutures or intraluminal stents. Asymmetric expansion of the false lumen can create wide separation of the renal arteries. This problem is addressed by reattaching the mobilized left renal artery to a separate opening in the graft or by performing a left renal artery bypass with a side graft.


Surgery_Schwartz

Surgery_Schwartz. of the renal arteries. This problem is addressed by reattaching the mobilized left renal artery to a separate opening in the graft or by performing a left renal artery bypass with a side graft. Wedges of dissecting mem-brane also are excised from the aorta adjacent to the proximal and distal anastomoses, which allows blood to flow through both true and false lumens. When placing the proximal clamp is not technically feasible, hypothermic circulatory arrest can be used to facilitate the proximal portion of the repair.OUTCOMESImprovements in anesthesia, surgical techniques, and periopera-tive care have led to substantial improvements in outcome after thoracic aortic aneurysm repair. When performed in specialized centers, these operations are associated with excellent survival rates and acceptable morbidity rates. The interpretation of out-comes data is complicated by site-specific variables, such as the number of years reported and whether data are taken from single-practice centers or


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Surgery_Schwartz. morbidity rates. The interpretation of out-comes data is complicated by site-specific variables, such as the number of years reported and whether data are taken from single-practice centers or from pooled, multicenter, or national registries, and by patient-specific variables, such as type of enrollment, urgency and extent of repair, concomitant proce-dures performed, and the presence of preexisting risk factors such as advanced age, previous cardiovascular repair, disease of any system or organ, or heritable conditions.Repair of Proximal Aortic AneurysmsRisks associated with the open repair of the proximal aorta vary by extent of repair and are greatest for repairs involving total arch replacement.71,214 All varieties of aortic root replacement have shown acceptable early mortality rates and few complica-tions. Two groups with 20 and 27 years’ experience with com-posite valve graft replacement reported early mortality rates of 5.6% and 1.9%, respectively; the more recent repairs had


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Surgery_Schwartz. and few complica-tions. Two groups with 20 and 27 years’ experience with com-posite valve graft replacement reported early mortality rates of 5.6% and 1.9%, respectively; the more recent repairs had better outcomes.215,216 Early mortality rates for stentless porcine Brunicardi_Ch22_p0853-p0896.indd 88501/03/19 5:42 PM 886SPECIFIC CONSIDERATIONSPART IIFigure 22-24. Illustration of distal aortic repair of a chronic dissection. A. Thoracoabdominal incision. B. Extent II thoracoabdominal aortic aneurysm resulting from chronic aortic dissection. The patient has previously undergone composite valve graft replacement of the aortic root and ascending aorta. After left heart bypass is initiated, the proximal portion of the aneurysm is isolated by placing clamps on the left sub-clavian artery, between the left common carotid and left subclavian arteries, and across the middle descending thoracic aorta. C. The isolated segment of aorta is opened by using electrocautery. D. The dissecting


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Surgery_Schwartz. between the left common carotid and left subclavian arteries, and across the middle descending thoracic aorta. C. The isolated segment of aorta is opened by using electrocautery. D. The dissecting membrane is excised, and bleeding intercostal arteries are oversewn. The aorta is prepared for proximal anastomosis by transecting it distal to the proximal clamp and separating this portion from the esophagus (not shown). E. The proximal anastomosis between the aorta and an appropriately sized polyester graft is completed with continuous polypro-pylene suture. F. After left heart bypass has been stopped and the distal aortic cannula has been removed, the proximal clamp is repositioned onto the graft, the other two clamps are removed, and the remainder of the aneurysm is opened. G. The rest of the dissecting membrane is excised, and the openings to the celiac, superior mesenteric, and renal arteries are identified. H. Selective visceral perfusion with oxygenated blood from the bypass circuit


Surgery_Schwartz

Surgery_Schwartz. dissecting membrane is excised, and the openings to the celiac, superior mesenteric, and renal arteries are identified. H. Selective visceral perfusion with oxygenated blood from the bypass circuit is delivered through balloon perfusion catheters placed in the celiac and superior mesenteric arterial ostia. Cold crystalloid is delivered to the renal arteries. The critical intercostal arteries are reattached to an opening cut in the graft. I. To minimize spinal cord ischemia, the proximal clamp is repositioned distal to the intercostal reattachment site. A second oval opening is fashioned in the graft adjacent to the visceral vessels. Selective perfusion of the visceral arteries continues during their reattachment to the graft. A separate anas-tomosis is often required to reattach the left renal artery. J. After the balloon perfusion catheters are removed and the visceral anastomosis is completed, the clamp is again moved distally, restoring blood flow to the celiac, renal, and superior


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Surgery_Schwartz. artery. J. After the balloon perfusion catheters are removed and the visceral anastomosis is completed, the clamp is again moved distally, restoring blood flow to the celiac, renal, and superior mesenteric arteries. The final anastomosis is created between the graft and the distal aorta. (Reproduced with permission from Creager MA, Dzau VS, Loscalzo J: Vascular Medicine, 7th ed. Philadelphia, PA: Elsevier/Saunders; 2006.)Left heartbypasscircuitCold renalperfusionsystemFalselumenABCDEtissue root replacements are also low, ranging from 3.6% to 6.0%.217-221 Early mortality rates for contemporary valve-sparing approaches to aortic root replacement are quite low (1%–2%) in experienced centers.77,78,80,222,223 Late survival rates after valve-sparing root procedures range from 97% to 99% at 5 years80,222,223 and approach 94% at 10 years.80Repairs incorporating the ascending aorta and aortic arch have acceptable outcomes; risk increases with patient-specific factors such as severe


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Surgery_Schwartz. 99% at 5 years80,222,223 and approach 94% at 10 years.80Repairs incorporating the ascending aorta and aortic arch have acceptable outcomes; risk increases with patient-specific factors such as severe atherosclerosis224 or as larger sections of the aortic arch are incorporated into the repair.225,226 A revised surgical strategy—such as the use of hypothermic circulatory arrest—is often needed to avoid clamping atherosclerotic sections in the “porcelain” aorta. In Zingone and colleagues’ series224 of 64 patients who underwent replacement of atherosclerotic ascend-ing aorta, hypothermic circulatory arrest was used in 61 patients (95%). Even though these patients had substantial comorbidity and 83% underwent concomitant cardiac repairs, acceptable rates of early mortality (11%) and stroke (6%) were obtained. Other Brunicardi_Ch22_p0853-p0896.indd 88601/03/19 5:42 PM 887THORACIC ANEURYSMS AND AORTIC DISSECTIONCHAPTER 22Figure 22-24. (Continued)studies indicate that the enhanced risk of


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Surgery_Schwartz. were obtained. Other Brunicardi_Ch22_p0853-p0896.indd 88601/03/19 5:42 PM 887THORACIC ANEURYSMS AND AORTIC DISSECTIONCHAPTER 22Figure 22-24. (Continued)studies indicate that the enhanced risk of neurocognitive distur-bances in ascending repairs using circulatory arrest are not offset by lower rates of early mortality.227,228 Regarding extended proxi-mal repair, reported early mortality rates after traditional stage 1 elephant trunk repairs (primarily using island reattachment strate-gies) range from 2.3 to 13.9%.229-233Contemporary mortality rates for extensive proximal aortic repair have improved as new strategies and modified adjuncts have been adopted. For example, by adopting contem-porary approaches, we have reduced early mortality for stage 1 elephant trunk repairs from 12% to 2% in our patients.86,230 Similarly, in a report by Kazui and colleagues234 covering 20 years of experience and 472 consecutive patients who under-went aortic arch repair with selective ACP, operative


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Surgery_Schwartz. in our patients.86,230 Similarly, in a report by Kazui and colleagues234 covering 20 years of experience and 472 consecutive patients who under-went aortic arch repair with selective ACP, operative mortality was 16.0% for early repairs and 4.1% for more recent repairs. Other contemporary reports of the use of techniques such as moderate hypothermia and Y-graft approaches235-238 indicate similarly improved outcomes; early mortality ranges from 1% to 7%, stroke rates range from 1% to 6%, and no cases of para-plegia are reported. Although paraplegia has traditionally been an unusual and infrequent complication of aortic arch repair, it has been reported as a complication of “long” elephant trunk approaches239 and frozen elephant trunk approaches.240Because of the heterogeneity of hybrid arch approaches and the tendency to use these approaches in high-risk patients, results of hybrid arch repair are difficult to interpret. In a recent report from our group,65 among 319 consecutive


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Surgery_Schwartz. arch approaches and the tendency to use these approaches in high-risk patients, results of hybrid arch repair are difficult to interpret. In a recent report from our group,65 among 319 consecutive patients who underwent total arch replacement in the last 8.5 years, 274 patients had traditional open repair and 45 patients had hybrid zone 0 exclusion repairs. The rate of permanent adverse outcome (death, persistent neurologic deficit at dis-charge, or persistent hemodialysis at discharge) was not sig-nificantly different between the two groups. A higher overall stroke rate was noticed in the hybrid group, reinforcing the importance of catheter skills and careful wire manipulation. A meta-analysis conducted by Koullias and Wheatley241 of data from 15 studies with 463 patients found an average 30-day mortality rate of 8.3%; stroke, 4.4%; paraplegia, 3.9%; and endoleak, 9.2%. Of note, relatively few repairs (30%) were performed “off-pump,” and the majority of repairs used cardiopulmonary


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Surgery_Schwartz. 30-day mortality rate of 8.3%; stroke, 4.4%; paraplegia, 3.9%; and endoleak, 9.2%. Of note, relatively few repairs (30%) were performed “off-pump,” and the majority of repairs used cardiopulmonary bypass or hypothermic circulatory arrest. Additionally, several reports of small series have documented increased risk of acute retrograde aortic dissection during hybrid arch repairs; rates range from 0% to 7.5%, and these patients face significant mortality risk (ranging from 33% to 100%) should this occur.108,109,242-244Brunicardi_Ch22_p0853-p0896.indd 88701/03/19 5:42 PM 888SPECIFIC CONSIDERATIONSPART IITreatment of Acute Ascending Aortic DissectionThe International Registry of Acute Aortic Dissection (IRAD) provides the most comprehensive data on contemporary out-comes in patients with acute aortic dissection. This registry was established in 1996 and has accumulated data from >7000 patients treated for acute aortic dissection at 51 centers in 12 countries. An IRAD analysis of data


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Surgery_Schwartz. acute aortic dissection. This registry was established in 1996 and has accumulated data from >7000 patients treated for acute aortic dissection at 51 centers in 12 countries. An IRAD analysis of data from 776 patients who underwent surgical repair of acute ascending aortic dissection revealed an in-hospital mortality rate of 23.8%.245 The investiga-tors identified several preoperative predictors of early mortality, including age >70 years, previous cardiac surgery, hypotension or shock at presentation, abrupt onset of symptoms, migrat-ing pain, cardiac tamponade, preoperative renal failure, pulse deficit, and evidence of myocardial ischemia or infarction on ECG.245,246 In a report from IRAD, in-hospital mortality after surgical treatment had decreased from 25% in 1995 to 18% in 2013.247 The German Registry for Acute Aortic Dissection (GERAADA) has collected data on more than 3300 patients from 56 centers since 2006. 248 In a report of 1436 patients with acute proximal dissection that


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Surgery_Schwartz. German Registry for Acute Aortic Dissection (GERAADA) has collected data on more than 3300 patients from 56 centers since 2006. 248 In a report of 1436 patients with acute proximal dissection that was surgically repaired using hypothermic circulatory arrest with or without unilateral and bilateral ACP, the early mortality rates ranged from 13.9% to 19.4%; the 628 patients with unilateral ACP had the lowest rate of early death.249 Operative mortality reported by North American centers varies from 5% to 17%; improvements in out-comes may be related to the implementation of protocol-based management and the assembly of thoracic aortic teams.203Repair of Distal Aortic AneurysmsEndovascular Repair of Descending Thoracic Aortic Aneurysms. In the earliest series of endovascular repairs of descending thoracic aortic aneurysms, mortality and morbidity were difficult to assess. Most of the reported series were small and included a large proportion of high-risk patients with sub-stantial


Surgery_Schwartz

Surgery_Schwartz. descending thoracic aortic aneurysms, mortality and morbidity were difficult to assess. Most of the reported series were small and included a large proportion of high-risk patients with sub-stantial comorbidity.250,251 Subsequent evidence from pivotal, nonrandomized trials that compared patients who underwent endograft exclusion with historical or concurrent patients who underwent open repair252-254 showed that the stent graft groups had significantly less morbidity and early mortality than the open repair groups, although in two of the trials, a nonsig-nificant between-group difference was observed in the rate of stroke.252,254 Five-year comparative data show that the two groups differed significantly in their aneurysm-related mortality rates (2.8% for endovascular patients and 11.7% for open repair patients) but not in their rates of all-cause mortality (which were 32% and 31%, respectively).255 Additional pivotal trial 5-year outcomes256 indicate the growing disparity between


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Surgery_Schwartz. for open repair patients) but not in their rates of all-cause mortality (which were 32% and 31%, respectively).255 Additional pivotal trial 5-year outcomes256 indicate the growing disparity between aneurysm-related (96.1%) and all-cause survival (58.5%) in patients with endovascular repair, leading some to comment on the possible futility of repair in many patients.257 Among 8967 patients iden-tified in the National Inpatient Sample database (8255 with open repair and 712 with endovascular repair), the odds of death were 46% lower among patients who underwent endovascular repair rather than open repair.56 The endovascular repair group also had lower odds of postoperative neurologic, cardiac, and respi-ratory complications.Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms. Contemporary results of open repairs of descending thoracic aortic aneurysms, including those performed in select patients with chronic dissection, indicate that early mor-tality rates range


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Surgery_Schwartz. results of open repairs of descending thoracic aortic aneurysms, including those performed in select patients with chronic dissection, indicate that early mor-tality rates range from 4.1% to 8.0%, renal failure rates range from to 4.2% to 7.5%, and paraplegia rates range from 2.3% to 5.7%; stroke rates are generally lower, ranging from 1.8% to 2.1%.258-260 In our series, although the risk of paraplegia increased with the extent of repair, the risk of mortality was greatest for those under-going repair of the proximal two thirds of the descending aorta.258 As expected, stroke rates after distal aortic repairs were highest when the clamp site was near the left subclavian artery.Contemporary series of open thoracoabdominal aortic repairs show acceptable survival. Reported outcome rates range from 5% to 12% for early mortality, 3.8% to 9.5% for paraple-gia, 1.7% to 5.2% for stroke, and 6% to 12% for renal compli-cations.261-265 Many of these series summarize 10 to 20 years of surgical


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Surgery_Schwartz. from 5% to 12% for early mortality, 3.8% to 9.5% for paraple-gia, 1.7% to 5.2% for stroke, and 6% to 12% for renal compli-cations.261-265 Many of these series summarize 10 to 20 years of surgical experience,262-265 although some present a shorter but more contemporary experience.261 Even for complex tho-racoabdominal aortic repairs, such as stage 2 elephant trunk repairs, several centers report acceptable early mortality rates ranging from 0% to 10%.229-233 Worse outcomes are also docu-mented, as in a statewide, nonfederal analysis of data from 1010 patients whose early mortality rate was 25%. Of note, 40% of these patients were treated at centers averaging only one tho-racoabdominal aortic aneurysm repair per year.266 Cowan and colleagues,267 who examined the influence of familiarity with the procedure on rates of mortality and morbidity after tho-racoabdominal aortic aneurysm repair, reported that patients treated at low-volume centers fared less well. Replacing the entire


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Surgery_Schwartz. with the procedure on rates of mortality and morbidity after tho-racoabdominal aortic aneurysm repair, reported that patients treated at low-volume centers fared less well. Replacing the entire thoracoabdominal aorta (i.e., performing an extent II repair) carries the highest risk of death, bleeding, renal failure, and paraplegia.118,262,263 Early survival has been estimated at 79% at 2 years,268 and mid-term survival has been estimated at 63% at 5 years.265 In our recent report of 3309 repairs,269 the overall mortality rate was 7.5%, and the rate of operative death was higher in extent II and III repairs than in extent I and IV. Perma-nent paraplegia and paraparesis occurred in 2.9% and 2.4% of patients, respectively, and the incidence of paraplegia in patients 50 years of age or younger was only 1.1%. Estimated survival after repair was 84% ± 1% at 1 year, 64% ± 1% at 5 years, 37% ± 1% at 10 years, and 18% ± 1% at 15 years.Treatment of Descending Thoracic Aortic


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Surgery_Schwartz. of age or younger was only 1.1%. Estimated survival after repair was 84% ± 1% at 1 year, 64% ± 1% at 5 years, 37% ± 1% at 10 years, and 18% ± 1% at 15 years.Treatment of Descending Thoracic Aortic DissectionNonoperative Management. The in-hospital mortality rate is 8.7% for patients with acute descending aortic dissection who receive nonoperative treatment247; however, when IRAD stratified patients according to clinical presentation, the mor-tality rate for patients with uncomplicated dissection was less than 4%, whereas the mortality rate for patients with compli-cated dissection was more than 20%.174,270 The primary causes of death during nonoperative management are rupture, malper-fusion, and cardiac failure. Risk factors associated with treat-ment failure—defined as death or need for surgery—include an enlarged aorta, persistent hypertension despite maximal treatment, oliguria, and peripheral ischemia. Among patients who receive nonoperative treatment for descending aortic


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Surgery_Schwartz. for surgery—include an enlarged aorta, persistent hypertension despite maximal treatment, oliguria, and peripheral ischemia. Among patients who receive nonoperative treatment for descending aortic dis-section and who survive the acute period, approximately 90% remain alive 1 year later, and approximately 76% are alive 3 years later.271Endovascular Treatment. For patients with complicated acute descending thoracic aortic dissection, including rupture and malperfusion of the visceral or renal arteries, an endovas-cular approach is ideal. The Stanford group reported a 93% technical success rate for endovascular reperfusion of an isch-emic bed.272 Their experience with the use of first-generation stent grafts to treat acute complicated descending dissections Brunicardi_Ch22_p0853-p0896.indd 88801/03/19 5:42 PM 889THORACIC ANEURYSMS AND AORTIC DISSECTIONCHAPTER 22was also encouraging: Complete thrombosis of the false lumen occurred in 79% of patients. The early mortality rate was 16%,


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Surgery_Schwartz. 88801/03/19 5:42 PM 889THORACIC ANEURYSMS AND AORTIC DISSECTIONCHAPTER 22was also encouraging: Complete thrombosis of the false lumen occurred in 79% of patients. The early mortality rate was 16%, comparable to that associated with open techniques.273 A meta-analysis of observational studies of endovascular repair, which included 248 patients with acute descending thoracic aortic dissection, found a 30-day mortality rate of 9.8%.274 When compared with early mortality rates obtained from IRAD data,174 this rate is substantially lower than the rate associated with open surgical treatment and is similar to the rate achieved with nonoperative management. However, patients with com-plicated acute descending dissection remain susceptible to late events; at 1 year, survival is approximately 70%, and reinterven-tion is needed in about 10% of survivors.275The ADSORB trial276 focused on patients with uncom-plicated acute descending thoracic aortic dissection. Patients were randomly assigned


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Surgery_Schwartz. and reinterven-tion is needed in about 10% of survivors.275The ADSORB trial276 focused on patients with uncom-plicated acute descending thoracic aortic dissection. Patients were randomly assigned to optimal medical therapy alone (n = 31) or endovascular repair plus optimal medical therapy (n = 30).277 The 1-year results showed aortic remodeling with false lumen thrombosis and reduced diameter in the group treated with endovascular repair.The INSTEAD-XL trial involved 140 patients with stable, early-chronic descending thoracic aortic dissection who were randomly assigned to either endovascular repair plus opti-mal medical treatment or optimal medical therapy alone.211 The eagerly anticipated 5-year data showed that endovascular repair was associated with greater survival and slower disease progression.CONCLUSIONSAortic aneurysm may present as localized or extensive dis-ease. The availability and development of adjuncts and endo-vascular techniques have supported the constant


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Surgery_Schwartz. disease progression.CONCLUSIONSAortic aneurysm may present as localized or extensive dis-ease. The availability and development of adjuncts and endo-vascular techniques have supported the constant evolution of surgical strategies to tackle these complex problems. Repair strategies range from isolated, totally endovascular aortic repair for descending thoracic aneurysms to extensive total aortic and staged replacements with a combination of both open and endovascular techniques. Regardless of the difficulty of accu-rately assessing the risks associated with aortic repair, surgical repair of the thoracoabdominal aorta clearly remains the most challenging aortic repair in terms of mortality and morbidity. Accordingly, replacing the entire thoracoabdominal aorta (i.e., performing an extent II repair) carries the highest risk of death, renal failure, and paraplegia.69,70,261,263,269ACKNOWLEDGMENTSThe authors wish to thank Susan Y. Green, MPH, and Stephen N. Palmer, PhD, ELS, for editorial


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Surgery_Schwartz. repair) carries the highest risk of death, renal failure, and paraplegia.69,70,261,263,269ACKNOWLEDGMENTSThe authors wish to thank Susan Y. Green, MPH, and Stephen N. Palmer, PhD, ELS, for editorial assistance; Scott A. Weldon, MA, CMI, and Carol P. Larson, CMI, for creating the illus-trations; and Kapil Sharma, MD, and Raja Gopaldas, MD, for their substantial contributions to the chapters published in the 9th and 10th editions of this book, on which this updated chapter is based.REFERENCESEntries highlighted in bright blue are key references. 1. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommit-tee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg. 1991;13(3):452-458. 2. Bickerstaff LK, Pairolero PC, Hollier LH, et al. Thoracic aortic aneurysms: a population-based


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Surgery_Schwartz. American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg. 1991;13(3):452-458. 2. Bickerstaff LK, Pairolero PC, Hollier LH, et al. Thoracic aortic aneurysms: a population-based study. Surgery. 1982;92(6):1103-1108. 3. Shen YH, LeMaire SA. Molecular pathogenesis of genetic and sporadic aortic aneurysms and dissections. Curr Probl Surg. 2017;54(3):95-155. A contemporary, comprehensive review of the pathobiology underlying aortic disease. 4. Eagle KA, GenTAC Consortium. Rationale and design of the National Registry of Genetically Triggered Thoracic Aor-tic Aneurysms and Cardiovascular Conditions (GenTAC). Am Heart J. 2009;157(2):319-326. 5. Segura AM, Luna RE, Horiba K, et al. Immunohistochemistry of matrix metalloproteinases and their inhibitors in thoracic aortic aneurysms and aortic valves of patients with Marfan’s syndrome. Circulation. 1998;98(19 suppl):II331-II337. 6. Neptune ER, Frischmeyer PA, Arking DE, et al. Dysregula-tion of TGF-β activation


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Surgery_Schwartz. bicuspid aortic valves: a surgical pathology study of 542 cases (1991 through 1996) and a literature review of 2,715 addi-tional cases. Mayo Clin Proc. 1999;74(1):14-26. 24. Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol. 1984;53(6):849-855. 25. LeMaire SA, Wang X, Wilks JA, et al. Matrix metalloprotein-ases in ascending aortic aneurysms: bicuspid versus trileaflet aortic valves. J Surg Res. 2005;123(1):40-48. 26. Fedak PW, de Sa MP, Verma S, et al. Vascular matrix remod-eling in patients with bicuspid aortic valve malformations: implications for aortic dilatation. J Thorac Cardiovasc Surg. 2003;126(3):797-806. 27. Koullias GJ, Korkolis DP, Ravichandran P, et al. Tissue microarray detection of matrix metalloproteinases, in dis-eased tricuspid and bicuspid aortic valves with or without pathology of the ascending aorta. Eur J Cardiothorac Surg. 2004;26(6):1098-1103. 28. Martin LJ, Ramachandran V, Cripe LH, et al. Evidence in favor


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Surgery_Schwartz. history of thoracic aortic aneu-rysms: indications for surgery, and surgical versus non-surgical risks. Ann Thorac Surg. 2002;74(5):S1877-S1880. This classic longitudinal study identified “hinge points” for complications of ascending and descending thoracic aortic aneurysm, forming the basis for key diameter thresholds for elective repair. 37. Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple predic-tion based on size. Ann Thorac Surg. 2002;73(1):17-27. 38. Murdoch JL, Walker BA, Halpern BL, Kuzma JW, McKusick VA. Life expectancy and causes of death in the Marfan syn-drome. N Engl J Med. 1972;286(15):804-808. 39. Michel PL, Acar J, Chomette G, Iung B. Degenerative aortic regurgitation. Eur Heart J. 1991;12(8):875-882. 40. Prenger K, Pieters F, Cheriex E. Aortic dissection after aortic valve replacement: incidence and consequences for strategy. J Card Surg. 1994;9(5):495-498. 41. Bonow RO. Bicuspid aortic valves and


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Surgery_Schwartz. on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;67(6):724-731. Important clarification of conflicting guidelines regarding indications for surgical treatment in patients with bicuspid aortic valve. 44. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guide-lines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Associa-tion for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiogra-phy and Interventions, Society of Interventional Radiol-ogy, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121(13):e266-e369. Compre-hensive guidelines regarding a broad range of diagnosis and treatment issues, based on review and ranking of the available evidence in


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Surgery_Schwartz. paraplegia rates after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 2003;75(2):508-513. 70. LeMaire SA, Miller CC, III, Conklin LD, et al. A new pre-dictive model for adverse outcomes after elective thora-coabdominal aortic aneurysm repair. Ann Thorac Surg. 2001;71(4):1233-1238. 71. Preventza O, Coselli JS, Price MD, et al. Elective primary aortic root replacement with and without hemiarch repair in patients with no previous cardiac surgery. J Thorac Cardio-vasc Surg. 2017;153(6):1402-1408. 72. Gott VL, Cameron DE, Alejo DE, et al. Aortic root replace-ment in 271 Marfan patients: a 24-year experience. Ann Tho-rac Surg. 2002;73(2):438-443. 73. Preventza O, Mohamed AS, Cooley DA, et al. Homograft use in reoperative aortic root and proximal aortic surgery for endo-carditis: a 12-year experience in high-risk patients. J Thorac Cardiovasc Surg. 2014;148(3):989-994. 74. Carrel TP, Berdat P, Englberger L, et al. Aortic root replace-ment with a new stentless aortic valve


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Surgery_Schwartz. a 12-year experience in high-risk patients. J Thorac Cardiovasc Surg. 2014;148(3):989-994. 74. Carrel TP, Berdat P, Englberger L, et al. Aortic root replace-ment with a new stentless aortic valve xenograft conduit: pre-liminary hemodynamic and clinical results. J Heart Valve Dis. 2003;12(6):752-757. 75. Deleuze PH, Fromes Y, Khoury W, et al. Eight-year results of Freestyle stentless bioprosthesis in the aortic position: a single-center study of 500 patients. J Heart Valve Dis. 2006;15(2):247-252. 76. Oury JH. Clinical aspects of the Ross procedure: indica-tions and contraindications. Semin Thorac Cardiovasc Surg. 1996;8(4):328-335. 77. Coselli JS, Hughes MS, Green SY, et al. Valve-sparing aortic root replacement: early and midterm outcomes in 83 patients. Ann Thorac Surg. 2014;97(4):1267-1273. 78. Coselli JS, Volguina IV, LeMaire SA, et al. Early and 1-year outcomes of aortic root surgery in patients with Marfan syndrome: a prospective, multicenter, comparative study. J Thorac


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Surgery_Schwartz. JS, Volguina IV, LeMaire SA, et al. Early and 1-year outcomes of aortic root surgery in patients with Marfan syndrome: a prospective, multicenter, comparative study. J Thorac Cardiovasc Surg. 2014;147(6):1758-1766, 1767.e1751-e1754. This report details the early and 1-year outcomes of an international prospective study comparing valve-sparing and valve-replacing root operations in patients with Marfan syndrome. Although patients in both groups had excellent early outcomes, those who underwent valve-sparing procedures had a higher incidence of late aortic valve regur-gitation, raising concerns about long-term durability. 79. David TE, Ivanov J, Armstrong S, Feindel CM, Webb GD. Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta. Ann Thorac Surg. 2002;74(5):S1758-S1761. 80. Kvitting JP, Kari FA, Fischbein MP, et al. David valvesparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective


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