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Management of Chronic Descending Thoracic and Thoracoabdominal Dissection…
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a b c
Fig. 6 Coil embolization and glue injection of a patent false lumen. Large patent false lumen following TEVAR (a). Deployment of coils and injection of glue in the false lumen (b, red arrow).
Postoperative CTA showing thrombosed false lumen and decreased total aortic diameter (c)
in combination with open surgery. In our opinion, for most patients, TEVAR and
open surgery are complimentary, not competitive, in the treatment of CTBAD.
The future of TEVAR for CTBAD probably lies in the proper use of fenestrated
and/or branched stent-grafts proximally and distally and at the peri-visceral level.
This would eliminate suboptimal landing zones. Proximal thoracic aortic operations
may hold the key to the technical success of TEVAR by creating the ideal proximal
landing zone. This could be accomplished with open arch debranching operations or
with the use of branched arch stent-grafts. When total aortic coverage is planned,
staging the procedure may decrease the risk of spinal cord injury.
Disclosures
Terumo Aortic: investigator, advisory board, speaker.
WL Gore: investigator.
Medtronic: investigator, advisory board, speaker.
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R. Assi and W. Y. Szeto
Management of Chronic Dissection
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of the Descending Thoracic and
Thoracoabdominal Aorta:
Open Approach
CuneytKöksoy, AliceLe Huu, andJosephS.Coselli
Introduction
Although the chronic phase of aortic dissection is generally considered to begin
2weeks after the onset of dissection-related symptoms, open repair of chronic distal
aortic dissection is typically performed a few years after the acute precipitating
event. The dissection process itself substantially weakens the outer aortic wall, leading to aortic dilatation; thus, over a highly variable period, a dissected aorta that is
originally of normal diameter often dilates and becomes aneurysmal. Chronic dissection in the distal aorta occurs in survivors of acute DeBakey type I and III dissection events (Fig.1). Regardless of type, chronic aortic dissection is a progressive
disease that necessitates lifelong management to avoid late rupture and ischemic events.
C. Köksoy
Division of Cardiothoracic Surgery, Michael E.DeBakey Department of Surgery,
Baylor College of Medicine, Houston, TX, USA
A. Le Huu
Division of Cardiothoracic Surgery, Michael E.DeBakey Department of Surgery,
Baylor College of Medicine, Houston, TX, USA
Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
J. S. Coselli (
Division of Cardiothoracic Surgery, Michael E.DeBakey Department of Surgery,
Baylor College of Medicine, Houston, TX, USA
Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
Department of Cardiovascular Surgery, CHI St. Luke’s Health—Baylor St. Luke’s Medical
Center, Houston, TX, USA
e-mail: jcoselli@bcm.edu
J. S. Coselli et al. (eds.), Aortic Dissection and Acute Aortic Syndromes,
https://doi.org/10.1007/978-3-030-66668-2_30
*)
423© Springer Nature Switzerland AG 2021
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C. Köksoy et al.
ab
Fig. 1 Drawings showing the repair of chronic aortic dissection. (a) Gross dilatation of the distal
aorta, 6years after proximal aortic repair in a survivor of DeBakey type I aortic dissection. (b) The
completed extent II thoracoabdominal aortic repair; a 4-branched graft was used to replace widely
displaced visceral arteries. (c) A narrow true lumen (double arrows) within a dilatated distal aorta
in a survivor of DeBakey type III aortic dissection, 5years after onset. (d) The completed extent II
thoracoabdominal aortic repair; a single patch incorporates the 4 visceral arteries. Used with permission of Baylor College of Medicine
Chronic distal aortic dissection affects roughly 15–40% of patients who undergo
open repair of the descending thoracic (DTA) and thoracoabdominal aorta (TAAA)
[1–5]. Our review of 4275 DTA and TAAA repairs performed between 1986 and
2019 identied 1362 (31.9%) chronic aortic dissections of DeBakey types I (n=578,
13.5%), IIIa (n=150, 3.5%), and IIIb (n=634, 14.8%). Compared with the majority of patients who undergo open repair for degenerative aneurysm, patients with
chronic dissection tend to be a decade younger (i.e., 50s vs 60s) and have far fewer
comorbidities related to the atherosclerotic process. Additionally, approximately
1in 4 patients with chronic distal aortic dissection has Marfan syndrome (MFS) or
a related heritable thoracic aortic disease, as compared to 1 in 10 patients with
degenerative aneurysm without dissection [1, 6, 7].
Factors suggested to signicantly affect chronic aneurysm development after
aortic dissection include poorly controlled hypertension and anatomic factors such
as a maximal aortic diameter ≥4cm in the acute phase, continued patency of the
false lumen, partial thrombosis of the distal false lumen, and a proximal entry tear
≥10mm [8–11].
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Natural History
The chronically dissected aorta tends to dilate at a faster rate than a non-dissected
one. Although it is generally assumed that both DeBakey types of chronically dissected aorta dilate at similar rates, evidence suggests otherwise [12, 13]. In survivors of DeBakey type I dissection, the persistence of a pressurized false lumen has
been associated with subsequent distal aneurysm formation, need for intervention,
and greater mortality [10, 14]. In an attempt to thrombose the false channel and
thereby decrease the risk of late aneurysm formation, endovascular strategies have
been developed to exclude segments of the false lumen in both acute (≤2weeks
since onset) [15] and chronic [16] aortic dissection. The effectiveness of such
approaches is dependent on a variety of factors, including the extent of aortic dissection, because downstream portions of the false lumen—those without endovascular obliteration—continue to be pressurized and may perfuse upstream portions in
a retrograde fashion.
Indications forRepair
Even if the entire distal aorta is dissected, dissection alone is not a sufcient indication for open graft replacement. Managing chronic dissection typically requires
regularly repeated imaging studies and enhanced awareness of emerging symptoms
through patient-education and optimization efforts (including, at a minimum, smoking cessation and strict blood pressure control).
Current US practice guidelines [17] recommend elective open aortic repair in
asymptomatic patients with chronic dissection of the distal aorta when its diameter
exceeds 5.5cm (Class I recommendation; level of evidence B). Although the guidelines do not expressly state it, a lower diameter-based threshold is generally recommended if the patient has a heritable thoracic aortic disease (e.g., MFS) or if the rate
of dilatation exceeds 0.5cm/year.
Patients who develop symptoms and can withstand open repair should undergo it
regardless of distal aortic diameter. Common indications for emergency repair of
chronic distal aortic dissection include rupture or acute dissection superimposed on
an existing chronic dissection (because such “double” dissection tends to progress
rapidly to aortic rupture). Specic symptoms, when present, are usually related to
aortic expansion and consequent compression of surrounding structures, or to malperfusion related to aortic dissection. Rarely, stulas develop in patients with
chronic distal aortic dissection, especially those who have been previously treated
with endovascular aortic repair. The onset of symptoms is usually considered an
indication of impending rupture or signicant malperfusion and should prompt
urgent evaluation. Pain is the most common symptom and may arise in the chest,
back, abdomen, or left ank; it may be described as sharp or stabbing acute pain or
as refractory pain. Additional symptoms may be related to embolization, frank
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rupture, or either acute-onset dissection or expanding chronic dissection. Plaque
and thrombus may embolize distally, causing occlusion and thrombosis of the visceral, renal, or lower-extremity branches and subsequent malperfusion. Cold, blue,
or painful extremities, spontaneous paraplegia, abdominal pain, nausea, vomiting,
incontinence, and abnormal urination can all signify malperfusion caused by aortic
dissection.
C. Köksoy et al.
Indications forReoperation
Because chronic aortic dissection is progressive, treating it commonly requires
more than one aortic procedure. Elective repairs are generally limited to aneurysmal
portions of the dissected aorta. In contrast, emergency repairs are generally limited
to symptomatic portions of the aorta, even if other segments are aneurysmal; this
strategy is undertaken in hopes of reducing operative risk.
For many years, the treatment paradigm for patients with acute DeBakey type III
dissection dictated medical management. Today, however, such patients are often
treated with thoracic endovascular aortic repair (TEVAR). Likewise, patients with
chronic distal aortic dissection are now candidates for TEVAR.Recent reports suggest that in nearly 70% of patients who undergo TEVAR for chronic distal aortic
dissection, the aortic diameter does not regress afterward [18, 19]. Evidence also
suggests that reintervention after TEVAR is more common in patients with chronic
dissection than in patients with aneurysm; 17–18% of patients who undergo TEVAR
to treat chronic aortic dissection need additional open or endovascular repair, as
compared to 10–15% of aneurysm patients [20, 21]. The most serious failures, such
as continued aortic expansion, type I endoleak, and infection (with or without stula), are typically treated with open repair [22]. Reportedly, open repair rates after
TEVAR for acute and chronic dissection are 10% and 15%, respectively [23].
Therefore, open aortic repair as a secondary procedure after previous endovascular
aortic therapy constitutes an important treatment option, even in the endovascular era.
Surgical Management
Preoperative Evaluation
Comorbidities that are typically considered to contribute to operative risk should be
carefully evaluated and modied whenever possible to mitigate risk; likewise, preoperatively evaluating patients’ physiologic reserve is critical to obtaining a benecial outcome. A history and physical exam constitute the initial assessment. All
patients, except those who require emergency repair, should undergo a thorough
preoperative evaluation emphasizing cardiac, pulmonary, and renal function, as well
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as a careful review of imaging studies. We routinely obtain a transthoracic echocardiogram, a coronary angiogram, pulmonary function tests, and a carotid duplex
scan, as well as laboratory panels to assess coagulation, liver, and kidney function.
The most common complication after thoracic and thoracoabdominal aortic repairs
is pulmonary dysfunction, including that necessitating prolonged ventilator dependence [1, 24]. Therefore, pulmonary function testing, including arterial blood gases
and spirometry, is routinely performed before surgery. Also, because patients with
severely impaired renal function are at elevated risk of death, kidney function should
be evaluated [25].
Preoperative imaging with computed tomography is a cornerstone of surgical
decision making. The diameter of the aorta is measured throughout the diseased and
non-aneurysmal portions. Potential sites for aortic clamping and cannulation are
reviewed for calcication, dissection, and mural thrombus. Branching vessels, such
as the visceral and renal arteries, are carefully assessed for stenotic origins and their
spatial orientation relative to each other; close attention is paid to anatomic variants.
In chronic aortic dissection, it is especially important to determine whether blood
entering branching arteries is supplied by the true lumen, the false lumen, or both.
The extent of the aneurysmal portions of the chronically dissected aorta is identied
proximally and distally; the degree of calcication and atheroma dictates the sites
for clamping the aorta and cannulation for left heart bypass (LHB). The lumen of
each artery is examined for areas of stenosis that may require endarterectomy or
stenting.
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Surgical Treatment andAdjuncts
Open distal aortic repair necessitates clamping the descending thoracic aorta,
which creates downstream ischemic conditions that affect the spinal cord and
abdominal viscera. To alleviate these complications, we routinely use a multimodal
approach to organ protection during these operations that is largely based on the
extent of repair (Fig.2) [26]. However, because patients with chronic aortic dissection tend to have higher rates of distal aortic reoperation (which is thought to
increase the likelihood of postoperative spinal cord decit from further interruption of feeding arteries), protective adjuncts are more liberally used to benet
select patients (Table1) [27]. To protect the spinal cord, we use mild passive hypothermia, cerebrospinal uid drainage (CSFD), LHB, sequential cross-clamping,
and selective reimplantation of intercostal or lumbar arteries [28–30]. We use
CSFD for extent I and II repairs, for extent IV repair in patients who have had a
previous DTA or extent I TAAA repair, and for extent III repair when we anticipate
replacing the iliac vessels. We intermittently deliver cold renal solution to the kidneys to protect them from ischemic damage and prevent acute renal failure [31].
We also deliver isothermic blood from the LHB circuit to the celiac axis and the
superior mesenteric artery (SMA) to minimize ischemic times for the abdominal organs.
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III III IV DTAA
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Fig. 2 Illustration of repairs. The Crawford classication system describing the 4 extents of thoracoabdominal aortic aneurysm (TAAA) repair is shown, along with a more limited descending
thoracic aortic aneurysm (DTAA) repair (here, repair does not extend beyond the diaphragmatic
hiatus or involve the visceral arteries). Crawford extent II TAAA repair carries the greatest operative risk. Used with permission of Baylor College of Medicine
Table 1 The use of adjuncts for organ protection during open repair of chronic distal aortic
dissection
Extent of
repair CSFD LHB
DTA +/− +/− − − +/−
TAAA I + + +/− +/− +/−
TAAA II + + + + +
TAAA III +/− +/− +/− + +/−
TAAA IV +/− − − + +/−
CSFD cerebrospinal uid drainage, DTA descending thoracic aneurysm, LHB left heart bypass,
SMA superior mesenteric artery, TAAA thoracoabdominal aortic aneurysm
+: Generally use; −: Generally do not use; +/−: May use depending on patient characteristics and
intraoperative ndings
Adapted from Ouzounian etal. [27]
Isothermic blood to
SMA/celiac artery
Cold renal
perfusion
Reimplantation of
segmental arteries
Preoperative Preparations
The perfusion team sets up a cell saver, as well as the LHB circuit. Standard intravenous access includes a large-bore peripheral intravenous line and a central venous
catheter. Hemodynamic monitoring requires a Swan-Ganz catheter and a right
radial or brachial arterial line. A temperature probe in the nasopharynx is used to
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