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Management of Chronic Dissection of the Descending Thoracic and Thoracoabdominal…
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Fig. 11 Completed repair of DeBakey type III dissection in which a branched graft was used to
reattach the visceral arteries. (Upper inset) A single visceral patch incorporates the celiac axis,
superior mesenteric artery, and both renal arteries. (Lower inset) A three-vessel patch incorporates
the celiac axis, superior mesenteric artery, and right renal arteries; the left renal artery is reattached
as a button. Used with permission of Baylor College of Medicine
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C. Köksoy et al.
is slowly started on a solid diet, in conjunction with stool softeners and laxatives.
Patients can be discharged from the hospital 7–10days after surgery in ideal circumstances. If the patient has normal renal function, then a computed tomography
scan with intravenous contrast of the chest, abdomen, and pelvis is requested for
baseline measurements. Higher MAP goals are maintained for 4–6weeks after surgery to prevent late neurological complications.
Follow-up
After repair, the patients remain at risk for further aortic pathology. A repeat computed tomography scan should be performed annually for 2–3years after surgery. In
the absence of disease, the frequency of scans can be decreased to every 2–3years.
For young patients, magnetic resonance imaging to limit exposure to ionizing radiation should be considered.
Open Repair After Endovascular Repair
Serious complications of prior endovascular aortic repair often necessitate an open
procedure. Additionally, patients who underwent prior aortic arch replacement with
a frozen elephant trunk extension may need subsequent distal aortic repair (Fig.12).
Fig. 12 Intraoperative photo of an extent II thoracoabdominal aortic aneurysm repair performed
after a frozen elephant trunk repair of the transverse aortic arch. (Inset) The stent-graft–to-graft
anastomosis is secured with a strip of felt. Used with permission of Baylor College of Medicine
Management of Chronic Dissection of the Descending Thoracic and Thoracoabdominal…
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To account for the presence of a stent-graft, we modify our standard incision to
maximize exposure (i.e., enter through the fth intercostal space rather than the
sixth, or use a thoracoabdominal approach either to revise a prior endovascular
abdominal aortic repair or, often, to remove the endovascular stent-graft all together).
Many times, the proximal landing zone of the stent-graft impinges on the brachiocephalic vessels branching off the aortic arch; in such cases, it is often difcult to
safely clamp the aorta, so it may be necessary to use hypothermic circulatory arrest,
which at our center is atypical for this procedure.
Stent-grafts can be fully or partly extirpated [22, 35, 36]. Partial extirpation of
the stent-graft may be a useful strategy in patients without infection (Fig.13). Partial
extirpation should be considered when the stent-graft is found to be wellincorporated, when the patient’s hemodynamics are unstable in the operating room,
or when inammation or scar tissue is found in the area, making it unsafe to separate the endograft from the aortic wall. For example, if a portion of an endograft
cannot be removed from the aortic arch without causing undue tissue trauma, it is
preferable to leave it in place and trim off the rest of the stent-graft. It is not thought
that partial extirpation leads to migration of the remaining portion of the endograft,
device failure, component separation, or rupture during follow-up.
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Outcomes
When performed in specialized centers, surgical repair of distal aortic dissection
achieves good survival with acceptable morbidity [37]. In contemporary studies of
chronic distal dissection repair, the rate of early mortality is 6–8%; stroke, 1–4%;
paraplegia, 1–3%; and renal failure necessitating dialysis, 4–5% [5, 7, 38–43]. Our
own outcomes have been generally good, with greater risk for patients undergoing
Crawford extent II repair (Table 2). Early outcomes are comparable after open
repair for chronic DeBakey type I and type III aortic dissections. Recently, our
series of 466 patients with either chronic type I or type III aortic dissection, we
determined that mortality was 6% for both types (n= 14 for each group) [41]. In
patients with chronic DeBakey type I dissection undergoing open distal aortic aneurysm repair, factors reportedly associated with early death are greater age, chronic
obstructive pulmonary disease, and clamping proximal to the left subclavian artery
[6]. Acceptable results have been also observed in patients with MFS dissection
[12, 44].
Regarding late survival, Conway and colleagues [5] reported 77% survival at
7years, and Estrera and coauthors [39] reported 60% survival at 10years. Preventza
etal. [41] associated DeBakey types I and II with similar rates of survival (74% at
6years). Open repair appears durable; Zoli etal. [45] reported 83% freedom from
distal aortic reoperation at 10years, and Estrera etal. [39] reported 94% freedom
from reoperation at 20years. However, the risk of disease progression requiring
subsequent repair in an adjacent aortic segment is not insignicant; we reported
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Fig. 13 Illustrations depicting partial endograft explantation in a patient with chronic DeBakey
type III aortic dissection after previous open replacement of the proximal portion of the descending
thoracic aorta (left). Afterward, the distal aorta dilated progressively; therefore, the patient underwent endovascular repair 3years later. However, progressive expansion continued, necessitating
further repair. (Right) Extent III thoracoabdominal aortic aneurysm (TAAA) repair was performed.
Because the proximal portion of the stent-graft was well-adhered to the aortic wall, it was incorporated into the repair, and only the distal portion was removed. Used with permission of Baylor
College of Medicine
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Results of 1362 open descending thoracic or thoracoabdominal aortic aneurysm repairs
Table 2
(1986–2019)
Extent of repair No. patients Operative deaths ParaplegiaaStroke
DTA 211 9 (6.5%) 2 (0.9%) 4 (1.9%) 4 (1.9%)
TAAA I 391 23 (5.9%) 4 (1.0%) 11 (2.8%) 12 (3.1%)
TAAA II 539 39 (7.2%) 13 (2.4%) 14 (2.6%) 34 (6.3%)
TAAA III 139 11 (7.9%) 4 (2.9%) 1 (0.7%) 10 (7.2%)
TAAA IV 85 4 (4.7%) 0 0 2 (2.4%)
Total 1362 86 (6.3%) 23 (1.7%) 30 (2.2%) 62 (4.6%)
DTA descending thoracic aneurysm, TAAA thoracoabdominal aortic aneurysm
a
Persisting at the time of hospital discharge or operative death. Operative deaths include 30-day
deaths and any deaths during the initial hospitalization period, including after transfer to another
hospital
a
Renal failure
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a
85% freedom from progressive aortic repair at 7 years, and Estrera et al. [39]
reported 82% freedom at 20years.
In conclusion, open repair of chronic descending thoracic or thoracoabdominal
aortic dissection generally has good patient outcomes and tends to be durable.
However, the progressive nature of residual chronic dissection often necessitates
subsequent repair of nearby aortic segments.
Acknowledgments The authors express gratitude to Stephen N.Palmer, PhD, ELS (of the Texas
Heart Institute), and Susan Y.Green, MPH, for editorial assistance, and to Scott A.Weldon, MA,
CMI, for creating the illustrations and assisting with image selection.
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Diagnosis andManagement ofRuptured
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Thoracic Aortic Aneurysms
ChristopherLau, MarioGaudino, ErinIannacone, andLeonardN.Girardi
Introduction
A ruptured thoracic aortic aneurysm (rTAA) is a lethal entity associated with a high
rate of mortality. A majority of patients with rTAA die before reaching a hospital
and those who survive the initial event often have ruptured aortas contained by the
mediastinal tissues. Population level studies have found the incidence of rTAA to be
5 per 100,000 and only 41% of patients were alive upon arrival to a hospital. Fiftyfour percent of patients die within 6h of symptom onset and 76% die within 24h.
The most common location of rupture is the ascending aorta (54%) followed by the
descending aorta (30%), and aortic arch (15%) [1].
Thoracic aneurysm ruptures in the various segments of the aorta require different
operative approaches and skillsets for a successful repair. Similarly, the outcomes
and operative risks of repair in different segments varies considerably. In the ascending aorta, most ruptures are associated with an aortic dissection and there is little
controversy that the preferred surgical approach is with open repair via median
sternotomy [2]. In the descending thoracic aorta, controversy exists regarding the
optimal approach, whether that is an endovascular or traditional open repair. Both
solutions have their limitations and unfortunately, there does not seem to be an ideal
solution to date [3].
C. Lau (*) · M. Gaudino · E. Iannacone · L. N. Girardi
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
e-mail: chl9077@med.cornell.edu
J. S. Coselli et al. (eds.), Aortic Dissection and Acute Aortic Syndromes,
https://doi.org/10.1007/978-3-030-66668-2_31
447© Springer Nature Switzerland AG 2021
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C. Lau et al.
Clinical Presentation
Thoracic aneurysms have a protracted, indolent clinical course and aneurysms
remain asymptomatic until there is a catastrophic aortic event, such as rupture or
dissection. For this reason, the clinical presentation of thoracic aneurysms occurs in
two extremes: an asymptomatic incidentally discovered aneurysm or an acutely
symptomatic aortic rupture or dissection. Those who present with pain are considered to have symptomatic aneurysms and surgical repair is indicated. Ruptured
TAA fall into this latter category and the most common symptom upon presentation
is severe chest pain, often radiating to or in association with back pain. Other clinical signs including a tearing sensation, dyspnea, tachycardia, and hemodynamic
compromise.
While a majority of patients with rTAA likely expire in the eld due to hemodynamic collapse, those who survive to reach the hospital have a broad spectrum of
clinical presentation. In the best case scenario, there is a contained rupture and the
presenting symptom is pain. These patients may even be severely hypertensive,
which is sometimes itself the inciting cause of the rupture. These patients require
immediate anti-impulse therapy with heart rate and blood pressure management in
order to prevent further progression of the rupture while diagnostic and operative
planning ensues. On the other end of the spectrum, patients may present with instability and impending hemodynamic collapse due to cardiac tamponade or free rupture. This group requires immediate volume resuscitation, support with vasoactive
medications, and operative repair.
For asymptomatic TAA, current practice guidelines recommend surgical repair
of aortic aneurysms with diameter >5.5cm in the general population, with exceptions made for populations with increased risk of aortic events at smaller diameters. Patients at higher risk of aortic events, such as those with connective tissue
disorder, family history of aortic dissection/rupture, or bicuspid aortopathy, are
recommended for surgery at smaller diameters of 5cm or less. On the other hand,
patients with complex TAA disease, such as thoracoabdominal aortic aneurysms
(TAAA), who are expected to have higher operative risk are given a higher threshold of 6cm [4]. These recommendations are based on accumulating evidence that
there exists an inection point at 6cm where the risk of rupture or dissection dramatically increases [5] (Fig.1). Thus a recommendation for prophylactic surgery
at 5.5cm would decrease the rate of aortic events signicantly but does not eliminate this risk.
In fact, a signicant number of patients who present with aortic events have
aneurysms of smaller sizes, which would not normally indicate a need for surgery.
At the smaller diameters of less than 5cm, aortic events mostly consist of dissection
rather than rupture. At 5.0–5.9cm, rupture risk begins to increase in prominence
and the rate of rupture/dissection is 3% while rupture alone is 1.7%. With increasing
diameter to over 6.0cm, the rate of rupture alone increases signicantly to 3.6% per
year and rupture/dissection/death exceeds 10% [5]. Thus, continued monitoring for
aortic growth and prophylactic surgery once aneurysms reach size thresholds is
necessary to decrease the rate of fatal aortic events.
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