Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3850_Библиотеки_им_академика_М_И_Перельмана

During the clamp-and-go era, aortic dissection was considered a risk factor for neurological deficit in pa­tients undergoing surgery of the thoracoabdominal aor­ta [18]. With the use of distal aortic perfusion and CSF drainage, however, chronic dissection no longer poses a threat [33]. We recently showed similar low rates of paraplegia for patients who received adjuncts when un­dergoing thoracoabdominal aortic surgery, whether they had aortic dissection or not, 3.6% versus 4.7%, respec­tively. However, various surgical technical modifications are required in repairing dissected thoracoabdominal aorta, particularly in the acute phase. Identification of the true versus the false lumen is imperative. The parti­tion/septum between the two lumens is excised (Fig. 13.11 a). Before sewing the graft, we usually rein­force both proximal and distal ends of the dissected aorta with a running 4-0 polypropylene suture. Addi­tional interrupted pledgeted polypropylene sutures are then placed in the posterior and anterior walls for further reinforcement (Fig. 13.11b). Whereas we always attempt to reattach patent lower intercostal arteries dur­ing graft replacement of the descending thoracic and thoracoabdominal aorta, we advocate ligation of all pat­ent intercostal and lumbar arteries in the acutely dis­sected aorta, to avoid catastrophic bleeding associated with the friable tissues. Patent lower intercostal arteries can be safely reattached in chronic dissection using our described technique. In general, we replace all aneurys­mal aortic segments, but leave the nonaneurysmal seg­ment even if dissected.