DISECCION AÓRTICA
La disección aórtica se caracteriza por la creación de una falsa luz en la capa
media de la pared aórtica.
La forma típica de inicio sería un desgarro en la íntima a través del cual la
sangre, impulsada por la presión con la que circula penetraría en la capa media
disecando la pared aórtica.
Este nuevo trayecto de la sangre a través de la pared
de la Aorta es la “Falsa Luz”.
La parte interna de la pared disecada de la aorta es lo
que en la literatura en inglés se denomina “Intimal
Flap”.
A medida que progresa la disección pueden crearse
nuevos orificios en la capa íntima de la Aorta, tanto
de salida de la sangre procedente de la falsa luz
como de reentrada de sangre procedente de la luz
verdadera.
Aunque lo habitual es que la sangre progrese de
forma anterógrada a lo largo de la falsa luz, también
puede progresar hacia detrás, extendiéndose
proximalmente.
La distensión de la luz falsa puede hacer que la luz
verdadera se vea constreñida, disminuyendo el
calibre previo de la aorta.
También puede suceder que la disección se inicie
por la ruptura de los vasa vasorum dentro de la capa
media de la Aorta, dando lugar a un “Hematoma
Intramural”, que puede progresar hasta perforar la
capa íntima y comunicar así la falsa luz con la
verdadera. De hecho, en un 13% de las autopsias de pacientes con diagnóstico previo de
DA no se encuentra ninguna falta de continuidad en la íntima.
Clasificación
► Por la localización:
Aproximadamente el 65% de las Disecciones se inician en la Aorta Ascendente (a <5cm
de la Válvula Aórtica), 10% en el arco aórtico, 20% en la Aorta Torácica (justo después
de la subclavia izq.), y un 5% en la Aorta abdominal.
a) De Bakey:
I: inicio: Aorta Ascendente + Arco aórtico ó incluso Aorta descendente,
II: inicio: Aorta Ascendente exclusivamente, sin afectar al arco aórtico.
III: inicio: Aorta Descendente progresando distalmente, aunque puede
extenderse de forma retrógrada al arco aórtico y a la Aorta ascendente.
b) Stanford:
A: todas las que afecten a la Aorta ascendente, independientemente del lugar en
el que se inicien,
1
B: las demás. (Las de arco aórtico no quedan bien definidas: en general son “A”)
c) -Proximal (DeBakey types I and II or Stanford type
A), (hasta subclavia izq)
-Distal (DeBakey type III or Stanford type B)
Khan (2002) recomienda esta clasificación porque las
otras dejan la duda en casos en que solo esté afectado el
arco (y no la Ao Asc)
► Por el Tiempo de presentación:
a) Aguda: Menos de dos semanas
b) Crónica: dos semanas o más.
► Nueva clasificación (Svensson 1999) (Erbel 2001) (adoptada por la Task Force of the
European Society of Cardiology)
Clase 1 : Disección clásica con Luz Verdadera y
Falsa, con/sin comunicación.
Clase 2 : Hemorragia o Hematoma intramural
Clase 3 : Pequeña Disección solo con abombamiento
de la pared aórtica
Clase 4 : Ulceración de una placa aórtica, siguiendo
a la ruptura de la placa.
Clase 5 : Disección aórtica traumática o iatrogénica.
Recuerdo anatómico de la Aorta abdominal y
los troncos supraaórticos.
2
Etiología y Patogénesis
El factor clave parece ser la degeneración de la media.
La HTA (70-80% de los casos) y la Edad avanzada son dos de rasgos más típicos. El
pico de incidencia está en la 6ª y 7ª décadas (55 en proximal, 65 en distal), y afecta el
doble o triple a los hombres que a las mujeres.
Son factores predisponentes la Arteriosclerosis y algunas enfermedades hereditarias del
tejido conectivo como los Síndromes de Marfan (5 a 9% de la Disecciones, y la
mayoría de las que se dan en <40 años) y el S. de Ehlers Danlos. También las E.
autoinmunes, Anuloectasia, Predisposición familiar, Artritis Reumatoide, LES…
Otros factores de riesgo son la Válvula Aórtica Bicúspide (en 7-14%) de las disecciones
y la Coartación Aórtica.
Otros: Embarazo (la mitad de las disecciones en mujeres <40 años se presenta en
embarazadas, a veces con S de Marfan asociado), S de Noonan y Turner, Arteritis
(sobretodo la arteritis de células gigantes, el abuso de cocaína (Eagle 2002)...
Los Traumatismos , la Cirugía Cardiac), el Cateterismo, o el BCPA también pueden
actuar como causa etiológica. La Disección post Cirugía cardiaca ocurre a veces al de
varios meses o años (Stanger 2002), sobre todo de reemplazamiento valvular aórtico y
mas si se trataba de IAo con Aorta de paredes delgadas. En el registro del IRAD no
parece conllevar una mayor mortalidad (Collins 2004, IRAD).
Clínica
Dolor: (96%) de los casos. Las Disecciones crónicas pueden no presentar dolor en el
momento del diagnóstico. Típicamente es súbito y severo desde el principio. Puede ser
migratorio (17%) siguiendo el camino de la disección. La
localización es importante ya que se ha visto que en los casos de
dolor anterior está afectada la Aorta ascendente en un 90 % de los
casos (Spittell), y en caso de dolor interescapular está afectada la
Ao descendente también en un 90%. Así mismo el dolor en el
cuello, mandíbulas, etc. se asocia a la Disección de Aorta
ascendente, y el dolor abdominal, de espalda o piernas a la
afectación de aorta descendente.
En algunos casos (raros) es de características pleuro-pericárdicas
por hemorragia y pericarditis en la cavidad pericárdica, pudiendo
dar lugar a un diagnóstico erróneo. El Taponamiento cardiaco
conlleva una mortalidad del 25% en las primeras 24 horas.
Otros síntomas: Insuficiencia cardiaca congestiva (casi siempre por IAo) en un 7%,
Síncope (9%), ACV(5%), Neuropatía isquémica periférica, Paraplejia, PCR, Muerte
súbita.
El síncope suele ser un signo de gravedad, a menudo producido por hemopericardio o
mas raramente hemotórax (Brahmajee,2002) .
Exploración
- HTA: en el 70% de las distales y en el 36% de las proximales.
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- Hipotensión : se da en el 25% de las proximales (frecuentemente por taponamiento
cardiaco), y en el 4% de las distales. La afectación de las arterias braquiocefálicas
puede inducir a error (pseudo-hipotensión).
- Pulsos disminuidos o asimétricos (se cen en 50% de las proximales y en 15% de las
distales) por obliteración o estrechamiento de la luz.
- Soplo de I Ao: (en 35-50% de las proximales). Con frecuencia previo a la disección,
por afectación crónica del aparato valvular aórtico. La Regurgitación aórtica puede
producirse en la disección proximal por dilatación de la raíz aórtica, por despegamiento
de una de las valvas aórticas, o por prolapso de la íntima hacia el ventrículo izq.
Izq: íntima intacta comprimiendo la luz verdadera y causando
malperfusión de una rama de la aorta.
dcha. : La ruptura de la íntima puede o no devolver el flujo a la
rama afectada.
La sangre contenida en la falsa luz puede actuar comprimiendo
la salida de un de las ramas de la aorta. Por eso a veces la
ruptura de la falsa luz puede mejorar la isquemia.
- Manifestaciones neurológicas: 6-19%. ACV (3-6%. Paraplejia.
Coma. Por afectación carotídea, espinal…
- Infarto renal, Fracaso renal e HTA severa por compromiso de
la arteria renal (5-8%).
- Isquemia e infarto mesentérico (3-5%).
- Déficit de pulsos femorales (12%) por compromiso de las
arterias ilíacas, con dolor torácico mínimo que nos puede
confundir con embolismo periférico.
- IAM: es poco frecuente : 1-2% por afectación del
ostium coronario (más el derecho).
Puede confundir el diagnóstico, lo que en caso
de trombolísis puede ser catastrófico. . .
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- Otras manifestaciones clínicas pueden ser hemotórax, hemoptisis y hematemesis por
roturas en el espacio pleural, bronquios o esófago.
Ocasionalmente se han descrito roturas en la aurícula derecha o izquierda, en el
ventrículo derecho con fallo cardíaco. También, Síndrome de vena cava superior,
pulsación esternoclavicular, masa pulsátil cervical y síndrome de Horner.
La mortalidad sube un 1-2%/h (>40% al de 1 semana, >50% al de un mes) (Khan, 2002
70% en la 1ª semana y 80% a las 2 s. Sin cirugía 90% fallecen al de 3 meses. En 1995
Fann, de Stanford, reportaba una mortalidad por encima del 25% en pacientes
intervenidos entre 1963 y 1992 por disección A o B, aguda o crónica: en 360 pacientes).
Apaydin (2002) también señala una mortalidad del 25%. Ehrlich (2000) del Mount Sinai
del 15,4% (19/124). Mészáros (2000) de Hungría 68% en las primeras 48 horas.
Nienaber (2004) señala una mayor mortalidad en mujeres 832% vs 22% (IRAD)
En 1996 se creó un Registro Internacional de Disección Aórtica : IRAD:
International Registry of Aortic Dissection (18 centros en 6 países) (Hagan 2000), cuyos
datos en cuanto a la clínica resumimos a continuación (Trimarchi 2005).
Variable
Total (n = 526)
Sobrev. (n =
394)
Exitus (n =
132) (25%)
P
Dolor (cualquier)
470 (89.4)
354 (89.8)
116 (87.9)
.53
Inicio brusco
426 (85.5)
322 (85.4)
104 (86.0)
.88
Dolor en el pecho
416 (81.6)
316 (82.7)
100 (78.1)
.25
Dolor abdominal
110 (22.0)
82 (21.9)
28 (22.2)
.94
Severidad: dolor severo, o máximo
378 (91.3)
278 (89.4)
100 (97.1)
.02
Dolor migratorio
69 (14.2)
44 (12.1)
25 (20.5)
.02
Síncope
98 (19.4)
69 (18.2)
29 (23.2)
.22
Déficit de pulso (cualquier)
139 (31.0)
90 (26.9)
49 (43.0)
.001
Fallo cardiaco congestivo
27 (5.4)
25 (6.7)
2 (1.6)
.03
Déficit neurológico (nuevo)
68 (13.6)
45 (11.8)
23 (19.5)
.03
ECG normal
153 (31.0)
127 (33.9)
26 (22.0)
.02
ECG con HTVI
101 (21.6)
79 (22.2)
22 (19.8)
.60
ECG con Isquemia miocárdica
94 (19.9)
64 (17.8)
30 (26.8)
.04
ECG con IAM, Q nuevas, o alt. ST
28 (6.0)
16 (4.5)
12 (10.9)
.01
Isquemia mioc. Preoperatoria
52 (10.4)
35 (9.3)
17 (13.9)
.14
IAM preoperatorio
18 (3.6)
10 (2.7)
8 (6.6)
.06
Isquemia-infarto mesentérico
10 (2.0)
8 (2.1)
2 (1.6)
>.99
Isquemia EE
48 (9.7)
29 (7.8)
19 (15.8)
.009
FRA
22 (4.4)
16 (4.3)
6 (5.0)
.75
Taponamiento cardiaco
78 (15.7)
44 (11.8)
34 (27.6)
<.0001
5
Estado hemodinámico preoperatorio en pacientes con Disección tipo “A” (IRAD)
Variable
Total (n = 526)
Sobrev (n = 394)
Exit (n = 132)
P
TA S >150 mm Hg
160 (32.4)
128 (34.2)
32 (26.7)
.12
TA S 100-149 mm Hg
213 (42.9)
176 (46.9)
37 (30.6)
.002
TA S <100 mm Hg
88 (17.6)
50 (13.3)
38 (30.4)
<.0001
Shock o TC (TAS ≤80 mm Hg)
82 (16.1)
47 (12.3)
35 (27.6)
<.0001
TA S <100 mm Hg
153 (31.0)
79 (21.4)
74 (59.2)
<.001
TA S 100-149 mm Hg
262 (53.9)
219 (60.5)
43 (34.7)
<.001
Disfunción VI
63 (13.0)
34 (9.3)
29 (24.2)
<.001
Disfunción VD
31 (6.4)
10 (2.8)
21 (17.5)
<.001
TA al ingreso
Hemodinámica peroperatoria
Datos demográficos y antecedentes de los pacientes con Disección “A” quirúrgicos
Variable
Total (n = 526)
Sobrev (n = 394)
Exit (n = 132)
P
n (%)
526 (100.0)
394 (74.9)
132 (25.1)
—
Edad
59.7 ± 13.6
58.7 ± 13.2
62.5 ± 14.2
.005
Edad ≥70 a
139 (26.5)
91 (23.2)
48 (36.4)
.003
Mujeres
158 (30.1)
108 (27.5)
50 (37.9)
.02
Marfan
31 (6.0)
25 (6.4)
6 (4.8)
.51
Hipertensión
354 (68.9)
268 (69.3)
86 (67.7)
.75
Aterosclerosis
138 (26.9)
100 (25.8)
38 (30.2)
.34
Aneurisma aórtico conocido
51 (10.0)
39 (10.1)
12 (9.7)
.90
Disección aórtica previa
14 (2.7)
14 (3.6)
0 (0.0)
.03
Diabetes mellitus
16 (3.2)
13 (3.4)
3 (2.4)
.77
Cirugía cardiaca previa
76 (17.2)
53 (15.9)
23 (21.1)
.21
Prótesis Aórtica previa
22 (4.4)
13 (3.5)
9 (7.4)
.07
Disecc o Aneur intervenido
25 (5.0)
18 (4.8)
7 (5.8)
.66
BP AoCo previo
31 (6.3)
21 (5.6)
10 (8.1)
.32
Cirugía mitral previa
2 (0.4)
2 (0.5)
0 (0.0)
>.99
Iatrogénico
28 (5.8)
19 (5.2)
9 (7.8)
.30
Válvula aórtica bicúspide
15 (4.9)
12 (5.2)
3 (3.9)
>.99
6
EXPLORACIONES
Exploración física:
El paciente suele impresionar de gravedad y estar bastante ansioso. En los
aneurismas crónicos a veces el dolor no es tan lacerante. Hay que buscar signos de
hipoperfusión de las extremidades, del cerebro, o de otras vísceras. Es importante, ante
la sospecha de Disección, explorar los pulsos femorales, radiales y carotídeos y tomar la
TA en ambos brazos. También se debe prestar especial atención a la función renal.
Sospechar isquemia intestinal (dolor, acidosis…). La presencia de síncope o ACV
incrementa la gravedad. La pérdida de perfusión a nivel de las intercostales y lumbares
puede llevar a isquemia medular y paraplejia.
Es relativamente fácil confundir el cuadro con otros como IAM, TEP. Pericarditis,
Dolor músculo-esquelético, etc. Los síntomas pueden variar en el tiempo a medida que
la disección progresa o se producen reentradas en la verdadera luz.
Como ya hemos dicho, puede haber taquicardia e HTA, pero también Hipotensión por
taponamiento (muy mal pronóstico, Bayegan 2001), IAo, Rotura aórtica, IAM asociado,
etc. A la Auscultación puede oírse soplo de IAo, roce pericárdico, S3, o disminución
de la ventilación por derrame o hemotórax.… Puede haber ingurgitación yugular por
TC. También S de V Cava S, S de Horner, Hemoptisis, y compresión de vías aéreas o
parálisis de cuerdas vocales. .
Radiografía de Tórax:
A menudo es la primera exploración encaminada a establecer el diagnóstico. El
signo característico es la distorsión de la silueta aórtica y el ensanchamiento
mediastínico. En caso de calcificación aórtica puede a veces verse la calcificación de la
íntima separada del borde externo de la silueta ( ±1 cm ). Sin embargo hay que tener
muy en cuenta que un mediastino ensanchado o una aorta tortuosa (frecuente en los
ancianos) no confirma ni descarta per se la existencia de una disección aórtica.
7
En ocasiones el principal valor de la RX puede ser el ayudar a diagnosticar otras
posibles causas del dolor o la insuficiencia cardiaca (neumotórax, atelectasia, neoplasia,
EAP…).
Si es posible se debe comparar con RX previas.
Es relativamente frecuente el derrame pleural (+ izq) sobretodo en disección de Aorta
torácica descendente.
ECG:
Puede servir para descartar IAM. Hay que tener en cuenta que la afectación coronaria en
la Disección proximal puede afectar a las coronarias y producir IAM.
Otros hallazgos frecuentes son la HTFVI secundaria a cardiopatía hipertensiva.
En sí mismo tiene escaso valor para diagnosticar la presencia de Disección.
Laboratorio:
Puede haber alteraciones derivadas de las complicaciones de la Disección (Crp↑, etc.).
Recientemente se ha publicado la posible utilidad de la detección de miosina (Suzuki
2000), pero no suele ser una prueba disponible. La disección al dañar la media liberaría
proteínas estructurales como la miosina de cadena pesada, a la circulación, que podrían
ser detectadas por inmunoensayo. Los niveles se elevan significativamente en las 6
primeras horas de la disección. Niveles > 2.5 µg/L serían sugestivos, pero también
puede aumentar en el IAM. Con >10 µg/L la especificidad es del 100%.
D-dímeros: parece que están generalmente elevados (en torno a 9,4 µg/mL 0,6-55)
[normal 0.5 µg/mL], pero hace falta mas estudios. (Perez, 2004)
(Weber. D-dimer in Acute Aortic Dissection. Volume 123 • Number 5 • May 2003)
Técnicas diagnósticas de confirmación (Imagen)
Los objetivos son: 1) Confirmar el diagnóstico, 2) determinar si la Aorta
ascendente está afectada (A) o solo la descendente (B), 3) Identificar todos los datos
posibles de la disección: punto de origen y salida (s), extensión, reentradas, calibre de la
luz verdadera y falsa, ramas da la aorta afectadas, presencia de trombos en la falsa luz,
afectación de las coronarias, regurgitación valvular aórtica, hemopericardio, u
ocupación pleural….
Las técnicas mas utilizadas son: la Aortografía, la TAC, la Resonancia
Magnética, y la Ecografía (Transtorácica y Transesofágica).
Deben ser interpretadas por un experto ya que puede haber imágenes que simulen
disección sin serlo. (Batra 2000. Radiographics.20:309-320. Pitfalls in the Diagnosis of Thoracic
Aortic Dissection at CT )
Aortografía
El diagnóstico se basa en la presencia de signos directos (visualización de la luz falsa y
verdadera, o del Flap de la íntima) o indirectos (deformidad de la aorta, engrosamiento
de la pared aórtica, anormalidades en las ramas arteriales, y regurgitación aórtica. La luz
falsa se visualiza en el 87%, el Flap en 70%, y el punto de origen en 56% (Earnest).
8
►Izq:
Dilatación de la raíz aórtica, T=luz verdadera, F: falsa luz, I: Flap de la íntima.
LV: ventrículo izq: la abundancia de contraste en su interior es indicativa de regurgitación.
►Centro: La luz verdadera está mas opacificada que la falsa. Flechas: se aprecian dos planos del
Flap. CA: estrechamiento de la carótida derecha. (Isselbache, NEJM 328:35.
►Dcha.: Ruptura traumática del istmo aórtico con pseudoaneurisma (substracción digital)
La angiografía se practica desde hace mas de 40 años y era el procedimiento estándar
hasta la llegada de técnicas alternativas. Suele ser bien tolerada. Su sensibilidad y
especificidad estarían en torno a 88 y 94% respectivamente (Erbel), aunque su
sensibilidad sería solo del 77% en caso de hematoma intramural (Bansal). Son ventajas
la posibilidad de delinear con precisión la extensión de la disección y las ramas
afectadas, así como la presencia de regurgitación aórtica o de afectación coronaria.
Inconvenientes: que es un procedimiento invasivo, que no siempre está disponible, que
lleva tiempo, y que su sensibilidad y especifidad puede ser menor que con otras
técnicas.
TAC con contraste
Lo característico es encontrar dos Luces separadas por el Flap, o diferenciadas
por la distinta captación de contraste. Tiene una sensibilidad y una especificidad que
pueden llegar con la TAC helicoidal al 96 y 100% respectivamente.
Es rápido y suele estar disponible. También precisa contraste y tiene el inconveniente de
que el orificio de entrada puede no verse y que tampoco permite ver claramente si hay o
no regurgitación aórtica. Puede haber confusiones diagnósticas (Thoongsuwan, 2002)
9
Disección B
Disección B + Hemotórax
AngioTAC
Disección de Aorta descendente.
I= Flap de la íntima
T= Luz verdadera
F= Luz falsa
En LePage, 2001 pueden verse numerosas figuras.
RMN
Proporciona una información muy completa, tan buena o mejor que la de
cualquiera de las otras técnicas y además no es invasiva ni requiere contraste. Tiene una
sensibilidad y especificidad del 98 % (Nienaber). Es el método más completo.
El mayor inconveniente suele ser la escasa disponibilidad, el tiempo necesario y la
dificultad de obtenerla en pacientes inestables (shock ,IOT, etc.).
Está contraindicado en pacientes con MP y con modelos antiguos de prótesis valvulares.
10
(A) Plano oblicuo sagital mostrando una
disección distal al origen de la subclavia izq,
(B) reconstrucción axial
(C) reconstrucción sagital
(Vogt. MR angiography of the chest. Radiologic
Clinics of North America. Volume 41: 1 • January
2003)
Ecocardiografía
Es un método rápido y que suele estar disponible. Aquí también el diagnóstico
lo da la imagen del Flap ondulando y separando la luz verdadera de la falsa. En el
Doppler los flujos de la luz verdadera y falsa tienen un patrón de color diferente.
a) Transtorácico:
Tiene una sensibilidad del 59 al 85%, y una especificidad del 63 al 96%.
b) Transesofágico
Puede ser necesario sedar y puede ser mal tolerado (HTA, bradicardia,
broncoespasmo, etc.), pero no es frecuente. La parte distal de la Aorta ascendente puede
no visualizarse bien por la interposición de la Traquea o los Bronquios. La sensibilidad
diagnóstica es de cerca del 100% (para diagnosticar el punto de origen 73%, trombos
68%, regurgitación aórtica y derrame pericárdico100%). La especificidad estaría en 97
% para Erbel y en 77% para Nienaber.
Puede servir también para diagnosticar si hay afectación coronaria (aunque no sustituye
a la coronariografía).
Fig. izq: Se observa una aorta dilatada en la que: T= Luz verdadera
I= Flap. F= Luz Falsa. /// Fig. dcha.: L=Luz aórtica. H= hematoma (no se ve Flap)
11
ECO Doppler transesofágico de la aorta
descendente disecada, en que se muestra el lugar
de desgarro de la íntima: Se evidencia el flujo
sistólico en naranja, por la luz verdadera, y un
jet azul de flujo de alta velocidad que cruza
hacia la luz falsa a través de un orificio en al
Flap de la íntima.
Eco transesofágico de la Aorta ascendente
proximal.
LA: aurícula izq.
AV: válvula aórtica
I: Flap
T: Luz verdadera
F: Falsa luz
Misma vista con Doppler
T: Luz verdadera (azul)
F: Luz falsa naranja con flujo retrógrado
12
Top: Biplane TEE in the
longitudinal plane left ventricular
outflow tract view demonstrating
an aortic dissection beginning at
the sinotubular junction with the
intimal flap (curved arrow)
separating the true and false
lumens.
Bottom: Biplane TEE in the
horizontal plane of the aortic root
demonstrating the intimal flap
(curved arrow) separating the
true and false lumens and a
patent left main coronary artery.
AO = aorta; AV = aortic valve;
FL = false lumen; LA = left
atrium; LM = left main coronary
artery; MV = mitral valve
(Willens. Transesophageal Echocardiography in the Diagnosis of Diseases of the Thoracic Aorta.
Chest.;116:1772-1779. 1999 )
Ultrasonografía intravascular (catéter por arteria femoral)
Tiene la ventaja de que se visualiza bien la aorta abdominal que es inasequible
para la ECO transesofágica y es particularmente útil para guiar la colocación de
endoprótesis.
Permite analizar la disección en toda su extensión y detectar las entradas y reentradas y
parece que puede ser el mejor método para visualizar la afectación de las ramas de la
aorta y el Hematoma intramural, así como as placas ulceradas. Se ha utilizado para guiar
la fenestración y la colocación de stent (endoprótesis). Los nuevos transductores
permiten además la incorporación del Doppler.
Elección de la técnica.
Braunwald considera que el método inicial preferente es el ETE y que hay hospitales donde el
paciente va a quirófano únicamente con dicha exploración. Si no está disponible entonces se
debe practicar primero una TAC con contraste y quizá mas adelante, incluso con el paciente ya
en quirófano se puede evaluar con ETE. En la revisión de Moore (2002) se analizan los
métodos utilizados en el IRAD.
13
La RMN es un método excelente para situaciones menos urgentes y para seguimiento evolutivo.
La aortografía puede ser de especial utilidad cuando es preciso evaluar la afectación de las
ramas de la Aorta. Es controvertida la indicación de Coronariografía (tanto en la afectación
coronaria por la disección, como en la cardiopatía isquémica previa, que puede complicar el
procedimiento quirúrgico y la evolución posterior, aunque parece que la incidencia de IAM
postoperatorio es bastante baja.
Sensibilidad
Especificidad
TAC helicoidal
83–100%
87–100%
ETE
95–100%
85–96%
RMR
96–100%
98–100%
Aortografía
86–89%
75–94%
HEMATOMA INTRAMURAL
(Nienaber2002.. Intramural Hematoma in Acute Aortic Syndrome. Circulation.;106:284. Evangelista.
Acute Intramural Hematoma of the Aorta: A Mystery. Circulation 111(8) 1 March 2005; 1063-1070 ).
Se diagnosticó en 5,7% de pacientes del IRAD. 60% tienen afectación del arco distal.
Los pacientes suelen ser algo mayores que en la disección (69 vs 62 años).
El dolor es incluso mas intenso, pero tienen menos isquemia periférica o IAo.
El 16% (30-50% según otros) progresaron a Disección y/o ruptura.
Mortalidad similar pero algo menor tanto en el grupo proximal como distal.
Regresión en 10%. Actitud quirúrgica similar a la de las otras disecciones
(A=quirúrgico, B : conservador). Song (2002) encuentra una tasa de resolución bastante
apreciable sin cirugía. Kodolitsch (2003) encuentra que el HIM en Aorta ascendente
requiere cirugía urgente independientemente de su diámetro.
Arteriograma mostrando un HIM de aorta descendente.
Evolución de un HIM de
Aorta descendente, con
formación de un
aneurisma, y su posterior
resolución con una
endoprótesis.
14
ÚLCERA AÓRTICA ATEROSCLERÓTICA PENETRANTE
La UP, como su nombre indica, sería una ulceración de una lesión
arteriosclerótica aórtica que penetra en la lámina elástica interna, formando un
hematoma en la capa media de la aorta torácica descendente, permaneciendo localizado
o extendiéndose unos centímetros, sin formar una segunda luz.
Frecuentemente originan aneurismas aórticos saculares o fusiformes. En el 25%
de los casos causan pseudoaneurisma aórtico y en un 8% conducen a rotura aórtica. La
progresión a una DAo extensa es rara.
En Hayashi 2000 pueden verse numerosas figuras.
Izq: Sagittal contrast-enhanced MRI of penetrating atherosclerotic ulcer of the ascending aorta
(arrowhead).
Dcha: TEE view of the descending thoracic aorta in the longitudinal plane. An atherosclerotic
aortic ulcer (U) is manifested by the presence of a crater with overhanging borders in the
atherosclerotic plaque. An intramural hematoma originates from the ulcer with propagation into
the aortic wall.
From: Khan: Chest, Volume 122(1).July 2002.311-328
15
IRAD
Variable
Total (n = 526)
Sobrev (n = 394)
Exit (n = 132)
P
ECO Transesofágico
417 (79.3)
313 (79.4)
104 (78.8)
.87
TAC
358 (68.1)
274 (69.5)
84 (63.6)
.21
Aortografía
100 (19.0)
83 (21.1)
17 (12.9)
.04
RMN
25 (4.8)
22 (5.6)
3 (2.3)
.12
RX normal (disección)
65 (14.3)
55 (16.0)
10 (8.9)
.06
Mediastino ensanchado (RX)
279 (61.5)
199 (58.2)
80 (71.4)
.01
Hematoma Intramural
28 (5.4)
19 (4.9)
9 (6.9)
.37
Regurgitación aórtica
300 (62.6)
227 (63.2)
73 (60.8)
.64
Derrame pericárdico
228 (46.3)
170 (45.7)
58 (48.3)
.62
Afectación coronaria
57 (14.2)
44 (14.3)
13 (13.8)
.90
Desgarro íntima en Ao Asc
186 (41.6)
145 (43.2)
41 (36.9)
.25
Desgarro íntima en arco aórtico
26 (5.8)
18 (5.4)
8 (7.2)
.47
Origen en raíz aórtica
193 (39.0)
137 (36.8)
56 (45.5)
.09
Origen en aorta ascendente
271 (54.7)
214 (57.5)
57 (46.3)
.03
Origen en arco aórtico
19 (3.8)
12 (3.2)
7 (5.7)
.28
Appendix
Score=Age · 0.5331 + Sex · 0.3244 + Abrupt Onset Chest Pain at Presentation · 0.9569 + Pulse
Deficit at Presentation · 0.7089 + Abnormal ECG at Presentation · 0.5714 · Renal Failure at
Presentation or Before Surgery · 1.5616 + Hypotension/Shock/Tamponade at Presentation ·
1.0876, with Age an indicator for Age 70; Sex an indicator with female=1, male=0; and the
other variables being indicators for respective conditions. Note logit (probability of in-hospital
death)=Score + (-2.94), where -2.94 is the intercept.
16
TRATAMIENTO DE LA DISECCION AORTICA
En la disección tipo A, el tratamiento es quirúrgico.
En algunos pacientes el riesgo quirúrgico puede ser tan elevado que desaconseje
la cirugía (patología concomitante severa: paciente en muy mala situación, infarto
cerebral, renal, miocárdico o intestinal extensos, etc.). Las disecciones crónicas también
son quirúrgicas. Con frecuencia evolucionan a aneurisma.
En la disección tipo B, en principio el tratamiento es médico, salvo
complicaciones (dolor persistente, HTA incontrolable, evidencia de expansión o
amenaza de ruptura del aneurisma, y compromiso visceral, renal o de EEII).
Algunos centros con experiencia en cirugía de aorta torácica están operando con
excelentes resultados quirúrgicos disecciones agudas tipo B de bajo riesgo. Las
disecciones B crónicas deben operarse cuando el diámetro llega a 6-6,5 cm.
Los pacientes con S de Marfan, un gran falso aneurisma, afectación retrógrada, o
complicaciones, son con más frecuencia candidatos a cirugía. El objetivo en los casos
quirúrgicos es evitar la ruptura y la afectación visceral. Suele afectar más al lado
izquierdo (arteria renal izq o los vasos iliacos izq).
En el Hematoma intramural y la Úlcera penetrante el grupo de Yale
recomienda cirugía precoz cuando afectan a la aorta ascendente, y tratamiento médico,
pero con menor “umbral” para decidir cirugía, haciendo controles de imagen a los 3-5
días de tratamiento médico.
Tratamiento Médico
Inicialmente el objetivo es controlar el dolor y estabilizar hemodinámicamente.
Analgesia:
Incluso antes de proceder a administrar hipotensores se debe tratar el dolor, lo que por sí
mismo ayuda al control de la TA.
Morfina 10 mg/1mL
Bolos 2-10 mg ( 0,1 mg/Kg sbc.im.iv)
Perfusión ± 3-6 Amp/d
Otros analgésicos (Toradol, Paracetamol, etc.)también pueden utilizarse, según la
intensidad y las circunstancias de cada paciente. (P.ej: Mórfico+Toradol+Primperán en
PC)
En cualquier caso se atenderá a la intensidad del dolor, al estado de conciencia, a la
capacidad respiratoria, tolerancia hemodinámica, etc.,
17
Estabilización hemodinámica:
Ante la sospecha de disección se debe proceder a control hemodinámico estricto
de la TA.
En caso de Hipertensión se debe procurar mantener TA máxima en torno a 110 mmHg
y FC 60-80 X´, teniendo en cuenta que es esencial también disminuir la fuerza de
eyección (dp/dt),
Para ello se utiliza NTP + β-bloqueante, o β-bloqueante solo. Pueden utilizarse también
Solinitrina, Nicardipina, o IECA, Verapamilo, Diltiazem en caso de contraindicación
para betabloqueantes.
- Nitroprusiato, (Nipride)
Puede dar taquicardia refleja y aumentar la contractilidad y el dp/dt, por lo que debe
asociarse con β-B. Puede, además, aumentar la isquemia miocárdica al derivar flujo
sanguíneo a otras zonas vasodilatadas, y disminuir la TA diastólica. Puede dar
hipoxemia, por inhibición de la vasoconstricción refleja producida por la hipoxia.
A dosis altas puede producir toxicidad por cianidas.
NTP
50 mg/5mL
50/250Gl
1mL= 200 μg
0,2-2-8g/Kg/min
60 Kg:
2-36-146 mL/h
- Trandate, (Labetalol)
Es α y β bloqueante (7 veces + beta que alfa por vía iv, y 3:1 por vía oral). Efecto
cronotrópico e inotrópico negativo. El efecto α-bloqueante inhibe la vasoconstricción
refleja. Su acción dura 6 horas.
Muy utilizado en disección aórtica tanto pre- como post- operatoriamente.
En Bolos: 15-20 mg en 2´, luego 20-80 mg/15´, hasta un máximo de 300 mg.
En Disecciones algunos señalan la conveniencia de no administrar dosis de carga por el
peligro de hipotensión.
LAB
100mg/20mL
200/200 Gl
1mL=1mg
1-4 mg X´ hasta ≈300 mg, o respuesta adecuada
- Esmolol (Brevibloc), ESM : 1Amp=2,5 gr (para dilución), 1 vial= 100 mg. 250-500
μg /kg/min en 1 min + 50 μg /kg/min durante 4 minutos. Repetir la secuencia cada 5
min hasta 4 veces, aumentando 50 μg /kg/min, hasta que se consiga el efecto deseado,
luego suele bastar con 50-25 μg /kg/min, o menos, para mantenimiento. Retirar también
lentamente (posible crisis hipertiroidea)
Cardioselectivo de acción ultracorta (comienza a actuar en 2 minutos, alcanza nivel
terapéutico en 5 y revierte en 10-20). Inotrópico negativo: baja el gasto. Puede usarse en
pacientes con broncoespasmo. Baja mas la TA que la FC.
Es una de las drogas más utilizadas.
ESM
1Amp: 2,5 g 2,5 gr/250G
1mL=10mg
25-50-300 g/Kg/min
18-80 mL/h
La presencia de Hipotensión/Shock en caso de disección, suele constituir una urgencia
quirúrgica. Puede ser por hemorragia, taponamiento cardiaco, regurgitación aórtica, etc.
Puede ser muy peligroso tratar de drenar un hemopericardio por punción, fuera del
ámbito del quirófano. Tanto el shock como el déficit neurológico severo o el TC se
asocian a malos resultados (Long 2003).
18
Tratamiento Quirúrgico
El objetivo inicial es evitar la ruptura hacia el saco pericárdico o hacia la Pleura,
y el compromiso de las arterias coronarias o de la válvula aórtica.
Los pacientes en coma, con severa afectación neurológica por la disección tienen un
pésimo pronóstico.
Son intervenciones que propician el sangrado por lo que resultan útiles los
antifibrinolíticos (Aprotinina, EACA, etc). También es habitual precisar Plasma,
plaquetas, crioprecipitado…
► Tratamiento de la Disección Aórtica tipo A
Se hace con CEC, anulando clásicamente la A Femoral, o la Aorta ascendente.
Los procedimientos a utilizar son diversos (Kallenbach, 2004).
Si hay regurgitación aórtica se hace resuspensión o reemplazamiento de la
Válvula Aórtica (según el grado de distorsión), resección de la disección, e interposición
de un tubo de Dacron. En S de Marfan se prefiere la sustitución completa. Si es posible
es aconsejable conservar la válvula nativa. (Harringer 1999), (Graeter 2000), aunque las
técnicas de remodelación no en todas las series han dado buenos resultados (Leyh 2002) .
Puede usarse Teflon para reforzar las zonas de sutura y cola biológica (Bio Glue) para
mejorar la integridad tisular para recibir los injertos. El uso de BioGlue (Raanani 2004)
consigue el cierre de la falsa luz en >50% de los pacientes, y ha reducido el número de
reemplazamientos valvulares, así como la incidencia de complicaciones postoperatorias,
aunque tiene cierto riesgo de redisección y de necrosis de pared aórtica (Kazui (2001).
Si la raíz aórtica está muy deteriorada y no se puede reconstruir se puede colocar un
tubo valvulado (Bentall) (Prifti 2000). (Frecuente en S de Marfan con ectasia previa).
El desarrollo de injertos impermeables como el Dacron, los injertos impregnados de
colágeno (Hemashield), los injertos aórticos de anatomía variada, los injertos
recubiertos de Gel (gel-coated Carbo-Seal Ascending Aortic Prothesis) y la utilización
de parada circulatoria en hipotermia profunda, con perfusión cerebral retrógrada o
anterógrada, han mejorado notablemente los resultados quirúrgicos, aunque la
mortalidad sigue siendo considerable (20-35%).
Si está afectado el arco aórtico suele ser preciso utilizar Hipotermia profunda y Parada
circulatoria. No lo es en los casos limitados a la aorta ascendente.
Válvula nativa resuspendida dentro de una prótesis tubular.
Simon, 1995
19
A: Resuspensión con preservación de la válvula
aórtica nativa. Las capas disecadas son
aproximadas en cada comisura con suturas
dobles reforzadas con “almohadillas”.
B: Resuspensión completada.
C: Se colocan unas finas tiras de teflon (de 8–10
mm de ancho ) por dentro y por fuera de la
circunferencia de la Aorta (los ostium coronarios
no estarían aquí afectados).
D: la pared aórtica quedaría en “ sandwich”
entre las tiras de teflon con las suturas dobles
englobadas. (Fleck, 2003)
E: sutura del tubo de Dacron a la aorta proximal
reconstruida.
Refuerzo de la aorta distal con
tiras de teflon, interna y externa,
previo a la sutura del extremo
distal del tubo de Dacron.
20
► Tras haber completado la sutura distal, el tubo es
canulado para reestablecer el flujo anterógrado.
► La sutura proximal es estabilizada inyectando
BioGlue, y se procede a anastomosar el cabo proximal
del injerto.
-------------------------
Sutura de un tubo valvulado de St
Jude al anillo aórtico. (Bentall)
Bentall.
Coronarias
implantadas
21
La cirugía sobre el arco aórtico, cuando es precisa, es muy delicada y compleja. El
arco es la porción de la aorta que se extiende entre el origen del tronco braquiocefálico
(o art.Innominada) y el origen de la arteria subclavia izquierda.
Las intervenciones en esta zona requieren habitualmente bypass cardiopulmonar
con hipotermia, y un periodo de parada circulatoria, que puede llegar hasta unos 30-40
minutos a 15-18 grados. Puede haber déficit neurológico difuso o focal postoperatorio
en 3-18% de los pacientes intervenidos, aunque raramente hay déficit severo
permanente.
En los aneurismas de arco aórtico, la cirugía se reserva para casos en que la
dilatación es de >5,5-6 cm, hay síntomas neurológicos, o el tamaño va aumentando. En
la disección es indicación quirúrgica cuando hay desgarro de la íntima en el arco, el arco
está roto, la parte externa del arco está adelgazada y hemorrágica, y cuando la parte
interna está fragmentada
Reemplazamiento de aorta ascendente y hemiarco aórtico.
Reemplazamiento de Aorta Ascendente y
Arco aórtico
Implantación en bloque de los
troncos supraaórticos, no afectados,
y resecados previamente, en el tubo
de Dacron.
22
Cuando está además afectada la Aorta descendente se puede colocar una “trompa de
elefante” (Hanafusa, 2002) (Safi 2000 y 2004), realizando en un segundo tiempo el
tratamiento de la zona distal disecada (anastomosis a la aorta, a otro tubo, o fijación de
stent sobre la trompa).
Reemplazamiento de aorta ascendente y arco aórtico +
Trompa de elefante.
A, Reconstructed 3D MRI after
percutaneous use of a customized stentgraft to connect a surgically inserted
elephant trunk with the upper abdominal
aorta in order to exclude an aneurysm
that had formed at the distal end of the
elephant trunk (B);
after placement of the customized stentgraft, the thoracic aneurysm was
successfully excluded from circulation
with thrombus formation around the
stent-graft protheses (C).
Resultados:
Trimarchi-2 (IRAD 2005) (18 hospitales en 8 países) reseña los resultados
quirúrgicos en 529 pacientes con Disección Tipo A: Se reemplazó la Aorta ascendente
en el 92% de los pacientes intervenidos, y el arco aórtico en el 31.5% (en 23 % se hizo
sustitución parcial y en 12% completa).
En 14% se reemplazó válvula + raíz + Aorta Ascendente con injerto valvulado.
En 91% se hizo parada circulatoria hipotérmica, con perfusión cerebral
anterógrada en 52%. Se reemplazó la válvula aórtica en 23%, y precisaron CABG
simultáneo 16%.
23
La mortalidad intrahospitalaria fue del 25% /31% en los inestables y 17% en los
estables). El 13% precisó reintervención.
El intervalo entre los síntomas y la intervención fue de 79 horas (38 en los
fallecidos y 93 en los sobrevivientes) . Entre el diagnóstico y la intervención
transcurrieron 4 horas.
En el 21% la cirugía se demoró mas de 24 horas (por necesidad de nuevas pruebas
diagnósticas, estabilización, disponibilidad, etc), de los que sobrevivieron 85%.
Tratamiento y Complicaciones en Diseccion tipo “A” (Trimarchi)
Variable
Total
Sobrev.
Exitus
Cirugía
Tto Médico.
P
436 (79.7) 320 (73.4) 116 (26.6)
111 (20.3) 49 (44.1) 62 (55.9)
----------- Complicaciones ---------Déficit Neurológico 97 (17.8) 55 (14.9) 42 (23.9)
Coma/Alt concienc. 80 (15.3) 34 (9.7) 46 (27.1)
Isquemia Miocárdica 57 (11.2) 33 (9.5) 24 (14.9)
Isquemia mesentérica 16 (3.2)
7 (2.0)
9 (5.6)
FRA
28 (5.6) 10 (2.9) 18 (11.3)
Hipotensión
137 (27.0) 59 (17.0) 78 (48.8)
Taponamiento C.
84 (16.5) 34 (9.9) 50 (31.1)
Isquemia EE.
48 (9.5) 25 (7.3) 23 (14.5)
*
<0.0001
0.01
<0.0001
0.07
0.03
0.0002
<0.0001
<0.0001
0.01
En series de pocos pacientes Hirotani (2000,) refiere sustitución total del arco con
mortalidad del 11%, Kato (2002) del 5,3%).
Factores predictivos asociados a mortalidad:
Variables at presentation
Overall
type A
%
Percent
among
survivors
Percent
among
deaths
Model
P
value
Mortality, odds
ratio (95% CI)
History of aortic valve replacement
4.4
3.5
7.4
.02
3.12 (1.16-8.40)
Migrating chest pain
14.2
12.1
20.5
.001
2.77 (1.49-5.15)
Presenting hypotension as sign of AAD
17.6
13.3
30.4
.02
1.95 (1.08-3.52)
Presenting shock or tamponade
24.7
19.5
40.7
.002
2.69 (1.41-5.11)
Preoperative cardiac tamponade
15.7
11.8
27.6
.01
2.22 (1.17-4.22)
Preoperative limb ischemia
9.7
7.8
15.8
.04
2.10 (1.00-4.38)
24
En relación a la edad, Mehta (2002), en un análisis de los pacientes del IRAD
encuentra que solamente el 64% de los pacientes mayores de 70 años (que eran un 32%
del total) fueron intervenidos, (frente al 86% de los menores de 70).
Su mortalidad fue del 43%.
Cuando analiza los pacientes con Disección “B” del IRAD (383) encuentra un 41% >70
años, con una mortalidad del 16% vs el 10% en los <70 años. La malperfusión visceral
y el shock se asocian a la mayor mortalidad (28 y 56% respectivamente). Mehta (2004).
► Tratamiento de la Disección aórtica tipo B:
En principio el tratamiento suele ser preferentemente médico, para control del
dolor y la HTA, salvo complicaciones, aunque es un tema recientemente cuestionado.
(Umaña (Stanford). Is medical therapy still the optimal treatment strategy for patients with acute type B
aortic dissections? . J Thorac Cardiovasc Surg;124:896-910. 2002).
El objetivo de la cirugía es evitar la ruptura y la afectación visceral. Entre el 70
y el 80% de los pacientes sobreviven a la fase aguda, y la fase subaguda, solo con
tratamiento médico.
La cirugía aquí, tiene una mortalidad por encima del 30% y la incidencia de
paraplejia postoperatoria también está próxima a esos niveles. (Lansman, 2002, del
Mount Sinai refiere una mortalidad del 0%, aunque con un 47% de complicaciones
importantes en 34 pacientes con disección B aguda que requirieron cirugía).
Roseborough 2004, del Jhons Hopkins refiere una mortalidad del 13% (12/92) con tratamiento
médico, y del 18% (4/22) en los que requirieron intervención.
Pueden constituir indicación quirúrgica, la ruptura, el dolor incoercible, la
progresión de la disección a pesar de tratamiento médico enérgico, los síndromes de
malperfusión orgánica o la imposibilidad de controlar la TA.
La presencia de S de Marfan, o de grandes falsos aneurismas, el desarrollo de
hematomas periaórticos o mediastínicos que amenacen romperse, o la afectación
retrógrada del arco aórtico (Kaji, 2003), son factores que pueden aconsejar una cirugía
mas temprana La parálisis aguda no solo no contraindica la cirugía sino que la puede
hacer el único medio de recuperación al lograr la revascularización.
El tipo de cirugía a realizar es diverso (Sustitución parcial de la aorta, Bypass
extraanatómico, etc) . (Hsu, 2005)
Sin embargo, incluso en presencia de complicaciones hay un interés creciente y
preferente en el tratamiento endovascular con stent, manteniendo una actitud
conservadora (tratamiento médico) en casos no complicados.
Bell (2003), señala que el tto. endovascular de una disección complicada tipo B
incluiría: cubrir el punto de entrada con la endoprótesis + fenestración de la íntima +
stents en las ramas aórticas obstruidas. El tto. endovascular también puede ser útil en el
tto de las complicaciones no cardiacas de la cirugía de la disección (Beregui 2003)
♦ Fenestración:
El objetivo es crear una comunicación entre la luz verdadera y la falsa, cuando la
verdadera está comprimida por la falsa, y ello crea un compromiso isquémico de las
ramas aórticas viscerales o de los miembros. Se hace introduciendo una aguja
(Brockenborough) que perfora la íntima desde la luz menor a la mayor (generalmente
25
desde la verdadera a la falsa luz), dilatando después el orificio con un balón de 12-15
mm de diámetro y 20-40 mm de largo. Indicada en presencia de isquemia intestinal o de
los miembros o en FRA.
La reparación quirúrgica de la aorta torácica disecada consigue una recuperación
de pulsos periféricos en 90%. Sin embargo los pacientes con isquemia renal pueden
tener una mortalidad del 50-70%, y del 87% en isquemia mesentérica o isquemias
periféricas. Con Fenestración quirúrgica la mortalidad varia entre el 20 y 60%, lo que ha
hecho acrecentar el interés por la utilización de la Fenestración con balón endovascular
percutáneo.
El cierre de la puerta de entrada parece esencial para que se reconstruya la
verdadera luz y se trombose la falsa, y también aquí las técnicas percutáneas (incluso en
el arco) pueden ser eficaces.
La obstrucción estática de una rama arterial de la aorta pudiera ser vencida con
la colocación de un stent en el vaso original. Los stent a diversos niveles de la luz
verdadera aórtica pueden así mismo mejorar el flujo a las diversas ramas de la aorta, con
o sin la utilización, además, de la fenestración con balón.
♦ Endoprótesis:
(Excelente Revisión en Lee 2004 de Stanford)
Se utiliza para corregir la compresión de la verdadera luz y mejorar así el flujo
distal. El objetivo es taponar la puerta o puertas de entrada, con lo que la comunicación
proximal entre las dos luces queda sellada. Esto favorece la trombosis y obliteración de
la falsa luz.
Se debe evitar ocluir el origen del tronco celíaco, mesentérica superior y arterias
renales. En base a cuidadosas mediciones obtenidas en los procedimientos de imagen
se coloca una (o mas) endoprótesis de hasta 18 cm y 25-35 mm de diámetro, mediante
técnica de Seldinger, por femoral.
Durante el procedimiento (que suele requerir anestesia general) se intenta
mantener una TA de 50-60 con NTP, durante corto tiempo. En Stanford utilizan de
rutina ECO intravascular.
Tras desplegar el injerto puede utilizarse un balón de látex intraluminal para “pegar” el
injerto a la pared aórtica. Pueden colocarse stent en el ostium de las ramas de la aorta
afectadas por obstrucción.
Aortograma antes y después de
colocar un Stent sobre la puerta
de entrada.
Izq: la flecha señala el paso de
contraste desde la luz verdadera
(T) a la falsa (F) a través del
desgarro.
Dcha: solo se ve la luz verdadera.
Dake. N Eng J Med 340 (20):
1546, Figure 1 May 20, 1999
Tras la colocación del stent puede haber una reacción febril, con elevación de la Proteína C
Reactiva, que desaparece espontáneamente o se trata con antiinflamatorios no esteroideos.
Una complicación temible es el daño neurológico espinal con paraplejia. Algunos propugnan el
drenaje profiláctico del LCR o la monitorización de potenciales evocados . También se ha
utilizado con buenos resultados el drenaje de LCR como tratamiento (5 de 13 recuperaron).
26
Acute type B aortic dissection in a 44-year-old man; note the communications between the
true and false lumen at the thoracic and abdominal level. After stent-graft placement across the proximal
thoracic entry, the entire aorta including the abdominal segment is reconstructed with time, with complete
"healing" of the dissected aortic wall and closure of distal communication.
Intravascular ultrasound image of leaking
pseudoaneurysm of previously repaired ruptured
thoracic aortic aneurysm. Note the color flow of
the obvious breakdown of the proximal anastamosis.
This patient was treated with a stent graft that
covered the entry site, and the patient's symptoms of
pain and hemothorax resolved.
Intravascular ultrasound images
of type B aortic dissection
extending down to the abdominal
aorta with catheter within true
lumen (t). Note that the left renal
artery (L) comes off the true lumen,
while the right renal artery (R)
comes off the false lumen (f).
27
Criteria for endovascular repair of thoracic aortic disease at Harbor-UCLA Medical
Center. Lee 2004.
Thoracic aortic aneurysm
Type B aortic dissection
Descending thoracic aneurysm >5.5 cm
Acute dissection with intractable pain,
uncontrollable hypertension, progression of
dissection, or end-organ ischemia
Aneurysm 4.5–5.5 cm with increase in size by
0.5 cm in last 6 months or twice size normal
Chronic dissection with aneurysmal dilatation
of proximal descending aorta
Saccular aneurysm or penetrating ulcer
Chronic dissection with acute symptoms
Nonaneurysmal proximal and distal aortic neck Entry tear at least 1 cm from left subclavian
measures between 22 and 40 mm (dependent
orifice (potentially 2 cm if plan to cover
on device availability)
subclavian)
No extension of aneurysm into abdominal
aorta (distal neck at least 2 cm above celiac)
No entry site of dissection that is proximal to
subclavian or involves arch or ascending
portion of aorta
Devices available that are suitable for patient's anatomy
Patent iliac or femoral arteries that allow introduction of 22–25 F delivery sheath (device
dependent)
Life expectancy at least 6 months
Able to consent for appropriate trials and follow-up protocols
28
Consideraciones para elección del tratamiento en la Disección aórtica.
► Cirugía
Es el tratamiento de lección el la Disección tipo A
Indicada en Disección tipo B, complicada con:
Extensión retrógrada a la aorta ascendente
Disección en S de Marfan
Ruptura o amenaza inminente de ruptura (ej.: formación de aneurisma sacular
(¿endoprótesis?)
Progresión con compromiso de órganos vitales (¿stent?)
► Tratamiento médico
Es el tratamiento de elección Disección tipo B no complicada
Disección estable, aislada, del arco
Disección estable tipo B (crónica, 2 semanas desde el inicio)
► Tratamiento endovascular intervencionista
Stent-grafts para sellar la puerta de entrada a la falsa luz y aumentar el diámetro
de la verdadera luz, comprimida por la falsa.
Disección tipo B inestable.
S de Malperfusión (proximal aortic stent-graft and/or distal
fenestration/stenting of branch arteries)
Disección tipo B estable (en estudio)
Nienaber, Aortic Dissection: New Frontiers in Diagnosis and Management
Part II: Therapeutic Management and Follow-Up. Circulation. 2003;108:772.)
Bavaria (2002) señala las siguientes medidas que han mejorado el pronóstico quirúrgico:
1. Admisión directa a quirófano para diagnóstico (ETE) y tratamiento, sin pasar por
Cardiología.
2. ETE intraoperatoria.
3. Monitorización Neurocerebral (60% de los pac.): EEG, Potenciales evocados. Enfriando a
3ºC por debajo del silencio eléctrico (usualmente a Tª nasofaringea 15-20ºC). Si no tenían
monitorización enfriaban al menos durante 45 minutos antes de la intervención abierta del arco
aórtico. Administran además1 g de Solumedrol, 1 g de magnesio, y 2.5 mg/kg de Lidocaina tras
iniciar la CEC.
4. Reconstrucción abierta del arco aórtico (mejor hemiarco) con perfusión cerebral retrógrada
o anterógrada. (vía femoral, axilar dcha, o subclavia).
5. Perfusión anterógrada del injerto de arco aórtico tras la finalización de la reconstrucción
del arco.
6. Resuspensión valvular en la mayoría de los pacientes sin patología de las valvas o la raíz
aórtica previas.
7. Creación de una capa "neo-media" usando teflon o Bioglue para reforzar las paredes de los
senos y la aorta y obliterar la falsa luz
29
Aneurisma Aórtico Torácico y Abdominal
(Isselbacher: Circulation, Volume 111(6).February 15, 2005.816-828)
(http://www.eurostar-online.org/)
Son dilataciones localizadas de la Aorta. Puede ocurrir a cualquier nivel. La
prevalencia se considera que ha aumentado 40 veces en los últimos 50 años. Es 4 veces
mas frecuente en varones (5-10% de los mayores de 60 años tienen un aneurisma
aórtico, la mayoría de ellos asintomáticos).
Pueden afectar a uno o varios segmentos de la aorta.
El 60% afectan a la raíz aórtica y/o la Aorta ascendente
y el 40% a la aorta descendente. El 10% afectan al
arco, y el 10% a la aorta torácica y abdominal. Son
frecuentes por debajo de las renales.
Se producen, en general, por la degeneración de la
media, favorecida por la edad y por la Hipertensión.
► Etiología: S. Marfan, S. familiar de Aneurisma
aórtico, Válvula aórtica bicúspide, Ateroesclerosis
/sobretodo en los de aorta descendente), Sífilis (raro
actualmente), S. de Turner, Arteritis aórtica, Disección
aórtica crónica, Traumatismo…
► Clínica : La mayoría son asintomáticos. Otras
producen signos por compresión de estructuras vecinas
(tos, disnea, neumonitis, disfagia…) o Insuficiencia aórtica, por regurgitación. La
complicación mayor es la Ruptura o la Disección.
Crecen ≈ 0,1 cm /año. Con menos de 5 cm se el peligro de ruptura es de un 2% anual, y
del 3% para los que miden 5-6 cm. Por encima de 6 cm el riesgo aumenta más del
doble. Ruptura, shock y malperfusión son signos de mal pronóstico (Genoni, 2002).
► Clasificación de los aneurismas toraco-abdominales (Crawford).
30
► Diagnóstico:
Al igual que en las disecciones los RX, la Ecografía, la TAC , la RMN y la
angiografía son los métodos mas usuales.
◄ Standard axial image from a contrast-enhanced CT scan showing what
appears to be an oval-shaped descending thoracic aortic aneurysm,
appearing to measure as much as 8.0×5.2 cm in diameter (arrows).
B
◄ Three-dimensional reconstruction in a left anterior oblique view of
same CT scan demonstrating that the descending aorta is tortuous and was
consequently cut off-axis (dotted arrow) on axial CT image. The true
maximal diameter of this aortic segment was only 5.6 cm (solid arrow)
►Contrast-enhanced CT scan demonstrating a
7.5×8.3-cm ascending thoracic aortic aneurysm.
A indicates ascending; D, descending.
A transthoracic echocardiogram, in a parasternal long-axis
view, demonstrating a dilated aortic root (4.4 cm) and
ascending aorta (4.2 cm). Whereas the aortic root is well
visualized, the ascending aorta is less so, as is often the case
with transthoracic imaging.
RV indicates right ventricle; LV, left ventricle; and LA, left
atrium.
►Angioresonancia mostrando un aneurisma
de aorta torácica de 4,7 cm
31
► Tratamiento:
En los de Aorta ascendente la cirugía está indicada a partir de 5,5 cm. Los
Marfan o los casos de válvula bicúspide se operan antes (a partir de 5 cm). En
intervención de un aneurisma que afecte al arco se debe practicar coronariografía en
>40 años. Es aconsejable también TAC craneal y Doppler de TSA previos a la cirugía.
Los de Aorta torácica descendente se operan a partir de 6 cm. (Mitsumasa 2003)
Abdominal: El riesgo es la ruptura, fundamentalmente a partir de 50-55 mm (“grandes”)
en que sería del 10% en 12 meses, entre 30-39 mm (“muy pequeños”) el riesgo de
ruptura es escaso (0,4% en 12 meses) (Aneurysm Detection and Management Veteran
Affairs Cooperative Study (ADAM study). (Shakibaie 2004)
La cirugía electiva convencional consiste en la inserción de un tubo de Dacron,
que puede estar bifurcado, y que es suturado dentro del saco aórtico, para “excluir” el
segmento afectado.
La mortalidad quirúrgica (en electiva) es del 5-10%, y el periodo de recuperación se
alarga varios meses.
La mortalidad del aneurisma abdominal roto está alrededor del 80% (Shakibaie, 2004).
Reparación endovascular:
Efectuada por primera vez en Argentina en 1991 (Juan Parodi). Se introduce un
injerto “compactado”, bifurcado o no, a través de la arteria femoral con control RX. Se
despliega la “endoprótesis” y se fija con resortes de alambre o stents algunos de los
cuales tienen ganchos o lengüetas que penetran en la pared del vaso. Las mediciones
previas deben ser muy cuidadosas. Dake (2) (1999) refiere el tto con endoprótesis en
Disección A y B.
Aunque las ventajas son obvias, los resultados a largo plazo no están claros (en
cuanto a la durabilidad y la seguridad de las endoprótesis no suturadas), y es
problemática su utilización en caso de buenos candidatos para cirugía.
La incidencia de pacientes que requieren reintervención es escasa (Grabenwoger,2004)
Es necesaria la colaboración interdisciplinar (RX, Cardiología, Cirugía, etc) para
optimizar los resultados (Herold 2002).
Imágenes en : (Therasse. Stent-Graft Placement for the Treatment of Thoracic Aortic
Diseases. RadioGraphics;25:157-173. 2005)
Leurs (2005) recoge los resultados en 443 pacientes del Eurostar y de UK.
Nienaber (2005) dice que es necesario precisar mejor a que pacientes beneficia realmente.
Doss (2005) compara el tratamiento quirúrgico (28p) o con endoprótesis (32p), en 60
pacientes agudos con lesión de aorta torácica (27 rupturas de aneurisma, 15 disecciones
B perforadas, y 18 rupturas traumáticas). Aunque la mortalidad perioperatoria fue de 5
(18%) vs 1 (3%), favorable a la endoprótesis, pasado un año hubo 4 fallecimientos en el
grupo de endoprótesis (3 relacionadas con el procedimiento) y 1 en el grupo quirúrgico
(no relacionada con la cirugía). También la morbilidad fue mayor, a largo plazo, en el
grupo de endoprótesis.
Bortone (2004) refiere buenos resultados a corto y medio plazo en 110 pacientes con patología
de aorta descendente, incluida disección B aguda.
Marin (2003) revisa los resultados en 817 pacientes en 10 años.
32
Martín (2005) de Asturias, reporta sus resultados en 15 pacientes y revisa el tema (en español).
A: reconstrucción de la tomografía computarizada previa
a la intervención en un paciente con aneurisma de aorta
torácica que englobaba el origen de la subclavia
izquierda. Diámetro proximal (34,1 mm) y diámetro distal
(31,1 mm), aneurisma (73,2 mm) relleno con un gran
trombo mural. Flecha grande: trombo mural. Doble flecha:
bypass desde la aorta ascendente al tronco supraaórtico.
B: el mismo caso, una vez implantada la endoprótesis
Martín.Tratamiento percutáneo de las afecciones de la
aorta torácica. Una labor multidisciplinaria. REC 58;1:2733. 2005
► Complicaciones : a) Inmediatas: FRA, Infarto intestinal, Embolismo EEII, Ruptura
de la falsa luz, paraplejia, S. postimplantación (fiebre,↑Prot C Reactiva, y leucocitosis)
b) Tardías: fractura, migración o prolapso, erosión a esófago, infección, leak
endovascular, embolización distal, isquemia intestinal, expansión y ruptura del
aneurisma tratado. (Gowda, 2003).
En 1996 se estableció el Proyecto Eurostar que es un registro europeo de pacientes a
los que se ha efectuado reparación endovascular de un aneurisma aórtico.
http://www.eurostar-online.org/
Con mas de 7000 pacientes, de 66 Hospitales, es la mayor base de datos al respecto.
De 6264 pacientes con aneurisma abdominal (En/05), 5887 son varones y 377 mujeres.
Edad media = 72,3 años. La Estancia media hospitalaria fue 5,8 días. Hubo
complicaciones intraoperatorias relacionadas con el procedimiento en 299 (+ 168
posteriormente), y no se pudo completar el procedimiento en 99. Complicaciones de
otro tipo (sistémicas) en 703. Anestesia general en 4371 pac. Duración del
procedimiento 131 minutos.
La mortalidad precoz fue del 2,4%, y a 30 días cerca del 10%. La incidencia de
endoleak en los meses posteriores está en torno al 10%.
De 522 pacientes (Feb 05), de 53 hospitales, con aneurisma torácico, el 78% fueron
varones, y la edad media fue de 63 años. Etiología: arteriosclerótica 268, Traumática
62, Postdisección 163. En 74 hubo disección + aneurisma y en 94 disección sin
aneurisma, aneurisma solo en 352. En 491 se utilizó anestesia general. En casi la mitad
se implantó mas de un Stent. El procedimiento duró una media de 132 minutos. En 50
hubo complicaciones relacionadas con el Stent, en 53 complicaciones arteriales, en 5
no se consiguió realizar el procedimiento. Secuelas neurológicas en 52 y
complicaciones sistémicas en 122. La estancia media en UCI fue de 5 día, y la
hospitalaria de 15. Murieron en periodo precoz 61 pacientes, y 94 en el primer mes.
33
◄ Composite aortic graft repair of
aneurysm involving the aortic root and
ascending thoracic aorta. The coronary
arteries are excised as buttons, and the
aneurysm is resected to the level of the
aortic annulus, with sacrifice of the native
aortic valve. A prosthetic valve is attached
directly to a Dacron graft, and this
composite graft is sewn directly to the
annulus. The native coronary buttons are
then reimplanted into the graft.
(©Massachusetts General Hospital
Thoracic Aortic Center.)
From: Isselbacher: Circulation, Volume
111(6).February 15, 2005.816-828
◄Valve-sparing procedure to repair an
aneurysm involving the aortic root and
ascending thoracic aorta. The aortic
sinuses are excised, but the valve leaflets
are not. The leaflets are then placed within
the lumen of a Dacron graft that is then
sewn directly to the aortic annulus. The
valve leaflets are then reimplanted within
the base of the graft to restore
competency.
◄Repair of an aneurysm involving
ascending thoracic aorta and arch by
using a multilimbed prosthetic graft
34
Reparación de un Aneurisma de Aorta descendente
Reparación con endoprótesis. Se avanza hasta el lugar de anclaje y se expande el cabo proximal y
luego se ancla el distal (respecto a la aorta). El saco aneurismático alrededor del stent acaba
trombosándose.
(A) Computed tomography scan and drawing of a
patient with mega aorta–fusiform aneurysmal
disease involving the ascending, arch, and all of
the thoracoabdominal aorta. (B) First stage of
repair including resection and replacement of the
ascending aorta and transverse aortic arch using
the elephant-trunk technique and coronary artery
bypass grafting with vein grafts for coronary
artery occlusive disease. (C) Drawing and
aortogram following completion of repair
including ascending, transverse aortic arch, all of
thoracoabdominal aorta, and reattachment of
intercostal, visceral, and renal vessels.
Coselli. Descending and Thoracoabdominal
Aneurysm. Cap. 48. In: Cohn LH, Edmunds LH
Jr, eds. Cardiac Surgery in the Adult. New York:
McGraw-Hill, 2003.
35
► Lugar de canulación:
El lugar habitual de canulación para la CEC es la aorta ascendente, pero en caso de
disección aneurisma, o severa arteriosclerosis se utilizan otros lugares, entre los cuales
el mas usado ha sido la arteria femoral, con perfusión retrógrada. Con frecuencia
creciente se utilizan otros accesos como la arteria axilar (Neri 1999), el tronco
braquiocefálico, o incluso el ápex cardiaco.
La perfusión retrógrada con canulación femoral o iliaca produce una distribución del
flujo similar a la de la perfusión anterógrada, pero puede dar lugar a múltiples
complicaciones (desgarros, disección, estenosis tardías, trombosis, sangrado, fístula
linfática, infección, ateroembolismo coronario o cerebra, isquemia distal en EEII….) ,.
La complicación mas peligrosa es la disección retrógrada (0,2-1,3% de incidencia), que
conlleva una mortalidad de cerca del 50%.
Fusco (2004) de Yale, la continúa recomendando.
Es más recomendable (Cohn), sobretodo en la cirugía del arco aórtico, usar
preferentemente la arteria axilar derecha que suele estar poco o nada afectada en la
arteriosclerosis. Strauch (2004), del Mount Sinai, refiere su utilización en 284 pacientes
con cirugía de aorta ascendente o sustitución del arco, entre 1999 y 2003, con una
mortalidad hospitalaria del 4,6% y ACV permanente en 4,6% (morbimortalidad
combinada:6,6%).
Se evita así la perfusión retrógrada a través de una aorta abdominal y torácica
frecuentemente enfermas, así como las turbulencias que se crean en la canulación de
aorta ascendente. Además es muy útil para la perfusión cerebral anterógrada durante la
reconstrucción del arco. La circulación del brazo derecho está bastante bien suplida por
colaterales o puede mantenerse con “flush” retrógrados. Como complicaciones puede
dar trombosis o lesión del plexo braquial, y otros problemas (Schachner 2005).
Se ha descrito la canulación directa de la aorta ascendente en caso de disección, con
control ecográfico, en un lugar libre de disección, en caso de dificultad para la
canulación axilar o subclavia (japonesas pequeñitas) . (Yamada 2003). (Noiseux 2003)
Además de la monitorización convencional, es muy útil la ecografía TE intraoperatoria.
Algunos utilizan monitorización EEG continua.
No se recomienda la protección con barbitúricos por su efecto sobre la función cardiaca.
Se administran Corticoides. Spielvogel (2003) utiliza 2 gr de Solumoderín al inicio si se
prevé parada circulatoria. Si la parada es > de 30 minutos se administran 125 mg/6h
durante 24 h postoperatorias y 125mg/12 horas otras 12 horas.
Protección Cerebral
En las operaciones que afectan al arco aórtico es esencial conseguir una
adecuada protección cerebral, es decir proteger al cerebro mientras se accede
quirúrgicamente a los vasos que lo irrigan.
El objetivo es minimizar el daño isquémico originado por la parada circulatoria y evitar
embolizaciones (aéreas, o de material ateromatoso).
Se han utilizado varias técnicas (Souza, 2003 http://perfline.com/ ):
- Hipotermia profunda con Parada Circulatoria. La temperatura se baja a menos de
20ºC, perfundiendo una solución fría (en torno a 10º-15º), lo que disminuye el consumo
de Oxígeno cerebral y atenúa la liberación de neurotransmisores y oxidantes, durante
los periodos de isquemia y reperfusión. La Tª puede medirse a varios niveles: en la
36
vejiga, en la arteria pulmonar, en el esófago, en el recto, en la nasofaringe, o en la
membrana timpánica.
Para estimar la adecuación de la respuesta a la hipotermia pueden utilizarse parámetros
como el silencio EEG, una saturación venosa yugular del 95%, o simplemente esperar a
tener una Tª < 20º en nasofaringe o membrana timpánica al menos 30 minutos antes de
parar la circulación. (Stecker 2001).
Con esta técnica, si se sobrepasan los 40 minutos, la incidencia de ACV aumenta
mucho, y a partir de 65 minutos se disparan las cifras de mortalidad. Si la intervención
lo permite pueden intercalarse periodos de parada circulatoria de 10-20 minutos, con
periodos de perfusión de 10-15.
La cabeza puede ser envuelta en hielo como protección adicional.
Tanto el enfriamiento como el recalentamiento deben hacerse lentamente. (Prêtre 2003)
Algunos como Lai (2002), de Stanford, cuestionan su utilidad real.
- Perfusión cerebral selectiva anterógrada parcial o bilateral.
Puede utilizarse “en lugar de” la Hipotermia + PC, o “además de”. Se usó ya en los años
60 (De Bakey). Si se trata de cirugía programada se debe evaluar antes, si hay estenosis
carotídea (>70% de estenosis) y el funcionalismo del Polígono de Willis (con Doppler,
angiografía, EEG, etc.).
Los vasos cerebrales son perfundidos individualmente en conjunto, a menudo a través
de injertos con múltiples salidas, por las que se efectúa perfusión de forma secuencial.
Se perfunde a 10-18ºC, a un flujo de 10-20 mL/Kg/min, limitando la presión de
perfusión a 30-70 mmHg.
La perfusión unilateral (cánula en art subclavia derecha) tiene algunas ventajas en
cuanto al riesgo de disección o el correcto posicionamiento de la cánula. El hemisferio
izquierdo se perfundiría a través del polígono de Willis y en menor medida a través de
colaterales cervicofaciales. Es importante que la carótida y la subclavia izquierdas estén
ocluidas para evitar pérdidas.
Con PA (P anterógrada) Hagl (2001) del Mount Sinai encuentra menor incidencia de
complicaciones neurológicas en 717 pacientes sobrevivientes de cirugía aórtica con parada
hipotérmica:145 con reemplazamiento total del arco y 25 con trompa de elefante (588
pacientes con solo Hipotermia profunda, 43 con PR asociada y 86 con PA) .Mortalidad
total 10%. Daño neurológico permanente 5,7%, transitorio 3,3%).
Dossche (1999)(2000), refiere una mortalidad del 8,5% en cirugía de aorta torácica
proximal (60 aneurismas, 26 aneurismas postdisección, 16 disección A), utilizando
perfusión anterógrada. Lo mismo Okita 2001.
Di Eusanio (2003) compara la perfusión anterógrada con la hipotermia , con resultados
algo mejores con PA.
Küçüker 2005 refiere un 2,2% de complicaciones neurológicas con perfusión
anterógrada canulando arteria braquial derecha.
(Veeragandham. Experience with antegrade bihemispheric cerebral perfusion in aortic arch
operations . Ann Thorac Surg;66:493-499. 1998)
- Perfusión cerebral retrógrada: perfundiendo a través de la Vena Cava Superior a 818ºC, a 25-40 mmHg de presión de perfusión, y a flujos de 250-400 mL/min. Se
comenzó a utilizar en 1980.La incidencia de complicaciones es similar a la de la técnica
anterior. Bavaria (1995). La perfusión efectiva (en cuanto a nutrición cerebral) es muy
escasa (≈5%) y de distribución poco homogénea. (Tanoue. 1999)
Inicialmente varios autores encontraron mejoría significativa en sus resultados usando la
perfusión retrógrada:(Brux 1995).(Deeb 1995). Ehrlich (1999). Esmailian (1999)
37
El empleo de una u otra técnica es controvertido. Barnard (2004) estudiando 408
artículos al respecto, concluye que la perfusión anterógrada como complementaria de la
hipotermia profunda con PC, es superior a la perfusión retrógrada o la hipotermia + PC
solas, aunque señala que el nivel de evidencia es pequeño. Parecido, Sinatra 2001. Fleck
(2003) no encuentra mejoría al añadir PR a la Parada circulatoria.
Safi de Houston en 1997 reportaba una mortalidad del 6% con hipotermia y perfusión
retrógrada.
Se pueden utilizar diversos medios de monitorización neurofisiológica (Ganzel, 1997)
Izq: Perfusión anterógrada bilateral,
obtenida por canulación selectiva del TBC y
de la A. Carótida izq.
Dcha (arriba): Perfusión cerebral
retrógrada vía Vena Cava superior.
Dcha (abajo): Perfusión anterógrada
unilateral vía arteria Subclavia derecha.
Prevención de Paraplejia
Debe prevenirse fundamentalmente en las intervenciones que afectan a la aorta
torácica o toracoabdominal. La médula espinal está parcialmente protegida por la
hipotermia sistémica, pero se necesita protección adicional. Se pueden monitorizar los
potenciales evocados somato-sensitivos o motores. Los vasos intercostales son
clampados de uno en uno, antes de iniciar el BP cardiopulmonar, y solo son sacrificados
si los potenciales evocados están conservados a los 10 minutos del clampaje. Algunos
aconsejan continuar la monitorización de los potenciales evocados hasta que el paciente
despierte, y luego explorar la funcionalidad de las EE horariamente durante 72h. Si hay
una alteración de los PE o se deteriora la función motora se procede a aumentar la TA y
disminuir la presión intratecal mediante drenaje del LCR.
Uso de Cola biológica
Se ha utilizado sobretodo en Europa, para reforzar los tejidos aórticos tras la
Disección.
38
Perfusión cerebral anterógrada del TBC y de la
carótida izquierda (10 mL/Kg/min)
(40 mm Hg). (La circulación sistémica se
establece por otra cánula en aorta ascendente)
La subclavia izq. está clampada.
Injerto de 4 ramas de “Intervascular”
C: sutura del extremo distal a
la aorta descendente, (parte
inferior del cuerpo sin
perfusión). D: Se clampa el
cabo proximal y se hace
perfusión sistémica
anterógrada a través de la 4ª
rama. Se sutura la 3ª rama a
la subclavia izq. y se
desclampa. E: El cabo
proximal se sutura a la aorta
ascendente y se inicia
perfusión a las coronarias. F y
G: Se anastomosan el TBC y
la Carótida izq. H se retira la
4ª rama utilizada para perfusión anterógrada sistémica.
(T Total bomba: 166 minutos, T Perfusión selectiva: 94 minutos, T parada circulatoria para la
anastomosis distal: 55 minutos. Mortalidad en 120 pacientes: 2,5%, 16% en emergencia. Daño
neurológico permanente 2,5%.
Kazui 1996, 2000. Use of aortic arch branched graft in the treatment of aortic arch aneurysm or aortic
dissection. http://www.intervascular.com/us/clinicalarticles_4.html
Hagl C,. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection
technique in high-risk patients J Thorac Cardiovasc Surg 2001;121(6):1107-1121. Mount Sinai
All 717 patients who survived ascending aorta–aortic arch operations through a median sternotomy since
1986 were examined for factors influencing stroke. 17 of the 734 patients died in the operating room or
shortly thereafter before adequate assessment of neurologic function was possible. Fifty-six of the
operative survivors died before discharge from the hospital, resulting in an overall mortality of 10%. 24
ACV transitorio, 22 ACV permanente.
39
Hagl (2001) . The simplified technique for selective ACP used at Mount Sinai, showing incorporation of
the cerebral vessel graft into the
arch repair. A, The cap of cerebral
vessels, dissected from the native
arch, is sutured to an appropriately
shaped 14- to 16-mm Hemashield
graft by using a running 3-0
polypropylene suture reinforced
with Teflon felt. B, An arterial
inflow cannula has been inserted,
the proximal end of the graft has
been clamped, and selective ACP
has been initiated with blood at
15°C to 20°C to achieve pressure
of 50 to 60 mm Hg in either radial
artery (flow rate, 800-1200
mL/min). A second Hemashield
graft is shown after the reinforced
distal anastomosis has been
completed and the proximal
anastomosis is being constructed.
C, The arch reconstruction is
being completed by means of a
graft-to-graft anastomosis of the
proximal-distal arch and cerebral
vessel grafts during a brief (5-10 minute) interval of HCA. D, The completed repair. This technique can
be combined with axillary artery cannulation to minimize risk of embolization.
Bachet Antegrade cerebral perfusion with cold
blood: a 13-year experience. Ann Thorac Surg
1999;67:1874-1878.
The perfusion circuit of the brain and the coronary
arteries with cold blood. Ox = oxygenator; P1 =
roller pump for the cold blood perfusion; P2 = roller
pump for the main circuit; E1 = extra heat exchanger
for the cerebral circuit (10–12°C); E2 = heat
exchanger of the main circuit (28°C).
40
Otro método usando un injerto “trifurcado”. Perfusión selectiva anterógrada a través
de la arteria axilar derecha.
Spielvogel. Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion
Ann Thorac Surg 2002;74:S1810-S1814
41
Steps in attaching the grafts. A) Ascending
aortic replacement is completed; the intimal
tear is seen to originate between the orifices of
the innominate artery and the left carotid
artery. B) The innominate artery is dissected
free and a 10-mm Dacron graft is anastomosed
to it in an end-to-end fashion during
circulatory arrest. Antegrade selective cerebral
perfusion is begun through the innominate
artery graft. C) A 14-mm Dacron graft is
anastomosed to the button containing the left
carotid and left subclavian arteries. Both grafts
are used for antegrade cerebral perfusion. D) A
22-mm tubular graft with an elephant trunk is
anastomosed to the descending aorta. This
graft is then sewn to the proximal aortic graft
in an end-to-end fashion. E) After attachment
of the left carotid/subclavian button graft to the
new aortic arch, perfusion of the lower body
and of the left carotid and left subclavian
arteries is initiated via the femoral artery
cannula. The arch graft is cross-clamped
proximal to the left carotid/subclavian
anastomosis. The graft to the innominate artery
is sewn to the ascending aortic graft during
warming. Apaydin.2001. Tex Heart Inst
J. 2001; 28(4): 288–291.
A continuación se reseña la bibliografía por orden alfabético. En primer lugar
se citan las Revisiones, Capítulos de Libros, etc, que solo ocasionalmente son citados
en el texto. Luego los artículos referentes a ensayos clínicos, resultados, etc, que sí van
referenciados en el texto.
Haciendo click en el nombre correspondiente en el texto previo se accede a la
referencia bibliográfica, y desde ella al artículo completo en Word (más fácil de leer) o
en PDF (mejor para imprimir o escuchar).
42
BIBLIOGRAFÍA
REVISIONES
Anderson. Ascending Aortic Aneurysms. Chapter 46. In: Cohn LH, Edmunds LH Jr, eds. Cardiac
Surgery in the Adult. New York: McGraw-Hill,:11231148. 2003. Word
Ankel. Aortic Dissection. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice,
5th ed., Copyright © Mosby, Inc. 2002. Word
Bowlby. Aortic Dissection (PTG). Ferri: Ferri's Clinical Advisor: Instant Diagnosis and Treatment,
2005 ed., Copyright © Mosby, Inc. 2005. Word
Braunwald: Disección. Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed., Copyright
© W. B. Saunders Company. 2001. Word (volver)
Braunwald:Aneurisma. Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed., Copyright
© W. B. Saunders Company. 2001. Word
Cheng-Zaas: The Osler Medical Handbook, 1st ed., Copyright © Johns Hopkins University. Aortic
Dissection. 2003. Word
Coselli. Descending and Thoracoabdominal Aneurysm. Cap. 48. In: Cohn LH, Edmunds LH Jr, eds.
Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003. Word (volver)
Creager. Atherosclerotic Vascular Disease Conference. Writing Group V: Medical Decision Making and
Therapy. Circulation.;109:2634-2642. 2004. Word
REVISION
Eurostar: http://www.eurostar-online.org/
Evangelista. Historia natural y tratamiento del síndrome aórtico agudo. R Esp Card 57:667-679. 2004.
REVISIÓN EN ESPAÑOL. Word PDF
Gleason. Trauma to Great Vessels. In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult.
New York: McGraw-Hill,:12291250. 2003. Word
Gomez. E-medicine: Diseccióon aortica. 2005. Word
Hals. PC Textbook - Management of Abdominal Aortic Aneurysm. Word
Isselbacher. Thoracic and Abdominal Aortic Aneurysms . Circulation; 111: 816-828, 2005. PDF
Khan. Clinical, Diagnostic, and Management Perspectives of Aortic Dissection. Chest;122:311-328.
2002. REVISIÓN. Word PDF
(volver)
Knaut. Aortic emergencies. Emergency Medicine Clinics of North America. Volume 21 • Number 4 •
November 2003. Word PDF
REVISIÓN
Kouchoukos. Surgery of the thoracic aorta. N Engl J Med. Jun 26;336(26):1876-88. 1997. Word PDF
REVISION.
Lee. Stanford. Current status of thoracic aortic endograft repair. Surgical Clinics of North America
Volume 84 • Number 5 • October 2004. Word PDF
(volver)
REVISIÓN
Levine. Thoracoabdominal Aneurysm Repair: Anesthetic Management. International Anesthesiology
Clinics. Care of the Vascular Patient. 43(1):39-60, Winter 2005. Word PDF
REVISIÓN
Miller: Thoracoabdominal aortic aneurysm surgery. Miller's Anesthesia, 6th ed.,. 2005. Word
43
Nelson. Aneurysm Thoracic. E-medicine. 2005. Word
Nienaber and Eagle. Aortic Dissection: New Frontiers in Diagnosis and Management: Part I: From
Etiology to Diagnostic Strategies. Circulation;108:628-635. 2003. REVISIÓN Word PDF
Nienaber and Eagle. Aortic Dissection: New Frontiers in Diagnosis and Management: Part II:
Therapeutic Management and Follow-Up. Circulation;108:772-778. 2003. REVISIÓN Word. (volver)
Prêtre. Deep Hypothermic Circulatory Arrest. Cap. 13. In: Cohn LH, Edmunds LH Jr, eds. Cardiac
Surgery in the Adult. New York: McGraw-Hill, 2003. Word (volver)
Randall. Aortic Dissection .Chap 45. Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult.
McGraw-Hill, 2003. Word
Riddell, Endovascular Abdominal Aortic Aneurysm Repair. International Anesth Clin 43(1). 7991.Winter 2005 . REVISIÓN. Word PDF
Riambau. Tratamiento endovascular de las lesiones de la aorta torácica: estado actual. Rev Esp Cardiol;
58: 1 – 5. 2005. REVISIÓN Word
Rogers. Aortic Disasters.Emergency Medicine Clinics of North America.Volume 22 • Number 4 •
November 2004. REVISIÓN Word PDF
Sawhney. Aortic Intramural Hematoma. An Increasingly Recognized and Potentially Fatal Entity.
Chest.;120:1340-1346. 2001.
REVISIÓN
Word PDF
Souza. Antegrade cerebral perfusion during surgical management of aortic arch lesions. The Handbook
of Cardiovascular Perfusion
Word (volver)
Dossche and associates have used the technique popularized by Kazui since 1995, for bilateral antegrade
selective cerebral perfusion. In short, the technique consisted of the following. Patients were cooled down
to nasopharingeal temperature of 220C to 250C. Systemic circulation was then arrested and the aortic
arch was opened in continuity with the rest of the aneurysm. Under visual control and with the patient in
Trendelenburg position, the cannulas for antegrade cerebral perfusion were inserted into the innominate
and left common carotid artery; for the innominate artery usually a 15F-18F retrograde coronary sinus
perfusion cannula with manual-inflating cuff and silicone body was used, for the left common carotid
artery, a 13F-14F cannula was inserted. In addition, the left subclavian artery was either clamped or
occluded with a Fogarty catheter. Blood was then perfused into both arteries at a rate of 10 ml/kg/min
using a single roller pump separated from the systemic circulation. The cerebral perfusion pressure was
adjusted to maintain a right radial pressure of 40 to 70 mmHg. During the period of body circulation
arrest, nasopharingeal temperatures and blood temperatures are kept at 250C; occasionally, the EEG
disappeared during cooling of the patient, but was usually restored within a few minutes when the brain
became perfused with blood at 250C. If available, transcranial Doppler measurements of blood velocity
of the middle cerebral artery (MCA) confirmed the proper placement and function of both cannulas.
Open distal aortic anastomosis was made in all procedures. While performing the distal aortic
anastomosis, blood perfusion to the lower half of the body was arrested. After completion of the distal
anastomosis CPB is restarted and rewarming begins. After rewarming up to about 360C, the patient was
weaned off the CPB. Dossche, Kazui and several other authors have found the described technique
superior to DHCA alone or in combination with retrograde cerebral perfusion. More recently, Aebert and
associates described a similar technique with cannulation of the right subclavian artery.
Spielvogel. Aneurysms of the Aortic Arch .Chapter 47. In: Cohn LH, Edmunds LH Jr, eds. Cardiac
Surgery in the Adult. New York: McGraw-Hill,:11491168. 2003. Word (volver)
THE MERCK MANUAL, Sec_ 16, Ch_ 211, Diseases Of The Aorta. Word
Townsend. Thoracic aortic aneurysms. Sabiston Textbook of Surgery, 17th ed., 2004. Word
Zappa. Thoracic Aortic Aneurysms. Word
44
Zamorano. Guías de práctica clínica de la Sociedad Española de Cardiología en enfermedades de la
aorta. Rev Esp Cardiol; 53: 531 – 541. 2000. Word PDF
ARTÍCULOS
Apaydin. Perioperative risk factors for mortality in patients with acute type a aortic dissection. Ann
Thorac Surg 2002;74:2034-2039. 2002. Word (volver)
Between 1993 and 2001, 108 consecutive patients (86 men; mean age, 53 years) underwent emergent
operations for AADA. All patients but 2 underwent replacement of the ascending aorta with an open
distal anastomosis during a period of hypothermic circulatory arrest. In addition, 22 patients had hemiarch
and 5 had total arch replacement. Aortic root was replaced in 20 and repaired with gelatin-resorcinolformaldehyde glue in 39 patients; aortic valve was separately replaced in 3, resuspended in 24, and
remained untouched in 22 patients.
RESULTS: Overall in-hospital mortality was 25%. Mortality rate was significantly higher in patients with
preoperative dissection complications than in those without (21/36 [58%] vs 6/72 [8%], p < 0.001). In
multivariate analysis, predictors of mortality were presence of rupture, renal failure, and intestinal
malperfusion, duration of cardiopulmonary bypass 200 minutes, blood loss 500 mL, and transfusion of
blood 4 units
Apaydin.Cerebral Perfusion through Separate Grafts for Repair of Acute Aortic Dissection with Torn
Arch. Tex Heart Inst J. ; 28(4): 288–291. 2001. Word (volver)
We have modified the technique of cerebral perfusion through anastomosed grafts for repair of acute arch
dissections that require total arch replacement. We have performed this operation on a 71-year-old man
with an acute type-A dissection and an arch tear between the orifices of the brachiocephalic arteries. We
used 2 separate grafts for the brachiocephalic arteries and minimized brain ischemia by initiating
antegrade selective cerebral perfusion after the 1st anastomosis. The patient had an excellent outcome.
This method is simple and provides effective protection. Cerebral ischemic time can be kept under 30
minutes without need of a sophisticated pump setup or a multibranched graft.
Barnard. In aortic arch surgery is there any benefit in using antegrade cerebral perfusion or retrograde
cerebral perfusion as an adjunct to hypothermic circulatory arrest? . Interactive Cardiovascular and
Thoracic Surgery 3:621-630. (2004). Word. PDF. (volver)
Altogether 408 papers were found using the reported search, of which 16 presented the best evidence to
answer the clinical question. The author, journal, date and country of publication, patient group studied,
study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude
that antegrade cerebral perfusion is superior as an adjunct to hypothermic circulatory arrest when
compared to retrograde cerebral perfusion or hypothermic circulatory arrest alone, although clinical
evidence for this from prospective clinical trials is weak.
Batra. Radiographics.20:309-320. Pitfalls in the Diagnosis of Thoracic Aortic Dissection at CT.
Two hundred seventy-five computed tomographic (CT) angiograms of the thoracic aorta were obtained
over a period of approximately 4 years in patients with suspected or known aortic dissection. A variety of
pitfalls were encountered that mimicked aortic dissection. (Muchas figuras: libre acceso en Internet).
2000. Word PDF (volver)
Bavaria. Retrograde Cerebral and Distal Aortic Perfusion During Ascending and Thoracoabdominal
Aortic Operations. Ann Thorac Surg;60:345-352. 1995. Word (volver)
For proximal aortic procedures, the stroke rate was 12% using cardiopulmonary bypass and 48% using
hypothermic circulatory arrest. The addition of retrograde cerebral perfusion decreased the stroke rate to
0% (p < 0.01) and the mortality rate to 7.1% compared with 37% for hypothermic circulatory arrest (p <
0.05). For thoracic and thoracoabdominal aortic operations, straight cross-clamping resulted in a 27% rate
of spinal cord injury and a 24% rate of renal failure, whereas the addition of distal aortic bypass resulted
in a statistically significant reduction (p < 0.01) in neurologic injury to 7% and a notable, but not
statistically significant, decrease in renal failure to 13%. Distal aortic bypass also reduced the mortality
rate from 22% to 7% (p < 0.05).
Conclusions. Retrograde cerebral perfusion decreases the stroke rate and mortality rate in proximal aortic
operations and distal aortic perfusion decreases the rates of neurologic injury, renal failure, and mortality
in thoracoabdominal aortic operations.
45
Bavaria. Advances in the treatment of acute type A dissection: an integrated approach. Ann Thorac
Surg;74:S1848-S1852. 2002. Word PDF (volver)
Bayegan. Acute type A aortic dissection: the prognostic impact of preoperative cardiac tamponade. Eur J
Cardiothorac Surg;20:1194-1198. 2001. Word (volver)
Conclusion: Patients with acute type A aortic dissection and signs of preoperative cardiac tamponade
without palpable pulses had a 16-fold increased risk for poor outcome, particularly preoperative death. In
contrast, cardiac tamponade with palpable pulses was not associated with increased frequency of MOF/inhospital mortality.
Bell. Endovascular treatment of thoracic aortic disease. Heart;89:82 2003. Word PDF (volver)
Endovascular treatment of complicated type B dissection includes covering the primary entry tear with a
stent graft, percutaneous fenestration of the intimal flap, and stenting of obstructed aortic side branches.
The most common complication of endoluminal repair is damage to the access artery. As with open
surgery, paraplegia is the most devastating complication of endoluminal repair of thoracic aortic disease.
The incidence of paraplegia following endoluminal repair for thoracic aneurysmal disease is comparable
to open surgery (2–5%). CSF drainage for open surgery is used to reduce raised CSF pressure, which
occurs on aortic cross clamping and consequently improves spinal cord perfusion. There have also been
reports of successful reversal of delayed onset paraplegia with CSF drainage for both open surgery and
endoluminal repair. There have been a total of 13 reported cases of paraplegia following endoluminal
repair, of which 5/13 (38%) recovered with CSF drainage.
Beregi. Endovascular treatment of acute complications associated with aortic dissection: midterm results
from a multicenter study. J Endovasc Ther. Jun;10(3):486-93. 2003. Word
CONCLUSIONS: Endovascular treatment of noncardiac acute complications associated with aortic
dissection has favorable early and midterm outcomes.
Bortone. Endovascular Treatment of Thoracic Aortic Disease. Circulation.;110:II-262 – II-267. 2004.
Word PDF (volver)
From March 1999 to October 2003, 132 patients (113 male and 19 female, mean age 62±14 years) were
enrolled. They were divided into 4 groups: aneurysms (43, group A), post-traumatic lesions (24, group
B), and complicated type B dissections (43, group C). Twenty-two further patients, with chronic type B
dissection and not suitable for endovascular or surgical or hybrid techniques because of multiple entry
tears without difference between the true and false lumen and poor clinical conditions, were obliged to
receive medical management only (group D). An optimal deployment with exclusion of the aneurysm
and/or closure of the entry tear in dissection was achieved in 96.4% (106/110) of the patients that were
discharged in good conditions within 6 days. No spinal cord injuries were observed. Conclusions—
Endovascular treatment of thoracic aortic diseases, even in the acute phase, may represent a valid option
with a low mortality rate. Moreover, the efficacy is proved in the middle-term whereas the long-term
follow-up is still pending.
Brahmajee. Syncope in acute aortic dissection: Diagnostic, prognostic, and clinical implications.
American Journal of Medicine Volume 113 • Number 6 • October 15, 2002. Word (volver)
Brux. Retrograde Cerebral Perfusion: Anatomic Study of the Distribution of Blood to the Brain. Ann
Thorac Surg;60:1294-1298. 1995. Word (volver)
Despite apparently good clinical results with retrograde cerebral perfusion during operation on the aortic
arch, there is still concern about the real distribution of the blood injected in the superior vena cava to the
brain, especially when the internal jugular vein is valvulated (88% of the cases).
Castañer. CT in Nontraumatic Acute Thoracic Aortic Disease: Typical and Atypical Features and
Complications. Radiographics.;23:S93-S110. 2003. Word
Chiappini. Surgery for acute type a aortic dissection: is advanced age a contraindication?. Ann Thorac
Surg;78:585-590: cardiovascular. 2004. Word
Between 1976 and 2001, 315 patients underwent emergency operation for acute type A dissection: 245
were younger than 70 years (group 1) and 70 patients were 70 years of age and older (group 2). Early and
late outcomes of both groups were compared.
RESULTS: The hospital mortality rates were 20.5% in group 1 and 17.6% in group 2 (p = 0.751). The
mean extracorporeal circulation time was 192.6 ± 65.2 minutes and 185.7 ± 58.4 minutes in groups 1 and
46
2, respectively (p = 0.42). The mean cross-clamp time was 116.3 ± 45.8 minutes and 100 ± 36.7 minutes
in groups 1 and 2, respectively (p = 0.009). Actuarial survival rates were 77.1% after a mean follow-up
time of 259 ± 9 months for patients of group 1 and 80% after 77 ± 5 months for patients of group 2,
without any statistically significant difference (p = 0.619).
Chiappini. Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487
consecutive patients. Eur Heart J 26:2; 180-186. En 2005. Word PDF
From 1976 to 2003, 487 patients with acute type A aortic dissection treated surgically were enrolled.
Twenty-five pre-operative and intra-operative variables were analysed to identify conditions influencing
early and late morbidity and early mortality. The in-hospital mortality rate including operative death was
22% (107 patients). Multivariable analysis indicated that pre-existing cardiac disease (RR=3.7, 95%
CI=1.8–7.4) and cardiopulmonary resuscitation (RR=6.8, 95% CI=2.3–20.2) were independent predictors
of in-hospital death. The causes of in-hospital mortality were low cardiac output in 32 patients (6.6%),
major brain damage in 24 patients (5.9%), haemorrhage in 11 patients (2.2%), sepsis in nine patients
(1.8%), visceral ischaemia in eight patients (1.6%), multiple organ failure in seven patients (1.4%),
rupture of the thoracic aorta in six patients (1.2%), respiratory failure in six patients (1.2%), and four
intra-operative deaths. The follow-up was 100% complete. The actuarial survival was 94.9±1.2% and
88.1±2.6%, at 5 and 10 years, respectively.
Collins. Differences in Clinical Presentation, Management, and Outcomes of Acute Type A Aortic
Dissection in Patients With and Without Previous Cardiac Surgery. Circulation.;110:II-237 – II-242.
2004. Word (volver)
Our study highlights differences in clinical characteristics, management, and outcomes of AAD patients
with PCS. Importantly, PCS, with the exception of previous AVR, does not adversely influence early
outcomes of AAD patients, including those undergoing surgical repair
Dake, Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med
340,1546-1552. 1999. Word PDF (volver) (volver-2)
Placement of endovascular stent–grafts across the primary entry tears was technically successful in all 19
patients. Complete thrombosis of the thoracic aortic false lumen was achieved in 15 patients (79 percent),
and partial thrombosis was achieved in 4 (21 percent). Revascularization of ischemic branch vessels, with
subsequent relief of corresponding symptoms, occurred in 76 percent of the obstructed branches. Three of
the 19 patients died within 30 days, for an early mortality rate of 16 percent (95 percent confidence
interval, 0 to 32 percent). There were no deaths and no instances of aneurysm or aortic rupture during the
subsequent average follow-up period of 13 months.
Dangenais. Changing trends in management of thoracic aortic disease: Where do we stand with thoracic
endovascular stent grafts?. Can J Cardiol. Feb;21(2):173-8. 2005. Word
Data on long-term outcomes are required before applying thoracic endovascular stent grafts to patients
with a lower operative risk..
David. Surgery for acute type A aortic dissection. Ann Thorac Surg;67:1999-2001. 1999. Word
There were 109 patients: 81 men and 28 women, with a mean age of 57 years, range 23 to 80. Most
patients were acutely ill and 15 were in shock at the time of surgery. Operations were performed under
cardiopulmonary bypass with femoral artery and right atrial cannulation. In 55 patients, the aorta was
clamped and retrograde femoral perfusion was used throughout the procedure (group I). In 54 patients, no
clamp was used; under circulatory arrest the primary tear was resected whether in the ascending aorta or
transverse arch, and antegrade cardiopulmonary bypass was started after completion of the distal
anastomosis (group II). Postoperative computed tomographic or magnetic resonance scans were
completed annually. Results. There were 16 operative deaths (15%): 11 (20%) in group I, and 5 (9.2%)
in group II (p = 0.10). There were 10 strokes: 8 (14.5%) in group I and 2 (3.7%) in group II (p = 0.05).
After a mean follow-up time of 59 ± 45 months for group I, 31 (56%) patients were alive, and after a
mean follow-up time of 45 ± 26 months for group II, 44 (81%) patients were alive. The actuarial survival
of group II was higher than group I, but the difference was not significant (p = 0.09). Postoperatively, a
patent false lumen was found in 91% of group I patients and in 59% of group II (p = 0.01).
Conclusions. This study suggests that avoidance of aortic clamping, resection of the primary tear in the
ascending aorta or transverse arch, and antegrade perfusion after completion of the distal anastomosis
improve the early and late outcomes of surgery for acute type A aortic dissection.
47
Deeb. Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity.
J Thorac Cardiovasc Surg;109:259-268. 1995. Word (volver)
Di Eusianio. Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during
ascending aorta-hemiarch replacement: a retrospective comparative study. J Thorac Cardiovasc
Surg;125(4):849-854. 2003. Word PDF (volver)
Between January 1995 and September 2001, 289 patients (mean age, 62.2 ± 13.2 years; urgent status,
122/289 [42.2%]) underwent ascending aorta-hemiarch replacement with the aid of antegrade selective
cerebral perfusion (161 patients) or deep hypothermic circulatory arrest (128 patients).
Results: Overall hospital mortality was 11.4% (deep hypothermic circulatory arrest group, 13.3%;
antegrade selective cerebral perfusion group, 9.9%; P = .375). A logistic regression analysis revealed
acute type A dissection (P = .001; odds ratio, 4.3) and age of greater than 70 years (P = .019; odds ratio,
2.5) to be independent predictors of hospital mortality. The permanent neurologic dysfunction rate was
9.3% (deep hypothermic circulatory arrest group, 12.5%; antegrade selective cerebral perfusion group,
7.6%; P = .075). Renal dysfunction (postoperative creatinine level of >250 µmol/L; deep hypothermic
circulatory arrest, 10 [7.8%]; antegrade selective cerebral perfusion, 6 [3.7%]; P = .030), as well as
prolonged intubation time (deep hypothermic circulatory arrest, 3.8 ± 6.3 days; antegrade selective
cerebral perfusion, 2.2 ± 2.5 days; P = .005) were more common in the deep hypothermic circulatory
arrest group. Conclusion: The use of antegrade selective cerebral perfusion and deep hypothermic
circulatory arrest during ascending aorta-hemiarch replacement resulted in acceptable hospital mortality
and neurologic outcome. Reduced postoperative intubation time and better renal function preservation
were observed in the antegrade selective cerebral perfusion group.
Doss. Emergency endovascular interventions for acute thoracic aortic rupture: Four-year follow-up
Read at the Thirtieth Annual Meeting of The Western Thoracic Surgical Association, Maui, Hawaii, June
23-26, 2004. Journal of Thoracic and Cardiovascular Surgery. 2005. Word (volver)
Sixty patients aged 28 to 83 years were admitted to our institution with an acute rupture of the thoracic
aorta (27 ruptured aneurysms, 15 perforated type B dissections, 18 traumatic ruptures). Twenty-eight
patients were treated surgically with cardiopulmonary bypass, and 32 patients were acutely treated with
an endovascular stent graft. Perioperatively, there were 1 death (3.1%) among the 32 patients in the
endovascular group and 5 deaths (17.8%) among the 28 patients in the surgical group. There were 4 late
deaths in the endovascular group and 1 in the surgical group. There were 2 access failures in the
endovascular group. There were 1 stroke in the endovascular group and 1 case of paraplegia in the
surgical group. Three patients in the endovascular group had endovascular leaks develop that required
reintervention. Two patients in the endovascular group had late thrombosis of the left subclavian artery.
Conclusion : Despite encouraging early outcomes, midterm results suggest a trend toward increased
reintervention and late complication rates in the endovascular group.
Dossche. Bilateral antegrade selective cerebral perfusion during surgery on the proximal thoracic aorta.
Eur J Cardiothorac Surg;17:462-467. 2000. Word. (volver)
Dossche. Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta. Ann Thorac
Surg;67:1904-1910. 1999. Word (volver)
From May 1989 through April 1997, 106 patients underwent surgery on the thoracic aorta using
circulatory arrest and antegrade selective cerebral perfusion. Mean age was 64.0 ± 11.5 years. Unilateral
antegrade cerebral perfusion was used in 37 patients (35%), bihemispheric antegrade cerebral perfusion in
69 patients (65%). Mean antegrade cerebral perfusion time was 50.5 ± 20.5 minutes. Indication for
surgery was atherosclerotic aneurysm in 60 (56.5%) patients, postdissection aneurysm in 26 (24.4%),
acute type A dissection in 16 (15.1%), other in 4 (4.0%). Results. Hospital mortality was 8.5%
Eagle. Cocaine-Related Aortic Dissection in Perspective. Circulation.;105:1529. 2002. Word. PDF
In the present issue of Circulation, Hsue and colleagues1 report on their 20-year experience with acute
aortic dissection at an inner-city hospital. Remarkably, their findings indicate that 14 (37%) of 38 patients
treated for acute dissection reported having used cocaine in the minutes or hours preceding their
presentation. Cocaine, particularly crack cocaine, seemed to have played a significant role in precipitating
aortic dissection among this cohort of young (age 41±8.8 years), predominantly black (11 of 14; 79%),
and hypertensive (11 of 14; 79%) individuals. This study represents the largest cohort of cocaine-related
dissection ever reported.
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Eggebrecht. Endovascular stent-graft treatment of aortic dissection: determinants of post-interventional
outcome. Eur Heart Journal;26:489-497. 2005. Word PDF
A total of 38 patients (62±10 years, 32 male) with acute (n=10) and chronic (n=28) type B-AD were
treated with endovascular stent-grafts. The implantation procedure was successful in all patients. Periprocedural non-fatal complications occurred in four (11%) patients. Overall, 4/38 (11%) patients died
during the in-hospital period. Patients undergoing stent-graft placement for acute AD had a significantly
higher in-hospital mortality than patients with chronic AD (40 vs. 0%, P=0.001). During a median followup of 18 (1–57) months, there were six additional deaths. Overall survival rates were 97.4±2.6% at 30
days, 80.4±6.7% at 1 year, 73.2±7.8% at 2 years, and 54.9±16.9% at 4 years. Patients with a poor clinical
health status (ASA class > 3) had a significantly reduced life expectancy compared with patients with
only moderate co-morbidities (ASA class 3) (1-year survival rate 28.6±17.1 vs. 92.6±6.7%, P=0.0001).
Multivariable analysis revealed that a poor clinical health status (ASA>3) pre-operatively (HR=29.5, 95%
CI 1.5–581.9, P=0.026) and increased age (HR=1.1, 95% CI 0.9–1.2, P=0.084) were independent
determinants of post-interventional mortality.
Conclusion Endovascular stent-graft treatment is a safe alternative for patients with AD. The preoperative clinical health status of the patient is the most important determinant of post-interventional
outcome. Careful patient selection is thus of particular importance.
Ehrlich. (Mount Sinai). Predictors of Adverse Outcome and Transient Neurological Dysfuntion
Following Surgical Treatment of Acute Type A Dissections. Circulation.;108:II-318. 2003. PDF
Ehrlich. Surgical treatment of acute type a dissection: is rupture a risk factor?. Ann Thorac
Surg;73:1843-1848. 2002. Word
Ehrlich. Results of Immediate Surgical Treatment of All Acute Type A Dissections. Circulation.;102:III248. 2000. Word PDF (volver)
One hundred twenty-four consecutive patients with acute type A aortic dissection between 1984 and 1998
were reviewed. All underwent operation with resection of the intimal tear and open distal anastomosis:
107 patients had surgery within 24 hours and 17 patients had surgery within 72 hours of symptom onset.
Median age was 62 years (23 to 89); 89 were men. Forty-three patients had ascending aortic replacement
only, 72 had hemiarch repair, in 2 the entire arch was replaced, and in 7 replacement included the
proximal descending aorta. The aortic valve was replaced in 54 patients, resuspended in 52, and
untouched in 18. Hospital mortality rate was 15.3% (19 of 124): of these, 3 patients died during surgery, 4
had fatal rupture of the distal aorta before discharge, and 2 died of malperfusion-related complications.
Multivariate analysis revealed age >60, hemodynamic compromise, and absence of hypertension as
preoperative indicators of hospital death (P<0.05); the presence of new neurological symptoms was a
significant preoperative risk factor in univariate analysis. Ominous intraoperative factors included
contained hematoma and a comparatively low esophageal temperature but not cerebral ischemic time
(mean 32 minutes). The site of the intimal tear did not influence outcome, but mortality rate was higher
with more extensive resection: 43% with resection including the descending aorta died versus 14% with
only ascending aorta or hemiarch replacement. Overall 5- and 10-year survival was 71% and 54%,
respectively; among discharged patients (median follow-up 41 months) survival was 84% and 64% versus
expected US survival of 92% and 79%. Conclusions—Immediate surgical treatment of all acute type A
dissections with resection of the intimal tear and use of hypothermic circulatory arrest for distal
anastomosis results in acceptable early mortality rates and excellent long-term survival.
Ehrlich. Impact of retrograde cerebral perfusion on aortic arch aneurysm repair. J Thorac Cardiovasc
Surg;118:1026-1032. 1999. Word PDF (volver)
Fifty-five patients had profound hypothermic circulatory arrest alone, and 54 patients had supplemental
cerebral protection with retrograde cerebral perfusion. Mean age was 61 ± 13 years and 58 ± 14 years,
respectively (mean ± standard deviation). Twenty-two preoperative and intraoperative characteristics,
including age, sex, acuity, presence of aortic dissection, and aneurysm rupture, were similar in the 2
groups (P > .05).
Results: Mean circulatory arrest times (in minutes) were 30 ± 19 in the group without retrograde cerebral
perfusion and 33 ± 19 in the group with retrograde cerebral perfusion, respectively. Analysis revealed that
patients operated on with the use of retrograde cerebral perfusion had significantly lower hospital
mortality (15% vs 31%; P = .04) and in-hospital permanent neurologic complications (9% vs 27%;P = .01
Erbel. Diagnosis and management of aortic dissection: Task Force on Aortic Dissection, European
Society of Cardiology. Eur Heart Journal;22:1642-1681. 2001. PDF (volver)
49
Erbel. GENERAL CARDIOLOGY: Diseases of the thoracic aorta. Heart;86:227-234. 2001. Word PDF
Esmailian. Retrograde Cerebral Perfusion as an Adjunct to Prolonged Hypothermic Circulatory Arrest.
Chest.;116:887-891. 1999. Word PDF (volver)
RCP is a reliable and technically appealing tool that does the following: (1) it improves DHCA safety and
is applicable in a variety of clinical settings with relative ease; (2) it potentially provides oxygen and
nutritional support to the brain during DHCA; (3) it helps remove air and other debris from the cerebral
vessels; and (4) it is useful in dealing with congenital heart disease and tumor extension into the IVC.
Evangelista. Acute Intramural Hematoma of the Aorta: A Mystery in Evolution. Circulation;111:10631070. 2005. Word PDF
We studied 1010 patients with acute aortic syndromes who were enrolled in the International Registry of
Aortic Dissection (IRAD) to delineate the prevalence, presentation, management, and outcomes of acute
IMH by comparing these patients with those with classic aortic dissection (AD). Fifty-eight (5.7%)
patients had IMH, and this cohort tended to be older (68.7 versus 61.7 years; P<0.001) and more likely to
have distal aortic involvement (60.3% versus 35.3%; P<0.001) compared with 952 patients with AD.
Patients with IMH described more severe initial pain than did those with AD but were less likely to have
ischemic leg pain, pulse deficits, or aortic valve insufficiency; moreover, they required a longer time to
diagnosis and more diagnostic tests. Overall mortality of IMH was similar to that of classic AD (20.7%
versus 23.9%; P=0.57), as was mortality in patients with IMH of the descending aorta (8.3% versus
13.1%; P=0.60) and the ascending aorta (39.1% versus 29.9%; P=0.34) compared with AD. IMH limited
to the aortic arch was seen in 7 patients, with no deaths, despite medical therapy in only 6 of the 7
individuals. Among the 51 patients whose initial diagnostic study showed IMH only, 8 (16%) progressed
to AD on a serial imaging study.
Conclusions--The IRAD data demonstrate a 5.7% prevalence of IMH in patients with acute aortic
syndromes. Like classic AD, IMH is a highly lethal condition when it involves the ascending aorta and
surgical therapy should be considered, but this condition is less critical when limited to the arch or
descending aorta. Fully 16% of patients have evidence of evolution to dissection on serial imaging.
Fann, Surgical Management of Aortic Dissection During a 30-Year Period. Circulation.;92:113-121.
1995. Word (volver)
Between 1963 and 1992, 360 patients (256 men and 104 women; mean±1 SD age, 57±14 years)
underwent surgery for aortic dissection: 174 patients had an acute type A (AcA), 46 an acute type B
(AcB), 106 a chronic type A (ChA), and 34 a chronic type B (ChB) aortic dissection. The overall
operative mortality rate was 24±8% (26±3% for AcA, 39±8% for AcB, 17±4% for ChA, and 15±6% for
ChB, [±70% confidence limit]). The operative mortality rates for patients with acute aortic dissection
(AcA or AcB) were assessed for five time "windows": 1963 to 1972 (42±8%), 1973 to 1977 (37±8%),
1978 to 1982 (15±6%), 1983 to 1987 (27±6%), and 1988 to 1992 (26±6%). Logistic regression analysis
suggested that the low operative mortality rate during the 1978-to-1982 interval occurred by chance.
Multivariate analysis showed earlier operative year, hypertension, cardiac tamponade, renal dysfunction,
and older age were independent determinants of operative death. Actuarial survival rates (including early
deaths) after 5, 10, and 15 years for AcA patients were 55%, 37%, and 24%; for AcB, 48%, 29%, and
11%; for ChA, 65%, 45%, and 27%; and for ChB, 59%, 45%, and 27%. Multivariate analysis revealed
that older age and previous operation were significant predictors for late death. Freedom from reoperation
for all patients was 84%, 67%, and 57% at 5, 10, and 15 years, respectively.
Conclusions Although the operative mortality rate decreased over time for patients with aortic dissection,
the risk for those with acute aortic dissection during the last 10 years (1983 to 1992) is probably more
realistic than that observed in the preceding 5-year interval (1978 to 1982). The operative mortality rates
for patients with chronic aortic dissection have remained relatively static. Earlier diagnosis of acute aortic
dissection before development of cardiac tamponade and renal impairment is critical to improve the
operative salvage rate
Fleck. A double patch sandwich technique for surgical repair of acute aortic dissection type A. Ann.
Thorac. Surg.;76:499-502. 2003. Word (volver)
Fleck. The incidence of transient neurologic dysfunction after ascending aortic replacement with
circulatory arrest. Ann Thorac Surg;76:1198-1202. 2003. Word (volver)
Between January 1997 and January 2003, 160 consecutive patients (130 type A dissections [81%] and 30
elective atherosclerotic aneurysms [19%]) had surgical repair with DHCA for a thoracic aortic aneurysm
50
limited to the ascending aorta. From those, 40 patients (25%) underwent DHCA alone, whereas in 13
patients (8%) antegrade cerebral perfusion and in 103 patients (64%) retrograde cerebral perfusion was
used for further brain protection.
RESULTS: The overall incidence of TND was 18% (28 of 160) with a significant association between
duration of circulatory arrest and the incidence of TND (13.8% in DHCA < 30 minutes versus 37.9% in
DHCA > 40 minutes; p < 0.05). Furthermore the severity of TND was directly associated with the
duration of circulatory arrest and age. In contrast, however, the use of retrograde cerebral perfusion had
no influence on the incidence of TND, (p < 0.05). Intensive care unit stay as well as hospital stay were
prolonged in the patients with TND (intensive care unit 14.3 ± 14.2 days versus 10.8 ± 13.7 days, p <
0.05; hospital stay 15.6 ± 10.1 days versus 11.4 ± 7.9 days, p < 0.05).
CONCLUSIONS: Duration of DHCA, regardless of whether retrograde cerebral perfusion was used, was
the most important predictor of the incidence of transient neurologic dysfunction in patients who had
replacement of the ascending thoracic aorta.
Fusco. Femoral Cannulation is Safe for Type A Dissection Repair. Ann Thorac Surg;78:1285-1289.
2004. Word (volver)
Ganzel. Neurophysiological monitoring to assure delivery of retrograde cerebral perfusion. J Thorac
Cardiovasc Surg;113:748-57. 1997. Word (volver)
Thirty patients underwent complex aortic procedures necessitating circulatory arrest, 22 with retrograde
cerebral perfusion. The mean retrograde perfusion pressure of 40 mm Hg (30 to 49 mm Hg, 95%
confidence interval) and flow rate of 1.2 L/min (0.9 to 1.6 L/min) necessary to achieve documented
retrograde cerebral perfusion was much higher than previously recommended. During both retrograde
cerebral perfusion and rewarming, cerebral oximetric monitoring guided adjustments in perfusion
parameters to limit the rate of desaturation to 0.4% per minute (0.3% to 0.6%). With retrograde cerebral
perfusion there was a rapid (1) recovery of electroencephalographic activity during rewarming (21
minutes [range 16 to 26 minutes]) and (2) return of consciousness after the operation (81% [58% to 95%,
95% confidence interval] awake by 12 hours). There was no transcranial Doppler evidence of cerebral
edema with retrograde cerebral perfusion. Two neurologic complications occurred in the 22 patients
managed with retrograde cerebral perfusion and one in the eight patients managed with arrest only.
Conclusions: Multimodality neurologic monitoring assured optimal brain cooling and bihemispheric
delivery of retrograde cerebral perfusion. Necessary retrograde pressure and flow were often higher than
values previously reported. Avoidance of profound cerebral venous oxygen desaturation during
retrograde cerebral perfusion and rewarming was associated with rapid recovery of neurologic function.
Genoni. Predictors of complications in acute type B aortic dissection. Eur J Cardiot Surg;22:59-63. 2002.
Word (volver)
Rupture, shock and malperfusion are significant predictors of poor survival in patients with acute type B
aortic dissection..
Gowda. Endovascular Stent Grafting of Descending Thoracic Aortic Aneurysms. Chest.;124:714-719.
2003. Word PDF (volver)
The placement of endoluminal stent-grafts to exclude the rupture sites of descending thoracic aortic
aneurysms is a technically feasible and relatively safe procedure. It may improve the short-term outcomes
of patients with dissecting thoracic aneurysms with or without rupture or dissection. Extended follow-up
is necessary to determine the long-term outcome. At the present time, it seems to be an acceptable option
in high-risk elderly patients and in patients for whom no other feasible therapy exists.
Grabenwoger. Secondary surgical interventions after endovascular stent-grafting of the thoracic aorta.
Eur J Cardiothorac Surg;26:608-613. 2004. Word (volver)
The objective of the study was to evaluate mid-term durability and need for reinterventions after
endovascular stent-grafting (ESG) in descending aortic aneurysms and dissections. Patients and Methods:
Between November 1996 and February 2003 a total of 80 patients underwent ESG for the following
indications: atherosclerotic aneurysms (50/80; 63%), type B dissections (20/80; 25%), penetrating ulcers
(6/80; 8%), traumatic aneurysms (4/80; 5%). Two types of commercially available ESG (Talent,
Medtronic, Santa Rosa, CA and Excluder, WL GORE, Flagstaff, AZ) were inserted via the femoral artery
in 53 patients, via the iliac artery in 21 patients and via the abdominal aorta in 6 patients. Results: Inhospital mortality was 3.8% (n=3). Type I endoleak formation requiring endovascular reintervention was
observed in 3.8% (n=3). Surgical reintervention became necessary in 4 patients (4/80; 5%). One patient
experienced a retrograde type A dissection, detected in the 3 month control after ESG of an acute type B
51
dissection, consecutively undergoing frozen elephant trunc repair. Three patients with late type I endoleak
formation (mean interval: 62 months) after ESG (two atherosclerotic aneurysms, one penetrating ulcer)
underwent open thoraco-abdominal repair in deep hypothermia or left heart bypass technique. All patients
had an uneventful postoperative course. Conclusions: Occurrence of late endoleak formation requiring
surgical reintervention after ESG is acceptably low.
Graeter. Valve-preserving operation in acute aortic dissection type A. Ann Thorac Surg;70:1460-1465.
2000. Word (volver)
From October 1995 to December 1999, 52 patients (35 men, 17 women) underwent repair of AADA.
Patient ages ranged from 30 to 83 years. Composite replacement was chosen for degenerated aortic valves
or prior valve replacement (group A; n = 8). With normal root diameter, supracommissural replacement
of the ascending aorta was performed (group B; n = 22). For preexisting root dilatation the aortic root was
either remodeled (root diameter 30 to 50 mm, group C; n = 17) or the valve reimplanted within a vascular
graft (root diameter more than 50 mm, group D; n = 5).
Results. All patients underwent either proximal (n = 46) or total (n = 6) arch replacement under
circulatory arrest. Eight patients (15.4%) died (group A: n = 3; group B: n = 3; group C: n = 2). Freedom
from aortic regurgitation of grade 2 or more at 2 years was 100% in groups A and D, 90.9% in group C,
and 75% following supracommissural replacement. At 2 years freedom from proximal reoperation was
100% in groups A, C, and D and 84.5% in group B.
Conclusions. In AADA valve-preserving root replacement leads to improved stability of aortic valve
function without an increased operative risk. Midterm results are promising and may show further
superiority over supracommissural aortic replacement in the future.
Hagan, The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.
JAMA 283,897-903. (2000). Word PDF (volver)
Participants A total of 464 patients (mean age, 63 years; 65.3% male), 62.3% of whom had type A
dissection.
Main Outcome Measures Presenting history, physical findings, management, and mortality, as assessed
by history and physician review of hospital records.
Results While sudden onset of severe sharp pain was the single most common presenting complaint, the
clinical presentation was diverse. Classic physical findings such as aortic regurgitation and pulse deficit
were noted in only 31.6% and 15.1% of patients, respectively, and initial chest radiograph and
electrocardiogram were frequently not helpful (no abnormalities were noted in 12.4% and 31.3% of
patients, respectively). Computed tomography was the initial imaging modality used in 61.1%. Overall inhospital mortality was 27.4%. Mortality of patients with type A dissection managed surgically was 26%;
among those not receiving surgery (typically because of advanced age and comorbidity), mortality was
58%. Mortality of patients with type B dissection treated medically was 10.7%. Surgery was performed in
20% of patients with type B dissection; mortality in this group was 31.4%.
Conclusions Acute aortic dissection presents with a wide range of manifestations, and classic findings
are often absent. A high clinical index of suspicion is necessary. Despite recent advances, in-hospital
mortality rates remain high.
Hagl. Hypothermic circulatory arrest with and without cold selective cerebral perfusion: impact on
neurological recovery and tissue metabolism in an acute porcine model Eur J Cardiothorac Surg;26:7380. 2004. Word PDF
Hagl. Mount Sinai. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain
protection technique in high-risk patients J Thorac Cardiovasc Surg;121:1107-1121. 2001. Word PDF
(volver)
Methods: All 717 patients who survived ascending aorta–aortic arch operations through a median
sternotomy since 1986 were examined for factors influencing stroke. Temporary neurologic dysfunction
was assessed in all patients who survived the operation without stroke since 1993. Multivariate analyses
were carried out to determine independent risk factors for neurologic injury.
Results: Independent risk factors for stroke were as follows: age greater than 60 years (P < .001; odds
ratio, 4.5); emergency operation (P = .02; odds ratio, 2.2); new preoperative neurologic symptoms (P =
.05; odds ratio, 2.9); presence of clot or atheroma (P < .001; odds ratio, 4.4); mitral valve replacement or
other concomitant procedures (P = .055; odds ratio, = 3.7); and total cerebral protection time, defined as
the sum of hypothermic circulatory arrest and any retrograde or antegrade cerebral perfusion (P = .001;
odds ratio, 1.02/min). In 453 patients surviving operations without stroke after 1993, independent risk
factors for temporary neurologic dysfunction included age (P < .001; odds ratio, 1.06/y), dissection (P =
52
.001; odds ratio, 2.2), need for coronary artery bypass grafting (P = .006; odds ratio, 2.1) or other
procedures (P = .023; odds ratio, 3.4), and total cerebral protection time (P < .001; odds ratio, 1.02/min).
When all patients with total cerebral protection times between 40 and 80 minutes were examined, the
method of cerebral protection did not influence the occurrence of stroke, but antegrade cerebral
perfusion resulted in a significant reduction in incidence on temporary neurologic dysfunction (P =
.05; odds ratio, 0.3).
Conclusions: The occurrence of stroke is principally determined by patient- and
disease-related factors, but use of antegrade cerebral perfusion can significantly reduce the occurrence of
temporary neurologic dysfunction.
Hanafusa. Total arch replacement with elephant trunk procedure for retrograde dissection. Ann Thorac
Surg;74:S1836-S1839. 2002. Word PDF (volver)
From January 1995 to December 2001, 12 (8.6%) consecutive patients aged 40 to 71 years underwent
total arch replacement with an elephant trunk procedure through a median sternotomy for retrograde
dissection of the ascending aorta (acute: 10, chronic: 2) among 139 patients with type A dissection. The
intimal tear was located in the descending aorta in all patients. Dissection extended proximally to the
aortic root in 7 patients and to the ascending aorta in 5, and extended distally to the abdominal aorta in 4
and to the common iliac artery in 8. Hospital mortality occurred in 1 patient (8%) owing to multiple organ
failure after malperfusion of the renal arteries. Postoperatively the false lumen in the descending aorta
was closed in all patients who survived but the false lumen in the abdominal aorta was patent in 9. The
thoracic and abdominal aorta had slight dilatation in 2 patients.
Harringer. Ascending Aortic Replacement With Aortic Valve Reimplantation. Circulation.;100:II-24.
1999. Word (volver)
From July 1993 to November 1998, a replacement of the ascending aorta with a repair of the aortic valve
was performed in 75 patients (53 men and 22 women aged 50±19 years). Twenty-one patients (28%) had
Marfan syndrome, and 11 patients (15%) had an aortic dissection, type Stanford A (6 acute, 5 chronic). In
17 patients (23%), concomitant replacement of the aortic arch was necessary. Clinical and
echocardiographic follow-up was performed in 6- to 12-month intervals for a cumulative study period of
137 patient-years. No operative deaths occurred. Two patients (3%) died 5 and 20 months
postoperatively. Three patients (4%) with progressive aortic insufficiency required aortic valve
replacement after 9, 11, and 14 months. The repairs have now remained stable for 65 months (mean,
22±20 months). Other valve-related complications did not occur. Conclusions—Our results demonstrate
that this type of aortic valve repair achieves excellent results in selected patients.
Hayashi. Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept.
Radiographics.;20:995-1005. 2000. Word PDF (volver)
Herold. Endoluminal stent graft repair for acute and chronic type B aortic dissection and atherosclerotic
aneurysm of the thoracic aorta: an interdisciplinary task. Eur J Cardiothorac Surg;22:891-897. 2002.
Word (volver)
Between August 1999 and August 2001, endovascular stent graft repair was performed in 34 patients (27
male, seven female) with a mean age of 68.6±7 years (range 58–84). Indication for treatment was an
acute Type B aortic dissection in six patients (18%), a symptomatic chronic Type B dissection in 12
patients (35%), a true aneurysm of the descending aorta in seven patients (21%) and an atherosclerotic
contained rupture of the descending aorta in nine (26%) patients. Out of six acute type B dissections three
patients (8.8%) and one patient (2.9%) out of the chronic dissection group were in severe haemorrhagic
shock, ventilated and required high-dose adrenergic support. The others (30 patients, 88.3%) remained
symptomatic despite maximum medical treatment. In a special case a combined surgical and endoluminal
stent graft repair was performed. Individually manufactured Talent, Medtronic AVE (33), and Gore (1)
stents were used. Follow-up examination was performed 1 week after implantation and repeated every 3
months (mean follow-up 8 months, range 1–24). Results: In all patients the aneurysm or the entry of the
dissection could be excluded. The observed hospital mortality was 2.9% (one patient). No perivascular
leakage, no stent dislocation, no neurological deficit or perfusion impairment was observed. All patients
except four were extubated immediately after the procedure and discharged from hospital on
postoperative day 2–3. The late procedure-related mortality was 5.8% (two patients) resulting in an
overall mortality of 8.8% (three patients). Conclusion: Stent graft repair is a safe and feasible treatment
option for selected patients, especially in emergency situations, if the aortic lesions can be clearly
identified and localized. The use of biplane X-ray control combined with simultaneous intravascular and
transoesophageal ultrasound imaging in an interdisciplinary approach enables a more precise targeting of
the stent landing zone, resulting in low morbidity and mortality rates
53
Higami. Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral
oxygen saturation during aortic arch reconstruction Ann Thorac Surg;67:1091-1096. 1999. Word PDF
Hirotani. Results of a total aortic arch replacement for an acute aortic arch dissection. J Thorac
Cardiovasc Surg;120:686-691. 2000. Word (volver)
During the past 4 years, 27 consecutive patients who had an aortic arch dissection underwent a total aortic
arch replacement. Twenty-five patients underwent an emergency operation. In 5 patients the intimal tear
was located in the aortic arch, but in the rest of the patients, it was located in the ascending aorta or the
proximal descending aorta. To obliterate any false channels, gelatin-resorcin-formol glue was used.
Results: The hospital mortality was 11%, and no cerebral complications were observed. Postoperative
aortography and computed tomography showed no evidence of any persisting false channels in 15
patients (65%). During the follow-up period (ranging from 5 months to 4 years), two patients underwent a
reoperation because of the recurrence of a dissection at the sinus of Valsalva. All patients, except for one
who died after a reoperation, are still alive and free from any serious events at this writing.
Hsu. Outcome of Medical and Surgical Treatment in Patients With Acute Type B Aortic Dissection. Ann.
Thorac. Surg.;79:790-794. 2005. Word (volver)
In the last 8 years, 107 patients were admitted for acute type B aortic dissection. We medically treated
patients at the time of onset with antihypertensives. Surgery was considered if there is intractable pain,
uncontrolled hypertension, severe aortic branch malperfusion, or aneurysm expansion.
RESULTS: Twenty-nine patients had pleural effusion (27%), 9 patients had leg ischemia (8%), 5 patients
had impending rupture, and 2 patients had aneurysm enlargement exceeding 60 mm on repeated imaging
studies. A total of 16 patients (15%) underwent surgical intervention: 8 extra-anatomical bypass for leg
ischemia, 1 in situ infrarenal aortoiliac bypass for distal aortic obstruction, and 7 thoracic aortic graft
replacement. Of the 8 patients with extra-anatomic bypass, 3 patients died: 2 patients died of catastrophic
aortic rupture 2 and 9 days after bypass, and 1 patient died of dissection progression to type A lesion 9
days after bypass. There was no in-hospital death in 92 medically treated patients. Follow-up was 92%
complete. The mean follow-up duration was 36.1 months (range, 2 to 96 months). The 6-month, 1-year,
and 5-year survival rates of all patients were 96.2 ± 1.9%, 95.2% ± 2.1%, and 95.2% ± 2.1%.
CONCLUSIONS: Medical treatment of acute type B aortic dissection produced good outcomes. Central
aortic procedures such as aortic fenestration and endovascular stenting should be the preferred methods to
treat patients with acute type B aortic dissection and leg ischemia because there was high risk of central
aortic complications after extra-anatomic bypass.
IRAD-manuscripts. 2000. Word
Kaji. Long-Term Prognosis of Patients With Type B Aortic Intramural Hematoma. Circulation.;108:II307. 2003. PDF
Kaji. Prognosis of Retrograde Dissection From the Descending to the Ascending Aorta.
Circulation.;108:II-300. 2003. Word PDF (volver)
Study population consisted of 109 patients with acute type A AD. There were 27 patients (25%) with
retrograde AD and 82 patients (75%) with intimal tear in the ascending aorta (antegrade AD). In
antegrade AD patients, 60 patients underwent surgery and 22 patients were treated medically. In
retrograde AD patients, 14 patients showed localized crescentic high attenuation area along the ascending
aortic wall without enhancement in computed tomography. Transesophageal echocardiography revealed
complete thrombosis of false lumen (FL) in the ascending aorta (retrograde thrombosed). The remaining
13 patients showed incomplete or no thrombosis (retrograde nonthrombosed). All retrograde
nonthrombosed AD patients underwent surgery except for 1 patient with stroke, whereas all retrograde
thrombosed AD patients were treated medically. In-hospital mortality rate of retrograde AD patients was
significantly lower than that of antegrade AD patients (15% versus 38%, P=0.027). The survival rates in
retrograde AD patients were all 85% at 1, 2, and 5 years, which were significantly higher than those of
antegrade AD patients (63%, 62%, and 57%, respectively)(P=0.009). Conclusions— Patients with type
A retrograde AD have better medium-term prognosis than patients with antegrade AD. Retrograde AD
patients with thrombosed FL in the ascending aorta could be treated medically with timed surgical repair.
Kallenbach. Evolving Strategies for Treatment of Acute Aortic Dissection Type A. Circulation;110:II243-II-249. 2004. Word PDF (volver)
54
Between October 1990 and October 2003, we operated on 295 patients (pts) for AADA. Follow-up was
complete for 257 pts (87%). Supracommissural replacement (SCR) of the ascending aorta was applied to
145 pts, 64 pts received a composite replacement (comp), and 48 pts were treated with the aorta valvesparing (AVS) reimplantation technique. Pts in SCR were older compared with AVS and comp
(P=0.002), gender (overall 65% male, P=0.143) and presence of Marfan syndrome (overall 5%, P=0.109)
were comparable. Cannulation of the aorta was performed more often in AVS (58%) than in comp (19%)
or SCR (22%; P<0.001). Mean operation time, extracorporeal circulation time, and aortic cross-clamp
time differ significantly between groups (P<0.001, respectively). Stay in the intensive care unit (P=0.12)
and time of hospitalization (P=0.32) were comparable. Overall perioperative mortality was 24% and did
not show significant differences between groups (AVS 10.4% versus comp 28% versus SCR 26%;
P=0.053). Incidence of neurological complications was similar between groups (P=0.95). Mean time of
follow-up was shorter for AVS (19±20 months) compared with comp (48±48 months) and SCR (46±45
months). Survival at 5 years was comparable with 89% for AVS, 85% for comp, and 80% for SCR
(P=0.61). Two patients from AVS (4.1%) required reoperation for failure of the reconstructed valve. Pts
in comp required less aortic reoperations than pts in SCR (comp 6.3% versus SCR 22%; P=0.005).
Conclusions—: In acute aortic dissection type A, the reimplantation technique leads to results comparable
to established techniques.
Katz. Distribution of cerebral flow using retrograde versus antegrade cerebral perfusion Ann Thorac
Surg;67(4):1065-1069. 1999. Word PDF
Kato. The results of total arch graft implantation with open stent-graft placement for type A aortic
dissection. J Thorac Cardiovasc Surg;124:531-540. 2002. Word
From October 1994 through October 1999, 19 patients with type A aortic dissection (13 acute and 6
chronic dissections) underwent total arch graft implantation with open-style stent-graft placement. After
achievement of general anesthesia and hypothermic extracorporeal circulation, we replaced the dissected
ascending aorta and neck vessels with a 4-branched graft and repaired the descending aorta with a stent
graft to close the entry site completely and to obtain better peripheral perfusion. We then examined the
acute-phase and chronic-phase results and the outcomes of the false lumen and dissected aorta.
Results: There were 1 (5.3%) hospital death and 2 late deaths. The survivals at 1 and 3 years were 89.5%
and 82.6%, respectively. The following complications occurred in the perioperative period: 1 stroke, 2
cases of temporary paraparesis, 2 cases of temporary hemodialysis, and 3 cases of mediastinitis. No
pulmonary complications were observed.
Kazui. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm
redissection of the aortic root. Ann Thorac Surg;72:509-514. 2001
Word PDF (volver)
From January 1983 to September 2000, 130 patients had emergency operation for acute type A aortic
dissection. Of them, 57 patients underwent root reconstruction using biologic glues and 4 patients (7.0%)
developed redissection of the aortic root associated with moderate to severe aortic regurgitation 5 to 27
months after the initial operation. In all patients, the proximal false lumen was obliterated with infusion of
gelatin-resorcinol-formaldehyde (GRF) glue or BioGlue and the aorta was reinforced with Teflon felt
strip or Surgicel placed on its outside wall. Conclusions. The use of biologic glues for reapproximating
the layers of the dissected aortic root is associated with a certain amount of risk of aortic wall necrosis.
Therefore, care should be taken to ensure proper use of these glues. Full root replacement could be a
preferable technique for treating redissection of the aortic root.
Kazui. Extended total arch replacement for acute type a aortic dissection: experience with seventy
patients. J Thorac Cardiovasc Surg. Mar;119(3):558-65. 2000. Word PDF
Between December 1988 and August 1998, 70 patients underwent emergency graft replacement of both
the ascending aorta and the total aortic arch for acute type A aortic dissection. All operations were
performed with hypothermic extracorporeal circulation, selective cerebral perfusion for cerebral
protection during aortic arch repair, and open distal anastomosis. Concomitant procedures included aortic
valve resuspension in 18 patients, composite graft replacement in 10 patients, and coronary artery bypass
grafting in 5 patients.
Results: The early mortality rate was 16% (11 of 70 patients). Multivariable analysis showed that renalmesenteric ischemia and coronary artery bypass grafting were independent determinants for early death.
Survival rates at 3 and 5 years postoperatively, including the early deaths, were 75% ± 5% and 73% ±
6%, respectively. Multivariable analysis showed that renal-mesenteric ischemia and en bloc repair were
independent determinants for late death. Freedom from reoperation was 91% ± 4% and 77% ± 8% at 3
55
and 5 years, respectively. Multivariable analysis showed that anastomotic leakage was the only significant
determinant for late reoperation.
Kazui. Extended aortic replacement for acute type a dissection with the tear in the descending aorta. J
Thorac Cardiovasc Surg;112:973-978. 1996. Word (volver)
Kirsch. Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic
dissection. J Thorac Cardiovasc Surg;123:318-325. 2002. Word
Between 1980 and 2000, a total of 160 consecutive patients (mean age 57.5 ± 13.3 years, 126 men)
underwent surgery for acute type A aortic dissection. Proximal repair was performed by means of
ascending aorta replacement with valve resuspension in 130 cases (81.3%), composite graft replacement
in 19 cases (11.9%), separate aortic valve and ascending aorta replacement in 7 cases (4.4%), and aortic
repair in 1 case (0.6%). Distal repair required arch replacement in 23 cases. Follow-up time averaged 4.51
± 5.6 years per patient. Results: Survival estimates after initial operation were 66.1% ± 3.8%, 57.7% ±
4.2%, 52.2% ± 4.6%, and 42.5% ± 5.8% at 1, 5, 10, and 15 years, respectively. Thirty patients required 37
reoperations at a mean interval of 5.7 ± 4.5 years after the initial operation. Freedoms from reoperation
were 96.9% ± 1.8%, 74.7% ± 5.3%, 60.8% ± 6.8%, and 39.3% ± 9.1% at 1, 5, 10, and 15 years,
respectively. Reoperations included procedures on the proximal aorta (aortic root or valve) in 21 cases
and on the distal aorta or its side branches in 19 cases
von Kodolitsch. Intramural Hematoma of the Aorta. Predictors of Progression to Dissection and Rupture.
Circulation.;107:1158. 2003. Word PDF (volver)
A multicenter study was conducted comprising 66 patients with IMH and hospital admission 48 hours
after onset of initial symptoms. Among these, progression to aortic dissection or rupture occurred in 30
(45%) and death occurred in 13 (20%) patients within 30 days. Late progression was noted in 14 (21%)
and death in 11 (17%) patients, yielding a 1-, 2-, and 5-year survival of 76%, 73%, and 43%, respectively.
In a set of 9 variables, multivariate analysis identified IMH location in the ascending aorta (type A;
P=0.02) and moderately ectatic aortic diameters (49±13 mm with progression versus 57±16 mm without
progression; P=0.03) as independent predictors of early progression. In type A IMH, early mortality was
8% with swift surgery versus 55% without surgery (P=0.004). The risk of late progression of IMH was
independently associated with age at index diagnosis (P=0.01) and absence of ß-blocker therapy during
follow-up (P=0.03). Kaplan-Meier analysis confirmed improved 1-year survival of IMH with ß-blocker
therapy (95% versus 67% without ß-blockers; P=0.004).
Conclusions— Regardless of aortic diameter, IMH of the ascending aorta (type A) is at high risk for early
progression, and, thus, undelayed surgical repair should be performed. Moreover, oral ß-blocker therapy
may improve long-term prognosis of IMH independent of anatomical location.
Küçüker. Arch repair with unilateral antegrade cerebral perfusion. Eur J Cardiothorac Surg;27:638-643.
2005. Word (volver)
Between January 1996 and March 2004, 181 patients underwent aortic arch repair via the right upper
brachial artery with the use of low-flow (8–10ml/kg per min) antegrade selective cerebral perfusion under
moderate hypothermia (26°C). Mean patient age was 58±12 years. Presenting pathologies were Stanford
type A aortic dissection in 112, aneurysm of ascending and arch of aorta in 67, and isolated arch
aneurysm in two patients. Ascending and/or partial arch replacement was performed in 90 patients and
ascending and total arch replacement in 91 patients (including 27 with elephant trunk). In a subset of
patients, renal and hepatic effects of ischemic insult were assessed. Free hemoglobin and lactate
dehydrogenase levels were measured pre and postoperatively to identify hemolytic effects of brachial
artery cannulation. Results: Mean antegrade cerebral perfusion time was 36±27min. Three patients with
acute proximal dissection died due to cerebral complications. One patient had transient right hemiparesis.
Total major neurological event rate was 2.2%. Brachial artery was able to carry full cardiopulmonary
bypass flow with mild hemolysis. Renal and hepatic tests showed no deleterious effects of limited
ischemia at moderate hypothermia. Conclusions: Arch repair with antegrade cerebral perfusion through
right brachial artery has excellent neurological results, provides technical simplicity and optimal repair
without time restraints, does not necessitate deep hypothermia and requires shorter CPB and operation
times.
Kunzelman. Aortic root and valve relationships: Impact on surgical repair. J Thorac Cardiovasc
Surg;107:162-170. 1994. Word
56
Lai. Stanford. Does Profound Hypothermic Circulatory Arrest Improve Survival in Patients With Acute
Type A Aortic Dissection?. Circulation;106:I-218-I-228. 2002. Word PDF (volver)
Methods Records of 307 patients with acute type A aortic dissection from 1967 to 1999 were
retrospectively reviewed. The influence of repair using PHCA (n=121) versus without PHCA (n=186) on
death and freedom from distal aortic reoperation was analyzed using multivariable Cox regression
models. Propensity score analysis identified a subset of 152 comparable patients in 3 quintiles (QIII–V) in
which the effects of PHCA (n=113) versus no PHCA (n=39) were further compared.
Results For all patients, 30-day, 1-year, and 5-year survival estimates were 81±2%, 74±3%, and 63±3%
(±1 SE). Survival rates and actual freedom from distal aortic reoperation was not significantly different
between treatment methods in the entire patient cohort nor in the matched patients in quintiles III–V.
Treatment method was not associated with differences in early major complications, late survival, or
distal aortic reoperation rates in the entire patient sample or in quintiles III–V.
Conclusions Aortic repair with or without circulatory arrest was associated with comparable early
complications, survival, and distal aortic reoperation rates in patients with acute type A aortic dissection.
Despite the lack of concrete evidence favoring the use of PHCA, it does no harm, and most of our group
uses PHCA regularly because of its practical technical advantages and theoretical potential merit.
Lansman. Mount Sinai.Acute type B aortic dissection: surgical therapy . Ann Thorac Surg;74:S1833S1835. 2002. Word PDF (volver)
Surgery for acute type B aortic dissection is associated with significant mortality. We report the results
for 34 consecutive patients who underwent urgent surgery because they met criteria for operation during
the acute phase (< 14 days) of acute type B dissection.
METHODS: The average patient age was 64 (32 to 88) years. Indications for surgery were persistent pain
(12), threatened exsanguination (18), malperfusion (renal [3], limb [3]), rapid aortic enlargement (4), and
uncontrolled hypertension (1). The mean interval from onset of pain to operation was 7 (1 to 14) days.
Resection included the proximal descending aorta in 32, the distal aortic arch in 10, extension to the
diaphragm in 10, and involved a thoracoabdominal procedure in 3. Surgical techniques included
hypothermic circulatory arrest (16 [47%]), distal bypass, monitoring of somatosensory-evoked potentials,
sequential intercostal sacrifice (average, 5.6 pairs), cerebrospinal fluid drainage, and steroid
administration. RESULTS: There was no hospital mortality. Important complications occurred in 16
patients (47%): 10 respiratory requiring tracheostomy, six infectious, four dialysis, two myocardial
infarctions, and two neurologic (one transient stroke, one paraplegia). Mean intensive care unit and
hospital stays were 10 (3 to 32) and 35 (7 to 107) days. Survival at 5 and 10 years was 80% and 57%,
respectively (mean follow-up, 5.8 years). CONCLUSIONS: Patients meeting criteria for urgent surgery
have a low perioperative risk for mortality and paraplegia, and are relatively free from long-term aortarelated complications. These findings warrant consideration of earlier surgery for appropriate patients
with acute type B aortic dissection.
LePage. Aortic Dissection.CT Features that Distinguish True Lumen from False Lumen. AJR; 177:207211. 2001. Word PDF (volver)
Leurs. Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR
and United Kingdom Thoracic Endograft registries. Vasc Surg. Oct;40(4):670-9; discussion 679-80.
2004. Word PDF (volver)
Four hundred forty-three patients underwent endovascular repair of thoracic aortic disease between
September 1997 and August 2003 (EUROSTAR, 340 patients; UK, 103 patients). Patients represented 4
major disease groups: degenerative aneurysm (n = 249), aortic dissection (n = 131), false anastomotic
aneurysm (n = 13), and traumatic aortic injury (n = 50). RESULTS: Mean age in the entire study group
was 63 years. Fifty-two percent of patients were deemed at high risk for open surgery because of major
comorbidity. Sixty percent of patients underwent an elective procedure, and 35% required emergency
treatment. Conventional indications for treatment of aortic dissection, including aortic expansion,
continuous pain, rupture, or symptoms of branch occlusion constituted the basis for endograft placement
in 57% of patients, whereas in 43% of patients aortic dissections were asymptomatic. Primary technical
success was obtained in 87% of patients with degenerative aneurysm and in 89% with aortic dissection.
Paraplegia was a postoperative complication in 4.0% of patients with degenerative aneurysm and 0.8% of
patients with aortic dissection (not significant). Thirty-day mortality in the entire study group was 9.3%,
with mortality rates after elective procedures of 5.3% for degenerative aneurysms and 6.5% for aortic
dissection. Mortality for degenerative aneurysm after emergency repair was higher (28%; P <.0001) then
after elective procedures. For aortic dissection the emergency repair rate was 12% (not significant
compared with elective repair of aortic dissection, and P = .025 compared with emergency repair of
57
degenerative aneurysm). One-year follow-up was complete in 195 patients. The outcome at 1 year was
more favorable for aortic dissection than for degenerative aneurysm with regard to aortic expansion (0%
vs 15%; P = .001) and late survival (90% vs 80%; P = .048). In the groups with false anastomotic
aneurysm and traumatic aortic injury, 30-day mortality rates were 8% and 6%, respectively.
CONCLUSION: This multicenter experience demonstrates acceptable rates for operative mortality and
paraplegia after endovascular repair of thoracic aortic disease. Outcome after 30 days and 1 year was
more favorable for aortic dissection than for degenerative aneurysm. However, the durability of this
technique is currently unknown, and continued use of registries should provide data from long-term
follow-up.
Leyh. High Failure Rate After Valve-sparing Aortic Root Replacement Using the "Remodeling
Technique" in Acute Type A Aortic Dissection. Circulation.;106:I-229. 2002. Word PDF (volver)
From August 1995 to November 2000, 30 patients with acute type A dissection received valve-sparing
aortic root replacement. Two different techniques were performed: the "remodeling" technique, first
described by Yacoub in 1983 (8 patients) and the "reimplantation" technique, initially described by David
and Feindel, in 1992 (22 patients). Endpoints of the study were early and late mortality, as well as aortic
valve-related complications and reoperations.
Results The mean follow-up time was 22.6±15.4 months. The overall 30 day mortality was 17% (5/29)
and the late mortality 4% (1/24). During the observation period, 4 patients had to be reoperated (n=3) for
acute aortic valve regurgitation after aortic root remodeling and for acute aortic valve endocarditis (n=1)
after aortic root reimplantation. In the 3 patients with acute aortic valve regurgitation, symptoms occurred
44, 24, and 17 months after the initial operation in these patients. Intraoperatively prolapsing aortic
leaflets because of commissural detachment was found in all 3 cases. In all other patients the latest
echocardiographic follow-up examination revealed freedom from aortic regugitation higher than grade 1.
Conclusions The high failure rate of aortic root remodeling inpatients with acute type A aortic dissection
is discouraging. Whether this technique should be applied in acute type A aortic dissection is
questionable. In contrast, aortic root reimplantation lead to favorable midterm outcome
Long. Preoperative shock determines outcome for acute type A aortic dissection. Ann. Thorac.
Surg.;75:520-524. 2003. Word (volver)
Average age was 59 ± 2 years. Comorbidities included hypertension (66%), coronary artery disease
(17%), and Marfan’s syndrome (11%). At presentation, 23% were in shock, 17% had neurologic
dysfunction, and 36% had coronary ischemia. The aortic valve was preserved in 55. Distal aortic
anastomosis was performed under aortic cross-clamp ("closed") in 32 and "open" under circulatory arrest
in 38 patients. Operative mortality was 18.6% (13 of 70 patients). Patients in shock had an operative
mortality of 50% compared with stable patients of 9% (p = 0.0002). Mortality was similar regardless of
technique. Univariate analysis revealed preoperative shock (p = 0.0002), tamponade (p = 0.003), and
neurologic deficit (p = 0.02) to be associated with mortality. Multivariate analysis revealed hemodynamic
stability (odds ratio = 0.10, p = 0.04) and outside transfer (odds ratio = 0.12, p = 0.03) to be negative
predictors of mortality. Of 57 survivors, follow-up was 93% complete for an average of 46 ± 6 months.
The overall late reoperation rate was 24.6% (14 of 57 patients) at 50.3 ± 12.3 months. Twelve patients
(21%) underwent future aortic aneurysmal repair. No difference in reoperation rate was seen comparing
"closed" (26%) with "open" (18%; p = 0.46). Of 42 preserved native valves, only 3 (7.1%) needed future
valve replacement.
CONCLUSIONS: In our experience, operative mortality was determined by preoperative hemodynamic
instability. Technique did not impact survival or late reoperation. Early diagnosis and repair is critical to
improving survival
Marin. Endovascular stent graft repair of abdominal and thoracic aortic aneurysms: a ten-year experience
with 817 patients. Ann Surg. Oct;238(4):586-93; discussion 593-5. 2003. Word PDF (volver)
Over a 10-year period, 817 patients were treated with ESGs for AAA (723) or TAA (94). Patients
received 1 of 12 different stent graft devices. Technical and clinical success of ESGs was reviewed, and
the incidence of procedure-related complications was analyzed.
Results: The mean age was 74.3 years (range, 25–95 years); 678 patients (83%) were men; 86% had 2 or
more comorbid medical illnesses, 67% of which included coronary artery disease. Technical success, on
an intent-to-treat basis was achieved in 93.8% of patients. Primary clinical success, which included
freedom from aneurysm-related death, type I or III endoleak, graft infection or thrombosis, rupture, or
conversion to open repair was 65 ± 6% at 8 years. Of great importance, freedom from aneurysm rupture
after ESG insertion was 98 ± 1% at 9 years. There was a 2.3% incidence of perioperative mortality. One
hundred seventy five patients died of causes not related to their aneurysm during a mean follow-up of
58
15.4 months. Conclusions: Stent graft therapy for aortic aneurysms is a valuable alternative to open
aortic repair, especially in older sicker patients with large aneurysms. Continued device improvements
coupled with an enhanced understanding of the important role of aortic pathology in determining
therapeutic success will eventually permit ESGs to be a more durable treatment of aortic aneurysms.
Martín. Tratamiento percutáneo de las afecciones de la aorta torácica. Una labor multidisciplinaria. Rev
Esp cardiol. Enero Volumen 58 - Número 01 p. 27 - 33 . 2005. Figura stent. Word (volver)
Matalanis. A retrospective comparative study of deep hypothermic circulatory arrest, retrograde, and
antegrade cerebral perfusion in aortic arch surgery J Thorac Cardiovasc Surg;9(3):174-179. 2003.
Mehta. Acute type B aortic dissection in elderly patients: clinical features, outcomes, and simple risk
stratification rule. Ann. Thorac. Surg.;77:1622-1628. 2004. Word (volver)
Mehta. Chronobiological Patterns of Acute Aortic Dissection. Circulation;106:1110-1115. 2002. PDF
Mehta, Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes
in the current era, J Am Coll Cardiol. 40 (2002), pp. 685–692. (volver)
Mehta. Predicting Death in Patients With Acute Type A Aortic Dissection. Circulation.;105:200. 2002.
Word
Mészáros. Epidemiology and Clinicopathology of Aortic Dissection. Chest.;117:1271-1278. 2000.
Word (volver)
A population-based longitudinal study over 27 years on a study population of 106,500, including 66
hospitalized and 18 nonhospitalized consecutively observed patients.
Results: Altogether, 86 cases of aortic dissection were found in 84 patients, corresponding to a
2.9/100,000/yr incidence. Sixty-six of the 84 patients (79%) were admitted to the hospital, and 18 patients
(21%) died before admission. Their ages ranged from 36 to 97 years, with a mean of 65.7 years. The
male/female ratio was 1.55 to 1. A total of 22.7% of the hospitalized patients died within the first 6 h,
33.3% within 12 h, 50% within 24 h, and 68.2% within the first 2 days after admission. Six patients were
operated on, with a perioperative mortality of two of six patients and a 5-year survival of two of six
patients. All patients who were not operated on died. Pain was the most frequent initial symptom. Every
patient had some kind of cardiovascular and respiratory sign. Neurologic symptoms occurred in 28 of 66
patients (42%). Five patients presented with clinical pictures of acute abdomen and two with acute renal
failure. Trunk arteries were affected in 33 of the 80 autopsied cases (41%), and rupture of aorta was seen
in 69 cases (86%). In five cases, spontaneous healing of dissection was also found. The ratio of
proximal/distal dissections was 5.1 to 1. All 18 prehospital cases were acute. Fifty-nine cases (89.4%)
were acute at admission, and 7 cases (10.6%) were chronic dissections. Hypertension and advanced age
were the major predisposing factors.
Mitsumasa. Optimal treatment of type B acute aortic dissection: long-term medical follow-up results.
Ann Thorac Surg;75:1781-1784. 2003. Word PDF (volver)
In the last 8 years, 79 patients were admitted to our hospital with type B acute aortic dissection. We
medically treated patients at the time of onset, regardless of the aortic diameter and blood patency status
in the false lumen. If the maximum diameter of dissected aorta exceeded 60 mm in any stage, early or
elective surgery was performed. The mean follow-up duration was 41.2 months. We evaluated operation
free rate and actuarial survival rate.
RESULTS: Thirteen patients underwent early or elective operations of the descending aorta. At the time
of onset, the maximum aortic diameter of these patients was significantly larger than that of medically
managed patients (55.8 ± 4.4 mm vs 44.6 ± 8.2 mm; p = 0.0004). Two patients underwent emergency
axillo-femoral bypass for leg ischemia. Of the other 64 patients, who were medically managed, 2 patients
had type A dissection develop during follow-up, 3 died during the initial hospital stay (1 from rupture, 1
from bronchial asthma, and 1 from gut ischemia), and 1 died of pneumonia 6 months after onset.
Operation free rate was 98.6% at 1 month, 90.0% at 1 year, 78.7% at 3 years, and 69.5% at 8 years.
Actuarial survival rate of medically managed patients was 98.4% at 1 month and 93.5% at 8 years.
CONCLUSIONS: Medical treatment of type B acute aortic dissection produced good results. Surgical
intervention for type B dissection should be done when the maximum aortic diameter exceeds 60 mm
59
Moffatt. Endovascular Stent Management of Thoracic Aneurysms and Dissections. Card Surg Adult;
Cap 49. 2:1191-1204. 2003. Word
Moon. Influence of retrograde cerebral perfusion during aortic arch procedures Ann Thorac
Surg;74(2):426-431. 2002. Word PDF
Moon. Washington University. St Luis.Does the extent of proximal or distal resection influence outcome
for type A dissections? . Ann Thorac Surg;71:1244-1249. 2001. Word
From 1984 to 1999, 119 patients underwent repair of an acute type A dissection. Distal resection was to
the ascending aorta in 78 (66%) and hemiarch in 41 (34%) patients. Proximally, the aortic valve was
preserved in 69 (58%) patients, 40 (34%) underwent composite valve grafting, and 10 (8%) underwent
separate graft and valve replacement.
Results. Operative mortality was higher for separate graft and valve (50% ± 16%) than for valve
preservation (16% ± 5%) or composite grafts (20% ± 7%) (p < 0.05). Hemiarch replacement did not
increase operative risk compared to distal reconstruction to the ascending aorta (17% ± 6% versus 22% ±
5%, p > 0.71). Conclusions. An aggressive surgical approach, including a full root or hemiarch
replacement, is not associated with increased operative risk and should be considered when type A
dissections extensively involve the valve, sinuses, or arch.
Moore. Choice of computed tomography, transesophageal echocardiography, magnetic resonance
imaging, and aortography in acute aortic dissection: International Registry of Acute Aortic Dissection
(IRAD). Am J Card; 89;N10 • May 15, 2002. Word PDF (volver)
Neri. Cerebral autoregulation after hypothermic circulatory arrest in operations on the aortic arch Ann
Thorac Surg;77:72-80. 2004. PDF
Neri, Axillary artery cannulation in type a aortic dissection operations. J Thorac Cardiovasc
Surg;118:324-329. 1999. Word PDF
22 of 152 operations (14.4%) for acute type A aortic dissection were performed with the use of the
axillary artery for the arterial inflow. Axillary artery cannulation was undertaken in the presence of
femoral arteries bilaterally compromised by dissection in 12 patients (54.5%), abdominal aorta and
peripheral aneurysm in 5 patients (22.7%), severe atherosclerosis of both femoral arteries in 3 patients
(13.6%), and aortoiliac occlusive disease in 2 patients (9.1%). In all patients, distal anastomosis was
performed with an open technique after deep hypothermic circulatory arrest. Retrograde cerebral
perfusion was used in 9 patients (40.9%).
Results: Axillary artery cannulation was successful in all patients. The left axillary artery was cannulated
in 20 patients (90.9%), and the right axillary artery was cannulated in 2 patients (9.1%). Axillary artery
cannulation followed an attempt of femoral artery cannulation in 15 patients (68.2%). All patients
survived the operation, and no patient had a cerebrovascular accident. No axillary artery thrombosis, no
brachial plexus injury, and no intraoperative malperfusion were recorded in this series. Two patients
(9.1%) died in the hospital of complications not related to axillary artery cannulation.
Conclusions: In patients with type A aortic dissection in whom femoral arteries are acutely or chronically
diseased, axillary artery cannulation represents a safe and effective means of providing arterial inflow
during cardiopulmonary bypass.
Niederhäuser. Conservative treatment of the aortic root in acute type a dissection. Eur J Cardiothorac
Surg;15:557-563. 1999. Word
In acute type A dissection long-term results of conservative aortic root surgery were compared with the
outcome of primary valve and/or root replacement. Methods: Between 1985 and 1995, 199 patients (mean
age 59 years, 154 men) were operated on. The aortic root was involved in the dissection process and
valve incompetence of varying degree was present without exception. Replacement of a proximal aortic
segment was standard procedure in all patients. The aortic valve was preserved in 126 patients:
commissural suture resuspension (12 patients), root reconstruction with GRF-glue (gelatine-resorcinformaldehyde/glutaraldehyde-glue) (114 patients). Valve replacement was performed in 73 patients (50
composite grafts, 23 valve prostheses with separate supracoronary grafts). Preoperative risk factors (valve
replacement vs. preservation): coronary artery disease (11 vs. 8%, NS), tamponade (18 vs. 17%, NS),
unstable hemodynamics (22 vs. 15%, NS), renal failure (4 vs. 6%, NS), neurologic disorder (19 vs. 32%,
NS). Results: The overall early mortality was 23.6% (47/199 patients) and increased after commissural
suture resuspension compared with GRF-glue reconstruction (P=NS).
60
Nienaber. To stent or not to stent aortic dissection: good news for a chosen few, but who? . European
Heart Journal. Vol. 26 No. 5 Pp. 431-432. (March 2005). Word PDF (volver)
Nienaber. Gender-Related Differences in Acute Aortic Dissection. Circulation;109:3014-3021. 2004.
Word (volver)
Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected
by AAD (32.1% of AAD), women were significantly older and had more often presented later than men
(P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less
common. In-hospital complications of hypotension and tamponade occurred with greater frequency in
women, resulting in higher in-hospital mortality compared with men. After adjustment for age and
hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04),
predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than
men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32%
versus 22% in men despite similar delay, surgical technique, and hemodynamics.
Nienaber.Intramural Hematoma in Acute Aortic Syndrome.Circulation.106:284 2002. Word PDF
(volver)
Nienaber, Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J
Med 340,1539-1545. (1999).
Noiseux. Aortic cannulation for type A dissection: guidance by transesophageal echocardiography.
Interactive Cardiovascular and Thoracic Surgery 2:178-180(2003) Word PDF (volver)
Ascending aorta remains the preferred site of arterial cannulation for cardiopulmonary bypass but this
approach may be risky in the presence of aortic aneurysm, aortic dissection or severe arteriosclerosis.
Femoral artery cannulation with retrograde flow is the usual alternative under these circumstances.
However, aorto-iliac aneurysm, occlusive disease, or distal extension of the aortic dissection may
preclude the use of femoral arterial cannulation [1,2]. Alternative cannulation sites include the axillary or
innominate arteries and the apex of the left ventricle [1–5]. This report describes an innovative technique
for cannulation during repair of acute type A aortic dissection, which permits direct aortic arch
cannulation and antegrade flow. Transesophageal echocardiography (TEE) is used to identify the true
lumen of the distal arch and to guide arterial cannulation.
O'Gara. Case 12-2004 - A 38-Year-Old Woman with Acute Onset of Pain in the Chest. N Engl J
Med;350:1666-1674. 2004. Word PDF
Okita. Prospective comparative study of brain protection in total aortic arch replacement: deep
hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion
Ann Thorac Surg;72(1):72-79. 2001. Word PDF (volver)
60 consecutive patients who underwent total arch replacement through a midsternotomy were alternately
allocated to one of two methods of brain protection: deep hypothermic circulatory arrest with retrograde
cerebral perfusion (RCP: 30 patients) or with selective antegrade cerebral perfusion (SCP: 30 patients).
Hospital mortality occurred in 2 patients in the RCP group (6.6%) and 2 in the SCP group (6.6%). New
strokes occurred in 1 (3.3%) of the RCP group and in 2 (6.6%) of the SCP group (p = 0.6). The incidence
of transient brain dysfunction was significantly higher in the RCP group than in the SCP group (10,
33.3% vs 4, 13.3%, p = 0.05. Conclusions. Both methods of brain protection for patients undergoing total
arch replacement resulted in acceptable levels of mortality and morbidity. However, the prevalence of
transient brain dysfunction was significantly higher in patients with the RCP.
Passage. BioGlue surgical adhesive—an appraisal of its indications in cardiac surgery. Ann Thorac
Surg;74:432-437. 2002. PDF
Perez. D-Dimers in the Emergency Department Evaluation of Aortic Dissection. Acad Emerg
Med;11:397-400. 2004. Word (volver)
Prifti. Early and long-term outcome in patients undergoing aortic root replacement with composite graft
according to the Bentall's technique. Eur J Cardiothorac Surg;21:15-21. 2002. Word (volver)
Raanani. 'BioGlue' for the repair of aortic insufficiency in acute aortic dissection. J Heart Valve Dis.
Sep;13(5):734-7. 2004. Word (volver)
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Rokkas. Single-stage extensive replacement of the thoracic aorta: the arch-first technique. J Thorac
Cardiovasc Surg;117:99-105. 1999. Word PDF
Roseborough. Jhons Hopkins. Twenty-year experience with acute distal thoracic aortic dissections. J
Vasc Surg. Aug;40(2):235-46. 2004. Word (volver)
There were 119 patients who fit the criteria of ADDA. Medical management was performed in 92
patients, with an overall mortality in this group of 13% (12/92 patients). Major morbidity occurred in 34
of the 83 surviving patients managed nonoperatively. Percutaneous interventions consisting of aortic
fenestration and branch vessel stenting in 5 patients had a mortality rate of 40% and was only effective in
the treatment of isolated renal artery malperfusion. Twenty-two patients underwent aortic surgery for
complications or risk of impending rupture. Postoperative mortality was 18% (4/22 patients). Significant
risk factors for death were rupture, acute renal failure, mesenteric ischemia, and age >70. No patient who
had surgical fenestration required reoperation on the tailored segment.
Safi. Houston. Staged Repair of Extensive Aortic Aneurysms: Long-term Experience With the Elephant
Trunk Technique. Annn Surg 240(4), pp 677-685. October 2004. Word PDF (volver)
Between January 1991 and March 1995, 161 patients were operated on for aneurysms of the ascending
aorta and transverse arch. Thirty-three of the patients (20%) had an aneurysm of the ascending aorta only
and 128 (80%) had aneurysms of both the ascending aorta and the transverse arch. All the patients
underwent cardiopulmonary bypass, profound hypothermia, and circulatory arrest, and 120 (74%) also
underwent retrograde cerebral perfusion. Median pump time was 143 minutes (range, 21 to 461 minutes).
Median circulatory arrest time was 42 minutes (range, 8 to 111 minutes), and median myocardial
ischemic time was 71 minutes (range, 14 to 306 minutes).
Results. The overall 30-day mortality rate was 6% (9 patients) and the incidence of stroke was 4% (7
patients). The use of retrograde cerebral perfusion demonstrated a protective effect against stroke (3 of
120 patients, or 3%) compared with no retrograde cerebral perfusion (4 of 41 patients, or 9%; odds ratio,
0.24; confidence interval, 0.06 to 0.99; p < 0.049). This was most significant in patients more than 70
years of age; none of the 36 elderly patients who received retrograde cerebral perfusion had a stroke,
compared with 3 of the 13 (23%) who did not (p < 0.003). Only pump time was associated with an
increased risk of stroke (odds ratio, 1.01; 95% confidence interval, 1.00 to 1.02; p < 0.005). Pump time
also was associated with increased mortality (odds ratio, 1.01; 95% confidence interval, 1.00 to 1.02; p <
0.008). Conclusion. Retrograde cerebral perfusion decreased the incidence of stroke in patients
undergoing repair of aneurysms of the ascending aorta and transverse arch.
Safi, Houston. Staged Repair of Extensive Aortic Aneurysms. Morbidity and Mortality in the Elephant
Trunk Technique. Circulation.;104:2938. 2001. Word PDF
Between February 1991 and May 2000, we performed a total of 1146 aortic aneurysm operations. Of
these, 182 (15.9%) operations were first- or second-stage elephant trunk procedures, performed in a total
of 117 patients. Stage 1 was completed in all 117 patients. Stage 2 was completed in 65 (55.6%) of 117
patients. Thirty-day mortality rate for the first stage was 5.1% (6 of 117). Mortality rate during the
interval between operations was 3.6% (4 of 111), of which 75% (3of 4) were the result of aneurysm
rupture. Thirty-day mortality rate for the second stage was 6.2% (4 of 65). A total of 43 patients did not
return for second-stage repair. Among these patients, within an average period of 3.4 years (range, 1.5
months to 4.9 years), 13 of 43 (30.2%) died, 4 of 13 (30.8%) as the result of rupture. Two of 117 (1.7%)
first-stage patients had postoperative stroke. No spinal cord dysfunction occurred in second-stage
patients.
Conclusions— Extensive aortic aneurysms can be repaired with acceptable morbidity and mortality rates
through the use of the elephant trunk technique. Death was most commonly the result of rupture, both in
interval patients awaiting scheduled second-stage repair and in patients who did not return. After the first
stage, prompt treatment of the remaining segment is crucial to the success of staged repair.
Safi. Impact of Retrograde Cerebral Perfusion on Ascending Aortic and Arch Aneurysm Repair. Ann
Thorac Surg;63:1601-1607. 1997. Word (volver)
Sakurada. Comparative experimental study of cerebral protection during aortic arch reconstruction Ann
Thorac Surg;61(5):1348-1354. 1996. Word
Schachner. Technical problems and complications of axillary artery cannulation. Eur J Cardiothorac
Surg;27:634-637. 2005. Word (volver)
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Sixty-five patients underwent cannulation of the axillary artery. The indication for operation was acute
aortic dissection type A in 57%, chronic aortic dissection in 8%, aortic aneurysm in 18%,
pseudoaneurysm in 3%, and others in 14%. Results: Technical problems and complications occurred in
14%, and in 11% the perfusion had to be switched to either femoral (n=5) or aortic cannulation (n=2).
Arterial damage or dissection of the axillary artery or the aorta occurred in 0% of the sidegraft technique,
whereas they were found in 9% with direct cannulation (P=n.s.). Cannulation problems or insufficient
CPB flow due to a narrow vessel occurred in 0% of the sidegraft technique, whereas they were found in
4% with direct cannulation (P=n.s.). Malperfusion in aortic dissections occurred in 20% of the sidegraft
technique, whereas they were found in 0% with direct cannulation (P=0.016). No postoperative
complications related to axillary cannulation which were evaluated by clinical examination, such as
brachial plexus injury, axillary artery thrombosis or local wound infection were observed. Conclusions:
Although axillary artery cannulation is an attractive alternative to femoral cannulation there needs to be
an alertness for technical problems
Schäfers. Valve-preserving replacement of the ascending aorta: remodeling versus reimplantation. J
Thorac Cardiovasc Surg;116:990-996. 1998. Word
Of 107 patients undergoing operation for proximal aortic disease between October 1995 and November
1997, 40 patients had morphologically intact aortic valve leaflets in conjunction with dilatation of the
aortic root. Of these, 15 patients underwent an operation as a surgical emergency for acute aortic
dissection type A. In 29 instances, root remodeling in conjunction with ascending aortic replacement was
performed; 11 patients underwent radical replacement of the proximal aorta with reimplantation of the
aortic valve. Partial or total arch replacement was performed additionally in 27 of these patients. Other
concomitant procedures were coronary artery bypass grafts (n = 11) and mitral reconstruction (n = 1).
Results: Two patients died after repair of acute aortic dissection, for a total operative mortality rate of 5%.
No patient died after elective surgery. Aortic valve function could be effectively restored with both
techniques
Scheinert. Endoluminal stent–graft placement for acute rupture of the descending thoracic aorta.
European Heart Journal. Vol. 25 No. 8; 694-700 (April 2004). Word PDF
A total of 31 consecutive patients underwent interventional treatment for perforating lesions of the
descending aorta. In 21 cases (group A), the aortic perforation was due to rupture of a descending thoracic
aneurysm or dissection, whereas 10 patients (group B) were treated for traumatic transection of the
descending aorta. A total of 42 endoprostheses were implanted.
The implantation procedure was successful in all cases without peri-interventional complications. In one
case, implantation of a second endoprosthesis became necessary due to type I endoleak. Overall, the 30day mortality was 9.7%. As all three deaths occurred in group A, the mortality rate in this group was
14.3% versus 0% in group B. Similarly, postinterventional complications were more prevalent, with
28.6% in group A (renal failure ; stroke ) versus 10.0% in group B (renal failure ). No paraplegia and no
further deaths or ruptures occurred during follow-up (mean 17 months).
Sebastià. Aortic Dissection: Diagnosis and Follow-up with Helical CT. Radiographics.;19:45-60.
Vall D’Hebron. Muchas Figuras. 1999. Word PDF
Settepani. Aortic valve-sparing operations in patients… Interactive Cardiovascular and Thoracic
Surgery. Feb 2005. PDF
Shakibaie. Indications for operative management of abdominal aortic aneurysms. ANZ J S: 74(6); 470–
476 June 2004. Word PDF.
(volver)
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Simon. Aortic Valve Resuspension in Ascending Aortic Aneurysm Repair With Aortic Insufficiency.
Ann Thorac Surg;60:176-180. 1995. Word (volver)
In selected patients undergoing ascending aortic aneurysm repair who have normal aortic leaflets but
secondary aortic regurgitation, the native valve can be spared through this novel operation. The aortic
annulus size is reduced significantly, thereby effectively eliminating hemodynamically significant aortic
regurgitation. The intermediate-term results are promising, but the long-term durability of this type of
repair needs to be determined.
Sinatra. Emergency operation for acute type A aortic dissection: neurologic complications and early
mortality. Ann Thorac Surg;71(1):33-38. 2001. Word PDF (volver)
85 pacientes. All patients underwent surgical procedures under deep hypothermic circulatory arrest.
Antegrade or retrograde cerebral perfusion was used in 23 patients (27.1%) and 18 patients (21.2%),
respectively. Forty-three patients underwent arch/hemiarch replacement and the ascending aorta was
replaced in 42 patients. Overall mortality rate was 25.9% (22 of 85 patients). Multiple logistic regression
analysis showed that lack of cerebral perfusion (p = 0.021) and postoperative renal failure (p = 0.006)
were the best predictors for hospital death. Twenty-one patients (24.7%) experienced neurologic
accidents. The risk factor for postoperative neurologic complication was lack of cerebral perfusion (p =
0.013). Hospital mortality was 13% (3 of 23 patients) and 16.7% (3 of 18 patients) in the antegrade and
retrograde cerebral perfusion groups (p > 0.05) and neurologic deficit was 13% (3 of 23 patients) and
11.1% (2 of 18 patients), respectively (p > 0.05).
Conclusions. Hospital mortality and neurologic complications in patients undergoing emergent operation
for acute type A aortic dissection were reduced when cerebral perfusion was used with deep hypothermic
circulatory arrest.
Song. Outcomes of medically treated patients with aortic intramural hematoma. American Journal of
Medicine. Volume 113 • Number 3 • August 15, 2002. Word
(volver)
A total of 124 patients with acute aortic intramural hematoma (41 in the proximal aorta and 83 in the
distal aorta) was enrolled from five institutions in South Korea. Patients received medical treatment
without surgery. A follow-up imaging study was performed in 105 patients. Pericardial (59% [n = 24] vs.
11% [n = 9], P <0.004) and pleural effusions (63% [n = 26] vs. 45% [n = 37], P = 0.05) were more
common in patients with the proximal type than in those with the distal type. In-hospital mortality was
somewhat higher with proximal hematomas (7% [n = 3 deaths] vs. 1% [n = 1 death], P = 0.11). A followup imaging study in 36 patients with proximal hematomas confirmed resorption of the hematoma in 24
patients (67%) and development of aortic dissection in 9 (25%). Resorption was confirmed in 54 (78%) of
the 69 patients with distal hematomas who underwent follow-up imaging; localized aortic dissection
developed in 11 (16%) of these patients. The 3-year survival rate was 78% in the proximal type and 87%
in the distal type (P = 0.10).
Conclusion: Patients with aortic intramural hematoma had a high rate
of resorption with medical treatment regardless of the affected site. Further investigation is necessary to
determine the optimal treatment strategy and timing of surgical intervention, especially for patients with
proximal hematomas.
Spielvogel. Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion.
Ann Thorac Surg;74:S1810-S1814 . 2002.
Word
(volver)
22 pacientes.
Stanger. Late dissection of the ascending aorta after previous cardiac surgery: risk, presentation and
outcome. Eur J Cardiothorac Surg;21:453-458. 2002. Word (volver)
Dissection of the ascending aorta occurred in 83 patients, of whom 11 (13.2%, six acute and five chronic)
had undergone previous cardiac surgery (four aortic valve replacements (AVR), two double valve
replacements (DVR), two AVR+coronary artery bypass grafts (CABG), three CABGs). Conclusions:
Type-A aortic dissection can follow cardiac operations at any time with no typical interval or associated
histology and with high overall hospital mortality. Male patients with arterial hypertension are at
increased risk.
Stecker. Deep hypothermic circulatory arrest: I. Effects of cooling on electroencephalogram and evoked
potentials. Ann Thorac Surg;71:14-21. 2001. Word PDF (volver)
Strauch. Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement. Ann
Thorac Surg;78:103-108. 2004.. Word (volver)
109 pac. The mean nasopharyngeal temperature when periodic complexes appeared in the
electroencephalogram after cooling was 29.6°C ± 3°C, electroencephalogram burst-suppression appeared
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at 24.4°C ± 4°C, and electrocerebral silence appeared at 17.8°C ± 4°C. The N20-P22 complex of the
somatosensory evoked response disappeared at 21.4°C ± 4°C, and the somatosensory evoked response
N13 wave disappeared at 17.3°C ± 4°C. The temperatures of these various events were not significantly
affected by any patient-specific or surgical variables, although the time to cool to electrocerebral silence
was prolonged by high hemoglobin concentrations, low arterial partial pressure of carbon dioxide, and by
slow cooling rates. Only 60% of patients demonstrated electrocerebral silence by either a nasopharyngeal
temperature of 18°C or a cooling time of 30 minutes.
Suzuki. Clinical Profiles and Outcomes of Acute Type B Aortic Dissection in the Current Era: Lessons
From the International Registry of Aortic Dissection (IRAD). Circulation;108:II-312-317. 2003.
Word PDF
Factors associated with increased in-hospital mortality on univariate analysis were hypotension/shock,
widened mediastinum, periaortic hematoma, excessively dilated aorta (6 cm), in-hospital complications of
coma/altered consciousness, mesenteric/limb ischemia, acute renal failure, and surgical management (all
P<0.05). A risk prediction model with control for age and gender showed hypotension/shock (odds ratio
[OR] 23.8, P<0.0001), absence of chest/back pain on presentation (OR 3.5, P=0.01), and branch vessel
involvement (OR 2.9, P=0.02), collectively named ‘the deadly triad’ to be independent predictors of inhospital death.
Suzuki, Diagnostic implications of elevated levels of smooth-muscle myosin heavy-chain protein in acute
aortic dissection: the smooth muscle myosin heavy chain study. Ann Intern Med 133,537-541. 2000.
Word PDF
Patients with acute aortic dissection who presented within 3 hours after onset had elevated levels of
circulating smooth-muscle myosin heavy-chain protein. In these patients, the assay had a sensitivity of
90.9%, a specificity of 98% compared with healthy volunteers, and a specificity of 83% compared with
patients who had acute myocardial infarction; the clinical decision limit was 2.5 µg/L. All patients with
proximal lesions had elevated levels of smooth-muscle myosin heavy-chain protein, and only patients
with distal lesions had decreased levels (<2.5 µg/L).
Svensson. Intimal tear without haematoma. Circulation;99:1331-1336. 1999. Word (volver)
Tanoue. Comparative study of retrograde and selective cerebral perfusion with transcranial Doppler. Ann
Thorac Surg;67(3):672-675. 1999. Word PDF (volver)
Retrograde cerebral perfusion (RCP) is a simple technique and is expected to provide cerebral protection.
However, its optimum management and limitations remain unclear. Transcranial Doppler has been used
to monitor cerebral perfusion. Using this Doppler technique, we compared cerebral blood flow for RCP
with that for selective cerebral perfusion.The measurement of middle cerebral artery blood flow velocities
with transcranial Doppler technique is practicable during selective cerebral perfusion but difficult during
RCP. The increase in middle cerebral artery blood flow velocities after RCP indicates reactive hyperemia
and reflects the critical decrease in cerebral blood flow during this type of perfusion.
Therasse. Stent-Graft Placement for the Treatment of Thoracic Aortic Diseases. RadioGraphics;25:157173. 2005. Word (volver)
Stent-graft placement is now an alternative to surgery for the treatment of descending thoracic aortic
aneurysms, ulcers, and fistulas and is sometimes indicated in cases of mycotic aneurysm, posttraumatic
aortic rupture, or thoracic descending aortic dissection. Pretreatment imaging is crucial for evaluating
patient eligibility, selecting the appropriate stent-graft, and planning the intervention. Stent-graft
treatment of long atherosclerotic aneurysms, lesions close to aortic branch vessels, and aortic dissections
is subject to technical pitfalls, and adverse events such as endoleaks, stent migration or misplacement,
aortic perforation, and vascular trauma will require specific interventions, although they occur in only a
minority of patients. Thoracic stent-graft placement in good surgical candidates remains controversial
because long-term results are unknown. However, short-term morbidity and mortality rates from
endovascular treatment compare favorably with those from surgery, and stent-graft placement is proving
to be a safe, minimally invasive, and effective treatment for thoracic aortic diseases and is already the best
option in many affected patients who are poor surgical candidates.
Thoongsuwan. Chest CT Scanning for Clinical Suspected Thoracic Aortic Dissection: Beware the
Alternate Diagnosis. Emergency Radiology 9: 257-261. (2002). PDF (volver)
We performed a retrospective medical records review of 86 men and 44 women (ages ranging between 23
and 106 years) with clinically suspected aortic dissection, for CT scan findings and final clinical
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diagnoses. We found aortic dissection in 32 patients (24.6%), 22 of which were Stanford classification
type A and 10 Stanford type B. In 70 patients (53.9%), chest pain could not be explained by the CT scan
findings. However, in 28 patients (21.5%), CT scanning did reveal an alternate diagnosis that, along with
the clinical impression, probably explained the patients' presenting symptoms, including: hiatal hernia (7),
pneumonia (5), intrathoracic mass (4), pericardial ef-fusion/hemopericardium (3), esophageal
mass/rupture (2), aortic aneurysm without dissection (2), pulmonary embolism (2), pleural effusion (1),
aortic rupture (1), and pancreatitis (1). In cases where there is clinical suspicion of aortic dissection, CT
scan findings of an alternate diagnosis for the presenting symptoms are only slightly less common than
the finding of aortic dissection itself. Although the spectrum of findings will vary depending upon your
patient population, beware the alternate diagnosis.
Trimarchi. Contemporary results of surgery in acute type A aortic dissection: The International Registry
of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg;129:112-122. 2005. Word PDF
(volver) (volver 2º). A comprehensive analysis was completed of 290 clinical variables and their
relationship to surgical outcomes in 526 of 1032 patients enrolled in the International Registry of Acute
Aortic Dissection from 1996 through 2001. Extracted cases, categorized according to risk profile, were
defined as unstable (group I) in the presence of cardiac tamponade; shock; congestive heart failure;
cerebrovascular accident; stroke; coma; myocardial ischemia, infarction, or both; electrocardiograms with
new Q waves or ST elevation; acute renal failure; or mesenteric ischemia-infarction at the time of the
operation. Outside of an unstable condition, patients were categorized as stable (group II).
Results: The overall in-hospital mortality was 25.1%. Mortality in group I was 31.4% compared with
16.7% in group II (P < .001). Independent preoperative predictors of operative mortality were history of
aortic valve replacement (odds ratio = 3.12), migrating chest pain (odds ratio = 2.77), hypotension as sign
of acute type A aortic dissection (odds ratio = 1.95), shock or tamponade (odds ratio = 2.69), preoperative
cardiac tamponade (odds ratio = 2.22), and preoperative limb ischemia (odds ratio = 2.10).
Umaña. Is medical therapy still the optimal treatment strategy for patients with acute type B aortic
dissections? . J Thorac Cardiovasc Surg;124:896-910. 2002. Word (volver)
Objective: The optimal treatment of patients with acute type B dissections continues to be debated.
Methods: A 36-year clinical experience of medical and surgical treatments in 189 patients was
retrospectively analyzed. Results: Shock (hazard ratio 14.5, 95% confidence interval 4.7-44.5, P < .001)
and visceral ischemia (hazard ratio 10.9, 95% confidence interval 3.9-30.3, P < .001) largely
predominated as determinants of death, along with 6 other risk factors (arch involvement, rupture, stroke,
previous sternotomy, and coronary or lung disease), which roughly doubled the hazard of death. Female
sex was a significant but weaker predictor of death. Renal dysfunction, year of presentation, age, and
mode of therapy (medical vs surgical) had no important bearing on overall survival. The actuarial survival
estimates for all patients were 71%, 60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were
similar for the medical and surgical patients. Conclusions: The prognosis for patients with acute type B
aortic dissection is bleak and determined primarily by dissection-related and patient-specific risk factors,
which do not appear to be readily modifiable.
Veeragandham. Experience with antegrade bihemispheric cerebral perfusion in aortic arch operations .
Ann Thorac Surg;66:493-499. 1998. Word PDF (volver)
There was no in-hospital or 30-day mortality. The blood product requirements were significantly less with
moderate hypothermia. One patient suffered cerebrovascular accident (5%). None of the 7 patients with
cerebral perfusion times of 60 to 120 minutes had any neurologic deficits. These results are superior to
those reported for hypothermic circulatory arrest with or without retrograde cerebral perfusion.
Conclusions. Antegrade bihemispheric cerebral perfusion is an optimal adjunct for cerebral protection
during aortic arch operations.
Vilacosta. Síndrome aórtico agudo. Rev Esp Cardiol; 56: 29 – 39. 2003. Word PDF
Vogt. MR angiography of the chest. Radiologic Clinics of North America. Volume 41: 1 • January 2003.
Word (volver)
Weber. D-dimer in Acute Aortic Dissection. Volume 123 • Number 5 • May 2003. Word PDF PDF-2
(volver)
The result of the d-dimer test was positive (ie, > 0.5 μg/mL) in all patients (sensitivity of the test, 100%)
with a mean value of 9.4 μg/mL and a range of 0.63 to 54.7 μg/mL. The degree of the elevation was
correlated to the delay from the onset of symptoms to laboratory testing (mean, 12.6 h; range, 1 to 120 h)
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and showed a trend to the extent of the dissection, but not to the outcome (14 patients could be
discharged; 10 patients died).
Conclusions:Based on our observation, we suggest that testing for d-dimer should be part of the initial
assessment of patients with chest pain, especially if aortic dissection is suspected. A negative test result
makes the presence of the disease unlikely.
Westaby. Editorial comment.Eur J Cardiothorac Surg;27:632-633. 2005.
Westaby. Aortic Valve Conservation in Acute Type A Dissection . Ann Thorac Surg;64:1108-1112.
1997. Word
We retrospectively studied 64 patients with an acute type A dissection, an ascending aortic tear, and
aortic regurgitation operated on by the same surgeon between 1988 and 1996. Three had Marfan's
syndrome and 2 had a bicuspid valve. The valves in all patients without Marfan's syndrome were repaired
with gelatin-resorcinol-formol glue. The valve and root were reinvestigated by echocardiography. Some
patients underwent nuclear magnetic resonance imaging.
Results. There were four hospital (6%) and three late deaths. Aortic root reoperation was required in 2 of
the 60 survivors (3.3%) and operation on the distal aorta in 2. Root reoperations were required within 3
years. The remaining proximal repairs remained stable.
Conclusions. The native aortic valve can be conserved in most patients, and glue repair is durable
Wiesenfarth. E-medicine Disección aórtica. 2004. Word
Willens. Transesophageal Echocardiography in the Diagnosis of Diseases of the Thoracic Aorta. Part 1.
Aortic Dissection, Aortic Intramural Hematoma, and Penetrating Atherosclerotic Ulcer of the Aorta.
Chest.;116:1772-1779. 1999. Word PDF (volver)
Winsor. Inadequate hemodynamic management in patients undergoing interfacility transfer for suspected
aortic dissection . American Journal of Emergency Medicine. Volume 23 • Number 1 • January 2005.
Word PDF
Yamada. Central cannulation for type A acute aortic dissection . Interactive Cardiovascular and
Thoracic Surgery 2:175-177(2003). Word PDF (volver)
Yoshida. Thoracic Involvement of Type A Aortic Dissection and Intramural Hematoma: Diagnostic
Accuracy—Comparison of Emergency Helical CT and Surgical Findings. Radiology 228:430-435. 2003.
Word
CONCLUSION: Emergency helical CT of the thorax depicts findings that are highly accurate in the
evaluation of acute type A AD and IMH
Yu. Late outcome of patients with aortic dissection: study of a national database. Eur J Cardiothorac
Surg;25:683-690. 2004. Word
A total of 5654 cases of aortic dissection (3871 males) were collected from the National Health Insurance
Databases from 1996 to 2001. Age, gender, Marfan syndrome, and initial treatment modality were the
main factors to be investigated. Corrective group was defined by surgical operation with cardiopulmonary
bypass and palliative group for the remaining. Late aortic events were defined by late aneurysmal
evolution of diseased aorta needing surgical intervention or death of aortic causes from 6 months to 6
years. Results: The incidence of aortic dissection was 43 per 1 000 000 population in our country.
Corrective group accounted for 19.3% of them and palliative group for 80.7%. Marfan syndrome
accounted for 1.5% of all cases (4.3% of corrective surgery group). The rate of freedom from mortality at
1, 6 months, and 6 years was 80.4±1.3, 69.0±1.5, and 56.5±2.9% for corrective group and 89.5±0.5,
78.4±0.6, and 46.1±1.35% for palliative group. Nearly half of the late mortalities were attributed to
atherosclerosis-related conditions (cardiac, stroke, or aortic causes). The incidence of late aortic events
was 2.48% per year on an average, comparable between corrective and palliative groups. This incidence
increased since the fourth year after their initial episode. For corrective group, young age was a risk factor
of late aortic events (relative risk of 0.60–0.82 per decade, P=0.037). For palliative group, Marfan
syndrome and male gender were risk factors of late aortic events (relative risk of 4.08–10.7, P<0.001 in
the former; relative risk of 1.46–2.1, P=0.002 in the latter).
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