Excision of the aortic wall in the surgical treatment of acute type-A aortic dissection.

Between March 1986 and September 1988, 38 patients underwent extended aortic resection (aortic valve, ascending aorta, and arch) for acute type-A aortic dissection with aortic valve insufficiency; deep hypothermia and circulatory arrest were used. All patients were operated on within 17 hours of the onset of symptoms. In the first 24 patients, operation was performed by the "inclusion technique." In the last 14 patients, the "excision technique" was used: the ascending aorta and arch was excised, and the aorta was transected at the beginning of the descending thoracic tract. Excision and transection were considered essential to prevent back flow from the false lumen, which is the main source of bleeding, and to allow all anastomoses to be constructed beyond the limits of dissection. The only anastomosis to the dissected aorta was at the distal end of the graft. One of the 14 patients died (7.1%). One patient was reopened for bleeding: blood was issuing from the attachment of the carotid trunks, and the defect was repaired by interposing a bifurcated Dacron graft between the arch graft and the carotid arteries. Extended aortic excision meets the principle of either eliminating as far as possible the diseased aorta or controlling intraoperative and postoperative bleeding. An operation of great magnitude can be considered a life-saving procedure when compared with the high risk of acute type-A aortic dissection.