Van Arsdell G S, David T E, Butany J
Division of Cardiac Surgery, Toronto Hospital, Ontario, Canada.
Circulation. 1998 Nov 10;98(19 Suppl):II299-302; discussion II302-4.
This study was undertaken to review autopsy findings in operative and nonoperative settings to define anatomic pathology, cause of death, and theoretical implications of operative and perfusion management strategies for acute Stanford type A dissection.
Fifty autopsies for acute type A dissection performed between 1977 and 1995 were reviewed. Twenty-nine patients had no operative therapy (group A). Twenty-one patients received an operation (group B). Cause of death in the nonoperated group was tamponade or rupture in 23 patients (23 of 29, 79%). In the operated group, 1 patient died of rupture (1 of 21, 5%). The 2 most common causes of death in the operated group were major brain injury (7 of 21, 33%) and cardiac failure (7 of 21, 33%). Intimal disruption was present in 92% of patients (45 of 49). Twenty-four percent of these (12 of 49) had a secondary intimal injury site. Theoretic femoral arterial perfusion and application of an ascending aortic cross clamp would have left 42% of patients (21 of 50) at risk of false lumen perfusion against the aortic cross clamp. Replacement of the ascending aorta alone would have left residual arch intimal disruption in 32% of patients (16 of 50). Open arch inspection and repair when appropriate would have left a minimum number of patients with distal intimal disruption (8 of 50, 16%).
Operative therapy successfully manages the primary cause of death in acute type A dissection. A theoretical repair that uses the open arch technique followed by antegrade perfusion eliminates or minimizes the risk of false lumen perfusion in the greatest number of patients. This technique may diminish neurological injury and distal anastomosis bleeding, thereby improving outcomes.
