Management of descending aortic dissection

Background. Experience with 100 consecutive patients with acute dissection of the descending aorta seen at the Yale Center for Thoracic Aortic Disease over a 10-year period is reported. Methods. Clinical records from the Yale Center for Thoracic Aortic Disease from 1988 to 1998 were analyzed. This computerized data base included information regarding patients' demographics, history, presenting symptomatology, diagnostic imaging, early hospital course, treatment strategy, and long term follow up (office visits, echocardiography, computerized tomography, magnetic resonance imaging, and home phone calls). Results. The average size of the aorta at the time of dissection was 5.05 cm. Nine patients died (six of complications directly related to the thoracic aorta). Sixty of the 91 surviving patients had a benign course, and 31 had a course complicated by rupture (8), vascular occlusion (17), early expansion or extension (12), and continued pain (4); multiple complications were seen in some patients. Forty-two patients came to operation (22 early and 20 late): 32 direct aortic replacements, 6 fenestration procedures, and 4 thromboexclusions, There were six postoperative deaths and six paraplegias. Clinical experience with the alternative procedures of fenestration and thromboexclusion found both procedures safe and effective for selected categories of patients. Review of the literature indicated that direct aortic replacement in the setting of acute descending aortic dissection continues to carry a very high mortality (28%-65%) and paraplegia rate (30%-35%), leaving room for consideration of alternative procedures. Conclusions. We recommend a "complication-specific" approach to acute descending aortic dissection: medical management with "antiimpulse therapy" for uncomplicated acute descending dissections and surgical intervention for complicated dissections. Surgical therapy varies for the specific complication: for rupture direct aortic replacement is recommended; for vascular occlusion fenestration; and for acute expansion or impending rupture, direct aortic replacement, with thromboexclusion as an option. Chronic descending aortic dissection is treated according to general guidelines for descending aortic aneurysms, with operation for symptoms or enlargement > 6.5 cm. (C) 1999 by The Society of Thoracic Surgeons.