Dissecting aneurysms of the aorta

[Intensive care management of acute diseases of the aorta]

Acute aortic diseases represent a group of complex severe and often fatal medical conditions. Although they are significantly rarer than cardiac or thromboembolic events, they are an important differential diagnosis to be ruled out, e.g., in the clinical work-up of acute chest pain.Treatment, especially surgical interventions, depends on the progression, extent and size of the pathology and whenever possible should be performed in specialized centers with the appropriate experience.Intensive care monitoring is advisable as a range of peracute complications can occur even in initially stable patients. Depending on the clinical presentation and affected structures, a number of severe complications need to be anticipated by critical care physicians. Additionally, a notable symptom is severe and refractory hypertension, especially in the acute phase. This article provides a summary of the most frequent clinical pictures and corresponding treatment options. Furthermore, the principles of initial patient stabilization and treatment as well as the perioperative management of complex surgical procedures on the aorta are discussed.

Challenging Current Conservative Management of Uncomplicated Acute Type B Aortic Dissections

Introduction

Despite weak evidence, current treatment guidelines for uncomplicated acute type B aortic dissection (uATBAD) consistently recommend intensive and rapid lowering of systolic blood pressure and heart rate.

Report

The case of a 62 year old man with uATBAD, who was treated according to guidelines, is presented. Owing to an unknown chronic occlusion of the left carotid artery combined with intensive hypotensive treatment, the patient developed a cerebral infarct.

Discussion

The case illustrates a severe complication of the widely accepted management of uATBAD. This case, along with scrutiny of guidelines and the evidence behind these guidelines, provoke questions regarding the rationale of current conservative management, and whether it should be challenged with alternative strategies employing a more cautious blood pressure regimen. It also highlights the importance of evaluating the vessels of the supra-aortic trunk when determining the extent of the dissection.

[Surgery of the ascending aorta and aortic arch]

The surgical therapy of the ascending aorta and the aortic arch with its supraarotic branches has been, and still is, one of the major challenges in the therapy of the aorta. There have been major developments in the endovascular therapy field, which can be used as a complementary or even sometimes as an alternative to the standard surgery. Therefore, an interdisciplinary approach is a prerequisite for optimal therapy planning for such patients. The risk of operating under circulatory arrest has been markedly reduced due to the continued development of cardiosurgical techniques, especially selective cerebral perfusion and mild hypothermia. Further developments of the therapy of aortic diseases via alternative approaches are expected in the near future. However, the conventional surgical therapy for pathologies in the ascending aorta (with/out the aortic valve) and the aortic arch is still the gold standard.

Surgical repair of dissection of the upper descending thoracic aorta and discrete ascending aortic aneurysm

This report describes successful staged surgical repair in 2 patients with dissection of the upper descending thoracic aorta (DeBakey type III) with coexisting discrete Marfan's aneurysms of the ascending aorta. Initial repair of the descending aortic dissection was done through a left thoracotomy using a transverse aorta--femoral artery shunt in 1 patient and a left ventricular apex--femoral artery shunt without systemic heparinization in the other. Emphasis is placed on the need for pharmacological reduction of blood pressure during aortic cross-clamping as well as the use of a shunt to prevent dissection of the ascending aortic aneurysm. In both patients, subsequent repair of the ascending aortic aneurysm was accomplished using composite graft replacement of the aortic valve and ascending aorta. This operation is advised for such patients even in the absence of notable aortic valve incompetence.