Intraoperative descending aortic dissection during aortic root replacement: successful management

Iatrogenic Aortic Dissection Associated With Cardiac Surgery: A Narrative Review

Iatrogenic aortic dissection (iAD) is a relatively rare but a life-threatening complication associated with cardiac surgery. All members of the team caring for cardiac surgical patients (surgeons, perfusionists, and anesthesiologists) must be familiar with this complication to minimize its incidence and improve outcome. The present narrative review focuses on iAD occurring intraoperatively and during the early postoperative period (within 1 month) of cardiac surgery. The review also addresses iAD that occurs late (beyond 1 month) after cardiac surgery and iAD associated with other procedures. iAD occurs in about 0.06% of cases when the ascending aorta is the site of arterial cannulation, in about 0.6% when the femoral or iliac arteries are used, and in about 0.5% when the axillary or subclavian arteries are used. Mortality is estimated to be 30% but is more than double if not recognized until the postoperative period. Site of origin of dissection is most commonly the arterial inflow cannula (∼33%). Other common sites are the aortic cross-clamp or partial occlusion clamp (∼29%) and the proximal saphenous vein anastomosis site (14%). Sixty percent of cases occur during coronary artery bypass graft (CABG) surgery and 17% during aortic valve surgery with or without CABG. iAD may be somewhat less common in off-pump versus on-pump CABG but is still not very rare. Risk factors, presentation, diagnosis, and management are reviewed in detail as is the key role of the use of echocardiography in the early diagnosis of iAD and for guiding its management.