Chronic Type A Aortic Dissection

Abstract

Stanford Type A aortic dissection is a rapidly progressing disease process that is often fatal without emergent surgical repair. A small proportion of Type A dissections go undiagnosed in the acute phase and are found upon delayed presentation of symptoms or incidentally. These chronic lesions may have a distinct natural history that may have a better prognosis and could potentially be managed differently then those presenting acutely. The method of repair depends on location and extent of the false lumen, as well as involvement of critical structures and branch arteries. Surgical repair techniques similar to those employed for acute dissection management are currently first-line therapy for chronic cases that involve the aortic valve, sinuses of Valsalva, coronary arteries, and supra-aortic branch arteries. In patients with high-risk for surgery, endovascular repairs have been successful, and active development of delivery systems and grafts will continue to enhance outcomes. We present two cases of chronic Type A aortic dissection and review the current literature.

Key Words

Chronic aortic dissection - Stanford Type A dissection - Thoracic endovascular aortic repair

• References

• 1 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey Jr DE. , et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol 2010; 15: e27-129 . DOI: 10.1016/j.jacc.2010.02.015
• 2 Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H. , et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J 2014; 35: 2873-2926 . DOI: 10.1093/eurheartj/ehu281
• 3 Rylski B, Milewski RK, Bavaria JE, Branchetti E, Vallabhajosyula P, Szeto WY. , et al. Outcomes of surgery for chronic type A aortic dissection. Ann Thorac Surg 2015; 99: 88-94 . DOI: 10.1016/j.athoracsur.2014.07.032
• 4 Pompilio G, Spirito R, Alamanni F, Agrifoglio M, Polvani G, Porqueddu M. , et al. Determinants of early and late outcome after surgery for type A aortic dissection. World J Surg 2001; 25: 1500-1506 . DOI: 10.1007/s00268-001-0160-y
• 5 Carnevale D, Lembo G, Frati G. Chronic type A aortic dissection: Could surgical intervention be guided by molecular markers?. J Cell Mol Med 2011; 15: 1615-1619 . DOI: 10.1111/j.1582-4934.2011.01314.x
• 6 Eggebrecht H, Plicht B, Kahlert P, Erbel R. Intramural hematoma and penetrating ulcers: Indications to endovascular treatment. Eur J Endovasc Surg 2009; 38: 659-665 . DOI: 10.1016/j.ejvs.2009.09.001
• 7 Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A. , et al. Diagnosis and management of aortic dissection. Eur Heart J 2001; 22: 1641-1681 . DOI: 10.1053/euhj.2001.2782
• 8 Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O’Gara PT. , et al. Aortic valve and ascending aorta guidelines for management and quality measures. Ann Thorac Surg 2013; 95: 1491-1505 . DOI: 10.1016/j.athoracsur.2012.12.027
• 9 Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg 2015; 149: 144-154 . DOI: 10.1016/j.jtcvs.2014.07.109
• 10 Metcalfe MJ, Karthikesalingam A, Black SA, Loftus IM, Morgan R, Thompson MM. The first endovascular repair of an acute type A dissection using an endograft designed for the ascending aorta. J Vasc Surg 2012; 55: 220-222 . DOI: 10.1016/j.jvs.2011.06.116
• 11 Kolvenbach RR, Karmeli R, Pinter LS, Zhu Y, Lin F, Wassilijew S. , et al. Endovascular management of ascending aortic pathology. J Vasc Surg 2011; 53: 1431-1438 . DOI: 10.1016/j.jvs.2010.10.133
• 12 Nordon IM, Hinchliffe RJ, Morgan R, Loftus IM, Jahangiri M, Thompson MM. Progress in endovascular management of type A dissection. Eur J Vasc Endovasc Surg 2012; 44: 406-410 . DOI: 10.1016/j.ejvs.2012.07.018
• 13 Ronchey S, Serrao E, Alberti V, Fazzini S, Trimarchi S, Tolenaar JL. , et al. Endovascular stenting of the ascending aorta for type A aortic dissections in patients at high risk for open surgery. Eur J Vasc Endovasc Surg 2013; 45: 475-480 . DOI: 10.1016/j.ejvs.2013.01.033
• 14 Brechtel K, Kalender G, Stock UA, Wildhirt SM. Hybrid debranching and TEVAR of the aortic arch off-pump, in re-do patients with complicated chronic type-A aortic dissections: A critical report. J Cardiothorac Surg 2013; 8: 188 . DOI: 10.1186/1749-8090-8-188
• 15 Palma JH, Gaia DF, Guilhen JS, Buffolo E. Endovascular treatment of chronic type A dissection. Interact Cardiovasc Thorac Surg 2008; 7: 164-166 . DOI: 10.1510/icvts.2007.165027