Surgical options

Surgical options

Type A (or type I and II) dissections Those involving the ascending aorta usually require surgical intervention. The chest is opened through a median sternot omy and CPB is commenced, often with core cooling down to 18°C based on the technique used. The aorta is cross-clamped as high up the ascending aorta as possible and opened. Cardio plegic solution is infused into the coronary ostia to arrest the heart in diastole. If the intimal tear is present and localised, the ascending aorta is excised with the tear and replaced with a synthetic g raft. The distal anastomosis is performed with circulatory arr est. Recently there have been attempts to carry out endovascular stenting of type A dissections with variable Adolf Kussmaul , 1822–1902, Professor of Medicine at, successively , Heidelberg, Erlangen, Freiburg and Strasbourg, Germany . the setting of acute type I dissection is debatable and is based on the clinical picture and surgical experience. Type B (or type III) dissections Initially , these are best managed medically with antihyperten - sive drugs and monitoring on an acute care unit. Intervention is indicated in complicated cases if the pain increases (signalling impending rupture) or fails to resolve; or when the dissection is associated with evidence of malperfusion (organ, limb or cutaneously placed neurological symptoms). The use of per endovascular stents is currently the standard intervention of choice in patients with complicated type B dissection, and surgery is reserved for the rare case that is not suitable for stenting.