Focused Issue of This Month Current Status of Acute Aortic Disease Treatment KayHyun Park, MD Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine Email : drkhpark@yahoo.co.kr J Korean Med Assoc 2008; 51(4): 347-356 Abstract About 1,000 patients undergo aortic surgery annually in Korea. Unlike Western countries, emergency surgery for dissection or ruptured aneurysm is more frequent than elective cases. Because timely diagnosis and intervention are essential for improving the treatment outcome, medical professionals should be provided with accurate knowledge about the nature of the diseases and currently available treatment modalities along with their results. Aortic dissection is the most frequent among the acute aortic diseases. Although there is a wide variation in surgical results between hospitals, experienced centers are reporting early survival rates higher than 90% after a surgery for acute type A dissection. The majority of the patients with acute type B dissection can be treated medically. For those who have serious complications such as rupture or malperfusion, catheter based intervention became a promising alternative to surgery. Aortic intramural hematoma and penetrating atherosclerotic ulcer are known to have better prognosis than dissection. However, treatment plans should be decided individually, because many of such lesions can progress into dissection or rupture. Because the result of surgery for ruptured degenerative aneurysm is poor, surveillance and timely intervention is of utmost importance. The mortality rate after elective aortic surgery has come into a satisfactory range; 10% for the thoracic and 5% for the abdominal aorta. Endovascular repair has been established as an effective treatment for the abdominal aortic aneurysm. However, its effectiveness and proper indications for thoracic aortic diseases are not fully determined. Refinement of device and combination with surgical repair (hybrid technique) will widen the indication of stent grafting. Keywords : Aorta; Aortic dissection; Aortic aneurysm 347
Park KH Figure 1. Trend in annual number of aortic surgery in Korea. 348
Current Status of Acute Aortic Disease Treatment ascending aorta replacement hemiarch replacement total arch replacement aortic root replacement (Bentall) Figure 2. Extent of aortic replacement for acute type A dissection. A C E B D F Figure 3. Computed tomographic scan images of various malperfusion syndrome caused by aortic dissection. (A) True lumen compression in right common carotid artery causing stroke. (B) Obstruction of arch branches by mobile intimal flap causing cerebral ischemia and arm ischemia. (C), (D) Malperfusion of left main coronary artery causing acute myocardial infarction. (E), (F) Occlusion of superior mesenteric artery causing bowel infarction. 349
Park KH Figure 4. Extended replacement of the aorta and open insertion of stent graft for acute type A dissection. Figure 5. Rationale of fenestration for acute type B aortic dissection. 350
Current Status of Acute Aortic Disease Treatment A B C D Figure 6. Aortic intramural hematoma (A, B) and penetrating ulcer (C, D). 351
Park KH onset 12 months 22 months Figure 7. Spontaneous absorption of intramural hematoma seen in serial CT scans. CT finding Op finding Figure 8. Aortic intramural hematoma accompanied by an intimal defect. 352
Current Status of Acute Aortic Disease Treatment Figure 9. Stent graft for the thoracic aorta. 353
Park KH 354
Current Status of Acute Aortic Disease Treatment 11. Kim YW. Report of nationwide questionnaire survey for abdominal aortic aneurysm treatment in Korea. Korean J Vasc Surg 2005; 21: 10-15. 12. Beaver TM, Herrbold FN, Hess PJ, Klodell CT, Martin TD. Transferring diagnosis versus actual diagnosis at a center for thoracic aortic disease. Ann Thorac Surg 2005; 79: 1957-1960. 13. Svensson LG, Kouchoukos NT, Miller DC. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stentgrafts. Ann Thorac Surg 2008; 85: S1- S41. 14. Suzuki T, Mehta RH, Ince H, Nagai R, Sakomura Y, Weber F, Sumiyoshi T, Bossone E, Trimarchi S, Cooper JV, Smith DE, Isselbacher EM, Eagle KA, Nienaber CA; International Registry of Aortic Dissection. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the international registry of aortic dissection (IRAD). Circulation 2003; 108 (S1): II312 - II317. 15. Hata M, Shiono M, Inoue T, Sezai A, Niino T, Negishi N, Sezai Y. Optimal treatment of type B acute aortic dissection: long term medical followup results. Ann Thorac Surg 2003; 75: 1781-1784. 16. Yu HY, Chen YS, Huang SC, Wang SS, Lin FY. Late outcome of patients with aortic dissection: study of a national database. Eur J Cardio thorac Surg 2004; 25: 683-690. 17. Olsson C, Eriksson N, Stahle E, Thelin S. Surgical and long term mortality in 2634 consecutive patients operated on the proximal thoracic aorta. Eur J Cardio thorac Surg 2007; 31: 963-969. 18. Westaby S, Bertoni GB. Fifty years of thoracic aortic surgery: lessons learned and future directions. Ann Thorac Surg 2007; 83: S832-S834. 19. Westaby S, Saito S, Katsumata T. Acute type A dissection: conservative methods provide consistently low mortality. Ann Thorac Surg 2002; 73: 707-713. 10. Bavaria JE, Brinster DR, Gorman RC, Woo YJ, Gleason T, Pochettino A. Advances in the treatment of acute type A aortic dissection: an integrated approach. Ann Thorac Surg 2002; 74: S1848 -S1852. 11. Geirsson A, Szeto WY, Pochettino A, McGarvey ML, Keane MG, Woo YJ, Augoustides JG, Bavaria JE. Significance of malperfusion syndrome prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardio thorac Surg 2007; 32: 255-262. 12. Watanuki H, Ogino H, Minatoya K, Matsuda H, Sasaki H, Ando M, Kitamura S. Is emergency total arch replacement with a modified elephant trunk technique justified for acute type A aortic dissection? Ann Thorac Surg 2007; 84: 1585-1591. 13. Halstead JC, Spielvogel D, Meier DM, Rinke S, Bodian C, Malekan R, Ergin MA, Griepp RB. Composite aortic root replacement in acute type A dissection: time to rethink the indications? Eur J Cardio thorac Surg 2005; 27: 626-633. 14. Geirsson A, Bavaria JE, Swarr D, Keane MG, Woo YJ, Szeto WY, Pochettino A. Fate of the residual distal and proximal aorta after acute type A dissection repair using a contemporary surgical reconstruction algorithm. Ann Thorac Surg 2007; 84: 1955-1964. 15. Kato M, Kuratani T, Kaneko M, Kyo S, Ohnishi K. The results of total arch graft implantation with open stentgraft replacement for type A aortic dissection. J Thorac Cardiovasc Surg 2002; 124: 531-540. 16. Sakaguchi G, Komiya T, Tamura N, Kimura C, Kobayashi T, Nakamura H, Furukawa T, Matsushita A. Patency of distal false lumen in acute dissection: extent of resection and prognosis. Interactive Cardiovasc Thorac Surg 2007; 6: 204-208. 17. Kusagawa H, Shimono T, Ishida M, Suzuki T, Yasuda F, Yuasa U, Onoda K, Yada I, Hirano T, Takeda K, Kato N. Changes in false lumen after transluminal stent graft placement in aortic dissections. Six years experience. Circulation 2005; 111: 2951-2957. 18. Czerny M, Zimpfer D, Rodler S, Funovics M, Dorfmeister M, Schoder M, Marta G, Weigang E, Gottardi R, Lammer J, Wolner E, Grimm M. Endovascular stent graft placement of aneurysms involving the descending aorta originating from chronic type B dissections. Ann Thorac Surg 2007; 83: 1635-1640. 19. Vilacosta I, San Roman JA. Acute aortic syndrome. Heart 2001; 85: 365-368. 20. Neri E, Capannini G, Carone E, Diciolla F, Sassi C. Evolution toward dissection of an intramural hematoma of the ascending aorta. Ann Thorac Surg 1999; 68: 1855-1856. 21. Von Kodolitsch Y, Csosz SK, Koschyk DH, Schalwat I, Loose R, Karck M, Dieckmann C, Fattori R, Haverich A, Berger J, Meinertz T, Nienaber CA. Intramural hematoma of the aorta. Predictors of progression to dissection and rupture. Circulation 2003; 107: 1158-1163. 22. Song JK, Kim HS, Kang DH, Lim TH, Song MG, Park SW, Park SJ. Different clinical features of aortic intramural hematoma versus dissection involving the ascending aorta. J Am Coll Cardiol 2001; 37: 1604-1610. 23. Park KH. Prevalence of intimal defect in the patients with surgically treated acute type A intramural hematoma of the aorta. Korean J Thorac Cardiovasc Surg 2007; 40: 733-744. 24. Cho KR, Stanson AW, Potter DD, Cherry KJ, Schaff HV, Sundt TM 3rd. Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch. J Thorac Cardiovasc Surg 2004; 127: 1393-1399. 355
Park KH 25. Grabenwoger M, Fleck T, Czerny M, Hutschala D, Ehrlich M, Schoder M, Lammer J, Wolner E. Endovascular stent graft placement in patients with acute thoracic aortic syndromes. Eur J Cardiothorac Surg 2003; 23: 788-793. 26. Elefteriades JA. Natural history of thoracic aortic an: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg 2002; 74: S1877- S1880. Peer Reviewers Commentary 356