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Rationale for a Conservative Approach and Arguments Against Aggressive Surgical Approaches

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Controversies in Aortic Dissection and Aneurysmal Disease

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Abstract

Type A dissection is one of the few remaining true surgical emergencies. Without surgery, the risk of death is still as high as 50 % at 48 h. Patients must therefore have a repair as early as possible to have a chance of survival. In the last four to five decades, surgeons have gained experience of more complex operations for the aortic root and arch in the elective setting. Encouraged by their success, some have proposed performing the same complex operations in cases of type A dissection. In this chapter we put forward a number of arguments against these aggressive approaches. The fundamental counter-argument is that the emergency dissection patient is quite different from the elective aneurysm patient. In aneurysm cases, the patient arrives in theatre in a stable situation and any malperfusion that may exist has been compensated for. Patients presenting as emergencies with type A aortic dissection are unstable and ill-prepared for the insult of the operation. The accompanying systemic inflammatory response to arterial dissection will be compounded by extra-corporeal circulation and hypothermia if used. The “instantaneous risk to life” imposed by type A aortic dissection immediately follows this tearing though the arterial media and only falls below risks offered by surgery after 14 days. Considering these issues, operations for these patients must be prompt and swift in order to minimise the additional insult of surgery. This chapter summarises the evidence in support of this position.

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Author information

Authors and Affiliations

  1. Department of Cardiothoracic Surgery, Papworth Hospital, Ermine Street South, Cambridge, Cambridgeshire, CB29NG, UK

    Priya Sastry MA, BCChir, MRCS

  2. Department of Surgery, Papworth Hospital, Papworth Everard, UK

    Stephen R. Large MA, MS, FRCS, MRCP, MBA, PaE

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  1. Priya Sastry MA, BCChir, MRCS
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  2. Stephen R. Large MA, MS, FRCS, MRCP, MBA, PaE
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Corresponding author

Correspondence to Stephen R. Large MA, MS, FRCS, MRCP, MBA, PaE .

Editor information

Editors and Affiliations

  1. University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom

    Robert S. Bonser

  2. University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom

    Domenico Pagano

  3. Thoracic and Cardiovascular Surgery Depts., Hannover Medical School, Hannover, Germany

    Axel Haverich

  4. University Hospitals Birmingham, Queen Elizabeth Hospital & Centre, Birmingham, United Kingdom

    Jorge Mascaro

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Sastry, P., Large, S.R. (2014). Rationale for a Conservative Approach and Arguments Against Aggressive Surgical Approaches. In: Bonser, R., Pagano, D., Haverich, A., Mascaro, J. (eds) Controversies in Aortic Dissection and Aneurysmal Disease. Springer, London. https://doi.org/10.1007/978-1-4471-5622-2_10

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  • DOI: https://doi.org/10.1007/978-1-4471-5622-2_10

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  • Online ISBN: 978-1-4471-5622-2

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