Page 497 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 42: Aortic Dissection 367

A B C

FIGURE 42-17. “Elephant trunk” procedure with stent-grafting of the descending thoracic aorta. A. The entire aorta is aneurysmal, but most notably the arch, descending thoracic, and
proximal abdominal aorta. B. The aortic valve has been replaced. A suprasinus tube graft replaces the ascending aorta and the entire arch, with the terminal portion of the graft (the “elephant
trunk”) hanging free in the descending aorta. The abdominal aorta has been narrowed for the stent-graft “landing site.” Incidental aortohepatic and aortosuperior mesenteric artery bypasses
have been performed. C. The nitinol stent-graft has been placed endovascularly from the terminal portion of the elephant trunk to the landing site in the abdominal aorta. (Reproduced with
permission from Dr Lars Svensson, Cleveland Clinic Foundation, 2004.)
RESULTS stroke, and renal failure. Complications specific to surgical repair of
■ MORBIDITY type B dissections include paraplegia/paraparesis (up to 40% with rup-

ture), renal and intestinal ischemia, recurrent laryngeal nerve palsy, and
Patients undergoing surgical repair of type A aortic dissections are subject chylothorax. Important late complications of both type A and type B
74
to the same postoperative complications as with any open-heart proce- dissections include late aneurysm formation and redissection of the
dure. Early complications include myocardial infarction, low-output aorta. In type A dissections moderate to severe aortic insufficiency is
syndrome (systolic BP <90 mm Hg with an elevated pulmonary wedge present late in 5% to 20% of patients with insufficiency preoperatively.
pressure requiring inotropic support), arrhythmia, bleeding, respira- This is usually well tolerated, with over 80% of these patients not requir-
tory complications (prolonged ventilation, atelectasis, and effusion), ing valve replacement at 10 years follow-up. 75

A B

Teflon
felt

Hematoma
Graft

FIGURE 42-18. Repair of type B dissection. A. The intimal tear is just distal to the left subclavian artery. B. The descending aorta is replaced with a Dacron graft with felt reinforcement of
the suture lines.

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