Late acute aortic dissection after coronary artery bypass

Abstract

We assume that postoperative pericardial scarring and adhesions provide some protection against progression of the dissection and therefore suggest that preferred treatment in non-stable patients should be surgical. In stable patients, close follow-up and blood pressure control are beneficial. Late ascending aortic dissection after CABG is rare, and treatment presents a clinical dilemma. We treated eight patients with post-CABG late acute aortic dissection. Three underwent surgical replacement of the ascending aorta. One died after surgery, and the other two had an uneventful recovery. Five patients were treated conservatively. No standard treatment guidelines exist for late acute aortic dissection after CABG. We assume that postoperative pericardial scarring and adhesions provide some protection against progression of the dissection, and suggest that preferred treatment in non-stable patients should be surgical. In stable patients, close follow-up and blood pressure control are beneficial.

Outcomes of Patients Presenting With Acute Type A Aortic Dissection in the Setting of Prior Cardiac Surgery

“…Others have also advocated a conservative approach, citing excellent late survival (80%-100% at 1.5-6.5 years) with primary medical management. [5][6][7] However, these studies had very small sample sizes and included patients who were clinically stable at the time of presentation. The presence of adhesions and their presumed protective effect against rupture and tamponade has been suggested as a potential reason for improved survival with medical therapy.…”

“…[5][6][7] Several justifications are offered for this, including protection from aortic rupture and aortic insufficiency conferred by adhesions from previous surgery and previous aortic valve replacement, respectively.…”

“…3,4 Some have argued a history of PCS should favor a nonoperative approach. [5][6][7] Several justifications are offered for this, including protection from aortic rupture and aortic insufficiency conferred by adhesions from previous surgery and previous aortic valve replacement, respectively. 8 This study from the International Registry of Acute Aortic Dissection (IRAD) aims to determine the impact of PCS on the presentation and outcomes of patients with TAAAD.…”

Cardiac and Aortic Reoperation for Patients withFunctional Grafts after CABG

“…1) However, treatment for such patients presents a complex clinical dilemma, especially for those with functional grafts after CABG. [2][3][4] The optimal choice of management for cardiac or aortic reoperation after CABG is inconclusive, and reports are sporadic. 2) The management of patent arterial grafts including the ITA during repeated cardiovascular surgery after CABG has also been controversial.…”

“…Specific guidelines for optimal management have not been established, and reports have been sporadic. Shinfeld et al 2) found that patients with type A ascending aortic dissection, who had undergone a CABG, have an additional advantage, insofar as their mediastinal adhesions prevent or delay progression of the dissection. Westaby et al 12) have achieved a lower mortality rate (6.3%) by applying a conservative method with preservation of the native aortic valve in high-risk patients.…”