The cardiovascular diseases

THE AORTIC DISSECTION

- Definition
- A few explanations
- The Symptoms
- How to make the diagnosis?
- The Causes
- Prognosis
- Treatment
- Conclusion

TREATMENT

1 - Goal:

To restore the anatomical integrity of the aortic wall and possibly of its branches.

2 - Means:

a - The medical treatment

It is a complete rest in intensive care units with a treatment decreasing the B.P.:

- The major painkillers are used (morphine if necessary);

- Stresskillers bring an interesting contribution;

- The decline of the maximal B.P. below 120-130 mmHg (12-13) for the systolic arterial pressure (the maximal one) is a major imperative. To this end, antihypertensive drugs are often used by i.v.

b - The prosthetics treatment

Implanting a prosthesis in the artery, in order to block up the false channel in which blood is engulfed, can treat some shapes of aortic dissections.

This technique is achieved in a radiological environment and consists in putting a “wire netting” on the dissected zone.

The results of this technique are globally good.

Installation of a “wire netting” at the level of the aortic dissection zone during an arteriography.

The decompression of the false channel is also possible by achieving a ”fenestration” operation, i.e. the opening of the false channel.

c - The surgical treatment

* In the dissection of the initial part of the aorta, the surgery under extracorporeal circulation and with opening of the thorax achieves the resection of the ascending aorta and its orifice of entry, and its replacement by a Terylene® prosthesis.

* In the attack of the terminal part of the aorta, 2 techniques exist:

- One is the resection of the dissected aorta by opening the left lateral thorax and its replacement by a prosthesis.

- The other technique consists in inverting the circulatory flow and creating a clot of the dissected area.

- In most cases, it is useless to replace the aortic valve.

The aortic surgery is sufficient to assure a sufficient competence. In case of Marfan disease or aortic dystrophy, the replacement is however necessary.

- In case of an attack of the heart arteries (coronary arteries), a coronary reimplantation or a bypass is sometimes necessary.

- The complex staged or iterative dissections call on sequential resections of the dissected segments with possible arterial reimplantation.

Scan picture of the endoprosthesis placed on the gate of the aortic dissection.

3 - Results of the surgical treatment:

In spite of the surgery, the dissections of the initial part of the aorta reach a 30% mortality. In case of an attack of the distal part of the aorta, mortality also reaches 30% in case of surgery.

Remotely, the results are excellent, whatever in terms of functional result or survival. The Marfan disease is a specific problem.

4 - Monitoring:

The monitoring is clinical and radiological by non invasive exams:

- The B.P. must be maintained strictly within the normal;

- The scan or the nuclear magnetic resonance imaging (MRI), or even the trans-oesophageal cardiac ultrasound permits to control the calibre of the aorta and the state of the false channel. An exam achieved just before leaving the hospital is used as a reference. The rhythm is then yearly, or even more frequent according to the case.

Control scanner showing the “wire netting” at the level of the starting point of the dissection.

The indications of belated new surgery are very rare: residual aortic insufficiency, recidivation of dissection or development of an aneurysm.

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File last reviewed on dec 18, 2011