Case 7
Dissection all the way around
If the aorta is dissected all the way from mid ascending aorta to iliacs what operation would you do ?
Partly depends on philosophy! No good having a perfect operation but a dead patient.
Options include:
1. Tube graft in ascending aorta, with high aortic clamp, and femoral artery cannulation. If the entry tear is in the removed portion of ascending aorta this is relatively low risk and not a bad option.
2. Tube graft in ascending aorta, hemi arch replacement under circulatory arrest, and femoral artery cannulation. If no entry tear in ascending aorta then you should enter the arch to look for intimal tear, to try and exclude with a hemi arch replacement.. If you still can't see tear then just replacing the proximal arch is an option.
Good solutions but high risk to patient!
3. Tube graft in ascending aorta, and full arch replacement regardless of entry site
4. Tube graft in ascending aorta, full arch replacement regardless of entry site, and elephant trunk so that any future aneurysmal dilation of descending aorta secondary to dissection can be more easily dealt with.
The risk of subsequent aneurysmal dilation of the descending aorta can be predicted post operatively by whether the false lumen disappears post surgery. this can be evaluated via CT or MRI.