Acute Aortic Syndromes

Acute aortic syndromes are a constellation of pathologies including acute aortic dissection, intramural hematoma, penetrating atherosclerotic ulcers, and aortic rupture. An acute aortic syndrome involving the ascending aorta is an indication for emergent surgical repair. Acute aortic syndromes involving the descending aorta are typically treated initially with aggressive medical management then repaired through an endovascular or open approach electively. More urgent repair is indicated with rupture, pending rupture, expanding aneurysms, persistent acute pain, and malperfusion syndromes. The goals of open repair of acute ascending aortic syndromes are resolution of cardiac tamponade, malperfusion of end organs, and acute aortic insufficiency, and prevention of aortic rupture. Principles of surgical repair include median sternotomy, excision of the primary entry tear for aortic dissection, followed by reconstruction of the aortic root, ascending aorta, and aortic arch, management of the aortic valve to achieve competency, and ensuring patent coronary arteries and aortic arch vessels to maintain myocardial, cerebral, and upper and lower body perfusion. Venous cannulation is achieved through the right atrium or femoral vein. The most common arterial cannulation strategy is femoral, while alternatives include right axillary artery, intrathoracic right subclavian, innominate, or carotid arteries, and direct modified Seldinger central aortic cannulation of the true lumen. In the setting of acute dissection of the ascending aorta with visceral or extremity malperfusion syndrome, an increasing number of centers perform endovascular fenestration and stenting to restore end-organ perfusion followed by staged open surgical repair of the proximal aorta.