Surgery for Aortic Dissection

At NYU Langone, surgeons may manage an aortic dissection with a procedure designed to repair or replace tissue in the wall of the aorta that’s been damaged by the tear.

Surgeons either insert a tube called a stent to prevent blood from flowing into the false lumen that forms between the layers of the aorta during a dissection, or they replace the damaged parts of the aorta with a synthetic material.

Endovascular Surgery

Although most type B aortic dissections are treated with medication, you may need surgery if you develop ischemia, a condition in which the dissection prevents the flow of blood to certain organs or to the legs.

Your doctor may recommend endovascular surgery to remove the blockage. In this minimally invasive procedure, the surgeon makes small incisions in the groin to access the femoral artery in the leg, which allows the doctor to reach the aorta. If necessary, small incisions can be made in the chest instead of the groin.

A thin wire is advanced through the artery and to the area near the aortic dissection, always staying within the true lumen, or natural passageway, of the aorta. The surgeon fits a thin tube called a sheath over the wire, slides it to the location of the dissection, and withdraws the wire.

He or she then guides a stent graft, a fabric tube covered with a metal mesh, through the sheath to the dissection. The surgeon expands the stent graft to fit the diameter of the aorta.

The stent supports the aorta, allowing it to heal by cutting off the blood flow to the false lumen, which is a new channel for blood flow that was created by the tear in the aortic wall. It also reinforces the aorta and can therefore prevent an aortic aneurysm, or bulging of the aortic wall, from developing in the weakened aorta. 

Sometimes, the surgeon uses a “fenestrated” stent graft, which is customized to fit the person’s aorta and has specifically placed holes, or fenestrations, that allow blood to flow to the arteries that lead to important organs, such as the kidneys. This device allows the surgeon to repair the aorta without affecting blood flow, even if the dissection is located near important arterial branches that supply blood to vital organs.

Recovery from endovascular surgery is significantly quicker than that from open surgery. You can expect to remain in the hospital for two to three days after surgery. Because your aorta and heart need rest to heal, your doctor may recommend that you refrain from driving and lifting anything heavier than 10 pounds for 10 days after surgery.

Open Heart Surgery

Type A aortic dissections are located in the ascending aorta, the part that exits the heart. These typically require emergency surgery—as do dissections involving the arch that forms the top of the aorta—because the dissection can split open, or “unzip,” the aorta. 

This can cause bleeding into the pericardium, the sac-like membrane that envelops the heart, or into the abdomen. This bleeding can lead to cardiac tamponade, a potentially fatal condition in which the blood accumulating in the pericardium puts pressure on the heart, preventing it from working properly. 

In open heart surgery, the surgeon makes a large incision in the chest and opens the sternum, or breastbone, with surgical tools. Then he or she sutures, or sews together, the “flap,” which is the partition between the layers of the aortic wall created by the dissection.

Sections of the aorta are replaced with a synthetic material called Dacron®, which usually lasts a lifetime. Prior to the procedure, surgeons give you a nutrient-rich solution intravenously that safely slows the heart until it’s nearly stopped to allow for surgery. 

Because open heart surgery is a complex procedure, it can lead to serious complications. You can expect to remain in the intensive care unit for several days after surgery. This allows your doctor to monitor you for signs of internal bleeding, heart attack, kidney failure, infection, and ischemia, a condition in which organs, such as the kidneys, are deprived of oxygen-rich blood. 

Stents may also be implanted during open surgery to repair Type A aortic dissections.

After you return home, your doctor may advise you not to drive for 1 to 2 weeks and to avoid lifting anything heavier than 10 pounds for 4 to 6 weeks. This is because your aorta and heart require rest and time to heal.

You may have a CT scan or MRI scan after surgery to ensure that your aorta is healing properly. Your doctor may prescribe a medication called a beta blocker to control your blood pressure. 

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