Perioperative Type I Aortic Dissection during Conventional Coronary Artery Bypass Surgery: Risk Factors and Management
DOI:
https://doi.org/10.1532/HSF98.20081032Abstract
Objectives: Perioperative iatrogenic type I aortic dissection (PIAD) is a rare but potentially fatal complication of conventional coronary artery bypass surgery (CCABG). Prompt recognition and repair of PIAD may significantly improve outcomes.
Methods: We reviewed the hospital records of patients with PIAD occurring as a complication of CCABG at Siyami Ersek Thoracic and Cardiovascular Surgery Center from January 2001 through June 2007. During this period, 10,130 CCABG were performed and 21 patients (0.20%) with PIAD were identified. We compared variables for these 21 patients with 603 patients without PIAD (control group).
Results: PIAD occurred intraoperatively in 19 patients (90%) and during the early postoperative period (first 6 hours) in 2 patients (10%) who underwent CCABG. Dissections were noticed after removal of the aortic crossclamp in 11 patients, during aortic cannulation in 3 patients, and after removal of the partial-occlusion clamp in 5 patients. Patients with and without PIAD differed significantly in regard to sex (P = .05), history of hypertension (P = .001), and history of severe concomitant peripheral arterial disease (PAD) (P = .001). The diameter of the aorta was significantly wider in patients with PIAD. (3.83 ± 0.9 vs 2.93 ± 0.46 cm, P = .019). The occurrence of high cardiopulmonary bypass (CPB) pressure (?120 mmHg) was significantly higher in the PIAD patients than the non-PIAD patients (28.6% vs 3.3%, P = .0001). Seven PIAD patients (33.3%) died preoperatively and 3 (14.2%) died postoperatively.
Conclusion: PIAD is frequently fatal. Risk factors for PIAD during or after CCABG include female sex, history of PAD and hypertension, increased aortic diameter, and high CPB pressure.
References
Archer AG, Choyke PL, Zeman RK, Green CE, Zuckerman M. 1986. Aortic dissection following coronary artery bypass surgery: diagnosis by CT. Cardiovasc Intervent Radiol 9:142-5.nBlakeman BM, Pifarre R, Sullivan HJ, et al. 1988. Perioperative dissection of the ascending aorta: types of repair. J Card Surg 3:9-14.nChavanon O, Carrier M, Cartier R, et al. 2001. Increased incidence of acute ascending aortic dissection with off-pump aortocoronary bypass surgery? Ann Thorac Surg 71:117-21.nCollins JS, Evangelista A, Nienaber CA, et al. 2004. International registry of acute aortic dissection (IRAD) differences in clinical presentation, management, and outcomes of acute type a aortic dissection in patients with and without previous cardiac surgery. Circulation 14: II237-42.nEpperlein S, Mohr-Kahaly S, Erbel R, Kearney P, Meyer J. 1994. Aorta and aortic valve morphologies predisposing to aortic dissection. Eur Heart J 15:1520-7.nFleck T, Czerny M, Koinig H, Hutschala D, Wolner E, Grabenwoger M. 2003. The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest. Ann Thorac Surg 76:1198-202.nFleck T, Ehrlich M, Czerny M, Wolner E, Grabenwoger M, Grimm M. 2006. Intraoperative iatrogenic type A aortic dissection and perioperative outcome. Interact Cardiovasc Thorac Surg 5:11-4.nGravlee GP. 2000. Cardiopulmonary bypass: principles and practice. New York: Lippincott Williams and Wilkins; p 587.nKirklin JW, Barratt-Boyes BG. 1993. Cardiac surgery. New York: Churchill-Livingstone; p 102-3.nKouchoukos NT, Dougenis D. 1997. Surgery of the thoracic aorta. N Engl J Med 336:1876-88.nLarson EW, Edwards WD. 1984. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 53:849-55.nLitchford B, Okies JE, Sugimura S, Starr A. 1976. Acute aortic dissection from cross-clamp injury. J Thorac Cardiovasc Surg 72:709-13.nMizutani S, Usui A, Akita T, Ueda Y. 2003. Management of intraoperative aortic dissection with a direct cannulation on the intimal flap. Interact Cardiovasc Thorac Surg 2:636-8.nMurphy DA, Craver JM, Jones EL, Bone DK, Guyton RA, Hatcher CR Jr. 1983. Recognition and management of ascending aortic dissection complicating cardiac surgical operations. J Thorac Cardiovasc Surg 85:247-56.nNienaber CA, Eagle KA. 2003. Aortic dissection: new frontiers in diagnosis and management; part II: therapeutic management and follow-up. Circulation 12:772-8.nRobicek F, Thubrikar MJ. 1994. Haemodynamic considerations regarding the mechanism and prevention of aortic dissection. Ann Thorac Surg 58:1247-53.nRuchat P, Hurni M, Stumpe F, Fischer AP, von Segesser LK. 1998. Acute ascending aortic dissection complicating open-heart surgery: cerebral perfusion defines the outcome. Eur J Cardiothorac Surg 14:449-52.nStanger O, Oberwalder P, Dacar D, Knez I, Rigler B. 2002. Late dissection of the ascending aorta after previous cardiac surgery: risk, presentation and outcome. Eur J Cardiothorac Surg 21:453-8.nStill RJ, Hilgenberg AD, Akins CW, Daggett WM, Buckley MJ. 1992. Intraoperative aortic dissection. Ann Thorac Surg 53:374-9.nWilliams CD, Suwansirikul S, Engelman MR. 1974. Thoracic aortic dissection following cannulation for perfusion. Ann Thorac Surg 18:300-4.n
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