Describe steps of Indications definitive Surgical Treatment?
Indications for Definitive Surgical Treatment : Surgery is indicated in all acute proximal dissections.
Indications for surgery for acute distal dissection complicated by the following:
1) Progression with vital organ compromise.
2) Rupture or impending rupture.
3) Retrograde extension into the ascending aorta.
4) Dissection in Marfans syndrome.
Operation for acute dissection is done to prevent death from cardiac tarnponade or exsanguination by rupture. Operation also helps to restore blood supply to vital organs. It is not always possible to remove the entire false channel in some patients. So the operation is palliative rather than curative. In ascending aorta, the dissection could cause acute valve regurgitation (AR) or obstruction of coronary ostia. In such cases, aortic valve resuspension, aortic valve replacement or replacement of aortic root and ascending aorta with a composite graft (Bental procedure) or with an aortic allograft may be required.
Acute myocardial infarction induced by dissection, coma, paraplegia, renal failure and ischaemia of the lower extremities and abdominal viscera are not contra indications for surgery. They may improve after surgery.
In cases of acute distal dissection (De Bakey Type III) medical treatment is indicated. Complication occurring in such cases as rupture or impending rupture, rapid expansion of aortic diameter, ischaemia of visceral organs, kidneys or limbs, uncontrolled hypertension, intractable pain in spite of medical treatment and haemothorax or haemoptysis will require surgical treatment. Marfans syndrome has generally poor results with medical therapy and so surgery is preferred.