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Aortic dissection surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]; Aarti Narayan, M.B.B.S [3]; Hardik Patel, M.D.

Overview

Any dissection that involves the ascending aorta is considered a surgical emergency, and urgent surgical consultation is recommended. There is a 90% 3-month mortality among patients with a proximal aortic dissection who do not undergo surgery. These patients can rapidly develop acute aortic insufficiency (AI), tamponade or myocardial infarction (MI).

Surgery

Indications for Operative Repair of a Type B Dissection

Dissections involving only the descending aorta can generally be managed medically, but indications for surgery include the following:

Contraindications to the Operative Repair of a Type A Dissection

Even acute MI in the setting of dissection is not a surgical contraindication. Acute hemorrhagic stroke is, however, a relative contraindication, due to the necessity of intraoperative heparinization.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines[1]

Recommendations for Multidisciplinary Aortic Teams

Class I
1. For patients with acute aortic disease that requires urgent repair, a multidisciplinary team should determine the most suitable intervention(Level of Evidence: C-EO)
Class IIa
2. For patients who are asymptomatic with extensive aortic disease, or who may benefit from complex open and endovascular aortic repairs, or with multiple comorbidities for whom intervention is considered, referral to a high-volume center (performing at least 30-40 aortic procedures annually) with experienced surgeons in a Multidisciplinary Aortic Team is reasonable to optimize treatment outcomes.(Level of Evidence: C-LD)

Recommendations for Shared Decision-Making

Class I
1. In patients with aortic disease, shared decision-making is recommended when determining the appropriate thresholds for intervention, deciding on the type of surgical repair, choosing between open surgical versus endovascular approaches; and in medical management and surveillance(Level of Evidence: C-LD)

2. In patients with aortic disease who are contemplating pregnancy or who are pregnant, shared decision-making is recommended when considering the cardiovascular risks of pregnancy, the diameter thresholds for prophylactic aortic surgery, and the mode of delivery.(Level of Evidence: C-EO)

Recommendations for Surgical Considerations for Non-syndromic Heritable TAA and No Identified Genetic Cause

Class I
1. In asymptomatic patients with aneurysms of the aortic root or ascending aorta with non-syndromic heritable thoracic aortic dis-ease (nsHTAD) and no identified genetic cause, determining the timing of surgical repair requires shared decision-making and is informed by known aortic diameters at the time of aortic dissection, TAA repair, or both in affected family members(Level of Evidence: C-LD)

2. In asymptomatic patients with aneurysms of the aortic root or ascending aorta with  nsHTAD and no identified genetic cause but no information on aortic diameters at the time of dissection or aneurysm repair in affected family members and who have no high-risk features for adverse aortic events (Table 9) it is recommended to repair the aorta when the maximal diameter reaches ≥5.0 cm(Level of Evidence: C-LD)

Class IIa
3. In patients with aneurysms of the aortic root or ascending aorta with nsHTAD and no identified genetic cause and a maximal aortic diameter of ≥4.5 cm, who have high-risk features for adverse aortic events (Table 9), or who are undergoing cardiac surgery for other indications, aortic repair is reasonable when performed by experienced surgeons in a Multidisciplinary Aortic Team(Level of Evidence: C-LD)

Recommendations for Marfan Syndrome Interventions: Replacement of the Aortic Root in Patients With Marfan Syndrome Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I
1. In patients with Marfan syndrome and an aortic root diameter of ≥5.0 cm, surgery to replace the aortic root and ascending aorta is recommended.(Level of Evidence: B-NR)
Class IIa
2. In patients with Marfan syndrome, an aortic root diameter of ≥4.5 cm, and features associated with an increased risk of aortic dissection (see Table 10), surgery to replace the aortic root and ascending aorta is reasonable, when performed by experienced surgeons in a Multidisciplinary Aortic Team.(Level of Evidence: B-NR)

3. In patients with Marfan syndrome and a maxi-mal cross-sectional aortic root area (cm2) to patient height (m) ratio of ≥10, surgery to replace the aortic root and ascending aorta is reasonable, when performed by experienced surgeons in a Multidisciplinary Aortic Team.(Level of Evidence: C-LD)

Class IIb
4. In patients with Marfan syndrome and an aortic diameter approaching surgical threshold, who are candidates for valve-sparing root replacement (VSRR) and have a very low surgical risk, surgery to replace the aortic root and ascending aorta may be reasonable when performed by experienced surgeons in a Multidisciplinary Aortic Team(Level of Evidence: C-LD)

Recommendations for Diagnostic Testing, Surveillance, and Surgical Intervention for Aortic Dilation in Turner Syndrome

Class IIa
6. In patients with Turnery syndrome who are ≥15 years old and have an ASI of ≥2.5 cm/m2plus risk factors for aortic dissection (Table 12), surgical intervention to replace the aortic root, ascending aorta, or both is reasonable.(Level of Evidence: C-LD)
Class IIb
In those without risk factors for aortic  dissection, surgical intervention to replace the aortic root, ascending aorta, or both may be considered.(Level of Evidence: C-EO)

Recommendations for BAV Aortopathy Interventions: Replacement of the Aorta in Patients With BAV Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class IIa
3. In patients with a BAV, a diameter of the aortic root or ascending aorta of 5.0 cm to 5.4 cm, and an additional risk factor for aortic dissection (Table 14), surgery to replace the aortic root, ascending aorta, or both is reasonable, when performed by experienced surgeons in a Multidisciplinary Aortic Team.(Level of Evidence: B-NR)


Recommendations for Initial Surgical Considerations in Acute Type A Aortic Dissection Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I
1. In patients presenting with suspected or con-firmed acute type A aortic dissection, emer-gency surgical consultation and evaluation and immediate surgical intervention is recom-mended because of the high risk of associated life-threatening complications.(Level of Evidence: B-NR)
Class IIa
2. In patients presenting with acute type A aortic dissection, who are stable enough for transfer, transfer from a low- to a high-volume aortic center is reasonable to improve survival.(Level of Evidence: B-NR)

3. In patients presenting with nonhemorrhagic stroke complicating acute type A aortic dis-section, surgical intervention is reasonable over medical therapy to reduce mortality and improve neurologic outcomes.(Level of Evidence: B-NR)

Recommendations for Management of Malperfusion Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I
1. In patients with acute type A aortic dissection presenting with renal, mesenteric, or lower extremity Malperfusion, it is recommended to proceed to immediate operative repair of the ascending aorta.(Level of Evidence: B-NR)
Class IIa
2. In patients with acute type A aortic dissection presenting with clinically significant mesenteric (celiac, SMA) Malperfusion, either immediate operative repair of the ascending aorta or immediate mesenteric revascularization via endovascular or open surgical intervention by those with this expertise before ascending aortic repair is reasonable(Level of Evidence: C-LD)

Recommendations for Surgical Repair Strategies in Acute Type A Aortic Dissection Referenced studies that support the recommendations are summarized in the Online Data Supplement

Aortic Repair Strategies

Class I
1. In patients with acute type A aortic dissection and a partially dissected aortic root but no significant aortic valve leaflet pathology, aortic valve resuspension is recommended over valve replacement(Level of Evidence: B-NR)

2. In patients with acute type A aortic dissection who have extensive destruction of the aortic root, a root aneurysm, or a known genetic aortic disorder, aortic root replacement is recommended with a mechanical or biological valved conduit.(Level of Evidence: B-NR) 3. In patients with acute type A aortic dissection undergoing aortic repair, an open distal anastomosis is recommended to improve survival and increase false-lumen thrombosis rates.(Level of Evidence: B-NR) 4. In patients with acute type A aortic dissection without an intimal tear in the arch or a significant arch aneurysm, hemiarch repair is recommended over more extensive arch replacement.(Level of Evidence: B-NR)

Class IIb
In selected patients who are stable, valve-sparing root repair may be reasonable, when performed by experienced surgeons in a Multidisciplinary Aortic Team.(Level of Evidence: C-LD)

5. In patients with acute type A aortic dissection and a dissection flap extending through the arch into the descending thoracic aorta, an extended aortic repair with antegrade stenting of the proximal descending thoracic aorta may be considered to treat Malperfusion and reduce late distal aortic complications.(Level of Evidence: C-LD)


Perfusion and Cannulation Strategies

Class IIa
6. In patients with acute type A aortic dissection undergoing surgical repair, axillary cannulation, when feasible, is reasonable over femoral cannulation to reduce the risk of stroke or retrograde Malperfusion.(Level of Evidence: B-NR)

7. In patients with acute type A aortic dis-section undergoing surgical repair who require circulatory arrest, cerebral perfusion is reasonable to improve neurologic out-comes.(Level of Evidence: B-NR) 8. In patients with acute type A aortic dis-section undergoing surgical repair, direct aortic26,27 or innominate artery28 cannulation with imaging guidance is reasonable as an alternative to femoral or axillary  cannulation(Level of Evidence: B-NR)

Recommendations for the Management of Acute Type B Aortic Dissection Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I
2. In patients with acute type B aortic dissection and rupture or other complications (Table 27), intervention is recommended(Level of Evidence: C-LD)

In patients with rupture, in the presence of suitable anatomy, endovascular stent grafting, rather than open surgical repair, is recommended.(Level of Evidence: C-EO)

Class IIa
In patients with other complications, in the presence of suitable anatomy, the use of endovascular approaches, rather than open surgical repair, is reasonable.(Level of Evidence: C-LD)
Class IIb
3. In patients with uncomplicated acute type B aortic dissection who have high-risk anatomic features (Table 28), endovascular management may be considered(Level of Evidence: B-R)

Recommendations for Management of IMH Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I
1. In patients with complicated (Table 29) acute type A or type B aortic IMH, urgent repair is recommended(Level of Evidence: B-NR)

2. In patients with uncomplicated acute type A IMH, prompt open surgical repair is recommended(Level of Evidence: B-NR) 3. In patients with uncomplicated acute type B IMH, medical therapy as the initial management strategy is recommended.(Level of Evidence: B-NR)

Class IIa
4. In patients with type B IMH who require repair of the distal aortic arch or descending thoracic aorta (zones 2-5) and have favorable anatomy, endo-vascular repair is reasonable when performed by surgeons with endovascular expertise.(Level of Evidence: C-LD)

5. In patients with type B IMH who require repair of the distal aortic arch or descending thoracic aorta (zones 2-5) and have unfavorable anatomy for endovascular repair, open surgical repair is reasonable.(Level of Evidence: C-LD)

Class IIb
In selected patients with uncomplicated acute type A IMH who are at increased operative risk and do not have high-risk imaging features (Table 30), an initial or expectant approach of medical management may be considered.(Level of Evidence: C-LD)

6. In patients with uncomplicated type B IMH and high-risk imaging features (Table 30), intervention may be reasonable(Level of Evidence: C-LD)

Recommendation for Long-Term Management After Acute Aortic Dissection and IMH Referenced studies that support the recommendation are summarized in the Online Data Supplement

Class I
1. In patients with a previous acute aortic dissection and IMH, whether initially treated medically or with intervention, who have chronic residual TAD and an aneurysm with a total aortic diameter of ≥5.5 cm, elective thoracic aortic repair is  recommended( Level of Evidence: B-NR)

Recommendations for Replacement of the Aorta in Patients With Loeys-Dietz Syndrome

Class I
1. In patients with Loeys-Dietz syndrome and aortic dilation, the surgical threshold for prophylactic aortic root and ascending aortic replacement should be informed by the specific genetic variant, aortic diameter, aortic growth rate, extra-aortic features, family his-tory, patient age and sex, and physician and patient preferences (Table 11)(Level of Evidence: C-LD)
Class IIb
2. In patients with Loeys-Dietz syndrome attrib-utable to a pathogenic variant in TGFBR1, TGFBR2, or SMAD3, surgery to replace the intact aortic arch, descending aorta, or abdominal aorta at a diameter of ≥4.5 cm may be considered, with the specific genetic variant, patient age, aortic growth rate, family history, presence of high-risk features (Table 11), and surgical risk informing the decision.(Level of Evidence: C-EO)

2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases[2]

Surgical Intervention in Aortic Dissection

Class IIa
” The axillary artery should be considered as first choice for cannulation for surgery of the aortic arch and in aortic dissection. (Level of Evidence: C)”

2010 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines (DO NOT EDIT)[3]

Surgical Intervention for Acute Thoracic Aortic Dissection (DO NOT EDIT)[3]

Class I
“1. For patients with ascending thoracic aortic dissection, all aneurysmal aorta and the proximal extent of the dissection should be resected. A partially dissected aortic root may be repaired with aortic valve resuspension. Extensive dissection of the aortic root should be treated with aortic root replacement with a composite graft or with a valve sparing root replacement. If a DeBakey Type II dissection is present, the entire dissected aorta should be replaced. (Level of Evidence: C)”

Intramural Hematoma Without Intimal Defect (DO NOT EDIT)[3]

Class IIa
“1. It is reasonable to treat intramural hematoma similar to aortic dissection in the corresponding segment of the aorta. (Level of Evidence: C)”

Genetic Syndromes (DO NOT EDIT)[3]

Class IIa
“1. It is reasonable to consider surgical repair of the aorta in all adult patients with Loeys-Dietz syndrome or a confirmed TGFBR1 or TGFBR2 mutation and an aortic diameter of 4.2 cm or greater by transesophageal echocardiogram (internal diameter) or 4.4 to 4.6 cm or greater by computed tomographic imaging and/or magnetic resonance imaging (external diameter).[4] (Level of Evidence: C)”
“2. For women with Marfan syndrome contemplating pregnancy, it is reasonable to prophylactically replace the aortic root and ascending aorta if the diameter exceeds 4.0 cm.[5] (Level of Evidence: C)”
“3. If the maximal cross-sectional area in square centimeters of the ascending aorta or root divided by the patient’s height in meters exceeds a ratio of 10, surgical repair is reasonable because shorter patients have dissection at a smaller size and 15% of patients with Marfan syndrome have dissection at a size smaller than 5.0 cm.[6][7][8] (Level of Evidence: C)”

Preoperative Evaluation (DO NOT EDIT)[3]

Class I
“1. In preparation for surgery, imaging studies adequate to establish the extent of disease and the potential limits of the planned procedure are recommended. (Level of Evidence: C)”
“2. Patients with thoracic aortic disease requiring a surgical or catheter-based intervention who have symptoms or other findings of myocardial ischemia should undergo additional studies to determine the presence of significant coronary artery disease. (Level of Evidence: C)”
“3. Patients with unstable coronary syndromes and significant coronary artery disease should undergo revascularization prior to or at the time of thoracic aortic surgery or endovascular intervention with percutaneous coronary intervention or concomitant coronary artery bypass graft surgery. (Level of Evidence: C)”
Class IIa
“1. Additional testing is reasonable to quantitate the patient’s comorbid states and develop a risk profile. These may include pulmonary function tests, cardiac catheterization, aortography, 24-hour Holter monitoring, noninvasive carotid artery screening, brain imaging, echocardiography, and neurocognitive testing. (Level of Evidence: C)”
“2. For patients who are to undergo surgery for ascending or arch aortic disease, and who have clinically stable, but significant (flow limiting), coronary artery disease, it is reasonable to perform concomitant coronary artery bypass graft surgery. (Level of Evidence: C)”
Class IIb
“1. For patients who are to undergo surgery or endovascular intervention for descending thoracic aortic disease, and who have clinically stable, but significant (flow limiting), coronary artery disease, the benefits of coronary revascularization are not well established.[9][10][11] (Level of Evidence: B)”

Choice of Anesthetic and Monitoring Techniques (DO NOT EDIT)[3]

Class I
“1. The choice of anesthetic techniques and agents and patient monitoring techniques should be tailored to individual patient needs to facilitate surgical and perfusion techniques and the monitoring of hemodynamics and organ function. (Level of Evidence: C)”
Class III (Harm)
“1. Regional anesthetic techniques are not recommended in patients at risk of neuraxial hematoma formation due to thienopyridine antiplatelet therapy, low-molecular-weight heparins, or clinically significant anticoagulation.[12] (Level of Evidence: C)”
“2. Routinely changing double-lumen endotracheal (endobronchial) tubes to single-lumen tubes at the end of surgical procedures complicated by significant upper airway edema or hemorrhage is not recommended. (Level of Evidence: C)”
Class IIa
“1. Transesophageal echocardiography is reasonable in all open surgical repairs of the thoracic aorta, unless there are specific contraindications to its use. Transesophageal echocardiography is reasonable in endovascular thoracic aortic procedures for monitoring, procedural guidance, and/or endovascular graft leak detection.[13][14][15] (Level of Evidence: B)”
“2. Motor or somatosensory evoked potential monitoring can be useful when the data will help to guide therapy. It is reasonable to base the decision to use neurophysiologic monitoring on individual patient needs, institutional resources, the urgency of the procedure, and the surgical and perfusion techniques to be employed in the open or endovascular thoracic aortic repair.[16][17] (Level of Evidence: B)”

Transfusion Management and Anticoagulation in Thoracic Aortic Surgery (DO NOT EDIT)[3]

Class IIa
“1. An algorithmic approach to transfusion, antifibrinolytic, and anticoagulation management is reasonable to use in both open and endovascular thoracic aortic repairs during the perioperative period. Institutional variations in coagulation testing capability and availability of transfusion products and other prothrombotic and antithrombotic agents are important considerations in defining such an approach.[18] (Level of Evidence: C)”

Brain Protection During Ascending Aortic and Transverse Aortic Arch Surgery (DO NOT EDIT)[3]

Class I
“1. A brain protection strategy to prevent stroke and preserve cognitive function should be a key element of the surgical, anesthetic, and perfusion techniques used to accomplish repairs of the ascending aorta and transverse aortic arch.[19][20][21][22][23][24][25] (Level of Evidence: B)”
Class III (Harm)
“1. Perioperative brain hyperthermia is not recommended in repairs of the ascending aortic and transverse aortic arch as it is probably injurious to the brain.[26][27][28] (Level of Evidence: B)”
Class IIa
“1. Deep hypothermic circulatory arrest, selective antegrade brain perfusion, and retrograde brain perfusion are techniques that alone or in combination are reasonable to minimize brain injury during surgical repairs of the ascending aorta and transverse aortic arch. Institutional experience is an important factor in selecting these techniques.[29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52] (Level of Evidence: B)”

Spinal Cord Protection During Descending Aortic Open Surgical and Endovascular Repairs (DO NOT EDIT)[3]

Class I
“1. Cerebrospinal fluid drainage is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury.[53][54][55] (Level of Evidence: B)”
Class IIa
“1. Spinal cord perfusion pressure optimization using techniques, such as proximal aortic pressure maintenance and distal aortic perfusion, is reasonable as an integral part of the surgical, anesthetic, and perfusion strategy in open and endovascular thoracic aortic repair patients at high risk of spinal cord ischemic injury. Institutional experience is an important factor in selecting these techniques.[56][57][58] (Level of Evidence: B)”
“2. Moderate systemic hypothermia is reasonable for protection of the spinal cord during open repairs of the descending thoracic aorta.[59] (Level of Evidence: B)”
Class IIb
“1. Adjunctive techniques to increase the tolerance of the spinal cord to impaired perfusion may be considered during open and endovascular thoracic aortic repair for patients at high risk of spinal cord injury. These include distal perfusion, epidural irrigation with hypothermic solutions, high-dose systemic glucocorticoids, osmotic diuresis with mannitol, intrathecal papaverine, and cellular metabolic suppression with anesthetic agents.[58][60][61][62] (Level of Evidence: B)”
“2. Neurophysiological monitoring of the spinal cord (somatosensory evoked potentials or motor evoked potentials) may be considered as a strategy to detect spinal cord ischemia and to guide reimplantation of intercostal arteries and/or hemodynamic optimization to prevent or treat spinal cord ischemia.[63][64][65] (Level of Evidence: B)”

Renal Protection During Descending Aortic Open Surgical and Endovascular Repairs (DO NOT EDIT)[3]

Class III (Harm)
“1. Furosemide, mannitol, or dopamine should not be given solely for the purpose of renal protection in descending aortic repairs.[66][67] (Level of Evidence: B)”
Class IIb
“1. Preoperative hydration and intraoperative mannitol administration may be reasonable strategies for preservation of renal function in open repairs of the descending aorta. (Level of Evidence: C)”
“2. During thoracoabdominal or descending aortic repairs with exposure of the renal arteries, renal protection by either cold crystalloid or blood perfusion may be considered.[68][69][70] (Level of Evidence: B)”

References

  1. ↑ Writing Committee Members. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW; et al. (2022). “2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines”. J Am Coll Cardiol. doi:10.1016/j.jacc.2022.08.004. PMID 36334952 Check |pmid= value (help).
  2. ↑ “2014 ESC Guidelines on the diagnosis and treatment of aortic diseases”. European Heart Journal. 35 (41): 2873–2926. 2014. doi:10.1093/eurheartj/ehu281. ISSN 0195-668X.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE; et al. (2010). “2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine”. Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780.
  4. ↑ Loeys BL, Schwarze U, Holm T; et al. (2006). “Aneurysm syndromes caused by mutations in the TGF-beta receptor”. N. Engl. J. Med. 355 (8): 788–98. doi:10.1056/NEJMoa055695. PMID 16928994. Unknown parameter |month= ignored (help)
  5. ↑ Pearson GD, Devereux R, Loeys B, Maslen C, Milewicz D, Pyeritz R; et al. (2008). “Report of the National Heart, Lung, and Blood Institute and National Marfan Foundation Working Group on research in Marfan syndrome and related disorders”. Circulation. 118 (7): 785–91. doi:10.1161/CIRCULATIONAHA.108.783753. PMC 2909440. PMID 18695204.
  6. ↑ Svensson LG, Blackstone EH, Feng J; et al. (2007). “Are Marfan syndrome and marfanoid patients distinguishable on long-term follow-up?”. Ann. Thorac. Surg. 83 (3): 1067–74. doi:10.1016/j.athoracsur.2006.10.062. PMID 17307461. Unknown parameter |month= ignored (help)
  7. ↑ Gott VL, Greene PS, Alejo DE; et al. (1999). “Replacement of the aortic root in patients with Marfan’s syndrome”. N. Engl. J. Med. 340 (17): 1307–13. doi:10.1056/NEJM199904293401702. PMID 10219065. Unknown parameter |month= ignored (help)
  8. ↑ Svensson LG, Khitin L (2002). “Aortic cross-sectional area/height ratio timing of aortic surgery in asymptomatic patients with Marfan syndrome”. J. Thorac. Cardiovasc. Surg. 123 (2): 360–1. PMID 11828302. Unknown parameter |month= ignored (help)
  9. ↑ Boden WE, O’Rourke RA, Teo KK; et al. (2007). “Optimal medical therapy with or without PCI for stable coronary disease”. N. Engl. J. Med. 356 (15): 1503–16. doi:10.1056/NEJMoa070829. PMID 17387127. Unknown parameter |month= ignored (help)
  10. ↑ Cinà CS, Devereaux PJ (2006). “Coronary-artery revascularization before elective major vascular surgery. McFalls EO, ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG. N Engl J Med. 2004; 351: 2795-804”. Vasc Med. 11 (1): 61–3. PMID 16669417. Unknown parameter |month= ignored (help)
  11. ↑ Poldermans D, Schouten O, Vidakovic R; et al. (2007). “A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V Pilot Study”. J. Am. Coll. Cardiol. 49 (17): 1763–9. doi:10.1016/j.jacc.2006.11.052. PMID 17466225. Unknown parameter |month= ignored (help)
  12. ↑ Horlocker TT, Wedel DJ, Benzon H; et al. (2003). “Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation)”. Reg Anesth Pain Med. 28 (3): 172–97. doi:10.1053/rapm.2003.50046. PMID 12772135.
  13. ↑ “Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography”. Anesthesiology. 84 (4): 986–1006. 1996. PMID 8638856. Unknown parameter |month= ignored (help)
  14. ↑ Fattori R, Caldarera I, Rapezzi C; et al. (2000). “Primary endoleakage in endovascular treatment of the thoracic aorta: importance of intraoperative transesophageal echocardiography”. J. Thorac. Cardiovasc. Surg. 120 (3): 490–5. doi:10.1067/mtc.2000.108904. PMID 10962409. Unknown parameter |month= ignored (help)
  15. ↑ Abe S, Ono S, Murata K; et al. (2000). “Usefulness of transesophageal echocardiographic monitoring in transluminal endovascular stent-graft repair for thoracic aortic aneurysm”. Jpn. Circ. J. 64 (12): 960–4. PMID 11194291. Unknown parameter |month= ignored (help)
  16. ↑ Dong CC, MacDonald DB, Janusz MT (2002). “Intraoperative spinal cord monitoring during descending thoracic and thoracoabdominal aneurysm surgery”. Ann. Thorac. Surg. 74 (5): S1873–6, discussion S1892–8. PMID 12440684. Unknown parameter |month= ignored (help)
  17. ↑ Meylaerts SA, Jacobs MJ, van Iterson V, De Haan P, Kalkman CJ (1999). “Comparison of transcranial motor evoked potentials and somatosensory evoked potentials during thoracoabdominal aortic aneurysm repair”. Ann. Surg. 230 (6): 742–9. PMC 1420937. PMID 10615928. Unknown parameter |month= ignored (help)
  18. ↑ Ferraris VA, Ferraris SP, Saha SP; et al. (2007). “Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline”. Ann. Thorac. Surg. 83 (5 Suppl): S27–86. doi:10.1016/j.athoracsur.2007.02.099. PMID 17462454. Unknown parameter |month= ignored (help)
  19. ↑ Akashi H, Tayama K, Fujino T; et al. (2000). “Cerebral protection selection in aortic arch surgery for patients with preoperative complications of cerebrovascular disease”. Jpn. J. Thorac. Cardiovasc. Surg. 48 (12): 782–8. PMID 11197822. Unknown parameter |month= ignored (help)
  20. ↑ Ehrlich MP, Fang WC, Grabenwöger M; et al. (1999). “Impact of retrograde cerebral perfusion on aortic arch aneurysm repair”. J. Thorac. Cardiovasc. Surg. 118 (6): 1026–32. PMID 10595974. Unknown parameter |month= ignored (help)
  21. ↑ Di Eusanio M, Wesselink RM, Morshuis WJ, Dossche KM, Schepens MA (2003). “Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study”. J. Thorac. Cardiovasc. Surg. 125 (4): 849–54. doi:10.1067/mtc.2003.8. PMID 12698148. Unknown parameter |month= ignored (help)
  22. ↑ Hagl C, Ergin MA, Galla JD; et al. (2001). “Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients”. J. Thorac. Cardiovasc. Surg. 121 (6): 1107–21. doi:10.1067/mtc.2001.113179. PMID 11385378. Unknown parameter |month= ignored (help)
  23. ↑ Reich DL, Uysal S, Sliwinski M; et al. (1999). “Neuropsychologic outcome after deep hypothermic circulatory arrest in adults”. J. Thorac. Cardiovasc. Surg. 117 (1): 156–63. PMID 9869770. Unknown parameter |month= ignored (help)
  24. ↑ Reich DL, Uysal S, Ergin MA, Bodian CA, Hossain S, Griepp RB (2001). “Retrograde cerebral perfusion during thoracic aortic surgery and late neuropsychological dysfunction”. Eur J Cardiothorac Surg. 19 (5): 594–600. PMID 11343938. Unknown parameter |month= ignored (help)
  25. ↑ Usui A, Yasuura K, Watanabe T, Maseki T (1999). “Comparative clinical study between retrograde cerebral perfusion and selective cerebral perfusion in surgery for acute type A aortic dissection”. Eur J Cardiothorac Surg. 15 (5): 571–8. PMID 10386399. Unknown parameter |month= ignored (help)
  26. ↑ Grigore AM, Grocott HP, Mathew JP; et al. (2002). “The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery”. Anesth. Analg. 94 (1): 4–10, table of contents. PMID 11772792. Unknown parameter |month= ignored (help)
  27. ↑ Grocott HP, Mackensen GB, Grigore AM; et al. (2002). “Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery”. Stroke. 33 (2): 537–41. PMID 11823666. Unknown parameter |month= ignored (help)
  28. ↑ Bar-Yosef S, Mathew JP, Newman MF, Landolfo KP, Grocott HP (2004). “Prevention of cerebral hyperthermia during cardiac surgery by limiting on-bypass rewarming in combination with post-bypass body surface warming: a feasibility study”. Anesth. Analg. 99 (3): 641–6, table of contents. doi:10.1213/01.ANE.0000130354.90659.63. PMID 15333386. Unknown parameter |month= ignored (help)
  29. ↑ Kunihara T, Grün T, Aicher D; et al. (2005). “Hypothermic circulatory arrest is not a risk factor for neurologic morbidity in aortic surgery: a propensity score analysis”. J. Thorac. Cardiovasc. Surg. 130 (3): 712–8. doi:10.1016/j.jtcvs.2005.03.043. PMID 16153918. Unknown parameter |month= ignored (help)
  30. ↑ Schepens MA, Dossche KM, Morshuis WJ, van den Barselaar PJ, Heijmen RH, Vermeulen FE (2002). “The elephant trunk technique: operative results in 100 consecutive patients”. Eur J Cardiothorac Surg. 21 (2): 276–81. PMID 11825735. Unknown parameter |month= ignored (help)
  31. ↑ Deeb GM, Williams DM, Quint LE, Monaghan HM, Shea MJ (1999). “Risk analysis for aortic surgery using hypothermic circulatory arrest with retrograde cerebral perfusion”. Ann. Thorac. Surg. 67 (6): 1883–6, discussion 1891–4. PMID 10391332. Unknown parameter |month= ignored (help)
  32. ↑ Ehrlich MP, Schillinger M, Grabenwöger M; et al. (2003). “Predictors of adverse outcome and transient neurological dysfunction following surgical treatment of acute type A dissections”. Circulation. 108 Suppl 1: II318–23. doi:10.1161/01.cir.0000087428.63818.50. PMID 12970253. Unknown parameter |month= ignored (help)
  33. ↑ Fleck TM, Czerny M, Hutschala D, Koinig H, Wolner E, Grabenwoger M (2003). “The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest”. Ann. Thorac. Surg. 76 (4): 1198–202. PMID 14530011. Unknown parameter |month= ignored (help)
  34. ↑ Moshkovitz Y, David TE, Caleb M, Feindel CM, de Sa MP (1998). “Circulatory arrest under moderate systemic hypothermia and cold retrograde cerebral perfusion”. Ann. Thorac. Surg. 66 (4): 1179–84. PMID 9800803. Unknown parameter |month= ignored (help)
  35. ↑ Okita Y, Takamoto S, Ando M, Morota T, Matsukawa R, Kawashima Y (1998). “Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation of early death, stroke, and delirium to the duration of circulatory arrest”. J. Thorac. Cardiovasc. Surg. 115 (1): 129–38. PMID 9451056. Unknown parameter |month= ignored (help)
  36. ↑ Ueda Y, Okita Y, Aomi S, Koyanagi H, Takamoto S (1999). “Retrograde cerebral perfusion for aortic arch surgery: analysis of risk factors”. Ann. Thorac. Surg. 67 (6): 1879–82, discussion 1891–4. PMID 10391331. Unknown parameter |month= ignored (help)
  37. ↑ Wong CH, Bonser RS (1999). “Does retrograde cerebral perfusion affect risk factors for stroke and mortality after hypothermic circulatory arrest?”. Ann. Thorac. Surg. 67 (6): 1900–3, discussion 1919–21. PMID 10391335. Unknown parameter |month= ignored (help)
  38. ↑ Di Eusanio M, Schepens MA, Morshuis WJ; et al. (2003). “Brain protection using antegrade selective cerebral perfusion: a multicenter study”. Ann. Thorac. Surg. 76 (4): 1181–8, discussion 1188–9. PMID 14530009. Unknown parameter |month= ignored (help)
  39. ↑ Di Eusanio M, Schepens MA, Morshuis WJ, Di Bartolomeo R, Pierangeli A, Dossche KM (2002). “Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients”. J. Thorac. Cardiovasc. Surg. 124 (6): 1080–6. doi:10.1067/mtc.2002.124994. PMID 12447172. Unknown parameter |month= ignored (help)
  40. ↑ Di Eusanio M, Tan ME, Schepens MA; et al. (2003). “Surgery for acute type A dissection using antegrade selective cerebral perfusion: experience with 122 patients”. Ann. Thorac. Surg. 75 (2): 514–9. PMID 12607664. Unknown parameter |month= ignored (help)
  41. ↑ Kazui T, Yamashita K, Washiyama N; et al. (2002). “Impact of an aggressive surgical approach on surgical outcome in type A aortic dissection”. Ann. Thorac. Surg. 74 (5): S1844–7, discussion S1857–63. PMID 12440678. Unknown parameter |month= ignored (help)
  42. ↑ Kazui T, Yamashita K, Washiyama N; et al. (2007). “Aortic arch replacement using selective cerebral perfusion”. Ann. Thorac. Surg. 83 (2): S796–8, discussion S824–31. doi:10.1016/j.athoracsur.2006.10.082. PMID 17257929. Unknown parameter |month= ignored (help)
  43. ↑ Numata S, Ogino H, Sasaki H; et al. (2003). “Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion”. Eur J Cardiothorac Surg. 23 (5): 771–5, discussion 775. PMID 12754031. Unknown parameter |month= ignored (help)
  44. ↑ Sasaki H, Ogino H, Matsuda H, Minatoya K, Ando M, Kitamura S (2007). “Integrated total arch replacement using selective cerebral perfusion: a 6-year experience”. Ann. Thorac. Surg. 83 (2): S805–10, discussion S824–31. doi:10.1016/j.athoracsur.2006.10.094. PMID 17257931. Unknown parameter |month= ignored (help)
  45. ↑ Strauch JT, Spielvogel D, Lauten A; et al. (2004). “Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement”. Ann. Thorac. Surg. 78 (1): 103–8, discussion 103–8. doi:10.1016/j.athoracsur.2004.01.035. PMID 15223412. Unknown parameter |month= ignored (help)
  46. ↑ Kamiya H, Hagl C, Kropivnitskaya I; et al. (2007). “Quick proximal arch replacement with moderate hypothermic circulatory arrest”. Ann. Thorac. Surg. 83 (3): 1055–8. doi:10.1016/j.athoracsur.2006.09.085. PMID 17307459. Unknown parameter |month= ignored (help)
  47. ↑ Matalanis G, Hata M, Buxton BF (2003). “A retrospective comparative study of deep hypothermic circulatory arrest, retrograde, and antegrade cerebral perfusion in aortic arch surgery”. Ann Thorac Cardiovasc Surg. 9 (3): 174–9. PMID 12875639. Unknown parameter |month= ignored (help)
  48. ↑ Okita Y, Minatoya K, Tagusari O, Ando M, Nagatsuka K, Kitamura S (2001). “Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion”. Ann. Thorac. Surg. 72 (1): 72–9. PMID 11465234. Unknown parameter |month= ignored (help)
  49. ↑ Zierer A, Aybek T, Risteski P, Dogan S, Wimmer-Greinecker G, Moritz A (2005). “Moderate hypothermia (30 degrees C) for surgery of acute type A aortic dissection”. Thorac Cardiovasc Surg. 53 (2): 74–9. doi:10.1055/s-2004-830458. PMID 15786004. Unknown parameter |month= ignored (help)
  50. ↑ Svensson LG, Nadolny EM, Kimmel WA (2002). “Multimodal protocol influence on stroke and neurocognitive deficit prevention after ascending/arch aortic operations”. Ann. Thorac. Surg. 74 (6): 2040–6. PMID 12643393. Unknown parameter |month= ignored (help)
  51. ↑ Okita Y, Ando M, Minatoya K, Kitamura S, Takamoto S, Nakajima N (1999). “Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch”. Ann. Thorac. Surg. 67 (1): 72–8. PMID 10086527. Unknown parameter |month= ignored (help)
  52. ↑ Svensson LG, Crawford ES, Hess KR; et al. (1993). “Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients”. J. Thorac. Cardiovasc. Surg. 106 (1): 19–28, discussion 28–31. PMID 8321002. Unknown parameter |month= ignored (help)
  53. ↑ Coselli JS, LeMaire SA, Köksoy C, Schmittling ZC, Curling PE (2002). “Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial”. J. Vasc. Surg. 35 (4): 631–9. PMID 11932655. Unknown parameter |month= ignored (help)
  54. ↑ Khan SN, Stansby G (2004). “Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery”. Cochrane Database Syst Rev (1): CD003635. doi:10.1002/14651858.CD003635.pub2. PMID 14974026.
  55. ↑ Safi HJ, Miller CC, Huynh TT; et al. (2003). “Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection”. Ann. Surg. 238 (3): 372–80, discussion 380–1. doi:10.1097/01.sla.0000086664.90571.7a. PMC 1422700. PMID 14501503. Unknown parameter |month= ignored (help)
  56. ↑ Estrera AL, Miller CC, Chen EP; et al. (2005). “Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage”. Ann. Thorac. Surg. 80 (4): 1290–6, discussion 1296. doi:10.1016/j.athoracsur.2005.02.021. PMID 16181856. Unknown parameter |month= ignored (help)
  57. ↑ Safi HJ, Hess KR, Randel M; et al. (1996). “Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II”. J. Vasc. Surg. 23 (2): 223–8, discussion 229. PMID 8637099. Unknown parameter |month= ignored (help)
  58. ↑ 58.0 58.1 Hollier LH, Money SR, Naslund TC; et al. (1992). “Risk of spinal cord dysfunction in patients undergoing thoracoabdominal aortic replacement”. Am. J. Surg. 164 (3): 210–3, discussion 213–4. PMID 1415916. Unknown parameter |month= ignored (help)
  59. ↑ Svensson LG, Khitin L, Nadolny EM, Kimmel WA (2003). “Systemic temperature and paralysis after thoracoabdominal and descending aortic operations”. Arch Surg. 138 (2): 175–9, discussion 180. PMID 12578415. Unknown parameter |month= ignored (help)
  60. ↑ Cambria RP, Davison JK, Carter C; et al. (2000). “Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: A five-year experience”. J. Vasc. Surg. 31 (6): 1093–102. PMID 10842145. Unknown parameter |month= ignored (help)
  61. ↑ Cambria RP, Davison JK, Zannetti S; et al. (1997). “Clinical experience with epidural cooling for spinal cord protection during thoracic and thoracoabdominal aneurysm repair”. J. Vasc. Surg. 25 (2): 234–41, discussion 241–3. PMID 9052558. Unknown parameter |month= ignored (help)
  62. ↑ Woloszyn TT, Marini CP, Coons MS; et al. (1990). “Cerebrospinal fluid drainage and steroids provide better spinal cord protection during aortic cross-clamping than does either treatment alone”. Ann. Thorac. Surg. 49 (1): 78–82, discussion 83. PMID 2297277. Unknown parameter |month= ignored (help)
  63. ↑ Schurink GW, Nijenhuis RJ, Backes WH; et al. (2007). “Assessment of spinal cord circulation and function in endovascular treatment of thoracic aortic aneurysms”. Ann. Thorac. Surg. 83 (2): S877–81, discussion S890–2. doi:10.1016/j.athoracsur.2006.11.028. PMID 17257945. Unknown parameter |month= ignored (help)
  64. ↑ Ogino H, Sasaki H, Minatoya K, Matsuda H, Yamada N, Kitamura S (2006). “Combined use of adamkiewicz artery demonstration and motor-evoked potentials in descending and thoracoabdominal repair”. Ann. Thorac. Surg. 82 (2): 592–6. doi:10.1016/j.athoracsur.2006.03.041. PMID 16863770. Unknown parameter |month= ignored (help)
  65. ↑ Guerit JM, Witdoeckt C, Verhelst R, Matta AJ, Jacquet LM, Dion RA (1999). “Sensitivity, specificity, and surgical impact of somatosensory evoked potentials in descending aorta surgery”. Ann. Thorac. Surg. 67 (6): 1943–6, discussion 1953–8. PMID 10391345. Unknown parameter |month= ignored (help)
  66. ↑ Perdue PW, Balser JR, Lipsett PA, Breslow MJ (1998). ““Renal dose” dopamine in surgical patients: dogma or science?”. Ann. Surg. 227 (4): 470–3. PMC 1191298. PMID 9563531. Unknown parameter |month= ignored (help)
  67. ↑ Hager B, Betschart M, Krapf R (1996). “Effect of postoperative intravenous loop diuretic on renal function after major surgery”. Schweiz Med Wochenschr. 126 (16): 666–73. PMID 8658094. Unknown parameter |month= ignored (help)
  68. ↑ Jacobs MJ, de Mol BA, Legemate DA, Veldman DJ, de Haan P, Kalkman CJ (1997). “Retrograde aortic and selective organ perfusion during thoracoabdominal aortic aneurysm repair”. Eur J Vasc Endovasc Surg. 14 (5): 360–6. PMID 9413376. Unknown parameter |month= ignored (help)
  69. ↑ Köksoy C, LeMaire SA, Curling PE; et al. (2002). “Renal perfusion during thoracoabdominal aortic operations: cold crystalloid is superior to normothermic blood”. Ann. Thorac. Surg. 73 (3): 730–8. PMID 11899174. Unknown parameter |month= ignored (help)
  70. ↑ Svensson LG, Coselli JS, Safi HJ, Hess KR, Crawford ES (1989). “Appraisal of adjuncts to prevent acute renal failure after surgery on the thoracic or thoracoabdominal aorta”. J. Vasc. Surg. 10 (3): 230–9. PMID 2778885. Unknown parameter |month= ignored (help)

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