- Surgery for aortic dissection involves either type A or type B lesions depending on the involvement of the ascending aorta. Complications of aortic dissection include aortic regurgitation, coronary occlusion, rupture, tamponade, ischemic organs, and stroke. - Redo aortic and Bentall surgery can be performed but are higher risk due to fragile tissues. Outcomes are reasonable when surgery is performed at an experienced center. Personal experience shows redo surgery mortality of 12% and major morbidity between 10-30% depending on instability and comorbidities.

1. Surgery for Aortic Dissection
Dicky A.Wartono,MD
CV surgeon Harapan Kita National Cardiovascular Centre Jakarta 2021

2. Nothing to disclose

4. The Surgical Perspective
- system based on the presence or
absence of ascending aortic
involvement
- more distal dissections involving the
aortic arch and descend- ing thoracic
aorta are considered type B lesions
Wheat MW Jr. Acute dissecting aneurysms of the aorta: diagnosis and treatment—1979. Am Heart J 1980;99(3):373–387.
Appelbaum A, Karp RB, Kirklin JW. As- cending vs descending aortic dissections. Ann Surg 1976;183(3):296–300.
Wong DR, Lemaire SACJ, Coselli JS. Man- aging dissections of the thoracic aorta. Am Surg 2008;74(5):364–380.
Miller DC, Stinson EB, Oyer PE, et al. Op- erative treatment of aortic dissections: ex- perience with 125 patients over a
sixteen- year period. J Thorac Cardiovasc Surg 1979;78(3):365–382

5. Radiology /medical Perspective
- an unclear problematic area
- proximal aortic dissection involving
the aorta proximal to the origin of the
left sub- clavian artery
- the original Stanford article
Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 2002;122(1):311–328.
Castañer E, Andreu M, Gallardo X, Mata JM, Cabezuelo MA, Pallardó Y. CT in non- traumatic acute thoracic aortic
disease: typ- ical and atypical features and complications. RadioGraphics 2003;23(Spec No):S93– S110.
McMahon MA, Squirrell CA. Multidetector CT of aortic dissection: a pictorial review. RadioGraphics 2010;30(2):445–
460.
Liu Q, Lu JP, Wang F, Wang L, Tian JM. Three-dimensional contrast-enhanced MR angiography of aortic dissection: a
pictorial essay. RadioGraphics 2007;27(5):1311–1321.

6. Complication of Aortic Dissection
A - Aortic Regurgitation
O - Occlusion of Coronary
R - Rupture
T - Tamponade
I - Ischemic Organ
C -CVA

7. AORTIC ROOT PATHOLOGY
Congenital
Infection/inflamation
Trauma
Others
Dissection
Aneurysm
Concomintant Valve Dis
-AS/AR
-Bicuspid Aortic Valve (BAV)
ROSS (Mod)BENTALL VALVE SPARRING

8. Complication of Aortic Dissection
A - Aortic Regurgitation
O - Occlusion of Coronary
R - Rupture
T - Tamponade
I - Ischemic Organ
C -CVA
”Just” prximal procedures are enough??
Proximal & Hemi arch??
Proximal & Total Arch ??

9. Distal Anastomosis

10. Better survival with extended approach

11. The Addition of the Hemi-Arch Replacement to Aortic Root Surgery does NOT increase Operative Mortality
Badiwala M, Rinewalt D, Kruse J, Li Z, Andrei AC, McCarthy PM, Malaisrie SC. 2014
Addition of a hemi-arch replacement using DHCA to the modified Bentall
Procedure does not significantly increase stroke and bleeding complications,
nor mortality

13. • On Bypass… temp 28.. VF
• (Clamp)… Aortotomy
• Composite implantation
• L-button
• Temp 26’C.. HCA
• Open distal anastomosis (L subclav to Inominate A)
• Re warm.. Aortic Clamp… R button

14. Aortotomy & Periaortic dissection
(Excise aortic valve leaflets)
Coronary button Preparation

15. Prostetic suture

16. Implantation of the Right coronary into the graft

18. 76 yo male caucasian
Severe chest pain
w/ sign of anterior ischemia
1y after Bentall oveseas
for type A dissection
Redo Bentall
Discharge POD 18
uneventful

33. Implantation of the Left coronary into the graft

34. Redo Aortic/ Bentall Surgery
2017 – 2021, Personal Data)

35. Redo Aortic/ Bentall Surgery
2017 – 2021, Personal Data)
Mortality :
1 pts w/ prothesis endocarditis
3 (1) pts w/ jammed prothesis
1 pts w/ coronary button aneurysm
Morbidity
Persisten stroke : 2 pts
Req hemodyalisis : 2 pts
Prolonge ventilator : 2 pts

37. retrograde
type A dissection
55 yo F
Suddent onset of chest
pain, dyspneutic
3 m after TEVAR for
type B dissection

38. retrograde
type A dissection
55 yo F
Suddent onset of chest
pain, dyspneutic
3 m after TEVAR for
type B dissection
Discard POD 14
uneventfull

39. retrograde
type A dissection
55 yo F
Suddent onset of chest
pain, dyspneutic
3 m after TEVAR for
type B dissection
Discard POD 14
uneventfull

43. Personal experiences (2017-2021) n=23
• Mean age : 56 yo (45% female)
• 2017-18-19 : 1 – 9 - 7
• Aortic pathology
– Aneurysm : 1
– Chronic type B Disc : 13
– Arch hybrid : 3
– AAA : 3
• Reintervention
– Age : mean 58 yo
– Endoleak : 10
– Retrograde type A : 6
– Stent problm : 3
– Infection : 1
• 30d mortality : 12 (sepsis)
• Re operation : 4 (bleeding)
• Stroke : 2 (1 temp + 1 permn)
• Paraplegia : 1 (temp)
• Renal failure : 2 (temp)
• Vent >24j : 4
• LOS : 16d
• 1y Re hoptl : 2 (stroke)

46. Testing Proximal Anastomosis

47. Ann Thorac Surg 2003;76:499–502

49. Ann Thorac Surg 2002;74:1071–4

50. Meta Analysis Harapan Kita**
Total Adjust* Total Adjusted*
Bleeding Redo 18 1.4 22 2.1
Cardiac
3rd block 2.1 1.4 3 1
Inotropic Supp 56 21 76 18
VF 11 0.7 5 0
Respiratory 22 2.8 23 2
Chronic Dialysis 9 1.7 11.2 0
Infection 11 1.7 33 4.2
Mortality 22 1 18.8 1
Mean LOS 18 13.3 29 15
Ann Thorac Surg 2014;76:698–703
*Adjusted for unstab preop, multiple comorbidity, multiple procedures, redo bentall, conversion

51. • Conclusions
• Surgery for Dissection, is a safest & less painfull option, with
reasonable outcome
• Redo aortic surgery & conversion from endo procedures do
exist
• Timing of Surgery, most contributing factor
• There are few option for managing fragile tissue

52. Thank You