Aortic disease can be classified according to the disease process (dissection versus aneurysm) and its location (ascending, transverse arch, descending thoracic, and thorocoabdominal aorta). Although less common that many other thoracic disease, aortic pathology represents a difficult surgical challenge. The key is early diagnosis and prompt management. Diagnostic modalities including high-resolution CT scans, magnetic resonance imaging angiography, and echocardiography are routinely used to help direct therapeutic decisions.
Acute aortic dissections, depending on location, usually require urgent surgical repair. Chronic dissections often will increase in size and act more like aneurysms, or dilations of the weakened aortic wall. These situations can lead to aortic rupture or recurrent dissection resulting in coronary occlusion, aortic valve insufficiency, stroke, cardiac tamponade, and death. As such, our goal is to intervene prior to the development of these morbid and possibly fatal complications.
Therapeutic options include direct surgical replacement of the diseased aortic segments. These procedures can be quite challenging and often require multimodal approaches, including strategies for spinal cord protection, hypothermic circulatory arrest, and brain protection.
Patients with aneurysms of the first part of the aorta – the aortic root and/or ascending aorta – can present a specific set of issues with regard to the aortic valve. Patients with collagen vascular disorders, such as Marfan’s syndrome, have a weakness in the aortic wall while preserving normal valve function. Traditional approaches have been to perform a Bentall procedure which replaces the aortic valve with a mechanical prosthesis, thus submitting the patient to lifelong anticoagulation. At UNC, we have adopted an aggressive strategy to preserve the native valve by performing valve-sparing root replacement (either the David or Yacoub procedure – depending on the particular situation). With these procedures, patients no longer have the diseased aortic segment, but still have the function of their own aortic valve, thus avoiding any complications associated with an artificial valve.