Skip to main content
SpringerLink
Log in

Prise en charge chirurgicale de la dissection aortique

Surgical management of acute aortic dissection

  • Mise au Point / Update
  • Published:
Réanimation

Résumé

La dissection aortique, qu’elle soit aiguë ou chronique représente toujours un défi pour le clinicien. Relativement rare, au pronostic spontané sombre à court terme, sa prise en charge n’est pas toujours aisée. Des études récentes basées sur le Registre international des dissections aortiques ont permis de mieux identifier les différentes formes de présentation de cette pathologie et d’apporter des outils cliniques pour aider le clinicien. Néanmoins, le diagnostic en urgence repose toujours sur une imagerie spécifique dont l’échographie transoesophagienne et la tomodensitométrie. La prise en charge chirurgicale en urgence est primordiale lorsque la dissection intéresse l’aorte ascendante. Elle le devient rarement en cas de dissection n’intéressant que l’aorte descendante. Passé le cap aigu grâce à une sanction chirurgicale urgente et adaptée, la dissection aortique va évoluer vers une pathologie chronique avec un risque anévrysmal et de rupture de l’aorte restante disséquée responsable d’une morbimortalité importante à moyen et long termes. C’est pourquoi un patient opéré d’une dissection aortique devra être suivi à vie, spécifiquement à la recherche de ces complications et pris en charge précocement par son chirurgien le cas échéant.

Abstract

Acute or chronic aortic dissections still represent a major challenge for the clinician. Despite its rarity, management is not easy, generally resulting in a bad short-term prognosis. Yet, recent studies based on the International registry of acute aortic dissection assessed clinical tools to help the clinician identifying the various presentations of aortic dissection. Emergency diagnosis relies on specific imaging including transesophageal echocardiography and computed tomography. Emergent surgical treatment is mandatory when the dissection involves the ascending aorta. Once the critical phase treated, the aortic dissection usually progresses to a chronic disease with aneurismal transformation and risks of tearing in the remaining dissected aorta, leading to significant mid- and long-term morbidity and mortality. Therefore patients previously treated for aortic dissection have to be tightly monitored during their whole life and rapidly reoperated if required.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Références

  1. Hiratzka LF, Bakris GL, Beckman JA, et al (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 for Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Interventional Radiology, Society of Thoracic Surgeons, and Society for VaScular Medecine (developed in collaboration with the American College of Emergency Physicians). J Am Coll Cardiol 55:e27–e129

    Article  PubMed  Google Scholar 

  2. Tsai TT, Trimarchi S, Nienaber CA (2009) Acute aortic dissection: perspectives from the international registry of acute aortic dissection (IRAD). Eur J Vasc Endovasc Surg 37:149–59

    Article  PubMed  CAS  Google Scholar 

  3. Coady MA, Rizzo JA, Goldstein LJ, Elefteriades JA (1999) Natural history, pathogenesis, and etiology of thoracic aortic aneurysms and dissections. Cardiol Clin 17:615–35

    Article  PubMed  CAS  Google Scholar 

  4. Sullivan PR, Wolfson AB, Leckey RD, Burke JL (2000) Diagnosis of acute thoracic aortic dissection in the emergency department. Am J Emerg Med 18:46–50

    Article  PubMed  CAS  Google Scholar 

  5. Delsart P, Claisse G, Bouabdallaoui N, et al (2011) Syndromes aortiques aigus: organiser la prise en charge médicale à la phase aiguë et au long cours. Presse Med 40:34–42

    Article  PubMed  Google Scholar 

  6. Erbel R, Alfonso F, Boileau C, et al (2001) Diagnosis and management of aortic dissection. Recommendations of the Task Force on aortic dissection, European Society of Cardiology. Eur Heart J 22:1642–81

    Article  PubMed  CAS  Google Scholar 

  7. Mészáros I, Mórocz J, Szlávi J, et al (2000) Epidemiology and clinicopathology of aortic dissection. Chest 117:1271–8

    Article  PubMed  Google Scholar 

  8. Olsson C, Thelin S, Stahle E, et al (2006) Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation 114:2611–8

    Article  PubMed  Google Scholar 

  9. Hagan PG, Nienaber CA, Isselbacher EM, et al (2000) International registry of acute aortic dissection (IRAD): new insights from an old disease. JAMA 283:897–903

    Article  PubMed  CAS  Google Scholar 

  10. Rousseau H, Verhoye JP, Heautot JF (2009) Les syndromes aortiques aigus. Springer, Paris, 52 p

    Book  Google Scholar 

  11. Braverman AC (2010) Acute aortic dissection: Clinician update. Circulation 122:184–8

    Article  PubMed  Google Scholar 

  12. Golledge J, Eagle KA (2008) Acute aortic dissection. Lancet 372:55–66

    Article  PubMed  Google Scholar 

  13. Nathan DP, Xu C, Gorman JH, et al (2011) Pathogenesis of acute aortic dissection: a finite element stress analysis. Ann Thorac Surg 91:458–64

    Article  PubMed  Google Scholar 

  14. De Bakey ME, Henley WS, Cooley DA (1965) Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg 49:130–49

    Google Scholar 

  15. Daily PO, Trueblood HW, Stinson EB, et al (1970) Management of acute aortic dissection. AnnThorac Surg 10:237–42

    Article  CAS  Google Scholar 

  16. Bachet J (2004) Dissections aiguës de l’aorte: physiopathologie et diagnostic. EMC 42-743-A

    Google Scholar 

  17. Pape LA, Tsai TT, Isselbacher EM, et al (2007) Aortic diameter >5.5 cm is not a good predictor of type A aortic dissection. Observations from the international registry of acute aortic dissection. Circulation 116:1120–7

    Article  PubMed  Google Scholar 

  18. Rogers AM, Hermann LK, Booher AM, et al (2011) Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation 123:2213–8

    Article  PubMed  Google Scholar 

  19. Umaña JP, Lai DT, Mitchell RS, et al (2002) Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections? J Thorac Cardiovasc Surg 124:896–910

    Article  PubMed  Google Scholar 

  20. Trimarchi S, Eagle KA, Nienaber CA, et al (2010) Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the international registry of acute aortic dissection (IRAD). Circulation 122:1283–9

    Article  PubMed  Google Scholar 

  21. Kodama K, Nishigami K, Sakamoto T, et al (2008) Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection. Circulation 118:S167–70

    Article  PubMed  Google Scholar 

  22. Nienaber CA, Eagle KA (2003) Aortic dissection: new frontiers in diagnosis and management: part I: from etiology to diagnostic strategies. Circulation 108:628–35

    Article  PubMed  Google Scholar 

  23. Ranasinghe AM, Bonser RS (2010) Biomarkers in acute aortic dissection and other aortic syndromes. J Am Coll Cardiol 56:1535–41

    Article  PubMed  CAS  Google Scholar 

  24. David TE, Feindel CM (1992) An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 103:617–21

    PubMed  CAS  Google Scholar 

  25. Yacoub MH, Gehle P, Chandrasekaran V (1998) Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 115:1080–90

    Article  PubMed  CAS  Google Scholar 

  26. Chen LW, Dai XF, Lu L, et al (2010) Extensive primary repair of the thoracic aorta in acute type A aortic dissection by means of ascending aorta replacement combined with open placement of triple-branched stent graft. Circulation 122:1373–8

    Article  PubMed  Google Scholar 

  27. Roux D, Brouchet L, Concina P, et al (2002) Type-A acute aortic dissection: combined operation plus stent management. Ann Thorac Surg 73:1616–8

    Article  PubMed  Google Scholar 

  28. Schoenhoff FS, Schmidli J, Eckstein FS, et al (2007) The frozen elephant trunk: an interesting hybrid endovascular-surgical technique to treat complex pathologies of the thoracic aorta. J Vasc Surg 45:597–9

    Article  PubMed  Google Scholar 

  29. Ramadan R, Azmoun A, Al-Attar N, et al (2011) Wrapping of the ascending aorta in acute type A retrograde aortic dissection. Ann Thorac Surg 92:e49–50

    Article  PubMed  Google Scholar 

  30. Eggebrecht H, Nienaber CA, Neuhäuser M, et al (2006) Endovascular stent-graft placement in aortic dissection: a metaanalysis. Eur Heart J 27:489–98

    Article  PubMed  Google Scholar 

  31. Nienaber CA, Rousseau H, Eggebrecht H, et al (2009) Randomized comparison of strategies for type B aortic dissection: the Investigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 120:2519–28

    Article  PubMed  Google Scholar 

  32. Rampoldi V, Trimarchi S, Eagle KA, et al (2007) Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg 83:55–61

    Article  PubMed  Google Scholar 

  33. Bachet JE, Termington JL, Dreyfus G, et al (1994) Aortic dissection. Prevalence, cause, and results of late reoperations. J Thorac Cardiovasc Surg 108:199–205

    PubMed  CAS  Google Scholar 

  34. Kirsch M, Legras A, Bruzzi M, Louis N (2011) Fate of the distal aorta after surgical repair of acute De Bakey type I aortic dissection: a review. Arch Cardiovasc Dis 104:125–30

    Article  PubMed  Google Scholar 

  35. Shores J, Berger KR, Murphy EA, et al (1994) Progression of aortic dilatation and the benefit of long-term beta-adrenergic blockade in Marfan’s syndrome. N Engl J Med 330:1335–41

    Article  PubMed  CAS  Google Scholar 

  36. Tsai TT, Evangelista A, Nienaber CA, et al (2006) Long-term survival in patients presenting with type A acute aortic dissection: insights from the international registry of acute aortic dissection (IRAD). Circulation 114(1 Suppl):I350–6

    PubMed  Google Scholar 

  37. Tsai TT, Fattori R, Trimarchi S, et al (2006) Long-term survival in patients presenting with type B acute aortic dissection: insights from the international registry of acute aortic dissection. Circulation 114:2226–31

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Service de chirurgie cardiaque, CHU sud, CHU d’Amiens, avenue René Laënnec-Salouël, F-80054, Amiens cedex 1, France

    L. Fournot

  2. Service de chirurgie thoracique, vasculaire et transplantation cardiopulmonaire, 133, avenue de la Résistance, F-92350, Le Plessis-Robinson, France

    D. Boulate

  3. Service de chirurgie thoracique et cardiovasculaire, Institut de cardiologie, groupe hospitalier Pitié-Salpêtrière, Université Paris VI, Pierre et Marie Curie, 47-83 boulevard de l’Hôpital, F-75651, Paris cedex 13, France

    M. Kirsch & P. Leprince

Authors
  1. L. Fournot
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D. Boulate
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Kirsch
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. P. Leprince
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to L. Fournot.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Fournot, L., Boulate, D., Kirsch, M. et al. Prise en charge chirurgicale de la dissection aortique. Réanimation 22, 600–609 (2013). https://doi.org/10.1007/s13546-013-0684-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13546-013-0684-9

Mots clés

Keywords

Search

Navigation