Video by Eric Roselli, M.D.
Staff Surgeon in the Cleveland Clinic Department of Thoracic and Cardiovascular Surgery
Specialties: Adult cardiac surgery, thoracic aortic surgery, endovascular approaches to cardiothoracic diseases, minimally invasive valve repair and replacement, high-risk valve surgery, endovascular stent and prosthetic valve research.
Hello. My name is Dr. Eric Roselli. I am a cardiothoracic surgeon here at the Miller Family Heart & Vascular Institute. I’d like to talk to you today about aortic dissections.
Your aorta is the large artery that leaves your heart and provides oxygen-rich blood throughout your body. This blood vessel is made up of three layers. In certain circumstances, a tear develops in the inner layer. When this occurs, the aorta then bleeds into itself through the middle layer, extending this tear and leads to a separation, or delamination, of the layers of the aorta. This separation of layers of the aortic wall is what is medically known as an aortic dissection.
This type of tear can be caused by high blood pressure, the presence of an aneurysm, atherosclerosis (or buildup of plaque in the arteries), certain genetic conditions like a bicuspid aortic valve, connective tissue diseases which run in families, as well as traumatic injury after a car crash or from a high fall.
When this dissection initially occurs and the layers of the aorta are forced apart, it usually presents as severe, sharp, tearing pain in your chest and back. Essentially you feel your aorta ripping apart.
When aortic dissection first occurs, about 40 percent of patients die immediately from complete rupture and bleeding out from the aorta. The risk of dying can be as high as one to three percent per hour until the patient gets treatment. Treatment of aortic dissection depends upon the location of the tear. Tears closer to the heart can be immediately life-threatening and usually require surgery to repair or replace the first segment of the aorta where the tear started. The risk of dying from this urgent surgery is about 10 to 20 percent, depending on the condition of the patient at the time of arrival.
For patients with tears further down the aorta, further from the heart, surgery may not be necessary initially, but intensive medical therapy is. These patients are first managed using intravenous blood pressure medications and close, careful monitoring. The need for surgical intervention may then be delayed for a matter of months to years depending on the severity of their tear. The exception occurs in patients where the downstream tear cuts off blood flow to the vital organs including the kidneys, intestines, lower extremities, or even the spinal cord. Like dissections that occur close to the heart, these patients require urgent intervention to save their lives.
Once a patient survives the initial event, either with or without surgery, regular follow-ups are critical, as people who survive an aortic dissection are prone to developing aneurysms later on – during what is referred to as the chronic phase. During the chronic phase, the weakened, dissected aortic wall can degenerate.
Over time, the stress of blood flow between aortic layers can cause the weakened area of the aorta to bulge like a balloon, stretching the aorta into what is called an aneurysm – with the risk for late rupture and associated death. Eventually, many patients may require multiple operations to repair late developing aneurysms.
While this diagnosis may sound dismal, the prognosis is improving. At the Miller Family Heart & Vascular Institute, we have one of the largest aortic practices in the world – with experience with every aortic repair and replacement technique. Depending on the extent of aorta involved, a durable repair may require open surgery where the aorta is replaced with a fabric tube called a graft that is directly sewn in place of the diseased aorta. Alternatively, the surgeon may use a stent graft which is a fabric tube supported by metal wire stents (like a scaffold) to repair the aorta. The stent grafts are delivered “endovascularly” which means they are placed over a wire through a small incision in the groin and then delivered upstream into the aorta and deployed by releasing the stents like a spring.
Cleveland Clinic surgeons are also involved in clinical trials looking at better ways to treat aortic dissection using newer and investigational endovascular devices and hybrid surgical techniques. We are also evaluating the processes leading to dissection so that we may intervene before patients develop these life-threatening complications.
Another option that is commonly required in patients with aortic dissections is a hybrid approach, utilizing a combination of conventional open surgery and endovascular stentgraft techniques. One of the most common hybrid procedures is called the “elephant trunk” procedure. During this procedure an open operation is performed to repair the aorta close to the heart, as well as the aortic arch – the segment of the aorta where the blood supply to the brain originates. In addition to this, an additional graft is left hanging into the descending, or downstream aorta, like the trunk of an elephant. This elephant trunk provides a durable place to land an endovascularly placed stentgraft during an additional procedure. Newer hybrid procedures involve surgery and reconstruction of the aortic arch blood vessels without the use of the heart lung machine in combination with stent grafts to repair complex aortic dissections in the chest.
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