Acute type-A dissection of the aorta: which diagnostic modes remain for surgical indication?

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Abstract
The natural course of acute type-A dissection of the aorta (AADA)implies a mortality of 50% within the initial 2 days. Preoperativediagnostic tests have to be expeditious while avoiding hypertension anddirect manipulation of the aneurysm to prevent aortic rupture. Since 1979,51 patients have been operated upon for AADA. The diagnosis was establishedby one or more of the following methods: transthoracic echocardiography(TTE); transesophageal echocardiography (TEE); conventional angiography(CA); intravenous digital subtraction angiography (DSA); and computedtomography with bolus injection of contrast medium (CT). TTE (n = 26)showed a dissection in 72%, suggested an intimal flap in 25%, and missedthe diagnosis in 1 case. CT (n = 15) and DSA (n = 10) failed to indicatedissection in 1 case each. CA (n = 27) demonstrated dissection in everycase but was the most time-consuming and stressful method. Since theintroduction of combined transthoracic and transesophagealechocardiography, no other diagnostic methods have been used. On the basisof this experience, we propose the following diagnostic plan: 1. in AADA,the demonstration of an intimal flap in the ascending aorta by TTE/TEE isan indication for immediate surgery without further diagnostic measures (10patients: no false-positive findings); 2. if a dissection is suggested byTTE/TEE, then DSA is performed if the supra-aortic branches are suspectedto be compromised; CT is preferred if an extrapericardial aortic rupture issuspected; 3. the time-consuming and stressful diagnostic approach ofconventional angiography is no longer indicated.

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