Anaesthesia for aortic dissection and major aortic surgery

Meet the patient

A 58-year-old man arrives with sudden tearing chest pain radiating to the back, sweating, and a pulse deficit in the left arm. CT angiography confirms a Stanford Type A dissection involving the arch. His blood pressure is 190 over 100, heart rate 110. The cardiac surgical team is activated, the perfusionist is called, and you have minutes to control the shear stress before the theatre is ready.^[4][5]

Two questions own this case: can you drop the rate and pressure fast enough to stop the dissection extending without killing the patient through hypotension or tamponade? and is your team ready for a sternotomy that may need circulatory arrest? Everything below serves those two questions.^[4]

References9ShowHide

1. [1]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery N Engl J Med, 2017.PMID 29130845
2. [2]Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists J Am Soc Echocardiogr, 2013.PMID 23998692
3. [3]Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives J Thromb Haemost, 2023.PMID 37062523
4. [4]Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines Circulation, 2022.PMID 36322642
5. [5]Suzuki T, Isselbacher EM, Nienaber CA, et al. Type-selective benefits of medications in treatment of acute aortic dissection (from the International Registry of Acute Aortic Dissection [IRAD]) Am J Cardiol, 2012.PMID 21944678
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7. [7]Poon SS, Estrera A, Oo A, Field M Is moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion superior to deep hypothermic circulatory arrest in elective aortic arch surgery? Interact Cardiovasc Thorac Surg, 2016.PMID 27209532
8. [8]Pereira RM, Guerra N, Ferreira R, et al. Contemporary Clinical Practices in Anticoagulation Management During Cardiopulmonary Bypass: A Europe-Wide Survey Interdiscip Cardiovasc Thorac Surg, 2026.PMID 41787968
9. [9]Yoshitani K, Kawaguchi M, Kawamata M, et al. Cerebrospinal fluid drainage to prevent postoperative spinal cord injury in thoracic aortic repair J Anesth, 2021.PMID 32980925