Surgery for thoracic aortic pathology is challenging and is associated with significant early and late mortality and morbidity. In recent decades advances in diagnostic imaging, surgical techniques, myocardial and cerebral protection, and graft design have significantly improved outcomes. Patient assessment is focused on timely surgery to prevent the catastrophic complications of aortic dissection and rupture. The major challenge perioperatively is minimisation of ischaemic injury to end organs and particularly to the brain and spinal cord.
Acute aortic dissection is the most common life-threatening thoracic aorta emergency and carries a mortality of 50% in the first 48 hours. Early recognition and diagnosis of aortic dissection is therefore essential. Open surgical intervention is required for ascending aortic dissection. Medical or endovascular management may be appropriate if the ascending aorta and aortic arch are not involved.
Thoracic aortic aneurysms are usually asymptomatic and chronic in nature. Surgery is usually indicated for large (≥5.5 cm for the ascending aorta, ≥6 cm for the aortic arch, ≥6.5 cm for the descending aorta) or rapidly expanding aneurysms (>1 cm per year), or once a patient develops symptoms. Earlier surgery is advocated for patients with connective tissue disorders such as Marfan's syndrome because of an increased risk of rupture.
The advent of endovascular stent technology has opened the door for a minimally-invasive approach to the treatment of aortic pathology with encouraging early and medium-term outcomes reported.