Future Imaginations

A feasible complete endovascular treatment of an acute type A aortic dissection has not been developed. Stent-graft procedures have been conducted for aortic arch aneurysms, including intentional covering of one or more of the supraaortic trunks, occasionally associated with surgical implant of intrathoracic bypasses in cases of debranching of the aortic arch (Figure 17.5).

Figure 17.5. Complete debranching of the aortic arch covered by a stent graft for arch aneurysm and intrathoracic bypass between ascending aorta, innominate artery, and left common carotid artery.

In spite the fact that aortic aneurysms and dissections have different characteristics, a total endovascular approach for type A dissections could be hypothesized as well, with the accomplishment of new endografts. In the future, treatment of this catastrophic disease can also foresee indications for limited surgery in patients admitted in hospital in extreme conditions. The IRAD experience shows that an unstable hemodynamic preoperative condition is associated with a particularly poor outcome4, making surgical intervention an heroic attempt.

Currently, new methods of preventions of the disease are developing. Causes of dissections, as ascending aortic aneurysms or Marfan's patients are treated with more aggressive surgical approaches, when the aortic diameter is less than 6 cm and less than 5.5 cm, respectively66. Specific hypotensive drugs, like beta-blockers, are more frequently administrate in the young population affected by hypertension. Genetics knowledge today allows us to assess high-risk patients; soon, it could became therapy. In the future, we could expect a lower expectancy of acute dissections and probably a limited traditional surgical approach, clarifying the basis for a more specific and effective role of surgery.

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