The evolution of medical and surgical management of acute aortic dissection.

SINCE 1761 when Morgangni described in detail the clinical course and the pathologic findings in three fatal cases of aortic dissection,' the grave prognosis of this disease has been well recognized. Throughout the 19th century and the first half of the 20th century, the true incidence of aortic dissection was not realized. In his classic monograph written in 1934, Shennan was able to collect only 300 cases from the world literature over a period of 150 years.2 Although Shennan's report exhaustively documented the clinical and pathologic features of aortic dissections and clarified the probable pathogenesis of this disease, recognition of dissection during life remained infrequent and treatment remained symptomatic. The extremely high mortality rate of aortic dissection either untreated or with supportive medical treatment was documented in 1958 by Hirst in a review of 505 dissections reported in the English literature over a 21 year period.3 In this series the mortality rate was 50% at four days, 75% at two weeks and 90% after three months. Hirst's review also emphasized the protean manifestations of acute dissections, the infrequency of correct antemortem diagnosis (40%), and the increasing overall incidence of dissections to approximately one in 363 autopsies. During the past 20 years with the routine availability of angiography, the premortem diagnosis has increased sharply and is now generally greater than 90% (unpublished data).4' This increased rate of correct diagnosis has led to the realization that acute aortic dissection is the most common catastrophic illness involving the aorta,6 occurring at a rate of at least 2,000 new cases per year in the United States.4' Until 1955, surgical treatment of aortic dissections had been confined to local fenestration procedures; results were poor.3' 8, ' During the past 20 years, since DeBakey, Cooley and Creech reported their early successful experiences with surgical treatment,8 treatment of aortic dissection has evolved rapidly. For dissections confined to the descending aorta, these workers employed excision and graft replacement of the proximal portion with obliteration of the false lumen distally. DeBakey initially treated dissections arising in the ascending aorta by creation of a wide re-entry passage from the false to the true lumen in the descending aorta, but abandoned this basically palliative approach after only