Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies

AbstractAcute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. Abstracts were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.

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Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection

Aorta ◽

10.12945/j.aorta.2016.14.039 ◽

2016 ◽

Vol 04 (02) ◽

pp. 33-41 ◽

Cited By ~ 1

Author(s):

Tyler Gunn ◽

Sotiris Stamou ◽

Nicholas Kouchoukos ◽

Kevin Lobdell ◽

Kamal Khabbaz ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Dissection ◽

Operative Mortality ◽

Survival Rates ◽

Surgical Techniques ◽

Type A ◽

Acute Type ◽

Actuarial Survival ◽

Type A Aortic Dissection ◽

Replacement Procedure

Background: The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure. Methods: All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution’s Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed. Results: The operative mortality rates were 17%, 29%, and 18%, for AV resuspension, AVR, and root replacement, respectively. Operative mortality (p = 0.459) was comparable between groups. Hemorrhage related re-exploration did not differ significantly between groups (p = 0.182); however, root replacement procedures tended to have decreased rates of bleeding when compared to AVR (p = 0.067). The 10-year actuarial survival rates for the AV resuspension, Bentall, and AVR groups were 72%, 56%, and 36%, respectively (log-rank p = 0.035). Conclusions: The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.

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Surgical Management of Acute Type A Aortic Dissection: An Overview

Indian Journal of Clinical Cardiology ◽

10.1177/2632463620978047 ◽

2021 ◽

pp. 263246362097804

Author(s):

Sreedhar Reddy Nagaradona ◽

Krishna Machiraju ◽

Srinivasulu Reddy Kurapati ◽

Srinivas Boggula ◽

Sridhar Anumala Setty ◽

...

Keyword(s):

Aortic Dissection ◽

Aortic Wall ◽

False Lumen ◽

Type A ◽

Ascending Aorta ◽

Acute Type ◽

Aortic Arch Replacement ◽

Type A Aortic Dissection ◽

The Past ◽

Catastrophic Disease

Acute type A aortic dissection is a catastrophic disease that develops from a tear within the intima of the aortic wall, thereby creating a false lumen in the ascending aorta. Early suspicion, diagnosis, and prompt surgery play a key role in the survival of patients. It is a surgical emergency and requires replacement of the ascending aorta/aortic root with or without aortic arch replacement. Over the past decade the surgical outcomes have improved in specialized tertiary centers.

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BioGlue cerebral embolism following acute type A aortic dissection repair

10.22541/au.162499214.42109052/v1 ◽

2021 ◽

Author(s):

Manabu Yamasaki ◽

Kohei Abe ◽

Ryota Nakamura ◽

Rihito Tamaki ◽

Hiroyasu Misumi

Keyword(s):

Aortic Dissection ◽

False Lumen ◽

Surgical Techniques ◽

Type A ◽

Cerebral Embolism ◽

Total Arch Replacement ◽

Acute Type ◽

Type A Aortic Dissection

The outcomes of surgery for Acute Stanford type A aortic dissection (ATAAD) have significantly improved in recent decades due to advances in surgical techniques and, surgical adhesives such as BioGlue. However, this convenient material can sometimes cause complications such as thrombotic embolism and pseudoaneurysm. Here, we present the case of a 61-year-old male with ATAAD who successfully underwent total arch replacement. Five days after the surgery, he collapsed due to right hemiplegia. We immediately performed cerebral thrombectomy and removed the thrombotic embolus caused by BioGlue, which was used to obliterate the false lumen of the dissected aorta during ATAAD repair.

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Faculty Opinions recommendation of Determinants of operative mortality in patients with ruptured acute type A aortic dissection.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725830578.793510506 ◽

2015 ◽

Author(s):

John Augoustides

Keyword(s):

Aortic Dissection ◽

Operative Mortality ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection

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Initial Management of Acute Type-A Aortic Dissection with a Thrombosed False Lumen: A Retrospective Cohort Study

Surgery Today ◽

10.1007/s00595-004-2798-1 ◽

2004 ◽

Vol 34 (8) ◽

Cited By ~ 6

Author(s):

Yoshihiko Kurimoto ◽

Kiyofumi Morishita ◽

Nobuyoshi Kawaharada ◽

Johji Fukada ◽

Yasufumi Asai ◽

...

Keyword(s):

Cohort Study ◽

Aortic Dissection ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

False Lumen ◽

Type A ◽

Acute Type ◽

Initial Management ◽

Type A Aortic Dissection

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Do oral anticoagulants impact outcomes and false lumen patency after repair of acute type A aortic dissection?

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2021.09.009 ◽

2021 ◽

Author(s):

Igor Vendramin ◽

Daniela Piani ◽

Andrea Lechiancole ◽

Nunzio Davide de Manna ◽

Sandro Sponga ◽

...

Keyword(s):

Aortic Dissection ◽

Oral Anticoagulants ◽

False Lumen ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection

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Clinical significance of a false lumen pathway through the arch in acute type A aortic dissection and its influence on cervical branch compromise

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezu474 ◽

2014 ◽

Vol 48 (5) ◽

pp. 671-678 ◽

Cited By ~ 2

Author(s):

Hiroshi Nagamine ◽

Manami Miyazaki ◽

Naohiro Wakabayashi ◽

Hiroaki Sugita ◽

Hiroiku Hara ◽

...

Keyword(s):

Aortic Dissection ◽

Clinical Significance ◽

False Lumen ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection

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Influence of Patent False Lumen on Secondary Dilation of the Distal Aorta Following Surgery for Acute Type A Aortic Dissection

Advances in Understanding Aortic Diseases ◽

10.1007/978-4-431-99237-0_32 ◽

2009 ◽

pp. 197-197 ◽

Cited By ~ 1

Author(s):

Naoyuki Kimura ◽

Masashi Tanaka ◽

Hideo Adachi ◽

Atsushi Yamaguchi ◽

Takashi Ino

Keyword(s):

Aortic Dissection ◽

False Lumen ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection ◽

Patent False Lumen

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Interfacility Transfer of Medicare Beneficiaries With Acute Type A Aortic Dissection and Regionalization of Care in the United States

Circulation ◽

10.1161/circulationaha.118.038867 ◽

2019 ◽

Vol 140 (15) ◽

pp. 1239-1250 ◽

Cited By ~ 12

Author(s):

Andrew B. Goldstone ◽

Peter Chiu ◽

Michael Baiocchi ◽

Bharathi Lingala ◽

Justin Lee ◽

...

Keyword(s):

Aortic Dissection ◽

Operative Mortality ◽

Type A ◽

High Volume ◽

The United States ◽

Acute Type ◽

Medicare Beneficiaries ◽

Type A Aortic Dissection ◽

High Volume Hospital

Background: The feasibility and effectiveness of delaying surgery to transfer patients with acute type A aortic dissection—a catastrophic disease that requires prompt intervention—to higher-volume aortic surgery hospitals is unknown. We investigated the hypothesis that regionalizing care at high-volume hospitals for acute type A aortic dissections will lower mortality. We further decomposed this hypothesis into subparts, investigating the isolated effect of transfer and the isolated effect of receiving care at a high-volume versus a low-volume facility. Methods: We compared the operative mortality and long-term survival between 16 886 Medicare beneficiaries diagnosed with an acute type A aortic dissection between 1999 and 2014 who (1) were transferred versus not transferred, (2) underwent surgery at high-volume versus low-volume hospitals, and (3) were rerouted versus not rerouted to a high-volume hospital for treatment. We used a preference-based instrumental variable design to address unmeasured confounding and matching to separate the effect of transfer from volume. Results: Between 1999 and 2014, 40.5% of patients with an acute type A aortic dissection were transferred, and 51.9% received surgery at a high-volume hospital. Interfacility transfer was not associated with a change in operative mortality (risk difference, –0.69%; 95% CI, –2.7% to 1.35%) or long-term mortality. Despite delaying surgery, a regionalization policy that transfers patients to high-volume hospitals was associated with a 7.2% (95% CI, 4.1%–10.3%) absolute risk reduction in operative mortality; this association persisted in the long term (hazard ratio, 0.81; 95% CI, 0.75–0.87). The median distance needed to reroute each patient to a high-volume hospital was 50.1 miles (interquartile range, 12.4–105.4 miles). Conclusions: Operative and long-term mortality were substantially reduced in patients with acute type A aortic dissection who were rerouted to high-volume hospitals. Policy makers should evaluate the feasibility and benefits of regionalizing the surgical treatment of acute type A aortic dissection in the United States.

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