Limited versus extended repair for type A aortic dissection involving the aortic arch

Abstract Background Type A aortic dissection is an emergency with high morbidity and mortality when surgery is not performed. Few cases are described in the literature about aortic dissection during pregnancy. A correlation between pregnancy and aortic dissection is mainly reported in patients with family history and connective tissue disorders, such as Marfan’s syndrome (MS), Loeys–Dietz’s syndrome, and Ehlers–Danlos’s syndromes, and patients with bicuspid aortic valve (BAV); exceptional cases are also described in patients without risk factors. Case presentation A 22-year-old young woman with MS, ascending aorta dilation, and BAV became pregnant. During labor, she experienced a short-term chest pain with spontaneous resolution. The electrocardiogram (ECG) and cardiac biomarkers were negative for acute coronary artery disease, but no transthoracic echocardiogram (TTE) was performed. A caesarean section was performed without complications. After 1 month, a routine TTE showed a chronic ascending aortic dissection involving the aortic arch and supra-aortic vessels. Due to a normally functioning aortic valve, the David operation was performed (sparing aortic valve) with the replacement of the aortic arch and supra-aortic vessels. Conclusions Aortic dissection is a rare cardiovascular complication that can occur during pregnancy and is associated with very high-risk mortality. We have reported a rare case of undiagnosed type A aortic dissection involving the aortic arch during unplanned pregnancy in patients with BAV and MS, subsequently treated with the David surgery and replacement of ascending aortic arch and supra-aortic vessels. A closer clinical and instrumental follow-up is necessary in this particular group of patients at risk. Awareness of all physicians involved is mandatory.

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Enlargement of aortic arch vessels after surgical repair of type A aortic dissection

Journal of Vascular Surgery ◽

10.1016/j.jvs.2016.09.056 ◽

2017 ◽

Vol 65 (3) ◽

pp. 669-675 ◽

Cited By ~ 3

Author(s):

Takashi Yamauchi ◽

Suguru Kubota ◽

Toshihiro Ohata ◽

Kosei Hasegawa ◽

Hideki Ueda

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Surgical Repair ◽

Type A ◽

Type A Aortic Dissection

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Stroke in acute type A aortic dissection: the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD)

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa197 ◽

2020 ◽

Vol 58 (5) ◽

pp. 1027-1034 ◽

Cited By ~ 1

Author(s):

Raphaelle A Chemtob ◽

Simon Fuglsang ◽

Arnar Geirsson ◽

Anders Ahlsson ◽

Christian Olsson ◽

...

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Type A ◽

Pericardial Tamponade ◽

Acute Type ◽

Aortic Arch Replacement ◽

Type A Aortic Dissection ◽

Total Aortic Arch Replacement ◽

Cerebral Malperfusion ◽

Mortality Hazard Ratio

Abstract OBJECTIVES Stroke is a serious complication in patients with acute type A aortic dissection (ATAAD). Previous studies investigating stroke in ATAAD patients have been limited by small cohorts and have shown diverging results. We sought to identify risk factors for stroke and to evaluate the effect of stroke on outcomes in surgical ATAAD patients. METHODS The Nordic Consortium for Acute Type A Aortic Dissection database included patients operated for ATAAD at 8 Scandinavian Hospitals between 2005 and 2014. RESULTS Stroke occurred in 177 (15.7%) out of 1128 patients. Patients with stroke presented more frequently with cerebral malperfusion (20.6% vs 6.3%, P < 0.001), syncope (30.6% vs 17.6%, P < 0.001), cardiogenic shock (33.1% vs 20.7%, P < 0.001) and pericardial tamponade (25.9% vs 14.7%, P < 0.001) and more often underwent total aortic arch replacement (10.7% vs 4.7%, P = 0.016), compared to patients without stroke. In the 86 patients presenting with cerebral malperfusion, 38.4% developed stroke. Thirty-day and 5-year mortality in patients with and without stroke were 27.1% vs 13.6% and 42.9% vs 25.6%, respectively. Stroke was an independent predictor of early- [odds ratio 2.02, 95% confidence interval (CI) 1.34–3.05; P < 0.001] and midterm mortality (hazard ratio 1.68, 95% CI 1.27–2.23; P < 0.001). CONCLUSIONS Stroke in ATAAD patients is associated with increased early- and midterm mortality. Preoperative cerebral malperfusion and impaired haemodynamics, as well as total aortic arch replacement, were more frequent among patients who developed stroke. Importantly, a large proportion of patients presenting with cerebral malperfusion did not develop a permanent stroke, indicating that signs of cerebral malperfusion should not be considered a contraindication for surgery.

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Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2017.07.016 ◽

2018 ◽

Vol 105 (2) ◽

pp. 505-512 ◽

Cited By ~ 1

Author(s):

Fernando Fleischman ◽

Ramsey S. Elsayed ◽

Robbin G. Cohen ◽

James M. Tatum ◽

S. Ram Kumar ◽

...

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection

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Different aortic arch surgery methods for type A aortic dissection: clinical outcomes and follow-up results

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivaa095 ◽

2020 ◽

Vol 31 (2) ◽

pp. 254-262

Author(s):

Yunxing Xue ◽

Jun Pan ◽

Hailong Cao ◽

Fudong Fan ◽

Xuan Luo ◽

...

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Clinical Outcomes ◽

Type A ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Type A Aortic Dissection ◽

Aortic Arch Surgery

Abstract OBJECTIVES The aim of this study was to investigate the clinical outcomes and follow-up results among 5 main aortic arch surgery methods for type A aortic dissection in a single centre. METHODS From 2002 to 2018, 958 type A aortic dissection patients who received surgical repair were divided into 5 groups according to the arch surgery method: hemiarch replacement (n = 206), island arch replacement (n = 54), total arch replacement with frozen elephant trunk (n = 425), triple-branched stent (n = 39) and fenestrated stent (n = 234). The indications for the different arch methods were related to the patient’s preoperative status, the location and extent of the dissection and the surgical ability of the surgeons. A comparative study was performed to identify the differences in the perioperative data, and the Kaplan–Meier analysis was used to assess the long-term survival and reintervention rates. Thirty matched surviving patients that were included in each group completed Computed tomography angiography to determine long-term reshaping effect. RESULTS The 30-day mortality rate was 15.8%, and there was no difference among the 5 groups (P = 0.848). The follow-up survival rates were similar among the 5 groups (P = 0.130), and the same was true for patients without reintervention (P = 0.471). In the propensity matching study, patients with stents (frozen elephant trunk, triple-branched stent, fenestrated stent) had a slower aortic dilation rate and a higher ratio of thrombosis in the false lumen at the descending aortic and abdominal aortic levels than patients without stents. CONCLUSIONS No standard method is available for arch surgery, and indications and long-term effects should be identified with clinical data. In our experiences, simpler surgical procedures could reduce mortality in critically ill patients and stents in the distal aorta could improve long-term reshape effects.

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