An Integrated Approach for Treatment of Acute Type A Aortic Dissection

Background and objective: We reviewed a single-institution experience to verify the impact of surgery during different time intervals on early and late results in the treatment of patients with type A acute aortic dissection (A-AAD). Materials and Methods: From 2004 to 2021, a total of 258 patients underwent repair of A-AAD; patients were equally distributed among three periods: 2004–2010 (Era 1, n = 90), 2011–2016 (Era 2, n = 87), and 2017–2021 (Era 3, n = 81). The primary end-point was to assess whether through the years changes in indications, surgical strategies and techniques and increasing experience have influenced early and late outcomes of A-AAD repair. Results: Axillary artery cannulation was almost routinely used in Eras 2 (86%) and 3 (91%) while one femoral artery was mainly cannulated in Era 1 (91%) (p < 0.01). Retrograde cerebral perfusion was predominantly used in Era 1 (60%) while antegrade cerebral perfusion was preferred in Eras 2 (94%,) and 3 (100%); (p < 0.01). There was a significant increase of arch replacement procedures from Era 1 (11%) to Eras 2 (33%) and 3 (48%) (p < 0.01). A frozen elephant trunk was mainly performed in Era 3. Hospital mortality was 13% in Era 1, 11% in Era 2, and 4% in Era 3 (p = 0.07). Actuarial survival at 3 years is 74%, in Era 1, 78% in Era 2, and 89% in Era 3 (p = 0.05). Conclusions: With increasing experience and a more aggressive approach, including total arch replacement, repair of A-AAD can be performed with low operative mortality in many patients. Patient care and treatment by a specific team organization allows a faster diagnosis and referral for surgery allowing to further improve early and late outcomes.

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Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe?

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0037-1604451 ◽

2017 ◽

Vol 66 (03) ◽

pp. 215-221 ◽

Cited By ~ 5

Author(s):

Nestoras Papadopoulos ◽

Petar Risteski ◽

Theresa Hack ◽

Mahmut Ay ◽

Anton Moritz ◽

...

Keyword(s):

Surgical Treatment ◽

Aortic Dissection ◽

Cerebral Perfusion ◽

Circulatory Arrest ◽

Type A ◽

Hypothermic Circulatory Arrest ◽

Acute Type ◽

Elephant Trunk ◽

Type A Aortic Dissection ◽

Antegrade Cerebral Perfusion

Objectives Surgery for acute type A aortic dissection (AAD) remains a surgical challenge with considerable risk of morbidity and mortality. Antegrade cerebral perfusion (ACP) has been popularized, offering a more physiologic method of brain perfusion during complex aortic arch repair, often necessary in setting of AAD. The safe limits of this approach under moderate-to-mild systemic hypothermic circulatory arrest (≥ 28°C) are yet to be defined. Thus, the current study investigates our clinical results after surgical treatment for AAD in patients with a selective ACP and systemic circulatory arrest time of ≥ 60 minutes in moderate-to-mild hypothermia (≥ 28°C). Methods Between January 2000 and April 2016, 63 consecutive patients underwent surgical treatment for AAD employing selective ACP during moderate-to-mild systemic hypothermia (≥ 28°C) with prolonged ACP and circulatory arrest times. Patients' mean age was 59 ± 15 years, and 39 patients (62%) were men. Hemiarch replacement and total arch replacement were performed in 13 (21%) and 50 (79%) patients, respectively. Frozen elephant trunk, arch light, and elephant trunk technique were performed in nine (14%), six (10%), and three patients (5%), respectively. Clinical data were prospectively entered into our institutional database. Mean late follow-up was 6 ± 4 years and was 98% complete. Results Cardiopulmonary bypass time accounted for 245 ± 81 minutes and the myocardial ischemic time accounted for 140 ± 43 minutes. Mean duration of ACP was 74 ± 12 minutes. The mean lowest core temperature accounted for 28.9 ± 0.8°C. Unilateral ACP was performed in 44 patients (70%); bilateral ACP was used in the remaining 19 patients (30%). Intensive care unit stay reached 6 ± 5 days. New onset of acute renal failure requiring hemofiltration was observed in 8% of patients (n = 5). New postoperative permanent neurologic deficits were found in five patients (8%) and transient neurologic deficits in six patients (10%). There was one case of paraplegia. Thirty-day mortality and in-hospital mortality were 8 (n = 5) and 11% (n = 7), respectively. Overall survival at 5 years was 76 ± 9%. Conclusion Our preliminary data suggest that selective ACP during moderate-to-mild systemic hypothermic circulatory arrest (≥ 28°C) can safely be applied for more than 1 hour even in the setting of AAD.

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Extended repair for acute type A aortic dissection: long-term outcomes of the frozen elephant trunk technique beyond 10 years

The Journal of Cardiovascular Surgery ◽

10.23736/s0021-9509.20.11293-x ◽

2020 ◽

Vol 61 (3) ◽

Cited By ~ 3

Author(s):

Wei-Guo Ma ◽

Yu Chen ◽

Wei Zhang ◽

Qing Li ◽

Jian-Rong Li ◽

...

Keyword(s):

Aortic Dissection ◽

Type A ◽

Acute Type ◽

Frozen Elephant Trunk ◽

Long Term Outcomes ◽

Elephant Trunk ◽

Type A Aortic Dissection ◽

Elephant Trunk Technique ◽

Frozen Elephant Trunk Technique

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Type A aortic dissection: involvement of carotid artery and impact on cerebral malperfusion

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492320984329 ◽

2020 ◽

pp. 021849232098432

Author(s):

Wahaj Munir ◽

Jun Heng Chong ◽

Amer Harky ◽

Mohamad Bashir ◽

Benjamin Adams

Keyword(s):

Carotid Artery ◽

Aortic Dissection ◽

Type A ◽

Current Evidence ◽

Management Approach ◽

Complex Nature ◽

Acute Type ◽

Type A Aortic Dissection ◽

Cerebral Malperfusion ◽

The Impact

Acute type A aortic dissection is a surgical emergency and management of such pathology can be complex with poor outcomes when there is organ malperfusion. Carotid artery involvement is present in 30% of patients diagnosed with acute type A aortic dissection, and given its emergency and complex nature, there is much controversy regarding the approach, extent of treatment, and timing of the intervention. It is clear that the occurrence of cerebral malperfusion adds an extra layer of complexity to the decision-making framework for treatment. Standardization and validation of the optimal management approach is required, and this should ideally be addressed with large-scale studies. Nonetheless, current literature supports the need for rapid recognition and diagnosis of acute type A aortic dissection with cerebral malperfusion, immediate and extensive surgical repair, and the appropriate use of cerebral perfusion techniques. This paper aims to discuss the current evidence regarding the impact of carotid artery involvement in both the management and outcomes of acute type A aortic dissection.

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Surgical outcomes of total arch replacement with modified elephant trunk technique in type A aortic dissection: insights from single-center experience

Asian Cardiovascular and Thoracic Annals ◽

10.1177/02184923211070115 ◽

2022 ◽

pp. 021849232110701

Author(s):

Jian Li ◽

Yueyun Zhou ◽

Wei Qin ◽

Cunhua Su ◽

Fuhua Huang ◽

...

Keyword(s):

Aortic Dissection ◽

Type A ◽

Total Arch Replacement ◽

Hospital Death ◽

Acute Type ◽

Elephant Trunk ◽

Type A Aortic Dissection ◽

Elephant Trunk Technique ◽

Visceral Malperfusion ◽

Cerebral Malperfusion

Background Total arch replacement with modified elephant trunk technique plays an important role in treating acute type A aortic dissection in China. We aim to summarize the therapeutic effects of this procedure in our center over a 17-year period. Methods Consecutive patients treated at our hospital due to type A aortic dissection from January 2004 to January 2021 were studied. Relevant data of these patients undergoing total arch replacement with modified elephant trunk technique were collected and analyzed. Results A total of 589 patients were included with a mean age of 53.1 ± 12.2 years. The mean of cardiopulmonary bypass, cross-clamping, and selected cerebral perfusion time were 199.6 ± 41.9, 119.0 ± 27.2, and 25.1 ± 5.0 min, respectively. In-hospital death occurred in 46 patients. Multivariate analysis identified four significant risk factors for in-hospital mortality: preexisting renal hypoperfusion (OR 5.43; 95% CI 1.31 – 22.44; P = 0.020), cerebral malperfusion (OR 11.87; 95% CI 4.13 – 34.12; P < 0.001), visceral malperfusion (OR 4.27; 95% CI 1.01 – 18.14; P = 0.049), and cross-clamp time ≥ 130 min (OR 3.26; 95% CI 1.72 – 6.19; P < 0.001). The 5, 10, and 15 years survival rates were 86.4%, 82.6%, and 70.2%, respectively. Conclusions Total arch replacement with modified elephant trunk technique is an effective treatment for acute type A aortic dissection with satisfactory perioperative results. Patients with preexisting renal hypoperfusion, cerebral malperfusion, visceral malperfusion, and long cross-clamp time are at a higher risk of in-hospital death.

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