Possible factors affecting the mortality rate in patients undergoing surgery for aortic type A dissection

Objectives: Aortic dissections of type A are clinical emergencies that can prove fatal if not managed promptly in specialized care facilities. Poor clinical management is the cause of approximately 1% of deaths in patients; however, with advances in clinical practice, diagnostic imaging and clinician awareness, the mortality rate has been dramatically reduced to below 30% in most international centers. We examined the potential factors involved in mortality after surgery for type A dissections. Methods: In this descriptive-analytical study, patients who underwent acute aortic dissection surgery in the Shahid Madani Hospital of Tabriz, Iran, between March 2009 and March 2020 were evaluated. Exclusion criteria included those who died before the surgery, patients with descending aortic dissection, and high-risk patients for surgery who were candidates for medical treatment. Among 185 operated patients, 137 were included. Males comprised 62.8% of the patients. Their mean (±SD) age was 53.9 (±15.3) years. Results: Age (p-value < 0.0001), the presence of hypertension (p-value = 0.015), the amount of packed red blood cell transfusion (p-value = 0.024) and the amount of platelet transfusion (p-value = 0.018) were associated with increased mortality. Duration of intubation, use of fresh frozen plasma, postoperative drainage, duration of intensive care unit recovery, high serum creatinine, duration of aortic clamping, brain protection method, and smoking were not associated with increased mortality. Conclusions: These findings suggest that participants' mortality is dependent on several variables. Mortality of the patients with type A dissection can be reduced by interventions and reducing those factors.

Revisiting the Death and Autopsy of King George II

It is commonly accepted that King George II died of an acute aortic dissection. The origin of this association derives from retelling of the official autopsy performed by Dr. Frank Nicholls. While there is no doubt that King George II did have a Stanford Type A dissection, critical descriptions in the report point to a more likely cause of death.

EP.WE.202Atypical presentation of Acute Aortic Dissection Standford type A dissection

Introduction Acute aortic dissection type A (AADA), a tear in the intima lining of the aorta, is a surgical emergency and contributes to high mortality rate if not managed promptly with surgical intervention. Case presentation We describe a case of a 63-year-old female with a history of hypertension presented with presumed seizure and hypotension to the emergency department. She did not have Computed Tomography (CT) chest despite having hemopericardium on her CT abdomen and pelvis. Her condition deteriorated to pericardial effusion, cardiac tamponade, multi-organ failure and shock. A diagnosis of AADA was only found on the stage of post-mortem. Conclusion AADA may not present with classical symptoms of tearing chest pain. The combination of hypotension and neurological deficit should trigger hospital team to consider aortic dissection higher up in the differential diagnosis for shock. If there is unclear diagnosis for an acutely unwell patient, hospital team should review the case and radiological imaging again. Hemopericardium on CT abdomen, pelvis should trigger hospital team to request for a CT chest to look out for the cause of hemopericardium. AADA is fatal without prompt surgical intervention. Immediate diagnosis can significantly reduce the mortality rate.

En Bloc Arch Reconstruction With the Frozen Elephant Trunk Technique for Acute Type a Aortic Dissection

Objective: The study objective was to evaluate the effect of en bloc arch reconstruction with frozen elephant trunk (FET) technique for acute type A aortic dissection.Methods: 41 patients with acute Stanford type A dissection underwent en bloc arch reconstruction combined with FET implantation between April 2018 and August 2020. The mean age of the patients was 46 ± 13 years, and 9 patients were female. One patient had Marfan syndrome. Six patients had pericardial tamponade, 9 had pleural effusion, 5 had transient cerebral ischemic attack, and 3 had chronic kidney disease.Results: The hospital mortality rate was 9.8% (4 patients). 2 (4.9%) patients had stroke, 23 (56.1%) had acute kidney injury, and 5 (12.2%) had renal failure requiring hemodialysis. During follow-up, the rate of complete false lumen thrombosis was 91.6% (33/36) around the FET, 69.4% (25/36) at the diaphragmatic level, and 27.8% (10/36) at the superior mesenteric artery level. The true lumen diameter at the same three levels of the descending aorta increased significantly while the false lumen diameter reduced at the two levels: pulmonary bifurcation and the diaphragm. The 1-, 2-and 3-year actuarial survival rates were 90.2% [95% confidence interval (CI), 81.2–99.2], 84.2% (95% CI, 70.1–98.3) and 70.2% (95% CI, 42.2–98), respectively.Conclusions: In patients with acute type A dissection, en bloc arch reconstruction with FET technique appeared to be feasible and effective with early clinical follow-up results. Future studies including a large sample size and long-term follow-up are required to evaluate the efficacy.

Transcatheter Closure of Anastomotic Leakage of Aortic Root after Aortic Surgery for Type A Dissection: Two Case Reports

Background: Anastomotic leakage of postoperative aortic dissection is an intractable complication with different clinical manifestations. It is important to detect and manage anastomotic leakage in a timely manner. This case report describes 2 patients who were admitted to the hospital with different clinical manifestations and were diagnosed with aortic root anastomotic leakage through imaging. Both patients received transcatheter closure treatment with definite early effects.Case presentation: Two middle-aged women with aortic root anastomotic leakage who were admitted with different clinical manifestations and received transcatheter closure.Conclusion: Paying attention to the clinical manifestations and imaging diagnosis of patients after aortic dissection surgery is important for early detection of disease progression. Transcatheter closure can be used as an alternative treatment who cannot tolerate secondary thoracotomy due to its small trauma and exact efficacy in the near and medium terms, but further follow-up is needed for long-term clinical outcomes.

Endovascular therapies for Type B Aortic Dissection

: Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, type B aortic dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as primary strategy is favored. However, there has been a recent paradigm shift in management of TBAD due to late aneurysmal degeneration of TBAD increasing morbidity and mortality at longer-term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.

Expanding Perigraft Seroma after A scending Aorta Replacement

BackgroundPerigraft seroma is a persistent and sterile fluid confined within a fibrous pseudomembrane surrounding a graft that develops after graft replacement. Development of perigraft seroma is an uncommon complication that occurs after the surgical repair of the thoracic aorta using woven polyester grafts. mechanism underlying perigraft seroma formation remains unclear.Case presentationHerein, we describe the case of 77-year-old man who underwent repeat sternotomy for the treatment of large perigraft seroma 1 year after ascending aorta replacement for acute type A dissection. After removing a cloudy yellow fluid, we covered the prosthetic graft with fibrin glue and wrapped it with a new graft. Bacterial culture and laboratory examination of the fluid confirmed the final diagnosis of perigraft seroma, and there was no evidence of recurrence. The area in which fluid accumulated around the graft shrunk 1 year after surgery.ConclusionsThe cause of a expanding perigraft after repair of the thoracic aorta remains unknown. Physicians should be aware that chronic expanding mediastinal seroma with Dacron grafts is one of the rare postoperative complications of thoracic aortic surgery. Applying fibrin glue to the graft surface might effectively prevent the recurrence of perigraft seroma.