Abstract
Background: Preoperative coronary angiography is often not performed in acute Type A dissection. We examined differences in the incidence of pre-existing coronary disease and subsequent coronary events between patients undergoing acute Type A dissection repair and patients undergoing elective proximal aortic aneurysm repair. Methods: From 2000 to 2015, there were 154 acute Type A dissection repairs and 457 elective proximal aortic aneurysm repairs. We performed a retrospective review to evaluate preoperative coronary disease and postoperative coronary interventions such as percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG). Results: A total of 31 (20%) dissection patients and 123 (27%) elective surgery patients had preoperative evidence of coronary artery disease (p = 0.094). All elective surgery patients but only six (4%) dissection patients had preoperative coronary catheterization. More CABGs were performed in the elective surgery group (19%) than in the dissection group (3%, p < 0.001). There were no differences in the incidence of prior PCI, CABG, or myocardial infarction between groups. Following dissection repair, four patients required coronary interventions. Of these, two (1.3%) experienced chest pain and underwent PCI at 4.7 and 4.3 months postoperatively, respectively, and another two experienced symptoms and required PCI at 5 and 7 years, respectively. The 30-day and 14-year mortality rates after dissection repair were 13% and 24%, respectively. Although the dissection group had poorer survival than the elective surgery group (p < 0.001), there was no difference in conditional survival after aortic-related deaths over the first year were censored (p = 0.104). Conclusions: Given the low incidence of missed significant coronary disease (1.3%), it is reasonable to perform Type A dissection repair without coronary angiography.
Highlights
Acute Type A dissection is an emergent condition that requires timely operative intervention
We examined differences in the incidence of pre-existing coronary disease and subsequent coronary events between patients undergoing acute Type A dissection repair and patients undergoing elective proximal aortic aneurysm repair
Coronary angiography was not routinely performed prior to Type A dissection repairs at our institution, we found a very low incidence (2 out of 154 patients, 1.3%) of missed coronary artery disease that became symptomatic soon after surgery and required subsequent coronary intervention
Summary
Acute Type A dissection is an emergent condition that requires timely operative intervention. While aortography allows the diagnosis of concomitant native coronary artery disease during evaluation for dissection, the diagnosis of acute aortic dissection has largely been supplanted by computed tomographic angiography and sometimes magnetic resonance imaging [1], largely due to the widespread accessibility and reproducibility of these modalities. Rizzo et al found high operative mortality among patients with Type A dissection who had preoperative angiography, whereas there were no deaths due to aortic rupture or coronary artery disease complications among patients taken directly to surgery following noninvasive diagnosis of acute Type A dissection [6]. We examined differences in the incidence of pre-existing coronary disease and subsequent coronary events between patients undergoing acute Type A dissection repair and patients undergoing elective proximal aortic aneurysm repair. Conclusions: Given the low incidence of missed significant coronary disease (1.3%), it is reasonable to perform Type A dissection repair without coronary angiography
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