Acute type-A Dissection Research Articles

Aortic arch de-branching for suspected expanding perigraft haematoma after previous acute type-A dissection repair with AMDS stent: a technique for a potential future problem

BackgroundAcute Stanford type- A aortic dissections make up a large part of emergency cardiac surgery. They also carry a significant burden of morbidity. New techniques to aid aortic remodelling include the Ascyrus Medical Dissection Stent (AMDS): Its increasing use, looks to present a potential problem in cases where surgery involving the aortic arch may be required.Case reportWe present the case of a 49-year-old male who underwent urgent redo-surgery for total arch replacement and de-branching following recent replacement of the ascending aorta for acute type-A dissection, where an AMDS stent was deployed. The patient underwent total arch replacement with a stented tri-furcate prosthesis and de-branching of arch vessels with the stent landed inside the previous AMDS, to good effect.ConclusionThis case highlights a possible approach to aortic arch surgery in patients who have previous had AMDS insertion.

Axillary vs Femoral Arterial Cannulation in Acute Type A Dissection: International Multicenter Data

BackgroundCannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD). MethodsThe study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral. ResultsThe proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia. ConclusionsAxillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.

The Clinical Impact of the Extension of Acute Type A Aortic Surgery on Long-Term Outcomes: Should We Tend to Be Conservative?

Background and Objectives: Despite advances in surgical techniques, industry adjuncts, and cerebral perfusion techniques, the in-hospital mortality rate of type A acute dissection (TAAD) remains at 15-30%. This study aimed to investigate the influence of different extents of aortic resection on survival and quality of life (QoL) after long-term follow-up. Materials and Methods: A retrospective observational trial was performed, including 165 patients operated upon for TAAD. Patients were divided into two groups according to the extent of their aortic repair: the first group comprised patients who had ascending aorta replacement and the second included patients who had hemiarch or total arch replacement. The groups were compared with regard to their baseline characteristics, operative characteristics, survival, complications, and QoL during nine years of follow-up. Results: The mean follow-up time was 75.6 months (1-108 months). The mean survival in the ascending aorta repair group was 89.651 (81.242-98.061) months and was 54.801 (40.053-69.548) months in the hemiarch and arch group; the difference between the groups was significant (log-rank p < 0.001). The rate of new postoperative neurological deficits was statistically higher in the hemiarch and arch group (17.5% vs. 8.4%, p = 0.045), the most common being stroke, and was also more frequent in the hemiarch and arch group than in the ascending aorta group (with statistical significance (15.7% vs. 6.5%)). The mean SF-12 physical score from the QoL questionnaire was higher in the ascending aorta replacement group than in the hemiarch and arch group (50.1 ± 7.3 vs. 44.0 ± 11.9, p = 0.017). Additionally, the mean SF-12 mental score was higher in the ascending aorta replacement group (52.3 ± 7.3 vs. 47.1 ± 12.8, p = 0.032). Conclusions: A more aggressive approach involving aortic arch repair means a lower survival rate and lesser quality of life after long-term follow-up in comparison with the replacement of the ascending aorta. If clinically applicable, a more defensive strategy may be considered.

Early results of frozen elephant trunk in acute type-A dissection in 1445 patients

BackgroundWe aimed to briefly describe the use of total arch replacement with frozen elephant trunk in our center's 12-year treatment of acute type A dissection and the early postoperative results. We summarized the practical experience of this procedure in our center and performed regression analyses to find the independent risk factors for major complications. MethodsConsecutive patients with acute type A dissection having surgical total arch replacement with the implantation of a frozen elephant trunk were collected from January 2010 to December 2021 and were included in the analysis. For each major operation-related complication, independent risk factors were identified using both univariate and multivariate regression models. ResultsIn our institution, the total arch replacement with frozen elephant trunk procedure is used more frequently each year and makes up 70% of the surgical procedures for acute type A dissection. The overall postoperative mortality rate was 6.2%, which declined as the techniques (including surgical procedures, organ perfusion protection etc.) improved. Other complications include: 11.7% for continuous renal replacement therapy, 5.7% for stroke, 17.8% for ICU stay longer than 7 days, 10.9% for prolonged mechanical ventilation, and so on. According to regression analysis, different major complications had different independent risk factors. Several factors, such as advanced age, impaired renal function, and extended cardiopulmonary bypass time, were found to be implicated in nearly all of the complications. ConclusionTotal arch replacement plus frozen elephant trunk strategy is a safe surgical method for extensive acute type A dissection. Some factors, such as advanced age, impaired renal function, and prolonged cardiopulmonary bypass time, might be associated with poor prognosis.

Outcomes of Surgery for Acute Type-A Dissection in Octogenarians Versus Non-Octogenarians: A Systematic Review and Meta-Analysis

Acute Type-A aortic dissection (ATAAD) is a cardiothoracic emergency that requires urgent intervention. Elderly status, particularly aged >80 years, is an independent risk factor for mortality and morbidity. The mid-term outcomes of this age group are also unknown. This systematic review and meta-analysis of observational studies was therefore performed to analyse short-term and mid-term mortality and morbidity in octogenarians following surgery for ATAAD.

Abstract 11310: Neurologic, Renal, and Visceral Malperfusion are Associated With Increased Mortality in Acute Type A Dissection but Not Lower Extremity Malperfusion

Introduction: The aim of this study was to evaluate malperfusion in patients presenting with acute type A dissection (ATAD) and correlate with mortality based on organ system involved. Methods: A registry of all patients who underwent ATAD repair at our tertiary referral center between 2002 and 2018 was retrospectively queried. Patients with type B aortic dissection and chronic type A aortic dissections (time from presentation &gt; 14 days) were excluded. Malperfusion syndromes at presentation including central nervous system (brain and spinal cord), visceral renal, and lower extremity (LE) were documented. Preoperative and intraoperative variables were analyzed, and post-operative outcomes were correlated with the malperfused organ system. Results: From 2002 to 2018, 378 patients underwent ATAD repair at our tertiary referral center. The average age was 57 years, 68% were male, and 51% were white. Approximately 70% of the cohort were transferred from an outside hospital. A total of 124 patients (33%) presented with malperfusion of at least one organ: 16% (N=62) LE, 8% (N=31) brain, 8% (N=30) renal, 3% (N=11) with visceral malperfusion, and 2% (N=8) with spinal cord malperfusion. On multivariate analysis, 30-day mortality was significantly increased in patients presenting with visceral ischemia (OR=3.7, P=0.04). The average follow-up was 2.3 years. Kaplan Meier survival curves showed a significant decrease in long term survival in patients presenting with brain (P=0.01), visceral (P=0.002), and renal ischemia (P&lt;0.001). No difference in short or long-term survival was seen in patients presenting with LE ischemia (P=0.28). Conclusions: In this review, 33% of ATAD patients presented with malperfusion of at least one organ system. Visceral malperfusion was associated with poor short-term survival, whereas CNS, renal, and visceral malperfusion had decreased long term survival. LE malperfusion had no association with short or long-term mortality.

OUTCOMES OF AXILLARY VS FEMORAL ARTERIAL CANNULATION IN ACUTE TYPE A DISSECTION REPAIR: AN INTERNATIONAL MULTICENTRE STUDY

Single center studies suggest axillary arterial cannulation is safe to perform in Acute Type A Dissection (ATAD) and may be associated with reduced stroke risk. Cannulation strategies in ATAD are variable with no consensus as to the safest and most effective technique. We therefore sought to compare perioperative outcomes of Axillary versus Femoral arterial cannulation in a large cohort of ATAD among the global IRAD Investigators.

Risk factors for impaired neurological outcome after thoracic aortic surgery.

BackgroundWe aimed to identify risk factors for an impaired postoperative neurological outcome after thoracic aortic surgery.MethodsData from all patients undergoing thoracic aortic surgery between 2010 and 2020 at our institution were collected and analyzed retrospectively. Logistic regression analysis was used to identify independent risk factors for permanent postoperative neurological deficit (ND) (stroke), which was defined as a ND lasting at least seven days.ResultsThoracic aortic surgery was performed in 1,334 patients. Of these, 286 (21.4%) underwent emergency surgery. The mean EuroSCORE II was 8.6±10.1. A perioperative stroke occurred in 94 patients (7.0%). Of all strokes, 62.8% (n=59) were considered of embolic and 24.5% (n=23) of hemodynamic origin. In elective procedures, stroke rates ranged from 0.5% after valve-sparing root replacement to 8.1% after arch surgery. Adjusted logistic regression identified advanced age [>70 years; odds ratio (OR), 1.83; P=0.009], acute type A dissection (ATAD) (OR, 1.69; P=0.0495), aortic arch surgery (OR, 3.24; P<0.001), concomitant coronary artery bypass grafting (CABG) (OR, 2.19; P=0.005), and high extracorporeal circulation (ECC) time (>230 min; OR, 1.70; P=0.034) as independent risk factors for all strokes. Secondary endpoint analyses revealed that risk factors for hemodynamic stroke were arch surgery, advanced age (>70 years), atherosclerosis, and ATAD. Risk factors for embolic stroke were arch surgery, concomitant CABG and preoperative cerebral malperfusion.ConclusionsIdentified independent risk factors for all strokes were advanced age, ATAD, arch surgery, concomitant CABG, and high ECC time. Hemodynamic and embolic strokes show distinct risk profiles.

Direct Axillary Artery Cannulation for Aortic Surgery: Lessons From Contemporary Experiences

BackgroundThis study seeks to assess the outcomes of direct axillary artery (AX) cannulation for thoracic aortic surgery. MethodsFrom October 2009 to November 2021 direct AX cannulation was planned in 515 patients for thoracic aortic pathology. An important aspect of our technique is that the cannula is not inserted deeper than 3 cm. AX cannulation–related events included shift of cannulation site from the initial site, vascular injury, and iatrogenic dissection. ResultsHalf of the patients had acute type A dissection (ATAD). An angled cannula was used in 442 patients and a straight cannula in 73 patients (14.2%) after August 2020. A previously cannulated AX was reused in 36 patients (7.0%). Mortality and stroke rates were 5.4% (ATAD vs non-ATAD: 8.0% vs 2.8%, P = .008) and 2.7% (ATAD vs non-ATAD: 4.6% vs 0.8%, P = .034), respectively. AX cannulation–related events were observed in 2.7% of patients. There was no difference in the vascular injury rate between ATAD and non-ATAD cases (1.6% vs 0.4%, respectively; P = .385), between different cannula types (angled vs straight: 0.9% vs 1.4%, P = 1.00), or between primary and redo AX cannulation cases (0.8% vs 2.8%, respectively; P = .791). On multidetector computed tomography analysis using automated 3-dimensional images, the mean distance from the thoracoacromial artery to the vertebral artery on the right and left sides was 8.70 cm and 8.69 cm, respectively. ConclusionsDirect AX cannulation for thoracic aortic repair is safe and carries a low rate of vascular injury, especially in elective cases. Our direct cannulation technique, which includes not inserting a cannula deeper than 3 cm, seems to be safe in not occluding the vertebral artery.

Direct Axillary Artery Cannulation for Type A Dissection and Impact of Dissected Innominate Artery

BackgroundThis study assessed the safety of direct axillary artery (AX) cannulation for acute type A dissection (ATAD) repair, including the impact of innominate artery dissection (IAD). MethodsOf 281 consecutive patients who underwent ATAD repair from 2007 to 2020, preoperative computed tomography was available in 200 (IAD, n = 101; non-IAD, n = 99). IAD with compromised true lumen was defined as dissection in which the false lumen was greater than 50% of the IA diameter (n = 75 of 101). ResultsAX cannulation was attempted in 188 patients (94.0%), with a 1.6% vascular injury rate (3 patients), comprising bypass to the distal AX in 2 patients and local dissection in 1 patient. Deep hypothermic circulatory arrest was used for the distal repair in 89.5% of patients. Right AX cannulation was used in 80.2% of patients with IAD and in 88.9% without IAD (P = .075). Patients with IAD had more cerebral (21.8% vs 5.1%, P = .001) and arm malperfsion (11.9% vs 4.0%, P = .075). Operative death and stroke were comparable between non-IAD (8.1% vs 7.9%, P = 1.00) and IAD (4.0% vs 5.3%, P = .689) groups. The right AX was successfully used in 77.3% of IAD patients with a compromised true lumen, with comparable hospital outcomes to noncompromised IAD patients. Upper extremity malperfusion, multiorgan malperfusion, low ejection fraction, and female sex were predictors for noncannulation of the right AX. ConclusionsRoutine direct AX cannulation strategy is safe in ATAD repair. Right AX cannulation can be used in most patients with IAD, even with a compromised true lumen, with low mortality, stroke, and vascular injury rates.

Abstract 16957: Ascending Thoracic Aortic Aneurysm Wall Stresses Evolve in Parallel With Diameter Growth

Introduction: Guidelines for ascending thoracic aortic aneurysm (ATAA) repair use ATAA diameter, with repair recommended at ≥5.5cm, but ATAA biomechanics may better predict acute type A dissection (ATAD) risk. However, little is known regarding changes in wall stresses among clinically followed patients with &lt;5.5cm ATAA over time. This information is important for patient risk stratification. Hypothesis: We hypothesized that peak ATAA wall stresses would change over time in a patient-specific fashion alongside diameter. Methods: 31 nonsurgical ATAA patients (&lt;5.5cm and growth &lt;0.5cm/year) with computed tomography angiography (CTA) scans taken 3 to 5 years apart were identified. Images were used to construct patient specific three-dimensional ATAA models. Peak diastolic circumferential stresses were determined along the ascending aorta (AA), sinotubular junction (STJ), and aortic sinuses using finite element analysis. Diameters at both time points were measured from CTA scans by a single radiologist blinded to stress results. Stress and diameter distributions were compared using paired t-tests. Results: In the overall population, ATAA diameter increased over time (4.39±0.4 cm vs. 4.43±0.4 cm, p=0.02), while diastolic circumferential stresses along the aorta did not significantly change. However, we found two distinct patient groups: one where wall stresses increased and one where stresses decreased over time. Separate analysis of these groups showed significant changes in circumferential stress in all three aortic regions (488 ± 120 vs. 340 ± 63 kPa for the sinuses, 472 ± 127 vs 345 ± 76 kPa for the STJ and 337 ± 54 vs 277 ± 28 kPa for AA, p&lt;0.001), and significant increase in diameter in the group with increasing stresses (p=0.02). Conclusions: In this nonsurgical group, there is no statically significant change of peak ATAA wall stresses at diastole over 3-5 years. The patients with increased stress were found to be associated with increases in diameter during the corresponding time period. More patient specific data is required to investigate the interaction between wall biomechanics and aortic remodeling. Our results lay the foundation for developing patient-specific ATAD risk predictors for ATAD using patient-specific wall stress changes.

Endovascular exclusion of the entire aortic arch with branched stent-grafts after surgery for acute type A aortic dissection

BackgroundThe treatment of residual pathology of the aortic arch after surgical repair for type A acute dissection (AAD) represents a therapeutic challenge. Recently, new branched endovascular devices have expanded the possibility of aortic arch stent-grafting (ASG) with proximal landing in zone 0. The aim of this retrospective, single-center study was to evaluate outcomes of patients with a history of surgical repair for AAD undergoing ASG with branched devices.MethodsWe analyzed patients undergoing ASG after treatment for type AAD with 2 different branched devices: Nexus (dual-module, single branch, off-the-shelf) and RelayBranch (single-module, dual branch, custom-made). Before ASG, surgical bypass of supra-aortic vessels was performed according to patient's anatomy and to the selected device. All patients underwent clinical and computed tomography scan evaluation before hospital discharge, at 6 months, and on a yearly basis thereafter.ResultsFrom March 2017 to April 2019, 4 consecutive patients underwent ASG after surgery for AAD at our institution. Mean time from surgery for AAD to ASG was 20 months. Mean age at the time of ASG was 72 years. Nexus and Relay were implanted in 2 patients each. All patients survived and were successfully discharged. Mean intensive care unit stay and hospital stay were 3 and 19 days, respectively. We did not observe any major adverse events. At a mean follow-up of 28 months, all patients are alive and computed tomography scans showed good anatomic results with no endoleaks.ConclusionsThis preliminary experience shows that ASG after surgery for AAD is feasible and provides encouraging clinical and anatomic early results.

A modified axillo-femoral perfusion for acute type a aortic dissection accompanied with lower limb malperfusion

BackgroundLower limb malperfusion accompanied with acute type A dissection (AAD) is reported to be an independent predictor for mortality. Timely treatment is required. However, staged approach to restore the perfusion of the ischemic leg before aortic repair has a continuously increase risk of aortic rupture. Aortic repair under isolated axillary artery perfusion also has the risk of prolonging leg ischemia. Here we introduce our experience in performing axillo-femoral perfusion, which is supposed to bring benefits for treating lower limb malperfuison.MethodsThirty patients who suffered AAD accompanied by lower limb ischemia enrolled in our study. All patients received aortic repair as soon as possible using the modified axillo-femoral perfusion approach. The cardiopulmonary bypass and cooling started with the right axillary artery perfusion. Then the femoral artery of the ischemic side was exposed and sewn to a graft connected with another inflow cannula. The rectal temperature was about 31 °C when the femoral perfusion started. The perfusion of the ischemic legs preoperative was estimated after the surgery by the clinical signs, the saturation of the distal-limb, and computed tomography scan.ResultsTwenty-eight patients got good perfusion of the lower body after the surgery. Two patients received femoral-femoral artery bypass immediately after surgery because of the thrombosis in the right common iliac artery, without further injury. No peripheral vessels damage occurred, and no compartment fasciotomy or amputation needed. One patient died for the sepsis and the subsequent multi organ failure 28 days postoperative.ConclusionsThe modified axllio-femoral perfusion could restore the lower limbs’ perfusion simultaneously during the aortic surgery without neither delaying dissection repair nor prolonging the ischemic time. It is a simple, but safe and effective technique.

Type A aortic dissection in patients over the age of seventy in the UK.

Recent guidelines have stated that age alone should not be a limiting factor for offering life-saving surgery to patients with acute type A dissection (ATAD). The objective of this study was to review the outcomes of patients above the age of 70 undergoing surgery for type A aortic dissection (TAAD) in the UK. Prospectively collected data of procedures undertaken on patients with an age of 70 years or more were extracted from the National Institute for Cardiovascular Outcomes Research (NICOR) National Adult Cardiac Surgery Audit registry. All operations were performed in England and Wales between 1 April 2007 and 31 March 2013. The primary outcome for this study was in-hospital mortality. The secondary outcome was mid-term mortality followed up to 5 years. A total of 507 patients were included in the study. The highest number of procedures performed by a single surgeon during the study period was 12. The overall in-hospital mortality rate for all ATAD patients aged 70 or over was 22.5% (114 patients); the stroke rate was 11% (57) and postop dialysis rate 15% (76). ATAD is a life-threatening condition with a high mortality rate if left untreated. Our results show that surgery for ATAD in patients over 70 is feasible with acceptable mortality rates. However, similar to previous studies, rates of stroke in older patients may be higher. The present study supports the notion that age should not be a discriminating factor in operating on patients with TAAD.

Long-term experience with valve-sparing root reimplantation surgery in tricuspid aortic valve.

To analyze our long-term experience with valve-sparing reimplantation technique in treating aortic root aneurysm, aortic regurgitation, and aortic dissection in patients with tricuspid aortic valve. Between March 1998 and October 2018, 303 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 52.9 ± 15years. Time to event analysis was performed with the Kaplan-Meier method. Risk of death, reoperation, and aortic regurgitation (AR) recurrence were analyzed using the cox-regression method. In-hospital mortality was 1% (n = 3) of which two were admitted for acute aortic dissection. Median follow-up was 5.81years ([IQR]: 2.8-10years). Thirty-nine patients (14.4%) died during follow-up. At 5 and 10years, overall survival was 92 ± 2%and 75 ± 4.9%, respectively. Seventeen patients required late aortic valve reoperation. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR > 2+ and AR > 1+ at 10years was 91 ± 4% and 71.5 ± 4.6%, respectively. Significant multivariate predictors of death included age, New York Heart Association dyspnea class (NYHA), type A acute dissection (TAAD), and preoperative left ventricular end-diastolic diameter (LVEDD). Significant multivariate predictors of AR recurrence included indication for surgery, previous cardiac surgery, and presence of preoperative AR. Freedom from events like major bleeding, thromboembolic events, and infective endocarditis at 10years were 97%, 98%, and 96%, respectively. Aortic valve-sparing with the reimplantation technique has been performed for over two decades in our institution, and the results in patients with tricuspid aortic valve (TAV) are excellent in terms of survival and freedom from valve-related adverse outcomes including valve reoperation. These results continue supporting the use of valve sparing root replacement using the reimplantation technique (VSRR) in patients with aortic aneurysm, irrespective of whether they have preoperative AR or not. VSRR is safe, durable, and reproducible, but further follow-up, well into the second decade is still necessary.

28 yaşında bir bireyde dört gündür devam eden bacak ağrısı kardiyopulmoner bypass altında bir cerrahi gerektirir mi? Genç bir hastada akut tip A aort diseksiyonu

Type A dissections of the ascending aorta is usually seen in elderly hypertensive patients. This diagnosis may not come to minds in young people with atypical symptoms. We aim to emphasize that this pathology should be kept in mind as a differential diagnosis also in young patients in this case report of an 28-year-old male patient who have right lower extremity pain for last 4 days and diagnosed with acute type A dissection.

Rapid Diagnosis and Treatment of Patients with Acute Type A Aortic Dissection and Malperfusion Syndrome May Normalize Survival to that of Patients with Uncomplicated Type A Aortic Dissection.

Objectives Malperfusion syndrome in the setting of acute Type A dissection (ATAD) is typically associated with poor prognosis. We evaluated the contemporary outcomes of patients with ATAD presenting with and without malperfusion syndrome who underwent aortic surgery. Methods We performed a single-center, retrospective review of 103 consecutive patients that underwent surgery for ATAD. The cohort was dichotomized by patients with and without malperfusion syndromes. Multivariate and bivariate analyses were performed to evaluate association between the presence of malperfusion syndrome and operative outcomes. Results A total of 29 (28.1%) patients presented with malperfusion syndrome. The 30-day mortality for patients presenting with and without malperfusion was 13.7 and 9.4%, respectively ( p = 0.49). Patients with malperfusion syndrome had a shorter mean admission-to-incision interval of 4.3 ± 2.5 hours compared with 6.3 ± 4.6 hours for those without malperfusion ( p = 0.02). Difference in 30-day mortality for patients with and without malperfusion syndrome was found to be nonsignificant on multivariate regression analysis (odds ratio: 1.53; 95% confidence interval: 0.40–5.82, p = 0.49). Conclusions This series demonstrated that there was nonsignificant difference in early- or midterm outcomes for patients with and without malperfusion syndrome. Patients with malperfusion were taken to the operating room more rapidly than those without, which offers a potential explanation for the comparable outcome of the malperfusion cohort.

Cause of Death Following Surgery for Acute Type A Dissection: Evidence from the Canadian Thoracic Aortic Collaborative.

Surgery confers the best chance of survival following acute Type A dissection (ATAD), yet perioperative mortality remains high. Although perioperative risk factors for mortality have been described, information on the actual causes of death is sparse. In this study, we aimed to characterize the inciting events causing death during surgical repair of ATAD. Nine centers participated in the study. We included all patients who died following surgical repair for ATAD between January 2007 and December 2013. An aortic surgeon at each site determined the primary cause of death from seven predetermined categories: cardiac, stroke, hemorrhage, other organ ischemia (peripheral, renal, or visceral), multiorgan failure, sepsis, or other causes. Additional characteristics and variables were analyzed to delineate potential modifiable factors for mortality. Of the 692 surgeries for ATAD, there were 123 deaths (17.8% mortality rate). Mean age at death was 66 years. Events contributing to death were: cardiac (25%), stroke (22%), hemorrhage (21%), multiorgan failure (12%), other organ ischemia (11%), sepsis (4%), and other causes (5%). Neurologic injury at presentation was a predictor of stroke as the inciting cause of death (p = 0.04). Peripheral, renal, or visceral ischemia at presentation was highly predictive of death due to these presenting ischemic conditions (p = 0.004). We found no associations between cardiogenic shock, tamponade, or cardiopulmonary bypass duration and cardiac death. Operative mortality for ATAD remains high in Canada. Nearly 70% of deaths arise from cardiac failure, stroke, or hemorrhage. Therefore, novel surgical, hybrid, and endovascular strategies should target these three areas.

Total Arch Replacement Versus More Conservative Management in Type A Acute Aortic Dissection

Surgical management of aortic arch in type A acute dissection (TAAD) is controversial. This study compared short-term and long-term outcomes of total arch replacement (TAR) interventions versus more conservative arch management (CAM). Between 1997 and 2012, 240 patients underwent TAAD surgery in our institution; 53 (22.1%) received TAR and 187 (77.9%) received CAM. Compared with CAM patients, those undergoing TAR were younger (59.1 vs 64.4 years, p = 0.004) and were less likely to present with cardiogenic shock (3.8 vs 14.4, p = 0.02). Distal site of intimal tear (arch or descending aorta) was predictive of TAR management (odds ratio [OR], 9.1; p < 0.001). Hospital mortality was similar in the groups (24.1% vs 22.6%; p = 0.45), and no other significant differences were observed in terms of major postoperative complications. Age (OR, 1.047; p = 0.007) and cardiopulmonary bypass time (OR, 1.005 per minute; p = 0.05) emerged as independent predictors of hospital death. The TAR management did not affect hospital mortality (propensity score [PS] adjusted OR: 1.51, p = 0.36). On Kaplan-Meier analysis, 7-year survival (TAR, 52.1% ± 0.9% vs CAM, 57.2% ± 4.2%, log-rank p = 0.9) and freedom from aortic re-intervention (TAR, 71.6% ± 1.3% vs CAM, 85.4% ± 3.9%, log-rank p = 0.3) were similar. The PS-adjusted Cox regression showed no relationship between type of arch management and follow-up survival (hazard ratio [HR], 1.001; p = 0.8) or need for re-intervention (HR, 1.507; p = 0.4). In our experience TAR and CAM were associated with similar hospital mortality and morbidity rates. Nevertheless, the more extensive arch interventions were not protective for long-term survival and freedom from aortic re-intervention. Thus, in TAAD patients TAR remains indicated by site of intimal tear and patient-specific factors.

Subclavian artery cannulation provides superior outcomes in patients with acute type-A dissection: long-term results of 290 consecutive patients

The short-term results of subclavian artery cannulation (SC) for acute type-A dissection repair have been reported to be superior in regard to mortality and neurological outcomes when compared to femoral cannulation (FC). This study evaluates the long-term results of subclavian artery cannulation versus femoral cannulation for repair of acute type-A dissection with particular regard to neurological deficits, mortality and the need for re-operations. From 1992-2005, 346 patients underwent surgical repair of acute type-A dissection of which 290 patients survived the operation. SC was performed in 114 patients and FC in 176 patients. Follow-up (FU) was completed in 89.5% (n = 259) and the medium FU-period was 42 months (SC) and 69 months (FC). Endpoints were persistence of neurological-deficits, mortality, major complications and necessity for re-operations. Overall survival and disease-free survival at 5 years were significantly higher in the SC group (83% vs. 71%; p = 0.022 and 74% vs. 61%; p = 0.044). Freedom of re-operation also appeared to be higher in the SC group (89% vs. 79%; p = 0.125). During the follow-up period, 28 patients (11/114 vs. 17/176; p = 0.58) suffered from neurological deficits of which 16 patients had permanent neurological-deficits at the 5 year follow-up. Of these patients, significantly more belonged to the FC group indicating an improved neurological-outcome for the SC group (3/11 vs. 13/17; p = 0.019). This study demonstrates excellent long-term outcomes after emergency surgery for acute type-A dissection. Subclavian artery perfusion represents an excellent approach to repair acute type-A dissection. Beside a significantly reduced long-term mortality, this technique provides an improved neurological outcome and a higher disease-free survival-rate.