International Registry Of Acute Aortic Dissection Research Articles

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.

Abstract 13752: Current Management and Outcomes of Acute Intramural Hematoma

Background: Optimal management of intramural hematoma (IMH) remains controversial. Previous studies offer conflicting information on how outcomes differ between patients with acute aortic dissection (AAD) and IMH. Methods: Patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2023 were stratified by AAD and IMH. True IMH, defined as the presence of intramural hematoma in the absence of both double lumen and intimal flap, was noted in 605 patients (7.7%). Results: IMH was more common in Type B patients (12.7% IMH versus 5.1% with Type A). In both groups, IMH patients were older (mean age 70.4 vs. 61.3 years, p&lt;0.001) and less frequently male (51.4% vs. 67.2%, p&lt;0.001). Marfan Syndrome was less common with IMH (1.1% vs. 4.0%, p&lt;0.001).For both dissection types, IMH patients less frequently demonstrated presenting mesenteric ischemia (Type A: 0.8% vs. 4.3%, p=0.003; Type B: 0.7% vs. 6.3%, p&lt;0.001) or limb ischemia (Type A: 3.2% vs. 12.3%, p&lt;0.001; Type B: 2.7% vs. 9.3%, p&lt;0.001). Tamponade at presentation was more common in Type A IMH (17.9% vs. 11.6%, p=0.005). Type B IMH patients had less presenting renal failure (7.5% vs. 16.9%, p&lt;0.001). Medical management alone was more commonly employed as a treatment strategy for IMH versus AAD, both in Type A (18.8% vs. 8.7%, p&lt;0.001) and Type B (78.7% vs. 56.9%, p&lt;0.0001). Correspondingly, Type B IMH patients had less endovascular management (15.6% vs. 29.3%, p&lt;0.001). Surgery was delayed beyond 48 hours of diagnosis in almost twice as many surgical Type A IMH patients (14.9% vs. 8.4%, p=0.009). Additionally, medically managed type A IMH patients had lower mortality than those with AAD (33.3% vs. 58.0%, p=0.001), although medical mortality was still higher than that of surgical patients with IMH (33.3% vs. 12.0%, p&lt;0.001). Kaplan-Meier analyses of 1-year post-discharge death, late intervention, and aortic growth were similar between groups. Conclusions: Intervention was less common among patients with IMH for both Type A and Type B. While a select subset of non-operative IMH patients had more favorable in-hospital outcomes compared to those with AAD, this mortality was still higher than for those IMH patients receiving surgery.

Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community

ObjectiveThe International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years. MethodsIRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents. ResultsNinety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index. ConclusionsIRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.

TEVAR in TBAD with high-risk features? Not so quickly!!!

For decades, the vascular community has debated the concept of vulnerable plaque to predict the risk of a devastating stroke in patients with asymptomatic carotid disease. It was, at times, rigorous and generated high-quality publications and led, in part, to randomized trials and nested registries. The term high-risk features (HRFs) has gained more credibility after the publication of the reporting standards from the Society for Vascular Surgery (SVS)-Society of Thoracic Surgeons (STS).1Lombardi J.V. Hughes G.C. Appoo J.J. Bavaria J.E. Beck A.W. Cambria R.P. et al.Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.J Vasc Surg. 2020; 71: 723-747Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar It would make sense to offer a preemptive thoracic endovascular aneurysm repair (TEVAR) in patients with HRFs in the hope of avoiding an open thoracoabdominal aortic aneurysm repair and its impact on patients and their families. However, somehow, we skipped the rigorous debate. We easily traded evidence for “common sense.” Except for one feature (aortic diameter of >40 mm), none have been validated prospectively or replicated in large case series. The combined SVS-STS committee used a single paper with mixed data and incomplete follow-up to justify adding persistent pain and hypertension to the list of HRFs, which might explain the boom of unnecessary TEVAR for uncomplicated type B aortic dissection.2Trimarchi S. Eagle K.A. Nienaber C.A. Pyeritz R.E. Jonker F.H. Suzuki T. et al.International Registry of Acute Aortic Dissection InvestigatorsImportance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).Circulation. 2010; 122: 1283-1289Crossref PubMed Scopus (153) Google Scholar Potter et al queried the Vascular Quality Initiative (VQI) for current practice patterns regarding the timing of TEVAR in patients with type B aortic dissection and refractory hypertension and/or pain and/or rapid expansion.3Potter H.S. Ding L. Han S.M. Weaver F.A. Beck A.W. Malas M.B. et al.Impact of high-risk features and timing of repair for 1 acute type B aortic dissections.J Vasc Surg. 2022; 76: 364-371Abstract Full Text Full Text PDF Scopus (2) Google Scholar They excluded ruptures, malperfusion, and uncomplicated designation (the SVS-STS considers HRF as a subset of complicated dissection). There was no comparison to those without HRFs nor to those treated medically (VQI does not record at present). I do credit the authors for being an honest messenger to tell what happens after the SVS puts out a guiding document. I find it alarming that, of 1100 patients who met the inclusion criteria, 309 received a TEVAR within 48 hours from admission just because they had one or more HRFs. This practice led to 11% stroke rate (compared with 2.3% when TEVAR was delayed to 15 days). Their conclusion was to delay intervention for at least 2 weeks from symptom onset to improve survival and lower the rate of acute complications. However, if intervention can be delayed for 2 weeks without penalty to the patient, we all should ask, why repair earlier if at all? We are due for course correction by prospectively validating HRFs, and the VQI would be most suited for such study. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Impact of high-risk features and timing of repair for acute type B aortic dissectionsJournal of Vascular SurgeryVol. 76Issue 2PreviewThe new Society for Vascular Surgery/Society for Thoracic Surgery reporting standards for type B aortic dissection (TBAD) categorize clinical presentations of aortic dissection into uncomplicated, high-risk features (HRF), and complicated groups. Although it is accepted that complicated dissections require immediate repair, the optimal timing of repair for HRF has yet to be established. This study aims to identify the ideal timing of thoracic endovascular aortic repair (TEVAR) for HRF, as well as outcomes associated with specific HRF. Full-Text PDF

Location of Aortic Enlargement and Risk of Type A Dissection at Smaller Diameters

BackgroundPrevious work has demonstrated that more than one-half of acute type A aortic dissections (ATADs) occur at a maximal aortic diameter (MAD) of <5.5 cm. However, no analysis has investigated whether ATAD risk at smaller MADs is more common with modest dilation of the aortic root (AR) or supracoronary ascending aorta (AA) in patients without genetically triggered aortopathy. ObjectivesThis study sought to determine if the segment of modest aortic dilation affects risk of ATAD. MethodsUsing the International Registry of Acute Aortic Dissection (IRAD) database from May 1996 to October 2016, we identified 667 ATAD patients with MAD <5.5 cm. Patients were stratified by location of the largest proximal aortic segment (AR or AA). Patients with known genetically triggered aortopathy were excluded. MADs at time of dissection were compared between AR and AA groups. Secondary outcomes included operation, postoperative outcomes, and long-term survival. ResultsOf patients with ATAD at an MAD <5.5 cm, 79.5% (n = 530) were in the AA group and 20.5% (n = 137) in the AR group. Modestly dilated ARs (median MAD 4.6 cm [IQR: 4.1-5.0 cm]) dissected at a significantly smaller diameter than modestly dilated AAs (median MAD 4.8 cm [IQR: 4.4-5.1 cm]) (P < 0.01). AR patients were significantly younger than AA patients (58.5 ± 13.0 years vs 63.2 ± 13.3 years; P < 0.01) and more commonly male (78% vs 65%; P < 0.01). Postoperative and long-term outcomes did not differ between groups. ConclusionsATAD appears to occur at smaller diameters in patients with modest dilation in the AR vs the AA (4.6 vs 4.8 cm). These findings may have implications for future consensus guidelines regarding the management of patients with aortic disease.

The importance of what proposed is not diminished if you are the first or the second.

The German Registry for Acute Type A Aortic Dissection (GERAADA) score was designed to predict the 30-day mortality from data of 2537 patients who underwent surgery for type A aortic dissection (TAAD), operated on from 2006 to 2015. Pollari et al. [1], in their comment, stated that ‘The GERAADA score represents not only the first score dedicated for this scope but also the first score for emergency cardiac surgery ever concepted’. In the paper where the GERAADA score was proposed [2], the authors wrote as well that ‘The GERAADA score is the first of its kind or use in patient suffering from acute type A aortic dissection,…’. Purpose of this letter is not to discuss the validity of the GERAADA score but to remember that our group [3] in 2006 proposed a similar score, the Aortic Dissection Mortality Score, based on 616 patients operated on from 1986 to 2004 of TAAD. The interest of that model was due to the (at that time) recent results from the International Registry of Acute Aortic Dissection (IRAD) [4]. Patients who, for different reasons, were not operated on had a mortality of 58%, or a survival of 42%. Although in our series all the patients were operated on, we thought, when predicted mortality reached 58%, surgery could not be mandatory but had to be performed only after careful evaluation of the clinical and anatomical situation. In that study, 35 patients had an expected mortality of 58% or higher. In these patients, the possibility to survive, according to the IRAD survey, is comparable for surgery and medical treatment. A qualitative analysis of these patients showed that 19 of these had a cardiac tamponade, and surgery was inevitable so far as life is concerned (expected mortality was 70.5% and observed mortality was 63.1%), but for the remaining 16 patients, medical treatment could be considered a better option (expected mortality was 69.1% and observed mortality was 68.7%).

HISTOPATHOLOGY AIDING IN THE DIAGNOSIS OF AN ATYPICAL CASE OF AORTIC DISSECTION

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Aortic dissection (AD) often presents as acute severe chest or back pain and hemodynamic compromise[1,2]. Early and accurate diagnosis and treatment are crucial for survival. Multiple imaging modalities can be used to demonstrate the dissection, including Computed Tomographic Angiography (CTA), Magnetic Resonance Angiography (MRA), and Transesophageal Echocardiography (TEE). We present a case where a patient with atypical presentation of AD underwent multiple diagnostic studies with inconsistent results. CASE PRESENTATION: A 47-year-old male with history of hypertension, asthma, and tobacco use presented with sudden onset of left-hand numbness, tingling, and pain with associated changes of color in his hand. Patient had sensory deficits in the left hand and left big toe. A left upper extremity (LUE) venous duplex was unremarkable. CTA of the chest showed a filling defect in the right posterior ascending aorta suggestive of an intimal flap. Esmolol was initiated. TEE did not reveal AD. Heparin was initiated. Arterial Doppler of the LUE was negative for any atherosclerotic or thrombotic diseases or evidence of obstruction. The following day, the patient experienced crushing chest pain radiating to the back. Transthoracic echocardiogram showed filling defect in the ascending aorta. Patient was operated on emergently. Although a frank AD was not observed, a mobile pedunculated mass was reported. The affected segment of the aorta was resected and a graft was used for repair. Histopathology results showed focal adventitial hemorrhage and degenerative medial changes consistent with AD. DISCUSSION: In this case of atypical AD diagnosis was not made early due to atypical symptoms and inconclusive and inconsistent imaging studies. The definitive diagnosis was made through histopathology, as even the inspection at time of surgery was inconclusive for AD, given unusual gross appearance. Painless dissection is encountered only in 6.4% of cases [3]. Conventional CT scanning has a sensitivity of 83-95% but it drops to <80% in the ascending aorta[4-7]. MRA or TEE is typically performed next to confirm the diagnosis. Despite a sensitivity of 98%[8,9], TEE was unremarkable in this case. The features of the AD on histopathology, including the presence of the intimal tear, hemorrhage near the adventitial layer, and medial degeneration confirmed the diagnosis. In a recent large cardiovascular registry, >60% of cases of AD were first identified at autopsy[10,11]. CONCLUSIONS: This case represents a diagnostic challenge and highlights the possibility of uncommon presentation of AD, and the importance of taking the results of multiple imaging modalities into consideration to confirm the diagnosis. In this case, and due to unusual gross appearance during surgery, histopathology was necessary to confirm the diagnosis. It is extraordinarily rare to require histopathology to confirm diagnosis of AD at time of surgery. REFERENCE #1: 1.Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283:897 REFERENCE #2: 2. Evangelista A, Isselbacher EM, Bossone E, et al. Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research. Circulation 2018; 137:1846. 3. Fatima S, Sharma K. Painless Aortic Dissection-Diagnostic Dilemma With Fatal Outcomes: What Do We Learn?. J Investig Med High Impact Case Rep. 2017;5(3):2324709617721252. 4. Nienaber CA, von Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993; 328:1. 5. LePage MA, Quint LE, Sonnad SS, et al. Aortic dissection: CT features that distinguish true lumen from false lumen. AJR Am J Roentgenol 2001; 177:207. REFERENCE #3: 6. Shiga T, Wajima Z, Apfel CC, et al. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Arch Intern Med 2006; 166:1350. 7. Hayter RG, Rhea JT, Small A, et al. Suspected aortic dissection and other aortic disorders: multi-detector row CT in 373 cases in the emergency setting. Radiology 2006; 238:841. 8. Moore AG, Eagle KA, Bruckman D, et al. Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International Registry of Acute Aortic Dissection (IRAD). Am J Cardiol 2002; 89:1235. 9. Hartnell G, Costello P. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993; 328:1637; author reply 1638. 10. Hosoda Y. [Pathology of aortic dissection]. Nihon Geka Gakkai Zasshi. 1996 Oct;97(10):873-8. 11. Huynh N, Thordsen S, Thomas T, Mackey-Bojack SM, Duncanson ER, Nwuado D, Garberich RF, Harris KM. Clinical and pathologic findings of aortic dissection at autopsy: Review of 336 cases over nearly 6 decades. Am Heart J. 2019 Mar;209:108-115. DISCLOSURES: No relevant relationships by Matthew Darrow, source=Web Response No relevant relationships by Muhammad Mufty, source=Web Response No relevant relationships by Pradyumna Tummala, source=Web Response

Type A Acute Aortic Dissection Presenting With Cerebrovascular Accident at Advanced Age

Our aim was to analyze outcomes of patients aged 70 years or above presenting with type A acute aortic dissection (TAAAD) and cerebrovascular accident (CVA). A retrospective analysis of the International Registry of Acute Aortic Dissection (IRAD) was conducted. Patients aged 70 years or above (n=1449) were stratified according to presence or absence of CVA before surgery (CVA: n=110, 7.6%). In-hospital outcomes and mortality up to 5 years were analyzed. Additionally, in-hospital outcomes of patients who received medical management were described. No patient presenting with CVA over the age of 87 years underwent surgery. The rates of in-hospital mortality and post-operative CVA were significantly higher in patients presenting with CVA (in-hospital mortality: 32.7% vs 21.7%, P = 0.008; post-operative CVA: 23.4% vs 8.3%, P < 0.001). Presence of CVA was independently associated with significantly increased in-hospital mortality (odds ratio 2.99, 95% confidence interval 1.35 - 6.60, P = 0.007). In survivors of the hospital stay, presenting CVA had no independent influence on mortality up to 5 years (hazard ratio 1.52, 95% confidence interval 0.99 - 2.31, P = 0.54). In medically managed patients, exceedingly high rates of in-hospital mortality (71.4%) and CVA (90.9%) were noted. Patients presenting with TAAAD and CVA at ≥ 70 years of age are at significantly increased risk of in-hospital mortality, although long-term mortality is not affected in hospital survivors. Medical management is associated with poor outcomes. We believe that surgical management should be offered after critical assessment of comorbidities.

Sex-Based Aortic Dissection Outcomes From the International Registry of Acute Aortic Dissection

BackgroundWorse outcomes have been reported for women with type A acute aortic dissection (TAAD). We sought to determine sex-specific operative approaches and outcomes for TAAD in the current era. MethodsThe Interventional Cohort (IVC) of the International Registry of Acute Aortic Dissection (IRAD) database was queried to explore sex differences in presentation, operative approach, and outcomes. Multivariable logistic regression was performed to identify adjusted outcomes in relation to sex. ResultsWomen constituted approximately one-third (34.3%) of the 2823 patients and were significantly older than men (65.4 vs 58.6 years, P < .001). Women were more likely to present with intramural hematoma, periaortic hematoma, or complete or partial false lumen thrombosis (all P < .05) and more commonly had hypotension or coma (P = .001). Men underwent a greater proportion of Bentall, complete arch, and elephant trunk procedures (all P < .01). In-hospital mortality during the study period was higher in women (16.7% vs 13.8%, P = .039). After adjustment, female sex trended towards higher in-hospital mortality overall (odds ratio, 1.40; P = .053) but not in the last decade of enrollment (odds ratio, 0.93; P = .807). Five-year mortality and reintervention rates were not significantly different between the sexes. ConclusionsIn-hospital mortality remains higher among women with TAAD but demonstrates improvement in the last decade. Significant differences in presentation were noted in women, including older age, distinct imaging findings, and greater evidence of malperfusion. Although no distinctions in 5-year mortality or reintervention were observed, a tailored surgical approach should be considered to reduce sex disparities in early mortality rates for TAAD.

Effect of Aortic Valve Type on Patients Who Undergo Type A Aortic Dissection Repair

Aortic valve replacement (AVR) is common in the setting of type A aortic dissection (TAAD) repair. Here, we evaluated the association between prosthesis choice and patient outcomes in an international patient cohort. We reviewed data from the International Registry of Acute Aortic Dissection (IRAD) interventional cohort to examine the relationship between valve choice and short- and mid-term patient outcomes. Between January 1996 and March 2016, 1290 surgically treated patients with TAAD were entered into the IRAD interventional cohort. Of those, 364 patients undergoing TAAD repair underwent aortic valve replacement (AVR; mean age, 57 years). The mechanical valve cohort consisted of 189 patients, of which 151 (79.9%) had a root replacement. The nonmechanical valve cohort consisted of 5 patients who received homografts and 160 patients who received a biologic AVR, with a total of 118 (71.5%) patients who underwent root replacements. The mean follow-up time was 2.92 ± 1.75 years overall (2.46 ± 1.69 years for the mechanical valve cohort and 3.48 ± 1.8 years for the nonmechanical valve cohort). After propensity matching, Kaplan-Meier estimates of 4-year survival rates after surgery were 64.8% in the mechanical valve group compared with 74.7% in the nonmechanical valve group (p = 0.921). A stratified Cox model for 4-year mortality showed no difference in hazard between valve types after adjusting for the propensity score (p = 0.854). A biologic valve is a reasonable option in patients with TAAD who require AVR. Although this option avoids the potential risks of anticoagulation, long-term follow up is necessary to assess the effect of reoperations or transcatheter interventions for structural valve degeneration.

Temperature Management During Circulatory Arrest: We Have the Ingredients, But What Is the Recipe?

The debate regarding the best approach to hypothermia during circulatory arrest continues. In this issue of The Annals of Thoracic Surgery, Pupovac and colleagues 1 Pupovac S.S. Hemli J.M. Bavaria J.E. et al. Moderate versus deep hypothermia in type A acute aortic dissection repair: insights from the International Registry of Acute Aortic Dissection. Ann Thorac Surg. 2021; 112: 1893-1900 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar analyze the data from the International Registry of Acute Aortic Dissection (IRAD) for patients undergoing acute type A dissection repair under moderate hypothermic circulatory arrest (MHCA) or deep hypothermic circulatory arrest (DHCA) and report equivalent stroke and mortality rate in the 2 groups, both in the unmatched and the propensity-matched cohorts. While this report from the IRAD investigators adds to a growing body of literature that supports the safety of MHCA, there are some confinements of this report that should be recognized as these data are interpreted and applied. Moderate Versus Deep Hypothermia in Type A Acute Aortic Dissection Repair: Insights from the International Registry of Acute Aortic DissectionThe Annals of Thoracic SurgeryVol. 112Issue 6PreviewThe optimal strategy for cerebral protection during repair of type A acute aortic dissection has yet to be determined. We sought to determine the impact of differing degrees of hypothermia in patients undergoing acute dissection repair. Full-Text PDF

Clinical Features and Outcomes of Pregnancy-Related Acute Aortic Dissection

Women with aortopathy conditions are at risk for pregnancy-related aortic dissection, and these conditions may not be recognized until after the aortic dissection occurs. To examine the clinical characteristics, imaging features, and outcomes in women with pregnancy-related acute aortic dissection. A cohort study, comprising data from the International Registry of Acute Aortic Dissection (IRAD) (February 1, 1998, to February 28, 2018). The multicenter referral center study included 29 women with aortic dissection during pregnancy or less than 12 weeks post partum in IRAD from 1998 to 2018. Clinical features of pregnancy-related aortic dissection to be studied included underlying aortopathy, aortic size, type of aortic dissection, timing of dissection, hypertension, and previous aortic surgery. A total of 29 women (mean [SD] age, 32 [6] years) had pregnancy-related aortic dissection, representing 0.3% of all aortic dissections and 1% of aortic dissection in women in the IRAD. Among women younger than 35 years, aortic dissection was related to pregnancy in 20 of 105 women (19%). Thirteen women (45%) had type A aortic dissection, and 16 women (55%) had type B. Aortic dissection onset was known in 27 women (93%): 15 during pregnancy, 4 in the first trimester, and 11 in the third trimester; 12 were post partum, occurring a mean (SD) of 12.5 (14) days post partum. At type A aortic dissection diagnosis, the mean (SD) aortic diameters were sinus of Valsalva, 54.5 (5) mm and ascending aorta, 54.7 (6) mm. At type B aortic dissection diagnosis, the mean (SD) descending aortic diameter was 32.5 (5) mm. Twenty women (69%) had an aortopathy condition or a positive family history: 13 women (65%) with Marfan syndrome, 2 women (10%) with Loeys-Dietz syndrome, 2 women (10%) with bicuspid aortic valves, 2 women (10%) with a family history of aortic disease, and 1 woman (5%) with familial thoracic aortic aneurysm. Aortopathy was not recognized until after aortic dissection in 47% of the women. Twenty-eight women (97%) survived aortic dissection hospitalization. Aortic dissection complicating pregnancy is rare. Most pregnancy-related aortic dissection is due to an aortopathy often not diagnosed until after aortic dissection. In this study, type A aortic dissections were associated with a dilated aorta, and type B aortic dissections often were not. Recognition of underlying conditions and risks for aortic dissection may improve management of pregnancy in women with aortopathy.

Lesson learned from the International Registry of Acute Aortic Dissection (IRAD)

Lesson learned from the International Registry of Acute Aortic Dissection (IRAD)

OUTCOMES FOLLOWING ENDOVASCULAR THERAPY IN TYPE B ACUTE AORTIC DISSECTION STRATIFIED BY RISK LEVEL

The International Registry of Acute Aortic Dissection (IRAD) previously showed a longitudinal trend of decreasing in-hospital and 5 year post discharge mortality of Type B acute aortic dissection (TBAAD). However, this decline was not observed among the subgroup of TBAAD receiving endovascular

Neurological Event Rates and Related Risk Factors in Acute Type B Aortic Dissections Treated by TEVAR – Results from the International Registry of Acute Aortic Dissection (IRAD)

Neurological Event Rates and Related Risk Factors in Acute Type B Aortic Dissections Treated by TEVAR – Results from the International Registry of Acute Aortic Dissection (IRAD)

Influence of Age on Clinical Presentation, Therapeutic Options, and Outcome in Chinese Patients with Acute Aortic Dissection.

It has been shown in previous studies that Chinese patients with acute aortic dissection (AD) were approximately 10 years younger than patients from western countries. However, there is a lack of studies concerning the age-related differences in clinical characteristics and outcomes in Chinese patients with acute AD. A total of 1,061 patients with AD (570 type A and 491 type B AD) were enrolled between 2006 and 2008. The clinical characteristics were compared between the patients in our study and those in the International Registry of Acute Aortic Dissection (IRAD). Compared with patients in the IRAD, those in our study were relatively younger, comprised more males, and had a higher proportion of Marfan syndrome but received fewer surgical interventions. When stratified by 10-year age, younger patients were more likely to have type A AD, familial AD, and Marfan syndrome, whereas older patients tended to comprise more females and type B AD. As age increased, the proportion of surgical intervention gradually decreased regardless of the type of AD. During a median follow-up of 2.2 years, 147 patients died, of whom 94 (63.9%) had type A AD and 53 (36.1%) had type B AD. Long-term mortality increased with increasing age, especially in patients above 70 years old. Furthermore, the recurrence rate of AD was higher in both the young and the older patients. In conclusion, compared with western patients with AD, Chinese patients have distinct characteristics and more attention should be paid to the young and older patients because of their high long-term mortality and recurrence rate.

ASSESSING THE ACCURACY OF THE SIMPLE RISK PREDICTION MODEL FOR ACUTE TYPE A AORTIC DISSECTION OVER TIME

In-hospital mortality following Type A acute aortic dissection (TAAAD) repair was 23.9% in a 2007 International Registry of Acute Aortic Dissection (IRAD) report. Recent publications have described surgical mortality as low as 12.2%. This study evaluates the fitness of a previously published risk

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Experience With the Axillary Artery as an Arterial Cannulation Site in Patients With Acute Type A Aortic Dissection

The optimal arterial cannulation site in patients undergoing surgical management of acute type A aortic dissection (ATAAD) remains controversial. The axillary artery is rarely involved in the dissection process, provides antegrade flow in the descending aorta and minimises intraoperative malperfusion. The purpose of this study is to evaluate a single surgeon's experience of axillary artery cannulation for ATAAD repair. All consecutive patients over a 15-year period having surgical repair of ATAAD were included in this study. There were 55 patients with a mean age of 67years. The most common risk factors were hypertension (83.6%), connective tissue disease (7.3%) and a bicuspid aortic valve (7.3%). Axillary artery cannulation was performed on 50 patients (90.9%) and was contraindicated in the remaining five patients. Forty-nine patients survived to 30days with a 10.9% 30-day mortality rate. There was one confirmed stroke (1.8%) and no new malperfusion noted postoperatively. There were no major axillary artery complications or new dissection related to cannulation. We attribute these results, which are lower than those reported in the International Registry of Acute Aortic Dissection (IRAD) database, to axillary artery cannulation providing antegrade flow in the descending aorta from the outset and reducing intraoperative malperfusion. We believe this technique offers a cerebroprotective advantage and also facilitates selective antegrade cerebral perfusion (SACP) when aortic arch replacement is required. We believe the axillary artery is the ideal cannulation site of ATAAD and helps to reduce mortality and neurological complications in this high-risk group of patients.

Malperfusion syndromes in type A aortic dissection: what we have learned from IRAD.

Patients presenting with type A acute aortic dissection (TAAD) complicated by malperfusion syndromes represent one of the highest surgical risk cohorts for cardiovascular surgeons. In the setting of aortic dissection, end-organ ischemia may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral and/or limb ischemia. In TAAD patients with malperfusion, notwithstanding continuous improvement in diagnostic and management strategies, surgical and clinical outcomes remain poor and the optimal therapy is controversial. The present review aimed to assess current evidence on TAAD patients with the complication of malperfusion, as enunciated by the International Registry of Acute Aortic Dissection (IRAD) investigators.