Underwent Acute Type A Aortic Dissection Repair Research Articles

PC024. Lower Limb Malperfusion in Acute Type A Dissection

Acute type A aortic dissection (ATAD) presenting with acute limb ischemia (ALI) has been identified as a predictor of in-hospital mortality. This study examines the outcome of patients presenting with ATAD with ALI. A prospectively collected database was queried for all cases of ATAD repaired between 2002 and 2018 at a tertiary referral center. Patients presenting with ALI were identified. Comparisons between groups with and without lower extremity ALI were made. For continuous variables, univariate two-group comparisons were performed. For categorical variables, univariate two-group comparisons are performed. Statistical significance is set at P < .05. During this period, 378 patients (average age, 56.9 years) underwent ATAD repair. Of these, 62 patients (16.4%) presented with ALI; 35 patients (9.2%) presented with isolated ALI, whereas 27 (7.1%) had concomitant malperfusion in at least one other organ system. Of the 62 patients presenting with ALI, 46 (74.2%) underwent proximal aortic repair alone; 16 (25.8%) also underwent lower extremity vascular intervention (Fig). In the latter part of the study, perfusion of the ischemic limb was accomplished during repair of the ATAD through a side perfusion cannula directly from the bypass circuit (10 patients). There were six amputations (9.7%) performed in the ALI group, two of which had peripheral vascular repairs. Fasciotomies were performed on 18 patients; of these, 5 had concomitant peripheral vascular repairs. Of the 55 patients with ALI surviving past 24 hours, 34 (61%) had resolution of their lower limb ischemia with proximal repair only. The 30-day survival was decreased in patients who presented with any organ malperfusion (P = .012). However, in patients with isolated ALI, there was no significant difference in 30-day mortality (11.4%) compared with the group with no malperfusion (15.7%; P = .5). Sixteen patients underwent peripheral vascular procedures for their limb ischemia, including 10 patients who underwent bypass procedures (7 femoral-femoral, 1 axillary-femoral-femoral, and 2 axillary-femoral), with 1 patient dying within 24 hours. All six patients with adequate follow-up imaging demonstrated asymptomatic occlusion of the bypass graft. In this group, computed tomography angiography showed recanalization of the occluded native arteries. Proximal repair of ATAD resolves most associated ALI. Isolated ALI did not increase 30-day mortality. All patients with follow-up who underwent extra-anatomic bypass developed asymptomatic graft occlusion. This was attributed to competitive flow from the remodeled native arterial system.

Acute type A aortic dissection repair in younger patients.

To evaluate the surgical outcomes and midterm results of patients under 50 years old with acute type A aortic dissection (AAAD). The study population included 51 patients who underwent AAAD repair between 2003 and 2016. Of these 51 patients, 46 (90.1%) were males and 14 (27.5%) had connective tissue disorders. Twenty-five patients (49.0%) had a body mass index >25.0 kg/m2 and two patients were pregnant. Total arch replacement was performed in 39 patients (76.5%) and hemiarch replacement in 12 patients (23.5%). Twenty patients (39.2%) underwent concomitant surgeries, including root replacement, lower limb bypass, or coronary artery bypass grafting. There was one in-hospital death (2.0%). Median follow-up was 55 months and overall survival rates were 87.7% at 5 years and 81.9% at 10 years. Rates of freedom from reoperation were 60.2% at 5 years and 50.2% at 10 years. Eighteen patients (35.3%) required reoperation, due to progressive aortic dilatation, new dissection in the aortic root, infection, and hemolysis. A patent false lumen represented a significant risk factor for reoperation (P < 0.001). Four patients (7.8%) underwent reoperation within 3 months after the initial repair. Surgical outcomes after AAAD repair for young patients were satisfactory. A patent false lumen significantly increased the need for reoperation (P = 0.002), but did not affect long-term survival. Close follow-up is mandatory after the initial repair in young patients following AAAD.

Operative Strategies and Outcomes in Type A Aortic Dissection After the Enactment of a Multidisciplinary Aortic Surgery Team.

The purpose of this study was to compare operative strategies and patient outcomes in acute type A aortic dissection (ATAAD) repairs before and after the implementation of a multidisciplinary aortic surgery team. Between May 2005 and July 2014, 101 patients underwent ATAAD repair at our institution. A dedicated multidisciplinary aortic surgery team (experienced aortic surgeon, perfusionists, cardiac anesthesiologists, nurses, and radiologists) was formed in 2010. We retrospectively compared ATAAD repair outcomes in patients before (2005-2009, N = 39) and after (2010-2014, N = 62) implementation of our program. Expected operative mortality was calculated using the International Registry of Acute Aortic Dissection preoperative predictive model. This study demonstrated a significant reduction in operative mortality after implementation of the aortic surgery program (30.8% vs. 9.7%; P = 0.014). There was also an increase in the complexity of surgical technique and perfusion strategies with fewer postoperative complications related to respiratory (P < 0.0001) and renal failure (P = 0.034). Baseline demographics were similar, and there was no statistically significant difference in International Registry of Acute Aortic Dissection predictive variables between the 2 groups. However, there was a 3.5-fold reduction in the observed-to-expected (O/E) operative mortality ratio. There was a 50% increase in volume with a significant number of patients being admitted directly to our aortic center for ATAAD repair, thus avoiding delay in operation related to transfers from a secondary hospital. Patient outcomes are improved when the surgical treatment of ATAAD is managed by a high-volume multidisciplinary aortic surgery team.

Outcomes of Acute Type A Dissection Repair Before and After Implementation of a Multidisciplinary Thoracic Aortic Surgery Program

The purpose of this study was to compare the results of acute type A aortic dissection (ATAAD) repair before and after implementation of a multidisciplinary thoracic aortic surgery program (TASP) at our institution, with dedicated high-volume thoracic aortic surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Outcomes of ATAAD repair may be improved when operations are performed at specialized high-volume thoracic aortic surgical centers. Between 1999 and 2011, 128 patients underwent ATAAD repair at our institution. Records of patients who underwent ATAAD repair 6 years before (n = 56) and 6 years after (n = 72) implementation of the TASP were retrospectively compared. Expected operative mortality rates were calculated using the International Registry of Acute Aortic Dissection pre-operative prediction model. Baseline risk profiles and expected operative mortality rates were comparable between patients who underwent surgery before and after implementation of the TASP. Operative mortality before TASP implementation was 33.9% and was statistically equivalent to the expected operative mortality rate of 26.0% (observed-to-expected mortality ratio 1.30; p = 0.54). Operative mortality after TASP implementation fell to 2.8% and was statistically improved compared with the expected operative mortality rate of 18.2% (observed-to-expected mortality ratio 0.15; p = 0.005). Differences in survival persisted over long-term follow-up, with 5-year survival rates of 85% observed for TASP patients compared with 55% for pre-TASP patients (p = 0.002). ATAAD repair can be performed with results approximating those of elective proximal aortic surgery when operations are performed by a high-volume multidisciplinary thoracic aortic surgery team. Efforts to standardize or centralize care of patients undergoing ATAAD are warranted.

VS10P DOES THE IRAD SCORE PREDICT IN‐HOSPITAL MORTALITY AFTER SURGICAL TREATMENT OF ACUTE TYPE A AORTIC DISSECTION?

Purpose: A risk model for predicting in‐hospital mortality after surgical repair of acute type A aortic dissection (AAAD) was recently developed from data from the International Registry of Acute Aortic Dissection (IRAD). We sought to determine whether the IRAD risk model would accurately predict in‐hospital mortality in our series of patients with AAAD.Methodology: We retrospectively reviewed peri‐operative data from 88 patients who underwent AAAD repair on our service between 2003 and 2008. Data were collected for each of the variables in the proposed IRAD risk model for predicting in‐hospital mortality; the IRAD model was fit to these data. The IRAD risk score was calculated for each patient, and then patients were stratified into 8 groups according to their score. We compared the observed and predicted mortalities and used the likelihood ratio chi‐square test to evaluate model fit.Results: The observed in‐hospital mortality was 18% (n = 16). The variables used in the IRAD model were not significantly associated with mortality in our patients. Furthermore, in groups 2 through 8, agreement was poor between predicted and observed mortality rates: respectively, 5% vs. 10% for group 2, 10% vs. 21% for group 3, 15% vs. 33% for group 4, 25% vs. 17% for group 5, 35% vs. 50% for group 6, 45% vs. 29% for group 7, and 60% vs. 33% for group 8. The likelihood ratio chi‐square test confirmed that the IRAD model fit our data poorly (chi‐square = 10.68; degrees of freedom, 7; p = 0.15).Conclusion: The IRAD risk model did not accurately predict in‐hospital mortality in our AAAD patients. Prospective validation studies are needed before the IRAD score can be considered for adoption as a tool for making clinical decisions.