RETRACTED ARTICLE: Combined Interventional and Surgical Treatment for Acute Aortic Type A Dissection

Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.

Management of acute aortic syndromes

Acute aortic syndrome (AAS) is a modern term to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges. These conditions include aortic dissection, intramural haematoma (IMH), and penetrating atherosclerotic ulcer (PAU and aortic rupture); trauma to the aorta with intimal laceration may also be considered. The common denominator of AAS is disruption of the media layer of the aorta with bleeding within IMH, along the aortic media resulting in separation of the layers of the aorta (dissection), or transmurally through the wall in the case of ruptured PAU or trauma. Population-based studies suggest that the incidence of acute dissection ranges from 2 to 3.5 cases per 100 000 person-years; hypertension and a variety of genetic disorders with altered connective tissues are the most prevalent risk conditions. Patients with AAS often present in a similar fashion, regardless of the underlying condition of dissection, IMH, PAU, or contained aortic rupture. Pain is the most commonly presenting symptom of acute aortic dissection and should prompt immediate attention including diagnostic imaging modalities (such as multislice computed tomography, transoesophageal ultrasound, or magnetic resonance imaging). Prognosis is clearly related to undelayed diagnosis and appropriate surgical repair in the case of proximal involvement of the aorta; affection of distal segments of the aorta may call for individualized therapeutic approaches favouring endovascular in the presence of malperfusion or imminent rupture, or medical management.