Extent of Aortic Replacement in Type A Dissection: Current Answers for an Endless Debate

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.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Clinical impact of turn-up anastomosis in the treatment of type A acute aortic dissection

BACKGROUND

The management of anastomosis and hemostasis of the dissected aorta remains challenging. This study aims to establish an optimal surgical strategy for type A acute aortic dissection by reviewing single-center data using the turn-up anastomosis technique.

METHODS

Between 2003 and 2015, 264 consecutive patients with type A acute aortic dissection who underwent emergency surgery within 14 days of symptom onset were enrolled.

RESULTS

The mean age of the patients was 67.7 ± 13.4 years, and 129 were males. The operative time and surgical bleeding were 390.9 ± 144.5 min and 2983.8 ± 3026.5 mL, respectively. In-hospital mortality was observed in 25 patients (9.4%), and 3 (1.1%) experienced uncontrolled bleeding (from the aortic root in two patients and coagulopathy due to dabigatran in one patient). Immediate reopening for bleeding was performed in 20 patients, and bleeding from the aortic anastomosis was observed at three proximal and two distal sites. Proximal re-dissection was observed in 18 patients; in all of which, glue was used, although two re-ruptures of the aortic root were observed among those without glue use. The rates of freedom from all-cause death, aortic death, and aortic events at postoperative 5 years were 78.5 ± 2.7%, 86.8 ± 2.1%, and 74.4 ± 2.9%, respectively. When these values were stratified according to the operative extent, no significant differences were observed.

CONCLUSIONS

Turn-up anastomosis facilitates short circulatory arrest, short operative time, and stable hemostasis, with few anastomotic complications during surgery for type A acute aortic dissection.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion?

OBJECTIVE

The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion.

METHODS

From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143).

RESULTS

The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30).

CONCLUSIONS

Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.

Postoperative acute respiratory dysfunction and the influence of antibiotics after acute type A aortic dissection surgery: A retrospective analysis

OBJECTIVES

Surgery for acute type A aortic dissection is associated with several perioperative complications, such as acute respiratory dysfunction (ARD). The aim of this study was to investigate perioperative risk factors involved in the development of ARD and whether antibiotic treatment has an impact.

METHODS

243 patients underwent surgery for acute type A aortic dissection between 2008 and 2017. The patients were retrospectively divided into the ARD and NON-ARD group. ARD was defined as PaO2/FiO2 ≤ 200 mmHg (PF ratio) within 48 hours after surgery. All patients received either narrow- or broad-spectrum antibiotics.

RESULTS

After the exclusion of 42 patients, 201 patients were analyzed. The PF ratio of the ARD group was significantly lower than of the NON-ARD group within the first 7 days. ARD patients (n = 111) were significantly older (p = .031) and had a higher body mass index (BMI) (p = .017). ARD patients required longer postoperative ventilation (2493 vs. 4695 [min], p = .006) and spent more days in the intensive care unit (7.0 vs. 8.9 [days], p = .043) compared to NON-ARD. The mortality was significantly lower for ARD than for NON-ARD patients (p = .030). The incidence of pneumonia was independent of the antibiotic treatment regime (p = .391). Renal and neurological complication rate was higher in patients treated with broad-spectrum antibiotic.

CONCLUSION

ARD is the main complication (55%) that occurs approximately 24 hours after surgery for acute type A aortic dissection. The preoperative risk factors for ARD were higher age and increased BMI. Patients on broad-spectrum antibiotics did not show an improved postoperative outcome compared to patients with narrow-spectrum antibiotics.

Outcomes of Liu's aortic root repair and valve preservation in patients with type A dissection and aortic regurgitation

OBJECTIVES

To evaluate short- and medium-term outcomes following Liu's aortic root repair and valve preservation in patients with acute type A aortic dissection complicated by moderate-to-severe aortic regurgitation (AR).

METHODS

From October 2011 to July 2018, a total of 324 consecutive patients underwent emergency surgery for acute type A aortic dissection. There were 122 patients (38%) with moderate-to-severe AR, of whom 82 (67%) underwent Liu's aortic root repair and valve preservation. Aortic computed tomography angiography and echocardiography were performed at discharge, 6 and 12 months postoperatively, and annually thereafter. We focused on assessing the survival and aortic root and valve durability in the 82 patients.

RESULTS

The 30-day, 1-year, 3-year and 6-year survival estimates were 94%, 90%, 85% and 81%, respectively. At a median follow-up of 36.5 (interquartile range 24.9-50.9) months, all patients were free from reoperation. No residual false lumens in the aortic root, recurrent aortic root dissections or aortic root pseudoaneurysms were observed during the follow-up period. Only 1 patient (1%) presented with moderate AR at 6 months, which remained asymptomatic with no significant changes over a 3-year period. The remaining patients showed satisfactory valve function with an AR grade of mild (27%) or trace or none (72%). In the competing risk analysis, the incidence of recurrence of AR was 2% at 8 years.

CONCLUSIONS

Liu's aortic root repair and valve preservation is a safe and effective operative strategy that achieves favourable short- and medium-term outcomes for acute type A aortic dissection with moderate-to-severe AR.

Pre-emptive thoracic endovascular aortic repair is unnecessary in extended type A (DeBakey type I) aortic dissections

OBJECTIVE

Pre-emptive thoracic endovascular aortic repair (TEVAR) improves late survival and limits progression of disease after type B aortic dissection, but the potential value of pre-emptive TEVAR has not been evaluated after type A dissection extending beyond the aortic arch (DeBakey type I). The purpose of this study was to compare disease progression and need for aortic intervention in survivors of acute, extended type A (ExTA) dissections after initial repair of the ascending aorta versus acute type B aortic dissections.

METHODS

Consecutive patients presenting with ExTA or type B dissections between 2011 and 2018 were studied. Forty-three patients with ExTA and 44 with type B dissections who survived to discharge and had follow-up imaging studies were included in the analysis. Study end points included progression of aortic disease (>5 mm growth or extension), need for intervention, and death.

RESULTS

The groups were not different for age, sex, atherosclerotic risk factors, or extent of dissection distal to the left subclavian artery. Following emergent ascending aortic repair, five ExTA patients (12%) underwent TEVAR within 4 months after discharge. Despite optimal medical treatment, 29 type B patients (66%) underwent early or late TEVAR (P < .001). During a mean follow-up of 38 ± 30 months, 38 ExTA patients (88%) did not require intervention-23 (53%) of whom showed no disease progression. In comparison, during a mean follow-up of 18 ± 6 months, 14 type B patients (32%) did not require intervention-nine (20%) of whom showed no disease progression (P = .003). There was one aortic-related late death in the ExTA group and two in the type B group. Compared with ExTA patients, type B patients had significantly worse intervention-free survival and intervention/growth-free survival (log rank, P < .001).

CONCLUSIONS

In contrast with type B dissections, these midterm results demonstrate that one-half of ExTA aortic dissections show no disease progression in the thoracic or abdominal aorta, and few require additional interventions. After initial repair of the ascending aorta, pre-emptive TEVAR does not seem to be justified in patients with acute, ExTA dissections.

Primary repair of re-entry intimal tear in a patient with limited extension of acute type A aortic dissection

Principles of type A aortic dissection surgery emphasize the importance of operative survival and long-term outcome. Various surgical strategies have emerged aiming for improved freedom of reoperation but they can be technically demanding or associated with higher operative risks. We report a type A aortic dissection case with extension of the dissection to the proximal descending aorta where a re-entry intimal tear was identified. Instead of extensive aortic arch repair, we managed the tear with a primary suture closure technique. In conjunction with a hemiarch repair of the proximal aorta, this approach enabled a prompt and complete resolution of the false lumen at minimal cost of circulatory arrest time.