Surgery for Acute Type A Aortic Dissection

Acute aortic syndrome: nationwide study of epidemiology, management, and outcomes

BACKGROUND

Epidemiological studies on acute aortic syndrome (AAS) have relied largely on unverified administrative coding, leading to wide-ranging estimates of incidence. This study aimed to evaluate the incidence, management, and outcomes of AAS in Aotearoa New Zealand.

METHODS

This was a national population-based retrospective study of patients presenting with an index admission of AAS from 2010 to 2020. Cases from the Ministry of Health National Minimum Dataset, National Mortality Collection, and the Australasian Vascular Audit were cross-verified with hospital notes. Poisson regression adjusted for sex and age was used to investigate trends over time.

RESULTS

During the study interval, 1295 patients presented to hospital with confirmed AAS, including 790 with type A (61.0 per cent) and 505 with type B (39.0 per cent) AAS. A total of 290 patients died out of hospital between 2010 and 2018. The overall incidence of aortic dissection including out-of-hospital cases was 3.13 (95 per cent c.i. 2.96 to 3.30) per 100 000 person-years, and this increased by an average of 3 (95 per cent c.i. 1 to 6) per cent per year after adjustment for age and sex adjustment on Poisson regression, driven by increasing type A cases. Age-standardized rates of disease were higher in men, and in Māori and Pacific populations. The management strategies used, and 30-day mortality rates among patients with type A (31.9 per cent) and B (9.7 per cent) disease have remained constant over time.

CONCLUSION

Mortality after AAS remains high despite advances over the past decade. The disease incidence and burden are likely to continue to increase with an ageing population. There is impetus now for further work on disease prevention and the reduction of ethnic disparities.

[Present-day policy of surgical treatment for type A acute aortic dissection]

A surgical intervention for type A acute aortic dissection is the only effective method of treatment making it possible to prevent the development of life-threatening complications and to attain clinical recovery of the patient. Supracoronary replacement of the ascending aorta and the proximal portion of the aortic arch is considered to be the classical and most commonly used method of an open operative intervention. On the one hand, it is technically the simplest and shortest operation, and on the other, this surgical technique is often accompanied by long-term proximal and distal complications, and first of all those caused by a persistent false lumen. The accumulated surgical experience and contemporary operative techniques, as well as advances of intensive therapy in treatment of type A acute aortic dissection make it possible to currently perform more extensive primary resections in order to improve the remote results. Total aortic arch replacement, including the use of the 'frozen elephant trunk' technique leads to fast thrombosis of the false lumen, preventing progression of the disease of the thoracic aorta and promoting its positive remodelling. The article describes the perioperative therapeutic policy accepted and pursued in our medical facility, also presenting the authors' opinion on the role and place of the 'frozen elephant trunk' technique in rendering medical care for patients with type A acute aortic dissection.

Evaluation of Acute Aortic Dissection Type a Factors and Comparison the Postoperative Clinical Outcomes between Two Surgical Methods

BACKGROUND

Although aortic dissection is a rare disease, it causes high level of mortality. If ascending aorta gets involved in this disease, it is known as type A. According to small number of studies about this disease in Iran, this study conducted to detect the factors related to acute aortic dissection type A, its surgery consequences and the factors affecting them.

MATERIALS AND METHODS

In this historical cohort study, all patients having acute aortic dissection type A referring to Chamran Hospital from 2006 to 2012 were studied. The impact of two surgical methods including antegrade cerebral perfusion (ACP) and retrograde cerebral one (RCP) on surgical and long-term mortality and recurrence of dissection was determined. The relation of mortality rate and hemodynamic instability before surgery, age more than 70 years old, ejection fraction lower than 50%, prolonged cardiopulmonary bypass pump (CPBP) time and excessive blood transfusion, was assessed.

RESULTS

Surgery and long-term mortality and recurrence of dissection were 35.3%, 30.8% and 30.4%. Surgical and long-term death in the patients being operated by ACP method was lower than those one being operated by RCP (P < 0.001). Excessive blood transfusion and unstable hemodynamic condition had significant effect on surgical mortality (P = 0.014, 0.030, respectively). CPBP time and unstable hemodynamic condition affected long-term mortality significantly (P = 0.002).

CONCLUSION

The result found that ACP is the preferable kind of surgery in comparison with RCP according to the surgical and long-term mortality.

Hypertensive Emergency in Aortic Dissection and Thoracic Aortic Aneurysm-A Review of Management

Over the last few decades, treatment for aortic dissection and thoracic aortic aneurysms has evolved significantly with improvement in outcomes. Treatment paradigms include medical, endovascular and surgical options. As aortic dissection presents as a hypertensive emergency, diligent control of BP is of utmost importance in order to reduce the progression of dissection with possible aortic branch malperfusion. Treatment should begin on arrival to the emergency department and continues in the intensive care unit, endovascular suite or the operating room. Novel antihypertensive medications with improved pharmacological profile and improved surgical techniques, have improved the prognosis of patients with aortic aneurysm and/or aortic dissection. Nevertheless, morbidity and mortality remain high and hypertensive emergency poses a significant challenge in aortic dissection and thoracic aortic aneurysms.

Follow-up paradigms for stable aortic dissection

While limited data exist on which follow-up paradigms for chronic aortic dissections can be based, what information is present suggests that long-term follow-up is mandatory. In spite of the treatment modality, deaths from aortic disease continue to accrue and repeat interventions are often required over long-term follow-up. The only prospective trial data available indicate a roughly equal incidence of secondary interventions during the first and second year. Recent studies with longer follow-up suggest that the likelihood of a need for intervention ultimately diminishes. With increasing time after presentation, it may be possible to decrease the frequency of follow-up interrogations. Definitive recommendations in this regard, however, must await the availability of longer-term data.

Midterm results of aortic arch replacement in a stanford type a aortic dissection with an intimal tear in the aortic arch

Background and Objectives

Stanford type A aortic dissection is a potentially catastrophic event that requires surgical repair, on an emergency basis. The extent of arch repair that should be carried out during emergency surgery of this type is controversial. This study was designed to evaluate the results of arch replacement carried out during acute type A dissection.

Subjects and Methods

28 patients with Stanford type A dissection and who underwent arch replacement between 1995 and 2006 were reviewed.

Results

Hospital mortality was 3.6% (1 patient), and transient neurocognitive dysfunction was observed in 5 patients. During the follow-up period (mean 26±20 months; range 1 to 66 months), 3 patients underwent reoperation due to descending thoracic or abdominal aortic aneurysm. There was no late death. Follow up computed tomography was performed in 15 patients and false lumen disappeared totally or partially in 10 patients (66.7%).

Conclusion

Arch replacement for acute Stanford type A dissection may decrease the risk of late complications related to false lumen and lead to an excellent midterm survival rate.

Management of the ascending aorta in patients with bicuspid aortic valve disease

Bicuspid aortic valve (BAV) disease is the most common form of congenital heart disease, affecting 1-2% of the population. Only 20% of patients will maintain normal valve function throughout their life and more than 30% of patients will develop serious morbidity. It is a highly heritable condition, with transmission likely to be autosomal dominant. Patients with BAV have a 10-fold risk of aortic dissection when compared to the normal population. Management of BAV associated aortopathy represents a significant clinical challenge.