Chronic Type A Aortic Dissection: Two Cases and a Review of Current Management Strategies

Minimally Invasive Approach for Replacement of the Ascending Aorta towards the Proximal Aortic Arch

Objectives: In recent years, minimally invasive approaches have been used with increasing frequency, even for more complex aortic procedures. However, evidence on the practicability and safety of expanding minimally invasive techniques from isolated operations of the ascending aorta towards more complex operations such as the hemiarch replacement is still scarce to date. Methods: A total of 86 patients undergoing elective surgical replacement of the ascending aorta with (n = 40) or without (n = 46) concomitant proximal aortic arch replacement between 2009 and 2023 were analyzed in a retrospective single-center analysis. Groups were compared regarding operation times, intra- and postoperative complications and long-term survival. Results: Operation times and ventilation times were significantly longer in the hemiarch replacement group. Despite this, no statistically significant differences between the two groups were observed for the duration of the ICU and hospital stay and postoperative complication rates. At ten-year follow-up, overall survival was 82.6% after isolated ascending aorta replacement and 86.3% after hemiarch replacement (p = 0.441). Conclusions: Expanding the indication for minimally invasive aortic surgery towards the proximal aortic arch resulted in comparable postoperative complication rates, length of hospital stay and overall long-term survival compared to the well-established minimally invasive isolated supracommissural ascending aorta replacement.

Delayed surgical strategy for type A aortic dissection associated with acute hepatitis C cryoglobulinaemia

An aortic dissection is a condition resulting from a tunica intima tear of the aortic wall creating a ‘false lumen’. An acute Stanford type A (involves the aortic arch and/or ascending aorta) aortic dissection requires emergency surgical repair. To our knowledge, we report the first case in the literature where the treatment for an acute type A aortic dissection was intentionally delayed. This was decided following a multidisciplinary team discussion where it was agreed that the patient’s active hepatitis C infection should be treated prior to surgery. The patient re-presented to the hospital 4 months later with acute dyspnoea and orthopnoea where he was diagnosed with an acute-on-chronic type A aortic dissection with trachea compression. This was successfully treated with emergency surgery. However, the patient suffered residual dyspnoea, likely due to phrenic nerve injury demonstrating the impact of untreated aortic arch distension on the neighbouring trachea and phrenic nerve.

Chronic Thoracic Aortic Dissection: How to Treat, When to Intervene

Thoracic aortic dissection (AD) is associated with increased morbidity and mortality. Acute aortic syndrome is the first presentation of the disease in most cases. While acute AD management follows concrete guidelines because of its urgent and life-threatening nature, chronic AD is usually overlooked, although it concerns a wide spectrum of patients surviving an acute event. Acute AD survivors ultimately enter a chronic aortic disease course. Patients with chronic thoracic AD (CTAD) require lifelong surveillance and a proportion of them may present with symptoms and late complications demanding further surgical or endovascular treatment. However, the available data concerning the management of CTAD is sparse in the literature. The management of patients with CTAD is challenging as far as determining the best medical therapy and deciding on intervention are concerned. Until recently, there were no guidelines or recommendations for imaging surveillance in patients with chronic AD. The diagnostic methods for imaging aortic diseases have been improved, while the data on new endovascular and surgical approaches has increased significantly. In this review, we summarize the current evidence in the diagnosis and management of CTAD and the latest recommendations for the surgical/endovascular aortic repair of CTAD.

A Case of Chronic Aortic Dissection With Hemopericardium and Tamponade

Type A aortic dissection involves the separation of the wall of the ascending aorta into a true lumen and a false lumen. The finding of an aortic dissection in a patient experiencing mild to moderate symptoms for several weeks may be surprising for clinicians, given the severity of the underlying process. Here, we present an 88-year-old patient who was admitted to our hospital due to orthopnea and leg swelling for the past two to three weeks and was found to have a chronic dissection of the ascending aorta, complicated by hemopericardium and tamponade. The existing literature very rarely reports chronic type A aortic dissection with tamponade on presentation.

Cor-Knot automated fastener in distal anastomosis of total aortic arch replacement: A case report

Cor-Knot fastener use in sternotomy-based aortic arch procedures has not been reported. We present Cor-Knot fastener use over a Hegar dilator in an anatomically challenging total aortic arch replacement with no short-term and/or long-term complications.

Case Report: Are We Witnessing an Increase of Chronic Ascending Aortic Dissection as a Collateral Effect to the COVID-19 Pandemic?

Background: The COVID-19 (coronavirus disease 2019) pandemic is reducing health care accessibility to non-life-threatening diseases, thus hiding their real incidence. Moreover, the incidence of potentially fatal conditions such as acute type A aortic dissection seems to have decreased since the pandemic began, whereas the number of cases of chronic ascending aortic dissections dramatically increased. We present two patients whose management has been affected by the exceptional sanitary situation we are dealing with. Case report: A 70-year-old man with chest pain and an aortic regurgitation murmur had his cardiac workup delayed (4 months) because of sanitary restrictions. He was then diagnosed with chronic type A aortic dissection and underwent urgent replacement of ascending aorta and aortic root. The delay in surgical treatment made the intervention technically challenging because the ascending aorta grew up to 80 mm inducing strong adhesions and chronic inflammation. The second case report concerns a 68-year-old woman with right lower-limb pain who was diagnosed with deep vein thrombosis. However, a CT scan to exclude a pulmonary embolism could not be realized until 5 months later because of sanitary restrictions. When she eventually got the CT scan, it fortuitously showed a chronic dissection of the ascending aorta. She underwent urgent surgery, and the intervention was challenging because of adhesions and severe inflammation. Conclusion: Delayed treatment due to sanitary restrictions related to COVID-19 pandemic is having a significant impact on the management of potentially life-threatening conditions including type A aortic dissection. We should remain careful to avoid COVID-19 also hitting patients who are not infected with the virus.

Middle-Aged Man With Unstable Angina and an Inaccessible Right Coronary Artery

Acute myocardial ischemia and infarction from retrograde dissection of the aortic root into the coronary ostia is a potentially fatal condition. Unrecognized type A aortic dissection at the time of angiography for acute coronary syndrome (ACS) carries a high burden of morbidity and mortality. Cardiac computed tomography angiography (CCTA) has emerged as one of the instrumental tools in the diagnosis of retrograde coronary involvement from type A aortic dissections. We present a case of ACS secondary to retrograde aortic dissection extending into the right coronary artery (RCA) suspected during coronary angiography and confirmed by CCTA. The patient was managed surgically with aortic root replacement and coronary artery bypass grafting.

The future of stenting in patients with type A aortic dissection: a systematic review

Acute type A aortic dissection (ATAAD) carries high morbidity and mortality rates and is a clinical emergency. The reported mortality rate is 50% to 65% within the first 48 hours without surgical intervention. Open surgery therefore remains the gold standard management for ATAAD. However, in patients who are deemed unfit for surgery and where possible, endovascular repair offers a useful alternative to medical treatment alone or high-risk open surgical repair. Several case reports, case series, and retrospective studies have reported good outcomes following endovascular treatment. The endovascular option also has comparable early and late outcomes, favourable aortic remodelling, and satisfactory overall survival despite having a higher-risk patient cohort. However, stenting in patients with ATAAD undoubtedly still has several limitations and technical challenges.

Chronic Type A Aortic Dissection: Rare Presentation of Incidental Pericardial Effusion

Aortic dissection is the most devastating sequelae of aortopathy other than aortic rupture. However, aortic dissection can be asymptomatic in the acute phase with delayed symptomatic presentation or incidental diagnosis upon chest imaging. We report a case of a 63-year-old male who was diagnosed with pericardial effusion upon preoperative workup for elective cholecystectomy. Further investigations confirmed hemorrhagic pericardial effusion secondary to a chronic dissecting ascending aortic aneurysm. The patient condition was successfully managed with open surgical repair with an uneventful postoperative course. This case demonstrates an extremely rare presentation of incidental hemorrhagic pericardial effusion caused by a chronic dissecting ascending aortic aneurysm.

Retrospective Comparative Analysis of Computed Tomography Findings of Acute and Chronic Aortic Dissections and Intramural Hematomas

PURPOSE

The objective of this study was to assess the reliability of ancillary imaging findings in distinguishing acute from chronic aortic dissection (AD) and intramural hematoma (IMH) using computed tomography angiography (CTA).

MATERIALS AND METHODS

Two radiologists specializing in cardiothoracic and vascular imaging reviewed paired CTAs of patients with AD or IMH who underwent CTA in the acute (within 24 h of presentation) and chronic settings. The radiologists were blinded to the temporal order of the CTAs. Minimum and maximum flap thicknesses and presence or absence of pleural effusion, pericardial effusion, mediastinal hematoma or fat standing, and mediastinal lymphadenopathy were recorded.

RESULTS

Patients included 25 male individuals and 13 female individuals with a mean age of 59 years (range: 34 to 87 y). The group included 29 AD and 9 IMH cases. The median interval between the paired CTs was 542 days (range: 100 to 2533 d). Respectively, the mean minimum flap thicknesses in the acute and chronic AD were 1.3 and 1.4 mm (P=0.3), and the mean maximum flap thicknesses were 2.7 and 2.9 mm (P=0.29). The incidences of ancillary findings in acute and chronic AD and IMH were as follows: pleural effusion (55% vs. 37%, P=0.143), pericardial effusion (8% vs. 11%, P=1.0), lymphadenopathy (47% vs. 47%, P=1.0), and periaortic fat stranding (87% vs. 76%, P=0.344).

CONCLUSIONS

Ancillary CT imaging findings traditionally ascribed to acute AD and IMH are also often found in the chronic setting and are not reliable indicators of acuity. Flap thickness in AD may not be a reliable imaging indicator of acuity of AD.

The fate of unrepaired chronic type A aortic dissection

OBJECTIVES

The current guidelines do not consider chronic type A aortic dissection as one of the triggers for prophylactic aortic repair, and an aortic diameter of 55 mm is considered the threshold for surgery.

METHODS

From the institutional database, we retrieved 82 patients who were diagnosed as having chronic type A aortic dissection but did not undergo immediate surgical repair from 1997 to 2016. The primary outcome was a composite of adverse aortic events defined as aortic rupture and sudden death. Conversion to elective surgery during follow-up was regarded as competing risk for adverse events.

RESULTS

The median value of the maximal aortic diameter at baseline was 55.2 mm. During a median follow-up of 77.1 months, 19 adverse events occurred while 9 patients received elective aortic repair. On multivariable competing risk analyses, baseline aortic diameter and age emerged as significant and independent factors associated with aortic events. The estimated rates of aortic event within 5 years were 12.0%, 19.4%, and 29.7% for aortic diameters of 50, 60, and 70 mm, respectively, with escalating risk rates as age increased for the given aortic diameters.

CONCLUSIONS

In unrepaired chronic type A aortic dissection, aortic events were not infrequent even for patients with an aortic diameter of less than 55 mm. This finding indicates that there may be a need to lower the surgical threshold for chronic type A aortic dissection.

Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection

Background

Several methods of arch vessel reconstruction, such as en bloc (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD).

Methods

From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified en bloc arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up.

Results

In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%.

Conclusions

Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using en bloc technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.