Malperfusion in type A aortic dissection: results of emergency central aortic repair

Current Status of Treatment for the Acute Type A Aortic Dissection in Japan

Presenting the current status of patient outcomes with acute type A aortic dissection in Japan. The Japanese Association for Thoracic Surgery (JATS), Japanese Registry of All cardiac and Vascular Disease (JROAD), Japan Registry of Acute Aortic Dissection (JRAD), Japan Cardiovascular Surgery Database (JCVSD), National Clinical Database (NCD), The Tokyo acute aortic super network, and J-Open caRdiac aortic arCH DisEase replacement Surgical TheRApy (J-ORCHESTRA) database were used. The incidence of AAD ranged from 10 to 20 per 100,000 population. Thirty percent of patients were older than 70 years. Malperfusion syndrome or ruptured aorta was found in 10-20%. Over 90% of patients had surgery within 24-hour after diagnosis. The mortality tended to be higher in the super-acute phases from onset to surgical treatment. Acute organ malperfusion requires an accurate and prompt diagnosis to proceed with an appropriate intervention before repairing the central aorta. Antegrade cerebral perfusion was used in 70-80% and deep hypothermic circulatory arrest with/without retrograde cerebral perfusion in 20-30%. High-moderate or mild hypothermia was applied in more than 50% of patients. Replacement of the ascending aorta was performed in 70% and total arch replacement in 30%. Treatment with frozen elephant trunk as well as thoracic endovascular aortic repair (TEVAR) has increased. The aortic valve was replaced in 8-10%. Thirty-day mortality was 9.0-10%. The number of operations has increased over time. Stroke occurred in 10-12%. Although the early outcomes are acceptable, there is still room to be improved in patients with preoperative comorbidities.

FL% is associated with the severity of acute DeBakey type I aortic dissection in patients undergoing frozen elephant trunk and total arch replacement

Objectives

The diameter, area, and volume of the true lumen and false lumen (FL) have been measured in previous studies to evaluate the extent of DeBakey type I aortic dissection. However, these indicators have limitations because of the irregular shapes of the true and false lumens and the constant oscillation of intimal flap during systole and diastole. The ratio of arch lengths seems to be a more reliable indicator. FL% was defined as the ratio of the arch length of FL to the circumference of the aorta at the different levels of the aorta. The purpose of this article was to investigate whether FL% is a predictor of the severity of acute DeBakey type I aortic dissection in patients undergoing frozen elephant trunk (FET) and total arch replacement.

Methods

In this retrospective observational study, we analyzed a total of 344 patients with acute DeBakey type I aortic dissection that underwent FET and total arch replacement at our center from October 2015 to October 2019. The patients were divided into two groups by cluster analysis according to the perioperative course. Binary logistic regression analyses were performed to determine whether FL% could predict the severity of acute DeBakey type I aortic dissection. The area under the receiver operating characteristic curve (AUROC) was used to assess the power of the multivariate logistic regression model for the severity of acute DeBakey type I aortic dissection.

Results

The patients in the ultra-high-risk group (109 patients) had significantly more severe clinical comorbidities and complications than the patients in the high-risk group (235 patients). The ascending aortic FL% [odds ratio (OR), 11.929 (95% CI: 1.421-100.11); P = 0.022], location of initial tear [OR, 0.68 (95% CI: 0.47-0.98); P = 0.041], the degree of left iliac artery involvement [OR, 1.95 (95% CI: 1.15-3.30); P = 0.013], and the degree of right coronary artery involvement [OR, 1.46 (95% CI: 1.01-2.12); P = 0.045] on preoperative computed tomography angiography were associated with the severity of acute DeBakey type I aortic dissection. The AUROC value of this multivariate logistic regression analysis was 0.940 (95% CI: 0.914-0.967; P < 0.001). The AUROC value of ascending aortic FL% was 0.841 (95% CI: 0.798-0.884; P < 0.001) for the severity of acute DeBakey type I aortic dissection in patients undergoing FET and total arch replacement.

Conclusions

Ascending aortic FL% was validated as an essential radiologic index for assessing the severity of acute DeBakey type I aortic dissection in patients undergoing FET and total arch replacement. Higher values of ascending aortic FL% were more severe.

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.

Extra-anatomic revascularization and a new cannulation strategy for preoperative cerebral malperfusion due to severe stenosis or occlusion of supra-aortic branch vessels in acute type A aortic dissection

Objectives

Acute type A aortic dissection (ATAAD) with severe stenosis or occlusion of the true lumen of aortic arch branch vessels often leads to an increased incidence of severe postsurgical neurological complications and mortality rate. In this study, we aimed to introduce our institutional extra-anatomic revascularization and cannulation strategy with improved postoperative outcomes for better management of patients with cerebral malperfusion in the setting of ATAAD.

Methods

Twenty-eight patients with ATAAD complicated by severe stenosis or occlusion of the aortic arch branch vessels, as noted on combined computed tomography angiography of the aorta and craniocervical artery, between January 2021 and June 2022 were included in this study. Basic patient characteristics, surgical procedures, hospitalization stays, and early follow-up results were analyzed.

Results

The median follow-up duration was 16.5 months (interquartile range: 11.5-20.5), with a 100% completion rate. The 30-day mortality rates was 7.1% (2/28 patients); two patients had multiple cerebral infarctions on preoperative computed tomography and persistent coma. Postoperative transient neurological dysfunction occurred in 10.7% (3/28) of the patients, and no new permanent neurological dysfunction occurred. Of all the patients, 3.6% (1/28) had novel acute renal failure. No other deaths, secondary surgeries, or serious complications occurred during the early follow-up period.

Conclusions

Use of extra-anatomic revascularization and a new cannulation strategy before cardiopulmonary bypass is safe and feasible and may reduce the high incidence of postoperative neurological complications in patients with ATAAD and cerebral malperfusion.

A novel classification, management and long-term outcomes of coronary artery involvement in acute aortic dissection

BACKGROUND

To introduce a new and simple classification and management of coronary artery involvement in aortic dissection and report results.

METHODS

Coronary artery involvement was classified into two types according to the integrity of coronary intima: simple lesion (type S) and complex lesion (type C). Complex lesions were treated by CABG and simple lesions were treated by ostial repair or reimplantation. Data were collected and analyzed retrospectively.

RESULTS

From January 2010 to December 2019, 267 consecutive patients were enrolled in the study, and among them complex lesions occurred in 27 patients (11.1%) and simple lesions was found in 240 patients(89.9%). Eleven untreated vessels with simple lesion were found to be involved again in the same operation and treated by CABG. The two type groups had comparable operative mortality (type S vs. type C, 9.6% vs. 18.5%, P = 0.28). 221 patients received follow-up with a median duration of 52 months. The overall survival rates at 1, 5, and 10 years postoperatively were 88.9%, 85.7%, and 79.8% in type S group and 79.2%, 79.2%, and 79.2% in type C group, respectively (P = 0.47). For the patients who received CABG and survived at discharge, radiographic follow-up with a median duration of 28 (IQR 7-55.5) months showed the freedom from occlusion of vein graft at 1, 5, and 10 years postoperatively were 87.5%, 70.0%, 28.0%.

CONCLUSIONS

According to the new classification, two types of lesions could be treated by corresponding methods with satisfactory early and long-term results. Unrepaired coronary artery was at a risk of re-involvement. Vein graft onto arteries without atherosclerosis still had a high occlusion rate.

Impact of time from symptom onset to operation on outcome of repair of acute type A aortic dissection with malperfusion

OBJECTIVES

We analyzed patients with acute type A aortic dissection complicated by malperfusion syndrome to establish whether the timing of operative treatment and the location of malperfusion are factors in determining outcomes.

METHODS

A total of 331 patients with acute type A aortic dissection were treated surgically between August 2003 and May 2019. Eighty-four patients (25%) presented with preoperative malperfusion syndrome. Fifty-eight patients with malperfusion syndrome (69%) were transferred to the operating room within 5 hours of the onset of symptoms (immediate repair); 26 patients (31%) were transferred after 5 hours (later repair). We analyzed the effects of immediate aortic repair on surgical outcomes.

RESULTS

There was no significant difference in the early mortality rates between patients with immediate and later aortic repair, which were 20.0% (n = 11/58) and 26.9% (n = 7/19), respectively (P = .12). Preoperative coronary malperfusion was the only predictor of early mortality. The cumulative 5-year survivals of patients with malperfusion syndrome in the immediate and later repair groups were 76.7% and 45.4%, respectively. A significant difference was noted in the long-term outcomes between the 2 groups (P = .02). On multivariable Cox survival analysis, coronary malperfusion and shock on arrival were associated with increased long-term mortality (P < .01 and P = .04). Conducting surgery within 5 hours of the onset of symptoms was a significant predictor of favorable long-term outcome (P = .03).

CONCLUSIONS

Although preoperative coronary malperfusion and shock on arrival worsened the long-term outcomes in patients undergoing aortic repair for acute type A aortic dissection with preoperative malperfusion syndrome, conducting an operation within 5 hours of the onset of symptoms significantly improved their long-term outcomes.

Persistent malperfusion after central aortic repair in acute type I aortic dissections

OBJECTIVE

Acute dissection involving the ascending aorta and extending beyond the innominate artery (DeBakey type I) may be associated with acute ischemic complications owing to branch artery malperfusion. The purpose of this study was to document the prevalence of noncardiac ischemic complications associated with type I aortic dissections that persisted after initial ascending aortic and hemiarch repair, necessitating vascular surgery intervention.

METHODS

Consecutive patients presenting with acute type I aortic dissections between 2007 and 2022 were studied. Patients who underwent initial ascending aortic and hemiarch repair were included in the analysis. Study end points included the need for additional interventions after ascending aortic repair and death.

RESULTS

There were 120 patients (70% men; mean age, 58 ± 13 years) who underwent emergent repair for acute type I aortic dissections during the study period. Forty-one patients (34%) presented with acute ischemic complications. These included 22 (18%) with leg ischemia, 9 (8%) with acute strokes, 5 (4%) with mesenteric ischemia, and 5 (4%) with arm ischemia. After proximal aortic repair, 12 patients (10%) had persistent ischemia. Nine patients (8%) required additional interventions for persistent leg ischemia (n = 7), intestinal gangrene (n = 1), or cerebral edema (craniotomy, n = 1). Three other patients with acute stroke had permanent neurologic deficits. All other ischemic complications resolved after the proximal aortic repair despite mean operative times exceeding 6 hours. Comparing patients with persistent ischemia with those whose symptoms resolved after central aortic repair, there were no differences in demographics, distal extent of dissection, mean operative time for aortic repair, or need for venous-arterial extracorporeal bypass support. Overall, 6 of the 120 patients (5%) suffered perioperative deaths. Hospital deaths occurred in 3 of the 12 patients (25%) with persistent ischemia vs none of 29 patients who had resolution of the ischemia after aortic repair (P = .02). Over a mean follow-up of 51 ± 39 months, no patient required an additional intervention for persistent branch artery occlusion.

CONCLUSIONS

One-third of patients with acute type I aortic dissections had associated noncardiac ischemia, prompting a vascular surgery consultation. Limb and mesenteric ischemia most often resolved after the proximal aortic repair and did not require further intervention. No vascular interventions were performed in patients with stroke. Although the presence of acute ischemia at presentation did not increase hospital or 5-year mortality rates, persistent ischemia after central aortic repair seems to be a marker for increased hospital mortality after type I dissections.

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.

The impact of CK-MB elevation in patients with acute type A aortic dissection with coronary artery involvement

Background

Acute type A aortic dissection (ATAAD) is a fatal disease and requires emergency surgery. In particular, it is known that mortality is high when a coronary artery is involved. However, the degree of myocardial damage of the coronary acute artery involvement (ACI) varies and may or may not increase creatine kinase muscle and brain isoenzyme (CK-MB). It is unknown how CK-MB elevation affects the surgical outcome. This study compared the surgical results between the two groups of ACI with or without CK-MB elevation.

Methods

Among 348 patients who underwent an emergency operation for acute type A aortic dissection, there were 28 (8.0%) patients complicated by ACI and underwent additional coronary artery bypass grafting. We divided 26 of those patients into two groups; the MI group ( with CK-MB elevation) and the NMI group (without CK-MB elevation), and compared both groups.

Results

Of the 26, sixteen were in the MI group, and ten were in the NMI group. The average CK-MB in the MI group was 225.5 IU/L, and that in the NMI group was 13.5 IU/L. The mean time from onset to surgery was 248 min in the MI group and 250 min in the NMI group. There was statistical significance in mortality ( 69% vs. 13%, p = 0.03). There was no significance in major complications (ICU days, reintubation, reoperation, pneumonia, sepsis).

Conclusions

Acute coronary artery involvement was associated with 8.0% of patients with ATAAD, and 62% had myocardial ischemia with CK-MB elevation. The MI group had significantly higher mortality than the NMI group. It is crucial for cases with suspected ACI to obtain coronary perfusion as soon as possible to prevent CK-MB from elevating.

Effects of a frozen elephant trunk on postoperative renal dysfunction in acute type A aortic dissection extending into the renal artery

BACKGROUND

We investigated the effects of frozen elephant trunk (FET) implantation on clinical outcomes in patients with acute type A aortic dissection (ATAAD) extending into the renal artery (RA).

METHODS

Between May 2016 and April 2021, 136 patients underwent surgery for ATAAD at our hospital. Patients who died within 7 days postoperatively and those without preoperative contrast-enhanced computed tomography (CT) data were excluded from the study. The remaining 125 patients were included in this study. A preoperative CT-documented RA abnormality was found in 53 patients. Clinical outcomes, including renal dysfunction and CT findings, were compared between 29 patients with and 24 patients without the FET prosthesis.

RESULTS

Among the 53 patients with RA abnormalities, origin of the RA from the false lumen was the most common type of abnormality. The percentage of men and rate of arch repair were higher, and the operation, cardiopulmonary bypass, and lower body hypothermic circulatory arrest times were longer in the FET than in the non-FET group. Early mortality rates were similar between groups. The incidence of postoperative acute kidney injury (AKI) was lower in the FET group (35% vs. 67%, p = 0.028). Multivariable analysis showed that FET implantation was associated with a low incidence of AKI (odds ratio: 0.28, 95% confidence interval: 0.08-0.96; p = 0.043). Among the 125 patients with or without RA abnormalities, no predictor of AKI was identified.

CONCLUSION

FET implantation protected against postoperative AKI in patients with ATAAD extension into the RA.

Visceral and renal malperfusion syndromes in acute aortic dissection type A: the fate of the branch vessel

BACKGROUND

Malperfusion in acute aortic dissection is not uncommonly observed and associated with a highly significant increase in mortality and morbidity. Of the various malperfusion syndromes, visceral and renal involvement is the most challenging in terms of correct and timely diagnosis as well as the choice of management strategy. The aim of this study was to identify the pathology and associated fate of each visceral and renal vessel in acute type A dissections.

METHODS

Over a 12-year period, 167 consecutive patients with acute dissection type A extending into the thoracoabdominal aorta were included and radiographic images analyzed with a focus on individual branch vessel pathology and dependent organ perfusion.

RESULTS

Sixty-five patients (39%) were diagnosed with radiological signs of malperfusion on the CT Images. Of those, 20% expired during the hospital stay, compared to 8% without malperfusion. The left renal artery was the most frequently affected by dissection (31%) or false lumen supply (28%). False lumen perfusion was more often associated with manifest malperfusion than an extension of the dissection flap into the branch vessel. During the study period, there was no preference of surgical procedure treating the malperfusion.

CONCLUSIONS

Malperfusion of the visceral/renal branches of a dissected aorta represents a manifest indicator for postoperative mortality and morbidity. Neither clinical outcome, nor the fate of individual vessels can reliably be predicted prior to proximal reconstruction and thus, surgical strategy cannot generally be defined alone by radiological findings.

"Time is aorta?": Timeliness of surgical repair in type A aortic dissection

Acute type A aortic dissection is a life‐threatening event that requires prompt management, a complex interaction among the timing of aortic surgical repair, presence or absence of organ malperfusion, and surgical outcomes exists. Whether resection of intimal entry tear should be deferred after reversal of malperfusion and end‐organ ischemia is a matter of controversy. In fact, the timing of aortic repair should be considered within the clinical presentation and baseline characteristics of each patient. Moreover, every effort should be made to minimize times between symptom onset, diagnosis, and surgery.

An increased prothrombin time-international normalized ratio in patients with acute type A aortic dissection: contributing factors and their influence on outcomes

PURPOSE

We investigated factors contributing to coagulopathy in patients with acute type A aortic dissection (ATAAD) and coagulopathy's influence on patient outcomes.

METHODS

We grouped 420 patients who underwent ATAAD repair-none under anticoagulation therapy or with liver disease-by the prothrombin time-international normalized ratio (PT-INR) at admission:  <  1.2 (no coagulopathy, n  =  371), 1.2-1.49 (mild coagulopathy, n  =  33), or  ≥  1.5 (severe coagulopathy, n  =  16). We then compared the clinical presentation, dissection morphology, and outcomes among the groups. We assessed the PT-INR in relation to the preoperative hemodynamics and searched for factors predictive of a PT-INR  ≥  1.2.

RESULTS

The transfusion volume and operation time were increased among patients with coagulopathy (P  <  0.05). The in-hospital mortality (15.2-37.5% vs. 5.1%, P  < 0.001) and 5-year survival (61.1-74.4% vs. 87.6%) were relatively poor for these patients. The median PT-INR was 1.03 (0.97-1.1) for patients with stable hemodynamics (n  =  318), 1.11 (1.02-1.21) for those in shock (blood pressure  <  80 mmHg) not given cardiopulmonary resuscitation (CPR) (n  =  81), and 1.1 (1.0-1.54) for those in shock given CPR (n  =  21) (P  < 0.001). A multivariable analysis identified shock (P  <  0.001), a partially thrombosed false lumen (P  =  0.006), and mesenteric malperfusion (P  =  0.016) as predictive variables.

CONCLUSIONS

Shock, a partially thrombosed false lumen, and mesenteric malperfusion appear to be predictive of dissection-related coagulopathy, which influences outcomes negatively.

The effects of DeBakey type acute aortic dissection and preoperative peripheral and cardiac malperfusion on the outcomes after surgical repair

Introduction

Emergent surgical repair of DeBakey type I and II acute aortic dissection represents the standard of care to prevent lethal complications.

Aim

Evaluation of the effect of extension of aortic dissection (AAD) according to DeBakey classification, type I and II AAD, and the relationship with preoperative peripheral and myocardial malperfusion on early outcome and the mid-term follow-up period.

Material and methods

A total of 135 patients who underwent AAD surgery between January 2015 and October 2019 were analysed.

Results

In total 103 patients were affected by DeBakey type I AAD and 32 by DeBakey type II; 56 patients preoperatively showed peripheral, cardiac malperfusion, or both. Intra-operative mortality was 11%. Postoperative peripheral, cardiac malperfusion, and intraoperative and postoperative mortality were lower for type II AAD. The protective factor for intra- and postoperative 60-day mortality was type II AAD (RR = 0.03, p = 0.001); independent predictors were hypertension, and preoperative cardiac and renal-visceral malperfusion. At 5 years the overall survival was 74 ±6.9%. Independent predictors of reduced survival were major extension of type I AAD (RR = 5.37, p < 0.05) and preoperative cardiac malperfusion (RR = 5.78, p < 0.05). Five-year freedom from cardiac death, redo surgical operation, and new vascular procedures on the thoracic and abdominal aorta was 92 ±5.7%, 99 ±1.2%, and 81 ±7.2%, respectively. Extension of DeBakey type I AAD into the thoracic-abdominal aorta segment was also a predictor of the need for new vascular procedures (RR = 1.66, p = 0.05).

Conclusions

A more favourable anatomy of DeBakey type II AAD is associated with better early and late outcomes after aortic repair. This is due to a lower incidence of peripheral and cardiac malperfusion.

Clinical outcomes of a fenestrated frozen elephant trunk technique for acute type A aortic dissection

OBJECTIVES

We investigated the outcomes of a fenestrated frozen elephant trunk (FET) technique performed without reconstruction of one or more supra-aortic vessels for aortic repair in patients with acute type A aortic dissection.

METHODS

We investigated 22 patients who underwent the fenestrated FET technique for acute type A aortic dissection at our hospital between December 2017 and April 2020. The most common symptom was chest pain and/or back pain. Nine patients presented with malperfusion and 1 with cardiac arrest, preoperatively. A FET was deployed under hypothermic circulatory arrest and manually fenestrated under direct vision. Single fenestration was made in the FET in 15 patients, 2 fenestrations in 5 patients and a total fenestrated technique in 2 patients. Concomitant procedures were performed in 5 patients.

RESULTS

The cardiopulmonary bypass, aortic cross-clamp and hypothermic circulatory arrest times were 181 ± 49, 106 ± 43 and 37 ± 7 min, respectively. In-hospital mortality, stroke, or recurrent nerve injury did not occur in any patient. One patient developed paraparesis, which completely recovered at discharge. During the follow-up period (mean 18 ± 7 months), 1 patient died of heart failure. Fenestration site occlusion did not occur. Follow-up computed tomography (mean 12 ± 6 months postoperatively) revealed that the maximal aortic diameter remained unchanged at the levels of the distal end of the FET, the 10th thoracic vertebra and the coeliac artery; however, the aortic diameter was significantly reduced at the level of the pulmonary artery bifurcation.

CONCLUSIONS

The fenestrated FET technique is a simple, safe and effective procedure for selected patients with acute type A aortic dissection.

Early coronary reperfusion using only guidewires for acute type A aortic dissection

Coronary malperfusion with acute type A aortic dissection is a fatal complication. It is controversial whether to prioritize central repair or coronary reperfusion. Lifesaving becomes even more difficult if a patient has pericardial haemorrhage. Herein, we report a case of acute type A aortic dissection associated with left coronary malperfusion and pericardial haemorrhage, wherein reperfusion of the left coronary artery was performed using only guidewires, and central repair could be performed without major delay. Coronary reperfusion using only guidewires can be a revolutionary therapeutic strategy for this disease.

Short-term outcomes of acute coronary involvement in type A aortic dissection without myocardial ischemia: a multiple center retrospective cohort study

Background

To evaluate the early prognosis and management of acute coronary involvement (ACI) in type A aortic dissection (ATAAD) patients without myocardial ischemia (MI).

Methods

We conducted a retrospective cohort study on a multicenter database. A total of 931 ATAAD patients without MI underwent thoracic aortic surgery between 2018 and 2019 in the Acute Aortic Syndrome Cooperation Network (AASCN) and were enrolled in our study. Patients were divided into two groups: ACI group and non-ACI group.

Results

There were 139 ACI patients (14.9%) and 792 non-ACI patients (85.1%) in our cohort. ACI group had higher 30-day mortality after surgery than non-ACI group (log-rank test: P = 0.028,Cox regression: hazard ratio [HR], 2.3; 95% confidence interval [95% CI], 1.1–5.39; P = 0.047), especially in sub-group of advanced age (53–80 years; HR, 4.0; 95% CI, 1.3–12.8; P = 0.017), low diastolic blood pressure (29-69 mmHg, HR, 3.8; 95% CI, 1.3–11.2; P = 0.018), low systolic blood pressure (51–119 mmHg, HR, 3.6; 95% CI, 1.1–12.4; P = 0.040), high body mass index (BMI;27.25–47.52 kg/m²; HR, 3.7; 95% CI, 1.3–10.7; P = 0.015) and high hemoglobin (>145 g/L; HR, 4.3; 95% CI, 1.2–16.0; P = 0.030). Acute renal failure was significant more in ACI group than non-ACI group (24.5% vs. 15.9%; P = 0.014).

Conclusions

ACI increases the short-term postoperative mortality and acute renal failure in ATAAD patients without MI. ATAAD patients with ACI may need a narrower control range of blood pressure even if without myocardial ischemia.

Trial registration

ChiCTR1900022637. Retrospectively registered 19 April 2019.

Acute Type A Aortic Dissection With Cardiopulmonary Arrest at Presentation

BACKGROUND

Management of acute type A aortic dissection (AADA) presenting with cardiopulmonary arrest (CPA) may require aggressive cardiopulmonary resuscitation (CPR), including extracorporeal CPR followed by aortic repair. This study evaluated the early and long-term outcomes of patients with preoperative CPA related to AADA.

METHODS

Between September 2003 and August 2019, 474 patients with AADA were brought to our hospital, 157 (33.1%) presenting with CPA. Their mean age was 74.3 ± 11.3 years and prevalence of out-of-hospital CPA 90%, and causes of CPA were cardiac tamponade in 75%, hemothorax in 10%, and coronary malperfusion in 10% of cases. In the same time periods 2974 patients with CPA were transported, and AADA was 4.8% of all cause of CPA.

RESULTS

Return of spontaneous circulation was achieved in 26 patients (17%) and extracorporeal CPR was required in 31 (20%); 131 CPA patients (83%) died before surgery, 24 (15%) underwent aortic repair, and 2 (1%) received nonsurgical care. Hospital mortality was 90%, and none survived without aortic repair. Of patients achieving return of spontaneous circulation 17 underwent aortic repair, 13 survived, and 5 fully recovered. All patients with extracorporeal CPR died: 24 before surgery and 7 postoperatively. There were significant differences in hospital mortality between patients who did and did not undergo aortic repair (P < .01). Aortic repair was the only significant predictor of long-term survival (P < .01).

CONCLUSIONS

AADA with CPA is associated with significantly high mortality; however aortic repair can be performed with a 30% likelihood of functional recovery, if return of spontaneous circulation is achieved. Preoperative extracorporeal membrane oxygenation is not recommended in this patient cohort.

Long-term outcomes of treatment with different stent grafts in acute DeBakey type I aortic dissection

BACKGROUND

We developed an integrated triple-branched stent to treat acute DeBakey type I aortic dissection (AD) and modified it to enhance its adaptability. However, whether the patients treated by the modified stent would achieve better long-term prognosis is unknown.

METHODS

This study enrolled 147 patients with acute DeBakey type I AD. The original integrated triple-branched stents were used in 57 patients (Group A) between July 2012 and August 2013, and the modified stents in 90 patients (Group B) between September 2013 and March 2015. Clinical characteristics, surgical data, postoperative complications, mortality, and follow-up data of the two groups were analyzed.

RESULTS

The two groups presented comparable early death rates (Group A = 7.0%, Group B = 5.9%; p = .719). The incidence of postoperative acute kidney injury (AKI) was lower in Group B (10.0%) versus Group A (24.6%) (p = .018). Compared with the original integrated triple-branched stent graft, the modified stent could reduce the risk of early postoperative AKI (OR [95% CI] = 0.36 [0.14, 0.94]). Early endoleak rates were significantly lower in Group B (1.0%) compared to Group A (9.4%) (p = .004). During follow-up, there were five deaths in Group A (9.4%) and six deaths in Group B (7.2%) (p = .646). Chronic kidney injury (7.5% vs. 3.6%; p = .311), delayed endoleak (11.3% vs. 4.8%; p = .157), and late reinterventions (7.5% vs. 2.4%; p = .155) in the two groups were similar.

CONCLUSIONS

In patients with acute DeBakey type I AD, the modified stent showed feasible and safe treatment outcomes and reduced early endoleak rates. However, the long-term effects were similar to the original treatment.

Treatment strategies for malperfusion syndrome secondary to acute aortic dissection

OBJECTIVE

Presenting our experience of treating patients with organ malperfusion secondary to acute aortic dissection.

PATIENTS

Among 383 patients who underwent aortic repair for acute type A aortic dissection from 1999 to 2017, 107 patients were operated on because of vascular complications. Fourteen patients had coronary, 50 had brain, 3 had paraplegia, 13 had superior mesenteric artery, 21 had lower limb, and 16 had combined organ malperfusion. Age was 65.8 years.

RESULTS

In coronary malperfusion, three had a preoperative percutaneous coronary intervention, and two had mechanical support. All underwent repair of the aorta. Hospital mortality was 28.5%. Fifty patients had brain malperfusion. Hemiplegia was found in 28 patients, transient ischemic attack in 10, and coma in 12. The level of consciousness was severe in 12, moderate in 18, and mild in 20. Twenty-eight percent died of a stroke. Nine had direct perfusion from the right common carotid artery, and the consciousness level was improved in 5 patients. Eight patients had mesenteric malperfusion. Four patients had a central aorta repair first, and four patients had peripheral intervention first. Three patients had a bypass grafting to the superior mesenteric artery, and one had a catheter intervention. Postoperative mortality was found in four patients due to bowel necrosis and six required resections of the bowel.

CONCLUSION

Acute organ malperfusion caused by the aortic dissection requires accurate and prompt diagnosis to proceed with an appropriate intervention before repairing the central aorta for preventing irreversible organ damage.

Early superior mesenteric artery revascularization for acute type A aortic dissection with cardiac tamponade and mesenteric malperfusion

We report herein the successful treatment of a case of acute type A aortic dissection complicated by cardiac tamponade and mesenteric malperfusion. The patient was a 60-year-old man with back and abdominal pain and in shock, who was transported to our hospital 2 h after symptom onset. Computed tomography revealed DeBakey type I dissection with massive hemopericardium and obstruction of both the celiac artery and superior mesenteric artery. After emergency pericardiotomy and removal of the hematoma, superior mesenteric artery-external iliac artery bypass was constructed with a vein graft, and this restored mesenteric perfusion. Open distal hemiarch replacement was then performed. The postoperative course was uneventful. Superior mesenteric artery revascularization achieved immediately after release of the cardiac tamponade prevented further mesenteric ischemia and paved the way for the aortic repair.

Type A aortic dissection complicated by malperfusion syndrome

PURPOSE OF REVIEW

Malperfusion is present in up to 40% of acute type A aortic dissections (ATAADs) and results in increased morbidity and mortality. This review presents different management strategies in patients with ATAAD and malperfusion to improve outcomes.

RECENT FINDINGS

While the ideal management strategy of ATAAD complicated by malperfusion has yet to be determined, the literature provides evidence for additional techniques to be used in conjunction with central aortic repair to reduce mortality.

SUMMARY

Recent findings support a role for initial reperfusion and delayed central aortic repair, although optimal management strategy remains debated.

Factors related to white blood cell elevation in acute type A aortic dissection

Aortic dissection may induce a systemic inflammatory reaction. The etiological backgrounds for elevation of the white blood cell count remain to be clarified. In 466 patients with acute type A aortic dissection treated surgically within 48 hours of symptom onset, the etiologic background of an elevated admission white blood cell count and the effect of such elevation on outcomes were assessed retrospectively. Patients’ white blood cell count differed significantly in relation to the extent of dissection, with a median (25th, 75th percentile) white blood cell count of 10.4 (8.1, 13.9) x 10³/μL for dissection confined to the ascending aorta, 10.5 (8.2,13.) 10³/μL for dissection extending to the aortic arch/descending aorta, 11.1 (8.2, 13.7) x 10³/μL for extension to the abdominal aorta, and 13.3 (9.8, 15.9) x 10³/μL for extension to the iliac artery (p<0.001). With 11.0 x 10^3/μL used as the cut-off value for white blood cell count elevation, multivariable analysis showed current smoking (p<0.001; odds ratio, 2.79), dissection extending to the iliac artery (p = 0.006; odds ratio, 1.79), age (p = 0.007, odds ratio, 0.98), and no coronary ischemia (p = 0.027, odds ratio, 2.22) to be factors related to the elevated white blood cell count. Mean age differed significantly between patients with and without an elevated white blood cell count (62.3 vs. 68.3 years, p <0.001). Although in-hospital mortality was similar (7.5% vs.10.9%, p = 0.19), 5-year survival was lower in patients without an elevated count (85.7% vs. 78.6%, p = 0.019), reflecting their more advanced age. In conclusion, our data suggest that dissection morphology and patient age influence the acute phase systemic inflammatory response associated with an elevated white blood cell count in patients with ATAAD. A better understanding of this relation may help optimize diagnosis and perioperative care.