A contemporary analysis of outcomes for operative repair of type A aortic dissection in the United States

Background: Mortality rates following acute type A aortic dissection (ATAAD) repair are reduced when operations are performed by a high-volume acute aortic dissection (AAD) team, leading to efforts to centralize ATAAD care. Here, we describe our experience with ATAAD repair by our AAD team over the last 10 years, with a focus on patient selection, transfer protocols, operative approach, and volume trends over time.Methods: An AAD team was implemented at our institution in 2005, with dedicated high-volume AAD surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Further process improvements were made in 2013 to facilitate the rapid transfer of ATAAD patients to our institution using stream-lined triage, diagnostic, and transfer protocols for patients with suspected ATAAD (RACE-AD protocol). Volume trends and outcomes were assessed longitudinally over this period. in-hospital mortality rates of less than 10% were maintained over the study period.Conclusions: Centralization of ATAAD care has begun to occur at our center, with maintenance of low mortality rates for ATAAD repair. These data confirm a net positive impact on regional ATAAD outcomes through transfer of patients to a high-volume center with dedicated AAD surgeons.

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The utility of the aortic dissection team: outcomes and insights after a decade of experience

Andersen¹,

Benrashid²,

Ross³

et al. 2016

“…Any leaks are repaired at this stage. In-hospital mortality after surgery for acute type A aortic dissection in the United States has been reported to be 21 [1995][1996][1997][1998][1999][2000][2001][2002][2003]]-26% [2003][2004][2005][2006][2007][2008] in two studies based on the Nationwide Inpatient Sample (14,15). Due to techniques described above and improvements in perioperative care, the acute mortality for 889 patients presenting (from 2000-2014) with acute aortic syndrome of the ascending aorta at our institution was 5-10% (16).…”

Section: Aortic Root Managementmentioning

confidence: 99%

Surgical techniques in type A dissection

Hussain

Svensson

2016

Acute aortic dissection is a surgical emergency that must be urgently managed, with the primary goal of restoring flow to the dominant true lumen in the downstream aorta. Our preference at the Cleveland Clinic is for an open distal anastomosis technique without aortic clamping, as it permits more accurate approximation of dissected layers and more homeostatically secure anastomosis. During this procedure we employ right axillary end-to-side graft perfusion, followed by deep hypothermic circulatory arrest and antegrade brain perfusion. The distal anastomosis is performed without felt strips or glue. Critical to achieving a successful outcome is meticulous de-airing of the arch, diligent myocardial protection, and a water-tight anastomosis prior to discontinuing cardiopulmonary bypass.

“…The optimal surgical management is still an open question and several issues remain under debate. Emergency surgery is the mainstay of therapy but hospital mortality still ranges from 15% to 30% (1)(2)(3)(4). Given the high risk profile of patients with acute aortic dissection and the technical complexity of the necessary interventions, a conservative tear-oriented aortic replacement (more often a supra-coronary ascending/ hemiarch replacement) with commissural resuspension and re-establishment of the dominant blood flow in the distal true lumen currently represents the most common surgical approach.…”

Section: Perspectivementioning

confidence: 99%

Descending endograft for DeBakey type 1 aortic dissection: pro

Berretta¹,

Eusanio²

2016

The surgical management of patients with DeBakey type 1 acute aortic dissection (DBT1-AAD) represents a major challenge for aortic surgeons. It has been demonstrated that the distal false lumen remains patent in about 70% to 80% of patients undergoing DBT1-AAD surgery and that a patent false lumen worsens the prognosis. In order to improve long term outcomes and reduce the frequency of late aneurysm formation and reoperation, a more aggressive primary operation involving total arch replacement (TAR) and concomitant antegrade stenting of the descending thoracic aorta (DTA) with a frozen elephant trunk (FET) has been introduced. Such extensive operations, however, remain controversial due to their increased technical complexity and perceived higher operative mortality and morbidity. This perspective article will overview the rationale behind, and the potential advantages and current evidence for, FET surgery in acute aortic dissection.