State of the Art Review: Surgical Treatment of Acute Type A Aortic Dissection

Abstract

Acute type A aortic dissection (ATAAD) is a life-threatening event that requires immediate surgical treatment. Improvements in surgical treatment, graft technology, organ protection and imaging techniques have led to improved clinical outcomes. Individualized treatment concepts have emerged based on more advanced planning tools that allow for a tailored approach even in complex situations such as multi-level malperfusion. This review provides an overview of the current surgical treatment of ATAAD, focusing on new disease classifications, preoperative computed tomography angiography (CTA) assessment, new prosthesis and stent technologies, and organ-protection strategies.

Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in type A aortic dissection?

“…An interesting finding in the reports of the AMDS device is the resolution of the dissection involving the supra-aortic vessels following the procedure. Montagner et al 8 and Mehdiani et al 29 reported the resolution of malperfusion involving the supra-aortic vessels in all patients in their respective independent cohorts. Bozso et al 27 reported that 95% of preoperatively identified malperfused vessels were re-perfused post-operatively.…”

“…However, patients who are implanted with the AMDS device must undergo open hemi-arch replacement prior to the antegrade introduction of the bare stent into the arch, which has been associated with inferior outcomes relative to FET. 7,8 Thoraflex hybrid in clinical practice Since its introduction in 2010, THP quickly established itself as the eminent device for the treatment of complex aortic arch pathologies. 9 The FET procedure using THP has yielded consistent and positive short-and long-term outcomes, leading to its rising acceptance in the surgical community over the other available devices.…”

“…7,25,26 The German experience Two German-published cohorts have reported perioperative data on the use of the AMDS device in treating ATAAD. Montagner et al 8 reported their experience at the German Heart Centre using the AMDS device. Table 1 highlights some of the baseline characteristics, operative data and clinical outcomes of their recruited patients.…”

“…6 Several grafts have been developed to facilitate the FET procedure, with the Thoraflex Hybrid Prosthesis (THP) developed by Terumo Aortic (Vascutek, Scotland, UK) being the most notable HP available commercially. Another approach recently outlined by Bozso et al 7 and Montagner et al 8 uses the novel Ascyrus Medical Dissection Stent (AMDS; Ascyrus Medical, Boca Raton, FL, USA). The AMDS is deployed as a non-covered stent along the aortic arch as an adjunct to prior hemi-arch replacement.…”

Cerebral Protection Strategies and Stroke in Surgery for Acute Type A Aortic Dissection

“…Although acute type A aortic dissection (ATAAD) is rare, it is a possibly lethal event that presents cardiac surgeons with major challenges [ 1 , 2 , 3 ]. Even though ATAAD is still associated with high mortality and morbidity rates, thirty-day mortality has dropped to an average of 17% [ 4 ].…”