Surgical treatment strategies for patients with type A aortic dissection involving arch anomalies

Abstract

ObjectiveThe aim of the study was to investigate surgical modalities and outcomes in patients with type A aortic dissection involving arch anomalies.MethodPatients with type A aortic dissection who underwent surgical treatment at our center between January 2017 and 31 December 2020 were selected for this retrospective analysis. Data including computed tomography (CT), surgical records, and cardiopulmonary bypass records were analyzed. Perioperatively survived patients were followed up, and long-term mortality and aortic re-interventions were recorded.ResultA total of 81 patients with arch anomalies were included, 35 with “bovine” anomalies, 23 with an aberrant right subclavian artery, 22 with an isolated left vertebral artery, and one with a right-sided arch + aberrant left subclavian artery. The strategies of arch management and cannulation differed according to the anatomic variation of the aortic arch. In total, seven patients (9%) died after surgery. Patients with “bovine” anomalies had a higher perioperative mortality rate (14%) and incidence of neurological complications (16%). Overall, four patients died during the follow-up period, with a 6-year survival rate of 94.6% (70/74). A total of four patients underwent aortic re-intervention during the follow-up period; before the re-intervention, three received the en bloc technique (13.6% 3/22) and one received hybrid therapy (11.1% 1/9).ConclusionWith complete preservation and reconstruction of the supra-arch vessels, patients with type A aortic dissection combining arch anomalies can achieve a favorable perioperative prognostic outcome. Patients who received the en bloc technique are more likely to require aortic re-intervention than patients who underwent total arch replacement with a four-branched graft vessel. Cannulation strategies should be tailored according to the variation of anatomy, but routine cannulation with the right axillary artery can still be performed in most patients with arch anomalies, even for patients with an aberrant right subclavian artery.

Medical–Surgical Implications of Branching Variation of Human Aortic Arch Known as Bovine Aortic Arch (BAA)

“…Regarding the implications of surgical treatment of AADA in patients with BAAs, the perioperative mortality rate recorded in the cohort studied by Zhu et al [36] is somewhat consistent with previous studies conducted by Ma et al [53] and Waterford et al [54] who concluded that the documented perioperative mortality rate in patients with AADA was between 5 and 15%. There is research reporting a higher frequency of neurological problems in patients with AADA [41], which is consistent with the findings of the studies included in our review that patients with AADA experienced more neurological complications and perioperative deaths compared to those with various AA abnormalities.…”

“…Zhu et al [36] found that in patients with BAAs undergoing surgical treatment for AADA, the perioperative mortality rate aligns with rates reported in previous studies by Ma et al [53] and Waterford et al [54], which indicated a mortality rate of 5-15%. One study [23] showed a higher likelihood of neurological adverse events in patients with BAAs, which was supported by the findings of Zhu et al [36], who reported higher rates of neuro-related complications and perioperative fatality rate in patients with BAAs compared to those with different other anomalies.…”

“…Of the 81 patients with AA abnormalities, 35 had BAAs. Of all patients with AA anomalies, those with BAAs had the highest perioperative mortality (14%) and the highest incidence of neurological complications (16%) [36].…”