The results of an entry-oriented strategy for acute type A aortic dissection in octogenarians: an 18-year experience

Abstract

OBJECTIVES The aim of this study was to evaluate the 18-year results of emergency operations for acute type A aortic dissection, especially in octogenarians. METHODS We reviewed 199 patients who underwent surgical aortic repair of an acute type A aortic dissection from January 2001 to December 2018. If the primary entry existed in the ascending aorta, we limited the extent of the replacement to within the ascending aorta. We analysed the early and late outcomes and identified the predictive factors for in-hospital death and difficulty of direct discharge to home. RESULTS The hospital mortality was 16%. The causes of death were postoperative bleeding (n = 8, 4%), intestinal ischaemia (n = 6, 3%), respiratory failure (n = 5, 3%), systemic inflammatory response syndrome (n = 4, 2%), low output syndrome (n = 3, 2%), sudden death (n = 3, 2%), myonephrotic metabolic syndrome (n = 2, 1%) and stroke (n = 1, 1%). Multivariable analysis revealed that an estimated glomerular filtration rate <30 (P = 0.006), malperfusion (P = 0.001), rupture (P < 0.001) and cross-clamping time (P = 0.003) were independent predictive factors of in-hospital death. Age was not a significant factor for predicting in-hospital death. Ascending aorta replacement (P = 0.013), advanced age (P = 0.002) and prolonged extracorporeal circulation time (P = 0.009) were independent predictive factors of difficulty in direct discharge to home. In the late follow-up period, the 5-year survival and aortic event-free rates were 62.2% and 88.9% in octogenarians, respectively. CONCLUSIONS From the perspective of saving lives, the results of emergency surgery for octogenarians were acceptable. Avoiding the postoperative decline in activities of daily living in octogenarians is a consideration going forward.

Outcome of emergency surgery for acute type A aortic dissection in octogenarians

“…Data regarding the surgical outcomes in octogenarians were limited and the results were conflicting. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] In this study, we reported an improved surgical outcome by using a standard conservative approach of right subclavian artery cannulation, no aortic cross-clamp, selective antegrade cerebral perfusion, moderate systemic hypothermia, reinforced sandwich technique, and a strategy of limited aortic resection. The majority of operative survivors were discharged alive and well.…”

“…With increasing experience and improving surgical techniques in AAAD surgery, the operative mortality rate among octogenarians has declined to less than 30%, especially in experienced centers. [12][13][14][15][16][17][18][19][20][21] However, a significant number of the operative survivors had compromised quality of life. Hata et al 12 have reported that 17% of operative survivors were bedridden and 46% were demented.…”

“…techniques, the operative mortality rate among octogenarians has declined to 6%-26% in recent reports. [12][13][14][15][16][17][18][19][20] Nevertheless, a significant number of operative survivors were bedridden, demented, or ventilator-dependent, and had a compromised quality of life. [6][7][8][9][10][11][12][13] Being alive and well after discharge was the most important issue after AAAD surgery in octogenarians.…”

Surgical outcomes of acute type A aortic dissection in septuagenarians and octogenarians

“…Igarashi et al reported that in 199 patients and 25 octogenarians with ATAAD, multivariate logistic regression analysis identified chronic kidney disease as a significant factor for hospital mortality ( p = 0.006; odds ratio, 10.93; 95% CI, 1.996–59.846). 10 Maisat et al 16 reported that prolonged mechanical ventilation was significantly associated with increased hospital mortality and increased ICU and hospital low-output syndrome. In a large Japanese study, Ohnuma et al 17 analyzed the Japanese Diagnosis Procedure Combination database, a Japanese case-mix classification system linked with a payment system.…”

Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample

“…Although there is evidence of temporally improving surgical outcomes of ATAAD repair in recent decades, [1][2][3] short-term mortality in surgical patients remains substantial at approximately 15% to 30%. [3][4][5][6][7][8][9][10][11][12][13] In addition to hemodynamic compromise, degree of malperfusion, and burden of comorbidities, age has been consistently identified as a risk factor for intra-and postoperative mortality for patients undergoing surgical repair for ATAAD. 1,2,6,9,11,12,[14][15][16][17][18][19][20][21][22][23][24][25] Given the aging population of the United States and the rising prevalence of thoracic aortic disease in older patients, 24,26 it is becoming increasingly important to understand contemporary outcomes in this patient population.…”