Time and Risk Analysis for Acute Type A Aortic Dissection Surgery Performed by Hypothermic Circulatory Arrest, Cerebral Perfusion, and Open Distal Aortic Anastomosis

Abstract

Background: Hypothermic total circulatory arrest, retrograde or antegrade cerebral perfusion, and open distal anastomosis are important stages of surgical management and cerebral protection for acute type A dissections. Among the factors that influence survival are the transfer time to hospital from the onset of symptoms, in-hospital transfer time to operation, organ malperfusion, preoperative risk factors, and intraoperative variables. The aim of this study was to analyze time and risk factors during surgical management. Methods: Between September 1996 and March 2002, a total of 26 patients with acute type A aortic dissection were operated. Sixteen patients (61.5%) were male and mean age was 49 (13.1 years (range: 26-68). The diagnosis was based on clinical examination, telecardiography, transthoracic echocardiography, computerized tomography, and angiography. Hypothermic total circulatory arrest, retrograde or antegrade cerebral perfusion and open distal anastomosis were used during the procedures. Operative techniques were as follows: supracoronary ascending aortic replacement (17 patients), aortic root and ascending aortic replacement with flanged composite grafting technique (5 patients), replacement of ascending aorta and hemiarcus (1 patient), aortic root and ascending aortic replacement with modified Bentall technique (1 patient), replacement of ascending aorta and arcus (1 patient), and total arcus replacement with elephant trunk technique and modified Bentall procedure (1 patient). Results: The early postoperative mortality rate within the first 30 days was 26.9%, and the late postoperative mortality rate was 15.8%. Two patients (7.7%) developed major neurological complications during the postoperative period. Time to admission, durations of total circulatory arrest, crossclamp, cardiopulmonary bypass, and intubation were longer, and postoperative blood loss was greater in patients who died during early postoperative period, although the differences did not reach statistical significance. Duration of total circulatory arrest was longer in patients who developed neurological dysfunction compared to patients without this complication; this difference also did not reach statistical significance. Conclusions: Total circulatory arrest, cerebral perfusion, and open distal anastomosis are reliable options in the surgical management of acute type A aortic dissections. With open distal anastomosis aortic arcus can be evaluated, distal anastomosis can be performed more easily, and postoperative neurological recovery is hastened. In the present study, although statistical significance could not be reached due to limited sample size, the time to admission, durations of total circulatory arrest, cross-clamp, and cardiopulmonary bypass, and the amount of postoperative chest output seem to influence postoperative survival.

Is There a Weekend Effect in Surgery for Type A Dissection?: Results From the Nordic Consortium for Acute Type A Aortic Dissection Database

“…Second, we did not have complete data for all patients regarding time variables. Third, the mortality risk during the first hours after symptoms has, in previous reports, been estimated to be 1% to 2% per hour, indicating the need for immediate repair [1,14,18].…”

Evidence, Lack of Evidence, Controversy, and Debate in the Provision and Performance of the Surgery of Acute Type A Aortic Dissection

“…In diagnosed cases, time from initial symptoms to hospital presentation approximates 1 to 2 h (87). Delayed admission adversely affects outcome (101). Once admitted, the time to diagnosis varies greatly (102); 50% of patients have a time to diagnosis Ͼ6 h in Europe and Ͼ15 h in the United States, with 75% of patients having diagnostic times Ͼ3 to 4 h (87).…”

Thromboelastometry Based Early Goal-Directed Coagulation Management Reduces Blood Transfusion Requirements, Adverse Events, and Costs in Acute Type A Aortic Dissection: A Pilot Study

“…Surgery of the aortic arch is complex, and bleeding complications are still within the leading causes of death [1][2][3][4][5][6]. Furthermore, blood transfusion is associated with increased morbidity and mortality [7][8][9][10][11][12].…”