Acute type A aortic dissection complicated by stroke: Can immediate repair be performed safely?

Estrera, Anthony L.; Garami, Zsolt; Miller, Charles C.; Porat, Eyal E.; Achouh, Paul; Dhareshwar, Jayesh; Meada, Riad; Azizzadeh, Ali; Safi, Hazim J.

doi:10.1016/j.jtcvs.2006.07.026

Cited by 141 publications

(139 citation statements)

References 13 publications

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“…Shortening the length of time between onset of cerebral symptoms and dissected aortic surgery was critical for improved outcomes in this subset of patients. Estrera et al [23] reported improved outcomes in AAAD patients who underwent cardiac surgeries within 10 h of neurological symptom onsets.…”

Section: [22]mentioning

confidence: 99%

The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival

Nardi¹,

Olevano²,

Bassano³

et al. 2017

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How to cite this article: Nardi P, Olevano C, Bassano C, Bovio E, Cecchetti L, Forlani S, Ruvolo G. The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival. Vessel Plus 2017;1:77-83. Aim:To evaluate whether postoperative malperfusion (PM) affected in-hospital and longterm survival in acute type A aortic dissection (AAAD) surgical patients and to identify risk factors for PM. Methods: Patients who underwent AAAD surgery at a single institution between January 2005 and March 2015 were retrospectively analyzed. Results: Twohundred fourteen patients with complete data were identified. At presentation, 119 patients (55.6%) showed preoperative malperfusions: 68 (31.8%) were cerebral, 38 (17.7%) were renal, and 13 (6.1%) were mesenteric. PM was found in 55 patients (25.7%). In-hospital mortality was 47.3% (26/55) vs. 22.6% (36/159) in PM and non-PM patients, respectively (P < 0.0001). Independent predictors for in-hospital mortality included being 75 years or older [odds ratio (OR): 1.1, 95% confidence interval (CI): 1.03-1.13, P < 0.001] and having renal PM (OR: 53.5, 95% CI: 3.97-721.3, P < 0.01). Five-year survival was 78.6 ± 7.8% vs. 93.9 ± 3.4% in PM and non-PM patients, respectively (P < 0.001). Independent predictors for long-term survival were being at least 75 years old (OR: 3.7, 95% CI: 0.9-14.0, P = 0.05) and having renal PM (OR: 28.6, 95% CI: 1.8-462.0, P = 0.01). PM and intimal tears distal to the ascending aorta or the proximal aortic arch were also risk factors. Conclusion: PM, especially with renal involvement, is associated with in-hospital mortality and reduced long-term survival. AAAD surgeries reduced preoperative malperfusions. Sites of cannulation and interventions requiring circulatory arrest during cardiopulmonary bypass were not predictors of PM. Key words:Acute type aortic dissection, aortic surgery, malperfusion, survival ABSTRACTArticle history:

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Section: [22]mentioning

confidence: 99%

The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival

Nardi¹,

Olevano²,

Bassano³

et al. 2017

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“…Other investigators stated that neurologic findings may be reversible, and immediate surgery should not be contraindicated. 50,51) Broad cerebral infarction, however, may cause severe brain edema by cardiopulmonary bypass. In such cases, delayed surgery may be recommended.…”

Section: Cerebral Malperfusionmentioning

confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.Keywords: aortic dissection, malperfusion, complication, echocardiography A cute type A aortic dissection (AAAD) not only causes sudden death at the time of onset but leads to various life-threatening complications. In spite of improved diagnostic imaging and surgical strategies, in-hospital mortality is still high, and patients who have survived often suffer from sequelae that make subsequent quality of life poor. This article is aimed to review the latest literature and ideas to seek the best possible way to minimize undesirable results.Various complications of AAAD caused by separation of the aortic wall to outer and inner layers are summarized as three categories: 1) aortic rupture due to disruption of the outer layer; 2) malperfusion caused by the inner layer, that is, the intimal flap; and 3) aortic regurgitation by a deformed aortic valve, leading to acute heart failure. Approximately 20% of patients instantaneously die due to aortic rupture, 1) and 1 to 2% of the remaining patients die every hour unless appropriately treated. 2) Although surgical outcomes are gradually improving, in-hospital mortality of surgical patients (repair on the aortic root to the arch) in 2009 was as high as around 10%, according to the Japanese database. 3) For the further improvement of outcomes, problems should be solved in each of preonset, pre-hospital, and in-hospital stages. In this review, the latter two stages are discussed first, since most of the literature focuses on these stages. After that, the issue of pre-onset stage, i.e., prevention is discussed. DelayeD DiagnosisIn consideration of the natural history of AAAD, the "chain of onset-to-sur...

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“…Moreover, some cases fully recovered by immediate surgery within 3 hour after ER arrival [5]. Our patient showed left hemiplegia perioperatively, which was not aggravated by immediate surgery, revealing minimal cerebral ischemic changes on MRI.…”

Section: Discussionmentioning

confidence: 53%

“…Emergency surgery in patients with those risk factors usually is avoided because of high mortality and morbidity. One reason, avoiding surgery, is that anticoagulant use during intraoperative extracorporeal circulation may promote hemorrhagic cerebral infarction or posttraumatic intracranial hemorrhage [5]. Regarding our patient, despite three preoperative poor prognostic factors, the recovery suggests that the effects of these factors remained minimal.…”

Section: Discussionmentioning

confidence: 66%

“…Poor prognosis has been reported with cardiopulmonary arrest (CPA) [2], aortic branch occlusion [3] [4] [5] [6], severe consciousness disturbance [4], and cerebral vascular disorders (CVD) [4] in the preoperative period. We report a case of AAAD, requiring emergency surgery and recovering after out-of-hospital CPA with good neurological outcome.…”

Section: Introductionmentioning

confidence: 99%

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Recovery from Out-of-Hospital Cardiopulmonary Arrest Due to Type A Acute Aortic Dissection: A Case Report

Sugawara¹,

Kurihara²,

Ohtsubo³

et al. 2016

CRCM

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Case: A 55-year-old man without past medical histories suffering from back pain for two weeks was successfully resuscitated from an 8-min cardiopulmonary arrest (CPA) and was brought to our hospital by ambulance. Computed tomography demonstrated type A acute aortic dissection (AAAD) with brachiocephalic artery occlusion. After admission, Glasgow Coma Scale score improved to E1VTM4, and voluntary movement was noted only in the right limbs. Outcome: The patient underwent emergency grafting of the ascending aorta and innominate artery under deep hypothermic circulatory arrest. After surgery, the patient recovered with mild disorientation and left hemiplegia. Magnetic resonance imaging of the head revealed no large infarction but revealed multiple acute ischemic changes. One year later, the patient demonstrated independent walk and successfully returned to work life. Conclusions: Immediate resuscitation and surgery resulted in good recovery from CPA after AAAD.

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Acute type A aortic dissection complicated by stroke: Can immediate repair be performed safely?

Cited by 141 publications

References 13 publications

The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival

The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Recovery from Out-of-Hospital Cardiopulmonary Arrest Due to Type A Acute Aortic Dissection: A Case Report

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