Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Abstract

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...

Usefulness of Transesophageal Echocardiography in Guiding Acute Aortic Dissection Management During Open Repair of an Abdominal Aortic Aneurysm

“…When operated by experienced physicians, the diagnostic ability of TEE for thoracic AD is high, similar to that of CT and magnetic resonance imaging. 2 The salient features of using TEE relative to the other modalities are as follows: it easily can be performed in the operating room or at the bedside; it enables the visualization of blood flow, which can help diagnose malperfusion and the presence of a false or true lumen; [2][3][4][5] and it enables the detection of ongoing AD, such as in the present case. This case report highlights the fact that perioperative TEE can be helpful for diagnosing a rare complication during AAA surgery and for deciding the appropriate management for type-A AD in this rare clinical course.…”

Simplicity, skills, and pitfalls of ascending aortic cannulation for type A aortic dissection

“…Overall, we consider that the merits of simultaneously using femoral artery perfusion override the demerits. Another demerit of femoral perfusion is malperfusion, which can be overcome using TEE to detect superior mesenteric artery malperfusion [1], which we plan as the next step.…”

“…During surgery for type A aortic dissection, the perfusion route is of great interest to improve the outcome of the procedure [1]. There are several choices of route, which include femoral artery, axillary artery, ascending aorta, and left ventricular apex.…”

Women Tend to Have the Ascending Aorta Involvement and the Rupture in Acute Aortic Dissection

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