Aggressive Aortic Arch and Carotid Replacement Strategy for Type A Aortic Dissection Improves Neurologic Outcomes

Abstract

An algorithmic approach to TAAD including (1) rapid transport-to-incision-to-cardiopulmonary bypass established centrally, (2) neurocerebral monitoring, (3) liberal use of total arch replacement for clearly defined indications (and hemiarch for all others), and (4) common carotid arterial replacement for concomitant carotid dissections significantly improves outcomes.

The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair

“…Many centers incorporate adjunctive cerebral perfusion techniques in an effort to improve neurologic outcomes [2][3][4][5][6][7][8]. Patients at our institution typically undergo arch reconstruction using either deep hypothermic arrest and retrograde cerebral perfusion (DHCA/RCP) or moderate hypothermic arrest and antegrade cerebral perfusion (MHCA/ACP).…”

Evolution of surgical therapy for Stanford acute type A aortic dissection

“…The Cleveland Clinic and more recently Gleason's team at the University of Pittsburgh have reported that a more extensive operation, i.e., total arch replacement, was associated with a trend towards lower early and late survival, though the differences were not statistically significant (81,147). Finally, total arch replacement has not been shown to improve the freedom from late distal aortic reintervention compared with more conservative arch management in propensity score analyses from South Korea and Italy (148,149).…”

Differential aspects of ascending thoracic aortic dissection and its treatment: the North American experience

“…Reportedly, both deep and moderate levels of hypothermia during the period of circulatory arrest have been used successfully (14)(15)(16)(17)22). Different cannulation strategies have been advocated (19,21,(23)(24)(25)(26)(27). Early application of the crossclamp during the cooling period has been reported (7,23), as has a clampless technique (15)(16)(17)(18)(19).…”

“…Overall operative mortality reported by North American centers varies from 5% to 17% (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23) and may improve after protocol-based management is implemented and a thoracic aortic team is assembled (30,34). Mortality associated specifically with iatrogenic acute type A dissection has been recently reported as 27% after open surgical repair and up to 33-50% after TEVAR (6)(7)(8).…”

“…The primary goal of the operation is to prevent immediate death; the secondary goal is to promote long-term survival and avoid further reoperation on the distal aorta. Major aortic surgery centers have described various extents of surgical repair with hemiarch (i.e., proximal arch) or total arch replacement and different adjuncts for brain protection [antegrade or retrograde cerebral perfusion (RCP)] (13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Most North American centers (13)(14)(15)(16)(17)(18)(19)23) tend to favor ascending aorta and hemiarch replacement, with more extensive arch replacement in cases in which the arch is dilated more than 4.5-5 cm or the tear involves the aortic arch.…”