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

Abstract

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.

Associated bare stenting of distal aorta with a Djumbodis® system versus conventional surgery in type A aortic dissection

“…In any instance, the use of DDS system has not worsened early prognosis in the treated group, despite it being an uncovered balloon expandable stainless steel stent, which is perhaps the most feared device for use in type A acute dissections (6). Therefore, the concept of treating the descending aorta with endovascular devices at the same time of conventional surgery (1,2,4,16) is also supported by the present series, which is based on antegrade insertion of the stent during circulatory arrest.…”

“…However, there is still a paucity of comparative studies to support this strategy compared to a more conventional hemiarch repair (6). Furthermore, exposing acute patients to an additional procedure, compared to standard treatment, is sometimes perceived as excessively high-risk in the context of an aortic disease with an already poor prognosis (7).…”

Systematic Review Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

“…In most patients, the aortic dissection process frequently extends through the arch and the conventional treatment has been hemiarch replacement leaving the downstream aorta untouched (2,3). Several study groups, with the aim to reduce the risk of re-intervention and to obliterate the false lumen, recommended a more extensive approach involving total replacement of aortic arch with possible elephant trunk in selected patients (4,5).…”

The Condition of Distal Aorta After Proximal Reconstruction for Dissection in Marfan Syndrome

“…Согласно многочисленным опубликован-ным работам [11][12][13], данный фактор является неза-висимым предиктором роста неоперированных отде-лов аорты. Во всех опубликованных работах выделялась группа пациентов с синдромами диспла-зии соединительной ткани, а в некоторых работах синдром Марфана выделялся как достоверный пре-диктор неблагоприятного исхода в отдаленном пери-оде [14].…”