Evolution of surgical therapy for Stanford acute type A aortic dissection

Abstract

Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small?The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.

Image Predictors of Treatment Outcome after Thoracic Aortic Dissection Repair

“…The accuracy and speed of CT angiography allow for rapid diagnosis and rapid patient transfer to an experienced multidisciplinary thoracic aortic referral center, when necessary. In critical situations, patients may be transferred directly to the operating room, where they are anesthetized, and transesophageal echocardiography is performed to confirm the presence of a dissection involving the ascending aorta and to evaluate downstream flow dynamics (3).…”

“…The primary entry tear is located in the aortic arch in 10%-30% of patients, which necessitates covering the ostium of one or more arch branches to establish a secure proximal landing zone (3,41). To address the anatomic location of the primary intimal tear, the aortic arch is divided into five landing zones (41,42).…”

“…The treatment of thoracic aortic dissection remains highly challenging. Despite numerous innovations in early diagnosis, medical management, surgical techniques, and perioperative care, mortality and morbidity remain high in patients with thoracic aortic dissection (1)(2)(3).…”

“…Although no clear scoring guideline is introduced in this classification, these six specific anatomic and clinical features of the pathologic process have been emphasized to supplement the traditional DeBakey and Stanford classification schemes of aortic dissections. For example, the location of the primary intimal tear is now considered an important variable affecting the type of surgical or endovascular treatment (3).…”

Serum Biomarker Identification by Mass Spectrometry in Acute Aortic Dissection

“…AD is caused by tearing of the local endothelium, which is gradually stripped due to the impact of blood stream flow. This lesion expands, and two lumens (true and false) form within the aorta, resulting in manifestations that include tearlike pain [4, 5]. The aorta, the trunk blood vessel of the body, directly bears the pressure generated by the heart beat.…”