Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection

Sultan, Ibrahim; Bianco, Valentino; Patel, Himanshu J.; Arnaoutakis, George J.; Eusanio, Marco Di; Chen, Edward P.; Leshnower, Bradley G.; Sundt, Thoralf M.; Sechtem, Udo; Montgomery, Daniel; Trimarchi, Santi; Eagle, Kim A.; Gleason, Thomas G.

doi:10.1016/j.jtcvs.2019.11.003

Cited by 68 publications

(49 citation statements)

References 33 publications

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“…Cerebral ischemia (CI) is a common comorbidity in aTAAD patients. The prevalence rate is 15.1% according to newly reported data from the International Registry of Acute Aortic Dissection (IRAD) (1), which is higher than the previously reported rate of 6% (2,3). Thus, patients with CI have a significantly higher mortality rate of 25.7-40.2% than the cohort without CI at 12.0-22.7%.…”

Section: Introductionmentioning

confidence: 81%

Prompt surgery is effective for acute type A aortic dissection with cerebral ischemia

Xue¹,

Tang²,

Zhu³

et al. 2021

J Thorac Dis

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Background: Acute type A aortic dissection (aTAAD) with preoperative cerebral ischemia (CI) is common and lethal, but the timing and treatment method remain uncertain. We retrospectively reviewed our aTAAD patients with CI and analyzed the outcomes and related risk factors. Methods: From January 2011 to December 2019, 1,173 patients diagnosed with aTAAD from Nanjing Drum Tower Hospital were enrolled. Among them, 131 patients had CI preoperatively (CI group), and 1,042 patients were in the non-CI group. One hundred eight in the CI group and 984 in the non-CI group received central repair surgery. Fifteen patients had postoperative cerebral complications (CC) and 93 had non-CCs. ROC curves were used to identify the safe duration of preoperative CI. Results: The CI group was older (56.3 vs. 53.2 years, P=0.013) and had lower rates of pain, chest pain and back pain (77.9% vs. 94.4%, 75.4% vs. 87.5% and 30.8% vs. 42.3%, respectively) than the non-CI group.The CI group had a higher rate of preoperative hypotension and tamponade (13.7% vs. 6.0%, 26.9% vs.10.4%, respectively; P=0.000). More patients in the CI group did not receive central repair surgery, and the CI had higher mortality (28.2% vs. 15.9%). CI without central repair surgery was a strong risk factor for mortality. CI patients with CC after central repair had a higher mortality, and preoperative coma was the strongest risk factor for postoperative CC.A duration between CI symptoms and central repair surgery of less than 12.75 hours is recommended. Conclusions: Prompt surgery is effective for aTAAD with CI, and preoperative coma and a safe duration longer than 12.75 hours would predict worse outcomes.

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Section: Introductionmentioning

confidence: 81%

Prompt surgery is effective for acute type A aortic dissection with cerebral ischemia

Xue¹,

Tang²,

Zhu³

et al. 2021

J Thorac Dis

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“…Patient selection is crucial, and all but one of our cerebral malperfusion patients who underwent surgery presented without additional vascular bed involvement. Several other studies also report favorable outcomes for patients surviving immediate surgical management of ATAAD with cerebral malperfusion 22‐25 …”

Section: Discussionmentioning

confidence: 96%

Management of malperfusion: New York approach and outcomes

2020

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Background and Aim Aortic branch malperfusion complicates up to one‐third of acute type A aortic dissection (ATAAD), and it is a strong predictor of poor outcomes. We analyzed our results for the surgical management of this high‐risk cohort. Methods We queried our aortic database for consecutive patients undergoing ATAAD repair. Those presenting with malperfusion were compared with those without. Outcomes were compared using univariate and multivariate analysis. Results From 1997 to 2019, a total of 336 patients underwent ATAAD repair. A total of 97 ATAAD patients presented with malperfusion. Malperfusion patients were more likely to be male (54.8% vs. 75.3%; p = .001), have had a prior myocardial infarction (11.9% vs. 26.8%; p = .001), to present with preoperative renal dysfunction (22.2% vs. 54.6%; p < .001), and to present with shock (12.6% vs. 28.9%; p = .001). The malperfusion group more often underwent coronary artery bypass grafting (5.4% vs. 24.7%; p < .001), and required additional noncardiac procedures 10.3% of the time. Operative mortality (0.8% vs. 15.5%; p < .001) and major adverse events (MAEs) (7.6% vs. 20.6%; p = .001) were both greater for the malperfusion patients. Ejection fraction, diabetes, and malperfusion were predictors of MAEs. Cerebral, coronary, mesenteric, and multiple vascular bed malperfusion were predictors of MAEs, while extremity, renal, and spinal were not. Conclusion Improving outcomes for this high‐risk cohort requires rapid diagnosis and reversal of ischemia while minimizing the risk of aortic rupture, irrespective of the strategic approach.

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“…In their 54 comatose patients, medical management was instituted in 18 and none survived. Recently, Sultan et al 24 reported that patients with brain malperfusion were older and more likely to present with peripheral malperfusion, cardiac tamponade, and in shock. In‐hospital mortality was 25.7%, and postoperative permanent neurological injury or acute kidney injury occurred in 17.5%, and 28.3%, respectively.…”

Section: Discussionmentioning

confidence: 99%

Treatment strategies for malperfusion syndrome secondary to acute aortic dissection

Okita

Okada

2020

J Card Surg

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Objective Presenting our experience of treating patients with organ malperfusion secondary to acute aortic dissection. Patients Among 383 patients who underwent aortic repair for acute type A aortic dissection from 1999 to 2017, 107 patients were operated on because of vascular complications. Fourteen patients had coronary, 50 had brain, 3 had paraplegia, 13 had superior mesenteric artery, 21 had lower limb, and 16 had combined organ malperfusion. Age was 65.8 years. Results In coronary malperfusion, three had a preoperative percutaneous coronary intervention, and two had mechanical support. All underwent repair of the aorta. Hospital mortality was 28.5%. Fifty patients had brain malperfusion. Hemiplegia was found in 28 patients, transient ischemic attack in 10, and coma in 12. The level of consciousness was severe in 12, moderate in 18, and mild in 20. Twenty‐eight percent died of a stroke. Nine had direct perfusion from the right common carotid artery, and the consciousness level was improved in 5 patients. Eight patients had mesenteric malperfusion. Four patients had a central aorta repair first, and four patients had peripheral intervention first. Three patients had a bypass grafting to the superior mesenteric artery, and one had a catheter intervention. Postoperative mortality was found in four patients due to bowel necrosis and six required resections of the bowel. Conclusion Acute organ malperfusion caused by the aortic dissection requires accurate and prompt diagnosis to proceed with an appropriate intervention before repairing the central aorta for preventing irreversible organ damage.

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Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection

Cited by 68 publications

References 33 publications

Prompt surgery is effective for acute type A aortic dissection with cerebral ischemia

Prompt surgery is effective for acute type A aortic dissection with cerebral ischemia

Management of malperfusion: New York approach and outcomes

Treatment strategies for malperfusion syndrome secondary to acute aortic dissection

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