The impact of surgical strategy on survival after repair of type A aortic dissection

Lawton, Jennifer S.; Liu, Jingxia; Kulshrestha, Kevin; Moon, Marc R.; Damiano, Ralph J.; Maniar, Hersh S.; Pasque, Michael K.

doi:10.1016/j.jtcvs.2015.03.023

Cited by 50 publications

(32 citation statements)

References 24 publications

(32 reference statements)

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“…2 The single approach in our recent report that strictly adhered to the points stressed by David and colleagues 1 in their landmark article written in 1999 (in an effort to reduce operative mortality) and highlighted in Figure 1 of his recent contribution 3 was found to be associated with the lowest long-term mortality when compared with the other surgical approaches. These principles included the avoidance of an aortic crossclamp, performance of an open distal anastomosis, and perfusion in the antegrade fashion via the graft after completion of the distal anastomosis.…”

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confidence: 79%

Acute type A aortic dissection 101

Lawton

2015

The Journal of Thoracic and Cardiovascular Surgery

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I was delighted to read ''Surgery for Acute Type A Aortic Dissection'' by Tirone David and colleagues 1 and devoured it with intense interest. Readers will find that technical pearls can be found throughout the article. This contribution elegantly and clearly describes a safe and reliable method to perform this emergency procedure to achieve acceptable mortality when the stakes are high.The surgical approach to acute type A aortic dissection at Washington University is varied and largely surgeon dependent, as previously described. 2 The single approach in our recent report that strictly adhered to the points stressed by David and colleagues 1 in their landmark article written in 1999 (in an effort to reduce operative mortality) and highlighted in Figure 1 of his recent contribution 3 was found to be associated with the lowest long-term mortality when compared with the other surgical approaches. These principles included the avoidance of an aortic crossclamp, performance of an open distal anastomosis, and perfusion in the antegrade fashion via the graft after completion of the distal anastomosis. The majority of the patients at Washington University in this operative strategy group underwent a consistent approach designed to adhere to that described by David and colleagues. 1 This surgical technique was the same approach that Dr David 3 now reports in great detail for hemodynamically unstable patients and at Washington University was consistently performed on all patients regardless of hemodynamic status with the following exceptions:Femoral artery cannulation was performed before sternotomy with a Y set-up in the arterial tubing for later switch to perfusion via the graft (assuming good femoral pulse preoperatively and no visible dissection in femoral artery on direct inspection, and wire confirmed in the true aortic lumen by transesophageal echocardiography at the time of placement). Sternotomy followed by bicaval venous cannulation with the stopcock in line adjacent to the superior vena cava (SVC) cannula for retrograde cerebral perfusion was performed (a single inferior vena cava cannula was placed if active aortic bleeding suspected, and in this case, the pericardium was left intact over ascending aorta until deep hypothermic circulatory arrest temperature was reached). An aortic cannula was never placed on the ascending aorta or arch vessels. A left ventricular (LV) vent via right superior pulmonary vein was placed in all patients (pulmonary artery vent was added in rare cases in which LV distention from aortic insufficiency was present and persistent despite intermittent manual compression of the LV and LV venting was functional). At the time of deep hypothermic circulatory arrest (18 C via arterial and venous line blood temperatures), a snare was placed around the SVC cannula, continuous retrograde cerebral perfusion was infused via the SVC, and 1 L of retrograde cardioplegia followed by maintenance retrograde cardioplegia (300 mL every 20 minutes while the heart was ischemic) was administered. This temper...

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confidence: 79%

Acute type A aortic dissection 101

Lawton

2015

The Journal of Thoracic and Cardiovascular Surgery

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“…Perfusion strategy is also an important aspect to repair of type A dissection, regardless of the extent of repair. In a publication from Washington University in St. Louis in 2015 examining 196 patients who underwent repair of type A dissection [16], we found that avoidance of cross-clamping, use of deep hypothermic circulatory arrest, and antegrade reperfusion after aortic replacement were associated with the best long-term survival. Although there was some selection bias in this report favoring a less-aggressive approach in patients whose long-term survival or functional state was in question, the absence of any one of these techniques was associated with a decrement in survival.…”

Section: Distal Extent Of Surgery In Type a Dissectionmentioning

confidence: 95%

“…Similarly, our group maintains an awareness that cross-clamp application can potentially increase the incidence of malperfusion, particularly when retrograde femoral perfusion is used. As this publication demonstrates, it is not only the extent of replacement of the aorta proximally and distally that is important but also the conduct of the operation and management of perfusion that contribute to long-term outcomes in type A dissection repair [16].…”

Section: Distal Extent Of Surgery In Type a Dissectionmentioning

confidence: 99%

Extent of Aortic Replacement in Type A Dissection: Current Answers for an Endless Debate

Waterford

Gardner

Moon

2018

The Annals of Thoracic Surgery

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“…The safety of femoral cannulation in general has been questioned, though, given concerns about pressurization of the false lumen and malperfusion, which could be compounded when the distal ascending aorta is cross-clamped (104,110,134). Evaluation of the risk associated with cross-clamping the aorta during the cooling phase and prior to PHCA have provided divergent results: some studies have reported increased risk (110,121,135), and others have failed to show excess morbidity or mortality (130,136).…”

Section: The Arch Cerebral Protection and Cannulation Strategymentioning

confidence: 99%

Evolution of surgical therapy for Stanford acute type A aortic dissection

Chiu¹,

Miller²

2016

ASVIDE

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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.

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The impact of surgical strategy on survival after repair of type A aortic dissection

Abstract: The operative strategy of group 1 (no cross-clamp, use of DHCA and antegrade perfusion) was associated with a highly significant improvement in survival, despite a lack of statistical difference in the incidence of persistent false aortic lumen between groups.

Cited by 50 publications

References 24 publications

Acute type A aortic dissection 101

Acute type A aortic dissection 101

Extent of Aortic Replacement in Type A Dissection: Current Answers for an Endless Debate

Evolution of surgical therapy for Stanford acute type A aortic dissection

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