Type A aortic dissection in aneurysms having modelled pre-dissection maximum diameter below 45 mm: should we implement current guidelines to improve the survival benefit of prophylactic surgery?

Abstract

OBJECTIVES Current guidelines recommend prophylactic replacement of the ascending aorta at an aneurysmal diameter of >55 mm to prevent acute Type A aortic dissection (TAAD) in non-Marfan patients. Several publications have challenged this threshold, suggesting that surgery should be performed in smaller aneurysms to prevent this devastating disease. We reviewed our experience with measuring aortic size at the time of TAAD to validate the existing recommendation for prophylactic ascending aorta replacement. METHODS All patients who had been admitted for TAAD to our emergency department from 2014 to 2019 and underwent ascending aorta replacement were included. Marfan patients were excluded. The maximum diameter of the dissected aorta was measured preoperatively using CT scan. We estimated the aortic diameter at the time of dissection to be 7 mm smaller than the measured maximum diameter of the dissected aorta (modelled pre-dissection diameter). RESULTS Overall, 102 patients were included. Of these, 67 were male (65.6%) and 35 were female (34.4%), and the cohort’s mean age was 65 ± 12.1 years. In addition, 66% were treated for arterial hypertension. The mean maximum modelled pre-dissection diameter was 39.6 ± 4.8 mm: 39.1 ± 5.1 mm in men and 40.7 ± 2.8 mm in women (P = 0.1). The cumulative 30-day mortality rate was 19.6% (20/102). CONCLUSIONS TAAD occurred at a modelled aortic diameter below 45 mm in 87.7% of our patients. Therefore, the current aortic diameter threshold of 55 mm excludes ∼99% of patients with TAAD from prophylactic replacement of the ascending aorta. The maximum diameter of the ascending aorta warrants reappraisal and this parameter should be a distinct part of a personalized decision-making process that also takes into account age, gender and body surface area to establish the surgical indication for preventive aorta replacement aimed to improve the survival benefit of this procedure.

Bentall–De Bono procedure for aortic regurgitation and intraoperative rupture of moderately dilated ascending aorta: A case report

“…В рекомендациях основными факторами, влияющими на принятие решения о профилактическом протезировании восходящей аорты, отмечают абсолютный диаметр, скорость расширения, индивидуальный и семейный анамнез, возраст пациента [1][2][3]. Некоторые авторы считают, что индивидуальные параметры больного (рост, вес) следует также принимать во внимание, поскольку индексированные диаметры аорты относительно площади поверхности тела нагляднее показывают риск неблагоприятных событий и должны использоваться в качестве критерия для хирургического вмешательства [9][10][11]. Помимо абсолютных значений, важный критерий аорты в норме -геометрия корня и восходящего отдела, так как восходящая аорта имеет сложное (нелинейное) строение с определенным взаимоотношением образующих ее отделов [12].…”

Association of dissected ascending aorta diameter with preoperative adverse events in patients with acute type A aortic dissection

“…Existing and current guidelines recommend replacing the ascending aorta if the size reaches 5.5 cm in patients without Marfan syndrome[ 6 , 13 ]. On the other hand, the exact threshold of aortic size (< 5.5 cm) for early (preventive) operation remains a grey zone in current indications and guidelines, because in most patients with acute aortic dissection, the maximum aortic diameter is approximately 5 cm or less[ 14 - 17 ].…”

Case Report: Are We Witnessing an Increase of Chronic Ascending Aortic Dissection as a Collateral Effect to the COVID-19 Pandemic?

“…We recently published our experience with ATAADs from 2014 to 2019. During the considered period, we treated 117 ATAADs in our center, which represents 3 to 5 ATAAD cases per month and had no chronic cases ( 4 ). However, between February and May 2020, the COVID-19 (coronavirus disease 2019) pandemic temporarily reduced health care accessibility.…”

“…As such, these statistics were noticeably altered, with only three confirmed ATAADs, which represented a decrease of ¾, compared to the usual volume. Nevertheless, we experienced two cases of chronic type A aortic dissection (CTAAD) in July 2020, which is a pathology we usually see only once every 5 years ( 4 ).…”