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• W3039046390 abstract "Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit. Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit. Central MessageSurgical strategies for acute type A aortic dissection vary among experienced centers. Limited index repair (ie, hemiarch) aimed at ensuring operative survival is the gold standard in most cases. Surgical strategies for acute type A aortic dissection vary among experienced centers. Limited index repair (ie, hemiarch) aimed at ensuring operative survival is the gold standard in most cases. Acute type A aortic dissection (ATAAD; Fig. 1) is a life-threatening surgical emergency that demands clear thinking along with an expeditious, adroit operative strategy in order to avoid catastrophe. Although the management of ATAAD has evolved considerably over the years, open surgical repair remains a complex operation associated with significant risk—most notably, an operative mortality between 12% and 20%.1Pape L.A. Awais M. Woznicki E.M. et al.Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the International Registry of Acute Aortic Dissection.J Am Coll Cardiol. 2015; 66: 350-358https://doi.org/10.1016/j.jacc.2015.05.029Crossref PubMed Scopus (423) Google Scholar, 2Conzelmann L.O. Weigang E. Mehlhorn U. et al.Mortality in patients with acute aortic dissection type A: Analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA).Eur J Cardiothorac Surg. 2016; 49: e44-e52https://doi.org/10.1093/ejcts/ezv356Crossref PubMed Scopus (139) Google Scholar, 3Lee T.C. Kon Z. Cheema F.H. et al.Contemporary management and outcomes of acute type A aortic dissection: An analysis of the STS adult cardiac surgery database.J Card Surg. 2018; 33: 7-18https://doi.org/10.1111/jocs.13511Crossref PubMed Scopus (48) Google Scholar, 4Helder M.R.K. Schaff H.V. Day C.N. et al.Regional and temporal trends in the outcomes of repairs for acute type A aortic dissections.Ann Thorac Surg. 2020; 109: 26-33https://doi.org/10.1016/j.athoracsur.2019.06.058Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 5Preventza O. Coselli J.S. Differential aspects of ascending thoracic aortic dissection and its treatment: The North American experience.Ann Cardiothorac Surg. 2016; 5: 352-359https://doi.org/10.21037/acs.2016.07.01Crossref PubMed Scopus (7) Google Scholar The operation's complexity is compounded by a lack of consensus regarding certain aspects of repair, such as organ protection techniques and the extent of proximal and distal aortic repair. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. The overarching goal of surgery in ATAAD is to prevent immediate death from aortic rupture or from sequelae of the dissection process (eg, cardiac tamponade, acute aortic valve regurgitation, or organ failure secondary to malperfusion syndrome [MPS]; Fig. 2). The “gold standard” approach to repairing the proximal aorta in ATAAD was pioneered by E. Stanley Crawford and colleagues at Baylor College of Medicine. In their landmark series,6Crawford E.S. Kirklin J.W. Naftel D.C. et al.Surgery for acute dissection of ascending aorta. Should the arch be included?.J Thorac Cardiovasc Surg. 1992; 104: 46-59Abstract Full Text PDF PubMed Google Scholar the authors advocated for immediate aortic repair through a median sternotomy, with resection of the primary entry tear, replacement of the ascending aorta with a Dacron vascular graft, and repair or replacement of the aortic root and valve as needed. In this series, approximately one third of patients also underwent replacement of the aortic arch; early mortality was 50% greater in these patients than in those without arch replacement. Thus, a philosophy was developed to limit the extent of repair, whenever possible, to enhance the likelihood of operative survival. In contemporary practice, repair of ATAAD involves the use of sophisticated adjunct techniques to increase tolerance to ischemia of the myocardium, brain, spinal cord, and visceral organs during surgery. These techniques provide protection by decreasing metabolic demand (hypothermia) or increasing metabolic supply (selective organ perfusion). The arterial cannulation site for cardiopulmonary bypass (CPB), the preferred temperature for hypothermic circulatory arrest, and cerebral perfusion techniques vary considerably across centers and geographically.2Conzelmann L.O. Weigang E. Mehlhorn U. et al.Mortality in patients with acute aortic dissection type A: Analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA).Eur J Cardiothorac Surg. 2016; 49: e44-e52https://doi.org/10.1093/ejcts/ezv356Crossref PubMed Scopus (139) Google Scholar,3Lee T.C. Kon Z. Cheema F.H. et al.Contemporary management and outcomes of acute type A aortic dissection: An analysis of the STS adult cardiac surgery database.J Card Surg. 2018; 33: 7-18https://doi.org/10.1111/jocs.13511Crossref PubMed Scopus (48) Google Scholar Historically, the femoral artery was used ubiquitously as the arterial inflow site for initiation of CPB during repair of ATAAD. The femoral artery is easily accessible and can generally achieve adequate true lumen flow. Nonetheless, the safety of femoral artery cannulation has been questioned due to the potential risk for retrograde embolization of atherosclerotic plaques to the brachiocephalic branches as well as the risk for malperfusion related to flow reversal in the distal aorta.7Moeller E. Nores M. Stamou S.C. Repair of acute type-A aortic dissection in the present era: Outcomes and controversies.Aorta (Stamford). 2019; 7: 155-162https://doi.org/10.1055/s-0039-3401810Crossref PubMed Scopus (5) Google Scholar Although the femoral artery remains the most common cannulation site used during repair of ATAAD in the United States,3Lee T.C. Kon Z. Cheema F.H. et al.Contemporary management and outcomes of acute type A aortic dissection: An analysis of the STS adult cardiac surgery database.J Card Surg. 2018; 33: 7-18https://doi.org/10.1111/jocs.13511Crossref PubMed Scopus (48) Google Scholar other sites have emerged as favorable alternatives. The right axillary, innominate, and right common carotid arteries are alternative cannulation sites that have been increasingly adopted, in part because they provide the added benefit of seamless initiation of selective cerebral perfusion. Recent studies have shown that cannulation of the right axillary artery may confer protection from both mortality4Helder M.R.K. Schaff H.V. Day C.N. et al.Regional and temporal trends in the outcomes of repairs for acute type A aortic dissections.Ann Thorac Surg. 2020; 109: 26-33https://doi.org/10.1016/j.athoracsur.2019.06.058Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,8Rosinski B.F. Idrees J.J. Roselli E.E. et al.Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach.J Thorac Cardiovasc Surg. 2019; 158: 647-659https://doi.org/10.1016/j.jtcvs.2018.11.137Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar and stroke4Helder M.R.K. Schaff H.V. Day C.N. et al.Regional and temporal trends in the outcomes of repairs for acute type A aortic dissections.Ann Thorac Surg. 2020; 109: 26-33https://doi.org/10.1016/j.athoracsur.2019.06.058Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,9Ghoreishi M. Sundt T.M. Cameron D.E. et al.Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database.J Thorac Cardiovasc Surg. 2020; 159: 2143-2154https://doi.org/10.1016/j.jtcvs.2019.06.016Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar in ATAAD. To better access these relatively small-caliber vessels, a small-diameter (8 mm or 10 mm) graft can be anastomosed end-to-side to the artery to facilitate cannulation. The axillary artery may not be the optimal cannulation site in hemodynamically unstable patients or those with large body habitus, given the added time required to expose it; conversely, the innominate artery is readily accessible within the sternotomy field and is thus a safe and effective alternative to the axillary artery.10Preventza O. Garcia A. Tuluca A. et al.Innominate artery cannulation for proximal aortic surgery: Outcomes and neurological events in 263 patients.Eur J Cardiothorac Surg. 2015; 48 (discussion 942): 937-942https://doi.org/10.1093/ejcts/ezu534Crossref PubMed Scopus (35) Google Scholar,11Preventza O. Price M.D. Spiliotopoulos K. et al.In elective arch surgery with circulatory arrest, does the arterial cannulation site really matter? A propensity score analysis of right axillary and innominate artery cannulation.J Thorac Cardiovasc Surg. 2018; 155 (1960.e1–1960.e4.): 1953-1960https://doi.org/10.1016/j.jtcvs.2017.11.095Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Central cannulation can be rapidly established via ultrasound-guided direct cannulation of the ascending aorta over a guidewire (ie, Seldinger technique).12Shimura S. Odagiri S. Furuya H. et al.Echocardiography-guided aortic cannulation by the Seldinger technique for type A dissection with cerebral malperfusion.J Thorac Cardiovasc Surg. 2020; 159: 784-793https://doi.org/10.1016/j.jtcvs.2019.02.097Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar This strategy is particularly useful when the dissection process extends into the brachiocephalic branches or when used as a rescue measure if malperfusion develops after CPB is initiated. Lastly, transapical aortic cannulation is especially useful in patients with profound hemodynamic instability. This technique can achieve rapid and reliable perfusion of the true lumen and obviates manipulation of the aorta or its branch vessels.13Wada S. Yamamoto S. Honda J. et al.Transapical aortic cannulation for cardiopulmonary bypass in type A aortic dissection operations.J Thorac Cardiovasc Surg. 2006; 132: 369-372https://doi.org/10.1016/j.jtcvs.2006.04.016Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar Nonetheless, concerns remain with respect to its safety, particularly in patients with a previous sternotomy, and to the risk for postoperative bleeding and late left ventricular pseudoaneurysm formation. Without a clear consensus regarding the optimal cannulation site, selection varies by patient-specific factors as well as by surgeon and institutional preferences.7Moeller E. Nores M. Stamou S.C. Repair of acute type-A aortic dissection in the present era: Outcomes and controversies.Aorta (Stamford). 2019; 7: 155-162https://doi.org/10.1055/s-0039-3401810Crossref PubMed Scopus (5) Google Scholar At our institution, we have moved to a strategy of right axillary or innominate artery cannulation in the vast majority of cases of ATAAD. Hypothermic circulatory arrest (HCA) is used during repair of ATAAD to facilitate open distal anastomosis during proximal aortic replacement. The use of HCA allows direct inspection of the aortic arch to assess the extent of the dissection process and permits more complete tissue resection at the distal anastomosis site. In contemporary practice, HCA is performed at various temperatures, from as low as 14.0°C to as high as 34.0°C.14Tian D.H. Wan B. Bannon P.G. et al.A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion.Ann Cardiothorac Surg. 2013; 2: 148-158https://doi.org/10.3978/j.issn.2225-319X.2013.03.13Crossref PubMed Google Scholar The early pioneers of aortic arch surgery achieved acceptable results by using profound HCA (≤14.0°C), a strategy that continues today as straight deep HCA (14.1°C‒20.0°C).15Ziganshin B.A. Rajbanshi B.G. Tranquilli M. et al.Straight deep hypothermic circulatory arrest for cerebral protection during aortic arch surgery: Safe and effective.J Thorac Cardiovasc Surg. 2014; 148 (discussion 898-900): 888-898https://doi.org/10.1016/j.jtcvs.2014.05.027Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Nevertheless, deep HCA alone provides only limited periods of brain safety (approximately 30 minutes) and is associated with intrinsic deleterious effects (eg, coagulopathy). In time, techniques were developed to supplement HCA during aortic arch repair by delivering cold, oxygenated blood to the brain via retrograde or antegrade cerebral perfusion (or both). Retrograde cerebral perfusion (RCP) through the snared superior vena cava gained prominence in aortic arch repair in the 1990s. When combined with direct aortic cannulation, RCP has the advantages of providing a less cluttered operative field, enabling the clearance of air and embolic debris from the brachiocephalic branches, and avoiding the clamping and snaring of branch arteries that may be dissected.12Shimura S. Odagiri S. Furuya H. et al.Echocardiography-guided aortic cannulation by the Seldinger technique for type A dissection with cerebral malperfusion.J Thorac Cardiovasc Surg. 2020; 159: 784-793https://doi.org/10.1016/j.jtcvs.2019.02.097Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,16Estrera A.L. Garami Z. Miller C.C. et al.Acute type A aortic dissection complicated by stroke: Can immediate repair be performed safely?.J Thorac Cardiovasc Surg. 2006; 132: 1404-1408https://doi.org/10.1016/j.jtcvs.2006.07.026Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar Used at deeply hypothermic temperatures, RCP has lost favor in recent decades due to the aforementioned challenges associated with deep HCA and because of experimental and clinical studies that have signaled inadequate oxygen delivery with this strategy.17Bonser R.S. Wong C.H. Harrington D. et al.Failure of retrograde cerebral perfusion to attenuate metabolic changes associated with hypothermic circulatory arrest.J Thorac Cardiovasc Surg. 2002; 123: 943-950https://doi.org/10.1067/mtc.2002.120333Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar,18Usui A. Oohara K. Liu T.L. et al.Comparative experimental study between retrograde cerebral perfusion and circulatory arrest.J Thorac Cardiovasc Surg. 1994; 107: 1228-1236https://doi.org/10.1016/s0022-5223(94)70042-7Abstract Full Text PDF PubMed Google Scholar However, a recent analysis of the Society of Thoracic Surgeons database found that adjunctive RCP, as compared with straight deep HCA, was associated with reduced risk for stroke in patients with ATAAD.9Ghoreishi M. Sundt T.M. Cameron D.E. et al.Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database.J Thorac Cardiovasc Surg. 2020; 159: 2143-2154https://doi.org/10.1016/j.jtcvs.2019.06.016Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The inception and increased adoption of antegrade cerebral perfusion (ACP) has driven a paradigm shift towards the use of warmer temperatures during aortic arch repair. ACP is commonly initiated through right axillary or innominate artery cannulation, and the primary advantage of this strategy is its ability to safely extend the duration of HCA at warmer nadir temperatures and consequently to mitigate coagulopathy.19Comas G.M. Leshnower B.G. Halkos M.E. et al.Acute type A dissection: impact of antegrade cerebral perfusion under moderate hypothermia.Ann Thorac Surg. 2013; 96: 2135-2141https://doi.org/10.1016/j.athoracsur.2013.06.085Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar,20Etz C.D. von Aspern K. da Rocha e Silva J. et al.Impact of perfusion strategy on outcome after repair for acute type A aortic dissection.Ann Thorac Surg. 2014; 97: 78-85https://doi.org/10.1016/j.athoracsur.2013.07.034Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar As a result, the use of moderate HCA (20.1°C‒28.0°C) with ACP has been readily adopted and has achieved outcomes equivalent to or better than deep HCA during repair of ATAAD.21Keeling W.B. Leshnower B.G. Hunting J.C. et al.Hypothermia and selective antegrade cerebral perfusion is safe for arch repair in type A dissection.Ann Thorac Surg. 2017; 104: 767-772https://doi.org/10.1016/j.athoracsur.2017.02.066Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,22Zierer A. El-Sayed Ahmad A. Papadopoulos N. et al.Fifteen years of surgery for acute type A aortic dissection in moderate-to-mild systemic hypothermia.Eur J Cardiothorac Surg. 2017; 51: 97-103https://doi.org/10.1093/ejcts/ezw289Crossref PubMed Scopus (18) Google Scholar Mild HCA (28.1°C‒34.0°C) is used less frequently in ATAAD, although acceptable results with this strategy have been reported.22Zierer A. El-Sayed Ahmad A. Papadopoulos N. et al.Fifteen years of surgery for acute type A aortic dissection in moderate-to-mild systemic hypothermia.Eur J Cardiothorac Surg. 2017; 51: 97-103https://doi.org/10.1093/ejcts/ezw289Crossref PubMed Scopus (18) Google Scholar Both unilateral and bilateral ACP can be used safely during repair of ATAAD23Norton E.L. Wu X. Kim K.M. et al.Unilateral is comparable to bilateral antegrade cerebral perfusion in acute type A aortic dissection repair.J Thorac Cardiovasc Surg. 2019; https://doi.org/10.1016/j.jtcvs.2019.07.108Abstract Full Text Full Text PDF Scopus (14) Google Scholar; nonetheless, we have found bilateral ACP to be superior in cases requiring prolonged HCA (≥30 minutes).24Preventza O. Simpson K.H. Cooley D.A. et al.Unilateral versus bilateral cerebral perfusion for acute type A aortic dissection.Ann Thorac Surg. 2015; 99: 80-87https://doi.org/10.1016/j.athoracsur.2014.07.049Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Although recent studies have shown that RCP may be a safe and effective alternative to ACP during aortic arch surgery,9Ghoreishi M. Sundt T.M. Cameron D.E. et al.Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database.J Thorac Cardiovasc Surg. 2020; 159: 2143-2154https://doi.org/10.1016/j.jtcvs.2019.06.016Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar,25Hameed I. Rahouma M. Khan F.M. et al.Cerebral protection strategies in aortic arch surgery: A network meta-analysis.J Thorac Cardiovasc Surg. 2020; 159: 18-31https://doi.org/10.1016/j.jtcvs.2019.02.045Abstract Full Text Full Text PDF Scopus (27) Google Scholar,26Svensson L.G. Blackstone E.H. Apperson-Hansen C. et al.Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial.J Thorac Cardiovasc Surg. 2015; 150 (1147.e1–1147.e11): 1140-1147https://doi.org/10.1016/j.jtcvs.2015.07.054Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar there are important limitations to these studies. First, direct comparison of outcomes between the two strategies was limited by heterogeneity between cohorts with respect to systemic cannulation site, the temperature of HCA, and the proportion of ATAAD cases. Second, the overall period of HCA was often relatively short, such that a detectable difference in neurological insult may not have emerged yet. At our institution, we favor a strategy of moderate HCA (24°C) with bilateral ACP (10‒15 mL/kg/min; whenever feasible, cannulating either the innominate or right axillary artery along with the left common carotid artery) to provide extended cerebral protection during repair of ATAAD (Fig. 3). In cases with extensive dissection of the brachiocephalic branches, we may be limited to unilateral ACP. We also use near-infrared spectroscopy to dynamically assess regional cerebral oxygen saturation and to dynamically adjust flow. In patients with ATAAD, the true lumen is often compressed by the false lumen (Fig. 1). MPS is defined by clinical evidence of end-organ dysfunction secondary to branch vessel occlusion (Fig. 2) and includes myocardial ischemia (coronary arteries), syncope or stroke (brachiocephalic branches), mesenteric ischemia (celiac trunk or mesenteric arteries), renal failure (renal arteries), and acute limb ischemia (brachial or iliofemoral arteries). Up to 30% of patients with ATAAD present with MPS, and these patients require more procedures and have greater morbidity and mortality than those without MPS.27Geirsson A. Szeto W.Y. Pochettino A. et al.Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: Outcomes and need for additional revascularizations.Eur J Cardiothorac Surg. 2007; 32: 255-262https://doi.org/10.1016/j.ejcts.2007.04.012Crossref PubMed Scopus (173) Google Scholar, 28Girdauskas E. Kuntze T. Borger M.A. et al.Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369https://doi.org/10.1016/j.jtcvs.2009.04.059Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar, 29Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: Observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145 (390.e1): 385-390https://doi.org/10.1016/j.jtcvs.2012.01.042Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar, 30Pacini D. Leone A. Belotti L.M.B. et al.Acute type A aortic dissection: Significance of multiorgan malperfusion.Eur J Cardiothorac Surg. 2013; 43: 820-826https://doi.org/10.1093/ejcts/ezs500Crossref PubMed Scopus (71) Google Scholar, 31Czerny M. Schoenhoff F. Etz C. et al.The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: Results from the GERAADA registry.J Am Coll Cardiol. 2015; 65: 2628-2635https://doi.org/10.1016/j.jacc.2015.04.030Crossref PubMed Scopus (145) Google Scholar For patients with ATAAD complicated by MPS, the optimal management strategy—particularly the timing of central aortic repair—remains controversial. A systematic approach emphasizing teamwork between surgeons and interventionalists may be beneficial. The conventional treatment strategy for ATAAD complicated by MPS is expeditious open surgical repair to restore distal true lumen flow and ameliorate the MPS. Experienced groups from Weill Cornell Medicine and Stanford University have adjudicated this strategy32Girardi L.N. Krieger K.H. Lee L.Y. et al.Management strategies for type A dissection complicated by peripheral vascular malperfusion.Ann Thorac Surg. 2004; 77 (discussion 1314): 1309-1314https://doi.org/10.1016/j.athoracsur.2003.09.056Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar,33Chiu P. Tsou S. Goldstone A.B. et al.Immediate operation for acute type A aortic dissection complicated by visceral or peripheral malperfusion.J Thorac Cardiovasc Surg. 2018; 156 (24.e3): 18-24https://doi.org/10.1016/j.jtcvs.2018.01.096Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar; in these studies, the mortality rate for immediate central aortic repair was similar between patients with ATAAD complicated by MPS and those without MPS. Other groups believe that immediate surgery in the face of MPS poses a prohibitive risk and instead favor upfront interventions to revascularize the affected organs, with delayed central aortic repair after the MPS is resolved. Coronary malperfusion can be managed with upfront percutaneous coronary intervention or concomitant repair of the coronary ostia vs coronary artery bypass grafting at the time of central aortic repair.34Kreibich M. Bavaria J.E. Branchetti E. et al.Management of patients with coronary artery malperfusion secondary to type A aortic dissection.Ann Thorac Surg. 2019; 107: 1174-1180https://doi.org/10.1016/j.athoracsur.2018.09.065Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Although severe cerebral malperfusion (ie, presenting with stroke or profound encephalopathy) is sometimes viewed as a contraindication to surgery, several studies have shown that expeditious central aortic repair can produce acceptable outcomes.12Shimura S. Odagiri S. Furuya H. et al.Echocardiography-guided aortic cannulation by the Seldinger technique for type A dissection with cerebral malperfusion.J Thorac Cardiovasc Surg. 2020; 159: 784-793https://doi.org/10.1016/j.jtcvs.2019.02.097Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,16Estrera A.L. Garami Z. Miller C.C. et al.Acute type A aortic dissection complicated by stroke: Can immediate repair be performed safely?.J Thorac Cardiovasc Surg. 2006; 132: 1404-1408https://doi.org/10.1016/j.jtcvs.2006.07.026Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar,35Tsukube T. Hayashi T. Kawahira T. et al.Neurological outcomes after immediate aortic repair for acute type A aortic dissection complicated by coma.Circulation. 2011; 124: S163-S167https://doi.org/10.1161/CIRCULATIONAHA.110.011551Crossref PubMed Scopus (51) Google Scholar Strategies to address cerebral malperfusion include rapidly implemented direct aortic cannulation, endovascular stenting of the carotid arteries, or cut down and direct perfusion of these arteries before or during repair. Visceral malperfusion can be temporized before central aortic repair with percutaneous dissection flap fenestration or branch vessel stenting.36Yang B. Rosati C.M. Norton E.L. et al.Endovascular fenestration/stenting first followed by delayed open aortic repair for acute type A aortic dissection with malperfusion syndrome.Circulation. 2018; 138: 2091-2103https://doi.org/10.1161/CIRCULATIONAHA.118.036328Crossref PubMed Scopus (36) Google Scholar Restoration of true lumen flow frequently resolves lower-extremity malperfusion; iliofemoral malperfusion can also be addressed with an axillofemoral or femoral-femoral bypass graft before or during central aortic repair. The major limitation of all strategies that defer immediate central aortic repair is the risk for death from aortic rupture or progressive organ failure in the interval between presentation and definitive aortic repair. For this reason, delayed aortic repair should be considered only in patients with overwhelming end-organ dysfunction secondary to MPS and relatively stable hemodynamic and aortic dimensional parameters. ATAAD most commonly stems from a primary tear that originates in the ascending aorta and involves the noncoronary sinus. In some cases, the dissection process may involve the right or left coronary sinuses or extend to the aortic annulus, such that a decision must be made as to whether the aortic root and valve should be repaired or else replaced with either a prosthetic composite valve-graft conduit or a stentless porcine bioroot, or by using a valve-sparing aortic root replacement (VSARR) technique. Selection of the appropriate method should be guided by direct inspection plus adjunctive transesophageal echocardiography to assess the morphology of the aortic root and competency of the aortic valve. Repairs are typically made during rewarming after HCA. In most cases, the aortic root can be repaired by resuspending the aortic valve commissural posts and optionally reinforcing the aortic wall through full-thickness suture fixation and insertion of a custom-sized Teflon felt neomedia “tongue” within the noncoronary sinus (Fig. 4). The primary advantage of repairing the aortic root lies in its simplicity: The procedure involves minimal tissue disruption and preserves the native aortic valve, obviating the need for long-term anticoagulation. Rylski and colleagues37Rylski B. Bavaria J.E. Milewski" @default.
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• W3039046390 title "Contemporary Surgical Strategies for Acute Type A Aortic Dissection" @default.
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• W3039046390 doi "https://doi.org/10.1053/j.semtcvs.2020.06.025" @default.
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