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Surgery for acute type A aortic dissection
T E David1, S Armstrong, J Ivanov
1Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Ontario, Canada.
Insights
Surgical techniques avoiding aortic clamping and using antegrade perfusion for acute type A aortic dissection improve patient survival and reduce complications. This approach enhances early and late outcomes in patients undergoing this critical procedure.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Acute type A aortic dissection presents significant surgical challenges.
- Innovative surgical techniques are being developed to improve patient outcomes.
Purpose of the Study:
- To evaluate the impact of novel surgical strategies on early and late outcomes in patients with acute type A aortic dissection.
- Compare outcomes between aortic clamping with retrograde perfusion versus no-clamp techniques with antegrade perfusion.
Main Methods:
- Retrospective review of 109 patients with acute type A aortic dissection over 18 years.
- Group I (n=55): Aortic clamping with retrograde femoral artery perfusion.
- Group II (n=54): No aortic clamping, primary tear resection, antegrade perfusion after distal anastomosis.
Main Results:
- Group II showed a trend towards lower operative mortality (9.2% vs 20%) and significantly fewer strokes (3.7% vs 14.5%).
- Long-term survival was higher in Group II (81% vs 56%), though not statistically significant.
- Patent false lumen rates were significantly lower in Group II (59% vs 91%).
Conclusions:
- Avoiding aortic clamping and employing antegrade perfusion improves early and late outcomes for acute type A aortic dissection.
- Resection of the primary tear is crucial in these advanced surgical techniques.
- These findings support the adoption of no-clamp strategies in managing acute type A aortic dissection.
Background:
Several innovative approaches have been introduced in the surgical treatment of acute type A aortic dissection. This study examines the effects of these new techniques on the early and late outcomes of patients with this disease.
Methods:
The records of patients who had surgery for acute type A aortic dissection during an 18 year interval were reviewed. There were 109 patients: 81 men and 28 women, with a mean age of 57 years, range 23 to 80. Most patients were acutely ill and 15 were in shock at the time of surgery. Operations were performed under cardiopulmonary bypass with femoral artery and right atrial cannulation. In 55 patients, the aorta was clamped and retrograde femoral perfusion was used throughout the procedure (group I). In 54 patients, no clamp was used; under circulatory arrest the primary tear was resected whether in the ascending aorta or transverse arch, and antegrade cardiopulmonary bypass was started after completion of the distal anastomosis (group II). Postoperative computed tomographic or magnetic resonance scans were completed annually.
Results:
There were 16 operative deaths (15%): 11 (20%) in group I, and 5 (9.2%) in group II (p = 0.10). There were 10 strokes: 8 (14.5%) in group I and 2 (3.7%) in group II (p = 0.05). After a mean follow-up time of 59 +/- 45 months for group I, 31 (56%) patients were alive, and after a mean follow-up time of 45 +/- 26 months for group II, 44 (81%) patients were alive. The actuarial survival of group II was higher than group I, but the difference was not significant (p = 0.09). Postoperatively, a patent false lumen was found in 91% of group I patients and in 59% of group II (p = 0.01).
Conclusions:
This study suggests that avoidance of aortic clamping, resection of the primary tear in the ascending aorta or transverse arch, and antegrade perfusion after completion of the distal anastomosis improve the early and late outcomes of surgery for acute type A aortic dissection.