Surgical strategies in elderly patients with acute type A aortic dissection-a systematic review

Acute type A aortic dissection (ATAAD) is a life-threatening emergency requiring urgent surgery. Advanced age is a major risk factor for operative mortality and strongly influences treatment decisions. This systematic review evaluates perioperative characteristics, surgical strategies in regard to outcomes and mortality in patients older than 70 years undergoing ATAAD repair. A PRISMA-guided database search identified original studies published between 2000 and 2025. Early and late outcomes were pooled, with thirty-day mortality as the primary endpoint and postoperative complications, organ dysfunction and quality of life as secondary endpoints. Key aspects of ATAAD management, including patient selection, extent of repair, cerebral protection and perioperative organ protection strategies, were systematically analyzed. Of 1,910 screened studies, 41 publications including 3,969 elderly patients were analyzed, encompassing randomized, observational and case-control designs. Preoperative malperfusion occurred in 22.8% of patients, most commonly cerebral (16.7%) and renal (13.5%). When analyzed within their respective cohorts, the majority of patients received standard of care ascending aorta or hemiarch replacement. This was followed by total arch replacement and root replacement. Mean cardiopulmonary bypass, cross-clamp and circulatory arrest times were 201, 104 and 45 min, respectively, at 23 °C. Postoperative morbidity was substantial, with neurological complications (12%), delirium (30%), respiratory failure (21%) and dialysis-dependent renal failure (22%). 30-day mortality was in average 21% and was mainly due to bleeding, low cardiac output and multiple organ failure. Long-term quality of life, assessed by SF-36, remained satisfactory. However, data was overall heterogeneously presented and therefor limited interpretability concerning the addressed endpoints. ATAAD surgery in elderly patients remains challenging due to frailty and comorbidities. Careful patient selection and treatment in specialized centers are essential. Despite the emerging hybrid and endovascular approaches, open repair was the most commonly reported intervention. The available data suggests that advanced age was not consistently associated with withholding surgical treatment, especially in cases of absence of malperfusion.