The aortic window: a temporal framework for acute type A aortic dissection

Area of Science:

• Cardiovascular Surgery
• Health Systems Management
• Emergency Medicine

Background:

• Acute type A aortic dissection (ATAAD) presents a critical surgical emergency with significant mortality.
• Despite excellent outcomes in high-volume centers, population-level results for ATAAD are poor, indicating systemic issues in care coordination.
• Current ATAAD care lacks a standardized, time-based pathway from initial presentation to surgical intervention.

Purpose of the Study:

• To develop a novel, time-based framework for managing acute type A aortic dissection.
• To address the gap in population-level outcomes by proposing a systems-level solution.
• To establish a measurable pathway for improving emergency response and surgical coordination in ATAAD.

Main Methods:

• Synthesized current epidemiology, guidelines, registry data, and national audits.
• Modeled the framework on successful time-critical pathways for myocardial infarction, stroke, trauma, and sepsis.
• Incorporated multidisciplinary, patient, and public input to create the "aortic window" pathway.

Main Results:

• Introduced the "aortic window," a phased pathway (RACE and RESTORE) from emergency department arrival to surgical incision.
• Defined ED-to-incision time as the primary endpoint to capture pre-diagnosis delays.
• Proposed a structured framework with defined process and outcome measures for coordinated care improvement.

Conclusions:

• The "aortic window" reframes ATAAD as a time-critical emergency manageable with organizational solutions.
• The proposed framework offers a structured and measurable basis for improving ATAAD care coordination.
• Further prospective evaluation is needed to validate the proposed targets and pathway effectiveness.