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Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection

Published on Nov 15, 2019in The Journal of Thoracic and Cardiovascular Surgery5.261
路 DOI :10.1016/j.jtcvs.2019.11.003
Ibrahim Sultan10
Estimated H-index: 10
,
Valentino Bianco7
Estimated H-index: 7
+ 10 AuthorsThomas G. Gleason28
Estimated H-index: 28
Abstract
Abstract Background The strategy for intervention remains controversial for patients presenting with type A aortic dissection (TAAAD) and cerebral malperfusion with neurologic deficit. Methods Surgically managed patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) were evaluated to determine the incidence and prognosis of patients with cerebral malperfusion. Results A total of 2402 patients underwent surgical repair of TAAAD. Of these, 362 (15.1%) presented with cerebral malperfusion (CM) and neurologic deficits and 2040 (84.9%) patients had no neurologic deficits (NCM) at presentation. Patients with CM were less likely to present with chest pain (66% vs 86.5%; p Conclusions Fifteen percent of patients with TAAAD presented with CM and neurologic deficits. Despite the fact that this subset of the population was older and more likely to present with peripheral malperfusion, cardiac tamponade, and in shock, in-hospital survival was noted in nearly 75% of the patients. Surgeons may continue to offer lifesaving surgery for TAAAD to this critically ill cohort of patients with acceptable morbidity and mortality.
  • References (34)
  • Citations (2)
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References34
Newest
#1Koji Kawahito (Jichi Medical University)H-Index: 6
#2Naoyuki Kimura (Jichi Medical University)H-Index: 14
Last. Kei Aizawa (Jichi Medical University)H-Index: 6
view all 4 authors...
Background Although outcomes of acute type A aortic dissection (ATAAD) have improved, malperfusion remains associated with high morbidity and mortality rates, and its optimal therapeutic treatment is unknown. Emergency central repair has been performed as our first-line approach for malperfusion. Here, we analyzed outcomes of ATAAD with malperfusion and reassessed emergency central repair.
Source
#1Keiji Uchida (Yokohama City University Medical Center)H-Index: 14
#2Norihisa Karube (Yokohama City University Medical Center)H-Index: 5
Last. Munetaka Masuda (Yokohama City University Medical Center)H-Index: 2
view all 9 authors...
Abstract Objective The control of malperfusion is the key to improving the outcomes of surgery for type A acute aortic dissection. We revised our treatment strategy to reperfuse each ischemic organ before central repair. Methods Our current early reperfusion strategy consists of percutaneous coronary artery intervention for coronary malperfusion, direct surgical fenestration for carotid artery occlusion, active perfusion of the superior mesenteric artery for visceral malperfusion, and external s...
9 CitationsSource
#1Peter Chiu (Stanford University)H-Index: 9
#2Sarah Tsou (Stanford University)H-Index: 2
Last. Michael P. Fischbein (Stanford University)H-Index: 21
view all 6 authors...
Abstract Objective To evaluate the effect of visceral, renal, or peripheral malperfusion on the outcome of acute type A aortic dissection. Methods We performed a retrospective review of the acute type A aortic dissection experience at Stanford Hospital between January 2005 and December 2015. Inverse probability weighting was used to account for differences between patients who experienced malperfusion syndromes and those who did not. Weighted logistic regression was used to evaluate in-hospital ...
8 CitationsSource
#1Paolo BerrettaH-Index: 12
#2Santi TrimarchiH-Index: 43
Last. Marco Di EusanioH-Index: 27
view all 6 authors...
Patients presenting with type A acute aortic dissection (TAAD) complicated by malperfusion syndromes represent one of the highest surgical risk cohorts for cardiovascular surgeons. In the setting of aortic dissection, end-organ ischemia may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral and/or limb ischemia. In TAAD patients with malperfusion, notwithstanding continuous improvement in diagnostic and management strategies, surgical and cli...
3 CitationsSource
#1Ibrahim Sultan (University of Pittsburgh)H-Index: 10
#2Tyler J. WallenH-Index: 9
Last. Prashanth Vallabhajosyula (UPenn: University of Pennsylvania)H-Index: 20
view all 9 authors...
Background and Aim Concomitant endovascular stent grafting of the descending thoracic aorta during open repair for acute DeBakey I aortic dissection can be performed in patients with extensive dissection and malperfusion. We analyzed the effects of this strategy on distal aortic remodeling. Methods From 2006-2014, acute DeBakey I dissection patients without primary aortic arch tear undergoing open distal hemiarch reconstruction (Standard group) versus those undergoing hemiarch with descending th...
9 CitationsSource
#1Pradeep Narayan (UoB: University of Bristol)H-Index: 12
#2Chris A Rogers (UoB: University of Bristol)H-Index: 35
Last. Alan J. Bryan (UoB: University of Bristol)H-Index: 36
view all 6 authors...
Abstract Background Although generally better outcomes are reported in patients undergoing early repair of type A aortic dissection, patients who survive the first 48聽hours self-select themselves toward better outcomes as well. Malperfusion is another important determinant of outcome in these patients. The aim of this study was to examine the hypothesis that malperfusion, not the timing of operation, is the dominant determinant of outcome in repair of type A aortic dissection. Methods A total of...
8 CitationsSource
#1Prashanth Vallabhajosyula (UPenn: University of Pennsylvania)H-Index: 20
#2Jean Paul Gottret (UPenn: University of Pennsylvania)H-Index: 2
Last. Joseph E. Bavaria (UPenn: University of Pennsylvania)H-Index: 64
view all 13 authors...
Background In acute DeBakey I aortic dissection presenting with malperfusion syndromes, we assessed whether standard open repair with concomitant antegrade stent grafting (thoracic endovascular aneurysm repair; TEVAR) of the descending thoracic aorta (DTA) improves outcomes compared with standard repair alone. Methods From 2005 to 2012, 277 patients with acute DeBakey I dissection underwent emergent operation. Of these, 104 patients (37%) presenting with end-organ malperfusion were divided into ...
11 CitationsSource
#1Joshua Goldberg (NYMC: New York Medical College)H-Index: 2
#2Steven L. Lansman (NYMC: New York Medical College)H-Index: 7
Last. David Spielvogel (NYMC: New York Medical College)H-Index: 7
view all 6 authors...
Acute type A aortic dissection (ATAAD) is a vascular catastrophe, with a mortality of 1% per hour for the first 48 hours without surgical intervention. Of the diverse causes of morbidity and mortality associated with ATAAD, malperfusion, which complicates 20%-50% of cases, is particularly lethal. Although malperfusion can affect any vascular bed, this review focuses on the 3 most devastating: coronary, cerebral, and visceral malperfusion syndromes (MPS). Essentially, there are 3 methods of resto...
3 CitationsSource
#1Ibrahim SultanH-Index: 10
#2Jeremy McGarveyH-Index: 1
Last. Wilson Y. Szeto (UPenn: University of Pennsylvania)H-Index: 51
view all 6 authors...
Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA, USA *These authors contributed equally to this work. Correspondence to: Wilson Y. Szeto. Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Penn Presbyterian Medical Center, 51 N 39th St, Heart & Vascular Pavilion 2A, Philadelphia, PA 19104, USA. Email: wilson.szeto@uphs.upenn.edu.
10 CitationsSource
#1Dhaval Trivedi (University of Pittsburgh)H-Index: 3
#2Forozan Navid (University of Pittsburgh)H-Index: 7
Last. Thomas G. Gleason (University of Pittsburgh)H-Index: 28
view all 8 authors...
Background International registries for acute type A aortic dissection (TAAD) demonstrate stagnant operative mortality rates in excess of 20% and stroke rates of 9% to 25%, with little global emphasis on stroke reduction or carotid involvement. Cerebral malperfusion with TAAD has been linked to poorer outcome. We hypothesize that concomitant carotid dissection or complex dissection flaps in the arch play a major role in stroke development and that aggressive reconstruction of the arch and caroti...
24 CitationsSource
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Newest
#1Yuichi Ueda (NARA: National Archives and Records Administration)H-Index: 34
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