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Commentary: A tailored strategy for repair of acute type A aortic dissection: Balancing risk versus benefit

  • Wael Ahmad
    Correspondence
    Address for reprints: Oliver J. Liakopoulos, MD, Department of Cardiac Surgery, Kerckhoff-Clinic Bad Nauheim, Campus Kerckhoff, University of Giessen, Benekestr. 2-8, 61231 Bad Nauheim, Germany.
    Affiliations
    Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
    Search for articles by this author
  • Oliver J. Liakopoulos
    Affiliations
    Department of Cardiac Surgery, Kerckhoff-Clinic Bad Nauheim, Campus Kerckhoff, University of Giessen, Giessen, Germany
    Search for articles by this author
Published:January 19, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.01.038
      Figure thumbnail fx1
      Wael Ahmad, MD, and Oliver J. Liakopoulos, MD
      This study underscores the safety and efficacy of a well-balanced, patient-risk-orientated operative strategy in patients with acute type A aortic dissection.
      See Article page 1698.
      Current surgical aortic repair strategies for the treatment of acute type A aortic dissection vary in extent and technical complexity. Consequently, clinical outcomes, including operative mortality, complication rates, and reintervention rates, differ depending on the chosen repair strategy, extent of repair, and the underlying aortic pathology. The expert consensus document of the European Association for Cardio-Thoracic Surgery and the European Society for Vascular Surgery recommends performing extended procedures in the arch to prevent disease progression and to anticipate future endovascular modular distal extension, especially for patients with concomitant pathologies in the descending aorta.
      • Czerny M.
      • Schmidli J.
      • Adler S.
      • van den Berg J.C.
      • Bertoglio L.
      • Carrel T.
      • et al.
      Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS).
      However, a look into the literature reveals conflicting data; in their meta-analysis of 2221 patients, Poon and colleagues
      • Poon S.S.
      • Theologou T.
      • Harrington D.
      • Kuduvalli M.
      • Oo A.
      • Field M.
      Hemiarch versus total aortic arch replacement in acute Type A dissection: a systematic review and meta-analysis.
      demonstrated no difference in mortality or long-term reintervention/reoperation rates between hemiarch and total arch repair (TAR). Similar results were reported by others.
      • Di Eusanio M.
      • Berretta P.
      • Cefarelli M.
      • Jacopo A.
      • Murana G.
      • Castrovinci S.
      • et al.
      Total arch replacement versus more conservative management in Type A acute aortic dissection.
      ,
      • Zhang H.
      • Lang X.
      • Lu F.
      • Sakamoto T.
      • Matsumori M.
      • Okada K.
      • et al.
      Acute type A dissection without intimal tear in arch: proximal or extensive repair?.
      On the other hand, Omura and colleagues
      • Omura A.
      • Miyahara S.
      • Yamanaka K.
      • Sakamoto T.
      • Matsumori M.
      • Okada K.
      • et al.
      Early and late outcomes of repaired acute DeBakey type I aortic dissection after graft replacement.
      suggested that reintervention in the distal aorta might be reduced in patients after TAR, and Yamamoto and colleagues
      • Yamamoto H.
      • Kadohama T.
      • Yamaura G.
      • Tanaka F.
      • Takagi D.
      • Kiryu K.
      • et al.
      Total arch repair with frozen elephant trunk using the “zone 0 arch repair” strategy for type A acute aortic dissection.
      reported favorable results with low operative mortality and reintervention rates using zone 0 arch repair. Conversely, others have shown higher mortality and permanent neurologic deficit rate associated with TAR.
      • Lio A.
      • Nicolò F.
      • Bovio E.
      • Serrao A.
      • Zeitani J.
      • Scafuri A.
      • et al.
      Total arch versus hemiarch replacement for Type A acute aortic dissection: a single-center experience.
      • Kim J.B.
      • Chung C.H.
      • Moon D.H.
      • Ha G.J.
      • Lee T.Y.
      • Jung S.H.
      • et al.
      Total arch repair versus hemiarch repair in the management of acute DeBakey type I aortic dissection.
      • Vallabhajosyula P.
      • Gottret J.P.
      • Robb J.D.
      • Szeto W.Y.
      • Desai N.D.
      • Pochettino A.
      • et al.
      Hemiarch replacement with concomitant antegrade stent grafting of the descending thoracic aorta versus total arch replacement for treatment of acute DeBakey I aortic dissection with arch tear.
      Lau and colleagues
      • Lau C.
      • Robinson B.
      • Farrington W.J.
      • Rahouma M.
      • Gambardella I.
      • Gaudino M.
      • et al.
      A tailored strategy for repair of acute type A aortic dissection.
      present their more than 20-year institutional experience and report outcome data of 343 patients who underwent surgical repair for DeBakey Type I or Type II aortic dissection with special focus on the extent of repair. Clinical outcomes were compared between a conservative group (n = 240 patients) of patients who received root-sparing repair/hemiarch repair performed in most patients with advanced age and more comorbidities, and an extensive repair group (n = 103). The latter consisted of younger patients with connective tissue disease who would benefit in the long-term from a more complete aortic repair, and who underwent root replacement/arch repair. As expected, the conservative group had significantly shorter cardiopulmonary bypass, crossclamp, and circulatory arrest times. Overall operative mortality was low (5.6%) with no significant difference between the conservative and extensive repair group (7.1% vs 2.0%; P = .101). Although the rate of permanent neurologic deficit (3.8% vs 1.0%) did not differ between groups, the authors demonstrate a higher rate for the composite secondary end point; that is, major adverse events (eg, mortality, cerebrovascular event, dialysis, and tracheostomy) and major adverse pulmonary events (eg, prolonged intubation, reintubation, and tracheostomy) in the older and multimorbid conservative group. Both strategies resulted in comparable mid- and long-term survival rates with a 10-year survival of 63% and 66% in the conservative versus extensive repair groups, respectively. Naturally, aortic reinterventions/reoperations involved predominantly the distal aorta (93%) and were more frequently performed in the younger extensive repair group (12.8% at 5-year follow-up and 21% at 10-year follow-up) that had a higher incidence of connective tissue disease.
      The patient-specific surgical approach presented by the authors resulted in favorable clinical outcomes in the conservative group with similar short- and long-term survival compared with the extensive group. This underscores the safety and efficacy of a well-balanced, patient-risk-orientated operative strategy in patients with acute type A aortic dissection.

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      • A tailored strategy for repair of acute type A aortic dissection
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients.
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