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Faggion Vinholo et al. Vessel Plus 2024;8:11 Vessel Plus
DOI: 10.20517/2574-1209.2023.150

Review Open Access

Acute type A aortic dissection: when not to operate,

a review

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1
1,2
1,2
Thais Faggion Vinholo , Jake Awtry , Robert Semco , Paige Newell , Ashraf A. Sabe 1
1
Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA.
2
Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA.
3
Harvard Medical School, Boston, MA 02115, USA.
Correspondence to: Dr. Ashraf A. Sabe, Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School,
75 Francis St., Boston, MA 02115, USA. E-mail: asabe@bwh.harvard.edu
How to cite this article: Faggion Vinholo T, Awtry J, Semco R, Newell P, Sabe AA. Acute type a aortic dissection: when not to
operate, a review. Vessel Plus 2024;8:11. https://dx.doi.org/10.20517/2574-1209.2023.150
Received: 5 Dec 2023 First Decision: 8 Jan 2024 Revised: 18 Feb 2024 Accepted: 29 Feb 2024 Published: 11 Mar 2024

Academic Editor: Manel Sabaté Copy Editor: Fangling Lan Production Editor: Fangling Lan

Abstract
Acute type A aortic dissection (ATAAD) is a surgical emergency with a nonoperative mortality rate of up to 1% per
hour and an operative mortality rate as high as 24%. Therefore, evaluation of comorbidities and patient
presentation characteristics prompts a pause for risk stratification before proceeding to the operating room, as
emergent surgery may not always be the optimal approach. This comprehensive review explores key
considerations in ATAAD management, emphasizing the need for nuanced decision making, by considering
medical management and delayed surgery as an alternative management approach for high-risk populations such
as the frail or patients who have a history of cardiac surgery. Beyond the immediate threat of aortic rupture, organ
malperfusion stands out as the most feared complication of ATAAD, also elevating perioperative risk significantly.
In such cases, careful assessment of patient’s hemodynamic status is paramount. For stable patients, a thorough
preoperative strategy and multidisciplinary discussions are encouraged. Notably, the advent of endovascular
techniques provides viable lower-risk alternatives to the traditional open approach. The consequences of ATAAD
surgical intervention extend beyond the immediate procedural concerns, with a substantial impact on the patient’s
overall function. Prioritizing patient-centered care becomes imperative in aligning management with individual
goals of care. This review seeks to provide insights into these considerations by offering a stepwise approach to
patient-centered decision-making in ATAAD management.

Keywords: Acute type A aortic dissection, aortic surgery, dissection repair, medical management, frailty, organ
malperfusion, patient-centered care, previous cardiac surgery

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

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