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Page 2 of 11 Faggion Vinholo et al. Vessel Plus 2024;8:11 https://dx.doi.org/10.20517/2574-1209.2023.150

INTRODUCTION
Acute type A aortic dissection (ATAAD) is a surgical emergency that affects approximately 10,000 patients
[1]
per year in the United States alone and, if left untreated, is associated with serious complications including
mortality. The estimated incidence is likely an underestimation; multiple studies have indicated that the
[2,3]
incidence of ATAAD is higher than initially believed due to a significant number of patients who never
make it to the hospital and, as a result, are not properly diagnosed with ATAAD. In fact, a post-mortem
autopsy study revealed ATAAD to be the cause of death in 7% of patients initially presumed to have
[4]
succumbed to cardiopulmonary arrest . Prompt surgical intervention is typically warranted for ATAAD,
given that the mortality rate in patients managed nonoperatively can be as high as 1%-2% per hour during
[5,6]
[7]
the first 48 h . However, despite advancements in technique and perioperative management , surgical
intervention itself can have a mortality rate of up to 24% [8-12] . Therefore, the decision on whether to proceed
with emergent operative repair depends on weighing a patient’s acute surgical risk against the known high
risk associated with nonoperative management. Identifying surgical risk factors is critical in providing
guidance for clinical decision making during these emergent scenarios. The aim of this review is to inform
treatment decisions in this complex patient group by highlighting elements to consider when deciding
whether ATAAD should be operated on. The importance of patient stratification should be emphasized,
and in certain scenarios, medical treatment, or optimization prior to surgery involving pain control, anti-
impulse therapy, antihypertensive therapy through vasodilatation, and blockage of the sympathetic beta
response should be considered.

FRAILTY AND THE ELDERLY
The aging population is rapidly increasing and the presentation of ATAAD in octogenarians is not
infrequent . Frailty, identified as an independent predictor of late mortality in patients undergoing surgical
[13]
[14]
repair for ATAAD , presents a complex challenge. Although frailty scoring systems have been developed
and implemented in medicine [8,15,16] , their use still lags within the field of cardiac surgery. For instance,
ATAAD-specific scores, such as the German Registry for Acute Type A Aortic Dissection (GERAADA)
score, exclude frailty [17,18] consideration when assessing mortality, leaving clinicians to rely on an “eyeball
test” or functional status inquiries with patients and their families [19,20] . The emergent nature of aortic
dissections complicates frailty assessments due to urgency and symptoms, often leading to age being used as
a proxy for frailty .
[8]

While surgery is generally advised for ATAAD, its expected benefits may be diminished in elderly patients,
a demographic inherently at higher risk. A study leveraging the International Registry of Acute Aortic
Dissection (IRAD) found that surgery did not offer a survival benefit compared to medical management in
octogenarian patients presenting with ATAAD . Similarly, a systematic review focusing on octogenarian
[21]
patients revealed a twofold higher likelihood of short-term (30-day or in-hospital) mortality following
surgery for ATAAD compared to non-octogenarians [Figure 1]. These results were comparable to
[22]
previously published systematic reviews [23,24] .

Several factors contribute to the higher perioperative mortality observed in elderly ATAAD patients. Elderly
patients typically exhibit fewer symptoms [22,25] , leading to later and more complicated dissections. The
elderly population is also prone to complications on admission, such as cardiac tamponade and prolonged
intubation [25,26] . Ultimately, elderly patients may have higher perioperative mortality simply by having less
reserve than their younger counterparts.

Importantly, frail elderly patients with concomitant malperfusion issues face even worse prognostic
outcomes, exacerbating the challenges associated with frailty. Cerebral degenerative diseases like dementia