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Page 4 of 11 Faggion Vinholo et al. Vessel Plus 2024;8:11 https://dx.doi.org/10.20517/2574-1209.2023.150

In summary, the decision for emergency surgery in elderly patients with ATAAD remains controversial.
Acknowledging the higher short-term and in-hospital mortality compared to younger patients after
[25]
ATAAD , surgical treatment may still provide better outcomes than conservative management. However,
the decision to offer surgery requires a frank discussion about expected surgical complications, their impact
on the patient’s global function, independence, and alignment with individual goals of care. Recognizing the
complexities of assessing frailty in emergent scenarios emphasizes the need for a nuanced, individualized
approach, where frailty assessment takes precedence over age alone in guiding treatment decisions.

PREVIOUS CARDIAC SURGERY
Chest re-entry following a previous cardiac surgery (PCS) presents a range of potential complications that
contribute to elevated operative mortality. A study employing propensity matching revealed higher
observed mortality rates in patients undergoing reoperative surgery compared to those with a virgin chest
[33]
(8.37% vs. 6.07%, P = 0.01) . The adherence of the heart to the posterior table of the sternum raises the risk
of right ventricular injury. Additionally, individuals with a history of coronary artery bypass grafting
[34]
(CABG) face the risk of graft injury upon re-entry , along with heightened difficulty in achieving
myocardial protection, necessitating exposure of the left internal mammary artery amidst extensive
adhesions.

Patients with previous cardiac surgery often present with more comorbidities on admission and experience
longer cardiopulmonary bypass and aortic cross-clamp times during the reoperation , contributing to a
[35]
higher rate of perioperative complications. It is important to remember that patients with PCS may have
different symptoms during presentation due to cardiac sympathetic nervous system denervation during
their prior operation , potentially leading to delayed diagnosis. Patients who are in this category should be
[36]
worked up with this caveat in mind.

The question of whether PCS itself is an independent risk factor for patients undergoing surgery for
ATAAD is still under debate. Multiple studies have shown that major adverse events are more frequent in
patients with previous chest entry [37,38] . Those with previous cardiac surgery had worse medium-term
[39]
survival (51.7% vs. 71.2% at 5 years, P = 0.020) [Figure 2] . Likewise, the survival rates within the 5- and
10-year periods were significantly lower in patients who had previous cardiac surgery compared to those
[35]
who had not (56% vs. 72%, P = 0.004) .

Despite some studies suggesting that patients with ATAAD who have undergone PCS may have adhesions
that potentially offer a protective effect against tamponade and aortic rupture [37,40,41] , the data are not
consistent. In a large, contemporary multicenter study, Bjurbom et al. found no evidence of previous
cardiac surgery being an independent risk factor for mortality after ATAAD repair . However, the PCS
[39]
group encountered more major adverse events including 30-day mortality, perioperative stroke,
postoperative cardiac arrest, or de novo dialysis . Likewise, in a recently published multicenter study,
[39]
patients with previous PCS undergoing cardiac surgery had similar early and long-term outcomes compared
with those of virgin entry , though with a higher incidence of surgical revision for bleeding .
[42]
[42]
Yang et al. proposed offering surgery to these patients on an elective basis if they are hemodynamically
stable at presentation. They described improved mortality when performing ATAAD repair on
hemodynamically stable patients who had undergone PCS on an elective basis rather than urgently
(16.7% vs. 30%) .
[43]