Page 220 - Read Online

Faggion Vinholo et al. Vessel Plus 2024;8:11 https://dx.doi.org/10.20517/2574-1209.2023.150 Page 5 of 11

Figure 2. Acute type A aortic dissection survival after surgery comparing patients with (red line) and without previous cardiac surgery
(blue line [P = 0.020]). (Reproduced from Bjurbom and colleagues, with permission from Elsevier).

Considering these factors, when providing surgical management for this high-risk population, it is crucial to
thoroughly assess the details of prior surgeries and their maintenance. For instance, individuals who have
undergone CABG should ideally undergo left heart catheterization to inspect the grafts thoroughly prior to
aortic repair. Similarly, for patients who have undergone valve surgery, careful attention to the previously
managed valve is imperative. This comprehensive approach ensures a thorough evaluation, addressing
specific considerations related to the patient’s surgical history and optimizing the overall management
strategy. Additionally, these meticulous assessments are of paramount importance as they may also
influence the decision on whether concomitant surgery is required during the repair of ATAAD.

In summary, patients with PCS presenting with ATAAD should be carefully considered for surgery.
Surgical planning , including strategies for obtaining imaging preoperatively or establishing
[44]
cardiopulmonary bypass prior to re-entry , should be thorough as there is potential for significant injury
[34]
upon re-entry. Lastly, there may be cases that can be optimized prior to surgery and wait for a maximum of
2-3 days, especially when patients are hemodynamically stable at the time of presentation.

ORGAN MALPERFUSION
ATAAD may result in inadequate blood supply to vital organs, termed malperfusion. If sufficient blood
supply is not reestablished within a suitable time period, it may result in end-organ ischemia and, in the
presence of signs, symptoms and radiographic evidence of malperfusion, constitute a malperfusion
syndrome . Besides aortic rupture, malperfusion is the most feared potential complication of ATAAD. It
[45]
affects about 20%-50% of patients and has been quoted to have perioperative mortality as high as
29%-89% . Furthermore, malperfusion syndrome has been shown to be an independent risk factor for in-
[46]
hospital mortality for ATAAD patients. In a recently published meta-analysis, malperfusion was identified
as a significant preoperative risk factor for early death after ATAAD surgical repair [OR 3.45,
95%CI:(2.24, 5.31)] .
[46]

Malperfusion in ATAAD can occur through various mechanisms, including the collapse of the true aortic
lumen, occlusion of vessel branch ostia by intimal dissection flap, or thrombosis of the branch, all of which