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Faggion Vinholo et al. Vessel Plus 2024;8:11 https://dx.doi.org/10.20517/2574-1209.2023.150 Page 7 of 11

to be equivalent to patients who did not present with malperfusion syndrome at all [54,55] . This approach is
particularly important when deep hypothermic circulatory arrest is contemplated, which poses an even
greater insult via enduring visceral ischemia. Notably, if central repair is addressed first, one must consider
the possibility of reperfusion syndrome when flow is restored to true lumen.

More recently, promising results have been demonstrated for a TEVAR-first approach, in which the true
lumen of the descending aorta and occluded vessel branches are stented open prior to surgical repair of the
ascending aorta. One institution reports 30% mortality after TEVAR-first (n = 3 out of 10) for patients with
ATAAD and mesenteric malperfusion, compared to 69.2% mortality after ascending/arch repair first,
though notably, an additional three patients in the TEVAR-first group died before aortic replacement and
[56]
this group was likely biased towards more hemodynamically stable patients . Another institution reported
a 2-year survival rate of 71.8% with this approach in patients with ATAAD, of whom 44% had visceral
malperfusion .
[57]

Thoughtful deliberation should be had before considering patients with malperfusion for open repair in the
setting of ATAAD because of such high perioperative risk. In 2022, the American College of Cardiology and
American Heart Association guidelines recommended immediate surgical repair of the ascending aorta for
patients with renal, mesenteric, or lower extremity malperfusion . However, for patients presenting with
[47]
clinically significant signs of mesenteric malperfusion in particular, it is reasonable to pursue either
immediate surgical repair of the ascending aorta or immediate endovascular or surgical mesenteric
[47]
revascularization followed by ascending aortic repair .

PATIENT-CENTERED CARE
Recently, there has been an increased interest in the integration of palliative care involvement for critical
illness requiring surgery. Nevertheless, it is still relatively underused. Additionally, palliative care
involvement during emergency situations such as the presentation of ATAAD has its limitations.

Hesitation of palliative care involvement has been particularly pronounced within the field of cardiothoracic
surgery. The focus of cardiac surgery has historically been recovery and not palliation; hence, the hesitation
[58]
of palliative care team involvement is likely due to the conflict in terminology . While cardiac surgeons
attempt to restore a patient’s life by offering surgery, the “palliative” term may give a negative connotation
and make surgeons feel uneasy about involving this multidisciplinary team. However, a frank conversation
of the best and worst possible clinical outcomes is warranted to facilitate effective patient decision making,
especially because surgeons have been known to be particularly optimistic about potential surgical
[58]
outcomes.

Multidisciplinary palliative care teams may not be immediately available during emergent situations. Hence,
we must do better as surgeons and be able to conduct these conversations ourselves. As proposed by
Nakagawa, palliative care conversations will address both spiritual and physiologic stress, reduce symptom
burden, and provide emotional support to all involved .
[59]

PATIENT REFUSAL OF BLOOD PRODUCTS
Patients who suffer ATAAD typically have higher blood product transfusion requirements, likely due to the
length of surgery and the use of protective hypothermia . Approximately 3.7% of patients experience
[60]
[61]
uncontrollable hemorrhage, constituting 20% of the total fatalities in this population . Consequently, some
surgeons would consider the refusal of blood product transfusion as a contraindication for ATAAD repair.
If the patient does not consent to blood transfusion, the risk of perioperative mortality will likely increase,