Page 223 - Read Online

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

and consideration of medical management or delay in surgery instead may be pursued. Nevertheless, one
should not assume patients’ preferences regarding blood product transfusion based on their other beliefs,
especially given that patients may hold different opinions about different types of blood products.

BRIEF WORD ON SCORING SYSTEMS FOR ATAAD
As previously mentioned, open surgical repair, despite being considered the gold standard for ATAAD, still
comes with a notable risk of operative mortality. Consequently, several scoring models have been developed
to predict risk factors for ATAAD patients undergoing surgical repair. Currently, there are four established
scoring systems: Centofanti, GERAADA, IRAD, and UK Aortic scores. These models exhibit varying
degrees of accuracy in predicting mortality, underscoring the need for periodic revalidation, especially when
dealing with unique patient challenges. Future research endeavors should focus on refining these scores to
address the specific complexities associated with diverse clinical scenarios. This refinement aims to provide
a more comprehensive and reliable predictive tool, enhancing its utility in guiding surgical decisions for
ATAAD patients .
[62]

FUTURE PROSPECT: ENDOVASCULAR REPAIR OF ATAAD
Given the heightened risk profiles of populations outlined in this article, there has been a dedicated effort to
explore and innovate strategies for endovascular repair options in the context of ATAAD. Although the
application of TEVAR for ATAAD is still in its early phases, including experimental studies conducted with
[63]
animal models , existing research already suggests that TEVAR is not only feasible but also holds the
potential for superior outcomes compared to medical management alone.

For patients to be eligible for endovascular treatment, anatomic feasibility is paramount. Factors such as the
location of the entry tear, ascending aortic diameter, involvement of critical structures like the aortic root or
coronary arteries, and identification of an appropriate landing zone are crucial considerations .
[64]

A systematic review of 20 studies comprising 311 patients undergoing TEVAR for acute, subacute, or
chronic type A aortic dissection demonstrates the procedure’s feasibility in highly selective cases. The
incidence of technical failure, stroke, and endoleaks was notably low at 0.22%, 0.1%, and 8.52%, respectively.
While the 30-day postoperative complication rate stood at 7.08%, late complications occurred in 16.89% of
patients. Encouragingly, one-, three-, and five-year survival rates were estimated at 87.15%, 82.52%, and
82.31%, respectively . The study suggests that TEVAR is a viable option for carefully selected patients who
[65]
are not suitable for open surgery, but further research is needed to address technical challenges and establish
its long-term efficacy.

CONCLUSION
The management of ATAAD demands a nuanced and individualized approach tailored to the risk profile of
each patient. Although early surgical repair remains the mainstay of management for appropriate operative
candidates, the high risk of morbidity must be considered before proceeding to the operating room,
particularly for frail patients, the elderly, those who have undergone previous cardiac surgery, and those
with active organ malperfusion. In the highest-risk patients, medical management coupled with frank goals
of care discussion may be preferable to avert surgery that is unlikely to be successful or to preserve an
acceptable quality of life. Encouragingly, burgeoning endovascular techniques may offer lower-risk
alternatives to traditional open approaches, potentially expanding the population of patients able to undergo
effective early intervention. As the acute management options for ATAAD expand, perioperative risk
scoring systems will increasingly aid patient-centered surgical decision making, though ongoing refinement
is necessary to include new patient stratification concepts such as frailty. In summary, this comprehensive