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Acute Type A Aortic Dissection: A Vascular Surgeon’s Perspective
Vy C. Dang1, Michael J. Reardon, MD2, Maham Rahimi, MD, PhD3.
1Texas A&M University School of Medicine, Bryan, TX, USA, 2Department of Cardiovascular Surgery – Cardiac Surgery, Houston Methodist Hospital,, Houston, TX, USA, 3Department of Cardiovascular Surgery – Vascular Surgery, Houston Methodist Hospital, Houston, TX, USA.

OBJECTIVE: Acute Type A aortic dissection (ATAAD) is a morbid condition with a mortality rate of 23.8% that requires emergent diagnosis and surgical treatment. End-organ ischemia has long-been reported as a complication of aortic dissection, with mesenteric malperfusion demonstrating a 63.2% mortality rate in ATAAD. In this paper, we review predictive variables of in-hospital mortality and risk-scoring systems and propose a definition of complicated ATAAD based on preoperative patient assessment. Within this classification, we further define cardiac-complicated and vascular-complicated ATAAD presentations based on clinical, laboratory, and radiographic findings (Table 1) to better justify which specialty should operate on the patient first. METHODS: We present a narrative literature review of papers published between 2000 to 2021 that demonstrate statistically significant risk factors of postoperative mortality in ATAAD repair. The search was performed on the electronic database PubMed using the following terms: “type A aortic dissection”, “complications”, “malperfusion”, “clinical presentation”, “laboratory”, and “imaging”. Publications describing preoperative risk-stratification systems were selected for review. Full texts of each publication were examined for duplicate cases; references were assessed for relevance and inclusion in the paper. RESULTS: 12 articles were included in this review. The authors analyze significant predictors of in-hospital mortality, along with describing and validating original risk-stratification systems. Patients presenting with hemodynamic instability should be recognized as having cardiac-complicated ATAAD, which necessitates emergent Type A repair. Hemodynamic instability is due to associated aortic insufficiency, coronary malperfusion, cardiac tamponade, aortic rupture, and/or neurological malperfusion. Meanwhile, mesenteric malperfusion with hemodynamic stability is defined as vascular-complicated ATAAD, which presents clinically as malperfusion syndrome. The extent of mesenteric malperfusion can be evaluated through visualization of branch vessel obstruction, lactate levels (<2, 2 to 5, 5 to 8, >8 mmol/L), and base deficit (0 to -5, -5 to -7, -7 to -10, ≥-10). Severe mesenteric malperfusion warrants consideration of endovascular treatment before central aortic repair. CONCLUSIONS: Our described classification of cardiac- and vascular-complicated ATAAD requires validation through single- and multi-center retrospective studies. With validation, our efforts may provide guidance in the systematic preoperative assessment of ATAAD patients to determine the appropriate initial intervention to reduce morbidity and mortality.

Table 1. Features of complicated ATAAD.
Cardiac-complicatedHypotensionAbnormal ECGAbnormal TTE (eg, aortic rupture, aortic insufficiency, pericardial tamponade)
SyncopeElevated troponin
Intractable chest pain
Vascular-complicatedAbdominal painElevated lactateAbnormal CTA (eg, mesenteric, renal, LE malperfusion)
Absence of peripheral pulsesElevated creatinine

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