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Impact of a multidisciplinary acute aortic dissection program: Improved outcomes with a comprehensive initial surgical repair strategy

Published:September 07, 2021DOI:https://doi.org/10.1016/j.jvs.2021.08.058

      Abstract

      Objective

      As part of a multidisciplinary aortic dissection (AD) program, a more comprehensive repair strategy for patients with acute type A aortic dissection (ATAAD) and frequent endografting for suitable patients with type B aortic dissection (ATBAD) was adopted in 2015. The aim of this study was to evaluate the impact of these changes.

      Methods

      This study is a retrospective review of a prospective database containing all patients treated for acute AD between 2003 and 2020. Patients were grouped based on differing repair strategies (pre 2015 vs post 2015). Clinical characteristics, procedural details, and survival data were analyzed.

      Results

      During this time, 323 patients (210 pre, 113 post) were treated for acute AD at our institution. There were 221 patients with ATAAD (149 pre, 72 post) and 102 patients with ATBAD (61 pre, 41 post). The majority (60%) were males, with a mean age of 65.9 ± 15.2 years. There were no differences in cardiovascular risk factors or demographics between the groups. After 2015, fewer patients with ATAAD underwent medical management alone (15% pre vs 4% post; P = .014), and most that underwent surgical intervention had a total arch or aggressive hemiarch repair (27% pre vs 78% post; P < .001). Seventy-four patients (73%) with ATBAD were treated medically, whereas 28 underwent medical management and endografting (23% pre, 34% post; P = .214). For all patients with AD, 30-day mortality was significantly improved (26% pre vs 10% post; P < .001) especially among patients who underwent ATAAD surgery (23% pre vs 9% post; P = .018). Three-year Kaplan-Meier survival estimates showed survival improvement among patients with ATAAD (Log rank P-value = .019); however, this improvement does not extend to type B dissections or the overall cohort. A survival analysis landmarked to 30 days after initial presentation showed no statistical difference in survival from 30 days to 3 years post-presentation.

      Conclusions

      A more comprehensive repair strategy in the management of patients with acute AD resulted in improved overall patient outcomes and significantly decreased 30-day mortality, even though more complex repairs were performed. The long-term impact of the changes made to our program remains to be evaluated.

      Keywords

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      References

        • Trimarchi S.
        • Nienaber C.A.
        • Rampoldi V.
        • Myrmel T.
        • Suzuki T.
        • Mehta R.H.
        • et al.
        • International Registry of Acute Aortic Dissection Investigators
        Contemporary results of surgery in acute type A aortic dissection: the International Registry of Acute Aortic Dissection experience.
        J Thorac Cardiovasc Surg. 2005; 129: 112-122
        • Hagan P.G.
        • Nienaber C.A.
        • Isselbacher E.M.
        • Bruckman D.
        • Karavite D.J.
        • Russman P.L.
        • et al.
        The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.
        JAMA. 2000; 283: 897-903
        • Tsai T.T.
        • Trimarchi S.
        • Nienaber C.A.
        Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD).
        Eur J Vasc Endovasc Surg. 2009; 37: 149-159
        • Halstead J.C.
        • Meier M.
        • Etz C.
        • Spielvogel D.
        • Bodian C.
        • Wurm M.
        • et al.
        The fate of the distal aorta after repair of acute type A aortic dissection.
        J Thorac Cardiovasc Surg. 2007; 133: 127-135
        • Fattouch K.
        • Sampognoro R.
        • Navarra E.
        • Caruso M.
        • Pisano C.
        • Coppola G.
        • et al.
        Long-term results after repair of type A acute aortic dissection according to false lumen patency.
        Ann Thorac Surg. 2009; 88: 1244-1250
        • Westaby S.
        • Saito S.
        • Katsumata T.
        Acute type A dissection: conservative methods provide consistently low mortality.
        Ann Thorac Surg. 2002; 73: 707-713
        • Nienaber C.A.
        • Rousseau H.
        • Eggebrecht H.
        • Kische S.
        • Fattori R.
        • Rehders T.C.
        • et al.
        • INSTEAD Trial
        Randomized comparison of strategies for type B aortic dissection: the Investigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.
        Circulation. 2009; 120: 2519-2528
        • Nienaber C.A.
        • Kische S.
        • Rousseau H.
        • Eggebrecht H.
        • Rehders T.C.
        • Kundt G.
        • et al.
        • INSTEAD-XL trial
        Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial.
        Circ Cardiovasc Interv. 2013; 6: 407-416
        • Tan M.E.S.H.
        • Morshuis W.J.
        • Dossche K.M.E.
        • Kelder J.C.
        • Waanders F.G.J.
        • Schepens M.A.A.M.
        Long-term results after 27 years of surgical treatment of acute type A aortic dissection.
        Ann Thorac Surg. 2005; 80: 523-529
        • Trimarchi S.
        • Eagle K.A.
        • Nienaber C.A.
        • Pyeritz P.E.
        • Jonker F.H.
        • Suzuki T.
        • et al.
        • International Registry of Acute Aortic Dissection (IRAD) Investigators
        Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).
        Circulation. 2010; 122: 1283-1289
        • Kimura N.
        • Tanaka M.
        • Kawahito K.
        • Yamaguchi A.
        • Ino T.
        • Adachi H.
        Influence of patent false lumen on long-term outcome after surgery for type A aortic dissection.
        J Thorac Cardiovasc Surg. 2008; 136 (1166.e1-1166.e3): 1160-1166
        • Fillinger M.F.
        • Greenberg R.K.
        • McKinsey J.F.
        • Chaikof E.L.
        • Society for Vascular Surgery Ad Hoc Committee on TEVAR Reporting Standards
        Reporting Standards for thoracic endovascular aortic repair (TEVAR).
        J Vasc Surg. 2010; 52: 1022-1033
        • Grau J.B.
        • Kuschner C.E.
        • Ferrari G.
        • Wilson S.R.
        • Brizzio M.E.
        • Zapolanski A.
        • et al.
        Effects of a protocol-based management of type A aortic dissection.
        J Surg Res. 2015; 197: 265-269
        • Pape L.A.
        • Tsai T.T.
        • Isselbacher E.M.
        • Oh J.K.
        • O’gara P.T.
        • Evangelista A.
        • et al.
        • International Registry of Acute Aortic Dissection (IRAD) Investigators
        Aortic diameter > or =5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD).
        Circulation. 2007; 116: 1120-1127
        • Landenhed M.
        • Engstrom G.
        • Gottsater A.
        • Caulfield M.P.
        • Hedblad B.
        • Newton-Cheh C.
        • et al.
        Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study.
        J Am Heart Assoc. 2015; 4: e001513
        • Landcaster T.
        • Stead L.
        • Silagy C.
        • Sowden A.
        Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library.
        BMJ. 2000; 321: 355-358
        • Isselbacher E.M.
        • Bonaca E.P.
        • Di Eusanio M.
        • Froehlich J.
        • Bassone E.
        • Sechtem U.
        • et al.
        • International Registry of Aortic Dissection (IRAD) Investigators
        Recurrent aortic dissection observations from the International Registry of Aortic Dissection.
        Circulation. 2016; 134: 1013-1024
        • Yu Hy
        • Chen Y.S.
        • Huang S.C.
        • Wang S.S.
        • Lin F.Y.
        Late outcome of patients with aortic dissection: study of a national database.
        Eur J Cardiothorac Surg. 2004; 25: 683-690
        • Bernard Y.
        • Zimmermann H.
        • Chocron S.
        • Litzler J.F.
        • Kastler B.
        • Etievent J.P.
        • et al.
        False lumen patency as a predictor of late outcome in aortic dissection.
        Am J Cardiol. 2001; 87: 1378-1382
        • Ghoreishi M.
        • Sundt T.M.
        • Cameron D.E.
        • Holmes S.D.
        • Roselli E.E.
        • Pasrija C.
        • et al.
        Factors associated with acute stroke after type A aortic dissection repair: an analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database.
        J Thorac Cardiovasc Surg. 2020; 159: 2143-2154.e3
        • Rizvi A.Z.
        • Sullivan T.M.
        Incidence, prevention, and management in spinal cord protection during TEVAR.
        J Vasc Surg. 2010; 52: 86S-90S
        • Myssiorek D.
        Recurrent laryngeal nerve paralysis: anatomy and etioloty.
        Otolaryngol Clinc North Am. 2004; 37: 25-44
        • Lodewyks C.L.
        • White C.W.
        • Bay G.
        • Hiebert B.
        • Wu B.
        • Baker M.
        • et al.
        Vocal cord paralysis after thoracic aortic surgery: incidence and impact on clinical outcomes.
        Ann Thorac Surg. 2015; 100: 54-58
        • Harris K.M.
        • Strauss K.C.
        • Duval C.
        • Unger B.T.
        • Kroshus T.J.
        • Inampudi S.
        • et al.
        Multidisciplinary standardized care for acute aortic dissection. Design and initial outcomes of a regional care model.
        Circ Cardiovasc Qual Outcomes. 2010; 3: 424-430
        • Thorsgard M.E.
        • Morrissette G.J.
        • Sun B.
        • Eales F.
        • Kshettry V.
        • Flavin T.
        • et al.
        Impact of intraoperative transesophageal echocardiography on acute type-A aortic dissection.
        J Cardiothoracic Vasc Anesth. 2014; 28: 1203-1207
        • Andersen N.D.
        • Ganapathi A.M.
        • Hanna J.M.
        • Williams J.B.
        • Gaca J.G.
        • Hughes G.C.
        Outcomes of acute type a dissection repair before and after implementation of a multidisciplinary thoracic aortic surgery program.
        J Am Coll Cardiol. 2014; 63: 1796-1803
        • Bavaria J.E.
        • Brinster D.R.
        • Gorman R.C.
        • Woo J.
        • Gleason T.
        • Pochettino A.
        Advances in the treatment of aortic dissection: an integrated approach.
        Ann Thorac Surg. 2003; 74 (discussion: S1857-63): S1848-S1852
        • Aggarwal B.
        • Raymond C.E.
        • Randhawa M.S.
        • Roselli E.
        • Jacob J.
        • Eagleton M.
        • et al.
        Transfer metrics in patients with suspected acute aortic syndrome.
        Circ Cardiovas Qual Outcomes. 2014; 7: 780-782
        • Andersen N.D.
        • Benrashid E.
        • Ross A.K.
        • Pickett L.C.
        • Smith P.K.
        • Daneshmand M.A.
        • et al.
        The utility of the aortic dissection team: outcomes and insights after a decade of experience.
        Ann Cardiovasc Surg. 2016; 5: 194-201
        • Chikwe J.
        • Cavallaro P.
        • Itagaki S.
        • Seigerman M.
        • Diluozzo G.
        • Adams D.H.
        National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality.
        Ann Thorac Surg. 2013; 95: 1563-1569
        • Goldstone A.B.
        • Chiu P.
        • Baiocchi M.
        • Lingala B.
        • Lee J.
        • Rigdon J.
        • et al.
        Interfacility transfer of Medicare beneficiaries with acute type A aortic dissection and regionalization of care in the United States.
        Circulation. 2019; 140: 1239-1250
        • Evangelista A.
        • Salas A.
        • Ribera A.
        • Ferreira-Gonzalez I.
        • Cuellar H.
        • Pineda V.
        • et al.
        Long-term outcomes of aortic dissection with patent false lumen: predictive role of entry tear size and location.
        Circulation. 2012; 125: 3133-3141
        • Kreibich M.
        • Rylski B.
        • Kondov S.
        • Morlock J.
        • Scheumann J.
        • Kari F.A.
        • et al.
        Endovascular treatment of acute type A aortic dissection-the Endo Bentall approach.
        J Vis Surg. 2018; 4: 69