Acute type A aortic dissection: when not to operate, a review

Abstract

Acute type A aortic dissection (ATAAD) is a surgical emergency with a nonoperative mortality rate of up to 1% per hour and an operative mortality rate as high as 24%. Therefore, evaluation of comorbidities and patient presentation characteristics prompts a pause for risk stratification before proceeding to the operating room, as emergent surgery may not always be the optimal approach. This comprehensive review explores key considerations in ATAAD management, emphasizing the need for nuanced decision making, by considering medical management and delayed surgery as an alternative management approach for high-risk populations such as the frail or patients who have a history of cardiac surgery. Beyond the immediate threat of aortic rupture, organ malperfusion stands out as the most feared complication of ATAAD, also elevating perioperative risk significantly. In such cases, careful assessment of patient’s hemodynamic status is paramount. For stable patients, a thorough preoperative strategy and multidisciplinary discussions are encouraged. Notably, the advent of endovascular techniques provides viable lower-risk alternatives to the traditional open approach. The consequences of ATAAD surgical intervention extend beyond the immediate procedural concerns, with a substantial impact on the patient’s overall function. Prioritizing patient-centered care becomes imperative in aligning management with individual goals of care. This review seeks to provide insights into these considerations by offering a stepwise approach to patient-centered decision-making in ATAAD management.

Keywords

Acute type A aortic dissection / aortic surgery / dissection repair / medical management / frailty / organ malperfusion / patient-centered care / previous cardiac surgery

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