When to Consider Deferral of Surgery in Acute Type A Aortic Dissection: A Review

Ann Thorac Surg. 2020 Aug 31;S0003-4975(20)31425-9. doi: 10.1016/j.athoracsur.2020.08.002. Online ahead of print.

Abstract

Background: Acute type A aortic dissection (ATAAD) is a surgical emergency with an operative mortality of up to 30%, a rate which has not changed meaningfully in over two decades. A growing body of research has highlighted several comorbidities and presenting factors in which delay or permanent deferral of surgery may be considered; however, modern comprehensive summative reviews are lacking. The urgency and timing of this review are underscored by significant challenges in resource utilization posed by the COVID-19 pandemic. This review provides an update on the current understanding of risk assessment, surgical candidacy, and operative timing in patients with ATAAD.

Methods: A literature search was conducted through PubMed and Embase databases to identify relevant studies relating to risk assessment in ATAAD. Articles were selected via group consensus based on quality and relevance.

Results: Several patient factors have been identified which increase risk in ATAAD repair. In particular, frailty, advanced age, prior cardiac surgery, and use of novel anticoagulant medications have been studied. The understanding of malperfusion syndromes has also expanded significantly, including recommendations for surgical delay. Finally, approaches to triage have been significantly influenced by resource limitations related to the ongoing COVID-19 pandemic. While medical management remains a reasonable option in carefully selected patients at prohibitive risk for open surgery, endovascular therapies for treatment of ATAAD are rapidly evolving.

Conclusions: Early surgical repair remains the preferred treatment for most patients with ATAAD, however, improvements in risk stratification should guide appropriate delay or permanent deferral of surgery in select individuals.

Publication types

  • Review