Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.1055/s-0039-1695729
Improving Outcomes of Iatrogenic Type A Aortic Dissection during Cardiac Surgery
Funding Isaac George received consulting fees from Edwards, Medtronic, Boston Scientific, Bolton, and Gore.Publication History
06 November 2018
24 April 2019
Publication Date:
26 November 2019 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00039245/201904/lookinside/thumbnails/10-1055-s-0039-1695729_180056-1.jpg)
Abstract
Background Iatrogenic Type A aortic dissection (IAD) is a rare but devastating complication of cardiac and aortic surgery with reported operative mortality of 30 to 50%. In this study, we report our experience with IAD and propose a standardized approach to management.
Methods From January 1, 2000 through December 31, 2016, 23,275 patients underwent cardiac surgery at our institution. We identified 15 patients who developed IAD. Our approach to management included (1) immediate repair, (2) involvement of a second attending surgeon, (3) aggressive monitoring of malperfusion, (4) securing true lumen arterial perfusion access and systemic cooling, and (5) performance of hemiarch or total arch replacement based on the presence of suspected brain malperfusion. The index operation was also completed at the same time. Patient preoperative characteristics, operative sequence and technique, complications, and outcomes were analyzed with chart review.
Results The incidence of IAD at our institution was 0.06% (n = 15). A disproportionate percentage of patients had aneurysmal ascending aortas (33.3%). The index surgery consisted of aortic surgery in five patients (33.3%), coronary bypass in three patients, valve surgery in five patients, and transplantation in one patient. The mechanism of dissection was aortic cannulation in 66.7% and aortic root vent site cannulation in 13.3%. In 46.7% of patients, the IAD was first recognized based on clinical evidence such as aortic hematoma, pericardial bleeding, or abnormal perfusion line pressures. In 40.0%, the diagnosis was made with intraoperative echocardiography without any clinical manifestations. The timing of the diagnosis was at the initiation of cardiopulmonary bypass initiation in 60.0%, while in 40.0% it was recognized after discontinuation of bypass. Hemiarch was done in 73.3% and total arch replacement performed in 13.3%. Isolated ascending repairs were done in two patients. Bypass and cross-clamp times were 229.5 ± 212.7 minutes and 130.5 ± 109.5 minutes, respectively. In-hospital mortality in our cohort was 6.7%. While stroke occurred in one patient, no visceral organ malperfusion was recognized.
Conclusions Incidence of IAD is low with cannulation of an aneurysmal aorta being a risk factor. A standardized approach may result in reduced operative mortality.
-
References
- 1 Still RJ, Hilgenberg AD, Akins CW, Daggett WM, Buckley MJ. Intraoperative aortic dissection. Ann Thorac Surg 1992; 53 (03) 374-379 , discussion 380
- 2 Fleck T, Ehrlich M, Czerny M, Wolner E, Grabenwoger M, Grimm M. Intraoperative iatrogenic type A aortic dissection and perioperative outcome. Interact Cardiovasc Thorac Surg 2006; 5 (01) 11-14
- 3 Williams ML, Sheng S, Gammie JS, Rankin JS, Smith PK, Hughes GC. Richard E. Clark Award. Aortic dissection as a complication of cardiac surgery: report from the Society of Thoracic Surgeons database. Ann Thorac Surg 2010; 90 (06) 1812-1816 , discussion 1816–1817
- 4 Leontyev S, Borger MA, Legare JF. , et al. Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients. Eur J Cardiothorac Surg 2012; 41 (03) 641-646
- 5 Narayan P, Angelini GD, Bryan AJ. Iatrogenic intraoperative type A aortic dissection following cardiac surgery. Asian Cardiovasc Thorac Ann 2015; 23 (01) 31-35
- 6 Hagan PG, Nienaber CA, Isselbacher EM. , et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283 (07) 897-903
- 7 Ehrlich M, Fang WC, , Grabenwo ̈ger, M, Cartes-Zumelzu F, Wolner E, Havel M. Perioperative risk factors for mortality in patients with acute type A aortic dissection. Circulation 1998; 98 (Suppl II): 294-298
- 8 Miller DC, Mitchell RS, Oyer PE, Stinson EB, Jamieson SW, Shumway NE. Independent determinants of operative mortality for patients with aortic dissections. Circulation 1984; 70 (3 Pt 2, Suppl I) I153-I164
- 9 DeBakey ME, McCollum CH, Crawford ES. , et al. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery 1982; 92 (06) 1118-1134
- 10 Bachet J, Goudot B, Dreyfus GD. , et al. Surgery for acute type A aortic dissection: the Hospital Foch experience (1977-1998). Ann Thorac Surg 1999; 67 (06) 2006-2009 , discussion 2014–2019