Treatment of patients in the immediate and long-term periods of acute aortic dissection of type A complicated by malperfusion syndrome

Introduction. Acute aortic dissection type A is still considered one of the most formidable conditions in urgent surgery. The occurrence of malperfusion significantly worsens the results of treatment, leading to an increase in the incidence of complications and mortality. Patients who have undergone reconstructive interventions in the acute period require dynamic observation due to the development of aortic remodeling, leading in some cases to repeated dissection.
Aim. To improve the results of surgical treatment of patients with acute type A aortic dissection and malperfusion.
Materials and methods. From 2006 to 2021, 117 patients with acute type A aortic dissection and malperfusion were treated at the Interregional Clinical and Diagnostic Center of the Ministry of Health of the Republic of Tatarstan, Kazan, 107 of whom received surgical treatment.
Results. The following factors had a statistically significant impact on survival: aortic rupture with hemotamponade, myocardial infarction, anastomotic bleeding, renal and coronary malperfusion. The right coronary artery, brachiocephalic trunk, common carotid, renal and common iliac arteries had a significant effect (p < 0.05) on the occurrence of malperfusion with a true lumen narrowing degree of at least 60%. Remodeling of the aorta and its branches requiring correction occurred in every 5th (17%) case.
Discussion. The introduction of new predictors of unfavorable outcome is an urgent problem; their dissemination and implementation makes it possible to modernize existing treatment methods. The problem of aortic remodeling in patients after acute dissection is the most pressing in modern aortic surgery, because repeated acute aortic syndrome against the background of the previous development of a more malignant disease.
Conclusions. In the acute period, it is necessary to carefully assess the presence of risk factors and the degree of narrowing of the true branches of the aorta in order to reduce thelevel of complications and mortality. To prevent acute aortic syndrome, it is necessary to monitor pathological remodeling of the aorta.

1. Clinical Guidelines. Guidelines for the Diagnosis and Treatment of Aortic Diseases (2017). Kardiologiya i Serdechno-Sosudistaya Khirurgiya. 2018;11(1):7–67. (In Russ.) Available at: https://www.mediasphera.ru/issues/kardiologiya-i-serdechno-sosudistaya-khirurgiya/2018/1/1199663852018011007.

2. Khubulava GG, Shikhverdiev NN, Peleshok AS, Kravchuk VN, Krivopalov VA, Volkov AM et al. Acute aortic syndrome: management of surgical treatment in a megalopolis. Russian Journal of Thoracic and Cardiovascular Surgery. 2019;61(5):387–395. (In Russ. ) https://doi.org/10.24022/0236-2791-2019-61-5-387-395.

3. Charchian ÉR, Abugov SA, Khachatryan ZR, Puretskiĭ MV, Khovrin VV, Skvortsov AA, Belov YuV. Postoperative care in patients with DeBakey type I aortic dissection: criteria of aortic remodeling and risk factors of disease progression. Pirogov Russian Journal of Surgery. 2019;(5):6–17. (In Russ.) https://doi.org/10.17116/hirurgia20190516.

4. Khokhlunov SM, Kuznetsov DV. The state of cardiovascular surgery in the Volga Federal District in 2022. Russian Journal of Thoracic and Cardiovascular Surgery. 2024;66(1):29–35. (In Russ.) https://doi.org/10.24022/0236-2791-2024-66-1-29-35.

5. Chiappini B, Schepens M, Tan E, Dell’ Amore A, Morshuis W, Dossche K et al. Early andlate outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J. 2005;26(2):180–186. https://doi.org/10.1093/eurheartj/ehi024.

6. Bonser RS, Ranasinghe AM, Loubani M, Evans JD, Thalji NM, Bachet JE et al. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol. 2011;58(24):2455–2474. https://doi.org/10.1016/j.jacc.2011.06.067.

7. Belov YuV, Charchian ЕR, Stepanenko AB, Gens AP, Khachatryan ZR. Surgical treatment of DeBakey type 1 aortic dissection. Pirogov Russian Journal of Surgery. 2018;(7):8–17. (In Russ.) https://doi.org/10.17116/hirurgia201878.

8. Berretta P, Trimarchi S, Patel HJ, Gleason TG, Eagle KA, Di Eusanio M. Malperfusion syndromes in type A aortic dissection: what we have learned from IRAD. J Vis Surg. 2018;4:65. https://doi.org/10.21037/jovs.2018.03.13.

9. https://elibrary.ru/gencdi.

10. Sabe AA, Percy ED, Kaneko T, Plichta RP, Hughes GC. When to Consider Deferral of Surgery in Acute Type A Aortic Dissection: A Review. Ann Thorac Surg. 2021;111(6):1754–1762. https://doi.org/10.1016/j.athoracsur.2020.08.002.

11. Khubulava GG, Shikhverdiev NN, Peleshok AS, Kravchuk VN, Krivopalov VA, Volkov AM et al. Acute aortic syndrome: predictors of hospital mortality. Russian Journal of Thoracic and Cardiovascular Surgery. 2019;61(4):317–322. (In Russ.) https://doi.org/10.24022/0236-2791-2019-61-4-317-322.

12. Sayed A, Munir M, Bahbah EI. Aortic Dissection: A Review of the Pathophysiology, Management and Prospective Advances. Curr Cardiol Rev. 2021;17(4):e230421186875. https://doi.org/10.2174/1573403X16666201014142930.

13. Czerny M, Rylski B. Acute type A aortic dissection reconsidered: it’s all about thelocation of the primary entry tear and the presence or absence of malperfusion. Eur Heart J. 2021;43(1):53–55. https://doi.org/10.1093/eurheartj/ehab664.

14. Bachet J. Commentary: Acute type A dissection-Should we systematically replace the aortic root? J Thorac Cardiovasc Surg. 2021;161(2):495–496. https://doi.org/10.1016/j.jtcvs.2019.11.084.

15. Norton EL, Farhat L, Wu X, Kim KM, Fukuhara S, Khaja MS et al. Managing Malperfusion Syndrome in Acute Type A Aortic Dissection With Previous Cardiac Surgery. Ann Thorac Surg. 2021;111(1):52–60. https://doi.org/10.1016/j.athoracsur.2020.04.132.

16. Murillo H, Molvin L, Chin AS, Fleischmann D. Aortic Dissection and Other Acute Aortic Syndromes: Diagnostic Imaging Findings from Acute to Chronic Longitudinal Progression. Radiographics. 2021;41(2):425–446. https://doi.org/10.1148/rg.2021200138.

17. Uchida K, Minami T, Cho T, Yasuda S, Kasama K, Suzuki S et al. Results of ascending aortic and arch replacement for type A aortic dissection. J Thorac Cardiovasc Surg. 2021;162(4):1025–1031. https://doi.org/10.1016/j.jtcvs.2020.02.087.