Clinical trends in optimal treatment strategy for type A acute aortic dissection

The mortality rate in emergency surgical intervention for type A acute aortic dissection (AAD) has been variously reported as 15%-30%. These findings are often derived from series spanning 10-20 years. Many factors, such as surgical techniques, use of sealed prosthesis, access to cardiopulmonary bypass, cerebral protection techniques, and postoperative surveillance, have markedly changed during this long time interval, influencing the recently improved surgical outcomes. Earlier referral to the operating theater improves surgical results before dissection-related complications become irreversible. Preoperative malperfusion of the vital organ, pulse less shock, and required cardiopulmonary resuscitation are independent predictors of operative mortality. Deep hypothermia itself and very long cerebral perfusion are associated with a higher incidence of neurological injury. Moderate hypothermic circulatory arrest (28 °C) followed by aggressive rapid rewarming is safe and makes the surgery much quicker while providing a less-invasive procedure. Especially for octogenarians, recently developed less-invasive techniques are quite attractive. When the entire aortic arch replacement is required, additional open-stent implantation is effective to avoid further dilatation of descending false lumen. According to a review of previous reports, recent advances in surgical techniques are quite likely to have lowered the mortality of emergency operations for AAD to less than 10%.