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External Aortic Support and Other Alternative Strategies in the Management of Aortic…
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bodies including the British National Institute for Health Research (NIHR), the
research wing if the NHS, the British Heart Foundation, and the Medical Research
Council to devise a controlled study to compare this novel approach with the established operations. The NIHR Research Design Service helped us identify two decision-making nodes which might be amenable to testing. One was the timing: put
bluntly to ‘go for it’ or to procrastinate, or to put it more gently, the ‘early/defer’
dilemma. The other was whether to have the more predictable mechanical solution
and accept life-long anticoagulation or accept the less durable but more attractive
valve sparing operation. We published these considerations in an attempt to organise a trial [19, 20]. There was no prospect of professional equipoise as has been
illustrated by arguments made in opposition to this conservative approach [21–23].
It should be noted that neither total root replacement nor valve sparing root replacement have been evaluated with animal experiments or controlled trials.
We then focussed on establishing an informed patients’ perspective. The decision
nodes were explored, along with other factors, using the Ottawa decision support
framework. We found that people have cogently weighted and strongly expressed preferences on both the ‘early/defer’ question and the ‘conserve/replace’ choice [24].
Evidence concerning thromboembolism and bleeding with mechanical valves is plentiful and includes randomised trials [25, 26] and there has been a meta- analysis of the
two approaches for root replacement [3, 4]. The decision is amenable to evidence based
balancing of the pros and cons and is thus realistically not a matter for random assignment. The absence of randomly derived control data is therefore a limitation we have
to live with for now. What we can do is to ensure that patients who are to have a prophylactic operation face perioperative risks as low as are achievable. They should be
given evidence-based estimates of the durability of the operations available and reliable
estimates of future failure and complications from the best available observational data.
A further limitation of our current knowledge of the PEARS operation is that
because of the skewed accrual of patients with a recent upsurge there are relatively
few patients with long-term follow-up. The best available data is on VSRR, especially the 1-year report of the Aortic Valve Operative Outcomes in the Marfan
Patients Study [AVOOMPS] [3]. A strength shared by PEARS and AVOOMPS is
that both kept a record on ‘intention to treat’. All patients scheduled for PEARS
(N=117) and VSRR (N=239) have been reported (Table2). The age, gender and
aneurysm diameters for PEARS are similar to those for VSRR.There was one early
death in each group. The differences in operation time and the use of cardiopulmonary bypass are evident.
While the median and inter-quartile range (IQR) of aortic dimensions are comparable between PEARS and VSRR in AVOOMPS, the IQR excludes 25% of
patients which is a large number to be regarded as statistical ‘outliers’ for a potentially lethal disease. There were 7 patients in the PEARS series with aortic root
dimensions <40cm and were below the 6th centile. These were from 66th to 122nd
in the series and as can be seen from Fig.3, they were the more recent patients operated on in the last 2years. Further comparisons can be made but are difcult because
of the variations in the nature and severity of aortic disease, comorbidity, use of
cardiopulmonary bypass, myocardial ischaemia and circulatory arrest. Patients
included in the AVOOMPS study would not all have been eligible for PEARS.Because
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J. Pepper
CAD modelling and rapid prototyping, loosely referred to as 3D printing, are prerequisites for the procedure, PEARS is an elective operation. Interestingly, a quarter
of PEARS patients had some aortic regurgitation before operation and this was
deliberately corrected in some by using an undersized (95%) ExoVasc mesh. This
possibility is being explored further and there are reasons to believe that this is feasible in a wider group of patients [27].
In two patients we have seen progression of aortic regurgitation following
PEARS.The point of note is that parts of the right and non-coronary sinuses were not
covered by the mesh for clinical reasons. Over years these areas expanded resulting in
regurgitation due to single leaet prolapse thus providing an accidental experiment
comparing supported and unsupported sinuses in the same patient. This is in line with
earlier evidence where only the more accessible part of the aortic root was covered with
prosthetic material. This part was stabilised while the uncovered part continued to dilate
[28]. Stabilising the aortic root dimension and architecture has preserved aortic leaet
function well. There has been freedom from valve and aortic related events in longer
term follow-up. There have been no bleeding or embolic events or endocarditis.
Early in the experience we used conservative criteria. A relatively early departure
was in patients in whom mitral valve regurgitation was determining the need for
surgery. PEARS was used rather than leave the aortic root unprotected and presenting trouble at a later date [29]. Other possible indications for the PEARS procedures
include Loeys-Dietz Syndrome (LDS), complex congenital cardiac corrections presenting later in life, and an enlarging ascending aorta in patients with a bicuspid
aortic valve but normal haemodynamics. The nature of LDS is such that it may be a
prime indication for the PEARS operation because the event of rupture or dissection
is rarely preceded by slow dilatation.
We have recently monitored 24 consecutive patients who underwent the PEARS
procedure in the lead hospital from 2004 to 2012 [30]. Mean follow-up was
6.3±2.6years with 19 of the 24 patients (80%) completing at least 5years review.
The PEARS implant keeps the aortic root size stable and prevents dilatation in
Marfan patients. At the same time, it was observed that the unsupported segments,
the aortic arch and the descending aorta, remain prone to dilatation over time and so
close follow-up is mandatory as is the case in Bentall and VSRR operations.
Conict of Interest J.Pepper has no nancial interest whatever in the company which manufacture the PEARS implant, Exostent Ltd.
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Management ofOperative Complications
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After Type AAortic Dissection Repair
MichaelP.Robich andJenniferS.Lawton
Introduction
Acute aortic syndromes often require urgent operation and these can be among the
most technically challenging operations that cardiac surgeons perform. Specically,
patients with type A aortic dissection (TAD) are often taken to the operating room
without the complete evaluation afforded to elective cardiac surgery patients, and
often in a less than ideal physiologic state (Fig.1). The decision to move forward
with surgical intervention must be made with the essence of time in mind. Acute
co-morbidities such as shock, cardiac tamponade, aortic regurgitation, myocardial
ischemia, cerebral ischemia, paraplegia, renal/mesenteric ischemia, and limb ischemia may make the decision to operate more challenging. Careful recognition and
prompt management of these complications can also make TAD operations some of
the most rewarding operations that cardiac surgeons perform (Table1).
While much of the patient’s post-operative course will be determined in the operating room, the acute and chronic co-morbidities of the patient will also impact the
types and severity of complications encountered after surgery. The in-hospital mortality rate has been reported to be 10–35% [1–3]. The morbidity rate after surgery is
higher. Common complications after operative management of type A aortic dissections (TAD) include: bleeding, malperfusion, myocardial ischemia, aortic complications, neurologic complications, and multisystem organ failure.
M. P. Robich
Department of Cardiac Surgery, Heart and Vascular Institute, Tufts University Medical
Center, Boston, MA, USA
J. S. Lawton (
Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Medical University,
Baltimore, MD, USA
e-mail: Jlawton4@jhmi.edu
J. S. Coselli et al. (eds.), Aortic Dissection and Acute Aortic Syndromes,
https://doi.org/10.1007/978-3-030-66668-2_34
*)
483© Springer Nature Switzerland AG 2021
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M. P. Robich and J. S. Lawton
b
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g
c
Fig. 1 Representative computed tomography images demonstrating acute type A aortic dissection. First panel top (a) Axial view with type A aortic dissection visible in ascending and descending aorta. First panel middle (b) Axial view with type A aortic dissection visible in the aortic arch
(Previously published in Lawton JS.Acute type A aortic dissection 101. J Thorac Cardiovasc Surg
2015;150:769–770). First panel bottom (c) Axial view with type A aortic dissection visible in the
proximal aortic arch. Second panel top (d) Axial view with type A aortic dissection with classic
ap visible in the descending aorta and intramural hematoma in the ascending aorta. Second panel
bottom (e) Axial view with type A aortic dissection with intramural hematoma visible in the
ascending and descending aorta. Third panel top (f) Sagittal view with type A aortic dissection
visible in the descending aorta. Third panel bottom (g) Coronal view with type A aortic dissection
visible in the ascending aorta and proximal arch
Bleeding/Coagulopathy
Bleeding and coagulopathy after repair of a type A aortic dissection are common.
Aortic surgery has been associated with more blood utilization than any other cardiac operation [4]. In a 2001 single center study, the average patient undergoing
elective aortic surgery under DHCA received 4units of red blood cells in the operating room, 2.6units post-operatively and 58% of patients required ve of more units
of blood [5]. A number of factors contribute to bleeding including: raw surface area
of the exposed false lumen, disseminated intravascular coagulopathy (DIC), hypothermia, thrombocytopenia, extent of aortic replacement (long length of suture line),
and duration of the operation. Reported rates of takeback for bleeding after urgent
aortic surgery are 20–25%. In one study, 56% of patients required return to the operating room for re-exploration after type A aortic dissection repair [6]. In this paper,
independent predictors of massive post-operative bleeding after multivariable
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Table 1 Complications of Type A aortic dissection repair
Complications of Type A aortic dissection repair
Bleeding—hypothermia, platelet destruction, DIC, acidosis
Malperfusion—coronary, limb, abdominal, brain
Neurologic complications—stroke, spinal cord ischemia, neuropathy, delirium
Myocardial ischemia—malperfusion, dissection, embolism, obstruction
Aortic complications—root, descending thoracic
Complications discussed in this chapter are listed (No abbreviations)
485
logistic regression included: hypertension (increased the odds of bleeding threefold),
coronary artery disease (increased bleeding by 6 times), organ malperfusion
(increased bleeding twofold) and preoperative dual antiplatelet therapy (sixfold
increased risk). Increased time on cardiopulmonary bypass also led to a higher risk
of massive bleeding. Another study of TAD patients showed a re-exploration rate of
24% and reported risk factors for bleeding included: aortic arch replacement (relative risk (RR) 1.4), cardiac tamponade (RR 4), age less than 70years (RR 2), preexisting cardiac disease (RR 2) and need for CPR (RR 5). The Mayo clinic has described
a stable 8% re-operation rate for bleeding after TAD surgery over a 20-year period [7].
Preoperatively, the patient with type A aortic dissection is likely to be in DIC as
the exposed non-endothelial surface of the false lumen can drive a consumptive
coagulopathy [8, 9]. This has been demonstrated in aortic dissection by a decrease
in factors II, V, VII, X and XII with a signicant elevation in brin/brinogen split
products [10]. Cardiopulmonary bypass (CPB) causes similar disruptions in the
coagulation cascade potentially compounding the consumptive coagulopathy [11],
and platelets are destroyed in several ways leading to low quantity and poor function.
Additionally, exposure to collagen in the false lumen results in further platelet
consumption and decreased aggregation [12, 13].
Hypothermic circulatory arrest is a strategy often employed in the repair of
TAD.Traditionally, deep hypothermic circulatory arrest (DHCA) with cooling core
body temperature to 18°C was standard. The major goal of this technique was to
protect the brain and avoid neurologic injury during circulatory standstill [14, 15].
The coagulopathy associated with cooling is initially due to platelet dysfunction
when temperatures are mildly reduced (35 °C). At temperatures below 33 °C
however, there are more signicant platelet effects and alterations in the kinetics of
proteins in the coagulation cascade [16]. The presence of acidosis signicantly
worsens the coagulopathy associated with hypothermia, as suggested in the “lethal
triad” in trauma—shock, acidosis and hypothermia [17]. While DDAVP and
brinogen can be used to treat the coagulopathy of hypothermia, acidosis will
negate the effects [18].
The use of moderate hypothermic arrest (MHCA) (core body temperature>20°C)
with regional brain cooling has recently grown in popularity for several reasons
including a perceived reduction in coagulopathy [19]. In a single institution retrospective study that evaluated bleeding risk in aortic operations with DHCA vs.
MHCA there were no differences in transfused blood products, coagulation laboratory values, morbidity or mortality [20]. However, the extent of the operation
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M. P. Robich and J. S. Lawton
inuences the risk of bleeding. Dr. Svensson showed in his experience that the average type A dissection operation required 4units of blood, while a total arch required
6units [21]. As with all cardiac surgery, blood transfusion during aortic surgery has
been associated with worse short and long-term outcomes [4, 22]. There have been no
randomized trials evaluating bleeding with different techniques in hypothermic arrest.
Several techniques may be utilized to reduce bleeding during urgent aortic surgery (Table2). A reliable surgical plan and meticulous surgical technique are paramount. A number of leaders in the eld of aortic surgery have described safe and
effective approaches to acute aortic syndromes [23–26]. The aphorism, “Go in dry,
come out dry” is good reminder to maintain hemostasis throughout the operation. If
axillary cannulation is performed, it is important to make sure the access site is
hemostatic and a sump cardiotomy suction may be strategically utilized to avoid
unnecessary blood loss during the operation. There are a number of hemostatic
agents available [27] as adjuncts to hemostasis, and good surgical techniques such
as choosing the correct graft size, mandating incorporation of aortic adventitia in
the anastomosis, using felt or other material to buttress the suture line, and avoiding
undue tension are critical [28]. Transfusion guided by standard coagulation laboratory values or viscoelastic hemostatic assays such as thromboelastography (TEG)
and rotational thromboelastometry (ROTEM) are currently the best means to correct coagulopathy. As in trauma massive transfusion, balanced ratios of 1:1:1 of
blood, FFP and platelets are important to avoid dilutional coagulopathy. Similarly,
intraoperative blood salvage with Cell Saver provides great value, but also washes
out coagulation factors as part of saving red blood cells and its judicious use will
help prevent coagulopathy. Recombinant Factor VII may also be used to attempt to
reduce signicant post-operative bleeding. It has been shown to reduce bleeding
without a signicant increase in stroke, renal failure or mortality [29]. Postoperative
bleeding may be formidable and efforts to minimize bleeding are vital to the survival of the patient.
Table 2 Strategies to minimize bleeding after repair of Type A aortic dissection
Strategies to minimize bleeding after repair of Type A aortic dissection
“Go in dry, come out dry”
Avoid blood loss from axillary and other cannulation sites
Warm core body temperature to at least 35.5°C prior to weaning from CPB
Pack mediastinum during heparin reversal
Use of Bioglue or other hemostatic agents
Avoid acidosis
Judicious use of cell saver
Directed transfusion based on coagulation studies
1:1:1 RBC: FFP: platelet for massive transfusion
TEG/ROTEM to guide blood product transfusion
Consider use of Factor VII
Strategies discussed in this chapter are listed. CPB is cardiopulmonary bypass, RBC is red blood
cells, FFP is fresh frozen plasma, TEG is thromboelastogram, ROTEM is rotational
thromboelastometry
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Malperfusion
Malperfusion in patients with TAD results in end organ ischemia and is secondary
to limited perfusion of a false lumen, ap coverage or sheering of the ostia (Fig.2).
The obstruction of blood ow may be static, resulting in persistent ischemia or
dynamic, leading to intermittent ischemia. Malperfusion syndrome occurs when the
ischemia leads to end organ dysfunction and infarction [30]. Malperfusion is present
in 10–30% of patients on initial evaluation for acute aortic dissection and is the
second leading cause of death after aortic rupture [31]. In the treatment of patients
with TAD, the traditional approach is repair of the proximal aorta with the goal of
preventing death, restoring distal ow, and re-establishing the true lumen [32]. In
patients who present with malperfusion and a signicant lactic acidosis the prognosis
is poor [33]. Mortality has been demonstrated to increase with increasing base
decit (BD) at presentation in one study and all patients with BD > −10 with
abdominal malperfusion died. Similarly, the International Registry of Acute Aortic
Dissection (IRAD) data have demonstrated increased mortality rates in patients
with mesenteric or limb ischemia [34].
Recently, there has been interest in the management of malperfusion prior to
aortic repair [35] (Fig. 3). If there are no high risk features of the TAD such as
impending rupture, pericardial/pleural effusion or myocardial ischemia, this
approach can be considered. This approach involves the use of endovascular
techniques to fenestrate the dissection ap, stent the true lumen, or stent an
obstructed visceral branch. The results of this approach in retrospective reports have
shown improvement in survival in this complicated group of patients [36]. If
malperfusion is recognized in the operating room after aortic repair, expeditious
treatment to relieve the ischemia or manage tissue at risk is needed. This may
involve percutaneous intervention to restore ow to visceral arterial branches or the
lower extremities. Exploratory laparotomy to examine intra-abdominal end organs
may be helpful and is generally low risk [37]. Additionally, femoral to femoral
bypass can restore ow to an ischemic limb.
In the immediate post-operative setting the diagnosis of intra-abdominal malperfusion can be challenging. Patients are often sedated and on mechanical ventilation
which makes symptom assessment and physical exam difcult. On physical exam
the abdomen may be distended, although this is non-specic. The lactate may be
elevated as the metabolic byproducts of cardiopulmonary bypass and hypothermic
circulatory arrest wash out. The patient may be hemodynamically unstable and
unable to be safely transported for CT scan. In cases in which the patient is critically
ill and suspicion of intra-abdominal catastrophe is high, the best course may be
exploratory laparoscopy or laparotomy. Often these procedures can be performed in
the ICU if transport is considered too risky. One study utilizing the IRAD database
noted that the incidence of mesenteric ischemia was 4% and mortality in mesenteric
ischemia was signicantly higher (up to 95% in patients managed medically vs.
42% in patients managed surgically or with a hybrid approach) [38].
Diagnosing limb ischemia is often more straightforward. There will usually be a
pulse decit in one or both limbs which are cool and mottled. Knowing the
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Fig. 2 Representative computed tomography images demonstrating malperfusion in type A aortic
dissection patients. First panel top (a) Axial view with right renal artery supplied by the true lumen
and left renal artery (red arrow) supplied by the false lumen (Previously published in Lawton etal.,
The profound impact of combined severe acidosis and malperfusion on operative mortality in the
surgical treatment of type A aortic dissection. J Thorac Cardiovasc Surg 2018;155:897–904.). First
panel middle (b) Axial view with superior mesenteric artery (red arrow) supplied by the false
lumen (Previously published in Lawton etal., The profound impact of combined severe acidosis
and malperfusion on operative mortality in the surgical treatment of type A aortic dissection. J
Thorac Cardiovasc Surg 2018;155:897–904.). First panel bottom (c) Axial view with malperfusion
of the left femoral artery (red arrow). (Previously published in Lawton etal., The profound impact
of combined severe acidosis and malperfusion on operative mortality in the surgical treatment of
type A aortic dissection. J Thorac Cardiovasc Surg 2018;155:897–904.). Second panel top (d)
Axial view with malperfusion of the left renal artery (red arrow). Second panel bottom (e) Axial
view with malperfusion of the left renal artery (red arrow) with multiple areas of intimal ap noted.
Third panel (f) Sagittal view with extensive disease of the dissected thoracic and abdominal aorta
and malperfusion of the celiac artery (red arrow). Fourth panel (g) Magnied sagittal view with
malperfusion of the superior mesenteric artery (red arrow) due to intramural hematoma. (Previously
published in Ong, C, Lawton JS, etal., The strongest risk factor for operative mortality in Acute
Type A aortic dissection is acidosis: validation of risk model. Seminars in thoracic and
Cardiovascular Surgery https://doi.org/10.1053/j.semtcvs.2020.02.023). Fourth panel (h)
Magnied coronal view with malperfusion of the abdominal aorta due to intramural hematoma
(red arrow). (Previously published in Ong, C, Lawton JS, etal., The strongest risk factor for
operative mortality in Acute Type A aortic dissection is acidosis: validation of risk model. Seminars
in thoracic and Cardiovascular Surgery
panel (i) Magnied axial view with malperfusion of the left renal artery (red arrow). (Previously
published in Ong, C, Lawton JS, etal., The strongest risk factor for operative mortality in Acute
Type A aortic dissection is acidosis: validation of risk model. Seminars in thoracic and
Cardiovascular Surgery https://doi.org/10.1053/j.semtcvs.2020.02.023)
https://doi.org/10.1053/j.semtcvs.2020.02.023). Fourth
pre- operative pulse exam will help identify a change following aortic repair. Open
or percutaneous techniques can be used to revascularize the limb. There should be a
low threshold to perform a concomitant fasciotomy following signicant
malperfusion. In the IRAD database, 10% of patients presented with limb ischemia.
The mortality rate for those with limb ischemia was 15% as compared to 7% in
those without [34]. Over 90% were treated by endovascular means (fenestration or
aorto-iliac stenting), and limb salvage rate was 93% [38].
h
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