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\begin{document}

\title{Emergency surgery for Type A Aortic Dissection in Octogenarians -- do we
still err on the side of caution?}



\author[1]{Amer Harky}%
\author[2]{Niraj Kumar}%
\author[3]{William Wang}%
\author[1]{Mark Field}%
\affil[1]{Liverpool Heart and Chest Hospital NHS Foundation Trust}%
\affil[2]{University College London}%
\affil[3]{Queen Mary University of London Barts and The London School of Medicine and Dentistry}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\textbf{Emergency surgery for Type A Aortic Dissection in Octogenarians
-- do we still err on the side of caution?}

\emph{Running head: elderly and aortic dissection}

Amer Harky MRCS, MSc\textsuperscript{1,2,3*}, Niraj S Kumar
BSc\textsuperscript{4}, William Wang\textsuperscript{5}, Mark Field
DPhil (Oxon), FRCS (C-Th)\textsuperscript{1,2,3}

1. Department of Cardiothoracic Surgery, Liverpool Heart and Chest
Hospital, Liverpool, United Kingdom

2. Department of integrative biology, Faculty of Health and life
science, University of Liverpool, Liverpool, United Kingdom

3. Liverpool Centre for Cardiovascular Science, University of Liverpool
and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

2. University College London Medical School, University College London,
London, United Kingdom

3. Barts and The London School of Medicine and Dentistry, Queen Mary
University of London, London, United Kingdom

\textbf{*Corresponding Author}

Amer Harky

MRCS, MSc

Department of Cardiothoracic Surgery

Liverpool Heart and Chest Hospital

Liverpool, UK

E-mail: amer.harky@lhch.nhs.uk

Phone: +44-151-600-1616

\textbf{Conflict of Interest: None}

\textbf{Funding: None}

\textbf{Data availability:} Data sharing is not applicable to this
article as no new data were created or analysed in this study.

\textbf{Key words:} Surgery, Cardiothoracic, Type A Dissection,
emergency surgery

\textbf{IRB approval, consent statement and clinical trial
registration:} N/A

Emergency surgery for acute type A aortic dissection (ATAAD) in elderly
patients has been an area of careful consideration; within a population
of higher frailty and reduced quality of life, best practice and optimal
outcomes remain controversial. This problem is augmented by the growing
number of ATAAD cases arising from an increasingly ageing population.
Estimates from some studies suggests an increase of 50\% of ATAAD cases
in those with over 75 years of age in the coming years, leading to
increased need for a more precise data and best practice
guidelines\textsuperscript{1}.

Surgical intervention for ATAAD in octogenarians is associated with high
morbidity and mortality rates, and therefore, patients in this age range
are often declined emergency surgical repair owing to the risks of
surgical mortality and a limited gain to life expectancy with poor
tolerance to post-operative complications \textsuperscript{1}. However,
medical therapy is not necessarily a better option; the German registry
for ATAAD reported a survival rate of only 40\% at the first 48 hours,
with only 25\% surviving to 2 weeks\textsuperscript{2}. On the contrary,
Dumfarth et al. reported higher 30-day survival rate among their cohort
of 90 octogenarians with ATAAD that underwent surgical repair (61.2\% vs
34.8\% in the medical treatment group)\textsuperscript{3}.

Octogenarians with ATAAD present with a wide range of clinical
presentations and comorbidities, which will dictate the risk of the
surgery along with their age, further causing controversy among the
decision to operate and the assessment of risk vs benefits. The study by
Bojko et al. of 70 octogenarian's vs 165 septuagenarians reported no
difference in 30-day survival risk (28.6\% vs 21.2\%, p=0.29), and no
difference in the survival until 4 years after the surgery (p=0.07),
after which the septuagenarians showed greater survival
benefit\textsuperscript{4}. In our experience, outcomes for
octogenarians who have experienced complex aortic surgery that included
a period of deep hypothermic circulatory arrest (DHCA) were severely
impacted\textsuperscript{5}. Out of the 457 patients (24 octogenarians)
who underwent a period of DHCA, elective in-hospital mortality and
stroke rates were higher (16.7\% and 22.2\%)\textsuperscript{5}. Another
interesting point of note is the discharge arrangements, only 56\% of
the patients were safely discharged\textsuperscript{5}. As such, age
alone is not a factor in selecting patients for whom emergency ATAAD
repair surgery should be performed. Other factors such as mortality,
stroke rate, and discharge arrangements are critical information to
consider when making decisions\textsuperscript{5}.

Nevertheless, given the high-risk nature of the surgery and the
potential adverse outcomes associated with repair, there have been
suggestions to use less invasive methods and more conservative
techniques to improve the outcomes and recognise that extensive repair
will not always yield the same benefit that one might expect in a
younger patient.\textsuperscript{6} Chen et al. implemented this
approach in their cohort of octogenarian patients with a 16.7\% 30-day
mortality rate and 34.7\% 5-year mortality
probability\textsuperscript{7}. Similar results have been seen from
Japanese cohort study by Suzuki et al. who reported hospital mortality
of 10.2\% and 47.5\% mortality rate at 8 years\textsuperscript{8}.

Despite the life-saving implications of this surgery, the
quality-of-life following surgery is also of utmost importance to
patient care. We note that the conservative approach used by Chen et al.
was most effective in reducing post-operative complications, with 81.7\%
of all surgical octogenarians being discharged alive and well, defined
as a clinical status free from tracheostomy, permanent dialysis, and
severe neurologic dysfunction at discharge. This can be compared to
32.0\% of octogenarians being discharged home post-operatively in the
cohort analysed by Bojko et al.\textsuperscript{4} In this patient
population, even a successful surgery can often lead to a series of
severe cerebrovascular or bleeding-related complications, which are
avoided by restricting usage of intensive operative methods and
techniques.

However, a criticism of this study and most others is the lack of data
on surgical turndowns. Surgeons will understandably pick the winners and
those amongst the octogenarian population that are physiologically less
than their chronology. It is incumbent on all authors to capture and
present the entire cohort of referrals to better understand patient
selection. For this reason caution should be exercised in accepting
conclusions that octogenarians may be safely offered surgery. We would
advocate a patient specific approach which apart from the acute
presentation and past medical history/co-morbidities, also includes
measures of frailty, cognition, and functional performance. Options
should include other treatments such as best medical therapy and where
anatomy and pathology allows, TEVAR. We should remember that IRAD data
on mortality per hour is historic and likely surpassed by contemporary
aggressive and improved ITU level care. Lastly, patient consent in the
form of shared decision making is crucial. The authors outcomes are
impressive; however, we caution against publication bias and surgical
prowess in the approach to octogenarians with acute Type A disease.
Discharge alive is an important outcome measure but equally so is
discharge destination and quality of life.

Further work to optimise the surgical pathway and develop operative
experience, as well as obtaining more detailed analysis of outcomes from
larger studies will help us to fully maximise the improvement in quality
of life that is possible from emergency surgical intervention.

\emph{References} :

1. Howard DPJ, Banerjee A, Fairhead JF, et al. Population-based study of
incidence and outcome of acute aortic dissection and premorbid risk
factor control: 10-year results from the Oxford Vascular
Study.\emph{Circulation} . 2013;127(20):2031-2037.
doi:10.1161/CIRCULATIONAHA.112.000483

2. Rylski B, Suedkamp M, Beyersdorf F, et al. Outcome after surgery for
acute aortic dissection type A in patients over 70 years: data analysis
from the German Registry for Acute Aortic Dissection Type A
(GERAADA).\emph{Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac
Surg} . 2011;40(2):435-440. doi:10.1016/j.ejcts.2010.11.073

3. Dumfarth J, Peterss S, Luehr M, et al. Acute type A dissection in
octogenarians: does emergency surgery impact in-hospital outcome or
long-term survival?+. \emph{Eur J Cardiothorac Surg} .
2017;51(3):472-477. doi:10.1093/ejcts/ezw387

4. Bojko MM, Suhail M, Bavaria JE, et al. Midterm outcomes of emergency
surgery for acute type A aortic dissection in octogenarians. \emph{J
Thorac Cardiovasc Surg} . 2022;163(1):2-12.e7.
doi:10.1016/j.jtcvs.2020.03.157

5. Harky A, Bailey G, Othman A, Shaw M, Field M. The life in their years
versus the years in their life. \emph{J Thorac Cardiovasc Surg} .
2021;161(5):e361-e362. doi:10.1016/j.jtcvs.2020.11.113

6.Hata M, Suzuki M, Sezai A, Niino T, Unosawa S, Furukawa N, Minami K.
Less invasive quick replacement for octogenarians with type A acute
aortic dissection. The Journal of thoracic and cardiovascular surgery.
2008 Aug 1;136(2):489-93.

7. Chen JW, Sainbayar N, Hsu RB, Outcome of emergency surgery for acute
type A aortic

dissection in octogenarians. Journal of cardiac surgery, 2021,
pre-print.

8. Suzuki T, Asai T, Kinoshita T. Emergency Surgery for Acute Type A
Aortic Dissection in

Octogenarians Without Patient Selection. \emph{Ann Thorac Surg} .
2019;107(4):1146-1153. doi:10.1016/j.athoracsur.2018.10.010

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