Letter:
To the Editor,
The article ”Acute Aortic Dissection Type A: Impact of Aortic
Specialists on Short and Long-Term Outcomes” by Habib on
el.1 has been read with great enthusiasm. The
concisely written article was a privilege to read, and we applaud the
authors’ endeavors. The authors have cogently written a wide range of
scenarios. Acute Aortic Dissection Type A (AADTA) improves short-term
and long-term fatality ratios, postoperative consequences, and the
proportion of patients handled by Aortic Specialists Surgeons (ASS) and
General Cardiac Surgeons (Non-ASSs).
We agreed that AADTA patients should undergo surgery immediately to
prevent blood loss, protect vital organs such as the brain, kidneys, and
heart, and enable a healthy, prosperous life for the
patient.2,3 AADTA is associated with a high mortality
rate, with the majority of untreated patients dying within two weeks.
However, we would like to add a few points that, in our opinion, would
improve the quality of this article and add to the existing knowledge of
this fatal disease. First, we assume that a variety of treatments are
available for AADTA treatment. The authors have not highlighted
alternative therapies such as Invasive Endovascular Treatment
(IET).4 Despite good surgical results, there is still
a risk for morbidity and mortality in elderly patients at high risk for
surgery.4 The endovascular repair will gain popularity
as an alternative treatment for ascending aortic disease in selected
high-risk patients, but more research is needed4. AKI was diagnosed in
382 of 941 patients (40.6%), including 105 (11%) postoperative
patients. There was preoperative malperfusion of the kidneys (5.1%), of
which 69.0% developed AKI.5 AKI is a common
complication after surgery for AADTA, and it predicts adverse long-term
outcomes independently. However, one-third (1/3) of patients presenting
with renal malperfusion did not develop postoperative AKI, possibly
because surgical repair restored renal blood flow.5
The authors should have also described the critical condition of Cranial
Stroke. Twenty percent (38/189) of patients undergoing AADTA repair had
stroke (58% unilateral, 43% bilateral [p =.33]). All strokes were
ischemic in nature. The causes of ischemic stroke were embolic (58%),
hypoperfusion (26%), mixed (11%), and unknown (5%). There was no
correlation between intraoperative variables and neuroanatomy or stroke
mechanism. 40% (n = 15) of patients presented with preoperative carotid
dissection, while 10% (n = 4) developed intracranial large vessel
occlusion following surgery (LVO). Strokes related to AADTA are severe
at presentation, resulting in significant disability. ⁶ One in ten
ischemic strokes are caused by LVO and may be treatable endovascularly6.
Stroke prevention is complicated by its heterogeneous location and
etiology. Given advancements in endovascular therapy,6future trials may evaluate the significance of early neuroimaging and
concurrent stroke treatment.