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Does profound hypothermic circulatory arrest improve survival in patients with acute type A aortic dissection?

Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif 94305-5247, USA.
Circulation (Impact Factor: 14.95). 10/2002; 106(12 Suppl 1):I218-28.
Source: PubMed

ABSTRACT No evidence exists that profound hypothermic circulatory arrest (PHCA) improves survival or reduces the likelihood of distal aortic reoperation in patients with acute type A aortic dissection.
Records of 307 patients with acute type A aortic dissection from 1967 to 1999 were retrospectively reviewed. The influence of repair using PHCA (n=121) versus without PHCA (n=186) on death and freedom from distal aortic reoperation was analyzed using multivariable Cox regression models. Propensity score analysis identified a subset of 152 comparable patients in 3 quintiles (QIII-V) in which the effects of PHCA (n=113) versus no PHCA (n=39) were further compared.
For all patients, 30-day, 1-year, and 5-year survival estimates were 81+/-2%, 74+/-3%, and 63+/-3% (+/-1 SE). Survival rates and actual freedom from distal aortic reoperation was not significantly different between treatment methods in the entire patient cohort nor in the matched patients in quintiles III-V. Treatment method was not associated with differences in early major complications, late survival, or distal aortic reoperation rates in the entire patient sample or in quintiles III-V.
Aortic repair with or without circulatory arrest was associated with comparable early complications, survival, and distal aortic reoperation rates in patients with acute type A aortic dissection. Despite the lack of concrete evidence favoring the use of PHCA, it does no harm, and most of our group uses PHCA regularly because of its practical technical advantages and theoretical potential merit.

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    • "Lansman and coworkers [21] noticed that in their series of 34 patients undergoing surgery for type B AAD the use of hypothermic circulatory arrest was reserved in 16 cases with no operative mortality and low incidence of paraplegia. According to Shimokawa and colleagues [20] and Lai and coworkers [22] we firmly believe that proximal clamp can be safely placed in a preferred fashion in all cases when dissection does not involve the aortic arch. It is obvious that further investigations will confirm this statement. "
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    ABSTRACT: The aim of the study was to analyze surgical and endovascular results in the treatment of acute type B aortic dissection (B AAD). Retrospective and observational analysis with patient inclusion between January 2001-December 2008 and follow-up ranged from 2 to 96 months (median = 47.2) was performed. Out of 51 consecutive patients with B AAD, 11 (21.6%) had to undergo open surgery (OS) and 13 (25.5%) endovascular treatment (TEVAR). There was a significantly difference in early mortality in the TEVAR group (0/13,0%) vs OS group (4/11,36.4%, P < 0.05) and in the incidence of paraplegia/paraparesis (OS 2,28.6% vs TEVAR 1,7.7%, P < 0.05), renal failure (OS 3, 42.8% vs TEVAR 1, 7.7%, P < 0.05), respiratory failure (OS 2,28.6% vs TEVAR 1,7.7%, P < 0.05) and cerebrovascular accident (OS 1,14.3% vs TEVAR 0,0%, P < 0.05). The late mortality at a follow-up was 30.8% (4/13) in the TEVAR group and 42.8% (3/7) in the OS group, respectively (P = not significant). The cumulative survival rate after 1, 3 and 8 years was 93%, 84%, and 69% in the TEVAR group and 86%, 71% and 57% in the OS group, respectively. Endoleaks were diagnosed in 2/13 endovascular patients (15.4%). TEVAR group had a significantly reduction in early mortality and postoperative complications. No significant differences were found in terms of cumulative survival at follow-up. On this basis TEVAR could be considered an option in the treatment of these complex cases with all proper reservation especially related to the small sample sizes examined.
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    ABSTRACT: Surgical treatment of patients with acute type A aortic dissections has improved early survival from 10-20 to approximately 80%. Data supporting several other treatment recommendations in patients with aortic dissection, however, are less convincing. We hypothesized that applying strict principles of evidence-based medicine would invalidate most of the recommendations in these published papers. We conducted a literature search asking three questions: (1) Is the use of routine circulatory arrest and an 'open distal' anastomosis technique better than traditional aortic cross clamping? (2) Does a persistent false lumen in the distal aorta wall have an adverse influence on long-term event-free survival? and (3) Is primary surgical or medical treatment of patients with Stanford acute type B dissections preferable in terms of long-term event-free survival? We searched Entrez Pubmed (National Library of Medicine) for all papers on these topics from 1980 to January 2003. Screening 3164 papers identified using the search terms 'aortic dissection' and 'treatment' yielded 15 papers fulfilling a set of a priori inclusion criteria. No study had a design that allowed unequivocal conclusions; moreover, the heterogeneity in study design and patient populations precluded formal meta-analysis. The difficulties inherent in conducting stringent clinical studies addressing various treatment strategies for patients with aortic dissection hamper their quality and weaken their recommendations for different treatment options. Specifically, no conclusive evidence exists favoring use of an open distal anastomosis in patients with acute type A dissections or complete elimination of flow in the distal aortic false lumen; similarly, medical therapy of patients with acute type B aortic dissections has no proven advantage over surgical treatment.
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