Analysis of risk factors for neurological dysfunction in patients with acute aortic dissection type A: data from the German Registry for Acute Aortic Dissection Type A (GERAADA)

OBJECTIVES: Acute aortic dissection type A (AADA) is associated with major adverse events, such as transient or persistent neurological dysfunction (ND), which may be patient-, disease- or surgery-related. There is a lack of consensus regarding risk factors for ND in AADA patients. The aim of this study was to analyse and identify risk factors for new postoperative ND after aortic repair for AADA. METHODS: Between July 2006 and June 2010, 2137 AADA patients were enrolled in the multi-centre, prospective German Registry of AADA (GERAADA). Perioperative data were prospectively gathered from 50 institutes in Austria, Switzerland and Germany, and multivariate logistic regression analysis was pe…

Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†.

Ischaemic spinal cord injury (SCI) remains the Achilles heel of open and endovascular descending thoracic and thoracoabdominal repair. Neurological outcomes have improved coincidentially with the introduction of neuroprotective measures. However, SCI (paraplegia and paraparesis) remains the most devastating complication. The aim of this position paper is to provide physicians with broad information regarding spinal cord blood supply, to share strategies for shortening intraprocedural spinal cord ischaemia and to increase spinal cord tolerance to transitory ischaemia through detection of ischaemia and augmentation of spinal cord blood perfusion. This study is meant to support physicians cari…

German registry for acute aortic dissection type A (GERAADA)--lessons learned from the registry.

A German registry for acute aortic dissection type A (GERAADA) was initiated by the Working Group for Aortic Surgery and Interventional Vascular Surgery of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in July 2006. This web-based database was developed to record the data of patients who had undergone surgery for aortic dissection type A. From analyzing the data, we aim to learn how to improve surgical treatment and to identify parameters affecting patient outcome. In the beginning, 33 cardiac centers participated via online access to the registry on the GSTCVS' homepage. Since then, 43 centers in Germany, Switzerland and Austria have begun entering data on the pre- an…

True-lumen collapse of the ascending aorta in acute type A aortic dissection

The future of aortic surgery in Europe

At least every ten years, each specialty should reflect upon its past, its present and its future, in order to be able to reconfirm the direction in which it is headed, to adopt suggestions from inside and outside and, consequently, to improve. As such, the aim of this manuscript is to provide the interested reader with an overview of how aortic surgery and (perhaps more accurately) aortic medicine has evolved in Europe, and its present standing; also to provide a glimpse into the future, trying to disseminate the thoughts of a group of people actively involved in the development of aortic medicine in Europe, namely the Vascular Domain of the European Association of Cardio-Thoracic Surgery …

Successful Management of Fulminant Pulmonary Embolism Using a Novel Portable Extracorporeal Life Support System

A 46-year-old man presented to the emergency room with pain in his left leg, dyspnea, and general cyanosis. During examination he collapsed and required resuscitation. Under suspicion of pulmonary embolism, a new portable "click 'n run" extracorporeal life support system (LIFEBRIDGE-B(2)T [Medizintechnik AG, Ampfing, Germany]) was implanted by the femoral vessels under resuscitation within 15 minutes of presentation. The patient was stabilized, despite severe decompensation (pH, 6.8), and could be transferred for a computed tomographic scan, which confirmed massive pulmonary embolism. Still connected to the life support system, the patient was transferred to the operating room. After a pulm…

Lessons Learned from the German Registry for Acute Aortic Dissection Type A (GERAADA) and Expectations for the Future

The German Registry for Acute Aortic Dissection type A (GERAADA) is a prospective observational clinical multicenter registry that was launched in 2006. With more than 2,500 patients included from over 50 recruiting centers it is—to our knowledge—the most representative register for acute aortic dissection type A (AADA) currently available. We examined mortality and post-operative events as well as the influence of various pre- and intraoperative factors on these endpoints. Among patients registered, 30-day mortality is 15.9 %. 13.4 % of patients experienced postoperatively a new neurological deficit and a total of 10.5 % of patients suffered from permanent neurological impairment 30 days a…

The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection

Abstract Background Malperfusion adversely affects outcomes in patients with acute type A aortic dissection, but reliable quantitative data are lacking. Objectives The aim of this study was to analyze the impact of various forms of malperfusion on early outcome. Methods A total of 2,137 consecutive patients enrolled in GERAADA (German Registry for Acute Aortic Dissection Type A) who underwent surgery between 2006 and 2010, of whom 717 (33.6%) had any kind of pre-operative malperfusion, were retrospectively analyzed. Results All-cause 30-day mortality was 16.9% and varied substantially according to the number of organ systems affected by malperfusion (none, 12.6%; 1 system, 21.3%; 2 systems,…

Iatrogenic acute aortic dissection type A: insight from the German Registry for Acute Aortic Dissection Type A (GERAADA)†

OBJECTIVES: Previous investigators have reported a grave prognosis for iatrogenic acute aortic dissection (iAADA), but such studies are limited by their small sample sizes. The purpose of the current study was to analyse the clinical characteristics, current management and surgical outcomes in a large number of iAADA patients identified through a multicentre registry. METHODS: Between July 2006 and June 2010, 50 centres participated in the German Registry for Acute Aortic Dissection Type A (GERAADA). Of the 2137 patients included, 100 (5%) had iAADA. We compared the clinical features and 30-day outcomes of patients with iatrogenic and spontaneous acute aortic dissection type A (sAADA). RESU…

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)☆

Objective: The number of elderly patients undergoing emergency surgery for acute aortic dissection type A (AADA) is rising. Published results report a higher risk for thesepatients comparedwith younger patients. The aim of our study wasto analyse the surgicaloutcomeof these patients and to identify those at risk. Methods: Between July 2006 and June 2009, 44 centres participating in the German Registry for Acute Aortic Dissection Type A (GERAADA) reported a total of 1558 patients. As many as 381 patients were between 70 and 80 years of age (septuagenarians), while 83 patients were 80 years and older (octogenarians). We compared the clinical features and events occurring 30 days after surgery…

Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Thoracic endovascular aortic repair (TEVAR) is an emerging treatment modality, which has been rapidly embraced by clinicians treating thoracic aortic disease.1–4 Fundamentally, it is a far less invasive approach than open surgery and its availability and relative ease of application has changed and extended management options in thoracic aortic disease, including in those patients deemed unfit or unsuitable for open surgery. In the operating room, this requires considerable perceptual, cognitive and psychomotor demands on the operators. The dramatic expansion of TEVAR activity has necessarily prompted a requirement to systematically consider the indications, appropriateness, limitations and…

Reevaluation of direct true lumen cannulation in surgery for acute type A aortic dissection.

Background The optimal mode of arterial cannulation in acute type A aortic dissection is controversial. We retrospectively investigated our experience with direct true lumen cannulation as an alternative to standard cannulation procedures. Methods From April 2004 to August 2007, 29 patients (20 men, 9 women; mean age of 63.2 ± 12.6 years) underwent emergency operation for acute type A aortic dissection with direct true lumen cannulation. After venous drainage into the venous reservoir, the ascending aorta was completely transected in the region between the sinotubular junction and innominate artery. After visual and digital identification of the true lumen, the arterial cannula was directly…

Strategies for endovascular aortic repair in aortobronchial and aortoesophageal fistulas.

Objective To report our experience of thoracic endovascular aortic repair (TEVAR) for acute bleeding originating from the thoracic aorta in patients with aortobronchial fistula (ABF) or aortoesophageal fistula (AEF). Patients and Methods A total of nine patients (three woman) were treated from September 1995 to March 2012 by TEVAR for ABF (n = 5) and AEF (n = 4). The implants (N = 14) were introduced with fluoroscopic guidance via the aorta (n = 1), the iliac (n = 2), or femoral (n = 11) artery, respectively. Results All aortic lesions could be sealed successfully. Perioperative morbidity was 0% in the ABF group and 50% (2 of 4) in the AEF group and no procedure-related morbidity was noted …

Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA)

Acute aortic dissection type A (AADA) is an emergency with excessive mortality if surgery is delayed. Knowledge about independent predictors of mortality on surgically treated AADA patients is scarce. Therefore, this study was conducted to identify pre- and intraoperative risk factors for death.Between July 2006 and June 2010, 2137 surgically treated patients with AADA were enrolled in a multicentre, prospective German Registry for Acute Aortic Dissection type A (GERAADA), presenting perioperative status, operative strategies, postoperative outcomes and AADA-related risk factors for death. Multiple logistic regression analysis was performed to identify the influence of different parameters …

Intraoperative neuroprotective drugs without beneficial effects? Results of the German Registry for Acute Aortic Dissection Type A (GERAADA).

OBJECTIVES: Cerebral protection during acute aortic dissection Type A (AADA) surgery may be affected by perfusion strategies and ischaemic protective drugs. METHODS: We analysed the impact of intraoperative barbiturate, steroid and mannitol use and adjunctive cerebral perfusion (CP), on 30-day mortality and new postoperative mortality-corrected permanent neurological dysfunction (PNDmc) in the German Registry for Acute Aortic Dissection Type A. RESULTS: Two thousand one hundred and thirty-seven AADA patients were registered over a 4-year period. The overall 30-day mortality was 16.9%, and the overall rate of PNDmc was 10.0%. A total of 48% of patients received no neuroprotective drugs (cont…

Symptomatic atherosclerotic occlusive disease of all supra-aortic arch vessels treated with total aortic arch rerouting.

We present an uncommon case of symptomatic atherosclerotic occlusive disease of all supra-aortic arch vessels and its surgical treatment by total aortic arch rerouting after endarteriectomy of all target vessels.

How to do it: direct true lumen cannulation technique of the ascending aorta in acute aortic dissection type A†

In acute aortic dissection type A (AADA), direct true lumen cannulation (DTLC) of the ascending aorta is a fast and safe cannulation site providing antegrade perfusion of the supraaortic and visceral vessels. An Overholt clamp is passed around the ascending aorta to place a Mersilene tape for later securing of the arterial cannula. After draining venous blood into the cardiopulmonary bypass system (CPB), the ascending aorta is transected and the aortic lumen inspected. The true lumen is identified and an arterial cannula inserted directly. Finally, the cannula is secured with the previously placed tape and CPB is initiated. DTLC can be used as arterial cannulation standard technique in oper…

Evidence, Lack of Evidence, Controversy, and Debate in the Provision and Performance of the Surgery of Acute Type A Aortic Dissection

Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or t…

Acute aortic dissection type A

Abstract Background Acute aortic dissection type A (AADA) is a life-threatening vascular emergency. Clinical presentation ranges from pain related to the acute event, collapse due to aortic rupture or pericardial tamponade, or manifestations of organ or limb ischaemia. The purpose of this review was to clarify important clinical issues of AADA management, with a focus on diagnostic and therapeutic challenges. Methods Based on a MEDLINE search the latest literature on this topic was reviewed. Results from the German Registry for Acute Aortic Dissection Type A (GERAADA) are also described. Results Currently, the perioperative mortality rate of AADA is below 20 per cent, the rate of definitive…

Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, ther…

Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection: Analysis of the German Registry for Acute Aortic Dissection Type A

Objective Patients treated with an extensive approach including total aortic arch replacement for acute aortic dissection type A may have a favorable long-term prognosis by treating the residual false lumen. Our goal was to analyze the operative strategy for treatment of type I DeBakey aortic dissection from the German Registry for Acute Aortic Dissection Type A (GERAADA) data. Methods A total of 658 patients with type I DeBakey aortic dissection and entry only in the ascending aorta were identified in the GERAADA. Patients in group A underwent replacement of the ascending aorta with hemiarch replacement. Patients in group B received extensive treatment with total arch replacement or conven…

Acute Aortic Dissection Type A : Age-related Management and Outcomes Reported in the German Registry for Acute Aortic Dissection Type A (GERAADA) of Over 2000 Patients

To determine the association between age and clinical presentation, management and surgical outcomes in a large contemporary, prospective cohort of patients with acute aortic dissection type A (AADA).AADA is one of the most life-threatening cardiovascular diseases, and delayed surgery or overly conservative management can result in sudden death.The perioperative and intraoperative conditions of 2137 patients prospectively reported to the multicenter German Registry for Acute Aortic Dissection Type A were analyzed.Of all patients with AADA, 640 (30%) were 70 years or older and 160 patients (7%) were younger than 40 years. The probability of aortic dissection extension to the supra-aortic ves…

Management of Patients With Aortic Dissection

Cardiovascular diseases have become the leading cause of death in countries with high medical standards. Acute aortic syndromes—particularly acute aortic dissection—are playing an increasingly important part in this development (1). Acute aortic dissection has an extremely high mortality rate after the occurrence of an initial manifestation, so a standardized treatment algorithm is crucial for patient survival. On the basis of selected recent publications, the aim of this study was to review the current status of the management of aortic dissection and formulate recommendations for treatment.

German Registry for Acute Aortic Dissection Type A (GERAADA)--new software design, parameters and their definitions.

BACKGROUND The working group for aortic surgery and interventional vascular surgery of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) initiated the web-based German Registry for Acute Aortic Dissection type A (GERAADA). It is the project's aim to collect standardized data from a large pool of patients with acute aortic dissections type A (AADA) to gain a deeper insight and knowledge to improve surgical therapies and perioperative management for these patients in the future. METHODS In addition to new medical insights, the working group has gained more experience over the last 4 years in how to collect valid and high-quality data. This experience led us to revise the dat…