UPMC Cardiothoracic Experts Report Management and Outcomes for acute Type A Aortic Dissection Patients with Cerebral Malperfusion Using Multicenter International Data

Type A acute aortic dissection (TAAAD) is a complex, emergency condition that requires immediate surgical intervention. It is characterized by a tear in the inner layer of the aorta which causes symptoms such as chest pain, back pain, and hypertension. Diagnosis and surgical intervention are further complicated when TAAAD patients present with cerebral malperfusion (CM), which is the case for a significant portion of the patient population.  

There are limited data on CM in the TAAAD patient population and existing literature is mostly limited to single-center studies and case reports. Therefore, UPMC cardiothoracic experts – in collaboration with aortic experts from multiple academic centers across the world – compared management and outcomes for TAAAD patients with CM to patients without cerebral malperfusion using multicenter international data from the International Registry of Acute Aortic Dissection (IRAD) in the report, “Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection.” 

UPMC has been an integral member of the IRAD along with other 55 aortic centers of excellence from across the world that make up the international research consortium. Established in 1996, IRAD reports robust data on acute aortic dissection from patient presentation to outcomes. 

While the widely accepted standard of care for aortic dissection is immediate surgery, data in this report substantiate rapid reperfusion followed by central aortic repair in carefully selected TAAAD and CM cases. 

Of the 2402 TAAAD patients reported in the IRAD between 2010 and 2017, 362 (15.1%) presented with CM. It is critical to identify CM when present in this patient population as it adversely impacts surgical outcomes of TAAAD. 

Researchers determined that TAAAD patients with CM from the consortium were more likely to:

• Experience syncope, concomitant pulse deficits, and shock on presentation. 
• Have a DeBakey I dissection (63.8% vs 47.1%; P < .001), periaortic hematoma (25.2% vs 17.5%; P = .009), and pericardial effusion (53.8% vs 40.6; P < .001) on presentation. 
• Have increased incidence of postoperative cerebrovascular accidents (17.5% vs 7.2%; P < .001), coma (9.3% vs 2.6%; P < .001), acute kidney injury (28.3% vs 18.1%; P < .001), limb ischemia (19.8% vs 8.5%; P < .001), hypotension (15.5% vs 10.8%; P = .014), cardiac tamponade (9.2% vs 6.2%; P = .045), and prolonged ventilation (34.5% vs 22.8%; P < .001). 

In-hospital mortality for TAAAD patients with CM was significantly greater (25.7% vs 12.0%; P < .001) than that of TAAAD patients without cerebral malperfusion. The presentation of CM makes a surgically challenging situation even more difficult to diagnose and manage. However, rapid reperfusion followed by central aortic repair in select TAAAD patients with CM can be advantageous, as demonstrated by multiple institutions including UPMC that have used aggressive revascularization of the carotid arteries, percutaneous endovascular right carotid and brachiocephalic artery stenting, and other techniques to limit CM time. 

To speak with a UPMC expert about the diagnosis, treatment, and management of TAAAD and CM, call 412-770-4949.