Who performs the surgery for an aortic dissection?

Who Performs Aortic Dissection Surgery

Aortic dissection surgery should be performed by experienced surgeons who are part of a Multidisciplinary Aortic Team at high-volume aortic centers to achieve optimal patient outcomes. 1

The Multidisciplinary Aortic Team

The 2022 ACC/AHA guidelines for aortic disease management strongly emphasize the importance of a Multidisciplinary Aortic Team approach for patients with aortic dissection. This team typically includes:

• Experienced aortic surgeons with specialized training in complex aortic procedures
• Cardiac anesthesiologists
• Perfusionists
• Specialized nursing staff
• Radiologists with expertise in aortic imaging
• Cardiologists with expertise in aortic disease

Evidence for Team-Based Approach

Research demonstrates significant improvements in outcomes when aortic dissection surgery is performed by specialized teams:

• A study showed a 3-fold reduction in operative mortality (30.8% to 9.7%) after implementation of a multidisciplinary aortic surgery program 2
• Another study revealed that surgery performed by aortic specialists resulted in 30-day mortality of 10% compared to 26% when performed by non-specialists 3
• Long-term mortality at 14 years was 26% with aortic specialists versus 52% with non-specialists 3

Surgical Approach Based on Dissection Type

The specific surgical approach depends on the type of aortic dissection:

• Type A dissection (involving ascending aorta):

  • Requires immediate surgical repair
  • Performed through median sternotomy
  • May involve composite graft implantation, valve-sparing procedures, or ascending aortic replacement 1

• Type B dissection (isolated to descending/abdominal aorta):

  • Uncomplicated cases: Often managed medically with surveillance
  • Complicated cases: Endovascular repair (TEVAR/EVAR) as first-line treatment 4
  • Open surgical repair for specific cases with anatomic considerations

Importance of Surgical Experience

The learning curve for aortic dissection surgery is steep:

• Surgeons need to perform approximately 25 aortic dissection surgeries to achieve mortality rates below 10% 5
• Higher surgeon volume correlates with lower in-hospital mortality (r = -0.58, P = 0.010) 5
• Aortic specialists perform more complex procedures (43% vs 17.3% aortic root procedures) with shorter cross-clamp times (89 vs 105 min) 3

Procedural Considerations

The surgical procedure for aortic dissection involves:

1. For Type A dissections:

   • Median sternotomy approach
   • Establishment of cardiopulmonary bypass (often via femoral artery and right atrium)
   • Aortic mobilization and visualization of innominate artery and aortic root
   • Replacement of affected segments with appropriate grafts 1

2. For Type B dissections requiring intervention:

   • Endovascular approaches are preferred when anatomically suitable
   • Open repair through posterolateral chest incision when necessary
   • Extracorporeal circulation via left heart bypass or femorofemoral bypass 1

Patient Referral Considerations

The 2022 ACC/AHA guidelines recommend:

• Patients with acute Type A aortic dissection should be considered for transfer to high-volume aortic centers if clinically stable 1
• Centers with Multidisciplinary Aortic Teams have demonstrated improved survival rates 1, 2
• Patient-centered care in referral aortic centers with specialized teams should be prioritized to improve surgical outcomes 6

Conclusion

The evidence clearly demonstrates that aortic dissection surgery outcomes are significantly better when performed by experienced aortic surgeons working within Multidisciplinary Aortic Teams at high-volume centers. This specialized approach results in lower mortality rates, fewer complications, and better long-term survival.