title: Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection.
abstract: 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 techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.
authors: University Hospitals Birmingham, National Health Service Foundation Trust, Edgbaston, Birmingham, United Kingdom. robert.bonser@uhb.nhs.uk
authors: Robert S
authors: RS
authors: Bonser
authors: Aaron M
authors: AM
authors: Ranasinghe
authors: Mahmoud
authors: M
authors: Loubani
authors: Jonathan D
authors: JD
authors: Evans
authors: Nassir M A
authors: NM
authors: Thalji
authors: Jean E
authors: JE
authors: Bachet
authors: Thierry P
authors: TP
authors: Carrel
authors: Martin
authors: M
authors: Czerny
authors: Roberto
authors: R
authors: Di Bartolomeo
authors: Martin
authors: M
authors: Grabenwöger
authors: Lars
authors: L
authors: Lonn
authors: Carlos A
authors: CA
authors: Mestres
authors: Marc A A M
authors: MA
authors: Schepens
authors: Ernst
authors: E
authors: Weigang
mesh_terms: D000208:Acute Disease; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D013504:Cardiovascular Surgical Procedures / Q000009:adverse effects / Q000379:methods; D006801:Humans; D007431:Intraoperative Complications; D012307:Risk Factors