title: Long-term outcomes after immediate aortic repair for acute type A aortic dissection complicated by coma.
abstract: OBJECTIVE
  The management of acute type A aortic dissection complicated by coma remains controversial. We previously reported an excellent rate of recovery of consciousness provided aortic repair was performed within 5 hours of the onset of symptoms. This study evaluates the early and long-term outcomes using this approach.
  
  
  METHODS
  Between August 2003 and July 2013, of the 241 patients with acute type A aortic dissection brought to the Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, 30 (12.4%) presented with coma; Glasgow Coma Scale was less than 11 on arrival. Surgery was performed in 186 patients, including 27 (14.5%) who were comatose. Twenty-four comatose patients underwent successful aortic repair immediately (immediate group). Their mean age was 71.0 ± 11.1 years, Glasgow Coma Scale was 6.5 ± 2.4, and prevalence of carotid dissection was 79%. For brain protection, deep hypothermia with antegrade cerebral perfusion was used, and postoperative induced hypothermia was performed. Neurologic evaluations were performed using the Glasgow Coma Scale, National Institutes of Health Stroke Scale, and modified Rankin Scale.
  
  
  RESULTS
  In the immediate group, the time from the onset of symptoms to arrival in the operating theater was 222 ± 86 minutes. Hospital mortality was 12.5%. Full recovery of consciousness was achieved in 79% of patients in up to 30 days. Postoperative Glasgow Coma Scale and National Institutes of Health Stroke Scale improved significantly when compared with the preoperative score (P < .05), and postoperative activities of daily living independence (modified Rankin Scale <3) was achieved in 50% of patients. The mean follow-up period was 56.5 months, and the cumulative survival was 48.2% after 10 years. Cox proportional hazards regression analysis indicated that immediate repair (hazard ratio, 4.3; P = .007) was the only significant predictor of postoperative survival over a 5-year period.
  
  
  CONCLUSIONS
  The early and long-term outcomes as a result of immediate aortic repair for acute type A aortic dissection complicated by coma were satisfactory.
authors.affiliation: Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan. Electronic address: t-tsukube@kobe.jrc.or.jp.
authors.forename: Takuro
authors.initials: T
authors.lastname: Tsukube
authors.affiliation: Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan.
authors.forename: Tomonori
authors.initials: T
authors.lastname: Haraguchi
authors.affiliation: Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan.
authors.forename: Yasushi
authors.initials: Y
authors.lastname: Okada
authors.affiliation: Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan.
authors.forename: Ritsu
authors.initials: R
authors.lastname: Matsukawa
authors.affiliation: Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan.
authors.forename: Shuichi
authors.initials: S
authors.lastname: Kozawa
authors.affiliation: Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan.
authors.forename: Kyoichi
authors.initials: K
authors.lastname: Ogawa
authors.affiliation: Division of Cardiovascular Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Okita
mesh_terms: D000203:Activities of Daily Living; D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D003128:Coma / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D007564:Japan; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D016016:Proportional Hazards Models; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality