Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review

Sherif Sultan; Yogesh Acharya; Keegan Chua Vi Long; Mohamed Hatem; Mohieldin Hezima; David Veerasingham; Osama Soliman; Niamh Hynes

doi:10.3389/fsurg.2023.1157457

Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review

Front Surg. 2023 Mar 28:10:1157457. doi: 10.3389/fsurg.2023.1157457. eCollection 2023.

Authors

Sherif Sultan^{1

2

3}, Yogesh Acharya^{1

2}, Keegan Chua Vi Long¹, Mohamed Hatem¹, Mohieldin Hezima¹, David Veerasingham⁴, Osama Soliman³, Niamh Hynes^{2

3}

Affiliations

¹ Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland.
² Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland.
³ CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland.
⁴ Department of Cardiothoracic Surgery, University Hospital Galway, University of Galway, Galway, Ireland.

Abstract

Background: Thoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.

Methods: This is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.

Results: There were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.

Conclusion: Acute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.

Keywords: acute aortic syndrome (AAS); hybrid endovascular repair; stent-graft induced new entry tear (SINE); thoracic endovascular aneurysm repair (TEVAR); thoraco-abdominal aorta.