Background: Type A aortic dissection (TAAD) involves a tear in the intimal layer of the thoracic aorta proximal to the left subclavian artery, and hence, carries a high risk of mortality and morbidity and requires urgent intervention. This dissection can extend into the main coronary arteries. Coronary artery involvement in TAAD can either be due to retrograde extension of the dissection flap into the coronaries or compression and/or blockage of these vessels by the dissection flap, possibly causing myocardial ischaemia. Due to the emergent nature of TAAD, coronary involvement is often missed during diagnosis, thereby delaying the required intervention. Aims: The main scope of this review is to summarise the literature on the incidence, mechanism, diagnosis, and treatment of coronary artery involvement in TAAD. Methods: A comprehensive literature search was performed using multiple electronic databases, including PubMed, Ovid, Scopus and Embase, to identify and extract relevant studies. Results: Incidence of coronary artery involvement in TAAD was seldom reported in the literature, however, some studies have described patients diagnosed either preoperatively, intraoperatively following aortic clamping, or even during autopsy. Among the few studies that reported on this matter, the treatment choice for coronary involvement in TAAD was varied, with the majority revascularizing the coronary arteries using coronary artery bypass grafting or direct local repair of the vessels. It is well-established that coronary artery involvement in TAAD adds to the already high mortality and morbidity associated with this disease. Lastly, the right main coronary artery was often more implicated than the left. Conclusion: This review reiterates the significance of an accurate diagnosis and timely and effective interventions to improve prognosis. Finally, further large cohort studies and longer trials are needed to reach a definitive consensus on the best approach for coronary involvement in TAAD.
Background: The management of aortic arch pathologies represents a great challenge and is associated with high rates of mortality and morbidity. A superior endovascular approach via thoracic endovascular aortic repair (TEVAR) has been introduced to treat arch pathologies with specifically designed endografts. This approach was shown to benefit patients who are deemed ‘high risk’ for undergoing OSR as it is a greatly less invasiveness option and thus, yields lower rates of morbidity and mortality. Aims: This commentary aims to discuss the recent study by Tan et al. which reports original data on the neurological outcomes after endovascular repair of the aortic arch using the RELAY™ Branched device. Methods: We carried out a literature search on multiple electronic databases including PubMed, Ovid, Google Scholar, Scopus and EMBASE in order to collate research evidence on the neurological outcomes of endovascular aortic arch repair with TEVAR. Results: Tan and colleagues showed through their original clinical data that the RELAY™ Branched device has a high rate of technical success and favourable neurological outcomes. There were no reported neurological deficits in patients who received the triple-branched RELAY™ Branched device. Conclusion: The RELAY™ Branched endograft is well-established for candidates for aortic arch endovascular repair with favourable neurological outcomes. Multiple considerations can help control the incidence of stroke following endovascular repair. These include optimization of the supra-aortic vessels’ revascularization, weighting the embolic risk in patients with atheromatous disease, and careful preoperative assessment to select the best candidates for arch endovascular repair
Frozen elephant trunk (FET) has in recent times become a mainstay for total arch replacement (TAR) in aortovascular surgery and is indicated in order to treat a spectrum of complex aortic pathologies. However, despite associated excellent post-operative results it is incredibly important to recognise potential adverse complications such as negative aortic remodelling, endoleak and distal stent-graft induced new entry so that outcomes can be further improved. Below we provide commentary on a recent article in the Journal of Cardiac Surgery discussing the topic. Despite the fascinating outcomes of this systematic review and meta-analysis the heterogeneity of the literature regarding these adverse outcomes remains an issue which can only be solved with large multi-centre trials directly comparing graft types as well as indications for surgery.