Background: Acute type A aortic dissection is a life-threatening clinical emergency that necessitates immediate surgical intervention with an estimated mortality rate of approximately 1–2% per hour. When complicated by malperfusion, the perioperative mortality rate is reported to be increased by up to 39%. Malperfusion can affect many vascular beds with varying incidence and severity, resulting in coronary, cerebral, visceral, peripheral, renal or spinal malperfusion. The primary aim of this systematic review and meta-analysis is to investigate the epidemiology of specific types of organ malperfusion in acute type A aortic dissection and to analyse the impact on the survival outcomes associated with each malperfusion type. Methods: Electronic databases PubMed, MEDLINE and Embase were searched through to September 2024 to identify original studies that presented data on the incidence and the survival outcome of organ malperfusion in association with acute type A aortic dissection. The extracted data included patient characteristics and incidence of organ-specific malperfusion. Primary outcomes were the respective in-hospital mortality rate associated with each organ-specific malperfusion and a proportional meta-analysis was conducted to pool results. Quality assessment was performed using the modified National Institutes of Health quality assessment tool for single-arm observational studies. Results: A total of 40 studies met the inclusion criteria, including a total of 35 361 patients. Peripheral limb malperfusion was the most prevalent with a pooled incidence of 12% (95% c.i. 10 to 14). This was followed by lower limb or iliofemoral with 11% (95% c.i. 9 to 14). Spinal malperfusion was the lowest with 1% (95% c.i. 1 to 2). The pooled mortality rate with organ malperfusion varied between 18 and 36%. Within this population the highest mortality rate was associated with mesenteric malperfusion with 36% (95% c.i. 28 to 45). Following this the highest mortality rate was found with coronary at 33% (95% c.i. 26 to 40) and cerebral at 28% (95% c.i. 24 to 33) malperfusion. Conclusion: Survival during hospital admission after acute type A aortic dissection can vary depending on the presence and type of malperfusion, with mesenteric, coronary and cerebral malperfusion being associated with the highest in-hospital mortality rates. Organ-specific malperfusion syndromes should be considered when assessing the perioperative risk and surgical planning of patients undergoing surgical repair for acute type A aortic dissection.

Background: Women undergoing cardiac surgery have been historically recognized to carry higher periprocedural mortality risk. We aimed to investigate the influence of sex on clinical presentation, perioperative, and long-term outcomes in patients who undergo surgery for ascending aortic aneurysm. Methods: We conducted a retrospective review of 1148 consecutive patients (380 [33.1%] female) who underwent thoracic aortic surgery under moderate hypothermic circulatory arrest for ascending aortic aneurysms between 2001 and 2021. Baseline and operative characteristics, in-hospital mortality, and survival were compared between male and female patients before and after propensity-score-matched (PSM) analysis. Results: Women were significantly older (median age: 69 [IQR: 63–75] vs. 67 [IQR: 58–73]; P < 0.001), while men had a higher prevalence of aortic valve stenosis, bicuspid valve and coronary artery disease at the time of surgery (P < 0.05). After PSM, EuroSCORE II (4.36 [2.68; 6.87] vs. 3.22 [1.85; 5.31]; p < 0.001), and indexed aortic diameter were significantly higher in female patients (2.94 [2.68; 3.30] vs. 2.58 [2.38; 2.81] cm/m2, p < 0.001). In the matched cohort, men were more likely to experience postoperative delirium (18.1% vs. 11.5%; P = 0.002), and postoperative neurological deficits (6.7% vs. 3.0%, P = 0.044),. Female patients were more likely to receive postoperative packed red blood cells (p = 0.036) and fresh frozen plasma (p = 0.049). In-hospital and 30-day mortality was similar between both groups. Long-term survival was comparable between both groups with 88% vs. 88% at 5 years, 76% vs. 71% at 10 years, and 59% vs. 47% at 15 years. Conclusion: Female patients required more transfusions, while males had a higher incidence of postoperative delirium and neurological deficits. Differences in preoperative age and timing of surgery between the sexes could be attributed to variations in comorbidity profiles and the greater prevalence of concomitant surgery indications in males.

Background: Acute type A aortic dissection (ATAAD) is a life-threatening medical emergency that requires urgent surgical intervention. The mainstay surgical approach to treating ATAAD with aortic arch involvement is total arch replacement (TAR). The frozen elephant trunk (FET) procedure involves TAR with hybrid endovascular stenting of the DTA in a single step using a hybrid prosthesis (HP). The prime example of a FET HP is Thoraflex Hybrid Prosthesis (THP). Another treatment option is the novel Ascyrus Medical Dissection Stent (AMDS) that is deployed as a non-covered stent along with the aortic arch as an adjunct to prior hemi-arch replacement. Aims: This comparative review highlights the clinical applications and outcomes of THP and AMDS in the treatment of ATAAD and discusses the main differences between both approaches. Methods: A comprehensive literature search was conducted using multiple electronic databases including PubMed, Google Scholar, Ovid, Scopus and Embase. Results: TAR with FET can be considered the superior approach to managing ATAAD with arch involvement relative to AMDS with hemi-arch replacement due to more optimal clinical outcomes. Upon comprehensively searching the literature, early mortality was substantially lower with FET ranging from 0–11% compared to 12.5–18.7% using AMDS, with more favourable long-term survival. The incidence of kidney injury and new stroke post-FET ranged from 3–20% and 5–16%, and 11–37.5% and 0–18.8% following AMDS implantation. However, evidence supporting the use of AMDS is extremely limited. Meanwhile, TAR with FET is a well-established and well-described procedure for ATAAD repair. Conclusion: Despite the novel nature of AMDS, its clinical safety and effectiveness are yet to be proven. In conclusion, THP remains the best evidenced-based approach to treat ATAAD in this era.