Acute type A aortic dissection (TAAD) remains one of the most challenging conditions in cardiovascular surgery. The need for concomitant coronary revascularization by coronary artery bypass grafting (CABG) may arise in several scenarios, including dissection-related involvement of the coronary ostia, pre-existing coronary artery disease, or complications occurring during root reconstruction.
Adding coronary bypass grafting to an already complex operation may prolong operative times, extend cardiopulmonary bypass duration, and potentially increase perioperative risk. However, the available evidence on the true impact of this concomitant procedure remains limited. Against this background, the aim of the study was to assess the clinical outcomes of patients undergoing TAAD repair with associated coronary revascularization and to identify risk factors related to the need for CABG.
The study analyzed data from ERTAAD, a multicenter registry including patients who underwent surgery for acute type A aortic dissection across multiple European centers. A total of 3633 patients underwent surgical treatment for TAAD between January 2005 and March 2021, and 292 of them (8.04%) required concomitant coronary revascularization.
The authors used several statistical models for data analysis, including multivariable logistic regression, LASSO logistic regression, and bootstrapping, with the aim of identifying predictors of in-hospital mortality and factors associated with the need for concomitant coronary surgery.
Among all patients who underwent surgical repair for TAAD, 8.04% (n = 292) required concomitant coronary revascularization during the procedure.
Patients undergoing coronary surgery had a 2.52-fold higher likelihood of in-hospital death, with a mortality rate of 33% in patients who underwent coronary revascularization (CABG) vs 16% in those who did not undergo CABG (p adjusted < .001).
Among the independent risk factors for in-hospital mortality identified in the multivariable analysis were the need for preoperative invasive mechanical ventilation, the need for concomitant coronary surgery, urgent procedures, the presence of peripheral malperfusion, the year in which the procedure was performed, and renal failure.
The multivariable analysis identified several independent predictors of the need for concomitant CABG. These included the presence of genetic syndromes, significant mitral regurgitation, and aortic root involvement, particularly when the noncoronary sinus or the right coronary sinus was affected. However, in a subsequent subanalysis that incorporated intraoperative variables, aortic root replacement did not predict the need for concomitant coronary revascularization (p = .11).
After discharge, survival analysis at 1, 5, and 10 years showed significant differences between the 2 groups (92.2%, 81.6%, and 63.7% vs 85.8%, 74.4%, and 56.5%, respectively; p = .012; hazard ratio = 1.42).
The authors concluded that the need for coronary revascularization during TAAD surgery identifies a subgroup of patients with greater anatomic complexity and a worse prognosis, translating into a higher risk of perioperative death.
COMMENTARY:
Coronary involvement in the setting of acute type A aortic dissection represents a major surgical challenge. In these patients, the surgeon must simultaneously address a potentially lethal aortic condition and ensure adequate myocardial perfusion, which may at times require additional coronary bypass grafting.
The study by Dell’Aquila et al provides relevant insight into this clinical scenario by analyzing a large cohort drawn from a multicenter European registry. One of the most important findings is that approximately 1 in every 12 patients undergoing surgery for TAAD requires concomitant coronary revascularization, underscoring that this is not an uncommon situation in routine practice.
The results show that CABG is associated with higher in-hospital and long-term mortality. However, this association likely reflects the greater clinical severity and anatomic complexity of these patients rather than the direct effect of the revascularization procedure itself. In many cases, the need for CABG is related to coronary malperfusion or extension of the dissection into the coronary ostia, conditions that, like other forms of dissection-related malperfusion, are themselves associated with a worse prognosis.
Another relevant aspect of the study is the identification of anatomic factors associated with the need for revascularization, which may help improve surgical planning and preoperative risk stratification. Information provided by multicenter registries such as ERTAAD is especially valuable for a better understanding of the clinical heterogeneity of type A aortic dissection.
Among the study limitations, its observational and retrospective design deserves emphasis, because it may introduce selection bias and limits the ability to establish causal relationships. In addition, both the indication for and the technique of coronary revascularization may vary among centers, adding a degree of heterogeneity to the findings.
Despite these limitations, the study makes a meaningful contribution to understanding the clinical impact of concomitant coronary revascularization during surgery for type A aortic dissection. Its findings reinforce the importance of detailed anatomic assessment and an individualized surgical strategy, particularly in patients with suspected coronary involvement.
REFERENCE:
Dell’Aquila AM, Georgevici AI, Wisniewski K, Szabó G, Onorati F, Demal T, et al. Risk Profile and Outcomes of Patients Requiring Coronary Revascularization as Concomitant Procedure to Repair of Type A Aortic Dissection. Ann Thorac Surg. 2026 Feb;121(2):329-336. doi: 10.1016/j.athoracsur.2025.09.038.
