ATAAD is a life-threatening emergency requiring prompt surgical treatment. CM, which affects approximately 11–15% of surgically treated patients and may be accompanied by coma, further complicates perioperative decision-making. Because specific recommendations for this subgroup remain limited, the present study evaluated early and late outcomes of an aortic-repair-first strategy without preoperative cerebral reperfusion. The investigators assessed postoperative results according to the presence or absence of cerebral hypoperfusion and also analysed outcomes based on the severity of preoperative neurological deficits.

This single-centre Japanese cohort included 378 patients who underwent surgical repair within two weeks of symptom onset between 2007 and 2019. Surgery proceeded immediately—even in cases of coma—provided that neuroimaging did not demonstrate an established, extensive cerebral infarction. The primary endpoint was all-cause mortality; secondary endpoints included cardiovascular mortality and post-discharge cerebrovascular events. No patient received early cerebral reperfusion.

The operative technique followed a conventional approach, consisting of aortic replacement up to the primary entry tear or, more frequently in younger individuals, total arch replacement. Antegrade cerebral perfusion was routinely used.

CM was identified in 74 patients (20%). This subgroup included younger patients, predominantly male, with more frequent involvement of the brachiocephalic or right common carotid artery. Operative and cardiopulmonary bypass times were significantly shorter in the non-CM group.

Operative mortality was low and comparable between groups (5.4% in CM vs. 4.6% in non-CM), with no significant differences after adjustment for confounders. However, perioperative ischaemic stroke occurred more frequently in patients with CM (27% vs. 5.3%). Moderate to severe disability at discharge (mRS ≥3) was also more common (20% vs. 3%).

Within the CM cohort, 41 patients were asymptomatic, 13 presented transient deficits and 20 had persistent symptoms. Perioperative stroke occurred most frequently in patients with persistent symptoms (50%), followed by asymptomatic patients (22%) and those with transient symptoms (7.7%). Three patients required decompressive craniectomy, and three underwent carotid stenting for true-lumen collapse, leading to clinical improvement. Among patients in preoperative coma, one died of early postoperative bleeding; the remainder achieved partial or full recovery of consciousness.

Median follow-up was 2.1 years, with no significant differences between groups in all-cause or cardiovascular mortality, nor in the incidence of post-discharge cerebrovascular events. At five years, all-cause mortality was similar (17.4% in CM vs. 13.7% in non-CM), as was cardiovascular mortality (7.0% vs. 9.7%). Within the CM group, five-year mortality varied according to preoperative symptoms and was highest among patients with transient deficits.

Overall, although cerebral malperfusion increased the risk of in-hospital stroke, it did not translate into higher mortality. A substantial proportion of patients—including 65% of those with persistent deficits and several who presented in coma—experienced neurological improvement after immediate aortic repair without cerebral revascularization. These findings support consideration of urgent surgery even in patients with severe neurological compromise.

COMMENTARY:

This study provides meaningful insight into the management of acute type A aortic dissection complicated by cerebral malperfusion. Although several methodological limitations prevent definitive conclusions, the results highlight several clinically relevant points. First, even in the presence of severe neurological impairment—including coma—early surgical repair may restore cerebral function, as reflected by the 65% recovery rate among patients with persistent neurological deficits. Second, while operative mortality did not differ between groups, patients with CM experienced a markedly higher incidence of perioperative stroke. Third, asymptomatic patients with severe carotid stenosis demonstrated a substantial risk of perioperative stroke (22%) and moderate-to-severe disability at discharge (17%), underscoring the need for more precise diagnostic and therapeutic approaches for this subgroup. Fourth, long-term mortality was comparable regardless of CM status.

These findings align with previous IRAD analyses, which reported five-year survival rates of 23.8% and 0% for medically managed patients with stroke or coma, compared with 67.1% and 57.1% for those treated surgically. This reinforces the benefit of operative management, even in neurologically compromised individuals.

Several cerebral reperfusion strategies—such as carotid transection, femoral-to-carotid bypass, or direct carotid perfusion—have been described, though none has demonstrated clear superiority. This highlights the ongoing need for research in this area.

In the absence of robust evidence supporting early revascularization, the present results suggest that urgent aortic repair without preoperative cerebral reperfusion is a reasonable strategy, even in patients with severe neurological symptoms or coma.

REFERENCE:

Kuroda Y, Tsumaru S, Wada Y, Nagasawa A, Arai Y, Marui A, et al. Outcomes following surgery for acute type A aortic dissection complicated by cerebral malperfusion based on the aortic-repair-first strategy. Eur J Cardiothorac Surg. 2025 Jul 1;67(7):ezaf209. doi: 10.1093/ejcts/ezaf209.