ADULT – Original Submission|Articles in Press

Midterm Outcomes in Type A Aortic Dissection Repair With and Without Malperfusion in a Hybrid Operating Room

Published:December 22, 2022DOI:
      Treatment approach to type A aortic dissection with malperfusion, immediate open aortic repair vs upfront endovascular treatment, remains controversial. From January 2017 to July 2021, 301 consecutive type A repairs were evaluated at our institution. Starting in 2019, all type A aortic dissections were performed in a fixed-fluoroscopy, hybrid operating room. Propensity score matching was used to control baseline patient characteristics between traditional and hybrid operating room approaches. There were 144 patients in the traditional group and 157 in the hybrid group. In the hybrid group, 41% (64/157) underwent intraoperative angiograms, and of those, 58% (37/64) received at least 1 endovascular intervention. Following propensity matching, 125 patients remained in each the traditional and hybrid groups. Thirty-day survival was significantly improved in the hybrid cohort at 96.7% (122/125) as compared to the traditional cohort at 87.2% (109/125) (P = 0.002). There were no significant differences in perioperative paralysis (1.6% vs 1.6%, P > 0.9), new hemodialysis (12% vs 9.6%, P = 0.5), fasciotomy (2.4% vs 5.6%, P = 0.20, and exploratory laparotomy (1.6% vs 4.8%, P = 0.3). The hybrid operating room approach to type A aortic dissection, provides the ability to immediately assess distal malperfusion and perform endovascular interventions at the time of open aortic repair, and is associated with significantly higher 30-day and 2-year survival when compared to a stepwise repair approach in a traditional operating room.

      Graphical Abstract


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Seminars in Thoracic and Cardiovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Berretta P
        • Trimarchi S
        • Patel HJ
        • et al.
        Malperfusion syndromes in type A aortic dissection: What we have learned from IRAD.
        J Vis Surg. 2018; 4: 65
        • Chiu P
        • Tsou S
        • Goldstone AB
        • et al.
        Immediate operation for acute type A aortic dissection complicated by visceral or peripheral malperfusion.
        J Thorac Cardiovasc Surg. 2018; 156: 18-24.e3
        • Yang B
        • Rosati CM
        • Norton EL
        • et al.
        Endovascular fenestration/stenting first followed by delayed open aortic repair for acute Type A aortic dissection with malperfusion syndrome.
        Circulation. 2018; 138: 2091-2103
        • Khoo CY
        • Liew TYS
        • Mathur S
        Systematic review of the efficacy of a hybrid operating theatre in the management of severe trauma.
        World J Emerg Surg. 2021; 16: 43
        • Di Eusanio M
        • Trimarchi S
        • Patel HJ
        • et al.
        Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.
        J Thorac Cardiovasc Surg. 2013; 145: 385-390.e1
        • Narayan P
        • Rogers CA
        • Benedetto U
        • et al.
        Malperfusion rather than merely timing of operative repair determines early and late outcome in type A aortic dissection.
        J Thorac Cardiovasc Surg. 2017; 154: 81-86
        • Leshnower BG
        • Keeling WB
        • Duwayri YM
        • et al.
        The “thoracic endovascular aortic repair-first” strategy for acute type A dissection with mesenteric malperfusion: Initial results compared with conventional algorithms.
        J Thorac Cardiovasc Surg. 2019; 158: 1516-1524
        • Lawton JS
        • Moon MR
        • Liu J
        • et al.
        The profound impact of combined severe acidosis and malperfusion on operative mortality in the surgical treatment of type A aortic dissection.
        J Thorac Cardiovasc Surg. 2018; 155: 897-904
        • Yang B
        • Patel HJ
        • Williams DM
        • et al.
        Management of type A dissection with malperfusion.
        Ann Cardiothorac Surg. 2016; 5: 26574
        • Uchida K
        • Karube N
        • Kasama K
        • et al.
        Early reperfusion strategy improves the outcomes of surgery for type A acute aortic dissection with malperfusion.
        J Thorac Cardiovasc Surg. 2018; 156: 483-489
        • Patel HJ
        • Williams DM
        • Dasika NL
        • et al.
        Operative delay for peripheral malperfusion syndrome in acute type A aortic dissection: A long-term analysis.
        J Thorac Cardiovasc Surg. 2008; 135: 1288-1295
        • Yang B
        • Norton EL
        • Rosati CM
        • et al.
        Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: A 20-year experience.
        J Thorac Cardiovasc Surg. 2019; 158: 675-687.e4
        • MacGillivray TE
        • Gleason TG
        • Patel HJ
        • et al.
        The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection.
        J Thorac Cardiovasc Surg. 2022; 163: 1231-1249