Acute aortic dissection type A: Impact of aortic specialists on short and long term.

To the editor, The article “Acute Aortic Dissection Type A: Impact of Aortic Specialists on Short and Long‐Term Outcomes” by Khan et al. has been read with great enthusiasm. The concisely written article was a privilege to read, and we applaud the authors' endeavors. The authors have cogently written a wide range of scenarios. Acute aortic dissection type A (AADTA) improves short‐term and long‐term fatality ratios, postoperative consequences, and the proportion of patients handled by Aortic Specialists Surgeons (ASS) and General Cardiac Surgeons (non‐ASSs). We agreed that AADTA patients should undergo surgery immediately to prevent blood loss, protect vital organs such as the brain, kidneys, and heart, and enable a healthy, prosperous life for the patient. AADTA is associated with a high mortality rate, with the majority of untreated patients dying within 2 weeks. However, we would like to add a few points that, in our opinion, would improve the quality of this article and add to the existing knowledge of this fatal disease. First, we assume that a variety of treatments are available for AADTA treatment. The authors have not highlighted alternative therapies such as invasive endovascular treatment (IET). Despite good surgical results, there is still a risk for morbidity and mortality in elderly patients at high risk for surgery. Endovascular repair will gain popularity as an alternative treatment for ascending aortic disease in selected high‐risk patients, but more research is needed. Acute kidney injury (AKI) was diagnosed in 382 of 941 patients (40.6%), including 105 (11%) postoperative patients. There was preoperative malperfusion of the kidneys (5.1%), of which 69.0% developed AKI. AKI is a common complication after surgery for AADTA, and it predicts adverse long‐term outcomes independently. However, one‐third of patients presenting with renal malperfusion did not develop postoperative AKI, possibly because surgical repair restored renal blood flow. The authors should have also described the critical condition of Cranial Stroke. Twenty percent (38/189) of patients undergoing AADTA repair had stroke (58% unilateral, 43% bilateral [p = .33]). All strokes were ischemic in nature. The causes of ischemic stroke were embolic (58%), hypoperfusion (26%), mixed (11%), and unknown (5%). There was no correlation between intraoperative variables and neuroanatomy or stroke mechanism. 40% (n = 15) of patients presented with preoperative carotid dissection, while 10% (n = 4) developed intracranial large vessel occlusion (LVO) following surgery. Strokes related to AADTA are severe at presentation, resulting in significant disability. One in 10 ischemic strokes are caused by LVO and may be treatable endovascularly. Stroke prevention is complicated by its heterogeneous location and etiology. Given advancements in endovascular therapy, future trials may evaluate the significance of early neuroimaging and concurrent stroke treatment.