Repair of acute type A aortic dissection in comatose patients.

In this issue of the Journal, Most et al. [1] attempt to give further insight into the dilemma of indications to surgical repair of acute type A aortic dissection (AADA) in patients presenting with pre-operative neurological dysfunction. The topic has been the focus of numerous institutional and registry reports in the past [2–4]. Although a formal consensus has not yet been reached, there is worldwide agreement that newly presenting neurological injury greatly increases hospital risk, in terms of mortality and morbidity, but does not represent per se a contraindication to repair [2]. In addition, no apparent impact on late mortality has thus far been reported, even though functional recovery may be incomplete in some patients, leading to significant permanent disability [2, 3]. Several prior reports have suggested that extent of functional recovery may be satisfactory in patients presenting with acute focal motor or sensory disorders (stroke) [2], whereas this may not hold true for patients presenting with coma, a condition affecting from 3 to 14% of AADA patients [3, 4]. Perhaps the most original contribution of this study is the effort to retrospectively risk-stratify patients based on the degree of functional recovery at the mid-term clinical follow-up [1]. Similar to previous studies, unfortunately , Most et al. [1] fall short of addressing the controversial issue of granting surgical repair to comatose patients with AADA. The patho-physiology of coma in acutely dissected patients is often multifactorial, since anatomical factors such as head-neck vessels involvement, frequently coexist with circulatory collapse (due to tamponade, low output and acute aortic valve regurgita-tion), sequelae of acute hypoxia (due to stroke or cardiorespira-tory failure) and of sedation, to aide transport and minimize further brain damage. In addition, coma manifests more often in elderly patients, with greater comorbidities and splanchnic or limb malperfusion, all phenomenal risk factors for hospital mortality and morbidity [3]. Last but not least, comatose patients rely on family, when present, to express consent to life-saving therapies , thereby increasing the burden of decision on relatives and physicians. Not surprisingly, the subgroup of AADA patients presenting with coma is the one most frequently denied surgical management , with as many as one-third of comatose patients assigned to medical therapy [3, 4]. However, the ultimate decision is always left to the surgeon on call and no institution has thus far reported prospective application of a risk score or management algorithm to deal with this taxing …