Acute type A dissection in octogenarians: does emergency surgery impact in-hospital outcome or long-term survival?

Objectives Surgical therapy for acute aortic dissection type A (AADA) in octogenarians carries high morbidity and mortality. The role of isolated medical treatment in this setting is controversial. The aim of this study is to determine whether risk of surgery for AADA outweighs risk of death from medical treatment only. Methods From 2002 to 2015, 90 consecutive octogenarians (mean age, 83.5 ± 3 years) were treated for AADA at three institutions: 67 patients underwent surgery, 23 patients received medical treatment. Analysis of early and late outcome was performed. Results Patients in the medical treatment group were significantly older than in the surgical group (84.9 ± 3.7 vs 83 ± 2.5 years, P  = 0.008) and in a more critical state. In patients undergoing surgical repair, perioperative mortality was 14.9% ( n  = 10). Rate of prolonged ventilation (63.2% vs 5.9%; P  < 0.001) and renal failure (35.1% vs 5.9%, P  = 0.029) was significantly higher in the surgical group. Thirty-day survival was impaired in the medical treatment group (34.8% vs 61.2% in the surgical group; P  = 0.032). Coronary artery disease (OR 3.95, 95% CI 1.16-13.49; P  = 0.029) and complicated dissections (OR 5.28, 95% CI 1.48-18.88; P  = 0.010)-composite variable of preoperative resuscitation, neurological injury and malperfusion-emerged as independent risk factors for 30-day mortality in the surgical group. There was no difference in long-term survival. Conclusions Emergency surgery for AADA in octogenarians is associated with relatively high intraoperative mortality and may reasonably be avoided in patient with complicated presentation. Despite better immediate survival after surgery, long-term survival does not differ between medical and surgical patients, reflecting the extremely advanced point in life cycle octogenarians.