The impact of age in acute type A aortic dissection: a retrospective study

Abstract

Background
Acute type A aortic dissection (aTAAD) is a lethal disease and age is an important risk factor for outcomes. This retrospective study was to analyze the impact of age stratification in aTAAD, and to provide clues for surgeons when they make choices of therapy strategies.

Methods
From January 2011 to December 2019, 1092 aTAAD patients from Nanjing Drum Tower Hospital received surgical therapy. Patients were divided into 7 groups according to every ten-year interval (20–80 s). The differences between the groups were analyzed in terms of the baseline preoperative conditions, surgical methods and postoperative outcomes of patients of different age groups. During a median follow-up term of 17 months, the survival rates were compared among 7 groups through Kaplan–Meier analysis.

Results
The median age was 52.0 years old in whole cohort. The multiple comorbidities were more common in old age groups (60 s, 70 s, 80 s), while the 20 s group patients had the highest proportion of Marfan syndrome (28.1%). Preoperative hypotension was highest in 80 s (16.7%, P = 0.038). Young age groups (20–60 s) had a higher rate of root replacement and total arch replacement, which led to a longer duration of operation and hypothermic circulation arrest. The overall mortality was 14.1%, the tendency of mortality was increased with age except 20 s group (33.3% in 80 s, P = 0.016). The postoperative morbidity of gastrointestinal bleeding and bowel ischemia were 16.7% and 11.1% in 80 s group.

Conclusions
Age is a major impact factor for aTAAD surgery. Old patients presented more comorbidities before surgery, the mortality and complications rate were significantly higher even with less invasive and conservative surgical therapy. But the favorable long-term survival indicated that the simple or less extensive arch repair is the preferred surgery for patients over 70 years old.

Full text

Wangetal. Journal of Cardiothoracic Surgery (2022) 17:40
https://doi.org/10.1186/s13019-022-01785-y
RESEARCH ARTICLE
The impact ofage inacute type Aaortic
dissection: aretrospective study
Jun‑Xia Wang1,2, Yun‑Xing Xue1,2†, Xi‑Yu Zhu1,2, Ho‑Shun Chong1,2, Zhong Chen1,2, Qing Zhou1,2,
Jason‑Zhensheng Qu3 and Dong‑Jin Wang1,2*
Abstract
Background: Acute type A aortic dissection (aTAAD) is a lethal disease and age is an important risk factor for
outcomes. This retrospective study was to analyze the impact of age stratification in aTAAD, and to provide clues for
surgeons when they make choices of therapy strategies.
Methods: From January 2011 to December 2019, 1092 aTAAD patients from Nanjing Drum Tower Hospital received
surgical therapy. Patients were divided into 7 groups according to every ten‑year interval (20–80 s). The differences
between the groups were analyzed in terms of the baseline preoperative conditions, surgical methods and postop‑
erative outcomes of patients of different age groups. During a median follow‑up term of 17 months, the survival rates
were compared among 7 groups through Kaplan–Meier analysis.
Results: The median age was 52.0 years old in whole cohort. The multiple comorbidities were more common in old
age groups (60 s, 70 s, 80 s), while the 20 s group patients had the highest proportion of Marfan syndrome (28.1%).
Preoperative hypotension was highest in 80 s (16.7%, P = 0.038). Young age groups (20–60 s) had a higher rate of root
replacement and total arch replacement, which led to a longer duration of operation and hypothermic circulation
arrest. The overall mortality was 14.1%, the tendency of mortality was increased with age except 20 s group (33.3% in
80 s, P = 0.016). The postoperative morbidity of gastrointestinal bleeding and bowel ischemia were 16.7% and 11.1%
in 80 s group.
Conclusions: Age is a major impact factor for aTAAD surgery. Old patients presented more comorbidities before
surgery, the mortality and complications rate were significantly higher even with less invasive and conservative surgi‑
cal therapy. But the favorable long‑term survival indicated that the simple or less extensive arch repair is the preferred
surgery for patients over 70 years old.
Keywords: Aortic dissection, Age, Surgical therapy
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Background
Age has shown to be a strong independent impact factor
of outcomes in acute type A aortic dissection (aTAAD),
while treatment strategies and surgical methods
differentiate according to age stratification. Old age has
long been thought to increase the risk of surgery, which
likely explains the higher rate of medical therapy espe-
cially in patients older than 70years old [1]. As the aging
of population increases, surgical techniques and periop-
erative management continue to improve, advanced age
is no longer a major deterrent of surgical repair of aTAAD
albeit conservative therapy is chosen by patients and phy-
sicians [2, 3]. Studies have shown that the average age of
patients with aTAAD is 55years old in China, a decade
younger than that in the western countries [4, 5]. So an
Open Access
*Correspondence: dongjinwang_gl@163.com
†Jun‑Xia Wang and Yun‑Xing Xue have contributed equally to the study
and shared the first authorship
1 Department of Cardiothoracic Surgery, Affiliated Drum Tower
Hospital, Medical School of Nanjing University, 321 Zhongshan Road,
Nanjing 210000, Jiangsu, China
Full list of author information is available at the end of the article
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Wangetal. Journal of Cardiothoracic Surgery (2022) 17:40
extensive one-stage surgery, total arch replacement and
frozen elephant trunk, has become the preferred surgical
strategy in China to avoid reintervention [6, 7]. ere are
also reports on one-stage total aortic arch replacement in
other counties.
However, as the number of patients with aTAAD
increases in age groups in China, especially in the groups
of 60–80 years of age, the long-term survival of this
extensive surgery is largely unknown. Should age be fac-
tored in the consideration before such an extensive sur-
gery be planed? e age-stratified clinical characteristics,
treatment strategies, and outcomes in Chinese patients
are not yet known. e aim of this retrospective study
is to investigate the clinical characteristics, treatment
strategy and surgical outcomes of aTAAD in different age
stratification groups in our center.
Methods
Patients
Between January 2011 and December 2019, a total
of 1174 patients with aTAAD were admitted to Nan-
jing Drum Tower Hospital (NDTH). 1092 patients who
underwent open surgical repair were divided into seven
groups according to every ten-year interval (20–80s) and
82 patients who did not undergo surgical therapy were
excluded. Diagnosis of aTAAD was confirmed by com-
puted tomographic angiography (CTA) scanning within
two weeks after the onset of symptoms.
All clinical data were collected prospectively by admis-
sion and during the in-hospital stay. We retrieved the
data retrospectively by review of hospital records. e
study was conducted in accordance with the Declaration
of Helsinki (as revised in 2013). e current study was
approved by the institutional review board of Nanjing
Drum Tower Hospital (2020-185-01).
Treatment
Patients diagnosed with aTAAD were transferred to
cardiac surgery intensive care unit and optimal medi-
cal therapy was initiated. ose with the signs of severe
low blood pressure and tamponade will be taken in the
operating room direct from emergency. Open surgery
was recommended for all patients, but for patients with
advanced age, dissection associated organ malperfusion
or family refusal, medical therapy was the treatment of
choice. e patients received open surgery underwent
general anesthesia via a standard median sternotomy
after signing the informed consents. Cardiopulmonary
bypass (CPB) was initiated with femoral artery or axillary
artery arterial cannulation and right atrium or superior/
inferior venous cannulation. Deep or mild hypothermic
circulatory arrest (HCA) was used in all patients. Selec-
tive antegrade or retrograde cerebral perfusion was
applied for brain protection during the period of HCA
at operating surgeon’s choice. e distal aortic arch sur-
gical strategy included partial arch replacement, total
arch replacement with or without frozen elephant trunk
(Microport Corp.Ltd, Shanghai, China) and arch stent
(Yuhengjia Sci Tech Corp.Ltd, Beijing, China) based on
the pathological involvement of the aortic arch [7–9].
After finishing the distal repair, the re-warming stage
begun as the proximal part of aorta or root was being
reconstructed and the patients were weaned off CPB.
Bentall procedure or root reinforcement reconstruction
was applied based on the anatomic indications [10, 11].
e patients were transferred to the floor after recovering
in cardiac surgery ICU, and discharged from the hospital
per institution protocol.
Statistical analysis
Statistical analysis was performed with SPSS 26.0 (IBM
Corp. Released 2019. IBM SPSS Statistics for Macin-
tosh, Version 26.0. Armonk, NY: IBM Corp.). Descriptive
statistics were used to describe patient characteristics
throughout the study. Means and standard deviations
were presented for normally distributed continuous vari-
ables whereas median and the interquartile ranges were
computed to describe non-normally distributed continu-
ous data. Categorical data are presented as frequency
distributions and simple percentages. Between group dif-
ferences were analyzed using a Student’s t-test, Kruskal–
Wallis H test or Mann–Whitney U-test for continuous
variables and a Chi-square or Fisher’s exact test for cat-
egorical variables. e survival curve was draw using
Kaplan–Meier method and compared using the log-rank
test. e median follow-up time was calculated with
reverse Kaplan–Meier method. Statistical significance
was considered when P < 0.05.
Results
Demographics andPreoperative characteristics
Eighty-two of the 1174 aTAAD patients chose medi-
cal management that was chosen by 30.8% of patients in
80years group due to rupture of the dissection (Fig.1a,
b). e patients aged 40–60years constituted the larg-
est proportion of patients (71.2%) and the youngest 20s
(2.9%) and oldest 80s (1.6%) groups accounted for mini-
mum percentage of patients. ere was higher propor-
tion of female patients as age increases.
Further analysis showed that the 20s group patients
had the highest proportion of connective tissue diseases
(Marfan’s syndrome) (28.1%). History of hypertension
was present in 63% patients ages between 40 and 70years
old and hypotension on admission was highest in 80 s
group (16.7%, P = 0.038) (Table1). e average BMI was
25.6 with the highest 33.1 in 30s group and lowest 19.5
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Wangetal. Journal of Cardiothoracic Surgery (2022) 17:40
in 80s group. ere is significantly increased history of
stroke (9.6% vs 1.9%, OR 5.5, 95% CI 2.6–11.5), coronary
artery disease (CAD) (5.9% vs 2.0%, OR 3.1, 95% CI 1.3–
7.2) in patients over 70years old.
Pain was the main presenting symptom, while chest
pain presented as similar among groups. Preoperative
malperfusion were present in 34% of patients with no sig-
nificant difference among age groups.
Fig. 1 a Number and sex ratio of patients in different age groups of our center; b The reason for non‑surgery after admission. The main reason was
a rupture
Table 1 Baseline demographics and characteristics
BMI body mass index, CAD coronary artery disease, COPD chronic obstructive pulmonary disease
Total 20s 30s 40s 50s 60s 70s 80s P value
Number 1092 32 146 281 286 211 118 18
Age 52 (62–44) 27 (28–25) 35.5(38–32) 45 (47–43) 54 (56–52) 64 (66–62) 74 (76–71) 82.5(84.25–80) < 0.001
Male 816 (74.7%) 30 (93.8%) 127 (87.0%) 244 (86.8%) 211 (73.8%) 130 (61.6%) 64 (54.2%) 10 (55.6%) < 0.001
BMI (kg/m2) 25.6 ± 4.6 25.8 ± 5.4 27.4 ± 5.7 26.4 ± 4.7 25.4 ± 4.1 24.7 ± 4.0 24.1 ± 3.9 23.4 ± 3.9 < 0.001
Hypertension 807 (73.9%) 12 (37.5%) 95 (65.1%) 215 (76.5%) 219 (76.6%) 162 (76.8%) 92 (78.0%) 12 (66.7%) < 0.001
Marfan 26 (2.4%) 9 (28.1%) 4 (2.7%) 10 (3.6%) 2 (0.7%) 1 (0.5%) 0 (0%) 0 (0%) < 0.001
Diabetes 40 (3.7%) 0 (0%) 3 (2.1%) 8 (2.8%) 9 (3.1%) 11 (5.2%) 7 (5.9%) 2 (11.1%) 0.181
Smoke 250 (22.9%) 10 (31.3%) 34 (23.3%) 77 (27.4%) 71 (24.8%) 40 (19.0%) 14 (11.9%) 4 (22.2%) 0.019
Alcohol 167 (15.3%) 3 (9.4%) 28 (19.2%) 44 (15.7%) 54 (18.9%) 25 (11.8%) 11 (9.3%) 2 (11.1%) 0.098
End stage kidney disease 23 (2.1%) 0 (0.0%) 4 (2.7%) 5 (1.8%) 11(3.8%) 0 (0.0%) 3 (2.5%) 0 (0.0%) 0.072
Stroke history 31 (2.8%) 0 (0%) 1 (0.7%) 5 (1.8%) 7 (2.4%) 5 (2.4%) 10 (8.5%) 3 (16.7%) 0.001
CAD history 27 (2.5%) 0 (0%) 2 (1.4%) 3 (1.1%) 5 (1.7%) 9 (4.3%) 6 (5.1%) 2 (11.1%) 0.020
COPD history 11 (1.0%) 0 (0%) 1 (0.7%) 2 (0.7%) 3 (0.3%) 3 (1.4%) 2 (3.4%) 0 (0%) 0.919
AF history 10 (0.9%) 0 (0%) 1 (0.7%) 1 (0.4%) 2 (0.7%) 3 (1.4%) 2 (1.7%) 1 (5.6%) 0.273
Pain 1007 (92.3%) 28 (87.5%) 134 (91.8%) 262 (93.2%) 264 (92.3%) 194 (91.9%) 109 (92.4%) 17 (94.4%) 0.936
Chest 942 (86.3%) 28 (87.5%) 125 (85.6%) 244 (86.8%) 251 (87.8%) 179 (84.8%) 102 (86.4%) 15 (83.3%) 0.965
Back 433 (39.7%) 9 (28.1%) 59 (40.4%) 110 (39.1%) 122 (42.7%) 78 (37.0%) 50 (42.4%) 5 (27.8%) 0.565
Abdominal 59 (5.4%) 0 (0%) 10 (6.8%) 19 (6.8%) 12 (4.2%) 10 (4.7%) 5 (4.2%) 3 (16.7%) 0.197
Leg 32 (2.9%) 2 (6.3%) 5 (3.4%) 9 (3.2%) 8 (2.8%) 6 (2.8%) 2 (1.7%) 0 (0%) 0.848
Malperfusion
Cerebral 108 (9.9%) 0 (0%) 9 (6.2%) 26 (9.3%) 32 (11.2%) 21 (10%) 19 (16.1%) 1 (5.6%) 0.062
Limb 165 (15.1%) 7 (21.9%) 20 (13.7%) 49 (17.4%) 46 (16.1%) 30 (14.2%) 12 (10.2%) 1 (5.6%) 0.397
Bowel 47 (4.3%) 0 (0%) 4 (2.7%) 13 (4.6%) 13 (4.5%) 10 (4.7%) 7 (5.9%) 0 (0%) 0.666
Myocardial 52 (4.8%) 2 (6.3%) 11 (7.5%) 10 (3.6%) 14 (4.9%) 10 (4.7%) 5 (4.2%) 0 (0%) 0.646
Hypotension 64 (5.9%) 1 (3.1%) 4 (2.7%) 11 (3.9%) 20 (7.0%) 19 (9.0%) 6 (5.1%) 3 (16.7%) 0.040
Pericardial tamponade 131 (12.0%) 4 (12.5%) 5 (3.4%) 26 (9.3%) 39 (13.6%) 34 (16.1%) 22 (18.6%) 1 (5.6%) 0.001
Coronary artery involvement 215 (19.7%) 11 (34.4%) 28 (19.2%) 53 (18.9%) 62 (21.7%) 39 (18.5%) 21 (17.8%) 1 (5.6%) 0.278
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Wangetal. Journal of Cardiothoracic Surgery (2022) 17:40
Operative characteristics
e duration of surgery, CPB, X-clamp and HCA
decreased with advanced age starting from age group
of 50 years old. Cannulating both femoral and axillary
artery were preferred arterial cannulation approach com-
pared to single femoral or axillary artery. Bentall proce-
dure accounted for a large part of root methods in young
age group (43.8% in 20s) and total arch replacement with
FET had a higher rate in age group of 50s (45.8%), 60s
(41.7%) than the 70s (26.3%) and 80s (16.7%) (P < 0.001)
(Table2).
Immediate postoperative outcomes
One hundred and fifty-four patients (14.1%) died within
30days after surgery, 93 (60.4%) from circulatory fail-
ure, 21 (13.6%) neurological complications, 15 (9.7%)
aortic rupture, 13 (8.4%) respiratory failure or other
reasons, 12 (7.8%) gastrointestinal bleeding or ischemia
(Table3). Group 80 s had significantly higher mortal-
ity than group 70s (33.3% vs 18.6%, P = 0.016) (Fig.2a).
A decreasing trend of mortality rate in 70s and 80s
group was shown with year (Fig.2b). Age was related
to postoperative complications. e stroke rates (died
and not died) were 8.5%, 5.1% and 5.6% in 60s, 70s and
80s group respectively. Among patients succumbed in
the 80-year group, there were significant high rate of
GI bleeding and ischemia (16.7% and 11.1%, respec-
tively) compared with other groups of 50s, 60s and
70s (1.4%, 0%, 0.8%, respectively). e 70s group had
higher duration of ICU stay when compared with other
groups (20 s group: P = 0.048, 30 s group: P = 0.047,
50s group: P = 0.011); however, the duration of hospital
stay showed no significant difference in all age groups.
ere was no significant difference in mechanical ven-
tilation, reintubation, tracheotomy, neurological com-
plications, renal complications and re-exploration. e
20 s group showed lowest postoperative neurological
and gastrointestinal complications as they presented at
admission (Table3).
Table 2 Operative data
OP operation, HCA hypothermic circulatory arrest, CPB cardiopulmonary bypass, ACP antegrade cerebral perfusion, RCP retrograde cerebral perfusion, VSRR valve
sparing root reconstruction, FET frozen elephant trunk technique
Total 20s 30s 40s 50s 60s 70s 80s P value
Number 1092 32 146 281 286 211 118 18
Hour from onset to admis‑
sion 10 (18–6) 10 (20–6) 10 (18–7) 10 (18–7) 9 (16–6) 10 (20–6) 10 (18–6) 9 (12–5) 0.374
Hours from admission to
surgery 6 (12–3) 9 (12–3) 6 (13–3) 6 (14–3) 5 (12–3) 5 (12–2) 5 (10–3) 6 (12–3) 0.049
OP duration 8.0 ± 2.1 8.2 ± 2.1 8.2 ± 2.1 8.3 ± 2.2 7.8 ± 2.3 7.7 ± 1.9 7.7 ± 1.9 7.1 ± 1.6 < 0.001
Cannulation
Ascending 20 (1.8%) 2 (6.3%) 3 (2.1%) 5 (1.8%) 3 (1.0%) 5 (2.4%) 2 (1.7%) 0 (0%) 0.521
Femoral 231 (21.2%) 7 (21.9%) 18 (12.3%) 36 (12.8%) 68 (23.8%) 61 (28.9%) 33 (28.0%) 8 (44.4%) 0.000
Axillary 233 (21.3%) 3 (9.4%) 25 (17.1%) 64 (22.8%) 56 (19.6%) 50 (23.7%) 30 (25.4%) 5 (27.8%) 0.281
Femoral + axillary 608 (55.7%) 20 (62.5%) 100 (68.5%) 176 (62.6%) 159 (55.6%) 95 (45.0%) 53 (44.9%) 5 (27.8%) 0.000
HCA 30.3 ± 11.1 29.2 ± 15.6 32.4 ± 12.6 30.7 ± 10.8 29.7 ± 10.8 30.6 ± 11.1 28.7 ± 8.5 24.8 ± 8.7 0.021
CPB 240.0 ± 76.1 238.8 ± 64.4 253.6 ± 74.2 245.9 ± 81.4 237.7 ± 76.7 234.7 ± 75.9 228.3 ± 66.9 219.3 ± 61.1 0.012
X‑clamp 166.8 ± 61.1 168.5 ± 47.4 179.8 ± 59.3 169.8 ± 72.3 164.1 ± 57.6 163.1 ± 57.8 157.8 ± 49.1 159.7 ± 59.8 0.049
Cerebral perfusion < 0.001
No perfusion 140 (12.8%) 7 (21.9%) 10 (6.8%) 23 (8.2%) 43 (15.0%) 39 (18.5%) 14 (11.9%) 4 (22.2%)
ACP 886 (81.1%) 25 (78.1%) 130 (89.0%) 250 (89.0%) 226 (79.0%) 153 (72.5%) 91 (77.1%) 11 (61.1%)
RCP 66 (6.0%) 0 (0%) 6 (4.1%) 8 (2.8%) 17 (5.9%) 19 (9.0%) 13 (11.0%) 3 (16.7%)
Root procedure < 0.001
No 17 (1.6%) 2 (6.3%) 2 (1.4%) 5 (1.8%) 3 (1.0%) 3 (1.4%) 2 (1.7%) 0 (0%)
Root reconstruction 828 (75.8%) 13 (40.6%) 99 (67.8%) 213 (75.8%) 214 (74.8%) 174 (82.5%) 101 (85.6%) 14 (77.8%)
Bentall 228 (20.9%) 14 (43.8%) 38 (26.0%) 60 (21.4%) 68 (23.8%) 30 (14.2%) 14 (11.9%) 4(22.2%)
VSRR 19 (1.7%) 3 (9.4%) 7 (4.8%) 3 (1.1%) 1 (0.3%) 4 (1.9%) 1 (0.8%) 0 (0%)
Arch procedure < 0.001
Sub‑arch 211 (19.9%) 7 (21.9%) 18 (12.3%) 40 (14.2%) 49 (17.1%) 47 (22.3%) 45 (38.1%) 7 (38.9%)
Total arch + FET 515 (47.1%) 19 (59.4%) 88 (60.3%) 156 (55.5%) 131 (45.8%) 88 (41.7%) 31 (26.3%) 3 (16.7%)
Arch stent 361 (33.0%) 6 (18.8%) 40 (27.4%) 85 (30.2%) 106 (37.1%) 74 (35.1%) 41 (34.7%) 8 (44.4%)
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Wangetal. Journal of Cardiothoracic Surgery (2022) 17:40
Follow‑up
927 (84.9%) patients completed followed up and the
median follow-up was 17 months (1–102 months).
e 17-month survival rate was 82%. irty- eight dis-
charged patients died during follow-up, 1 (3.1%) in 20s
group, 4 (12.5%) in 30s group, 8 (25%) in 40s group, 7
(21.9%) in 50s group, 9 (28.1%) in 60s group, 8 (25%) in
70s group, and 1 (3.1%) in 80s group. Figure3a shows
the mortality associated with age, the general tendency
is that mortality increases with increasing age, 15.6%
in 20s group, 7.5% in 30s group, 11.7% in 40s group,
14.3% in 50s group, 17.1% in 60s group, 18.6% in 70s
group, and 33.3% in 80s group; however, the mortal-
ity of patients over 70years old decreased over these
years while the ratio of these patients remains relatively
stable. Among the patients who died, 10 (26.3%) from
aortic rupture, 5 (13.2%) from neurological complica-
tions, and 2 (5.3%) patients died for stent leakage. 137
patients had readmissions, of whom 34 (24.8%) patients
had thoracoabdominal aortic dissection/aneurysm
which is the leading cause of readmission. Figure3b, c
shows the ratio of patients readmission for recurrence
of aortic dissection, the tendency of readmission for
abdominal aortic dissection decreased with age.
Table 3 Postoperative data
ICH intracranial hemorrhage, GI gastrointestinal, CRRT continuous renal replacement therapy, ICU intense care unit
Total 20s 30s 40s 50s 60s 70s 80s P value
Number 1092 32 146 281 286 211 118 18
30 day‑mortality 154 (14.1%) 5 (15.6%) 11 (7.5%) 33 (11.7%) 41 (14.3%) 36 (17.1%) 22 (18.6%) 6 (33.3%) 0.016
Mechanical ventilation 56.2 ± 79.1 71.6 ± 130.2 61.2 ± 90.4 55.2 ± 69.6 57.5 ± 93.8 52.9 ± 63.3 49.3 ± 51.0 67.6 ± 80.4 0.808
Reintubation 70 (6.4%) 4 (12.5%) 6 (4.1%) 14 (5.0%) 23 (8.0%) 12 (5.7%) 11 (9.3%) 0 (0%) 0.199
Tracheotomy 44 (4.0%) 2 (6.3%) 4 (2.7%) 11 (3.9%) 10 (3.5%) 7 (3.3%) 10 (8.5%) 0 (0%) 0.216
ICH 9 (0.8%) 0 (0%) 1 (0.7%) 1 (0.4%) 5 (1.7%) 1 (0.5%) 1 (0.8%) 0 (0%) 0.609
Stroke 59 (5.4%) 0 (0%) 3 (2.1%) 14 (5.0%) 17 (5.9%) 18 (8.5%) 6 (5.1%) 1 (5.6%) 0.155
Paraplegia 23 (2.1%) 0 (0%) 4 (2.7%) 9 (3.2%) 7 (2.4%) 2 (0.9%) 1 (0.8%) 0 (0%) 0.489
GI bleeding 13 (1.2%) 0 (0%) 1 (0.7%) 4 (1.4%) 4 (1.4%) 0 (0%) 1 (0.8%) 3 (16.7%) 0.000
Limb ischemia 13 (1.2%) 0 (0%) 1 (0.7%) 5 (1.8%) 2 (0.7%) 5 (2.4%) 0 (0%) 0 (0%) 0.396
Bowel ischemia 16 (1.5%) 0 (0%) 3 (2.1%) 3 (1.1%) 3 (1.0%) 2 (0.9%) 3 (2.5%) 2 (11.1%) 0.025
Surgical site infection 37 (3.4%) 2 (6.3%) 3 (2.1%) 10 (3.6%) 9 (3.1%) 11 (5.2%) 2 (1.7%) 0 (0%) 0.484
Acute renal failure 339 (31.0%) 10 (31.3%) 50 (34.2%) 89 (31.7%) 97 (33.9%) 56 (26.5%) 31 (26.3%) 6 (33.3%) 0.525
CRRT 127 (11.6%) 2 (6.3%) 14 (9.6%) 35 (12.5%) 28 (9.8%) 27 (12.8%) 16 (13.6%) 5 (27.8%) 0.246
Reexploration 64 (5.8%) 0 (0%) 6 (4.1%) 14 (5.0%) 26 (9.1%) 11 (5.2%) 6 (5.1%) 0 (0%) 0.119
ICU stay (days) 5 (8–3) 4 (6–3) 5 (7–3) 6 (10–3) 5 (8–3) 5 (9.5–3) 6 (10–4) 5 (12–3) 0.046
Hospital stay (days) 20.8 ± 13.1 21.9 ± 11.4 20.5 ± 10.0 21.7 ± 13.2 19.5 ± 11.5 21.8 ± 14.5 20.5 ± 17.2 14.4 ± 10.8 0.236
Fig. 2 a Ratio of mortality in different age groups. b Ratio and mortality of ≥ 70 years old patients each year, and the overall mortality fluctuation
from 2011 to 2019
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Wangetal. Journal of Cardiothoracic Surgery (2022) 17:40
Discussion
e average age of aTAAD patients was significantly
younger in China, the results from Sino-RAD was
50.5 years [12] and 52 years in our center’s previous
reports [5]13. In this study, we found the median age of
patients of aTAAD is 52. Furthermore, there was a sig-
nificant increasing number of aTAAD patients in 70s and
80 s group who underwent surgical repair. e under-
lining reasons maybe multi-factorial. One of the main
reasons is the increasing awareness of aTAAD among
the public and emergency room physicians particularly
since the introduction of our aTAAD refereral program
(6h life circle); the second is attributed to the improve-
ment of surgical successful rate of aTAAD surgery; and
3rd maybe related to the recent increase of national and
regional healthcare coverage [14] and especially in the
second half of the study period (2016–2019). For older
patients with aTAAD, the optimal treatment strategy is
in debate depending on the risk and benefit ratio and the
upper age limit is unknown. A study by Trimarchi etal.
using IRAD data showed that patients older than 70years
old received higher rates of medical therapy than those
of surgical repair (28.6% vs 10.9%; P < 0.0001), and there
was no difference in survival between the two treatment
Fig. 3 a Survival functions of different age groups. b The reintervention rate of different age groups. c. The ratio of readmission for aortic dissection
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Page 7 of 8
Wangetal. Journal of Cardiothoracic Surgery (2022) 17:40
strategies (55.8% vs 53.8%; P = 0.32) [1]. Our results are
consistent with the above findings. e increasing risks
and lower predictable late survival rate contributed to
the lower proportion of open surgery. Many studies have
shown that advanced age is related to poor postoperative
survival, the long-term survival and the quality of daily
life [15–17]. e poor outcome in patients of advanced
age may have deterred the Septuagenarian and Octo-
genarian from undergoing extensive total arch surgery
because there is no better alternative treatment such as
endovascular repair.
Our present study also demonstrated that the propor-
tion of patients who received surgical treatment over
70 years old remained relatively stable in last decade
in our center. e higher 30 mortality in this group of
patients suggested the negative impact of surgery on the
postoperative recovery of patients with advanced age. In
addition, the favorable long-term survival indicated that
the simple or less extensive arch repair is the preferred
surgery for patients over 70years old. is finding is also
corroborated by other studies [2]18.
Chest pain is the common clinical presentations of
aTAAD for younger patients; however, the main etiol-
ogy of aTAAD for patients in their 20s is connective tis-
sue disorders, such as Marfan syndrome while history of
hypertension is more common in patients of aging 30, 40
and 50s. Compared to the patients older than 70years,
the surgical strategies are totally different. More exten-
sive surgical methods are applied for younger patients
in order to avoid re-intervention because of aortic
events [19–23]. Our study demonstrated that the recur-
rence rate of aTAAD was significantly lower in younger
patients between 30 and 50 years old. e patients of
20s group had the highest recurrent AD, consistant with
the findings in Marfan’s syndrome paitents reported by
Isselbacher etal. from the IRAD data [24]. e ratio of
readmission for aortic dissection is also decreased with
age. Because older patients had more complications than
younger patients. ese complications not only affect
the time and strategies of surgery, but also affect the out-
comes of the patients. And they had to have readmission
to deal with the complications after surgery. On the con-
trary, the 20s group had readmission most likely to deal
with the recurrent aortic dissection. erefore, extensive
surgery strategy with higher surgical risk could not lower
late recurrence and re-intervention.
e mode of the age was in the 40s group, these patients
were at the middle age of their life. It was necessary to pay
more attention to their long term follow up and the quality
of life. In the next years, we would focus on their changes
and show what would happen to these post-operative
aortic dissection patients. For the increasing number of
hypertension patients in China, it was meaningful to know
whether the 40s group patients could totally recovery from
the emergency surgery and go back to the society.
Limitations
First, the retrospective study has its design limitation.
Data were collected retrospectively so there are defects
like incomplete, missing or inaccurate to report the event.
e long-term survival rate would be underestimate as the
follow-up interval is large and the follow-up time of some
patients is shorter than one year. Second, the data obtained
are of a single center and therefore could not represent the
whole population. ird, as the number of patients in 20s
and 80s group being limited, there is a need for further
studies.
Conclusions
Age is a major impact factor for aTAAD surgery. Old
patients presented more comorbidities before surgery, the
mortality and complications rate were significantly higher
even with less invasive and conservative surgical therapy.
But the favorable long-term survival indicated that the sim-
ple or less extensive arch repair is the preferred surgery for
patients over 70years old.
Abbreviations
aTAAD: Acute type A aortic dissection; AD: Aortic dissection.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s13019‑ 022‑ 01785‑y.
Additional le1. The number of patients admitted to Gulou hospital for
aTAAD each year from 2011 to 2019.
Acknowledgements
Not applicable.
Authors’ contributions
J‑XW and Y‑XX designed the study. J‑XW, Y‑XX, X‑YZ and ZC collected and
analyzed the data together. J‑XW, Y‑XX, H‑SC and QZ drafted the article and
submitted the manuscript. D‑JW and J‑ZQ supervised this study. All authors
read and approved the final manuscript.
Funding
This work was supported by the National Natural Science Foundation of China
(Nos. 81970401, 8210021727) and Jiangsu Provincial Key Medical Discipline
(ZDXKA2016019).
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or
analysed during the current study.
Declarations
Ethical approval and consent to participate
The current study was approved by the institutional review board of Nanjing
Drum Tower Hospital (2020‑185‑01) and adhered to the tenets of the Declara‑
tion of Helsinki.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 8 of 8
Wangetal. Journal of Cardiothoracic Surgery (2022) 17:40
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no conflicts of interest.
Author details
1 Department of Cardiothoracic Surgery, Affiliated Drum Tower Hospital,
Medical School of Nanjing University, 321 Zhongshan Road, Nanjing 210000,
Jiangsu, China. 2 Institute of Cardiothoracic Vascular Disease, Nanjing Uni‑
versity, Nanjing, China. 3 Department of Anesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital, Boston, MA, USA.
Received: 14 October 2021 Accepted: 13 March 2022
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