Time Is Essential: Where Can We Improve in Acute Aortic Dissection?

Objectives: Survival in acute aortic dissection (AADA) has been closely linked to the time delay from the onset of symptoms to operative treatment. An optimal national setup of rescue services within western countries has thus been repeatedly demanded. However, delays prior to the start of surgery are still common. Here the various logistic components within our own referral network (radius, 100 km) determining the timing to definitive treatment were analyzed.

Methods: Between January 2017 and August 2019, 76 patients suffering from AADA (iatrogenic dissections excluded) were treated at our tertiary referral center. Fifty-five (72.4%) came from other hospitals and 21 (27.6%) were directly admitted to our center. Data of prehospital care and logistics were documented as part of the clinical routine. Data are presented as medians and 25th to 75th percentiles, or absolute numbers, and percentages.

Results: Median age was 69 years (56–75 years) and 29 (38.2%) were female. Median BMI was 26.2 kg/m² (24.2–29.7 kg/m²). Four patients (5.3%) presented with an intramural hematoma.

Among the referring centers, median time to diagnosis (from onset of symptoms) was 3.3 (1.7–11.5) hours and median transfer-time was 4.8 (3.0–20.5) hours. Transfer was by air in 23 (42.6%) and ground based in 31 (57.4%) cases. Median time from admission at our center until start of anesthesia was 1.0 (0.4–1.9) hours. Total time from onset of symptoms to start of anesthesia was 6.2 (3.9–24.5) hours on average.

Patients primarily admitted at our hospital showed a median time to diagnosis of 3.0 (1.4–4.8) hours and a mean time until start of anesthesia of 1.8 (1.0–4.4) hours. Onset of-symptoms to start of anesthesia was 6.0 (4.2–12.6) hours.

Patients with prolonged time to diagnosis either presented delayed at the initial hospital or presented with atypical symptoms such as a stroke.

Conclusion: Despite a tight-knit emergency service system important delays in the time of onset of symptoms to time of surgery still occur in AADA. Whereas transfer times from peripheral hospitals are not a real issue, the variability of the time to diagnosis at any location demonstrates how important education and thus awareness are in the optimization of the treatment of this disease. Networks allowing data transfer from the emergency services and the primary care facility to tertiary centers may unstring the handling of the potentially lethal first hours following AADA.

No conflict of interest has been declared by the author(s).