Top Things to Know: Multidisciplinary Collaboration in the Performance of Aortic Surgery

Updated: October 22, 2026
  1. Intraoperative care of patients undergoing complex aortic interventions depends on the continuous and coordinated work of multiple professionals, including but not limited to surgeons, anesthesiologists, and perfusionists, working together as part of a multidisciplinary aortic team (MAT). These surgeries often require disruption of normal circulatory pathways, necessitating seamless coordination and communication within the MAT to protect at-risk organs and successfully complete the aortic repair.
  2. Acute Type A aortic dissection (ATAAD) is a life-threatening cardiovascular emergency with pre-hospital mortality up to 40%, and perioperative mortality of 10% to 25%. Early surgical intervention is required to prevent or treat its complications, which include cardiac tamponade, severe aortic regurgitation with heart failure and shock, coronary dissection with myocardial ischemia, end-organ malperfusion, and vessel rupture.
  3. ATAAD repair is tear oriented, aiming to exclude the entry tear. Ascending aortic replacement with an open distal anastomosis (hemiarch aortic replacement) and aortic valve commissural resuspension allows for treatment and prevention of many ATAAD complications. The repair may need to be extended to include root replacement or extended arch replacement with or without a frozen elephant trunk depending on the location and extent of the entry tear, as well as presence of malperfusion or aneurysmal disease.
  4. Establishing cardiopulmonary bypass (CPB) for acute type A aortic dissection (ATAAD) requires consideration of the primary intimal tear, extent of dissection, hemodynamic stability, cannulation safety, and cerebral protection. Cannulation site selection significantly influences perfusion and surgical outcomes. Although the femoral artery has traditionally been used, its retrograde perfusion may increase the risk of malperfusion, dissection extension, and embolization. Alternative cannulation sites, including the axillary, innominate, and direct aortic approaches, may be appropriate depending on patient and procedural factors.
  5. Open repair of the arch is done under hypothermic circulatory arrest (HCA): the body is cooled and circulation is briefly interrupted to create a bloodless field. Multi-modality cerebral protection strategies during HCA include moderate or deep hypothermia, antegrade or retrograde cerebral perfusion, and pharmacologic interventions to reduce cerebral metabolic rate.
  6. Continuous, multi-site multi-modality monitoring guides these cases. It includes arterial pressure lines matched to the cannulation site that are often placed in both the upper and lower extremities. Cerebral monitoring such as near-infrared spectroscopy (NIRS), which noninvasively tracks brain oxygen levels and processed electroencephalography (EEG) which non-invasively tracks brain electrical activity and provides valuable information regarding anesthetic depth and cerebral protection during HCA.
  7. Open repair of thoracic and thoracoabdominal aortic aneurysms (TAAA) carries high risk, including cardiac, pulmonary, renal, and neurologic complications, most seriously spinal cord injury that causes paraplegia. A careful preoperative work-up (CT angiography, as well as cardiac, pulmonary, and renal testing) and optimization such as smoking cessation and prehabilitation help lower that risk.
  8. Monitoring is matched to the extent of disease and the surgical approach. It can include multiple arterial pressure lines, transesophageal echocardiography (to monitor cardiac and valvular function and image the ascending and descending aorta), spinal cord protection with cerebrospinal fluid (CSF) drainage, as well motor or somatosensory evoked potential (MEP or SSEP) monitoring, which signal spinal cord function in real time.
  9. Lung isolation (selective right-lung ventilation) is frequently needed during open TAAA repairs, which can be accomplished with a double lumen tube (DLT) or a bronchial blocker (BB). Both can be difficult to place in patients with aortic airway compression. DLT leads to superior lung isolation, but has more complications such as sore throat, hoarseness, and tracheal injury. Regardless of the intubation approach, lung-protective ventilation is of critical importance to mitigate post-operative pulmonary dysfunction.
  10. A major source of morbidity in open TAAA repair is the cross-clamping of the thoracoabdominal aorta, which induces proximal hypertension and distal ischemia. Perfusion strategies include no perfusion (clamp and sew), passive shunts, left heart bypass, CPB, and extra-corporeal membrane oxygenation. Perfusion strategies vary significantly and depend on the extent of the repair, conduct of the operation, as well as institutional and surgeon preference.

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Citation

DeAnda A Jr, Steppan J, Boskovski MT, Cherry AD, Dickey RA, Gray DeAngelis K, Ibekwe SO, Tseng EE; on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Education and Publication Committee; Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Peripheral Vascular Disease; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and the Council on Cardiovascular Radiology and Intervention. Multidisciplinary collaboration in the performance of aortic surgery: a scientific statement from the American Heart Association. Circulation. Published online October 22, 2026. doi: 10.1161/CIR.0000000000001490 Please let me know if you need anything else.
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