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Ikeno Y, Koh EY, Estrera GA, Bernal LR, Sandhu H, Miller CC, Estrera AL, Tanaka A. Morphology of true lumen and surgical outcomes of acute type A aortic dissection repair with superior mesenteric artery malperfusion. J Vasc Surg 2024:S0741-5214(24)01899-8. [PMID: 39321896 DOI: 10.1016/j.jvs.2024.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 09/16/2024] [Accepted: 09/16/2024] [Indexed: 09/27/2024]
Abstract
BACKGROUND Acute type A aortic dissection (ATAD) can cause visceral malperfusion. Central aortic repair may resolve malperfusion, but some require further intervention. This study aimed to review outcomes after ATAD presenting with visceral malperfusion and to evaluate the predictive value of true lumen (TL) morphologies in preoperative computed tomography scan for persistent superior mesenteric artery (SMA) ischemia after central repair. METHODS Open surgical repair of ATAD performed between 2008 and 2023 at our institution was reviewed retrospectively. Patients with central repair first approach were included for analysis. Patients with inadequate computed tomography scan data to assess luminal morphology were excluded. TL morphology was reviewed at the diaphragm level and categorized as concave or convex. The malperfusion pattern, static vs dynamic, was assessed at SMA orifices. Data were analyzed using a contingency table and parametric and nonparametric methods. RESULTS A total of 543 open ATAD repairs were performed. Of these, 263 patients were eligible under the inclusion criteria and, subsequently, analyzed. The mean age was 57±14, and 83 (31%) patients were female. SMA malperfusion developed in 42 (16%) of the 263 patients, including 26 patients with dynamic obstruction, 6 patients with static obstruction, and 10 patients with dynamic and static obstruction. Regarding dissection flap morphology, 78 patients (30%) exhibited concave morphology, while 185 patients (70%) had convex morphology. TL diameter was significantly larger in convex than concave (concave: 6 mm vs convex: 16 mm; P < .0001). The prevalence of clinically significant SMA malperfusion was higher in concave-shaped TL (concave 41% vs convex 5%; P < .0001). Dynamic SMA obstruction was more frequently observed in the concave group (concave 72% vs convex 30%; P < .001). However, significantly more patients with convex-shaped TL required bowel resection than concave (concave 13% vs convex 70%; P < .001). The operative mortality was higher in the convex group, although statistically insignificant (concave 19% vs convex 50%; P = .0059). CONCLUSIONS Central repair first strategy could resolve more than 80% of SMA malperfusion in ATAD when the TL is concave-shaped at the level of the diaphragm. Convex-shaped TL morphology was associated with less incidence of SMA malperfusion but was more frequently associated with static obstruction and higher incidence of bowel resection. The morphology evaluation of the TL at the diaphragm level may be simple and beneficial for surgical planning for ATAD presenting with SMA malperfusion.
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Affiliation(s)
- Yuki Ikeno
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Ezra Y Koh
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Gregory A Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Lucas Ribe Bernal
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Harleen Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, TX.
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Nakajima T, Shibata T, Mukawa K, Miura S, Arihara A, Mizuno T, Nakanishi K, Iba Y, Kawaharada N. Treatment Strategies for Acute Aortic Dissection With Malperfusion: A Retrospective Study. Cureus 2024; 16:e65822. [PMID: 39219975 PMCID: PMC11363006 DOI: 10.7759/cureus.65822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Aortic dissection with malperfusion necessitates emergency surgery and is associated with poor outcomes. Therefore, in this study, we analyzed patients' treatment courses from the initial management to hospital discharge in cases of acute aortic dissection (AAD) with malperfusion and investigated the risk factors associated with mortality. METHODS We evaluated cases of AAD with malperfusion treated at our institution over a 16-year period from 2007 to 2022. The primary endpoint was in-hospital mortality. The study's primary outcome measure was mortality during hospitalization. We collected and analyzed data encompassing preoperative patient characteristics, Stanford classification, sites of preoperative malperfusion, surgical techniques employed, and postoperative complications. These variables were examined to identify factors associated with in-hospital mortality. RESULTS During the study period, 366 patients were admitted with AAD, 102 of whom had malperfusion. There were 62 men (61%) and 40 women (39%), with a mean age of 64 ± 13 years (range: 28-87 years). According to the Stanford classification, 75 (74%) and 27 (26%) patients had type A and B aortic dissection, respectively, and 29 patients (28%) presented with shock. Preoperative malperfusion sites included the brain, coronary arteries, abdominal viscera, limbs, and spinal cord in 40 (39%), 10 (10%), 34 (33%), 52 (51%), and six (6%) patients, respectively. Eleven (11%) patients required immediate intervention in the emergency department. The treatments administered to the patients were as follows: ascending aortic replacement, 30 (29%) patients; aortic arch replacement, 34 (33%) patients; root replacement, three (3%) patients; thoracic endovascular aortic repair (TEVAR), 12 (12%) patients; non-anatomic bypass, five (5%) patients; and conservative management, five (5%) patients. In-hospital mortality occurred in 23 (23%) patients. Multivariate logistic regression analysis identified preoperative coronary malperfusion as an independent risk factor of mortality. CONCLUSION Preoperative coronary malperfusion is an independent risk factor for in-hospital mortality in patients with AAD presenting with malperfusion.
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Affiliation(s)
| | - Tsuyoshi Shibata
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Kei Mukawa
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Shuhei Miura
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Ayaka Arihara
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Takakimi Mizuno
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | | | - Yutaka Iba
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
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Yu W, Liang Y, Gao J, Xie D, Xiong J. Surgical choice for the treatment of partial intestinal ischemic necrosis caused by acute type a aortic dissection combined with malperfusion of superior mesenteric artery. J Cardiothorac Surg 2024; 19:286. [PMID: 38734628 PMCID: PMC11088173 DOI: 10.1186/s13019-024-02790-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 05/03/2024] [Indexed: 05/13/2024] Open
Abstract
Acute type A aortic dissection is a severe cardiovascular disease characterized by rapid onset and high mortality. Traditionally, urgent open aortic repair is performed after admission to prevent aortic rupture and death. However, when combined with malperfusion syndrome, the low perfusion of the superior mesenteric artery can further lead to intestinal necrosis, significantly impacting the surgery's prognosis and potentially resulting in adverse consequences, bringing. This presents great significant challenges in treatment. Based on recent domestic and international research literature, this paper reviews the mechanism, current treatment approaches, and selection of surgical methods for poor organ perfusion caused by acute type A aortic dissection. The literature review findings suggest that central aortic repair can be employed for the treatment of acute type A aortic dissection with inadequate perfusion of the superior mesenteric artery. The superior mesenteric artery can be windowed and (/or) stented, followed by delayed aortic repair. Priority should be given to revascularization of the superior mesenteric artery, followed by central aortic repair. During central aortic repair, direct blood perfusion should be performed on the distal true lumen of the superior mesenteric artery, leading to resulting in favorable therapeutic outcomes. The research results indicate that even after surgical aortic repair, intestinal ischemic necrosis may still occur. In such cases, prompt laparotomy and necessary necrotic bowel resection are crucial for saving the patient's life.
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Affiliation(s)
- Wenbo Yu
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Yuan Liang
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Jianfeng Gao
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Dilin Xie
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Jianxian Xiong
- First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China.
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Krishna Moorthy PS, Sakijan AS, Permal D, Gaaffar IF, Kepli AS, Sahimi HI. Current review of acute type A aortic dissection in Malaysia. Indian J Thorac Cardiovasc Surg 2023; 39:297-307. [PMID: 38093916 PMCID: PMC10713945 DOI: 10.1007/s12055-023-01608-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 12/17/2023] Open
Abstract
Acute type A aortic dissection (ATAAD) still poses significant challenges and management dilemmas for cardiovascular surgeons worldwide. Despite the continuous improvement in diagnosis and management strategies for ATAAD, clinical outcomes remain poor and the optimal therapy is still debatable especially those with malperfusion syndrome (MPS). This review is based on the current literature and includes the results from the Aortic Registry of National Heart Institute of Malaysia (NHIM) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is often delayed leading to variable outcomes. High index of suspicion and urgent treatment is required to tackle this dynamic disease which include the variation in presentation and clinical course. Different surgical techniques and perfusion strategies have been described to save patients. Complex techniques such as total arch replacement (TAR) with frozen elephant trunk and valve sparing root surgery may provide long-term benefit in selected patients, but require significant surgical expertise and experience.
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Affiliation(s)
- Paneer Selvam Krishna Moorthy
- Department of Cardiothoracic & Vascular Surgery, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Abdul Samad Sakijan
- Department of Imaging & Non-Invasive Laboratory, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Deventhiran Permal
- Department of Imaging & Non-Invasive Laboratory, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Intan Fariza Gaaffar
- Clinical Research Department, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Aini Syakirin Kepli
- Clinical Research Department, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Haidatul Insyirah Sahimi
- Clinical Research Department, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
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Minamidate N, Wakisaka H, Hachiro K, Miyashita F, Morimoto M, Kondo Y, Enomoto M, Takashima N, Suzuki T. Is central repair with coronary artery bypass grafting enough for multi-organ malperfusion in acute type A aortic dissection with coronary malperfusion? Asian J Surg 2023; 46:5449-5453. [PMID: 37311670 DOI: 10.1016/j.asjsur.2023.05.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVES Acute type A aortic dissection with coronary malperfusion syndrome is rare but associated with high mortality. Multi-organ malperfusion is an independent predictor of acute type A aortic dissection. Coronary malperfusion requires treatment, but it is not feasible to treat all malperfusions. The adequacy of "central repair and coronary artery bypass grafting" for patients with coronary and other organ malperfusion is unknown. METHODS Of the 299 patients who underwent surgery between 2008 and 2018, 21 patients with coronary malperfusion, who received cental repair with coronary artery graft bypass, were analyzed retrospectively. They were divided; into Group M (n = 13, coronary and other organ malperfusion) and Group O (n = 8, coronary malperfusion only). The patient background, surgical content, details of malperfusion, surgical mortality and morbidity, and long-term outcome were compared. RESULTS There was no difference in operation time (205 ± 30 vs. 266 ± 88, p = 0.49), but the time from arrival to circulatory arrest tended to be shorter in Group M (81 vs. 134, p = 0.05). Among Group M, cerebral malperfusion was the most common at 92%. Two of the three cases with mesenteric malperfusion died. The mortality of Group M and Group O was 13% and 15% (P = 0.85), respectively. There was no difference in long-term mortality (p = 0.62). CONCLUSIONS Central repair and coronary artery bypass grafting is a sufficiently acceptable treatment for patients with acute type A aortic dissection and multi-organ malperfusion, including coronary malperfusion.
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Affiliation(s)
- Naoshi Minamidate
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan.
| | - Hodaka Wakisaka
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Kohei Hachiro
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Fumihiro Miyashita
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Masanori Morimoto
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Yasuo Kondo
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Masahide Enomoto
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Noriyuki Takashima
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
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