Malperfusion in acute type A aortic dissection: how we handle the challenge?

Treatment Strategies for Acute Aortic Dissection With Malperfusion: A Retrospective Study

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.

Surgical choice for the treatment of partial intestinal ischemic necrosis caused by acute type a aortic dissection combined with malperfusion of superior mesenteric artery

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.

Current review of acute type A aortic dissection in Malaysia

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.

Is central repair with coronary artery bypass grafting enough for multi-organ malperfusion in acute type A aortic dissection with coronary malperfusion?

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.