Long-term outcomes of surgical aortic fenestration for complicated acute type B aortic dissections

Surgical and endovascular repair for type B aortic dissections with mesenteric malperfusion syndrome: A systematic review of in-hospital mortality

OBJECTIVES

Mesenteric malperfusion is a feared complication of aortic dissection, with high mortality. The purpose of this study was to systematically review in-hospital mortality (IHM) of endovascular and surgical management of acute and chronic Stanford type B aortic dissections (TBAD) complicated by mesenteric malperfusion (MesMP).

METHODS

A systematic search of English language articles was conducted in relevant databases. Data on patient demographics, procedure details, and survival outcomes were collected. Reports were classified by type of intervention performed. Studies that failed to report patient-level outcomes based on specific intervention performed or IHM were excluded. Retrospective chart review of previously published data from a single institution was also performed to further identify cases of TBAD that were managed endovascularly. The Fisher exact test was performed to determine statistical significance.

RESULTS

In total, 37 articles were suitable for inclusion in this systematic review, which yielded 149 patients with a median age 55.0 years (interquartile range, 46.5-65 years) and 79% being male. Overall, in-hospital mortality was 12.8% (19/149) and was similar between endovascular and open surgical interventions (13% vs 11%, P = .99). Among endovascular strategies, IHM was greater, although not statistically significant in the thoracic endovascular aortic repair group compared with the fenestration/stenting without thoracic endovascular aortic repair group (24% vs 11%, P = .15).

CONCLUSIONS

Multiple strategies exist for the management of TBAD with MesMP; however, a majority of cases were managed endovascularly. Despite advances in therapies, mortality remains high at 13%.

Retrograde stenting of the superior mesenteric artery is the procedure of choice for dissection of the aorta with mesenteric compromise

Acute mesenteric ischemia secondary to aortic dissection in type A and type B is a true vascular surgical emergency. Presentation can be subtle or dramatic, and time to revascularization is limited before irreversible changes occur. The literature recognizes the catastrophic consequences of acute superior mesenteric artery occlusion and the need for urgent revascularization, often before central aortic repair in type A. There is no optimal revascularization technique described in this scenario. We present a case of type A aortic dissection with acute dynamic and static superior mesenteric artery occlusion and describe treatment that resulted in successful salvage of the bowel and the patient's life.

Redo surgery for extensive chronic type A dissecting aneurysm following a Bentall operation

INTRODUCTION

Despite the technical improvements, redo surgery on the aortic root and arch is still associated with high morbidity and mortality due to the trauma of repeat open-heart surgery and technical complexity. We present the case of extended chronic type A dissecting aneurysm that developed after a Bentall operation, which was successfully treated by applying a modified long elephant trunk technique and surgical aortic fenestration.

CASE PRESENTATION

A 77-year-old man, who had previously undergone a Bentall procedure and an abdominal surgery, developed a type A aortic dissection. At presentation, the aortic dissection extended from the proximal arch to the terminal aorta, which were treated with an axillobifemoral bypass. After 8 months follow-up, the dissecting aneurysm had extended and the visceral arteries were perfused from the false lumen, without re-entry. We successfully repaired a complicated and extended chronic type A dissecting aneurysm by applying a modified long elephant trunk technique and surgical aortic fenestration. Postoperatively, the thoracic aorta false lumen was thromboexcluded, and the visceral perfusion was preserved through the fenestration.

CONCLUSION

In the treatment of complicated aortic arch diseases especially in redo cases, appropriate strategies are mandatory to achieve optimal outcomes. In the extended aortic dissection without the reentry for visceral perfusion, a primary entry closure may lead to visceral ischemia. Modified long elephant trunk technique combined with fenestration technique may be one of the useful techniques to treat the complicated aortic dissection extending to the terminal aorta.

Update in the management of type B aortic dissection

Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.

Surgical Fenestration for Lower Limb Ischemia Developing from Chronic Type B Aortic Dissection: A Report of 2 Cases

Lower limb ischemia caused by type B aortic dissection typically presents with a leg-threatening condition in the acute phase. However, in some cases, lower limb ischemia symptom develops as intermittent claudication in the chronic phase. Although surgical fenestration has been used for treating ischemic complications of aortic dissection, it has recently become an alternative option for such cases because of the significant advance of endovascular treatments. We report 2 cases of chronic type B aortic dissection complicated by lower limb ischemia. Two male patients aged 57 and 43 years presented with intermittent claudication more than 2 weeks after the onset of the disease. On the basis of anatomic condition of the dissected aorta, we successfully performed surgical fenestration through a median laparotomy. In the current endovascular era, surgical fenestration remains an effective and durable option for treating lower limb ischemia caused by chronic type B aortic dissection.

Lower limb malperfusion in type B aortic dissection: a systematic review

BACKGROUND

Lower limb malperfusion (LLM) syndrome occurs in up to 40% of complicated type B aortic dissections (TBAD) and in up to 71% of TBAD with malperfusion syndrome. This syndrome is associated with higher 30-day mortality. The aim of this systematic review was to provide clinical and procedural data of patients with LLM syndrome secondary to TBAD.

METHODS

The PubMed database was systematically searched from January 2000 to June 2014 for English-language publications reporting on demographic data of patients with LLM secondary to TBAD.

RESULTS

A total of 29 papers were included (10 original articles and 19 case reports), reporting on a total of 138 patients (mean age =58±12 years; male =87%). Lower limb complications developed in acute and chronic TBAD in 134 (97%) and 4 (3%) cases, respectively. LLM presented with acute limb ischemia in 120 (87%) patients. Bilateral clinical presentation occurred in 56% (40/72) of cases. LLM was the only clinically detected malperfusion in 52% of cases (44/84). In 40% (35/84) and 25% (21/84) of cases, LLM was clinically associated with renal and visceral malperfusion, respectively. Radiological imaging showed renal, celiac trunk and superior mesenteric artery involvement in 53% (47/88), 31% (27/88) and 34% (30/88) of cases, respectively. Medical, surgical and endovascular treatments were performed in 22 (16%), 51 (37%) and 65 (47%) patients, respectively. Thirty-day morbidity was 31% (13/42) and 46% (6/13) following surgical and endovascular treatment, respectively. Thirty-day mortality was 14% (5/36) and 8% (2/26) following surgical and endovascular treatment, respectively.

CONCLUSIONS

LLM syndrome secondary to TBAD usually developed during the acute phase and, in most cases, presented with acute limb ischemia. Bilateral clinical presentation occurred in more than half of cases. Renal and visceral malperfusion were frequently associated with lower limb flow reduction but LLM was the only clinically detected malperfusion in more than half of patients. Surgical fenestration was burdened with significant complication rates and 30-day mortality. Endovascular procedures showed lower mortality but complication rates remained high.

Acute aortic emergencies--part 2: aortic dissections

Patients with aortic disease are some of the highest acuity patients that emergency clinicians encounter. Dissection is the most common aortic catastrophe and involves separation of the aortic layers in a longitudinal fashion leading to diminished perfusion and systemic ischemia. Characteristics of pain, branch vessel involvement, and incidence lead to an understanding of patient presentation, morbidity, and mortality. Diagnosis, selection of diagnostic studies, the degree of preoperative ischemia, and risk of operative mortality can be accomplished using validated clinical decision tools. Emergency interventions are guided by the type of dissection according to the Stanford classification system. Medical management includes pain control and anti-impulse, antihypertensive therapy through vasodilatation and blockage of the sympathetic β-response. The patient may then be evaluated for open surgical intervention, aortic fenestration, endovascularly placed stent grafts, or a combination possibly in a staged approach. Morbidity includes rupture, stroke, paraplegia, acute renal failure, bowel ischemia, and peripheral ischemia.

Simultaneous Surgical Treatment of Type B Dissection Complicated With Visceral Malperfusion and Abdominal Aortic Aneurysm: Role of Aortic Fenestration

Aortic dissection occurs in about 5% of patients with coexistent abdominal aortic aneurysm (AAA); combined type B dissection complicated with visceral malperfusion and AAA is an uncommon aortic emergency and patients presenting with complications of thoracic aortic dissection have a dismal prognosis related to difficulties in treatment strategies. Despite tremendous improvement of endovascular techniques, surgical aortic fenestration represents a quick, safe, and effective procedure able to restore flow in an otherwise malperfused aorta. This procedure has to be kept in mind because subsets of patients cannot be treated conventionally due to either prohibitive risk of aortic replacement, anatomic contraindication, or limitations of percutaneous procedures. Herein we report a case of a patient presenting with type B aortic dissection complicated by visceral malperfusion and AAA which was successfully treated simultaneously by open AAA repair and surgical fenestration. We focus on the mechanism of malperfusion and on the role of surgical fenestration.

Role of the femorofemoral crossover graft in acute lower limb ischemia due to acute type B aortic dissection

Acute limb ischemia due to type B aortic dissection is rare and continues to be a management challenge. A case series is presented here with the aim of assessing the outcomes of treatment with a femorofemoral crossover graft with or without thoracic stent graft insertion. This is a combined retrospective and prospective review of nine cases of acute lower limb ischemia secondary to acute type B aortic dissection. The presenting features, radiological findings, treatment and outcomes were reviewed. Five patients had a femorofemoral crossover graft (FFXO) alone, two an FFXO with a thoracic stent graft and the eighth a thoracic and iliac stent. The other case was initially treated conservatively but subsequently required an FFXO. The mean follow-up was 16 (3-51) months. A further two thoracic stents were placed during the follow-up period. Thus five out of nine patients (56%) required aortic stenting. This series suggests that an FFXO is a reliable treatment for acute limb ischemia due to type B aortic dissection. However, these patients are often complex with ischemia in other vascular beds and are at risk of subsequent aneurysmal dilation.

Early malperfusion, ischemia reperfusion injury, and respiratory failure in acute complicated type B aortic dissection after thoracic endovascular repair

BACKGROUND

The aim of this study was to determine the early mortality and major complications of acute complicated type B aortic dissection (ACBD) after thoracic endovascular aortic repair (TEVAR).

METHODS

Twenty-six consecutive patients with ACBD who underwent TEVAR were included. Clinical indications before TEVAR and in-hospital mortality and major complications after TEVAR were analyzed and compared with similar reports.

RESULTS

TEVAR was technically successful in all cases. In-hospital mortality occurred in four patients (15%), and major complications occurred in an additional four patients (15%). Three of the four (75%) of the deaths were associated with malperfusion and ischemia reperfusion injury (IRI), and 3/4 (75%) of the major complications were caused by respiratory failure (RF).

CONCLUSIONS

In-hospital mortality associated strongly with severe end-organ malperfusion and IRI, while major complications associated with RF, during TEVAR. Our results indicate that malperfusion, IRI and respiratory failure during TEVAR should be carefully monitored and aggressively treated.

Acute aortic dissection type A

Background

Acute aortic dissection type A (AADA) is a life-threatening vascular emergency. Clinical presentation ranges from pain related to the acute event, collapse due to aortic rupture or pericardial tamponade, or manifestations of organ or limb ischaemia. The purpose of this review was to clarify important clinical issues of AADA management, with a focus on diagnostic and therapeutic challenges.

Methods

Based on a MEDLINE search the latest literature on this topic was reviewed. Results from the German Registry for Acute Aortic Dissection Type A (GERAADA) are also described.

Results

Currently, the perioperative mortality rate of AADA is below 20 per cent, the rate of definitive postoperative neurological impairment approaches 12 per cent and the long-term prognosis after surviving the acute phase of the disease is good. Many pathology- and therapy-associated factors influence the outcome of AADA, including prompt diagnosis with computed tomography and better cerebral protection strategies during aortic arch reconstruction. Endovascular technologies are emerging that may lead to less invasive treatment options.

Conclusion

AADA is an emergency that can present with a wide variety of clinical scenarios. Advances in the surgical management of this complex disease are improving outcomes.