Mesenteric Malperfusion Syndromes in Type A Aortic Dissection: Current Management Strategies

The Year in Aortic Surgery: Selected Highlights From 2023

This article reviews the recent and relevant literature to the field of aortic surgery. Specific areas highlighted include outcomes of Stanford type A dissection, management of acute aortic syndromes, management of aortic aneurysms, and traumatic aortic injury. Although the focus was on articles from 2023, literature from prior years also was included, given that this article is the first of a series. Notably, the pertinent sections from the 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management Aortic Disease are discussed.

Prognostic impact of branch vessel involvement on organ malperfusion and mid-term survival in patients with acute type A aortic dissection

BACKGROUND

This study aimed to investigate the impact of branch vessel involvement on organ malperfusion and mid-term survival in patients with acute type A aortic dissection (ATAAD).

METHODS

Between January 2019 and December 2020, 493 consecutive patients with angiographically confirmed ATAAD were retrospectively analysed. Preoperative computed tomography angiography parameters (branch artery involvement, longitudinal extent of dissection) were reviewed. The incidence of organ malperfusion, in-hospital mortality, and mid-term outcomes of patients with and without branch vessel involvement were compared.

RESULTS

Branch vessel involvement was detected in 407 patients (82.6%), and organ malperfusion was observed in 234 patients (47.5%). The incidence of organ malperfusion was significantly higher in patients with branch vessel involvement compared with patients without it (52.6% vs. 23.3%, p < 0.001). Patients with coronary artery involvement (32.5%) were more likely to manifest as clinical malperfusion, whereas it occurred only 19.4% in patients with renal artery involvement. In-hospital mortality was higher in patients with branch vessel involvement (19.9% vs. 8.1%, p = 0.010). Median follow-up time was 16.1 months. Two-year survival rate was lower in patients with branch vessel involvement (76.3% vs. 84.5%, p = 0.085) or organ malperfusion (68.3% vs. 86.0%, p < 0.001). Multivariable analysis identified cardiac, cerebral, visceral and renal malperfusion as independent predictors for in-hospital mortality.

CONCLUSIONS

Only a small proportion of branch vessel involvement was associated with corresponding organ malperfusion in patients with ATAAD. Branch vessel involvement had a greater effect on short-term outcomes than mid-term survival, and organ malperfusion was related to a worse prognosis beyond it.

Revascularization-first strategy versus central repair-first strategy for acute type A aortic dissection complicated with mesenteric malperfusion syndrome: A meta-analysis

OBJECTIVE

The optimal therapeutic strategy for acute type A aortic dissection (ATAAD) accompanied by mesenteric malperfusion syndrome (mMPS) has not been fully elucidated. The intent of this meta-analysis was to analyze the effectiveness and safety of the revascularization-first strategy among patients with ATAAD complicated with mMPS through comprehensive comparisons with the central repair-first strategy.

METHODS

Studies relevant to the comparison of the outcomes of early reperfusion combined with delayed proximal aortic repair and initial central repair in the treatment of ATAAD complicated with mMPS, were systematacially searched using PubMed, Cochrane Library, Web of Science and Embase up to June 30, 2022. And the primary outcome was early mortality, with mesenteric complications, adverse aortic events and hypothermic circulatory arrest (HCA) time served as the secondary outcomes. Screening of the relevant studies, data extraction, and assessment of the included studies were conducted by two authors independently. Standard statistical procedures provided in Review Manager 5.3 were used to perform all statistical analyses.

RESULTS

Five studies comprising 72 patients in total were included into the quantitative synthesis. In-hospital/30-day mortality was significantly reduced in patients receiving the revascularization-first strategy than in those with the central repair-first strategy, with a pooled risk ratio (RR) of 0.46 (p = .04, 95% confidence interval [CI]: 0.22-0.95). The revascularization-first strategy resulted in a lower incidence of mesenteric complications compared with the central repair-first strategy, with a pooled RR of 0.15 (p = .0002, 95% CI: 0.05-0.41). Moreover, no significant difference was found in the comparison of the revascularization-first strategy and central repair-first strategy regarding adverse aortic events (p = .31, 95% CI: 0.44-12.78). Compared with central repair-first, a longer HCA time was observed in revascularization-first with mean difference of 9.91 (p = .02, 95% CI: 1.34-18.48).

CONCLUSIONS

The revascularization-first strategy presented a lower in-hospital/30-day mortality and mesenteric complications than the central repair-first strategy without increasing the incidence of adverse aortic events. However, the revascularization-first strategy indicated a longer HCA time than the central repair-first strategy.