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Background: Immediate open repair of acute type A aortic dissection (ATAAD) is traditionally recommended to prevent death from aortic rupture. However, organ failure due to malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. Methods: From 1996–2017, among 597 ATAAD patients, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decade, as well as observed mortalities with those expected with an “upfront OR for every patient” approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA models). Results: Overall, in-hospital mortality improved between the two decades (21.0% vs. 10.7%, p<0.001). In the second decade, for MPS patients initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% (p=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio = 6.63, 95%CI 1.5–29, p=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the “upfront OR for every patient” models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all ATAAD patients were significantly lower (p≤0.03). Conclusions: Immediate open repair is the strategy to prevent death from aortic rupture for the majority of ATAAD patients. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by open aortic repair at resolution of organ failure. Related to an abstract (“Malperfusion Syndrome Management in Acute Type A Aortic Dissection: Two-Decade Experience”) presented at the AHA Scientific Sessions 2017 (Anaheim, CA, Nov 2017).

Adipose-derived stem cells together with VEGF transduction can enhance the survival and quality of transplanted fat tissues.