A modified axillo-femoral perfusion for acute type a aortic dissection accompanied with lower limb malperfusion

Abstract

Background: Lower limb malperfusion accompanied with acute type A dissection (AAD) is reported to be an independent predictor for mortality. Timely treatment is required. However, staged approach to restore the perfusion of the ischemic leg before aortic repair has a continuously increase risk of aortic rupture. Aortic repair under isolated axillary artery perfusion also has the risk of prolonging leg ischemia. Here we introduce our experience in performing axillo-femoral perfusion, which is supposed to bring benefits for treating lower limb malperfuison. Methods: Thirty patients who suffered AAD accompanied by lower limb ischemia enrolled in our study. All patients received aortic repair as soon as possible using the modified axillo-femoral perfusion approach. The cardiopulmonary bypass and cooling started with the right axillary artery perfusion. Then the femoral artery of the ischemic side was exposed and sewn to a graft connected with another inflow cannula. The rectal temperature was about 31°C when the femoral perfusion started. The perfusion of the ischemic legs preoperative was estimated after the surgery by the clinical signs, the saturation of the distal-limb, and computed tomography scan. Results: Twenty-eight patients got good perfusion of the lower body after the surgery. Two patients received femoralfemoral artery bypass immediately after surgery because of the thrombosis in the right common iliac artery, without further injury. No peripheral vessels damage occurred, and no compartment fasciotomy or amputation needed. One patient died for the sepsis and the subsequent multi organ failure 28 days postoperative. Conclusions: The modified axllio-femoral perfusion could restore the lower limbs' perfusion simultaneously during the aortic surgery without neither delaying dissection repair nor prolonging the ischemic time. It is a simple, but safe and effective technique.

Malperfusion syndromes in acute type A aortic dissection do not affect long‐term survival in Chinese population: A 10‐year institutional experience

“…Most patients with lower limb malperfusion could recover after reconstitution of true lumen flow by surgery within the hyperacute period. Otherwise, interventional fenestration with stent implantation 21 or femoral‐femoral/axillary‐femoral 22 bypass was performed after surgery.…”

Malperfusion in Acute Type A Aortic Dissection: Management Strategies

“…Li et al (2020) report good outcomes in 30 patients with a compound allio-femoral perfusion with aortic surgery therapeutic approach. 23,41 With respect to prognosis, the majority of studies confirm that as an isolated finding, limb ischaemia is not a risk factor for mortality if operated upon, with rates similar to a general population who present without organ malperfusion. 12 However, the presence of limb malperfusion makes it more likely for other malperfusion syndromes to manifest.…”

“…12,25 Its presence still confers a risk of mortality to the patient, so effectively timed management remains crucial. 23 Clinically, in addition to the classic tearing chest pain associated with aortic dissection, weak or absent pulses and blood pressure variation in the limbs is an early indication of limb malperfusion, confirmed with CT angiography. 38 When considering management for limb malperfusion, historically, immediate repair of the aortic arch without prior revascularisation has been preferred.…”

“…39,42,43 Moreover, it bears mentioning that there is also the risk of limb tissue necrosis associated with a delay in primary repair, which leaves the patient vulnerable to further morbidity as limb ischemia is prolonged. 23,43 Theoretically, the proposed approaches are reperfusion followed by primary repair to the aortic arch. 44 However, this approach is still risky given the high initial mortality rate accompanying untreated dissection in the first 48 hours.…”

“…Li et al (2020) report good outcomes in 30 patients with a compound allio-femoral perfusion with aortic surgery therapeutic approach. 23,41…”