Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome

Abstract

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).

Thoracic Aortic Emergencies: Presenting Pathologies and Treatment Strategies

“…Patients who present with Stanford type A or B aortic dissection or IMH with malperfusion, defined as ongoing arterial obstruction, or malperfusion syndrome, defined as malperfusion accompanied by end-organ ischemia confirmed by clinical symptoms (severe abdominal pain, vomiting, bloody diarrhea, oliguria) and correlative laboratory values, may be treated differently than those without malperfusion. [43][44][45][46] Careful review of imaging including origins of branch vessels from the true or false lumen is critical. Static obstruction of a branch vessel, defined as extension of dissection into the branch vessel with insufficient or absent reentry tear, should be noted, as these vascular beds may not be corrected by central aortic repair and may require additional true lumen stenting.…”

“…47,48 At some centers, patients with aortic dissection and malperfusion syndrome are treated with aortic fenestration with true lumen stenting prior to central aortic repair, although postoperative fenestration is also performed when needed. 44 This treatment strategy is temporizing and has been shown to be effective in reducing morbidity in patients with malperfusion syndrome prior to operative central aortic repair. 43,44 The fenestration technique has been detailed in the literature but will be discussed briefly.…”

Commentary: Building bridges, not walls

“…Table 1 highlights similarities and differences between the Emory and Michigan experiences. 2,3 As has been recognized by most, mesenteric malperfusion syndrome portends a dismal prognosis when associated with ATAAD. Like the Michigan group, the Emory group had evolved their strategy during the study period, because no good approach had yielded acceptable results up to this point.…”

“…2 The premise of expeditious reperfusion of the mesenteric vascular bed and delayed proximal aortic repair is not novel, having been adopted by the Michigan group with the use of endovascular aortic fenestration and target vessel stenting. 3 Leshnower and colleagues 2 performed a retrospective analysis of the Emory experience with 618 repaired ATAADs and identified 34 (5.5%) patients who presented with mesenteric malperfusion. The definition used for mesenteric malperfusion was a combination of clinical, chemical, and radiographic parameters, and it appears reasonable in view of the difficulties in confirming this diagnosis in general.…”

“…Comparison between the Michigan (fenestration)3 and Emory (thoracic endovascular aortic repair first) 2 strategies to treat acute type A aortic dissection with visceral and mesenteric malperfusion LFTs, Liver function tests; PT, prothrombin time; TEVAR, thoracic endovascular aortic repair; SMA, superior mesenteric artery. *Only includes the second decade of the Michigan experience.…”