Malperfusion syndromes in type A aortic dissection: what we have learned from IRAD

Berretta, Paolo; Trimarchi, Santi; Patel, Himanshu J.; Gleason, Thomas G.; Eagle, Kim A.; Eusanio, Marco Di

doi:10.21037/jovs.2018.03.13

Cited by 64 publications

(69 citation statements)

References 33 publications

(59 reference statements)

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“…Sixteen patients (4.8%) of our ATAAD cohort presented with coronary malperfusion. This is less than the 10%–15% reported in large databases, but similar to the single‐institution series ranging from 6.1% to 11.3% 2,5,20,27‐29 . All had electrocardiogram evidence of ischemia, in agreement with the findings from Neri et al 20 Seven patients (43.8%) were initially diagnosed with MI and found to have ATAAD during cardiac catheterization.…”

Section: Discussionsupporting

confidence: 83%

“…Acute type A aortic dissection (ATAAD) is a highly lethal disease with a 30‐day mortality of 90% without surgical intervention 1 . Despite decades of advances in diagnosis and management, operative mortality (OM) of up to 20% is expected even when performed at specialized aortic centers reporting to large databases like the International registry of acute aortic dissections (IRADs), the German registry for acute aortic dissection type A, and the Nordic Consortium for ATAAD 1‐4 . Malperfusion of aortic branch vessels is both common and catastrophic, affecting up to one‐third of ATAAD cases, and strongly predicting poor outcomes 5 .…”

Section: Introductionmentioning

confidence: 99%

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Management of malperfusion: New York approach and outcomes

2020

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Background and Aim Aortic branch malperfusion complicates up to one‐third of acute type A aortic dissection (ATAAD), and it is a strong predictor of poor outcomes. We analyzed our results for the surgical management of this high‐risk cohort. Methods We queried our aortic database for consecutive patients undergoing ATAAD repair. Those presenting with malperfusion were compared with those without. Outcomes were compared using univariate and multivariate analysis. Results From 1997 to 2019, a total of 336 patients underwent ATAAD repair. A total of 97 ATAAD patients presented with malperfusion. Malperfusion patients were more likely to be male (54.8% vs. 75.3%; p = .001), have had a prior myocardial infarction (11.9% vs. 26.8%; p = .001), to present with preoperative renal dysfunction (22.2% vs. 54.6%; p < .001), and to present with shock (12.6% vs. 28.9%; p = .001). The malperfusion group more often underwent coronary artery bypass grafting (5.4% vs. 24.7%; p < .001), and required additional noncardiac procedures 10.3% of the time. Operative mortality (0.8% vs. 15.5%; p < .001) and major adverse events (MAEs) (7.6% vs. 20.6%; p = .001) were both greater for the malperfusion patients. Ejection fraction, diabetes, and malperfusion were predictors of MAEs. Cerebral, coronary, mesenteric, and multiple vascular bed malperfusion were predictors of MAEs, while extremity, renal, and spinal were not. Conclusion Improving outcomes for this high‐risk cohort requires rapid diagnosis and reversal of ischemia while minimizing the risk of aortic rupture, irrespective of the strategic approach.

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Section: Discussionsupporting

confidence: 83%

Section: Introductionmentioning

confidence: 99%

Management of malperfusion: New York approach and outcomes

2020

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“…Two of the most commonly cited preoperative factors that portend worse prognosis are the presence of MPS and renal dysfunction 7,9,11,18 . Berretta et al examined IRAD data and showed that while all forms of MPS were associated with increased mortality, mesenteric ischemia was particularly devastating and carried a 2.5-fold increase in mortality (63% vs. 24%) 19 . Our data show equally distressing outcomes with 83% of cases presenting with mesenteric ischemia resulting in death.…”

Section: Discussionmentioning

confidence: 99%

Impact of time between diagnosis to treatment in Acute Type A Aortic Dissection

Matthews

Madison

Timsina

et al. 2021

Sci Rep

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There is a paucity of data describing the effect of time interval between diagnosis and surgery for Acute Type A Aortic Dissection. We describe our 8-year experience and investigate the impact of time interval between symptom onset, diagnosis and surgery on outcomes. Retrospective single-center study utilizing our Society of Thoracic Surgeons registry and patient records. Subjects were grouped by time interval between radiographic diagnosis and surgical treatment: Group A (0–4 h), Group B (4.1–8 h), Group C (8.1–12 h), and Group D (12.1 + h). Data were analyzed to identify factors associated with mortality and outcomes. 164 patients were included. Overall mortality was 21.3%. Group C had the greatest intervals between symptom onset to diagnosis to surgery, and also the highest mortality (66.7%). Preoperative tamponade, cardiac arrest, malperfusion, elevated creatinine, cardiopulmonary bypass time, and blood transfusions were associated with increased mortality, while distance of referring hospital was not. Time intervals between symptom onset, diagnosis and surgery have a significant effect on mortality. Surgery performed 8–12 h after diagnosis carries the highest mortality, which may be exacerbated by longer interval since symptom onset. Time-dependent effects should be considered when determining optimal strategy especially if inter-facility transfer is necessary.

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“…The malperfusion syndrome can affect different vascular beds depending upon the exact location of the aortic tear: spinal cord, visceral, renal, and lower extremities [ 7 , 8 ]. It is found in 20–40% of patients with Stanford A aortic dissection.…”

Section: Introductionmentioning

confidence: 99%

“…The malperfusion syndrome may be complicated by a wide variety of symptoms. Nevertheless, early diagnosis is important in avoiding damage to organs and the subsequent inflammatory cascade that can affect the treatment success and patient prognosis [ 7 , 8 ].…”

Section: Introductionmentioning

confidence: 99%

Hybrid two-stage repair of Stanford A dissection with visceral or peripheral malperfusion

Wang

Zhuang

Chen

et al. 2020

J Cardiothorac Surg

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Background The present study aimed to evaluate the effect of two-stage hybrid aortic repair at the distal aorta of Stanford A dissection with malperfusion. Methods This retrospective case series included 20 patients with Stanford A dissection administered two-stage thoracic endovascular aortic repair (TEVAR) about 1 month after central repair because of visceral or limb malperfusion. The patients were examined by computed tomography (CT) angiography at 3, 6, 12 and 24 months after operation. Recovery of malperfusion and true lumen index were evaluated during follow-up. Results Twenty patients underwent two-stage hybrid aortic repair, including 11 males and 9 females. The follow-up time was 24 ± 7 months. No intervention-related complications were observed, including stent graft-induced new re-entry tears, death, stroke and spinal cord injury. Malperfusion in all cases was corrected. The true lumen was not enlarged enough 1 month after the first surgery. Thrombosis of the false lumen was observed around the elephant trunk at the carina level and the celiac artery. Three months after second stage TEVAR, the false lumen thrombosis was resorbed; in addition, the trunk was fully expanded at the carina level, and the true lumen was enlarged at the celiac artery. Conclusions Two-stage hybrid aortic repair for residual true lumen in the distal aorta 1 month after initial surgery is helpful for descending aorta remodeling and effective in treating malperfusion. This procedure may be a good option for patients suffering from Stanford A dissection with small true lumen in the distal aorta and malperfusion.

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Malperfusion syndromes in type A aortic dissection: what we have learned from IRAD

Cited by 64 publications

References 33 publications

Management of malperfusion: New York approach and outcomes

Management of malperfusion: New York approach and outcomes

Impact of time between diagnosis to treatment in Acute Type A Aortic Dissection

Hybrid two-stage repair of Stanford A dissection with visceral or peripheral malperfusion

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