Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: A 20-year experience

Abstract

Objective: To assess outcomes of endovascular reperfusion followed by delayed open aortic repair for stable patients with acute type A aortic dissection and mesenteric malperfusion syndrome (mesMPS).Methods: Among 602 patients with acute type A aortic dissection who presented to our center from 1996 to 2017, all 82 (14%) with mesMPS underwent upfront endovascular fenestration/stenting. Primary outcomes were in-hospital mortality and long-term survival. Patients with acute type A aortic dissection with no malperfusion syndrome of any organ (n ¼ 419) served as controls.Results: In-hospital mortality of all comers with mesMPS was 39%. After endovascular fenestration/stenting, 20 mesMPS patients (24%) died from organ failure and 11 patients (13%) died from aortic rupture before open aortic repair, 47 patients (58%) underwent aortic repair, and 4 patients (5%) survived without open repair. No patients died from aortic rupture during the second decade (2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017). The significant risk factors for death from organ failure after endovascular reperfusion were acute stroke (odds ratio, 23; 95% confidence interval, 4-144; P ¼ .0008), gross bowel necrosis at laparotomy (odds ratio, 7; 95% confidence interval, 1.4-34; P ¼ .016), and serum lactate 6 mmol/L (odds ratio, 13.5; 95% confidence interval, 2-97; P ¼ .0097). There was no significant difference in operative mortality (2.1% vs 7.5%; P ¼ .50) or long-term survival between patients with mesMPS who underwent open aortic repair after recovering from mesMPS and patients with no malperfusion syndrome.

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.…”

“…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. 49 True lumen access is obtained followed by IVUS examination of the entire aorta.…”

Management of malperfusion syndrome in acute type A aortic intramural hematoma

“…ATAAIMH has similar risk factors and complications as classic acute type A aortic dissection (ATAAD), including presence of malperfusion syndrome (MPS), which is associated with increased mortality. Management of MPS in classic ATAAD remains debated, but upfront endovascular reperfusion via transcatheter techniques and delayed aortic repair has shown favorable outcomes (12)(13)(14)(15). Although ATAAIMH is less often complicated by MPS (1)(2)(3)7,8,16), there is a paucity of information regarding MPS in the setting of ATAAIMH.…”

“…In this study, we report the outcomes of ATAAIMH patients with visceral or extremity MPS (malperfusion with tissue/organ necrosis and end-organ dysfunction) treated with upfront endovascular reperfusion through fenestration/ stenting of critically malperfused organ system(s) by interventional radiology (IR) followed by aortic repair at resolution of organ failure (12)(13)(14)(15) and without visceral or extremity MPS treated with immediate aortic repair.…”

Commentary: Management of mesenteric malperfusion syndrome in patients with type A aortic dissection: An unsettled issue

“…The operative mortality for the 82 patients with mesenteric MPS was significantly higher than that for those without mesenteric MPS (39% vs 7.5%; P < .001); for those who underwent both endovascular revascularization and open aortic repair, however, inhospital mortality and major postoperative complications were not significantly different from those of patients who had no mesenteric MPS (2.1% vs 7.7%; P ¼ .23), suggesting that the impact of this complication could potentially be eliminated if promptly and successfully treated. Another important finding of Yang and colleagues 8 is represented by the recognition of stroke, bowel necrosis at laparotomy, and elevated serum lactate (6 mmol/L) as independent predictors of death from organ failure after resolution of malperfusion. This is further important information that can guide us in selecting which patient would benefit the most from a staged approach.…”