Treatment strategies for malperfusion syndrome secondary to acute aortic dissection

Abstract

Objective Presenting our experience of treating patients with organ malperfusion secondary to acute aortic dissection. Patients Among 383 patients who underwent aortic repair for acute type A aortic dissection from 1999 to 2017, 107 patients were operated on because of vascular complications. Fourteen patients had coronary, 50 had brain, 3 had paraplegia, 13 had superior mesenteric artery, 21 had lower limb, and 16 had combined organ malperfusion. Age was 65.8 years. Results In coronary malperfusion, three had a preoperative percutaneous coronary intervention, and two had mechanical support. All underwent repair of the aorta. Hospital mortality was 28.5%. Fifty patients had brain malperfusion. Hemiplegia was found in 28 patients, transient ischemic attack in 10, and coma in 12. The level of consciousness was severe in 12, moderate in 18, and mild in 20. Twenty‐eight percent died of a stroke. Nine had direct perfusion from the right common carotid artery, and the consciousness level was improved in 5 patients. Eight patients had mesenteric malperfusion. Four patients had a central aorta repair first, and four patients had peripheral intervention first. Three patients had a bypass grafting to the superior mesenteric artery, and one had a catheter intervention. Postoperative mortality was found in four patients due to bowel necrosis and six required resections of the bowel. Conclusion Acute organ malperfusion caused by the aortic dissection requires accurate and prompt diagnosis to proceed with an appropriate intervention before repairing the central aorta for preventing irreversible organ damage.

Direct bilateral carotid artery cannulation can be better strategy for acute aortic dissection involving both carotid arteries

“…The flap prevents the blood flow in the ostium and causes the restriction of the blood flow to the organ. This mechanism we mentioned is responsible for approximately 80% of malperfusion syndromes 4 …”

“…This mechanism we mentioned is responsible for approximately 80% of malperfusion syndromes. 4 This neurological deficit may occur due to cerebral embolism of a flap fragment that is detached from its place or from tears and hematomas in the carotids. Therefore, it is vital that the perfusion strategy be fast and effective in acute aortic dissections with carotid involvement.…”

Rescue Percutaneous Stenting for Cerebral Malperfusion With Acute Aortic Dissection Following TAVR

“…Conversely, 1 report showed the effectiveness of arch vessel stenting after surgical aortic repair for patients with persistent brain malperfusion ( 5 ). Furthermore, peripheral intervention before central aortic repair would prevent severe organ damage, which leads to the improvement of clinical outcomes ( 6 , 7 ).…”

Retrograde Carotid Stenting Using Newly Released Venous Stent for Cerebral Malperfusion in Type A Aortic Dissection

“…Early mortality after open surgery has been reported in 4.1% to 50% of patients. [3][4][5][6][7][8][9][10][11][12][13] The IRAD study demonstrated higher mortality with dissection involving the branches of the aorta.…”