Malperfusion of the Thoracoabdominal Vasculature in Aortic Dissection

Abstract

Ischemic damage to vital organs supplied by the thoracoabdominal aorta greatly increases the overall risk of aortic dissection. Of 320 patients operated upon for aortic dissection since 1985, 33 (10.3%) underwent operations directed at the relief of malperfusion (15/158 acute type A; 9/18 acute type B; 4/78 chronic type A; 5/66 chronic type B). Organs affected were the kidneys in 32; the bowel in 20; and the spinal cord in 1, while critical lower extremity ischemia was present in 11 patients. In total, 64 vascular areas were affected. Fenestration of the dissecting membrane with or without infrarenal grafting was the procedure performed most frequently in 25, followed by replacement of the descending or thoracoabdominal aorta in 6, and bypass grafting or direct revascularization of individual side branches in 6. Six other operations targeted at the affected organs were done. Twenty-four patients underwent one-stage operation for malperfusion; in 11, early reoperation after primary aortic repair was necessary, while 2 patients were operated electively. Ten of 33 patients died in hospital, 7 of malperfusion-induced complications. Of three late deaths, one was related to sequelae of malperfusion. We conclude that immediate diagnosis and prompt relief of malperfusion offer the best prospects for patient survival. Membrane fenestration appears to be the method of choice for treating malperfusion in most patients, and must be directed to the level of aortic and/or side branch obstruction.

Endovascular Management of Thoracic Dissections

“…44 Primary surgical aortic repair results in successful revascularization in the vast majority of patients with type B dissection; however, the presence of renal or mesenteric ischemia has been correlated with especially high surgical mortality rates of 70% and 87%, respectively. 24,43,45,46 For this reason, alternative surgical procedures have been explored to address organ ischemia specifically. In particular, surgical aortic fenestration has been shown to relieve malperfusion syndrome in 93% to 100% of cases, with an in-hospital mortality rate of 0% to 43%.…”

Organ malperfusion in acute aortic dissection

“…, In the literature, the mortality in aortic dissection with malperfusion has been reported to be about 30%. 2,[9][10][11] In the present series, the operative mortality in the malperfusion group was 31.3%. That in the nomalperfusion group was ILl %, which was significantly lower than that in the malperfusion group and superior to that in other reports.P The brain was affected in 3-7% of aortic dissection patients, the spinal cord in 1-3%, the intestine in 1-6%, the kidney in 3-10%, and the lower extremities in 3-24%, in the literature.…”

Endoluminal treatment of aortic dissection

“…Ischaemia involving the spinal, coeliac, mesenteric, and renal or lower extremity vessels occurs in approximately 10-30% of the patients with aortic dissection [15,16,17]. In 1988, Shimshak et al first reported relief of claudication following balloon angioplasty of the true lumen of the abdominal aorta [32].…”

“…Patients with organ ischaemia are often poor candidates for anaesthesia and surgery. Surgical procedures may be technically difficult and operative mortality reported in literature ranges between 25 and 51%, mortality being higher in patients with critical mesenteric or renal ischaemia [1,15,16,17]; thus, percutaneous measures for relief of such ischaemia can significantly improve the prognosis in these patients. Over the past decade, successful relief of such ischaemia using less invasive interventional radiological techniques has been reported with procedure related mortality ranging between 0 and 25% [5,6,7,8,9,10,19,20].…”

“…Post-operative persistence of ischaemia in the type-A dissections, or the presence of such ischaemia in the type-B dissections may necessitate further measures downstream in 10-30% of the patients. Until a few years ago, such thoraco-abdominal malperfusion was treated by surgery or re-surgery [1,15,16,17,18]. Surgical therapy was aimed at creating a re-entry in the form of fenestration of the intimal flap or establishing bypasses to the ischaemic vessels [1].…”