Management of visceral malperfusion complicated with acute type A aortic dissection

Yamashiro, Satoshi; Arakaki, Ryoko; Kise, Yuya; Ichikawa, Hitoshi; Kuniyoshi, Yukio

doi:10.1093/icvts/ivv159

Cited by 47 publications

(29 citation statements)

References 10 publications

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“…In the setting of visceral malperfusion, the correct management and timing of aortic repair is still a subject of debate. While there is general agreement that early reperfusion is critical for mesenteric malperfusion, it is not clear whether initial central aortic repair or percutaneous and/or extra-anatomic reperfusion best accomplishes that end (3,30,31). Some groups, given the unpredictable nature of TAAD and its potential for rupture, suggest immediate central aortic repair followed by investigation and treatment of residual malperfusion (3,32).…”

Section: Mesenteric Malperfusionmentioning

confidence: 99%

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

et al. 2018

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Patients presenting with type A acute aortic dissection (TAAD) complicated by malperfusion syndromes represent one of the highest surgical risk cohorts for cardiovascular surgeons. In the setting of aortic dissection, end-organ ischemia may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral and/or limb ischemia. In TAAD patients with malperfusion, notwithstanding continuous improvement in diagnostic and management strategies, surgical and clinical outcomes remain poor and the optimal therapy is controversial. The present review aimed to assess current evidence on TAAD patients with the complication of malperfusion, as enunciated by the International Registry of Acute Aortic Dissection (IRAD) investigators.

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Section: Mesenteric Malperfusionmentioning

confidence: 99%

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

et al. 2018

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“…This delayed treatment strategy involved early endovascular treatment with a complete or partial resolution of organ ischemia, followed by timely aortic surgeries. [16,17] While this management approach may be beneficial in a specific subpopulation, [18,19] Given the high mortality of patients with mesenteric malperfusion (40-100%), initial management with an interventional procedure treating the condition should be considered. [20,21] In fact, previous data suggested that mesenteric malperfusion was associated with the highest mortality rates when compared to malperfusions occurring in any other organ systems.…”

Section: [9]mentioning

confidence: 99%

The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival

Nardi¹,

Olevano²,

Bassano³

et al. 2017

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How to cite this article: Nardi P, Olevano C, Bassano C, Bovio E, Cecchetti L, Forlani S, Ruvolo G. The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival. Vessel Plus 2017;1:77-83. Aim:To evaluate whether postoperative malperfusion (PM) affected in-hospital and longterm survival in acute type A aortic dissection (AAAD) surgical patients and to identify risk factors for PM. Methods: Patients who underwent AAAD surgery at a single institution between January 2005 and March 2015 were retrospectively analyzed. Results: Twohundred fourteen patients with complete data were identified. At presentation, 119 patients (55.6%) showed preoperative malperfusions: 68 (31.8%) were cerebral, 38 (17.7%) were renal, and 13 (6.1%) were mesenteric. PM was found in 55 patients (25.7%). In-hospital mortality was 47.3% (26/55) vs. 22.6% (36/159) in PM and non-PM patients, respectively (P < 0.0001). Independent predictors for in-hospital mortality included being 75 years or older [odds ratio (OR): 1.1, 95% confidence interval (CI): 1.03-1.13, P < 0.001] and having renal PM (OR: 53.5, 95% CI: 3.97-721.3, P < 0.01). Five-year survival was 78.6 ± 7.8% vs. 93.9 ± 3.4% in PM and non-PM patients, respectively (P < 0.001). Independent predictors for long-term survival were being at least 75 years old (OR: 3.7, 95% CI: 0.9-14.0, P = 0.05) and having renal PM (OR: 28.6, 95% CI: 1.8-462.0, P = 0.01). PM and intimal tears distal to the ascending aorta or the proximal aortic arch were also risk factors. Conclusion: PM, especially with renal involvement, is associated with in-hospital mortality and reduced long-term survival. AAAD surgeries reduced preoperative malperfusions. Sites of cannulation and interventions requiring circulatory arrest during cardiopulmonary bypass were not predictors of PM. Key words:Acute type aortic dissection, aortic surgery, malperfusion, survival ABSTRACTArticle history:

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“…However, few studies have examined CPB improvement strategies aimed at visceral and lower-body perfusion. We and others propose that maintaining the continuity of lower-body blood flow may be important for avoiding visceral organ dysfunction and post-operative mortality [42,43].…”

Section: Discussionmentioning

confidence: 99%

Retrograde inferior vena caval perfusion for total aortic arch replacement surgery (RIVP-TARS): study protocol for a multicenter, randomized, controlled trial

Lin

Tan

Hao

et al. 2019

Preprint

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Background: During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, organs in the lower body such as the viscera and spinal cord are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood. Methods: This study is designed as a multicenter, computer-generated randomized, controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS.A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, who will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, who will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction and gastrointestinal complications. All patients will be analyzed according to the intention- to-treat protocol. Discussion: This study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS. Trial registration. Clinicaltrials.gov, NCT03607786. Registered on 30 July 2018.

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Management of visceral malperfusion complicated with acute type A aortic dissection

Cited by 47 publications

References 10 publications

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

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

The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival

Retrograde inferior vena caval perfusion for total aortic arch replacement surgery (RIVP-TARS): study protocol for a multicenter, randomized, controlled trial

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