Optimal management of acute type A aortic dissection with mesenteric malperfusion: Table 1:

Abstract

Acute type A aortic dissection (TAAD) remains a morbid condition; although overall outcomes have improved, patients presenting with preoperative malperfusion syndromes continue to have excessive mortality following conventional open surgical repair. Mesenteric malperfusion is generally associated with the worst prognosis and postoperative mortality in this group. With advances in the endovascular treatment of aortic pathology, options now exist to percutaneously manage mesenteric malperfusion prior to central aortic repair. This strategy may be associated with improved outcomes. To review this, a best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with acute type A aortic dissections with mesenteric malperfusion, does management of the malperfusion prior to central aortic repair reduce perioperative mortality'. Overall, more than 309 papers were found as a result of the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that, in patients with acute TAAD complicated by mesenteric malperfusion, initial management with percutaneous interventional procedures to reverse the malperfusion followed by delayed central aortic repair is a reasonable strategy; this is because of the extremely poor prognosis associated with immediate central aortic repair in this group.

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

“…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.…”

Differential outcomes of type A dissection with malperfusion according to affected organ system

“…Patients with malperfusion had longer hospital lengths of stay {20 vs. 12 [8][9][10][11][12][13][14][15][16][17][18] days, P=0.006}, as well as more reoperations for postoperative hemorrhage (24.0% vs. 5.6%, P=0.01) and a greater number of postoperative CNS events (44.0% vs. 18.3%, P=0.01).…”

“…The presence of mesenteric malperfusion has been identified as a predictor of a poor prognosis in several studies (9)(10)(11)(12). In one of the largest series, Di Eusanio et al reviewed the International Registry of Acute Aortic Dissection, a database compiled from 18 contributing centers and comprised of 1,809 consecutive patients presenting with an acute, type A dissection, to better understand the influence of mesenteric malperfusion on outcomes.…”

Total aortic repair: the new paradigm in the treatment of acute type A aortic dissection

“…Advanced imaging including 4-D magnetic resonance imaging (MRI) scanning (20) has allowed a deeper appreciation of the pathogenesis of long-term complications and morbidity associated with a persistent FL. In particular, malperfusion, hitherto a marker of high mortality, is now a modifiable risk factor and one that can be predicted and treated with a demonstrable improvement in overall outcomes (21). Many of the aortic-centric institutions around the globe, including our own groups, are beginning to advocate a more proactive initial surgical strategy.…”

“…In the acute phase this can induce distal organ malperfusion due to static or dynamic obstruction of aortic branch vessels (23,24). Importantly, the manifestation of ischemia in some territories such as the bowel can be quite subtle, right until they advance to the irreversible stage (21). In the chronic phase, FL patency is associated with an increased growth rate of the distal aorta and a higher incidence of reoperation or of adverse aortic events (25)(26)(27)(28).…”