Outcomes of emergency surgery for acute type A aortic dissection complicated by malperfusion syndrome

Successful management of iliofemoral and visceral malperfusion syndrome in acute type A aortic dissection with endovascular revascularization followed by delayed proximal aortic repair

“…Despite advances in imaging and endovascular techniques, there is still consequential in-hospital mortality ranging from 11% to 21.5% for ATAAD with MPS related to its dynamic pathology. 2,6 Our cases illustrate that survival can be optimized by addressing MPS first taking into consideration the patient must be stable, and the risk of aortic rupture must be lower than the risk of death due to malperfusion followed by watchful waiting and then delayed proximal repair.…”

“…There are three approaches to treat ATAAD patients with MPS. [2][3][4][5][6] First is emergency open proximal aortic repair, which will restore true lumen and branch vessel perfusion through intimal flap excision. The Pittsburgh group demonstrated patients with ATAAD with MPS who undergo emergency proximal aortic repair require more total arch replacements.…”

“…There are three approaches to treat ATAAD patients with MPS 2‐6 . First is emergency open proximal aortic repair, which will restore true lumen and branch vessel perfusion through intimal flap excision.…”

Author Reply to Commentary: The Scylla and Charybdis of acute type A aortic dissection: Malperfusion and rupture

“…We read with great interest and appreciation the commentary by Dr Jean Bachet about our manuscript describing outcomes of immediate operative repair of acute type A aortic dissection (ATAAD) complicated by malperfusion syndrome (MPS). 1 At our institution, we employ a (central) surgery-first approach for all-comers with ATAAD, whether complicated by MPS or not. We do not initially stabilize patients with MPS with endovascular reperfusion of the requisite malperfused vascular bed (via fenestration or stenting), followed by definitive operative repair after metabolic perturbations have been reversed, as some institutions have advocated.…”

“…2 Conversely, this study found that in-hospital mortality was 22% for patients with MPS, which is lower than the reported 33% for the delayed operative approach. 1 By implication, the risk of aggravating systemic metabolic abnormalities under hypothermic circulatory arrest, leading to multisystem organ failure and death, may be overstated when compared with the risk of allowing aortic rupture to occur. While further prospective comparative research is needed, we agree with Dr Bachet that, "even if MPS may be an independent predictor of short-term mortality and reduced mid-term survival for patients with ATAAD, the present study highlights the importance of rapidly restoring true lumen perfusion by addressing first the aortic lesions without operative delay."…”