Provisional extension to induce complete attachment of an endovascular repair for acute type A aortic dissection with visceral malperfusion

Abstract

Video clip is available online.Patients with type A aortic dissection (AAD) and mesenteric malperfusion have greater in-hospital mortality risk than patients with AAD without mesenteric malperfusion (63% vs 24%). 1 Using the PETTICOAT (provisional extension to induce complete attachment) technique as a first-line strategy before proximal repair, we resolved our patient's visceral malperfusion. CASE REPORTA 39-year-old man with Marfan syndrome, hypertension, and a history of substance abuse transferred to our facility with rapid-onset, sharp parasternal and abdominal pain, and copious melena. His systolic blood pressure was 170-180 mm Hg; anti-impulse therapy began. Initial laboratory results included elevated serum lactate (8.3 mmol/L) and creatinine levels (1.71 mg/dL). Computed tomography revealed a DeBakey type I aortic dissection extending from the aortic root between the left main and right coronary artery ostia to beyond the common iliac artery bifurcation (Figure 1). Dynamic malperfusion of the celiac, superior mesenteric, and From the Divisions of

Commentary: Early malperfusion syndrome—a new concept

“…necrosis and failure, such as bloody stools, peritoneal signs, severe metabolic acidosis and shock, and multiorgan failure, as in the case described by Preventza and colleagues 1 In those patients, we frequently find dead bowel at laparotomy. We can define this stage as late MPS.…”

“…4,5 For patients with late visceral MPS from either dynamic or static malperfusion, we strongly recommend first resolving the malperfusion endovascularly with fenestration/stenting 4,5 or TEVAR with aortic stent graft and, as indicated, branch artery stents, 1,3 then performing delayed open aortic repair after the patients recover from multiorgan failure, acidosis, and acute respiratory distress syndrome and can tolerate cardiopulmonary bypass and hypothermic circulatory arrest. 1,[3][4][5] The management of early visceral MPS can be guided based on the mechanism of malperfusion: dynamic versus static, keeping in mind that in many cases it is mixed dynamic and static. Dynamic malperfusion is caused by the aortic dissection flap covering and occluding the orifice of the aortic branch vessels, such as the SMA.…”

Commentary: A complex problem seeking the ideal solution

“…This option has the added value of promoting TL expansion and malperfusion relief; it has been shown to improve TL reexpansion of the distal aorta and improve end-organ perfusion. 3 In the current issue of the Journal, Preventza and colleagues 4 present a creative solution for acute type A aortic dissection (TAAD) complicated with visceral malperfusion. Classic teaching dictates that patients with acute TAAD, even those suffering from visceral malperfusion, require initial open repair of the proximal aorta, assuming that stabilizing the TL through the aortic repair resolves organ malperfusion.…”

Commentary: Not every untreated acute type A dissection will rupture, but every untreated malperfusion will result in death

“…Surgeons have started adopting the strategy of treating the malperfusion first followed by delayed open repair with excellent outcomes, 2,3 including a case report published in the September 2020 issue of JTCVS Techniques. 4 The indication for endovascular treatment should be MPS, not just malperfusion. The difference between malperfusion and MPS is similar to the difference between bacteremia and sepsis, or HIV and AIDS.…”

“…2,3 This technique can reliably treat only dynamic malperfusion, such as in this case report. 4 It is not uncommon to see the distal aorta collapse after stent grafts are placed in the true lumen of the descending thoracic aorta, probably secondary to limited re-entry tears in the distal false lumen. This Like many successful stories of innovation, persistence and collaboration win in the end.…”