Visceral Malperfusion in Aortic Dissection: The Michigan Experience.

One of the most dreaded complications of acute aortic dissection is end-organ malperfusion. We summarize current evidence and describe our treatment paradigm in the setting of malperfusion in aortic dissection. Given the difficulty with identifying isolated visceral malperfusion in aortic dissection, both in the literature as well as in our practice, we have broadened the discussion to include data examining the presentation complex of malperfusion, particularly if mesenteric ischemia is identified. The approach to treating malperfusion syndrome is different depending on whether the patient presents with type A dissection vs type B dissection with malperfusion. Although thoracic endovascular aortic repair has emerged as the dominant strategy for resolving malperfusion for complicated type B dissection, fenestration may still have a role in its treatment. In contrast, for type A aortic dissection presenting with visceral malperfusion, the concept of operative repair after restoration of end-organ perfusion has been proposed with increasing frequency in recent reports. At the University of Michigan, we apply a patient-specific algorithm, based on the presence of malperfusion with end-organ dysfunction. In those patients presenting with visceral malperfusion, we prefer to first fenestrate, await resolution of the malperfusion syndrome and then perform central aortic repair. We recognize that other groups have implemented similar algorithms to reduce the dismal results of operative procedures in this cohort. However, the most appropriate period of delay remains unknown and there is a persistent risk of rupture before repair is performed. Future studies should be performed to determine whether these various treatment paradigms have merit.