Bradley G Leshnower1, W Brent Keeling2, Yazan M Duwayri3, William D Jordan3, Edward P Chen2. 1. Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga. Electronic address: bleshno@emory.edu. 2. Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga. 3. Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
Abstract
OBJECTIVE: Acute type A dissection with mesenteric malperfusion is a rare but lethal variant of aortic dissection. This study examines outcomes from various treatment algorithms. METHODS: A review from 2003 to 2017 of the Emory Aortic Database identified 34 patients who presented with acute type A dissection with mesenteric malperfusion. Outcomes from 4 different treatment strategies were analyzed: ascending aortic/arch replacement followed by laparotomy (n = 13), axillary-bifemoral artery bypass followed by ascending/arch replacement (n = 3); ascending/arch and concomitant antegrade thoracic endovascular aortic repair (TEVAR) (n = 5), and TEVAR followed by delayed ascending/arch replacement (TEVAR-1st) (n = 13). RESULTS: The mean age of all patients was 53 ± 13 years and was equivalent among the groups. The incidence of concomitant renal and ileofemoral malperfusion was 52% and 41%, and the initial serum lactate level was 4.3 ± 2.1 mmol/L. Overall mortality was 55.8%. In the ascending aortic/arch replacement followed by laparotomy group, 77% of patients had postoperative bowel necrosis or intractable acidosis and the mortality was 69.2%. All patients in the axillary-bifemoral artery bypass followed by ascending/arch replacement group survived, but 66% required postoperative dialysis. In the ascending/arch and concomitant antegrade/TEVAR group, the mortality was 80% secondary to persistent postoperative bowel necrosis or intractable acidosis. Three patients in the TEVAR-1st group died before aortic replacement. In the 10 patients who underwent TEVAR followed by delayed aortic replacement, the mortality was 30%. There were no cases of postoperative bowel necrosis or intractable acidosis in the TEVAR-1st group. CONCLUSIONS: The TEVAR-1st strategy delays central aortic replacement until end-organ ischemia has resolved. This novel paradigm serves as a bridge to decision, and may improve survival compared with conventional treatment strategies in acute type A dissection with mesenteric malperfusion.
OBJECTIVE: Acute type A dissection with mesenteric malperfusion is a rare but lethal variant of aortic dissection. This study examines outcomes from various treatment algorithms. METHODS: A review from 2003 to 2017 of the Emory Aortic Database identified 34 patients who presented with acute type A dissection with mesenteric malperfusion. Outcomes from 4 different treatment strategies were analyzed: ascending aortic/arch replacement followed by laparotomy (n = 13), axillary-bifemoral artery bypass followed by ascending/arch replacement (n = 3); ascending/arch and concomitant antegrade thoracic endovascular aortic repair (TEVAR) (n = 5), and TEVAR followed by delayed ascending/arch replacement (TEVAR-1st) (n = 13). RESULTS: The mean age of all patients was 53 ± 13 years and was equivalent among the groups. The incidence of concomitant renal and ileofemoral malperfusion was 52% and 41%, and the initial serum lactate level was 4.3 ± 2.1 mmol/L. Overall mortality was 55.8%. In the ascending aortic/arch replacement followed by laparotomy group, 77% of patients had postoperative bowel necrosis or intractable acidosis and the mortality was 69.2%. All patients in the axillary-bifemoral artery bypass followed by ascending/arch replacement group survived, but 66% required postoperative dialysis. In the ascending/arch and concomitant antegrade/TEVAR group, the mortality was 80% secondary to persistent postoperative bowel necrosis or intractable acidosis. Three patients in the TEVAR-1st group died before aortic replacement. In the 10 patients who underwent TEVAR followed by delayed aortic replacement, the mortality was 30%. There were no cases of postoperative bowel necrosis or intractable acidosis in the TEVAR-1st group. CONCLUSIONS: The TEVAR-1st strategy delays central aortic replacement until end-organ ischemia has resolved. This novel paradigm serves as a bridge to decision, and may improve survival compared with conventional treatment strategies in acute type A dissection with mesenteric malperfusion.
Authors: Michael Tien; Andrew Ku; Natalia Martinez-Acero; Jessica Zvara; Eric C Sun; Albert T Cheung Journal: J Cardiothorac Vasc Anesth Date: 2019-08-28 Impact factor: 2.628
Authors: Paolo Nardi; Carlo Bassano; Calogera Pisano; Claudia Altieri; Maria Sabrina Ferrante; Monica Greci; Dario Buioni; Fabio Bertoldo; Andrea Farinaccio; Giovanni Ruvolo Journal: Kardiochir Torakochirurgia Pol Date: 2021-05-15