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Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: A 20-year experience.

ABSTRACT: OBJECTIVE:To assess outcomes of endovascular reperfusion followed by delayed open aortic repair for stable patients with acute type A aortic dissection and mesenteric malperfusion syndrome (mesMPS). METHODS:Among 602 patients with acute type A aortic dissection who presented to our center from 1996 to 2017, all 82 (14%) with mesMPS underwent upfront endovascular fenestration/stenting. Primary outcomes were in-hospital mortality and long-term survival. Patients with acute type A aortic dissection with no malperfusion syndrome of any organ (n = 419) served as controls. RESULTS:In-hospital mortality of all comers with mesMPS was 39%. After endovascular fenestration/stenting, 20 mesMPS patients (24%) died from organ failure and 11 patients (13%) died from aortic rupture before open aortic repair, 47 patients (58%) underwent aortic repair, and 4 patients (5%) survived without open repair. No patients died from aortic rupture during the second decade (2008-2017). The significant risk factors for death from organ failure after endovascular reperfusion were acute stroke (odds ratio, 23; 95% confidence interval, 4-144; P = .0008), gross bowel necrosis at laparotomy (odds ratio, 7; 95% confidence interval, 1.4-34; P = .016), and serum lactate ≥6 mmol/L (odds ratio, 13.5; 95% confidence interval, 2-97; P = .0097). There was no significant difference in operative mortality (2.1% vs 7.5%; P = .50) or long-term survival between patients with mesMPS who underwent open aortic repair after recovering from mesMPS and patients with no malperfusion syndrome. CONCLUSIONS:In patients with acute type A aortic dissection with mesMPS, endovascular fenestration/stenting, and delayed open aortic repair achieved favorable short- and long-term outcomes. Surgeons should consider correcting mesenteric malperfusion before undertaking open aortic repair in patients with mesMPS, especially those with acute stroke, gross bowel necrosis at laparotomy, or serum lactate ≥6 mmol/L.

SUBMITTER: Yang B

PROVIDER: S-EPMC6570582 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectiveThe study objective was to evaluate the progression of dissected distal aorta in patients with acute type A aortic dissection with malperfusion syndrome treated with endovascular fenestration/stenting and delayed open aortic repair.MethodsFrom 1996 to 2021, 927 patients presented with acute type A aortic dissection. Of these, 534 had DeBakey I dissection with no malperfusion syndrome and underwent emergency open aortic repair (no malperfusion syndrome group), whereas 97 patients with malperfusion syndrome underwent fenestration/stenting and delayed open aortic repair (malperfusion syndrome group). Sixty-three patients with malperfusion syndrome treated with fenestration/stenting were excluded due to no open aortic repair, including death from organ failure (n = 31), death from aortic rupture (n = 16), and discharged alive (n = 16).ResultsCompared with the no malperfusion syndrome group, the malperfusion syndrome group had more patients with acute renal failure (60% vs 4.3%, P < .001). Both groups had similar aortic root and arch procedures. Postoperatively, the malperfusion syndrome group had similar operative mortality (5.2% vs 7.9%, P = .35) and permanent dialysis (4.7% vs 2.9%, P = .50), but more new-onset dialysis (22% vs 7.7%, P < .001) and prolonged ventilation (72% vs 49%, P < .001). The growth rate of the aortic arch (0.38 vs 0.35 mm/year, P = .81) was similar between the malperfusion syndrome and no malperfusion syndrome groups. The descending thoracic aorta growth rate (1.03 vs 0.68 mm/year, P = .001) and abdominal aorta growth rate (0.76 vs 0.59 mm/year, P = .02) were significantly higher in the malperfusion syndrome group. The cumulative incidence of reoperation over 10 years (18% vs 18%, P = .81) and 15-year survival outcome (50% vs 48%, P = .43) were similar between the malperfusion syndrome and no malperfusion syndrome groups.ConclusionsEndovascular fenestration/stenting followed by delayed open aortic repair was a valid approach for patients with malperfusion syndrome.

Project description:ObjectiveThe study objective was to evaluate the management of malperfusion in acute type B aortic dissection with endovascular fenestration/stenting.MethodsFrom 1996 to 2018, 182 patients with an acute type B aortic dissection underwent fenestration/stenting for suspected malperfusion based on imaging, clinical manifestations, and laboratory findings. Data were obtained from medical record review and the National Death Index database.ResultsThe median age of patients was 55 years. Signs of malperfusion included abdominal pain (61%), lower-extremity weakness (27%), nonpalpable lower-extremity pulses (24%), and abnormal lactate, creatinine, liver enzymes, and creatine kinase levels. Confirmed hemodynamically significant malperfusion affected the spinal cord (2.7%), celiac (24%), superior mesenteric (40%), renal (51%), and iliofemoral (43%) arterial distributions. Of the 182 patients, 99 (54%) underwent aortic fenestration/stenting, 108 (59%) had 1 or multi-branch vessel fenestration/stenting, 5 (2.7%) had concomitant thoracic endovascular aortic repair, 17 (9.3%) had additional thrombolysis or thromboembolectomy, and 48 (26%) received no intervention. After fenestration/stenting, 24 patients (13%) required additional procedures for necrotic bowel or limb and 9 patients (4.9%) had subsequent aortic repair (thoracic endovascular aortic repair, open repair) before discharge. The new-onset paraplegia was 0%. The in-hospital mortality was 7.7% over 20+ years and 0% in the last 8 years. The 5- and 10-year survivals were 72% and 49%, respectively. The significant risk factors for late mortality were age and acute paralysis (hazard ratio, 3.5; both P < .0001). Given death as a competing factor, the 5- and 10-year cumulative incidence of reintervention was 21% and 31% for distal aortic pathology, respectively.ConclusionsPatients with acute type B aortic dissection with malperfusion can be managed with endovascular fenestration/stenting with excellent short- and long-term outcomes. This approach is particularly helpful to patients with static malperfusion of aortic branch vessels.

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Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: A 20-year experience.

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