Hybrid repair of acute type A aortic dissection with visceral malperfusion syndrome.
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ABSTRACT:
SUBMITTER: Ni B
PROVIDER: S-EPMC8311454 | biostudies-literature | 2021 Jun
REPOSITORIES: biostudies-literature
Publications
Hybrid repair of acute type A aortic dissection with visceral malperfusion syndrome.
Ni Buqing B Gu Jiaxi J Li Minghui M Shao Yongfeng Y
JTCVS techniques 20201126
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Project description: Not available
| S-EPMC8303074 | biostudies-literature
Project description:A 69-year-old woman with a history of graft replacement for abdominal aortic aneurysm developed a complicated type B aortic dissection that resulted in renal malperfusion after thoracic endovascular aortic repair (TEVAR). The primary entry tear was formed at the aortic arch and the false lumen (FL) continued to the abdominal aorta. The distal end of the FL formed a pouch-like blind alley above the suture line of the bifurcated abdominal graft. The true lumen (TL) was compressed and caused severe limb ischemia. The right renal artery (rRA) originated from the FL. The patient had initially undergone emergent axillofemoral bypass for limb malperfusion. Three weeks later, restenosis of the TL caused visceral malperfusion, and a huge thrombus formed in the FL pouch. TEVAR expanded the TL and restored visceral vascularization. However, the expanded TL compressed the thrombus in the blind alley to the rRA orifice and caused right renal malperfusion. The history of abdominal graft replacement may have increased the risk of a thrombotic event after TEVAR. Primary TEVAR may have helped prevent thrombus formation in the FL pouch. <Learning objective: This case report describes visceral arterial embolism induced by endovascular aortic repair (TEVAR) for type B aortic dissection in a patient with prior abdominal aortic grafting. A huge thrombus formed in the blind pouch of the false lumen (FL) above the graft suture line. TEVAR expanded the true lumen and the FL thrombus occluded a visceral artery with FL origin. Post-graft replacement has a risk of thrombus formation in the FL pouch and thrombus compression in visceral arteries.>.
| S-EPMC6149603 | biostudies-literature
Project description:ObjectiveTo assess the outcomes of emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair in patients with acute type A aortic dissection with lower extremity (LE) malperfusion syndrome (MPS); that is, necrosis and dysfunction of the lower extremity.MethodsFrom 1996 to 2019, among 760 consecutive acute type A aortic dissection patients 512 patients had no malperfusion syndrome (Non-MPS), whereas 26 patients had LE-MPS with/without renal MPS and underwent endovascular fenestration/stenting, open aortic repair, or both. Patients with coronary, cerebral, mesenteric, and celiac MPS, or managed with thoracic endovascular aortic repair, were excluded (n = 222). All patients with LE-MPS underwent upfront endovascular fenestration/stenting except 1 patient (with signs of rupture) who initially underwent emergency open aortic repair.ResultsAmong the LE-MPS patients, 17 (65%) had LE pain, 15 (58%) had abnormal motor function with 8 (31%) having paralysis, 10 (38%) had LE pallor, 17 (65%) had LE paresthesia, and 20 (77%) had LE pulselessness. Of the 25 patients undergoing upfront endovascular fenestration/stenting, 16 went on to open aortic repair, 3 survived to discharge without aortic repair, and 6 died before aortic repair (3-aortic rupture and 3-organ failure). In-hospital mortality among all patients was significantly higher in the LE-MPS group (31% vs 6.3%; P = .0003). Among those undergoing open aortic repair, postoperative outcomes were similar between groups, including operative mortality (18% vs 6.5%; P = .10). LE-MPS was a significant risk factor for in-hospital mortality (odds ratio, 6.0 [1.9, 19]; P = .002).ConclusionsIn acute type A aortic dissection, LE-MPS was associated with high in-hospital mortality. Emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair may be a reasonable approach.
| S-EPMC9667713 | biostudies-literature
Project description:BackgroundImmediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients.MethodsFrom 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an "upfront OR for every patient" approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models).ResultsOverall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P<0.001). In the second decade, for patients with MPS initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% ( P=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5-29; P=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P≤0.03).ConclusionsImmediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.
| S-EPMC6339462 | biostudies-literature
Project description: Not available
| S-EPMC11329172 | biostudies-literature
Project description:BackgroundPatients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes.MethodsFrom 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS.ResultsCompared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%), and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality.ConclusionsBecause of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.
| S-EPMC7736272 | biostudies-literature
Project description: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.
| S-EPMC6570582 | biostudies-literature
Project description:ObjectiveThe study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion.MethodsFrom January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143).ResultsThe median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30).ConclusionsHemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.
| S-EPMC7935741 | biostudies-literature
Project description:Type B aortic dissection (TBAD) in the presence of an existing aortic endograft is a rare, but potentially catastrophic, event. False lumen pressurization and propagation leads to several failure modes. Endograft collapse can lead to spinal cord, visceral, or lower extremity ischemia, and rupture of a previously sealed aneurysm sac is often fatal. A successful treatment strategy must incorporate the patient's symptoms, urgency of intervention, extent of dissection, and the location and status of the existing graft. In this series, we present three cases of TBAD complicating prior endovascular aortic repairs-infrarenal, iliac branched, and thoracoabdominal branched endografts-successfully treated with tailored, hybrid interventions.
| S-EPMC10238611 | biostudies-literature
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.
| S-EPMC10328804 | biostudies-literature