Early reperfusion strategy improves the outcomes of surgery for type A acute aortic dissection with malperfusion

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 156; no. 2; pp. 483 - 489
• Main Authors: Uchida, Keiji, Karube, Norihisa, Kasama, Keiichiro, Minami, Tomokazu, Yasuda, Shota, Goda, Motohiko, Suzuki, Shinichi, Imoto, Kiyotaka, Masuda, Munetaka
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.08.2018
• Subjects: acute aortic dissection; Aged; Aneurysm, Dissecting - surgery; Aortic Aneurysm - surgery; Brain - blood supply; Coronary Vessels - surgery; early reperfusion; Female; Humans; Ischemia - surgery; Lower Extremity - blood supply; Male; malperfusion; Middle Aged; Reperfusion - methods; Time Factors; Viscera - blood supply; malperfusion; AR; CT; MP; acute aortic dissection; early reperfusion; ER
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2018.02.007

The control of malperfusion is the key to improving the outcomes of surgery for type A acute aortic dissection. We revised our treatment strategy to reperfuse each ischemic organ before central repair. Our current early reperfusion strategy consists of percutaneous coronary artery intervention for coronary malperfusion, direct surgical fenestration for carotid artery occlusion, active perfusion of the superior mesenteric artery for visceral malperfusion, and external shunting from the brachial artery to the femoral artery for lower limb ischemia. Central repair is performed without delay after reperfusion therapy, but if irreversible organ damage is recognized, further aggressive treatment is discontinued. Among 438 patients who underwent initial treatment for type A acute aortic dissection, malperfusion in one or more organs was diagnosed in 108 patients (24%). We applied an early reperfusion strategy in 33 patients, (coronary, 14 patients; carotid, 4; visceral, 7; lower extremity, 8). Central repair was then performed in 28 patients. One patient (3.6%) died of pneumonia; 27 patients overcame the ischemic organ damage and survived. Among the 108 patients with malperfusion, 10 patients (9.3%) were treated medically without early reperfusion and central repair. During the same period, mortality from central repair procedures in patients with malperfusion who had not received early reperfusion therapy was 12 of 65 (18%), and the mortality of patients without malperfusion was 9 of 262 (3.4%). Malperfusion was a serious risk factor for hospital death, but the mortality rate of the patients with an early reperfusion strategy was significantly (P < .01) lower than the patients without early reperfusion. Our strategy might improve the outcomes of surgery for type A acute aortic dissection with malperfusion. This strategy enables us to avoid unproductive central repair procedures in irreversibly damaged patients.