The "thoracic endovascular aortic repair-first" strategy for acute type A dissection with mesenteric malperfusion: Initial results compared with conventional algorithms.

Abstract

Acute type A dissection with mesenteric malperfusion is a rare but lethal variant of aortic dissection. This study examines outcomes from various treatment algorithms. 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). 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. 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.