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. 2019 Sep;158(3):675-687.e4.
doi: 10.1016/j.jtcvs.2018.11.127. Epub 2018 Dec 14.

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

Bo Yang  1 , Elizabeth L Norton  2 , Carlo Maria Rosati  3 , Xiaoting Wu  3 , Karen M Kim  3 , Minhaj S Khaja  4 , G Michael Deeb  3 , David M Williams  4 , Himanshu J Patel  3
Affiliations

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

Bo Yang et al. J Thorac Cardiovasc Surg. 2019 Sep.

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.

Keywords: acute type A aortic dissection; aortic surgery; endovascular fenestration/stenting; malperfusion syndrome; mesenteric malperfusion.

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Conflict of interest statement

Conflict of interest: Dr. David Williams is on the Medical Advisory Board of Boston Scientific and Drs. David Williams and Himanshu Patel are consultants with Gore on an unrelated device. No conflict of interests related to this study.

Figures

Figure 1.
Figure 1.
Management and short-term outcomes of patients with mesenteric malperfusion syndrome. IR = endovascular reperfusion by interventional radiology; MesMPS = mesenteric malperfusion syndrome.
Figure 2.
Figure 2.
Short-term outcomes of patients with mesenteric malperfusion syndrome (MesMPS) after endovascular reperfusion by interventional radiology (IR). IR = endovascular reperfusion by interventional radiology; MesMPS = mesenteric malperfusion syndrome.
Figure 3.
Figure 3.
Overall long-term survival of patients with mesenteric malperfusion syndrome vs. those with no (mesenteric or non-mesenteric) malperfusion syndrome (non-MPS): A. Survival since hospital admission, all MesMPS patients (n=82) vs. non-MPS patients; B. Survival since open aortic repair, surgical MPS patients (n=47) who underwent open aortic repair vs. non-MPS patients. MPS = malperfusion syndrome; Non-MPS = no malperfusion syndrome.
None
Short-term outcomes of patients with MesMPS after percutaneous endovascular reperfusion.
See this image and copyright information in PMC

Comment in

References

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