Management strategies for type A dissection complicated by peripheral vascular malperfusion

BACKGROUND: End-organ malperfusion is a dreaded complication of type A aortic dissections. Different strategies have been proposed to manage this complex cohort of patients. Ideal management includes the rapid restoration of organ perfusion while avoiding catastrophic rupture and tamponade. We present our experience with primary aortic repair as the optimal method of patient management. METHODS: From July 1997 until April 2003, 101 patients underwent dissection repair and were assessed for malperfusion of the central nervous system, renal, visceral or extremity circulation. Patients with coronary artery malperfusion were analyzed separately. Aortic repair was performed expeditiously utilizing femoral bypass, circulatory arrest, and antegrade perfusion after completion of the distal anastomosis. Persistent malperfusion led to additional procedures. In-hospital morbidity, end-organ salvage, and mortality were determined. Chi-square analysis defined variables contributing significantly to outcome. RESULTS: Twenty-three patients presented with malperfusion. The operative mortality for the entire cohort with malperfusion, 4.4% (n = 1), was not greater than those without it, 5.1% (n = 4). Five patients required additional procedures following aortic repair, a majority in patients with persistent extremity ischemia. All deficits resolved except for one patient with spinal ischemia and one with visceral ischemia. Visceral malperfusion was highly lethal with a mortality of 33% (n = 1). All other patients presenting with malperfusion survived to discharge. CONCLUSIONS: Patients with malperfusion in the setting of acute type A dissection should undergo immediate aortic reconstruction as the primary means of reestablishing end-organ perfusion. Early postoperative intervention for persistent deficits leads to a gratifyingly high rate of end-organ salvage.