Abstract
ObjectiveTo describe our experience of nine patients with extra-anatomical bypass for clinically ischemic distal limb during repair of acute Type A aortic dissection (ATAAD).MethodsWe retrospectively examined a series of nine patients who underwent surgery for ATAAD. We identified a subset of the patients who presented with concomitant radiographic and clinical signs of lower limb ischemia. All but one patient (axillobifemoral bypass) underwent femorofemoral crossover grafting by the cardiac surgeon during cooling.ResultsOne hundred eighty-one cases of ATAAD underwent surgery during the study period with a mortality of 19.3%. Nine patients had persistent clinical evidence of lower limb ischemia (4.9%) and underwent extra-anatomical bypass during cooling. Two patients underwent additional fasciotomies. Mean delay from symptoms to surgery in these nine patients was 9.5 hours. Two patients had bilateral amputations despite revascularisation and, of note, had long delays in presentation for surgery (> 12 hours). There were no mortalities during these inpatient episodes. Outpatient radiographic follow-up at the first opportunity demonstrated 100% patency.ConclusionOur experience suggests that, during complicated aortic dissection, limb ischemia may have a devastating outcome including amputation when diagnosis and referral are delayed. Early diagnosis and surgery are crucial in preventing this potentially devastating complication.
Highlights
Recognising and treating successfully an emergency complicated acute Type A aortic dissection (ATAAD) is a real challenge despite the recent advances in aortic surgery
Limb ischemia was diagnosed by clinical signs and symptoms and was confirmed on the computed tomography angiogram (CTA) of the aorta where there was little or no contrast seen in distal aortic branches or if a dissection and/or thrombus occluded the distal aortic iliac or femoral vessels
Acute renal failure requiring continuous venovenous hemofiltration (CVVH) dialysis occurred in 20.4% of the patients, cerebrovascular accident (CVA) in 11% of the patients, with paraplegia in 0.6%
Summary
Recognising and treating successfully an emergency complicated acute Type A aortic dissection (ATAAD) is a real challenge despite the recent advances in aortic surgery. ATAAD is a lethal condition with a mortality rate of as high as 50-60% in the first 48 hours of presentation if left untreated. A complicated ATAAD with malperfusion syndrome carries significant mortality and morbidity even before admission for definitive management[1,2]. The urgent repair of ATAAD addresses the correction of the proximal extent of the pathology. There are rare conditions in which distal dissection can result in malperfusion of vital organs, the abdomen, or the lower limbs, and the prognosis in such cohort is poor. Evident lower limb ischemia is a rare event and it is sometimes difficult to recognise
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