Management of vital organ malperfusion in acute aortic dissection: proposal of a mechanism-specific approach

Abstract

We report our strategy for malperfusion accompanying acute aortic dissection, especially that involving the abdominal organs, which is based on the mechanism and includes percutaneous management. From 1991 through October 2005, a total of 38 of 135 (28%) patients with acute dissection presented with organ malperfusion. Altogether, 31 had type A dissection. The involved vascular territories were coronary in 8, brain in 16, celiac and superior mesenteric in 6, renal in 10, and lower limb in 13. For the abdominal organs, the mechanisms of the malperfusion were classified into the aortic type (n = 3) and the branch type (n = 13). The branch type was further divided into the orifice type (n = 8) and distal type (n = 5). All but one patient with type A dissection underwent a central aortic operation with resection of the entry site. Revascularization of the ischemic organ was added by bypass grafting or direct reconstruction. Distal organ malperfusion accompanying type B dissection was treated by the mechanism-specific approach. That is, the aortic type was treated by surgical fenestration, whereas the branch type was treated by percutaneous stenting. The one hospital death (2.6%) was due to brain infarction. Although a central aortic operation alone successfully reversed aortic-type malperfusion in all three patients, it was not effective for branch-type malperfusion in five of six vascular territories. Surgical fenestration did not successfully reverse branch-type renal malperfusion in two patients. Percutaneous stenting was successful in all three vessels with branch-type malperfusion. Central aortic operation or fenestration is effective for aortic-type malperfusion, whereas the branch type may require stenting or bypass grafting.