Management Strategy for Lower Extremity Malperfusion Due to Acute Aortic Dissection

Abstract

OBJECTIVE Aortic dissection can result in devastating cerebral, visceral, renal, spinal, and extremity ischemia. We describe the management and outcomes of patients presenting with aortic dissection and lower extremity malperfusion (LEM). METHODS A single-center institutional aortic database was queried for patients with aortic dissection and LEM from 2011 to 2019. The primary end point was resolution of LEM after aortic repair. Secondary end points were amputation, in-hospital mortality, time to intervention, and postoperative complications. RESULTS Of 769 patients with aortic dissection, 42 (5.5%) presented acutely with LEM: 16 with Stanford type A and 26 Stanford type B aortic dissection (age 55 ± 13 years; 90% men). Most presented as Rutherford IIB symptoms, but patients with type A had Rutherford III more often, compared with those with type B. Aortic repair was performed before limb interventions in 36 patients (86%; 19 TEVAR, 16 open arch and ascending repair, and 1 open descending aortic repair with fenestration). Seven (19%) had immediate failure with persistent malperfusion recognized in the operating room and underwent additional limb intervention, including extra-anatomic revascularization (n = 4), iliac stenting (n = 2), and femoral patch with septal fenestration or tacking (n = 2). Three patients (8%) had early delayed failure requiring extra-anatomic bypass in two and amputation in one. In contrast, six patients had limb-first intervention with extra-anatomic revascularization. None had immediate failure, but one-half had early delayed failure requiring proximal aortic intervention: two TEVAR and one open aortic fenestration. Limb-first patients were more likely to have early delayed failure compared with aortic dissection treated first patients (50% vs 8%; P = .029). The amputation rate was 2%, occurring in one type A patient. The overall in-hospital mortality was 7% (n = 3), with no difference between type A and type B aortic dissection. There was no difference in surgical site infection, postoperative dialysis need, stroke, and myocardial infarction. CONCLUSIONS In patients presenting with acute aortic dissection with limb ischemia, resolution of the malperfusion occurs in the majority of cases after primary aortic dissection intervention, emphasizing the usefulness of urgent TEVAR for complicated type B and open repair of type A before lower extremity intervention. Limb-first interventions have a higher early delayed failure rate and thus require more frequent reoperation. However, the overall amputation rate in LEM owing to aortic dissection remains low.