Extremity Malperfusion Research Articles

Ileofemoral Malperfusion Complicating Type A Dissection: Revascularization Prevents Renal Failure

We report four cases of lower extremity malperfusion complicating acute type A dissection. Two patients were treated with acute type A dissection repair, followed by axillobifemoral bypass grafting when malperfusion persisted after aortic replacement and required dialysis. Two patients were managed with lower extremity revascularization procedures before acute type A dissection repair and had preserved renal function. Lower extremity revascularization before cardiopulmonary bypass minimizes ischemia and allows for controlled limb reperfusion under hypothermic conditions compared with delayed normothermic reperfusion when performed after acute type A dissection repair. This strategy may increase limb function salvage and decrease the incidence of dialysis after acute type A dissection repair in patients presenting with lower extremity malperfusion.

Acute Descending Aortic Dissections: Management of Visceral, Spinal Cord, and Extremity Malperfusion

Acute descending aortic dissection is considered the most catastrophic event affecting the aorta and occurs two to three times more often than rupture of abdominal aortic aneurysms. The therapeutic aim in treating acute dissection is not only directed at the prevention of aneurysmal development and rupture but also to prevent and treat complications such as malperfusion syndrome. According to Lauterbach and coworkers patients with symptomatic malperfusion syndromes have a 51% mortality rate compared with a 29% mortality rate in patients who do not. The surgical in-hospital mortality rate in patients with mesenteric or peripheral vascular ischemic complications may be as high as 89%. Despite an improvement in diagnosing dissections and malperfusion syndromes, and despite improved operative techniques and a better understanding of the significance of perioperative care, the surgical mortality rate can be as high as 50%. Endovascular techniques are constantly evolving that provide an alternative to open procedures. The goal of this article was to review the pathogenesis of malperfusion syndromes in aortic dissection, discuss the current modalities to treat malperfusion of the spinal cord, viscera, and extremities, and examine the results of the treatments used today.

Cerebral complications associated with selective perfusion of the arch vessels

Background. Few studies have determined risk factors for postoperative cerebral complications associated with surgery of the aortic arch using selective cerebral perfusion. Methods. Between November 1992 and December 1998, 113 patients underwent aortic arch repair combined with selective cerebral perfusion. For each patient, three arch vessels were perfused using a single roller pump at a rectal temperature of 23°C. Results. Among the 108 patients who underwent postoperative neurologic assessment, 25 patients (23%) suffered from cerebral complications. Five patients (5%) suffered from transient neurologic disturbance and 17 patients (16%) suffered from stroke, and 7 patients (7%) of the preceding 17 patients had residual neurologic disturbance upon discharge. Three patients (3%) with either preoperative coma (n = 1) or post bypass cardiac arrest (n = 2) sustained severe global cerebral dysfunction. The occurrence of cerebral complications was not related to cerebral perfusion time. Independent risk factors for cerebral complications included a history of cerebrovascular disease, perioperative shock, distal anastomosis below the left pulmonary artery, malperfusion of extremities, and older age (> 60 years). Conclusions. Although high-level brain function was well preserved in most patients, the incidence of stroke when using current selective cerebral perfusion techniques is still high.