Outcomes of Endovascular Repair among Patients Presenting with Abdominal and Peripheral Malperfusion Syndromes following Surgery for Stanford-A, Debakey-1 Aortic Dissection

Objectives: In the majority of patients with Stanford type-A, Debakey type-1 aortic dissection, thoracic surgery obliterates or reduces false lumen perfusion in the descending aorta by removing the proximal entry tear. A few patients suffer from acute postoperative abdominal or peripheral malperfusion, a rare but life-threatening condition. We evaluated the outcomes of endovascular repair among them.

Methods: A single-center retrospective review of patients presenting with acute abdominal or peripheral malperfusion within 30 days subsequent to surgery for acute type-A aortic dissection at our institution from 2010 to 2019.

Result: Of 966 patients undergoing surgery for type-A dissections, 33 (3.3%) patients developed acute abdominal or peripheral malperfusion at a median of 2 days [IQR: 1, 5] postoperatively. Eleven (33.3%) of the patients showed initial signs of malperfusion prior to thoracic surgery. 32 patients underwent endovascular repair and one died before intervention. Median age was 61 years [IQR: 49, 73]. 12 (35.3%) patients were female. 10 (29.4%) patients had undergone hybrid procedures which included frozen elephant trunk operations (N = 7) or implantation of an AMDS stent (N = 3). There was mesenteric vessel, renal artery, and iliac involvement in 22 (66.7%), 3 (9.1%), and 2 (6.1%) patients respectively, while 6 (18.2%) patients had multiple region involvement. Aortic stents alone were used in 11 (34.4%) patients, branch artery stents in 15 (46.9%) patients, while 6 (18.7%) patients required a combination. Of patients receiving aortic stents, 10 (58.8%) received bare metal stents (BMS) alone. The dissection membrane was fenestrated in two (6.25%) patients. Endovascular intervention successfully reestablished circulation to the affected arteries in all patients. One patient required additional local lysis and two patients suffered early restenosis after initial reperfusion. Cumulative survival postintervention was 56.3% (SE: 0.88) at 30 days, 53.1% (SE: 0.88) at 1 year and 46.5% (SE: 0.99) at 5 years. On univariate analysis, mortality was associated with lactic acid level (p = 0.009), creatinine level (p = 0.018), and PH (p = 0.003) prior to intervention.

Conclusion: Endovascular treatment effectively restores vascular perfusion in cases of malperfusion syndromes following surgery for type A dissection. Timely intervention prior to acidosis is associated with higher survival. Patients who survive 30 days do well at 5-year follow-up.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
19 February 2021