Abstract
Malperfusion syndrome is a lethal medical condition, which affects 25–40% of patients with acute aortic dissection. Obstruction of aortic branch vessels caused by the dissection can endanger one or more vital organs, and timely and adequate management is crucial to restore flow. In type A dissection with malperfusion, treatment consists of primary ascending aortic graft replacement and is associated with high rates of mortality. An alternative strategy is to perform endovascular fenestration and stenting first, to resolve malperfusion, and delay open repair. In type B dissections, TEVAR is the first choice of treatment. In selected patients, endovascular fenestration can also offer favorable outcomes. In type B dissection, open surgical techniques are actually limited to patients in whom endovascular repair is contraindicated or has previously failed. In this setting, surgical fenestration can be effective at reversing ischemia, whereas open graft replacement can be adopted when the aorta is enlarged. Extra-anatomical bypass grafting is useful in high-risk patients with only lower limb ischemia.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Conrad M, Cambria R. Aortic dissection. In: Cronenwett J, Johnston KW, editors. Rutherford’s vascular surgery. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 2179–85.
Czerny M, Schoenhoff F, Etz C, Englberger L, Khaladj N, Zierer A, et al. The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: results from the GERAADA registry. J Am Coll Cardiol. 2015;65:2628–35.
Suzuki T, Mehta RH, Ince H, Nagai R, Sakomura Y, Weber F, et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation. 2003;108:S312–7.
Fattori R, Cao P, De Rango P, Czerny M, Evangelista A, Nienaber C, et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol. 2013;61:1661–78.
Jonker FH, Patel HJ, Upchurch GR, Williams DM, Montgomery DG, Gleason TG, et al. Acute type B aortic dissection complicated by visceral ischemia. J Thorac Cardiovasc Surg. 2015;149:1081–6.
Benedetto U, Mohamed H, Vitulli P, Petrou M. Axillary versus femoral arterial cannulation in type A acute aortic dissection: evidence from a meta-analysis of comparative studies and adjusted risk estimates. Eur J Cardiothorac Surg. 2015;48:953–9.
Rylski B, Beyersdorf F, Kari FA, Schlosser J, Blanke P, Siepe M. Acute type A aortic dissection extending beyond ascending aorta: limited or extensive distal repair. J Thorac Cardiovasc Surg. 2014;148:949–54.
Martens A, Beckmann E, Kaufeld T, Umminger J, Fleissner F, Koigeldiyev N, et al. Total aortic arch repair: risk factor analysis and follow-up in 199 patients. Eur J Cardiothorac Surg. 2016;50:904–8.
Di Eusanio M, Trimarchi S, Patel HJ, Hutchison S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013;145:385–90.
Patel HJ, Williams DM, Dasika NL, Suzuki Y, Deeb GM. Operative delay for peripheral malperfusion syndrome in acute type A aortic dissection: a long-term analysis. J Thorac Cardiovasc Surg. 2008;135:1288–95.
Midulla M, Renaud A, Martinelli T, Koussa M, Mounier-Vehier C, Prat A, et al. Endovascular fenestration in aortic dissection with acute malperfusion syndrome: immediate and late follow-up. J Thorac Cardiovasc Surg. 2011;142:66–72.
Crawford TC, Beaulieu RJ, Ehlert BA, Ratchford EV, Black JH 3rd. Malperfusion syndromes in aortic dissections. Vasc Med. 2016;21:264–73.
Vallabhajosyula P, Gottret JP, Bavaria JE, Desai ND, Szeto WY. Endovascular repair of the ascending aorta in patients at high risk for open repair. J Thorac Cardiovasc Surg. 2015;149:S144–50.
Moulakakis KG, Mylonas SN, Dalainas I, Kakisis J, Kotsis T, Liapis CD. Management of complicated and uncomplicated acute type B dissection. A systematic review and meta-analysis. Ann Cardiothorac Surg. 2014;3:234–46.
Canaud L, Faure EM, Ozdemir BA, Alric P, Thompson M. Systematic review of outcomes of combined proximal stent-grafting with distal bare stenting for management of aortic dissection. Ann Cardiothorac Surg. 2014;3:223–33.
Patel HJ, Williams DM, Meerkov M, Dasika NL, Upchurch GR Jr, Deeb GM. Long-term results of percutaneous management of malperfusion in acute type B aortic dissection: implications for thoracic aortic endovascular repair. J Thorac Cardiovasc Surg. 2009;138:300–8.
Trimarchi S, Segreti S, Grassi V, Lomazzi C, Cova M, Piffaretti G, et al. Open fenestration for complicated acute aortic B dissection. Ann Cardiothorac Surg. 2014;3:418–22.
Trimarchi S, Jonker FH, Muhs BE, Grassi V, Righini P, Upchurch GR, et al. Long-term outcomes of surgical aortic fenestration for complicated acute type B aortic dissections. J Vasc Surg. 2010;52:261–6.
Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Bossone E, et al. Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2006;114:S357–64.
Lansman SL, Hagl C, Fink D, Galla JD, Spielvogel D, Ergin MA, et al. Acute type B aortic dissection: surgical therapy. Ann Thorac Surg. 2002;74:S1833–5.
Gargiulo M, Bianchini Massoni C, Gallitto E, Freyrie A, Trimarchi S, Faggioli G, et al. Lower limb malperfusion in type B aortic dissection: a systematic review. Ann Cardiothorac Surg. 2014;3:351–67.
Patel HJ, Williams DM. Endovascular therapy for malperfusion in acute type B aortic dissection. Op Tech Thor Cardiovasc Surg. 2009;14:2–11.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer-Verlag GmbH Austria, part of Springer Nature
About this chapter
Cite this chapter
de Beaufort, H.W.L., Kamman, A.V., Trimarchi, S. (2019). Management of Aortic Malperfusion Syndromes in Aortic Dissection. In: Stanger, O., Pepper, J., Svensson, L. (eds) Surgical Management of Aortic Pathology. Springer, Vienna. https://doi.org/10.1007/978-3-7091-4874-7_63
Download citation
DOI: https://doi.org/10.1007/978-3-7091-4874-7_63
Published:
Publisher Name: Springer, Vienna
Print ISBN: 978-3-7091-4872-3
Online ISBN: 978-3-7091-4874-7
eBook Packages: MedicineMedicine (R0)