Treating lower extremity malperfusion syndrome in acute type A aortic dissection with endovascular revascularization followed by delayed aortic repair

• Authors: Elizabeth L Norton, Emory University; Felix Orelaru, St. Joseph Mercy; Aroma Naeem, Michigan Medicine; Xiaoting Wu, Michigan Medicine; Karen M Kim, Michigan Medicine; David M Williams, Michigan Medicine; Shinichi Fukuhara, Michigan Medicine; Himanshu J Patel, Michigan Medicine; Michael G Deeb, Michigan Medicine; Bo Yang, Michigan Medicine
• Journal Title: JTCVS Open
• Volume: Volume 10
• Publisher: Elsevier Inc | 2022-01-01, Pages 101-110
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1016/j.xjon.2022.02.017
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Radiology
• Keywords: ARDS, acute respiratory distress syndrome; ATAAD, acute type A aortic dissection; CK, creatine kinase; LE, lower extremity; LE-MPS, lower extremity malperfusion syndrome; MPS, malperfusion syndrome; aortic dissection; endovascular; lower extremity; malperfusion syndrome; non-MPS, No malperfusion syndrome; open aortic repair

Abstract

Objective: To assess the outcomes of emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair in patients with acute type A aortic dissection with lower extremity (LE) malperfusion syndrome (MPS); that is, necrosis and dysfunction of the lower extremity. Methods: From 1996 to 2019, among 760 consecutive acute type A aortic dissection patients 512 patients had no malperfusion syndrome (Non-MPS), whereas 26 patients had LE-MPS with/without renal MPS and underwent endovascular fenestration/stenting, open aortic repair, or both. Patients with coronary, cerebral, mesenteric, and celiac MPS, or managed with thoracic endovascular aortic repair, were excluded (n = 222). All patients with LE-MPS underwent upfront endovascular fenestration/stenting except 1 patient (with signs of rupture) who initially underwent emergency open aortic repair. Results: Among the LE-MPS patients, 17 (65%) had LE pain, 15 (58%) had abnormal motor function with 8 (31%) having paralysis, 10 (38%) had LE pallor, 17 (65%) had LE paresthesia, and 20 (77%) had LE pulselessness. Of the 25 patients undergoing upfront endovascular fenestration/stenting, 16 went on to open aortic repair, 3 survived to discharge without aortic repair, and 6 died before aortic repair (3-aortic rupture and 3-organ failure). In-hospital mortality among all patients was significantly higher in the LE-MPS group (31% vs 6.3%; P = .0003). Among those undergoing open aortic repair, postoperative outcomes were similar between groups, including operative mortality (18% vs 6.5%; P = .10). LE-MPS was a significant risk factor for in-hospital mortality (odds ratio, 6.0 [1.9, 19]; P = .002). Conclusions: In acute type A aortic dissection, LE-MPS was associated with high in-hospital mortality. Emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair may be a reasonable approach.