Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: A 20-year experience

J Thorac Cardiovasc Surg. 2019 Sep;158(3):675-687.e4. doi: 10.1016/j.jtcvs.2018.11.127. Epub 2018 Dec 14.


Objective: To assess outcomes of endovascular reperfusion followed by delayed open aortic repair for stable patients with acute type A aortic dissection and mesenteric malperfusion syndrome (mesMPS).

Methods: Among 602 patients with acute type A aortic dissection who presented to our center from 1996 to 2017, all 82 (14%) with mesMPS underwent upfront endovascular fenestration/stenting. Primary outcomes were in-hospital mortality and long-term survival. Patients with acute type A aortic dissection with no malperfusion syndrome of any organ (n = 419) served as controls.

Results: In-hospital mortality of all comers with mesMPS was 39%. After endovascular fenestration/stenting, 20 mesMPS patients (24%) died from organ failure and 11 patients (13%) died from aortic rupture before open aortic repair, 47 patients (58%) underwent aortic repair, and 4 patients (5%) survived without open repair. No patients died from aortic rupture during the second decade (2008-2017). The significant risk factors for death from organ failure after endovascular reperfusion were acute stroke (odds ratio, 23; 95% confidence interval, 4-144; P = .0008), gross bowel necrosis at laparotomy (odds ratio, 7; 95% confidence interval, 1.4-34; P = .016), and serum lactate ≥6 mmol/L (odds ratio, 13.5; 95% confidence interval, 2-97; P = .0097). There was no significant difference in operative mortality (2.1% vs 7.5%; P = .50) or long-term survival between patients with mesMPS who underwent open aortic repair after recovering from mesMPS and patients with no malperfusion syndrome.

Conclusions: In patients with acute type A aortic dissection with mesMPS, endovascular fenestration/stenting, and delayed open aortic repair achieved favorable short- and long-term outcomes. Surgeons should consider correcting mesenteric malperfusion before undertaking open aortic repair in patients with mesMPS, especially those with acute stroke, gross bowel necrosis at laparotomy, or serum lactate ≥6 mmol/L.

Keywords: acute type A aortic dissection; aortic surgery; endovascular fenestration/stenting; malperfusion syndrome; mesenteric malperfusion.

Publication types

  • Webcast

MeSH terms

  • Acute Disease
  • Aged
  • Aortic Aneurysm / complications
  • Aortic Aneurysm / mortality
  • Aortic Aneurysm / physiopathology
  • Aortic Aneurysm / surgery*
  • Aortic Dissection / complications
  • Aortic Dissection / mortality
  • Aortic Dissection / physiopathology
  • Aortic Dissection / surgery*
  • Blood Vessel Prosthesis Implantation* / adverse effects
  • Blood Vessel Prosthesis Implantation* / mortality
  • Endovascular Procedures* / adverse effects
  • Endovascular Procedures* / mortality
  • Female
  • Hospital Mortality
  • Humans
  • Male
  • Mesenteric Ischemia / etiology
  • Mesenteric Ischemia / physiopathology
  • Mesenteric Ischemia / surgery*
  • Middle Aged
  • Postoperative Complications / mortality
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Splanchnic Circulation*
  • Time Factors
  • Time-to-Treatment
  • Treatment Outcome