Lower Limb Malperfusion in Acute Type A Dissection
Rteil A, Shepard A, Nypaver T, Weaver M, Mohammad F, Nemeh H, Chamogeorgakis T, and Kabbani L. Lower Limb Malperfusion in Acute Type A Dissection. J Vasc Surg 2019; 70(3):e63.
J Vasc Surg
Objective: Acute type A aortic dissection (ATAD) presenting with acute limb ischemia (ALI) has been identified as a predictor of in-hospital mortality. This study examined the outcome of patients presenting with ATAD with ALI. Methods: A prospectively collected database was queried for all cases of ATAD repaired between 2002 and 2018 at a tertiary referral center. Patients with ALI were identified. Univariate comparisons between groups with and without lower extremity ALI were made. Results: During this period, 378 patients underwent ATAD repair, of whom 62 patients (16.4%) presented with ALI. Thirty-five patients (9.2%) presented with isolated ALI, whereas 27 (7.1%) had concomitant malperfusion in at least one other organ system. Of the 62 patients presenting with ALI, 46 (74.2%) underwent proximal aortic repair alone, whereas 16 (25.8%) patients also underwent lower extremity vascular intervention. The ischemic limb was perfused during repair of the ATAD by a side perfusion cannula from the bypass circuit in 10 patients. There were six amputations (9.7%) performed in the ALI group, two of which had peripheral vascular repairs. Fasciotomies were performed on 18 patients; of these, 5 had concomitant peripheral vascular repairs. Of the 55 patients with ALI surviving past 24 hours, 34 (61%) had resolution of the lower limb ischemia with proximal repair only. The 30-day survival was decreased in patients who presented with any organ malperfusion (P =.012). In patients with isolated ALI, there was no significant difference in 30-day mortality (11.4%) compared with the group with no malperfusion (15.7%; P =.5). Sixteen patients underwent peripheral vascular procedures for limb ischemia, including 10 patients who underwent bypass procedures (7 femoral-femoral, 1 axillary-femoral-femoral, and 2 axillary-femoral), with 1 patient dying within 24 hours. All six patients with adequate follow-up imaging had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries on computed tomography angiography. Conclusions: Proximal repair of ATAD resolves most associated ALI. Isolated ALI did not increase 30-day mortality. All patients with follow-up who underwent extra-anatomic bypass developed asymptomatic graft occlusion. This was attributed to competitive flow from the remodeled native arterial system.