Management Options for Acute Type A Aortic Dissection Complicated with Malperfusion Syndrome: Operative Delay or Immediate Repair?
Pp. 101-122 (22)
Li Zhang, François Dagenais and Siamak Mohammadi
Malperfusion in type A aortic dissection (TAAAD) describes symptoms and
signs of end-organ dysfunction attributable to low blood flow. It is associated with a
high mortality rate. Differentiating between static and dynamic malperfusion provides
some explanation of its pathophysiology. However, the surgical outcomes of patients
with malperfusion are yet to be improved despite progress in perioperative care. This
chapter addresses the issues associated with managing patients with TAAAD
complicated with malperfusion. We reviewed the major contemporary series to collect
the best clinical evidence. Although new techniques, such as percutaneous fenestration
and stenting, are emerging as alternative treatments, the best strategy for managing
patients with malperfusion is controversial. Some groups have proposed a nonsurgical
approach followed by delayed surgery for primary aortopathy. The pros and cons of this
strategy are discussed. Patient selection is critical. The delayed-surgery strategy
provides patients with mesenteric malperfusion or multiorgan malperfusion an option
when the surgical risk is prohibitively high. In contrast, immediate proximal aortic
repair is still indicated for coronary malperfusion.
Aortic repair, Arteriography, Cerebral, Coronary, Delayed surgery,
Dynamic malperfusion, False lumen, Intimal flap, Ischemia, Limb, Malperfusion,
Mesenteric ischemia, Percutaneous fenestration, Renal, Spinal cord, Static
malperfusion, Stenting, True lumen, Type A aortic dissection, Visceral.
Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, 2725 Chemin Ste-Foy, Quebec City, Quebec, Canada, G1V 4G5.