Intraoperative assessment and treatment of residual distal malperfusion improves outcomes in patients with acute Debakey I dissection.

Abstract

Objectives: Type A Aortic Dissection(TAAD) with malperfusion carries high mortality and morbidity despite current surgical techniques; new approaches are needed to improve outcomes. This study evaluates the outcomes of patients undergoing intraoperative assessment and treatment of distal malperfusion during central aortic repair.

Methods: A retrospective review of 551 TAAD patients from 2000-2023 identified 54 patients with clinical malperfusion of the mesenteric, renal, spinal cord, or iliofemoral based on clinical presentation, imaging, and biomarkers. Patients with radiological aortic branch involvement but without clinical symptoms were excluded. Patients were grouped into: Standard approach(n = 36), where central aortic repair was followed by postoperative ICU care, and Comprehensive approach(n = 18), where intraoperative evaluation for persistent malperfusion was conducted after termination of cardiopulmonary bypass, with immediate intervention if needed. The primary outcome was operative mortality. Secondary outcomes included resolution of malperfusion.

Results: Of 54 patients, 41%(n = 22) had mesenteric, 46%(n = 25) renal, 11%(n = 6) spinal and 76%(n = 41) Iliofemoral malperfusion. The comprehensive approach was significantly associated with reduced odds of the composite outcome(OR : 0.17, 95% CI: 0.04-0.63, p = 0.008) and increased odds of resolving malperfusion(OR : 4.55, 95% CI : 1.26-16.44, p = 0.021). In the mesenteric subgroup(n = 22), odds of malperfusion resolution were markedly higher(OR : 19.30, 95% CI: 2.17-171.65, p = 0.008). However, no significant associations were found in the limb(OR : 3.17, p = 0.107) or renal subgroups(OR : 4.38, p = 0.164).

Conclusions: Patients with TAAD undergoing immediate intraoperative evaluation to identify and treat distal malperfusion simultaneously with central aortic repair may benefit from lower rates of complications and bowel resection. Further studies with larger datasets are needed to validate this approach.