Management strategies for acute type A aortic dissection complicated by limb malperfusion

Abstract Objective: Acute type A aortic dissection complicated by limb malperfusion confers a risk of mortality to the patients. And,debates still exist about how to manage the predicament focused on reperfusion first or immediate repair.Here,we aimed to describe our experience with the management of acute type A aortic dissection (ATAAD) complicated by limb malperfusion.Methods: From January 1st 2020 to December 31st 2021, 22 consecutive patients were admitted to Xiamen Cardiovascular Hospital due to acute type A aortic dissection complicated by limb malperfusion. All perioperative variables were recorded and analyzed. Limb malperfusion was diagnosed according to the clinical symptom,computed tomography angiography ,and laboratory test. We adopt the clinical categories of acute limb ischemia to stratify severity of limb ischemia.Surgery strategies are as follows:Reperfusion first followed by central repair,immediate central repair,immediate central repair followed by stenting. Results: There were 21 males and 1 female with an average of (53.3±11.7) years. Management strategies were as follows :immediate central repair using total arch replacement with frozen elephant trunk in fifteen patients, endovascular stenting followed by central repair in four patients, and endovascular stenting after central repair in two patients.The average extracorporeal circulation time was 258.8 ± 70.5 min;the average aortic cross-clamp time was 177.9 ± 54.2 min; and the average circulatory arrest time was 45.5 ± 13.1 min. The early mortality rate was 13.6% (3/22). Two patients left the hospital voluntarily due to cerebral infarction and bleeding. One patient underwent fasciotomy for osteofascial compartment syndrome and was discharged uneventfully. Six patients underwent continuous renal replacement therapy and hemoperfusion.Conclusion: Central repair is safe and feasible for ATAAD complicated with limb malperfusion. For serious limb malperfusion, endovascular stenting followed by central repair is a good choice with continuous renal replacement therapy (CRRT) and hemoperfusion. Hospital mortality rate is high in cases with multiple organ malperfusion.