Commentary: Go with your gut: Evolving approaches in the treatment of type A dissection with visceral malperfusion

Central MessageThe TEVAR-PETTICOAT technique as a first-line approach before proximal aortic repair is a promising concept in the treatment of type A dissection with visceral malperfusion syndrome.See Article page 61. The TEVAR-PETTICOAT technique as a first-line approach before proximal aortic repair is a promising concept in the treatment of type A dissection with visceral malperfusion syndrome. See Article page 61. Acute type A dissection (ATAD) and visceral malperfusion syndrome represents among the most challenging and lethal surgical conditions.1Czerny M. Schoenhoff F. Etz C. Englberger L. Khaladj N. Zierer A. et al.The impact of pre-operative malperfusion on outcome in acute type a aortic dissection: results from the GERAADA Registry.J Am Coll Cardiol. 2015; 65: 2628-2635Crossref PubMed Scopus (144) Google Scholar, 2Geirsson A. Szeto W.Y. Pochettino A. McGarvey M.L. Keane M.G. Woo Y.J. et al.Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations.Eur J Cardiothorac Surg. 2007; 32: 255-262Crossref PubMed Scopus (173) Google Scholar, 3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar, 4Narayan P. Rogers C.A. Benedetto U. Caputo M. Angelini G.D. Bryan A.J. Malperfusion rather than merely timing of operative repair determines early and late outcome in type A aortic dissection.J Thorac Cardiovasc Surg. 2017; 154: 81-86Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 5Di Eusanio M. Trimarchi S. Patel H.J. Hutchison S. Suzuki T. Peterson M.D. et al.Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390.e1Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar Preventza and colleagues6Preventza O. Chatterjee S. Le Huu A. Coselli J.S. Provisional extension to induce complete attachment of 1 an endovascular repair for acute type A aortic dissection with visceral malperfusion.J Thorac Cardiovasc Surg Tech. 2020; 3: 61-63Google Scholar describe such a patient where the thoracic endovascular aortic repair (TEVAR)-provisional extension to induce complete attachment technique was successfully used as a first-line strategy before central aortic repair. Three critical questions persist in the treatment of patients with ATAD and visceral malperfusion: (1) Which patients benefit from a visceral-first strategy?, (2) What is the optimal technique for resolution of visceral malperfusion? and, (3) What should be the timing of proximal aortic repair following resolution of visceral malperfusion? Those with subclinical radiographic visceral malperfusion alone should be treated with immediate proximal aortic repair. These patients may benefit from arch intervention (eg, antegrade TEVAR, bare-metal arch stent, or hybrid arch stent-graft) to improve distal perfusion, although the optimal strategy remains unclear.7Erbel R. Aboyans V. Boileau C. Bossone E. Bartolomeo R.D. Eggebrecht H. et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (2024) Google Scholar, 8Appoo J.J. Bozinovski J. Chu M.W. El-Hamamsy I. Forbes T.L. Moon M. et al.Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery joint position statement on open and endovascular surgery for thoracic aortic disease.Can J Cardiol. 2016; 32: 703-713Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 9Smith H.N. Boodhwani M. Ouzounian M. Saczkowski R. Gregory A.J. Herget E.J. et al.Classification and outcomes of extended arch repair for acute type A aortic dissection: a systematic review and meta-analysis.Interact Cardiovasc Thorac Surg. 2017; 24: 450-459PubMed Google Scholar, 10Tsagakis K. Pacini D. Di Bartolomeo R. Benedik J. Cerny S. Gorlitzer M. et al.Arch replacement and downstream stent grafting in complex aortic dissection: first results of an international registry.Eur J Cardiothorac Surg. 2011; 39: 87-93Crossref PubMed Scopus (56) Google Scholar, 11Kotha V.K. Pozeg Z.I. Herget E.J. Moon M.C. Appoo J.J. Early Results of the PETTICOAT Technique for the Management of acute type A aortic dissection.Aorta (Stamford). 2017; 5: 124-128Crossref PubMed Google Scholar, 12Bozso S.J. Nagendran J. Chu M.W.A. Kiaii B. El-Hamamsy I. Ouzounian M. et al.Single-stage management of dynamic malperfusion using a novel arch remodeling hybrid graft.Ann Thorac Surg. 2019; 108: 1768-1775Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Patients with advanced visceral malperfusion syndrome with clinical or biochemical evidence of liver or bowel necrosis and concomitant hemodynamic stability (no aortic rupture or tamponade) are the subgroup of patients for whom a visceral-first strategy can be beneficial. Two main strategies exist to re-perfuse the visceral aortic branches, namely endovascular fenestration and a TEVAR-first technique. Endovascular fenestration involves percutaneous mechanical fenestration of the septum and often necessitates adjunctive procedures, including aortic stenting, branch vessel thrombolysis, or suction thromboembolectomy to address the static components of malperfusion.13Yang B. Rosati C.M. Norton E.L. Kim K.M. Khaja M.S. Dasika N. et al.Endovascular fenestration/stenting first followed by delayed open aortic repair for acute type A aortic dissection with malperfusion syndrome.Circulation. 2018; 138: 2091-2103Crossref PubMed Scopus (36) Google Scholar,14Yang B. Norton E.L. Rosati C.M. Wu X. Kim K.M. Khaja M.S. et al.Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: a 20-year experience.J Thorac Cardiovasc Surg. 2019; 158: 675-687.e4Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Patients with dynamic malperfusion could be treated with a proximal TEVAR with or without distal bare metal stents to re-expand the true lumen across the visceral segment of the aorta.6Preventza O. Chatterjee S. Le Huu A. Coselli J.S. Provisional extension to induce complete attachment of 1 an endovascular repair for acute type A aortic dissection with visceral malperfusion.J Thorac Cardiovasc Surg Tech. 2020; 3: 61-63Google Scholar,15Leshnower B.G. Keeling W.B. Duwayri Y.M. Jordan Jr., W.D. Chen E.P. The “thoracic endovascular aortic repair-first” strategy for acute type A dissection with mesenteric malperfusion: initial results compared with conventional algorithms.J Thorac Cardiovasc Surg. 2019; 158: 1516-1524Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,16Parsa C.J. McCann R.L. Hughes G.C. Novel approach to the treatment of distal malperfusion secondary to ascending aortic dissection.J Card Surg. 2010; 25: 220-222Crossref PubMed Scopus (8) Google Scholar Leshnower and colleagues15Leshnower B.G. Keeling W.B. Duwayri Y.M. Jordan Jr., W.D. Chen E.P. The “thoracic endovascular aortic repair-first” strategy for acute type A dissection with mesenteric malperfusion: initial results compared with conventional algorithms.J Thorac Cardiovasc Surg. 2019; 158: 1516-1524Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar reported 13 patients treated with a TEVAR-first approach in the setting of ATAD and visceral malperfusion syndrome, 2 of whom required distal extension of the covered stent with bare-metal stents to achieve resolution of malperfusion. In our opinion, a TEVAR-first approach, with distal bare-metal stents if necessary (as in this report) is likely the most reproducible and accessible method of endovascular visceral reperfusion. If a component of static malperfusion exists, further branch vessel intervention may be necessary. Regardless of approach, careful assessment by invasive hemodynamic measurements or angiography must be performed to ensure visceral reperfusion. A proportion of patients with late presentation will die of organ ischemia despite successful endovascular reperfusion. In both the Michigan and Emory experiences, a proportion of patients (13% and 7.7%, respectively), died of aortic rupture while awaiting open aortic repair.14Yang B. Norton E.L. Rosati C.M. Wu X. Kim K.M. Khaja M.S. et al.Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: a 20-year experience.J Thorac Cardiovasc Surg. 2019; 158: 675-687.e4Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,15Leshnower B.G. Keeling W.B. Duwayri Y.M. Jordan Jr., W.D. Chen E.P. The “thoracic endovascular aortic repair-first” strategy for acute type A dissection with mesenteric malperfusion: initial results compared with conventional algorithms.J Thorac Cardiovasc Surg. 2019; 158: 1516-1524Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar This mortality must be included when reporting the outcomes of a visceral-first strategy. Proximal aortic surgery should likely be undertaken as soon as metabolic homeostasis permits. Some patients will require a delay longer than 24 to 48 hours, including those with ongoing multiorgan failure/refractory shock, bowel necrosis, or acute respiratory distress syndrome. Treatment for patients with ATAD and mesenteric malperfusion syndrome must be individualized with consideration given to the full armamentarium of endovascular and open surgical techniques. The use of TEVAR with provisional extension as a first-line approach is a promising concept in the management of carefully selected patients presenting with this challenging condition.

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