Management Strategy For Lower Extremity Malperfusion Due To Acute Aortic Dissection
Anastasia Plotkin, MD, Gregory A. Magee, MD, MSc, Sukgu M. Han, MD, MS, Diana Vares, Vincent L. Rowe, MD.
University of Southern California, Los Angeles, CA, USA.
OBJECTIVES: Aortic dissection (AD) can be a devastating pathology resulting in visceral, spinal, and extremity ischemia. We describe the management and outcomes of patients presenting with AD and lower extremity malperfusion.
METHODS: A single-center institutional aortic database was queried for patients with AD from 2011-2019 and patients presenting with lower extremity malperfusion were analyzed. Primary endpoints were amputation and resolution of lower extremity malperfusion following aortic repair. Secondary endpoints were in-hospital mortality, type of surgical management, time to intervention, and postoperative complications.
RESULTS: Of 769 patients with AD, 43 (5.6%) presented acutely with lower extremity malperfusion. There were 17 type A aortic dissection (TAAD) and 26 type B aortic dissection (TBAD) patients. Average age was 55 ± 13 years and 93% were men. Aortic repair was performed prior to lower extremity operation in 37 (86%) patients (thoracic endovascular aortic repair in 19, open arch or ascending repair in 17, thoracic endovascular aortic repair in 19, and open descending aortic repair in 1). Resolution of limb malperfusion occurred after primary AD repair in 29 (78%). Six (16%) required additional limb intervention after AD repair including extra-anatomic revascularization in 4 and iliac stenting in 2. Fasciotomies were performed in 19 patients (51%) and 1 patient required amputation (2%). Six patients had limb first intervention with extra-anatomic revascularization- 3 underwent subsequent TEVAR, 1 had open aortic fenestration, and 2 had their AD medically managed. Three patients (2 open TAAD repairs in the AD first group, and 1 endovascular TBAD who had limb first intervention), suffered lower extremity paralysis (7%), all attributed to spinal cord ischemia. TAAD more commonly presented emergently (100% vs. 73%, p=0.03), but concomitant visceral ischemia was more common in TBAD (0% vs. 38%, p=0.003). Overall in-hospital mortality was 7% (3), with no difference between TAAD and TBAD. There was no difference in other postoperative complications. Median time to surgical intervention was 0.5 days (IQR: 0.3-2.4) and was longer in TBAD patients (0.4 [IQR: 0.2-0.4] vs. 1.4 [IQR: 0.5-3.2] days, p=0.03).
CONCLUSIONS: In patients presenting with acute AD with limb ischemia, resolution of the malperfusion occurs in the majority of cases after primary dissection intervention; emphasizing the utility of urgent TEVAR for type B and open repair of type A prior to lower extremity management.
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