Management Options for Acute Type A Aortic Dissection Complicated with Malperfusion Syndrome: Operative Delay or Immediate Repair?

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.

Keywords: 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.