The Role of the Vascular Surgeon in Acute Type 1 Aortic Dissections
Jack Doenges, Amy B Reed, Stephen Huddleston, R. James Valentine
University of Minnesota Medical Center, Minneapolis, MN
Background: Acute Stanford type A aortic dissections extending beyond the ascending aorta (DeBakey type 1) may be associated with acute ischemic syndromes due to branch artery occlusion. The purpose of this study is to document the prevalence of non-cardiac ischemic syndromes associated with type 1 aortic dissections necessitating vascular surgery involvement.
Methods: Consecutive patients presenting with acute type 1 aortic dissections between 2007 and 2022 were studied. Subjects who underwent initial ascending aortic and hemiarch repair were included in the analysis. Data were collected from the institutional electronic medical record, and CT angiogram images obtained before and after aortic repair were reviewed in detail. Study end points included need for additional interventions after ascending aortic repair and death.
Results: 120 subjects (70% men, mean age 58 + 13 y) underwent emergent ascending aortic and hemiarch repair for acute type 1 aortic dissections during the study period. 41 (34%) subjects presented with ischemic syndromes resulting in vascular surgery consultation. These included 22 (18%) with leg ischemia, 9 (8%) with acute strokes, 5 (4%) with mesenteric ischemia, and 5 (4%) with arm ischemia. Compared to subjects without acute ischemic syndromes, subjects with acute ischemia had a higher prevalence of dissections extending distal to the aortic bifurcation (P=.016). Following the proximal aortic repair, 12 (10%) subjects had persistent ischemic syndromes. Nine (8%) subjects required additional interventions for persistent leg ischemia (n=7), intestinal gangrene (n=1), or cerebral edema (craniotomy, n=1). Three other subjects with acute stroke had permanent neurologic deficits. All other acute ischemic syndromes resolved after the proximal aortic repair despite mean operative times exceeding six hours. Comparing subjects with ischemia who required intervention to those who did not, there were no differences in distal extent of dissection, mean operative time for aortic repair, or presence of residual aortic arch entry tears. Five of the nine subjects with acute stroke recovered neurologic function without intervention. Nine (7.4%) subjects suffered perioperative deaths. Hospital deaths occurred in three (25%) of the 12 subjects with persistent ischemia vs none of 29 subjects who had resolution of the ischemia after aortic repair (P = .02). During a mean follow up of 51 + 39 months, no subject required an additional intervention for persistent branch artery occlusion.
Conclusions: One-third of patients with acute type I aortic dissections had associated non-cardiac ischemia prompting vascular surgery consultation. Limb and mesenteric ischemia most often resolved after the proximal aortic repair and did not require further intervention. No vascular interventions were performed in patients with stroke. Persistent ischemia from branch artery occlusion appears to be a marker for increased mortality after type I dissections.
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