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

doi:10.21203/rs.3.rs-1864888/v1

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.

acute type A aortic dissection

limb malperfusion

management

Acute type A aortic dissection, a lethal catastrophe-generally requires salvage surgery to prevent rupture; however, some cases may complicated by organ malperfusion, from cerebral, coronary, visceral, renal, or iliofemoral artery ischemia due to a dissection flap or compression from the false lumen. Preoperative organ malperfusion has been reported to be strongly associated with early mortality and worse survival ^[1–3].Extremity ischemia caused by malperfusion affects 15%-40% of patients with acute aortic dissection^[4].

The management of acute type A aortic dissection complicated by limb ischemia remains controversial. Tear-oriented surgery has traditionally been performed to eliminate the risk of rupture. However, in some cases with severe malperfusion, the mortality from limb ischemia exceeds the mortality risk of rupture. With good control of blood pressure and heart rate, reperfusion should be considered as the initial procedure.

Reperfusion results in local and systemic cascade action of inflammatory mediators, including complement, interleukins, thromboxane and platelet-activating factor, resulting in cellular and endothelial injury, and ultimately leading to tissue edema. ^[5].Finally, reperfusion of the ischemic limb may cause extremity compartment syndrome which may necessitate amputation. Additionally, the muscle ischemic time are 4 h. Professor Robert B.Rutherford stratified the severity levels of acute limb ischemia into three categories^[6]: I, “viable”-not immediately threatened; II, “threatened”- implies reversible ischemia in a limb that is salvageable without major amputation if arterial obstruction is relieved quickly;IIa- marginally threatened and IIb immediately threatened. III, “irreversible”-permanent nerve damage inevitable.

Reperfusion of the ischemic limb can be performed by three surgical methods:(1) central repair using a frozen elephant trunk to expand the true lumen and decompress the false lumen, thus restoring blood flow to the malperfused limb;(2) percutaneous endovascular stent for treating obliteration of the aortic true lumen; and (3) extra-anatomic bypass,such as like femoral-femoral bypass and axillofemoral bypass, wherein a bypass graft reperfuses the occluded vessel. According to our protocol, the management strategies for aortic dissection complicated by limb ischemia are as follows:(1.) percutaneous stent implantation to reperfuse the ischemic limb followed by central repair;(2.) immediate central repair and evaluation of the pulse of the occluded arteries after repair.

This article describes our management strategies for treating acute type A aortic dissection complicated by limb malperfusion at our cardiovascular center. Additionally, we sought to establish an algorithm for patients presenting with peripheral vascular malperfusion.

The ethic committee of Xiamen Heart Centre approved this retrospective study and all patients provided informed consent. Patients who were diagnosed with acute type A aortic dissection between 2020 and 2021 at our center were retrospectively examined. As a cardiovascular center in Fujian province, we accepted cases of acute aortic emergency referred from areas in the Minnan District. The perioperative characteristics of the 22 patients are presented in Table 1.

Table1.Characteristic of patients with aortic dissection complicated with malperfusion

Characteristics
Patients(n)	22
Age(years)	53.3±11.7
Sex(female/male)	1/22
Leg site Ischemic left leg Ischemic right leg Bilateral ischemic leg	10 11 1
Hypertension	18
Chronic renal failure	6
Current somkers	12
Visceral malperfusion	5
Cerebral malperfusion	3
Pericardium effusion/Tamponade	4/0
Previous cardiac surgery	1
Moderate or severe aortic valve insufficiency	4
Mechanisms of the obstruction True lumen compressed by the false lumen Thrombosis	16 6
Categories of clinical acute limb ischemia I,IIa IIb	15 7
Interval time from the onset of symptom to hospital (h)	9.27±19.5

Although contrast increases the risk of nephropathy, prompt diagnosis is essential for appropriate management of aortic events. Therefore, patients with suspected type A acute aortic dissection underwent contrast-enhanced computed tomography angiography (CTA) and transthoracic echocardiography for assessment of intimal tear, evidence of pericardial effusion and aortic regurgitation, and blood supply to the aortic branch vessel. Limb malperfusion was defined as follows: (1) clinical signs and symptoms such as pedal pulse deficit, pain and cyanotic skin and (2) evidence from CTA- showing little contrast in distal aortic branches or thrombus-occluded iliac or femoral vessels.

Management strategies

According to our single-center protocol, the surgical strategies were as follows shown in Fig. 2: (1.) percutaneous stent implantation to reperfuse ischemic limb, followed by central repair; (2.) Immediate central repair and evaluation of the pulse of the occluded arteries after repair,and stent implantation,if necessary. The results are shown in Fig. 1. The decision to aortic dissection was made by a cardiac surgeon, vascular surgeon and anesthetist, depending on the symptoms, laboratory tests, and CT scanning analysis.

Stent implantation was considered if the limb ischemia degree belonged to IIb and III, and there was access to the true lumen. The stenting procedure has been described previously. Briefly,vascular surgeon introduced a guidewire into the sheath, and angiography was performed to confirm the true lumen. A balloon was inserted to expand the true lumen and a stent was inserted. After the procedure, angiography was performed again to confirm the vessel flow. Additionally, we examined the pulse of the pedal artery and the temperature of the skin to confirm reflow in the impaired artery

After evaluation by a multidisciplinary team, total arch replacement were performed using the frozen elephant trunk-Sun’s procedure ^[7]. Limbs were reassessed immediately after aortic repair, and revascularization procedures were performed urgently if any uncorrected persistent limb ischemia persisted.

All patients were observed closely in the intensive care unit, particularly for kidney and liver function. The biomarker creatine kinase (ck), myohemoglobin(myo), creatinine(crea) and mediators play pivotal role in ischemia-reperfusion damage. If osteofascial compartment syndrome is highly suspected, early fasciotomy is recommended to actively relieve pressure.

The main preoperative, intraoperative, and postoperative data for the global population are summarized in Tables 1 and 2.

Table 2

Intraoperative and postoperative outcomes
Characteristic(n = 22)
CPB time(min) Clamp time(min) Circulatory arrest time(min)	258.8 ± 70.5 177.9 ± 54.2 45.5 ± 13.1
Femoral Cannulation Right Left	13 5
CRRT + Homperfusion	6
ICU Stay(day)	10.03 ± 6.34
Central repair Reperfusion followed by central repair Central repair followed by reperfusion	15 4 2
Fasciotomy	1
Tracheotomy	1
Amputation	0
Outcome In hospital mortality	13.6%

The early mortality rate was 17.6%. Seventeen patients were diagnosed with acute type A aortic dissection complicated by limb malperfusion in our study; of those, five patients had visceral malperfusion, while three patients had cerebral malperfusion. All the patients showed hypertension and uncontrolled blood pressure. The mean age of the patients was 53.3 years, with a predominance of men (95.4%). Four patients had pericardial effusion, and none had tamponade. In total, immediate central repair procedure was performed in 68.1% of the cases; four patients underwent restoration of blood flow by stenting followed by central repair; and two patients were sent to the operative room immediately for central repair, after which we assessed the pulse of the artery and restored the flow supply by stenting. Most patients underwent aortic valve plasty and one patient underwent Wheat’s procedure. The mean clamp cross time was 177.9 minutes; 14 patients underwent unilateral irrigation, and 6 patients had bilateral irrigation based on cerebral oxygen saturation. Six patients who were highly suspected to show hyperinflammation received continuous renal replacement therapy (CRRT) combined with HA380(a hemoperfusion device in China) and recovered unevenly. One patient who had underwent the Bentall procedure and hemi-arch replacement due to Debakey II aortic dissection had previously undergone immediate total arch replacement followed by remedial stent implantation. However, he required early fasciotomy because of osteofascial compartment syndrome. Three patients died after central repair, with continuously elevated levels of lactate and unstable hemodynamics. One patient died after stent implantation at the proximal iliofemoral site, which revealed that more proximal iliofemoral malperfusion was correlated with high mortality rates than distal malperfusion ^[8]. Two patients showing complication by multiple organ malperfusion (cerebral, visceral and limb) were discharged voluntarily. Examples of patients with acute type A aortic dissection complicated by limb malperfusion, who were treated with different management strategies(immediate central repair or stent implantation followed by central repair) are shown in Fig. 1.

At follow-up, all the surviving patients showed good outcomes, including those who underwent stenting first followed by central repair, and one patient with fasciotomy is still undergoing rehabilitation training.

Pericardial effusion, aortic regurgitation, a ruptured flap and impaired perfusion are pivotal problems that should be addressed urgently. Most studies have reported poor outcomes of aortic dissection presenting with organ malperfusion ^{[1,9] [3]}. However, although different studies have reported their own experiences and yielded multiple insights into this issue, the optimal management for acute type A aortic dissection with concomitant malperfusion has not been established to be date.

Acute type A aortic dissection with extremity ischemia presents an interesting clinical conundrum regarding whether immediate central repair or limb reperfusion should take precedence. Central aortic repair, prevention of rupture, and direct revascularization of the affected arteries, restores blood flow into the true lumen by entry resection, after which a frozen elephant trunk can be used to expand the false lumen and solve malperfusion. In a retrospective study of 335 patients with acute type A aortic dissection. with or without coexisting limb ischemia, Charlton-Ouw et al adopted a strategy of immediate central repair followed by intraoperative or postoperative assessment to correct any limb ischemia. Malperfusion was resolved in 78.4% of these patients through expeditious central repair, and excellent results were achieved in the remaining patients after timely assessment and intervention. Girardi concluded that vascular malperfusion in the setting of acute type A dissection should be treated with immediate aortic reconstruction, and timely and active early postoperative intervention was essential ^[10]. Orihashi claimed that to solve the practical problems associated with the treatment of acute type A dissection with organ ischemia, real-time information on ischemia organs is very important for detecting changes, which is consistent with the opinions of Girardi et al. ^[11].In contrast, in a study of 1026 patients, Kawahito concluded that the effects of central repair were limited to severe or complex malperfusion, and ,emergency reperfusion of affected organs followed by central repair might be suggested ^[12]. Wakako Fujita reported stenting for acute aortic dissection with malperfusion as a bridge therapy ^[13].Many large-scale studies have emphasized the importance of early reperfusion first, followed by central repair, because in certain cases of severe malperfusion, the mortality from organ failure exceeds the mortality risk associated with rupture ^{[12] [14] [15] [16] [17] [18] [19] [20] [21]}.

As mentioned above, our algorithm was based on physical examination, imaging examinations, laboratory testing, categorization of acute limb ischemia, and evaluation by the cardiac surgeon, interventional cardiologist and anesthetist. We performed Sun’s procedure-total arch replacement using a tetrafurcated graft with stented elephant trunk implantation. Our results showed that most patients achieved good outcomes with central repair.

For the “Southwest of Min Province” district, we have popularized our slogan “Life-saving Circle with 4 hours, as shown in Fig. 1, and patients with suspected aortic dissection in this area can seek first aid at our center because of the importance of prompt treatment in aortic dissection, particularly for aortic dissection complicated by malperfusion. Physiological and anatomical studies have shown that irreversible muscle cell damage begins after 3 h of ischemia and is nearly complete at 6 h^[5].Since transportation and confirmation of diagnose is a time-consuming process, the mean time to restore blood flow in ischemic vessel can be as high as 14 h, which exceeds the muscle cell damage time limit and poses a great challenge to treatment.

The inflammatory responses following limb reperfusion syndrome, which present as hyperinflammation, can result in multiple-organ failure and death ^[5].Common therapeutic approaches such as fluid infusion can decrease the inflammatory response, but it can further aggravate tissue damage and lead to high mortality ^[22]. Extracorporeal hemoperfusion is being increasingly being used for the management of severe inflammatory states. A reduction in the levels of inflammatory mediators can result in good clinical outcomes^[23]. In 2010, Toshinori Totsugawa reported successful intraoperative endotoxin adsorption for visceral malperfusion complicating acute type A aortic dissection. He thought that mesenteric reperfusion could be exacerbated by systemic metabolic abnormalities and that hemoperfusion enables removal of circulating endotoxins before inition of the inflammatory cascade^[24].We recommend routine adsorption combined with continuous renal replacement therapy to remove inflammatory mediators and myoglobin, which will have beneficial therapeutic effects.

Acute type A aortic dissection with organ malperfusion is associated with higher postoperative mortality and morbidity rates ^[3].The GERAADA study revealed that the influence of the number of organs involved on the outcome differs substantially. Organ malperfusion involves cerebral and simultaneous visceral or limb malperfusion, which is challenging for surgeons. In our study, three patients died because of visceral and limb malperfusion manifesting as unstable hemodynamics. Two patients with multiple organ malperfusion were discharged on the basis of their relatives’ accord due to cerebral events, including bleeding and infarction.

This study had several limitations that were inherent to its retrospective design. First, because of the small sample size and limited clinical observation in pour study, well-designed prospective clinical trials are needed to confirm the efficacy of our algorithm. Second, we recognize that acute type A aortic dissection always involves dynamic obstruction by the dissection flap and static obstruction by the thrombosis, or both. Our protocol was primarily based on the clinical categorization of acute limb ischemia, physical examination and laboratory tests, regardless of the morphological state. We firmly believe that a morphological study of the complex extent of the aortic dissection process is crucial for treatment planning, but our staged procedure can achieve good results.

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 are high in cases with multiple organ malperfusion.

ATAAD

acute type a aortic dissection

CTA

computed tomography angiograph

CRRT:continuous renal replacement therapy

Ethics approval and consent to participate

The retrospective study was approved by the ethics committee of Xiamen Cardiovascular Hospital of Xiamen University can conformed to the Declaration of Helsinki. The requirement for informed consent was waived by Xiamen Cardiovascular Hospital based on the retrospective analysis of patient data.

Consent for publication

Not applicable

Funding:

No funding

Conflicts of interest:

No competing interest

Acknowledgements

Not applicable

Author contribution:

All authors take responsibility for the data and its analysis and revise of the manuscript. Xijie Wu designed the study and revised the final manuscript. Shibo Song wrote the manuscript and submitted it. Lin Lu, Hua Peng, Haifeng Qiang, Yuan Wu, Juxiang Wang and Hui Zhuang made substantial changes in the manuscript together. All authors read and approved the final manuscript.

Availability of Data and Material

Raw data supporting the obtained results are available at the corresponding author

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No competing interests reported.

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

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Abstract

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Introduction

Materials And Methods

Management strategies

Results

Discussion

Conclusion

Abbreviations

Declarations

References

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