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Nardi et al. Postoperative malperfusion in aortic dissection

involvement. Occurrences can result in dangerous queries were completely obtained from 214 patients.
end-organ ischemic dysfunctions, especially when
involving the brain. Clinical diagnoses are critical to the Surgical techniques
development of effective treatment strategies. Proper Prior to operative procedures, patients were
diagnoses also have important influence on immediate monitored with Swan-Ganz pulmonary artery
and long-term outcomes of treatment. [3-5] catheters, arterial cannulations to ensure continuous
arterial blood pressure measurements (i.e. radial or
Malperfusion following either type A or type B acute femoral measurements), and corporeal temperature
aortic dissection, is a fairly common complication. measurements (TC) during surgery (i.e. rectal,
It can involve several arterial regions including the esophageal, or tympanic measurements). Additionally,
cerebral, renal, or mesenteric segments, as well as cerebral monitoring was performed with near-infrared
the upper or lower limbs. In the Stanford Classification spectroscopy (INVOS System, Somanetics Corp.,
®
Type A Dissection (De Bakey Classification Types I and Troy, MI, USA) and transcranial Doppler measurements
II) surgical treatment can prevent this complication. In of blood flow velocities in the middle and/or anterior
the event of malperfusion, distal aortic percutaneous cerebral arteries of the Willis circle.
fenestration can allow blood flow to return to the true
lumen. Alternatively, when the distal aortic true lumen The heart was accessed through a complete median
is completely obstructed, an endovascular stent longitudinal sternotomy in all patients. Arterial access
can be inserted to recanalize the lower arteries (i.e. for cardiopulmonary bypass was through either the
the celiac trunk, renal, superior mesenteric and iliac femoral artery (n = 96), the right axillary artery (n =
arteries). The International Registry of Acute Aortic 96), or direct aortic cannulation (n = 22). Aortic repair
Dissection (IRAD) does not include malperfusion as was performed in conditions of circulatory arrest
an independent predictor of mortality. Nonetheless, and moderate hypothermia (25-28 °C) in 124 (58%)
several studies have supported the relevance of patients.
this complication, given that it increased in-hospital
mortality and adversely affected late survival. [6-9] Cerebral perfusion was given in 118 (55.1%) cases.
Fifty-three (24.8%) patients received unilateral
The aim of this study was to evaluate the effect selective antegrade perfusion across the right axillary
of postoperative malperfusion (PM) on in-hospital artery in the right common carotid artery. Sixty-five
mortality and long-term survival in patients undergoing (30.4%) patients received bilateral perfusion using the
surgery for AAAD in a single, high-volume aortic Kazui technique. [10,11]
surgery center.
Table 1: Preoperative characteristics, n (%)
METHODS Variable Overall non-PM PM P
(n = 214) (n = 159) (n = 55) value
Between January 2005 and December 2015, 227 Age (years), mean ± SD 62.5 ± 12.6 62.3 ± 13.5 63.2 ± 10.6 NS
patients (mean age 62.5 ± 12.6 years) underwent Male gender 156 (72.9) 114 42 NS
emergent operations for AAAD. The study was Clinical history
approved by the local Institutional Review Board, which Hypertension 188 (87.9) 138 50 NS
waived the need for patient consent. The preoperative Smoke habit 69 (32.2) 49 20 NS
2
patients’ characteristics are given in Table 1. BMI (kg/m ) > 30 48 (22.4) 33 15 NS
History of CAD 15 (7.0) 10 5 NS
Diabetes on insulin 11 (5.1) 7 4 NS
The diagnosis of malperfusion was based on clinical Previous cardiac surgery 9 (4.2) 6 3 NS
symptoms and/or imaging evidence, i.e. absence Dialisys-dependent
of organ perfusion as determined by computed renal failure 4 (1.8) 1 3 0.02
tomography (CT) scan angiography. Malperfusion, n (%)
Overall malperfusion 119 (55.6)
Malperfusion was classified as: cerebral if there was Brain 68 (31.8) 47 21 NS
presence of a focal or global stroke leading to brain Kidney 38 (17.7) 26 12 NS
function deterioration that persisted more than 24 h, or a Visceral 13 (6.1) 8 5 NS
transient ischemic attack; renal if there was an impairment Entry tear aortic dissection 115 (53.7) 91 24 NS
Ascending aorta
of renal function (e.g. anuria requiring continuous veno- Aortic arch 33 (15.4) 23 10 NS
venous hemofiltration, or a two-fold increase of creatinine Descending aorta 8 (3.7) 3 5 0.02
serum level); or mesenteric if there was evidence of tense Unknown 58 (27.1) 42 16 NS
abdominal or intestinal dysfunction, or increased serum PM: postoperative malperfusion; BMI: body mass index; CAD:
levels of liver and/or pancreatic enzymes. The database coronary artery disease; NS: not significant
78 Vessel Plus ¦ Volume 1 ¦ June 27, 2017