SURGICAL STRATEGIES IN MANAGING ORGAN MALPERFUSION AS A COMPLICATION OF AORTIC DISSECTION

Between December 1978 and March 1994, 48 of 312 patients who underwent surgery for aortic dissection were diagnosed with major vascular complications. There were 18 patients,vith type A dissection and 30 patients with type B. In 23 patients with acute dissection, the site of vascular obstruction was the abdominal aorta in 12 patients, brachiocephalic artery in 7, iliac artery in 4, left common carotid artery in 3 and thoracic aorta in 2. In 26 patients with chronic dissection, the site of vascular obstruction was the abdominal aorta in 13 patients, brachiocephalic artery in 10, renal artery in 5, iliac artery in 4, superior mesenteric artery in 2, left common carotid artery in 2 and celiac artery in 1. Fifteen patients underwent proximal repair of the aorta during the acute stage, including the ascending aorta in 6 patients, from ascending aorta to arch in 7, arch to descending aorta in 1, thoracoabdominal aorta in 1, and entry closure in 1. In the acute stage, eight patients had palliative surgery, including aortic fenestration in four patients, axillo-femoral bypass in two, cross-over bypass to the iliac or femoral artery in one, bypass to superior mesenteric artery in one, bypass to the renal artery in one, and ileum resection in one. During the chronic phase, seven patients with type B dissection, who had malperfused unilateral renal artery, underwent proximal aortic repair. Nineteen patients underwent palliative surgery in the chronic stage, including fenestration and graft replacement of the abdominal aorta in 15 patients, aorto-femoral bypass in 1, axillo-femoral bypass in 2, cross-over bypass to femoral artery in 1, and leg amputation in 1. Twenty-two patients, including 19 patients who had prior palliation, underwent aortic repair, which comprised Bentall operation in 1 patient, graft replacement of the arch in 2, descending aorta in 16, thoracoabdominal aorta in 1, and patch repair of the entry in 1. Six patients who underwent aortic repair during the acute phase died of multiorgan failure in two, bleeding in two, low cardiac output in one, stroke in one, and rupture of the descending aorta in one, Two patients who underwent palliation during the acute phase died of acute myonephropathic-metabolic syndrome. Four patients treated during the chronic stage died of acute renal failure (2) or low cardiac output syndrome (2). During subsequent follow-up, there were four deaths, due to multiorgan failure after redo-aortic surgery in one, lung cancer in one, stroke in one, and pulmonary emboli in one. Organ malperfusion caused by aortic dissection requires accurate and prompt diagnosis and appropriate intervention to prevent irreversible organ damage secondary to ischemia.