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Clinical Presentation, Management, and Short-Term Outcome of Patients With Type A Acute Dissection Complicated by Mesenteric Malperfusion: Observations From the International Registry of Acute Aortic Dissection
Study Questions:
What are clinical characteristics and outcomes of patients with type A acute dissection with and without mesenteric malperfusion, and how do outcomes vary as a function of therapeutic strategy (i.e., surgical/hybrid, endovascular, or exclusively medical management)?
Methods:
This was a retrospective analysis of 1,809 consecutive patients with type A acute dissection enrolled at 18 institutions between December 1995 and August 2010, in the International Registry of Acute Dissection (IRAD). Patients were categorized according to presence/absence of mesenteric malperfusion. All patients were classified according to three different therapeutic strategies: surgical/hybrid, endovascular, and exclusively medical therapy. Statistical analysis was used to identify predictors of in-hospital mortality in patients with mesenteric malperfusion.
Results:
Mesenteric malperfusion was detected in 68 (3.7%) of 1,809 patients with type A acute dissection. Overall in-hospital mortality was 63.2% (43 of 68) and 23.8% (414 of 1,741) in patients with and without mesenteric malperfusion, respectively (p < 0.001). In-hospital mortality of patients with mesenteric malperfusion receiving medical, endovascular, and surgical/hybrid therapy was 95.2% (20 of 21), 72.7% (8 of 11), and 41.7% (15 of 36), respectively (p < 0.001). Patients with mesenteric malperfusion were less likely to undergo surgical/hybrid treatment (52.9% vs. 87.9%, p < 0.001) and more likely to receive medical (30.9% vs. 11.6%; p < 0.001) or endovascular (16.2% vs. 0.5%; p < 0.001) management, when compared with patients without mesenteric malperfusion.
Conclusions:
While rare, type A acute aortic dissection complicated by mesenteric malperfusion carries a high risk of hospital mortality. When compared to exclusively medical or endovascular therapy, surgical/hybrid therapy is associated with the lowest in-hospital mortality.
Perspective:
This analysis of the IRAD database establishes the potential lethality of type A acute aortic dissection complicated by mesenteric malperfusion. Almost two-thirds of patients with mesenteric malperfusion died during hospitalization. Surgical/hybrid management appears to be associated with a better outcome, but patients with mesenteric malperfusion were less likely to undergo surgical treatment and more likely to receive medical or endovascular therapy. Although this analysis cannot establish the best therapeutic option for the management of type A acute dissection complicated by mesenteric ischemia, it does call attention to the potential underuse of the therapeutic strategy that may be associated with the best outcomes in this particularly vulnerable population.
Keywords: Hospital Mortality, Mesentery
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