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Revascularization-first strategy in acute aortic dissection with mesenteric malperfusion
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  • Kayo Sugiyama,
  • Hirotaka Watanuki,
  • Masaho Okada,
  • Yasuhiro Futamura,
  • Rei Wakayama,
  • Katsuhiko Matsuyama
Kayo Sugiyama
Aichi Medical University
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Hirotaka Watanuki
Aichi Ika Daigaku
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Masaho Okada
Aichi Medical University School of Medicine
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Yasuhiro Futamura
Aichi Medical University Hospital
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Rei Wakayama
Aichi Medical University
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Katsuhiko Matsuyama
Aichi Medical University Hospital
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Peer review status:ACCEPTED

20 Jun 2020Submitted to Journal of Cardiac Surgery
22 Jun 2020Submission Checks Completed
22 Jun 2020Assigned to Editor
22 Jun 2020Reviewer(s) Assigned
01 Jul 2020Review(s) Completed, Editorial Evaluation Pending
06 Jul 2020Editorial Decision: Revise Major
24 Jul 20201st Revision Received
27 Jul 2020Submission Checks Completed
27 Jul 2020Assigned to Editor
27 Jul 2020Reviewer(s) Assigned
31 Jul 2020Review(s) Completed, Editorial Evaluation Pending
05 Aug 2020Editorial Decision: Accept

Abstract

Background: Mesenteric malperfusion is a complication with a higher risk of in-hospital mortality because diagnosing mesenteric ischemia before necrotic change is difficult, and when it occurs, the patient’s condition has worsened. Although it contradicts the previous consensus on central repair-first strategy, the revascularization-first strategy was found to be significantly associated with lower mortality rates. The aim of this study is to present our revascularization-first strategy and assess the postoperative results for acute aortic dissection involving mesenteric malperfusion. Methods: Among 58 patients with acute type A aortic dissection at our hospital between January 2017 and December 2019, mesenteric malperfusion was noted in six. Four hemodynamically stable patients underwent mesenteric revascularization with endovascular intervention in a hybrid operation room before central repair, and two hemodynamically unstable patients underwent central repair before mesenteric revascularization. Results: No in-hospital mortality was recorded. All four patients with mesenteric revascularization-first strategy recovered with no symptoms related to mesenteric ischemia. Two patients with central repair-first strategy developed paralytic ileus for 1 week; one of them needed explorative laparotomy, but no patients needed colon resection. Conclusion: The revascularization-first strategy in cases of acute type A aortic dissection with mesenteric malperfusion may achieve favorable results. However, in cases with other-major organ malperfusion or having hemodynamically unstable status, the appropriate strategy is controversial. Close evaluation of mesenteric perfusion using multiple modalities and prompt revascularization are mandatory in these complicated cases. A hybrid operation room provides an ideal environment for this revascularization-first strategy.