RESULTS
A total of 58 patients were admitted with AAD involving the ascending
aorta. Of these patients, 6 (10%) presented with mesenteric
malperfusion. Baseline characteristics of these patients are presented
in Table I. The mean age was 58 (range, 46–72) years, and 5 patients
were men (83%). All 6 patients showed static dissection in the SMA
(Figure 2a, 2b), and 2 of them showed dissection in the celiac artery.
Three patients complained of abdominal pain, and all 6 patients
presented metabolic acidosis with elevated lactate and decreased base
excess. History of current smoking was detected in all 6 patients,
untreated hypertension was detected in 5, chronic respiratory diseases
including sleep apnea syndrome was detected in 3, chronic kidney disease
was found in 1 patient and paroxysmal atrial fibrillation was found in 1
patient. No patients had a family history of aortic dissection.
One patient had cerebral malperfusion, and 2 had moderate to severe
aortic valve regurgitation. No patients had cardiopulmonary
resuscitation and myocardial infarction; however, 2 patients presented
with hemodynamic instability due to cardiac tamponade.
Operative procedures and outcomes are presented in Table II. Four
patients underwent revascularization-first strategy in the hybrid OR,
and 2 underwent central aortic repair prior to revascularization because
of hemodynamic instability. As central aortic repair, total arch and
hemiarch replacement were performed in 3 patients each. Pulmonary vein
isolation was performed in 1 patient concomitantly. All patients were
weaned from cardiopulmonary bypass uneventfully. After surgery, 2
patients with central repair-first strategy underwent IVR for mesenteric
malperfusion. Explorative laparotomy (Figure 1b) was performed in 1
central repair-first patient because of prolonged metabolic acidosis
during surgery. Because the small bowel was viable but poorly perfused
entirely, the patient underwent prompt IVR with the chest open; as a
result, colon resection was not required. Another patient underwent IVR
immediately after central repair because of prolonged metabolic acidosis
after surgery. After IVR, because the acidosis was improved to a normal
range, colon resection was not required. All IVR procedures were
performed successfully (Figure 3a, 3b). Endovascular stenting to the SMA
was performed in all 6 patients, and stenting to celiac artery was
performed in 1. All 4 patients with revascularization-first strategy
recovered with no symptoms. On the contrary, 2 patients with central
repair-first strategy developed paralytic ileus for 1 week (Figure 1c).
No in-hospital mortality was recorded. Postoperative cerebral infarction
occurred in 2 of central repair-first patients and tracheostomy was
needed in them. Postoperatively, paroxysmal atrial fibrillation was
observed in 2 patients and no patients had renal complications. During
follow-up, MAAE occurred in 2 patients; additional thoracic endovascular
aortic repair (1 patient) in 7 months and redo total arch replacement (1
patient) in 3 months were performed. Major adverse cardiac or
cerebrovascular events occurred in 4 patients, of whom 3 developed
stroke; 2 had a cerebral infarction during hospital days and the other
had 3 months later, and 1 needed percutaneous catheter intervention in
10 months. One late mortality due to pneumonia was recorded in central
repair-first patients.