Abstract
BACKGROUND: We seek to compare the early and late outcomes of reperfusion-first vs. central repair-first strategies in patients with acute type A dissection (ATAAD) complicated by mesenteric malperfusion. METHODS: Among 68 patients, reperfusion-first strategy with superior mesenteric artery (SMA) stenting was adopted in 31 and central repair-first in 37, based on rupture risk and circulatory compromise, severity, time and mechanisms of mesenteric ischemia. Early and late outcomes were compared between two strategies. Follow-up was 100% at 3.3±1.4 years. RESULTS: Mean age was 50.6±11.4 years (59 males, 86.8%). The reperfusion-first group were more likely to have celiac artery involvement (74.2% vs. 48.6%, P =0.033) and peritoneal irritation signs (19.4% vs. 2.7%, P =0.025), while central repair-first group had more tamponade (27% vs. 3.2%, P =0.008). Early mortality was 48.6% (18/37) with central repair-first strategy vs. 19.4% (6/31) in reperfusion-first group ( P =0.012). Reperfusion-first patients had fewer gastrointestinal complications (12.9% vs. 54.1%, P <0.001) and respiratory failure (3.2% vs. 24.3%, P =0.017). At 5 years, SMA stent patency was 84%, and survival was significantly higher in reperfusion-first patients (80.6% vs. 45.9%, P =0.009), with similar freedom from adverse events between two groups (74.9% vs. 76.0%, P =0.812). Tamponade [hazard ratio (HR), 3.093; P =0.023], peritoneal irritation signs (HR, 8.559; P =0.006), and lactate (mmol/l) (HR, 1.279; P <0.001) were predictors for all-cause mortality. CONCLUSIONS: In this series of ATAAD patients with mesenteric malperfusion, the reperfusion-first strategy with SMA stenting significantly reduced the mortality risk and achieved favorable late survival and freedom from adverse events. These results argue favorably for the use of the reperfusion-first strategy in acute type A dissection with mesenteric malperfusion.