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.