Malperfusion in Type A Dissection: Consider Reperfusion First

Acute type A aortic dissection (ATAAD) is a vascular catastrophe, with a mortality of 1% per hour for the first 48 hours without surgical intervention. Of the diverse causes of morbidity and mortality associated with ATAAD, malperfusion, which complicates 20%-50% of cases, is particularly lethal. Although malperfusion can affect any vascular bed, this review focuses on the 3 most devastating: coronary, cerebral, and visceral malperfusion syndromes (MPS). Essentially, there are 3 methods of restoring flow to malperfused areas: central repair, fenestration, and direct revascularization of affected arteries. Of these, emergency central aortic repair is the accepted primary strategy, as it most expeditiously eliminates the risk of rupture, and accordingly, our protocol is to transfer ATAAD cases directly to the operating room. However, central repair is not necessarily the most expedient strategy for resolving malperfusion, and in some cases, malperfusion persists despite central repair. At some point, with certain cases of severe malperfusion, the mortality from end organ damage exceeds the mortality risk of rupture and recent reports suggest that these cases may be best managed by emergency reperfusion of the affected vascular bed, followed by central repair.