title: Management of limb ischemia in acute proximal aortic dissection.
abstract: BACKGROUND
  Management of limb and other malperfusion syndromes is controversial in acute type A aortic dissection. We assessed our hypothesis that urgent proximal aortic repair resolves most cases of limb ischemia without additional peripheral revascularization.
  
  
  METHODS
  We retrospectively reviewed operative cases of acute type A aortic dissection from 1999 to 2011. Our standard technique involved urgent replacement of the ascending aorta and hemiarch. Persistent limb ischemia after aortic repair was treated by bypass surgery. Comparisons between groups both with and without limb ischemia were made.
  
  
  RESULTS
  We repaired 335 cases during the study period. Sixty-one patients had limb ischemia (18.2%), of whom 51 were classified with lower limb ischemia (15.2%). All patients with upper limb ischemia survived to discharge without limb loss or death. Only 11 of the 51 patients with lower limb ischemia (21.6%) required peripheral revascularization after aortic repair. There was one case of lower limb loss resulting from delayed recognition of persistent ischemia. Renal dysfunction occurred in 21% of patients with isolated lower limb ischemia and in 31% of patients with uncomplicated dissection (P = .29). In-hospital mortality was 13.7% overall and 8.0% in patients with isolated lower limb ischemia (P = .89). There was no difference in long-term survival between isolated limb ischemia and uncomplicated cases (P = .54).
  
  
  CONCLUSIONS
  Most cases of limb ischemia resolve after immediate repair of acute type A aortic dissection. There is no difference in renal dysfunction or in-hospital or long-term mortality between patients with isolated limb ischemia and those with nonmalperfusion dissection. If ischemia persists, limb salvage is successful if revascularization is expeditious.
authors: Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School, Houston, TX, USA. Kristofer.CharltonOuw@uth.tmc.edu
authors: Kristofer M
authors: KM
authors: Charlton-Ouw
authors: Kaji
authors: K
authors: Sritharan
authors: Samuel S
authors: SS
authors: Leake
authors: Harleen K
authors: HK
authors: Sandhu
authors: Charles C
authors: CC
authors: Miller
authors: Ali
authors: A
authors: Azizzadeh
authors: Hazim J
authors: HJ
authors: Safi
authors: Anthony L
authors: AL
authors: Estrera
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D000784:Aortic Dissection / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D007668:Kidney / Q000503:physiopathology; D007674:Kidney Diseases / Q000209:etiology / Q000503:physiopathology; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D055815:Young Adult