title: Management of visceral malperfusion complicated with acute type A aortic dissection.
abstract: OBJECTIVE
  The extent of visceral malperfusion due to acute type A aortic dissection remains difficult to assess in view of the clinical signs that typically present at a late stage. We suspected that visceral malperfusion can persist after proximal aortic graft replacement despite redirecting blood flow into the true lumen. We therefore evaluated the operative outcomes of visceral malperfusion complicated with acute type A aortic dissection.
  
  
  METHODS
  Among 121 patients with acute type A aortic dissection treated at our hospital between January 2000 and December 2014, 10 (8.2%) were preoperatively complicated with visceral malperfusion. Eight of them had been treated by visceral arterial branch bypass followed by central repair, and 2 with circulatory instability had undergone central repair followed by laparotomy.
  
  
  RESULTS
  The 2 patients who underwent initial central repair required extensive intestinal resection due to necrosis and died of multiple organ failure related to visceral necrosis in hospital (hospital mortality rate, 20.0%). The ischaemic time (interval between the onset of dissection and visceral arterial revascularization) was significantly longer for patients who initially underwent central repair compared with those who were initially treated by visceral arterial revascularization. However, base excess and lactate levels did not significantly differ between the two groups.
  
  
  CONCLUSIONS
  We believe that if visceral ischaemia is severe and extensive in patients with type A aortic dissection, abdominal surgery should proceed before the aorta is surgically approached to avoid further irreversible ischaemic damage caused by circulatory arrest in organs with compromised perfusion.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan y3104@med.u-ryukyu.ac.jp.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Yamashiro
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.
authors.forename: Ryoko
authors.initials: R
authors.lastname: Arakaki
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.
authors.forename: Yuya
authors.initials: Y
authors.lastname: Kise
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Inafuku
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.
authors.forename: Yukio
authors.initials: Y
authors.lastname: Kuniyoshi
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D007564:Japan / Q000453:epidemiology; D007813:Laparotomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed; D014656:Vascular Surgical Procedures / Q000379:methods*; D014781:Viscera / Q000098:blood supply*
keywords: Aortic dissection; Superior mesenteric artery ischaemia; Visceral malperfusion