title: Need for Limb Revascularization in Patients with Acute Aortic Dissection is Associated with Mesenteric Ischemia.
abstract: BACKGROUND
  Acute aortic dissection (AAD) can cause limb ischemia due to branch vessel occlusion. A minority of patients have persistent ischemia after central aortic repair and require peripheral arterial revascularization. We investigated whether the need for limb revascularization is associated with adverse outcomes.
  
  
  METHODS
  We reviewed our cases of AAD from 2000 to 2014 and identified patients with malperfusion syndromes (coronary, cerebral, spinal, visceral, renal, or peripheral ischemia). Patients with DeBakey I/II (Stanford type A) dissection had urgent open repair of the ascending aorta. Patients with DeBakey III (Stanford type B) dissection were initiated on anti-impulse medical therapy and had either open aortic repair or thoracic endovascular aortic repair for malperfusion syndromes. Patients with persistent lower limb ischemia after aortic repair usually had either extra-anatomic bypass grafting or iliac stenting. Some DeBakey III patients had peripheral revascularization without central aortic repair. We performed univariate and multivariate analysis to determine the effects of need for limb revascularization and clinical outcomes.
  
  
  RESULTS
  We treated 1,015 AAD patients (501 [49.4%] DeBakey I/II and 514 [50.6%] DeBakey III) with a mean age of 59.7 ± 14.5 years (67.5% males). Aortic repair was performed in all DeBakey I/II patients and in 103 (20.0%) DeBakey III patients. Overall 30-day mortality was 11.3%. Lower limb ischemia was present in 104 (10.3%) patients and was more common in DeBakey I/II compared with DeBakey III dissections (65.4% vs. 34.6%; odds ratio [OR] 2.1, confidence interval [CI] 1.4-3.2; P = 0.001). Among the 40 patients who required limb revascularization, there was no difference in need for revascularization between DeBakey I/II and III patients. Patients requiring limb revascularization were more likely to have mesenteric ischemia compared with the rest of the cohort in both DeBakey I/II (P = 0.037) and DeBakey III dissections (P < 0.001) with worse 10-year survival (21.9 % vs. 59.2%, P < 0.001). When adjusted for other malperfusion syndromes, patients with limb revascularization had similar long-term survival compared to uncomplicated dissection patients (P = 0.960).
  
  
  CONCLUSIONS
  Patients requiring lower limb revascularization after treatment for AAD are more likely to have mesenteric ischemia and worse survival. The need for limb revascularization is a marker for more extensive dissection and should prompt evaluation for visceral malperfusion.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, TX. Electronic address: Kristofer.CharltonOuw@uth.tmc.edu.
authors.forename: Kristofer M
authors.initials: KM
authors.lastname: Charlton-Ouw
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX.
authors.forename: Harleen K
authors.initials: HK
authors.lastname: Sandhu
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX.
authors.forename: Samuel S
authors.initials: SS
authors.lastname: Leake
authors.affiliation: Sydney Medical School, The University of Sydney, Sydney, Australia.
authors.forename: Katherine
authors.initials: K
authors.lastname: Jeffress
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, TX.
authors.forename: Charles C
authors.initials: CC
authors.lastname: Miller
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, TX.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Durham
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, TX.
authors.forename: Tom C
authors.initials: TC
authors.lastname: Nguyen
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, TX.
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Estrera
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, TX.
authors.forename: Hazim J
authors.initials: HJ
authors.lastname: Safi
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, TX.
authors.forename: Ali
authors.initials: A
authors.lastname: Azizzadeh
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D015901:Angiography, Digital Subtraction; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D065666:Mesenteric Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012039:Regional Blood Flow; D012189:Retrospective Studies; D012307:Risk Factors; D013152:Splanchnic Circulation; D015607:Stents; D016896:Treatment Outcome