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Mesenteric ischemia in acute aortic dissection

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Abstract

Mesenteric ischemia complicated by acute aortic dissection (AAD) is uncommon, but serious, as there is no established treatment strategy and it can progress rapidly to multi-organ failure. Diagnosing mesenteric ischemia before necrotic change is difficult, not only for primary care physicians, but even for gastrointestinal or cardiovascular surgeons as it can occur at any time during surgery. Thus, measures need to be in place at the bedside to enable us to obtain information on visceral perfusion. It is often difficult to decide which of laparotomy or aortic repair should be performed first, especially when there is associated shock or malperfusion of other vital organs. The standard surgical procedures for mesenteric ischemia are prompt revascularization of the mesenteric artery and, if needed, resection of necrotic intestine. However, the development of endovascular treatment and the introduction of hybrid ORs have improved the treatment strategies for mesenteric ischemia. This article reviews the issues of “diagnosis” in relation to the mechanism of mesenteric ischemia, and discusses the current “treatment strategies”.

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References

  1. Di Eusanio M, Trimarchi S, Patel HJ, Hutchison S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013;145:385–90.

    Article  PubMed  Google Scholar 

  2. Yagdi T, Atay Y, Engin C, Mahmudov R, Tetik O, Iyem H, et al. Impact of organ malperfusion on mortality and morbidity in acute type A aortic dissections. J Card Surg. 2006;21:363–9.

    Article  PubMed  Google Scholar 

  3. Harrington DK, Ranasinghe AM, Shah A, Oelofse T, Bonser RS. Recommendations for haemodynamic and neurological monitoring in repair of acute type a aortic dissection. Anesthesiol Res Pract. 2011;2011:949034.

    PubMed  PubMed Central  Google Scholar 

  4. Yamashiro S, Kuniyoshi Y, Kise Y, Arakaki R. Delayed visceral malperfusion after Bentall procedure for type A acute aortic dissection. Interact CardioVasc Thorac Surg. 2012;15:794–6.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Ito T, Yasuda N, Kuroda Y, Sugawara M, Koyanagi T, Higami T. Acute gallbladder necrosis in a patient with acute type B aortic dissection. Ann Vasc Dis. 2013;6:748–50.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Muraki S, Fukada J, Morishita K, Kawaharada N, Abe T. Acute type A aortic dissection with intestinal ischemia predicted by serum lactate elevation. Ann Thorac Cardiovasc Surg. 2003;9:79–80.

    PubMed  Google Scholar 

  7. Watari M, Murakami H, Orihashi K, Sueda T, Matsuura Y, Kajihara H. Ammonia determination as an early indicator in experimental superior mesenteric artery occlusion. Hiroshima J Med Sci. 1997;46:159–67.

    CAS  PubMed  Google Scholar 

  8. Akutsu K, Matsuda H, Sasaki H, Minatoya K, Ogino H, Kasai S, et al. A case of acute type B aortic dissection: limited role of laboratory testing for the diagnosis of mesenteric ischemia. Ann Thorac Cardiovasc Surg. 2007;13:360–4.

    PubMed  Google Scholar 

  9. Güzel M, Sözüer EM, Salt Ö, İkizceli İ, Akdur O, Yazıcı C. The value of the serum I-FABP level for diagnosing acute mesenteric ischemia. Surg Today. 2014;44:2072–6.

    Article  PubMed  Google Scholar 

  10. Kurimoto Y, Morishita K, Fukada J, Kawaharada N, Komatsu K, Yama N, et al. A simple but useful method of screening for mesenteric ischemia secondary to acute aortic dissection. Surgery. 2004;136:42–6.

    Article  PubMed  Google Scholar 

  11. Davis CB, Kendall JL. Emergency bedside ultrasound diagnosis of superior mesenteric artery dissection complicating acute aortic dissection. J Emerg Med. 2013;45:894–6.

    Article  PubMed  Google Scholar 

  12. Orihashi K, Matsuura Y, Sueda T, Shikata H, Morita S, Hirai S, et al. Abdominal aorta and visceral arteries visualized by transesophageal echocardiography: technical considerations. Hiroshima J Med Sci. 1997;46:151–7.

    CAS  PubMed  Google Scholar 

  13. Orihashi K, Matsuura Y, Sueda T, Shikata H, Morita S, Hirai S, et al. Abdominal aorta and visceral arteries visualized with transesophageal echocardiography during operations on the aorta. J Thoracic Cardiovasc Surg. 1998;115:945–7.

    Article  CAS  Google Scholar 

  14. Orihashi K, Sueda T, Okada K, Imai K. Perioperative diagnosis of mesenteric ischemia in acute aortic dissection by transesophageal echocardiography. Eur J Cardiothorac Surg. 2005;28:871–6.

    Article  PubMed  Google Scholar 

  15. Ferlan G, Lospalluti M, Capone G, De Pasquale C. Mesenteric ischemia in a patient with an acute aortic dissection type A. One-step repair of the aortic and visceral lesions. Role of laparoscopy for timely diagnosis and treatment. Interact Cardiovasc Thorac Surg. 2011;12:835–6.

    Article  PubMed  Google Scholar 

  16. Tshomba Y, Coppi G, Marone EM, Bertoglio L, Kahlberg A, Carlucci M, et al. Diagnostic laparoscopy for early detection of acute mesenteric ischaemia in patients with aortic dissection. Eur J Vasc Endovasc Surg. 2012;43:690–7.

    Article  CAS  PubMed  Google Scholar 

  17. Orihashi K. Malperfusion in acute type a aortic dissection: unsolved problem. Ann Thorac Surg. 2013;95:1570–6.

    Article  PubMed  Google Scholar 

  18. Yamamoto M, Orihashi K, Nishimori H, Wariishi S, Fukutomi T, Kondo N, et al. Indocyanine green angiography for intra-operative assessment in vascular surgery. Eur J Vasc Endovasc Surg. 2012;43:e426–32.

    Article  Google Scholar 

  19. Orihashi K, Matsuura Y, Sueda T, Watari M, Okada K. Reversible visceral ischemia detected by transesophageal echocardiography and near-infrared spectroscopy. J Thorac Cardiovasc Surg. 2000;119:384–6.

    Article  CAS  PubMed  Google Scholar 

  20. Odagiri S, Koide S, Ariizumi K, Suzuki I, Kamabuchi K, Inamura S, et al. Successful right common iliac to superior mesenteric artery bypass for mesenteric ischemia associated with acute aortic dissection: report of a case. Surg Today. 1993;23:1014–7.

    Article  CAS  PubMed  Google Scholar 

  21. Shimamoto T, Komiya T. Clinical dilemma in the surgical treatment of organ malperfusion caused by acute type A aortic dissection. Gen Thorac Cardiovasc Surg. 2014;62:398–406.

    Article  PubMed  Google Scholar 

  22. Hisata Y, Matsumaru I, Yokose S, Hazama S. Successful repair of mesenteric ischemia in acute type A aortic dissection. Asian Cardiovasc Thorac Ann. 2014 [Epub ahead of print].

  23. Okada Y, Okimoto M, Katsumata M, Takeuchi S. Temporary perfusion for mesenteric ischemia with acute type A aortic dissection. Ann Thorac Surg. 2007;83:293–4.

    Article  PubMed  Google Scholar 

  24. Iida Y, Obitsu Y, Shigematsu H. Use of side branch of total arch replacement graft as bypass inflow to prevent visceral ischemia with type B aortic dissection. Gen Thorac Cardiovasc Surg. 2012;60:440–2.

    Article  PubMed  Google Scholar 

  25. Kato W, Fujita T, Uchida K, Munakata H, Hibino M, Fujii K, et al. Superior mesenteric artery plasty for type A acute aortic dissection with visceral ischemia. Gen Thorac Cardiovasc Surg. 2014 [Epub ahead of print].

  26. Linsen MA, Avontuur JA, Vos AW, Rauwerda JA, Wisselink W. False lumen thrombectomy of the superior mesenteric artery followed by iliomesenteric bypass after Stanford type B aortic dissection. Vascular. 2004;12:331–4.

    Article  PubMed  Google Scholar 

  27. Okada K, Sueda T, Orihashi K, Imai K, Sugawara Y, Hamamoto M. Rescue visceral revascularization without direct aortic surgery to treat malperfusion complicating type B aortic dissection. Ann Thorac Surg. 2005;80:318–20.

    Article  PubMed  Google Scholar 

  28. Kuo HN, Lai HC, Chang YW, Wang CC, Lee WL, Chan SW, et al. Axillofemoral bypass relieves visceral malperfusion in type B aortic dissection. Ann Thorac Surg. 2013;95:703–5.

    Article  PubMed  Google Scholar 

  29. Connell DA, Thomson KR, Gibson RN, Wall AJ. Stent placement in coeliac and superior mesenteric arteries to restore vascular perfusion following aortic dissection. Australas Radiol. 1995;39:68–70.

    Article  CAS  PubMed  Google Scholar 

  30. Saitoh Y, Ohmori H, Hari Y, Setozaki S, Harada H, Soeda T. Mesenteric artery fenestration for type B dissection with visceral ischemia. Asian Cardiovasc Thorac Ann. 2012;20:463–5.

    Article  PubMed  Google Scholar 

  31. Leprince P, Cluzel P, Bonnet N, Izzillo R, Pavie A, Gandjbakhch I. An endovascular stent relieves celiac and mesenteric ischemia in acute aortic dissection. Ann Thorac Surg. 2004;78:e3–5.

    Article  PubMed  Google Scholar 

  32. Massmann A, Kunihara T, Fries P, Schneider G, Buecker A, Schäfers HJ. Uncovered stent implantation in complicated acute aortic dissection type B. J Thorac Cardiovasc Surg. 2014;148:3003–11.

    Article  PubMed  Google Scholar 

  33. Vedantham S, Picus D, Sanchez LA, Braverman A, Moon MR, Sundt T 3rd, et al. Percutaneous management of ischemic complications in patients with type-B aortic dissection. J Vasc Interv Radiol. 2003;14(2 Pt 1):181–94.

    Article  PubMed  Google Scholar 

  34. Szeto WY, McGarvey M, Pochettino A, Moser GW, Hoboken A, Cornelius K, et al. Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection. Ann Thorac Surg. 2008;86:87–93.

    Article  PubMed  Google Scholar 

  35. Arthurs ZM, Titus J, Bannazadeh M, Eagleton MJ, Srivastava S, Sarac TP, et al. A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. J Vasc Surg. 2011;53:698–704.

    Article  PubMed  Google Scholar 

  36. Leshnower BG, Veeraswamy RK, Duwayri YM, Chen EP. The “TEVAR-first” approach to DeBakey I aortic dissection with mesenteric malperfusion. Ann Thorac Surg. 2014;97:693–6.

    Article  PubMed  Google Scholar 

  37. Fabre O, Vincentelli A, Willoteaux S, Beregi JP, Prat A. Preoperative fenestration for type A acute aortic dissection with mesenteric malperfusion. Ann Thorac Surg. 2002;73:950–1.

    Article  PubMed  Google Scholar 

  38. Tanaka K, Chikazawa G, Sakaguchi T, Totsugawa T, Tamura K, Yoshitaka H. Hybrid treatment for type A acute aortic dissection with multiorgan malperfusion. Ann Thorac Surg. 2014;98:1118–20.

    Article  PubMed  Google Scholar 

  39. Li M, Shu C, Li QM, Wang T, Fang K, Wang ZG. Midterm results of intentional celiac artery coverage during TEVAR for type B aortic dissection. J Endovasc Ther. 2013;20:276–82.

    Article  PubMed  Google Scholar 

  40. Kalangos A, Gemayel G, Vala D, Khabiri E, Mugnai D, Murith N. Ascending aorto-superior mesenteric artery bypass as a surgical option for revascularization in mesenteric ischemia associated with type B aortic dissection. Ann Vasc Surg. 2014;28:1036.

    Article  PubMed  Google Scholar 

  41. Holfeld J, Gottardi R, Zimpfer D, Funovics M, Schoder M, Holzenbein T, et al. Bail-out visceral bypass grafting for acute intestinal ischemia after endovascular stent-graft placement in a complicated type B dissection. Thorac Cardiovasc Surg. 2009;57:110–1.

    Article  CAS  PubMed  Google Scholar 

  42. Böckler D, Ockert S, Schumacher H, Allenberg JR. Images in vascular medicine. Undiagnosed fatal mesenteric ischemia in acute type B aortic dissection. Vasc Med. 2006;11:133–4.

    Article  PubMed  Google Scholar 

  43. Totsugawa T, Ozawa M, Kuinose M, Ishii S, Yoshitaka H, Tamaki T. Intraoperative endotoxin adsorption for visceral malperfusion complicating acute type A aortic dissection. Gen Thorac Cardiovasc Surg. 2010;58:134–7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiovascular Surgery, Second Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan

    Kazumasa Orihashi

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  1. Kazumasa Orihashi
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Correspondence to Kazumasa Orihashi.

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Orihashi, K. Mesenteric ischemia in acute aortic dissection. Surg Today 46, 509–516 (2016). https://doi.org/10.1007/s00595-015-1193-4

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