Extended arch repair with aortic-femoral/iliac bypass if necessary for treating lower extremity malperfusion secondary to acute type A aortic dissection

Abstract

In patients with acute type A aortic dissection (ATAAD) complicated by lower extremity (LE) malperfusion (MP), the optimal surgical approach and its outcomes remain a topic of debate. This study aimed to assess both in-hospital and midterm outcomes of our strategy, which involves extended arch repair with additional aortic-femoral or iliac bypass when required, for managing ATAAD with LE-MP. The study included 92 patients with ATAAD and LE-MP and 588 without MP who underwent surgical repair at our center over a 7-year period. From this cohort, 90 matched pairs (1:1) were selected. In-hospital and midterm outcomes were compared between groups in both unmatched and matched cohorts. Additional outcomes, including rates of lower-limb ischemia resolution after central repair alone, limb loss, and bypass patency, were documented. In total, 81 (88.0 %) LE-MP patients achieved resolution of lower-limb ischemia following extended arch repair alone, while 11 required additional aortic-femoral or iliac bypass procedures during the initial repair. Postoperatively, four (4.3 %) LE-MP patients underwent re-intervention due to persistent limb ischemia, with one (1.1 %) eventually requiring a minor amputation. In-hospital mortality for ATAAD patients with LE-MP was 15.2 %, significantly higher than that observed in ATAAD patients without MP (p < 0.001). LE-MP was associated with elevated operative mortality and morbidity in both multivariable and propensity score analyses, and a high cumulative mortality in Cox regression (HR 3.6, 95 % CI 2.2–5.7, p < 0.001). Patent aortic-femoral or aortic-iliac bypass was observed in six (85.7 %) patients during a median follow-up period of 26.1 months. Preoperative LE-MP in ATAAD patients is linked to poorer outcomes. Extended arch repair with selective aortic-femoral or iliac bypass may represent an effective strategy for treating ATAAD with LE-MP. • Key Findings: • With 15.2 % in-hospital morality, 92 patients with ATAAD and LE-MP were treated by our strategy. • After extended arch repair, 88.0 % patients achieved resolution of lower-limb ischemia. • 85.7 % patients with patent aortic-femoral/iliac bypass during a median follow-up of 26.1 months.