Endovascular Management of Malperfusion Syndromes in Aortic Dissection

Malperfusion Syndrome (MPS) refers to inadequate perfusion of end organs secondary to ongoing arterial obstruction of the aorta and its branches resulting in increased morbidity and mortality. While uncomplicated type B dissection can typically be monitored, type A or type B dissections with malperfusion syndrome are should be considered for hybrid treatment with an endovascular intervention.  In addition to pre-procedure CTA and labs, intra-procedure evaluation of the true lumen, false lumen, and branch vessels is performed with intravascular ultrasound (IVUS) and manometry to delineate static versus dynamic obstruction. Dynamic obstruction of the visceral arteries is typically treated first and can be relieved either with supraceliac dissection flap fenestration or exclusion of the entry tear by thoracic endovascular aortic repair, both of which will restore flow to the true lumen. Static obstruction requires stenting or other branch-artery intervention including branch artery fenestration, suction embolectomy, or thrombolysis. Throughout the procedure, IVUS and manometry are used to evaluate results of interventions with respect to continued hemodynamically significant obstruction. Endovascular intervention should be performed in conjunction with a multi-disciplinary team as patients are often complex and may require further procedures such as bowel resection or open aortic repair.