Comparison of reperfusion- and central repair-first strategies for acute type a dissection with mesenteric malperfusion: a single-center retrospective cohort study

Background: We seek to compare the early and late outcomes of reperfusion-first versus central repair-first strategies in patients with acute type A dissection (ATAAD) complicated by mesenteric malperfusion. Methods: Among 68 patients, reperfusion-first strategy with superior mesenteric artery (SMA) stenting was adopted in 31 and central repair-first in 37, based on rupture risk and circulatory compromise, severity, time and mechanisms of mesenteric ischemia. Early and late outcomes were compared between two strategies. Follow-up was 100% at 3.3±1.4 years. Results: Mean age was 50.6±11.4 years (59 males, 86.8%). The reperfusion-first group had more celiac artery involvement (74.2% vs. 48.6%) and peritoneal irritation signs (19.4% vs. 2.7%), while central repair-first group had more tamponade (27% vs. 3.2%). Early mortality was 48.6% (18/37) with central repair-first strategy versus 19.4% (6/31) in reperfusion-first group ( P =0.012). Reperfusion-first patients had fewer gastrointestinal complications (12.9% vs. 54.1%, P <0.001) and respiratory failure (3.2% vs. 24.3%, P =0.017). At 5 years, SMA stent patency was 84%, and survival was significantly higher in reperfusion-first patients (80.6% vs. 45.9%, P =0.009), with similar freedom from adverse events between two groups (74.9% vs. 76.0%, P =0.812). Tamponade (hazard ratio [HR], 3.093; P =0.023), peritoneal irritation signs (HR, 8.559; P =0.006), and lactate (mmol/L) (HR, 1.279; P <0.001) were predictors for all-cause mortality. Conclusions: In this series of ATAAD patients with mesenteric malperfusion, the reperfusion-first strategy with SMA stenting could significantly reduce the mortality risk and achieved favorable late survival and freedom from adverse events. These results argue favorably for the use of the reperfusion-first strategy in such patients.