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Address for reprints: Minhaj S. Khaja, MD, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22902.
Affiliations
Division of Vascular and Interventional Radiology, Department of Radiology & Medical Imaging, University of Virginia Health, Charlottesville, VaDivision of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Mich
Mesenteric malperfusion is a feared complication of aortic dissection, with high mortality. The purpose of this study was to systematically review in-hospital mortality (IHM) of endovascular and surgical management of acute and chronic Stanford type B aortic dissections (TBAD) complicated by mesenteric malperfusion (MesMP).
Methods
A systematic search of English language articles was conducted in relevant databases. Data on patient demographics, procedure details, and survival outcomes were collected. Reports were classified by type of intervention performed. Studies that failed to report patient-level outcomes based on specific intervention performed or IHM were excluded. Retrospective chart review of previously published data from a single institution was also performed to further identify cases of TBAD that were managed endovascularly. The Fisher exact test was performed to determine statistical significance.
Results
In total, 37 articles were suitable for inclusion in this systematic review, which yielded 149 patients with a median age 55.0 years (interquartile range, 46.5-65 years) and 79% being male. Overall, in-hospital mortality was 12.8% (19/149) and was similar between endovascular and open surgical interventions (13% vs 11%, P = .99). Among endovascular strategies, IHM was greater, although not statistically significant in the thoracic endovascular aortic repair group compared with the fenestration/stenting without thoracic endovascular aortic repair group (24% vs 11%, P = .15).
Conclusions
Multiple strategies exist for the management of TBAD with MesMP; however, a majority of cases were managed endovascularly. Despite advances in therapies, mortality remains high at 13%.
Endovascular and surgical management of type B aortic dissection with mesenteric malperfusion (TBAD-MesMP) have comparable in-hospital mortalities, which remain high despite advances in therapies.
Type B aortic dissection complicated with mesenteric malperfusion may be managed with open, endovascular, and hybrid treatment strategies, all of which still have significant in-hospital mortality and necessity for bowel resection despite advances in therapy. Further research into choosing the appropriate therapy is required.
Type B aortic dissection (TBAD) is a life-threatening condition in which a tear develops in the intima of the aortic wall distal to the origin of the left subclavian artery. TBADs are often stratified into uncomplicated versus complicated to determine management strategy. The standard of care for uncomplicated TBAD is medical management with blood pressure and heart rate control to prevent aortic rupture and propagation of the dissection. Complicated TBAD denotes dissection accompanied by aortic rupture, refractory pain, rapid aortic expansion, uncontrollable hypertension, or malperfusion.
Malperfusion syndrome is decreased flow to vascular territory resulting in tissue/end-organ necrosis and dysfunction secondary to dissection-related impairment of blood flow. In particular, mesenteric malperfusion (MesMP) has been associated with a particularly poor prognosis and a significant increase in mortality (3- to 4-fold increase).
), bloody diarrhea, tenderness to palpation, diminished blood flow in the superior mesenteric artery (SMA) with or without SMA thrombosis on computed tomography (CT) imaging, and signs of ischemia, such as thickened bowel wall, elevated lactate, and metabolic acidosis.
The signs and symptoms of MesMP can be persistent or intermittent, contributing to the diagnostic challenge, but the symptoms often correlate to the degree of obstruction.
Dynamic obstruction results from prolapse of the dissection flap across or into the ostium of the branch vessel, thereby obstructing flow with a degree of obstruction varying with blood pressure. Paradoxically, in many cases visceral organ perfusion improves with reduction in systemic blood pressure.
Dynamic obstruction can usually be resolved with restoration of the true lumen in continuity with the heart. In contrast, static obstruction results from extension of the dissection into the branch vessel with inadequate or absent reentry based on manometry. Static obstruction must be relieved by an intervention targeting the particular mechanism of true lumen compromise including stenting, thrombolysis, thromboembolectomy, and fenestration.
The presence of MesMP in type B aortic dissection classifies it as a complicated TBAD, therefore necessitating intervention following initial medical stabilization. With the advent of endovascular therapies over recent years, multiple options exist for treating complicated type B aortic dissection, including thoracic endovascular aortic repair (TEVAR), fenestration and stenting, and open surgical repair.
Endovascular therapy, specifically TEVAR, has been established as superior to open surgical repair for complicated TBAD in multiple studies and reviews.
Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy.
However, the primary goal of TEVAR is to cover the primary intimal tear to restore true lumen flow, which can resolve dynamic obstruction but does not reliably relieve static obstruction, which may require further intervention such as branch vessel stenting, thrombolysis, or thromboembolectomy. Endovascular fenestration with or without stenting with ancillary procedures such as thrombolysis can resolve both dynamic and static obstructions
in one setting. Therefore, multiple options are available for the treatment of complicated TBAD; however, the optimal strategy remains uncertain and will depend on the mechanism of obstruction. Herein we report a systematic review to evaluate the different treatment strategies for TBAD complicated by MesMP syndrome.
Methods
A systematic review was conducted of published literature on surgical or endovascular interventions performed for TBAD complicated by MesMP. This study was deemed exempt from formal institutional review by the institutional review board because identifiable human subjects were not studied. A systematic review of published literature on TBAD-MesMP was performed in adherence to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.
Microsoft Excel (Microsoft) was used during article selection and data extraction. The present study encompasses peer-reviewed articles written in English.
Literature Search Strategy
The PubMed database (including articles indexed in Medline), Web of Science, and Ovid were searched from 1980 until 2020. The search was performed using varying combinations of the following key words: “TBAD,” or “CTBAD,” or “complicated type B,” or “aortic dissection,” and “visceral malperfusion,” or “visceral ischemia,” or “mesenteric malperfusion,” or “mesenteric ischemia,” or “renal malperfusion,” or “renal ischemia,” or “bowel malperfusion,” or “bowel ischemia.”
Eligibility Criteria
Upon completion of the literature search, article selection was executed in a 2-step approach involving abstract review, followed by full-text review. First, any publications gathered during the primary literature search were grouped by title, and duplicates were removed. Subsequently, each abstract was assessed for relevance by 2 of the authors, and any interauthor disagreement concerning article relevance was discussed between the authors; if agreement could not be reached, the article was arbitrated by the senior corresponding author. Exclusion criteria during the abstract review phase are outlined in the Preferred Reporting Items for Systematic Review and Meta-Analysis flow diagram (Figure 1); studies were excluded for the following reasons: (1) study did not report type B aortic dissection; (2) study did not report patients who had visceral ischemia as a presenting sign; (3) study did not report an endovascular or surgical intervention; (4) study was unrelated, that is, involving ischemia of nonaortic etiology, interventions on non-native aorta, laboratory measurement studies, diagnostic techniques, or animal or in vitro studies; (5) study abstract was not written in English; (6) study was a conference abstract, letter to editor, commentary, review article, or meta-analysis article; or (7) study abstract was unavailable. In some instances, studies that did not explicitly state our inclusion criteria but were suggestive thereof were advanced to full-text review for further evaluation.
Figure 1PRISMA flow diagram documenting the selection process for articles included in the meta-analysis. No TBAD category includes papers focused on: TAAD, or non-A non-B aortic dissection. Unrelated category includes papers focused on: ischemia of non-aortic etiology, interventions on non-native aorta, laboratory measurement studies, diagnostic techniques, or animal or in-vitro studies. PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analysis; TBAD, type B aortic dissection; TAAD, type A aortic dissection.
Any study of humans involving the performance of surgical or endovascular intervention with measured outcomes of effectiveness and efficacy was moved into the second phase of article selection. Exclusion criteria for full-text review were as follows: (1) study failed to separate type B and type A or non-A non-B dissection data; (2) study failed to separate mesenteric ischemia from renal ischemia; (3) study full-text did not report patients who had mesenteric ischemia as a presenting sign; (4) study full-text did not report a surgical or endovascular intervention; (5) the study full-text was unrelated as described in abstract review criteria; (6) the study used national or international registry data; (7) the study full-text was not written in English; (8) the study failed to present patient-level data; (9) the study full-text was unavailable; and (10) the study failed to present in-hospital mortality. Potentially duplicated cohorts by the same authors were avoided by extensively reviewing study periods, patient selection methods, patient characteristics, and procedural/surgical technique. In these situations, the study with the largest patient cohort was chosen. When there was disagreement regarding article inclusion, a third author was consulted. No new studies were identified when the reference lists of these full-text studies were reviewed. Studies were carefully reviewed to ensure that there were no overlapping patient populations.
Analysis Techniques
Demographic and independent variables extracted include male to female ratio, age, type of aortic dissection treated (acute vs chronic), clinical presentation (ie, additional types of ischemic syndromes), and type of intervention. Retrospective chart review of previously published data from a single institution was performed to identify demographic variables that were not available in the published manuscript. Outcome (dependent) measures recorded include in-hospital mortality, need for additional surgeries, need for bowel resection, and length of stay.
Statistical analysis was performed using SPSS, version 25 (IBM Corp). The Fisher exact test was used for comparison of all categorical variables. The Mann–Whitney U test was used to compare distributions of age in the endovascular and surgical treatment groups. Since some of the articles in the analysis had more than 1 patient, a binary logistic regression was performed with article as random effect and type of intervention (endovascular vs surgical) as fixed binary variable to look for possible association of outcoming among patients from the same article.
Results
Studies Meeting Inclusion Criteria
In total, 385 articles were identified, of which 348 were excluded (Figure 1). No randomized controlled trials were found comparing the various surgical and endovascular treatment options for MesMP syndrome associated with type B aortic dissection. Review of the bibliographies of included articles yielded 54 additional studies. In total, 37 articles comprising 10 retrospective reviews and 27 case reports were included. A summary of these studies is provided in Table 1, and their respective outcomes in Table 2.
Treatment of visceral malperfusion in acute type B aortic dissection by percutaneous endovascular fenestration using a stent, with additional stenting of the true lumen.
Simultaneous surgical treatment of type B dissection complicated with visceral malperfusion and abdominal aortic aneurysm: role of aortic fenestration.
Ascending aorto-superior mesenteric artery bypass as a surgical option for revascularization in mesenteric ischemia associated with type B aortic dissection.
Treatment of visceral malperfusion in acute type B aortic dissection by percutaneous endovascular fenestration using a stent, with additional stenting of the true lumen.
Simultaneous surgical treatment of type B dissection complicated with visceral malperfusion and abdominal aortic aneurysm: role of aortic fenestration.
Ascending aorto-superior mesenteric artery bypass as a surgical option for revascularization in mesenteric ischemia associated with type B aortic dissection.
In total, 149 patients with MesMP (117 male/31 female; median age 55.0 years (interquartile range [IQR] 46.5-65 years)) were identified in the study. The cohort comprised 148 adults and 1 pediatric patient, an 11-year-old female (Leprince and colleagues
). The etiology of type B aortic dissection was only reported in 73% of studies, with the most common reported cause being hypertension/idiopathic. Two patients had Marfan syndrome (Payabyab and colleagues,
). There were no reported cases of aortic dissection secondary to trauma. Three patients had a previous history of aortic surgery for aneurysmal disease (Yoshiga and colleagues,
). The aortic dissection was classified as acute in 98% (146/149) of cases, acute-on-chronic in 0.7% (1/149) of cases, and chronic in 1.3% (2/149) of cases.
Clinical presentation was reported in 91.8% (34/37) of studies. Presentation and symptoms are reported in Table 1. The most common symptom in patients with MesMP was abdominal pain. Other concomitant clinical and radiographic malperfusion are reported in Table 1. MesMP was the sole ischemic complication in 26% (38/149) of patients and was accompanied by renal malperfusion alone in 22.1% (33/149) of patients, lower-extremity malperfusion alone in 15.4% (23/149), and both renal and lower-extremity malperfusion in 36.9% (55/149).
Treatment
Surgical and endovascular treatments were performed in 35 of 149 (23.5%) and 112 of 149 (75.2%) patients, respectively, whereas 2 patients (1.3%) had combination procedures. In the surgical group, open aortic reconstruction (open fenestration, open stenting, or open aortic replacement with graft), direct anatomic bypass, or indirect anatomic bypass were performed in 29 of 35 (82.8%), 4 of 36 (11.4%), and 2 of 35 (5.7%) cases, respectively. In the endovascular group, a thoracic endograft or an aortic stent alone was placed in 22 of 112 (19.6%) of cases, percutaneous fenestration alone was performed in 5/112 (4.5%) of cases, and branch stenting alone was performed in 17 of 112 (15.2%) of cases. A combination of TEVAR or aortic stent + fenestration, TEVAR or aortic stent + branch stenting, or fenestration + branch stenting was performed in 22 of 112 (19.6%), 5 of 112 (4.5%), 41 of 112 (36.6%), and of cases, respectively. Overall, 43.7% (49/112) of patients had only aortic interventions, whereas 56.3% (63/112) required a branch vessel intervention. Two patients had combination procedures, including one patient who had aortic fenestration then 6 hours later an SMA stent placed immediately followed by open direct anatomic bypass (n = 1)
Ascending aorto-superior mesenteric artery bypass as a surgical option for revascularization in mesenteric ischemia associated with type B aortic dissection.
Preoperative demographics, including age, sex, and dissection type, were similar between the endovascular and open repair groups. Concomitant renal, lower extremity, or renal + lower-extremity malperfusion was also similar between these 2 groups (Table 3).
Table 3Demographics, procedures, and outcomes among the open and endovascular repair treatment strategies for TBAD and MesMP
Branch vessel stenting and open bypass for the treatment of mesenteric malperfusion, stenting and bypass for other vascular territories not included.
5 (3.4)
4 (11)
0 (0)
.003
Outcomes
Bowel resection
17 (11)
5 (14)
11 (9.8)
.267
In-hospital mortality
19 (13)
4 (11)
15 (13)
.509
Data presented as median (25%, 75%) for continuous data and n (%) for categorical data. TBAD, Type B aortic dissection; MesMP, mesenteric malperfusion.
∗ Branch vessel stenting and open bypass for the treatment of mesenteric malperfusion, stenting and bypass for other vascular territories not included.
Overall in-hospital mortality was 12.8% (19/149). A summary of procedural and clinical outcomes is provided in Table 2. Clinical success, defined as resolution of malperfusion without in-hospital mortality, was similar between surgical and endovascular approaches (86.1% vs 84.4%) as was in-hospital mortality (11.4% vs 13.4%, P = .762). Necessity for bowel resection was also similar between surgical and endovascular approaches (14.3% vs 9.8%, P = .459) (Table 3). Within the surgical approach group (n = 35), systemic complications included multiorgan failure (n = 3), and acute renal failure (n = 2). Within the endovascular approach group (n = 112), systemic complications included conversion to type A dissection during TEVAR (n = 2), intraoperative aortic injury from sheath during TEVAR (n = 1), multiorgan failure (n = 2), respiratory failure (n = 2), acute renal failure (n = 1), and subacute ischemic infarcts with right-sided weakness (n = 1). Among the 2 patients receiving combination procedures, 50% (1/2) required a bowel resection and in-hospital mortality was 0%.
Within the surgical approaches, bowel resection was performed in 42.9% (3/7) of patients undergoing open aortic replacement, 0% (0/21) of patients undergoing open aortic fenestration or stenting, and 28.6% (2/7) of patients undergoing open bypass or other open procedure. In-hospital mortality was 14.3% in the open aortic replacement group, 14.3% in the open aortic fenestration or stenting group, and 0% in the open bypass or other open procedure group (Table 4). Statistical testing evaluating significance of difference between these subgroups was not performed given the small sample size and bias associated with multiple testing. Within the endovascular approaches, necessity for bowel resection was similar between any TEVAR and fenestration/stenting without TEVAR groups (9.5% vs 9.9%, P = .999), while in-hospital mortality was greater in the any TEVAR group (24% vs 11%) although not statistically significant (P = .153) (Table 5).
Table 4Demographics, procedures, and outcomes among surgical strategies for TBAD and MesMP
Branch vessel stenting and open bypass for the treatment of mesenteric malperfusion, stenting and bypass for other vascular territories not included.
4 (11)
0 (0)
0 (0)
4 (57)
Outcomes
Bowel resection
5 (14)
3 (43)
0 (0)
2 (29)
In-hospital mortality
4 (11)
1 (14)
3 (14)
0 (0)
Data presented as median (25%, 75%) for continuous data and n (%) for categorical data. TBAD, Type B aortic dissection; MesMP, mesenteric malperfusion.
∗ Other includes branch vessel thrombectomy, branch vessel fenestration, and branch vessel patch repair.
† Branch vessel stenting and open bypass for the treatment of mesenteric malperfusion, stenting and bypass for other vascular territories not included.
Branch vessel stenting for the treatment of mesenteric malperfusion, stenting and bypass for other vascular territories not included.
45 (40)
2 (9.5)
43 (47)
<.005
Outcomes
Bowel resection
11 (9.8)
2 (9.5)
9 (9.9)
.999
In-hospital mortality
15 (13)
5 (24)
10 (11)
.153
Data presented as median (25%, 75%) for continuous data and n (%) for categorical data. TEVAR, Thoracic endovascular aortic repair; TBAD, type B aortic dissection; MesMP, mesenteric malperfusion.
∗ Branch vessel stenting for the treatment of mesenteric malperfusion, stenting and bypass for other vascular territories not included.
Logistic regression did not demonstrate a significant relationship between the article published or type of intervention (endovascular vs surgery) with in-hospital mortality, P values of .758 and .331, respectively (Table 6).
Table 6Logistic regression of study author and intervention on in-hospital mortality
Length of stay was presented was presented in 16 studies, which corresponded to pooled median of 12.5 days (IQR, 8-21 days) (n = 98). Twenty studies reported data on how long they followed patients, which corresponded to a pooled median of 16 months (IQR, 12-49.5 months) (n = 38).
Discussion
In this systematic review, we analyzed type B aortic dissection complicated by MesMP and the variety of strategies for the management of this serious condition. We found that TBAD + MesMP was managed endovascularly in 75% of cases, surgically in 23%, and with open + endovascular combination in 2% of cases (Figure 2). Bowel resection was performed in 11% of patients, and overall in-hospital mortality was 12.8% and was similar between endovascular and surgical strategies (13% vs 11%). This study underscores the severity of TBAD with MesMP as well as many different management strategies. A summary of the findings, as well as an example case of endovascular management of TBAD + MesMP is presented in the Video Abstract.
Figure 2Diagram depicting the in-hospital mortality (IHM) of surgical repair (11.4%) versus endovascular repair (13.4%). Within the endovascular repair group (n = 112), in-hospital mortality was 24% in the TEVAR group versus 11% in the fenestration/stenting group. TEVAR, Thoracic endovascular aortic repair; MesMP, mesenteric malperfusion; TBAD, type B aortic dissection.
The management of aortic disease has seen an evolution in treatment strategy with the advent of new technologies, in particular endovascular therapies such as stent grafting. The increased use of endovascular therapies as seen in International Registry of Acute Aortic Dissection (IRAD)
was evident in this review, with 71% of cases treated endovascularly through 2007 and 81% of cases after 2007. However, over the past 13 years, ∼20% of TBADs with MesMP were managed with an open surgical strategy or combination endovascular and open strategy. Due to the many treatment strategies available, multiple aspects need to be considered when deciding the optimal strategy for each patient. First, one must consider the capabilities of both institution and physician as well as the working relationship between specialties of interventional radiology, cardiothoracic surgery, vascular surgery, and general surgery. The facility and physician must be comfortable with the chosen strategy. The highly variable strategies presented in this review highlight the differences in practice patterns, with each noncase report manuscript predominantly presenting one treatment option. For example, the studies by Verhoye and colleagues
presents endovascular fenestration/stenting. Second, the specific patient must be considered, including age, sex, comorbidities, dissection characteristics and extent, vascular territories malperfused, and type of malperfusion.
obstruction caused by aortic dissection can be static, dynamic, or a combination of the two, with the different etiologies determining treatment strategy. Dynamic obstruction results from the dissection flap of a collapsed true lumen prolapsing across the orifice of a branch vessel, such as the SMA, prohibiting flow into the branch vessel. Dynamic obstruction can be intermittent and vary in severity depending on the blood pressure. Static obstruction results from extension of dissection into a branch vessel without adequate re-entry, often causing false lumen thrombosis in the branch artery. While dynamic obstruction can be treated with open aortic repair or TEVAR with covering of the intimal tear, static obstruction usually requires targeted branch vessel intervention such as branch vessel stenting, thrombolysis, or thromboembolectomy. Therefore, the first step in managing TBAD with suspected MesMP (which presumes the physicians have some imaging confirmation of the dissection and some appreciation of the ongoing mechanism of possible obstruction) should be blood pressure control to limit severity of dynamic obstruction. In this review, 32% of patients required branch vessel stenting, and 3% had a direct vascular bypass, suggesting the presence of static obstruction. However, this is much lower than that reported in patients with TBAD and visceral malperfusion in an IRAD study,
in which ∼80% had evidence on CT scan of branch vessel involvement. Among those undergoing endovascular management, branch vessel stenting was much more prevalent in the fenestration/stenting group compared to the TEVAR group (47% vs 9.5%, P < .005). Therefore, in patients in which static obstruction is suspected (ie, those with branch vessel involvement on CT), endovascular fenestration/stenting could be the preferred strategy so that both dynamic and static obstruction can be addressed at the time of intervention.
With each patient in mind, risks of each procedure should be considered. For an open strategy, can a patient tolerate that open procedure? The strategy of open arch replacement with frozen elephant trunk requires cardiopulmonary bypass and crossclamping of the aorta. TEVAR requires an adequate landing zone and has associated risks, including retrograde type A dissection (n = 2 in this survey), risk of paralysis (not captured in this review) due to false lumen or intercostal artery thrombosis (not reported with fenestration/stenting
), and determining if it can resolve the malperfusion, especially if there is static obstruction, and risk of graft infection, especially in the presence of dead bowel. Fenestration/stenting allows quick assessment of hemodynamics and enables each branch vessel to be investigated,
but it requires expertise from interventional radiology and is not available at all hospitals. Complications of infradiaphragmatic arterial obstruction in this study, including renal failure and multisystem organ failure, were present in patients treated by both surgical and endovascular strategies. Two patients (1.8%) who underwent endovascular management, both TEVAR, suffered conversion to type A dissection. Each intervention and associated risks need to be considered for each specific individual patient, and the selected strategy should be tailored to the patient. In addition, the available physician and treatment team partially determines the choice of treatment. For example, if a cardiac surgeon is managing the patient, TEVAR is a valid option, but if an interventional radiologist is on the aortic team, then endovascular fenestration/stenting is also an option. Ideally, all of the treatment strategies are tools in the toolbox in the management of TBAD with MesMP, and the optimal treatment strategy will vary by facility, physician, and patient.
Hospitals can consider incorporating a MesMP response team to get all experts on board and decide on a patient-specific treatment, as numerous hospitals have done for the management of pulmonary embolism.
Following visceral reperfusion, a surgical consult should be placed to determine whether diagnostic laparoscopy/exploratory laparotomy is required, as it has been shown to decrease mortality.
Discriminating between adequate and inadequate mesenteric perfusion by visual and manual inspection of the bowel is more reliable after endovascular relief of obstruction of the SMA. In some circumstances, local surgical and endovascular facilities can enable bowel inspection at the time of reperfusion, as seen in included reports.
Simultaneous surgical treatment of type B dissection complicated with visceral malperfusion and abdominal aortic aneurysm: role of aortic fenestration.
In total, 17% (25/149) underwent diagnostic laparoscopy/exploratory laparotomy and bowel inspection, and 11% (17/149) underwent bowel resection, with similar rates of bowel resection among endovascular and open surgical strategies (10% vs 14%).
The overall in-hospital mortality of 13% for MesMP in this review is likely underestimated secondary to publication bias, since any visceral ischemia in the setting of TBAD is associated with a mortality of 31% per IRAD data.
Variable institutional definitions of malperfusion may also affect IHM. Endovascular and surgical management groups had similar mortality (11% vs 13%) in this cohort of TBAD with MesMPS, underscoring the severity of MesMPS in the setting of TBAD. In addition, malperfusion of additional vascular territories is associated with an increase in mortality.
This study is limited by available data and reported outcomes in manuscripts; therefore, more specific complication rates and hospital lengths of stay were unable to be determined. This study is also limited by sample size with a possibility of type II error. There are currently no standard guidelines for reporting of clinical outcome measures or mortality data, and thus a more general definition of in-hospital mortality was used as described above and no time-dependent patient outcomes, such as 30-day mortality, were analyzed. We hope this study serves as an impetus for future studies to present this data. In addition, the anatomical spectrum of SMA obstruction is not reported in most reviews, which limits comparison of mechanisms. There are currently no large prospective data sets comparing combinations of endovascular modalities, especially in the treatment of complicated TBAD. Future studies that compare these modalities, specifically looking at static versus dynamic malperfusion, are warranted.
Conclusions
Type B aortic dissection complicated with MesMP is a serious condition with open, endovascular, and hybrid treatment strategies available. Necessity for bowel resection and in-hospital mortality was similar between open and endovascular strategies; however, endovascular management is the most commonly used strategy.
Conflict of Interest Statement
M.S.K. reported speaking honoraria from Penumbra, Inc, Boston Scientific, and Medtronic; and grant funding from Boston Scientific, Inc, and the SIR Foundation, none of which are relevant to this paper. D.M.W. reported Medical Advisory Board of Boston Scientific, which is not relevant to this paper. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
A summary of the results of this study, conclusions and an example case of aortic fenestration for type B aortic dissection in mesenteric malperfusion is presented in the video. Video available at: https://www.jtcvs.org/article/S2666-2736(22)00307-2/fulltext.
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Optimal treatment of uncomplicated type B aortic dissection: JACC Review Topic of the Week.
Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy.
Treatment of visceral malperfusion in acute type B aortic dissection by percutaneous endovascular fenestration using a stent, with additional stenting of the true lumen.
Simultaneous surgical treatment of type B dissection complicated with visceral malperfusion and abdominal aortic aneurysm: role of aortic fenestration.
Ascending aorto-superior mesenteric artery bypass as a surgical option for revascularization in mesenteric ischemia associated with type B aortic dissection.
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