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Surgical and endovascular repair for type B aortic dissections with mesenteric malperfusion syndrome: A systematic review of in-hospital mortality

Open AccessPublished:August 08, 2022DOI:https://doi.org/10.1016/j.xjon.2022.07.012

      Abstract

      Objectives

      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%.

      Graphical abstract

      Figure thumbnail fx1

      Key Words

      Abbreviations and Acronyms:

      CT (computed tomography), IRAD (International Registry of Acute Aortic Dissection), MesMP (mesenteric malperfusion), SMA (superior mesenteric artery), TBAD (type B aortic dissection), TEVAR (thoracic endovascular aortic repair)
      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.
      • Tadros R.O.
      • Tang G.H.L.
      • Barnes H.J.
      • Mousavi I.
      • Kovacic J.C.
      • Faries P.
      • et al.
      Optimal treatment of uncomplicated type B aortic dissection: JACC Review Topic of the Week.
      Malperfusion refers to inadequate blood flow to a vascular territory and is present in approximately 20% to 30% of type B aortic dissections.
      • Tadros R.O.
      • Tang G.H.L.
      • Barnes H.J.
      • Mousavi I.
      • Kovacic J.C.
      • Faries P.
      • et al.
      Optimal treatment of uncomplicated type B aortic dissection: JACC Review Topic of the Week.
      ,
      • Fattori R.
      • Tsai T.T.
      • Myrmel T.
      • Evangelista A.
      • Cooper J.V.
      • Trimarchi S.
      • et al.
      Complicated acute type B dissection: is surgery still the best option? A report from the International Registry of Acute Aortic Dissection.
      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).
      • Velayudhan B.V.
      • Idhrees A.M.
      • Mukesh K.
      • Kannan R.N.
      Mesenteric malperfusion in acute aortic dissection: challenges and frontiers.
      Diagnosis of MesMP is based on clinical, radiographic, and laboratory features, including the presence of abdominal pain (most common symptom
      • Velayudhan B.V.
      • Idhrees A.M.
      • Mukesh K.
      • Kannan R.N.
      Mesenteric malperfusion in acute aortic dissection: challenges and frontiers.
      ), 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.
      • Yang B.
      • Norton E.L.
      • Rosati C.M.
      • Wu X.
      • Kim K.M.
      • Khaja M.S.
      • et al.
      Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: 20-year experience.
      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.
      • Velayudhan B.V.
      • Idhrees A.M.
      • Mukesh K.
      • Kannan R.N.
      Mesenteric malperfusion in acute aortic dissection: challenges and frontiers.
      Obstruction can be dynamic, static, or a combination of dynamic and static.
      • Williams D.M.
      • Brothers T.E.
      • Messina L.M.
      Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum.
      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.
      • Norton E.L.
      • Williams D.M.
      • Kim K.M.
      • Khaja M.S.
      • Wu X.
      • Patel H.J.
      • et al.
      Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.
      ,
      • Hughes G.C.
      • Andersen N.D.
      • McCann R.L.
      Management of acute type B aortic dissection.
      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.
      • Fattori R.
      • Tsai T.T.
      • Myrmel T.
      • Evangelista A.
      • Cooper J.V.
      • Trimarchi S.
      • et al.
      Complicated acute type B dissection: is surgery still the best option? A report from the International Registry of Acute Aortic Dissection.
      ,
      • Norton E.L.
      • Williams D.M.
      • Kim K.M.
      • Khaja M.S.
      • Wu X.
      • Patel H.J.
      • et al.
      Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.
      ,
      • Wilkinson D.A.
      • Patel H.J.
      • Williams D.M.
      • Dasika N.L.
      • Deeb G.M.
      Early open and endovascular thoracic aortic repair for complicated type B aortic dissection.
      Endovascular therapy, specifically TEVAR, has been established as superior to open surgical repair for complicated TBAD in multiple studies and reviews.
      • Eggebrecht H.
      • Nienaber C.A.
      • Neuhauser M.
      • Baumgart D.
      • Kische S.
      • Schmermund A.
      • et al.
      Endovascular stent-graft placement in aortic dissection: a meta-analysis.
      • Szeto W.Y.
      • McGarvey M.
      • Pochettino A.
      • Moser G.W.
      • Hoboken A.
      • Cornelius K.
      • et al.
      Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection.
      • Nienaber C.A.
      • Fattori R.
      • Lund G.
      • Dieckmann C.
      • Wolf W.
      • Kodolitsch Y.V.
      • et al.
      Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.
      • Zeeshan A.
      • Woo E.Y.
      • Bavaria J.E.
      • Fairman R.M.
      • Desai N.D.
      • Pochettino A.
      • et al.
      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
      • Norton E.L.
      • Williams D.M.
      • Kim K.M.
      • Khaja M.S.
      • Wu X.
      • Patel H.J.
      • et al.
      Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.
      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.
      • Shamseer L.
      • Moher D.
      • Clarke M.
      • Ghersi D.
      • Liberati A.
      • Petticrew M.
      • et al.
      Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation.
      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 thumbnail gr1
      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.
      Table 1Patient and study demographics
      StudyType of studyTotal patients in studyTotal patients with MesMPMedian age, ySex ratio (M:F)EtiologyChronicityClinical presentationAdditional malperfusion?
      Shiya et al, 2007
      • Shiiya N.
      • Matsuzaki K.
      • Kunihara T.
      • Murashita T.
      • Matsui Y.
      Management of vital organ malperfusion in acute aortic dissection: proposal of a mechanism-specific approach.
      RCS511551:0N/PAcuteN/P
      For Shiya et al. 2007, and Axtell et al. 2020, the clinical presentation for mesenteric malperfusion was not provided.
      R
      Miyachi et al, 2014
      • Miyachi H.
      • Onozawa S.
      • Akutsu K.
      • Shimuzu W.
      • Kumita S.I.
      • Tanaka K.
      • et al.
      Treatment of visceral malperfusion in acute type B aortic dissection by percutaneous endovascular fenestration using a stent, with additional stenting of the true lumen.
      CR11481:0HTNAcuteBack pain, elevated LFTsNo
      Suzuki et al, 2015
      • Suzuki K.
      • Shimohira M.
      • Hashizume T.
      • Shibamoto Y.
      Stent placement for acute superior mesenteric artery occlusion associated with type B aortic dissection.
      CR11501:0HTNAcuteAcute back/chest pain, normal labsNo
      Yamakado et al, 1998
      • Yamakado K.
      • Takeda K.
      • Nomura Y.
      • Kato N.
      • Hirano T.
      • Matsumura K.
      • et al.
      Relief of mesenteric ischemia by Z-stent placement into the superior mesenteric artery compressed by the false lumen of an aortic dissection.
      CR11581:0HTNAcuteSevere abdominal painNo
      Yoshiga et al, 2015
      • Yoshiga R.
      • Morisaki K.
      • Matsubara Y.
      • Yoshiya K.
      • Inoue K.
      • Matsuda D.
      • et al.
      Emergency thoracic aortic stent grafting for acute complicated type B aortic dissection after a previous abdominal endovascular aneurysm repair.
      CR11691:0HTN, hx of EVARAcuteWorsening abdominal pain and melenaLE
      Kazimerczak et al, 2018
      • Kazimierczak A.
      • Rynio P.
      • Gutowski P.
      • Jedrzejczak T.
      Endovascular stenting of a complicated type B aortic dissection in an 11-year-old patient: case report.
      CR11110:1Idiopathic (no marfanoid features)AcuteChest pain, peritonitis, sepsisR
      Leprince et al, 2004
      • Leprince P.
      • Cluzel P.
      • Bonnet N.
      • Izzillo R.
      • Pavie A.
      • Gandjbakhch I.
      An endovascular stent relieves celiac and mesenteric ischemia in acute aortic dissection.
      CR1163unkN/PAcuteAbdominal painNo
      Ito et al, 2003
      • Ito N.
      • Tsunoda T.
      • Nakamura M.
      • Iijima R.
      • Matsuda K.
      • Suzuki T.
      • et al.
      Percutaneous bare Z-stent implantation as an alternative to surgery for acute aortic dissection with visceral ischemia.
      CR11721:0HTNAcuteParalytic ileus and occult blood in gastric drainageR + LE
      Bao et al, 2010
      • Bao Q.
      • Chen L.
      Thrombotic mesenteric ischemia due to aortic dissection.
      CR11501:0N/PAcuteAcute abdominal painNo
      Chang et al, 2001
      • Chang W.T.
      • Kao H.L.
      • Liau C.S.
      • Lee Y.T.
      Aortic stenting on a type B aortic dissection with visceral and limb ischemia.
      CR11691:0HTNAcuteSevere abdominal pain, ileusR + LE
      Payabyab et al, 2017
      • Payabyab E.C.
      • Maloney A.H.
      • Brinster D.R.
      Undersized stent grafts for acute mesenteric ischemia in chronic type B dissection.
      CR11290:1MFS, HTNAcute on chronicAcute abdominal painNo
      Petrilli et al, 2013
      • Petrilli G.
      • Puppini G.
      • Calzaferri D.
      • Torre S.
      • Bugana A.
      • Faggian G.
      Emergency thoracic endovascular aneurysm repair in acute type B dissection with visceral malperfusion.
      CR11460:1N/PAcuteAcute abdominal painLE
      Santo et al, 2007
      • Santo K.
      • McCafferty I.
      • Guest P.
      • Bonser R.
      A fatal complication following hybrid total arch replacement with supra-aortic artery translocation and endovascular stenting.
      CR11560:1N/PAcuteElevated LFTs, back painR
      Son et al, 2012
      • Son S.A.
      • Lee Y.O.
      • Kim G.J.
      • Cho J.Y.
      • Lee J.T.
      Placement of endovascular stent graft in acute malperfusion syndrome after acute type II aortic dissection.
      CR11760:1N/PAcuteAbdominal painR
      Iyer et al, 2009
      • Iyer V.
      • Rigby M.
      • Vrabec G.
      • Sr
      Type B aortic dissection after endovascular abdominal aortic aneurysm repair causing endograft collapse and severe malperfusion.
      CR11771:0HTN, hx of EVARAcuteAbdominal pain, elevated lactate, LFTs, amylaseR + LE
      Verhoye et al, 2008
      • Verhoye J.P.
      • Miller D.C.
      • Sze D.
      • Dake M.D.
      • Mitchell R.S.
      Complicated acute type B aortic dissection: midterm results of emergency endovascular stent-grafting.
      RCS16340 (40-46)1:2HTNAcuteVariableLE (1), R + LE (1)
      Slonim et al, 1996
      • Slonim S.M.
      • Nyman U.
      • Semba C.P.
      • Miller D.C.
      • Mitchell R.S.
      • Dake M.D.
      Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration.
      RCS9547 (42-62)3:2HTN3 Acute

      2 Chronic
      VariableR + LE (2)
      Sfyroeras et al, 2011
      • Sfyroeras G.S.
      • Rubio V.
      • Pagan P.
      • Diethrich E.B.
      • Rodriguez J.A.
      Endovascular management of malperfusion in acute type B aortic dissections.
      RCS23563 (60-71)4:1HTNAcuteVariableR (1), R + LE + S (1)
      Lai et al, 2018
      • Lai C.H.
      • Chang K.H.
      • Chang S.L.
      • Lai H.C.
      • Lee W.L.
      • Liu T.J.
      Rescue intervention after three days of renal ischemia caused by acute complicated type B aortic dissection.
      CR11521:0HTNAcuteIntermittent abdominal painR
      Filippone et al, 2013
      • Filippone G.
      • Ferro G.
      • Duranti C.
      • La Barbera G.
      • Talarico F.
      Simultaneous surgical treatment of type B dissection complicated with visceral malperfusion and abdominal aortic aneurysm: role of aortic fenestration.
      CR11671:0HTNAcutePersistent abdominal painNo
      Howell et al, 1997
      • Howell J.F.
      • LeMaire S.A.
      • Kirby R.P.
      Thoracoabdominal fenestration for aortic dissection with ischemic colonic perforation.
      CR11401:0HTNAcuteAbdominal pain, bloody stool, perforated colon on CTR
      Kalangos et al, 2014
      • 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.
      CR11470:1HTNAcutePersistent abdominal painR
      Kuo et al, 2013
      • Kuo H.N.
      • Lai H.C.
      • Chang Y.W.
      • Wang C.C.
      • Lee W.L.
      • Chan S.W.
      • et al.
      Axillofemoral bypass relieves visceral malperfusion in type B aortic dissection.
      CR11581:0HTNAcuteBack and abdominal pain, elevated LFTsR + LE
      Kurumisawa et al, 2015
      • Kurumisawa S.
      • Sugaya A.
      • Akutsu H.
      • Takazawa I.
      • Ohki S.I.
      • Misawa Y.
      Delayed visceral ischemia induced by type B aortic dissection.
      CR11561:0HTNAcuteAcute abdominal pain, elevated LFTs and lactateR
      Okada et al, 2005
      • 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.
      CR11750:1N/PAcuteAcute abdominal painLE
      Saitoh et al, 2012
      • Saitoh Y.
      • Ohmori H.
      • Hari Y.
      • Setozaki S.
      • Harada H.
      • Soeda T.
      Mesenteric artery fenestration for type B dissection with visceral ischemia.
      CR11681:0N/PAcuteSevere acute back and abdominal painNo
      Wang et al, 1999
      • Wang N.
      • Wong D.T.
      • Rivera J.L.
      • Bansal R.C.
      • Gundry S.R.
      Repair of acute descending aortic dissection complicated by visceral ischemia.
      CR11320:1MFS, HTNAcuteSevere abdominal pain, vomiting, and bloody diarrheaLE
      Yamashiro et al, 2004
      • Yamashiro S.
      • Kuniyoshi Y.
      • Miyagi K.
      • Uezu T.
      • Arakaki K.
      • Koja K.
      Type B dissection complicated with subacute visceral ischemia.
      CR11631:0HTNAcuteSevere abdominal painNo
      Kim et al, 2014
      • Kim K.H.
      • Choi J.B.
      • Kuh J.H.
      Simultaneous relief of acute visceral and limb ischemia in complicated type B aortic dissection by axillobifemoral bypass.
      CR11781:0Ascending aorta replacement, HTNAcuteSevere back and abdominal painLE
      Trimarchi et al, 2010
      • Trimarchi S.
      • Jonker F.H.
      • Muhs B.E.
      • Grassi V.
      • Righini P.
      • Upchurgh G.R.
      • et al.
      Long-term outcomes of surgical aortic fenestration for complicated acute type B aortic dissections.
      RCS21454 (52-56)4:0HTNAcuteVariableR (2), LE (1)
      Williams et al, 1990
      • Williams D.M.
      • Brothers T.E.
      • Messina L.M.
      Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum.
      CR11461:0HTNAcuteSevere back painLE
      Axtell et al, 2020
      • Axtell A.
      • Eagleton M.
      • Conrad M.
      • Isselbacher E.
      • Sundt T.
      • Jassar A.
      Total arch replacement and frozen elephant trunk for acute complicated type B dissection.
      CR3358 (39, 76)3:0N/PAcuteN/P
      For Shiya et al. 2007, and Axtell et al. 2020, the clinical presentation for mesenteric malperfusion was not provided.
      No
      Panneton et al, 2000
      • Panneton J.M.
      • Teh S.H.
      • Cherry Jr., K.J.
      • Hofer J.M.
      • Gloviczki P.
      • Andrews J.C.
      • et al.
      Aortic fenestration for acute or chronic aortic dissection: an uncommon but effective procedure.
      RCS11272 (68, 76)1:1HTNAcuteVariableR (1), R + LE (1)
      Lauterbach et al, 2001
      • Lauterbach S.R.
      • Cambria R.P.
      • Brewster D.C.
      • Gertler J.P.
      • Lamuraglia G.M.
      • Isselbacher E.M.
      • et al.
      Contemporary management of aortic branch compromise resulting from acute aortic dissection.
      RCS187850 (45, 57)8:0N/PAcuteN/P
      For Shiya et al. 2007, and Axtell et al. 2020, the clinical presentation for mesenteric malperfusion was not provided.
      R (1), LE (1), R + LE (3)
      Uchida et al, 2009
      • Uchida N.
      • Shibamura H.
      • Katayama A.
      • Aishin K.
      • Sutoh M.
      • Kuraoka M.
      Surgical strategies for organ malperfusions in acute type B aortic dissection.
      RCS1301563 (53, 72)9:6N/PAcuteVariableLE (4), R + LE (4)
      Vedantham et al, 2003
      • Vedantham S.
      • Picus D.
      • Sanchez L.A.
      • Braverman A.
      • Moon M.R.
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      • et al.
      Percutaneous management of ischemic complications in patients with type-B aortic dissection.
      RCS11446 (41, 51)4:0HTN (4), cocaine (1)AcuteSevere abdominal pain, GI bleeding (1), metabolic acidosis (3)R (1), R + LE (3)
      Norton et al, 2020
      • Norton E.L.
      • Williams D.M.
      • Kim K.M.
      • Khaja M.S.
      • Wu X.
      • Patel H.J.
      • et al.
      Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.
      RCS1827353 (46, 61)62:11N/PAcuteVariableR (17), LE (10), R + LE (36), S (1)
      MesMP, Mesenteric malperfusion; M, male; F, female; RCS, retrospective case series; N/P, not provided; CR, case report; HTN, hypertension; LFT, liver function test; hx, history; EVAR, endovascular aortic repair; LE, lower extremity; R, renal; unk, unknown; MFS, Marfan syndrome; CT, computed tomography; GI, gastrointestinal; S, spinal.
      For Shiya et al. 2007, and Axtell et al. 2020, the clinical presentation for mesenteric malperfusion was not provided.
      Table 2Procedural and clinical outcomes
      StudyTotal patients with MesMPInterventionClinical success (%)IHMAdditional surgery/procedure?Need for bowel resection?Major complicationsLOS, d,

      median (first, third quartile)
      Follow-up, mo
      Shiya et al, 2007
      • Shiiya N.
      • Matsuzaki K.
      • Kunihara T.
      • Murashita T.
      • Matsui Y.
      Management of vital organ malperfusion in acute aortic dissection: proposal of a mechanism-specific approach.
      1BS (SMA)1000Diagnostic laparoscopyNNN/PN/P
      Miyachi et al, 2014
      • Miyachi H.
      • Onozawa S.
      • Akutsu K.
      • Shimuzu W.
      • Kumita S.I.
      • Tanaka K.
      • et al.
      Treatment of visceral malperfusion in acute type B aortic dissection by percutaneous endovascular fenestration using a stent, with additional stenting of the true lumen.
      1E-Fen + AS1000NNN2112
      Suzuki et al, 2015
      • Suzuki K.
      • Shimohira M.
      • Hashizume T.
      • Shibamoto Y.
      Stent placement for acute superior mesenteric artery occlusion associated with type B aortic dissection.
      1BS (SMA)1000Diagnostic laparoscopy; total arch replacementNConversion to TAAD on POD79024
      Yamakado et al, 1998
      • Yamakado K.
      • Takeda K.
      • Nomura Y.
      • Kato N.
      • Hirano T.
      • Matsumura K.
      • et al.
      Relief of mesenteric ischemia by Z-stent placement into the superior mesenteric artery compressed by the false lumen of an aortic dissection.
      1BS (SMA)1000NNN3012
      Yoshiga et al, 2015
      • Yoshiga R.
      • Morisaki K.
      • Matsubara Y.
      • Yoshiya K.
      • Inoue K.
      • Matsuda D.
      • et al.
      Emergency thoracic aortic stent grafting for acute complicated type B aortic dissection after a previous abdominal endovascular aneurysm repair.
      1TEVAR1000NNNN/P6
      Kazimerczak et al, 2018
      • Kazimierczak A.
      • Rynio P.
      • Gutowski P.
      • Jedrzejczak T.
      Endovascular stenting of a complicated type B aortic dissection in an 11-year-old patient: case report.
      1TEVAR + BS (SMA)1000NNIntraprocedural PEAs, but ROSC21N/P
      Leprince et al, 2004
      • Leprince P.
      • Cluzel P.
      • Bonnet N.
      • Izzillo R.
      • Pavie A.
      • Gandjbakhch I.
      An endovascular stent relieves celiac and mesenteric ischemia in acute aortic dissection.
      1TEVAR1000NNNN/P3
      Ito et al, 2003
      • Ito N.
      • Tsunoda T.
      • Nakamura M.
      • Iijima R.
      • Matsuda K.
      • Suzuki T.
      • et al.
      Percutaneous bare Z-stent implantation as an alternative to surgery for acute aortic dissection with visceral ischemia.
      1AS1000NNNN/P19
      Bao et al, 2010
      • Bao Q.
      • Chen L.
      Thrombotic mesenteric ischemia due to aortic dissection.
      1TEVAR1000Exploratory laparotomyYNN/PN/P
      Chang et al, 2001
      • Chang W.T.
      • Kao H.L.
      • Liau C.S.
      • Lee Y.T.
      Aortic stenting on a type B aortic dissection with visceral and limb ischemia.
      1TEVAR1000NNNN/P2
      Payabyab et al, 2017
      • Payabyab E.C.
      • Maloney A.H.
      • Brinster D.R.
      Undersized stent grafts for acute mesenteric ischemia in chronic type B dissection.
      1TEVAR1000NNN4N/P
      Petrilli et al, 2013
      • Petrilli G.
      • Puppini G.
      • Calzaferri D.
      • Torre S.
      • Bugana A.
      • Faggian G.
      Emergency thoracic endovascular aneurysm repair in acute type B dissection with visceral malperfusion.
      1TEVAR1000NNNN/PN/P
      Santo et al, 2007
      • Santo K.
      • McCafferty I.
      • Guest P.
      • Bonser R.
      A fatal complication following hybrid total arch replacement with supra-aortic artery translocation and endovascular stenting.
      1TEVAR01NNTAAD and intrapericardial rupture with cardiac arrest, death on POD1414N/P
      Son et al, 2012
      • Son S.A.
      • Lee Y.O.
      • Kim G.J.
      • Cho J.Y.
      • Lee J.T.
      Placement of endovascular stent graft in acute malperfusion syndrome after acute type II aortic dissection.
      1TEVAR1000NNN1612
      Iyer et al, 2009
      • Iyer V.
      • Rigby M.
      • Vrabec G.
      • Sr
      Type B aortic dissection after endovascular abdominal aortic aneurysm repair causing endograft collapse and severe malperfusion.
      1TEVAR1000NNN2111
      Verhoye et al, 2008
      • Verhoye J.P.
      • Miller D.C.
      • Sze D.
      • Dake M.D.
      • Mitchell R.S.
      Complicated acute type B aortic dissection: midterm results of emergency endovascular stent-grafting.
      33 TEVAR66.71Exploratory laparotomy (1)YMultiorgan failure (1)N/PN/P
      Slonim et al, 1996
      • Slonim S.M.
      • Nyman U.
      • Semba C.P.
      • Miller D.C.
      • Mitchell R.S.
      • Dake M.D.
      Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration.
      51 AS

      1 AS + BS (SMA)

      2 E-Fen

      1 E-Fen + AS
      1000Exploratory laparotomy (1)YAcute renal failure (1)N/PN/P
      Sfyroeras et al, 2011
      • Sfyroeras G.S.
      • Rubio V.
      • Pagan P.
      • Diethrich E.B.
      • Rodriguez J.A.
      Endovascular management of malperfusion in acute type B aortic dissections.
      55 TEVAR602NNRespiratory failure (2)8.5 (4.8, 12.5)12
      Lai et al, 2018
      • Lai C.H.
      • Chang K.H.
      • Chang S.L.
      • Lai H.C.
      • Lee W.L.
      • Liu T.J.
      Rescue intervention after three days of renal ischemia caused by acute complicated type B aortic dissection.
      1BS (CA)1000NNNN/P1
      Filippone et al, 2013
      • Filippone G.
      • Ferro G.
      • Duranti C.
      • La Barbera G.
      • Talarico F.
      Simultaneous surgical treatment of type B dissection complicated with visceral malperfusion and abdominal aortic aneurysm: role of aortic fenestration.
      1OAR (Graft) + S-Fen1000N
      Bowel inspected during OAR.
      NNN/P12
      Howell et al, 1997
      • Howell J.F.
      • LeMaire S.A.
      • Kirby R.P.
      Thoracoabdominal fenestration for aortic dissection with ischemic colonic perforation.
      1OAR (Graft)1000N
      Bowel inspected during OAR.
      YNN/P12
      Kalangos et al, 2014
      • 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.
      1E Fen + BS (SMA) + DB (Ao-SMA)1000NNN2116
      Kuo et al, 2013
      • Kuo H.N.
      • Lai H.C.
      • Chang Y.W.
      • Wang C.C.
      • Lee W.L.
      • Chan S.W.
      • et al.
      Axillofemoral bypass relieves visceral malperfusion in type B aortic dissection.
      1IDB (Ax-Fem)1000NNN2114
      Kurumisawa et al, 2015
      • Kurumisawa S.
      • Sugaya A.
      • Akutsu H.
      • Takazawa I.
      • Ohki S.I.
      • Misawa Y.
      Delayed visceral ischemia induced by type B aortic dissection.
      1OAR (S-Fen)1000N
      Bowel inspected during OAR.
      NN16N/P
      Okada et al, 2005
      • 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.
      1DB (LEIA-Ileocolic + LEIA-GEA)1000NNNN/P7
      Saitoh et al, 2012
      • Saitoh Y.
      • Ohmori H.
      • Hari Y.
      • Setozaki S.
      • Harada H.
      • Soeda T.
      Mesenteric artery fenestration for type B dissection with visceral ischemia.
      1OAR (S-Fen)1000N
      Bowel inspected during OAR.
      YNN/PN/P
      Wang et al, 1999
      • Wang N.
      • Wong D.T.
      • Rivera J.L.
      • Bansal R.C.
      • Gundry S.R.
      Repair of acute descending aortic dissection complicated by visceral ischemia.
      1OAR (Graft)1000Additional exploratory laparotomyY
      Exploratory laparotomy with bowel resection and primary anastomosis performed at outside hospital prior to transfer and aortic repair.
      NN/PN/P
      Yamashiro et al, 2004
      • Yamashiro S.
      • Kuniyoshi Y.
      • Miyagi K.
      • Uezu T.
      • Arakaki K.
      • Koja K.
      Type B dissection complicated with subacute visceral ischemia.
      1DB (RCIA-SMA and GDA)1000N
      Bowel inspected during OAR.
      NNN/P12
      Kim et al, 2014
      • Kim K.H.
      • Choi J.B.
      • Kuh J.H.
      Simultaneous relief of acute visceral and limb ischemia in complicated type B aortic dissection by axillobifemoral bypass.
      1IDB (Fem-Fem then Ax-Fem bypass)
      Planned fenestration and stenting cancelled due to resolution of ischemic signs following IDB.
      1000NNNN/P12
      Trimarchi et al, 2010
      • Trimarchi S.
      • Jonker F.H.
      • Muhs B.E.
      • Grassi V.
      • Righini P.
      • Upchurgh G.R.
      • et al.
      Long-term outcomes of surgical aortic fenestration for complicated acute type B aortic dissections.
      44 OAR (S-Fen)751NNMultiorgan failure (1)N/P192 (138, 216)
      Williams et al, 1990
      • Williams D.M.
      • Brothers T.E.
      • Messina L.M.
      Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum.
      1E Fen1000NNChronic mesenteric ischemia35NP
      Axtell et al, 2020
      • Axtell A.
      • Eagleton M.
      • Conrad M.
      • Isselbacher E.
      • Sundt T.
      • Jassar A.
      Total arch replacement and frozen elephant trunk for acute complicated type B dissection.
      31 hybrid
      Open total arch replacement with FET.


      2 hybrid
      Open total arch replacement with FET.
       + BS (SMA)
      1000NNCVA (1)15.0 (12.5, 21.5)N/P
      Panneton et al, 2000
      • Panneton J.M.
      • Teh S.H.
      • Cherry Jr., K.J.
      • Hofer J.M.
      • Gloviczki P.
      • Andrews J.C.
      • et al.
      Aortic fenestration for acute or chronic aortic dissection: an uncommon but effective procedure.
      21 OAR (S-Fen + graft)

      1 TEVAR + E-Fen
      501 (patient with OAR)NNAcute renal failure (1)N/PN/P
      Lauterbach et al, 2001
      • Lauterbach S.R.
      • Cambria R.P.
      • Brewster D.C.
      • Gertler J.P.
      • Lamuraglia G.M.
      • Isselbacher E.M.
      • et al.
      Contemporary management of aortic branch compromise resulting from acute aortic dissection.
      86 OAR (S-Fen)

      1 E-Fen + BS (SMA)

      1 OAR (Graft)
      87.51 (patient with E-fen + BS)N
      Bowel inspected during OAR.
      Y (1)Multi-organ failure (1), Permanent dialysis (1)17.5 (15, 28)N/P
      Uchida et al, 2009
      • Uchida N.
      • Shibamura H.
      • Katayama A.
      • Aishin K.
      • Sutoh M.
      • Kuraoka M.
      Surgical strategies for organ malperfusions in acute type B aortic dissection.
      151 TEVAR

      2 BS (CA/SMA, SMA)

      10 OAR (8 AS, 2 S-Fen)

      2 DB (SMA)
      803 (1 TEVAR, 2 OAR)N
      Bowel inspected during OAR.
      Y (1)Multi-organ failure (2), Intra-operative aortic injury from sheath during TEVAR (1)N/P45 (16, 60)
      Vedantham et al, 2003
      • Vedantham S.
      • Picus D.
      • Sanchez L.A.
      • Braverman A.
      • Moon M.R.
      • Sundt T. 3rd
      • et al.
      Percutaneous management of ischemic complications in patients with type-B aortic dissection.
      42 AS + E-Fem

      1 AS

      1 E-fen
      1000NNNN/PN/P
      Norton et al, 2020
      • Norton E.L.
      • Williams D.M.
      • Kim K.M.
      • Khaja M.S.
      • Wu X.
      • Patel H.J.
      • et al.
      Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.
      7340 E-Fen + BS

      17 E-Fen + AS

      11 BS

      1 E-Fen

      2 AS + BS

      1 TEVAR + BS

      1 TEVAR
      87.79

      (7 E-Fen + BS,

      1 E-Fen + AS

      1 BS)
      Exploratory laparotomy (10)

      DTAR (1)
      Y (8)N/P11.0 (8, 20)N/P
      MesMP, Mesenteric malperfusion; IHM, in-hospital mortality; LOS, length of stay; BS, branch vessel stenting; SMA, superior mesenteric artery; N, no; N/P, not provided; E-Fen, endovascular fenestration; AS, aortic stenting; TAAD, type A aortic dissection; POD, postoperative day; TEVAR, thoracic endovascular aortic repair; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; Y, yes; CA, celiac artery; OAR, open aortic repair; DB, direct bypass; Ao, aorta; IDB, indirect bypass; Fem-Fem, femoral to femoral artery bypass; Ax-Fem, axillary to femoral artery bypass; S-Fen, surgical fenestration; LEIA, left external iliac artery; GEA, gastroepiploic artery; RCIA, right common iliac artery; GDA, gastroduodenal artery; CVA, cerebrovascular accident; DTAR, descending thoracic aortic repair.
      Bowel inspected during OAR.
      Exploratory laparotomy with bowel resection and primary anastomosis performed at outside hospital prior to transfer and aortic repair.
      Planned fenestration and stenting cancelled due to resolution of ischemic signs following IDB.
      § Open total arch replacement with FET.

      Demographics and Presentation

      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
      • Leprince P.
      • Cluzel P.
      • Bonnet N.
      • Izzillo R.
      • Pavie A.
      • Gandjbakhch I.
      An endovascular stent relieves celiac and mesenteric ischemia in acute aortic dissection.
      ). 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,
      • Payabyab E.C.
      • Maloney A.H.
      • Brinster D.R.
      Undersized stent grafts for acute mesenteric ischemia in chronic type B dissection.
      Wang and colleagues
      • Wang N.
      • Wong D.T.
      • Rivera J.L.
      • Bansal R.C.
      • Gundry S.R.
      Repair of acute descending aortic dissection complicated by visceral ischemia.
      ), and 1 patient reportedly was using cocaine before the dissection (Vedantham and colleagues
      • Vedantham S.
      • Picus D.
      • Sanchez L.A.
      • Braverman A.
      • Moon M.R.
      • Sundt T. 3rd
      • et al.
      Percutaneous management of ischemic complications in patients with type-B aortic dissection.
      ). 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,
      • Yoshiga R.
      • Morisaki K.
      • Matsubara Y.
      • Yoshiya K.
      • Inoue K.
      • Matsuda D.
      • et al.
      Emergency thoracic aortic stent grafting for acute complicated type B aortic dissection after a previous abdominal endovascular aneurysm repair.
      Iyer and colleagues,
      • Iyer V.
      • Rigby M.
      • Vrabec G.
      • Sr
      Type B aortic dissection after endovascular abdominal aortic aneurysm repair causing endograft collapse and severe malperfusion.
      and Kim and colleagues
      • Kim K.H.
      • Choi J.B.
      • Kuh J.H.
      Simultaneous relief of acute visceral and limb ischemia in complicated type B aortic dissection by axillobifemoral bypass.
      ). 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)
      • 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.
      and 1 patient an open ascending/arch replacement with frozen elephant trunk and branch vessel stenting (n = 1).
      • Axtell A.
      • Eagleton M.
      • Conrad M.
      • Isselbacher E.
      • Sundt T.
      • Jassar A.
      Total arch replacement and frozen elephant trunk for acute complicated type B 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
      Total

      (n = 149)
      Open repair

      (n = 35)
      Endovascular repair

      (n = 112)
      P value
      Demographics
       Age55 (46, 65)57 (48, 68)53.5 (46, 63).103
       Sex, male117 (79)28 (80)88 (79).532
       Dissection type
      Acute146 (98)35 (100)109 (97)
      Acute-on-chronic1 (0.7)0 (0)1 (0.9).439
      Chronic2 (1.3)0 (0)2 (1.8)
       Additional malperfusion
      Renal33 (22)5 (14)26 (23)
      Lower extremity23 (15)9 (26)14 (12.5).074
      Renal + lower extremity55 (37)9 (26)46 (41)
      Procedure
       Aortic fenestration87 (58)16 (46)70 (62.5).059
       Aortic stenting40 (27)10 (29)29 (26).455
       Branch vessel stenting
      Branch vessel stenting and open bypass for the treatment of mesenteric malperfusion, stenting and bypass for other vascular territories not included.
      48 (32)1 (2.9)45 (40)<.005
       Open aortic replacement9 (6.0)7 (20)0 (0)<.005
       Open bypass
      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 resection17 (11)5 (14)11 (9.8).267
       In-hospital mortality19 (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.

      Procedural/Surgical Outcomes

      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
      Total

      (n = 35)
      Open aortic replacement

      (n = 7)
      Open fenestration or stenting

      (n = 21)
      Vascular bypass or other
      Other includes branch vessel thrombectomy, branch vessel fenestration, and branch vessel patch repair.


      (n = 7)
      Demographics
       Age57 (48, 68)57 (40, 63)56 (47, 65)68 (61, 77)
       Sex, male28 (80)6 (86)16 (76)6 (86)
       Dissection type
      Acute35 (100)7 (100)21 (100)7 (100)
      Acute-on-chronic0 (0)0 (0)0 (0)0 (0)
      Chronic0 (0)0 (0)0 (0)0 (0)
       Additional malperfusion
      Renal5 (14)2 (29)3 (14)0 (0)
      Lower extremity9 (26)1 (14)6 (29)2 (29)
      Renal + lower extremity9 (26)2 (29)5 (24)2 (29)
      Procedure
       Aortic fenestration16 (46)2 (29)13 (62)0 (0)
       Aortic stenting10 (29)2 (29)8 (38)0 (0)
       Branch vessel stenting
      Branch vessel stenting and open bypass for the treatment of mesenteric malperfusion, stenting and bypass for other vascular territories not included.
      1 (2.9)1 (14)0 (0)0 (0)
       Open aortic replacement7 (20)7 (100)0 (0)0 (0)
       Open bypass
      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 resection5 (14)3 (43)0 (0)2 (29)
       In-hospital mortality4 (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.
      Table 5Demographics, procedures, and outcomes among open endovascular strategies for TBAD and MesMP
      Total

      (n = 112)
      Any TEVAR

      (n = 21)
      Fenestration/stenting w/o TEVAR (n = 91)P value
      Demographics
       Age53.5 (46, 63)60 (46, 69)53 (46, 61)405
       Sex, male88 (79)11 (55)77 (85)<.005
       Dissection type.215
      Acute109 (97)20 (95)89 (98)
      Acute-on-chronic1 (0.9)1 (4.8)0 (0)
      Chronic2 (1.8)0 (0)2 (2.2)
       Additional malperfusion.558
      Renal26 (23)4 (19)22 (24)
      Lower extremity14 (12.5)4 (19)10 (11)
      Renal + lower extremity46 (41)5 (24)41 (45)
      Procedure
       Aortic fenestration70 (62.5)0 (0)70 (77)<.005
       Aortic stenting29 (26)2 (9.5)27 (30).094
       Branch vessel stenting
      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 resection11 (9.8)2 (9.5)9 (9.9).999
       In-hospital mortality15 (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
      CoefficientStandard errorWald testP value
      Intervention1.1211.1540.944.331
      Endovascular
      Surgical1.1211.1540.944.331
      Study5.815.758
      Verhoye et al, 2008
      • Verhoye J.P.
      • Miller D.C.
      • Sze D.
      • Dake M.D.
      • Mitchell R.S.
      Complicated acute type B aortic dissection: midterm results of emergency endovascular stent-grafting.
      Slonim et al, 1996
      • Slonim S.M.
      • Nyman U.
      • Semba C.P.
      • Miller D.C.
      • Mitchell R.S.
      • Dake M.D.
      Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration.
      19.06028,421.330.000.999
      Sfyroeras et al, 2011
      • Sfyroeras G.S.
      • Rubio V.
      • Pagan P.
      • Diethrich E.B.
      • Rodriguez J.A.
      Endovascular management of malperfusion in acute type B aortic dissections.
      18.12028,421.330.000.999
      Trimarchi et al, 2010
      • Trimarchi S.
      • Jonker F.H.
      • Muhs B.E.
      • Grassi V.
      • Righini P.
      • Upchurgh G.R.
      • et al.
      Long-term outcomes of surgical aortic fenestration for complicated acute type B aortic dissections.
      20.64228,421.330.000.999
      Panneton et al, 2000
      • Panneton J.M.
      • Teh S.H.
      • Cherry Jr., K.J.
      • Hofer J.M.
      • Gloviczki P.
      • Andrews J.C.
      • et al.
      Aortic fenestration for acute or chronic aortic dissection: an uncommon but effective procedure.
      19.67628,421.330.000.999
      Lauterbach et al, 2001
      • Lauterbach S.R.
      • Cambria R.P.
      • Brewster D.C.
      • Gertler J.P.
      • Lamuraglia G.M.
      • Isselbacher E.M.
      • et al.
      Contemporary management of aortic branch compromise resulting from acute aortic dissection.
      −1.12133,628.370.0001.000
      Uchida et al, 2009
      • Uchida N.
      • Shibamura H.
      • Katayama A.
      • Aishin K.
      • Sutoh M.
      • Kuraoka M.
      Surgical strategies for organ malperfusions in acute type B aortic dissection.
      20.10428,421.330.000.999
      Vedantham et al, 2003
      • Vedantham S.
      • Picus D.
      • Sanchez L.A.
      • Braverman A.
      • Moon M.R.
      • Sundt T. 3rd
      • et al.
      Percutaneous management of ischemic complications in patients with type-B aortic dissection.
      19.53328,421.330.000.999
      Norton et al, 2020
      • Norton E.L.
      • Williams D.M.
      • Kim K.M.
      • Khaja M.S.
      • Wu X.
      • Patel H.J.
      • et al.
      Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.
      −1.12134,808.630.0001.000
      Axtell et al, 2020
      • Axtell A.
      • Eagleton M.
      • Conrad M.
      • Isselbacher E.
      • Sundt T.
      • Jassar A.
      Total arch replacement and frozen elephant trunk for acute complicated type B dissection.
      19.38828,421.330.000.999
      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 thumbnail gr2
      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)
      • Jonker F.H.
      • Patel H.J.
      • Upchurch G.R.
      • Williams D.M.
      • Montgomery D.G.
      • Gleason T.G.
      • et al.
      Acute type B aortic dissection complicated by visceral ischemia.
      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
      • Verhoye J.P.
      • Miller D.C.
      • Sze D.
      • Dake M.D.
      • Mitchell R.S.
      Complicated acute type B aortic dissection: midterm results of emergency endovascular stent-grafting.
      and Sfyroeras and colleagues
      • Sfyroeras G.S.
      • Rubio V.
      • Pagan P.
      • Diethrich E.B.
      • Rodriguez J.A.
      Endovascular management of malperfusion in acute type B aortic dissections.
      present TEVAR, the study by Trimarchi and colleagues
      • Trimarchi S.
      • Jonker F.H.
      • Muhs B.E.
      • Grassi V.
      • Righini P.
      • Upchurgh G.R.
      • et al.
      Long-term outcomes of surgical aortic fenestration for complicated acute type B aortic dissections.
      presents open surgical fenestration, the study by Axtell and colleagues
      • Axtell A.
      • Eagleton M.
      • Conrad M.
      • Isselbacher E.
      • Sundt T.
      • Jassar A.
      Total arch replacement and frozen elephant trunk for acute complicated type B dissection.
      presents a hybrid approach with open total arch replacement and frozen elephant trunk placement, and the study by Norton and colleagues
      • Norton E.L.
      • Williams D.M.
      • Kim K.M.
      • Khaja M.S.
      • Wu X.
      • Patel H.J.
      • et al.
      Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.
      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.
      As pioneered by Williams and colleagues,
      • Williams D.M.
      • Brothers T.E.
      • Messina L.M.
      Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum.
      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,
      • Jonker F.H.
      • Patel H.J.
      • Upchurch G.R.
      • Williams D.M.
      • Montgomery D.G.
      • Gleason T.G.
      • et al.
      Acute type B aortic dissection complicated by visceral ischemia.
      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
      • Norton E.L.
      • Williams D.M.
      • Kim K.M.
      • Khaja M.S.
      • Wu X.
      • Patel H.J.
      • et al.
      Management of acute type B aortic dissection with malperfusion via endovascular 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,
      • Yang B.
      • Williams D.
      Reply from Authors: thoracic endovascular aortic repair versus fenestration/stenting: both effective weapons for the same disease.
      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.
      • Yang B.
      • Williams D.
      Reply from Authors: thoracic endovascular aortic repair versus fenestration/stenting: both effective weapons for the same disease.
      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.
      • Wright C.
      • Goldenberg I.
      • Schleede S.
      • McNitt S.
      • Gosev I.
      • Elbadawi A.
      • et al.
      Effect of a multidisciplinary pulmonary embolism response team on patient mortality.
      ,
      • Myc L.A.
      • Solanki J.N.
      • Barros A.J.
      • Nuradin N.
      • Nevulis M.G.
      • Earasi K.
      • et al.
      Adoption of a dedicated multidisciplinary team is associated with improved survival in acute 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.
      • Eltarawy I.G.
      • Etman Y.M.
      • Zenati M.
      • Simmons R.L.
      • Rosengart M.R.
      Acute mesenteric ischemia: the importance of early surgical consultation.
      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.
      • Filippone G.
      • Ferro G.
      • Duranti C.
      • La Barbera G.
      • Talarico F.
      Simultaneous surgical treatment of type B dissection complicated with visceral malperfusion and abdominal aortic aneurysm: role of aortic fenestration.
      ,
      • Howell J.F.
      • LeMaire S.A.
      • Kirby R.P.
      Thoracoabdominal fenestration for aortic dissection with ischemic colonic perforation.
      ,
      • Kurumisawa S.
      • Sugaya A.
      • Akutsu H.
      • Takazawa I.
      • Ohki S.I.
      • Misawa Y.
      Delayed visceral ischemia induced by type B aortic dissection.
      ,
      • Saitoh Y.
      • Ohmori H.
      • Hari Y.
      • Setozaki S.
      • Harada H.
      • Soeda T.
      Mesenteric artery fenestration for type B dissection with visceral ischemia.
      ,
      • Yamashiro S.
      • Kuniyoshi Y.
      • Miyagi K.
      • Uezu T.
      • Arakaki K.
      • Koja K.
      Type B dissection complicated with subacute visceral ischemia.
      ,
      • Uchida N.
      • Shibamura H.
      • Katayama A.
      • Aishin K.
      • Sutoh M.
      • Kuraoka M.
      Surgical strategies for organ malperfusions in acute type B aortic dissection.
      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.
      • Jonker F.H.
      • Patel H.J.
      • Upchurch G.R.
      • Williams D.M.
      • Montgomery D.G.
      • Gleason T.G.
      • et al.
      Acute type B aortic dissection complicated by visceral ischemia.
      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.
      • Girdauskas E.
      • Kuntze T.
      • Borger M.A.
      • Falk V.
      • Mohr F.W.
      Surgical risk of preoperative malperfusion in acute type A aortic dissection.
      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.

      Supplementary Data

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