Yamamoto Ryota, Kato Wataru, Tokuda Yoshiyuki, Yamaki Koshi, Morita Koji, Uemura Tomonari, Yamamoto Toshikuni, Ito Hideki, Yoshizumi Tomo, Terazawa Sachie, Narita Yuji, Mutsuga Masato
Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
Department of Cardiovascular Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.
Eur J Cardiothorac Surg. 2024 Dec 26;67(1). doi: 10.1093/ejcts/ezae452.
Mesenteric malperfusion in acute aortic dissection remains a life-threatening complication with no standardized treatment strategy. This study aimed to describe and evaluate the outcomes of our integrated approach combining exploratory laparotomy, immediate mesenteric reperfusion, and central aortic repair.
We retrospectively reviewed patients with acute aortic dissection with a preoperative diagnosis of mesenteric malperfusion who were treated between August 2011 and November 2022. Our surgical approach was to establish cardiopulmonary bypass, followed by exploratory laparotomy with mesenteric artery flow assessment using Doppler ultrasound and direct perfusion if needed, central aortic repair, and subsequent mesenteric artery reconstruction. The primary end-point was the 30-day operative mortality.
Among 217 patients with acute aortic dissection, 12 (5.5%) had mesenteric malperfusion on preoperative computed tomography. Ten patients underwent exploratory laparotomy, where Doppler ultrasonography revealed reduced mesenteric blood flow in five patients (2.3% of the total 217 patients). These patients underwent direct perfusion of the mesenteric artery via a side branch of the cardiopulmonary bypass circuit. Doppler ultrasound confirmed the restoration of mesenteric blood flow in all perfused patients. No bowel resections were required. The operative mortality in patients with mesenteric malperfusion was 20%. The causes of death were stroke (n = 1) and acute myocardial infarction (n = 1).
Our integrated surgical strategy combining central aortic repair with concurrent exploratory laparotomy and immediate mesenteric perfusion demonstrated technical feasibility in managing mesenteric malperfusion during aortic repair. Further prospective studies with larger cohorts are warranted to validate these findings.
急性主动脉夹层中的肠系膜灌注不良仍然是一种危及生命的并发症，尚无标准化的治疗策略。本研究旨在描述和评估我们采用的联合剖腹探查术、即刻肠系膜再灌注和主动脉中心修复的综合治疗方法的效果。
我们回顾性分析了2011年8月至2022年11月期间接受治疗的术前诊断为肠系膜灌注不良的急性主动脉夹层患者。我们的手术方法是建立体外循环，随后进行剖腹探查术，使用多普勒超声评估肠系膜动脉血流，必要时进行直接灌注，进行主动脉中心修复，随后进行肠系膜动脉重建。主要终点是30天手术死亡率。
在217例急性主动脉夹层患者中，12例（5.5%）术前计算机断层扫描显示存在肠系膜灌注不良。10例患者接受了剖腹探查术，其中多普勒超声显示5例患者（占217例患者总数的2.3%）肠系膜血流减少。这些患者通过体外循环回路的侧支对肠系膜动脉进行了直接灌注。多普勒超声证实所有接受灌注的患者肠系膜血流均恢复。无需进行肠切除术。肠系膜灌注不良患者的手术死亡率为20%。死亡原因是中风（n = 1）和急性心肌梗死（n = 1）。
我们将主动脉中心修复与同期剖腹探查术和即刻肠系膜灌注相结合的综合手术策略在主动脉修复过程中处理肠系膜灌注不良方面显示出技术可行性。需要进一步进行更大样本量的前瞻性研究来验证这些发现。
