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The “TEVAR-First” Approach to DeBakey I Aortic Dissection With Mesenteric Malperfusion

2014; Elsevier BV; Volume: 97; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2013.06.110

1552-6259

Bradley G. Leshnower, Ravi Veeraswamy, Yazan Duwayri, Edward P. Chen,

Cardiac Valve Diseases and Treatments

Acute DeBakey type 1 aortic dissection presenting with mesenteric malperfusion is a lethal variant of all dissection-related malperfusion syndromes with reported mortality rates of 38% to 75%. Conventional surgical treatment involves proximal aortic replacement to restore true lumen perfusion, followed by mesenteric revascularization if malperfusion persists. In an attempt to improve the dismal outcomes associated with this malperfusion syndrome, we have instituted a [thoracic endovascular aortic repair] "TEVAR-First" approach in hemodynamically stable patients, which allows for earlier true lumen expansion and resolution of the malperfusion syndrome. Acute DeBakey type 1 aortic dissection presenting with mesenteric malperfusion is a lethal variant of all dissection-related malperfusion syndromes with reported mortality rates of 38% to 75%. Conventional surgical treatment involves proximal aortic replacement to restore true lumen perfusion, followed by mesenteric revascularization if malperfusion persists. In an attempt to improve the dismal outcomes associated with this malperfusion syndrome, we have instituted a [thoracic endovascular aortic repair] "TEVAR-First" approach in hemodynamically stable patients, which allows for earlier true lumen expansion and resolution of the malperfusion syndrome. Acute DeBakey I aortic dissection (D1AD) with mesenteric malperfusion is a rare (3%) and lethal variant of aortic dissection [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar]. Emergent proximal aortic reconstruction to resect the primary intimal tear and restore true lumen flow, followed by open or endovascular mesenteric revascularization represents the current standard of care. However this treatment algorithm has resulted in a 63% mortality rate based upon the latest International Registry of Acute Aortic Dissection report [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar]. These dismal results are likely due to advanced end-organ injury due to prolonged ischemia prior to restoration of true lumen blood flow. In an attempt to improve survival in patients presenting with D1AD and mesenteric malperfusion, we have implemented a "TEVAR-First" approach to rapidly restore inflow to malperfused visceral aortic branches, followed by proximal aortic repair.Case ReportsPatient 1A 53-year-old morbidly obese female presented to an outside hospital with abdominal and right leg pain and was diagnosed with D1AD. Upon arrival to our institution, the patient was hemodynamically stable without abdominal or chest pain but had a cool, pulseless right leg and a serum creatinine of 2.1 mg/dL. A review of the computed tomography (CT) scan revealed a D1AD with left renal malperfusion and significant true lumen compression (true lumen ≤10% of total arterial cross sectional area) throughout the abdominal aorta and right iliac artery. There was no evidence of cardiac tamponade, coronary malperfusion, or mediastinal hematoma. The patient was taken to the hybrid operating room (OR) and catheters were placed in the true and false lumens under intravascular ultrasound (IVUS) guidance. The false lumen pressure of the visceral segment of the abdominal aorta was non-pulsatile and measured 60% of right radial systolic arterial pressure. The right femoral pressure was also non-pulsatile and 60% of right radial systolic arterial pressure. A Medtronic Valiant (Medtronic Inc, Minneapolis, MN) closed web thoracic endoprosthesis was deployed in the proximal descending thoracic aorta. Repeat pressure measurements revealed equal pressures in the right radial artery, the true and false lumens in the thoracic and abdominal aorta, and the right femoral artery. Completion aortogram showed reperfusion of the left renal artery and new malperfusion of the right renal artery. The IVUS confirmed a dynamic flap obstructing the right renal artery which was resolved with a bare metal stent. The patient was taken back to the intensive care unit, resuscitated for 12 hours, and then underwent aortic root, ascending, total arch replacement. The patient's postoperative course was complicated by pneumonia and respiratory failure requiring tracheostomy, but she was neurologically intact and was discharged on postoperative day 33 tolerating a diet with a creatinine of 0.9 mg/dL (Fig 1).Patient 2A 61-year-old female presented to an outside hospital complaining of abdominal pain. Upon arrival to our institution, the patient was hemodynamically stable but had persistent abdominal pain and a cool, pulseless right leg. A review of the CT scan revealed a D1AD with significant true lumen compression throughout the abdominal aorta and right iliac artery. The patient was taken to the hybrid suite and underwent emergent TEVAR with a GORE CTAG endoprosthesis (W.L. Gore Assoc, Flagstaff, AZ) deployed in the proximal descending thoracic aorta. A completion aortogram demonstrated resolution of the true lumen compression throughout the abdominal aorta; however, the right iliac artery true lumen remained compressed. A covered stent was deployed in the right common iliac artery that resolved the iliofemoral malperfusion and the patient regained a palpable dorsalis pedis pulse in the right foot. The patient was taken back to the intensive care unit, resuscitated, and returned to the OR 12 hours later for ascending aortic and hemiarch replacement. On postoperative day 2 the patient lost the pulse in her foot and a CT angiography revealed a thrombus in the below the knee popliteal artery. The patient returned to the OR for emergent thrombectomy of the popliteal artery which resolved the malperfusion. She had an uneventful postoperative course and was discharged home on postoperative day 13.CommentThe presence of a malperfusion syndrome in patients presenting with aortic dissection is a significant risk factor for mortality [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar, 2Deeb G.M. Patel H.J. Williams D.M. Treatment for malperfusion syndrome in acute type A and B aortic dissection: a long-term analysis.J Thorac Cardiovasc Surg. 2010; 140: S98-100Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Mesenteric ischemia represents one of the most lethal variants of all malperfusion syndromes with reported mortality rates ranging from 38% to 75% [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar, 2Deeb G.M. Patel H.J. Williams D.M. Treatment for malperfusion syndrome in acute type A and B aortic dissection: a long-term analysis.J Thorac Cardiovasc Surg. 2010; 140: S98-100Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. There are multiple factors for the dismal survival in these patients. Confirming the diagnosis of acute mesenteric ischemia in patients with aortic dissection can be challenging; abdominal pain is a nonspecific symptom which occurs in only 60% of patients [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar]. As in our series, mesenteric malperfusion is often associated with additional malperfused vascular beds, which increases the risk of mortality [3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Finally, the time from the onset of D1AD to the time of surgery is often prolonged. It is not uncommon for the diagnosis of D1AD to be made at an outside hospital. Crucial time elapses while the patient is transferred to the "definitive therapy" institution. This ultimately delays the time to reperfusion of the ischemic end organs.Thoracic endovascular aortic repair is a well-accepted therapy for the treatment of acute complicated DeBakey III dissection [4Szeto W.Y. McGarvey M. Pochettino A. et al.Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection.Ann Thorac Surg. 2008; 86: 87-93Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar]. Coverage of the primary intimal tear is the goal of TEVAR in DeBakey III dissections. This eliminates antegrade flow into the false lumen, depressurizes the false lumen, and usually resolves malperfusion. The primary intimal tear in D1AD is located proximal to the left subclavian artery. Therefore, the goal of TEVAR for D1AD with infradiaphragmatic aortic branch malperfusion is not to cover the primary intimal tear, but rather to mechanically expand the thoracic true lumen, thereby increasing inflow to the distal aorta. The IVUS is used in all dissection cases to both confirm true lumen access, and assist in graft sizing. In the 2 cases presented above, a single 15-cm endograft, deployed 2-cm distal to the left subclavian artery, achieved sufficient expansion of the thoracic true lumen to increase distal aortic inflow and relieve the mesenteric malperfusion. The primary intimal tear is subsequently resected at the time of proximal aortic reconstruction.The "TEVAR-First" approach is only appropriate in hemodynamically stable patients who do not exhibit radiographic or physiologic signs of aortic rupture, coronary malperfusion, or cardiac tamponade. In those situations, emergent proximal aortic reconstruction with concomitant axillary-femoral bypass to restore distal aortic perfusion is recommended. Although proximal aortic reconstruction with antegrade TEVAR through the open arch may provide the same end result radiographically, this method delays reperfusion of the ischemic end-organs. We have attempted this approach in patients with mesenteric ischemia and they have still required an axillary-bifemoral bypass, bowel resection and ultimately did not survive. The "TEVAR-First" approach is a more rapid method of reperfusing the ischemic distal aortic territories. Both patients in the current series had visceral and iliofemoral malperfusion resolved by endovascular therapy, based upon findings from their history and physical exam, combined with radiographic (angiography, IVUS) and physiologic (arterial pressure measurements) data. All patients were tolerating a regular diet and had unobstructed perfusion of the celiac, and superior and inferior mesenteric arteries on CT scans prior to discharge. Although there is a risk of mortality by delaying proximal aortic reconstruction, we believe that the "TEVAR-First" approach represents an improved treatment paradigm for patients with D1AD and mesenteric malperfusion. Acute DeBakey I aortic dissection (D1AD) with mesenteric malperfusion is a rare (3%) and lethal variant of aortic dissection [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar]. Emergent proximal aortic reconstruction to resect the primary intimal tear and restore true lumen flow, followed by open or endovascular mesenteric revascularization represents the current standard of care. However this treatment algorithm has resulted in a 63% mortality rate based upon the latest International Registry of Acute Aortic Dissection report [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar]. These dismal results are likely due to advanced end-organ injury due to prolonged ischemia prior to restoration of true lumen blood flow. In an attempt to improve survival in patients presenting with D1AD and mesenteric malperfusion, we have implemented a "TEVAR-First" approach to rapidly restore inflow to malperfused visceral aortic branches, followed by proximal aortic repair. Case ReportsPatient 1A 53-year-old morbidly obese female presented to an outside hospital with abdominal and right leg pain and was diagnosed with D1AD. Upon arrival to our institution, the patient was hemodynamically stable without abdominal or chest pain but had a cool, pulseless right leg and a serum creatinine of 2.1 mg/dL. A review of the computed tomography (CT) scan revealed a D1AD with left renal malperfusion and significant true lumen compression (true lumen ≤10% of total arterial cross sectional area) throughout the abdominal aorta and right iliac artery. There was no evidence of cardiac tamponade, coronary malperfusion, or mediastinal hematoma. The patient was taken to the hybrid operating room (OR) and catheters were placed in the true and false lumens under intravascular ultrasound (IVUS) guidance. The false lumen pressure of the visceral segment of the abdominal aorta was non-pulsatile and measured 60% of right radial systolic arterial pressure. The right femoral pressure was also non-pulsatile and 60% of right radial systolic arterial pressure. A Medtronic Valiant (Medtronic Inc, Minneapolis, MN) closed web thoracic endoprosthesis was deployed in the proximal descending thoracic aorta. Repeat pressure measurements revealed equal pressures in the right radial artery, the true and false lumens in the thoracic and abdominal aorta, and the right femoral artery. Completion aortogram showed reperfusion of the left renal artery and new malperfusion of the right renal artery. The IVUS confirmed a dynamic flap obstructing the right renal artery which was resolved with a bare metal stent. The patient was taken back to the intensive care unit, resuscitated for 12 hours, and then underwent aortic root, ascending, total arch replacement. The patient's postoperative course was complicated by pneumonia and respiratory failure requiring tracheostomy, but she was neurologically intact and was discharged on postoperative day 33 tolerating a diet with a creatinine of 0.9 mg/dL (Fig 1).Patient 2A 61-year-old female presented to an outside hospital complaining of abdominal pain. Upon arrival to our institution, the patient was hemodynamically stable but had persistent abdominal pain and a cool, pulseless right leg. A review of the CT scan revealed a D1AD with significant true lumen compression throughout the abdominal aorta and right iliac artery. The patient was taken to the hybrid suite and underwent emergent TEVAR with a GORE CTAG endoprosthesis (W.L. Gore Assoc, Flagstaff, AZ) deployed in the proximal descending thoracic aorta. A completion aortogram demonstrated resolution of the true lumen compression throughout the abdominal aorta; however, the right iliac artery true lumen remained compressed. A covered stent was deployed in the right common iliac artery that resolved the iliofemoral malperfusion and the patient regained a palpable dorsalis pedis pulse in the right foot. The patient was taken back to the intensive care unit, resuscitated, and returned to the OR 12 hours later for ascending aortic and hemiarch replacement. On postoperative day 2 the patient lost the pulse in her foot and a CT angiography revealed a thrombus in the below the knee popliteal artery. The patient returned to the OR for emergent thrombectomy of the popliteal artery which resolved the malperfusion. She had an uneventful postoperative course and was discharged home on postoperative day 13. Patient 1A 53-year-old morbidly obese female presented to an outside hospital with abdominal and right leg pain and was diagnosed with D1AD. Upon arrival to our institution, the patient was hemodynamically stable without abdominal or chest pain but had a cool, pulseless right leg and a serum creatinine of 2.1 mg/dL. A review of the computed tomography (CT) scan revealed a D1AD with left renal malperfusion and significant true lumen compression (true lumen ≤10% of total arterial cross sectional area) throughout the abdominal aorta and right iliac artery. There was no evidence of cardiac tamponade, coronary malperfusion, or mediastinal hematoma. The patient was taken to the hybrid operating room (OR) and catheters were placed in the true and false lumens under intravascular ultrasound (IVUS) guidance. The false lumen pressure of the visceral segment of the abdominal aorta was non-pulsatile and measured 60% of right radial systolic arterial pressure. The right femoral pressure was also non-pulsatile and 60% of right radial systolic arterial pressure. A Medtronic Valiant (Medtronic Inc, Minneapolis, MN) closed web thoracic endoprosthesis was deployed in the proximal descending thoracic aorta. Repeat pressure measurements revealed equal pressures in the right radial artery, the true and false lumens in the thoracic and abdominal aorta, and the right femoral artery. Completion aortogram showed reperfusion of the left renal artery and new malperfusion of the right renal artery. The IVUS confirmed a dynamic flap obstructing the right renal artery which was resolved with a bare metal stent. The patient was taken back to the intensive care unit, resuscitated for 12 hours, and then underwent aortic root, ascending, total arch replacement. The patient's postoperative course was complicated by pneumonia and respiratory failure requiring tracheostomy, but she was neurologically intact and was discharged on postoperative day 33 tolerating a diet with a creatinine of 0.9 mg/dL (Fig 1). A 53-year-old morbidly obese female presented to an outside hospital with abdominal and right leg pain and was diagnosed with D1AD. Upon arrival to our institution, the patient was hemodynamically stable without abdominal or chest pain but had a cool, pulseless right leg and a serum creatinine of 2.1 mg/dL. A review of the computed tomography (CT) scan revealed a D1AD with left renal malperfusion and significant true lumen compression (true lumen ≤10% of total arterial cross sectional area) throughout the abdominal aorta and right iliac artery. There was no evidence of cardiac tamponade, coronary malperfusion, or mediastinal hematoma. The patient was taken to the hybrid operating room (OR) and catheters were placed in the true and false lumens under intravascular ultrasound (IVUS) guidance. The false lumen pressure of the visceral segment of the abdominal aorta was non-pulsatile and measured 60% of right radial systolic arterial pressure. The right femoral pressure was also non-pulsatile and 60% of right radial systolic arterial pressure. A Medtronic Valiant (Medtronic Inc, Minneapolis, MN) closed web thoracic endoprosthesis was deployed in the proximal descending thoracic aorta. Repeat pressure measurements revealed equal pressures in the right radial artery, the true and false lumens in the thoracic and abdominal aorta, and the right femoral artery. Completion aortogram showed reperfusion of the left renal artery and new malperfusion of the right renal artery. The IVUS confirmed a dynamic flap obstructing the right renal artery which was resolved with a bare metal stent. The patient was taken back to the intensive care unit, resuscitated for 12 hours, and then underwent aortic root, ascending, total arch replacement. The patient's postoperative course was complicated by pneumonia and respiratory failure requiring tracheostomy, but she was neurologically intact and was discharged on postoperative day 33 tolerating a diet with a creatinine of 0.9 mg/dL (Fig 1). Patient 2A 61-year-old female presented to an outside hospital complaining of abdominal pain. Upon arrival to our institution, the patient was hemodynamically stable but had persistent abdominal pain and a cool, pulseless right leg. A review of the CT scan revealed a D1AD with significant true lumen compression throughout the abdominal aorta and right iliac artery. The patient was taken to the hybrid suite and underwent emergent TEVAR with a GORE CTAG endoprosthesis (W.L. Gore Assoc, Flagstaff, AZ) deployed in the proximal descending thoracic aorta. A completion aortogram demonstrated resolution of the true lumen compression throughout the abdominal aorta; however, the right iliac artery true lumen remained compressed. A covered stent was deployed in the right common iliac artery that resolved the iliofemoral malperfusion and the patient regained a palpable dorsalis pedis pulse in the right foot. The patient was taken back to the intensive care unit, resuscitated, and returned to the OR 12 hours later for ascending aortic and hemiarch replacement. On postoperative day 2 the patient lost the pulse in her foot and a CT angiography revealed a thrombus in the below the knee popliteal artery. The patient returned to the OR for emergent thrombectomy of the popliteal artery which resolved the malperfusion. She had an uneventful postoperative course and was discharged home on postoperative day 13. A 61-year-old female presented to an outside hospital complaining of abdominal pain. Upon arrival to our institution, the patient was hemodynamically stable but had persistent abdominal pain and a cool, pulseless right leg. A review of the CT scan revealed a D1AD with significant true lumen compression throughout the abdominal aorta and right iliac artery. The patient was taken to the hybrid suite and underwent emergent TEVAR with a GORE CTAG endoprosthesis (W.L. Gore Assoc, Flagstaff, AZ) deployed in the proximal descending thoracic aorta. A completion aortogram demonstrated resolution of the true lumen compression throughout the abdominal aorta; however, the right iliac artery true lumen remained compressed. A covered stent was deployed in the right common iliac artery that resolved the iliofemoral malperfusion and the patient regained a palpable dorsalis pedis pulse in the right foot. The patient was taken back to the intensive care unit, resuscitated, and returned to the OR 12 hours later for ascending aortic and hemiarch replacement. On postoperative day 2 the patient lost the pulse in her foot and a CT angiography revealed a thrombus in the below the knee popliteal artery. The patient returned to the OR for emergent thrombectomy of the popliteal artery which resolved the malperfusion. She had an uneventful postoperative course and was discharged home on postoperative day 13. CommentThe presence of a malperfusion syndrome in patients presenting with aortic dissection is a significant risk factor for mortality [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar, 2Deeb G.M. Patel H.J. Williams D.M. Treatment for malperfusion syndrome in acute type A and B aortic dissection: a long-term analysis.J Thorac Cardiovasc Surg. 2010; 140: S98-100Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Mesenteric ischemia represents one of the most lethal variants of all malperfusion syndromes with reported mortality rates ranging from 38% to 75% [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar, 2Deeb G.M. Patel H.J. Williams D.M. Treatment for malperfusion syndrome in acute type A and B aortic dissection: a long-term analysis.J Thorac Cardiovasc Surg. 2010; 140: S98-100Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. There are multiple factors for the dismal survival in these patients. Confirming the diagnosis of acute mesenteric ischemia in patients with aortic dissection can be challenging; abdominal pain is a nonspecific symptom which occurs in only 60% of patients [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar]. As in our series, mesenteric malperfusion is often associated with additional malperfused vascular beds, which increases the risk of mortality [3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Finally, the time from the onset of D1AD to the time of surgery is often prolonged. It is not uncommon for the diagnosis of D1AD to be made at an outside hospital. Crucial time elapses while the patient is transferred to the "definitive therapy" institution. This ultimately delays the time to reperfusion of the ischemic end organs.Thoracic endovascular aortic repair is a well-accepted therapy for the treatment of acute complicated DeBakey III dissection [4Szeto W.Y. McGarvey M. Pochettino A. et al.Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection.Ann Thorac Surg. 2008; 86: 87-93Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar]. Coverage of the primary intimal tear is the goal of TEVAR in DeBakey III dissections. This eliminates antegrade flow into the false lumen, depressurizes the false lumen, and usually resolves malperfusion. The primary intimal tear in D1AD is located proximal to the left subclavian artery. Therefore, the goal of TEVAR for D1AD with infradiaphragmatic aortic branch malperfusion is not to cover the primary intimal tear, but rather to mechanically expand the thoracic true lumen, thereby increasing inflow to the distal aorta. The IVUS is used in all dissection cases to both confirm true lumen access, and assist in graft sizing. In the 2 cases presented above, a single 15-cm endograft, deployed 2-cm distal to the left subclavian artery, achieved sufficient expansion of the thoracic true lumen to increase distal aortic inflow and relieve the mesenteric malperfusion. The primary intimal tear is subsequently resected at the time of proximal aortic reconstruction.The "TEVAR-First" approach is only appropriate in hemodynamically stable patients who do not exhibit radiographic or physiologic signs of aortic rupture, coronary malperfusion, or cardiac tamponade. In those situations, emergent proximal aortic reconstruction with concomitant axillary-femoral bypass to restore distal aortic perfusion is recommended. Although proximal aortic reconstruction with antegrade TEVAR through the open arch may provide the same end result radiographically, this method delays reperfusion of the ischemic end-organs. We have attempted this approach in patients with mesenteric ischemia and they have still required an axillary-bifemoral bypass, bowel resection and ultimately did not survive. The "TEVAR-First" approach is a more rapid method of reperfusing the ischemic distal aortic territories. Both patients in the current series had visceral and iliofemoral malperfusion resolved by endovascular therapy, based upon findings from their history and physical exam, combined with radiographic (angiography, IVUS) and physiologic (arterial pressure measurements) data. All patients were tolerating a regular diet and had unobstructed perfusion of the celiac, and superior and inferior mesenteric arteries on CT scans prior to discharge. Although there is a risk of mortality by delaying proximal aortic reconstruction, we believe that the "TEVAR-First" approach represents an improved treatment paradigm for patients with D1AD and mesenteric malperfusion. The presence of a malperfusion syndrome in patients presenting with aortic dissection is a significant risk factor for mortality [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar, 2Deeb G.M. Patel H.J. Williams D.M. Treatment for malperfusion syndrome in acute type A and B aortic dissection: a long-term analysis.J Thorac Cardiovasc Surg. 2010; 140: S98-100Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Mesenteric ischemia represents one of the most lethal variants of all malperfusion syndromes with reported mortality rates ranging from 38% to 75% [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar, 2Deeb G.M. Patel H.J. Williams D.M. Treatment for malperfusion syndrome in acute type A and B aortic dissection: a long-term analysis.J Thorac Cardiovasc Surg. 2010; 140: S98-100Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. There are multiple factors for the dismal survival in these patients. Confirming the diagnosis of acute mesenteric ischemia in patients with aortic dissection can be challenging; abdominal pain is a nonspecific symptom which occurs in only 60% of patients [1Di Eusanio M. Trimarchi S. Patel H.J. et al.Clinical presentation, management and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2013; 145: 385-390Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar]. As in our series, mesenteric malperfusion is often associated with additional malperfused vascular beds, which increases the risk of mortality [3Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection.J Thorac Cardiovasc Surg. 2009; 138: 1363-1369Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Finally, the time from the onset of D1AD to the time of surgery is often prolonged. It is not uncommon for the diagnosis of D1AD to be made at an outside hospital. Crucial time elapses while the patient is transferred to the "definitive therapy" institution. This ultimately delays the time to reperfusion of the ischemic end organs. Thoracic endovascular aortic repair is a well-accepted therapy for the treatment of acute complicated DeBakey III dissection [4Szeto W.Y. McGarvey M. Pochettino A. et al.Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection.Ann Thorac Surg. 2008; 86: 87-93Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar]. Coverage of the primary intimal tear is the goal of TEVAR in DeBakey III dissections. This eliminates antegrade flow into the false lumen, depressurizes the false lumen, and usually resolves malperfusion. The primary intimal tear in D1AD is located proximal to the left subclavian artery. Therefore, the goal of TEVAR for D1AD with infradiaphragmatic aortic branch malperfusion is not to cover the primary intimal tear, but rather to mechanically expand the thoracic true lumen, thereby increasing inflow to the distal aorta. The IVUS is used in all dissection cases to both confirm true lumen access, and assist in graft sizing. In the 2 cases presented above, a single 15-cm endograft, deployed 2-cm distal to the left subclavian artery, achieved sufficient expansion of the thoracic true lumen to increase distal aortic inflow and relieve the mesenteric malperfusion. The primary intimal tear is subsequently resected at the time of proximal aortic reconstruction. The "TEVAR-First" approach is only appropriate in hemodynamically stable patients who do not exhibit radiographic or physiologic signs of aortic rupture, coronary malperfusion, or cardiac tamponade. In those situations, emergent proximal aortic reconstruction with concomitant axillary-femoral bypass to restore distal aortic perfusion is recommended. Although proximal aortic reconstruction with antegrade TEVAR through the open arch may provide the same end result radiographically, this method delays reperfusion of the ischemic end-organs. We have attempted this approach in patients with mesenteric ischemia and they have still required an axillary-bifemoral bypass, bowel resection and ultimately did not survive. The "TEVAR-First" approach is a more rapid method of reperfusing the ischemic distal aortic territories. Both patients in the current series had visceral and iliofemoral malperfusion resolved by endovascular therapy, based upon findings from their history and physical exam, combined with radiographic (angiography, IVUS) and physiologic (arterial pressure measurements) data. All patients were tolerating a regular diet and had unobstructed perfusion of the celiac, and superior and inferior mesenteric arteries on CT scans prior to discharge. Although there is a risk of mortality by delaying proximal aortic reconstruction, we believe that the "TEVAR-First" approach represents an improved treatment paradigm for patients with D1AD and mesenteric malperfusion.