Acute Type A Dissection With Visceral and Limb Malperfusion
A 58-year-old man presents with sudden tearing chest pain. Blood pressure is 180/100 mmHg in the right arm and 110/70 mmHg in the left arm. He is oliguric, with creatinine 2.4 mg/dL, lactate 4.5 mmol/L, and a cool left leg. CT angiography shows an acute type A dissection from the aortic root to the iliac arteries. The false lumen compresses the true lumen in the abdomen, and the left common iliac artery is not opacified. Echocardiography shows moderate aortic insufficiency and a pericardial effusion without tamponade. Cardiac surgery and hybrid capabilities are available on site. The patient is alert and asks whether his leg can be fixed first.
1. What is your immediate management and cannulation strategy?
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This is a surgical emergency: acute type A dissection with malperfusion. I would control heart rate and blood pressure without causing profound hypotension, secure large-bore access, cross-match blood, and move directly to the operating room with transesophageal echocardiography. For cannulation, I favor the right axillary artery to provide antegrade perfusion and cerebral protection, and to reduce the risk of perfusing a false lumen. Femoral cannulation is less attractive because the left iliac is occluded and the right iliofemoral axis may also be involved. I would not delay repair for leg revascularization alone; restoring true-lumen flow after proximal repair often improves limb and visceral perfusion. If the leg remains critically ischemic after repair, then vascular intervention or fasciotomy is added. The patient should be counseled that paraplegia, stroke, renal failure, and death remain possible.
2. How would you address the aortic root, arch, and malperfusion intraoperatively?
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I would inspect the root and valve. With moderate AI and a nondilated root, a supracoronary graft with valve resuspension is reasonable; if the root is destroyed or aneurysmal, a modified Bentall is preferred. For the arch, I would perform a hemiarch repair under hypothermic circulatory arrest with antegrade cerebral perfusion if the tear extends into the arch, and avoid a total arch replacement unless the arch is the primary site of destruction. Malperfusion is managed by resecting the intimal flap, restoring true-lumen flow, and ensuring a stable distal anastomosis. I would monitor lactate, urine output, and limb perfusion after bypass; persistent visceral ischemia may require fenestration or stenting after the patient is stabilized. The priority is proximal repair, not simultaneous complete aortic replacement.