Acute type A aortic dissection complicated by malperfusion is a life – threatening emergency with perioperative mortality reported in the range of 29 to 89% [1,2,3]. Early diagnosis is very important for determining management modality. In this situation, many surgeons have advocated for the restoration of true lumen blood flow first. Techniques of fenestration have been developed to restore true lumen blood flow, nevertheless, the ideal management for malperfusion remains controversial [3]. Chiu et al. suggest that operative delay to perform fenestration would not have helped most patients with malperfusion [3]. We agree with this opinions. Especially in the context of ongoing end-organ ischemia, immediate surgery is more appropriate than restoration of true lumen blood flow by fenestration first.
In our case, ischemia time of both lower extremities was about 5 h and the restoration of true lumen blood flow was uncertain with the systemic perfusion via the axillary artery. Therefore, we performed antegrade distal perfusion of both lower extremities first.
Holland et al. reported that the mean flow in four arteries in the leg was 284 ± 21 mL/min in the common femoral artery [4]. In fact, the amount of blood needed for perfusion of both lower extremities was thought to be more, therefore, perfusion was performed at about 500 cc/min each. We performed antegrade distal perfusion with direct cannulation of both femoral arteries for even perfusion of both lower extremities.
Because we planned to perform left axillo-bifemoral bypass to resolve the malperfusion caused by static occlusion of the infra-renal aorta, the left axillary artery was used for CPB. Masashi et al.reported that the left axillary route is preferred over the right, because the left subclavian artery has a separate and downstream origin from the carotid artery [5].
Slonim et al. reported that percutaneous balloon fenestration of the intimal flap and endovascular stenting is an effective treatment for life-threatening ischemic complications of acute aortic dissection. Of the patients,14 patients were treated with stenting and fenestration, 24 with stenting alone, and 2 with fenestration alone [6]. However, we think, in the context of static malperfusion, restoration of true lumen blood flow may not be sufficient by eliminating the tear with the ascending or arch replacement and fenestration. If the size of the preoperative or postoperative fenestration is not appropriate, there may be ongoing false lumen pressurization resulting in persistent malperfusion. In that rationale, we thought, in our case, restoration of true lumen blood flow by eliminating the tear or fenestration would not sufficient, therefore, we performed immediate left axillo-bifemoral bypass after total arch replacement.