2 DISCUSSION
Outcomes of aortic repair for ATAAD have improved. According to a Japanese Association for Thoracic Surgery annual report, overall in-hospital mortality of patients who underwent aortic repair for ATAAD in 2015 was 9.6% (468/4875).4 Organ malperfusion associated with ATAAD remains a surgical challenge; patient-specific approaches are required. Shiiya et al. reported that sole central aortic repair failed to revascularize the abdominal organ(s) in 5 of 6 patients with aortic branch dissection.5 Uchida et al. reported favorable outcomes of a surgical strategy that prioritizes peripheral revascularization in patients with organ malperfusion.6 If a patient shows stable hemodynamics and branch-type malperfusion, early revascularization seems to be a feasible approach. Our patient’s ATAAD was complicated by severe mesenteric malperfusion resulting from occlusion of both the celiac artery and SMA. We think that sole central aortic repair or delayed SMA revascularization could have resulted in irreversible mesenteric ischemia.
Previously, we reported ATAAD complicated by malperfusion of at least one organ in 30.9% (308/1029) of patients and that we found obesity (body mass index >30 kg/m2), preoperative shock (systolic blood pressure <80 mmHg), and mesenteric malperfusion to be independent predictors of-in-hospital death for those with such malperfusion.7 Treatment of the ATAAD-induced cardiac tamponade is of paramount importance in patients undergoing immediate aortic repair; however, the optimal management technique remains controversial. Lin et al. reported similar outcomes between emergency subxiphoid pericardiotomy and emergency establishment of CPB.8 Pericardiotomy performed initially for hematoma removal poses a risk of continuous bleeding in cases of aortic rupture. Our case was complicated by cardiac tamponade leading to hemodynamic instability, but aortic rupture had not occurred. In cases of aortic rupture, CPB must be established promptly, before the aortic repair. Revascularization of abdominal organs would be the second priority in such cases.
In conclusion, in our case of ATAAD complicated by cardiac tamponade and severe mesenteric malperfusion, initial release of pericardial hematoma and revascularization of the SMA prevented further mesenteric ischemia and paved the way for aortic repair.