3. Outcomes of Lower Extremity Malperfusion Syndrome in Patients Undergoing Proximal Type A Aortic Dissection Repair
Cleveland Clinic
Cleveland, OH
United States - Contact Me
Eric E. Roselli, MD, is Chief of Adult Cardiac Surgery, Surgical Director of the Aorta Center, and on the teaching faculty at the Cleveland Clinic Lerner College of Medicine. He is certified by the American Board of Surgery and the American Board of Thoracic Surgery.
Dr. Roselli is an active member of the American Association for Thoracic Surgery and the Society of Thoracic Surgeons and has served as a chairman and member of the program committee for multiple national and international meetings, and co-authored practice guidelines for the treatment of patients with cardiovascular diseases. He has won several teaching awards and is the activity director for the Tall Rounds® graduate education program and podcast.
He has authored or co-authored over 250 book chapters and articles in peer-reviewed journals on root, arch, and thoracoabdominal aortic aneurysms and dissection, endovascular surgery, reoperations, aortic valve disease, cardiac tumors, atrial fibrillation and transcatheter device development.
Dr Roselli's research is focused on thoracic aortic dissection and aneurysms, and aortic valve and multi-valve disease. Specifically, his projects are directed at improving and developing safer and less invasive approaches to treat patients with these problems. He currently serves as the principal investigator and co-investigator for several device trials and holds several patents for novel devices to treat aortic disease. He regularly presents his work at medical and surgical conferences worldwide.
University of Pittsburgh Medical Center
Pittsburg, PA
United States - Contact Me
Dr. Irsa Hasan is a Cardiac Surgeon and an Assistant Professor of Cardiothoracic Surgery at the University of Pittsburgh Medical Center (UPMC). She earned her medical degree from University of Nebraska Medical Center and completed her general surgery residency at Mayo Clinic, Minnesota. She subsequently trained in cardiothoracic surgery at UPMC followed by an advanced robotic cardiac surgery fellowship at Cedars Sinai Medical Center. Her clinical practices encompasses all aspects of adult cardiac surgery with a clinical and scholarly focus on robotic cardiac surgery, endovascular heart valve therapies, mitral valve repair, and coronary artery disease.
Description
METHODS: Consecutive patients undergoing surgery for acute TAAD were identified from a prospectively maintained database. Perioperative variables were then compared between patients with and without LEM. Predictors of LEM, revascularization, and mortality were determined using univariable cox regression and Firth's penalized likelihood modeling.
RESULTS: A total of 601 patients from January 2007 to December 2021 underwent proximal aortic repair for acute TAAD at a quaternary care center. Of these, 85/601 (14%) patients presented with concomitant LEM. A comparison of perioperative variables between patients with and without LEM are described in Table 1. Kaplan-Meier estimated survival fared worse in patients with LEM compared to no LEM at 1, 5, and 10 years (84% vs 77%, 74% vs 71%, 65% vs 52%, p=0.03).
Within the LEM group, 15/85 (17%) patients underwent lower extremity revascularization. There were no significant differences in postoperative mortality and morbidity between the revascularization and no revascularization groups except for more frequent lower extremity fasciotomy after revascularization (p=0.003). No patients required lower extremity amputations. Preoperative CT imaging showed iliac artery thrombosis (p=0.03) and partial false lumen thrombosis (p=0.05) more frequently in the revascularization group. Significant predictors of revascularization included peripheral vascular disease (HR 3.7 [1.0-14.0], p=0.05) and pulse deficit (HR 5.6 [1.3-24.0], p=0.02) at presentation. Multivariable analysis revealed Caucasian race (HR 0.37 [0.2-0.8], p=0.02) and atrial fibrillation (HR 5.0 [1.6-14.9], p=0.004) were associated with worse survival.
CONCLUSION: This study finds patients with TAAD and LEM more often have significant underlying comorbidities, higher complication rates, and decreased survival compared to those without LEM. Within the LEM group, lower extremity revascularization did not lead to significant differences in postoperative morbidity and mortality. Careful consideration and optimization of predictors of revascularization and mortality as described in this study may improve clinical outcomes.