Successful limb salvage in acute type A aortic dissection with bilateral lower limb malperfusion by early cardiopulmonary bypass reperfusion and total arch replacement with frozen elephant trunk

We report a case of a 74-year-old man with acute type A aortic dissection (AADA) complicated by bilateral lower limb and renal malperfusion. Due to preoperative motor and sensory deficits, bilateral axillo-bifemoral grafts were used for arterial cannulation to initiate cardiopulmonary bypass and enable immediate limb reperfusion. Total arch replacement with a frozen elephant trunk was performed. To maintain lower limb perfusion perioperatively, a prophylactic ascending aorta-to-bilateral femoral artery bypass was constructed using the same grafts. Although the aorta-to-bilateral femoral artery bypass occluded within 1 week postoperatively due to true lumen expansion, limb perfusion was preserved, and no further revascularization was required. Continuous renal replacement therapy was initiated immediately postoperatively to prevent myonephropathic metabolic syndrome, leading to full renal recovery. The patient was discharged without neurological deficits or limb loss. This case underscores the effectiveness of early cardiopulmonary bypass reperfusion, temporary bypass, and renal support in AADA with limb malperfusion.