Narrative review of the thoracic endovascular aortic repair-first approach for mesenteric malperfusion in type A aortic dissection

The presence of malperfusion syndrome in type A aortic dissection (TAAD) is associated with a difficult and delayed diagnosis and high mortality. Current treatment paradigms have recently shifted towards correction of malperfusion followed by delayed proximal aortic repair approach for this challenging situation. This approach is based on the hypothesis that early restoration of blood flow to visceral tissue beds could prevent the lethal cascade of events leading to a necrotic bowel, persistent acidosis, and death. Several open and endovascular techniques have been described to address this treacherous complication. The objective of this work is to review the thoracic endovascular aortic repair (TEVAR)-first hybrid approach adopted at Emory University, in which a thoracic endograft is deployed in the true lumen first to restore adequate inflow to the relevant branch vessels. After successful reperfusion, aggressive volume resuscitation is adopted with the goal to correct metabolic acidosis under guarded conditions, while maintaining normotension for 24 hours. Proximal aortic repair is then performed using hypothermic circulatory arrest. This approach is suitable for hemodynamically stable patients with clinical and radiographic evidence of mesenteric ischemia and has shown improved outcomes with lower mortality rates, as compared to the conventional approach of emergent ascending aortic repair followed by laparotomy to address the presence of ischemic bowel.