The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis
Abstract Introduction Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric malperfusion represents the greatest risk to patients with respect to increased short-term mortality. In select patients...
| Main Authors: | , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
BMC
2023-08-01
|
| Series: | Journal of Cardiothoracic Surgery |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s13019-023-02341-y |
| _version_ | 1827633206391734272 |
|---|---|
| author | Aditya Eranki Ashley R Wilson-Smith Michael L Williams Aashray Gupta Campbell Flynn Jim Iliopoulos Con Manganas |
| author_facet | Aditya Eranki Ashley R Wilson-Smith Michael L Williams Aashray Gupta Campbell Flynn Jim Iliopoulos Con Manganas |
| author_sort | Aditya Eranki |
| collection | DOAJ |
| description | Abstract Introduction Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric malperfusion represents the greatest risk to patients with respect to increased short-term mortality. In select patients, it may be feasible to offer a staged approach by treating the mesenteric malperfusion first, optimizing the patient in the intensive care setting and then, following with a central aortic repair. The aim of this systematic review is to summarize cohort studies assessing the role of pre-operative interventions for mesenteric malperfusion. Methods An electronic literature search of five databases was performed to identify all relevant studies providing studies examining short-term mortality on patients who underwent either endovascular or open revascularisation of mesenteric ischemia prior to central aortic repair. The primary outcome was all-cause, short-term mortality. Secondary outcomes were comparative mortality between a delayed repair vs. aortic repair first strategy, rates of postoperative laparotomy, bowel resection, and mortality following delayed aortic repair. Results The search strategy identified 8 studies qualifying for inclusion, with a total of 180 patients who underwent delayed aortic surgery in the setting of mesenteric MPS. The weighted short-term mortality following a mesenteric revascularisation first, delayed aortic surgery strategy was 22.5%. This strategy was also associated with a significantly lower mortality than a central repair first strategy (OR 0.07, 95% CI 0.02–0.27), and a significantly lower rate of postoperative laparotomy/bowel resection (OR 0.05, 95% CI 0.02–0.14). If patients survive to receive central repair, the weighted short-term mortality postoperatively is low (2.1%). Conclusion A summary of this evidence reveals a lower short-term mortality in hemodynamically stable patients with mesenteric malperfusion, along with a reduction in postoperative laparotomy/bowel resections. Of those patients who survive to receive central repair, short-term mortality remains very low in the select group of hemodynamically stable patients. Further high-quality studies with randomized or propensity matched data are required to verify these results. |
| first_indexed | 2024-03-09T14:56:18Z |
| format | Article |
| id | doaj.art-90bf9f406eff4025bf89645f60b1f4c1 |
| institution | Directory Open Access Journal |
| issn | 1749-8090 |
| language | English |
| last_indexed | 2024-03-09T14:56:18Z |
| publishDate | 2023-08-01 |
| publisher | BMC |
| record_format | Article |
| series | Journal of Cardiothoracic Surgery |
| spelling | doaj.art-90bf9f406eff4025bf89645f60b1f4c12023-11-26T14:12:12ZengBMCJournal of Cardiothoracic Surgery1749-80902023-08-0118111110.1186/s13019-023-02341-yThe role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysisAditya Eranki0Ashley R Wilson-Smith1Michael L Williams2Aashray Gupta3Campbell Flynn4Jim Iliopoulos5Con Manganas6Department of Cardiothoracic Surgery, Royal Prince Alfred HospitalJohn Hunter HospitalDepartment of Cardiothoracic Surgery, Gold Coast University HospitalUniversity of AdelaideDepartment of Cardiothoracic Surgery, St George HospitalDepartment of Vascular Surgery, St George HospitalDepartment of Cardiothoracic Surgery, St George HospitalAbstract Introduction Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric malperfusion represents the greatest risk to patients with respect to increased short-term mortality. In select patients, it may be feasible to offer a staged approach by treating the mesenteric malperfusion first, optimizing the patient in the intensive care setting and then, following with a central aortic repair. The aim of this systematic review is to summarize cohort studies assessing the role of pre-operative interventions for mesenteric malperfusion. Methods An electronic literature search of five databases was performed to identify all relevant studies providing studies examining short-term mortality on patients who underwent either endovascular or open revascularisation of mesenteric ischemia prior to central aortic repair. The primary outcome was all-cause, short-term mortality. Secondary outcomes were comparative mortality between a delayed repair vs. aortic repair first strategy, rates of postoperative laparotomy, bowel resection, and mortality following delayed aortic repair. Results The search strategy identified 8 studies qualifying for inclusion, with a total of 180 patients who underwent delayed aortic surgery in the setting of mesenteric MPS. The weighted short-term mortality following a mesenteric revascularisation first, delayed aortic surgery strategy was 22.5%. This strategy was also associated with a significantly lower mortality than a central repair first strategy (OR 0.07, 95% CI 0.02–0.27), and a significantly lower rate of postoperative laparotomy/bowel resection (OR 0.05, 95% CI 0.02–0.14). If patients survive to receive central repair, the weighted short-term mortality postoperatively is low (2.1%). Conclusion A summary of this evidence reveals a lower short-term mortality in hemodynamically stable patients with mesenteric malperfusion, along with a reduction in postoperative laparotomy/bowel resections. Of those patients who survive to receive central repair, short-term mortality remains very low in the select group of hemodynamically stable patients. Further high-quality studies with randomized or propensity matched data are required to verify these results.https://doi.org/10.1186/s13019-023-02341-yAcute type a aortic dissectionMesenteric ischemiaMalperfusionManagementMesenteric malperfusionOutcomes |
| spellingShingle | Aditya Eranki Ashley R Wilson-Smith Michael L Williams Aashray Gupta Campbell Flynn Jim Iliopoulos Con Manganas The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis Journal of Cardiothoracic Surgery Acute type a aortic dissection Mesenteric ischemia Malperfusion Management Mesenteric malperfusion Outcomes |
| title | The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis |
| title_full | The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis |
| title_fullStr | The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis |
| title_full_unstemmed | The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis |
| title_short | The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis |
| title_sort | role of delayed aortic surgery in type a aortic dissection and mesenteric ischemia a systematic review and meta analysis |
| topic | Acute type a aortic dissection Mesenteric ischemia Malperfusion Management Mesenteric malperfusion Outcomes |
| url | https://doi.org/10.1186/s13019-023-02341-y |
| work_keys_str_mv | AT adityaeranki theroleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT ashleyrwilsonsmith theroleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT michaellwilliams theroleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT aashraygupta theroleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT campbellflynn theroleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT jimiliopoulos theroleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT conmanganas theroleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT adityaeranki roleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT ashleyrwilsonsmith roleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT michaellwilliams roleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT aashraygupta roleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT campbellflynn roleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT jimiliopoulos roleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis AT conmanganas roleofdelayedaorticsurgeryintypeaaorticdissectionandmesentericischemiaasystematicreviewandmetaanalysis |