Impact of the collateral network on central-repair-first strategy in superior mesenteric artery occlusion with type A acute aortic dissection

Surgery for acute type A aortic dissection with mesenteric malperfusion is challenging. Although the peripheral-reperfusion-first strategy has shown good results, more discussion regarding indicated patients is needed. This study aimed to describe the imaging features and surgical outcomes of mesenteric malperfusion and to clarify which cases should be considered for the peripheral-reperfusion-first strategy. A total of 200 patients underwent emergent aortic repair for acute type A aortic dissection at our institution between October 2011 and July 2019. Superior mesenteric artery occlusion on preoperative contrast-enhanced computed tomography was detected in 12 patients, who were categorized into two groups based on enhancement (n = 7) or non-enhancement (n = 5) of the superior mesenteric artery peripheral branches. Operative outcomes after central repair were compared between groups. Four patients in the enhanced group had no postoperative abdominal complications, and three patients required superior mesenteric artery bypass grafting with the central-repair-first strategy. However, all patients in the enhanced group survived and did not require intestinal resection. In contrast, four patients (80%) in the non-enhanced group had intestinal necrosis, three patients required intestinal resection, and one patient died from multiple organ failure. The presence or absence of an enhancement of the peripheral superior mesenteric artery by the collateral network could be helpful for decision-making. The central-repair-first strategy may be permitted in patients with enhanced peripheral branches. Conversely, in patients with non-enhanced peripheral branches, a more invasive assessment should be considered before central aortic repair, and peripheral-reperfusion-first strategy may be required.