OBJECTIVE: Cerebral malperfusion (CM) is a common comorbidity in acute type A aortic dissection (ATAAD), which is associated with high mortality and poor neurological prognosis. This meta-analysis investigated the surgical strategy of ATAAD patients with CM, aiming to compare the difference in therapeutic effectiveness between the central repair-first and the early reperfusion-first according to clinical outcomes.
METHODS: The meta-analysis and systematic review was conducted based on studies sourced from the PubMed, Embase, and Cochrane literature database, in which cases of ATAAD with CM underwent surgical repair were included. Data for baseline characteristics, mortality, survival were extracted, and risk ratio (RR) values and the pooled mortality were calculated.
RESULTS: A total of 17 retrospective studies were analyzed, including 1010 cases of ATAAD with CM underwent surgical repair. The pooled early mortality in early reperfusion group was lower (8.1%; CI, 0.02 to 0.168) than that in the central repair group (16.2%; CI, 0.115 to 0.216). The pooled long-term mortality was 7.9% in the early reperfusion cohort and 17.4% the central repair-first cohort, without a statistically significant heterogeneity (I [2] = 51.271%; p = 0.056). The mean time of symptom-onset-to-the-operation-room in all the reports was 8.87 ± 12.3 h.
CONCLUSIONS: This meta-analysis suggested that early reperfusion-first may achieved better outcomes compared to central repair-first in ATAAD patients complicated with CM to some extent. Early operation and early restoration of cerebral perfusion may reduce the occurrence of some neurological complications.
BACKGROUND: The meta-analysis was registered in the International Prospective Register of Systematic Reviews database (No. CRD CRD42023475629) on Nov. 8th, 2023.

OBJECTIVE: The mortality of acute type A aortic dissection (ATAAD) with malperfusion syndrome (MPS) is high. However, the management strategy remains controversial. We aimed to evaluate the strategy for MPS at our institution.
METHODS: Among 724 patients with ATAAD, 167 patients with MPS were treated with immediate central repair (1st stage) or an optimized strategy (2nd stage). In 2nd stage, the optimized strategy used was based on 6-hour threshold from symptom onset. For MPS with symptom onset within 6 hours, immediate central repair was performed followed by endovascular reperfusion if malperfusion persisted. With symptom onset beyond 6 hours, individualized delayed central repair was performed. We compared outcomes between the 1st and 2nd stage.
RESULTS: The in-hospital mortality of ATAAD was significantly decreased when the optimized strategy was used (4.3% in 2nd stage vs. 12.5% in 1st stage, P<0.01). In 2nd stage, the in-hospital mortality for MPS was decreased (10.2% vs. 33.9%, P<0.01). Moreover, the in-hospital mortality for MPS with symptom onset within or beyond 6 hours decreased from 24% to 7.5% and from 41.2% to 11.8%, respectively. The operative mortality of MPS in 2nd stage was comparable with patients without MPS (4.0% vs. 2.4%, P>0.05).
CONCLUSIONS: The optimized strategy significantly improved the outcomes of MPS. The 6-hour threshold from symptom onset could be very useful in determining the timing of central repair. For MPS with symptom onset within 6 hours, immediate central repair is reasonable. For those with symptom onset beyond 6 hours, individualized delayed central repair should be considered.

OBJECTIVE: 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.
METHODS: 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.
RESULTS: 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.
CONCLUSIONS: 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.

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient\'s condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.