Should limb revascularization take priority over dissection repair in type a aortic dissection presenting as isolated acute limb ischaemia

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was should limb revascularization take priority over dissection repair in acute type A aortic dissection (ATAAD) presenting as isolated acute limb ischaemia? Altogether 133 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Six studies showed that aortic repair alone resulted in the reperfusion of 60-100% of ischaemic lower limbs and recommended a strategy prioritizing aortic repair. In those with persistent isolated limb ischaemia post-aortic repair, expeditious peripheral revascularization procedures produced excellent patient outcomes comparable to those of ATAAD patients without malperfusion syndromes. In the remaining study, aortic repair was delayed in order to prioritize percutaneous reperfusion therapy aimed at treating the peripheral malperfusion. However, this resulted in one-third of patients not surviving to aortic surgery. We conclude that delaying aortic repair for limb reperfusion procedures results in unacceptably high mortality rates and that repair alone results in high reperfusion rates of ischaemic limbs. We therefore strongly recommend that aortic repair be the primary therapy for ATAAD patients even when limb ischaemia is the presenting feature. Limbs should be reassessed immediately after aortic repair and revascularization procedures undertaken urgently if any pulse deficits remain.