Mesenteric ischemia in acute aortic dissection

Abstract

Despite improved outcomes in acute aortic dissection in Japan, mesenteric ischemia remains a problem. This is largely due to difficulties in early diagnosis and treatment. To address this problem, this article will review several diagnostic modalities such as ultrasound and near-infrared spectroscopy, as well as surgical treatments. Ultrasound is useful for assessing mesenteric ischemia because it can be performed at bedside and it provides information on both morphology and perfusion in real time without exposure to radiation or contrast media. Malperfusion can be assessed at four sites between the aorta and intestine. Two causes of malperfusion, aortic type and branch type, can be assessed. Lack of intestinal movement can also indicate ischemia. Near-infrared light assesses regional oxygen saturation in the tissue, while fluorescent visualization using indocyanin green demonstrates vessels and tissue perfusion. Information provided by these imaging modalities can help guide treatment strategies. Future treatments include endovascular interventions combined with conventional surgical procedures. The hybrid OR may be helpful for such sophisticated treatments.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. 1.

    Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Masuda M, Okumura M, Doki Y, Endo S, Hirata Y, Kobayashi J, et al. Thoracic and cardiovascular surgery in Japan during 2014: annual report by The Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg. 2016;64:665–97.

    Article  Google Scholar 

  2. 2.

    Di Eusanio M, Trimarchi S, Patel HJ, Hutchison S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013;145:385–90.

    Article  PubMed  Google Scholar 

  3. 3.

    Takagi H, Watanabe T, Umemoto T. Mesenteric malperfusion complicated with type A acute aortic dissection. Int Angiol. 2015;34:445–53.

    CAS  PubMed  Google Scholar 

  4. 4.

    Tolenaar JL, Froehlich W, Jonker FH, Upchurch GR Jr, Rampoldi V, Tsai TT, et al. Predicting in-hospital mortality in acute type B aortic dissection: evidence from International Registry of Acute Aortic Dissection. Circulation. 2014;130(11 Suppl 1):45–50.

    Article  Google Scholar 

  5. 5.

    Gorla R, Erbel R, Kahlert P, Tsagakis K, Jakob H, Mahabadi AA, Schlosser T, Eggebrecht H, Bossone E, Jánosi RA. Diagnostic role and prognostic implications of d-dimer in different classes of acute aortic syndromes. Eur Heart J Acute Cardiovasc Care. 2017;6:379–88.

    Article  PubMed  Google Scholar 

  6. 6.

    Orihashi K. Mesenteric ischemia in acute aortic dissection. Surg Today. 2016;46:509–16.

    Article  PubMed  Google Scholar 

  7. 7.

    Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Management of visceral malperfusion complicated with acute type A aortic dissection. Interact Cardiovasc Thorac Surg. 2015;21:346–51.

    Article  PubMed  Google Scholar 

  8. 8.

    Shimamoto T, Komiya T. Clinical dilemma in the surgical treatment of organ malperfusion caused by acute type A aortic dissection. Gen Thorac Cardiovasc Surg. 2014;62:398–406.

    Article  PubMed  Google Scholar 

  9. 9.

    Muraki S, Fukada J, Morishita K, Kawaharada N, Abe T. Acute type A aortic dissection with intestinal ischemia predicted by serum lactate elevation. Ann Thorac Cardiovasc Surg. 2003;9:79–80.

    PubMed  Google Scholar 

  10. 10.

    Watari M, Murakami H, Orihashi K, Sueda T, Matsuura Y, Kajihara H. Ammonia determination as an early indicator in experimental superior mesenteric artery occlusion. Hiroshima J Med Sci. 1997;46:159–67.

    CAS  PubMed  Google Scholar 

  11. 11.

    Akutsu K, Matsuda H, Sasaki H, Minatoya K, Ogino H, Kasai S, et al. A case of acute type B aortic dissection: limited role of laboratory testing for the diagnosis of mesenteric ischemia. Ann Thorac Cardiovasc Surg. 2007;13:360–4.

    PubMed  Google Scholar 

  12. 12.

    Güzel M, Sözüer EM, Salt Ö, İkizceli İ, Akdur O, Yazıcı C. The value of the serum I-FABP level for diagnosing acute mesenteric ischemia. Surg Today. 2014;44:2072–6.

    Article  CAS  PubMed  Google Scholar 

  13. 13.

    Björck M, Koelemay M, Acosta S, Bastos Goncalves F, Kölbel T, Kolkman JJ et al. Editor’s choice—management of the diseases of mesenteric arteries and veins: clinical practice guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53:460–510.

    Article  PubMed  Google Scholar 

  14. 14.

    Morisaki A, Kato Y, Motoki M, Takahashi Y, Nishimura S, Shibata T. Delayed intestinal ischemia after surgery for type A acute aortic dissection. Ann Vasc Dis. 2015;8:255–7.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Yamashiro S, Kuniyoshi Y, Kise Y, Arakaki R. Delayed visceral malperfusion after Bentall procedure for type A acute aortic dissection. Interact Cardiovasc Thorac Surg. 2012;15:794–6.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Ito T, Yasuda N, Kuroda Y, Sugawara M, Koyanagi T, Higami T. Acute gallbladder necrosis in a patient with acute type B aortic dissection. Ann Vasc Dis. 2013;6:748–50.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Sato K, Itagaki R, Arao K, Makita K. Lifesaving treatment of acute Stanford B aortic dissection complicated by intestinal ischemia with stent placement in the superior mesenteric artery: a case report. Ann Vasc Dis. 2016;9:248–51.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Charlton-Ouw KM, Sandhu HK, Leake SS, Jeffress K, Miller Rd CC, Durham CA, et al. Need for limb revascularization in patients with acute aortic dissection is associated with mesenteric ischemia. Ann Vasc Surg. 2016;36:112–20.

    Article  PubMed  Google Scholar 

  19. 19.

    Orihashi K. Malperfusion in acute type a aortic dissection: unsolved problem. Ann Thorac Surg. 2013;95:1570–6.

    Article  PubMed  Google Scholar 

  20. 20.

    Muzzi L, Tommasino G, Guaccio G, Tucci E, Roviello F, Neri E. Trans-pericardal color Doppler ultra sound to assess blood flow in the visceral branches during type A dissection procedures complicated with mesenteric malperfusion. Ann Vasc Surg. 2017;44:420.e1–5.

    Article  Google Scholar 

  21. 21.

    Davis CB, Kendall JL. Emergency bedside ultrasound diagnosis of superior mesenteric artery dissection complicating acute aortic dissection. J Emerg Med. 2013;45:894–6.

    Article  PubMed  Google Scholar 

  22. 22.

    Orihashi K, Matsuura Y, Sueda T, Shikata H, Morita S, Hirai S, et al. Abdominal aorta and visceral arteries visualized by transesophageal echocardiography: technical considerations. Hiroshima J Med Sci. 1997;46:151–7.

    CAS  PubMed  Google Scholar 

  23. 23.

    Orihashi K, Matsuura Y, Sueda T, Shikata H, Morita S, Hirai S, et al. Abdominal aorta and visceral arteries visualized with transesophageal echocardiography during operations on the aorta. J Thoracic Cardiovasc Surg. 1998;115:945–7.

    CAS  Article  Google Scholar 

  24. 24.

    Orihashi K, Sueda T, Okada K, Imai K. Perioperative diagnosis of mesenteric ischemia in acute aortic dissection by transesophageal echocardiography. Eur J Cardiothorac Surg. 2005;28:871–6.

    Article  PubMed  Google Scholar 

  25. 25.

    Trimarchi S, Segreti S, Grassi V, Lomazzi C, Cova M, Piffaretti M, et al. Open fenestration for complicated acute aortic B dissection. Ann Cardiothorac Surg. 2014;3:418–22.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Crawford TC, Beaulieu RJ, Ehlert BA, Ratchford EV, Black JH III. Malperfusion syndromes in aortic dissection. Vasc Med. 2016;21:264–73.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Orihashi K, Sueda T, Okada K, Imai K. Near-infrared spectroscopy for monitoring cerebral ischemia during selective cerebral perfusion. Eur J Cardiothorac Surg. 2004;26:907–11.

    Article  PubMed  Google Scholar 

  28. 28.

    Orihashi K, Sueda T, Okada K, Imai K. Malposition of selective cerebral perfusion catheter is not a rare event. Eur J Cardiothorac Surg. 2005;27:644–8.

    Article  PubMed  Google Scholar 

  29. 29.

    Orihashi K, Sueda T, Okada K, Imai K. Detection and monitoring of complications associated with femoral or axillary arterial cannulation for surgical repair of aortic dissection. J Cardiothorac Vasc Anesth. 2006;20:20–5.

    Article  PubMed  Google Scholar 

  30. 30.

    Orihashi K, Matsuura Y, Sueda T, Watari M, Okada K. Reversible visceral ischemia detected by transesophageal echocardiography and near-infrared spectroscopy. J Thorac Cardiovasc Surg. 2000;119:384–6.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Ferlan G, Lospalluti M, Capone G, De Pasquale C. Mesenteric ischemia in a patient with an acute aortic dissection type A. One-step repair of the aortic and visceral lesions. Role of laparoscopy for timely diagnosis and treatment. Interact Cardiovasc Thorac Surg. 2011;12:835–6.

    Article  PubMed  Google Scholar 

  32. 32.

    Tshomba Y, Coppi G, Marone EM, Bertoglio L, Kahlberg A, Carlucci M, et al. Diagnostic laparoscopy for early detection of acute mesenteric ischaemia in patients with aortic dissection. Eur J Vasc Endovasc Surg. 2012;43:690–7.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Alemanno G, Somigli R, Prosperi P, Bergamini C, Maltinti G, Giordano A, et al. Combination of diagnostic laparoscopy and intraoperative indocyanine green fluorescence angiography for the early detection of intestinal ischemia not detectable at CT scan. Int J Surg Case Rep. 2016;26:77–80.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Yamamoto M, Orihashi K, Nishimori H, Handa T, Kondo N, Fukutomi T, et al. Efficacy of intraoperative HyperEye Medical System angiography for coronary artery bypass grafting. Surg Today. 2015;45:966–72.

    Article  PubMed  Google Scholar 

  35. 35.

    Yamamoto M, Orihashi K, Nishimori H, Wariishi S, Fukutomi T, Kondo N, et al. Indocyanine green angiography for intra-operative assessment in vascular surgery. Eur J Vasc Endovasc Surg. 2012;43:426–32.

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Kuriyama M, Yano A, Yoshida Y, Kubo M, Akita S, Mitsukawa N, et al. Reconstruction using a divided latissimus dorsi muscle flap after conventional posterolateral thoracotomy and the effectiveness of indocyanine green-fluorescence angiography to assess intraoperative blood flow. Surg Today. 2016;46:326–34.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Anayama T, Qiu J, Chan H, Nakajima T, Weersink R, Daly M, et al. Localization of pulmonary nodules using navigation bronchoscope and a near-infrared fluorescence thoracoscope. Ann Thorac Surg. 2015;99:224–30.

    Article  PubMed  Google Scholar 

  38. 38.

    Kitagawa H, Namikawa T, Munekage M, Akimori T, Kobayashi M, Hanazaki K. Visualization of the stomach’s arterial networks during esophageal surgery using the HyperEye Medical System. Anticancer Res. 2015;35:6201–5.

    CAS  PubMed  Google Scholar 

  39. 39.

    Namikawa T, Uemura S, Kondo N, Yamamoto M, Maeda H, Nishimori H, et al. Successful preservation of the mesenteric and bowel circulation with treatment for a ruptured superior mesenteric artery aneurysm using the HyperEye Medical System. Am Surg. 2014;80:E359-61.

    PubMed  Google Scholar 

  40. 40.

    Kamman AV, Yang B, Kim KM, Williams DM, Michael Deeb G, Patel HJ. Visceral malperfusion in aortic dissection: the Michigan experience. Semin Thorac Cardiovasc Surg. 2017;29:173–8.

    Article  PubMed  Google Scholar 

  41. 41.

    Odagiri S, Koide S, Ariizumi K, Suzuki I, Kamabuchi K, Inamura S, et al. Successful right common iliac to superior mesenteric artery bypass for mesenteric ischemia associated with acute aortic dissection: report of a case. Surg Today. 1993;23:1014–7.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Leprince P, Cluzel P, Bonnet N, Izzillo R, Pavie A, Gandjbakhch I. An endovascular stent relieves celiac and mesenteric ischemia in acute aortic dissection. Ann Thorac Surg. 2004;78:e3–5.

    Article  PubMed  Google Scholar 

  43. 43.

    Massmann A, Kunihara T, Fries P, Schneider G, Buecker A, Schäfers HJ. Uncovered stent implantation in complicated acute aortic dissection type B. J Thorac Cardiovasc Surg. 2014;148:3003–11.

    Article  PubMed  Google Scholar 

  44. 44.

    Connell DA, Thomson KR, Gibson RN, Wall AJ. Stent placement in coeliac and superior mesenteric arteries to restore vascular perfusion following aortic dissection. Australas Radiol. 1995;39:68–70.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Suzuki K, Shimohira M, Hashizume T, Shibamoto Y. Stent placement for acute superior mesenteric artery occlusion associated with type B aortic dissection. Case Rep Vasc Med. 2015;2015:485141.

    PubMed  PubMed Central  Google Scholar 

  46. 46.

    Szeto WY, McGarvey M, Pochettino A, Moser GW, Hoboken A, Cornelius K, et al. Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection. Ann Thorac Surg. 2008;86:87–93.

    Article  PubMed  Google Scholar 

  47. 47.

    Hisata Y, Matsumaru I, Yokose S, Hazama S. Successful repair of mesenteric ischemia in acute type A aortic dissection. Asian Cardiovasc Thorac Ann. 2016;24:169–71.

    Article  PubMed  Google Scholar 

  48. 48.

    Totsugawa T, Ozawa M, Kuinose M, Ishii S, Yoshitaka H, Tamaki T. Intraoperative endotoxin adsorption for visceral malperfusion complicating acute type A aortic dissection. Gen Thorac Cardiovasc Surg. 2010;58:134–7.

    Article  PubMed  Google Scholar 

  49. 49.

    Okada Y, Okimoto M, Katsumata M, Takeuchi S. Temporary perfusion for mesenteric ischemia with acute type A aortic dissection. Ann Thorac Surg. 2007;83:293–4.

    Article  PubMed  Google Scholar 

  50. 50.

    Iida Y, Obitsu Y, Shigematsu H. Use of side branch of total arch replacement graft as bypass inflow to prevent visceral ischemia with type B aortic dissection. Gen Thorac Cardiovasc Surg. 2012;60:440–2.

    Article  PubMed  Google Scholar 

  51. 51.

    Kato W, Fujita T, Uchida K, Munakata H, Hibino M, Fujii K, et al. Superior mesenteric artery plasty for type A acute aortic dissection with visceral ischemia. Gen Thorac Cardiovasc Surg. 2016;64:422–4.

    Article  PubMed  Google Scholar 

  52. 52.

    Mitsuoka H, Nakai M, Terai Y, Gotou S, Miyano Y, Tsuchiya K, et al. Retrograde stent placement for symptomatic spontaneous isolated dissection of the superior mesenteric artery. Ann Vasc Surg. 2016;35:203.e17-21.

    Article  PubMed  Google Scholar 

  53. 53.

    Tanaka K, Chikazawa G, Sakaguchi T, Totsugawa T, Tamura K, Yoshitaka H. Hybrid treatment for type A acute aortic dissection with multiorgan malperfusion. Ann Thorac Surg. 2014;98:1118–20.

    Article  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Kazumasa Orihashi.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Orihashi, K. Mesenteric ischemia in acute aortic dissection. Gen Thorac Cardiovasc Surg 66, 557–564 (2018). https://doi.org/10.1007/s11748-018-0970-6

Download citation

Keywords

  • Aortic dissection
  • Malperfusion
  • Mesenteric ischemia