Malperfusion in Acute Type A Aortic Dissection: Unsolved Problem

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Malperfusion in Acute Type A Aortic Dissection: Unsolved Problem Kazumasa Orihashi, MD, PhD The Annals of Thoracic Surgery Volume 95, Issue 5, Pages 1570-1576 (May 2013) DOI: 10.1016/j.athoracsur.2013.02.025 Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Transesophageal echocardiograms showing malperfusion in case 39. (A) Patent right coronary artery (RCA). (B) Occluded left main truncus (LMT) without detectable blood flow compressed by false lumen (FL) (arrow). (C) Compressed true lumen (TL) in the abdominal aorta (AO) (arrowheads) with malperfused celiac artery (CEA). (D) No detectable blood flow in superior mesenteric artery (SMA). (E) Restored TL (arrowheads) in the aorta with slit-like recovery of TL in SMA after femoral arterial perfusion. (F) Restored flow in left anterior descending artery (LAD) and left circumflex artery (LCX) after aortic repair. (G) Incomplete recovery of TL in SMA after aortic repair. (A-AO = ascending aorta.) The Annals of Thoracic Surgery 2013 95, 1570-1576DOI: (10.1016/j.athoracsur.2013.02.025) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Transesophageal echocardiograms for case 47. (A, B) Intact left subclavian artery (SCA) and common carotid artery (CCA). (C, D) Left SCA with antegrade flow in distal portion but retrograde flow in the middle portion (yellow arrows). Retrograde blood flow from the right vertebral artery (VA) is seen (white arrows). (E) Occlusion of innominate artery (IA) with false lumen (FL) filled with thrombus. Blood flow was of to-and-fro pattern (dashed arrow). (F) Undetectable blood flow (dashed arrow) in right CCA despite apparent flow signal detected in the vein. (G) Malperfused right CCA after right AXA perfusion. (H) Slit-like recovery of true lumen in IA (arrows) with turbulent blood flow in the arch. (I) Antegrade blood flow (white arrow) in the right VA directed toward the vertebra. The right SCA is indicated as dashed line. (J) Restored blood flow (yellow arrow) in the TL of right CCA. The inset shows the scanning planes in the corresponding transesophageal echocardiograms. The Annals of Thoracic Surgery 2013 95, 1570-1576DOI: (10.1016/j.athoracsur.2013.02.025) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Transesophageal echocardiograms in case 46. (A) Avulsed intima at the orifice of right coronary artery (RCA) perfused from false lumen (FL). (TL = true lumen) (B) Intact left main truncus (LMT) to left anterior descending artery (LAD). (C) Dissection in the innominate artery (IA) without blood flow in the FL. (D) Occluded right common carotid artery (CCA) at its orifice. The IA and right subclavian artery (SCA) are well perfused. (E, F) Good blood flow in the LMT, LAD, and left circumflex artery (LCX) after aortic root replacement. (G, H) Restored blood flow in the TL of right CCA after aortic repair (in short-axis and long-axis views). The Annals of Thoracic Surgery 2013 95, 1570-1576DOI: (10.1016/j.athoracsur.2013.02.025) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Computed tomograms and schematic illustrations of procedures for the right femoral artery in case 42. (A) Preoperative assessment; right leg was malperfused. (B) Postoperative assessment; both legs were adequately perfused. The left iliac artery was recanalized with true lumen perfusion after aortic repair. (C) Procedures carried out on the right femoral artery. The true lumen remained occluded under right axillary artery (AXA) perfusion and was selectively perfused through a cannula without resistance. However, thrombus in the false lumen disturbed distal perfusion. As the thrombus was aspirated, distal perfusion improved. The Annals of Thoracic Surgery 2013 95, 1570-1576DOI: (10.1016/j.athoracsur.2013.02.025) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions