Peripheral veno-arterial extracorporeal membrane oxygenation as a bridge to surgery in type A aortic dissection: a review on strategic approach to managing malperfusion syndrome

Background: Acute Type A aortic dissection (ATAAD) is a critical cardiovascular emergency characterized by high mortality rates and complex management challenges. The presence of a tear in the ascending aorta often extends into the aortic arch and descending thoracic aorta, leading to malperfusion syndrome, a severe condition resulting from obstructed blood flow to vital organs. Despite the high risks associated with ATAAD, the use of Peripheral Veno-Arterial (VA), Extracorporeal Membrane Oxygenation (ECMO) remains controversial. This intervention aims to maintain systemic circulation and organ perfusion, potentially stabilizing patients prior to surgical repair. Materials and methods: A narrative review of the literature was conducted through a comprehensive search of PubMed and Embase databases, covering the period from January 2000 to March 2025. Keywords included “ECMO”, “Type A Aortic Dissection”, “malperfusion”, and “bridge to surgery”, among others. Although this is a narrative review, the methodology was guided by the PRISMA guidelines to ensure transparency and reproducibility in the selection and reporting of the included studies. Results: Ten relevant articles were identified, including observational studies, case series, and reviews. This narrative review presents the role of peripheral VA ECMO in managing ATAAD, focusing on the timing of ECMO initiation and its implications for patient outcomes. The approach emphasizes rapid deployment following confirmation that the iliac and femoral arteries are free from dissection involvement, ensuring safe cannulation and effective circulatory support. The discussion also explores ECMO’s role as a bridge to surgery, detailing its impact on preventing malperfusion to critical organs such as the brain, kidneys, and splanchnic organs. Conclusion: While VA ECMO offers a potential lifeline for patients with severe ATAAD, its application must be carefully considered within an integrated treatment strategy. The ongoing debate and emerging research underscore the need for further studies to define clear guidelines and optimize ECMO’s use in this high-risk patient population. The balance between preventing malperfusion and managing increased myocardial workload presents a complex clinical challenge, necessitating continued investigation and dialogue within the medical community.