Pancreatic Ischemia in Acute Type A Aortic Dissection: Correlation of Surgical Outcomes with CT Findings

Abstract Objective To evaluate the impact of pancreatic ischemia on outcomes of acute type A aortic dissection (ATAAD) with visceral malperfusion syndrome. Methods Among 588 consecutive patients with ATAAD, 19 sustained visceral ischemia preoperatively. Our routine was a central repair-fist strategy using root, ascending aortic, and/or total arch repair, followed by visceral artery reperfusion, if necessary. Based on CT evidence of inadequate pancreatic blood supply, patients were divided into pancreatic ischemia (n = 5) and nonischemia (n = 14) groups. Outcomes were compared between the two groups, and correlation of CT findings to mortality was evaluated. Results Two groups were otherwise comparable except that the pancreatic ischemia group tended to have more dual antiplatelet therapy (100% vs 35.7%), acidosis (pH 7.23 vs 7.42), higher base excess (−10.5 vs −1.5 mmol/L), lactate (8.9 vs 3.0 mmol/L), leukocytes (18940 vs 13450/μL), and blood amylase (354.5 vs 66.6 U/L), and lower phosphate (1.1 vs 2.0 mmol/L) (all P < 0.05). Pancreatic ischemia group had longer operative time (574 vs 330 min, P = 0.004) and required more platelet infusion (1.4 vs 0.3 units, P = 0.002) and dialysis for acute kidney injury (100% vs 28.6%, P = 0.011), with an operative mortality of 100% vs 7.1% in the nonischemia group (1/14, P < 0.001). Follow-up was 100% at mean 4.3 ± 2.0 years. Kaplan–Meier survival was 85.7% at 1 month and 78.6% through 5 years for the nonischemia group. Operative mortality was 100% when 2 or more visceral branches were involved, and 16.7% when one visceral branch was involved. Conclusion In patients with ATAAD, pancreatic ischemia was associated with a 100% mortality following central repair, probably due to the involvement of 2 or 3 visceral branches supplying the pancreas. An upfront reperfusion-first strategy with visceral artery stenting or fenestration should be preferred when 2 or 3 visceral branches are involved.