Mesenteric malperfusion represents one of the most devastating complications of aortic dissection. Intestinal ischaemia may evolve rapidly and can persist even after central aortic repair. Once bowel necrosis and systemic inflammatory response develop, mortality rises dramatically.
Historically, these patients were transferred directly to the operating room for immediate aortic repair. However, operating on a patient with severe metabolic derangement and ongoing visceral ischaemia exposes them to extreme physiological stress. Moreover, central repair does not invariably resolve dynamic compression of the true lumen at the mesenteric level.
The initial reperfusion strategy challenges this traditional sequence by prioritizing restoration of visceral perfusion before definitive aortic surgery. Through endovascular fenestration and/or selective stent implantation, the goal is to re-establish true lumen flow, reverse ischaemia and metabolic deterioration, and stabilize the patient before open surgery under safer physiological conditions. This approach should be reserved for cases in which reperfusion can be achieved promptly and effectively, without delaying life-saving surgery in unstable patients.
Serial computed tomography plays a pivotal role by confirming technical success, documenting changes in true and false lumen dynamics, and demonstrating recovery of visceral perfusion—findings that correlate with clinical evolution.
The authors aimed to determine whether this staged strategy is associated with improved outcomes and to document, using imaging techniques, how reperfusion modifies visceral perfusion and aortic morphology. The study specifically focuses on patients in whom reperfusion was technically feasible and clinically justified.
From a clinical standpoint, metabolic parameters stabilized, abdominal symptoms resolved, and intestinal resection was avoided in a substantial proportion of cases (≈70%). Notably, a high percentage of patients subsequently underwent central aortic repair (≈80%) after a short and controlled period of physiological stabilization.
In cases where surgery was deferred, the interval between mesenteric reperfusion and central aortic repair was limited, with a median time to surgery of 9.1 hours (IQR 1.1–78.2 h), allowing correction of metabolic deterioration without introducing excessive delay.
Radiological follow-up over a mean period of 2.5 years did not demonstrate accelerated abdominal aortic dilatation in patients managed with an initial reperfusion strategy. On the contrary, serial computed tomographic angiography showed favourable remodelling, characterized by significant true lumen expansion and progressive false lumen reduction in distal segments. These findings suggest that the staged approach was not detrimental and may even exert a stabilizing effect on the distal aorta.
COMMENTARY:
This study addresses a central clinical dilemma in acute aortic pathology: operate first or reperfuse first. Its main contribution lies in demonstrating that restoration of mesenteric perfusion is not merely a technical success, but an intervention capable of substantially altering the patient’s clinical trajectory.
The correlation between radiological findings and clinical recovery reinforces a fundamental principle: in the presence of intestinal ischaemia, visceral perfusion must become an immediate priority. The study further underscores an increasingly accepted reality—acute type A aortic dissections should not all be managed according to a single algorithm.
Prudence remains essential. This strategy requires immediate access to experienced endovascular teams and must never postpone life-saving surgery in haemodynamically unstable patients. In addition, the sample size is limited and selection bias is unavoidable.
Nevertheless, the pathophysiological coherence of the strategy and the radiological evidence provided are compelling. Applied judiciously, the initial reperfusion strategy does not alter the underlying disease, but it may significantly modify its course, enabling patients with an initially ominous prognosis to reach definitive surgery under more favourable conditions.
In acute type A aortic dissection complicated by mesenteric malperfusion, the safest course may sometimes be, quite simply, to go with the flow.
REFERENCE:
Gao X, Ma WG, Liu JW, Yang R, Wang PF, Yuan YQ. Evolution of visceral arteries and distal aorta following reperfusion-first strategy for acute type A aortic dissection with mesenteric malperfusion. Eur J Cardiothorac Surg. 2025;67(12):ezaf409. doi:10.1093/ejcts/ezaf409.
