Managing End-Organ Ischemia in Acute Aortic Dissection

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At ISET 2025 on Tuesday, John Angle, MD, from the University of Virginia, presented a comprehensive discussion on managing end-organ ischemia in patients with acute aortic dissection. His presentation focused on the pathophysiology of malperfusion, diagnostic techniques, and treatment strategies, including fenestration, endografting, and branch vessel stenting. Dr. Angle highlighted both historical and recent clinical data, providing a structured approach to improving patient outcomes.  

Discussing malperfusion in aortic dissection, Dr Angle noted that it occurs due to dynamic and static obstructions within the dissected aorta, leading to organ ischemia. Dynamic obstruction is caused by flap movement, restricting blood flow and leading to hypoperfusion. Static obstruction results from luminal thrombosis or vessel compression, permanently blocking flow. Malperfusion should be assessed separately from the aortic dissection repair strategy, particularly in mesenteric ischemia, which requires urgent intervention.  

When diagnosing malperfusion, Dr. Angle emphasized the importance of a multimodal diagnostic approach, combining computed tomography angiography to identify true lumen compression and vessel involvement, intravascular ultrasound for real-time lumen assessment, and angiography/manometry to measure flow dynamics and confirm pressure gradients.  

Dr Angle then reviewed treatment approaches for malperfusion. These include beta-blockers and afterload reduction, which are crucial to minimize aortic shear stress and avoiding inotropic agents, as they can worsen dynamic obstruction. Endovascular techniques include fenestration, which creates a flow channel between the true and false lumen, equalizing pressures and restoring perfusion; it remains a key intervention for type A dissections, especially before open repair. Clinical data show high success rates in improving organ perfusion before definitive surgical repair. Fenestration remains a critical tool, especially in type A dissections, and is a viable alternative to TEVAR in type B cases.  

Endograft placement (thoracic endovascular aortic repair) seals the entry tear, preventing further blood flow into the false lumen, and is often combined with fenestration for better long-term stability. Branch vessel stenting is used if major vessels (renal, iliac, mesenteric arteries) remain compromised after fenestration, and a "kissing stents" technique improves flow into iliac arteries. Dr Angle then presented 2 case studies using these procedures along with long-term data on malperfusion treatment. 

Dr. Angle’s presentation reinforced the importance of early recognition, accurate diagnosis, and a multidisciplinary approach to managing end-organ ischemia in acute aortic dissection. As endovascular techniques evolve, tailored interventions based on patient anatomy and perfusion status will continue to improve outcomes in this complex patient population.